Fit-for-purpose, affordable body-powered prostheses

Lead Research Organisation: University of Salford
Department Name: School of Health and Society

Abstract

Upper limb loss can have devastating effects on an individual, particularly if that person is already surviving at a subsistence level. Prostheses can be used to replace the missing limb, offering both cosmetic and functional benefits. In lower and middle income countries (LMICs), conflict and road traffic accidents mean that demand for upper limb prostheses is high, however provision is sparse, and maintenance is a major challenge.

Body-powered (BP) prostheses have seen little development since the early 20th century, despite high self-reported rates of rejection. Nevertheless, BP prostheses are well suited for use in LMICs, being potentially simple to manufacture and maintain. If the reasons for rejection (e.g. limited functionality, cost and heat-related discomfort) can be addressed, BP prostheses offer a potentially viable solution. Therefore, this project will bring together an experienced team from across the UK, Uganda and Jordan to create a new BP prosthesis that is optimised for adoption by LMIC prosthetic services and acceptable to LMIC users. This will include establishing methods of fabrication, fitting and evaluation of the prosthesis which are appropriate to LMICs.

Our two LMIC partners (Uganda and Jordon) have been selected because of the unique challenges of prosthetic provision in these countries. Uganda is one of the least developed countries in the world, with poorly resourced and fragmented rehabilitation services. Jordan is an upper middle income country, with well-developed clinical training, but facing immense pressures on prosthetic services due, in part, to regional conflicts.

To achieve our goals, the following work packages (WPs) are planned:

WP1: The requirements of amputees in both Jordan and Uganda will be investigated using focus groups and questionnaires.
WP2: We will develop an engineering/human factors specification for a BP prosthesis optimised for LMICs by identifying the key features of the conventional BP prosthesis that determine its functionality and usability.
WP3: Informed by WP1 & 2 we will develop a new design, optimised for LMICs. We aim to restore a high level of functionality, in a culturally acceptable manner, and in a way that is well suited to local prescription, manufacture and fitting. To ensure local relevance, we will work closely with our partners in Jordan and Uganda.
WP4: In parallel to the work in WP3, we will address more ambitious design challenges, creating and testing a highly novel prototype in the laboratory. This division of the work will allow us to move quickly towards a practical solution for LMICs and to also include more novel but higher risk research.
WP5: There is currently no objective data on the extent to which prostheses are worn, how they are used, or the impact on daily life. We will develop a digital tool kit that includes a sensor system to capture both motion of the prosthetic arm and complementary data (for example, prosthetic hand opening/closing and location), and an Android app to provide feedback to designers, clinicians, and users.
WP6: To support the long term impact of this project, we will work with our LMIC partners to support improved provision (including local manufacture and better clinical support) and hence enable uptake of the new BP prosthesis.

Planned Impact

The work will impact on a number of communities, in several countries.

Uganda. In common with many other African countries not directly involved in conflict, the Ugandan economy, is accelerating, with annual growth forecast to be 5.6% in 2019 (http://www.worldbank.org/en/country/uganda/overview). The World Bank notes the Public Financial Management Act (2015) as a significant step towards improved financial management. Both the growing economy and improved regulations will encourage investment in the country. Through our collaboration with the Uganda Industrial Research Institute (UIRI), a government agency for industrialisation, we expect our project to take advantage of these economic opportunities, primarily through the establishment of a prosthetics manufacturing facility in Uganda. Such a facility would reduce the need for costly imports, provide opportunities for lower cost prosthesis production, and potentially export to relevant markets.
Through our knowledge exchange work in Uganda, we see a new cadre of allied health professionals emerging. These are 'tech-savy' individuals, looking to technological solutions to both guide their work and measure the impact of their work on patients. Through our web-based support and the new digital tool kit (sensors and associated app), we will demonstrate the value and impact of rich data on their work.

Jordan. Jordan's economy is under great pressure, due to the neighbouring conflicts in Syria and Iraq and the consequent impact on trade, tourism and public services. However, there is a centre of excellence in prosthetics based in the University of Jordan, with the capacity to expand its services and (through the University) nurture spin-outs. Brain/skills drain remains a major challenge. We focus our work in two areas, prosthetics services in Amman and in refugee camps. Neither of these provide good upper limb prosthetics provision and all rely on costly imports. We also recognise the need to move towards a multidisciplinary team approach to clinical support for upper limb amputees and our planned work with other Universities in Jordan will support this. Our partners, International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF)are both aware of the challenges involved in upper limb prosthetics delivery to refugee populations and we will be advised by them (through our Advisory Board) on how best to impact on this service.
In a similar way to Uganda, we would envisage a new cadre of 'tech-savy' allied health professionals emerging and the links with Uganda will strengthen the feeling of community amongst these individuals.

Other LMICs. We would see the project as an exemplar for other countries, inspiring changes to training and moving the focus for purchasing decisions away from the high cost manufacturers based in the UK, EU and North America.

