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Next-generation devices to diagnose residuum health of individuals suffering from limb loss: A narrative review of trends, opportunities, and challenges
There is a need for diagnostic devices that can assist prosthetic care providers to better assess and maintain residuum health of individuals suffering from neuromusculoskeletal dysfunctions associated with limb loss. This paper outlines the trends, opportunities, and challenges that will facilitate the development of next-generation diagnostic devices.
Design
Narrative literature review.
Methods
Information about technologies suitable for integration into next-generation diagnostic devices was extracted from 41 references. We considered the invasiveness, comprehensiveness, and practicality of each technology subjectively.
Results
This review highlighted a trend toward future diagnostic devices of neuromusculoskeletal dysfunctions of the residuum capable to support evidence-based patient-specific prosthetic care, patient empowerment, and the development of bionic solutions. This device should positively disrupt the organization healthcare by enabling cost-utility analyses (e.g., fee-for-device business models) and addressing healthcare gaps due to labor shortages. There are opportunities to develop wireless, wearable and noninvasive diagnostic devices integrating wireless biosensors to measure change in mechanical constraints and topography of residuum tissues during real-life conditions as well as computational modeling using medical imaging and finite element analysis (e.g., digital twin). Developing the next-generation diagnostic devices will require to overcome critical barriers associated with the design (e.g., gaps between technology readiness levels of essential parts), clinical roll-out (e.g., identification of primary users), and commercialization (e.g., limited interest from investors).
Conclusions
We anticipate that next-generation diagnostic devices will contribute to prosthetic care innovations that will safely increase mobility, thereby improving the quality of life of the growing global population of individuals suffering from limb loss.
Individuals frequently experience neurological phantom and residuum limb pain alone or in combination with acute and chronic neuromusculoskeletal dysfunctions that could compromise their residuum health.
Residuum health depends on the synergy between intrinsic and extrinsic determinants associated with the residuum/prosthesis interface (Fig. 1A and B ).
Managing extrinsic determinants is particularly critical for individuals fitted with lower limb socket prostheses because the soft tissues of their residuum, particularly the skin, have limited physiological capacity to withstand daily mechanical constraints directly applied throughout the socket (e.g., relative movements between socket/residuum coupling, high-impact activities applying unnatural loading).
Altogether, these determinants can compromise the medical condition of a residuum considered holistically as a neuromusculoskeletal system (Fig. 1C). These dysfunctions often result in musculoskeletal overload and increased risks of osteoarthrosis of the ipsilateral and contralateral knees and hips and/or hyperlordosis.
A narrative review of the prevalence and risk factors associated with development of knee osteoarthritis after traumatic unilateral lower limb amputation.
Fig. 1Overview of intrinsic (A) and extrinsic (B) determinants of residuum health (C), corresponding to the medical condition of a residuum considered holistically as a neuromusculoskeletal system, affecting pathways throughout mobility scale (D).
A range of rehabilitation specialists diagnose the medical conditions of the whole individuals including the residuum. Altogether, they establish care plans, including a series of bespoke medical and/or prosthetic interventions considering personal needs, lifestyle, and affordability.
The effectiveness of total surface bearing compared to specific surface bearing prosthetic socket design on health outcomes of adults with a trans-tibial amputation: a systematic review.
Prosthetists design, manufacture, supply, and fit the prosthesis, including suspension methods using liners and sockets adjusted to the individual shape and condition of the residuum at a given time.
The effectiveness of total surface bearing compared to specific surface bearing prosthetic socket design on health outcomes of adults with a trans-tibial amputation: a systematic review.
Physiotherapists tailor exercise programs to achieve the individual's aims, focusing on the flexibility, strength, and stamina required to facilitate the best prosthetic use.
Individuals with compromised residuum health are more at risk to experiencing unsuccessful prosthetic fitting arrangements (Fig. 1D).
Those with a healthy residuum are more likely to maximize comfort, stability, and mobility when using a suitable prosthesis. In all cases, a satisfactory residuum/prosthesis interface is difficult to sustain.
