Economic Aspects of the Artificial Limb Industry

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Economic Aspects of the Artificial Limb Industry

McCarthy Hanger, Jr. *

In discussing the economic aspects of the artificial limb industry, I would like to begin with a description of its general nature, then sketch briefly the historical development from the middle 19th century to date. This will enable us to visualize the progress being made and to make some observations as to the future.

An artificial limb or prosthesis is to a great extent a custom-made or individually fabricated device. The variations in size and contour of the anatomy of human beings are practically infinite. Because of the added variations in amputation conditions, such as site of amputation, size, shape and condition of stump, physical condition of the amputee himself, and the uses to which the prosthesis are to be put. the variations that are needed in the prosthesis to properly fit a given individual, are certainly no less and probably much greater than the variations in humans in general. The amputation stumps of new amputees are subject to gradual change in size and shape during the first few months, as they become accustomed to wearing a prosthesis, so that a limb which fits satisfactorily when it is first applied must be adjusted from time to time to maintain a correct fitting.

In prostheses for lower extremity, the principal functional characteristics desired are weight-bearing with reasonable comfort, and ambulation. If the prosthesis does not fit precisely the amputee may not be able to tolerate weight-bearing with any comfort, and the gait will be less than desirable. A small variation from the proper fit in the weight-bearing section of the prosthesis can cause intense discomfort.

In artificial arms or prostheses for upper extremity, the principal functional characteristics are the ability to grasp, to lift, and to put the prosthesis in the desired position. To obtain maximum efficiency in these functions a precise fitting of the prosthesis is necessary.

Therefore it is obvious that prostheses cannot be sold over the counter like an electric toaster, nor can they be sold by size like a pair of shoes. Each prosthesis must be made in accordance with careful anatomical measurements, frequently using plaster of paris moulds of the amputation slump, and must be fitted very precisely to the individual. As adjustments become necessary, these must be performed with a high degree of skill.

The better equipped shops or facilities in the prosthetic field have a considerable variety of tools and equipment. For example, one well equipped facility has 23 different types of power tools in use. One work bench will have 50 different hand tools. Examples of power tools in common use are band saws, disc, spindle and belt sanding machines, electric drills and grinders. Thus, they are more of the nature of time savers rather than substitutes for craftsmanship.

The necessity to handle each case individually, and the knowledge and skill required to perform the task satisfactorily, cause this industry to be much more of the nature of professional service than of mere manufacture and sale of a device.

Limited Size

There are no accurate figures available on the number of amputations performed, or of the number of amputees in the population. Widely varying estimates have been made by people interested in the problem. After reviewing all available figures, the headquarters of our association, the Orthopedic Appliance and Limb Manufacturers Association, estimates the number of amputations of arms and legs to be 25.000 per year. The number of amputees among the population of the United States is estimated at 840,000.

There are approximately 31,000 prostheses sold per year. I estimate the average selling price at $250.00. This would indicate a total volume of $7,750,000 per year.

When allowance is made for the costs of repairs, and other articles directly related to the use of limbs, such as special stump stockings, the total sales volume of the industry appears to be about nine million dollars per year. Obviously, this is one of the country's very small industries.

In our own company, we find that about one-half of our prosthesis sales are to new amputees, and one-half are for replacement of worn-out limbs. If this proportion holds good throughout the country, then only about 15,500 limbs per year are sold to the 25,000 new amputees, leaving 9,500 or 38% who are not supplied limbs. And, the estimated sale of 15,500 prostheses for replacements among the existing amputee population of 840,000 indicates the purchase of a limb by only 1.8% of them per year. If every amputee had a prosthesis this would indicate an average useful life of over 55 years per prosthesis. This is obviously incorrect.

I have estimated above that perhaps 62% of the new amputees receive prostheses. Applying this percent to the amputee population would indicate that approximately 520,000 amputees have received an appliance. The replacement sales of 15,500 per year would indicate that 3% of the amputees replace their appliances each year--an average life of over 33 years. This figure still appears incorrect.

Allowance must be made for persons who for reasons of age, extreme handicap, economic status or location in a remote area, do not receive a prosthesis. Also, because of their ages at time of amputation, many persons only need one prosthesis. Others, unable to master the prosthesis, discard it and so do not need a replacement. It is difficult to believe that these factors explain the discrepancies in the figures, and it would be very worthwhile if a census could be made which would reveal the true situation.

Size and Distribution of Facilities

If we can accept the estimate of 31,000 prostheses furnished per year and given a total population in the United States of 165,000,000, then the number of limbs furnished each year is of the order of 1 prosthesis for each 5,300 persons. Obviously, limb wearers form a very small segment of the population. For various reasons, amputees are more heavily concentrated in some areas than in others, proportionate to the general population.

There are approximately 700 qualified and competent Prosthetists (fitters of artificial limbs) in the country. Again using the figure of 31,000 prostheses per year, we get an average of forty-four and a half (44 1/2) limbs fitted by each Prosthetist. At an average cost of $250.00 per appliance, the annual volume per Prosthetist is an average of 311.125. Vet it requires an area of 236,000 population to support each Prosthetist.

It is therefore not surprising that the industry contains a large number of small shops consisting of one to four persons. Furthermore, many of these shops furnish not only prostheses, but orthopedic braces, surgical supports and other similar products. In large metropolitan centers, there are commonly shops staffed by from 5 to 15 persons and a few which are even larger.

Some Prosthetists are also qualified to fit orthopedic braces. There are other fitters who are qualified to fit orthopedic braces only. The latter are called "Orthotists." The combined total of qualified Prosthetists and Orthotists is about 1,100 persons.

There are approximately four hundred (400) qualified establishments where limbs or braces may be procured.

In view of the large amount of population required to sustain one Prosthetist, it is evident that very few are located in smaller towns or sparsely settled areas. Hence a considerable number of amputees living in such areas must travel long distances to have prostheses fitted and serviced. The industry at least partially offsets this inconvenience by the use of field representatives, or by shops operated part time.

In some such areas, there have been a few shops established by hospitals or similar institutions. Although figures are not available, I believe it could be demonstrated that the industry, which operates on a highly competitive cost basis, can furnish amputee service at a lower cost than a shop of this type. Where there are not enough amputees to support a commercial shop, a hospital shop is justified by the need for service, but when such a shop encroaches on the trade area of established shops, reducing their volume, it can make it difficult for the commercial shop to survive and provide adequate service to its other clients.

