Congenital Partial Hand Absence: What is the Impact of Fitting with an Electric Multi-Articulating Digit Prosthesis?
Diane J Atkins, OTR, FISPO
It has long been the belief of many rehabilitation professionals that fitting an individual with congenital partial hand absence, with a prosthesis, would not enhance their functional well-being. The sensation that would be sacrificed, and the ability of these individuals to be totally independent, appeared to out weigh the advantages a prosthesis might afford.
Terry Light, MD, in his chapter entitled "Hand Deficiencies" in the Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles , reinforces this belief by stating, "Although an upper limb prosthesis may facilitate rehabilitation in the traumatic amputee, it is usually a hindrance to the congenital amputee possessing a mobile hand and wrist, even when the fingers are absent." 1
Since the advent of electric multi-articulating digits , however, there is an increasing interest in adolescents wishing to explore the advantages, if any, of these state-of-the-art electric prostheses. Is it advantageous to fit an adolescent, with congenital partial hand absence, with an electric, multi-articulation prosthesis, and if so, what are the benefits?
In pediatric amputee rehabilitation, there are several traditional assumptions, and schools of thought, about individuals born with partial hand absence.
- These individuals are essentially independent in all activities of daily living (ADL) and require little, if any, adaptave equipment or device.
- Because sensation is critically important, covering the residuum, or fitting congenital partial hand absence with any type of prosthesis is often considered contraindicated.
- Other than a "passive" aesthetic prosthesis, there were not any functional prosthetic alternatives for this population.
In 2009, with the advent of the first electric multi-articulating hand, there was immediate interest by many individuals with hand or partial hand loss, to learn more about the first upper limb prosthetic device that initiated the movement and accuracy of the human hand. This electric hand prosthesis, the i-limb hand, offered 4 multi-articulating, powered digits and a rotatable thumb that allowed its digits to flex in a compliant, form fitting manner, and enabled the user to utilize multiple positions for maximizing grip options, and well as increasing motor dexterity.
This hand technology led the way for electric multiarticulation digits, the world's first externally powered electric multi-articulating digit solution for individuals with finger and partial hand loss . With this new technology, there is an emerging trend of adolescents, with congenital partial hand absence, wanting to be fit with a prosthesis.
One might ask, "What does it have to offer the individual with congenital partial hand limb absence, that hasn't been available before? This new digit technology offers appearance and the opportunity for bimanual function . This combination is something that has never been available before for those with congenital partial hand absence.
This study includes 3 adolescents with congenital partial hand absence who have been fit with an electric, multi-articulating digit prosthesis. A comprehensive evaluation and functional profile of these individuals was obtained at the outset of the fitting. Short and long term goals were identified, and advantages and disadvantages of the prosthesis were discussed. These individuals were fit, and at 3 months following delivery of the electric multi-articulating digit prosthesis, and occupational therapy directed prosthetic training, a comprehensive follow-up evaluation was conducted.
A comprehensive evaluation tool was designed to gather data as it related to device performance, client satisfaction with the device, independence, activity level, social adjustment, occupation, leisure/ recreation, overuse syndrome, pain, self image, goal setting, motivation, resiliency and quality of life.
The first graph represents some of the results that were recorded by three adolescents, with congenital partial hand absence, after having an opportunity to use electric multi-articulating digits. Some of the highest scores were reflected in their "feeling a greater potential for success," "overall feeling more capable," "less dependence on others," and an "improved ability to pursue special leisure and recreational activities."
The second graph represents "Ability vs. Perception." When asked how they perceived their ability, when compared to how others perceived them with their prosthesis, they responded that "others felt more comfortable with their appearance" and "others felt they were more capable" with their prosthesis.
Ability vs. Perception
Some of the abilities that these three individuals felt were now possible with the prehensile features of the hand included, using the "index point" feature to operate an ATM, cell phone and computer, as well as picking up small objects such as grapes and small candy with the "tip pinch" feature.
Perhaps the most important accomplishments they described as being possible now included several bimanual functional tasks. These tasks were not previously possible, or if they were, they needed to utilize compensatory body motions to accommodate "not having another hand." The following bimanual tasks were stated as being important to now be able to complete, as these were never before possible in a "2 handed" manner.
These bimanual tasks included:
- Ability to blow-dry and style hair,
- Open a bottle of water with two "hands"
- Fold laundry,
- Use a cell phone and take notes ,
- Tie shoelaces ,
- Hold a plate while serving food,
- Paint finger nails , and
- The ability to cut meat with 2 "hands" using a knife and fork.
In summary, three emerging trends appear in this follow-up evaluation of three adolescents fit with electric multi-articulating digits.
- Improved perception of their functional independence.
- Improved perception in how others perceived them in their ability to succeed.
- Improved perception of pain relief in the affected limb from previous overuse and body compensatory techniques.
Although preliminary, these results suggest that there appears to be a growing acceptance and desire in the adolescent individual, with congenital partial hand absence, to be fit with an electric, multi-articulating digit prosthesis. The interest to be more independent in two-handed activities, and a desire to have a more natural appearing hand, appears to outweigh the disadvantage of "losing sensation", when their partial hand is covered with a prosthesis.
Short and long term follow-up, with these and other adolescents with congenital partial hand absence who are fit with electric multi-articulating digits, is essential before any real conclusions can be drawn. These findings, however, suggest a significant "paradigm shift" in how adolescents, with congenital partial hand absence, are evaluated and advised regarding prosthetic alternatives, and demonstrate the need for additional evidence-based outcome studies of this unique population.
Clinical Assistant Professor Department of Physical Medicine and Rehabilitation Baylor College of Medicine Houston, Texas
- Light T: Hand Deficiencies, in Smith DG, Michael JW, Bowker JW (eds): Atlas of limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles , ed 3. Rosemont, IL, American Academy of Orthopedic Surgeons, 2004, pp.853-862.