Typically, individuals progress in both upward and downward mobility pathways, including nine typical states providing small, medium, and large mobility scales during rehabilitation and beyond, depending on various levels of satisfaction with prosthetic fitting, functional capacity, and need for aids (Fig. 1). Practically, individuals are often trapped going back and forth between unsatisfactory and satisfactory states depending on the pain experienced when ambulating on medium or large scales.
Subsequent frequent and too often permanent prosthesis abandonment causes unneeded physical and emotional distress, while increasing socioeconomic burdens.
Currently, clinical decisions are primarily based on a series of self-report questionnaires, physical examinations, medical tests, and imaging modalities to assess, and possibly visualize, residuum health. Decisions might also be informed by the evaluations of mechanical constraints applied to the residuum, electromyographic muscle activity, tridimensional kinematics, and dynamic parameters during static conditions and a few gait cycles
These laboratory-based datasets can be combined into neuromusculoskeletal models relying on inverse dynamics equations and/or finite element models to calculate kinetic data and tissue mechanics of ipsilateral or contralateral lower limbs and/or the residuum alone.
Assessing residuum health using these methods is often a trade-off between the required level of the comprehensiveness of outcomes, access to equipment, available human resources, and immediate need for outcomes. Furthermore, aggregating these datasets, let alone interfacing clinical and biomechanical devices, to gain a holistic understanding of dysfunctions is rarely achieved. For instance, cross-correlating the effects of outward and inward mechanical constraints applied on the residuum is difficult to evidence by medical imaging under real-life conditions. Practically, it is challenging to demonstrate the combined effects of socket design and prosthetic fittings on pistoning and clapping of the residuum within the socket responsible for skin damage.
Consequently, care providers have limited ways to establish patient-specific differential diagnoses based on the actual cause-effect relationships between medical and prosthetic care interventions and neuromusculoskeletal dysfunctions. Other than relying on pain, clinicians struggle to establish the true capacity of the residuum to transfer loads safely and identify the Goldilocks loading zone corresponding to “the right load at the right time” as defined by Pitkin and Frossard (2021) and Frossard et al. (2021).
Underloading may unnecessarily restrain mobility. Overloading may compromise tissue integrity over time.
1.3 Need for next-generation diagnostic devices
A preliminary root-cause analysis identified that the primary solution to unmet residuum healthcare needs is to develop an innovative diagnostic tool for neuromusculoskeletal dysfunctions, because this approach has the largest potential to improve current treatments and support emerging bionics solutions.
Clearly, there is a need for diagnostic devices capable of holistic assessments of neuromusculoskeletal dysfunctions and streamlining personalized evidence-based medical and prosthetic care (e.g., rehabilitation exercises, prosthesis fitting and alignments, gait retraining, computerized prosthesis control).
This technology gap can be addressed by exploiting the possible convergence between physical, digital, and biological systems characterizing Industry 4.0.
Next-generation diagnostic devices capable of acting synergistically as hubs by combining biosensors, medical imaging, and computational modeling data must be developed. Wireless, wearable, and noninvasive biosensors should capture the mechanical constraints and topography of residual tissues throughout the residuum during real-life static and dynamic conditions.
Computational modeling should integrate this information and provide a personalized digital twin of the residuum in near real time on a handheld device.
The main purpose of this narrative review is to outline the trends, opportunities, and challenges that will facilitate the identification, invention, and implementation phases of the biodesign of next-generation diagnostic devices.
Present and highlight the strengths and limitations of current technologies used to measure change of mechanical constraints and topography of the residual tissues as well as approaches for the computational modeling of the residuum;
B.
Introduce potential ways to alleviate some shortcomings of current technologies and approaches;
C.
Share the barriers and facilitators of engineering developments, clinical implementations, and commercialization pathways.
The supplementary material provides more information about the searches, key concepts, references extracted, and discussion points about the development of innovation device (e.g., ways to disrupt care, decline effect, barriers to development, technology readiness levels, roadmap for developments).