Historical Development

Man's attempt to find an adequate artificial substitute for the loss of an extremity begins with the earliest history of mankind. Throughout ancient writings we find many references to amputation stumps and artificial limbs. References to leg supports and to artificial hands are found as early as 500 BC.

Many ingenious devices, presenting evidence of skilled craftsmanship, and a gradually increasing knowledge of basic principles, were made throughout history. I will omit details however and cover only developments in the United States since the middle of the 19th century.

In the "Palmer Leg" was invented in Philadelphia and was claimed to be a great improvement over the Anglesby Leg, a somewhat earlier English design. The Palmer leg had a foot made somewhat on the modern American pattern but with a catgut cord and an anterior spring instead of rubber bumpers in the foot. The "Bly leg," invented and patented in by Douglas Bly, M.D., of Rochester. New York had lateral or side motion at the ankle like that of the natural leg. Dr. Bly is said to have been the first to introduce the curved knee joint, which is now generally used on all below knee limbs.

The Civil War gave great impetus to artificial limb development in the United States.

A. A. Marks was the first to introduce the use of the rubber foot, eliminating ankle motion because the resiliency of the rubber foot was thought to make it unnecessary. J. E. Hanger, the first to perfect the cordless ankle, also introduced and made popular the wood socket.

Many of the limbmakers of this period wore artificial limbs themselves, and while many of them actually thought they had achieved the maximum improvement in artificial limbs, newcomers were constantly announcing something better. Many of the claims made for their products were extravagant; nevertheless a great development in artificial limbs in the United States was made during this period.

The beginning of the twentieth century saw many new names contributing to the development of artificial limbs: the Rowley Brothers of Chicago, Detroit, and Pittsburgh; Frees and Pomeroy of New York: Milligan of Los Angeles: Gaines-Erb of Den-

ver; Hittenberger of San Francisco; Trautman, Winkley and Buchstein of Minneapolis. At the time the United States entered the First World War there were about 200 established artificial limb manufacturers in this country employing approximately 2,000 skilled workmen.

Until the time of World War I the limbmakers in this country, as in all others, were an unorganized group of rugged individualists, each going his own way. rarely speaking to his competitor, and much less consulting with him. There was little or no cooperation between the limbmakers and the surgeons; in fact the surgeon sometimes looked upon the limb-maker as some sort of shyster preying on the amputee, and avoided contact.

OALMA Founded:

In October, , the Surgeon General of the United States Army issued an invitation to the limbmakers of this country to come to Washington, D. C, to discuss the problem of supplying artificial limbs to war veterans. This meeting, no doubt, contributed more to the development of the science of prosthetics than any other occurrence in its history up to that time, for from this meeting originated the organization which is now known as the Orthopedic Appliance and Limb Manufacturers Association. Through the medium of this national organization, limbmakers and bracemakers meet on common ground and discuss their common problems. As a result, an entirely new conception of this industry has developed, as well as a great improvement in the ethical standards of the limbmakers and bracemakers, not only in their own business relationships but in their relationship with the medical profession as well. Through their national association, they have developed scientific and educational programs that are helpful to the limbmaker, the surgeon, and the amputee alike.

Inventions

Some of the more outstanding of the mechanical devices invented by members of the industry in the last 50 years are:

Many different designs of artificial hooks, which are designed to fulfil] particular needs such as those of the farmer, mechanic, or office worker, as well as the needs of daily living; ball bearing joints of several different designs for amputations below the knee or at the knee; the hip control or pelvic belt method of suspension of above the knee limbs; limbs made of aluminum alloy and of fiber; all-rubber functional ankle joints; mechanical hands of several different designs, which have contours resembling a human hand, and which provide grasp; non-functional hands with cosmetic plastic coverings which are quite life-like in appearance.

Government Research Program

Even though history records substantial progress, up to ten years ago there had never been an organized scientific program of research and development in the field of prosthetics.

Toward the close of World War II, the War Department undertook a program of research in limbs, in order to solve more adequately the problem of rehabilitation of the large number of veterans who had suffered amputations in active service. There was established, through the National Academy of Sciences-National Research Council, a Committee on Artificial Limbs, supported first by the office of the Surgeon General of the Army alone, and later by the Veterans Administration.

The research program can be classified broadly into four phases or types of activities:

First, fundamental studies of the nature of locomotion and related problems to form a basis for development of artificial legs, and fundamental studies of the normal and amputee biomechanics of the upper extremity, to form the basis for the solution of upper extremity problems.

Second, invention and development of devices.

Third is amputee case study and application of the first two phases to solution of specific amputee problems.

The fourth phase is the dissemination of the knowledge gained and the evaluation of its use in the field.

The outstanding development in lower extremity devices which has come into common use up to date is the suction socket method of suspension of the above the knee limb.

The Suction Socket limb represents a tremendous advance over any previous known type of prosthesis for this amputation. Greater control, greater freedom, reduction in the sensation of dead weight and greater neatness of fitting of the clothes, have made this prosthesis the preferred type wherever the conditions for its use are favorable.

Other devices which are gradually coming into use are the Navy type soft socket for below knee, variable cadence knee for above knee, and a new improved functional ankle which provides universal motion.

In upper extremity prostheses, there were developed the use of plastics for sockets and forearms, mechanical elbows and wrist units with greatly improved function, and new terminal devices. The principles of fitting and harnessing were studied and improved methods were developed.

While these new developments have greatly improved the function of prostheses, they also are generally more complicated. They require more time and skill to fabricate, to fit, and to maintain. Thus, they are more expensive.

The Certification Forms

The artificial limb industry never has had the resources or personnel available to undertake a program comparable to the government research program. The progress being made represents a very substantial improvement in the quality of service available to amputees. Therefore the members of the industry acknowledge and appreciate the great debt which they and the amputees themselves owe to this program.

Progress Toward Professional Status

Although the leaders in the industry starting at the time of World War I recognized the need for improvement in competence and in ethics, progress in this direction was slow and gradual up to . Then the industry set up a voluntary board to establish standards of competence, equipment and ethics, the American Board for Certification of the Prosthetic and Orthopedic Appliance Industry. This Board conducts examinations to determine the qualifications of fitters of artificial limbs and braces and gives qualified candidates the title of Certified Prosthetist or Certified Orthotist.

The Board examines shops or facilities where artificial limbs or braces are made and fitted to see that they are qualified to carry on this work. The progress since the advent of the Certification Board has been greatly accelerated. Certification by this Board is becoming recognized by the medical profession, by others concerned with rehabilitation of the handicapped, and by the general public as the emblem of recognition of qualified firms and fitters in this field.

