Human limbs are complex, so building mechanical replacements is no easy task. Despite major steps forwards in the science of prosthetics, there are still barriers to overcome in terms of making prostheses accessible, useful and specific to their user.
When Professor Laurence Kenney and Dr Alex Dickinson began their projects, they recognised that engineering alone cannot provide all the answers and that interdisciplinary collaboration would be essential to build devices that work for real people in the real world.
PROSTHETICS: FROM SCIENCE TO APPLICATION
Limb losses can occur from a multitude of injuries, diseases or genetic abnormalities. The science behind prosthetics is always becoming more sophisticated, with the most advanced prostheses having almost the same range of movements and functions as the limb they replace. However, such sophisticated models are staggeringly expensive and, for most prosthesis wearers and the healthcare systems that support them, more affordable solutions are needed. Alex explains, “Another issue is that the more precisely a prosthesis matches the function of the real limb, the less durable it is likely to be.”
Every person in need of a prosthesis will have a different set of circumstances, a different body on which the prosthesis needs to fit and differing requirements for what they need the prosthesis to fulfil. For instance, while some people may want a prosthesis purely for aesthetic purposes, others may need a functional prosthesis to sustain their livelihood. Overall, this means that it is impossible to mass-produce prostheses if they are to be effective; a bespoke approach is needed to tailor each prosthesis to the person it will fit.
A FOCUS ON LOWER MIDDLE INCOME COUNTRIES
Although the precise figure is not known, it is estimated that around 57.7 million people globally have suffered from a limb amputation stemming from a traumatic incident. Around 38% of these suffer from upper limb loss. “It’s also estimated that 64% of amputees live in LMICs, and their average age tends to be younger than in higher income countries,” explains Laurence.
There are several reasons why the majority of amputees may be concentrated in LMICs. Many of these nations have experienced conflict in recent decades, and even if the war may have ended, its legacy can live on in the form of unexploded landmines. When a landmine is stepped on, the ensuing explosion can easily lead to the victim losing a limb. “Other common causes of upper limb loss in LMICs include road traffic accidents and poor access to medical services, which could prevent a relatively minor affliction from progressing to a stage where amputation is needed,” says Laurence.
THE CASE OF CAMBODIA
Cambodia, where Alex’s project is focused, is a prime example of a nation with a higher-than-average need for prostheses. Brutal conflicts in the 1970s and 1980s, such as during the Khmer Rouge regime, included the placing of as many as ten million landmines. This has led to the nation having one of the highest amputation rates in the world. “Cambodian authorities and charities that work in the country have a lot to be proud of in terms of clearing landmines, providing prosthetic limbs and supporting prosthetic limb users with other services,” says Alex.
Despite these successes, a lot of work remains. “You may think that the barrier to helping these people is the cost of prosthetic limbs, but we already have some very robust, long-lasting and relatively inexpensive prostheses,” says Alex. “Bigger barriers to providing prosthetic limbs to people in LMICs are the lack of trained professionals and access issues, as many people live far away from clinics and are unable to travel or take time away from work.”
UGANDA AND JORDAN
“Globally, the World Health Organization estimates that only between 5 and 15% of people who need a prosthesis have access to one,” says Laurence. In Uganda, one of the least developed countries in the world, his team found that the absence of government support meant that the orthopaedic workshops in government-run hospitals were typically under-supplied with the equipment and materials they needed. “The lack of a coordinated purchasing system means that prices are high and patients often have to buy the materials they need themselves,” says Laurence. “For instance, we found that the cost of polypropylene, a plastic commonly used in prosthetics and many other applications, was about five times higher in Uganda compared to the UK.”
Jordan suffers less from poverty than Uganda and has a developed clinical infrastructure with well-trained staff. However, regional conflicts are catalysing the loss of limbs and destabilising the economy. “While service provision in Jordan is better than in Uganda, cost remains a barrier to many,” says Laurence. The different needs of people within these two countries are supplying useful lessons for the team, making it clear that there is no ‘one size fits all’ solution to making prostheses accessible to those who need them.
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