Education and work participation among adults with congenital unilateral upper limb deficiency in Norway: A cross-sectional study

Objectives

To describe level of education and work participation among adults with congenital unilateral upper limb deficiency (CUULD) in Norway and to explore associations between work participation and demographic and clinical factors.

Methods

Cross-sectional study. In 2012, a postal questionnaire was sent to 186 persons with congenital limb deficiency (CLD), age ≥ 20 years, registered at the TRS National Resource Center for Rare Disorders. In the original CLD study, 77 persons with CUULD responded. In this paper 64 persons with CUULD of working age (20–67 years) are included. Data on demographic factors as education level and work participation, and clinical factors including limb deficiency characteristics, chronic pain (Standardized Nordic Questionnaire), fatigue (Fatigue Severity Scale), physical and mental health (SF-36) were analyzed through descriptive and comparable statistics and logistic regression analyses.

Results

Sixty-four persons participated, mean age 43.4 (SD 13.7; range 20–67 years), 45 were women. Education level >13 years was reported by 34. Forty- three of the 64 participants were employed, 21 were prematurely retired (disability benefits). 11 of the 43 employed, and 6 of the 21 prematurely retired had completed vocational education. Physically demanding occupations (work activities that required standing, walking and lifting) were reported by 25 of the 43 employed and 13 of the 21 prematurely retired. 17 of the 64 reported need for further adaptions in their workplaces. The strongest predictors of work participation were younger age (OR 0.86) and good physical health (OR 1.21).

Conclusion

Two thirds of persons with CUULD were employed; while one third was prematurely retired and had left work earlier than expected. This suggests that persons with CUULD may experience challenges in work participation. Although levels of education were relatively high, several had chosen careers that required physical strain. Younger age and good physical health were the most important factors mediating work participation.

Functional Impact of Congenital Hand Differences: Early Results From the Congenital Upper Limb Differences (CoULD) Registry

PURPOSE

To characterize the functional, emotional, and social impact of congenital upper limb differences on affected children and families before treatment, using validated functional outcome instruments.

METHODS

From June 2014 to March 2016, 586 children with congenital upper limb differences from 2 pediatric hospitals were enrolled in the Congenital Upper Limb Differences registry. Demographic, clinical, and radiographic data were collected, and diagnoses categorized according to the Oberg-Manske-Tonkin classification. Functional outcomes were assessed in 301 patients using the Pediatric Outcomes Data Collection Instrument (PODCI) and Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) function, pain, anxiety, depression, and peer relationships modules.

RESULTS

The cohort had high median PODCI scores in all domains, ranging from 83 to 100 in children and adolescents. Patients had decreased PROMIS UE scores compared with population norms; however, they showed low scores for pain, anxiety, depression and higher scores in the peer relationship domain, respectively. Patients with entire limb involvement had higher PROMIS pain scores and lower PODCI UE and global functioning than those with differences limited only to the hand. Compared with those with bilateral involvement, patients with unilateral differences reported higher scores for PODCI sports global functioning, better PROMIS UE function, and lower pain scores. Additional orthopedic conditions and medical comorbidities negatively influenced all PODCI scores and PROMIS pain and UE function domains.

CONCLUSIONS

Children with congenital hand differences report decreased upper limb function but better peer relationships and positive emotional states compared with population norms.

CLINICAL RELEVANCE

The Congenital Upper Limb Differences registry is a valid source of information related to congenital upper limb differences in clinical practice. With continuous enrollment and longitudinal follow-up, the registry will increase the understanding of UE function and psychosocial aspects of health in pediatric population.

Left Ventricular Non-compaction in Holt-Oram Syndrome

Holt-Oram Syndrome is an autosomal dominant condition with complete penetrance and which involves upper limb skeletal and cardiac abnormalities. The latter can be structural defects or involve the conduction system. This report details the occurrence of left ventricular non-compaction in multiple family members with Holt-Oram Syndrome. It is recommended that patients with the Holt-Oram Syndrome be considered for comprehensive cardiac evaluation to exclude non-compaction cardiomyopathy as this may have significant prognostic implications.

Body structures and physical complaints in upper limb reduction deficiency: a 24-year follow-up study

OBJECTIVE

To describe upper body structures associated with upper limb reduction deficiency and the development of these structures over time, to examine the presence of physical complaints in this population, and to compare body structures and complaints between groups based on prosthesis use.

DESIGN

Prospective cohort study with a follow-up period of 24 years, with matched able-bodied controls.

SUBJECTS

Twenty-eight patients with unilateral below-elbow reduction deficiency fitted with myoelectric prostheses, aged 8-18 years at inclusion.

