Age at first prosthetic fitting and later functional outcome in children and young adults with unilateral congenital below-elbow deficiency: a cross-sectional study

Mothers' perspectives on the use and acceptability of 3d printed prosthesis by their children with congenital upper limb difference in India: a qualitative study

PURPOSE

Children with congenital upper limb difference (CULD) in India have limited access to treatment with conventional prostheses. 3D printed prosthetic devices (3DPP) can function as transitional prostheses for growing children with congenital transverse deficiency. They are low-cost and the designs are easily customized. However, functional outcomes, access, and acceptability are still unexplored in many clinical settings. This qualitative study sought perspectives from Indian mothers of children with CULD using 3DPP for the first time. The objective was to enhance understanding of 3DPP acceptability and to explore how their children utilized these devices.

METHOD

Semi-structured interviews were conducted with seven mothers of children aged 3 to 11 years with varying levels of CULD who had been fitted with a 3DPP for at least 1 month prior. The interviews aimed to gather insights into the children's daily experiences with the devices and the mothers' perceptions of 3DPP. Thematic analysis was carried out using an inductive approach.

RESULTS

Four major themes were identified through thematic analysis. They were: 1. Design and functionality of 3DPP, 2. Adaptation patterns, 3. Social attitudes and perceptions, and 4. Access to the Center for congenital hand differences: location and its services.

CONCLUSION

Our study explores the early-stage use and acceptance of 3DPP in India. Mothers reported several reasons for prosthesis abandonment including functional limitations, pain, and unmet expectations. The acceptability of 3DPP was moderate among close family, but social stigmatization was still a barrier to continued use. Addressing these issues and offering tailored solutions could be important to achieve successful 3DPP adaptation.

Listening to children with lower limb loss: Rationale, design, and protocol for delivery of a novel globally applicable research toolkit-Prosthetic user needs, quality of life, pain, and physical function

INTRODUCTION

Rehabilitation after childhood lower limb loss is complex and dependent on multiple stakeholders and environmental factors. While research with adults underscores the importance of involving prosthetic limb users and caregivers in discussions to drive innovation, children are often excluded or not effectively engaged. This protocol lays out the development and implementation protocol for an internationally applicable research toolkit which has been designed and evaluated around the essential presence of the child. Research domains span their unique prosthetic needs, quality of life, pain, and mobility.

METHODS AND ANALYSIS

Cohorts of children in contrasting environments were identified (Cambodia, Gaza Strip, and the UK) to provide a comprehensive global understanding of the child with lower limb loss. A literature review revealed a lack of appropriate tools for identifying paediatric prosthetic user requirements leading to the development of novel interview guides for each key stakeholder: child, caregiver, and prosthetist. The child's guide centred around enjoyment and engagement using card games and activities. A panel of experts in paediatric limb loss and mental health rigorously reviewed the guides. Guides were integrated with existing validated measures for quality of life, pain, and mobility to form a comprehensive toolkit. The toolkit was successfully piloted with 5 children, their families, and 2 prosthetists. This protocol lays out the toolkit rationale and implementation plan (Jan 2023 to Dec 2025). This work offers the opportunity for this cohort to enjoyably engage with research that seeks to radically improve prospects for all children living with limb loss. The outlined best practices ensure ethical considerations when working with vulnerable cohorts.

ETHICS AND DISSEMINATION

This study is approved to cover implementation at all geographical locations as well as the researcher institutions. Results will be disseminated through national and international conferences, as well as through manuscripts in leading peer-reviewed journals.

Patient-reported function, quality of life and prosthesis wear in adults born with one hand: a national cohort study

We invited individuals aged above 16 years with a congenital transverse reduction deficiency at and above the wrist born in Norway between 1970 and 2006 to complete the short version of the Disabilities of the Arm, Shoulder and Hand Outcome Measure, the 5-Level EuroQoL-5-Dimension instrument, the RAND 36-Item Short Form Health Survey and a single-item questionnaire on arm function, appearance, pain and prosthesis wear. Of 154 eligible participants, 58 (38%) responded. Their scores were not different from the general population. All had been offered prostheses, and 56 (97%) had been fitted at a median age of 1 year (interquartile range 0-2.8). Of the participants, 37 (64%) were still prosthesis wearers, while 21 (36%) were non-wearers or using gripping devices only. Prosthesis wearers had higher levels of 'vitality' as assessed by the RAND-36 and rated their arm appearance higher, but there were no other score differences, indicating that prosthesis rejection is not associated with worse functional outcomes.Level of evidence: III.