2. Methods
Information about the technologies suitable for integration into next-generation diagnostic devices was extracted from first-hand observations, gray literature, and peer-reviewed publications.
2.1 Search strategies
The electronic search included three databases: PubMed, EMBASE, and Google Scholar. We searched for a combination of generic and specific terms focusing on mechanical constraints, topography of the residuum tissue, and computational modeling of the residuum.
2.2 Selection criteria
We included references written in English focusing on residuum health, diagnostic devices, and/or at least one specific topic published between 2000 and 2021.
2.3 Evaluation
The technologies considered were subjectively assessed, considering the invasiveness of the apparatus, comprehensiveness of the outcomes, and practicality of the measurements.
3. Results
We included 41 references detailed in Table 1. Next, we present an overview of the importance, the strengths and limitations of each technology, as well as the current knowledge and technical gaps of emerging technologies that limit their integration in next-generation diagnostic devices.
Table 1Overview of the focuses for each of the 41 references considered that were produced by a total of 129 authors from 90 organizations in 18 countries between 2003 and 2022.
Measures of intrasocket load distribution due to inward and/or outward mechanical constraints are critical for evaluating of the quality of the suspension mechanisms and performance of the prosthetic fit.
The effectiveness of total surface bearing compared to specific surface bearing prosthetic socket design on health outcomes of adults with a trans-tibial amputation: a systematic review.
Both types of constraints are affected by the body weight and external load corresponding to the ground reaction forces and moments transmitted through the prosthesis to the socket and residuum.
3.1.1 Pressure sensors
Ko et al. (2021) and Pirouzi et al. (2014) indicated that changes in pressure and forces in the normal and tangential directions at the residuum/socket interface can be measured using a range of strain gauges, as well as piezoresistive, capacitive, and optical sensors.
They added that, in principle, off-the-shelf and easy-to-use sensors printed in ultrathin and lightweight circuits should be sufficiently flexible to conform to the irregular shape and size of residua with high spatial resolution.
The force distribution is often represented by a pressure map and investigated using finite element models as discussed below.
However, it is commonly accepted that the reliability and repeatability of measurements using these socket-pressure sensor technologies can be challenging. Furthermore, Ko et al. (2021) and Dickinson et al. (2017) highlighted that a tight fit between the socket, sensors, and residuum might only be partially achieved because of normal daily residuum volume fluctuations, leading users to add or remove socks when the socket is too loose or too tight, respectively.
Sensors placed in direct contact with the residuum might be deemed too invasive or become a part of the intervention, consequently, biassing diagnostic assessment over extended use.
3.1.2 Portable kinetic systems
In their review, Chadwell et al. (2020) confirmed that changes in the external load can be measured using portable kinetic systems.
State-of-the-art commercial systems include lightweight triaxial load cells that can send raw forces and moments wirelessly to a receiver connected to a nearby laptop fitted at the distal end of the residuum.
Long bouts of daily loading data can be saved using an embedded memory stick.
Specifically designed software programs are generally used to analyze the raw load and characterize loading profiles by the spatiotemporal gait variables, as well as loading boundaries, local extremum, loading rate, and impulse.
Load measurements can be conducted during an long bouts of daily activities, inside or outside clinical facilities, in accordance with the memory storage and battery life of the measurement device.
Development and preliminary testing of a device for the direct measurement of forces and moments in the prosthetic limb of Transfemoral amputees during activities of daily living.
The load measured during ecological assessments might be more reflective of the true daily constraints imposed on the residuum compared to conventional biomechanical assessments in clinical settings (e.g., inverse dynamics).
This direct loading measurement method showed differences in the load profile applied on the transtibial and transfemoral residuum by prostheses fitted with various types of components (e.g., microprocessor-controlled knees and energy-storing-and-returning feet) and alignments.
The lightweight and proximal positioning of a load cell was found to be only minimally invasive and generated no observable gait patterns disturbances.
