Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

742
Section III  Prostheses in Rehabilitation
Gluteus maximus strength is critical during initial load­
ing to generate the hip extension force in early stance that
lifts the center of gravity from lowest to highest point and
converts stance limb torque from internal to external rota­
tion. Extensor strength is the strongest predictor of pros­
thetic walking speed.33 In the absence of quadriceps and
with the inevitable atrophy of the hamstrings,34 hip exten­
sion and abduction display the greatest strength loss after
amputation.35 Atrophy of gluteal fast twitch fibers explains
the slower gluteal contraction latency periods observed in
amputated limbs.36 Greater demand and slower contractions
on the weakened amputated side hip extensors decrease the
user's ability to quickly raise the center of gravity from the
lowest point in dual limb stance to the highest point by mid­
stance,33 particularly if long prosthetic steps are emphasized
early in the rehabilitation process when gluteal strength is
weakest. As a result, prosthetic stance time is significantly
briefer than on the sound side, leading to shorter sound
limb swing phase duration and step lengths.37,38
Hip abductor weakness reduces the ability to maintain
the body in prosthetic limb stance. This leads to a similar
scenario in the frontal plane that also contributes to shorter
sound limb steps.39 Insufficient gluteus medius strength also
diminishes the confidence to maintain single limb stance
long enough to complete the normal lateral weight shift.
The prosthesis user compensates by placing the sound foot
farther from the midline, widening the base of support. The
wide base shortens the gluteus medius length–tension rela­
tionship, further impairing hip abduction strength while
simultaneously requiring a larger lateral weight shift. Hip
abductor weakness also plays a role in step-length asymme­
try, with weakness correlating with slower gait, shorter steps
on both sides, and decreased weight bearing on the pros­
thesis.39 Those with shorter amputation limbs have more
abductor weakness, demonstrated in midstance by faster
and/or greater pelvic drop.40,41 In both situations, longer
and/or wider steps disadvantage the gluteal muscles and can
undermine balance confidence.
In terminal stance, decreased prosthetic side hip extension
restricts the body's advance over the prosthetic foot causing the
sound limb to take a shorter step forward. Lack of sufficient hip
extension because of hip flexor contracture occurs in able-bod­
ied people but is more prevalent among people with lower-limb
amputation. Prolonged sitting during the rehabilitation process
that can continue at home because of decreased activity is com­
mon after amputation.24 The standard flexed bench alignment
of the transfemoral socket can accommodate mild hip flexion
contractures but reduces hip extension excursion.38
In the presence of limited hip extension range of motion,
users attempt to advance the body over the prosthesis by exag­
gerating anterior pelvic tilt40,41 with accentuated lumbar paraspi­
nal muscle use, leading to greater lumbar extension compared
to able-bodied people.42 Such compensation may lead to lower
back strains; people with both amputation and low back pain
had weaker back extensors.43 Increased demand for hip and
lumbar extension strength and range of motion might be met
with extra training to guard against low back pain. Abdominal
and hip strength is also critical to protect end-range lumbar
extension as well as to assist atrophied hip flexors.44
In normal gait, stance phase hip extension occurs
with rotation around the stance hip.29 Although often
observed as contralateral forward pelvic rotation, the
rotation occurs primarily at the hip. After amputation,
hip extension and contralateral forward rotation around
the prosthesis are greatly reduced compared to the sound
limb,40 because transection through the femur minimizes
transverse plane bony leverage. As a result, translation
of rotary forces from the limb to the socket is greatly
reduced because the femur rotates within the soft tissues
of the thigh. Any looseness in socket fit reduces the trans­
lated forces even more. In fact, unlike sound side or able-
bodied individuals, prosthetic stance phase is marked by
internal, rather than external, torque,41 which decreases
trunk counterrotation and arm swing (Figure 27-8). Less
trunk rotation is needed to counterbalance pelvic rota­
tion when the individual wears a prosthesis. Nevertheless,
when pelvic rotation is decreased, trunk rotation for pros­
thesis users is also diminished by limited joint mobility,
weaker abdominal strength, incoordination between pel­
vis and trunk, and habit.
FIGURE 27-8  Excessive internal rotation and lack of hip extension
in gait. (Courtesy Otto Bock Health Care, )

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
743
Lessened trunk rotation decreases the alternating for­
ward momentum that normally drives arm swing, leading to
decreased shoulder movement. The ipsilateral upper limb may
be unconsciously held posterior to the hip axis to maintain
a hip extension moment for enhanced stability (Figure 27-9).
For more experienced and usually healthier users who have
more confidence in the prosthesis and have striven to walk faster,
prosthetic steps may be shorter than those of the sound limb.18,45
Multiple years of hip flexor stretching increases hip extension
range.43 However, the iliopsoas often atrophies and weakens,44
providing insufficient power to protect the hip and lumbar
spine and to enable uniform step lengths. Increased lumbar
rotation that compensates for limited hip rotation after amputa­
tion may exacerbate low back pain.42 Regardless of which step is
shorter, coordination of trunk and pelvis is important to stabi­
lize the lumbar spine dynamically and produce sufficient trunk
and pelvic rotation to achieve symmetrical step length.
Prosthetic Solutions
The enhanced stance-phase stability of an MPK obviates the
need to use the arm to maintain a hip extension moment
throughout stance and allows the user to spend more
time on prosthetic single-limb stance, thus equalizing step
lengths and restoring the normal external rotation torque
in stance phase. A torque adaptor in the shank can augment
the limited contralateral forward pelvic rotation around the
prosthesis to position the foot in normal toe out at initial
loading. Regardless of the type of knee unit, significant hip
abductor strength is required for single-limb stance on the
prosthesis without contralateral pelvic drop or ipsilateral
trunk lean.
Training Solutions
Developing symmetry in prosthetic gait requires a compre­
hensive approach that reduces underlying joint and muscu­
lar impairments to optimize functional outcomes.46 For the
experienced wearer, the habit of keeping the arm behind the
hip is likely to be ingrained. Focused training is required
to restore normal trunk counterrotation and arm swing. To
enable the user to walk with as much symmetry as possible,
the person should have normal range of motion throughout
the lower limb, particularly the hip. Anterior hip capsular
tightness
limiting
hip
extension
range
is
com­
mon, being a result of prolonged sitting. Anteriorly
directed hip mobilization can help restore hip exten­
sion and rotation range (Figure  27-10).47 Additional
mobilization of the sacroiliac and lumbar joints may
also be beneficial. Soft-tissue mobilization or trigger-
point therapy for the iliopsoas followed by stretch­
ing48 can help maintain hip flexor flexibility49 and can be
performed in the prone position or with the patient lying
prone with the sound foot on the floor to help maintain or
increase hip range (Figure 27-11). Hip mobilization may
also result in gluteal strengthening.50,51
Once joint motion is optimized, gluteal strengthen must
be increased. These muscles minimize lumbar extension and
frontal plane gait compensations that typically result from
hip weakness. In addition to residual limb hip abduction
exercise performed side lying against a bolster,52 the person
can wear the prosthesis to perform closed chain exercises.
Forward step-ups are a challenge; however, lateral step-ups
on a low platform activate the gluteus medius.53 To progress
FIGURE 27-9  Reduced prosthetic side arm swing provides a hip
extension moment but causes gait asymmetry.
FIGURE 27-10  Anterior hip joint capsule mobilization.

744
Section III  Prostheses in Rehabilitation
a user's efforts, increase the step height gradually. Activities
involving prolonged stance on the prosthesis also develop
prosthetic side hip strength, especially hip abductors, for
example, standing on the prosthesis while pushing in the
opposite direction against a wall (Figure 27-12). More dynamic
activities include standing on the prosthesis while using
the sound limb to roll a ball on the floor, kicking against
Theraband,54 reaching in different directions around a circle
like the star excursion balance test,55 or maintaining the sound
limb on a stool or unstable surface while throwing a ball
(Figure 27-13). Using one hand to lightly maintain balance
is important for safety; however, if both hands are required,
the activity is probably too difficult and should be modified.
In addition to unilateral trunk bridging that focuses on glu­
teus maximus strengthening and control, hip extensor strength
can be developed wearing the prosthesis while standing or sim­
ulating gait positions. One method to activate the gluteus max­
imus is to stand with hands in front pushing forward against
a wall or kitchen counter, while leaning forward far enough
to lift the prosthetic heel off the floor. As the trunk shifts for­
ward over the forefoot, a hip flexion moment is created that
must be maintained with hip extensors to keep the heel high
(Figure 27-14). Promoting forefoot loading facilitates gluteus
maximus activation and trains the user to activate MPK func­
tions. Developing sufficient prosthetic side hip power to take
long sound limb steps can be performed by standing with the
prosthetic foot ahead of the intact foot facing a low stool. The
wearer steps forward with the sound limb progressing to higher
steps. This activity exaggerates the demands on the gluteus
maximus during initial loading and can be used to develop the
power needed for more challenging activities (Figure 27-15).
Strengthening the gluteus maximus, the primary exter­
nal rotator of the hip, is also vital in transforming the leg
torque from internal to external rotation after initial load­
ing. Activities described above such as the sound limb star
balance excursion test or exaggerated step lengths to ever
higher steps increase gluteal strength and develop pelvic rota­
tion around the prosthetic stance limb. Exercises that empha­
FIGURE 27-11  Hip flexor stretch.
A
B
FIGURE 27-12  Isometric hip abduction (A) and isometric hip external rotation (B) against a wall.

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
745
size hip rotator strength include pressing the contralateral
arm or leg back against a wall to promote isometric contra­
lateral trunk rotation (see Figure 27-12, B). Active rotation
around the prosthesis can be performed by turning the pel­
vis to point the sound foot as far around as possible in each
direction and then maintaining the position, using the hands
of a clock as a visual cue (Figure 27-16). Rotational activities
can be ­progressed by pivoting on both heels to turn the toes
in and out. Even more challenging is weight bearing through
the forefeet while turning first one then both heels medi­
ally and laterally (Figure 27-17). Pivoting with weight on the
toes develops hip strength and assists functional use of the
MPK during turns and sidesteps. For effective neuromuscular
reeducation and activation of the hip rotators, the therapist
may use cueing or apply resistance through the sound limb
(Figure 27-18). Pelvic rotation contributes to the overall goal
of uniform step length with faster gait speeds although spe­
cific pelvic motions may become less symmetrical.40
More advanced gluteal strengthening activities can inte­
grate trunk and upper-extremity function through exaggerated
elements of gait. One method is to face a wall, then press only
the ipsilateral hand against the wall while simultaneously lift­
ing the prosthetic heel off the floor and flexing the sound hip as
high as possible (see Figure 27-14). Avoid lumbar hyperexten­
sion to protect the back. Maintaining this position with spinal
stability activates the abdominal muscles and helps ­promote
contralateral pelvic rotation around the prosthesis with upper
trunk counterrotation and arm swing often impaired in gait.
FIGURE  27-13  Step standing with sound limb on an unstable
surface.
FIGURE 27-14  Pushing forward against wall while rising onto the
forefoot for hip extension and external rotation.
FIGURE 27-15  Sound limb to high step.

746
Section III  Prostheses in Rehabilitation
Spinal stabilization exercises increase prosthetic step length
and gait speed.45 Strengthening the hip flexors of both limbs
also helps protect the hip and spine as they extend in termi­
nal stance phase. Hip flexion generates power through swing
phase. Hip strengthening and functional proficiency are
important for both legs because sound limb hip rotation adds
impetus to prosthetic swing phase, trunk counterrotation, and
arm swing.
In addition to pelvic and trunk rotation training, addi­
tional practice may be necessary to make arm swing natural.
For example, facilitating arm swing through the shoulders or
with canes held in each hand by both user and therapist while
walking in synchronicity can help. Pelvic and trunk rota­
tion in gait can be progressed using resisted gait techniques.
With user and therapist facing each other, the therapist pro­
vides manual resistance to the user's pelvis or hands so that
while the user walks forwards they must push the thera­
pist back to integrate trunk counterrotation and arm swing
(Figure 27-19).
Functional activities to develop transverse plane rota­
tion and gait symmetry that can eventually be used for inde­
pendent practice by highly functioning individuals include
tandem balancing (Figure 27-20) and walking or grapevine
walking to encourage rotation around each hip as well as
A
B
FIGURE 27-16  Stepping and holding in hip rotation: internal (A) and external (B).
A
B
FIGURE 27-17  Pivoting in and out on both heels (A) and toes (B).

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
747
decrease the base of support. Floor markers placed evenly
apart can serve as visual cues for uniform step lengths while
a full-length mirror at the end of a walkway allows the pros­
thesis user to check the symmetry of arm movements and
general symmetry. A metronome provides an audible cue
to rectify asymmetric stance times. A treadmill can be used
to train progressive and consistent gait speed on level and
inclined surfaces. As the patient builds strength, confidence,
and awareness of muscle function and the limit of stabil­
ity, the ability to take normal length steps during functional
activities improves.
Other stance phase deviations discussed elsewhere in
this text, such as wide base of support and lateral trunk
lean or Trendelenburg, are unlikely to be affected spe­
cifically by MPK use, but may benefit from the proposed
training solutions. Regardless of prosthetic components,
training is required to minimize gait deviations and maxi­
mize function.
Swing Phase
Gait asymmetry can be affected by the difficulty transition­
ing from stance to swing phase. For able-bodied individuals,
ankle plantarflexion prior to swing phase raises the body, pro­
viding much of the propulsive power.29 Hip flexors contract
to decelerate end range hip extension, then initiate swing
phase with the adductors. The flexing hip and the forward
FIGURE 27-18  Resisted hip external rotation by therapist through
the sound knee.
FIGURE 27-19  Resisted gait with cane.
FIGURE 27-20  Tandem stance in a doorway.

748
Section III  Prostheses in Rehabilitation
­propulsion of the body create momentum that first passively
flexes the knee from heel off to early swing then extends the
knee through terminal swing when hip flexion is reversed by
the hip extensors. When momentum is reduced, as in slow
gait, the hamstring muscles flex the knee to assure toe clear­
ance augmenting foot dorsiflexion.
Amputation eliminates active ankle plantarflexion. Work
shifts to the iliopsoas muscle increasing power derived from
the hip flexor group by more than 50%.31 Without active knee
flexion, the hip flexors must contract even stronger to sup­
ply sufficient momentum to advance the limb through swing
phase. Unfortunately, the ipsilateral iliopsoas atrophies.44
Developing hip flexor strength can be difficult, especially
with shorter amputation limbs. The new user can have diffi­
culty advancing the limb, leading some to exaggerate hip flex­
ion by kicking the leg laterally to initiate swing. Exaggerated
kicking can lead to swing phase deviations like steppage
(exaggerated hip and knee flexion) that can linger long after
sufficient strength is restored.
Non-MPK hydraulic knee users must also switch their
knees from stance phase control knee flexion resistance to
swing phase resistance. This is generally accomplished in
knees such as the Mauch at the end of stance phase when the
wearer applies a knee hyperextension force with strong hip
extension contraction or at the end of swing phase by achiev­
ing full knee extension for at least 0.1 second.11 Although
unnatural at first, prosthesis users learn to perform the knee
extension motion without much thought.56 However, swing
phase is delayed and stance times asymmetric.37 When
momentum is not directed forward, such as when turning or
sidestepping, transition between stance and swing phase knee
resistance can be ineffective resulting in occasional circum­
duction, hip hiking, or vaulting if adequate swing resistance
is not activated. Knee collapse and falling may occur if stance
resistance is not activated.
Prosthetic Solutions
For the MPK user, transition between resistance phases is ini­
tiated intrinsically in response to electronic sensors. In the
C-Leg, the user must achieve knee extension for 0.1 second
with 70% body weight forefoot loading to disengage stance
control and allow swing-phase knee flexion. The amount of
body weight required can be adjusted depending on the user's
needs. Default settings of the specific MPK determine what
happens if the criteria are not met. For instance, the C-Leg
defaults to stance-phase control to protect the wearer from
knee collapse, a significantly improved safety feature com­
pared to non-MPK prostheses. Other MPK units, like the
Rheo Knee, default to swing-phase control to avoid toe drag
in swing phase.
Training Solutions
To insure that the user is comfortable bearing weight through
the prosthetic forefoot, activities involving forefoot loading
are critical. Pivoting can be practiced with weight on both
forefeet to allow rapid swing phase action during turns (see
Figure 27-17, B). Lateral weight shifts onto the toes with one
or two quick bounces can help prepare for side-stepping.
Forefoot bouncing can also be useful, as some MPKs, like
the Power Knee, use forefoot bounces as mechanical cues to
change knee resistance modes. Pushing off the forefoot to
kick into swing phase can assist forward walking or the quick
transition into swing phase necessary for a brief jog.
For those with decreased pelvic and trunk motion, abdom­
inal muscles may be recruited to assist swing phase, particu­
larly for people with amputation limbs shorter than 57% of
the sound length where hip flexors are weaker. Shorter limb
length correlates with increased pelvic tilting during gait
even after traumatic amputation.57 Core abdominal mobil­
ity exercises are even more important after hip disarticula­
tion or higher amputations that deprive the user of all active
hip motion.
Stairs and Ramps
Descents
Stairs and ramps remain difficult even for experienced users.
Descents and ascents pose different problems. As in walking,
limited prosthetic knee flexion is a particular problem when
descending stairs and declines. Limited shock attenuation
is particularly evident upon landing on the prosthetic limb
when descending stairs, curbs, or declines. Because the wearer
descends stairs onto the heel, not the forefoot as able-bodied
individuals do, more shock is transmitted to the extremity;
the user commonly feels a jolt upon landing. Although the
prosthetic limb is subjected to less vertical force than a nor­
mal limb upon landing, this force is more poorly attenuated
without the normal knee flexion and ankle dorsiflexion upon
loading. The hip on the prosthetic side must exert double
the extension force to control the knee. On the sound limb,
the relative lack of prosthetic knee flexion results in approxi­
mately 50% greater vertical impact forces as the body lowers
from a greater height.58,59 In fact, all sound limb joints experi­
ence increased stress in gait, exposing the sound side to more
risk of injury.30 As a result, most people with transfemoral or
higher amputations instinctively take smaller steps of shorter
duration to decrease ground reaction forces and muscle
demand on ramps whether descending or ascending.60 The
new wearer usually takes short prosthetic steps to prevent
accidental collapse and compensates with longer sound limb
steps to maintain speed, making gait asymmetrical.
Non-MPK hydraulic stance-control knees provide graded
resistance to knee motion beyond 20 degrees flexion, giving
time for the sound limb to alight onto the next lower step in
a step-after-step pattern, but most users still have noticeably
decreased prosthetic stance time when descending stairs.59
Descending ramps is more difficult than stairs because to
place the prosthetic foot flat on the ground without the nor­
mal ankle plantarflexion range, the prosthetic shank must
be thrust forward downhill creating a rapid, sizeable knee
flexion moment (Figure 27-21). Knee flexion resistance in a
non-MPK hydraulic stance control unit can be adequate on
shallow ramps, but knee flexion resistance is not always suf­
ficient on steeper ramps. Prosthetic users often hesitate when
descending ramps.