Development and Production of a Children's Upper-Limb Cycling Adapter Using 3D Printing

The research described in this study focuses on the development of an innovative upper-limb adapter for young children aged 1-3 years who have congenital upper-limb defects. The objective was to create a functional and affordable solution that allows children to engage more safely and actively in physical activities such as cycling. The adapter was designed within the DESIGN+ project at the University of West Bohemia in Pilsen in collaboration with the German company Ottobock. The development included a detailed analysis of hand movements during cycling, modelling using CAD software (NX 1888), prototype manufacturing through 3D printing, and subsequent testing. The result is an adapter that allows 360° rotation around the arm axis, provides natural hand movement while turning, and is made of soft material to enhance safety. Despite initial challenges and necessary prototype adjustments, a functional and reliable design was achieved. This adapter will contribute to improving the quality of life for children with upper-limb disabilities, supporting their coordination, strength, and confidence in daily activities.

The Use of ABILHAND-Kids in Children with Unilateral Congenital Below-Elbow Deficiencies and Acquired Amputation: An Italian Cross-Sectional Study

Congenital or acquired hand differences, including unilateral below-elbow deficiencies, present complex challenges in pediatric rehabilitation. Surgical management and prosthetic provision represent a big challenge to find a good balance for guaranteeing optimal hand function. There is no specific assessment tool for measuring these aspects in the Italian context. The present study investigates the psychometric properties of the ABILHAND-Kids in children with congenital unilateral below-elbow deficiencies and acquired amputation of the upper limb. We measure internal consistency using Cronbach coefficient alpha and the intraclass correlation coefficient (ICC) for measuring test-retest reliability. Differences in hand function in both children with acquired or congenital diseases were also investigated. Participants to the study were 107 (49 F and 58 M) children, with a mean (SD) age of 8.88 (4.25). For test retest reliability, conducted on a sub-sample of 58 children, the ICC was 0.92, while for internal consistency, the Cronbach coefficient alpha was 0.90. We did not find statistically significant differences in scoring (p = 0.33) in the use (mean 29.25 SD 6.58) or non-use of a prosthetic device (mean 30.74 SD 7.43), while statistically significant differences were found in hand function (p < 0.01) for children who had a congenital impairment (mean 31.87 SD 6.49) and children who had an acquired amputation (mean 27.77 SD 6.60). In conclusion, the ABILHAND-Kids showed good internal consistency and reliability and can capture differences in hand function in children with both congenital and acquired hand disorders.

Prosthetic home intervention induces cortical plasticity in paediatrics with congenital limb reduction

Paediatrics with congenital upper-limb reduction deficiency often face difficulties with normal development such as motor skills, needing assistance with daily activities such as self-care limitations with certain movements, sports, or activities. The purpose of this non-randomized longitudinal controlled trial was to assess, using intent-to-treat analysis, the effects of an 8-week home intervention of prosthetic use on the sensorimotor cortex in paediatrics with congenital upper-limb reduction deficiency. A paediatric population with congenital upper-limb reduction deficiency (n = 14) who were aged 6-18 years and who had a 20° or greater range of motion in the appropriate joint of the affected arm to move the body-powered prosthesis were enrolled. An age- and sex-matched control group (n = 14) was also enrolled. Participants were non-randomized and fitted with a custom low-cost 3D printed prosthesis and participated in 8 weeks of prosthetic use training at home. Control participants utilized a prosthetic simulator. The home intervention incorporated daily use training and exercises utilizing the prosthesis in direct use and assistive tasks explained by the researchers. After the home intervention, both groups displayed significant improvements in gross manual dexterity. During prosthetic use with the affected limb, significant increases in oxygenated hemodynamic responses were only displayed in the left premotor cortex of the upper-limb reduction deficiency group. The novel findings of this non-randomized longitudinal controlled trial suggest that the intervention may have improved the functional role of the left hemisphere which translated to the improvement of learning direction during adaptation to visuomotor control. The prosthetic home intervention was assumed to provide closed-loop training which could provide a direct benefit to the motor development of paediatrics with upper-limb reduction deficiency.

Functional Outcomes and Health-Related Quality of Life of Adults With Congenital Below-Elbow Amputation in North America

PURPOSE

Congenital below-elbow amputation (BEA) is a common upper-extremity anomaly and generally encompasses 2 diagnoses, symbrachydactyly and transverse deficiency. Little is known about the physical, mental, and social well-being of adults with congenital BEA. A deeper understanding of longitudinal outcomes within this population may help guide family conversations and counseling for patients with congenital BEA.