UK. Prosthetics services in the UK are coming under immense pressure due to the steep rise in demand (primarily lifestyle-driven) coupled with a rapid increase in the cost of top end componentry. The NHS needs to move towards a more evidence-based approach to practice and find a way of managing both demand and costs. Some of the lessons learnt from this project, including the use of digital evaluation tools and low cost designs, will be introduced into Salford University's prosthetics and orthotics curriculum at the end of the study, thereby having direct impact on the NHS.

Longer term impact. Towards the end of the project, we will evaluate the design advances coming from WP4, demonstrated through a highly novel prototype. We believe these will revolutionise body-powered prostheses and we will form a consortium to bid for near-market funding to produce a pre-commercial prototype. This has the potential to impact on the UK economy and amputees globally.
 
Description At the start of the project we recognised that demand for upper limb prostheses is high in lower and middle income countries (LMICs), but provision was very poor, depending on costly imported components and scarce, poorly trained prosthetic services; maintenance was a major challenge. We aimed to design and test a low-cost body-powered prosthesis, optimised for LMICs, establish local methods for fabrication, fitting and evaluation, and develop a toolbox to support prosthetics services for the longer term implementation of our novel designs. The key achievements are highlighted below:

1. Lived experiences of people with limb absence in Uganda and Jordan. There is a reasonably extensive literature on the impact of upper limb absence for those living in high resource settings. We carried out the first studies of the lives of persons with upper limb absence living in Uganda and Jordan. These emphasise the importance of suitable prosthetic provision, as well as highlighting both the positive and negative impacts of the society's attitudes towards disabled people.
2. Design of appropriate, upper limb prosthetic devices. We began the project with a focus on the development of an improved, shoulder-harness operated mechanical prostheses. Our scoping studies in Uganda and Jordan in year 1 of the project, together with our study on the limitations with such devices led us to refocus on simpler designs. We extended the scope of the design work to include adjustable sockets, which offer the potential to be manufactured and repaired locally. Both designs have been informed by extensive user engagement throughout (see below).
3. Virtual co-design methods. Co-design is well-established as the gold-standard approach to producing user-informed products. It typically involves designers and potential users meeting on a frequent basis, from the early concept stage through to the finished design. Covid and the climate emergency encouraged our team to rapidly develop virtual co-design methods. We bought together users in Uganda, with engineers in the UK, Uganda and Canada, and a prospective manufacture in the US. The co-design workshops have been very productive and serve as a model for future users.
4. Better supply chains impacting on prosthetics services in Uganda. It became clear from early in the project that public prosthetics services were extremely poorly funded, relying largely on donated components, and purchasing the materials needed to construct prosthetic sockets on an ad-hoc basis. This was a major barrier to delivering impact from the novel designs emerging from the project. The Salford and Makerere teams have worked with Knowledge for Change, other NGOs and government run facilities in Uganda to pilot a supply chain intervention to improve the reliability of supply, and reduce the cost of imported materials, such as polypropylene. The intervention has had an immediate positive impact on an orthopaedic workshop in Fort Portal and may have a country-wide impact in the coming years.
Exploitation Route The work is continuing. Through funding from the Tropical Health and Education Trust we are continuing to progress some of the designs. An MRC Health Systems Strengthening project, led by our partner at Makerere University, with the Salford team has been recommended for funding. This will consolidate the supply chain work and build on the adjustable socket work. We believe that the virtual co-design work is a valuable contribution to the field and will be publishing this shortly.
Sectors Environment,Healthcare

