Participation and quality of life in children and adolescents with congenital limb deficiencies: A narrative review

Child Amputee Prosthetics Project-Prosthesis Satisfaction Inventory (CAPP-PSI): Validation of Italian Version in Children with Upper Limb Amputation

Background: The Child Amputee Prosthetics Project-Prosthesis Satisfaction Inventory (CAPP-PSI) is a comprehensive instrument designed to measure satisfaction across functionality, aesthetic, and service domains. This study aimed to translate, culturally adapt, and evaluate the psychometric properties of the CAPP-PSI in an Italian pediatric population. Methods: Following international guidelines, the CAPP-PSI was translated and culturally adapted. Internal consistency was evaluated using Cronbach's alpha, while test-retest reliability was assessed with intraclass correlation coefficients (ICCs). Construct validity was measured by analyzing correlations among subscales. Results: A total of 113 children with congenital or acquired upper limb amputation, accompanied by their parents, were recruited from the Bambino Gesù Children's Hospital in Rome. The Italian CAPP-PSI demonstrated excellent internal consistency (Cronbach's alpha = 0.913) and strong test-retest reliability (ICC = 0.966). Subscale correlations showed strong relationships between child and parent satisfaction (r = 0.724, p < 0.01) and parent satisfaction with service (r = 0.612, p < 0.01), while moderate correlations were observed between child satisfaction and service (r = 0.434, p < 0.01). Conclusions: The Italian version of the CAPP-PSI is a reliable and valid tool for assessing prosthetic satisfaction in pediatric populations. It provides valuable insights for clinicians and researchers, supporting patient-centered care and targeted improvements in prosthetic design and services. Future studies should explore longitudinal outcomes and the role of psychosocial factors in prosthetic acceptance.

Short-term outcomes of gradual ulnar lengthening in multiple hereditary osteochondromas of the forearm with monolateral external fixator

Hereditary multiple exostoses is an autosomal dominant genetic condition primarily affecting long bones. Forearm deformities, including wrist ulnar deviation, ulnar shortening, radial or ulnar bowing, and radial head dislocation, are common manifestations. Gradual ulnar lengthening is suggested as a viable treatment option for managing these deformities. This retrospective single-center study included 15 forearms treated with gradual ulnar lengthening using a monolateral external fixator by a single surgeon. Clinical and radiological characteristics were recorded preoperatively and during follow-ups. The Wilcoxon signed-rank test compared preoperative and postoperative radiological and clinical parameters, while McNemar's test assessed changes in radial head dislocation or subluxation. Significant radiological improvements were observed post-treatment. Proportional ulnar length increased from a mean of 0.85 ± 0.10 preoperatively to 1.11 ± 0.03 at the last follow-up (P < 0.001). Ulnar variance decreased from a mean of 17.6 ± 5.58 mm preoperatively to 0.13 ± 1.81 mm at the last follow-up (P < 0.001), while radial bowing decreased from a mean of 0.06 ± 0.02 to 0.05 ± 0.01 at the last follow-up (P < 0.001). In addition, the radioarticular angle decreased significantly from a mean of 29.93 ± 7.34 to 20.20 ± 5.71° (P < 0.001). The incidence of radial head dislocation or subluxation decreased significantly, from 11 patients preoperatively to only one at the last follow-up. These findings demonstrate the effectiveness of gradual ulnar lengthening with a monolateral external fixator in correcting forearm deformities and reducing the incidence of radial head dislocation or subluxation.

Mental health screening in pediatric lower limb deficiency population

BACKGROUND

Youth with lower limb deficiency (LLD) may be at increased risk for mental health difficulties. However, guidelines around psychosocial screening are not well established.

OBJECTIVE

To describe the implementation and results of a mental health screening process in a multidisciplinary prosthetics clinic.

DESIGN

Survey.

SETTING

Outpatient specialty care clinic located within a children's hospital.

PATIENTS

All patients ages 0-18 years with LLD seen at a monthly multidisciplinary prosthetics clinic between September 2019 and January 2023 (n = 75).

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

Quality of life was measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric proxy survey. Psychological functioning was measured using the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

Descriptive statistics were used to determine the proportion of patients who endorsed clinically significant concerns. Of the 75 clinic visits during the study time frame, the psychosocial screeners were completed at 38 (51%). A total of 25 unique patients completed the screeners; 12 patients completed the screener more than once. The most commonly endorsed concerns on the PROMIS were issues with physical mobility (65%) and upper extremity function (40%). The SDQ revealed that a majority (62.5%) of the screened patients had an overall score above the clinical cutoff, indicating psychosocial distress in more than one area. The most commonly reported mental health concern was peer problems (62.5%). Post hoc analysis of repeat screenings indicated that most problems identified during the first screening persisted at follow-up screenings.