METHODS

The Shriners Hospitals for Children Health Outcomes Network was queried to identify all patients currently >18 years of age who had been seen as a child between 1975 and 2019 for congenital BEA at 1 of 20 Shriners Hospitals across North America. A unique health survey examining physical functioning, mental health, social outcomes, and health-related quality of life was constructed and sent by mail or in electronic form to eligible patients.

RESULTS

A total of 64 questionnaires were completed. Patients ranged between 18 and 34 years of age, and 70% were female. Nearly two-thirds of patients (64%) reported that a prosthesis was not required and only 14% reported daily prosthetic use. Although respondents reported below-average Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity scores, there were no differences in Short-Form 12 or Quick Disabilities of the Arm, Shoulder, and Hand scores relative to the US general population. Study participants had lower PROMIS Pain Intensity and higher PROMIS satisfaction with social roles and activities scores than the US general population, translating to clinically meaningful differences.

CONCLUSIONS

Although adults with congenital BEA report lower upper-extremity functional scores than the general population, they report no clear differences from normative values in self-efficacy, psychosocial well-being, health-related quality of life, or global life satisfaction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Moving a missing hand: children born with below elbow deficiency can enact hand grasp patterns with their residual muscles

Children with a unilateral congenital below elbow deficiency (UCBED) have one typical upper limb and one that lacks a hand, ending below the elbow at the proximal/mid forearm. UCBED is an isolated condition, and affected children otherwise develop normal sensorimotor control. Unlike adults with upper limb absence, the majority of whom have an acquired loss, children with UCBED never developed a hand, so their residual muscles have never actuated an intact limb. Their ability to purposefully modulate affected muscle activity is often assumed to be limited, and this assumption has influenced prosthetic design and prescription practices for this population as many modern devices derive control signals from affected muscle activity. To better understand the motor capabilities of the affected muscles, we used ultrasound imaging to study 6 children with UCBED. We examined the extent to which subjects activate their affected muscles when performing mirrored movements with their typical and missing hands. We demonstrate that all subjects could intentionally and consistently enact at least five distinct muscle patterns when attempting different missing hand movements (e.g., power grasp) and found similar performance across affected and typically developed limbs. These results suggest that although participants had never actuated the missing hand they could distinctively and consistently activate the residual muscle patterns associated with actions on the unaffected side. These findings indicate that motor control still develops in the absence of the normal effector, and can serve as a guide for developing prostheses that leverage the full extent of these children's motor control capabilities.

Difference between affected and unaffected sides of forearm bone length in children with congenital terminal transverse deficiencies at the level of carpal bone

The forearm of the affected sideis often shorter than that of the unaffected side in children with congenital terminal transverse deficiencies at the level of proximal or distal carpals. The aim of this study is to clarify the characteristics of forearm bone length in those children, especially to quantify the difference in forearm bone length between affected and unaffected sides. The subjects were children with carpal partial transverse deficiencies. The lengths of the radius and the ulna were measured in the radiographs. The lengths of affected and unaffected sides (A/U) were compared in order to quantify the discrepancy. The A/U ratio was defined as the length of the affected side divided by that of the unaffected side. The A/U ratios ranged from 77.1 to 99.0% in the radii and from 74.1 to 99.6% in the ulnae. In both the radius and ulna, the A/U ratios were significantly lower than the left/right ratios of normal adults. Additionally, the A/U ratios of the ulna were significantly lower than the A/U ratios of the radius. The forearm bones of affected side are significantly shorter than those of unaffected side. Although the cause remains unclear, it is possible that not only congenital factors but also acquired factors such as infrequent use of the affected upper limb are involved. A future longitudinal study is necessary to investigate whether length discrepancies can be reduced by using prostheses to increase the frequency of use on the affected limb.

Adolescents with congenital limb reduction deficiency: Perceptions of treatment during childhood and its meaning for their current and future situation

BACKGROUND

Children with congenital limb reduction deficiency live with the decisions made by their parents and healthcare professionals about treatments to be carried out during the first years of life. To understand better the meaning of treatment during childhood, it is necessary to listen to adolescents who have had this experience. The aim of this study was to investigate the perceptions of adolescents with congenital limb reduction deficiency concerning the treatment they received during childhood and what it meant to them currently and in the future.

METHODS

A descriptive design with a qualitative approach was used. Semi-structured interviews were conducted with 10 adolescents (six girls and four boys) with upper and/or lower limb reduction deficiency, median age 17.5 years (range 16-19). The interview data were analysed using a phenomenographic approach.