However, the overall loading data applied to the distal end of the residuum provided little information regarding the actual intrasocket pressure distribution.
Neuman et al. (2013) cross-compared intrasocket pressure distributions and external loads in two individuals with transtibial socket prostheses.
Regression estimates of pressure on transtibial residual limbs using load cell measurements of the forces and moments occurring at the base of the socket.
They suggested that the intrasocket pressure can be modeled as a function of the load measured at the base of the socket using stepwise linear multiple regression analysis. The force component was a strong predictor of the pressure distribution at the distal tibia, gastrocnemius, and popliteal regions throughout the stance. The moment component was a strong predictor of pressure in the patellar tendon region during forefoot loading.
More recently, McGrath et al. (2017) designed a rig capable of simulating intrasocket pressure on the patella tendon, popliteal depression, and fibula head according to the load applied by a transtibial prosthesis during the weight acceptance and push-off phases of a gait cycle.
3.1.3 Knowledge gaps for the assessment of mechanical constraints
Preliminary studies presented by Neuman et al. (2013) and McGrath et al. (2017) suggested that the invasiveness, comprehensiveness, and practicality of measurements of the mechanical constraints embedded in diagnostic devices can be significantly improved, provided that regional intrasocket pressures can be effectively predicted from external load profiles.
Regression estimates of pressure on transtibial residual limbs using load cell measurements of the forces and moments occurring at the base of the socket.
Another critical element of future diagnostic devices is the accurate assessment of topology or distribution of residuum tissues incorporating the skin, fat, muscles, and bone, as well as the fascia, tendons, and nerves under mechanical constraints. Changes in tissue distributions under static and dynamic conditions that mimic daily loading can be evidenced by changes in the depth of each tissue interface within the residuum using mainly a range of medical imaging and ultrasound information.
3.2.1 Conventional medical imaging
Dickinson et al. (2017) mentioned that a range of medical images can provide rapid and comprehensive visual and digital representations of the entire residuum.
However, these images are generally recorded using cumbersome equipment in clinical facilities while the individuals are lying down or standing up quasi-statically with or without the prosthesis. Dickinson et al. (2017) referred to a few studies that used upright magnetic resonance scanning, fluoroscopy, and dynamic Roentgen stereophotogrammetry to capture intrasocket movements under quasi-static loading, simulated gait, and more strenuous activities.
Practically, conventional medical imaging is therefore unable to capture the movements of tissues throughout the residuum under real-life loading conditions and when fitted with a socket and prosthesis (e.g., pistoning and clapping effects).
3.2.2 Dynamic anatomical ultrasonography
Langton et al. (2022) and Frossard et al. (2019, 2021, 2022) provided the proof-of-concept for a novel wearable, non-invasive, non-ionizing, dynamic anatomical ultrasonography (DAU) system to capture the residuum tissue compartment interface depths during dynamic loading through the socket in real time.
This system consists of a portable battery-powered ultrasound instrument (Olympus MX, Omniscan, Canada) that can operate up to eight individual single-element ultrasound transducers simultaneously in pulse-echo mode.
Preliminary experiments using a single ultrasound transducer suggested that the depths of replica skin/fat, fat/muscle, and muscle/bone tissue interfaces within a residuum test-phantom might be recorded over time using a ‘stripchart’ software tool, similar to the conventional time-position (M-mode) analysis utilized with clinical ultrasound scanners.
Furthermore, in vivo testing with a single able-bodied participant fitted with a pseudo-socket and liner demonstrated that the same DAU equipment could capture anteroposterior displacements of the femur and fat distribution during the flexion or extension of the thigh through the socket and silicone liner.
3.2.3 Knowledge gaps for measurements of in-vivo topography of residuum tissues
Improving the comprehensiveness and practicality of this DAU system, and more particularly, the capture, processing, and reporting of the various ultrasound signals, will be required to tackle technical issues, including, but not limited to, (A) the evidence-based physical distribution of the transducers around the socket that only minimally interfere with movements between the instrumented socket and intake thigh (e.g., position and orientation), (B) the integration of ultrasound data from all transducers (e.g., multiple M-mode plots across the residuum), and (C) the segmentation of each tissue (e.g., multiple fat/muscle interfaces within the cross-section of the residuum due to fat infiltration).