METHOD

Measurements of upper arm, trunk and spine were performed and study-specific questionnaires were answered at baseline and follow-up; the Brief Pain Inventory and the Quick Disability of Arm, Shoulder, and Hand questionnaires were answered at follow-up.

RESULTS

Both at baseline and follow-up, within-subjects differences in structures of the arm and trunk were shown in patients but not in controls. Spinal deviations, although small, were greater in patients compared to controls. Self-reported disability was higher in patients compared to controls. Differences in back pain and effect of prostheses use could not be shown.

CONCLUSIONS

Patients with unilateral below-elbow reduction deficiency have consistent differences in upper body structures. Deviations of the spine, probably of functional origin, do not progress to clinically relevant scoliosis.

Assessment of arm/hand functioning in children with a congenital transverse or longitudinal reduction deficiency of the upper limb

PURPOSE

Selection of appropriate functional tests and questionnaires to assess capacity (tests) and performance (questionnaires) of arm/hand functioning in children with congenital transverse or longitudinal (radius dysplasia) reduction deficiencies of the upper limb.

METHOD

A PubMed Medline search was performed. Tests and questionnaires were evaluated according to three criteria: (1) items represent bimanual daily activities, (2a) quality of movement is scored (tests) or (2b) difficulty in performing a task (questionnaires), (3) instrument is attractive for children aged 4 - 12.

RESULTS

We found 14 functional tests and nine questionnaires to measure arm/hand functioning. Three tests, the Assisting Hand Assessment (AHA), Unilateral Below Elbow Test (UBET) and University of New Brunswick Test of prosthetic function (UNB Test) and two questionnaires, the Prosthetic Upper limb Functional Index (PUFI) and the children's version of the ABILHAND (ABILHAND-Kids) met the criteria.

CONCLUSIONS

Two functional tests (AHA and UBET) and two questionnaires (ABILHAND-Kids and PUFI) were considered appropriate to assess arm/hand functioning in children with congenital reduction deficiencies of the upper limb, but require further study on psychometric properties for these patient groups.

Prenatal sonographic diagnosis of familial Holt-Oram syndrome associated with type B interrupted aortic arch

We present a rare case of familial Holt-Oram syndrome diagnosed sonographically at 18 weeks of gestation. The foetus had serious bilateral upper limb malformations, a ventricular septal defect and a type B interrupted aortic arch, while the mother had bilateral upper limb malformations only. The pregnancy was terminated. A pathological and radiological examination of the foetus confirmed the prenatal sonographic findings. Although genetic investigation of TBX5 mutations was not available in our locality at the time of diagnosis, the geneticists made a clinical diagnosis of familial Holt-Oram syndrome. The clinical features of our case completely fulfilled the strict diagnostic criteria for the syndrome. The cardiac malformations most commonly associated with Holt-Oram syndrome are atrial or ventricular septal defects. To the best of our knowledge, a prenatal diagnosis of Holt-Oram syndrome in association with a type B interrupted aortic arch has not been reported in the English literature before.

[Bilateral transversal humeral defect accompanied by defects of lower limbs--an attempt of improvement of upper limb's function by a reconstructive procedure, a case illustration]

Motor system is the most common localization of congenital defects. Disturbances of limb formation resulting in a total defect of a limb fragment are most difficult to treat. Transversal defects within the arm are usually unilateral and rarely accompanied by other congenital mutilations. The exceptional case is presented of a child with bilateral humeral transversal defect accompanied by transversal defect of a right thigh, and bilateral hip joint dysplasion. The etiology of the mutilation is unknown. The child was able to move on a wheel-chair as well as thanks to well innervated arm-stumps and a single foot to perform many activities of daily life, although some of them with a serious difficulty. The commonly stated decision was taken to operate the child aiming at improvement of limb's function. That was achieved by a reconstructive procedure creating a pincer-like enlargement of arm-stump's ending. Arm lengthening seems to be necessary in the near future.

Comparison of instruments to assess hand function in children with radius deficiencies

PURPOSE

For treatment evaluation of children with radius deficiencies (RDs), standardized assessment of hand function in performing activities is required. Instruments to measure hand function have been developed for other diagnoses. The current study aimed to find additional evidence for validity, reliability, and usefulness of these instruments for children with RDs.

