Fit-for-purpose, affordable body-powered prostheses

Lead Research Organisation: University of Salford
Department Name: Sch of Health Sciences

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 As part of the agreed pathways to impact work, Bernadette Deere and Steven McCormack, trainee NHS clinical scientists from North Bristol NHS Trust (Deere) and Royal Liverpool and Broadgreen University Hospitals NHS Trust (McCormack) carried out an elective placement aligned with the project. They visited Uganda in December 2018 and produced a report on how people in Uganda get their prostheses repaired. This was investigated from both a technical perspective, by interviewing orthopaedic technologists and observing prosthetic workshops, and from a client perspective, by interviewing prosthetic users. The findings are informing the development of a PhD project, for a biomedical engineering student in Uganda The student's work contributed to a paper presented at the WHO in Geneva in summer 2019. They also wrote a short article on the project, which is reported elsewhere in my submission
Sector Healthcare
Impact Types Societal

 
Description Royal Society Human Transformation 'moving and sensing' workshop
Geographic Reach National 
Policy Influence Type Participation in a national consultation
 
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 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 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 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 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 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