CONCLUSIONS

Clinically significant psychological concerns were common among the sample, indicating the need to address this aspect of patients' well-being. Preliminary data on repeat screenings suggest that clinically significant concerns may not self-resolve. Routine psychosocial screening is critical for early identification of mental health problems and timely referral to evidence-based psychological interventions.

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.

Prospective Multicenter Preliminary Validation of Limb Deformity-modified Scoliosis Instruments in Pediatric Patients With Limb Deformity

INTRODUCTION

There are few disease-specific patient-reported outcome measures (PROMs) for use in pediatric limb deformity (LD), with authors instead relying on generic PROMs such as the Pediatric Outcomes Data Collection Instrument (PODCI) to assess treatment outcomes from the patient's perspective. The purpose of this study was to perform preliminary validation of 2 disease-specific PROMs in pediatric patients with LD.

METHODS

LD modifications were created by substituting the word "limb" for "back" in the Early Onset Scoliosis Questionnaire (EOSQ, ages 10 and younger) and the Scoliosis Research Society (SRS, ages 11 to 18) survey, creating the LD-EOSQ and LD-SRS instruments. Children were preoperatively administered the age-appropriate LD-PROMs (n=34 LD-EOSQ; n=30 LD-SRS) and PODCI questionnaires. LD-PROMs were assessed for construct (convergent and discriminant) validity, floor and ceiling effects, content validity, and minimal clinically important difference.

RESULTS

Both LD-EOSQ and LD-SRS demonstrated excellent preliminary convergent validity with similar PODCI domains and discriminant validity with demographic information, deformity data, and LLRS-AIM scores. There were minimal floor or ceiling effects. Content validity was achieved in 100% of LD-EOSQ surveys and more than 80% of LD-SRS surveys. Minimal clinically important difference was 0.4 for LD-EOSQ and 0.3 for LD-SRS.

CONCLUSIONS

The LD-EOSQ for patients aged 10 and under and LD-SRS for patients aged 11 to 18 demonstrated preliminary validity and reliability in the pediatric LD population. These measures provide more information specifically related to familial impact in younger children and self-image and mental health in adolescents compared to the PODCI and should be further evaluated for use in these patients.

LEVEL OF EVIDENCE

Level II-diagnostic. Prospective cross-sectional cohort design.

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.

Prevalence pattern, phenotypic manifestation, and descriptive genetics of congenital limb deficiencies in Pakistan

BACKGROUND

Congenital limb deficiency (CLD) is a group of very rare disorders characterized by substantial hypoplasia or the complete absence of 1 or more bones of limbs. Congenital limb deficiency has a significant physical, clinical, and psychological burden on the affected individuals and their families. This cross-sectional study aimed to describe the prevalence pattern, phenotypic manifestations, and biodemographic factors associated with CLD in a cohort assembled from the Pakistani population from the Northwestern region.

METHODS

Through a prospective cross-sectional study, 141 individuals having 166 limbs with CLD were recruited during 2017-2021.

RESULTS

There were 77 (55%) individuals with transverse defects, 61 (43%) with longitudinal defects, and 3 (2%) with Intercalary defects. Among the patients with transverse defects, 52 had terminal amputations and 25 had symbrachydactyly. Among the longitudinal defects, thumb aplasia/hypoplasia was the most common presentation (20 patients), followed by oligodactyly (18), and radial hemimelia (18). Eighty six percent had upper-limb deficiencies, 83% had unilateral deficiencies, and 92% were sporadic in nature. The parental consanguinity was observed in 33% individuals, and 79% cases had an isolated presentation which may be indicative of the substantial role of nongenetic factors in the etiology of CLD.

CONCLUSIONS

This study demonstrates marked heterogeneity in CLD subtypes in the involvement of limbs and associated variables. There is a need to establish a national registry for CLD, molecular genetic diagnosis, and multidisciplinary medical and social rehabilitation services for these individuals.

The global birth prevalence of clubfoot: a systematic review and meta-analysis

Background

Estimates of the birth prevalence of clubfoot in low and middle income settings range from 0.5 to 2 per 1000 births. However, there is currently no estimate of global birth prevalence of clubfoot.

Methods

We conducted a systematic review of studies reporting the birth prevalence of clubfoot across all countries and regions worldwide in the last 10 years. Africa Wide Information, EMBASE, CINAHL, Global Health, LILACS and Medline databases were searched for relevant studies from January 1st 2012 to February 9th 2023. Pooled prevalence estimates were calculated using the inverse variance method, and a random effects model was applied to account for heterogeneity between studies. Quality appraisal was performed using a modified Newcastle-Ottawa Quality Assessment Scale for Cohort studies. This review was registered with PROSPERO, CRD42023398410.

Findings

The search generated 757 studies. Thirty-five studies from 36 countries and five WHO regions were included. The pooled prevalence of clubfoot was 1.18 per 1000 births (95% CI: 1.00-1.36) based on data from 44,818,965 births. The highest prevalence rates were observed in low- and middle-income countries, particularly in the South-East Asia Region (1.80, 95% CI: 1.32-2.28) and the Africa Region (1.31, 95% CI: 0.86-1.77). We estimate that 176,476 (95% CI: 126,126-227,010) children will be born with clubfoot globally each year.