There are now 345 Certified Facilities and over 1,000 Certified Prosthetists and Orthotists in the United States. They constitute almost 90% of the known qualified facilities and fitters.

The education program in this field consists of three types: Short courses in specialties, apprenticeship courses, and college courses. The Federal Government, the medical profession and the artificial limb industry have cooperated in holding short courses in the fabricating and fitting of the suction socket leg and the newly de-

signed artificial arms. Starting next spring, short courses are to be held to teach the latest developments in principles of fitting above knee limbs, the Navy type soft socket leg for below knee and other related subjects.

The generally accepted method for teaching skilled crafts has been apprenticeship. Through the joint efforts of the American Board for Certification and the Orthopedic Appliance and Limb Manufacturers Association, a national standard for apprenticeship programs was developed and is gradually being put into effect. This embodies the latest principles of apprentice education.

Considerable thought and discussion has been devoted to establishing college courses in prosthetics. The University of Buffalo has explored thoroughly the problems involved in such an undertaking and hopes to establish a school for this purpose in the near future.

Current Prosthetic Methods

This review of the nature of the industry, the history of its development and the latest changes occurring through research gives us the proper background for a discussion of Current Prosthetic Methods-a picture of the industry as it operates today.

The relatively small number of new amputations and of amputees in the population, scattered all over the United States, has required the artificial limb shops to be scattered throughout the country and has tended to cause them to be small. The extremely individual nature of each fitting of a prosthesis, together with the other factors just mentioned, explains why there have not been developed any machines capable of turning out prostheses in large numbers by essentially mechanical means.

Nevertheless, there are certain components of artificial limbs which can be produced mechanically in large job lots rather than individually by hand. For example, wooden or metal knees, shin pieces, ankle pieces, and feet are readily obtainable. Usually these prefabricated parts are capable of alterations so they can be fitted and aligned to the individual. There are also shops which specialize in the construction of complete limbs, made to individual measurements, on a wholesale basis. Through division of labor processes, the greatest possible mechanization, closer supervision, and large scale purchasing, such shops are able to realize increased efficiency and economy of production. There are a total of 12 such factories which made complete limbs, prefabricated parts, or sub assemblies.

Based on a sample survey of representative firms in the industry, it can safely be said that a very large majority of artificial limb companies use pre-fabricated parts to some extent. Probably one-half of the firms use pre-fabricated parts, rather than a hand-made corresponding part, for one-half of their construction requirements or better.

Almost all the metal joints used are produced by machine shops specializing in this work.

In upper extremity prosthetics the production of elbow units, wrist units, joints, and terminal devices, using machine tools and high precision manufacturing methods is prevalent. Mechanical and passive hands and cosmetic glove coverings are specialties which practically the entire industry purchases from one of ten establishments.

New tools are gradually coming into use in this country. There are now available adjustable walking legs, for providing a complete range of adjustment at the knee and ankle. In connection with the adjustable leg a transfer jig is used to transfer the alignment information to the permanent limb. The latest power tool is a high-speed low-powered cutter with automatic clutch, which greatly reduces the carving time required to prepare a wood socket for fitting, yet which eliminates the danger in using a cutter of high power.

Modern Rehabilitation

So much for the mechanical side; now let us cover the personal side, a new concept of amputee management which might be called "Modern Ideal Rehabilitation."

Since World War II, a great deal of thought and experimentation has been devoted to developing means of rehabilitating amputees, using some of the methods which were used in the Army hospitals during and after World War II. The procedures developed have proved to be a marked improvement. The more difficult the amputee's problem, the more valuable become these procedures of "Ideal Rehabilitation." The procedures followed will vary according to the particular needs of each patient, but will include part or all of the procedures described below.

The amputee is examined and his problem evaluated, by an experienced Prosthetics Clinic Team. This team usually consists of an Orthopedic Surgeon, or a Physiatrist, or both; a Physical Therapist, or an Occupational Therapist, and the Prosthetist. During the examination the patient is analyzed as an individual case. Then a course of rehabilitation is prescribed by the physician, including the therapy necessary, the type of prosthesis, and other special treatment or training required. The physician is in charge of the team and responsible for the entire program, but he calls on the knowledge and experience of each member of the team for consultation as well as to carry out their particular phases of the work.

The patient may receive pre-prosthetic therapy in which the stump is conditioned to provide the most efficient use of the prosthesis. When the patient actually begins to wear the prosthesis, the clinic team again works closely together in the rehabilitation program. The prosthesis itself has been fabricated according to the measurements and specifications taken by the Prosthetist. Careful attention is now given to fitting, adjustments, continued therapy, and training exercises, such as walking, sitting, steps, etc. Unusual problems may require a complete review and possible change of the prescription.

In the case of arm amputees, occupational therapy follows the fitting of the prosthesis. The amputee spends part of each day learning to use the prosthesis and to live an independent life. He is taught dexterity and manipulation through blocks, games, doorknobs, faucets, tools, etc.

On completion of training, the amputee must appear before the clinic team again for final Prosthetic Performance Check-out and official release by the physician.

By the use of the Prosthetics Clinic Team, the patient is brought closer to the goal of the physician and the prosthesis-maker-complete rehabilitation . Small problems, which might otherwise cause the patient to discard the limb, can be corrected and the problems which so often disturb the new limb wearer can be explained as they arise, with the result that a much larger percentage of amputees become satisfied limb wearers. Today, Prosthetics Clinic Teams are used throughout the United States, particularly in the large metropolitan centers.

Many clinic teams operate in a Rehabilitation Center, an establishment especially equipped for carrying out rehabilitation of persons having many different types of handicap.

While the procedures of Modern Ideal Rehabilitation are much more expensive, the amputee can return to useful life more quickly, and with a much higher degree of proficiency in the use of his prosthesis. In almost every case, the cost of these procedures is more than saved by the benefits obtained.

What of the Future

From the foregoing facts and trends, it is possible to predict certain possibilities and suggest alternate directions in which the industry may go. Probably the future developments will consist of a mixture of these rather than any one type of development.

With respect to the size and location of facilities, there are certain factors which lead toward centralization of artificial limb services and others which lead toward decentralization. As devices become more complicated, and as the standards of fitting reach higher, one would expect a greater specialization by prosthetists just as specialties developed in the medical profession. Thus, the artificial limb facility of the future would have several different technicians, each of whom specialized in a particular amputation. For example, one prosthetist specializing in arms, another prosthetist for below knee, ankle, and partial foot amputations, and a third prosthetist for above the knee, and hip and knee disarticulations. There might be, in addition, a manager who had a working knowledge of the appliances for all amputations, who could attend clinics, handle inquiries and outside calls, as well as the usual managerial functions.

