Prioritizing solutions to incorporate Prosthetics and Orthotics services into Iranian health benefits package: Using an analytic hierarchy process.

INTRODUCTION: Health benefits package (HBP) is regarded as one of the main dimensions of health financing strategy. Even with increasing demands for prosthetics and orthotics (P&O) services to approximately 0.5% of the world's population, only 15% of vulnerable groups have the chance to make use of such benefits. Inadequate coverage of P&O services in the HBP is accordingly one of the leading reasons for this situation in many countries, including Iran. AIMS: The main objective of this study was to find and prioritize solutions in order to facilitate and promote P&O services in the Iranian HBP. STUDY DESIGN: A mixed-methods (qualitative-quantitative) research design was employed in this study. METHODS: This study was conducted in two phases. First, semi-structured interviews were undertaken to retrieve potential solutions. Then an analytic hierarchy process (AHP) reflecting on seven criteria of acceptability, effectiveness, time, cost, feasibility, burden of disease, and fairness was performed to prioritize them. RESULTS: In total, 26 individuals participated in semi-structured interviews and several policy solutions were proposed. Following the AHP, preventive interventions, infant-specific interventions, inpatient interventions, interventions until 6 years of age, and emergency interventions gained the highest priority to incorporate in the Iranian HBP. CONCLUSION: A number of policy solutions were explored and prioritized for P&O services in the Iranian HBP. Our findings provide a framework for decision- and policy-makers in Iran and other countries aiming to curb the financial burdens of P&O users, especially in vulnerable groups.

Cost Analyses of Prosthetic Devices: A Systematic Review.

OBJECTIVE: To synthesize extant literature on the cost-effectiveness of prosthetic interventions and explore applicability to low- and middle-income country (LMIC) settings. DATA SOURCES: A systematic literature review using subject headings including "prosthetics," "amputation," and "cost analysis" was performed with PubMed, Embase, and Web of Science search engines, yielding 1194 articles. An additional 22 articles were identified via backward citation searching for 1144 total after duplicate removal. The search was last run in May of 2019. STUDY SELECTION: Studies were included if they conducted an economic analysis of an upper or lower extremity prosthetic device. Studies were excluded if (1) full text was unavailable in English; (2) study was a systematic review or meta-analysis; or (3) study did not have a prosthetic comparison group. Using DistillerSR software, 2 authors independently conducted title and abstract screening. One author conducted full-text screening. The proportion of initially identified studies that met final inclusion criteria was 1% (12 of 1144). DATA EXTRACTION: Data were dually extracted by 2 authors and reviewed by 3 additional authors. DATA SYNTHESIS: All included studies (N=12) examined lower extremity amputations comparing advanced technology. No studies were conducted in LMICs. Comparable data between studies demonstrated (1) the cost-effectiveness of microprocessor- over nonmicroprocessor-controlled knees for transfemoral amputation in high-income settings; (2) equivocal findings regarding osseointegrated vs socket-suspended prostheses; and (3) increased cost for ICEX and modular socket systems over patellar tendon-bearing socket systems with no functional improvement. CONCLUSIONS: There are few prosthetic cost analyses in the literature. Additional analyses are needed to determine the direct and indirect costs associated with prosthetic acquisition, fitting, and maintenance; the costs of amputee rehabilitation; and long-term economic and quality-of-life benefits. Such studies may guide future prosthetic and rehabilitative care, especially in resource-austere settings where prosthetic needs are greatest.

Impact of Time to Receipt of Prosthesis on Total Healthcare Costs 12 Months Postamputation.

OBJECTIVE: The objective was to assess the impact of a prosthesis and the timing of prosthesis receipt on total direct healthcare costs in the 12-mo postamputation period. DESIGN: Data on patients with lower limb amputation (n = 510) were obtained from a commercial claims database for retrospective cohort analysis. Generalized linear multivariate modeling was used to determine differences in cost between groups according to timing of prosthesis receipt compared with a control group with no prosthesis. RESULTS: Receipt of a prosthesis between 0 and 3 mos post lower limb amputation yielded a reduced total cost by approximately 0.23 in log scale within 12 mos after amputation when compared with the no-prosthesis group. Despite the included costs of a prosthesis, individuals who received a prosthesis either at 4-6 mos postamputation or 7-9 mos postamputation incurred costs similar to the no-prosthesis group. CONCLUSION: Earlier receipt of a prosthesis is associated with reduced spending in the 12 mos postamputation of approximately $25,000 compared with not receiving a prosthesis. The results of this study suggest that not providing or delaying the provision of a prosthesis increases costs by about 25%.

