Prosthetics in the Developing World-A Review of the Literature

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1996 20: 51Prosthet Orthot IntD. Cummings

Prosthetics in the developing world: A review of the literature

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Prosthetics and Orthotics International, 1996, 20, 51-60

Prosthetics in the developing world: a review of the literatureD. CUMMINGS

Texas Scottish Rite Hospitalfor Children, Dallas, USA

IntroductionPublications about prosthetics in thedeveloping world reflect the multiple concernsof health care providers working in thosecountries. Following a RECAL search of relatedliterature from 1961 to 1994, over 130publications were collected and reviewed.Although each geographical region, country.province or city poses unique challenges, thereis much overlap in the literature and most ofthese publications may be grouped into thefollowing general categories:key publications;prosthetics in the developing world;technical publications;war-related injuries and prosthetic and orthoticissues;paediatric prosthetic-orthotic care in developingcountries.Key publicationsIn the course of reviewing the literature,several publications which seemed tosummarize the body of available literature wereidentified and used as the foundation for theoutline above. These key articles also serve tohighlight important recumng themes and issuesthroughout the literature.In a review of prosthetics and orthotics indeveloping countries Sankaran (1984)introduces some general principles. Theseinclude a discussion of the types of devices andspecific components tolerated in the developingworld, quality of amputation surgery, cost,training, and production factors, and the needAll correspondence to be addressed toDon Cummings, Texas Scottish Rite Hospital forChildren, 2222 Welbom, Dallas,TX 75219, USA.

for devices to enable patients to squat, kneel,and sit on the floor. This overview is followedby a large table listing over 500 cities aroundthe developing world where prosthetic/orthoticcentres are located, including a brief notation ofthe type of work performed in each centre.

Along the path to developing andimplementing appropriate prosthetic/orthoticcare, one must consider multiple factors.Poonekar (1992) identifies a list of prevailingfactors affecting prosthetics and orthotics inIndia, but these could apply to much of thedeveloping world:

1.2.3.4.5.6.7.8.9.10.

Economic factorsSocial factorsCultural factorsClimatic factorsLocally available forms of technologyTime and distance constraintsPsychological factorsMaterials and resourcesReligious factorsAppropriate technology.

He feels that for an appliance to beappropriate in India, it must be:

1. Low cost2. Locally available3. Capable of manual fabrication4. Considerate of local climate and working5. Durable6. Simple to repair7. Simple to process using local production8. Reproducible by local personnel9. Technically functional (not gratuitously

conditions

capability

high-tech)51

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52 D. ummings10. Biomechanically appropriate11. As lightweight as possible12. Adequately cosmetic13. Psychosocially acceptable.

The establishment of prosthetic/orthoticprogrammes to aid developing countries is oftenaccomplished through a profusion ofgovernmental and non-governmental agencies.These programm es are generally of three types:1) research programmes aided by financialsupport in collaboration with institutions,agencies or organizations in a developedcountry, 2) programmes that introduce devicesor techniques into established orthotic andprosthetic centres in a particular country, and 3)programmes designed to establish centres incountries or regions where there are noorganized prosthetic/orthotic programmes. In adiscussion of a practical plan for such projectsPeizer (1977) suggests a three-step process.First, a programme should bring togetherrepresentatives of the host country and thesponsors for comprehensive planning meetings.Even at this early stage, he suggests that inputfrom ISPO can be helpful in regard to training,evaluation, and planning. The second phaseinvolves site visits, ideally utilizing ISPOrepresentatives to evaluate the capabilities,personnel, equipment and other needs of thehost country. In the third step, the programme isactually designed in great detail based on theinformation gathered during the first two stages.Peizer feels that this approach will he lp avoidmany common problems. He continues hisdiscussion with a detailed explanation of howan expert teaching team should be selected andthen prepared for training missions, and how thehost country can benefit m ost from their efforts.He em phasizes that training should be providedby experienced educators who understand theconditions under which their students mustpractice, and that all efforts should be gearedtoward a technology transfer that can actuallybe integrated into the host countrys health caresystem.From a broad perspective, any approach thatinvolves training of new prosthetists usingconventional techniques faces an uphill battle.Murdoch (1990) cites conservative estimatesthat 3 to 4 million people in the developingworld require a prosthesis, and that care for thisnumber would require equipping and training

50,000 to 100,000 prosthetists. Proponents ofCAD CAM (Computer Aided Design-ComputerAided Manufacture), suggest that by boostingefficiency and productivity of existingprosthetists, automated manufacture ofprostheses combined with modular componentsmay help diminish this shortfall. This approachis currently being tested in Hanoi, Vietnam bythe Prosthetic Research Foundation (Smith eral., 1992).At the heart of most of the literature is thedilemma of how to provide and implementappropriate prosthetic/orthotic care in thedeveloping world, where at least 80% of thoseneeding such care are urban and rural poor whocannot afford it. There are two very differentand often conflicting approaches to theproblem: the top-down approach of buyingand implementing technology packages fromthe west, and the simplistic approach oftraditional, primitive technology. Sethi (1989)feels that something is missing from this debate:

