Designing another upper limb prosthesis? Cue the undeserved praise now.
Aside from the general public whose knowledge of a niche area of healthcare I can forgive, the doling out of awards and accolades to those designing a solution to a poorly understood problem continues. The source of this today is a slew of start up ventures that spend considerable amounts of time performing their social media blitz, and need to spend an equal amount of time (dare I say more time) learning about the prosthesis user experience. Uploading a new 3D printed hand to a cloud, with a design that can’t interface with a socket, and then moving on to the next life challenge, is not noble or empowering. It’s online littering.
A common problem that exists in these approaches is the lack of a healthcare professional. At times, the healthcare perspective seems to be absent entirely. The public knows sci-fi. People like robotics. What on Earth is a neuroma? If the people unaffected by a limb absence like my invention, problem solved.
New “innovative” prosthetic designs should be geared towards a prosthetist who will assume liability if something happens to her client. Instead, we continue to see designs targeted to a public whose trust is often manipulated. The cost and speed of access to healthcare is discussed. The fact that the intervention doesn’t address the problem is relegated to a footnote, if it’s even present in the discourse.
Offering a solution relies on having an appreciation for the unique set of challenges that the user (adult and paediatric) face as they relate to age, occupation, and living arrangements. The needs of those that live in the large city centres differ from those that live in the suburbs or rural areas. The comprehensive approach taken by the Fit-4-Purpose Prosthetics team, specifically the early and considerable emphasis on understanding cultural constraints and local manufacturing abilities before developing design specifications, gives any potential solution more than a snowball’s chance in hell of success. Providing a transradial myoelectric device with a 2-axes powered-wrist, 5 knuckles, 6 fingers (other dimensions to come) to an individual who needs to lift heavy loads 10 hours per day, under excessive heat and humidity, without access to a charging system, simply creates a hefty fee invoice. It is not fit for purpose.
Maintaining an appropriate standard for prosthetic intervention irrespective of where in the world we are would be the ideal path to follow. Whether it’s a developed nation or LMIC (that’s low-to-middle-income country) healthcare is about restoring independence and maintaining dignity. If you provide a functional prosthesis that looks like nonsense, don’t expect the recipient to be grateful even if it was provided at no cost.
Adhering to this standard is often challenged when the desire to use local resources and locally trained individuals dictates what resources can and can’t be accessed. The current level of healthcare that we are trying to advance may not be sustainable itself. A prosthetic care facility that is heavily dependent on donations may experience complications in planning appointments and regular follow-ups if their fabrication materials (e.g. plaster, plastics, metals) or staff are not routinely available. Funding for the prosthesis can be a cruel game of chance. Non-profit organizations, NGOs, and charities face these challenges regularly.
For this reason, a selection of the Salford team assessed the capacity to deliver quality care by interfacing with local orthopaedic technologists in Uganda last summer, to learn where we might assist them in advancing their rehabilitation efforts. This also provided an opportunity to learn from the high degree of talent and creativity of the local technicians, fuelled by necessity of course. Designing inexpensive prostheses in the United Kingdom using its accessible tools and techniques (i.e. government grants, state-of-the-art community workspaces, university owned 3D printers) and then shipping them into a developing nation, doesn’t inspire change. It creates a crutch, a dependency on the foreign institution. A proof of concept is one thing; the ideal solution needs to be reproducible by the community it’s designed for.
The decision to focus on a body-powered device is a smart one. Body-powered devices provide a level of durability, proprioception, and reliability without requiring the user to have a knowledge of electronics and access to a computer interface (or electricity for that matter) to perform basic trouble shooting. Ad hoc repairs and jury-rigged solutions are more easily accomplished with hand tools that can still keep the user functional at a reduced level of function. This becomes important when the prosthesis fails – and it will – and access to service from a prosthetic clinic is limited or transportation to a service centre is crippling. If a myoelectric prosthesis fails, it’s rendered into a heavy body-powered prosthesis whilst maintaining the benefits of excess weight, longer service time, and increased likelihood that the user may adopt an attitude that the perceived benefits of a prosthesis, any type of prosthesis, is not worth the trouble.
All this to say that a focus specifically on the assistive device will not advance healthcare in any way. This has been tried before, and has repeatedly left something to be desired. Delivering a novel prosthesis without regard for the infrastructure needed to support it will ensure the device ends up in the classified sections within a calendar year, even if it was provided for free.
A prosthesis at no charge is terrific. But a useless tool remains useless, at any price.
-Ali Hussaini