Interpretation

This study provides a comprehensive estimate of the global prevalence of clubfoot and highlights the significant burden of this condition, particularly in low- and middle-income countries. The findings underscore the need for improving access to effective treatment and prevention strategies in resource-limited settings.

Funding

SR received funds from the Global Clubfoot Initiative and the Rhodes Trust.

Facilitators and barriers for participation in sports and physical activity for children with lower-limb absence: A systematic review

Sports and recreational activities offer physical and psychological benefits to children with limb absence. Understanding what facilitators and barriers exist for the participation in sports and physical activity is vital to aid stakeholders to continue enabling facilitators and develop means to tackle existing barriers so that all children with lower-limb absence can participate in sport and physical activity as they wish. The aim of this systematic review was to identify facilitators and barriers that children with lower-limb absence experience when wanting to participate in sports and physical activity. Systematic review. Five databases were used to identify the literature relating to facilitators and barriers to sports and physical activity for children with lower-limb absence. These were Medline, Scopus, Cochrane, SPORTDiscus, and CINAHL. Google scholar was used as a secondary source. The review followed the "Preferred Reporting Item for Systematic Reviews and Meta-Analysis" guidelines. The review identified 10 articles for inclusion that met predefined inclusion criteria. The identified peer-review articles date from 1999 to 2021. The number of published articles steadily increases up to 2010 and then increase rapidly from 2016 to 2021. The results show although there are facilitators for sports participation for children with limb absence, there are many barriers which continue to hinder many children from participating in sports and physical activity. Facilitators that exist include advancements in prosthetic design and technology, increased opportunities, and physical and social benefits. Barriers that were reported include prosthesis failure, stigma, and high costs.

Maternal Cigarette Smoking and Congenital Upper and Lower Limb Differences: A Systematic Review and Meta-Analysis

Maternal smoking during pregnancy has been associated with adverse effects on foetal development, including congenital limb anomalies. This systematic review aimed to provide an updated assessment of the association between maternal smoking during pregnancy and the risk of congenital limb anomalies. A systematic search was conducted to identify relevant studies published up to February 2023. Studies reporting on the relationship between maternal smoking during pregnancy and congenital digital anomalies or congenital limb reduction defects were included. Two independent reviewers screened the studies, extracted data, and assessed the quality of the included studies. Meta-analyses were performed to estimate the pooled odds ratios with 95% confidence intervals using fixed and random-effects models. In total, 37 publications comprising 11 cohort and 26 case-control studies were included in the systematic review. The meta-analysis demonstrated a significant increased risk of congenital limb reduction defects (pooled OR: 1.27, 95% CI: 1.18-1.38) in infants born to mothers who smoked during pregnancy. Similarly, a significant relationship was observed for the development of polydactyly/syndactyly/adactyly when considered as a single group (pooled OR: 1.32, 95% CI: 1.25-1.40). Yet, in contrast, no significant association was observed when polydactyly (pooled OR: 1.06, 95% CI: 0.88-1.27) or syndactyly (pooled OR: 0.91, 95% CI: 0.77-1.08) were considered individually. This systematic review provides updated evidence of a significant relationship between maternal smoking during pregnancy and increased risk of congenital limb anomalies. These findings highlight the potential detrimental effects of smoking on foetal limb development and underscore the importance of smoking cessation interventions for pregnant women to mitigate these risks.

Prenatal radiographic evaluation of congenital transverse limb deficiencies: A scoping review

BACKGROUND

Congenital transverse deficiencies are horizontal deficiencies of the long bones that occur with a reported incidence as high 0.38%. They can occur alone or represent a manifestation of a various clinical syndromes. Diagnosis has traditionally comprised of conventional radiography and prenatal imaging studies. There has been much advancement regarding prenatal imaging modalities to allow for early diagnosis and appropriate treatment.

AIM

To summarize the current state of knowledge on congenital transverse limb deficiencies and to provide an update regarding the radiographic evaluation of congenital transverse limb deficiencies.

METHODS

This IRB-exempt scoping review followed the PRISMA-ScR checklist for scoping reviews strictly. Five search engines were searched for a total of 265 publications. Four authors reviewed these during the screening process. Of these, 51 studies were included in our article. Prenatal magnetic resonance imaging (MRI), 3D Ultrasound, and multidetector Computed tomography (CT) exist are emerging modalities that have the potential to improve diagnosis.

RESULTS

Use of the appropriate classification system, three-dimensional ultrasonography with a maximum intensity projection, and appropriate use of prenatal MRI and prenatal CT can improve diagnosis and inter-provider communication.

CONCLUSION

Further scholarly efforts are required to develop improve standardized guidelines regarding the pre-natal radiographic evaluation of congenital limb deficiencies.