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
749
Prosthetic Solutions
As in level walking, MPK sensors provide data used to adjust
the real-time resistance needed for descent. For the typi­
cal MPK, full knee extension at terminal swing combined
with prosthetic heel weight bearing triggers knee flexion
resistance to match the individual's body weight, angle of
descent, and gait speed through a greater range of motion
(30 to 35 degrees) than provided by non-MPK units.22 Slow,
interrupted, or unsteady stair descent may cause insufficient
momentum to create full knee extension, thereby leaving
MPKs with swing-phase resistance default settings unready
to provide stance-phase stability; this deficiency can lead to
knee collapse. Collapse is less of a problem for the C-Leg,
which defaults to stance-phase knee resistance, even in knee
flexion ranges of 36 to 55 degrees.58 Prosthesis users func­
tioning at the Medicare K2 or K3 levels (see Table 27-2) per­
formed better on stairs and declines with MPK compared
to non-MPK hydraulic knees.61 After the MPK software
is adjusted and the user develops confidence and balance
through training, the wearer can descend steep declines with
significantly longer prosthetic steps that promote less asym­
metry and faster speeds.22
Training Solutions
To descend stairs, the MPK user must learn to place only the
rearfoot on the lower step and load substantial body weight
through the heel (see Figure 27-2). This foot placement triggers
the graded knee flexion resistance needed while leaving the toes
to angle down and progress to the next step as the knee bends.
To step down stairs onto the heel in this manner can be anxiety
producing for the new MPK user and should be practiced ini­
tially on the bottom step using a banister with guarding.
The prosthesis user can mitigate some of the impact shock
to the residual limb by reaching the entire leg down toward
the next step so the foot meets the lower stair with less impact.
Pelvic anterior depression62 enables positioning the foot for­
ward and down. This motion, derived from proprioceptive
neuromuscular facilitation, can be practiced on level ground
or by standing on a low platform to reach the heel forward
and down with a pelvic motion before returning to the start­
ing position.
Taking long prosthetic steps when descending a ramp
is unnatural to the person who has habitually used a non-
MPK prosthesis. This habit may be overcome. Training the
MPK user to (a) utilize pelvic anterior depression in terminal
swing, (b) activate the hip extensors to advance the body for­
ward during initial loading, (c) rotate the contralateral pelvis
around the stance hip in midstance, and (d) maintain weight
bearing through the prosthetic forefoot in terminal stance
facilitate a longer step on descent. A banister provides safety
during the training process until the new wearer develops
confidence to progress to resisted training and finally unas­
sisted declines.
Ascents
Most people with transfemoral amputation ascend stairs
in step-to fashion. A similar gait pattern is used for steep
inclines. When ascending, the wearer typically flexes the
sound limb more to make up for the lack of prosthetic side
elevation normally provided by ankle plantar flexion.60 In the
community, some people ascend stairs two steps at a time
with the sound limb to maintain the same speed as compan­
ions. Greater knee flexion, however, increases forces on all
sound limb joints when climbing stairs.59 In the stance phase
of ramp ascent, the prosthetic shank is thrust backward mak­
ing it difficult to advance the body forward and causing a
short step on the intact side.
Prosthetic Solutions
When ascending ramps, forefoot weight-bearing causes the
shank to be thrust backward exerting a strong knee exten­
sion moment. On stairs an MPK can sense increased knee
extension force and trigger the stair ascent mode that gives
less swing-phase resistance to knee flexion to help the foot
clear the edge of the next step. Software can be adjusted to
the user's needs. Once the foot is on the next step, however,
the user must exert considerable hip extensor power to lift
the body onto the next step, which is typically accomplished
with the assistance of a hand on a banister. In the absence
of a banister, step-over-step stair ascent is very difficult for
most users.
The Power Knee provides powered assistance to ascent.
The user must stop at the bottom stair for 3 seconds to
default to the standing state before ascending. Initiating knee
extension activates the assisted knee extension ­function.
FIGURE  27-21  Descending slopes creates large knee flexion
moments that can be controlled with the C-Leg. (Courtesy Otto
Bock Health Care, )

750
Section III  Prostheses in Rehabilitation
Data sent wirelessly from sensors strapped to the sound leg
help match prosthetic movement to the sound limb. At the
top of the stairs, the user must pause again for 3 seconds
to reset the MPK before walking. The powered mechanism
makes sounds noticeable to passersby; the noise bothers
some users.
The Genium uses a gyroscope and accelerometers to
recognize that the user is ascending a step. A quick hip
extension movement to drag the foot off the ground fol­
lowed by quick hip flexion lifts the foot to the next step
with prosthetic hip and knee flexion. Once the foot is on
the next higher step, the Genium provides maximal resis­
tance to further knee flexion upon bent-knee weight bear­
ing. Placement of the heel slightly off the step augments the
knee extension moment powered by hip extensors contrac­
tion and the body's forward momentum.
Training Solutions
Because of hip flexor weakness, the prosthesis user may
have to elevate or tilt the pelvis posteriorly using the
abdominals to gain sufficient elevation and to compen­
sate for limited prosthetic ankle dorsiflexion on stairs and
inclines. If the user stops on a step, restarting swing phase
up the stairs is difficult. Turning 45 degrees allows space for
foot to clear after a stop on the stairs without excessive hip
hiking. Ascending step-over-step requires great hip exten­
sor strength and usually the assistance of a banister. New
MPK designs, including the Power Knee and Genium, meet
this challenge. With these units, placing only the forefoot
on the next step with the heel off the step can help extend
the knee. The Power Knee only requires the user to initi­
ate knee extension with the hip extensors. Step-over-step
ascent with the Genium requires significant hip extensor
strength and is recommended only for active users at the
K3 and K4 levels (see Table 27-2).
Sitting and Squatting
Although navigating stairs can be difficult for people using
prosthetic knees, any knee bending and straightening activi­
ties like rising from a chair or squatting demands compen­
satory movements, which imposes added stress to the sound
limb. Many prosthetic knees require unloading the prosthe­
sis to allow the knee unit to bend so that the user can sit at a
speed similar to able-bodied individuals. As a result, many
prosthesis wearers stand with 10% to 30% more body weight
on the sound limb than on the prosthesis.39,63 Squatting with
both legs can be useful. For instance, the prosthesis user
may want to squat to reach down to a child (Figure 27-22)
or pick up something from the floor without bending from
the waist to avoid low back pain, which occurs in more
than 80% of people using transfemoral prostheses.44 After
30 degrees knee unit flexion, most MPKs provide insuffi­
cient flexion resistance to prevent collapse.58 Thus, for many
users, sit–stand transitions, especially squatting, become
single-limb activities that place substantial stress on the
sound limb. Potential solutions for sit-to-stand transitions
and squatting follow.
Prosthetic Solutions
When the wearer begins to sit down, MPKs like the C-Leg
and Rheo Knee provide controlled resistance to knee flexion
activated by prosthetic weight bearing. MPKs allow symmet­
rical distribution of weight between the feet to reduce stress
on the sound limb; resistance settings can be adjusted to the
needs of the user. Whether using non-MPK or MPK prosthe­
ses, wearers continue to bear weight asymmetrically and sit
slower than able-bodied individuals.63 To sit rapidly without
adjusting the resistance, MPKs that have swing-phase default
settings can be offloaded; this shifts stress to the sound limb
as with non-MPKs.30 Although MPKs allow symmetrical
weight bearing during stand-to-sit transitions, the user must
be trained to bear more weight on the prosthesis by sitting
down against the inner posterior socket wall with a hip exten­
sion force to offload the sound limb.
Most MPKs do not assist sit-to-stand activity; the user
depends greatly on sound limb strength to rise. The Power
Knee, however, assists user-initiated knee extension. A push
up from the chair armrests activates the assisted sit-to-stand
function. As compared with those wearing unpowered knee
units, prosthesis users rising with the Power Knee move with
greater symmetry with hip force closer to that exhibited by
able-bodied individuals.63 To sit using a Power Knee, the user
must pause to activate the default standing mode, then slowly
lower the body to the chair. If the sitting motion is stopped
midway, the Power Knee will support the user in a squat until
the prosthesis is unweighted. Transferring the weight to the
sound limb allows further knee unit bending.
Some MPKs provide special function modes that allow
squatting or prolonged standing. The C-Leg, for instance,
permits prosthetic weight bearing with the knee unit
flexed to any angle between 7 and 70 degrees, allowing
maximal support for squatting or bent-knee standing.
FIGURE 27-22  Maintaining a fixed degree of knee flexion with the
stand feature of the Compact C-Leg. (Courtesy Otto Bock Health
Care, )

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
751
The Compact knee, designed for K2-level users, offers the
same function in a 0- to 30-degree range. This mode is
activated by handheld wireless remote control unit, with
predetermined physical cues such as bouncing quickly
on the forefoot, but also more intuitively by lowering
the body to the desired degree of knee flexion and then
slightly straightening the prosthetic knee to turn on the
maximal knee flexion resistance needed to squat.17 The
Power Knee facilitates squatting by locking when the user
stops the stand-to-sit motion at the desired degree of knee
flexion.11
Training Solutions
When sitting, placing the MPK user's hands on the arm rests
enhances safety and decreases the chance that the user will fall
backward. Using arm rests, however, shifts the body weight
backward onto the heels rather than forward onto the fore­
feet, as in able-bodied sit-to-stand transitions. For those who
demonstrate the potential to stand unassisted, transferring
weight forward over the forefeet can be practiced from sur­
faces of decreasing height as the person improves. The user's
hands can be positioned anteriorly or on the thighs while aris­
ing. Placing both feet behind the knees helps advance weight
over the forefeet, but can be difficult because of limited pros­
thetic ankle dorsiflexion. The Proprio Foot user can dorsi­
flex the prosthetic ankle by tapping the heel or signaling with
the wireless remote to position the foot for sit-to-stand tran­
sitions. Keeping the spine straight minimizes patellar com­
pressive forces and back pain. Practicing at different speeds
on different seat heights and while holding objects of dif­
ferent weights can prepare the user for a range of functional
activities.
To develop the strength and control to master the squat­
ting feature of the C-Leg or Power Knee, the user should
practice single-limb squats with the sound limb. If unable,
the wearer can start by performing a wall squat with a chair
at hand for support. Methods to stimulate greater contribu­
tion of hip extensors on the amputated side will help in con­
trolling the descent to the desired knee flexion angle. Squats
on an unstable surface, such as a cushion or tilt board, per­
formed between parallel bars and with appropriate guard­
ing for safety, can be effective. Step-ups with the prosthesis
leading also help enable knee unit extension through forceful
hip extensor contractions. Gluteal strengthening exercises are
essential.
Fall Protection
People with leg amputation have a greater risk of falling
than do able-bodied individuals, with reported incidences
of 20% to 32% during rehabilitation64,65 and 52% within the
community.66 Falls occur when the wearer unexpectedly
bears weight on the flexed prosthetic knee, as can happen
when a user slips, stubs a toe, or steps on a rock unbal­
ancing the prosthetic foot and causing the knee unit to
bend. Stepping onto a flexed knee can also occur when the
user turns, takes small sidesteps, or stops suddenly pre­
venting the knee unit from fully extending and activating
stance-phase control. When using a hydraulic non-MPK,
tripping or stepping on an object leads to swing-phase
knee-­flexion resistance and increases the risk of falls.67
Slips may occur upon heel strike onto slick surfaces such
as ice. A slip causes very high demand for gluteal mus­
cle strength that must respond rapidly to the anterome­
dial shear upon landing.68 The muscles of prosthetic users,
including postural muscles like the erector spinae and
oblique abdominal muscles, do not consistently contract
when walking and respond to slips and trips slower than
the muscles of sound limbs or able-bodied people.68 The
wearer may adapt to the risk of unexpected knee insta­
bility by taking shorter prosthetic steps, which results in
slow, asymmetrical gait.
Prosthetic Solutions
Whether a stumble or fall will result from an unexpected
step onto a flexed knee depends greatly on the MPK default
setting. MPKs with swing phase knee resistance default set­
tings require great compensatory movements; otherwise, falls
occur even in younger people whose amputation etiologies
were nondysvascular.58 Knee collapse can also occur when
knee unit flexion exceeds the 30- to 35-degree range pro­
grammed for stance-phase resistance capacity.58 The Power
Knee and C-Leg default to stance-phase knee resistance and
will prevent collapse even after swing phase is interrupted.67 In
everyday situations, stance-phase default C-Leg users report
significantly fewer stumbles and falls69 and a safer experience
compared to non-MPK.70
Training Solutions
Because stumbling is unexpected, it is difficult to prepare
the new user. However, most slips result from the foot slid­
ing upon initial contact rather than in terminal stance.
Thus, the ­gluteal muscles are the most important group
to strengthen and the hip flexors are a secondary con­
cern. Consistent contraction of the core muscles through­
out gait, not typically present in prosthesis users, should
be developed and strengthened to allow stronger and faster
response to postural disturbances.68 Methods for strength­
ening gluteal muscles and integrating abdominal contrac­
tions in gait have been presented in training solutions for
asymmetric steps.
Practice in functional activities encountered in real life
also prepares users to respond to stumbles and falls. Obstacle
courses should include different walking surfaces and step­
ping up, over, and onto obstacles. Carrying items and per­
forming dual tasks can develop overall functional ability. With
training, MPK users can negotiate obstacle courses quickly
with fewer steps compared to those wearing non-MPK pros­
theses.71 Practice on outdoor terrain can enable the wearer to
participate fully in daily activities.
Other Activities
The user may wish to participate in activities that require
free-swinging knee function like biking, or locked knee func­
tion like prolonged standing.

752
Section III  Prostheses in Rehabilitation
Prosthetic Solutions
Non-MPK hydraulic or pneumatic knees sometimes have a
manual switch at the back of the knee that will switch the knee
to different modes of function.11 MPKs offer various modes of
function, but eliminate the need to operate a switch manually.
A physical cue like pushing down on the toes three times fol­
lowed by unweighting the leg for 1 second switches the mode
of operation from walking to free swinging for biking or max­
imal knee resistance for prolonged standing.17 Regardless of
whether wireless remote or leg movements are used to switch
functional modes, an electronic signal, either a series of beeps
or vibrations, confirms the change in setting to the user. The
Proprio Foot uses heel tapping to trigger the ankle to drop
into plantarflexion when the wearer sits and return to dor­
siflexion before the person stands. The user can also activate
these functions by a handheld wireless remote.11
Training Solutions
Remembering how to switch modes, performing the physical
cue, and hearing or feeling the confirming electronic signals
varies among users. As with gait training, forefoot weight-
bearing practice is a fundamental skill to develop. Heel tap­
ping to signal the Proprio Foot requires hip flexor strength
and coordination to move the prosthesis up and down.
Having the user practice initiating the cues and perceiving
the signals is important to the smooth, effective use of these
MPK features.
Although clinicians may focus on gait deviations that
persist despite dedicated training for even the most expe­
rienced and high-level users, wearers themselves tend to
focus more on their functional abilities. Even active pros­
thesis users typically take part in bouts of activity lasting
less than 2 minutes and averaging only 17 steps per min­
ute. Most wearers only engage in activity lasting more than
15 continuous minutes only once per day.72 Functional abil­
ity and attitude towards the prosthesis are the strongest pre­
dictors of patient satisfaction.73 Prosthetic outcomes can be
maximized through a clinical approach that addresses range
of motion and strength impairments while integrating func­
tional abilities to optimize participation in the pleasures and
challenges of real life.
OUTCOMES
Success of prosthetic fitting can be measured by objective fac­
tors, principally energy consumption, walking velocity, and
step symmetry, as well as subjective responses such as falls
history and quality-of-life questionnaires. Overall, prosthesis
users perform somewhat better and report greater satisfaction
when wearing MPK prostheses, than with less-­sophisticated
components. A few investigators compared function of peo­
ple wearing prostheses with various units. Even in the pres­
ence of laboratory evidence regarding the biomechanical
characteristics of MPK units, clinicians’ and wearers’ subjec­
tive reactions remain the mainstay of formulating prosthetic
prescription and thus determining prosthetic rehabilitation
outcomes.73,74
Physical characteristics appear to outweigh the importance
of a particular prosthetic component in determining the indi­
vidual's performance. Review of combat-associated amputa­
tions reveals that function and amputation limb length are
directly correlated, while energy consumption and length
are inversely related.75 Preserving the knee joint is critical
because energy consumption of men with unilateral trans­
femoral amputation exceeded that of subjects with transtibial
amputation during slow and fast level walking and traversing
slopes of two different inclines.76 People with mid length or
longer thighs, however, showed that no significant kinematic
or kinetic gait differences.57
Gait Studies
Laboratory comparisons of performance with prostheses
equipped with the C-Leg and the Mauch Swing and Stance
hydraulic knee units generally indicate that subjects walked
faster with the C-Leg by as much as 21%, depending on ter­
rain.18,69 Faster self-selected walking speed with a C-Leg did
not necessarily come at higher energy costs.77 One research
team, however, reported no significant differences in free
walking speed.56 Faster gait speeds obtained with people
after transfemoral amputation using the C-Leg compared to
non-MPK prostheses have also been documented in a case
report of one person with bilateral knee disarticulations.78
Laboratory comparison of subjects wearing the Endolite
Intelligent Prosthesis and non-MPK units reveal similar
results as those involving C-Leg.79
A goal of prosthetic fitting is to enable the patient to walk
as inconspicuously as possible. People wearing the C-Leg
exhibited less step-length asymmetry than when using a
hydraulic non-MPK unit.18,40,45 Kinematic analysis of sub­
jects walking with MPK units showed less delay between
late swing-phase knee extension and heel contact than with
other units.37
Optimum rehabilitation restores the individual's ability
to walk greater distances without appreciable fatigue. In
one study, subjects who wore prostheses with step coun­
ters and distance monitors took similar numbers of steps
and walked for equivalent durations in the home and com­
munity environments whether using the C-Leg or Mauch
knee units,72 while another group reported that wearing a
MPK prosthesis was associated with greater physical activ­
ity in the community.80 Much research involves measuring
oxygen consumption. Some investigators detected no sig­
nificant difference in oxygen cost of walking when com­
paring performance of subjects wearing the C-Leg and
hydraulic non-MPK units,77 whereas others suggest that
walking with C-leg is more energy efficient.71,81,82 Although
metabolic demand when wearing the microprocessor
Adaptive Knee was comparable to that of a hydraulic non-
MPK unit,83 use of the Intelligent Prosthesis was associated
with slightly reduced oxygen consumption.84–87 Four young
adults with traumatic amputation alternated wearing the
C-Leg and the Intelligent Prosthesis; their oxygen con­
sumption was similar, although much higher than required
by the able-bodied control subjects.79 Metabolic demand

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
753
with the Rheo Knee unit was slightly less than with the
C-Leg.88 In general, any MPK reduces energy consumption
modestly compared to a non-MPK, confirmed by labora­
tory comparison of adults walking with several types of
MPKs.58
Performance in other ambulatory activities: Sit-to-
stand transitions required less hip force for subjects wear­
ing the Power Knee as compared with performance with
the C-Leg or the Mauch Swing and Stance Control unit,
although all participants relied primarily on the intact
limb.63 The C-Leg offers more protection against tripping
as compared with non-MPK units. Three subjects par­
ticipated in a randomized study in which the examiner
tugged on a cord in an attempt to cause prosthetic knee
flexion. Unlike other knee units, the C-Leg either pro­
duced rapid knee extension or supported the wearer on
the flexed knee.67 Performance on stair and ramp descent
was safest with the C-Leg, as compared with the Rheo
Knee, Adaptive 2 Knee, and Hybrid Knee.58 On hill and
stair descent, MPK users exhibited smoother maneuver­
ing over obstacles, fewer stumbles, and superior mul­
titasking ability allowing many to advance to a higher
Medicare functional level.61 The Rheo Knee and the
C-Leg were associated with smoother gait and decreased
hip power generation as compared with performance
with the Mauch Swing and Stance Control unit.88 Subjects
who walked on a treadmill while solving mental problems
swayed less when tested with the Intelligent Prosthesis,
suggesting that it was not as cognitively demanding as
less-sophisticated knee units.89
Several research teams administered questionnaires
to people who wore prostheses equipped with C-Legs.
Respondents praised confidence, gait, and maneuverabil­
ity,70 as well as overall satisfaction.22 Scores on the Prosthesis
Evaluation Questionnaire were higher.69,71 Subjective response
to the Intelligent Prosthesis was also favorable, with users pre­
ferring it to nonmicroprocessor units when walking at dif­
ferent speeds and greater distances with less fatigue.90 Survey
respondents commended increased quality of life when wear­
ing MPKs.80
Although many studies of adults wearing MPKs have been
published, none has addressed such issues as mechanical
durability, effect of unit weight on performance, and whether
the cost of the units equates to substantially greater benefit.
Ideally, future research would involve larger sample sizes.
Nevertheless, at the present time, one can conclude that MPK
units can improve the quality of life of many people with
transfemoral amputation.
PRESCRIPTIVE CASES
Selecting the prosthesis that matches an individual's needs
requires taking into account the person's general health,
level and status of the residual limb, history of prosthetic
use, features and limitations of the available prosthetic com­
ponents, impact level of the intended use, and the individ­
ual's functional level. Manufacturers recommend MPKs
for low to moderate impact activities (Table 27-3) by users
at the Medicare K2 to K4 functional levels (see Table 27-2),
regardless of insurance company policies. After transfemoral
amputation many people may not attain the functional abil­
ity to become K2 community ambulators, walking at 3 km/h
(1.9  mph) and negotiating steps and curbs. Because gait
speeds are low for K2-level walkers, MPK units like the C-Leg
Compact with stance-phase control only are appropriate.
Prosthesis users who walk 5 km/h (3.1 mph), traverse daily
distances of 5 km (3.1 miles) including stairs, and engage
in moderate impact activities are at the K3 to K4 functional
level, thus both stance- and swing-phase features are recom­
mended. In addition to matching prosthetic components to
the individual's physical and functional needs, another ines­
capable consideration is the cost of incorporating a MPK.
Insurance will often reimburse the price of a MPK only for
users at the K3 to K4 levels. The cases that follow highlight
important considerations relevant to MPK prescription.
Those with hip disarticulation or higher amputations
can be considered at the K2 level if walking independently,
regardless of speed, although Medicare K levels are not pub­
lished for people other than unilateral transtibial and trans­
femoral amputation.
TABLE 27-3  Impact Levels
Levels
Target Activity
Typical Use
Low
Walking with small cadence variations
Daily walking with low foot forces. Examples: household tasks, gardening,
shopping, and occasional nonimpact sports such as golf and leisure
walking.
Moderate
Walking with variable cadence
Daily walking of long durations with moderate forces. Examples: aerobics,
jogging, sports like tennis, and vocational activities like lifting/carrying.
High
High cadence walking
Daily activities involving vigorous and repetitive actions with fast speeds
and high loading forces. Examples: distance jogging, running, jumping,
sports like basketball, and vocational activities like construction work.
Sport-Extreme

High impact sports and activities

Daily activities with high or extreme forces common in repetitive, fast,
and/or sustained activities. Examples: sprinting, long-distance running,
active military service.