RESULTS

The treatment received during childhood had contributed to shaping the adolescents, as shown in the emerging description categories Creating opportunities, Choosing one's own path and Belonging in a context. Their current situation fell into three categories: A continuous journey, indicating that they still used the skills learned during childhood; Leaving the door open, indicating that they were not currently using the skills learned during childhood, but felt that there could be opportunities ahead; and Closing a chapter, indicating that they had stopped using their prosthesis or assistive devices and no longer needed those skills. Further, the adolescents' thoughts about the future are portrayed in the categories Uncertainty about the future and Confidence about the future.

CONCLUSIONS

An understanding of the meaning of treatment received during childhood may help improve the delivery of treatment and continued support to meet the needs of children with congenital limb reduction deficiency in the short and long term.

A review of upper limb pediatric prostheses and perspectives on future advancements

Many complex factors affect whether a child with a congenital upper limb deficiency will wear a prosthetic limb. Ultimately, for a child to wear and use their prosthesis, it must facilitate the effective performance of daily tasks and promote healthy social interactions. Although numerous pediatric devices are available, most provide a single open-close grasp (if a grasping function is available at all) and often offer nonanthropomorphic appearances, falling short of meeting these criteria. In this narrative review, we provide a critical assessment of the state of upper limb prostheses for children. We summarize literature using quality of life measures and categorize driving factors affecting prosthesis use into two main groupings: psychosocial and physical functioning. We define psychosocial functioning as factors related to social inclusion/exclusion, emotional function, independence, and school functioning. Physical functioning is defined as factors associated with the physical use of a prosthesis. The reviewed literature suggests that psychosocial domains of quality of life may be influenced by a congenital limb deficiency, and currently available prostheses provide little benefit in the physical functioning domains. Finally, we discuss technological advancements in adult prostheses that have yet to be leveraged for pediatric devices, including describing recently developed adult electric hands that may improve physical functioning through multiple grasping configurations and provide more hand-like cosmesis. We outline actions necessary to translate similar technologies for children and discuss further strategies to begin removing barriers to pediatric device adoption.

Targeted Muscle Reinnervation in Children: A Case Report and Brief Overview of the Literature

Absence of the proximal upper limb, whether congenital or acquired, has a profound impact on quality of life. Targeted muscle reinnervation (TMR) was originally developed to improve functional control over myoelectric prostheses; however, it has also been shown to decrease phantom limb pain and neuroma pain as well as prevent neuroma formation. In children, whose rates of prosthetic use are considerably lower than adults, the effects of amputation on limb function can be devastating. To date, there is very little literature regarding the use of TMR in children. In this case report, we review the current literature and present the case of a 9-year-old boy with a transhumeral amputation secondary to a traumatic injury who underwent acute TMR at the time of wound closure. At 22 months follow-up, the patient is doing well with minimal pain, no evidence of neuroma formation, and signs of muscle reinnervation.

Caring for Children With Congenital Upper Extremity Differences

The purpose of this article is to provide information about the changing landscapes in research, treatment, civil rights' protection, disability awareness, and accepted terminology in the care of children with congenital upper limb differences. This knowledge can guide clinical and nonclinical conversations between patients and their families.

Changes in Sensorimotor Cortical Activation in Children Using Prostheses and Prosthetic Simulators

This study aimed to examine the neural responses of children using prostheses and prosthetic simulators to better elucidate the emulation abilities of the simulators. We utilized functional near-infrared spectroscopy (fNIRS) to evaluate the neural response in five children with a congenital upper limb reduction (ULR) using a body-powered prosthesis to complete a 60 s gross motor dexterity task. The ULR group was matched with five typically developing children (TD) using their non-preferred hand and a prosthetic simulator on the same hand. The ULR group had lower activation within the primary motor cortex (M1) and supplementary motor area (SMA) compared to the TD group, but nonsignificant differences in the primary somatosensory area (S1). Compared to using their non-preferred hand, the TD group exhibited significantly higher action in S1 when using the simulator, but nonsignificant differences in M1 and SMA. The non-significant differences in S1 activation between groups and the increased activation evoked by the simulator's use may suggest rapid changes in feedback prioritization during tool use. We suggest that prosthetic simulators may elicit increased reliance on proprioceptive and tactile feedback during motor tasks. This knowledge may help to develop future prosthesis rehabilitative training or the improvement of tool-based skills.