Zurich Appearance Score for Hands: Development and Validation of an Instrument for Assessing Hand Appearance in Congenital Upper Limb Differences

PURPOSE

The appearance of the hand is relevant to individual activity and participation. Improving appearance is often one of the essential goals of hand surgery. The aim of this study was to describe and validate an instrument for quantitatively assessing hand appearance in congenital upper limb differences (CULD).

METHODS

The Zurich Appearance Score for Hands (ZASH) was developed as a summed score of 6 items: 1 for overall appearance and 5 specific items for the skin, proportions of the hand, the number of digits, the shape of fingers and the thumb, and the position of the thumb. Each item can be rated on an 11-point Likert scale. Here, 448 participants (age, 14-83 years) were asked to rate the images of 17 hands, including standardized 3-dimensional photorealistic computer graphics and photographs of children's hands with or without CULDs, some after surgical correction. The sociodemographic characteristics of the participants were measured using a short questionnaire.

RESULTS

The ZASH score for all CULDs was significantly lower than the ZASH score for normal hands. Correlations for overall appearance and the ZASH score were high (r = 0.77-0.87). The internal consistency of all ZASH scores was good to excellent (Cronbach α = 0.82-0.94). The test-retest reliability in a subgroup of 54 participants was good (r = 0.53-0.79). The interrater reliability of the ZASH score was moderate (intraclass correlation = 0.47).

CONCLUSIONS

The ZASH is a valid and moderately reliable instrument for assessing hand appearance in children with CULDs.

CLINICAL RELEVANCE

Achieving the best possible appearance is the one of the most relevant goals of hand surgery. Assessment with validated instruments provides evidence on how to approach this goal. Further studies may clarify whether the ZASH can be recommended for all hand conditions and to what extent observers' sociocultural and professional backgrounds affect perception.

LIMB-Q Kids—German Translation and Cultural Adaptation

(1) Purpose: Lower limb deformities can have a severe impact on health-related quality of life (HRQL). LIMB-Q Kids is a new patient-reported outcome measure (PROM) aiming to elucidate the experience of 8–18-year-old patients before, during and after treatment, and to measure the different aspects of HRQL. The aim of this study was to translate and culturally adapt LIMB-Q Kids to German. (2) Methods: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines were followed. Three forward translations, a backward translation, an expert panel meeting with eight participants, and twenty cognitive debriefing interviews led to the final German version of LIMB-Q Kids. (3) Results: In the forward translations, 4/159 items were difficult to translate, and 2/159 items in the backward translation differed from the original English version. Cognitive debriefing interviews with 20 patients identified 7/159 items that were difficult to comprehend/answer, and 2 of these items were changed. (4) Conclusions: Lower limb deformities can have a great impact on children, and it is important to measure and consider the impact on HRQL. In order to be able to use PROMs in different countries, conceptually equivalent translations and cultural adaptations should be performed in order to ensure comprehensibility. The final German version of LIMB-Q Kids is ready for use in an international field test.

Low health-related quality of life in adult individuals with multiple limb deficiencies compared with population-based reference values

BACKGROUND

Knowledge on health-related quality of life (HRQoL) in multiple limb deficiencies (LDs) is limited.

OBJECTIVES

To investigate self-reported HRQoL in multiple LDs, assess differences between congenital LD and acquired LD and sex, and to evaluate associations between the types of LDs, demographic variables, and HRQoL.

STUDY DESIGN

Cross-sectional cohort study.

METHODS

A total of 106 individuals with multiple limb deficiencies treated at the EX-Center were invited by mail to fill out the Short Form-36 survey.

RESULTS

Responses from 62 participants, mean age ± SD 49.5 ± 14.2, showed that 43 had congenital LD and 19 had acquired LD. Responders reported reduced HRQoL in all Short Form-36 domains except Role-Emotional, compared with reference values (P < 0.05-<0.001). Individuals with a congenital LD reported worse Bodily Pain than acquired LD (P < 0.05), and women reported lower Physical Function than men (P < 0.05). Sick leave was negatively associated with physical composite score. Living in a rural area was positively associated with Mental Health (P < 0.01), and congenital LD was negatively associated with Vitality (P < 0.05).

CONCLUSIONS

Individuals with multiple LDs in Sweden have lower HRQoL compared with reference values. There are significant associations between sick leave and physical function, rural living and mental health, and the type of LD and vitality.

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.