754
Section III  Prostheses in Rehabilitation
CASE EXAMPLE 1:
The Active Athlete
A 29-year-old 110 kg (245 lb) former college athlete has a
transfemoral amputation resulting from a motorcycle acci­
dent 5 years ago. He has been using a non-MPK hydraulic
knee prosthesis for his everyday life, which includes work
as a sales representative during the week and recreational
basketball and tennis on the weekends. He jogs profi­
ciently using the skip-hop style but has gotten interested
in more sports activities and wants to run step-over-step
and potentially compete in athletic contests. He is ready
for a new prosthesis that can facilitate reaching his goals.
Questions to Consider
• What type of knee unit best matches his needs?
• What is his K level?
• How does his weight factor into the decision making
about which prosthesis to recommend?
• How does his recreational and exercise activity factor
into the recommended prosthesis?
Recommendation
His activities show K4 level functioning and would qualify
him for reimbursement of a MPK prosthesis by many insur­
ance companies. Although a MPK would be an excellent
choice for his everyday activities, MPKs are designed for
low-to-moderate-impact activities and could be overloaded
by the sustained and high-impact nature of his intended
sports. If he is going to proceed with only one prosthesis,
one with a non-MPK hydraulic knee unit such as the Mauch
Knee Plus may serve him best to meet his athletic goals.
Such a knee could be paired with a heavy-duty energy-stor­
ing foot designed to absorb shock like the Re-Flex VSP.
CASE EXAMPLE 2:
At Risk to Fall?
A 65-year-old woman underwent transfemoral amputa­
tion 4 years ago resulting from a thrombosis associated
with peripheral vascular and cardiovascular disease. She
was active prior to amputation. Her activity has increased
since the amputation and she has returned to work as a
school administrator using a weight-activated friction
brake knee unit. She gardens and enjoys leisure walking
in the community, although her strength and endurance
limit her from walking as fast or as far as she would like
and she has fallen twice in the past year. She has recently
qualified for Medicare and wants a prosthesis that can help
her reach her goals.
Questions to Consider
• What type of knee unit best matches her needs?
• What is her K level?
CASE EXAMPLE 3:
After Higher Amputation
A 44-year-old man had a hemipelvectomy 3 months ago
as a consequence of chondrosarcoma. His incision has
healed and he is ready for fitting. He has never used
a prosthesis but was very active until 1 year ago when
he underwent tumor resection and internal hemipel­
vectomy and suffered a bout of depression. After the
resection, he limited activity to working in an office and
curtailed most sporting activities other than occasional
walks in the park. Since his amputation, he has returned
to work as an accountant and is adept with crutches,
which he uses for light sports activities such as soccer
with his children. He uses a wheelchair for traversing
long distances. He complains that it is difficult to rise
from a chair or hold something in his hands while using
crutches. He lives with his wife and teenage sons in a
suburban two-story house. He is insured through his
employer and his prosthetist is confident that a MPK
prosthesis will be covered by insurance. His goals are to
continue work and family life with greater ease.
Questions to Consider
• What type of knee unit best matches his needs?
• What is his K level?
• What is his fall risk?
• How does his difficulty with rising from the seated
position factor into the recommended prosthesis?
Recommendations
As a previously active adult who is able to walk after hemi­
pelvectomy, he is comparable to the K2 functional level. His
status has been changing and his medical and prosthetic
prognoses remain unclear. He may achieve K3-level func­
• What is her fall risk?
• How does her leisure and exercise activity factor into
the recommended prosthesis?
Recommendations
Her activities demonstrate K2-level prosthetic functioning
with K3-level potential. Medicare and her employer-based
insurance may not approve a MPK because her functional
activities do not demand a varied cadence or fast walking
speed. Her age and general health status may also miti­
gate against her efforts to get reimbursed for the cost of a
MPK. However, community ambulating prosthesis users
are at heightened fall risk.66 Falls within her age group have
annual incidence rates from 19% to 60%, with as many
as 32% reporting injury.91 Although current reimburse­
ment practice often does not include a MPK for a K2-level
patient/client, she would benefit from using a MPK, par­
ticularly its stumble and fall protective features.

Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
755
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specific lumbopelvic pain: a pilot study. J Man Manip Ther.
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50. Yerys S, Makofsky H, Byrd C, et al. Effect of mobilization of the
anterior hip capsule on gluteus maximus strength. J Man Manip
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51. Makofsky H, Panicker S, Abbruzzese J, et al. Immediate effect of
grade IV inferior hip joint mobilization on hip abductor torque:
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52. Thompson DM. Rehabilitation for persons with transfemo­
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2000:521–542.
53. Mercer VS, Gross MT, Sharma S, et  al. Comparison of gluteus
medius muscle electromyographic activity during forward and lat­
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54. Gailey RS. Ten exercises to maximize the performance of your
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55. Leavey VJ, Sandrey MA, Dahmer G. Comparative effects of
6-week balance, gluteus medius strength, and combined programs
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56. Williams RM, Turner AP, Orendurff MS, et  al. Does hav­
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57. Baum BS, Schnall BL, Tis JE, et al. Correlation of residual limb
length and gait parameters in amputees. Injury. 2008;39:728–733.
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59. Schmalz T, Blumentritt S, Jarasch R. A comparison of differ­
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60. Vrieling AH, van Keeken HG, Schoppen T, et  al. Uphill and
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61. Hafner BJ, Smith DG. Differences in function and safety
between Medicare Functional classification level-2 and -3 trans­
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62. Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrative
Guide. 2nd ed. Berlin, Germany: Springer; 2000 82.
63. Highsmith MJ, Kahle J, Carey SL, et al. Kinetic asymmetry in
transfemoral amputees while performing sit to stand and stand
to sit movements. Gait Posture. 2011;34:86–91.
64. Pauley T, Devlin M, Heslin K. Fall sustained during inpatient
rehabilitation after lower limb amputation: prevalence and pre­
dictors. Am J Phys Med Rehabil. 2006;85:521–532.
65. Gooday HMK, Hunter J. Preventing falls and stump injuries in
lower limb amputees during inpatient rehabilitation: completion
of the audit cycle. Clin Rehabil. 2004;18:379–390.
66. Miller WC, Speechley M. The prevalence and risk factors of fall­
ing and fear of falling among lower extremity amputees. Arch
Phys Med Rehabil. 2001;82:1031–1037.
67. Blumentritt S, Schmalz T, Jarasch R. The safety of C-Leg®: bio­
mechanical tests. J Prosthet Orthot. 2009;21:2–15.
68. Yang J, Jin D, Ji L, et al. The reaction strategy of lower extrem­
ity muscles when slips occur to individuals with trans-femoral
amputation. J Electromyogr Kinesiol. 2007;17:228–240.
69. Kahle JT, Highsmith MJ, Hubbard SL. Comparison of nonmi­
croprocessor knee mechanism versus C-Leg® on prosthesis eval­
uation questionnaire, stumbles, falls, walking tests, stair descent,
and knee preference. J Rehabil Res Dev. 2008;45:1–14.
70. Berry D, Olsen M, Larntz K. Perceived stability, function, and
satisfaction among transfemoral amputees using ­microprocessor
and nonmicroprocessor controlled prosthetic knees: a multi­
center survey. J Prosthet Orthot. 2009;21:32–42.
71. Seymour R, Engbretson B, Kott K, et al. Comparison between
the C-Leg® microprocessor-controlled prosthetic knee and non-
microprocessor control prosthetic knees: a preliminary study of
energy expenditure, obstacle course performance, and quality of
life survey. Prosthet Orthot Int. 2007;31:51–61.
72. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention
effects on activity of lower-extremity amputees. Arch Phys Med
Rehabil. 2006;87:717–722.
73. Kark L, Simmons A. Patient satisfaction following lower-limb
amputation: the role of gait deviation. Prosthet Orthot Int.
2011;35:225–233.
74. Van der Linde H, Hofstad CJ, Geurts AC, et al. A systematic lit­
erature review of the effect of different prosthetic components
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Chapter 27  Advanced Rehabilitation for People with Microprocessor Knee Prostheses
757
75. Fergason J, Keeling JJ, Bluman EM. Recent advances in lower
extremity amputations and prosthetics for the combat injured
patient. Foot Ankle Clin. 2010;15:151–174.
76. Goktepe AS, Cair B, Yilmaz B, et al. Energy expenditure of walk­
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77. Orendurff MS, Segal AD, Klute GK, et al. Gait efficiency using
the C-Leg®. J Rehabil Res Dev. 2006;43:239–246.
78. Perry J, Burnfield JM, Newsam CJ, et al. Energy expenditure and
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79. Chin T, Machida K, Sawamura S, et  al. Comparison of dif­
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2006;30:73–80.
80. Kaufman KR, Levine JA, Brey RH, et al. Energy expenditure and
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81. Highsmith MJ, Kahle JT, Bongiorni DR, et al. Safety, energy effi­
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362–377.
82. Schmalz T, Blumentritt S, Jarasch R. Energy expenditure and
biomechanical characteristics of lower limb amputee gait: the
influence of prosthetic alignment and different prosthetic com­
ponents. Gait Posture. 2002;16:255–263.
83. Jepson F, Datta D, Harris I, et al. A comparative evaluation of
the Adaptive knee and Catech knee joints: a preliminary study.
Prosthet Orthot Int. 2008;32:84–92.
84. Buckley JG, Spence WD, Solomonidis SE. Energy cost of walk­
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85. Chin T, Sawamura S, Shiba R, et  al. Effect of an Intelligent
Prosthesis (IP) on the walking ability of young transfemoral
amputees: comparison of IP users with able-bodied people. Am
J Phys Med Rehabil. 2003;82:447–451.
86. Taylor MB, Clark E, Offord EA, et al. A comparison of energy
expenditure by a high level trans-femoral amputee using the
Intelligent Prosthesis and conventionally damped prosthetic
limbs. Prosthet Orthot Int. 1996;20:116–121.
87. Datta D, Heller B, Howitt J. A comparative evaluation of oxy­
gen consumption and gait pattern in amputees using Intelligent
Prostheses and conventionally damped knee swing-phase con­
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88. Johansson JL, Sherrill DM, Riley PO, et al. A clinical comparison
of variable-damping and mechanically passive prosthetic knee
devices. Am J Phys Med Rehabil. 2005;84:563–575.
89. Heller BW, Datta D, Howitt J. A pilot study comparing the cog­
nitive demand of walking for transfemoral amputees using the
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90. Datta D, Howitt J. Conventional versus microchip controlled
pneumatic swing phase control for trans-femoral amputees:
user's verdict. Prosthet Orthot Int. 1998;22:129–135.
91. Muir SW, Berg K, Chesworth B, et al. Use of the Berg Balance
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758
28
Athletic Options for Persons with Amputation
Mark Anderson and Carol Dionne
“Games, sport, that is what we must have.”
Sir Ludwig Guttman,1 Founder, Paralympic Games
The importance of participation in sports, recreation, and/or
physical activity for all is well understood. Numerous authors
have extolled the virtues of being physically active for both
physical and mental health, as well as the prevention of “hypo­
kinetic diseases,” such as obesity, diabetes, hypertension, and
cardiovascular disease. Benefits for individuals who partici­
pate in sports or recreational activities include maintenance
of normal muscle strength, flexibility, and joint structure
and function.2,3 These benefits are essential with the slowing
of the functional decline often associated with normal aging
or the presence of a disabling condition. Therefore, the goals
for increased physical activity for individuals with a disability
are to reverse deconditioning secondary to impaired mobil­
ity, to optimize physical functioning, and to promote overall
well-being.4
In addition to the physical benefits, participation in sports
or recreational activities has a significant psychological ben­
efit for both able-bodied and disabled individuals. Both body
image and quality-of-life scores have improved in individu­
als with disability who participate in physical activity and
sports.5–7 Participation in regular sport or vigorous recre­
ational activity has favorable effects on the emotional state
of adolescents.8 Many psychological constructs, such as
improved social acceptance, improved physical self-concept
and self-esteem, increased self-efficacy and self-confidence,
and a greater locus of control build upon the physical perfor­
mance accomplishments of the athlete with a disability.9 Even
though the benefits of participation in sports and physical
activity are well recognized, there is still a disconnect between
knowledge and action. This chapter discusses the importance
of athletics for persons with disabilities and describes athletic
activities and opportunities for active engagement in sports
and recreation available to persons with amputation and dis­
abilities associated with loss of limb.
More than half of the adults with disabilities in the United
States do not participate in any leisure-time physical activity
compared to one-third of adults without disability.10 This rein­
forces the notion that on average, people with a disability are
more inactive than the general population, which leads to the
questions, “What are the barriers for those with a disability to
their participation in sports or physical activities?” and, “What
motivates those with disabilities to participate in sports and
recreational activities?” The most common ­barriers11 to sports
participation for individuals with a disability are lack of money,
unsuitable local facilities, and health concerns. Additional bar­
riers are lack of local sports facilities, transportation issues, lack
of sports offerings for those with a disability, and lack of peer
with which to participate. Only 10% of those with a disability
report lack of motivation as a barrier to participate. Reasons for
participation include health benefits, a feeling of accomplish­
ment after participation, social contacts, and recommendation
from a physician or health care professional. In those with limb
deficiencies, age, level of amputation, and etiology of amputa­
tion do not appear to be related to sports participation follow­
ing lower-extremity amputation. However, a history of sports
participation prior to the amputation increases the likelihood
of sports participation following amputation.
OPPORTUNITIES FOR SPORTS OR RECREATION
PARTICIPATION
Sports for athletes with physical disabilities are governed by
various disabled sports organizations and national govern­
ing bodies which are disability-specific. In the United States,
the disabled sports organizations for athletes with amputa­
tion is Disabled Sports, USA (). The motto
of Disabled Sports, USA is, “If I can do this, I can do any­
thing!” and its mission is “to provide national leadership and
28
LEARNING OBJECTIVES
Upon completing the chapter, the reader will:
1. Discuss the relationship of physical exercise and sports to
health and prevention of “hypokinetic” disease.
2. Describe barriers that contribute to lack of participation in
athletics for persons with disabilities.
3. Identify organizations that support athletic participation
for persons with disabilities.
4. Compare the different sports and recreation activities
available for persons with limb loss.
5. Describe prosthetic components available to active partic­
ipation in sports of varying types.

Chapter 28  Athletic Options for Persons with Amputation
759
­opportunities for individuals with disabilities to develop inde­
pendence, confidence, and fitness through participation in
community sports, recreation, and educational programs.”12
Disabled Sports, USA is comprised of a nationwide network
of ­community-based chapters that offer a variety of sports/rec­
reational programs. In many instances, sports and recreation
participation are the final step in the rehabilitation process
of individuals following amputation. Sports participation not
only improves sports skills, but it allows ­individuals to expe­
rience the emotional highs and lows of winning and losing,
which prepares them to face daily challenges and changes fol­
lowing rehabilitation. Disabled Sports, USA, along with other
disabled sports organizations, is a member of the United States
Paralympic Committee, which sanctions and conducts compe­
titions and training camps to prepare athletes to represent the
United States at the Summer and Winter Paralympic Games.
The Paralympic Games are the major international multisports
event for athletes with physical disabilities, and are second to
only the Olympic Games in number of athletes participating.
These Games are organized and conducted under the super­
vision of the International Paralympic Committee and other
international sports federations. For athletes with amputation,
there are opportunities to compete in 16 different Summer
Paralympic sports and five different Winter Paralympic sports.
The U.S. Paralympics Committee also offers an Emerging
Sport Program, which is designed to identify, recruit, track,
support, and retain Paralympic-eligible athletes with physical
disabilities seeking to become internationally competitive. The
success of this program depends on the collaboration between
community and military programs, partner organizations,
military and veteran facilities, and national governing bodies.
Athlete recruitment and identification begins at the local
level. Potential athletes are identified in a variety of ways,
including military sport camps, site coordinators for spe­
cific sports or events, community programs, coaches, techni­
cal officials, or current athletes. Once an athlete is identified
as having high performance potential, the Emerging Sports
manager facilitates appropriate communication between
athlete(s) and local program(s), as well as with the appropri­
ate Paralympic sport coaches and high performance directors.
Assistance is provided to these athletes by way of connections
to local training resources, participation in select emerging
and/or national U.S. Paralympics Team camps and competi­
tions, as well as information regarding able-bodied competi­
tions, events and other general sport program opportunities
for developing and emerging athletes.
Summer Paralympic Sports
Summer Paralympic sports12 include archery, athletics (track
and field), cycling, equestrian, fencing, powerlifting, row­
ing, sailing, shooting, swimming, table tennis, tennis, sit­
ting volleyball, and wheelchair basketball. In 2016, triathlon
and canoe will make their Paralympic debut. Each sport has
its own unique set of requirements, which may necessitate a
modification of the traditional rules of the sport to allow the
disabled athlete to compete.
Archery
Archery has been a medal sport since the first Paralympic
Games in Rome in 1960. Athletes with physical disabili­
ties demonstrate their shooting precision and accuracy
from either a standing or seated (wheelchair) position,
in men's and women's categories. Paralympic competi­
tion ­format is identical to that of the Olympic Games.
Paralympic archers shoot 72 arrows from a distance of 70 m
at a ­target of 122 cm (approximately 48 inches), using a
recurve bow (Figure 28-1, A). For competitions other than
the Paralympics, athletes shoot at each of four distances.
Thirty-six arrows are shot at each distance. The two lon­
gest distances use a 122 cm target; the two shorter distances
A
B
FIGURE 28-1  Archery using (A) a recurve bow and (B) a compound
bow. (Courtesy Disabled Sports, USA.)