Use-Dependent Prosthesis Training Strengthens Contralateral Hemodynamic Brain Responses in a Young Adult With Upper Limb Reduction Deficiency: A Case Report

The purpose of the current case study was to determine the influence of an 8-week home intervention training utilizing a partial hand prosthesis on hemodynamic responses of the brain and gross dexterity in a case participant with congenital unilateral upper-limb reduction deficiency (ULD). The case participant (female, 19 years of age) performed a gross manual dexterity task (Box and Block Test) while measuring brain activity (functional near-infrared spectroscopy; fNIRS) before and after an 8-weeks home intervention training. During baseline, there was a broad cortical activation in the ipsilateral sensorimotor cortex and a non-focalized cortical activation in the contralateral hemisphere, which was non-focalized, while performing a gross manual dexterity task using a prosthesis. After the 8-week home intervention training, however, cortical activation shifted to the contralateral motor cortex while cortical activation was diminished in the ipsilateral hemisphere. Specifically, the oxygenated hemodynamics (HbO) responses increased in the medial aspects of the contralateral primary motor and somatosensory cortices. Thus, these results suggest that an 8-week prosthetic home intervention was able to strengthen contralateral connections in this young adult with congenital partial hand reduction. This was supported by the case participant showing after training an increased flexor tone, increased range of motion of the wrist, and decreased times to complete various gross dexterity tasks. Changes in HbO responses due to the home intervention training follow the mechanisms of use-dependent plasticity and further guide the use of prostheses as a rehabilitation strategy for individuals with ULD.

Brain lateralization in children with upper-limb reduction deficiency

BACKGROUND

The purpose of the current study was to determine the influence of upper-limb prostheses on brain activity and gross dexterity in children with congenital unilateral upper-limb reduction deficiencies (ULD) compared to typically developing children (TD).

METHODS

Five children with ULD (3 boys, 2 girls, 8.76 ± 3.37 years of age) and five age- and sex-matched TD children (3 boys, 2 girls, 8.96 ± 3.23 years of age) performed a gross manual dexterity task (Box and Block Test) while measuring brain activity (functional near-infrared spectroscopy; fNIRS).

RESULTS

There were no significant differences (p = 0.948) in gross dexterity performance between the ULD group with prosthesis (7.23 ± 3.37 blocks per minute) and TD group with the prosthetic simulator (7.63 ± 5.61 blocks per minute). However, there was a significant (p = 0.001) difference in Laterality Index (LI) between the ULD group with prosthesis (LI = - 0.2888 ± 0.0205) and TD group with simulator (LI = 0.0504 ± 0.0296) showing in a significant ipsilateral control for the ULD group. Thus, the major finding of the present investigation was that children with ULD, unlike the control group, showed significant activation in the ipsilateral motor cortex on the non-preferred side using a prosthesis during a gross manual dexterity task.

CONCLUSIONS

This ipsilateral response may be a compensation strategy in which the existing cortical representations of the non-affected (preferred) side are been used by the affected (non-preferred) side to operate the prosthesis. This study is the first to report altered lateralization in children with ULD while using a prosthesis. Trial registration The clinical trial (ClinicalTrial.gov ID: NCT04110730 and unique protocol ID: IRB # 614-16-FB) was registered on October 1, 2019 ( https://clinicaltrials.gov/ct2/show/NCT04110730 ) and posted on October 1, 2019. The study start date was January 10, 2020. The first participant was enrolled on January 14, 2020, and the trial is scheduled to be completed by August 23, 2023. The trial was updated January 18, 2020 and is currently recruiting.

Does pediatric hand transplantation undermine a child's right to an open future?

To date, pediatric hand transplantations have only been performed twice. The ethical issue most often discussed in the literature on this surgery concerns the risks of immunosuppression. While these risks are significant, they can be at least partially mitigated by selecting for patients who are already immunocompromised. Nevertheless, as we will argue, pediatric hand transplantation raises ethical issues that go beyond the risks of immunosuppression. In this paper, we focus on three additional ethical issues: the fact that pediatric hand transplantation aims to improve, rather than save life; the fact that it is an experimental surgery; and the fact that it will be performed on non-autonomous patients whose 'right to an open future' may potentially be undermined by the surgery. Taken together, we think that these considerations suggest that transplantation should be postponed until a child is mature enough to make their own decision about it.

