REVIEW ARTICLE/LITERATURE REVIEW
Early Upper-Limb Prosthetic Fitting and Brain Development: Considerations for Success

Peterson, Jennifer K. MA, PT; Prigge, Patrick CP, LP, FAAOP(D)
Author Information
Journal of Prosthetics and Orthotics: October 2020 – Volume 32 – Issue 4 – p 229-235
doi: 10.1097/JPO.0000000000000320

Abstract

Introduction

An infant with an upper-limb loss or absence presents uncertainty regarding how the deficiency will impact the ability to function physically and psychosocially in life. A decision needs to be made if and when to fit the child with an upper-limb prosthesis. Literature indicates that early prosthetic fitting of a unilateral transradial limb deficiency is a strong indicator of a child’s continued wear of a prosthesis later in life, whereas fitting a child at an older age is more likely to result in a rejection of the prosthesis. The increased acceptance of an upper-limb prosthetic device by early fitting may be explained by a perspective that has not been addressed extensively in the literature. This perspective is that fitting an infant with an upper-limb prosthetic device both affects and is affected by brain development. It is important to understand that the timing of fitting should correspond with the appropriate developing activity in the child’s brain. The purpose of this article is to illuminate how science of brain development informs the timing and device design when fitting a child with an upper-limb prosthesis, thereby establishing a successful protocol for prosthetic fitting.

Methods

Brain and grasp development literature is reviewed to explain how sensory and motor experiences help neural connections to be made within the brain during critical periods of development of a child’s life. The knowledge is used to explain why it is important to fit a child early in life with an upper-limb prosthesis and to inform the clinical team what type of prosthesis should be fitted during different stages of development.

Results

A protocol for successful early prosthetic fitting was developed that takes advantage of a child’s different and developing abilities at the various stages of brain and motor development.

Conclusions

Neurodevelopmental principles explain how neuronal connections are created when a child’s brain is most receptive to environmental input. A child’s use of motor skills to interact with the environment leads to cognitive, social and emotional development. Brain development studies, therefore, support early upper-limb prosthetic fitting. Because the development of grasp and the use of both hands together to manipulate an object is a progression, the timing of prosthetic fittings to match the needs of the developing brain is critical. Fitting an infant with a passive prosthesis and then soon transitioning to a myoelectric prosthesis allows the child’s brain to incorporate the active prosthetic grasp into the child’s motor planning and movement execution. Children as young as 12 months of age have shown the ability to control a myoelectric hand in contrast to an inability to control a body-powered terminal device until an older age. By fitting a child during the first 2 years of life with a myoelectric prosthesis, the time of rapid brain development while grasping ability is being established is not missed. Studies on brain development therefore support early upper-limb prosthetic fitting and provide a framework for a successful prosthetic fitting and treatment protocol.

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There is no international system to report the incidence of acquired and congenital upper-limb amputations, thus it is difficult to estimate the prevalence of upper-limb loss in infants. Studies from various countries reveal that a range of 2 to 7 infants per 10,000 live births per year are born with an upper-limb or lower-limb deficiency with upper-limb deficiency being more common.1

An infant with an upper-limb loss or absence presents parents with uncertainty regarding how the deficiency will impact the child’s ability to function physically and psychosocially in life. Among many decisions facing the parents is the decision if and when to fit the child with an upper-limb prosthesis. This requires analysis of many factors, including, but not limited to, the level of limb loss, the developmental stage of the child, the opinions of the prosthetist and therapist, the commitment of the parents, as well as the advantages and disadvantages of age appropriate prosthetic devices. Parents also become aware of the long-term physical effects of upper-limb absence. For example, people with upper-limb loss have an increased risk of developing chronic pain and overuse syndrome (also called cumulative trauma disorder or repetitive stress injury) of the musculoskeletal system.2–9 Parents will often consider whether or not the use of a prosthesis throughout life will help to prevent these medical issues.