There might be two or three additional employees capable of performing the tasks requiring less skill, such as repairing, painting and assembling. Such a facility could be quite efficient. It could give prompt service for rush orders and take care of amputees promptly when they come in for repairs and adjustments. However, a trade area of about seven hundred thousand population is needed to justify its existence.

The increasing ease of transportation would seem to foster greater centralization. On the other hand, amputee patients and their doctors in outlying areas seem more and more to demand nearby service. Amputees object to the time and expense involved In travelling great distances. In many instances they are willing to accept a lower quality of service or a less adequate prosthesis in order to avoid excessive travel. If the facilities are to be further decentralized, and the distances between them thereby reduced, then it is axiomatic that they will have to be smaller.

One of the leaders of the industry has visualized a practical method of operation for small but highly competent facilities as follows: All components of artificial legs and arms except the socket would be mass produced in a large variety of sizes by factories specializing in this work. The fitter would make and fit the socket of the prosthesis. Such a fitter might be a college graduate, who has been trained in one of the large mass production shops to be an expert fitter only. He spends the great majority of his time in fitting and adjusting limbs.

The typical facility might have one Prosthetist and one Orthotist in a medical center or rehabilitation center working closely with the doctor and the physical therapist. These fitters would be competent to handle the majority of amputees or amputee types, and brace cases. However, the unusually difficult case or rare type of condition would be referred to someone who specialized in that type of condition. There would be only a few, probably four to six, large facilities spread throughout the country where such specialists would work and which would also mass-produce components for limbs.

The use of Clinic Teams and of Rehabilitation Centers is well established, but it seems clear that there will be a steady increase of these in the years to come.

The Research Program is far from finished with its task. Much remains to be learned in this field. As new ideas and principles of fitting and amputee management are developed, they will be disseminated and become a part of the practices of the industry. In the development of devices, there are many fields yet to be explored, many devices which are in various stages of development. For example, improved methods of control of artificial hands to more closely approach the function of a natural hand will require many years of study. The application of external power to the operation of artificial arms holds possibilities. Hydraulic knees are still under development and test. Methods of providing more natural foot action, such as the solid ankle cushion heel foot, will continue to be investigated.

Many of the devices which will be developed will be much more complicated, more difficult to manufacture and to maintain and inevitably more expensive than the devices in use today. The use of the practices of Modern Ideal Rehabilitation and the more expensive devices, will inevitably mean that a great deal more money will be spent on each patient. However, when one considers the tremendous improvement in the quality of rehabilitation received, this increased cost certainly will be money well spent.

As the industry faces the future, it is well aware that its most important task is to furnish the amputee the best possible service. This will require constantly improved training and education, resulting in ever increasing skill, an ever higher standard of ethics, and convenience of location of service.

A large proportion of prostheses, perhaps as much as 60% of the total, are purchased by welfare agencies such as the Veterans Administration, Divisions of Vocational Rehabilitation and others. These agencies, operating on limited appropriations, are vitally concerned in economical prosthetic service, so they can rehabilitate as many eligible handicapped as possible. Yet they, too, want amputees to be rehabilitated in accordance with the best methods attainable.

Thus the challenge of the future to the industry is clear: it must continually improve its service to the amputee, yet it must do so at the most economical cost consistent with such service.

* Presented at the Symposium on Socio-Economic Aspects of Orthopedic Engineering, Dec. 30, ; 122nd Annual Meeting, American Association for the Advancement of Science, Atlanta, Georgia.

McCarthy Hanger, Jr. , is a graduate of Duke University and took a Master's degree in Business Administration from the University of Pennsylvania. He has been associated with J. E. Hanger, Inc., since and is now president of J. E. Hanger. Inc., of Missouri. During World War II, Mr. Hanger was an officer in the U. S. Naval Reserve.

Mr. Hanger was elected one of the seven directors of the American Board for Certification in . He is a past president of the Orthopedic Appliance and Limb Manufacturers Association. In , he received the C. H. Davies Award for Outstanding Service to the Artificial Limb and Brace profession.

VA research on

Prosthetics/Limb Loss

Introduction

In , Congress appropriated $15,000 for the purchase of artificial limbs for soldiers and seamen disabled in the service of the United States, to be expended under the direction of the Surgeon General of the United States.

In , the War Department (now the Department of Defense) was authorized to provide Union Veterans with transportation to and from their homes to a place where they could obtain their artificial limbs or devices, and to furnish those Veterans with new artificial limbs or devices every five years.

VA's involvement in providing prostheses to Veterans began in , when the Veterans Bureau, a predecessor agency to the Department of Veterans Affairs, was given the responsibility to provide artificial limbs and appliances to World War I Veterans.

Today, VA's Prosthetics and Sensory Aids Service is the largest and most comprehensive provider of prosthetic devices and sensory aids in the world. Although the term "prosthetic device" may suggest images of artificial limbs, it actually refers to any device that supports or replaces a body part or function.

VA provides a full range of equipment and services to Veterans, ranging from items worn by the Veteran, such as artificial limbs and hearing aids; to those that improve accessibility, such as ramps and vehicle modifications; to devices surgically placed in the Veteran, such as hips and pacemakers.

The department has more than 70 locations at which orthotics and prosthetics are custom-fabricated and fitted, using state-of-the-art componentry. A list of VA orthotic and prosthetic providers can be found here. VA also has more than 600 contracts with accredited orthotic and prosthetic providers to ensure access to care is provided near Veterans' homes. Each VA facility that is eligible for certification is accredited through the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) and/or the Board of Certification/Accreditation (BOC).

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Selected Major Accomplishments in VA Research

• : Introduced the first mobility and orientation rehabilitation-training program for blinded Veterans
• : Unveiled the first powered ankle-foot prosthesis, as part of a team with researchers at MIT and Brown University
• : Launched 3-year optimization study of the DEKA arm, as clinical partner with DEKA and DARPA
• :
  • Reported on new technology to help restore the sense of touch for those who have lost an upper limb and use an artificial hand
  • Began the first human study in the U.S. to investigate osseointegrated prosthetics, a system that allows a prosthetic leg to be attached directly to the remaining bone of an amputated lower limb
• :
  • FDA approved clinical use of the DEKA arm
  • Published a study of amputees' and clinicians' feedback using the DEKA arm, the first prosthetic arm capable of performing multiple simultaneous powered movements
• : Invented a wheelchair allowing users to crank up the push rims to a standing position, providing them with increased functionality and independence
• : Determined that knee replacement surgery could benefit some patients aged 85 and older
• : The MEBot robotic wheelchair, developed by a VA investigator, won the "Best New Concept" award in an international design competition

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See also:
Discover the Top 5 Benefits of a Hospital Bed at Home

Are you interested in learning more about lower limb prosthesis for sale? Contact us today to secure an expert consultation!