. . . a distinction is not being madebetween science and technology. We areconfusing expensive gadgetry with goodscience. This often is not so. It requiressome very sophisticated thinking to aniveat a simple solution. It is much easier towork out a complicated and expensivesolution. Indeed, whenever oneencounters an expensive and complicatedtechnology, one can take it that the basicissues have not been understood.Expensive gadgetry often possessesimpressive Symbolic Value as opposedto Use Value. What we want is more,and not less science in the developingworld (p. 118).He goes on to explain that the scientificapproach should be used to evaluate technologybeing used and designed for the developingworld, but that this approach is also subject tofailure if it ignores the lifestyles and cultures ofthe patients being served. As an example, hetraces the development of the Jaipur foot inIndia. He feels that the components success liesin its gradual method of development whichinvolved continuous interaction between thedevelopers of the component, those who wouldfabricate it using cost-effective locally availablematerials, and the amputees who wore the foot



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Prosthetics in the developing world 53day in and day out.Vossberg (1988), supports a similar approachwhen he analyzes orthoticlprosthetic techniquesin Colombia. He discusses three different levelsof service available in Colombia (thegovernment-controlled workshop, the workshopsupported by non-government organizations,and the private workshop), and how each isimpacted by the various forms of availableorthotic and prosthetic technology. He feels thatappropriate technology . .. ranges on anintermediate level between a stagnant,inconsistent, labour-intensive technology and animported, capital-intensive industrial mass-scaletechnology (p. 99). Unless it can be sustainedand made affordable to most patients afterfunding and technical support are removed, theimported high-tech approach appearsultimately to ignore the large poor sector of thepopulation; whereas the artisan or primitivetechnology approach takes a step backwards byplacing the burden of practice of a highlyspecialized profession in the hands of aconsiderable number of self-proclaimed orshort-term trained technicians . .(p. 98).In order to provide truly appropriatetechnology that copes with present and futuredemands, Vossberg (1988), lists a number ofpolicy guidelines that should be considered:formulate new ideas and examine approaches,methods and techniques in the field ofprosthetics and orthotics, which could best beapplied in a distinct environm entcreate a new type of orthopaedic technicianwho is able to initiate ideas for indigenousdesigns and detail their construction criteriato the production engineerreplace a technology which is characterizedby high costs and over-sophistication by onewhich is acceptable in terms of cost-benefitand effectiveness, technical appropriatenessand environmental adaptabilityexchange the feasibility studies and researchin the area of appropriate technology tointensify communication and cooperationamong the concerned institutions (p. 100).

In a related publication about appropriatetechnology transfer, Vossberg (1983, listspractical principles of technical training andcounselling in a developing country:give ample time to study and understand theinvestigate traditional methods and materialssocial environment

define the programmes priority areason the basis of these findings, developtest these in conditions which are typical ofspecify the appliances by means ofpropagate the philosophy of an appropriate

indigenous appliancesthe countryillustrations and descriptionsorthopaedic technology (p. 84).

Prosthetics in the developing worldIn 1976, the member countries of the WorldHealth Organization (WHO) agreed to includerehabilitation in their goal of Health for all bythe year 2000. Because it was later stated thatup to 90% of all disabled persons in developingcountries were largely neglected, theorganization decided on a rehabilitation modelappropriate for use as a supplement for existinginstitution-based services in developingcountries. This rehabilitation model has c om e tobe known as community-based rehabilitation(CBR) (Mitchell er al., 1989). Numerousarticles surveyed dealt specifically with variousaspects of CBR, and much of the literaturedealing with prosthetics and orthotics indeveloping countries has been permeated withmany of the concepts and terms originating inCBR.Ideally, CBR services consist of three levelsthat interact to provide appropriaterehabilitation services:1. Community level- ervices delivered by volunteer communityworkers, families of disabled persons,community agencies and organizations.- personnel who have health-related, but notdisability-specific backgrounds, e.g. generalpractitioners, nurses, midwives, teachers,social workers and auxiliary workers.- specialists in rehabilitation medicine,special education, vocational rehabilitationand social services. (Periquet, 1989, p. 95).Although there are numerous variations ofCBR, all appear to have the following generalprinciples in comm on:1. Community resources from the nucleus for

2. CBRis based on simplified and appropriate3. An effective referral and support system

2. Intermediate level

3. Specialized or tertiary level

CBR delivery.technology.