In all cases, the cross-validation of DAU and modeling data is required to overcome the current dearth of acousto-mechanical properties for human skin, fat, fascia, and muscle tissues (e.g., material stiffness and ultrasound velocity).
Clearly, more basic and applied work is needed to confirm the true value-add of the proposed DAU compared with conventional medical imaging. Reaching these milestones is required to confirm the hypothetical advantages of integrating DAU measurements within devices for diagnostic residuum health and, possibly, a broader spectrum of neuromusculoskeletal disorders and injuries.
3.3 Modeling
Numerical or computational modeling of the residuum, such as finite element analysis (FEA), can lead to the developments of a digital replica, commonly called “digital twin” of the residuum.
Dickinson et al. (2017) indicated that computational modeling has gained momentum over the last decades because of its capacity to demonstrate and simulate pathomechanics associated with residuum/prosthesis interfaces, facilitate the pre-clinical design of prosthetic attachment and rehabilitation programs, as well as reduce discomfort and treatment expenses.
Dickinson et al. (2017) reviewed 45 articles focusing on the FEA of lower limb residua, residuum/prosthesis interface mechanics, residual soft tissue internal mechanics, and identification of residuum tissues.
This comprehensive study showed that 33 (80%) and 8 (20%) studies published since 1990 focused on transtibial and transfemoral socket prostheses, respectively, but none examined knee disarticulation amputation.
Furthermore, the authors highlighted some shortcomings that substantially influence the prediction of soft tissue strain. Typically, the residual bone is considered a solid rigid tubular shape with a beveled open-ended distal end, although postoperative adaptive bone remodeling changes bone morphology (e.g., spurs due to heterotopic ossification, formation of aggressive bone edges, tumor growth, and bone bruise fractures). Soft tissues are modeled without explicitly considering muscle disuse atrophy, fatty infiltration, and stages of the healing process (e.g., suturing, anisotropic soft tissue contraction, skin granulation, and scar tissues).
For all studies except one, the skin, fat, and muscle compartments were constructed as single bulk soft tissue, without tissue-specific material parameters bespoke for individual participants.
Changes in residuum stiffness due to an increase in lymphatic and blood flow during muscle activation are rarely incorporated. The residuum volume is considered constant despite changes due to the short-term effects of muscle activation and subsequent transient changes in load distribution and loss of adequate socket fit throughout gait cycles. The authors also confirmed that pressure measurements are sometimes unreliable owing to the sensor's limited ability to fully comply with the residuum shape. Rather than considering the full range of loading conditions from the donning of liners, compression socks, and sockets to daily prosthetic use, studies input partially realistic boundary conditions extracted from inverse dynamics or, more recently, direct measurements using triaxial load sensors (e.g., pre-load, maximum loading, and magnitude at selected gait cycle events).
Moerman et al. (2016) proposed a patient-specific and data-driven computational framework for the automated design of a transtibial residuum/prosthetic interface, including a liner and socket.
This framework relies on imaging to record patient geometry and indentation to assess tissue mechanical properties as well as an automated creation of patient-specific designs, finite element analysis, design evaluation (e.g., FEBio and GIBBON), and computer-aided manufacturing. Ramasamy et al. (2018) also outlined a workflow for modeling the simulation analysis of one transfemoral residuum/socket interaction using a three-dimensional, continuum-mechanical, advanced finite element residual limb model.
An efficient modelling-simulation-analysis workflow to investigate stump-socket interaction using patient-specific, three-dimensional, continuum-mechanical, finite element residual limb models.
