Getting a Child a Myoelectric Prosthesis: Did We Miss the Bus?
Getting a Child a Myoelectric Prosthesis: Did We Miss the Bus?
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给孩子安装肌电假肢：我们错过了公共汽车吗？
DOI：
10.1097/jpo.0000000000000437
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发表时间：
2022-07
期刊：
影响因子：
--
通讯作者：
中科院分区：
文献类型：
--
作者：
2020年;32(4): 229-235。Peterson和Prigge的文章题为“早期上肢假肢安装和大脑发育：成功的考虑”，这是一篇发人深省的文章，试图将神经发育原理转化为儿科上肢假肢安装的协议。1先天性肢体缺陷儿童出生2年内安装肌电假体对大脑发育有积极影响的前提是一个值得继续研究的令人兴奋的方向。在这封信中，我们分享了我们对大脑发育的重要方面的看法，这些方面与抓握和精细运动表现有关，特别是生命最初3年的关键窗口的概念。人们认为，大脑在最初的几年里更具可塑性。然而，大脑在以后的岁月里继续发展的能力不应该被忽视。驱动精细运动技能发展的大脑感觉运动通路在童年和青春期基本成熟。2-7达到运动里程碑很重要；然而，最新的运动技能发展理论，即神经元群选择理论，8,9不强调“关键窗口”本身的概念——在此之后，精细的运动技能可能无法在大脑中学习或表征。根据这一理论，8个特定的大脑网络是根据表观遗传事件选择的，这些事件在个体之间是不同的，导致发育阶段或行为的差异。随着经验的不断积累，所选网络中的连接逐渐成熟，需要具备适应环境约束的能力。这些过程的时间线可能会持续到童年后期甚至青春期。特别令人感兴趣的是研究成人的抓握行为是如何发展的。虽然婴儿在1岁时就开始自主地抓握和使用精确的抓握，但在2岁左右才开始出现工具的使用和负责功能性物体操作的预期抓握控制。在8 - 11岁左右，孩子的抓握能力达到了成人的水平，提供了适应各种任务和环境约束的能力。神经生理学研究表明，6至10岁的儿童比大一点的儿童需要更多的注意力来完成同样的任务，3他们不成熟的大脑连接可能会抑制他们的运动表现。总的来说，证据表明从1岁到青春期有一个持续的敏感期，因为它与掌握控制有关。我们相信在第一年没有安装肌电义肢的儿童仍然可以从Peterson和Prigge所描述的方案中受益。问题仍然是，何时以及如何选择和适应大脑网络，以使受影响的肢体在儿童时期实现功能性肌电假肢的使用。作者提供了支持早期肌电肢体装配的良好证据（例如，体现和较低的排异率），我们希望研究继续填补知识空白。在此期间，如果一个孩子在2岁或3岁之前没有安装肌电义肢，这可能不是一个值得关注的问题。他们的大脑仍有剩余的童年和青春期成为一个熟练的肌电假肢使用者。
2020; 32 (4): 229–235. Peterson and Prigge’s article titled “Early Upper-Limb Prosthetic Fitting and Brain Development: Considerations for Success” is a thought-provoking article that attempts to translate neurodevelopmental principles into a protocol for pediatric upper-limb prosthetic fitting. 1 The premise that fitting a myoelectric prosthesis within 2 years of birth in children with congenital limb deficiency will positively affect brain development is an exciting direction for continued research. With this letter, we share our opinion on important aspects of brain development in relation to grasping and fine motor performance, particularly the concept of a critical window during the first 3 years of life. The brain is considered more plastic during these early years. However, the ability of the brain to continue to develop during later years should not be discounted. The brain’s sensorimotor pathways that drive fine motor skill development substantially mature throughout childhood and adolescence. 2–7 Achievement of motor milestones is important; however, the most current theory of motor skill development, neuronal group selection theory, 8, 9 deemphasizes the idea of a “critical window” per se—a time after which fine motor skills may not be learned or represented in the brain. As per this theory, 8 specific brain networks are selected based on epigenetic events, which are different across individuals resulting in variation in developmental stages or behavior. With ongoing experiences, connections in the selected network mature to entail the ability to adapt to environmental constraints. The timeline of these processes may continue until later childhood or even adolescence. Of particular interest are studies on how an adult-like grasp behavior develops. Although an infant begins to voluntarily grasp and use precision grip by the age of 1 year, tool use and anticipatory grasp control responsible for functional object manipulation10 only begin to emerge around the age of 2 years. 11–13 The control of grasp reaches an adult-like pattern around 8 to 11 years of age, 4, 11–13 providing an ability to adapt to a variety of task and environmental constraints. Neurophysiological studies have shown that children 6 to 10 years require more attention than older children to complete the same task, 3 and their immature brain connectivity may inhibit their motor performance. 14 Overall, evidence suggests a continuous sensitive period as it relates to grasp control from the age of 1 year through adolescence.We believe that children not fitted with a myoelectric prosthesis in their first year may still benefit from a protocol such as described by Peterson and Prigge. The question remains as to when and how the brain networks may be selected and adapted for the affected limb15 to achieve functional myoelectric prosthesis use during childhood. The authors provide good evidence in support of early myoelectric limb fitting (eg, embodiment and lower rejection rates), and we hope that research continues to fill the knowledge gaps. In the interim, it may not be a matter of concern if a child has not been fitted with a myoelectric prosthesis by year 2 or 3. Their brain still has the rest of childhood and adolescence to become a proficient myoelectric prosthesis user.
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