Affordable passive 3D-printed prosthesis for persons with partial hand amputation.

BACKGROUND AND AIM: Partial hand amputations are common in developing countries and have a negative impact on patients and their families' quality of life. The uniqueness of each partial hand amputation, coupled with the relatively high costs of prostheses, makes it challenging to provide suitable prosthetic solutions in developing countries. Current solutions often have long lead times and require a high level of expertise to produce. The aim of this study was to design and develop an affordable patient-specific partial hand prosthesis for developing countries. TECHNIQUE: The prosthesis was designed for a patient with transmetacarpal amputation (i.e. three amputated fingers and partial palm). The final design was passive, controlled by the contralateral hand, and utilized the advanced flexibility properties of thermoplastic polyurethane in a glove-like design that costs approximately 20 USD to fabricate. Quantitative and qualitative tests were conducted to assess performance of the device after the patient used the final design. A qualitative assessment was performed to gather the patient's feedback following a series of tests of grasp taxonomy. A quantitative assessment was performed through a grasp and lift test to measure the prosthesis' maximum load capacity. DISCUSSION: This study showed that the prosthesis enhanced the patient's manual handling capabilities, mainly in the form of grasp stability. The prosthesis was light weight and could be donned and doffed by the patient independently. Limitations include the need to use the contralateral hand to achieve grasping and low grasp strength. CLINICAL RELEVANCE: Persons with partial hand amputation in developing countries lack access to affordable functional prostheses, hindering their ability to participate in the community. 3D-printed prostheses can provide a low-cost solution that is adaptable to different amputation configurations.

Cost-effectiveness and budget impact of the microprocessor-controlled knee C-Leg in transfemoral amputees with and without diabetes mellitus.

BACKGROUND: The safe use of a prosthesis in activities of daily living is key for transfemoral amputees. However, the number of falls varies significantly between different prosthetic device types. This study aims to compare medical and economic consequences of falls in transfemoral amputees who use the microprocessor-controlled knee joint C-Leg with patients who use non-microprocessor-controlled (mechanical) knee joints (NMPK). The main objectives of the analysis are to investigate the cost-effectiveness and budget impact of C-Legs in transfemoral amputees with diabetes mellitus (DM) and without DM in Germany. METHODS: A decision-analytic model was developed that took into account the effects of prosthesis type on the risk of falling and fall-related medical events. Cost-effectiveness and budget impact analyses were performed separately for transfemoral amputees with and without DM. The study took the perspective of the statutory health insurance (SHI). Input parameters were derived from the published literature. Univariate and probabilistic sensitivity analyses (PSA) were performed to investigate the impact of changes in individual input parameter values on model outcomes and to explore parameter uncertainty. RESULTS: C-Legs reduced the rate of fall-related hospitalizations from 134 to 20 per 1000 person years (PY) in amputees without DM and from 146 to 23 per 1000 PY in amputees with DM. In addition, the C-Leg prevented 15 or 14 fall-related death per 1000 PY. Over a time horizon of 25 years, the incremental cost-effectiveness ratio (ICER) was 16,123 Euro per quality-adjusted life years gained (QALY) for amputees without DM and 20,332 Euro per QALY gained for amputees with DM. For the period of 2020-2024, the model predicted an increase in SHI expenditures of 98 Mio Euro (53 Mio Euro in prosthesis users without DM and 45 Mio Euro in prosthesis users with DM) when all new prosthesis users received C-Legs instead of NMPKs and 50% of NMPK user whose prosthesis wore out switched to C-Legs. Results of the PSA showed moderate uncertainty and a probability of 97-99% that C-Legs are cost-effective at an ICER threshold of 40,000 Euro (≈ German GDP per capita in 2018) per QALY gained. CONCLUSION: Results of the study suggest that the C-Leg provides substantial additional health benefits compared with NMPKs and is likely to be cost-effective in transfemoral amputees with DM as well as in amputees without DM at an ICER threshold of 40,000 Euro per QALY gained.