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54 D.Cummingsshould exist.4. CBR should use the existing social andcommunity infrastructure (Mitchell et al.,1989, p. 145).CBR appears to be here to stay for a while,and is generally an efficient, cost-effectiveapproach to awareness and prevention ofdisabilities and to delivery of rehabilitationservice, particularly in rural areas with noprevious access (Periquet, 1989). This approachwill undoubtedly continue to influencedevelopment of prosthetic services, trainingschemes, and cooperation between members ofthe rehabilitation team in developing countries.Some questions that remain to be answered arewhether or not prosthetics and orthotics fit theCBR model, and if so, on which level of CBRservice?Although prosthetic rehabilitation isconsistent with the WHOS goals, there areother reasons why even impoverished countrieshave a vested interest in developing prostheticcare. Staats (1993), observes three actiontriggers that create a powerful incentive for acountry to address the needs of its untreatedamputee population.The first of these he calls the mediaimperative for action. The high profile natureof amputation, particularly those that are warrelated or that affect children, easily capturesthe hearts and imagination of the media, andthrough them, potential donors andhumanitarian groups. The traumatic, disfiguringnature of amputation, followed by the positiveresults of prosthetic fitting are often dramatic,and carry a unique appeal for the media. As aresult, virtually any sustained news coverageabout disease, disaster, war or the aftermath ofwar includes at least visual documentation ofthe plight of the amputee. There can betremendous political pressure, therefore, for anation to address this highly visible problem.This political pressure is the second actiontrigger discussed by Staats. He explains thatsince a government cannot afford thedemoralizing impact upon its citizens of seeingits war veterans or civilian victims devoid ofmedical and prosthetic care, there is againtremendous pressure for a nation to provideprosthetic treatment or to accept outside help inthis area. Finally, in some countries, Staats hasobserved that the sheer numbers of amputeesare so high as to represent a political, economic

and social disaster. Hence, in addition to mediaand political pressure, there also exists a volumeimperative for action. Staats concludes byobserving that since prosthetic care will largelyremain a humanitarian effort in most developingcountries - meaning that most amputees willhave limited access to prosthetic care duringtheir entire life - primary goals for prosthesesshould be for comfort and durability.As a developing nation begins to address theneeds of its amputee population, it will oftenbegin to discover that a properly rehabilitatedpatient usually costs a government less moneythan a disabled person totally dependent ongovernment support (Stills, 1993, p. 45).Surveys of developing nations indicate thatmost of these nations realize that as theydevelop, the physical and social rehabilitationof disabled countrymen is an essential part of amodem community. But differences in thedegree and quality of care between countries areoften huge. The survey by Saugmann-Jensen(1959) suggests that these differences are morerelated to disparity in politics and financialpotential, and not to differing views on whetheror not prosthetic care is justified.Political and financial differences as well asvariances in climate, population distribution,transportation, communication, medicalinfrastructures, educational systems, andmultiple other factors combine to create starkcontrasts between countries abilities to developand provide prosthetic care. However, onecommon aspect of orthopaedic care indeveloping countries is that prosthetic centres inthe capital and other large cities are largelystaffed by prosthetists trained and employingtechniques acquired abroad. In smaller remotecommunities and rural areas, most care issubstandard and offered by unqualified staff(Kaphingst and Heim, 1985). This apparentwidespread disparity can only be improvedthrough appropriate education.Component production is emphasized in achapter by Kaphingst and H eim2 (1985), whodiscuss current prosthetic education an d trainingin the developing world. The authors concludethat because of staff shortages, large patientnumbers, lack of components, and immensepractical and financial challenges, prosthetistsin developing countries must be very creative,and probably need more and not less training.They recommend that training in the developing



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Prosthetics in the developing world 55world should not be simplified, rather it shouldfocus on more specific manual skills, andcomponent production should be part of thecurriculum.In a series of three articles on the subject,Fishman (1986, 1987) describes what he feelsare the three most serious challenges toappropriate prosthetic care in developingcountries:a) the low or marginal educational status andlimited potential of the individuals selectedto receive the training;b) the corresponding role, bench-work oriented,instruction most often devoid of texts, visualaids, examinations, or trained instructors;andc) the consequent inability of those completingthe trainingi) to comprehend and apply the scientific(biomechanical) rationale to prosthetic-orthotic fittings, andii) to m anage the logistical co mplexities(personnel, space, supplies, budgeting,scheduling, transportation, security, etc.)of organizing and maintaining a facilitythat can consistently provideprosthetic/orthotic appliances (Fishman,1986, p. 36).Fishman (1986) suggests a three-tieredapproach to tackling these challenges; improvededucational opportunities, widespreadavailability of locally-made components(engineers and component manufacturersshould be consulted for this), and ongoingimprovem ent of facility manag ement techniquesand basic prosthetic ortho tic skills.Numerous publications concerned with thestate of prosthetics and orthotics in thedeveloping world focus on specific challenges,statistics, demographics and clinical results inindividual countries, and a few larger volumesserve as references to services in manycountries. Although these each have merit, timeand space do not allow an individual review.Technical publicationsNumerous technical publications werereviewed and grouped into the generalcategories of: 1) fabrication techniques, 2)prosthetic feet, 3) general technical aids, 4)thermoplastics, and 5) CAD CAM. A briefsynopsis of each publication is included,followed by the authors names.