URL https://www.fit4purposeprosthetics.org/
 
Description Our research has fed into global health policy and impacted on prosthetics practices in Uganda. Specifically: - in 2019, we presented a paper on our work at the World Health Organisation's Global Report on Effective Access to Assistive Technology (GReAT) Consultation meeting. The paper and subsequent discussions are feeding into the definitive Global Report on Effective Access to Assistive Technology (GReAT) to be launched this Spring. - In sub-Saharan Africa, the picture is particularly dire, with prosthetics services being illustrative of much broader issues in the AT sector, including donor dependence, inappropriate designs, expensive and unreliable supply chains, and market fragmentation (Savage et al, 2021). In Uganda, prosthetics services have been developed, and to an extent supported by large NGOs (e.g. ICRC and Rotary Club). However, when ICRC withdrew, the level of support offered by successive governments left workshops poorly maintained and services badly disrupted. Indeed, even, when free healthcare is provided by public hospitals, users of prosthetic devices usually have to pay for the materials and/or the devices, or accept donated prostheses (when available). Local suppliers are scarce and orders from abroad are only made when a user has paid a percentage of the cost. This drives up the cost, introduces delays and additional visits, and makes access to spare parts/repair services a great challenge. The drivers for the large NGOs to support prosthetic services have often been conflicts, but in Uganda lifestyle and environmental factors are also frequent causes, and likely to grow in importance over time. Following 30 qualitative interviews with Key Informants and health workers focused on the challenges faced in providing services we found negative impacts from taxation (and double taxation); customs and inspection duties, the lack of VAT-exemption for P&O products in the Ugandan context and the inflationary impact of multiple distributor chains compounded by public procurement polices privileging 'pre-qualified' suppliers who are then able to massively inflate costs. In the public health sector an almost total reliance on foreign 'donors' relieves the Ministry of Health from political pressures to provide equipment and consumables for the production of P&O and assistive devices. IN practice government hospitals provide no funding at all for materials. Underlying all of this is the very high costs of raw materials used in P&O assembly in part arising from alack of coordination in supply chains with most workshops making sporadic very small scale (one-off) purchases when a person is able to cover their own costs. This translates into a situation where public workshops are only able to provide services on a to-pay basis and staff spend much of their time unable to use their skills and expertise. The immediate challenge is not a lack of skills (capabilities) as donors often assume but rather alack of the opportunity to use those skills due to poor infrastructure, equipment and materials. In addition to the interview work the team have developed an intervention model focused on 3 key aspects of the supply chain: 1. Consolidating National Demand In response to this the University of Salford (UoS) has been working in partnership with Knowledge For Change (K4C) and the leading supplier of medical supplies to the not-for-profit and private sector in Uganda, Joint Medical Stores (JMS). By providing an initial 'float' of $5000 to enable JMS to buy-in a larger volume of the 2 core materials (foam and polypropylene) - underwriting some of the risks faced when demand is uncertain. Most recently the intervention has led to JMS agreeing to become a (the) major supplier - they recently placed the first order for ~ $70k 2. Creating demand in the Public Workshops Whilst this first intervention will help to consolidate demand and put a downward pressure on price it does not solve the problem of a lack of government finance for people with disabilities who are unable to cover the costs of their own P&O devices. To address this challenge K4C has signed an MOU with FPRRH establishing a Public-Private-Partnership (PPP) to underwrite the costs of materials. K4C manages a student placement program based on Fair Trade Principles. In the past FPRRH has been paid £150 per student placement. K4C also provides Ugandan and volunteer UK staff to supervise such placements. The MOU provides that this funding can be used in future to cover the costs of vital consumables needed by the hospital with a ring-fencing option available to target resources in priority areas. The key priority at present is the orthopaedic workshop. Since October 2021 K4C has been providing materials to the workshop. K4C also deployed a UK accountant as a long-term volunteer attached to the workshop. Oliver Williams has assisted the orthopaedic team to collect accurate records on patients but also materials ordered and pricing mechanisms and identified potential new suppliers. As this work progresses we have seen productivity increase substantially and are monitoring this to improve our understanding of the costs of services. 3. Integrating donors in supply chain coordination In addition to the 2 'ubiquitous' products we have been working on (above) we also recognise that there is a specific need for more bespoke componentry: feet, hands, elbow and knee, wrist and ankle joints etc. We have developed a link with a UK-based NGO Legs For Africa (L4A) that supplies second hand components to LMICs. L4A have themselves faced some challenges in ensuring their donations are used and monitoring the use of them and have been restructuring their processes with a view to more focused engagement. K4C is currently negotiating a partnership arrangement with L4A to see if we can access a more reliable and predictable supply of components. We are aware that in the long-term reliance on secondhand supplies may not be efficient and effective. With that in mind we are also in touch with an NGO based in Geneva that supplies componentry to ICRC at a much lower cost than other competitors. This work is on-going. Virtual Workshops In the summer of 2021 Ackers, Kenney and Ssekitoleko applied for a small grant (£10k) from the Tropical Health and Education Trust (THET) to support a Virtual Prosthetics and Orthotics Knowledge exchange process. This has included the recruitment of the following 4 'Virtual Volunteers' through an open invitation process and contacting professional organisations: • Lee Wilan (Salford University Prosthetics and Orthotics Technician) • Jessica Concannon (Physiotherapist and NHS Scientist Training Programme specialising in Clinical Engineering) • Timothy Arthur (THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST) • Ella Mencel (BCUHB - Posture & Mobility Service)
First Year Of Impact 2019
Sector Healthcare
Impact Types Societal,Policy & public services

 
Description Dissemination of the first M-level module on physical behaviour monitoring for prosthetics and orthotics
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Ethical guidelines
Geographic Reach Multiple continents/international 
Policy Influence Type Contribution to new or Improved professional practice
URL https://cdn.ymaws.com/www.ispoint.org/resource/resmgr/research/ethical_considerations_to_po.pdf
 
Description Royal Society Human Transformation 'moving and sensing' workshop
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
Description Demonstrate the potential for virtual volunteering in the co-design of assistive technologies and consolidate existing relationships between clinicians in prosthetics and orthotics
Amount £10,000 (GBP)
Organisation Tropical Health & Education Trust (THET) 
Sector Charity/Non Profit
Country United Kingdom
Start 12/2021 
End 12/2022
 
Description EPSRC Centre for Doctoral Training in Prosthetics & Orthotics
Amount £5,526,315 (GBP)
Funding ID EP/S02249X/1 
Organisation Engineering and Physical Sciences Research Council (EPSRC) 
Sector Public
Country United Kingdom
Start 03/2019 
End 09/2027
 
