A Child's First Prosthesis

Considerable difference of opinion exists among experienced clinicians about when to fit a child with an upper limb prosthesis, what prehensor to fit, when and how to teach the child to operate the control system. Through experience with families and children with upper limb absence, and knowledge of child development, clinicians find that certain fitting practices and certain terminal devices are effective in meeting the prosthetic needs of most young children who have a missing limb below the elbow on one side. Although family circumstances and other factors also play an important role in prosthesis prescription, clinicians find that in "most cases" a pattern develops in their clinic for recommending the terminal device for a child’s first prosthesis. Similarly, clinics prefer certain terminal devices for the period when the child’s development shows readiness for more active terminal device use.

No recent systematic survey of the specialized centers in North America has documented the developmental indicators used by most clinics for fitting the first prosthesis, selecting the terminal device, and for deciding when children are ready to learn to operate the prehensor. In recent years, new terminal devices have become available, and fitting patterns change over time. This survey was conducted to give us a picture of fitting practices in 2001 for children with unilateral congenital below-elbow limb absence. The focus of this survey was on ways child development guides fitting and training practices.

Findings from the survey should meet several objectives. First, if we knew when clinicians provide infants and toddlers with upper limb prostheses and the kinds of components they prefer initially and in the next developmentally advanced stage, designers of new components could focus their efforts on serving the prevailing clinical needs with greater assurance of wide usage. They would also have better justification for the direction of their efforts and their components could be evaluated in appropriate settings. Second, published data on fitting practices could provide the basis for studies to compare efficacy of different fitting and training practice protocols. Third, findings from future surveys could clearly identify changes in patterns of patient care through comparison with findings from this survey. Fourth, clinics could explain to parents how and why their clinic’s recommendations differ or coincide with those of other clinics throughout the country.

Progress

A survey was developed to learn when and what kinds of prostheses clinicians in multi-disciplinary clinics fit to young children with absence of one upper limb. The survey was developed in cooperation with Dr. Eve Fielder, the director (a sociologist) of the UCLA Institute for Social Science Research.. The survey form was tested (inter-rater and test-re-test reliability plus content validity) by therapists in three centers. The survey was finalized and mailed to 80 clinics in North America. These clinics comprised all those listed by the Amputee Coalition of America (ACA) and the Association of Children’s Prosthetic-Orthotic Clinics. Fifty clinics (62%) responded to the survey. Of these 45 (56%) were usable (filled in completely and legible). Analysis was completed with assistance from a statistician on faculty at University of Southern California. Findings indicated that fitting and change to active terminal devices is occurring at an earlier age (average 6 months) than had been reported in the literature. Also, clinics are less likely to adhere to developmental guidelines than to fit at a given chronological age. Terminal device preferences do not vary significantly by area of the country or between the USA and Canada. Cost considerations are a greater influence in selecting an active than a passive terminal device. Training protocols have become shorter and parents are being asked to do more of the training at home than previously reported. Clinical staffs were asked to identify features they would like to see in a newly designed terminal device for young children. The desired features are a close match with the design goals for the Easy-Feed Hand. Results of the survey were presented at the 2002 meeting of the Association for Children’s Prosthetic-Orthotic Clinics and published in the Journal of Prosthetics / Orthotics, 15(1):11-17 in January, 2003.

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Last modified: July 28, 2005