Fabrication techniques1. Detailed text on alternative techniques fordesign and fabrication of trans-tibia1prostheses. Includes alignment, anatomy,casting, modification, sockets (leather,aluminium, resin, and wood construction),suspension systems, and fabrication of feet(including SACH and Jaipur designs). Thisis an excellent text for prosthetists indeveloping countries as well as forprosthetists wishing to learn about methodsand materials used in the developing world(Alternative limbmaking, 1989).2. Com plete manual for local production of anexoskeletal single axis knee componentcomplete with manual lock and extensionassist options. Includes drawings,photographs, and schematics (Telchow andGehrels, 1984).3. Tilting stubbies for bilateral trans-femoralamputees to connect and interchange withtheir full-length prostheses (Balakrishnan,1981).4. Use of cane and bamboo as alternativeconstruction materials for prostheses,orthoses, and assistive devices (B an eji andBanej i , 1984).5. Design of a hanging stump ischialbearing ring prosthesis for residual limbs inbad condition or otherwise unfittable limbs( C h a d el al., 1985).6. Kinematic analysis of knee-ankle designparameters for Afro-Asian cultures wherepatients kneel, squat and sit cross-legged.Includes a description of a six-bar linkagesystem designed to facilitate squatting(Chakraborty and Patil, 1988).7. Description of an AK prosthesis designedto facilitate squatting, and cross-leggedsitting. (Chaudry et al., 1981 and 1982).8. Design of a trans-femoral prosthesispermitting squatting through modificationsto conventional knees an do r adjustable kneeand ankle flexion stops (Guha et al., 1977).9. Design of a trans-femoral prosthesis toenable squatting using a modified Langsingle axis knee (M adhavan et al., 1977).10. Fabrication of trans-tibial and trans-fem oralprostheses using indigenous materials inIndia. Of interest is the use of a mixture ofpolyester resin and cork granules forfabrication (Girling, 1968).11. Use of locally-made components to



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56 D. ummingsfabricate prostheses. The design include aSACH foot, figure 8 cuff, and a single-axis kneedesign (Girling and Cumm ings, 1972).12. Design of a simplified low-maintenanceprosthesis for use in Thailand or othercountries where patients walk in water ormud (ie rice paddies). The designincorporates a laminated foot cut short to aChopart configuration with no rubbercomponents. This design purportedly aidspatients walking in water or mud andresists water damage, mildew and rotting(Kijkusol, 1986).13. Use of a peg-leg prosthesis for leprosypatients in rural areas (Kulkhari and Mehta,1982).14. Design of an inexpensive endoskeletalprosthesis using the Jaipur foot, conduitpipe and a hinge joint. The article alsopresents cost and durability concerns, andthe challenges of squatting, and sittingcross-legged with a prosthesis (Mohan et

al., 1992).15. A discussion on the use of local materialsto fabricate prostheses and orthoses indeveloping countries with an emphasisupon concerns for childrens devices(Oshin, 1981).16. Fabrication of an aluminium open-endedtrans-tibial prosthesis for use with theJaipur foot. The entire procesk offabrication reportedly requires about onehour, and relies upon the skills of local

artisans. The article emphasizes theadvantages of a highly efficient locallystaffed and supplied delivery system (Ringand Sethi, 1981).17. A general approach to providing prosthesesto rural or urban poor in developingcountries. The article addresses specificchallenges such as barefoot walking, sittingcross-legged or squatting, hotenvironments, and uneven terrain. Theauthor compares and contrasts traditionalSACH feet, Muller solid rubber feet, andthe Jaipur foot (Sethi, 1974).18. Modification of the Jaipur system for trans-tibial amputees by use of high-densitypolyethylene irrigation pipe instead ofaluminium for the socket and shank(Upadhayn et al., 1988).19. Fabrication of a laminated PTB styleprosthesis for use in India. Requires use of

plaster, an adjustable pylon, and thermosettingresin (Wollstein, 1972).20. Basic techniques for an epoxy laminatedPTB prosthesis. The technique describedincludes a directly-applied socket,plastazote liner, laminated hollow coneshank, and rubber tyre sole. A similartechnique for fabricating a non-articulatedtrans-femoral prosthesis is described(Pfaltzgraff, 1976 and 1966).Prosthetic feet1. Use of tyre sidewall to construct a crutchfoot (Broadhurst, 1988).2. A comparison of various SACH feet withemphasis on the advantages of the VelloreSACH foot design, which includes a tyrerubber sole to improve durability andenable limited barefoot walking (Lazarus et