Description The impact of international development research pre-2014/5.
Amount £29,884 (GBP)
Organisation United Kingdom Research and Innovation 
Sector Public
Country United Kingdom
Start  
 
Description Transformative Innovation in the Delivery of Assisted Living products and services (TIDAL)
Amount £948,972 (GBP)
Funding ID EP/W000717/1 
Organisation Engineering and Physical Sciences Research Council (EPSRC) 
Sector Public
Country United Kingdom
Start 07/2021 
End 08/2024
 
Title Data associated with Prince M et al. A pin-array method for capturing tissue deformation under defined pressure distributions and its application to prosthetic socket design 
Description This is the data associated with: Prince M, Kenney L, Howard D. A pin-array method for capturing tissue deformation under defined pressure distributions and its application to prosthetic socket design. Med Eng Phys. 2020; 84: 136-143.The Excel file is structured as follows:Tab 1: Raw data for figure 2Tab 2: Time series data used to generate figure 4aTab 3: Time series data used to generate figure 4bTab 4: Pad forces for study 2 (force required to push the pad down to the datum level)

 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? Yes  
URL https://salford.figshare.com/articles/dataset/Data_associated_with_Prince_M_et_al_A_pin-array_method...
 
Title Data associated with Prince M et al. A pin-array method for capturing tissue deformation under defined pressure distributions and its application to prosthetic socket design 
Description This is the data associated with: Prince M, Kenney L, Howard D. A pin-array method for capturing tissue deformation under defined pressure distributions and its application to prosthetic socket design. Med Eng Phys. 2020; 84: 136-143.The Excel file is structured as follows:Tab 1: Raw data for figure 2Tab 2: Time series data used to generate figure 4aTab 3: Time series data used to generate figure 4bTab 4: Pad forces for study 2 (force required to push the pad down to the datum level)

 
Type Of Material Database/Collection of data 
Year Produced 2020 
Provided To Others? Yes  
URL https://salford.figshare.com/articles/dataset/Data_associated_with_Prince_M_et_al_A_pin-array_method...
 