760
Section III  Prostheses in Rehabilitation
use an 80 cm target (approximately 36 inches). Distances are
90, 70, 50, and 30 m for men; 70, 60, 50, and 30 m for women.
Depending upon their classification based upon level and
number of amputations and the athletes’ functional ability,
athletes competing in other than the Paralympic Games may
use either a recurve bow or a compound bow (Figure 28-1, B).
Archery competition is open to male and female athletes with
upper or lower-extremity amputation/limb loss. Specialized
devices are also available to assist athletes with upper-
extremity prostheses in drawing back the bow and releasing
the string.
Athletics (Track and Field)
Athletics events are open to athletes in all disability classes
and have been a part of the Paralympic program since the
first Paralympic Games in Rome, Italy, in 1960. Events
include track (Figure 28-2, A) (running distances from 100 m
to 10,000 m, plus 4 × 100 m and 4 × 400 m relays), throwing
(Figure 28-2, B) (shot put, discus, and javelin), jumping (high
jump, long jump, and triple jump), pentathlon (long jump,
shot put, 100 m, discus and 400 m) and the marathon. The
rules of Paralympic track and field are almost identical to
those of its nondisabled counterpart. Paralympic track and
field competition is open to male and female athletes with
upper- and or lower-extremity single or multiple amputation/
limb loss. Prosthetic devices may be used. These have been
specifically developed to withstand the demands of sports
competition. International Paralympic Committee rules
require the use of leg prostheses in track events; however, the
use of prostheses in field events is optional.
Cycling
Cycling was first introduced as a Paralympic sport in 1984 in
Mandeville, England, and involved only those athletes with
cerebral palsy. However, it wasn't until 1992 that athletes with
amputation competed at the Paralympic Games in cycling.
At the 2004 Paralympic Games in Athens, handcycling (for
wheelchair users) made its debut as a medal event.
Athletes compete in both track (velodrome) and road
events. Track events generally consist of sprints as short as
200 m to time trials and pursuits up to 4 km. Relay races con­
sisting of three-person teams are also contested on the track.
Competition on the roads consists of time trials and road
races. In time trials, athletes start individually in staggered
intervals, racing mostly against themselves and the clock.
Road races consist of mass starts. Distances vary based on the
host country's discretion. Distances range from 5 km to 65 km
in length. Paralympic cycling competition is open to male and
female athletes with upper- and/or lower-extremity single or
multiple amputation/limb loss (Figure 28-3).
Equestrian
Equestrian made its debut appearance at the Paralympic
Games in 1996 with riders from 16 countries competing. By
the Paralympic Games in 2008, in Beijing, that number had
grown to 73 riders from 28 countries. Riders compete in two
dressage events; a championship test of set movements and
A
B
FIGURE 28-2  Paralympic athletic events include (A) running track
and (B) javelin.

Chapter 28  Athletic Options for Persons with Amputation
761
a freestyle test to music. There is also a team test for three or
four riders. Competitors are judged on their display of horse­
manship skills demonstrated through their use of commands
for walk, trot, and canter. Paralympic equestrian competition
is open to male and female athletes with upper- and/or lower-
extremity single or multiple amputation/limb loss.
Fencing
Fencing has been part of the Paralympic Games since 1960.
Athletes compete in wheelchairs that are fixed to the floor.
They rely on ducking, half-turns and leaning to dodge their
competitors’ touches. However, fencers can never rise up from
the seat of the wheelchair. The first fencer to score five touches
is declared the winner. Athletes play the best out of three
rounds and compete in single and team formats. Weapon cat­
egories for men include foil, epee and sabre. Women compete
in foil and epee. Paralympic fencing competition is open to
male and female athletes with upper- and/or lower-extremity
single or multiple amputation/limb loss.
Powerlifting
Powerlifting is one of the fastest growing Paralympic sports.
Paralympic athletes have been competing in powerlifting
since 1964; however, it was initially offered only to lifters with
spinal cord injuries. Currently, athletes from many different
disabled sports groups participate in the sport, assimilating
rules similar to those of nondisabled lifters. Athletes compete
only in the bench press, and they draw lots to determine order
of weigh-in and lifts. After the athletes are categorized within
the 10 different weight classes (male and female), they each
lift three times (competing in their respective weight class).
The heaviest “good lift” (within the weight class) is the lift
used for final placing in the competition. Paralympic power­
lifting competition is open to male and female athletes with
upper- and/or lower-extremity single or multiple amputation/
limb loss. There is currently a move to include the single-arm
press in powerlifting competitions for those individuals with
upper-extremity amputation, with the hope of making this a
Paralympic sport.
Rowing
Rowing is a relatively new Paralympic sport, making its first
appearance in Beijing in 2008. The sport was selected for
Paralympic inclusion in 2005, just 3 years after adaptive rowing
made its debut on the world championship level in 2002. The
rowing events include the men's and women's single sculls, the
trunk-arms double sculls and the legs-trunk-arms mixed four
with coxswain (Figure 28-4). Paralympic rowing competition
is open to male and female athletes with upper- and/or lower-
extremity single or multiple amputation/limb loss.
Sailing
Sailing first became a medal sport for the 2000 Paralympic
Games in Sydney, Australia. Three boat types raced at the
2008 Paralympic Games in Beijing: the 2.4mR, a single-person
keelboat; the SKUD-18, a two-person keelboat; and the Sonar,
a three-person keelboat, along with the high performance
SKUD-18 m, which must include one female and one person
deemed a Functional Classification System “1,” or severely dis­
abled, such as an athlete with quadriplegia. Sailors are seated
on the centerline for Paralympic events, but the boat can be
sailed with or without either of the seats and ­configured to suit
different sailors’ needs. Because of its design and control, the
FIGURE 28-3  Cycling.
FIGURE 28-4  Kayaking.

762
Section III  Prostheses in Rehabilitation
2.4mR was selected for single-person races. The boat's ease of
use allows for a level playing field, making tactical knowledge
the dominant factor in competition. The Sonar uses a versa­
tile crew-friendly design that is accommodating to athletes
with physical disabilities. It is used by sailors of all experience
and ability levels, from the novice to international competitors
(Figure 28-5). Paralympic sailing competition is open to male
and female athletes with upper- and/or lower-extremity single
or multiple amputation/limb loss.
Shooting
Shooting, divided into rifle and pistol events, air and .22
caliber, has been a Paralympic sport since 1976. The rules
governing Paralympic competition are those used by the
International Shooting Committee for the Disabled. These
rules take into account the differences that exist between dis­
abilities allowing ambulatory and wheelchair athletes to com­
pete shoulder to shoulder. Shooting matches athletes of the
same gender, with similar disabilities, against each other, both
individually and in teams. Paralympic shooting competition
is open to male and female athletes with upper- and/or lower-
extremity single or multiple amputation/limb loss.
Swimming
Swimming for men and women has been a part of the
Paralympic program since the first Games in 1960 in Rome,
Italy. Races are highly competitive and among the largest and
most popular events in the Paralympic Games. Paralympic
swimming competitions occur in 50-m pools and, while
competing, no prostheses or assistive devices may be worn.
Athletes compete in the following events: 50 m, 100 m and
400 m Freestyle; 100 m Backstroke; 100 m Breaststroke; 100 m
Butterfly; 200 m Individual Medley; 4 × 100 m Freestyle Relay
and 4 × 100 m Medley Relay. Paralympic swimming competi­
tion is open to male and female athletes with upper- and/or
lower-extremity single or multiple amputation/limb loss.
Table Tennis
Table tennis has been a part of the Paralympic program since
the inaugural Games in 1960. Rules governing Paralympic
table tennis are the same as those used by the International
Table Tennis Federation, although slightly modified for play­
ers using wheelchairs. Athletes must use the same quick tech­
nique and finesse in the games of competitors from various
disability groups, including men's and women's competitions,
as well as singles, doubles, and team contests. All matches
are played best-of-five games to 11 points. Paralympic table
tennis competition is open to male and female athletes with
upper- and/or lower-extremity single or multiple ­amputation/
limb loss.
Tennis
Wheelchair tennis first appeared at the Paralympic Games in
Barcelona in 1992 and is played on a standard tennis court
and follows many of the same rules as tennis. However, in
wheelchair tennis, a player is allowed to let the ball bounce
twice if necessary before hitting a return shot and the dou­
bles court lines are used for both singles and doubles. Also,
the athlete's wheelchair is considered to be a part of the body,
so rules applying to the player's body apply to the chair as
well. Paralympic wheelchair tennis competition is open to
male and female athletes with upper- and/or lower-extremity
­single or multiple amputation/limb loss.
Sitting Volleyball
Instituted in 1976 as a standing Paralympic sport, Paralympic
volleyball has now become exclusively a sitting sport.
Paralympic volleyball follows the same rules as its able-­bodied
counterpart with a few modifications to accommodate the
various disabilities (Figure 28-6). In sitting volleyball, the net
is approximately 3.5 feet high, and the court is 10 × 6 m with
a 2-m attack line. Players are allowed to block serves, but one
“cheek” must be in contact with the floor whenever they make
contact with the ball. Paralympic volleyball competition is
open to male and female athletes with upper- and/or lower-
extremity single or multiple amputation/limb loss.
Wheelchair Basketball
Basketball has been a part of the Paralympic Games since 1960
and originally played only by men with spinal cord injuries.
Now both men's and women's teams throughout the world,
with a variety of disabilities, compete in the sport. Many of
the same rules from its counterpart apply in the wheelchair
game. Although plays and tactics are ­similar, special rules,
FIGURE 28-5  Sailing. (Courtesy Disabled Sports, USA.)

Chapter 28  Athletic Options for Persons with Amputation
763
such as those to accommodate dribbling from a wheelchair,
are also in place. The sport is governed by the International
Wheelchair Basketball Federation. The International Wheelchair
Basketball Federation governs all aspects of the game, includ­
ing court size and basket height, which remain the same as
able-bodied basketball. Athletes in this event are grouped by
demonstrated playing ability, rather than strictly by medical
classification. Paralympic basketball competition is open to
male and female athletes with upper- and/or lower-extremity
single or multiple amputation/limb loss.
Winter Paralympic Sports
Just like the Summer Paralympic Games, the Winter Paralympic
games12 are held every 4 years following the conclusion of
the Winter Olympic Games in the host city of the Olympics.
Paralympic athletes with amputations compete in five winter
sports: alpine skiing; biathlon; cross-country ­skiing; curling;
and sled (sledge) hockey.
Alpine Skiing
Paralympic alpine skiing competition is open to male and
female athletes with amputation. There are four individual
events in alpine skiing: downhill, which started as a dem­
onstration event at the 1980 Paralympic Games in Norway;
­slalom; giant slalom, which was introduced as a demonstra­
tion event in 1984; and super-G. Mono-skiing (Figure 28-7, A)
was introduced in both alpine and Nordic events in 1988
at the Games in Innsbruck, Austria. Skiing equipment var­
ies, depending on the athlete's level and number of amputa­
tions. Athletes with double-leg amputation above the knee
(transfemoral) typically use two skis with two outriggers but
may also choose to sit ski in a mono-ski. Athletes with single
transfemoral amputation often use one ski with two outrig­
gers (Figure  28-7, B). Athletes with double-leg below-knee
(transtibial) amputation and those with single-leg transtibial
amputation may use two skis with two ski poles. Athletes with
double-upper-extremity amputations, regardless of level, ski
with two skis but no ski poles while single-upper-extremity
amputee athletes use two skis and one ski pole. If athletes
have one upper-extremity and one lower-extremity amputa­
tion, they may use ski equipment that facilitates the athletes’
best function.
Nordic Skiing
Paralympic Nordic skiing is a Winter Paralympic sport con­
sisting of two events: biathlon and cross country skiing.
Biathlon (Figure  28-8) combines elements of cross-country
skiing and target shooting. Athletes ski three 2.5-km loops
(7.5 km total), stopping after the first two loops to shoot at five
targets (10 targets total). One minute is added to the athlete's
finishing time for each miss. Biathlon has been a part of the
Paralympic Winter Games since 1992. Cross-country skiing
started with the Paralympic Games in Sweden in 1976. Cross-
country races range from 2.5 km to 20 km depending on dis­
ability and gender. Paralympic Nordic skiing competition is
open to male and female athletes with amputation/limb loss.
Curling
Paralympic curling is a wheelchair sport that was introduced
at the 2006 Paralympic Winter Games. As in able-bodied
curling, teams are composed of two competitors who throw
“stones” by hand or by the use of a stick towards a target at
the opposite end of the ice. However, there is no sweeping
and only competitors in wheelchairs are allowed to compete.
The object of the game is to get a team's stones as close to
the center of the target (the “house”) as possible. Six ends are
played with a possible extra end if the teams are tied after six.
Paralympic wheelchair curling competition is open to male
and female athletes with amputation/limb loss.
Sled (Sledge) Hockey
Sled hockey is a variation of ice hockey in which the athletes
compete on the ice by means of a sled. Just as in ice hockey,
sled hockey is played with six players (including a goalie) at a
time. Players propel themselves on their sled by use of spikes
on the ends of two three-foot-long sticks, enabling players to
push themselves as well as shoot and pass the puck. Rinks and
goals are regulation Olympic-size, and games consist of three
15-minute stop-time periods. Sledge hockey became a medal
sport in the 1994 Paralympic. Paralympic sled hockey com­
petition is open to male athletes with amputation/limb loss.
FIGURE 28-6  Sitting volleyball. (Courtesy Disabled Sports, USA.)

764
Section III  Prostheses in Rehabilitation
Nonparalympic Sports and Recreational Activities
for Individuals with Amputation
Although Paralympic sports are popular among individu­
als with amputation, there are many other sports and recre­
ational activities available to this population. Many of these
sports require little or no adaptation for participation by
those with amputation, allowing competition between able-
bodied and disabled individuals.
Badminton
Disabled badminton 13 is played by people with many differ­
ent disabilities, including those with both upper- and lower-
extremity amputation. Participants may compete either
standing or in a wheelchair. Disability badminton provides
players of different disabilities and backgrounds an opportu­
nity to participate in a common sport. Although more com­
mon in Europe, most people in the United States become
involved in badminton through word of mouth and people
introducing others to the sport. It is a growing sport with an
increasing number of participants taking up the game either
socially or competitively, or both. Both men and women in
all age groups participate in badminton, and the sport is in
the process of being evaluated for possible inclusion in the
Paralympic Games.
Fishing
Fishing 14 is a sport that can be enjoyed by anyone. There are
many different types of specialized equipment available to
the disabled angler, including rods, reels, line, rod ­holders,
A
B
FIGURE 28-7  Alpine skiing. A, Mono-ski. B, Outriggers. (Courtesy Disabled Sports, USA.)
FIGURE  28-8  Target shooting component of a Nordic skiing-
shooting biathlon. (Courtesy Disabled Sports, USA.)

Chapter 28  Athletic Options for Persons with Amputation
765
and tackle, including easy cast and electric fishing reels for
individuals who may have difficulties casting and reeling in
a fish. There are also harness rod holders which can mount
on a wheelchair or the side of a boat and allow an individ­
ual with limited use of their arm(s) to participate in recre­
ational fishing. Pontoon boats can provide easy accessibility
for those in wheelchairs. The Paralyzed Veterans of America
sponsors a variety of fishing tournaments for people with
disabilities, and there are disability fishing groups and clubs
that cater for children with disabilities who enjoy fishing.
They offer several bass fishing tournaments where those
interested in fishing can learn new skills or improve old
ones. The Paralyzed Veterans of America Bass Tour offers
Team/Open Competition, pairing disabled anglers with
able-­bodied boat partners. Those who prefer not to fish from
a boat can participate in the Bank Competition. Both nov­
ice and experienced anglers can compete for significant cash
and other prizes. Fishing Has No Boundaries, Inc. is another
nonprofit organization for all persons with disabilities that
has grown into a national organization with 23 chapters in
11 states. Fishing Has No Boundaries enables thousands of
people with disabilities to participate fully in the recreational
activity of fishing.
Hunting
As with fishing, hunting 13 is a recreational activity that can
be enjoyed by all, and any disability can be offset by adap­
tive hunting equipment and adaptive hunting techniques.
There are many different types of adaptive equipment that
can be used by either gun or bow hunters with either upper-
or lower-extremity amputation. This includes hunting blinds
that are more wheelchair friendly, protective clothing to make
cold weather hunting more enjoyable, adaptive tree stands,
tripod-mounted crossbow or gun rests, and wheelchair-based
gun rests. Federal, state, and local governments are providing
easier access to thousands of acres of trails, parks, and wilder­
ness areas. There are organizations and clubs with programs
for persons with disabilities who want to participate in hunt­
ing activities.
Golf
Just about anyone, regardless of ability level, can partic­
ipate in golf 15. This makes it one of the best sports for
people with disabilities, especially those with amputa­
tion (Figure 28-9). All amputees can successfully play golf,
including those with lower-extremity prostheses, where a
torsion absorber and rotator allow them to pivot to finish
their swing. For those with upper-extremity amputation,
they may play with just one arm, or if they play with one
arm and a prosthesis, there are a number of pieces of adap­
tive hardware that allow them to attach their prosthetic
arm to their club, allowing them to swing with both hands.
If they are unable to walk a full 18-hole course, they may
play golf from a seated position on a single-rider golf cart.
Numerous other devices exist to help golfers with amputa­
tion tee-up and retrieve their ball, better grip the club, and
aid their game.
Trail Orienteering
Conventional orienteering combines fast running with pre­
cise navigation, typically through forests or over moorland.
Trail orienteering16 is a discipline of the sport designed so
that people with disabilities could have meaningful orien­
teering competitions (Figure 28-10). It completely eliminates
the element of speed over the ground, but makes the map-
interpretation element much harder. Able-bodied people can
compete on equal terms with the disabled. Depending on
the level of difficulty, up to five control markers are hung at
each site and only one will correspond exactly with the con­
trol description and control circle position. Sites are chosen
so that they can be seen from a wheelchair-navigable path or
area, but they may be quite a distance into the forest or over
nonnavigable terrain. The only special equipment needed is a
compass. An escort can give the competitor physical help—
pushing a chair, holding and orienting map and compass,
even marking the control card with the decision according
to the competitor's instructions. However, it is an important
rule that escorts must not help in the decision-making pro­
cess; they can give as much physical help as may be necessary,
FIGURE 28-9  Golf. (Courtesy Disabled Sports, USA.)

