1 | 2015

AbstractThere is a rapidly increasing need for prosthetic devices in developing countries. While

the functionality of devices designed for advanced

countries can alleviate some of the problem, it is not

a good long-term solution. There are several

barriers to the successful implementation of western

devices into developing countries. Prosthetics in

developing countries need to be both cost effective

and durable. Equally important to the functionality

of the device, are the cultural and aesthetic

concerns. Both of which, must be considered in the

design and the implementation of a prosthetic

device in developing countries.

Background The purpose of a prosthetic is the same across all

countries and language barriers, to restore and

maintain a patients most value possessions their health and well-being. However, other important

considerations in the design and implementation of

a prosthetic device are the culture where the

prosthetic is being introduced, and the overall

cosmetic appearance of the device itself.1

The design of any prosthetic can be classified by

having three major components: the socket, the

extension, and the artificial appendage. The socket

serves as the interface between the device and the

amputated limb. The extension replaces the length

of the lost limb. The appendage attempts to replace

either the hand or the foot that was lost.2

From this, one would think that designing a

prosthetic device would be a universal pursuit,

being that a device in a first-world country and a

device in a third-world country would be designed

the same. In fact, just the opposite is true. There are

several factors other than the functionality of the

device that can affect the overall usability and

desire of the patient to use the device on a regular

basis. Some of the chief concerns that are unique to

the developing world are the availability of

valuable resources and the access to health care

personnel.1 These factors make designing a

prosthetic for a third world country a challenging

task. In this review, several different factors will be

analyzed and considered in the design and

implementation of prosthetic devices in

developing countries.

Physiological Basis Rapid Increase in the Amount of Amputees

The rate at which the upper-limb amputee

population is growing in developing countries is

exceedingly high. For example, in India alone, it is

estimated that 17,000 new patients will require a

prosthetic device each year. However, India is not

alone in its demand for prosthetic devices. While

disease, auto accidents, congenital defects, and

firearms are all sources of amputation, the most

common causes of amputation are farm accidents

and war in developing countries.3

Citizens in countries that are in civil war are

often at risk of becoming an amputee due to

combat, land mines, and war atrocities. Civilians in

war zones are often left without medical

infrastructure or first aid.4 One documented case of

war atrocities was in Sierra Leone, where hundreds

of civilians had their hands amputated during the

countrys civil war due to political reasons. In other countries, military and political unrest has

shown similar results. It is estimated that there is

around 1 amputee for every 650 citizens in

Afghanistan, 1 per 350 in Angola, and 1 per 400 in

Cambodia. Juxtaposed with 1 per 22,000 in the

United States demonstrates that his is clearly an

epidemic in developing countries, especially those

experiencing either political or civil unrest.3 In fact,

there have been more people injured or killed by

land mines than both of the atomic bombs dropped

on Hiroshima and Nagasaki combined in the

second half of the twentieth century.2

Michael Porter, Max Greenberg, Chris Hemmerich, Jung Kim, Venkatesh Raman

BME 401, Penn State University, Department of Biomedical Engineering

Designing Inexpensive and Durable Prosthetics for the Developing

World: A Review

2 | 2015

Current Approaches At the time of writing this review, there existed

few novel solutions to the problem of prosthetics in

developing countries. The standard approach to the

current problem is to implement technology that

already exists in technologically advanced

countries to these underserved countries. These

devices are extensive and each individual device

will not be described in detail in this review. As

discussed in the other parts of this review, this

strategy is not an ideal solution. Moreover, it is

insufficient for the reasons of cost, durability, and

lack of resources in these countries.

Materials

When designing devices for developing

countries, it is very important to consider what

material is being used to construct the device. For

example, materials such as wood, metal, and cloth

are commonly used in current designs. However,

these are not ideal because they are highly

susceptible to the harsh, humid environments that

are present in these areas. This is an important

consideration in countries where wading in water

is not only common, but is a daily occurrence for

many of the citizens.

Cyborg Beast

Recently, some engineers have begun to

consider 3D printing as a solution for low cost,

durable prosthetics. One such device, named the

Cyborg Beast is designed for use in children

because it can produce a prosthetic hand for a low

cost. The material choice for the device is

polylactic acid (PLA) because it is not only easy to

3D print, but is also a rugged material.5 It is also

biodegradable, which is an important consideration

in the choice of material in order to reduce the

overall carbon footprint and environmental impact

of the device.