Simulated robotic device malfunctions resembling malicious cyberattacks impact human perception of trust, satisfaction, and frustration

Robot assistants and wearable devices are highly useful; however, these artificial systems are susceptible to hackers. In this article, two sets of experiments were conducted. The first part of this study simulated a malicious attack on a prosthetic arm system to adversely affect the operation of the prosthetic system, while the perception of 10 human subjects was surveyed. These 10 able-bodied subjects controlled the prosthetic arm and hand with electromyogram signals, while an artificial sensation of touch was conveyed to their arms as they operated the system, which enabled them to feel what the prosthetic hand was grasping as they were asked to transport an object from one location to another. This haptic feedback was provided in both the normal and abnormal operational modes but was disabled in the extremely abnormal mode. The electromyogram control signals for the arm were reversed in both the abnormal and extremely abnormal modes. Results from the simulated malicious attack on a prosthetic arm system showed that the subjects found the haptic feedback helpful in both the normal and abnormal modes of operation. Both the abnormal and extremely abnormal modes of operation negatively impacted the self-reported levels of trust, satisfaction, and frustration with the prosthetic system as the subjects grasped and transported an object. While these metrics were negatively impacted by system malfunctions resembling a malicious attack on the control functionality, it was possible to rebuild them to their former higher levels after the functionality of the prosthetic system was restored. A parallel study in this article involved simulating a malicious attack on a robot assistant to unfavorably affect the delivery operation modes, while the perception of 20 human subjects was surveyed. Results showed that the simulated malfunctions unfavorably impacted the perception of trust, satisfaction, and frustration, but it was possible to restore these metrics in two different ways as the device functionality was restored.

Perceptions of ability among adults with upper limb absence: impacts of learning, identity, and community

Aims: The purpose of this research was to examine the lived experiences of adults with upper limb absence, specifically the interplay of device use, ability, and quality of life through semi-structured interviews. We sought to draw insight from these experiences to improve the practice and perceptions of adults with upper limb absence, prosthetists, and technology designers.Methods: Semi-structured interviews were conducted and interpreted with phenomenological analysis for fourteen individuals with acquired or congenital limb absence. Through an interpretive phenomenological analysis approach, researchers employed an inductive approach to coding and identification of central themes.Results: Participants shared high perceptions of ability and function, regardless of prosthesis or assistive technology use. Life experiences related to three dimensions strongly influenced perceptions of ability: (1) learning to live with upper limb absence, (2) developing their identity, and (3) connecting with their community. The diversity of experiences across participants highlighted the limitations of identifying "normative" pathways of recovery or device use, emphasizing the need for flexible and adaptable systems that can creatively support personal goals and needs.Conclusions: Integration of novel platforms for professional practice, supportive communities, and technology innovation can support the evolving needs and care of individuals with upper limb absence.Implications for rehabilitationIn this study, perceptions of ability were largely independent of prosthetic use and each individual developed a unique toolkit of devices and strategies to support function in daily life.Clinicians can support perceptions of ability by promoting opportunities for community development and life-long learning.Informal communities, such as online networks, can provide novel device designs, resources for learning, and societal awareness to empower individuals with limb absence.

Forearm lengthening and prosthetic management in children with transverse congenital forearm deficiency

In cases of transverse congenital forearm deficiency, achieving a good prosthesis fit during childhood remains a challenge. Ulnar lengthening is a treatment option for improving the prosthesis fit. The objective of this study was to evaluate surgical ulnar lengthening and the subsequent prosthesis fit. We reviewed four cases of ulnar lengthening in children with transverse congenital forearm deficiency. The procedure was evaluated in terms of the duration of lengthening, increase in ulnar length and healing index. The elbow range of motion, functional outcome (Prosthetic Upper Extremity Functional Index, PUFI) and time spent using the prosthesis per day were evaluated. The mean age at the time of the lengthening procedure was 3.5 years, the mean duration of lengthening was 58.3 days, the mean length gain was 21 mm, and the mean healing index was 70.1 days/cm. Elbow range of motion was restricted in one patient (100°-140°) and full in the other three patients. Based on the PUFI, 88.4% of activities were performed without the prosthesis. Children only used their prosthesis to perform specific tasks. Given the high complication rate and the lack of prosthesis use during daily activities, the main indication for forearm lengthening is a very short forearm that prevents prosthesis fitting. This procedure should be performed later in life - in adolescence.

Long-term results of early myoelectric prosthesis fittings: A prospective case-control study

BACKGROUND

Different recommendations exist regarding what age is best for first-time fitting of myoelectric hand prostheses in children.

OBJECTIVES

To compare prosthetic skill, prosthetic use and risk for rejection over time between children fitted with myoelectric hand prostheses before or after 2½ years of age.