New, Ongoing, and Published Research

To help meet the lifestyle and medical needs of Veterans who have lost limbs, VA researchers develop and test a wide variety of prosthetic devices. VA's goal is to offer Veterans prosthetics that will restore them to their highest possible level of functioning within their families, communities, and workplaces.

Some VA researchers are working on developing high-functioning artificial limbs that are very similar to their natural counterparts. Others are working on advanced wheelchair designs that promote mobility and independence for wheelchair users and make it easier to use a wheelchair.

Still other VA researchers are using functional electrical stimulation and other technologies to help those with weak or paralyzed muscles, and developing and testing state-of-the-art adaptive devices to help those with vision or hearing loss.

If you are interested in learning about joining a VA-sponsored clinical trial, visit our research study information page.

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&#; VA research centers

Many, but not all, of the latest innovations and discoveries in prosthetics research in the U.S. take place at VA centers. These centers generally work in close partnership with affiliated universities and other institutions, as well as commercial partners and other federal agencies.

VA's Advanced Platform Technology Center, in Cleveland, develops new technologies to help Veterans who have difficulties controlling bodily movements or sensory problems, and those who have lost limbs. Team members create new assistive and restorative technologies for dissemination within the rehabilitation community and commercialization by outside manufacturers.

The Center for Functional Electrical Stimulation, also in Cleveland, uses controlled electrical currents to help paralyzed muscles work again. The center focuses on the application of electrical currents to either generate or suppress activity in the nervous system. This technique is known as functional electrical stimulation (FES). FES can produce and control the movement of otherwise paralyzed limbs for standing and hand grasp, to activate visceral bodily functions such as bladder control or respiration, create perceptions such as skin sensibility, stop undesired activity such as pain or spasm, and facilitate natural recovery and accelerate motor relearning.

The Center for Wheelchairs and Associated Rehabilitation Engineering, part of the Human Engineering Research Laboratories (HERL) in Pittsburgh, has made important contributions to the design of wheelchairs, seating systems, and other mobility systems. HERL is a collaboration between the VA Pittsburgh Healthcare System and the University of Pittsburgh. Researchers at the center have been instrumental in developing novel innovations in wheelchair design&#;together, they hold 25 patents related to wheelchair design and assistive technologies. Innovations developed at the center range from using newer, lighter materials that make wheelchairs easier to maneuver to robotic extensions that can reach objects for the wheelchair's user. One example under development is the MEBot, a wheelchair that has six wheels, an onboard computer and software, and an array of high-tech sensors and actuators that help the user navigate uneven terrain.

The Center for Limb Loss and MoBility in Seattle is a research group focused on helping Veterans who have either lost a limb or experience leg and/or foot impairment by enhancing their ability to move around their environment. Research at the center aims to reduce the effects of functional and anatomical limb loss by exploring diseases that lead to impaired limb function and by developing state-of-the-art technologies for studying the foot. Research focuses on two groups of Veteran: those with musculoskeletal impairment at the foot and ankle, where pain and limitations in mobility are the key issues, and those at risk of lower limb amputation due to diabetes and foot ulceration, where loss of the foot or leg is a major concern.

The center's prosthetic engineering research focuses on limitations in mobility and discomfort experienced by all groups of Veterans with lower-limb amputation&#;including those with amputation secondary to peripheral vascular disease and diabetes; aging combat-injured Vietnam Veterans; and young, active Veterans who lost a limb through traumatic injury serving in Afghanistan or Iraq. This research compares existing prosthetic technologies and develops innovative new approaches.

The VA Center for Neurorestoration and Neurotechnology in Providence, Rhode Island, supports research into the development of brain-computer interfaces to help restore function in Veterans who are paralyzed, have experienced limb loss, or have difficulties in thinking or communicating. The center is a collaboration between the Providence VA Medical Center, Brown University, Butler Hospital, Lifespan, and Massachusetts General Hospital. CfNN seeks to develop, test, and implement new therapies and technologies that restore function for Veterans with disorders affecting the nervous system.

BrainGate is one such research project. Researchers have developed a neural interface system for individuals with paralysis that uses a small sensor implanted in the brain to record neural activity associated with intended arm movements.

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&#; Amputation and artificial limbs

The technology involved in creating artificial limbs has come a very long way since the Civil War. Today's VA researchers use leading-edge technologies such as robots and nanotechnology to create lighter limbs that integrate body, mind, and machine to look, feel, and respond like real arms and legs. They are also studying ways to best match prosthetic components with amputees' needs, including those whose active lifestyles mean they need high-performance prosthetics.

Other researchers are looking at new ways to care for what remains of limbs after surgery; enabling wounds to heal far more quickly than ever before; developing programs to teach caregivers complementary and alternative techniques to lessen the anxiety and pain associated with limb loss; and evaluating CT scans of diabetic feet to identify those patients who are at the highest risk for ulcers and amputation.

Ankle-foot prosthesis&#;In , VA collaborated with researchers at MIT and Brown University to introduce a powered ankle-foot prosthesis that uses tendon-like springs and an electric motor to move users forward. Studies have shown that patients using the powered ankle-foot expend less energy while walking, have better balance, and walk 15 percent faster. The device, originally sold as the BiOM ankle and now marketed as the Empower ankle, is available for Veterans using VA care and active-duty service members.

Osseointegration study&#;VA sponsored the first human study in the United States to investigate osseointegrated prosthetics, a system that allows a prosthetic limb to be attached through the skin directly to the remaining bone of the amputated limb. The study involved surgically implanting specially designed and coated titanium implants into the thigh bone of amputees who had lost their knee and lower leg. Once the bone grew into the implant, the prosthesis was attached directly to the metal connector of the implant without the need for a prosthetic socket to cover the remaining limb.

Ten amputees participated in the study at the George E. Wahlen VA Medical Center in Salt Lake City. Based on preliminary findings, the investigators say this research has the potential to improve amputees' mobility, function, and overall quality of life. A version of this implant for above-the-elbow amputees is currently in development.