Challenges to Alleviating Problem Barriers for Implementation of Existing

Technology in Developing Countries

While there are many upper-limb prosthetics that

have been developed in technologically advanced

countries, it is a very difficult task to implement

these devices in developing countries. The

overriding problem in the majority of developing

countries is the lack of funds available for

healthcare services. However, when there are

funds available, cultural considerations may

prevent developed technology to be successful in

developing countries. 1

One of the largest obstacles for the

implementation of medical devices for these

countries is the lack of trained medical personnel.

Beyond physically delivering the device to the user,

there are several other obstacles to provide

amputees the devices they need. Due to the nature

of the problem, there needs to be a degree of

personalized healthcare for the proper

implementation of the device. Each prosthetic

device needs to be properly fitted, aligned, and

adjusted by health care professionals before it can

properly be used. The World Health Organization

currently estimates that there is a deficit of

approximately 40,000 technicians. Moreover, they

also estimate that it would take over 50 years to

train just 18,000 more skilled technicians.6

Need for a Rugged Design

Although prosthetics are expensive, they are

necessary for patients in developing countries to be

able to work and earn a wage.3 Many developing

countries rely on an agricultural economy. This

requires the majority of citizens in these countries

to earn a living by doing manual labor, rather than

less strenuous and demanding tasks like office

work.2 Because most of the devices that currently

exist were designed for light use in developing

countries, these devices often do not last very long

in the hot climate where the devices are being

implemented. The exposure of these devices to dirt

and water can quickly wear down a device to a

point where it is no longer usable.3 In fact, a

conventional limb that is constructed from wood

and resin only has a life of 18 months in these

climates. This presents a major problem for users

of the device, who rely on the technology to do

their daily tasks.2

3 | 2015

Economic Impacts and Cost of Prosthetics

Conventional prosthetic devices are also very

expensive and many workers in developing

countries cannot afford to buy them. Many of the

workers in developing countries rely on manual

labor to support their families. When large portions

of the labor force can no longer work, it puts a

large strain on the economy of the country. The

nation will subsequently experience decreased

productivity and slowed economic development.

An amputee who does not have access to

prosthetics is at a severe disadvantage in a labor

force. Some of the least fortunate may even be

forced to beg to help them provide for their

families.3

In the United States, a body-powered upper-limb

prosthetic can cost more than $15,000. However,

even prosthetics that are made through aid

organizations such as the International Committee

of the Red Cross, can cost over $1,000 to produce

and properly fit and adjust.3 Prosthetics that are

made in the developing countries can possibly be a

little less expensive. It is estimated that these

devices can cost anywhere between $125 to $1,825,

depending on the country and the manufacturer.

This is a major problem because even though these

devices are cheaper, their lifetime cost can be in

the thousands of dollars due to maintenance, which

is very expensive for families in these countries

who live in rural areas, who live off $300 a year. It

can take years for a family to be able to afford one

prosthetic, let alone the maintenance and

replacements that can be needed as the device

wears out.2

Children who need prosthetics are at an even

larger disadvantage. Because they are constantly

growing, they will require many different

prosthetics before they reach adulthood, there is an

even larger burden on their families. Children

between the ages of 4 and 16 usually grow around

three-quarters of an inch each year. Because of this

growth, a new prosthetic is typically needed every

6 months to 1 year for a children, in comparison to

3 to 5 years for an adult.2

Cultural Considerations

It is very important to consider the culture to

which a device is being implemented. For example,

in many hot and humid environments, it is very

common for people to walk barefoot or with open

toed sandals. Commonly, footwear is removed

when entering a place of worship in these countries.