al., 1983).3. Design of a new all terrain foot,interchangeable with the Seattle foot. Thedesign has application for any prostheticuser who ambulates on uneven terrain or inwater (Matthews et al., 1993).4. Design of a solid rubber foot ending at theMP joint area and including a proximaltapered cone into which the socket andshank, generally aluminium, are glued. Thefoot is intended to benefit barefoot walkers,and provides greater adjustability to uneventerrain than traditional SACH feet (Muller,1957).5 . Performance measurement of the Jaipurfoot (North et al., 1974).6. Development of the Jaipur foot (Sethi,1972).7. Design and development of the Jaipur foot.Focuses on the need for multiaxial ankleadaptation for uneven terrain and typicalrural Indian life (Sethi et al., 1978).8. Rationale for the Jaipur foot anddevelopment of same (Technology fordeveloping countries, 1993).

Technical aids. equipment, seating systems etc1. Discussion of Com munity BasedRehabilitation and appropriate technology(Appropriate technical aids for disabledpeople (Bombay Seminar), 1988).2. Unique reference manual for fabrication ofmobility aids, (ie seating, positioning, beds,chairs, and walkers), using local



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Prosthetics in the developing world 51primitive materials such as bamboo, string,simple nails, etc. Because this manual usessimple drawings to depict what can befabricated and virtually no text, it isimmediately useful to local artisans with noneed for translation (Caston, 1982).3. Discussion of local production (in Africa),of assistive devices and equipment.Includes information on how to set up aworkshop, a description of the Jaipurprogramme and how to replicate itelsewhere, and descriptions of localproduction of orthoses, prostheses, chairs,wheelchairs, and assistive devices forchildren (Appropriate aids and equipmentfor disabled in Africa, 1988).4. Design of an anthropometer for use indeveloping countries. The article describesfabrication and use of a tool for researchand prosthetic/orthotic measurement(Davies and Shahnawaz, 1977).

5. Use of plywood, metal hinges and screwsto fabricate positioning splints for patientswith recent onset of polio (Varma, 1988).Thermoplastics1. Cost benefits of thermoplastics (whereavailable) are discussed (Oberg, 1991).2. General criteria for use of thermoplastics asopposed to wood, iron, aluminium, orleather (Thermoplastics in prosthetics andorthotics, 1993).CAD CAM in the developing world1. Design and development of CAD CAM foruse in developing countries. The paperfocuses upon non-contact, laser imaging,software for socket modifications,moulding tool production for manufactureof lightweight plastic components, andfield testing of results. The authorsconcept is to use a remote residual limbscanner to send data by modem to acentralized automated fabrication facility(Walsh et al., 1989).2. Implications of CAD CA M us e indeveloping countries. The paper includesrationale for and result of a trial CA D CA Mfacility in Hanoi, Vietnam (Smith et al.,1992).3. Report of an ISPO workshop on CADCAM in prosthetics and orthotics(Murdoch, 1988).

War-related injuries and pro sthetics andorthotics issuesIn the aftermath of a war, countries face agreat struggle for economic and socialrehabilitation, and literally tens of thousands ofpatients may require orthopaedic appliances. Insome countries like Cambodia, Afghanistan,Mozambique, Burma, Somalia, Ethiopia andAngola (to name a few), land-mines, bombs,and other ordnance may lie in a dormant statefor years before causing injury. In Cambodia,for instance, it is reported that in 1 990 alone, asmany as 6OOO people lost a leg or foot to mineexplosion (Stover and Charles, 1991).Without assistance from abroad, thereappears to be very little hope that prosthetic-orthotic care will be established until manyyears have passed. If fighting continues for anextended length of time, it is of course virtuallyimpossible to provide adequate prosthetic-orthotic care within the country. Angola, forinstance, after more than thirty years of war isreported to have the highest per capitapercentage of amputees in the world, andalthough the problem is being addressed,continued fighting makes service to ruralamputees virtually impossible (in Focus, 1993).Groups like the International Red Cross(ICRC) often begin initiatives to help disabledwar victims in countries like Eritrea before thefighting is over (in Focus, 1993). This earlyrelief generally requires the assistance of a teamof expatriate specialists with a systematic andhighly modular approach. Over time thesespecialists can help develop a network ofworkshops and provide training to local healthcare workers and gradually return theprosthetic-orthotic care into the nations hands.Most of the literature reviewed focused onthe challenges of providing prosthetic care inthe primitive conditions and overwhelmingneed following a war. More informationregarding methods, techniques, appropriatematerials and the establishment of long-termcentres is needed.