DEKA/LUKE arm&#;VA researchers and colleagues collected data on the DEKA advanced prosthetic arm over four years at four VA sites&#;New York; Tampa; Long Beach, California; and Providence, Rhode Island&#;and at the Center for the Intrepid, a military rehabilitation site in San Antonio, Texas. The study findings have been published in a number of journal articles, including two in in VA's Journal of Rehabilitation Research and Development.

The arm was developed by DEKA Integrated Solutions Corporation, based in Manchester, New Hampshire, with funding from the Defense Advanced Research Projects Agency (DARPA), through its Revolutionizing Prosthetics Program. It is the first prosthetic arm capable of performing multiple simultaneous powered movements.

The U.S. Food and Drug Administration approved the DEKA Arm System in May , paving the way for the device to be manufactured, marketed, and made available in the VA health care system. The DEKA arm is now available to the public as the LUKE arm, manufactured by Mobius Bionics.

In a study led by researchers from the Providence VA Medical Center and Brown University, 24 upper-limb amputees were fitted with a second generation (Gen 2) DEKA arm, and 13 were fitted with a third-generation arm (Gen 3). After being trained on its use, they were surveyed about their experiences.

In all, 79 percent of Gen 2 and 85 percent of Gen 3 users indicated that they either wanted to receive, or might want to receive, a DEKA arm. In addition, 95 percent of Gen 2 users and 91 percent of Gen 3 users indicated that they were able to perform new activities they had been unable to perform with their existing prosthetic device.

In July , two Veterans became the first VA patients to receive the arm for daily use.

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&#; Blind restoration and rehabilitation

In , approximately 130,428 Veterans in the U.S. were legally blind and more than 1 million Veterans had low vision that caused a loss of ability to perform daily activities, according to VA's Blind Rehabilitation Service.

Those figures are expected to increase as more Veterans from the Korean and Vietnam conflict eras develop vision loss from age-related diseases such as macular degeneration, diabetic retinopathy, and glaucoma. VA has also seen an increase in the number of Veterans who served in Afghanistan and Iraq who have experienced vision loss due to blast exposure and trauma.

In , VA researchers introduced the first mobility and orientation rehabilitation training program for blind persons. Today, VA's Center for Visual and Neurocognitive Rehabilitation, based at the Atlanta VA Health Care System, conducts research in visual rehabilitation, neurocognitive rehabilitation (i.e., improving brain function from injury), and retinal and neural repair to prevent and mitigate vision loss resulting from injury or disease. The center has a number of projects to help train blind people and those with low vision find their way around independently with greater ease. Investigators also work on projects related to improving access to eye care for Veterans living in rural regions.

Examples of projects include: "Bridging Animal and Human Models of Exercise-Induced Visual Rehabilitation," "Spatial Cognitive Training in Visual Impairment," "Acute Exercise Effects on Word Learning in Aging and Stroke-induced Aphasia," "Improving Access to Eye Care for Veterans&#;Spread Grant; VA Innovation Initiative," and "Dopamine Treatments for Diabetic Retinopathy."

In addition, the VA's Center for Prevention and Treatment of Visual Loss focuses on research to provide the earliest detection of vision loss. The goal is to prevent vision loss due to eye diseases such as glaucoma, radiation damage, and traumatic brain injury. The center is evaluating new diagnostic tools that provide better access to care through telemedicine and automated analysis using portable devices by non-eye care providers. Research is focused on novel interventions such as identifying which neurotrophic growth factors (i.e., proteins associated with growth and survival of neurons) are most effective at preventing vision loss.

Examples of projects include: "Therapy of Nocturnal Intraocular Pressure Elevation Causing Glaucoma Progression," "Automated Assessment of Optic Nerve Edema with Low-Cost Imaging," "Chronic Effects of Blast Injury: Analyses of Alzheimer Related Pathology," "Stem Cell Therapy for Glaucoma," and "Visual Sensory Impairments and Progression Following Mild Traumatic Bain Injury."

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&#; Using electrical signals to restore functioning

Many Veterans have serious spinal cord injuries and disorders that may interfere with the brain signals that control muscle movement. Others have become blind from the loss of photoreceptors (cells that are responsible for detecting light and therefore enable us to see) in the eye.

For Veterans with these and some other types of functional loss, VA investigators hope to restore functioning with electrical currents delivered through a neural prosthesis. A neural prosthesis is an electronic device that connects with the nervous system and supplements or replaces functions lost by diseases or injury.

VA's Advanced Platform Technology Center (APT), located at the Cleveland VA Medical Center, and the Center for Neurorestoration and Neurotechnology at the Providence VA Medical Center are working on a number of projects to extract signals from the brain's cortex for controlling assistive devices and detecting and diagnosing dysfunctional cortical activity. Some of their projects are described here and here.

Conveying a sense of touch&#;Researchers at the Advanced Platform Technology Center have developed a new kind of implanted electrical nerve interface that can convey a sense of touch on a prosthetic hand. They learned in that the implants continued to work after 24 months, and as of this writing they continue to work.

Sensors in the prosthetic hand measure the pressure applied as the hand closes around or presses against something. These measurements are converted into specially coded electrical signals and sent through wires to surgically implanted electrodes around nerves in the forearm and upper arm.

When the electrical signals reach the nerves, they are transmitted to the brain through healthy neural pathways not affected by the amputation. The brain interprets the sensation signals as if they had come from a normal hand. These researchers have since been funded by DARPA to further advance the work. Watch this video to learn more.

Electrical stimulation and spinal cord injuries&#;In , researchers at VA's APT Center and Case Western Reserve University completed a 10-year clinical trial to test a surgically implanted electrical stimulation system in people with spinal cord injuries. During the surgery, electrodes are implanted in muscles of the trunk and legs, and leads are connected to a stimulator.

By stimulating muscles, the system activates muscles to allow for standing, better balance, and exercise. Patients are given functional training and rehabilitation using the stimulation system, and are prescribed a course of exercise. Lab tests focus on strength, balance, and patients' abilities with or without the system.

In , researchers in Cleveland followed up on 22 spinal cord-injured patients an average of six years after they received implantation surgery, to determine whether the devices were still functioning and useful years after they were first implanted.

They found that 60 percent of the patients still used their neuroprostheses for exercise and other activities for more than 10 minutes per day. Early (first generation) implants still functioned correctly in almost 90 percent of the recipients of those devices. Second-generation implants, with slightly improved technology, still functioned in 98 percent of recipients. Overall, 94 percent of the participants in the study were satisfied with their prostheses.

In another study, Cleveland researchersfound that a lower-limb exoskeleton that combined an implanted neurosensor with an exoskeleton to stabilize and support users restored the ability to take steps in three individuals with complete paralysis. They believe that this approach is feasible for individuals with paraplegia and should be developed further.