As a result, it is very important that foot prosthetics

in these regions are aesthetically acceptable so that

the user will feel comfortable about displaying

their device in public. One device, the Jaipur foot

addresses these concerns with a removable heel

that simulates taking off ones footwear. It is also designed so that the user can sit cross-legged,

which is a practice that would be important in both

worship and in the culture. This device also allows

for users to climb trees, which is commonly done

in these regions to collect fruit to eat.1

Another consideration is cultures where it is

customary for younger citizens to genuflect or

kneel before their elders. People who fail to do this

would be considered disrespectful and it may even

be taken as an insult. When designing a device for

users in this country, biomedical engineers need to

enable a user of this device to be able to do this

easily.1

In very poor rural areas, everyone in the village

must work so that the village has enough food to

survive. Unfortunately, people who cannot work

are considered a burden to both their family and the

community as a whole. In cities, however, an

amputee may be seen as a burden because they are

taking work away from an able-bodied person,

who is believed to be able to do the task in a more

efficient manner. Amputees are given very little

consideration and there are not many opportunities

for rehabilitation. Many of the misconceptions

directed toward amputees stem from old traditions

and a lack of knowledge. Some humanitarian

groups are striving to help to clear up these

misconceptions and give amputees a chance to

work. It has been reported that there has been

progress in changing the attitudes of both the

able-bodied individuals and the amputees alike.4

4 | 2015

Rehabilitation

Equally important to the device itself, is the

rehabilitation of the user who receives such a

device. Although it will not be discussed in detail,

the rehabilitation process ideally begins as soon as

possible. Before, the patient even receives the

device, the patient needs to do pre-prosthetic

rehabilitation, which consists of activities such as

strengthening the muscles in their residual limb.

Once the patient is introduced to the prosthetic,

they should undergo more rehabilitation and

training with their specific device. The fit of the

device is of the utmost importance as well as the

overall comfort of the device. Ideally, the amputee

would then train with a health care professional in

order to become more accustomed to doing daily

tasks with their new device. However, as discussed,

it remains a challenge to provide enough workers

in developing countries.6

Opportunities for Engineering Solutions There are many opportunities for biomedical

engineers to help solve the problem presented in

this review. One such way, as discussed, is the

Cyborg Hand, which is a 3D printed hand that is

thought to be both durable and cost effective.

Engineers can try to build off advances such as

these in order to improve their designs and also to

try to extend their use to areas such as artificial legs

as well.

In addition, there is also a great opportunity for

engineers to develop new materials that can be

printed using 3D printing technology, which are

both cost effective, provide superior structural

support, and are good for the environment. Better

materials that are developed to be both cost

effective and durable can also be implemented to

existing devices to increase the usability of already

established solutions. By doing this, engineers will

have access to the many devices that already exist,

and modify them so that they are more suitable for

the hot climate where these devices have the

greatest need.

A third area where engineers can help to develop

design solutions is in the implementation of the

devices to the developing countries. Engineers

should work alongside other groups to help and

direct policy decisions that will eventually lead to a

better dispersion of their products to the people

that need them. In this manner, engineers will be

able to ensure that the products that are not going

to waste because they are not reaching the people

for whom they are intended.

Conclusion There is a large demand for prosthetics that are

both cost effective and durable. However, when

implementing these devices, the cultural of the

population should also be taken into consideration

so that the device will be in accord with the mores

of the people. Many important considerations must

be made when designing any medical device, such

as the materials. In addition, healthcare

infrastructure needs to be developed in these

countries to implement existing technology and to

develop new technologies for amputees.

References

1. Meanley, S. Different approaches and

cultural considerations in third world

prosthetics. 176180 (1995).

2. Strait, E. Prosthetics in Developing

Countries by. (2006).

3. Sitek, A. J. et al. Development of an

Inexpensive Upper-Extremity Prosthesis for

Use in Developing Countries. J. Prosthetics

Orthot. 16, (2004).

4. Staats, T. B. The rehabilitation of the

amputee in the developing world: a review of the literature. 4550 (1996).

5. Zuniga, J. et al. Cyborg beast: a low-cost

3d-printed prosthetic hand for children with

upper-limb differences. BMC Res. Notes 8,

(2015).

6. Walsh, N. E. & Walsh, W. S. Rehabilitation

of landmine victims - The ultimate

5 | 2015

challenge. Bull. World Health Organ. 81,

665670 (2003).

7. Shukla, G. D., Sahu, S. C., Tripathi, R. P. &

Gupta, D. K. A psychiatric study of

amputees. Br. J. Psychiatry 141, 5053 (1982).