766
Section III  Prostheses in Rehabilitation
but must not offer advice or opinions to the competitor. For
serious competitions, escorts are “swapped” so they do not
know the competitor they are helping.
Along with trail orienteering, other ambulatory sports/
activities may be appropriate for individuals with amputation.
For those who enjoy the outdoors, hiking (Figure 28-11, A),
mountain climbing (Figure  28-11, B), rock climbing
(Figure 28-11, C), and ropes courses (Figure 28-11, D) are
popular, as is snowboarding (Figure 28-11, E) during the win­
ter months. These activities are easily done with able-bodied
friends and can be done safely as long as normal outdoor
precautions are observed. For those activities that require
additional training or practice, there are many qualified
instructors available at most recreational areas for lessons or
instructions to increase enjoyment and reduce the likelihood
of injury while participating in these sports.
Sky Diving
Skydiving 17 is a sport that can involve skydivers who have one
or more amputated limbs. Because of their prosthetic devices,
amputee skydivers often have to compensate for the change in
weight with the positioning of their body for both themselves
and other divers in a formation. Many of these individuals
begin skydiving in tandem, making jumps while attached to
a certified jump instructor. However, as individuals become
more experienced, many progress to solo (accelerated free
fall) jumps. Modifications to prosthetic devices, particularly
lower-extremity prostheses, may need to be made because of
the forces incurred during landing after the jump.
Additional Water Sports and Activities
Besides swimming, there are numerous other water sports in
which individuals with amputation may participate. These
include surfing, windsurfing, water skiing, kayaking, and
scuba diving. Surfing18 for individuals with amputation can
be a fun and exciting sport (Figure 28-12, A). Individuals may
begin surfing while lying on the board, progressing to seated,
quadruped, kneeling, and finally standing. Once standing,
individuals may choose to surf with our without their pros­
thetic device.
Until recently, windsurfing19 has been an inaccessible sport
to people with amputations. However, equipment modi­
fications have made windsurfing accessible to people with
all types of disabilities. One may begin to windsurf in a fixed
or swivel seat attached to the windsurfing board. Outriggers
or flat-bottom pontoons can be attached to the sides of the
windsurfing board to provide additional stability. A standing
rail can be used on the board for someone to stand with an
instructor for support. One or two sails can be used so that
instructors can be on the windsurfing board to help assist.
Such adaptations open the sport up to men and women with
all types of disabilities, including amputation.
Water skiing20 has been adapted so that physically disabled
individuals can participate and compete (Figure  28-12, B).
Competition is held in three events, slalom, tricks and jump­
ing for lower-extremity amputees (above and below knee),
upper-extremity amputees, and individuals with both arm
and leg amputations. The skiers compete with the same water
ski equipment used by able-bodied skiers; however, the use of
a prosthetic device is optional.
Kayaking may be done solo or in tandem. To avoid entrap­
ment, individuals with lower-extremity amputations should
not wear a regular prosthesis in the kayak. A water-sports
prosthesis that can be strapped to the outside of the boat for
easy access is recommended. For those with upper-extremity
amputations, one-handed paddles may be used, or individu­
als may practice paddling using heavy tape or rubber rings
to secure their grip on the paddle, as conventional terminal
devices are not designed to hold paddles. Rowing prosthetics­
also are available for amputees using other types of water
crafts. For safety, wetsuits, helmets, and flotation devices are
recommended for all participants.
Scuba diving can be an excellent recreational activity for
individuals with amputation (see Figure 28-12, C). Because of
the buoyancy provided by the water, mobility issues are sig­
nificantly reduced, and scuba diving can be taught to swim­
mers with both upper- and lower-extremity amputation with
virtually no modifications. For some, scuba diving represents
total freedom because it affords one the opportunity to move
about without an assistive device in a barrier-free, gravity-free
environment. Many individuals choose to scuba dive without
their prostheses, but water-sport prostheses are available in
desired. As with able-bodied divers, the same basic safety and
equipment concerns apply to everyone.
FIGURE 28-10  Trail orienteering. (Courtesy Disabled Sports, USA.)

Chapter 28  Athletic Options for Persons with Amputation
767
A
C
E
D
B
FIGURE 28-11  Outdoor activities. A, Hiking. B, Mountain ­climbing.
C, Rock climbing. D, Ropes course. E, Snowboarding. (Courtesy
Disabled Sports, USA.)

768
Section III  Prostheses in Rehabilitation
PROSTHETIC COMPONENTS FOR ATHLETES
WITH AMPUTATION
Historically, people with amputation were considered
disabled. Without exception, they were marginalized in
activities of everyday life, most notably so in participa­
tion in recreational and competitive sports. Exoskeletal
prosthetics, essentially the only choice of artificial limb
design available at the time, were heavy and difficult to
manage while attempting to throw a ball or move at a var­
ied pace required in any skilled sport.21 Now, with the
advent of inclusion of people with all levels of ability, peo­
ple with amputation are part of the societal mainstream.
Most people with amputation receive rehabilitation to
improve overall function in order to return to the family,
to a workplace, and, more recently, to sport-related activ­
ity. Moreover, motivated people with amputation have
formed sport-enthusiast groups that have created the mar­
ket demand for improvement and acceleration of modifi­
cations to everyday use prosthetic limbs and creation of
more sport-­specific designs.
Prosthetic Components for Athletes with
Lower-Limb Amputation
Lower-limb prosthetics are commonly composed of a means of
suspension, a prosthetic socket, joint articulation (as needed),
shaft (or pylon), and foot. Prosthetics have now become modu­
lar in construction such that the athlete can still use the pros­
thetic socket of choice and interchange certain components to
meet the demands of a specific sport. Even recreational athletes
with amputation can enjoy sports using their usual prosthet­
ics with additional or interchangeable modification. However,
committed athletes with amputation must consider the biome­
chanical demands of their sport and apply the components that
allow safe and competitive participation, and choose prosthetic
components accordingly.13 For example triathletes may choose
to use a swimming prosthetic leg or opt not to use a pros­
thetic limb during the swimming portion of the competition.
Additionally, prosthetic design has advanced to the creation
of sport-specific prosthetics, such as for bicycling, swimming
and track and field competition. However, affordability of these
devices poses as a barrier to common accessibility.
A
B
C
FIGURE  28-12  Water sports. A, Surfing. B, Water skiing. C, Scuba diving. (Courtesy Disabled
Sports, USA)

Chapter 28  Athletic Options for Persons with Amputation
769
Once the residuum has sufficiently matured to be able
to accept the shear, torsion, and load demands playing in a
desired sport, athletes with amputation can be fitted with
prosthetics to help meet the rigors of training. Considerations
must be made for sports that demand high levels of shear,
such as those that involve running or cutting.22 These exces­
sive forces increase the risk of soft-tissue breakdown, pain,
time out of the prosthesis, and away from the sport. High
levels of activity also increase added perspiration within the
prosthetic socket, increasing the risk of infections and related
skin ­problems.23 Regardless of choice of prosthetic compo­
nents, proper prosthetic management and skin care are essen­
tial in sport.
Suspension and Sockets
If people recovering from limb amputation surgery set a goal
for participation in sport, they should closely consult with the
rehabilitation team, composed of the surgeon, physical ther­
apist, and specifically, the prosthetist, to create a prosthesis
to meet that goal. Added prosthetic suspension (cuff, straps,
sleeve) may be required for the prosthesis to remain intimate
to the residual limb, in light of expected changeable limb vol­
ume during play.24 And, as previously stated, the residuum
skin must be protected during participation in recreational
sports as well as every-day activities. Gel liners or sleeves
provide a protective socket-residuum interface to mini­
mize shear and other loading factors, particularly during the
early phases of recovery or during repetitive movements in
play.25 Thus, gel liners are also recommended for the higher-
level athletes. Special accommodation for boney areas at the
socket-­residuum interface should be considered and is usu­
ally warranted. Total-surface-bearing prosthetic sockets are
recommended because they are designed to disperse forces
evenly over the entire surface area of the residuum-socket
interface to minimize risk for soft-tissue breakdown.16,26
Knee Joints
There are a variety of computerized knee joints on the market
that are designed for user-matched walking speeds. However,
there has yet been a computerized knee joint designed to
withstand the rigors of “stop-start” running, cutting, jump­
ing, or swimming. The athlete with transfemoral amputation
can choose to use a mechanical running limb because it is a
simpler, more reliable knee joint design that can be controlled
in “real time.” Usually, however, the athletes depend on the
energy-storing running foot and the power of the hip exten­
sors to substitute for natural knee function. Alternatively,
athletes can choose to use no articulation at all, like when
competing in track and field events (Figure 28-13).
Lower Leg/Foot/Ankle Components
Prosthetics have now become modular in construction such
that the athlete can still use the socket of best fit and change
out the prosthetic components to minimize risk of injury
and maximize performance. Application of the appropri­
ate prosthetic foot to maximize efficiency towards symmet­
rical step lengths during varied walking speeds enables the
­recreational amputee to participate in higher levels of activity.
In some cases, prosthetic foot/ankle/knee components can be
interchanged using a “quick-release” coupler for use in spe­
cific sport-like activities. Forces that may negatively impact
the residual limb must be minimized with proper selection
of prosthetic components. Pylons, special-design prosthetic
ankles and heels that absorb and dissipate energy during load­
ing, are important considerations. Athletes with either trans­
tibial or transfemoral amputation who wish to run or sprint
typically use an energy-storing foot. This specialized foot is
constructed of materials that essentially “store” the energy
during locomotion and transfer energy with significant effi­
ciency to propel the athlete forward in walking or running
gait. This particular prosthetic foot is attached posterior to
the prosthetic socket. For the athletes involved in running or
sprinting, these high-performance carbon fiber foot compo­
nents are essential. This design enables the athlete with bilat­
eral or unilateral, transtibial or transfemoral, amputation to
participate and successfully compete in sports never before
considered. However, there are limitations to these designs.
For those who play sports on uneven ground and need ankle
designs that simulate foot pronation and supination, athletes
must depend on the older, mechanical designs to compete
with less risk for injury and falls.14
Athletes with Upper-Limb Amputation
Although there are fewer people with upper-limb amputa­
tion than with lower-extremity amputation, there is a grow­
ing number of those who are competing in sports who
require skilled use of the arms and hands. As with comput­
erized lower-extremity prosthetics, computerized upper-
extremity prosthetics pose an even more daunting obstacle
for pragmatic use in sport. So, prosthetic designers have
created, with use of the human-powered prosthesis, termi­
nal devices that are used to throw and catch a ball or hold
a bow and arrow. The devices do not simulate human anat­
omy, but are designed for performance in sport, not cosmesis
(Figure 28-14).16
FIGURE 28-13  Prosthetic suspension.

770
Section III  Prostheses in Rehabilitation
CHILDREN WITH AMPUTATION IN SPORT
It is very important for children with amputation to be physi­
cally active and fit to meet the added energy expenditure of
playing and competition using artificial limbs. This poses
a daunting challenge to those who create prosthetics for
these children. Typically, the prosthetic design is essentially
of ­simpler construction for use when the children are very
young. But, as children develop and grow, more complicated,
adult-level components are added to the prostheses. For
example, current pediatric knee components usually provide
control, shock absorption, and freedom to move like a grow­
ing child. Use of carbon-fiber energy-storing prosthetic feet
is considered the norm. However, these components must be
light, yet strong and sufficiently durable to enable the young
athlete to compete (Figure 28-15).27
PROSTHETICS IN SPORTS: WHAT IS BEST?
Despite many advances in the design and composition of
either upper- or lower-extremity prosthetic limbs, there is
no tangible evidence as to which component designs are best
FIGURE 28-15  Sports prosthesis without knee joint.
FIGURE 28-14  Upper-limb sports prosthesis.

Chapter 28  Athletic Options for Persons with Amputation
771
suited for any particular sport or amputee consumer group.
According to systematic review, there have been several stud­
ies whose aims were to determine the effectiveness of a group
of prosthetic foot-ankle or knee joint designs, but, because of
the poor quality and incomparability of research designs, no
conclusions could be drawn. Thus, choice of sports prosthetic
is currently made on an individualized, case-by-case, expert
opinion basis for those in competitive sport.18
SUMMARY
The value of active engagement in physical activity that
includes participation in sports and recreation for all indi­
viduals has been determined as an essential component
of healthy living. Persons with disabilities should have the
opportunity to participate in athletics of varying types and
engage in competitive sports. This chapter provides informa­
tion on the many competitive and noncompetitive athletic
options available to persons with disabilities associated with
limb loss. Health care providers working with persons with
amputation are encouraged to facilitate active involvement
in physical exercise by means that involve participation in
sports and recreational activities. Physical therapists, occu­
pational therapists, prosthetists, and orthotists should work
together with the individual with special needs to assure that
the most favorable equipment and materials and instructions
for use are provided for maximum participation.
REFERENCES
1. Whitteridge D, Guttmann L. 3 July 1899–18 March 1980. In:
Biographical Memoirs of Fellows of the Royal Society. Vol 29.
London: The Royal Society; 1983:226–244.
2. Pringle D. Winter sports for the amputee athlete. Clin Prosthet
Orthot. 1987;11(3):114–117.
3. Nolan L. Lower limb strength in sports-active transtibial ampu­
tees. Prosthet Orthot Int. 2009;23(3):230–241.
4. Murphy NA, Carbone PS. Promoting the participation of chil­
dren with disabilities in sports, recreation, and physical activi­
ties. Pediatrics. 2008;121:1057–1061.
5. Tatar Y. Body image and its relationship with exercise and sports
in Turkish lower-limb amputees who use prosthetics. Science
Sports. 2010;25:312–317.
6. Deans SA, McFadyen AK, Rowe PJ. Physical activity and qual­
ity of life: a study of a lower-limb amputee population. Prosthet
Orthot Int. 2008;32(2):186–200.
7. Groff DG, Lundberg NR, Zabriskie RB. Influence of adapted
sport on quality of life: perceptions of athletes with cerebral
palsy. Disabil Rehabil. 2009;31(4):318–326.
8. Steptoe A, Butler N. Sports participation and emotional wellbe­
ing in adolescents. Lancet. 1996;347:1789–1792.
9. Hutzler Y, Bar-Eli M. Psychological benefits of sports for dis­
abled people: a review. Scand J Med Sci Sports. 1993;3:217–228.
10. Rimmer JH, Wolf LA, Sinclair LB. Physical activity among adults
with a disability—United States, 2005. MMWR Morb Mortal
Wkly Rep. 2007;56(39):1021–1024.
11. Finch N, Lawton D, Williams J, et al. Young disabled people and
sports. Disability Survey 2000: Survey of young people with a dis­
ability and sport. Accessed 15.04.11.
12. Disabled Sports USA.
13. Badminton.
14. Take it Outside—Hunting, Fishing Adapt to Meet Physical
Abilities and Enhance Experience. Challenge Magazine. 2005;
10(2):29–31.
15. Golf is for Everyone. Challenge Magazine. 2005;10(1):23–26.
16. Trail Orienteering.
17. Amputee Skydiving.
Amputee_skydiving.
18. AmpSurf.
19. Windsurfing.
20. Disabled Water Skiing.
disabled-water-skiing.
21. Prince F, Allard P, Therrien RG, et  al. Running gait impulse
asymmetries in below-knee amputees. Prosthet Orthot Int.
1992;16:19–24.
22. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention
effects on activity of lower extremity amputees. Arch Phys Med
Rehabil. 2006;87:717–722.
23. Lyon CC, Kulkarni J, Zimerson E, et al. Skin disorders in ampu­
tees. J Am Acad Dermatol. 2000;42:501–507.
24. May BJ, Lockard MA. Prosthetics & Orthotics in Clinical Practice:
A Case Study Approach. Philadelphia: Davis; 2011.
25. Tazawa E. Analysis of torso movement of transfemoral amputees
during level walking. Prosthet Orthot Int. 1997;21:129–140.
26. Van der Linde H, Hofstad CJ, Geurts AC, et al. A systematic lit­
erature review of the effect of different prosthetic components
on human functioning with a lower-limb prosthesis. J Rehabil
Res Dev. 2004;41(4):555–570.
27. Wind WM, Schwend RM, Larson J. Sports for the physically
challenged child. J Am Acad Orthop Surg. 2004;12:126–137.

772
29
29
Rehabilitation for Children with Limb Deficiencies
Joan E. Edelstein
Maria, who was born without a left forearm and hand,
Bobby, who caught his foot in a powered lawn mower, and
George who is recovering from femoral sarcoma have dif­
ferent skeletal, neuromuscular, learning, and psychosocial
challenges from those of adults with amputation. Children
share some rehabilitation issues with adults, particularly
the basic components of the prosthesis and the essen­
tial elements of postoperative care. Other considerations,
however, are unique. Because children are smaller than
adults, the choice of prosthetic components is not as broad.
Youngsters grow and develop through the rehabilitation
process. In addition, young people legally, financially, and
emotionally depend on adults for their medical, surgical,
and rehabilitation care.
Clinicians concerned with comprehensive management
of children with limb deficiencies need to consider the causes
of limb deficiency, the relationship of developmental mile­
stones to prosthetic selection and use, and the psychosocial
factors that affect children in order to design optimal pro­
grams.1–3 Care of the infant born with a limb anomaly is habil­
itation, whereas management of someone who undergoes
amputation because of trauma or disease is rehabilitation.
Unless the distinction is relevant, however, habilitation
and rehabilitation are used interchangeably in this chapter.
Similarly, limb deficiency is used to designate both congeni­
tal and acquired limb absence. The overall goal of physical
therapy is to facilitate the normal developmental sequence
and prevent the onset of secondary impairments and func­
tional limitations such as contractures, weakness, and depen­
dence in self-care.
COMPREHENSIVE CONSIDERATIONS
IN CHILDHOOD
The philosophy of this chapter is that the child with a limb
deficiency is first and foremost a person, with the beauty,
delight, and promise inherent in all young people.
Classification and Causes of Limb Deficiencies
The International Organization for Standardization approved
a system of limb deficiency classification in 1989 (Figure 29-1).4
Congenital limb anomalies are described anatomically and
radiologically as transverse, in which no skeletal elements
exist below the level of normal development, or longitudinal,
in which a reduction or absence of elements is present within
the long axis of the limb, with normal skeletal elements usu­
ally present distal to the affected bone (Figure 29-1). This sys­
tem replaces older terms, such as phocomelia (distal segments
attached to the torso), amelia (complete absence of a limb), and
hemimelia (partial absence of a limb).
Limb deficiency is caused by congenital deficiency, trauma,
cancer, and disease. In the total U.S. population, peripheral
vascular disease among adults accounts for more than 80%
of amputations, with a greater than 25% rate of increase in
the latter half of the twentieth century. Rates of trauma- and
­cancer-related amputations are declining, whereas the inci­
dence of congenital deficiencies remains stable.5 A recent
survey of all children with lower-leg deficiencies in The
Netherlands indicated 73% with congenital deficiencies and
27% with amputations as a result of malignancies (9%), trauma
(8%), infection (4%), and other pathologies (6%).6
Among those with congenital limb anomalies, transverse
deficiency of the upper limb, especially the left extremity, is
the most common.7 McGuirk and associates found the over­
all prevalence of limb deficiency among 161,252 newborns
to be 0.7 per 1000 births. Thirty percent of the defects were
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to do
the following:
1. Relate developmental milestones to the habilitation of
children with congenital limb deficiency and rehabilita­
tion of those with amputation.
2. Describe how prostheses can be designed to accommo­
date longitudinal and circumferential growth so that fit
remains comfortable and the child can attain maximum
function.
3. Outline the ways a clinician can address psychosocial
concerns for infants, toddlers, school-age children, and
adolescents.
4. Compare prosthetic options for children of various ages
who have upper- or lower-limb deficiencies.
5. Specify the training goals for children of various ages fitted
with upper- and lower-limb prostheses.
6. Design a habilitation program for an infant born with
multiple limb deficiencies.