The proposed workflow involved data acquisition, modeling of the residuum using magnetic resonance imaging (e.g., image segmentation of fat, muscles, femur, liner, and socket, generation of the model), constitutive modeling of soft tissues (e.g., muscle model, tissue injury model), and loading and boundary conditions (e.g., donning, two-hour constant loading around 400 N = 50% bodyweight). These case series studies addressed some of the shortcomings highlighted by Dickinson et al. (2017), including the use of patient-specific data, input of pre-loading conditions associated with socket donning, and minimal user intervention to generate the models.
Nonetheless, these FEA were performed using static medical imaging and load inputs collected during short bipedal stance conditions with nearly full or half body weight; hence, they are unlikely to accurately represent in vivo conditions.
Other limitations preclude clinicians to routinely utilize computational models to facilitate clinical practice.
The outcomes of some models relying on gait cycle data can take up to several weeks of efforts away from point of care because the building and processing times of these models are resource-intensive and time-consuming (e.g., highly skilled staff, staff-hours, and CPU/GPU computing time). At this stage, the highlighted technical constraints of these multi-step computational models limit their clinical applicability.
3.3.2 Real-time modeling
Pizzolato et al. (2017) developed multiple neuromusculoskeletal models of lower limbs, including a study involving prosthetic gait.
Interestingly, some of this work has recently led to the integration of a personalized lower limb neuromusculoskeletal model and surrogate finite element model of soft tissues that enables the real-time estimation of 3D Achilles tendon stress and strain when walking using a handheld device.
3.3.3 Technology gaps for modeling and user-interface
The comprehensiveness and practicality of the user interface of diagnostic devices can be improved significantly by extending the real-time processing capabilities of the handheld device developed by Pizzolato et al. (2017) to the neuromusculoskeletal modeling of the residuum.
Ideally, healthcare providers should operate the personalized digital twin of a patient's residuum in real time during care using a range of qualitative and visual feedback approaches provided by a handheld device or in a virtual reality environment.
The and the healthcare team should also access critical information through a cloud-based dashboard to facilitate self-management and a continuum of care.
There is trend toward the development next-generation of diagnostic devices of neuromusculoskeletal disfunctions of residuum that can positively disrupt the provision of healthcare (e.g., shift paradigm in the prosthetic care, facilitate clinical trials of interventions, prevent emerging interventions to go through decline effect).
Systematic review of clinical practice guidelines for individuals with amputation: identification of best evidence for rehabilitation to develop the WHO’s package of interventions for rehabilitation.
Health service delivery and economic evaluation of limb lower bone-anchored prostheses: a summary of the Queensland artificial limb Service’s experience.
The review highlighted opportunities to develop wearable and noninvasive diagnostic devices integrating cutting-edge wireless biosensors to measure changes in mechanical constraints and topography of residuum tissues as well as computational modeling using medical imaging and FEA (Fig. 2).
Fig. 2Overview of the typical next-generation diagnostic devices integrating wireless biosensors to measure mechanical constraints (e.g., PKS: portable kinetic system) and change in topography of the residuum tissues (e.g., DAU: dynamic anatomical ultrasonography) as well computational modeling using medical imaging (e.g., MRI: magnetic resonance imaging), and models (e.g., FEA: finite element analysis) to animate a personalized digital twin of the residuum in real-time on a handheld device accessible by all prosthetic care providers. (TTA: transtibial amputation, TFA: transfemoral amputation, T: ultrasound transducer).
Several barriers must be overcome during the development of the next-generation diagnostic devices associated, but not limited to, the design (e.g., loading measurements, topography of residuum tissues during real-life activities, patient-specific computational modeling, gaps between technology readiness levels, minimum viable product, usability and acceptance), clinical roll-out (e.g., scope of practice of potential users, select primary users), and commercialization (e.g., reimbursement pathway, interest from investors). The most challenging barriers might be the:
•
Disparity in maturity between relevant technologies, which can be estimated using commonly accepted technology readiness levels (TRLs). The TRLs for loading measurements, the DAU system, and computational modeling approaches can be subjectively estimated at seven, two, and four, respectively. Moving forward, it will be essential to increase the TRLs of DAU to facilitate the integration of all parts and the use of diagnostic devices under real-world conditions.