Description Partnership between University of Salford, Knowledge for Change, Fort Portal Regional Referral Hospital, Joint Medical Stores and Legs4Africa 
Organisation Fort Portal Hospital
Country Uganda 
Sector Hospitals 
PI Contribution Interviews and observational visits in the early part of the Fit-for-purpose prosthetics project indicated the impact of sporadic and fragmented demand for prosthetics in Uganda was limiting the ability to order large volumes and negotiate more competitive prices. This is particularly the case for 2 key materials used in P&O manufacture: EVA (soft foam) and polypropylene (used to make sockets). These materials are not locally manufactured in Uganda or East Africa and are imported from overseas with key manufacturers based in Europe, China and India. At present, these materials are available at around 5x the cost in the UK. In response to this the University of Salford (UoS) has been working in partnership with Knowledge For Change (K4C) and the leading supplier of medical supplies to the not-for-profit and private sector in Uganda, Joint Medical Stores (JMS). By providing an initial 'float' of $5000 to enable JMS to buy-in a larger volume of these 2 materials - underwriting some of the risks faced when demand is uncertain we hope to be able to stimulate and focus demand so that JMS can, in future, become a major supplier and, as demand increases, price will reduce. As part of this process, we have been assessing the relative costs of different manufacturers and transport agents and the options in terms of obtaining VAT and inspection fee waivers. 2. Creating demand in the Public Workshops Whilst this first intervention will help to consolidate demand and put a downward pressure on price it does not solve the problem of a lack of government finance for people with disabilities who are unable to cover the costs of their own P&O devices. To address this challenge K4C has signed an MOU with FPRRH establishing a Public-Private-Partnership (PPP) to underwrite the costs of materials. K4C manages a student placement program based on Fair Trade Principles. In the past FPRRH has been paid £150 per student placement. K4C also provides Ugandan and volunteer UK staff to supervise such placements. The MOU provides that this funding can be used in future to cover the costs of vital consumables needed by the hospital with a ring-fencing option available to target resources in priority areas. The key priority at present is the orthopaedic workshop. Since October 2021 K4C has been providing materials to the workshop. K4C also deployed a UK accountant as a long-term volunteer attached to the workshop. Oliver Williams has assisted the orthopaedic team to collect accurate records on patients but also materials ordered and pricing mechanisms and identified potential new suppliers. As this work progresses we have seen productivity increase substantially and are monitoring this to improve our understanding of the costs of services. to date around 50 patients have received either new prosthetic or orthotic devices, or repairs to their existing devices. 3. Integrating donors in supply chain coordination In addition to the 2 'ubiquitous' products we have been working on (above) we also recognise that there is a specific need for more bespoke componentry: feet, hands, elbow and knee, wrist and ankle joints etc. We have developed a link with a UK-based NGO Legs For Africa (L4A) that supplies second hand components to LMICs. L4A have themselves faced some challenges in ensuring their donations are used and monitoring the use of them and have been restructuring their processes with a view to more focused engagement. K4C is currently negotiating a partnership arrangement with L4A to see if we can access a more reliable and predictable supply of components. We are aware that in the long-term reliance on secondhand supplies may not be efficient and effective. With that in mind we are also in touch with an NGO based in Geneva that supplies componentry to ICRC at a much lower cost than other competitors. This work is on-going. Virtual Workshops In the summer of 2021 Ackers, Kenney and Ssekitoleko applied for a small grant (£10k) from the Tropical Health and Education Trust (THET) to support a Virtual Prosthetics and Orthotics Knowledge exchange process. This has included the recruitment of the following 4 'Virtual Volunteers' through an open invitation process and contacting professional organisations: • Lee Wilan (Salford University Prosthetics and Orthotics Technician) • Jessica Concannon (Physiotherapist and NHS Scientist Training Programme specialising in Clinical Engineering) • Timothy Arthur (THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST) • Ella Mencel (BCUHB - Posture & Mobility Service) The focus of these workshops, to date, has been driven by the perceived needs of the Ugandan technicians. The first 2 workshops focused on Draping Technology. This technique used to make sockets in the UK has the potential to improve the quality but also, and importantly, to change the type of polypropylene used to a cheaper and more easily transportable type (with potentially major cost savings). In addition, the clinical scientists are working with the design teams in Portsmouth, Salford and Makerere on progressing hand designs and manufacturing options. The Rehabilitation Facility The work that has taken place in FPRRH has raised the volume of patients. This has raised issues about the use of an adjoining building previously used as a hostel for people receiving services from the workshop (at a time, 10 years ago, when ICRC actively supported this region of Uganda). The lack of productivity in the workshop led to the disuse of this building and proposals to the Hospital Management to change its use. Active lobbying by K4C has resulted in a new partnership with the hospital to establish a Multi-Disciplinary Rehabilitation and Virtual Learning Facility (confirmed by a 3rd MOU). Refurbishment of Female Ward and Virtual Learning Boardroom. We are currently linking this facility to another area of K4C work at the present time concerned with the prevention of amputation through improved diagnosis, prevention and treatment of diabetes. Plans are in place to establish the first Diabetic Foot Clinic in a Ugandan public health facility.
Collaborator Contribution The work has been led by Ackers (University of Salford), with the Makerere University team.
Impact The multi-disciplinary collaboration has had an immediate impact on the productivity of the Fort Portal Regional Referral Hospital. For over a decade, since the ICRC withdrew its support for the Fort Portal workshop, the clinicians have been very restricted in the services they offered. Focus was largely on repairs to existing devices, but even these were only deliverable with financial support from the individual patients. In the 3 and a half months since the service described above started the workshop has made: 6 Trans-tibial , 4 Trans-Femoral and 3 Through-Knee prostheses, 7 Ankle-Foot-Orthoses, 3 Knee Ankle-Foot-Orthoses, 7 other orthoses/footwear, and repaired around 20 people's existing devices.
Start Year 2021
 
