Children and adolescents with upper limb differences
Children and adolescents with upper limb differences engage in a range of play, self-care and leisure activities at home, school and in the community.
Children may use an upper limb prosthesis to engage in bimanual tasks, these are tasks that typically require the use of two hands together. Many children are very independent without using a prosthesis.
Children and adolescents who have upper limb differences are regularly seen in large hospital settings by interdisciplinary teams who work together to help them be as independent and active as they can be. Occupational therapists (OTs) work with children and adolescents to help them achieve age appropriate functional goals such as learning to tie their shoelaces or to ride a bike. Prosthetists work very closely with OTs to collaboratively prescribe prostheses to meet the functional need of the child or adolescent and to help them do the things they need and want to do as they get older.
Evidence for upper limb prosthesis prescription
There is ongoing debate internationally about the type and timing of upper limb prosthesis prescription. Given the lack of consensus in the literature to assist with prosthesis prescription, clinical experience often guides this process [1]. Prostheses can be prescribed to increase symmetry and postural alignment, to encourage bimanual function, to help them achieve their goals or as an aesthetic device [2].
Some authors propose that very early prosthesis prescription helps to incorporate the prosthesis into the child’s body schema or concept of their body in space [3]. Additional authors recommend that very early prosthesis prescription supports development of prosthetic skill as the child gets older [4]. Other studies do not support routine prosthesis prescription before 1 year of age [5, 6]. Some studies recommend prosthesis prescription before 3 years [1, 4] or 4 years of age [5]. A 2008 literature review found that individuals fitted within two years of birth (congenital) or six months of amputation (acquired) were 16 times more likely to continue to use their prosthesis [7].
A variety of prosthetic designs can be used with children [1]. Older children and adolescents who haven’t used a prosthesis as a young child or who have stopped using a prosthesis, may choose to trial a prosthesis to help them engage in specific functional tasks [5] such as cooking with their family. Many children do not use a prosthesis. One reason may relate to increased sensitivity in their residuum or ‘little arm’ [8]. Wearing a prosthesis means their ‘little arm’ is covered and they are unable to feel the objects they are handling, which may in turn impact on their use of their residuum [8]. This is one reason why some people choose not to use a prosthesis. Another reason may be that they find it easier to complete activities without a prosthesis.
The Royal Children’s Hospital (RCH), Melbourne
At RCH, Melbourne the prosthetist and the OT work collaboratively to provide education to children, adolescents and their families about upper limb prosthetic options. They help identify functional goals that may be achieved using the prosthesis and prescribe a prosthesis on an individual basis.
Three main types of UL prostheses are prescribed to children and adolescents; passive, myoelectric and body powered. Activity specific devices such as bike or cricket orthoses are also commonly prescribed to help children engage in sporting and social activities. Upper limb prostheses and these activity specific devices are manufactured by the prosthetist.
When a child has a new prosthesis or a new goal for an activity they want to complete, the OT will assist with training the child to use their prosthesis and ensure it is helpful at home, kinder and school [3]. An OT can also provide functional training to children who do not use a prosthesis, helping these children complete activities like tying their shoe laces, drawing and cutting with scissors.
At the RCH the OT and the prosthetist work with children, adolescents and families to ensure client centred, individualised prescription of prostheses is undertaken to help children and adolescents do the things they need and want to do, now and in the future.
Lisa Robin, Occupational Therapist & Phoebe Thomson, Senior Prosthetist Orthotist (Limb Deficiency Clinic – Royal Children’s Hospital Melbourne)
References:
Davids, J.R., et al., Prosthetic management of children with unilateral congenital below-elbow deficiency. J Bone Joint Surg Am, 2006. 88(6): p. 1294-300.
Korkmaz, M., et al., Evaluation of functionality in acquired and congenital upper extremity child amputees. Acta Orthopaedica et Traumatologica Turcica, 2012. 46(4): p. 262-8.
Egermann, M., P. Kasten, and M. Thomsen, Myoelectric hand prostheses in very young children. International Orthopaedics, 2009. 33(4): p. 1101-1105.
Kuyper, M.A., et al., Prosthetic management of children in the Netherlands with upper limb deficiencies. Prosthetics and Orthotics International, 2001. 25(3): p. 228-234.
James, M.A., et al., Impact of prostheses on function and quality of life for children with unilateral congenital below-the-elbow deficiency. Journal of Bone and Joint Surgery - Series A, 2006. 88(11): p. 2356-65.
Huizing, K., et al., Age at first prosthetic fitting and later functional outcome in children and young adults with unilateral congenital below-elbow deficiency: A cross-sectional study. Prosthetics and Orthotics International, 2010. 34(2): p. 166-74.
Biddiss, E. and T. Chau, Multivariate prediction of upper limb prosthesis acceptance or rejection. Disability & Rehabilitation Assistive Technology, 2008. 3(4): p. 181-92.
Reinkingh, M., et al., Stump sensibility in children with upper limb reduction deficiency. Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine, 2014. 46(1): p. 51-58.