Therapy and Training

The preprosthetic period is mainly focused on the needs of the parents (103). The family level of distress or stress related to the child's limb deficiency will vary (104). It is important during this initial contact for the clinic team to present an honest forecast of the prosthetic plan.

The parents should be encouraged to treat the child as they would a child with normal limbs. Many parents benefit from being introduced to other parents and children with similar limb deficiencies (106).

Typically, children younger than 3 years of age have therapy provided in the home. Prone position­ing is important for encouraging trunk extension and mobility. Gross motor milestones are generally not delayed, but may be affected by asymmetry imposed by unilateral upper limb deficiencies. Children com­pensate and substitute for the missing action of limbs. Therapists bridge the delivery of the prosthesis to the initiation of function and create a comfortable envi­ronment for children to explore options, with or with­out the prosthesis. The goal is to increase the child's awareness of the affected side, including the pros­thetic device. The child should also be encouraged to use the prosthesis for transitional movements, such as sitting to crawling, and leaning on the prosthesis for weight bearing while reaching with the dominant hand. The parent is encouraged to maintain telephone contact with the therapist to answer questions regard­ing follow-through with prosthetic usage. A recheck through the clinic should be scheduled within a month after delivery of the prosthesis and then every three to four months.

When the terminal device is activated, the thera­pist will again provide initial instruction to the par­ents and child. A structured approach to use of the terminal device assists parents, child, and therapist in gaining confidence and competence (106). The ther­apist will work with the child and parents using toys that encourage bimanual use, such as Lego bricks, pop beads, and stringing beads. Initially, it is useful to concentrate on activities that require the prosthetic side to hold while the dominant hand manipulates. When training a child in the use of a myoelectric hand using this control scheme, the therapist should encourage activities that cause the hand to open. Because of the placement of the electrode over the forearm extensors, activities that elicit an extensor activity are appropriate. Once the hand is open, the therapist can quickly place a toy in the hand and encourage the child to release it. The child will learn through repetition.

It is unrealistic and inappropriate to teach the child to use the prosthesis for dominant hand activities. Children with high-level bilateral upper- extremity limb deficiencies will utilize their feet in a natural manner. Assistance is necessary for donning and doffing pros- theses. The child with an isolated limb deficiency or amputation is capable of achieving age-level academic skills. Few studies have been done to define achieve­ment academically. Good social adjustment is reported for children with myoelectric prosthetic users (107). School placement is almost entirely within the reg­ular school system, with an Individual Education Program (IEP) to address educationally related func­tion. Occupational therapists will assist with issues of grasp and fine motor control for paper, computer, and ADL tasks needed in school. Informational pam­phlets have been developed for the teacher to prepare the able-bodied students for integration of children with physical disabilities into the regular education classroom.

Adapted physical education may be necessary, but regular physical education is often sufficient. The phi­losophy promoted for children with physical disability is that of “participation, not observation.” Participation in athletic endeavors such as skiing, tennis, and other more mundane exercise improves the self-concept of the child or adult with limb deficiency. Specialized, adaptive prosthetic components that enable unilateral or bilateral handless persons to participate in sports such as golf, shooting, and ball sports have escalated since the 1980s.

Functional assessments recently developed to determine the use of upper-extremity prosthetics and function have included Assisting Hand Assessment, the Prosthetic Upper Limb Functional Index, The University New Brunswick Test of Prosthetic Function, Child Amputee Prosthetic Project-Functional Status Index, Child Amputee Prosthetic Project-Functional Status Index Preschool, Shriners Hospital Upper Extremity Evaluation (SHUEE), Capacity for Myoelectric Control (101), and Unilateral Below Elbow Test (108-114). It is typical for children to perform activities of daily living with their prosthesis, but often choose not to utilize them (115). In addition, prosthetics are often utilized for specific tasks versus everyday tasks. Children typ­ically utilize nonprosthetic options ages 3.5 through 13 years of age (103).

Outcomes related to patient satisfaction are increas­ingly important to evaluate for prosthetics (116,117).

Recent studies have indicated that children with unilateral, below-elbow deficiencies who do not wear prostheses perform as well or better than their coun­terparts who wear prostheses (77).

Figure 13.14 Proposed nerve transfer for targeted muscle reinnervation of an individual with shoulder disarticulation amputation.