METHODS

In this study, 20 children with RDs (aged 4-12 years) participated; 16 were boys, and 13 children were unilaterally affected. Children were assessed using the Assisting Hand Assessment, the Unilateral Below Elbow Test, the Prosthetic Upper Extremity Functional Index, and ABILHAND-Kids. Construct and convergent validity of the instruments were studied focusing on predefined hypotheses and relationships with other instruments and the therapist's global assessment. Test-retest reliability was assessed in 10 children by means of the intraclass correlation coefficients and the smallest detectable differences.

RESULTS

For children with RDs, the Assisting Hand Assessment and the Prosthetic Upper Extremity Functional Index appeared to be the most valid function test and questionnaire according to the relationships found with type of RD, functional hand grips, and the therapist's global assessment of hand function. Regarding test-retest reliability, intraclass correlation coefficients ranged from 0.82 to 0.91, and smallest detectable differences were acceptably small.

CONCLUSIONS

The current results contribute to the evidence that the instruments, especially the Assisting Hand Assessment and the Prosthetic Upper Extremity Functional Index, provide valid and reliable results in children with RDs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic I.

Evaluation of arm and prosthetic functioning in children with a congenital transverse reduction deficiency of the upper limb

OBJECTIVE

To assess upper extremity functioning of children with unilateral transverse upper limb reduction deficiency, using standardized instruments, and to investigate their validity and reliability.

DESIGN

Cross-sectional study.

SUBJECTS

Twenty subjects aged 4-12 years; 9 prosthetic users and 11 non-users.

METHODS

The Assisting Hand Assessment, Unilateral Below Elbow Test, Prosthetic Upper extremity Functional Index and ABILHAND-Kids were assessed in all children. Users were tested with and without their prosthesis. We compared results of users and non-users, and of users with and without their prosthesis. Validity was determined by testing hypotheses and correlations with other measures. Test-retest reliability was assessed from repeated measurements in 10 children.

RESULTS

Children with an upper limb reduction deficiency performed well on daily activities. They could use their prosthesis in 68% of the activities, but were currently using it in only 30%. Children find their prosthesis useful for specific activities, rather than for daily activities in general. The Assisting Hand Assessment and Prosthetic Upper extremity Functional Index showed best validity; test-retest reliability was good to excellent.

CONCLUSION

The use of standardized instruments adds relevant information on functioning of children with an upper limb reduction deficiency. We found additional support for validity and reliability of, in particular, the Assisting Hand Assessment and Prosthetic Upper extremity Functional Index.

A rare and often unrecognized cerebromeningitis and hemodynamic disorder: a major cause of sudden death in somatic cell cloned piglets

In this study, we generated 40 somatic cell cloned (scNT) piglets. Of these, five piglets were stillborn, 22 scNT piglets died suddenly within the first week of life, and 1 piglet died after 40 days. Twelve scNT piglets are still healthy. The birth weights of compromised scNT piglets in comparison with those of normal scNT piglets are significantly reduced (0.80 +/- 0.29 vs 1.27 +/- 0.30 kg, p < 0.05), in spite of longer gestation (114 versus 120 day). Significant findings from histological examinations showed that approximately 25% (7/28) of scNT piglets showed severe congestion of lung and liver or neutrophilic inflammation in brain indicating that unexpected phenotypes can appear as a result of somatic cell cloning. Two-dimensional gel electrophoresis experiments revealed changes in the responses of several detoxification-related proteins related to stress and inflammation and found significant alterations in myocardium-specific proteins, indicating hemodynamic disorder. scNT piglets that survived to adulthood did not show any abnormality except skin and hair color depigmentation. The present study suggests that cerebromeningitis and hemodynamic disorder are a major risk factor for sudden early death of scNT piglets. Although we cannot completely exclude the possibility that scNT piglets are susceptible to specific respiratory infections, our data suggests that the early death of scNT clones is due to cardiopulmonary functional abnormalities and cerebromeningitis.

Functional analysis of upper limb deformities in osteogenesis imperfecta

The charts and radiographs of 159 children with osteogenesis imperfecta (OI) were retrospectively reviewed to measure the severity of upper limb deformities and to evaluate the functional outcome using the Pediatric Evaluation of Disability Inventory (PEDI). The patients were classified according to the Sillence classification modified by Glorieux: 51 type 1, 33 type 3, 54 type 4, and 21 5ype 5. Fifty-nine patients (37.1%) had deformities of their upper limbs. Children with type 3 OI had the highest incidence and the most severe deformities. The humerus was the most commonly involved bone, followed by the ulna and radius. Upper limb deformities were classified into four groups according to the severity of the maximum deformity angle. The mean self-care scores of PEDI were significantly low only in the group with severe deformities, but mobility scores were dramatically decreased in both the moderate and severe deformity groups. Therefore, upper limb deformities in children with OI do not represent only a cosmetic problem, but may also significantly impair functional activities of daily living.