As opposed to persons with lower-limb amputation, there is not a common consensus in the literature to either support or not support the fitting of a young child with an upper-limb prosthetic device. It is difficult to compare studies, as they analyze various deficiency levels, differing prosthetic device types, and other incomparable variables. In addition, assorted outcome measures are used, and success is defined differently in each study.10,11 In many cases, the sample sizes are small, inclusion criteria varies, the effectiveness and comfort of the socket is unknown, and there is no indication of whether or not upper-limb prosthetic training was provided.

The stated predictors of prosthetic device rejection or acceptance are varied.12–14 However, one predictor that stands out is that early prosthetic fitting of a unilateral transradial limb deficiency is a strong indicator of a child’s continued wear of a prosthesis later in life, whereas fitting a child at an older age is more likely to result in a rejection of the prosthesis.13–21 In a report by Biddiss and Chau,13 an ideal “time-to-fit” window was determined to be within 2 years of birth, which results in the child’s being “16 times more likely to continue prosthesis use.” The increased acceptance of an upper-limb prosthetic device by early fitting may be explained by a perspective that has not been addressed extensively in the literature. This perspective is that fitting an infant with an upper-limb prosthetic device both affects and is affected by brain development. The clinical approach and the corresponding results cited in literature strongly suggest that early pediatric fittings are appropriate.13–22 It is important to layer on the understanding of timing of fitting and device type to correspond with the appropriate developing activity in the child’s brain. The purpose of this article is to illuminate how science of brain development informs the timing and device design when fitting a child with an upper-limb prosthesis, thereby establishing a successful protocol for prosthetic fitting.

BRAIN AND GRASP DEVELOPMENT

Brain development is defined as “a complex series of dynamic and adaptive processes that operate throughout the course of development to promote the emergence and the differentiation of new neural structure and functions.”23 Information in the brain is processed by neuron cells. Although most neurons are present at birth, the neuron networks are not fully connected. As the brain develops, the connections are created.24 These connections are formed through sensory and motor experiences. It is during the first 3 years of life that a child’s brain is most plastic,25 when neuronal connections which affect the child for life are created and pruned.

Neurologists indicate that there are critical periods in development when stimulation actively shapes the brain circuitry.23,26,27 The required stimulation occurs during a child’s physical or play activities, and neural connections are created through the resulting sensory, movement, and vestibular interactions. Each experience builds upon earlier experiences and creates a scaffold for brain development.28 If a necessary experience does not occur during a critical time in development, the loss may not be able to be regained in the future.29 Therefore, interactions with the environment through physical activities or play are necessary for a child’s cognitive, physical, social, and emotional health.30 Play comprises much of a child’s daily activity and has been deemed so important for children that the United Nations High Commission for Human Rights recognizes play as a right of every child.31

The ability to grasp with a hand is a progression that begins at birth and continues to develop as a child matures. The capacity to use the hands together in a bimanual way develops at around 7 months of age, with skillful use beginning at 13 months.32 To develop bimanual upper-limb neuronal connections, it is important for the child to utilize both upper limbs. Kimmerle et al.33 found that “Role-differentiated bimanual manipulation requires each hand to perform different, but complementary, actions on one or more objects.” Ejaz et al.34 determined that hand use shapes brain organization. When a child is missing a hand or a portion of an upper limb, the upper limb is not utilized as much as the intact upper limb due to decreased length and an inability to grasp or pinch on the deficient side. In accordance with the brain development information cited previously, this leads to the possibility that there may be less information from the limb being processed by the brain for establishing neuronal connections.

In a study of how a prosthesis is represented in the brain, Van den Heiligenberg et al.35 concluded that the “neurophysiological embodiment of artificial limbs depends on prosthesis usage in everyday life” and “prosthesis usage also shapes large-scale brain reorganization.” Aymerich-Franch and Ganesh36 propose that having a functional artificial limb assists in the embodiment of a prosthetic device such that the user feels that the prosthesis is part of the body. To capture the critical periods in development when a child’s brain circuitry is being shaped, a prosthetic fitting protocol should include early introduction of an active grasp prosthesis. This allows grasp on the limb deficient side of the body for promotion of bimanual upper-limb use and assistance with achieving developmental milestones facilitated by participation in age appropriate activities.

