Cheryl Metcalf

Understanding the burden and pattern of health conditions is vital for health systems to plan services and allocate resources effectively. In many low- and middle-income countries (LMICs), data are limited and often derived from Global Burden of Disease (GBD) estimates, which rely on broad categories of conditions [1]. This can obscure the lived realities […]

Background: Personalized prosthetic socket design depends upon highly skilled prosthetists. They aim to balance functional human-prosthesis coupling with safe, comfortable load transmission from the prosthesis to the skeleton, through vulnerable skin and soft tissues. Both traditional plaster and computer-aided design and manufacturing (CAD/CAM) methods are iterative, and sharing knowledge is difficult. Evidence-generated (EG) sockets derived from past computer-aided socket design (CASD) records could provide a personalized starting point for limb fitting, potentially reducing time spent on basic design and enabling prosthetists to focus on more highly-skilled customization. Objective: This study aimed to assess the comfort of EG sockets, generated from past CASD records. Methods: A crossover trial compared EG sockets, derived from 163 previous transtibial devices, with conventional clinician-led CAD/CAM sockets. Noninferiority was assessed for the socket comfort score (SCS) outcome measure, and semistructured interviews provided in-depth user analysis. The setting was 3 UK National Health Service clinics, with 17 participants with 19 transtibial amputations. Results: EG sockets had no statistically significant difference in comfort compared with clinician-led control sockets (median SCS 8.6 for EG sockets and 8.8 for CAD/CAM controls; P=.43, effect size=0.05), but a lower variability in SCS across the group (95% CIs 8.0‐9.0 for EG and 7.5‐9.5 for CAD/CAM devices, respectively). Analysis of interviews revealed themes around fitting session experiences, similarities, and differences between the EG and CAD/CAM control sockets, and residual limb factors impacting perceptions of socket comfort. These provided insights into the participants’ experience of the study and the value of expert prosthetist input in socket design. Conclusions: EG sockets demonstrated noninferiority to conventional clinical CASD practice in terms of socket comfort. Both quantitative and qualitative results indicated how clinician input remains essential and is valued by prosthesis users. Work is underway to incorporate the EG sockets into CASD software such that they can act as a digital starting point for modification by expert clinicians at fitting, potentially reducing time spent on basic design, enabling prosthetists to focus on more highly-skilled customization and co-design with their patients.

Negative emotional and socioeconomic impacts can arise for a person with amputation when their prosthetic limb ceases to fit, is damaged, requires maintenance, or fails [1–4]. Clinic or workshop visits during early rehabilitation are most associated with socket suspension due to discomfort, and volume and shape changes in the residual limb as it matures and […]

Background: Understanding the burden of lower limb conditions (LLCs) is essential for effective health planning, yet data in low-resource settings like Nepal is scarce. LLCs, encompassing diverse issues such as pain, injuries and amputations, can profoundly impact mobility, well-being, and livelihoods. With limited healthcare access and growing non-communicable diseases, the scale and impact of LLCs in Nepal remain unknown. This study estimates the prevalence and distribution of person-reported LLCs, exploring their effects on daily living and regional disparities. Methods: To estimate the prevalence of LLCs a household survey was conducted in three selected districts of Nepal representing different ecological zones; Dolakha (Mountain), Lamjung (Hill) and Dang (Terai/Plan). Follow-up questions to 500 individuals with LLCs explored the conditions further, including their distribution by cause and by important characteristics at the individual and ecological zone levels. Results: A total of 2,525 households were surveyed and screened for LLCs. Six hundred and seventy one (26%) of households reported that there was at least one person with an LLC, and at the individual level 11.2% of adults reported an LLC. Sixty-five percent of LLC sufferers were women. Pain and discomfort was the most common problem (reported in 97% of those with an LLC), followed by injury/trauma (19%), deformity (7.2%), wounds (1.4%) and amputation (0.8%). We present the regions of the lower limb most affected, causes of conditions and the extent to which each condition affected participants’ ability to carry out activities of daily living. Conclusion: Our study shows a high prevalence of LLCs across diverse regions of Nepal, with pain and discomfort most frequently reported, and injuries and trauma common in specific areas. LLCs impair daily activities and employment, highlighting the need for tailored interventions and assistive technologies. Findings pave the way for larger-scale studies and scalable, cost-effective solutions.

Fifteen percent of the world’s population has a disability, over a billion people, and 80% live in lower and middle income countries (LMICs) [1]. The Global Burden of Disease study 2019 indicates the international prevalence of amputation at 176 million, which has increased by over 50% since 1990 [2]. The prevalence of major upper- and […]

A novel engagement methodology is presented for working with multi-sector stakeholders. The proposed methodology can be used to determine barriers and facilitators to translational research within a country-specific context by working with stakeholders in a responsive and collaborative way. A values-based stakeholder ethos throughout a research project lifecycle. This approach ensures the suitability and sustainability of research programmes being implemented within a complex ecosystem. A theoretical basis, drawn from academic and business innovation sectors, has been consolidated and adapted for practical application to design, direct and inform research in low resource settings; a complete engagement methodology is defined. The benefit of advocating an holistic approach and embedding stakeholder engagement has been applied in the prosthetics and orthotics sector in Cambodia. Considering these issues affects the legacy of any proposed change from a research programme, supporting capacity building, sector influence and ensuring relevance to partners; promoting trust for future collaborations.