Description Partnership between University of Salford, Knowledge for Change, Fort Portal Regional Referral Hospital, Joint Medical Stores and Legs4Africa 
Organisation Legs4Africa
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Interviews and observational visits in the early part of the Fit-for-purpose prosthetics project indicated the impact of sporadic and fragmented demand for prosthetics in Uganda was limiting the ability to order large volumes and negotiate more competitive prices. This is particularly the case for 2 key materials used in P&O manufacture: EVA (soft foam) and polypropylene (used to make sockets). These materials are not locally manufactured in Uganda or East Africa and are imported from overseas with key manufacturers based in Europe, China and India. At present, these materials are available at around 5x the cost in the UK. In response to this the University of Salford (UoS) has been working in partnership with Knowledge For Change (K4C) and the leading supplier of medical supplies to the not-for-profit and private sector in Uganda, Joint Medical Stores (JMS). By providing an initial 'float' of $5000 to enable JMS to buy-in a larger volume of these 2 materials - underwriting some of the risks faced when demand is uncertain we hope to be able to stimulate and focus demand so that JMS can, in future, become a major supplier and, as demand increases, price will reduce. As part of this process, we have been assessing the relative costs of different manufacturers and transport agents and the options in terms of obtaining VAT and inspection fee waivers. 2. Creating demand in the Public Workshops Whilst this first intervention will help to consolidate demand and put a downward pressure on price it does not solve the problem of a lack of government finance for people with disabilities who are unable to cover the costs of their own P&O devices. To address this challenge K4C has signed an MOU with FPRRH establishing a Public-Private-Partnership (PPP) to underwrite the costs of materials. K4C manages a student placement program based on Fair Trade Principles. In the past FPRRH has been paid £150 per student placement. K4C also provides Ugandan and volunteer UK staff to supervise such placements. The MOU provides that this funding can be used in future to cover the costs of vital consumables needed by the hospital with a ring-fencing option available to target resources in priority areas. The key priority at present is the orthopaedic workshop. Since October 2021 K4C has been providing materials to the workshop. K4C also deployed a UK accountant as a long-term volunteer attached to the workshop. Oliver Williams has assisted the orthopaedic team to collect accurate records on patients but also materials ordered and pricing mechanisms and identified potential new suppliers. As this work progresses we have seen productivity increase substantially and are monitoring this to improve our understanding of the costs of services. to date around 50 patients have received either new prosthetic or orthotic devices, or repairs to their existing devices. 3. Integrating donors in supply chain coordination In addition to the 2 'ubiquitous' products we have been working on (above) we also recognise that there is a specific need for more bespoke componentry: feet, hands, elbow and knee, wrist and ankle joints etc. We have developed a link with a UK-based NGO Legs For Africa (L4A) that supplies second hand components to LMICs. L4A have themselves faced some challenges in ensuring their donations are used and monitoring the use of them and have been restructuring their processes with a view to more focused engagement. K4C is currently negotiating a partnership arrangement with L4A to see if we can access a more reliable and predictable supply of components. We are aware that in the long-term reliance on secondhand supplies may not be efficient and effective. With that in mind we are also in touch with an NGO based in Geneva that supplies componentry to ICRC at a much lower cost than other competitors. This work is on-going. Virtual Workshops In the summer of 2021 Ackers, Kenney and Ssekitoleko applied for a small grant (£10k) from the Tropical Health and Education Trust (THET) to support a Virtual Prosthetics and Orthotics Knowledge exchange process. This has included the recruitment of the following 4 'Virtual Volunteers' through an open invitation process and contacting professional organisations: • Lee Wilan (Salford University Prosthetics and Orthotics Technician) • Jessica Concannon (Physiotherapist and NHS Scientist Training Programme specialising in Clinical Engineering) • Timothy Arthur (THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST) • Ella Mencel (BCUHB - Posture & Mobility Service) The focus of these workshops, to date, has been driven by the perceived needs of the Ugandan technicians. The first 2 workshops focused on Draping Technology. This technique used to make sockets in the UK has the potential to improve the quality but also, and importantly, to change the type of polypropylene used to a cheaper and more easily transportable type (with potentially major cost savings). In addition, the clinical scientists are working with the design teams in Portsmouth, Salford and Makerere on progressing hand designs and manufacturing options. The Rehabilitation Facility The work that has taken place in FPRRH has raised the volume of patients. This has raised issues about the use of an adjoining building previously used as a hostel for people receiving services from the workshop (at a time, 10 years ago, when ICRC actively supported this region of Uganda). The lack of productivity in the workshop led to the disuse of this building and proposals to the Hospital Management to change its use. Active lobbying by K4C has resulted in a new partnership with the hospital to establish a Multi-Disciplinary Rehabilitation and Virtual Learning Facility (confirmed by a 3rd MOU). Refurbishment of Female Ward and Virtual Learning Boardroom. We are currently linking this facility to another area of K4C work at the present time concerned with the prevention of amputation through improved diagnosis, prevention and treatment of diabetes. Plans are in place to establish the first Diabetic Foot Clinic in a Ugandan public health facility.
Collaborator Contribution The work has been led by Ackers (University of Salford), with the Makerere University team.
Impact The multi-disciplinary collaboration has had an immediate impact on the productivity of the Fort Portal Regional Referral Hospital. For over a decade, since the ICRC withdrew its support for the Fort Portal workshop, the clinicians have been very restricted in the services they offered. Focus was largely on repairs to existing devices, but even these were only deliverable with financial support from the individual patients. In the 3 and a half months since the service described above started the workshop has made: 6 Trans-tibial , 4 Trans-Femoral and 3 Through-Knee prostheses, 7 Ankle-Foot-Orthoses, 3 Knee Ankle-Foot-Orthoses, 7 other orthoses/footwear, and repaired around 20 people's existing devices.
Start Year 2021
 
Description Article about the project. UK universities lead the call to develop body-powered prostheses 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact An article was published by two trainnee clinical scientists on their Uganda placement, which was aligned to the Fit-for-purpose project.
Year(s) Of Engagement Activity 2019
URL https://www.ipem.ac.uk/Portals/0/SCOPE_DEC2019_WR.pdf?ver=2019-12-06-144158-610
 
Description Design Of Fit-For-Purpose, And Fit-For-Context, Purely Mechanical Upper Limb Prostheses - Symposium at the ISPO 2021 World Congress 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The symposium presented an overview of the project results to date. The symposium was largely run by ECR members of the team, providing them with opportunities to present their work at the primary prosthetics and orthotics conference. Presenters came from the Ugandan, Jordanian and UK-based teams and the workshop was delivered online.
Year(s) Of Engagement Activity 2021
URL http://www.ispo-congress.com/news/ispo-18th-world-congress-connects-participants-virtually-around-th...
 
