Exploring real world use of partial hand prostheses

Research problem

In Scotland around 400 partial hand amputations are performed every year yet very few are referred to prosthetic centres for prosthetic treatment. Until recently there were limited prosthetic options available for partial hand prosthetic restoration.

Presentation after partial hand amputation surgery varies considerably according to the surgical technique, extent of removal, scarring etc. As a result there is no standard presentation and no standard treatment.

There has recently been an increase in products available for this patient group.

Devices can be categorised into 5 areas;

Cosmetic - primary purpose is to restore the form of the missing body segment and may be shaped and coloured to match the remaining hand. These devices can be used passively and normally have no moving parts. An example of a cosmetic partial hand prosthesis would be a high definition silicone digit/s.

Positional - a mechanical set-up where digits can be positioned manually. These devices, often mechanical in appearance, can be used to assist with grasp activities.

Body Powered mechanical - mechanical device using body movement from other segments e.g. wrist flexion to activate movement. These devices, often mechanical in appearance, can be used to assist with grasp activities.

Externally powered - mechanical digits powered externally, normally by batteries housed above the wrist. Movement is controlled using switches such as myoelectrodes or micro switches housed within the socket. Different grasp patterns may be possible.

Assistive device - a activity specific device. The design of these vary depending on the presentation of the hand, need to the user, and activity where assistance is required. Examples include straps with connectors for cutlery, devices for helping hold/steer bicycle, musical instrument holders etc.



Assuming that the patient has an intact hand on their other side, the functional loss experienced by a person who has had a partial hand amputation may be low, however they may struggle with fine motor, precision and bimanual activities. Our experience has shown that the outcome measurement tools that are currently available are not sensitive enough to capture the degree of functional loss that a person with partial hand experiences and the advantages that they demonstrate when using a prosthetic device.



Psychological impact of a partial hand absence is also significant and for some individuals should be used as a measure for success when considering partial hand prosthetic treatment.



Aims To develop an outcome measurement tool for assessing the real world use of partial hand prostheses and assistive devices. Areas which may be explored are when is the device worn, what activities are conducted whilst the device is being worn, how does the user feel when wearing the device. Comparisons may be made against similar activities whilst not wearing a device.

The CDT students will help create solutions for amputees and people with debilitating conditions such as stroke and diabetes, reducing mortality and enabling them to live more satisfying, productive and fulfilling lives. These solutions, co-created with industry and people living with disabilities, will have direct economic and societal benefits. The principal beneficiaries are industry, P&O service delivery, people who need P&O devices, and society in general.
Industry
The novel methods, devices and processes co-created with users and industry will have a direct economic value to our industry partners (by the creation of IP, new products, and improved industry and academic links). Our CDT graduates will be the natural potential employees of our industry partners and for companies in the wider healthcare technology sector. This will help address the identified critical skills need and shortage leading to improvement in the UK's competitiveness in this rapidly developing and growing global market. The CDT outcomes will help UK businesses spread risk (because new developments are well founded) and more confidently enter new markets with highly skilled employees (CDT graduates).

P&O service delivery
Doctoral engineering graduates with clinical knowledge are needed to improve the deployment of advanced technologies in practice. Our main UK industry partner, Blatchford, stated: "As technology develops it will become easier for the end-user (the patient), but the providers (the clinicians) are going to need to have a higher level of engineering training, ideally to PhD level". The British Association of Prosthetists and Orthotists estimates that no more than ten practising P&O clinicians have a PhD in the UK. Long-term P&O clinical academic leadership will be substantially improved by the CDT supporting a select number of clinically qualified P&O professionals to gain doctorates.

Users
The innovation of devices, use of device and patient monitoring, and innovation approaches in LMIC should not only lead to improved care but also lower healthcare costs. Diabetes UK estimates that the total healthcare expenditure related to foot ulceration and amputation in diabetes was £1billion (2014-15), with 2/3 of this related to foot ulceration. Small innovations could lead to large cost savings if targeted at the right aspects of care (e.g. earlier adoption, and reducing device abandonment).
An ability to work is fundamental to a person's place in society and their sense of purpose and has a significant societal impact in all territories. This is perhaps greatest in LMIC where attitudes towards disability may still be maturing, and appropriate social care infrastructure is not always in place. In these cases, an ability to work is essential for survival.
Improved design approaches will impact on all users regardless of context, since the device solutions will better match local and individual user needs. Addressing issues related to prosthetic/orthotic device abandonment (e.g. cosmesis) and improved adherence should also lead to greater social participation. Improved device solutions will shift focus from what users "cannot do" to what they now "can do", and help progress attitudes towards acceptance of disability.
Societal
The majority of the global P&O users are of working age, and a key economic impact will be keeping users in work. The average age at amputation due to diabetes is just 52 in the USA but much younger in countries with less well-developed health care and trauma services (e.g. 38 in Iran). Diabetes UK reports that 35-50% of people are of working age at diagnosis and that there are around 70,000 foot ulcers in the UK, precursors to amputation. There is a similar concern for stroke survivors around a quarter of whom are of working age and are 2-3 times more likely to be out of work after eight years.