Discrepancy between the scope of practice and skills of healthcare professionals who may use the device. Their qualifications, training, and experience in measuring prosthetic loading, operating sonographic equipment, and manipulating advanced computational models may be limited or advanced. This issue can be circumvented by wisely identifying the most suitable primary user of the device and at which point of care the device should mainly be used across public and private health care organizations. As mentioned previously, next-generation diagnostic devices should be designed such that minimally skilled healthcare providers can operate them. These issues must be addressed at the onset of the development of the device during the identification phase of the biodesign innovation process.
•
Commercialization due to the typical limited interest of MedTech investors as highlighted by Raschke (2022).
However, investors are most likely to support robust business cases built around the biodesign innovation process.
4.2 Study limitations
The selection of studies targeted pre-established topics and was biased toward systematic reviews. We did not consider the strengths of the methodology, the level of evidence, and recommendations. Our appraisal of the potential contributions the technologies was subjective.
4.3 Future studies
A deeper understanding of the needs and outline of next-generation diagnostic devices will require multiple systematic literature reviews on all candidate technologies. The potential contributions of each approach should be appraised systematically, considering the invasiveness, comprehensiveness, and practicality of the measurements alongside the costs and the status of intellectual property.
The roadmap for the development of diagnostic devices is provided in Supplement Material.
5. Conclusions
This review outlined the technology trends, opportunities, and challenges associated with the development of next-generation diagnostic devices for residual limb neuromusculoskeletal dysfunctions. Practically, this review brings together key information facilitating the identification, invention, and implementation phases of the biodesign for diagnostic devices that can be used routinely by qualified clinicians at critical points of care. Despite of the current technical barriers, we argue that developing fully integrated, wearable, and noninvasive diagnostic devices is feasible and worthwhile.
Altogether, we anticipate that next-generation diagnostic devices will contribute to prosthetic care innovations including new bionic solutions that will safely increase the mobility of the growing global population of individuals with limb loss.
Financial support
This work is supported by Bionics Queensland Challenge 2021 Major Prize – Mobility, the Australian National Member Society of the International Society for Prosthetics and Orthotics (ANMS ISPO) through the Research Grant awarded in 2021 and the FY19 Defense Medical Research and Development Program through the Joint Program Committee 8/Clinical and Rehabilitative Medicine Research Program Restoring Warfighters with Neuromusculoskeletal Injuries Research Award (RESTORE) under Award No. W81XWH2110215-DM190659. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by these funding bodies (i.e., Bionics Queensland, ANMS ISPO, FY19 Defense Medical Research and Development Program).
Declaration of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgments
The authors wish to acknowledge Prof Robert Ware, Derek Smith and Antonio Grimm of Griffith University, Drs Umesh Shetty and Ravi Eswaren of Radiant Radiology for their insights, as well as Dr. Robyn Stokes of Bionics Queensland, Dr. Sally Cavenett of the AMNS-ISPO for their support.
A narrative review of the prevalence and risk factors associated with development of knee osteoarthritis after traumatic unilateral lower limb amputation.
The effectiveness of total surface bearing compared to specific surface bearing prosthetic socket design on health outcomes of adults with a trans-tibial amputation: a systematic review.
Development and preliminary testing of a device for the direct measurement of forces and moments in the prosthetic limb of Transfemoral amputees during activities of daily living.
Regression estimates of pressure on transtibial residual limbs using load cell measurements of the forces and moments occurring at the base of the socket.
An efficient modelling-simulation-analysis workflow to investigate stump-socket interaction using patient-specific, three-dimensional, continuum-mechanical, finite element residual limb models.
Systematic review of clinical practice guidelines for individuals with amputation: identification of best evidence for rehabilitation to develop the WHO’s package of interventions for rehabilitation.
Health service delivery and economic evaluation of limb lower bone-anchored prostheses: a summary of the Queensland artificial limb Service’s experience.
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