Osseointegrated prostheses for the rehabilitation of amputees (OPRA): results and clinical perspective.

Introduction: Patients who undergo extremity amputation have historically used socket prosthetics to ambulate and perform daily functions; however, these prosthetics can be limited by poor terminal control and wear issues. In patients who have difficulty wearing their prostheses or with upper extremity amputations, osseointegrated implants may offer better function and quality of life. The Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) was the first such device to become commercially available. Clinical trials have demonstrated benefit in patient gait, prosthetic use, and overall well-being, and new implants may be applied for various amputation levels.Areas covered: The OPRA, the most studied osseointegrated prosthetic stem, is reviewed, presenting indications, surgical procedure, complications, and results of clinical studies.Expert commentary: Osseointegration for amputees is an expanding field that has the potential to enhance rehabilitative potential. The OPRA implant is an effective device with a long life-span and low complication profile.

Proof of Concept of an Assistive Robotic Arm Control Using Artificial Stereovision and Eye-Tracking.

Assistive robotic arms have become popular to help users with upper limb disabilities achieve autonomy in their daily tasks, such as drinking and grasping objects in general. Usually, these robotic arms are controlled with an adapted joystick. Joysticks are user-friendly when it comes to a general approach to an object. However, they are not as intuitive when having to accurately approach an object, especially when obstacles are present. Alternatively, the combined use of artificial stereovision and eye-tracking seems to be a promising solution, as the user's vision is usually dissociated from their upper limb disability. Hence, the objective of this study was to develop a proof of concept for the control of an assistive robotic arm using a low-cost combination of stereovision and eye-tracking. Using the developed control system, a typically developed person was able to control the robotic arm successfully reaching and grasping an object for 92% of the trials without obstacles with an average time of 13.8 seconds. Then, another set of trials with one obstacle had a success rate of 91% with an average time of 17.3 seconds. Finally, the last set of trials with two obstacles had a success rate of 98% with an average time of 18.4 seconds. Furthermore, the cost of an eye-tracker and stereovision remains below 400$.

Self-aligning prosthetic device for older patients with vascular-related amputations: protocol for a randomised feasibility study (the STEPFORWARD study).

INTRODUCTION: The majority of older patients with a transtibial amputation are prescribed a standard (more rigid, not self-aligning) prosthesis. These are mostly suitable for level walking, and cannot adjust to different sloped surfaces. This makes walking more difficult and less energy efficient, possibly leading to longer term disuse. A Cochrane Review concluded that there was insufficient evidence to recommend any individual type of prosthetic ankle-foot mechanism. This trial will establish the feasibility of conducting a large-scale trial to assess the effectiveness and cost-effectiveness of a self-aligning prosthesis for older patients with vascular-related amputations and other health issues compared with a standard prosthesis. METHODS AND ANALYSIS: This feasibility trial is a pragmatic, parallel group, randomised controlled trial (RCT) comparing standard treatment with a more rigid prosthesis versus a self-aligning prosthesis. The target sample size is 90 patients, who are aged 50 years and over, and have a transtibial amputation, where amputation aetiology is mostly vascular-related or non-traumatic. Feasibility will be measured by consent and retention rates, a plausible future sample size over a 24-month recruitment period and completeness of outcome measures. Qualitative interviews will be carried out with trial participants to explore issues around study processes and acceptability of the intervention. Focus groups with staff at prosthetics centres will explore barriers to successful delivery of the trial. Findings from the qualitative work will be integrated with the feasibility trial outcomes in order to inform the design of a full-scale RCT. ETHICS AND DISSEMINATION: Ethical approval was granted by Yorkshire and the Humber-Leeds West Research Ethics Committee on 4 May 2018. The findings will be disseminated via peer-reviewed research publications, articles in relevant newsletters, presentations at relevant conferences and the patient advisory group. TRIAL REGISTRATION NUMBER: ISRCTN15043643.