PROTOCOL FOR SUCCESSFUL PEDIATRIC UPPER-LIMB PROSTHETIC FITTING

A thorough prosthetic and therapeutic assessment of a child creates the foundation for a successful pediatric upper-limb prosthetic fitting. During the assessment, the prosthetist and therapist gain information about the child’s anatomy, environment, activities, and abilities. The parents’ desires and commitment to the process need to be discerned. Component selection will depend on the information collected during the assessment such as the length of the residual limb, shape of the residual limb, age, availability of control inputs, and parents’ desires. The clinicians’ initial assessment should include a thorough review of prosthetic options and how each option will affect the child’s function, the advantages and disadvantages of wearing a prosthesis, and realistic expectations of the prosthetic fitting. Consideration of the prosthetic design and therapeutic approach needs to be determined. A team approach to prosthetic fitting is essential.37

PEDIATRIC PROSTHETIC FITTING PROGRESSION

There are five upper-limb prosthetic options38: passive, body-powered, externally powered (myoelectric), hybrid, and activity specific. Each type of prosthesis has its advantages and disadvantages.39 Appropriate prosthetic technology for adults is selected based on their daily activity needs. For pediatric patients, we propose a different selection methodology and fitting progression that takes advantage of the child’s different and developing abilities at the various stages of brain and motor development.

SIX MONTHS–INITIAL FITTING

As a child is learning to sit up and build strength and coordination with the upper limbs, the child should be fit with a passive prosthesis with a semi-flexible, passive hand attachment. This allows the child to become accustomed to wearing a prosthesis and to begin to explore upper-limb prosthetic movement in the environment. A passive prosthesis does not offer active grasp and release but provides arm length and the benefits of helping in the development of sitting balance, batting at objects, bringing two hands together for activities such as holding a large ball or stuffed animal, and crawling. At the proper stage of development, a prosthetic hand with a movable and grasp-capable thumb can be added to allow the child or parents to place objects in the device to encourage recognition that the prosthetic hand can hold and carry objects.

TWELVE TO 18 MONTHS–TRANSITION FROM PASSIVE TO ACTIVE PROSTHESIS

Just as the brain develops the motor plan for the intact hand to grasp objects, the brain has the opportunity to develop a similar motor plan for the upper limb with a deficiency. To make this possible, an active grasping terminal device is made available to the child on the affected side. The two prosthetic options that provide active grasp are a body-powered system and a myoelectric system.

A body-powered system uses a cable and harness and gross body motion of the shoulders and upper back to actuate a prosthetic hand or hook. This movement is not intuitive and requires a high expenditure of energy. Shaperman et al.40 objectively studied limb-deficient children’s body strength in comparison to the strength required to efficiently operate a body-powered prosthesis and concluded that infants and preschool age children are unable to produce the necessary force to produce sustained, effective grip. Hichert et al.41 found that even adults have difficulty operating a body-powered prosthesis without fatigue, discomfort, or pain. It would be expected that a young child may also experience the same negative consequences from attempting to operate a body-powered prosthesis. Shaperman42 concluded that children are unable to demonstrate full control of a body-powered prosthesis until 28 to 37 months. Because a child often cannot understand or accomplish control of the body-powered terminal device until at least 28 months42 due to lack of strength,40 lack of excursion ability, and lack of understanding of the cause and effect of the movements required to produce active grasp, we believe that fitting a child with a body-powered prosthesis at 12 to 18 months does not achieve the goal of providing early, active grasping ability.