What matters to children with lower limb deformities: an international qualitative study guiding the development of a new patient-reported outcome measure

BACKGROUND

Lower limb deformities include conditions such as leg length discrepancy, lower limb deficiency and associated angular and rotational deformities of the hips, knees, ankles and feet. Children with lower limb deformities often have physical limitations due to gait irregularities and pain. The differences in the appearance and function of their lower limbs can discourage participation in social, recreational and leisure activities, which may result in behavioural, emotional, psychological and social adjustment problems. The health-related quality of life (HRQL) of these children is often impacted due to the factors discussed above, as well as by the complex surgical procedures. Surgical treatment options for limb deformities in children vary from limb lengthening and reconstruction to amputation. The lack of evidence demonstrating superiority of either treatment options and their effect on HRQL limits the ability of healthcare providers to counsel families on the best evidence-based treatment option for them. This manuscript describes the international qualitative study which guided the development of a new patient-reported outcome measure (PROM). Individual semi-structured face-to-face interviews with children with lower limb deformities and their parents were conducted at five sites: Canada (2 sites), Ethiopia, India and the USA.

RESULTS

Seventy-nine interviews were conducted at five international sites. Five main themes emerged from the qualitative interviews and formed the basis of the conceptual framework. These themes were: 1) appearance, 2) physical health, 3) psychological health 4) school and 5) social health.

CONCLUSIONS

Lower limb deformities have a substantial impact on the HRQL of children. The concepts of interest identified in our study were similar across children from all countries. The conceptual framework guided the development of outcome scales specific to these patients. The information about the impact of various treatment options on the HRQL of children with lower limb deformities, collected using this new PROM, could be used to inform parents and children about outcomes (physical, social, psychological) associated with specific treatment options. This information could supplement other objective outcome information (e.g., complication rates, how the leg will look, etc.) to help families to come to a more informed decision on a child's course of treatment.

Rehabilitation Approach for a Child with Cerebral Palsy and Upper Limb Deficiency

Background

Congenital limb deficiency is a rare and intractable anomaly of the limbs; however, prostheses can partially complement the motor function and appearance of the missing limbs. The first prosthesis is usually prescribed for children with upper limb deficiencies at approximately 6-8 months of age. In affected children with additional problems associated with motor function, such as limb paralysis, the age for initiating prosthetic therapy and the benefit of prostheses in promoting and expanding their motor function and activities is unknown.

Case

In this case presentation, we describe a 25-month-old boy with cerebral palsy and left unilateral congenital upper limb deficiency caused by congenital constriction band syndrome. The patient could stand with assistance and crawl on his hands and knees. However, he was unable to walk with assistance or to stand on his own. A forearm prosthesis with a passive hand was prescribed and issued, and rehabilitation therapy for wearing and using the prosthesis was performed. At 34 months of age, the patient was able to walk forward using a walker with the prosthesis. Without the prosthesis, he still could not walk using a walker. The upper limb prosthesis also improved other movements such as sitting, standing, and tasks performed on a desk or on the floor.

Discussion

The prosthesis was apparently effective in improving motor function. Prosthesis prescription should be considered at an appropriate and early age considering individual developmental stages and needs, regardless of the existence of additional problems associated with motor function.

Using a 3D-Printed Prosthetic to Improve Participation in a Young Gymnast

BACKGROUND AND PURPOSE

The purpose of this case report was to investigate the application of a 3-dimensional (3D)-printed prosthetic hand to improve a child's participation, confidence, and satisfaction in gymnastic classes, specifically, horizontal bar-related skills.

SUMMARY OF KEY POINTS

A 9-year-old child was unable to participate in horizontal bar-related gymnastic skills due to a congenital hand deficiency. A prosthetic hand was designed, 3D printed, modified repeatedly, and incorporated into a program, which resulted in improvements in the child's ability to participate in gymnastics.

CONCLUSIONS

Using a 3D-printed upper limb prosthetic hand improved the child's participation, confidence, and satisfaction in her gymnastic classes permitting use of horizontal bar. To progress to higher-intensity activities, further safety measures and testing of the prosthetic hand are needed.

WHAT THIS CASE ADDS TO EVIDENCEBASED PRACTICE

A 3D-printed prosthetic hand was manufactured and customized allowing closely monitored, gradually increased, participation in horizontal bar gymnastics.

Physical performance of children with longitudinal fibular deficiency (fibular hemimelia)

PURPOSE

Longitudinal fibular deficiency (LFD) is the most common congenital long bone deficiency. This study aimed to objectively assess the physical performance of children and adolescents with LFD compared with unaffected peers, and to examine trends over age for subgroups of the LFD population.

METHODS

Differences between children with LFD and unaffected peers were examined with hand-held dynamometry for lower-limb muscle strength, Six-Minute Walk Test, Timed up and down stairs test, Star Excursion Balance Test, and Standing long jump.

RESULTS

Thirty-nine children with LFD and 284 unaffected peers participated. Children with LFD performed at a lower level than their unaffected peers, on all measures of physical performance (mean 2.1 z-scores lower, all p < 0.01), except in long jump (p = 0.27). When comparing the performance of children with LFD to their unaffected peers across four age groups, there was a significant between-groups difference on all strength measures, and on the Six-Minute Walk distance, between children with and without LFD. These differences were smallest in young children (3-6 years) and largest in the older children (15-18 years) (all p < 0.01). Children with no lengthening surgery performed better on the Six-Minute Walk Test, covering a greater distance during the test, than those who had surgery (mean difference 83 metres, p < 0.01). There were no significant differences between children who had or had not undergone an amputation.