Paediatric prosthetidorthotic careThere is really very little published aboutpaediatric prosthetidorthotic care in thedeveloping world, and certainly this is an areathat needs to be more adequately addressed inthe future. What is available, seems to indicate



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58 D. ummingsthat children with congenital limb deficienciesare just about as com mon in developingcountries as in the developed world, but there isvery little expertise available both surgicallyand prosthetically to deal with their problems.In many cases, children with congenital limbdeficiencies that would be converted toamputations in more developed countries aresimply left untreated.Sliman et al. (1991) discuss surgicaltreatment of children with longitudinaldeficiencies seen at the El Kassab Institute inManauba, Tunisia. Children with lower limbdeficiencies receive amputations and prostheticfitting when indicated, but children with upperlimb deficiencies receive no prostheticintervention. The inattention to upper limbfitting is not surprising, given the incredibleability of children to adapt, limited acceptanceof arm prostheses even in developed countries,and the high degree of complexity of armprostheses as well as the need for extensiveoccupational therapy to provide adequate long-term results (United Nations, 1974).Although a formalized treatment approachfor children exists in a few centres, there is anapparent lack of awareness in many parts ofIndia, (and one can assume most of thedeveloping world), regarding surgical treatmentandor prosthetic fitting for children (Sharma,1991). Cost factors alone undoubtedly affect anations ability to provide orthopaedic devicesto a population that will quickly outgrow themand require subsequent replacement. Thechallenge is further complicated by the highincidence of childhood pathologies indeveloping countries (including polio, cerebralpalsy, osteogenesis imperfecta, spina bifida,club feet, inherited disorders, war injuries, andmany others), and the inadequate infrastructureto care for these problems surgically, or toprovide adequate rehabilitation. Nevertheless,developing countries are becoming aware of thesocio-economic implications of leaving childrenuntreated, and there is growing interest inproviding prosthetic-orthotic care as well asadequate surgical intervention for thispopulation (Hanekon, 1988; Fernandez-Palazziet al., 1991; Oshin, 1 981).ConclusionMuch of the available literature emphasizesappropriate technology, but there is often great

disparity between what is considered trulyappropriate. In part, this term appears to havearisen from the Community BasedRehabilitation (CBR) movement, and onceagain, it is unclear how prosthetic care fits inwith the CBR model. Although the debate overappropriateness is an essential part of thegrowing process, some consensus would greatlyassist current and future organizations inplanning and implementing prosthetic-orthoticservices and training centres.In education, much has been accomplishedtoward establishing standards, but it appearsthat in actual practice, education in mostdeveloping countries ranges from the formal tothe chaotic, and that accepted standards arerarely adhered to. The reasons for this aremultiple, but one area of weakness in theliterature appears to be in cohesive educationalpackages of texts, and illustrations designed fortraining in developing countries. Undoubtedlysuch materials exist and are utilized by variousorganizations, but are not readily available inthis area.The debate over appropriate technology isevident in the technical literature as well aswhere publications range from primitivemethods to CAD CAM. Although CAD CA Mand high-tech approaches have been thesubject of controversy, it should be noted thatsuch projects have arisen as a result of theoverwhelming shortage of adequately trainedindividuals. Certainly the controversy over costsand sustainability are justified, but progressmust start somewhere, so the burden of proofremains in th e hands of such projects and theirdevelopers.A great deal of technical literature has beenwritten, and the large volume of literatureintended for developed countries should not beoverlooked as it can frequently be applied to thedeveloping world. Gaps exist, however. Thereare few outcome studies, and very fewdocumented component production techniquesfor developing countries. There appears to be asignificant need for durable prosthetic feet aswell as other components that can bemanufactured in-country, and the manyfacilities currently fabricating their owncomponents should collaborate with otherfacilities to compare results in order to aid thequest for the ideal, low cost, durable, locallymanufactured system.



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Prosthetics in the developing world 5 9Perhaps above all, the literature emphasizesthe enormity of the challenge of providingadequate prosthetic-orthotic care in thedeveloping world, the many ongoing efforts toaddress the needs of amputees in thesecountries, and the need for much morecommunication between countries and thevarious programm es that are in existence.