Description Evolving Trends of Rehabilitation and Assistive Technologies in Uganda 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The two-day Conference on the Evolving Trends of Rehabilitation and Assistive Technologies was a hybrid conference held on the 25th and 26th of November 2021 at Hotel Africana, Kampala Uganda.
There were over 200 individuals for both its virtual and physical attendance. Participants ranged from; stakeholders in Ugandan health sector, Ministry of Health, the National Medical Stores, academic researchers, medical professionals, orthopedic surgeons, Prosthetists, and Orthotists, to students and new personnel with a growing interest in the field.
The three sub-themes for this conference included;
Lived Experiences,
Improving the supply chain of Prosthetic and Orthotic devices and lastly,
Technologies.
Under the Lived experiences sub-theme, various participants that need and use prosthetics and orthotics devices shared stories on their journey before and after articulation of their limbs.

Shared Experiences from Rehabilitation User Groups and Individuals
Ms. Alinyikira Kawula Mourine (2nd from Left in the picture below) presented about how she attained her amputation from a car accident. She stated the hardships and stigma she experienced since 2016, including it turning out to be her identity within her community. She quoted that.
"This is when the community gives you a name regarding your amputation and in addition, some even go ahead to use you as a scarecrow for younger children."
Mr. Mark Giggs Kalibbala (2nd from Right in the picture below), with a 12-year spinal injury, also shared his story and the challenges of wheelchair access in Uganda, and how expensive it is to live life as a person with a disability, pointing out the need for reliable access points, universal and human-centered designing and friendly policies. Most significantly he stated how hard it is to access buildings and public transport.
Consequently, a medical personnel like Dr. Mwanje Geofrey an orthopedic surgeon at CoRSU (Comprehensive Rehabilitation services in Uganda) shared professional expertise on the causes of amputation to include:
1. Tumours (to reduce tumour bulk or reduce its spread)
2. Gangrene (dead tissue)
3. Chronic ulcers and infections
4. Trauma (severe crash injuries)
5. Severe burns and post burn contractures
6. Tissue sarcomas (osteosarcoma, neurofibromatosis, Ewing's sarcoma, etc).
A tutor at the Uganda Institute of Allied Health Mulago, Mr. Gizamba Henry talked about the orthopedics technology occupation and its perspective regarding rehabilitation services. He also shared about the 19 orthopedic workshops in Uganda, which is a start towards improving access to rehabilitation services for people with disabilities. In addition, he also mentioned that through collaboration and partnership this field can be improved.

Presentations from Experts, Academicians and Stakeholders in the Healthcare and Technology Sector
Health sector representatives from National Medical Stores shared about the supply chain of Prosthetic and Orthortic devices alongside its challenges such as; financing, and the long procurement process arising from organizational bureaucracy. This evidently portrayed the gap in evolution of Prosthetic and Orthotic technologies, thus a need for stakeholders to come together and devise means to grow the field to address limiting factors such as Access to various assistive technologies.
The conference had presentations from Prof. Laurence Kenney from the University of Salford and Dr. Mohammad Sobuh from the University of Jordan, who are part of the Fit 4 Purpose project teams involved in the design of the appropriate prostheses for Low and Middle-income Countries. They shared the progress of the project as well as, the future of body-powered prostheses especially for upper limb loss. Emphasis was put on collaboration with local governments, workshops, conferences, trainings and interested parties were requested to produce more results.
As part of the technologies segment, a team from CoRSU shared a presentation on the current use of 3D printing to make sockets for prosthetic devices. They indicated that more research and training is needed to make 3D fabrication more sustainable. For the segment on Innovations in assistive and rehabilitation technologies, there were presentations from Ms. Kyomukama Moreen and Ms. Nabwami Anita, both Makerere University students who are designing a Vision Belt for totally blind people.
Ms. Martha Mulerwa, a PhD student at the University of Salford presented about her work in designing a wrist for the Ugandan Context as part of the Fit 4 purpose project. Lastly, Mr. Owino Solomon with team shared a presentation on a project that involves the design of an adjustable metal-aided traction orthotic lumbar Sacral brace to alleviate low back pain.
There were two conference breakaway sessions, with one on customization of assistive technologies by the Katalemwa Cheshire Home of Rehabilitation services, and the other on 3D printing and fabrication by CoRSU.
The breakaway session on customization involved a demonstration on the development, design and application of a car-braking and acceleration system for people with disabilities. The braking system allows disabled people such as paraplegics to brake using their hands instead of their feet.
In the same session later on, presenters shared about the design process of an artificial limb for children, that enables them perform day-to-day activities such as walking and playing football. It was noted that the current limitation was in attaining a desirable cosmetic look. With a similar prosthetic device currently costing 800,000 UGX on the Ugandan market, the presenters from Katalemwa shared that they were able to assemble one at only 150,000 UGX since children need 6-monthly replacements, hence subsidizing costs

Closing Remarks from the Organizing Committee
Assoc. Prof. Erisa Mwaka Sabakaki, who is this Project's Principal Investigator (P.I) concluded the two day conference by thanking all partners, organisers and sponsors for getting involved and presenters for sharing their lived experiences.
He went ahead to encourage students to continue advertising their skill and maintain the necessary vibrancy in order to attract potential funders for future collaborations. He applauded the input by Dr. Robert Ssekitoleko for successfully revamping the Biomedical Engineering curriculum at Makerere University College of Health Sciences over the years. He encourages all sponsors to devise sustainability measures to improve the supply chain for rehabilitation and assistive technologies in Uganda
Year(s) Of Engagement Activity 2021
URL https://www.fit4purposeprosthetics.org/lived-experiences-by-rehabilitation-and-disability-groups-in-...
 