CONCLUSIONS

Children with LFD performed at a significantly lower level than unaffected peers on all measures of physical performance other than jumping. The largest differences were in older children. This paper provides baseline functional data for future interventions in LFD.

LEVEL OF EVIDENCE

Cross-sectional study.Implications for RehabilitationThis paper provides the first baseline functional data using validated objective measures on a consecutive cohort of children and adolescents with longitudinal fibular deficiency.Children with LFD performed significantly worse than their unaffected peers on all measures of physical performance other than jumping, with children falling further behind their peers as they age.Children who undergo an amputation typically have the most severe anatomical presentation and yet perform at an equivalent functional level.This paper identifies multiple modifiable impairments that represent potential opportunities for rehabilitation professionals to target with conservative treatment options to improve functional performance.

Reflections and future directions for psychological science in Prosthetics and Orthotics International

In the inaugural edition of Prosthetics and Orthotics International in 1977, Dr Sidney Fishman identified the Psychological Sciences as one of six indispensable areas of skill and knowledge in professional prosthetic-orthotic practice. Since then, there have been substantial changes and developments in the complexity and capabilities of assistive technologies, greater emphasis on understanding the relationships between people and enabling technologies, growing recognition of the importance of the contexts and environments that support their use, and changes in both health care services and the professional development of prosthetists and orthotists. The aim of this narrative review is to reflect on the role of Prosthetics and Orthotics International in shaping the evolving understanding of psychology in prosthetics and orthotics. There remains considerable potential and opportunity for the development and application of psychology in addressing the challenges of disability globally. However, a broad interpretation and application of the principles of rehabilitation psychology are needed if we are to meaningfully incorporate psychological science into the knowledge that informs prosthetic and orthotic practice.

Predictors of participation and quality of life following major traumatic injuries in childhood: a systematic review

OBJECTIVE

Review the literature on predictors of participation and quality of life in children and young people who sustained a traumatic brain injury (TBI), spinal cord injury (SCI), and/or multi-trauma in a motor vehicle or other accident or trauma.

DESIGN

This systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered on PROSPERO (registration number CRD42020131698). Electronic databases were searched for studies published between January 2000 and August 2020. Prospective and retrospective cohort studies were considered and risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

The search yielded 5771 articles of which 30 studies met the inclusion criteria. Nineteen studies included patients with TBI and 11 with SCI. No studies of patients with multi-trauma met criteria. Evidence was found for associations with various factors (e.g., injury severity, level of education, mental health problems), although these findings are limited due to the quality of the studies (5 studies moderate and 25 high risk of bias).

CONCLUSION

Research on predictors of participation and quality of life following major traumatic injuries in childhood is lacking. More methodologically sound prospective, longitudinal studies are needed across different injury groups to further elucidate predictors of outcome.IMPLICATIONS FOR REHABILITATIONWhile long-term participation and quality of life is influenced by injury characteristics (i.e., injury severity), a number of potential modifiable factors can be targeted to improve outcomes following traumatic injuries in childhood.Young people should be provided with support to stay in school and pursue further education.Early intervention and prevention of mental health problems may improve long-term outcomes.Better management of ongoing medical problems and greater support for functional independence may improve participation.

Compact and Lightweight Transradial Electric Prosthesis for Children with Forearm Deficiency

Children with congenital forearm deficiency have difficulty in daily activities and body balance problem. Since most electric prostheses have been developed for adult amputees, it is necessary to develop a compact and lightweight electric prosthesis for children to manipulate various daily objects. In this paper, we report a compact and lightweight transradial electric prosthesis for children with forearm deficiency. Based on an electric prosthesis termed as Finch for adult amputees, we designed a smaller electric prosthesis by using a compact actuator and a control unit. We downsized the fingers of the Finch without impairing the workability. The total weight of the developed prosthesis was 274 g, which was about 100 g lighter than that of the conventional electric prosthesis for children. The result of upper limb function evaluation using developed prosthesis participated in a child with congenital forearm deficiency demonstrated that the effectiveness of the prosthesis to manipulate daily objects.

International multiphase mixed methods study protocol to develop a patient-reported outcome instrument for children and adolescents with lower limb deformities

INTRODUCTION

Our recent systematic review has indicated the lack of a patient-reported outcome (PRO) instrument to measure health-related quality of life (HRQOL) of children and adolescents with lower limb deformities. We are developing a PRO instrument which will be applicable internationally across various countries. This manuscript describes our approach to the development of a new PRO instrument for measuring HRQOL for children and adolescents with lower limb deformities.