Chapter 29  Rehabilitation for Children with Limb Deficiencies
773
caused by genetic factors, 4% by teratogens, 35% by vascular
disruption, and 32% by an unknown cause.8
Powered lawn mowers9–11 and all-terrain vehicles12 are
responsible for many traumatic amputations among children
and adolescents.
Long-term followup of the Childhood Cancer Survivor
Study, which is composed of 14,054 individuals who have
survived for 5 or more years after cancer treatment, indi­
cates that osteosarcoma or Ewing sarcoma of the lower limb
or pelvis is the most common tumor; the median age at
diagnosis is 14 years.13 Some patients with tumor are treated
by various limb-sparing procedures, and others undergo
amputation. Long-term outcome is similar, although more
patients with amputation used walking aids and were less
satisfied with their status as children.14–19
Developmental Milestones
Motor skills develop in a predictable sequence, with well-
established milestones that mark achievement of impor­
tant functional abilities.20–22 In the absence of cerebral
maldevelopment or malformation, the infant born with a
limb anomaly or a young child who undergoes amputation
demonstrates physical control at approximately the same
time as an unaffected child does. Limb deficiency, however,
often alters how the developmental tasks and activities are
performed. For  example, the 5-month-old infant who has
only one intact leg will develop a distinctive style of crawl­
ing. Therapists who conduct initial evaluations of these chil­
dren focus on muscle strength, range of motion, gross motor
patterns, coordination, attention span, and interests.
All children, not just those with limb deficiency, display
varying rates of neuromuscular development. Chronological
age cannot provide a complete picture of a child's develop­
mental level. In this chapter, milestones pertaining to upper
and lower limb development are related to habilitation of
children with limb disorders.
Physical conditioning programs, especially active sports,
are important to enhance general health and endurance, par­
ticularly for those who wear a prosthesis. Play and games
increase coordination and improve strength. Swimming is
particularly beneficial because it does not traumatize the
limbs and does not require a prosthesis; nevertheless, some
children may be reluctant to display an anomalous limb.
Accommodating Growth
All children grow, regardless of congenital anomalies or
amputations. Prosthetic planning should incorporate mea­
sures to maintain comfortable socket fit and symmetrical
limb length. The preschool-age child may need a new pros­
thesis almost yearly. Those in grade school often require a
FIGURE  29-1  A, International Organization for Standardization/International Society for
Prosthetics and Orthotics system for classifying upper-limb congenital limb deficiencies. Lower-limb
transverse deficiencies are named in a similar fashion. Levels can also be described by naming the
absent bone(s). B, Lower-limb longitudinal limb deficiency. The shaded area represents missing seg­
ments. (Reprinted with permission from Murdoch G, Wilson AB (eds). Amputation: Surgical Practice
and Patient Management. Oxford, UK: Butterworth Heinemann, 1996. p. 352.)
Shoulder total
Upper arm total
Upper arm middle third
Forearm total
Forearm upper third
Carpal total
Carpal partial
Phalangeal total
Phalangeal partial
A
B
Longitudinal
Tibial total
Tarsus partial
Ray 1 total
1

774
Section III  Prostheses in Rehabilitation
new ­prosthesis every 12 to 18 months, and teenagers outgrow
prostheses every 18 to 24 months.1
Longitudinal growth is typically more rapid than circum­
ferential growth, a troublesome fact for children with lower-
limb deficiency. Reconstructive surgery, especially circular
(Ilizarov) fixation, suits children with minimal length dis­
crepancy, whereas amputation remains preferable for those
with severe limb loss.23 Too short a lower-limb prosthesis
disturbs the quality and efficiency of gait and substantially
increases energy cost. In contrast, an upper limb prosthesis
that is slightly short will probably not present a noticeable
asymmetry and will have little effect on bimanual activities.
Endoskeletal prosthetic components facilitate lengthening
and substitution of more sophisticated components.
Vigorous play causes considerable wear of the mechanical
parts of prostheses. These parts are also vulnerable because
of their small size and the sand, grass, and mud which chil­
dren find inviting. Youngsters are likely to wear out pros­
theses from everyday use before circumferential growth
necessitates a change. Signs of an outgrown socket include a
tendency of the residual limb to slip out of the socket, pain
or skin reddening caused by socket tightness, and a flesh roll
around the margin of the socket. Socket liners are a conve­
nient way to accommodate circumferential growth; as the
child grows, ­liners can be removed. Alternatively, the pros­
thesis can be fitted with several layers of socks; the child
eventually wears fewer socks to accommodate the added
residual limb girth. Flexible sockets fitted to extra-thick
frames are another way to accommodate growth. To fit the
larger residual limb, a new flexible socket is made and mate­
rial is ground from the frame.23
Prosthetic alignment should complement the immature
skeleton and joint capsules. Children with surgical amputa­
tions through the bony diaphysis or metaphysis may have
­terminal bony overgrowth (Figure 29-2). As these children
grow, terminal periosteal new bone may protrude beneath
the terminal subcutaneous tissue and skin. Without treat­
ment, a bursal sac forms and the skin becomes ecchymotic
and hemorrhagic. The underlying bone then ruptures the
bursal sac, and infection can occur.1 Overgrowth is a par­
ticular problem when the adolescent growth spurt begins.
Customary treatment is excision of the periosteal sac, tran­
section of the distal 2 to 3 cm of bone, and primary closure
of the incision. Children may require this procedure several
times during the growth period.24 Another approach is con­
tinuous skin traction, which can be used to maintain skin and
soft-tissue coverage over the distal end of the residual limb
until skeletal growth is complete. The difficulties of keeping
distal force on the limb day and night usually preclude this
method. Disarticulation preserves the distal epiphyseal plate
and thus is not associated with overgrowth.
Near-normal range of joint motion is an important deter­
minant of effective prosthetic use in children with limb
deficiencies, as well as in adults with amputation. Active
therapeutic exercise designed to increase joint excursion is
preferable to passive stretching, especially in the presence of
congenital contracture.2
Postoperative Care
Postoperative care is simpler for young children who undergo
amputation than for adolescents and adults. Ordinarily the
residual limb presents little or no edema and the wound heals
rapidly. Phantom pain can occur and is associated with the
extent of preoperative pain. Approximately one-fourth of those
with congenital limb deficiency or amputation before the age of
6 years have phantom sensation, with far fewer reporting phan­
tom pain.25 A pain diary may help older children and adoles­
cents cope with phantom pain from traumatic amputation.
Psychosocial Factors in Habilitation
and Rehabilitation
Habilitation amounts to more than selecting a suitable pros­
thesis and devising appropriate training. All children have
personalities that develop along with their physical growth.
Optimal emotional development occurs when parents and
clinicians promote wholesome interactions. The essential
message is that the child has a unique personality and that
independence commensurate with age can be fostered.
Infants
Infants learn trust when their basic needs are met. The baby
with limb anomaly has as much need for trusting, responsive
care as does the infant with normal limbs. Infants respond to
the anxieties of parents and others who interact with them.
Successful habilitation depends on the parents’ replacing the
FIGURE  29-2  Bony overgrowth of the fibula in the transtibial
amputation limb of a 7-year-old child. In the original amputation
surgery, the fibula was slightly shorter than the tibia. (Courtesy J. E.
Edelstein.)

Chapter 29  Rehabilitation for Children with Limb Deficiencies
775
expectation of a “perfect” infant with the reality of a baby who
happens to have a limb deficiency. Birth of a baby with a limb
deficiency can elicit intense emotion. Because such an event
is rare in any hospital, medical staff may display shock and
feelings of helplessness or revulsion. Some parents character­
ize the first few weeks after birth as a nightmare. They believe
they are alone with a unique and hopeless problem when
questions go unanswered or evaded. Reactions of the infant's
grandparents, siblings, and other family members influence
habilitation. Mourning for the loss of the ideal child is part of
the coping process.1
Newborns are too young for prosthetic fitting; never­
theless, early referral to a specialized clinic is highly desir­
able. The core team is composed of a pediatrician, physical
therapist, occupational therapist, and prosthetist. The team
should be able to draw on the expertise of psychologists,
social workers, orthopedists, and engineers, depending on
the needs of the child and family.2 Effective clinical team
management involves the family in rehabilitation decisions
and weighs management recommendations in light of the
immediate impact on the child's welfare and the long-term
consequences on his or her appearance and function as an
adult. An important resource is the Association of Children's
Prosthetic-Orthotic Clinics (6300 North River Road, Suite
727, Rosemont, IL 60018-4226; ). The associ­
ation, founded in 1958, has held an annual interdisciplinary
conference since 1972.
The clinical team creates an atmosphere in which par­
ents and their baby are welcome, encouraging conversation
about feelings and obtaining answers to questions. The team's
approach aims to maximize the child's function, while learn­
ing the parents’ style of dealing with unexpected events. Team
members should empathize with parents’ grief, which can
bear little relation to the extent of the infant's disability.1 Some
parents resist holding the baby, hide the deformity, avoid
direct contact, or withdraw into silence. When clinicians hold
the baby, parents usually realize that the infant really is lov­
able. Rather than denying any difference, the team fosters the
attitude that, yes, they know the child is different, but they
recognize and accept the baby for what the baby is and what
the baby can do.
Families may be interested in seeing pictures or exam­
ples of the type of prosthesis that the child will probably
use. Expectations regarding the extent of prosthetic resto­
ration, however, may be unrealistic. Parents should under­
stand what prosthetic and surgical possibilities exist so they
can make rational decisions for their child. Infants usually
receive the first prosthesis at approximately 6 to 9 months of
age.2,25 Comparing the performance of children fitted with an
upper-limb prosthesis before 1 year of age with those fitted
later indicates no difference in satisfaction with the prosthesis
nor functional use.26 Some parents find it difficult to accept
the prosthesis, believing that it draws attention to the limb
deficiency.
The team can also help parents of children who undergo
amputation because of trauma or disease cope with feelings of
guilt and shock. Team members assist the family in realizing
that they were not negligent in protecting the child against
injury or not recognizing symptoms of a disease process early
enough to prevent amputation.
In addition to clinical team management, families benefit
from participating in peer support groups in which they can
share concerns, exchange information, and observe children
CASE EXAMPLE 1
A Newborn with Congenital Transradial
Limb Deficiency
Mr. and Mrs. M. anticipated the birth of their second child
with great eagerness. Mrs. M. had excellent prenatal care
and an easy pregnancy. The couple prepared their 2-year-
old daughter for her new role as “big sister,” encouraging
her to feed her dolls bottles and push them in a stroller.
Their daughter also moved to a junior bed with a cover­
let that she chose. Mr. and Mrs. M. repainted the crib and
hung new curtains in the nursery. The grandparents flew
to town to await the birth and to help care for the older
child and the new baby.
S. M. was born a few days later in the local hospital. She
was a healthy, term infant with lusty lungs. The obstetrical
nurse wrapped her in a receiving blanket and presented her
to her proud parents. Mrs. M. was wheeled to her room for
an overnight stay. Once settled in her room, Mr. and Mrs.
M. unwrapped the baby, only to discover a left transradial
limb deficiency. Mrs. M. shouted to the nurse on duty that
someone had made a mistake. The nurse checked identifi­
cation bracelets and confirmed that S. M. was indeed her
daughter. Both Mr. and Mrs. M. were distraught that the
baby's left hand was missing. In his grief and anger, Mr. M.
threatened the nurse, medical staff, and hospital adminis­
tration with legal action. Mrs. M., meanwhile, was silent,
turning her head to the wall, refusing food and medica­
tion. Discharge to home with the baby is planned for the
next morning.
Questions to Consider
• Given Mrs. M.'s depression and Mr. M.'s anger, how
should the attending physician and nursing staff
proceed?
• What should the social worker or psychologist do to
provide appropriate guidance for the parents?
• How might the grandparents and older sister help Mr.
and Mrs. M. when they return home with their new
daughter?
• What is the most constructive response the physical
therapist can give when first meeting S. M. and her
parents?
• How can the physical therapist and occupational thera­
pist facilitate positive immediate and long-term family
interaction?

776
Section III  Prostheses in Rehabilitation
of various ages playing with and without prostheses. Some
groups publish newsletters that share information with those
who live too far from the meeting site. The Amputee Coalition
of America (900 East Hill Avenue, Suite 205, Knoxville, TN
37915; ) is a peer advocacy orga­
nization that produces a magazine, monographs, and vid­
eos; has annual conferences; operates the National Limb Loss
Information Center; sponsors a youth camping program,
national peer network, and limb-loss education and aware­
ness program, among many other activities.
Parental acceptance of and active cooperation in the train­
ing program are the most important factors in its success and
largely determine whether the child regards the prosthesis
as a tool in daily activities.1 Families need to learn skin care,
prosthetic operation, maintenance, and the capabilities and
limitations of the prosthesis. Outpatient training is preferable
to avoid homesickness, which can interfere with the child's
learning. In addition, the constant presence of one or both
parents during therapy sessions enables the entire family to
learn about prosthetic use and maintenance. Putting a pros­
thesis on an active child is a skill that takes time for parents
to master. Scheduling appointments after naps and meals is
generally more productive than attempting to coerce a tired
and hungry child to participate in therapy. Clinicians should
incorporate many brief activities in the treatment session, rec­
ognizing that infants have short attention spans. Therapists
who treat infants need to interpret nonverbal indications of
comfort or discomfort and satisfaction or dissatisfaction with
the prosthesis. For example, the infant who coos, smiles, and
engages in play is probably content with the prosthesis and
the function it offers, whereas a cranky, crying child may be
contending with an ill-fitting socket. As with all patients, the
clinician must frequently examine the child's skin, with par­
ticular attention to persistent redness, indicating high pres­
sure, and irritation, which may signal dermatitis.
Toddlers
Toddlers must develop self-control to acquire the auton­
omy necessary to cope with their environment. The interval
between 1 and 3 years of age is characterized by the devel­
opment of language and functional communication, asser­
tion of independence, and interpersonal control. Children
as young as 3 years should be informed of any impending
surgery, whether to revise a congenital anomaly or treat
disease or injury. Doll play can help the child understand
surgery and rehabilitation. Special dolls that depict ampu­
tations at various levels, with and without prostheses, are
available.
Children must resolve feelings of deprivation and resent­
ment that accompany the visible alteration of their bodies.1
Mobility, control, exploration, initiative, and creativity are
prime emotional developmental milestones for older tod­
dlers and young school-age children. Parents and professional
staff should encourage the child's independence. Facile use of
a prosthesis can help children maximize their psychological
potential. Children compare themselves with others and ask,
“Where is my other hand (or leg)?” Children form two body
images, one with and the other without the prosthesis. Parents
should be able to give a simple and truthful answer, clearly
stating that the child will not grow another hand, saying some­
thing like “you were born this way.”1 Similarly, children who
undergo amputation need a realistic answer to the question,
“What happened to you?” The child may engage parents in a
power struggle regarding prosthetic wearing. A firm yet gentle
CASE EXAMPLE 2
A Child with Congenital Transradial Limb Deficiency
S. M. eats heartily, allows her older sister to sprinkle talcum
powder on her, and is developing normally. She smiles and
gurgles when someone approaches her. By 6 months she
is sitting independently and can use both arms to clutch
stuffed toys. She grabs the railings of her crib, attempting
to pull herself to standing. The physical therapist recom­
mended that the family take S. M. to a rehabilitation center
that specializes in caring for children with amputations.
At the center, Mr. and Mrs. M. overcame their initial hesita­
tion and now participate enthusiastically in a peer ­support
group, in which a dozen parents of children with limb defi­
ciency trade advice and provide emotional support.
Mr. and Mrs. M. are concerned about unwelcome com­
ments regarding their daughter's appearance, both with an
empty sleeve and with the possibility of a hook terminal
device. They tried to persuade the clinical team to provide
S. M. with an infant passive mitt, which would disguise
the anomaly. The therapist showed Mr. and Mrs. M. that
the mitt has no prehensile capability. One of the members
of the support group extolled the virtues of a myoelectric
hand, so Mr. and Mrs. M. then argued that S. M. should be
provided with “only the best,” regardless of cost. Support
group members pointed out that S. M. was too small for
myoelectric fitting but might be a candidate in another
year or two. S. M. is fitted with a simple transradial pros­
thesis consisting of infant voluntary-opening hook, wrist
unit, socket, and infant harness. The prosthesis does not
have a cable.
Questions to Consider
• What activities in the clinic would help S. M. acclimate
to her new prosthesis?
• What activities would be appropriate for a home pro­
gram for the first week after prosthetic fitting?
• What types of bimanual activities can be accomplished
with a transradial prosthesis with a passive hand rather
than a cable-controlled terminal device?
• What toys can be recommended to the grandparents
that will help S. M. incorporate the prosthesis in her
play time?
• How can the prosthesis facilitate S. M.'s physical and
psychological development?

Chapter 29  Rehabilitation for Children with Limb Deficiencies
777
approach with a range of acceptable choices usually enables
the child to incorporate autonomy needs while gaining pros­
thetic proficiency.
The clinical team should value the parents’ comments
about their child and involve the family in all aspects of care.
The waiting room should have a variety of safe toys to make
visits more pleasant. Parents should be present during the
child's examination and prosthetic fitting to increase commu­
nication and thereby reduce anxiety and maximize effective­
ness of the prosthetic prescription and fitting process.
School-Age Children
School-age children need to become industrious and engaged
in planning and executing tasks. The upper- or lower-limb
prosthesis can be instrumental in fostering this important
psychological task. The clinical team can help prepare the
child and family for encounters with teachers, scout masters,
clergy, and other adults.
In group experiences, the child may have to deal with feel­
ings of social devaluation. The teacher or other group leader
is in a position to bolster the child's sense of self-worth. The
first day at school or camp can be the occasion when the child
displays the prosthesis and demonstrates its function. The
presentation usually dispels the mystery of the appliance and
shows that the prosthesis is simply a tool that makes it eas­
ier for its wearer to engage in certain activities. The teacher
should be aware of the appearance of the residual limb, the
child's function with and without the prosthesis, any environ­
mental or programmatic adaptations that the child may need,
and how to cope with prosthetic malfunction. Anticipating
awkward situations helps develop coping strategies. For
example, in a circle game, classmates may be reluctant to hold
hands with someone who wears an upper-limb prosthesis.
If the teacher holds the child's prosthetic hook, the other stu­
dents are likely to realize that it is not scary or unacceptable
to do so. School officials may be concerned about the ability
of a child with a prosthetic leg to maneuver in the classroom
and playground. Classmates’ natural curiosity should be dealt
with through honest, simple answers. Although teasing is
inevitable, the young child who feels secure understands that
taunts are merely crude expressions of interest.
Among school-age children with limb deficiencies, demo­
graphic variables (such as age, sex, socioeconomic status, and
degree of limb loss) are not significant predictors of self-esteem.
In contrast, social support, family functioning, self-perception,
and microstressors affect the child's adaptation. Many school-
age and older children respond favorably to scouting, camping,
and other group recreational activities. Sports programs, such
as skiing, horseback riding, and track events, are fun and give
children with disabilities pride in athletic achievement.
Older Children and Adolescents
Adolescents face the critical step of developing a satisfying
identity within themselves and with their peer groups. The
teenager may select times when prosthetic wear is not desir­
able, for example, eschewing an upper limb prosthesis during
a football game or discarding the leg prosthesis when swim­
ming or playing beach volleyball. Adults should nurture young
adults so they develop sufficient self-esteem to make satis­
fying decisions about when to use or remove the prosthesis.
Teenagers with limb loss must cope with being visibly different.
Young adults have to adapt to a culture designed for those
who do not have a disability and must evaluate whether peo­
ple relate to them as individuals or as people with handicaps.
During adolescence, feelings such as “Why did this happen to
me?” are often intensified. Adolescents constantly reexamine
their body image; group showering after physical education
class may be especially stressful for those with limb loss. Other
developmental concerns in which limb loss plays a role are
choosing a vocation, obtaining a driver's license, and engag­
ing in sexual activity. The clinical team needs to be sensitive
to concerns about privacy, confidentiality, and independence.
Adolescents with bone cancer who undergo an amputation
typically pass through a stage of initial impact when they learn
that the treatment plan includes amputation. This news may
be met with despair, discouragement, passive acceptance, or
violent denial. Informing the adolescent of the rehabilitation
process and the achievements of others can be helpful. The
next stage is retreat, during which the adolescent experiences
acute grief. Anger may be part of the coping process. The goal
of grieving is relinquishing hope of retrieving the lost object.
The staff can reinforce the patient's strengths and encourage
maximal independence. The third stage is acknowledgment,
when the adolescent is willing to participate in rehabilita­
tion and has incorporated the changed appearance into his
or her body image. Reconstruction, the final stage, involves
the return to developmentally appropriate activities, such as
school, sports, and dating.
CASE EXAMPLE 3
An Adolescent with Osteogenic Sarcoma
E. K., who is 15 years old, is scheduled tomorrow to have
surgical ablation of his right arm at the level of the humeral
epicondyles to remove an osteogenic sarcoma. Six months
ago he fractured his right radial head. Although the frac­
ture healed well, he noticed persistent tenderness at the
elbow with a firm mass that was increasing in size. His phy­
sician referred him to an orthopedist. After a series of bone
scans and biopsies, the orthopedist confirmed the diagno­
sis of osteogenic sarcoma and recommended immediate
amputation. E. K. and his parents refused the surgery and
traveled to four clinics in the surrounding states seeking
advice regarding treatment of the tumor. They explored
alternate methods of treatment, including herbal prepara­
tions to shrink the sarcoma, en bloc resection with implan­
tation of an endoprosthetic elbow joint, and amputation of
the arm distal to the epicondyles. After meeting with the
clinical team at the children's medical center and speak­
ing with several patients who had had surgery and reha­
bilitation, they reluctantly agreed to amputation during his
summer vacation.