Conception, design, and fabrication of novel cost-effective partial-hand prosthetic devices for a quadrilateral individual with limb loss.

BACKGROUND AND AIM: The author designed customized upper-limb prosthetic devices for a 22-year-old man with quadrilateral limb loss. The devices were created to meet his functional requirements, while remaining cost-effective. What made this solution unique was that it utilized low-cost items that were easily sourced and maintained. TECHNIQUE: Devices with polypropylene sockets, wooden positional fingers from an artist's wooden hand and a metal extension plate were conceptualized and manufactured. The patient gave written consent to the publication of information and photographs in this report. DISCUSSION: The devices allowed the individual to complete tasks he desired to be able to perform independently, which included using a computer mouse, aided by the devices. The devices utilized were low-cost and easily accessible materials, such as polypropylene and wood, to cater to financial constraints. The final design had positional fingers and an extension plate to restore surface area for grip, support, and opposition to enable the execution of daily tasks of living. CLINICAL RELEVANCE: A cost-effective method of fabricating partial-hand devices with easily accessible materials is described. The resulting devices were successful at restoring the upper-limb surface area for improved grip, support, and opposition for performance of daily tasks.

Health economic evaluation in orthotics and prosthetics: a systematic review protocol.

BACKGROUND: Health economic evaluations are essential to support health care policy and investment decisions. To date, health economic evaluations in orthotics and prosthetics have focused on discrete components of an orthosis/prosthesis (e.g. a microprocessor controlled prosthetic knee joint) rather than the broader service provided by orthotist/prosthetists. As such, the contribution to orthotic/prosthetic policy and investment decisions is unclear. Whilst there are opportunities to conduct more informative health economic evaluations that describe the costs and benefits of the orthotic/prosthetic service, it is important that prospective research is informed by a critical review of the method design challenges and an understanding of how this research can be improved. The aim of this systematic review is to critically appraise the existing orthotic/prosthetic health economic evaluation literature and therefore determine evidence gaps, critical method design issues and the extent to which the literature informs orthotic/prosthetic policy and investment decisions. METHODS: A comprehensive range of databases-AMED, EMBASE, MEDLINE and PsychINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Nursing and Allied Health, Web of Science, Cochrane Database of Systematic Reviews (CDSR) and specialty health economic databases-will be searched using National Library of Medicine Medical Subject Headings (MeSH) terms as well as the title, abstract, and keyword terms. Search terms related to the intervention (e.g. orthosis), including variants used by varying professional disciplines (e.g. brace), will be used in preference to defining the populations that use orthotic and prosthetic services (e.g. people living with rheumatoid arthritis). Search terms related to health economic evaluations will be guided by previously developed and tested search strings and align with recommendations by the Canadian Agency for Drugs and Technologies in Health. Articles meeting the inclusion criteria will be hand-searched for relevant citations, and a forward citation search using Google Scholar will also be conducted to identify early online articles not yet indexed in traditional databases. Original research published in the English language and after 1 January 2000 will be included. The Checklist for Health Economic Evaluation Reporting Standards (CHEERS) and the Consensus on Health Economic Criteria (CHEC)-Extended list will be used to appraise the methodological quality and identify sources of bias. Data extraction and appraisal will be conducted by one reviewer independently using appraisal instrument guidelines and a content specific decision aid with exemplars. A subsequent review by a second researcher will be undertaken to confirm the accuracy of the extraction and appraisal, and a final review by a third where consensus cannot be reached. The data will be extracted to a purpose-built data extraction template with decision-making guidelines to support consistency. Where possible, the findings of the review will be reported as a meta-analysis, although the heterogeneity of the literature will likely mean a narrative review that illuminates method design issues that contribute to imprecision and variation will be more appropriate. DISCUSSION: This protocol has been purposefully designed to summarise the existing evidence and appraise the methodological approaches used and the quality of the health economic evaluations in orthotics and prosthetics. What we learn from this review will be used to guide further work in this area and design more rigorous health economic evaluations into the future. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018116910.