Conversely, myoelectric prostheses have been fit with success since the 1980s on children as young as 1 year old.43,44 The reason a young child is able to control and use a myoelectric prosthesis is that it taps into normal physiological movement and neurological pathways that the brain is developing at this age. To activate a myoelectric prosthesis, an electrode is placed within the prosthetic socket to contact the skin overlying the desired muscle. When the muscle contracts, the electrode detects the electrical action potential, which then activates the terminal device. The first control strategy that is often used for a young child is single-site (“cookie-crusher”) control22,43,45 in which a muscle contraction controls the opening of the hand and muscle relaxation results in the closing of the hand. During therapeutic play activities, the child initially inadvertently contracts the muscle that controls the prosthetic hand. The child sees the spontaneous movement of the hand and begins to connect the muscle contraction to the hand movement. Soon the child realizes that he/she is in control of the hand with a very small muscle contraction, and it becomes conscious control.22 With continued therapeutic play activities and encouragement, the child begins to actively grasp items and to perform two-handed age-appropriate activities.

TWO TO THREE YEARS–CONTROL STRATEGY TRANSITION

A transition from single-site to dual-site myoelectric control is made based on a clinician’s clinical judgment. The change occurs when the clinician determines that a child’s communication skills and attention span have developed enough for the child to understand control instructions from the clinician.22 Dual-site control involves adding a second electrode to detect a second muscle, usually a flexor muscle, to actively close the terminal device. The new control system with proportional control allows the child to have control over the speed and grip force of the prosthetic hand during functional activities. A body-powered prosthesis can be introduced at this age, if desired, since the child should have the aptitude to understand the movements required to control a body-powered prosthesis.

OLDER THAN 3 YEARS–INTRODUCTION OF ACTIVITY-SPECIFIC PROSTHETIC DEVICE(S)

Because the myoelectric prosthesis cannot be worn during sport activities, sandbox play, and other activities that might damage the electronic equipment and motor, a child would benefit from being fitted with an activity-specific “sports” prosthesis. An activity-specific prosthesis has no electrodes, wires, or batteries and is, thus, safe to use around water, in dirt, and during rigorous activities. An activity-specific prosthesis often allows interchanging of terminal devices for different activities. These terminal ends will allow the child to participate in age-typical activities in a bimanual manner.

THERAPEUTIC APPROACH

Upper-limb prosthetic therapy is extremely important for providing the best possible chance for success with prosthetic function whether for an adult or child.46–49 In addition, therapeutic instruction in how to avoid compensatory body movements may prevent or reduce future overuse injuries. Providing therapy for a child is similar in many ways to providing therapy for an adult, but it is also more complicated and time-consuming. A therapist needs to be well versed in an upper-limb prosthetic therapy protocol48,50 and be able to modify the protocol for a child. The therapist leads the child through control training, repetitive drills, and functional training similarly to an adult, but it must be done through play. If not perceived by the child as play, which is the child’s primary channel for learning, the child will not be interested in participating. Therapy will help the child to use the prosthesis spontaneously, develop consistent gross grasp and fingertip grasp, learn to use vision and position sense in place of sensory feedback, learn how to preposition the prosthesis, incorporate the prosthesis into bimanual activities with proper body mechanics, develop fine motor control, develop self-help abilities, and develop problem-solving skills.

The therapeutic process includes educating the parents or caregivers since their participation is essential to the successful incorporation of a prosthesis into a child’s life. The parents need thorough instruction in prosthetic options and timelines for when the child will progress to more advanced prosthetic devices or components. A full-time wearing schedule is imperative, as the amount of time that a prosthesis is utilized correlates with a positive functional outcome.20 There is a time and possibly a financial commitment that is required for taking the child to the clinic for therapy and multiple prosthetic fittings and adjustments throughout the years. For success with prosthetic rehabilitation, the parents need to be fully committed to the therapeutic process.

DISCUSSION

Mano et al.51 in a study on the adaptive behavior and motor skills in children with upper-limb deficiency found that the children “have individual weaknesses in motor skill behaviors, and these weaknesses increase with age.” They concluded that it is important to develop improved strategies for prosthetic rehabilitation to assist these children. Although a prosthesis cannot replace the dexterity, strength, ability to heal itself, sensitivity, and cosmesis of a natural hand, it can provide the benefits of a tool and offers a solution to assist with performing daily activities. An active grasp upper-limb prosthetic device provides length and form similar to a sound upper limb that allows for active grasp and pinch. This union between the prosthesis and the environment enables the child to interact, play, and learn, which may contribute to healthy cognition, social, emotional, and physical development.