REFERENCESALTERNATIVEimbmaking: the manufacture and fitting oflow cost below knee prostheses./edited by ADamborough... er al..).-London: AHRTAG 1989.APPROPRIATEids and equipment for disabled people inAfrica; report of a seminar in Harare, Zimbabwe,March 20-26.1988. -Broma, Sweden: ICTA, 1988.BAW KRISH NAN (1981). T ilting stubbies: technicalnote. Prosther Orrhor Inr 5,85-86.BANERJI , BANERJIB (1984). A preliminary report onthe use of cane and bamboo as basic constructionmaterials for orthotic and prosthetic appliances.Prosther Orthor Inr 8,91-96.BROADHURST (1988). A low-tech crutch foot.Appropr iate Techno1 14( 4), 8-10.CHAKRABORTYK, PATE KM (1988) . Kinem aticanalysis of k nee-ankle mechanism for an above kneeprosthesis. Mech Res Commun 15,261-268.CHANDN, SRIVASTAVAK,MAISHAR (1985). Hangingstump prosthesis without socket for bad above-kneestumps: technical note. Prosther Orrhot Inr 9, 154-156.CHAIJLIHRYK, GUHASK, VERMASK (1982). Animproved above-knee prosthesis with functionalversatility. Prosthet Orthot In t 6 , 157-160.CHAUDHRYK, GUHASK , VERMASK 1981). Modularconcept in a multi-functional above knee prosthesis.Eng Med 10,155-158.DAVIES T, SHAHNAWAZ(1977). An anthropometerfor use in developing countries: equipment note.Ergonomics 20,317-320.F E R N A N D F Z - P mF, DE GUT[ERWDP. PALADNOR(1991). The care of the limb deficient child inVenezuela. Prosrher Orrhor Inr 15,156-159.FISHMAN (1986). Clinical prosthetic-orthotic servicesin the developing world. AOPA Almanac 34(9), 18-19.FISHMAN (1986). Prosthetics and orthotics in thedeveloping world - education. AOPA Almanac 34(5),36 .FISHMAN (1987). Prosthetics and orthotics in thedeveloping world - nternational assistance programs.AOPA Almanac 36(4),36-31.IN FOCUS 1993). Angola. Orrholener 1.7-8.IN FOCUS 1993 ). Eritrea Ortholener2,4-6.

GIRLING (1968). A method of constructing artificiallimbs in India. Prosther Int 3(4/5),32-36.GIRLING J, CUMMINGSG (1972). Artificial-limbfabrication without the use of commercially madecomponents. Prosrher Int 4(2), 21-25.GUH A K, CtuUDRY KK. MAD HAV ANG let alJ 11977).Above kn ee prosthesis permitting squatting. Med LifeSci Eng 15,25-33.HANEKONM (1988). A survey of children attending arehabilitation centre in Harare. Implications forrehabilitation. Cenrr A f r J Med 34 , 149-153.KAPHINGST, HEM S ' (1995). Education and training inprosthetics in the developing world. In: Amputationsurgery and lower limb prosthetics./edited by GMurdoch. R Donov an.-Oxford: Blackwell Scientific.p436-439.KAPHINGST, HEIMS (1985). Cultural considerationsand appropriate technology in orthopaedics fordeveloping countries. In : Amputation surgery and

lower limb prosthetics./edited by G Murdoch. RDonov an.-Oxford Blackwell Scientific. p384-389.KUKUSOLD (1986). Simplified, low cost below-kneeprosthesis. Prosrher Orrhor Int 10.96-98.KULKARNI N. MEHTA M (1 982) . Observ ations on peg-prostheses in leprosy. L-epr India 54,110-1 16 .LAZARUSS, SUDARARAJD, SELVAPADIANJ (1983).Comparative study of prosthetic feet with Velloremodified prosthetic foot. JRehabil Asia 24(1),5-10.MADHAVAN PG. HAUDHRYK, GUHASK (197 7). Newconcepts in AK prostheses. Med Life Sci Eng 3, 97 -102.MAITHEWSD, BURGESSE. Boom D (1993). The all-

terrain foot. J Prosrhet Orrhot 5,29-30.MITCHELLA. ZHUOD, WATTSGH (1989). Emergingpatterns of disability distribution in developingcountries.Inr Disabi l Studies 11, 145-148.MOHAND. S m K, RAW R (1992). Mathematicalmodelling and field trials of an inexpensiveendoskeletal above-knee prosthesis. Prosthet OrthotM U M (1957). A simple prosthesis for ruralamputees. J Bone Joint Surg 39B, 131.MURDOCH . CADICAM and the developing world.Report of ISPO Workshop on CAD/CAM inProsthetics and Orthotics, Seattle WA, Jun e 1988.MURWCH (1990). Editorial. Prosrher Orrhor In r 9(1),

1-2.NORTHJF, JONES D, GOVANNA ... (e t a l) (1974).Performance measurement of the Jaipur foot. Paperpresented at the C0ngress:ISPO Interbor, APO,Montreaux, Oct 8th-l2th, 19 74. 24pp.OBERG K (1991). Cost-benefits in orthopaedictechnology b y using thermoplastics in developingcountries. Prosthet Orrhor Inr 15, 18-22.OSHIN TA (1981). Indigenous substitutes for modernprostheses and orthoses.Prosther Orrhot Int 5,144- 146.