Description Interview about the Fit-for-purpose prosthetics project 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact I was interviewed by a reporter from Africa Science Focus about the project, as part of a podcast entitled "unravel disability with assistive tech"
Year(s) Of Engagement Activity 2020
URL https://www.buzzsprout.com/1257893/6877241-unravel-disability-with-assistive-tech
 
Description Interview with Research Professional 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact I was interviewed about the award by a journalist working for the Research Professional website
Year(s) Of Engagement Activity 2018
URL https://www.researchprofessional.com/0/rr/funding/insight/2018/3/My-winning-proposal---The-GCRF-is-n...
 
Description Presentation on Fit4purpose at a student society conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact I presented a talk on the work carried out in the Fit4purpose prosthetics projects at the 2021 Centre for Doctoral Training in Prosthetics & Orthotics conference. This student-organised event was attended by over 100 people and initiated some discussion amongst attendees.
Year(s) Of Engagement Activity 2021
URL https://www.cdtpando.com/cdtpando21
 
Description Presentation on the project to the ISPO Jordan and UASPO International P&O Congress 2019 (April 2019, Amman, Jordan) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I gave an invited talk on the project to this conference
Year(s) Of Engagement Activity 2019
 
Description Presentation to workshop organised by IIT Chenai (India) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact An invited talk as part of International Workshop on Recent Trends in Biomedical Instrumentation and Assistive Technology, organised by IIT Chenai
Year(s) Of Engagement Activity 2021
 
Description Siemens Platform for Investigation 'Prosthetics' - Public engagement event at the Manchester Museum of Science and Industry 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Feedback from the Museum event team is provided below:
I just wanted to send my thanks to you and your team of brilliant volunteers for putting on such a great Platform for Investigation event here on Saturday. The activities were really high quality and very engaging for visitors of all ages - it was great to shed some light on a really contemporary, cutting edge area of science and engineering.
Visitor numbers for the day are below:
Adults - 432
Children - 333
Total - 765

The postcard evaluation that we conduct every month during Pi asks visitors to state their level of agreement with the below outcomes:
• The activity has helped me/my group to learn new facts about science
• The activity has helped me/my group better understand that science is part of my/our everyday life
• The activity has helped me/my group better understand what scientists do
• The activity has encouraged me/my group to talk about science
• The activity has inspired me/my group to learn more about science after my/our visit

Saturday's evaluation saw 100% of evaluated visitors select either 'strongly agree' or 'agree' with all of these statements, and another visitor also wrote 'incredible - thankyou' as an additional comment on their postcard, so well done!

I should add as a caveat that it was only a very small sample taken, but it's great to see such overwhelmingly positive feedback - I do hope you're pleased.
Year(s) Of Engagement Activity 2020
 
Description Talk to an audience of Chinese therapists 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The presentation presented the Fit for purpose prosthetics and upper limb FES work at Salford. The talk was part of the 2020 Sino-British Rehab Tech Summit Forum
Year(s) Of Engagement Activity 2020
 
Description Workshop on prosthetics at the Ugandan Biomedical Engineering conference 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This event was run by co-investigator, Robert Ssekitoleko and colleagues, in Kampala, Uganda. The event helped to bring together the orthopaedic technicians with the biomedical engineers and share knowledge of the problems with prosthetics in Uganda, and potential solutions. Developments in the project were presented.
Year(s) Of Engagement Activity 2019
 
Description Workshop with students in University of Jordan 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Undergraduate students
Results and Impact A one-day workshop was held at the University of Jordan of 4th and 3rd year orthotics and prosthetics students. The workshop was run by The Jordanian partners Dr Mohammad Sobuh and his research assistant Nidaa Elyan. The workshop introduced the concept of activity monitoring and discussed different sensors that can be used to track the physical activities and relevant examples were given form the literature. Students were then allowed to measure their own activity for a short period of time using accelerometery-based activity monitors. Data was then presented and discussed in a simple way to understand how the gathered data can describe the activity performed. It was interesting to see how some students began to suggest potential applications for accelerometers in the field orthotics and prosthetics.
The workshop enriched the knowledge of the orthotics and prosthetics students and directed them towards a novel method to assess physical activity; a key aspect that is missing in the current curriculum. 2 students who attended the workshop got involved in a research project where activity monitoring is used to measure physical activity.
Year(s) Of Engagement Activity 2019