Reduced somatosensory hand representation in thalidomide-induced dysmelia as revealed by fMRI

The concept of cerebral plasticity suggests that the hand representation in somatosensory cortex is abnormal in congenital malformation disorders. To investigate this issue we studied 11 subjects with different degrees of upper extremity dysmelia due to thalidomide embryopathy in comparison to 10 control subjects. In the affected subjects fingers are typically missing in radio-ulnar order beginning with the thumb. Haemodynamic responses to electrical stimulation of the radial-most and ulnar-most fingers were measured in each subject using functional magnetic resonance tomography. The size of the hand area in the primary somatosensory cortex was estimated by calculating the Euclidian distance between corresponding activation peaks on the lateral postcentral gyrus. The cortical somatosensory hand representation was found to be significantly smaller in dysmelic subjects as compared with the control subjects (P <0.001). The shrinkage of the hand area was not proportional to the number of missing fingers. Furthermore, the cortical representation of the ulnar fingers in the dysmelic subjects was shifted towards the cortical thumb representation of the control group. We suggest that the unproportional reduction of the hand area together with the observed shift may reflect use-dependent rather than malformation-induced reorganization of the somatosensory hand area.

Shrinkage of Somatosensory Hand Area in Subjects With Upper Extremity Dysmelia Revealed by Magnetoencephalography

The effect of peripheral lesions on cerebral somatosensory representations is well studied for experimentally induced amputations and deafferentations acquired later in life. However, few studies have investigated the brain's capacity for plastic changes in congenital malformations. We studied somatosensory-evoked fields to electrical stimulation of the bordering fingers in 10 subjects with upper extremity dysmelia in comparison with 10 control subjects using a 122-channel whole-head magnetometer. The number of developed fingers varied between two and four in the affected subjects. We localized finger representations in the primary somatosensory cortex and calculated Euclidian distances to estimate the size of the somatosensory hand area. Euclidian distances were significantly smaller in dysmelic subjects (5.7 mm) than in control subjects (11.6 mm) and were related to the number of the developed fingers on the contralateral hand. In contrast, individual finger representations were not found to be reduced. We suggest that the shrinkage of the somatosensory hand area might be related to the congenital nature of the malformation, to the smaller anatomical hand size in the affected subjects, and/or to use-dependent effects due to impaired hand function.

Use-dependent cortical plasticity in thalidomide-induced upper extremity dysplasia: evidence from somaesthesia and neuroimaging

In this study cerebral reorganization was investigated in thalidomide-damaged subjects who use their feet to compensate for their malformed upper extremities. Tactile localization across toes was combined with fMRI to study use-dependent plasticity of the human somatosensory cortex. The manner of compensatory foot use was assessed by a questionnaire. In the behavioural experiment toes were stimulated with above threshold monofilaments and subjects had to report which toe was stimulated. When feet were employed for all everyday actions subjects made significantly fewer errors in the localization task. In subjects who use their feet only for specific actions such as grasping objects there were as many localization errors as in the control group of thalidomide-affected subjects with normal extremities. However, the patterns of mislocalizations were different with less errors occurring for the toe of the dominant foot involved in these actions. Functional MRI showed stronger haemodynamic responses to electrical stimulation of the toes in subjects using their feet for everyday actions as compared to controls. Our data show that long-term use of the feet for fine sensorimotor skills leads to better performance in tactile localization and changes in cerebral SI representation supporting the notion of use-dependent plasticity in the somatosensory cortex.

Cortical remapping in amputees and dysmelic patients: a functional MRI study

OBJECTIVES

To investigate motor cortex function in upper and lower limb amputees and dysmelic patients using fMRI.

MATERIAL AND METHODS

Five amputees and two dysmelic patients were examined. Motor and imagery tasks were defined according to each patient limb deficiency. Cortical activation patterns were analysed for each patient and compared between groups, integrating patients clinical data.

RESULTS

There is a consistent pattern of cortical reorganization in all amputees: predominance of activation in the ipsilateral motor cortex and extension to premotor and sensory areas of the contralateral cortex. On the contrary, cortical maps of dysmelic patients were similar to those of healthy volunteers, predominantly with activation of contralateral primary motor cortex areas.

CONCLUSIONS

fMRI discloses specific patterns of cortical reorganization on amputees and dysmelic patients, suggesting influence by prosthesis adaptation or stump use with dexterity. These findings could be further applied in influencing neurorehabilitation and development of prosthetic devices.