Purpose: Limb salvage surgery is a surgical procedure for tumour resection in bone and soft-tissue cancers. Guidelines aim to preserve as much function and tissue of the limb as possible. Surgical outcome data is routinely available as part of surgical reporting processes. What is less known are important non-oncological outcomes throughout recovery from both clinical and patient perspectives. The objective of this review was to explore non-oncological outcomes in patients diagnosed with sarcoma around the knee following limb salvage surgery. Materials and Methods: A scoping review methodology was used, and results analysed using CASP checklists. Results: Thirteen studies were included and following appraisal and synthesis, three themes emerged as providing important measures intrinsic to successful patient recovery: (1) physical function, (2) quality of life and, (3) gait and knee goniometry. Specifically, patients develop range of motion complications that alter gait patterns and patients often limit their post-operative participation in sport and leisure activities. Conclusions: This study has shown the importance of exploring confounding factors, adopting a holistic view of patient recovery beyond surgical outcomes, proposing evidence-based guidance to support and inform healthcare providers with clinical decision-making. This review highlights the paucity and lack of quality of research available, emphasising how under-represented this population is in the research literature.

Background: Real time clinical gait analysis (RTCGA) is often incorporated as part of a general or lower limb musculoskeletal (MSK) adult patient assessment. However, it is not known if RTCGA is clinically effective as a useful outcome measure or aids in decision making. Whether there is a clinical worth in conducting RTCGA in adult MSK consultations remains controversial. The aim of this study was to provide unique insights into MSK podiatrists use and opinions of RTCGA, using Posterior Tibial Tendon Dysfunction (PTTD) as an exemplar adult condition.Methods: A qualitative approach was employed to explore MSK podiatrists' views and experiences of RTCGA when assessing or treating patients with PTTD. Semi‐structured interviews were conducted via Skype video calls which were transcribed using an orthographic transcription method. Thematic analysis was employed to identify key meanings and report patterns within the data.Results: Twenty nine MSK podiatrists who used RTCGA in the assessment and treatment of PTTD participated in the study. Five themes were identified as 1) RTCGA Method; 2) Working with RTCGA; 3) RTCGA uses; 4) What could aid RTCGA; 5) How RTCGA skills are acquired. This is the first known study to explore this topic of relevance to clinicians and researchers alike. Clinical observations were not only kinematic, but also included patient perceived experiences such as pain and orthotic comfort with normative kinematic reference values not perceived as important to that management goal. The most common barefoot RTCGA observations performed were the rearfoot to leg angle, medial bulge, forefoot abduction and arch integrity. However, a high amount of variation in many gait observations was noted between participants. Documentation methods also varied with a four‐point scale system to grade motion and position most often employed and RTCGA was most often learnt through experience. The main barriers to performing RTCGA were clinical time and space restrictions.Conclusion: Findings from this study have provided a view of how podiatry MSK clinicians utilise RTCGA within their practice. MSK podiatrists use RTCGA as both an outcome measure and as an aid in decision making. This implies a perceived worth in conducting RTCGA, however further work is recommended that focusses on development of a national guideline to RTCGA to be adopted.

Background: Outcome measurement is essential to understand the impact of clinical interventions and the performance of services. Despite national and professional body encouragement, and successful examples of system level outcome measurement within some health care settings, many barriers still exist preventing outcome measurement from becoming embedded in clinical practice. Objectives: To explore the status of outcome measurement in prosthetic rehabilitation, as applied in clinical practice, with a view to identifying areas of future work aimed at making outcome measurement in prosthetic rehabilitation a meaningful and useful reality. Study Design: Narrative review Methods: A literature search of four databases was undertaken, following the PRISMA principals appropriate to narrative reviews, and using the search terms outcome, measure*, tool, scale, instrument, prosthe*, amput* and limb loss. A total of 1116 papers were identified. Following screening 35 papers, focusing on four main themes, were included in the review. Results: The four themes were 1) What outcomes should be measured? 2) How can these outcomes be measured? 3) What are the barriers to outcome measurement? and 4) What examples of routine outcome measurement currently exist in prosthetic practice?Conclusions: Successful outcome measurement in clinical practice is multifaceted. Understanding and embedding value at every step is key to success. Addressing the questions of `why’, `what’ and `how’ we measure outcome may move us closer to a consensus. Routine outcome measurement at the clinical level should ensure data collection is valuable to clinical practice, makes use of IT solutions and has all important organisational buy in.

Introduction: Plaster casting and manual rectification represent the benchmark prosthetic socket design method. 3D technologies have increasing potential for prosthetic limb design and fabrication, especially for enhancing access to these services in lower and middle income countries (LMICs). However, the community has a responsibility to verify the efficacy of these new digital technologies. This study’s objective was to assess the repeatability of plaster casting in vivo, specifically for clinically-relevant residuum shape and landmark capture, and to compare this with three clinically-used 3D scanners. Materials and Methods: A comparative reliability assessment of casting and 3D scanning was conducted in eleven participants with established transtibial amputation. For each participant, two positive moulds were cast by a prosthetist and digitised using a white light 3D surface scanner. Between casts, each participant’s residuum was scanned. The deviation between scan volumes, cross-sections and shapes was calculated.Results: 95% of the clinically-relevant socket shape surface area had a deviation between manual casts <2.87mm (S.D. 0.44mm). The average deviation by surface area was 0.18mm (S.D. 1.72mm). The repeatability coefficient of casting was 46.1ml (3.47%) for volume, and 9.6mm (3.53%) for perimeters. For all clinically-meaningful measures, greater reliability was observed for the Omega scanner, and worse for the Sense and iSense scanners, although it was observed that the Sense scanner performance was comparable to casting (95th percentile shape consistency). Conclusions: This study provides a platform to appraise new clinical shape capture technologies in the context of best practice in manual plaster casting, and starts the conversation of which 3D scanning devices are most appropriate for different types of clinical use. The methods and benchmark results may support prosthetists in acquiring and applying their clinical experience, as part of their continuing professional development.