STUDY DESIGN

Prospective case-control design.

METHODS

The cases were nine children fitted with myoelectric hand prostheses before the age of 2½ years, whereas the controls were 27 children who were fitted with myoelectric hand prostheses after the age of 2½ years. The Skills Index Ranking Scale was used to classify prosthetic skill, and prosthetic use was categorised based on wearing time and pattern. Independent samples tests were used to compare data between groups. To estimate and compare the risk of prosthesis rejection between groups and over time, survival analysis was used.

RESULTS

Cases showed prosthetic skill early, but controls had caught up by the age of 3½ years. Cases had a significant ( p = 0.046) decrease in prosthetic use at the age of 9 years. In the long term, cases had a higher percentage of prosthesis rejection.

CONCLUSIONS

Considering young children's development of prosthetic skill and prosthetic use over time, this study shows no additional advantages from fitting a myoelectric hand prosthesis before 2½ years of age. Clinical relevance Children may be fitted with myoelectric hand prostheses to assist in daily tasks and to prevent future over-use problems. Most children fitted with myoelectric hand prostheses before 4 years of age become regular users. No advantages of fitting myoelectric hand prostheses before 2½ years of age were observed.

Coactivation index of children with congenital upper limb reduction deficiencies before and after using a wrist-driven 3D printed partial hand prosthesis

Background

Co-contraction is the simultaneous activation of agonist and antagonist muscles that produces forces around a joint. It is unknown if the use of a wrist-driven 3D printed transitional prostheses has any influence on the neuromuscular motor control strategies of the affected hand of children with unilateral upper-limb reduction deficiencies. Thus, the purpose of the current investigation was to examine the coactivation index (CI) of children with congenital upper-limb reduction deficiencies before and after 6 months of using a wrist-driven 3D printed partial hand prosthesis.

Methods

Electromyographic activity of wrist flexors and extensors (flexor carpi ulnaris and extensor digitorum) was recorded during maximal voluntary contraction of the affected and non-affected wrists. Co-contraction was calculated using the coactivation index and was expressed as percent activation of antagonist over agonist. Nine children (two girls and seven boys, 6 to 16 years of age) with congenital upper-limb deficiencies participated in this study and were fitted with a wrist-driven 3D printed prosthetic hand. From the nine children, five (two girls and three boys, 7 to 10 years of age) completed a second visit after using the wrist-driven 3D printed partial hand prosthesis for 6 months.

Results

Separate two-way repeated measures ANOVAs were performed to analyze the coactivation index and strength data. There was a significant main effect for hand with the affected hand resulting in a higher coactivation index for flexion and extension than the non-affected hand. For wrist flexion there was a significant main effect for time indicating that the affected and non-affected hand had a significantly lower coactivation index after a period of 6 months.

Conclusion

The use of a wrist-driven 3D printed hand prosthesis lowered the coactivation index by 70% in children with congenital upper limb reduction deficiencies. This reduction in coactivation and possible improvement in motor control strategies can potentially improve prosthetic rehabilitation outcomes.

Relation between capacity and performance in paediatric upper limb prosthesis users

BACKGROUND

The International Classification of functioning, disability and health refers capacity to what an individual can do in a standardised environment and describes performance as what an individual really does and whether the individual encounters any difficulty in the real-life environment. Measures of capacity and performance can help to determine if there is any gap between them that may restrict participation. The aim of this study was to explore the relationship between capacity scores obtained in a standardised clinical setting and proportional ease of performance obtained from a real-life environment.

METHODS

The Assessment of Capacity for Myoelectric Control and the Prosthetic Upper Extremity Functional Index were used to assess capacity and performance in 62 prosthetic users (age 3-17). Spearman coefficient and generalised linear model were used to examine the association between these measures.

RESULTS

A strong correlation (Spearman = 0.75) was found between the capacity scores and the ease of performance. In both unadjusted and adjusted models, capacity was significantly associated with proportional ease of performance. The adjusted model showed that, by 1 unit increase in the Assessment of Capacity for Myoelectric Control score, the ratio of proportional ease of performance increases by 45%.

CONCLUSION

This implies that Assessment of Capacity for Myoelectric Control can be a predictor for ease of performance in real-life environment. Clinical relevance The ACMC scores may serve as an indicator to predict the difficulties that the children may encounter in their home environment. This prediction can help the clinician to make decisions, such that if the child requires more control training or is ready to move on to learn more complex tasks.