METHODS AND ANALYSIS

Three phases in the development of this PRO instrument are as described: (1) This phase involves the development of a conceptual framework of HRQOL and item pool that is used to inform a set of preliminary scales. We have developed a preliminary conceptual framework of HRQOL based on our systematic review. Qualitative interviews are being conducted at five sites in Canada, Ethiopia, India and the USA. An item pool will be generated from this qualitative phase. The preliminary items and scales will be sent out to children at the five participating centres. Cognitive debriefing interviews will gather detailed feedback on the items from the children. Expert opinion will be sought from clinicians from the participating centres. (2) During this phase, an international field-test study will be conducted to refine the scales and examine their psychometric properties. (3) During this phase, tests of reliability, validity and responsiveness will be conducted. Phase 1 will also involve translations and cultural adaptations. At the end of this study, we expect to produce an internationally applicable PRO instrument which is scientifically sound and clinically relevant to the lower limb deformity population.

ETHICS AND DISSEMINATION

This study is approved by Research Ethics Boards for each of the participating sites.Results of this study will be published in peer-reviewed journals and presented at national and international conferences. An integrated knowledge translation approach is applied to engage patients, families and clinicians from the start of the study.

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.

Gemstracker Expertise team Rotterdam arm and hand: Web-based monitoring of physical, social and emotional functioning in patients with upper limb amputations

BACKGROUND AND AIM

Patient-reported outcome measures are increasingly used to evaluate effectiveness of treatment. However, the use of 'paper and pencil' questionnaires is time-consuming for both patients and healthcare specialists. Therefore, the aim of this project was to develop a custom-built web-based monitoring system.

TECHNIQUE

We incorporated reliable and valid questionnaires on all domains of human functioning as described in the World Health Organization's Classification of Functioning, Disability and Health (ICF and ICF-CY). The method of remote follow-up enables long-term evaluation of PROMs. We specified monitoring protocols for both children and adults, split for different age groups with emphasis on health-related quality of life.

DISCUSSION

Time-efficient evaluation of PROMs may lead to higher compliance and an increase of client-centred practice. Moreover, evaluating PROMs facilitates patient empowerment and enables patients to make informed decisions about their treatment and healthcare needs. Clinical relevance We developed a web-based system for evaluation of PROMs. The system has enabled better informed decision-making for our clients.

Amputation and rotationplasty in children with limb deficiencies: current concepts

PURPOSE

Amputations and fitting surgery have a long history in children with limb deficiencies. With the current developments in limb reconstruction and new techniques in prosthetics, the indications for amputation and fitting surgery might have shifted, but still have a very important role in creating high functional performance, optimal participation and quality of life. The purpose of this current concepts article is to give an overview of the indications, dilemmas and technical considerations in the decision-making for amputation and fitting surgery. A special part of this overview is dedicated to the indications, variations and outcomes in rotationplasties.

METHODS

The article is based on the experience of a multidisciplinary reconstruction team for children with complex limb deficiencies, as well as research of the literature on the various aspects that cover this multidisciplinary topic.

RESULTS

For those children with a more severe limb deficiency, reconstruction is not always feasible for every patient. In those cases, amputation with prosthetic fitting can lead to a good result. Outcomes in quality of life and function do not significantly differ from the children that had reconstruction. For children with a postaxial deficiency with a femur that is too short for lengthening, and with a stable ankle and foot with good function, rotationplasty offers the best functional outcome. However, the decision-making between the different options will depend on different individual factors.

CONCLUSIONS

Amputations and rotationplasties combined with optimal prosthesis fitting in children with more severe limb deficiencies may lead to excellent short- and long-term results. An experienced multidisciplinary team for children with complex limb deficiencies should guide the patient and parents in the decision-making between the different options without or with prosthesis.

Health-related quality of life in adults with congenital unilateral upper limb deficiency in Norway. A cross-sectional study

PURPOSE

To examine subjective health-related quality of life (HRQoL) in adults with congenital unilateral upper limb deficiency (UULD) in Norway and to explore the associations between demographic and clinical factors and HRQoL.

METHOD

Cross-sectional study comparing HRQoL, measured by SF-36, among adults with UULD and an age- and gender-matched control group from the Norwegian general population (NGP).

RESULTS

Seventy-seven respondents, median age 42 years (range: 20-82); 71% were women. Most had left-sided (61%), below elbow (53%), transverse (73%) deficiency. Compared to the NGP, the UULD group reported reduced HRQoL on all SF-36 subscales except for the role emotional (RE) scale (p=0.321), mental health (MH) (p=0.055) and mental component summary (MCS) (p=0.064). The greatest difference was on the bodily pain (BP) scale (point difference of 20.0). Multiple linear regression models showed significant association between several physical- and mental SF-36 subscales and occupational status, occurrence of comorbidity and chronic pain.