Experiences of lower limb prosthetic users in a rural setting in the Mpumalanga Province, South Africa.

BACKGROUND:: Ambulation with a prosthesis is the ultimate goal of rehabilitation for a person with a major lower limb amputation. Due to challenges with prosthetic service delivery in rural settings, many patients with amputations are not benefitting from prosthetic interventions. Inaccessibility to prosthetic services results in worse functional outcomes and quality of life. Learning from the experiences of current prosthetic users in this setting can assist to improve prosthetic service delivery. OBJECTIVES:: To explore the experiences of lower limb prosthetic users and to understand the importance of a lower limb prosthesis to a prosthetic user in a rural area of South Africa. STUDY DESIGN:: A generic qualitative approach and an explorative design were utilised in this study. METHODS:: A semi-structured interview guide was used to collect data from nine prosthetic users in a rural area in the Mpumalanga province of South Africa. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Demographic details and information related to acute in-patient rehabilitation were analysed descriptively. RESULTS:: All participants were independent in activities of daily living with their prosthesis and participated actively in their community. Participants reported that their prosthesis was essential to their functioning. High travel cost was highlighted as a barrier to the maintenance of their prosthesis. Patients were dissatisfied with being unemployed. CONCLUSION:: Prosthetic intervention positively influences function, independence and community participation. Challenges relating to the accessibility, cost and maintenance of prosthetics should be a priority to ensure continued functional independence for prosthetic users. CLINICAL RELEVANCE: Understanding the importance of a prosthesis to a prosthetic user validates prosthetic intervention for persons living with an amputation in a rural setting and is vital in establishing and remodelling effective systems for prosthetic service delivery.

Patients with unilateral transfemoral amputation treated with a percutaneous osseointegrated prosthesis: a cost-effectiveness analysis.

Aims: The aim of this study was to compare the cost-effectiveness of treatment with an osseointegrated percutaneous (OI-) prosthesis and a socket-suspended (S-) prosthesis for patients with a transfemoral amputation. Patients and Methods: A Markov model was developed to estimate the medical costs and changes in quality-adjusted life-years (QALYs) attributable to treatment of unilateral transfemoral amputation over a projected period of 20 years from a healthcare perspective. Data were collected alongside a prospective clinical study of 51 patients followed for two years. Results: OI-prostheses had an incremental cost per QALY gained of €83 374 compared with S-prostheses. The clinical improvement seen with OI-prostheses was reflected in QALYs gained. Results were most sensitive to the utility value for both treatment arms. The impact of an annual decline in utility values of 1%, 2%, and 3%, for patients with S-prostheses resulted in a cost per QALY gained of €37 020, €24 662, and €18 952, respectively, over 20 years. Conclusion: From a healthcare perspective, treatment with an OI-prosthesis results in improved quality of life at a relatively high cost compared with that for S-prosthesis. When patients treated with S-prostheses had a decline in quality of life over time, the cost per QALY gained by OI-prosthesis treatment was considerably reduced. Cite this article: Bone Joint J 2018;100-B:527-34.

Cost-effectiveness of bone-anchored prostheses using osseointegrated fixation: Myth or reality?

BACKGROUND: In principle, lower limb bone-anchored prostheses could alleviate expenditure associated with typical socket manufacturing and residuum treatments due to socket-suspended prostheses. OBJECTIVE: This study reports (a) the incremental costs and (b) heath gain as well as (c) cost-effectiveness of bone-anchored prostheses compared to socket-suspended prostheses. STUDY DESIGN: Retrospective individual case-controlled observations and systematic review. METHODS: Actual costs were extracted from financial records and completed by typical costs when needed over 6-year time horizon for a cohort of 16 individuals. Health gains corresponding to quality-adjusted life-year were calculated using health-related quality-of-life data presented in the literature. RESULTS: The provision of bone-anchored prostheses costed 21% ± 41% more but increased quality-adjusted life-years by 17% ± 5% compared to socket-suspended prostheses. The incremental cost-effectiveness ratio ranged between -$25,700 per quality-adjusted life-year and $53,500 per quality-adjusted life-year with indicative incremental cost-effectiveness ratio of approximately $17,000 per quality-adjusted life-year. Bone-anchored prosthesis was cost-saving and cost-effective for 19% and 88% of the participants, respectively. CONCLUSION: This study indicated that bone-anchored prostheses might be an acceptable alternative to socket-suspended prostheses at least from a prosthetic care perspective in Australian context. Altogether, this initial evidence-based economic evaluation provided a working approach for decision makers responsible for policies around care of individuals with lower limb amputation worldwide. Clinical relevance For the first time, this study provided evidence-based health economic benefits of lower limb bone-anchored prostheses compared to typical socket-suspended prostheses from a prosthetic care perspective that is essential to clinicians and decision makers responsible for policies.