Current prosthetic technology is not without its disadvantages, but the drawbacks can often be mitigated through proper selection of components, comfortable and secure fit, and training. For example, the heat of wearing a socket can be reduced through open socket/frame designs, or the selection of a myoelectric prosthesis or self-suspending socket over a body-powered prosthesis can eliminate the need for a restrictive harness that reduces comfort and the available functional envelope.

A concern is often expressed that placing a prosthesis on a residual limb will block the child’s limb sensation and therefore affect the ability to interact with the environment.52 Although tactile sensation is reduced, the effect is mitigated by the brain’s ability to use sensory substitution. Sensory substitution is defined as “the use of one human sense to receive information normally received by another sense.”53 For example, visual information can substitute for missing tactile information. In addition, the prosthesis itself can act as a sensory substitution device. The child may not feel an object directly through the native skin of the remnant limb, but contact with the prosthesis may provide vibratory information through the socket-skin interface, and the movement of the prosthesis and intact joints provides proprioceptive information (sense of position and movement). Studies report that it is possible to trick the brain into thinking an inanimate object is part of the body through a remapping of the sense of touch in multisensory areas of the brain.53–60 By wearing and utilizing a prosthesis, the wearer develops a sense of ownership. When an object touches the prosthesis, the brain will interpret the information as tactile sensation from the prosthesis. In other words, the body is able to compensate for the reduced, direct tactile sense and learn in other ways. Thus, a child who wears a prosthesis still receives information regarding the environment.

An upper-limb prosthesis is usually no heavier than the same missing portion of the limb but may be perceived by the wearer as being heavier because the prosthesis is not directly linked to the wearer’s musculoskeletal system. Although it is assumed that added weight on the residual limb is a negative aspect of wearing a prosthesis, there is the positive aspect of balancing the wearer’s two body sides to place the center of mass along the spinal column. Individuals with congenital upper-limb loss have long been known to have an increased chance of developing spine abnormalities.61–64 When one limb is not utilized, the muscles on the affected side will not develop equally to the nonaffected side, and this imbalance along with having less weight on the affected side may lead to skeletal malalignment. Being able to use both upper limbs through the use of an upper-limb prosthesis promotes symmetrical muscle development and the development of a straight spinal column.

Relying on one hand to perform all activities of daily living puts stress on the intact upper limb, which could result in overuse/repetitive stress injuries such as carpal tunnel syndrome, tendonitis, and shoulder back and neck issues.2–9 An active grasp prosthesis improves the wearer’s ability to perform bimanual activities with proper posture and proper body mechanics, thus taking some of the burden off the intact upper limb to potentially reduce overuse issues.

CONCLUSIONS

Neurodevelopmental principles explain how neuronal connections are created when a child’s brain is most receptive to environmental input. A child’s use of motor skills to interact with the environment leads to cognitive, social, and emotional development. Brain development studies therefore support early upper-limb prosthetic fitting. Because the development of grasp and the use of both hands together to manipulate an object is a progression, the timing of prosthetic fittings to match the needs of the developing brain is critical. Use of a prosthesis influences how the brain develops, and conversely, how the brain develops influences upper-limb prosthetic use and acceptance. Fitting an infant with a passive prosthesis and then soon transitioning to a myoelectric prosthesis allows the child’s brain to incorporate the active prosthetic grasp into the child’s motor planning and movement execution. Children as young as 12 months of age have shown the ability to control a myoelectric hand in contrast to an inability to control a body-powered terminal device until an older age. By fitting a child during the first 2 years of life with a myoelectric prosthesis, the time of rapid brain development while grasping ability is being established is not missed. The child will be more likely to continue to wear a prosthesis and attain a level of proficiency for lifelong bimanual manipulation. In contrast, not providing early opportunity for active grasp on the affected side will promote the development of one-handedness.