Opinions of youngsters with congenital below-elbow deficiency, and those of their parents and professionals concerning prosthetic use and rehabilitation treatment

Background

Youngsters with unilateral congenital below-elbow deficiency (UCBED) seem to function well with or without a prosthesis. Reasons for rejecting prostheses have been reported earlier, but unfortunately not those of the children themselves. Furthermore, reasons for acceptance are underexplored in the literature.

Objectives

To investigate opinions of children and early and late adolescents with UCBED, and those of their parents and healthcare professionals, concerning (1) reasons to wear or not to wear prostheses and (2) about rehabilitation care.

Methods

During one week of online focus group interviews, 42 children of 8–12 y/o, early and late adolescents of 13–16 and 17–20 y/o, 17 parents, and 19 healthcare professionals provided their opinions on various topics. This study addresses prosthetic use or non-use of prosthetics and rehabilitation care. Data were analyzed using the framework approach.

Results

Cosmesis was considered to be the prime factor for choosing and wearing a prosthesis, since this was deemed especially useful in avoiding stares from others. Although participants functioned well without prostheses, they agreed that it was an adjuvant in daily-life activities and sports. Weight and limited functionality constituted rejection reasons for a prosthesis. Children and adolescents who had accepted that they were different no longer needed the prosthesis to avoid being stared at. The majority of participants highly valued the peer-to-peer contact provided by the healthcare professionals.

Conclusions

For children and adolescents with UCBED, prostheses appeared particularly important for social integration, but much less so for functionality. Peer-to-peer contact seemed to provide support during the process of achieving social integration and should be embedded in the healthcare process.

Use and functioning of the affected limb in children with unilateral congenital below-elbow deficiency during infancy and preschool age: a longitudinal observational multiple case study

BACKGROUND

Children with unilateral congenital below elbow deficiency (UCBED) lack a part of an arm, thereby lacking a part of the typical hand function. Little is known on the performance of daily activities in very young children with UCBED, usage of their affected arm with or without prosthesis during play, and neurological condition.

AIM

To explore daily activities, the use of the affected limb with or without prosthesis and neurological condition over time in young children with UCBED.

DESIGN

A longitudinal observational multiple case study.

METHODS

Four children with UCBED were assessed (first assessment at 3-16months) every 6-8months (follow-up 13-49months) with a video-recorded, standardized play session and a neurological examination. Yearly, functioning in daily activities was evaluated using the Pediatric Evaluation of Disability Inventory - Dutch Version (PEDI-NL). Play behaviour was assessed with and without prosthesis, where applicable (n=2). Video-analysis focused on achievement, exploration, variation and adaptability of the affected limb. Behavioural changes over time were plotted and analysed visually.

RESULTS

Over time, children with UCBED showed efficient usage of their affected arm during spontaneous play. Prosthesis use seemed to be associated with reduced manipulation, exploration, variation and adaptation. Three children showed minor neurological dysfunction. Functioning in daily activities was comparable to a norm population.

CONCLUSION

The short limb of children with UCBED is used as an exploratory, manipulatory and fixating tool from the beginning of infancy. Its value seems to be reflected in these children's normal functioning in daily life. Prosthetic use may lead to less effective performance.

Pattern recognition control of multifunction myoelectric prostheses by patients with congenital transradial limb defects: a preliminary study

BACKGROUND

Electromyography (EMG) pattern recognition offers the potential for improved control of multifunction myoelectric prostheses. However, it is unclear whether this technology can be successfully used by congenital amputees.

OBJECTIVE

The purpose of this investigation was to assess the ability of congenital transradial amputees to control a virtual multifunction prosthesis using EMG pattern recognition and compare their performance to that of acquired amputees from a previous study.

STUDY DESIGN

Preliminary cross-sectional study.

METHODS

Four congenital transradial amputees trained and tested a linear discriminant analysis (LDA) classifier with four wrist movements, five hand movements, and a no-movement class. Subjects then tested the classifier in real time using a virtual arm.

RESULTS

Performance metrics for the residual limb were poorer than those with the intact limb (classification accuracy: 52.1% ± 15.0% vs. 93.2% ± 15.8%; motion-completion rate: 49.0%± 23.0% vs. 84.0% ± 9.4%; motion-completion time: 2.05 ± 0.75 s vs. 1.13 ± 0.05 s, respectively). On average, performance with the residual limb by congenital amputees was reduced compared to that reported for acquired transradial amputees. However, one subject performed similarly to acquired amputees.

CONCLUSIONS

Pattern recognition control may be a viable option for some congenital amputees. Further study is warranted to determine success factors.