Direct medical costs of accidental falls for adults with transfemoral amputations.

BACKGROUND: Active individuals with transfemoral amputations are provided a microprocessor-controlled knee with the belief that the prosthesis reduces their risk of falling. However, these prostheses are expensive and the cost-effectiveness is unknown with regard to falls in the transfemoral amputation population. The direct medical costs of falls in adults with transfemoral amputations need to be determined in order to assess the incremental costs and benefits of microprocessor-controlled prosthetic knees. OBJECTIVE: We describe the direct medical costs of falls in adults with a transfemoral amputation. STUDY DESIGN: This is a retrospective, population-based, cohort study of adults who underwent transfemoral amputations between 2000 and 2014. METHODS: A Bayesian structural time series approach was used to estimate cost differences between fallers and non-fallers. RESULTS: The mean 6-month direct medical costs of falls for six hospitalized adults with transfemoral amputations was US$25,652 (US$10,468, US$38,872). The mean costs for the 10 adults admitted to the emergency department was US$18,091 (US$-7,820, US$57,368). CONCLUSION: Falls are expensive in adults with transfemoral amputations. The 6-month costs of falls resulting in hospitalization are similar to those reported in the elderly population who are also at an increased risk of falling. Clinical relevance Estimates of fall costs in adults with transfemoral amputations can provide policy makers with additional insight when determining whether or not to cover a prescription for microprocessor-controlled prosthetic knees.

Stratified cost-utility analysis of C-Leg versus mechanical knees: Findings from an Italian sample of transfemoral amputees.

BACKGROUND: The fitting rate of the C-Leg electronic knee (Otto-Bock, D) has increased steadily over the last 15 years. Current cost-utility studies, however, have not considered the patients' characteristics. OBJECTIVES: To complete a cost-utility analysis involving C-Leg and mechanical knee users; "age at the time of enrollment," "age at the time of first prosthesis," and "experience with the current type of prosthesis" are assumed as non-nested stratification parameters. STUDY DESIGN: Cohort retrospective. METHODS: In all, 70 C-Leg and 57 mechanical knee users were selected. For each stratification criteria, we evaluated the cost-utility of C-Leg versus mechanical knees by computing the incremental cost-utility ratio, that is, the ratio of the "difference in cost" and the "difference in utility" of the two technologies. Cost consisted of acquisition, maintenance, transportation, and lodging expenses. Utility was measured in terms of quality-adjusted life years, computed on the basis of participants' answers to the EQ-5D questionnaire. RESULTS: Patients over 40 years at the time of first prosthesis were the only group featuring an incremental cost-utility ratio (88,779 €/quality-adjusted life year) above the National Institute for Health and Care Excellence practical cost-utility threshold (54,120 €/quality-adjusted live year): C-Leg users experience a significant improvement of "mobility," but limited outcomes on "usual activities," "self-care," "depression/anxiety," and reduction of "pain/discomfort." CONCLUSION: The stratified cost-utility results have relevant clinical implications and provide useful information for practitioners in tailoring interventions. Clinical relevance A cost-utility analysis that considered patients characteristics provided insights on the "affordability" of C-Leg compared to mechanical knees. In particular, results suggest that C-Leg has a significant impact on "mobility" for first-time prosthetic users over 40 years, but implementation of specific low-cost physical/psychosocial interventions is required to retun within cost-utility thresholds.