Young children can be successful with incorporating prostheses into their daily activities if provided with multiple, properly fitting, and up-to-date prosthetic options. A thorough analysis of all factors is necessary by the care team and caregivers to determine which device would be of most benefit to a child. Fitting a child early and enforcing a consistent wearing schedule with parent and therapeutic follow-through contributes to functional prosthetic success. Along with functional prosthetic success comes an enhanced ability for a child to participate in age-appropriate activities that may lead to positive self-esteem and a positive quality of life. In addition, using an upper-limb prosthetic device may help a wearer to use proper body mechanics during activities. Proper body mechanics may reduce orthopedic changes in the spine and upper-body joints and reduce the potential for soft tissue overuse injuries in the future.

ACKNOWLEDGMENTS

These data and findings have not been previously presented. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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LETTERS TO THE EDITOR
Getting a Child a Myoelectric Prosthesis: Did We Miss the Bus?

Rose, Vivian L. MSPO, CPO; Parikh, Pranav J. PhD
Author Information
Journal of Prosthetics and Orthotics: July 2022 – Volume 34 – Issue 3 – p 132-133
doi: 10.1097/JPO.0000000000000437

This letter is in response to Peterson JK, Prigge PT. Early upper-limb prosthetic fitting and brain development: considerations for success. J Prosthet Orthot. 2020;32(4):229–235.

Peterson and Prigge’s article titled “Early Upper-Limb Prosthetic Fitting and Brain Development: Considerations for Success” is a thought-provoking article that attempts to translate neurodevelopmental principles into a protocol for pediatric upper-limb prosthetic fitting.1 The premise that fitting a myoelectric prosthesis within 2 years of birth in children with congenital limb deficiency will positively affect brain development is an exciting direction for continued research. With this letter, we share our opinion on important aspects of brain development in relation to grasping and fine motor performance, particularly the concept of a critical window during the first 3 years of life. The brain is considered more plastic during these early years. However, the ability of the brain to continue to develop during later years should not be discounted.

The brain’s sensorimotor pathways that drive fine motor skill development substantially mature throughout childhood and adolescence.2–7 Achievement of motor milestones is important; however, the most current theory of motor skill development, neuronal group selection theory,8,9 deemphasizes the idea of a “critical window” per se—a time after which fine motor skills may not be learned or represented in the brain. As per this theory,8 specific brain networks are selected based on epigenetic events, which are different across individuals resulting in variation in developmental stages or behavior. With ongoing experiences, connections in the selected network mature to entail the ability to adapt to environmental constraints. The timeline of these processes may continue until later childhood or even adolescence. Of particular interest are studies on how an adult-like grasp behavior develops. Although an infant begins to voluntarily grasp and use precision grip by the age of 1 year, tool use and anticipatory grasp control responsible for functional object manipulation10 only begin to emerge around the age of 2 years.11–13 The control of grasp reaches an adult-like pattern around 8 to 11 years of age,4,11–13 providing an ability to adapt to a variety of task and environmental constraints. Neurophysiological studies have shown that children 6 to 10 years require more attention than older children to complete the same task,3 and their immature brain connectivity may inhibit their motor performance.14 Overall, evidence suggests a continuous sensitive period as it relates to grasp control from the age of 1 year through adolescence.

We believe that children not fitted with a myoelectric prosthesis in their first year may still benefit from a protocol such as described by Peterson and Prigge. The question remains as to when and how the brain networks may be selected and adapted for the affected limb15 to achieve functional myoelectric prosthesis use during childhood. The authors provide good evidence in support of early myoelectric limb fitting (e.g., embodiment and lower rejection rates), and we hope that research continues to fill the knowledge gaps. In the interim, it may not be a matter of concern if a child has not been fitted with a myoelectric prosthesis by year 2 or 3. Their brain still has the rest of childhood and adolescence to become a proficient myoelectric prosthesis user.

Vivian L. Rose, MSPO, CPO
Pranav J. Parikh, PhD
Department of Health and Human Performance
University of Houston, Texas
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