778
Section III  Prostheses in Rehabilitation
REHABILITATION AND PROSTHETIC
DECISION MAKING
Not all children with limb deficiency benefit from prosthe­
ses. With certain upper-limb anomalies, the remaining por­
tion of the limb is more functional when bare than it would
be if it were covered by a prosthesis.1,25 Some children who
are born with bilateral arm absence generally use their feet
to play and can do almost everything they need to without
using complicated and heavy prostheses.25,27,28 In one large
study, approximately half of the children with unilateral con­
genital deficiencies and two-thirds of those with amputation
received prostheses. By the age of 12 years, two-thirds of those
who had prostheses were still using them.29
Rehabilitation of Children with Upper-Limb
Amputation
Because functional use of an upper-limb prosthesis often
involves control of a terminal device (substitute for the miss­
ing hand), the prosthetic design and the rehabilitation pro­
gram should be appropriate for the child's level of motor,
cognitive, and perceptual development.
Infants
Prosthetic fitting and training should complement an infant's
development. Although a prosthesis usually is not fitted until
babies are at least 6 months of age, earlier developmental
accomplishment paves the way for successful prosthetic use.
The average 2-month-old infant can hold objects with
both hands. The baby who lacks one or both hands typically
attempts to hug a stuffed animal with the forearms or upper
arms, capitalizing on the tactile sensitivity of the skin. The
normal 3-month-old can bring grasped objects to the mouth.
Three months is also the age when babies attempt two-handed
prehension, although this skill is not perfected until the child
attains sitting balance at age 6 to 9 months.3
The 4-month-old infant props on the forearms, shifts
weight to reach, and usually enjoys shaking noisy rattles
by using rapid elbow flexion and extension. An important
developmental step is reached at approximately the same age
when the child can manipulate objects with one hand while
the other hand stabilizes the toy. Simultaneous sitting and
manipulating are still challenging at this age. Increased trunk
strength enables the baby to reach unilaterally and bilaterally.
Bilateral coordination at 4 months allows the infant to reach
objects at the midline. Two-handed holding of a bottle typi­
cally occurs at approximately 4.5 months.22
By the fifth month, the infant can transfer toys from one
hand to the other and is thus aware of the usefulness of hold­
ing objects. The infant's dominant interest is in getting food;
exploring surroundings; and making social contact with
those who feed, hold, and provide care. Holding a large ball
encourages the infant to clasp objects between the arms.
Manipulating blocks or beads promotes stabilization of prox­
imal body parts to allow fine movements with distal parts.
Although a baby with intact limbs can get to the quadruped
position and shift weight from side to side,22 the infant who
is missing one or both arms will probably find that crawling
is impossible and will have difficulty coming to a sitting posi­
tion and pulling to a standing position.
Six months is generally considered the optimal age for
upper-limb prosthetic fitting (Figure 29-3).1 The baby with
unilateral amputation has achieved good sitting balance, can
free the sound hand for manual activities while sitting, and is
actively engaged in exploring the environment. The prosthe­
sis restores symmetrical limb length and enables the infant
to hold stuffed animals and similar toys at the midline. The
prosthesis also accustoms parents to the concept that a pros­
thesis will likely be a permanent part of their child's ward­
robe. Fitting can assuage parental guilt or shame regarding
their infant's abnormal appearance by replacing negative
reactions with a constructive device that enhances the baby's
development. Many parents seek a prosthetic hand to dis­
guise the limb anomaly. Early fitting provides experience that
will be the basis for the young person's later decision regard­
ing whether to continue with prosthetic use. Fitting earlier to
a rapidly growing infant makes the maintenance of socket fit
difficult. In addition, a younger baby may find the prosthesis
a hindrance during rolling maneuvers. Infants who are much
older than 6 months may resist a prosthesis that deprives
them of using the tactile sensation at the end of the residual
limb. Initial fitting after 2 years tends to result in greater rejec­
tion of the prosthesis because by then the child has developed
compensatory techniques.
At 8 months, most babies sit while manipulating objects
with both hands by using gross palmar grasp and controlled
release. A prosthesis aids in clasping large objects and sta­
bilizing smaller ones while the sound hand explores them.
An excellent student, E. K. is also the shortstop on his
high school varsity baseball team and plays the tuba in the
marching band. For the past two summers he has been a
counselor at a sports- and computer-oriented camp. The
family is committed to devoting all its financial and emo­
tional resources to enable E. K. to resume a full agenda
of academic and recreational activities. E. K. has compiled
considerable information regarding prostheses from the
Internet.
Questions to Consider
• What postoperative management would foster wound
healing and enable E. K. to become accustomed to a
prosthesis?
• How can the occupational therapist and physical thera­
pist help E. K. cope with loss of his dominant hand?
• Compare the advantages of a cable-controlled prosthe­
sis with a prosthesis having a myoelectrically controlled
terminal device and cable-controlled elbow unit.
• What terminal device would be most suitable for E. K.?
• How can the clinical team guide E. K. when he returns
to school in September?
• In what recreational activities can E. K. engage after his
amputation?

Chapter 29  Rehabilitation for Children with Limb Deficiencies
779
By 15 months, most children can place a pellet in a small con­
tainer and use crayons for scribbling and a spoon for feeding.
These skills can also be performed with a prosthesis.
The first prosthesis is usually passive, that is, it does not
have a cable or other operating mechanism. The terminal
device may be a hook or a passive mitt. The hook is covered
with pink or brown resilient plastic to disguise its mechanical
appearance. The plastic also blunts the impact of the hook as
infants explore with it, swiping themselves and others in the
vicinity. The hook may be a voluntary-opening design, with­
out a cable. Parents can place a rattle or other object in the
hook to acquaint the baby with prehension on the deficient
side. A few children start with the Child Amputee Prosthetics
Project (Los Angeles, CA) terminal device (Figure 29-4), which
functions in the voluntary-opening mode. Some infants have
a voluntary-closing hook on the first prosthesis (Figure 29-5);
in the absence of a cable, the hook holds the toy secured with
tape or a rubber band. The three options offer little differ­
ence in function. A fourth terminal device option is the infant
passive mitt. The mitt has a less-mechanical appearance than
other terminal devices but has no prehensile function; objects
can be taped to it for the amusement of the baby. The absence
A
B
FIGURE 29-3  Infant prosthetic hands. A, Centri passive hand.
B, Infant playing with Alpha hand. (A, Courtesy Fillauer Companies,
Inc., Chattanooga, TN.; B Courtesy TRS, Inc., Boulder, CO.)
A
B
FIGURE  29-4  Children's terminal devices. A, Voluntary-closing
hand. B, Boy wearing CAPP (Child Amputee Prosthetics Project)
Voluntary-opening terminal device on a transradial ­prosthesis
(A, Courtesy TRS, Inc., Boulder, Colo.; B, Courtesy Fillauer
Companies, Inc., Chattanooga, TN)

780
Section III  Prostheses in Rehabilitation
of a hooked configuration hampers use of the mitt when the
baby attempts to pull to standing at the side of the crib or play­
pen. Whatever the design, the terminal device is generally fit­
ted into a wrist unit at the distal end of the socket.
The thermoplastic socket is custom molded to a plas­
ter model of the child's residual limb. A fabric sock protects
the skin from pressure concentration imposed by the socket.
A snug fit is needed around the humeral epicondyles to sta­
bilize the prosthesis on the child's residual limb. Depending
on the rate of growth, changes may be needed every 2 to
4 months. If the anomaly is higher, the first prosthesis usually
does not have an elbow unit even if the anomaly is compa­
rable to transhumeral amputation.
Regardless of the level of limb loss, the prosthetic socket
is suspended on the infant's torso by a harness, which typ­
ically has more straps than an adult harness. The toddler
harness inhibits the infant's attempts to remove the pros­
thesis, whether deliberately or inadvertently during rolling
and crawling.
Clothing problems arise when a prosthesis is worn. The
rigid parts of the prosthesis eventually wear holes in fabric.
Shirts and blouses worn over the prosthesis should be loose
fitting; sleeves set at the natural shoulder line can interfere
with cable operation, thus raglan sleeves are preferable.
Training the infant fitted with a passive prosthesis usu­
ally begins with two sessions in a 1-week period and then at
periodic followup appointments. The first meeting should be
held when the baby is well rested and content. The therapist
or parent puts the prosthesis on the baby, who is then placed
on the floor with various toys. The therapist encourages the
parents to play with and handle the baby while the infant is
wearing the prosthesis. The baby may ignore the prosthesis
because its socket eliminates the sense of touch and because
the length of the prosthesis feels awkward. Parents should
present large toys that require the use of both arms. The basic
prosthesis allows the infant to cuddle a teddy bear, swat at
a dangling toys, and use both upper limbs for rolling and
crawling. Training involves instructing the parents and other
caregivers to gain familiarity with the prosthesis, care for the
infant's skin by making certain that the socket and harness
do not exert undue pressure, and provide toys that require
bimanual prehension (Box 29-1). Placing a rattle in the ter­
minal device is another way of acquainting the infant with
grasp on the side of limb deficiency. At the end of the session,
the therapist and parent remove the prosthesis to inspect the
child's skin for signs of irritation from the socket or harness.
Parents learn how to apply the prosthesis and how to encour­
age full-time wear except during baths, naps, and bedtime.
The baby may be rather awkward when sitting and moving
while adjusting to the weight of the prosthesis. Toys suitable
for the infant's developmental level, such as large balls, dolls,
A
B
FIGURE  29-5  Voluntary-closing terminal devices on prostheses. A,
Lite-Touch hand. B, Adept hook. (Courtesy TRS, Inc., Boulder, CO.)
Therapy sessions are designed to increase the infant's
• Comfort with the prosthesis
• Wearing tolerance
• Ability to clasp large objects
• Ability to use the prosthesis to aid in sitting and crawling
Parents of an infant with a prosthesis should do the
following:
• Apply and remove the prosthesis correctly
• Care for the child's skin
• Care for the prosthesis
• Recognize and report to the clinical team any prob­
lems with the prosthesis or child
BOX 29-1  Prosthetic Training Goals for Infants

Chapter 29  Rehabilitation for Children with Limb Deficiencies
781
stuffed animals, balloons, xylophones, and other noisy and
colorful objects, provide incentives for enjoying the prosthe­
sis. Parents can put a mallet or other toy in the hook so that
the infant can obtain pleasure from using the prosthesis. Push
and pull toys are appropriate when the child is able to stand
and cruise.25
Printed instructions, augmented by audiotapes or vid­
eotapes, are useful guides for the family. Instructions can
address parental concerns regarding the possibility that the
child may catch the prosthesis on table legs or use it to strike
themselves or others; children recover balance readily, and
peers are usually able to defend themselves.
At the second training session a few days later, the thera­
pist can assess the parents’ experiences. Donning and doff­
ing the prosthesis should be reviewed. Initially, the infant
may tolerate the prosthesis only for a few minutes. It should
be frequently applied during the day. Eventually, the child
should be able to wear it most of the day, except when sleep­
ing and bathing.
Subsequent followup sessions focus on the adequacy of
prosthetic fit and the child's readiness for the addition of a
cable to the prosthesis, substitution of a myoelectrically con­
trolled prosthesis for a passive one, or, in the case of the child
with transhumeral amputation, the addition of an elbow unit.
Toddlers
When the child is between the ages of 15 and 18 months, con­
trol cables may be added to traditional, body-operated pros­
theses (Figure 29-6). Active control may not become reliable
until the toddler is approximately 2.5 years of age, when the
understanding of cause and effect is established. Readiness for
the cable is indicated when the child wears the prosthesis full
time, can follow simple instructions, has an attention span of
at least 5 minutes, and will allow the therapist and prosthetist
to handle him or her. A toddler who resists instruction from
someone other than the parent may be too immature to learn
to control the prosthesis.
If the prosthesis has a voluntary-opening hook, it
should be fitted with a half- or a quarter-width rubber
band to facilitate opening. The tension in the terminal
device should be sufficient to let the child hold objects
but not so great that opening the hook is difficult. Young
children appear to use the voluntary-closing hook with
as much ease as the more traditional voluntary-opening
terminal devices. Box 29-2 summarizes the goals of pros­
thetic ­training for toddlers.
The training environment should be quiet, with a low table
holding a few toys that require bimanual grasp, such as large
beads and a string with a rigid tip. For the child with unilateral
amputation, the terminal device serves to hold an object, such
as a bead, while the child threads the string through the bead.
The therapist is on the child's prosthetic side, holding the child's
forearm at 90 degrees of elbow flexion, the optimal position of
cable operation. This position also keeps the terminal device
and the grasped object within the child's view. The adult moves
the child's forearm forward, flexing the shoulder, tensing the
cable, and causing the hook to operate. When the arm is moved
back (shoulder extension), the terminal device changes posi­
tion. A voluntary-opening hook opens with shoulder flexion,
whereas a voluntary-closing hook closes with shoulder flex­
ion. The therapist encourages the child to help with the control
motion. With either design, the initial training involves placing
a toy in the hook and encouraging the child to discover how
to keep it in place. With a ­voluntary-opening hook, the child
simply relaxes to allow the rubber bands or springs to keep the
hook fingers closed. The voluntary-closing hook requires that
the wearer exert tension on the control cable by the harness to
keep the hook closed. Children use the same control motions
as do adults, namely shoulder flexion or shoulder girdle pro­
traction for terminal device operation. The toddler may revert
to the earlier practice of opening the terminal device with the
sound hand; eventually he or she will find that cable opera­
tion is more efficient, allowing more complex bimanual play
maneuvers.
Reaching for objects with the sound hand is the child's
initial preference. To provide the child the necessary prac­
tice with the prosthesis, the therapist or parent should offer
large objects or toys that require bimanual grasp to operate.
Another technique to encourage prosthetic use is to have the
child hold one object in the sound hand and another in the
prosthesis. For example, two hand bells make twice as much
sound as one. With some young patients, prosthetic training
FIGURE  29-6  Children learning that shoulder flexion produces
terminal device operation because flexion tenses the control cable.
(Courtesy of TRS, Inc., Boulder, CO.)
Therapy sessions are designed to increase the toddler's
• Control of the terminal device
• Control of the elbow unit
• Use of the prosthesis in bimanual prehension
• Use of the prosthesis in functional activities
Parents of toddlers with prostheses should do the
following:
• Provide toys that require bimanual prehension
• Encourage use of the prosthesis as an assistive device
• Inspect the skin to determine whether the prosthesis
causes undue irritation
BOX 29-2  Prosthetic Training Goals for Toddlers

782
Section III  Prostheses in Rehabilitation
merely involves using the terminal device as a stabilizer rather
than as a prehensile tool; for example, the child may lean the
prosthesis onto a replica of a mailbox while placing objects
in the slot with the sound hand. The prosthesis also serves to
stabilize paper while the child draws and colors pictures.
Although children as young as 18 months have been fit­
ted with myoelectrically controlled transradial prostheses,30
those who are at least 3 years of age have an easier time learn­
ing to contract the appropriate flexors and extensors to close
and open the hand (Figure 29-7). The prosthesis is relatively
heavy, susceptible to breakdown, and needs more mainte­
nance than does a cable-operated device. To prepare the child
for a somewhat heavier myoelectric prosthesis, weight should
be gradually added to the passive prosthesis. Rudimentary
training begins with practice with the prosthesis off the arm.
At first, the therapist may place an electrode on the sound
forearm and ask the child to flex and extend the wrist to close
and open the fingers of the prosthetic hand. The therapist
then places an electrode on the forearm on the amputated side
and encourages the child to discover that contraction of the
forearm musculature on that side achieves the same results.
Motorized toys can be used to help the child practice delib­
erate contraction of flexors and extensors to cause an electric
train, for example, to go backward and forward, depending
on which electrode is stimulated. When the child gains rea­
sonable proficiency, the prosthetic socket can be made with
the electrodes embedded in it. Care must be taken to achieve
and maintain snug fit so that the electrodes are in constant
contact with the skin.
Whether the prosthesis is cable or myoelectrically con­
trolled, practice to gain prosthetic proficiency is the same.
The beginner experiences many instances of dropping objects
while learning the amount of muscle contraction or cable ten­
sion needed to maintain suitable terminal device closure. The
ability to close the terminal device around an object develops
before active release. Grasping an object from the tabletop is
difficult. Children attempting to put objects into their mouths
discover that the change in shoulder position alters the ten­
sion on the control cable. Similarly, children who drop toys
and try to retrieve them from the floor discover how to hold
the shoulder to maintain adequate cable tension. Those who
are wearing myoelectrically controlled prostheses also notice
that the prosthesis is easier to operate in some forearm posi­
tions than in others.
Moving pegs on a board affords the child practice in open­
ing and closing the terminal device. Tossing a beanbag is use­
ful for teaching terminal device opening, as is playing cards.
Cutting paper is another satisfying activity. The child holds
the paper in the terminal device and uses the scissors in the
sound hand. Prosthetic training should acquaint the child
with objects of various textures, sizes, and shapes. Resilient
foam toys are easier to grasp than are those made of rigid plas­
tic, wood, or metal. Playing with sewing cards, nested bar­
rels, and snap-apart beads; removing a toy from a drawstring
bag; opening a zipper; removing loose clothing; opening
small boxes of raisins; opening and closing felt-tipped pens;
and playing the xylophone entice the child to attempt grasping,
A
B
C
FIGURE 29-7  Myoelectric transradial prosthesis. A, Prosthesis. B,
Boy wearing right prosthesis playing with stuffed toy. C, Boy wearing
right prosthesis playing basketball. (Courtesy Otto Bock Orthopedic
Industry, Inc., Minneapolis, MN.)