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60 D. CummingsPEIZER E (1977). Planning prosthetic and orthoticprogrammes to aid developing countries. ProsthetOrrhor Int 1, 119-124.PERIQUET0 (1989). Community-based rehabilitation inPFALRGRAFFRE (1966). A simplified below-kneePFALTZGRAFF(1977). Principles for fabrication ofsimple lower limb prostheses. In: Th e disabled indeveloping countries, proceedings of a symposium onappropriate technology and delivery of health andwelfare services for the disabled in developingcountries, Oriel College, Oxford, 26-30 September1976.-London: Commonwealth Foundation. p26-28.P ~ ~ N E K A R. Prosthetics and orthotics in India. In:Report of a research planning conference - prostheticand orthotic research for the twenty-first century.Bethsheda, Maryland, 23-25 July 1992.-NationalInstitute of Child Health and Human Development.

the Philippines. Inr Di sab if Stud 11,95-96.prosthesis. Bull Prosthet Res 10(5), 48-57.

~233-239.RING RD, SETHIPK (1981). A rapid-fit limb usingalternative technology in India. JBiomed Eng 3, 318-319.SANKARAN (1984). Prosthetics and orthotics indeveloping countries. In? Rehabil Med 6,85-101.SAUGMANN-JENSEN(1959). A preliminary report on theeconomical aspects of providing prostheses, bracesand technical aids. Prosthese s Braces Tech Aidc 4, 8-11.SETHI PK (1972). A rubber foot for amputees inunderdeveloped countries. J Bone Joint Surg 54B,177-178.SETHI PK (1974). Lower limb prosthesis for amputees in

rural areas. In: Surgical rehabilitation inleprosy./edited by F McDowell, CD Enna.-Baltimore,Williams&Wilkins. p396-402.SETHI PK (1989). Technological choices in prostheticsand orthotics for developing countries. ProstherOrthot Inr 13, 117-124.SETHIPK, UDANATMP, KASLIWALSC ( e f al) (1978).Vulcanized rubber foot for lower limb amputees.Prosthet Orrhot Int 2, 125-136.SHARMAP (1991). The care of the limb deficient childSLIMAN, MRABET , DAGHFOUS... ( et a f ) 1991). Thecare of the limb deficient child in North Africa.Prosthet Orrhot Int 15, 152-155.

in India. Prosthet Orrhot In? 15, 143-145.

SMITH . Boom D, HARLAM... (e t all. Implications ofmodern prosthetic technologies in developingcountries. In: Report of a research planningconference- Prosthetic and orthotic research for thetwenty-first century, Bethsheda, Maryland, 23-25 July1992.-National Institute of Child Health and HumanDevelopment. p2 17-225.

STAATSB (1993). Fellowship report on cross culturalissues for appropriate technology prosthetics indeveloping countries.-Washington, DC: WorldRehabilitation Fund.STILLSML (1993). Practising O&P in a developing

country. O & P A l m n a c 42(7), 45.STOVER, CHARLESD (1991). The killing minefields ofCambodia. New Scientist 19 October, 26-30.TECHNOLOGYor developing countries? (1993).Ortholener 1.2-4.TELCHOW , GEHRELS (1984). Debre &it calf kneecomponent. Tanzania Training Centre for OrthopaedicTechnologistdGeman Agency for Technical Co-operation.THERMOPLASTICSn prosthetics and orthotics (1993).Ortholetter 1,s-6.U r n NATIONS.Report of the United Nationsinterregional seminar on Standards for the Training ofProsthetists: organized by the United Nations and theGovernment of Denmark with the co-operation of theInternational Committee on Prosthetics and Orthoticsof the International Society for Rehabilitation of theDisabled, Holte, Denmark, 1-9 July 1968 -New York:UN.UPADHAYA, SHARMAR, SHARMA(1988). Structuralmodification of Jaipur foot with high densitypolyethylene shank. J Rehabil Asia 29(1), 13-16.VARMA (1988). Simple splints. J Rehabil Asia 29(1),1-7.VOSSBERG (1988). The choice of prosthetic andorthotic technique for less developed countries:analysis and perspectives in Colombia. ProsthetOrthot Int 12,96- 100.VOSSBERG (1985). The development of orthopaedicappliances and low cost aids in least developedcountries. Prosther Orrhor In? 9,8346.WALSHNE, LANCASTERL, FAULKNER W (e t a l )(1989). A computerized system to manufactureprostheses for amputees in developing countries. JProsther Orthot 1, 165-181.WOLLSTEINJ (1972). Fabrication of a below-kneeprosthesis especially suitable in tropical countries.Prosthet In? 4(2), 5-8.WORLD EALTH RGANIZATION.esolution on DisabilityPrevention and Rehabilitation (A29-68).- Geneva:WHO, 1976.A f u l l list of the literature reviewed for this article isgiven in Appendix 2 of the Repon of the ConsensusConference on Appropriate Prosthetic Technology inDeveloping Countries.


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Prosthetics in the Developing World-A Review of the Literature