CONCLUSIONS

Persons with UULD reported reduced HRQoL on most SF-36 subscales, mostly in the physical health domain. Employment status, occurrence of comorbidity and chronic pain seem to have a negative impact on the HRQoL. Measures that can reduce pain and loss of function should be given particular attention in UULD rehabilitation. Implications for Rehabilitation Persons with congenital unilateral upper limb deficiency (UULD) who experience pain and discomfort should seek professional help for evaluating their everyday coping strategies. Professionals who meet persons with UULD should examine anomalies, comorbidity, pain and employment status before choosing advices and actions. Individually adapted grip-improving devices, environments, physical exercise and pain management programs should be implemented early to reduce pain, loss of function and decreased HRQoL. A multidisciplinary approach is often necessary when counseling persons with UULD.

Children with congenital limb deficiency in Norway: issues related to school life and health-related quality of life. A cross-sectional study

PURPOSE

To describe clinical features, issues related to school life and health-related quality of life (HRQOL) for children with congenital limb deficiency (CLD) and compare these children to Norwegian school children on HRQOL.

METHOD

Cross-sectional study. In 2010, a postal questionnaire, designed for this study and the Paediatric Quality of Life Inventory (PedsQL), was sent to 154 eligible parents of children with CLD, aged 6-18 years and registered at TRS National Resource Centre for Rare Disorders in Norway.

RESULTS

Response rate 44% (n = 67), median age 11 years, 42% were girls. Of the total group, 46 had unilateral upper limb deficiency (UULD) and 21 had multiple/lower limb deficiency (MLD/LLD). The most common UULD was below-elbow deficiency, of these, 65% used grip-improving devices, and 35% used prostheses. Children with UULD-reported PedsQL score similar to Norwegian schoolchildren (NSC). The MLD/LLD group was heterogeneous; most had below-elbow/knee deficiency. In this group, PedsQL scores were reduced for physical and social functioning compared with NSC. Compared with children with UULD, more children with MLD/LLD were restricted in participation because of pain and fewer participated in physical education with peers.

CONCLUSIONS

Most children with CLD participated with their peers and managed well in everyday life. Children with MLD/LLD seemed to have more challenges than children with UULD. Approximately one-third of all the children had assistive devices and/or practical assistance in school. Implications for Rehabilitation Most children with upper-limb deficiency (UULD) in Norway manage well in everyday life and have HRQOL equal to other Norwegian children. Many choose grip-improving devices instead of prostheses. Their preferences should be respected and taken into account as the need for new assistive devices arise. For children with pronounced disabilities, access to, and use of, assistive devices, adaptions and practical assistance may be important for participation. Cooperation with the child and the parents is necessary to find useful measures. Physical education and practical subjects may provide special challenges, both for children and their teachers. Children themselves often find good solutions and the tasks should be planned ahead in cooperation with them.

Congenital limb deficiency disorders

Congenital limb deficiency disorders (LDDs) are birth defects characterized by the aplasia or hypoplasia of bones of the limbs. Limb deficiencies are classified as transverse, those due to intrauterine disruptions of previously normal limbs, or longitudinal, those that are isolated or associated with certain syndromes as well as chromosomal anomalies. Consultation with a medical geneticist is advisable. Long-term care should occur in a specialized limb deficiency center with expertise in orthopedics, prosthetics, and occupational and physical therapy and provide emotional support and contact with other families. With appropriate care, most children with LDDs can lead productive lives.

Life situation of adults with congenital limb reduction deficiency in Sweden

PURPOSE

To describe the current life situation of adults with congenital limb reduction deficiencies (CLRD), living in Sweden, regarding their main daily occupation, leisure activities and self-reported general health.

METHODS

A cross-sectional survey was conducted using a study-specific questionnaire, sent by post. Hundred and seventeen persons with different extent, forms and levels of CLRD (mean age 33 years) responded to the questionnaire.

RESULTS

Work or study was the main occupation for 86% of the participants and 50% had completed a college or university education. About 7% were unemployed and 3% were on sick leave. The participants were highly involved in social and physical activities during leisure time. The majority reported good or very good general health.

CONCLUSION

This study is the first investigation of the life situation of adults with CLRD described with a perspective from Swedish society. The participants were educated and worked to a great extent, which corresponds well to the Swedish population as a whole. Further research is needed, especially with a focus on the internal perspective of life situation, different aspects of work capacity, occurences of strain injuries and the benefit of assistive devices among adults with CLRD. Implications for Rehabilitation People with CLRD require a health care system with a multi-professional rehabilitation team offering regular contact during their life time. Educational system offering study counselling on all education levels (from primary school to university) is an important type of support for people with any kind of deficiency, in order to find suitable education and profession. Work is of importance for an acceptable life situation. Rehabilitation for people with CLRD should emphasise facilitating their ability to work, through engagement in individual personal capacity and self-efficacy. The majority of people with CLRD are users of prostheses and assistive devices. The benefits of the devices are basic but the rehabilitation should also include aspects of usability and use worthiness for individuals in performing their daily activities.