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&#; BrainGate

VA has played a major role in supporting the development of BrainGate. The system, spearheaded by researchers at the Providence VA Medical Center in Rhode Island and Brown University, relies on microelectrodes implanted in the brain to pick up neural signals.

The electrodes are placed in a part of the brain that controls voluntary movement. They send signals to an external decoder that translates them into commands for electronic or robotic devices, such as an iPad or robotic arm.

The research team developing BrainGate hopes to create a technology that will restore movement, control, and independence to people with paralysis or limb loss from conditions including amyotrophic lateral sclerosis (ALS), stroke, and spinal cord injury.

BrainGate studies&#;In , a research team consisting of VA, Brown University, Harvard University, and Massachusetts General Hospital researchers successfully implanted electrodes in the brains of volunteers with paralysis affecting their arms and legs. The system allowed them to control robot arms with their thoughts, and they could continue to control a computer cursor accurately more than 1,000 days after the electrodes were initially implanted.

In , the BrainGate team reported the system could allow point-and-click communication by someone with incomplete locked-in syndrome, which can be caused by a spinal cord injury. In locked-in syndrome, patients are fully conscious but unable to move any muscles except for those that control eye movement. They can see, hear, smell, taste, and even feel, but may be unable to speak or vocalize at all. Those with incomplete locked-in syndrome can make small movements of the head, fingers, and toes.

Another BrainGate study found that volunteers using the system were able to acquire "targets" on a computer screen, such as letters on a keyboard, more than twice as quickly as in previous studies, thanks to advances in the system.

The BrainGate team is now studying whether the system can be effective as a means of natural, intuitive control of prosthetic limbs, or as a way to help patients move their own paralyzed limbs. The latter work is being carried out in partnership with the Cleveland FES Center.

A proof-of-concept study demonstrated that this combination of FES and BrainGate was successful in a quadriplegic Navy Veteran, who used electrodes implanted in his brain and in the muscles of his paralyzed arm and hand to use his own thoughts to control his arm and hand. This video shows how the system works, and how it offers potential help to people with paralysis in the future. The BrainGate team is currently working on the next generation of their system that will be fully implanted and wireless so it can be used at home without the assistance of a technician.

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&#; Hip and knee replacement

Age and knee replacement&#;In , researchers at the Iowa City VA Health System and the University of Iowa looked at whether knee replacement (total knee arthroplasty) is safe for Veterans aged 85 or older.

The researchers combined and analyzed data from 22 past studies to see whether they could make a determination on the risks and benefits of the procedure for older patients.

They found that while the available evidence suggested slight increases in mortality and complications for older patients, several of the studies reported that both older and younger patients were highly satisfied after surgery, and were able to function better.

The team therefore concluded that age alone should not rule out such surgery.

Hip and knee replacement not followed by increased physical activity&#;In , a researcher with the Durham VA Medical Center and others published a literature review of previous studies that found that while patients often have large reductions in pain and increased physical function and quality life after total hip or knee replacement, there were no corresponding increases in physical activity after six months, and only modest increases after a year. The researchers hypothesized that the lack of physical activity may be behavioral, since a sedentary lifestyle is hard to change.

Racial gaps in use of knee replacements&#;African American patients shown an informational video about knee replacement surgery were 85 percent more likely to undergo the surgery than those who did not view the video, according to a study conducted by researchers at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.

According to the researchers, African Americans are significantly less likely to have knee replacement surgery to relieve pain from arthritis, largely due to lack of knowledge about the treatment. The researchers concluded that this low-cost, patient-centered intervention could increase the use of an effective orthopedic procedure among minority patients.

A study by VA researchers also found that African American Veterans were less likely to undergo knee replacement surgery. Over a 10-year period, rates of knee replacements were much lower for black Veterans than white Veterans. Hispanic Veterans had the same rates of knee replacement as white Veterans. The researchers stated that the study shows the importance of developing ways to reduce racial differences in Veteran health care usage.

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&#; Wheelchair technology

MEBot robotic wheelchair&#;HERL is developing a robotic wheelchair called MEBot that can go up and down curbs and steps and maintain a level seat over uneven terrain&#;giving Veterans who use wheelchairs for mobility unprecedented freedom and independence both outdoors and inside homes, shops, and offices. The wheelchair has traction control; anti-skid braking; and powered seat functions, including tilt, recline, leg-rest, and elevation.

It has six wheels, an onboard computer and software, and an array of high-tech sensors and actuators. It is designed to navigate smoothly over gravelly or muddy roads, uneven slopes, wet grass, and other difficult terrain&#;and should allow users to avoid getting stuck on snow and ice.

The MEBot is now being tested at the center's lab, and may be commercially available within a few years. In , the MEBot won "Best New Concept" in the Blackwood Design Awards competition in Scotland, an international competition that seeks to discover and recognize brilliant innovations in independent living and accessibility. Watch a video of the MEBot here.

Waterproof, motorized wheelchair&#;Researchers at HERL have also developed the PneuChair, a motorized wheelchair that uses a tank of compressed air instead of batteries as an energy source. The chair weighs about 80 pounds and takes just 10 minutes to recharge. The PneuChair can go about 3 miles before the tank must be charged again&#;about one the third the distance that an electronic wheelchair can go on a fully charged battery. It was developed, in part, to be used at a water park for people with disabilities, but could also be used at beaches or pools. The design is simpler than an electronic wheelchair&#;lacking much of the software and electronics that are typically used for motorized chairs.

Improved standing wheelchair&#;In , a group at the Minneapolis VA Medical Center reported they had made improvements to the traditional standing wheelchair to help improve the ability of paralyzed Veterans to function. The researchers modified commercially available standing wheelchairs by adding a drive wheel that allows the push rim to rise so patients can reach it when they stand.

In existing models, patients who can't reach the push rim in the standing position are forced to sit before they can boost the chair and move themselves to a new location. The new chair, which is not yet available commercially, also keeps at least four of the chair's six wheels on the ground at all time, increasing both stability and maneuverability.

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&#; Exoskeletons

VA's Center on the Medical Consequences of Spinal Cord Injury is located at the James J. Peters VA Medical Center in the Bronx, New York. The center's mission is to improve Veterans' quality of life and increase their longevity by preventing and intervening in the secondary medical consequences that result from having a spinal cord injury. These consequences can include bone and muscle loss, and metabolic and cardiovascular changes. 