The \"Jaipur Foot\": India?s Most Popular Prosthetic for Amputees Is Not the Latest in Technology, but It's Still the Most Suitable Option for Many Patients Almost 50 Years after Its Development.

It is 8 a.m. on a December morning in Jaipur, Rajasthan, India. The day has just begun at Bhagawan Mahavir Vikalanga Sahayata Samithi (BMVSS), a nonprofit organization dedicated to fitting the disabled with artificial limbs (Figure 1). Slowly, patients from across India and neighboring countries gather in the center?s front yard. By the end of the day, more than 35 people will make a long journey back to their homes and communities outfitted with a new prosthetic leg or arm that will promise them a more active and functional future. The entire treatment is free.

Robotic lower limb prosthesis design through simultaneous computer optimizations of human and prosthesis costs.

Robotic lower limb prostheses can improve the quality of life for amputees. Development of such devices, currently dominated by long prototyping periods, could be sped up by predictive simulations. In contrast to some amputee simulations which track experimentally determined non-amputee walking kinematics, here, we explicitly model the human-prosthesis interaction to produce a prediction of the user's walking kinematics. We obtain simulations of an amputee using an ankle-foot prosthesis by simultaneously optimizing human movements and prosthesis actuation, minimizing a weighted sum of human metabolic and prosthesis costs. The resulting Pareto optimal solutions predict that increasing prosthesis energy cost, decreasing prosthesis mass, and allowing asymmetric gaits all decrease human metabolic rate for a given speed and alter human kinematics. The metabolic rates increase monotonically with speed. Remarkably, by performing an analogous optimization for a non-amputee human, we predict that an amputee walking with an appropriately optimized robotic prosthesis can have a lower metabolic cost--even lower than assuming that the non-amputee's ankle torques are cost-free.

Economic Value of Prosthetic Services Among Medicare Beneficiaries: A Claims-Based Retrospective Cohort Study.

CONTEXT: There are few studies of the economic impact or value of lower extremity prosthetic services. Results from this study can inform the value proposition concerning prosthetic services within military health, where over 40,000 Veterans with limb-loss receive care for their amputations through the Veterans Administration health care system. PURPOSE: To determine the extent to which Medicare patients who received selected prosthetic services had less health care utilization, lower Medicare payments, and/or fewer negative outcomes compared to matched patients not receiving these services. METHODS: This retrospective cohort analysis using Medicare claims data (2007-2010) and propensity score matching techniques to control for observable selection bias based on etiological diagnosis, comorbidities, patient characteristics, and historical health care utilization one year before the etiological diagnosis. FINDINGS: Patients who received lower extremity prostheses had comparable Medicare episode payments ($6,099 per-member-per-month for study group, $6,015 per-member-per-month for comparison group) and better outcomes than patients who did not receive prostheses. Study group patients were more likely to receive extensive outpatient therapy than comparison group patients (p < 0.05). Receiving physical therapy is associated with fewer hospitalizations and emergency room visits, and less facility-based care (p < 0.05), essentially offsetting the cost of the prosthetic over a 12-month time frame.

A Low-Cost, Open-Source, Compliant Hand for Enabling Sensorimotor Control for People with Transradial Amputations.

In this paper, we describe the design and implementation of a low-cost, open-source prosthetic hand that enables both motor control and sensory feedback for people with transradial amputations. We integrate electromyographic pattern recognition for motor control along with contact reflexes and sensory substitution to provide feedback to the user. Compliant joints allow for robustness to impacts. The entire hand can be built for around $550. This low cost makes research and development of sensorimotor prosthetic hands more accessible to researchers worldwide, while also being affordable for people with amputations in developing nations. We evaluate the sensorimotor capabilites of our hand with a subject with a transradial amputation. We show that using contact reflexes and sensory substitution, when compared to standard myoelectric prostheses that lack these features, improves grasping of delicate objects like an eggshell and a cup of water both with and without visual feedback. Our hand is easily integrated into standard sockets, facilitating long-term testing of sensorimotor capabilities.