Chapter 29  Rehabilitation for Children with Limb Deficiencies
783
holding, and releasing motions with the terminal device.31
Moving checkers or other markers from one location to
another on a game board is a good drill. The prosthesis is help­
ful when swinging and climbing on the playground, rolling a
wheelbarrow or doll carriage, jumping rope, and riding a tri­
cycle. Children with unilateral amputation usually regard the
intact limb as the dominant one. Many children with unilat­
eral amputation refer to the prosthesis as the helper, which cor­
rectly identifies its role as a device that assists the intact hand.
Functional training depends on the child's ability to reach
the mouth, waist, hips, feet, and perineum. Feeding, dressing,
writing, and personal hygiene are incorporated at the appro­
priate times. Thirty-month-old children can throw and catch
a ball, start uncomplicated dressing, and eat with a spoon
with little spillage. Children play in sand, earth, and water
and engage in rough-and-tumble activities, which can dam­
age the prosthesis and the skin. Daily inspection and atten­
tion to minor problems help avoid major prosthetic repairs
and skin disorders.
A 2-year-old with transhumeral amputation may have a
prosthesis with an elbow unit, although mastery of the elbow-
locking cable is unlikely to occur before the third birthday.
Strategies to self-manage donning and doffing the prosthesis
can be introduced to children as young as 3 years. They find
removing the prosthesis easier than applying it.
At 3 years of age, the child may begin to be curious about
the rotational possibilities of the wrist unit. Objects of vari­
ous shapes within reach oblige the child to turn the terminal
device in the wrist unit to the suitable position. Most objects
can be manipulated with the terminal device in the pronated
position; however, thin disks are more easily managed with
the terminal device in midposition, and small balls are best
cradled in the terminal device when it is rotated to the supi­
nated position. Holding the handlebars of a tricycle or manip­
ulating hand controls in other wheeled toys helps the child
learn how to use terminal device rotation in the wrist unit.
Prosthetic activities for the toddler should include eating,
drinking, dressing, and managing crayons and other writ­
ing implements. Three-year-olds blow soap bubbles, pull up
pants, pull a belt through loops in pants, and fill a cup with
water from a spigot.31
Throughout the toddler phase, work periods should alter­
nate with free play that may or may not involve the prosthesis.
Weekly training sessions are effective. Parents should inspect
the axilla; persistent redness indicates that the harness is
applying undue pressure. The home program should include
written suggestions regarding activities to promote bimanual
prehension, instructions concerning the care of the prosthe­
sis and the care of the child's skin, terminology pertaining to
parts of the prosthesis, and ideas regarding clothing that will
not impede prosthetic function.
School-Age Children
An important consideration for the growing child is a socket
large enough for comfortable fit and adequate prosthetic control.
The 4-year-old child is usually coordinated enough to
grasp fragile objects without breaking or crushing them.
With a voluntary-opening hook, the child must maintain
tension on the control cable to prevent the hook fingers
from snapping shut. A voluntary-closing terminal device
necessitates application of gentle tension on the cable rather
than forceful shoulder motion. With a myoelectrically con­
trolled hand, the child must minimally contract flexors so
that the fingers close on the object without undue pressure
(Figure 29-8). Four-year-olds can pour from containers, peel
a banana, sharpen a pencil with a hand-held sharpener, sew,
hammer nails, and apply adhesive bandages (Figure 29-9).
The average 5-year-old can open a milk container and sweep
with a brush and dust pan.31 Box 29-3 summarizes the goals
of prosthetic training for school-age children.
The pediatric prehension assessment provides a standard
clinical assessment of children with transradial amputation
by objectively scoring activities of daily living that require
repetitive use of a terminal device. Three test batteries cor­
respond to age groups of 2 to 3 years, 4 to 5 years, and 6 to
7 years. In test 1, the child is asked to string four large beads,
open four 35-mm film cans, separate three nested screw-top
barrels, assemble 10 interlocking beads, and separate a five-
piece notched plastic block. In test 2, the child uses a sewing
card, strings 10 small beads, sticks an adhesive bandage to the
table, cuts a paper circle and glues it to another paper, and
opens a small package of tissues. In test 3, the child is asked to
cut modeling plastic with a knife and fork, cut paper, discard
five playing cards from a hand of 10 cards, lace a shoe and tie
a bow, and wrap a book.31
Card games often fascinate children in elementary school.
Maintaining several cards in the terminal device and then
releasing the desired card involves a gradation of tension on
the control cable for prostheses equipped with a voluntary-
opening or -closing terminal device. Card playing is more dif­
ficult with a myoelectrically controlled prosthesis because the
child must contract the forearm flexors and extensors with
the correct amount of force at the appropriate time.32 The
5-year-old should be independent in dressing, except for but­
tons, shoelaces, and pullover shirts and sweaters. The child
FIGURE  29-8  Girl contracting forearm muscles to operate a
myoelectrically controlled terminal device. (Courtesy Otto Bock
Orthopedic Industry, Inc., Minneapolis, MN.)

784
Section III  Prostheses in Rehabilitation
also needs to learn how to take care of the prosthesis, keep it
clean, and ask for help when parts malfunction. Skin inspec­
tion is an essential part of training.
Older Children and Adolescents
Many older children are able to incorporate the prosthe­
sis in school activities. A myoelectric hook terminal device
(Figure 29-10) may be practical for the teenager who is inter­
ested in repairing bicycles and cars. Sports prostheses, such
as those with a terminal device designed to hold a basket­
ball, give wearers more opportunities to participate in group
activities (Figure 29-11).33 Teenagers may find that playing a
musical instrument is pleasurable. Simple adaptations, such
as fingering a trumpet with the sound hand and supporting
it with the prosthesis, can open a world of enjoyment to the
musician.34 Older adolescents should have vocational explo­
ration, vocational assessment, and, when indicated, job train­
ing. Obtaining a driver's license is a meaningful event for
most teenagers. The use of a prosthesis does not influence
the capacity to drive, although those with upper-limb defi­
ciency are more likely to use adaptive devices when driving
than those with lower-limb deficiency.35
Some adolescents with unilateral limb deficiency seek
escape from parental control by abandoning their prosthe­
ses, preferring to manage with the intact limb. A few young
people ultimately resume prosthetic wear on a full-time or
FIGURE 29-9  Bimanual activities. A, Large blocks. B, Playing a toy xylophone. C, Riding a tricycle.
D, Boy wearing right prosthesis pouring rice from a glass. (A and C, Courtesy TRS, Inc., Boulder,
CO; B, Courtesy J. E. Edelstein; D, Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)
A
B
C
D

Chapter 29  Rehabilitation for Children with Limb Deficiencies
785
occasional basis. Certain activities are more easily accom­
plished without the prosthesis or cannot be done with a
prosthesis. For example, prostheses are not worn when show­
ering. Individuals with transradial amputation may prefer to
stabilize objects in the antecubital fossa, using elbow flex­
ion, rather than use a prosthetic terminal device. Sometimes
simple equipment adaptation facilitates one-handed perfor­
mance, such as the use of a book holder, guitar pick band,
or camera grip. Some people become quite facile with the
remaining upper limb, learning to hit a baseball, and fold
laundry with one hand.
Functional outcome evaluation of children fitted with
unilateral upper prostheses is aided by the Prosthetic Upper
Extremity Functional Index administered to parents and older
children.36 Long-term followup of children with unilateral
transradial deficiency indicates that approximately 40% use
a passive prosthesis, 40% use a voluntary-closing terminal
device, and 15% use a myoelectrically controlled prosthesis.37
Of those trained to use a myoelectrically controlled prosthesis,
most report satisfaction with it even though many do not wear
it.38 Rejection of a prosthesis is somewhat less among children
who had been fitted at younger than 2 years of age39,40 or prior
to the age of 3 years.41 Prior to kindergarten, children wear the
prosthesis for an average of nearly 6 hours a day.42 Studies of
older children suggest that quality of life is about the same for
those who do and do not wear prostheses,43 with prostheses
used for specific activities.44 Overall, children with upper-limb
deficiency are as socially competent as able-bodied peers.45
Rehabilitation of Children with Lower-Limb Loss
Children with lower-limb deficiencies deserve clinic team
management similar to that described for those with upper-
limb deficiencies. Early referral to a clinical team is equally
important for the family with a child who has a lower-limb
amputation or limb deficiency. Peer support is also invalu­
able for parents who need to share concerns, suggestions,
and camaraderie with others who coping with a similar
situation. Treatment should suit the patient's developmen­
tal stage so that prosthetic use fosters achievement of key
milestones. Parents serve as the primary instructors of their
­children, with the guidance of the physical therapist and
other ­members of the clinical team.
Infants
Sitting balance is a major guide to lower-limb prosthetic
­fitting.1 The average age when babies accomplish independent
sitting is 6 months. Sitting depends on postural control and
antigravity muscle strength. Sitting balance and trunk stabili­
zation are also important for freeing the hands to explore the
environment.22 Box 29-4 summarizes the goals of rehabilita­
tion of infants with lower-limb malformation or amputation.
Infants who are 5 to 7 months of age discover the mobility
possibilities of crawling and creeping, moving from supine to
four-point and sitting positions, and moving to the hands and
knees from the sitting position.29 Crawling involves the alter­
nate action of the opposite arms and legs in a manner simi­
lar to walking. Hip extensors strengthen during crawling and
kneeling. Rocking on four points before launching into crawl­
ing is another important precursor to walking.
Most babies are able to overcome gravity to pull up to
a standing position and rise from kneeling to standing at
approximately 8 months. When pulling to a standing posi­
tion, the baby expends great energy bouncing and actively
disturbing balance. Bouncing gradually gives way to shifting
weight from side to side. The initial standing posture is wide
based, with the hips abducted, flexed, and externally rotated.
The base accommodates the child's new center of gravity
position, which is higher than when crawling. Maintaining
upright posture depends on sufficient maturity of the visual,
proprioceptive, and vestibular systems.
Stepping movements are common among 7-month-olds
who are supported. Cruising along furniture is a preferred mode
Therapy sessions assist the school-age child to do the
following:
• Maintain proper prosthetic fit
• Grasp firm and fragile objects without dropping or
crushing them
• Open and close the terminal device reliably
• Don and doff the prosthesis independently
• Dress independently
• Recognize when the prosthesis needs repair or alteration
Parents of school-aged children with prostheses should
do the following:
• Be independent in daily activities and play
BOX 29-3  Prosthetic Training Goals for
School-Age Children
FIGURE 29-10  Myoelectric Greifer terminal device on right tran­
sradial prosthesis. (Courtesy Otto Bock Orthopedic Industry, Inc.,
Minneapolis, MN.)

786
Section III  Prostheses in Rehabilitation
A
B
D
C
FIGURE 29-11  Activity-specific terminal devices. A, Boy swinging golf club with GolfPro terminal device. B, Adolescent playing hockey
with PowerPlay Hockey terminal device. C, Girl playing basketball wearing left transradial prosthesis with Mill's ReBound-Pro terminal
device. D, SuperSport terminal device. (Courtesy TRS, Inc., Boulder, CO.)

Chapter 29  Rehabilitation for Children with Limb Deficiencies
787
of locomotion when the child is approximately 10 months old.
Cruising strengthens the hip abductors. The typical nondis­
abled child stands alone at approximately 11 months and walks
alone at 12 months.20,46 The urge to walk is the culmination of
the endless pulling and standing activity that has occupied the
baby for several preceding months.
Some infants undergo surgery either to transform a con­
genitally anomalous limb into one that is more suitable for a
prosthesis, or as part of the treatment of a limb that has been
involved in trauma or in the presence of tumor. Skin graft­
ing in these instances does not result in adverse functional
outcome.47 Another intervention applicable to a few children
is limb lengthening using an Ilizarov apparatus. Long-term
outcomes are favorable, with average to above-average quality
of life.48–50 A very few children with myelodysplasia undergo
amputation of lower limbs that are severely contractured or
have intractable ulcers. Those with transtibial or more distal
amputation readily become prosthesis wearers.51
Regardless of the etiology of limb deficiency, the goal of
prosthetic fitting is to facilitate the child's attainment of motor
milestones.52 The infant who is missing a lower limb should
have prosthetic restoration at approximately 6 months, when
the baby has enough trunk control for sitting and is ready to
pull to a standing position. A simple prosthesis fosters sym­
metrical sitting balance and aids the baby's attempts to pull to
standing. In addition, the prosthesis equalizes leg length, adds
weight to the anomalous side, and obviates the tendency to
compensate with a one-legged standing pattern. Reducing the
weight asymmetry inherent in limb deficiency facilitates rota­
tional control of the trunk. The prosthesis enables standing and
walking. Otherwise, the world is circumscribed by the confines
of the stroller or playpen, and the deficiency becomes a source
of shame. Fitting before 6 months might hinder the baby's
efforts to turn from prone to supine position and back again.
The first prosthesis includes a solid-ankle, cushion-heel
(SACH) foot, the smallest foot manufactured (Figure 29-12).
Rubber-soled shoes give the infant more traction and are
therefore preferable to leather-soled shoes. The initial trans­
tibial prosthesis usually has a thigh corset (Figure  29-13),
primarily to help the child retain the prosthesis on the ampu­
tation limb. The prosthesis must be comfortable when the
baby stands, sits, squats, crawls, and climbs. A silicone socket
liner (Figure 29-14) may be desirable to protect sensitive skin
from chafing in the socket. The toddler with transfemoral
amputation starts with a prosthesis having a locked knee. By
3 years, most can manage an unlocked knee (Figure 29-15).
Polycentric knee units, with or without stance control, are
appropriate for school-age youngsters (Figure 29-16).53,54
During the first training session, the therapist and parent
confirm that the prosthesis fits comfortably, without redness of
the residual limb. Most of the handling of the child should be
done by the parent, rather than the therapist, so that the family
gains confidence in managing the child at home. Useful equip­
ment includes a play table, an elevated sandbox, a floor mat, a
rolling stool, a full-length mirror, steps, and a ramp. The parent
should encourage the child's standing on both feet by first sup­
porting the trunk and then gradually reducing the support. The
young child gains prosthetic tolerance and standing balance by
being near the table. Initially, the child may lean the torso against
the table while manipulating toys that require use of both hands.
Toys should be moved to places on the table where the child has
to reach in different directions, shifting weight. Eventually, the
child will move along the periphery of the table to place objects
in the desired location. When first learning to walk with a pros­
thesis, the child moves cautiously. Initially, the child takes small
steps and has a wide base, keeping the trunk upright and arms
abducted. The new prosthesis wearer resembles normal peers
who begin walking with increased hip and knee flexion, full-
foot initial contact, short stride, increased cadence, and relative
foot drop on the sound side in swing phase.20–22
At home, a sturdy table that is chest high to the child encour­
ages standing balance and cruising during play with toys placed
on the table. Raised sandboxes, blocks, finger paints, and pans
of water with floating toys all promote standing balance. A
playpen is a good environment to enable the baby to pull to
standing, cruise the perimeter, and sit when the baby wishes.
Balls are useful in prosthetic training. Kicking a ball requires
balance on one leg and flexion of the other leg. The baby starts
by holding on to a stable object with both hands, then with one,
and eventually letting go. Throwing a ball requires good bal­
ance and usually sustains the infant's interest. Wheeled toys,
such as a doll carriage, enable the child to walk with a modi­
cum of support. Placing toys where the child must take a few
steps to reach them fosters independent walking.
Young children frequently revert to crawling and sitting on
the floor as they grow accustomed to the prosthesis. Falling is
seldom a problem, inasmuch as the child generally lands on
the buttocks as an able-bodied child would. When the child
falls or tries to retrieve a toy on the floor, the parents and ther­
apist should let the young person explore the movement and
not be overly protective. Just as other children learn to walk
by supporting themselves on furniture, the child who wears
a prosthesis should have the same experience to develop
confidence. Parallel bars, walkers, and harnesses are seldom
advisable for children with unilateral amputation or bilateral
transtibial amputation.
Therapy sessions are designed to facilitate the infant's
• Comfort with the prosthesis
• Wearing tolerance
• Ability to stand by leaning against a table
• Ability to cruise around furniture
• Ability to walk with and without support from a doll
carriage or other supporting toy
Parents of infants with lower-limb prostheses should do
the following:
• Apply and remove the prosthesis correctly
• Care for the child's skin
• Care for the prosthesis
• Recognize and report any problems with the prosthesis
BOX 29-4  Prosthetic Training Goals for Infants
with Lower-Limb Deficiency

788
Section III  Prostheses in Rehabilitation
A prosthesis imposes weight-bearing loads on portions of
the leg not ordinarily used for this purpose. Consequently,
building tolerance to prosthetic wear is important so that skin
over weight-bearing areas can adjust to the pressure. During
the first week most infants tolerate 1 hour of wear, after which
the prosthesis should be removed and the skin examined.
After a 10- to 15-minute rest period, the prosthesis can be
reapplied for another hour. Signs of fatigue, limping, and the
avoidance of standing on the prosthesis indicate that the pros­
thesis is irritating and should be removed. The infant with
a transfemoral prosthesis should be checked to ­determine
whether skin near the proximal part of the prosthesis is
irritated by urine or feces, which may leak from the diaper.
Toddlers
By 15 months, toddlers are upright and mobile. The heel-toe
sequence replaces flat-foot contact during the second year.
Neurological maturation, changes in physique, and improved
strength are evident as the child's base of support narrows.
Muscular activity has matured into the adult pattern. Goals
for rehabilitation (Box 29-5) reflect the developmental activi­
ties of a preschool-age child.
A
C
B
D
FIGURE 29-12  Children's prosthetic feet. A, Solid-ankle, cushion-heel (SACH) foot. B, SACH feet adaptable for crawling and walking. C,
Flex Foot Junior. D, Boys running while wearing transfemoral prostheses with Flex-Run feet. (A, Courtesy Otto Bock Orthopedic Industry,
Inc., Minneapolis, MN; B, Courtesy TRS, Inc., Boulder, CO; C and D, Courtesy Össur Americas, )

Chapter 29  Rehabilitation for Children with Limb Deficiencies
789
Another milestone expected of all children, including the
child with a prosthesis, is running, which begins between 2 and
4 years of age. The flight phase (double float), the period when
both feet are off the ground, occurs by strong ­application of
propulsive force during late stance. The ­prosthetic foot offers
much less energy storage and release compared with the gas­
trocnemius. Consequently, the child with a prosthesis adopts
an asymmetric running gait that emphasizes propulsion
on the sound side. Two-year-olds can kick a ball accurately,
steer a push toy, and jump. As with running, jumping with a
prosthesis is primarily an action of the sound side. Games of
throwing and catching a ball or beanbag and tossing darts help
the toddler refine balance with the prosthesis.
The 3-year-old will probably leap, jump, gallop, climb
stairs step over step, and ride a tricycle. The tricycle pedal
should have a strap to secure the prosthetic foot. Jumping
from a step and hopping are other toddler stunts. Playground
equipment, such as a jungle gym, slide, swing, seesaw, sand­
box, and tunnels, is enticing. Children with unilateral trans­
tibial amputation achieve an almost normal gait and have no
difficulty in climbing inclines and stairs. Opportunities for
kneeling, managing various types of chairs, and getting to and
from the floor are additional elements in rehabilitation. The
child will need help in removing and donning the prosthesis.
School-Age Children and Adolescents
By 4 years of age, most children can descend stairs step
over step, ride a bicycle, and roller skate. Skates that clip
on the shoe are preferable to shoe skates; the latter require
that the prosthetic foot accommodate the height of the heel
in the shoe skate. Five-year-olds skip rope and play dodge
ball. Accurate kicking demonstrates balance on one foot
while transferring force to the ball. By age 6 years, most
children can don and doff the prosthesis independently.
They can start, stop, and change direction with ease as well
FIGURE 29-13  Transtibial prosthesis with thigh corset and a solid-
ankle, cushion-heel (SACH) foot. (Courtesy J. E. Edelstein.)
FIGURE  29-14  Silicone socket liner. (Courtesy Össur Americas,
)
FIGURE 29-15  Single-axis knee units with manual lock. (Courtesy
Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

790
Section III  Prostheses in Rehabilitation
as skip and hop for long distances. The child moves toward
independence in prosthetic management as well, taking
more responsibility for donning and doffing, skin inspec­
tion, and maintenance of the prosthesis (Box 29-6).
Children who undergo lower-limb amputation after
5 years may respond favorably to balance and gait train­
ing similar to that appropriate for adults. Physical therapy
emphasizes dynamic stability, weight shifting, control of the
prosthetic foot, and, in the case of the child with transfemo­
ral amputation, the knee unit (Figures 29-17 and 29-18).
Sports are particularly useful for developing self-esteem
as well as strength and coordination. Most children with
amputations take part in physical education classes at school,
sometimes with modified activity. Carbon acrylic or graphite
A
B
FIGURE 29-16  Polycentric knee units. (A, Courtesy Össur Americas, B, Courtesy Otto Bock Orthopedic Industry, Inc.,
Minneapolis, MN.)
Goals of rehabilitation for toddlers with lower-limb
­deficiency include the following:
• Full-time wear of the prosthesis, except for bathing
and sleeping
• Use of the prosthesis in age-appropriate ambulatory
activities
Parents of toddlers with lower-limb prostheses should do
the following:
• Encourage use of the prosthesis
• Provide toys and equipment that require age-appro­
priate activities
• Inspect the skin to determine whether the prosthesis
causes undue irritation
BOX 29-5  Prosthetic Training Goals for Toddlers
with Lower-Limb Deficiency
In later childhood and adolescence, rehabilitation includes
the following:
• Monitoring and maintaining proper prosthetic fit
• Inspecting the skin
• Donning and doffing the prosthesis independently
• Dressing independently
• Engaging in the full range of ambulatory activities
with the prosthesis
• Recognizing when the prosthesis needs repair or
alteration
Parents of school-age children and adolescents with
lower-limb prostheses should do the following:
• Encourage the young person's independence
• Provide opportunities for sports participation
BOX 29-6  Goals for School-Age Children and
Adolescents with Lower-Limb
Deficiency