Researchers at the center continue to study an Israeli technology that allows people with paralysis to stand, walk, and climb stairs, called ReWalk. ReWalk 6.0 is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with spinal cord injury to stand upright, walk, and turn. On their first day using the device, most people can stand and take a few steps, although it takes practice and training to use it properly.

Participants in past studies have lost fat tissue, their bowel function has improved, and their diabetes symptoms have been reduced. The center is now conducting a further trial on ReWalk's impact on mobility, bowel function, and cardio-metabolic health. The four-year study, involving 160 paralyzed Veterans with spinal cord injury at 10 VA medical centers, is examining the impact of the robotic exoskeleton on home and everyday life. Enrollment is expected to be completed in August .

In , ReWalk version 6.0 was approved for sale in the United States. In , VA announced it would provide the device to eligible Veterans who could benefit from it.

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&#; Dentures

Dentures can bring back the smile of those who have lost teeth because of aging, injury, and disease. Many denture wearers, however, must cope with a condition called dental stomatitis (thrush), in which the gums under the denture become sore and inflamed due to infection from a fungus known as candida.

VA researchers at the South Texas VA Health Care System are developing a new type of denture that fights stomatitis. The denture releases, over time, a drug that kills the candida fungus. In lab tests whose results were published in , the experimental product showed strong action against candida for up to 30 days, after which the device can be recharged with a fresh dose of drugs. More testing will be required, including a clinical trial, before the product is commercially available.

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More on Our Website

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Selected Scientific Articles by Our Researchers

Changes in physical activity after total hip or knee arthroplasty: a systematic review and meta-analysis of 6 and 12 month outcomes. Hammett T, Simonian A, Austin M, Butler R, Allen KD, Ledbetter L, Goode AP. Physical activity did not change at six months, and a small to moderate improvement was found at 12 months post-surgery, despite large improvements in quality of life, pain, and physical function. Arthritis Care Res (Hoboken). Jun;70(6):892-901.

Long-term performance and user satisfaction with implanted neuroprostheses for upright mobility after paraplegia: 2- to 14-year follow up. Triolo RJ, Bailey SN, Fogiyano KM, Kobetic R, Lombardo LM, Miller ME, Pinault G. Implanted lower-limb neuroprostheses can provide lasting benefits that recipients value. Arch Phys Med Rehabil. Feb;99(2):289-298.

Systematic review of measures of impairment and activity limitation for persons with upper limb trauma and amputation. Resnik L, Borgia M, Silver B. Cancio J. Few performance measures were recommended for patients with limb trauma and amputation. Arch Phys Med Rehabil. Sep;98(9):-.

Racial and ethnic differences in total knee arthroplasty in the Veterans Affairs health care system, -. Hausmann LRM, Brandt CA, Carroll CM, Fenton BT, Ibrahim SA, Becker WC, Burgess DJ, Wandner LD, Bair MJ, Goulet JL. Black-white differences in total knee arthroplasty appear to be persistent in VA, even after controlling for potential clinical cofounders. Arthritis Care Res (Hoboken). Aug;69:-.

A muscle-driven approach to restore stepping with an exoskeleton for individuals with paraplegia. Chang SR, Nandor MJ, Li L, Kobetic R, Foglyano KM, Schnellenberger JR, Audu ML, Pinault G, Quinn RD, Triolo RJ. A self-contained muscle-driven exoskeleton is a feasible intervention to restore stepping in individuals with paraplegia due to spinal cord injury. J Neurogen Rehabil. May 30:14(1):48.

Restoration of reaching and grasping movements through brain-controlled muscle stimulation in a person with tetraplegia: a proof-of-concept demonstration. Ajiboye AB, Willett FR, Young DR, Memberg WD, Murphy BA, Miller JP, Walter BL, Sweet JA, Hoyen HA, Keith MW, Peckham PH, Simeral JD, Donoghue JP, Hochberg LR, Kirsch RF. A report on an individual with high-cervical spinal cord injury who coordinated reaching and grasping movements using his own paralyzed arm and hand through implanted functional electrical stimulation and an intracortical brain-computer interface. Lancet. May 6;389():-.

Effect of a decision aid on access to total knee replacement for black patients with osteoarthritis of the knee: a randomized clinical trial. Ibrahim SA, Blum M, Lee GC, Mooar P, Medvedeva E, Collier A, Richardson D. A decision aid increased rates of total knee replacement among black patients. JAMA Surg. Jan 18;152(1);e.

Starting a new conversation: engaging Veterans with spinal cord injuries in discussion of what function means to them, the barriers/facilitators they encounter, and the adaptations they use to optimize function. Hill JN, Balbale S, Lones K, LaVela SL. Patients with spinal cord injuries highlight the concept of "normality," facilitators and barriers to function, and adaptations to optimize function. Disabil Health J. Jan:10(1):114-122.

Pilot testing of a variable stiffness transverse plane adapter for lower limb amputees. Pew C, Klute GK. A transverse rotation adapter with variable stiffness capability could be useful to help reduce stresses for a lower-limb amputee that result in soft tissue breakdown and discomfort. Gait Posture. Jan;51:104-108.

Proposed pedestrian pathway roughness thresholds to ensure safety and comfort for wheelchair users. Duvall J, Sinagra E, Cooper R, Pearlman J. Many public pathways are sufficiently rough to result in harmful vibrations and discomfort for wheelchair users. This study suggests a pathway roughness index threshold to protect wheelchair users against discomfort and possible health risks due to vibration exposure. Assist Technol. Sep 2:1-7. (Epub ahead of print)

Rechargeable anticandidal denture material with sustained release in saliva. Malakhov A, Wen J, Zhang BX, Wang H, Geng H, Chen XD, Sun Y, Yeh CK. A new denture material holds promise for long-term management of denture stomatitis. Oral Dis. Jul;22(5):391-8.

The effects of advanced age on primary total knee arthoplasty: a meta-analysis and systematic review. Kuperman EF, Schweizer M, Joy P, Gu X, Fang MM. Existing data supports offering total knee arthoplasty to select geriatric patients, although the risk of complications may be increased. BMC Geriatr. Feb 10;16:41.

Clinical translation of a high-performance neural prosthesis. Gilja V, Pandarinath C, Blabe CH, Nuyujukian P, Simeral JD, Sarma AA, Sorice BL, Perge JA, Jarosiewicz B, Hochberg LR, Shenoy KV, Henderson JM. Measured more than one year after implant, the BrainGate neural cursor-control system showed the highest published performance achieved by a person to date, more than double that of previous pilot clinical trial participants. Nat Med. Oct;21(10):-5.

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