When the members of the Local Organizing Committee (LOC) for the International Society for Prosthetics and Orthotics (I.S.P.O.) 20th World Congress initially formulated the theme for the Congress, we were faced with a difficult decision. Selection of the theme for a biennial, international, multidisciplinary event such as this needs to be selected with careful consideration to maximize the exposure of the topic to a larger audience and to increase the likelihood of future benefit for all involved. At the time, we were well aware of countless efforts to enact The 2030 Agenda for Sustainable Development,1 and the 17 Sustainable Development Goals (SDGs), and how prosthetics and orthotics (P&O)–and assistive technology more generally–are integral in our efforts to contribute to attaining these goals.2 It seemed fitting then to use this Congress as a means to increase awareness of the SDGs. In doing so, we hoped to be able to actively contribute by making use of this important event in attaining the objectives set out in The 2030 Agenda. This resulted in the 20th World Congress theme: “Science in Practice, Practice in Science: Collaboration and innovation towards sustainable rehabilitation,” which focuses on working toward sustainability across the field through sharing best practice, the development of novel devices, education, provision, and the interrelationships between science and practice. [...]

Various upper-limb prostheses have been designed for 3D printing but only a few of them are based on bio-inspired design principles and many anatomical details are not typically incorporated even though 3D printing offers advantages that facilitate the application of such design principles. We therefore aimed to apply a bio-inspired approach to the design and fabrication of articulated fingers for a new type of 3D printed hand prosthesis that is body-powered and complies with basic user requirements. We first studied the biological structure of human fingers and their movement control mechanisms in order to devise the transmission and actuation system. A number of working principles were established and various simplifications were made to fabricate the hand prosthesis using a fused deposition modelling (FDM) 3D printer with dual material extrusion. We then evaluated the mechanical performance of the prosthetic device by measuring its ability to exert pinch forces and the energy dissipated during each operational cycle. We fabricated our prototypes using three polymeric materials including PLA, TPU, and Nylon. The total weight of the prosthesis was 92 g with a total material cost of 12 US dollars. The energy dissipated during each cycle was 0.380 Nm with a pinch force of ≈16 N corresponding to an input force of 100 N. The hand is actuated by a conventional pulling cable used in BP prostheses. It is connected to a shoulder strap at one end and to the coupling of the whiffle tree mechanism at the other end. The whiffle tree mechanism distributes the force to the four tendons, which bend all fingers simultaneously when pulled. The design described in this manuscript demonstrates several bio-inspired design features and is capable of performing different grasping patterns due to the adaptive grasping provided by the articulated fingers. The pinch force obtained is superior to other fully 3D printed body-powered hand prostheses, but still below that of conventional body powered hand prostheses. We present a 3D printed bio-inspired prosthetic hand that is body-powered and includes all of the following characteristics: adaptive grasping, articulated fingers, and minimized post-printing assembly. Additionally, the low cost and low weight make this prosthetic hand a worthy option mainly in locations where state-of-the-art prosthetic workshops are absent.

With recent improvements in healthcare, individuals with Duchenne muscular dystrophy (DMD) have prolonged life expectancy, and it is therefore vital to preserve their independence. Hand function plays a central role in maintaining independence in daily living. This requires sufficient grip force and the ability to modulate it with no substantially added effort. Individuals with DMD have low residual grip force and its modulation is challenging and fatiguing. To assist their hand function, we developed a novel dynamic hand orthosis called SymbiHand, where the user's hand motor intention is decoded by means of surface electromyography, enabling the control of an electrohydraulic pump for actuation. Mechanical work is transported using hydraulic transmission and flexible structures to redirect interaction forces, enhancing comfort by minimizing shear forces. This paper outlines SymbiHand's design and control, and a case study with an individual with DMD. Results show that SymbiHand increased the participant's maximum grasping force from 2.4 to 8 N. During a grasping force-tracking task, muscular activation was decreased by more than 40% without compromising task performance. These results suggest that SymbiHand has the potential to decrease muscular activation and increase grasping force for individuals with DMD, adding to the hand a total mass of no more than 241 g. Changes in mass distributions and an active thumb support are necessary for improved usability, in addition to larger-scale studies for generalizing its assistive potential.

Upper extremity function is affected by a variety of neurological conditions. Robotic exoskeletons offer a potential solution for motor restoration. However, their systematic adoption is limited by challenges relative to human intention detection and device control. This position article offers a focused perspective on this topic. That is, on how knowledge gained from the design and implementation of human-machine interfaces (HMIs) for bionic arms can benefit the field of rehabilitation exoskeletons. Three broadly used HMIs in bionic arms are here investigated, including surface electromyography, impedance, and body-powered control. We propose that combinations of these HMIs could push forward upper extremity exoskeleton development. In this context, we provide concrete applicative examples in two selected clinical scenarios, including post-stroke and Duchenne muscular dystrophy individuals. The discussed solutions can open new avenues for the translation of robotic exoskeletons in a large set of clinical settings and enable a class of exoskeleton technologies that could support a broader range of impairment and disease types.

Operating a body-powered prosthesis can be painful and tiring due to high cable operation forces, illustrating that low cable operation forces are a desirable design property for body-powered prostheses. However, lower operation forces might negatively affect controllability and force perception, which is plausible but not known. This study aims to quantify the accuracy of cable force perception and control for body-powered prostheses in a low cable operation force range by utilizing isometric and dynamic force reproduction experiments. Twenty-five subjects with trans-radial absence conducted two force reproduction tasks; first an isometric task of reproducing 10, 15, 20, 25, 30 or 40 N and second a force reproduction task of 10 and 20 N, for cable excursions of 10, 20, 40, 60 and 80 mm. Task performance was quantified by the force reproduction error and the variability in the generated force. The results of the isometric experiment demonstrated that increasing force levels enlarge the force variability, but do not influence the force reproduction error for the tested force range. The second experiment showed that increased cable excursions resulted in a decreased force reproduction error, for both tested force levels, whereas the force variability remained unchanged. In conclusion, the design recommendations for voluntary closing body-powered prostheses suggested by this study are to minimize cable operation forces: this does not affect force reproduction error but does reduce force variability. Furthermore, increased cable excursions facilitate users with additional information to meet a target force more accurately.

In developing countries, the access of amputees to prosthetic devices is very limited. In a way to increase accessibility of prosthetic hands, we have recently developed a new approach for the design and 3D printing of non-assembly active hand prostheses using inexpensive 3D printers working on the basis of material extrusion technology. This article describes the design of our novel 3D-printed hand prosthesis and also shows the mechanical and functional evaluation in view of its future use in developing countries. We have fabricated a hand prosthesis using 3D printing technology and a non-assembly design approach that reaches certain level of functionality. The mechanical resistance of critical parts, the mechanical performance, and the functionality of a non-assembly 3D-printed hand prosthesis were assessed. The mechanical configuration used in the hand prosthesis is able to withstand typical actuation forces delivered by prosthetic users. Moreover, the activation forces and the energy required for a closing cycle are considerably lower as compared to other body-powered prostheses. The non-assembly design achieved a comparable level of functionality with respect to other body-powered alternatives. We consider this prosthetic hand a valuable option for people with arm defects in developing countries.

While designing a dynamic hand orthosis to assist during activities of daily living, the designer has to know whether a concept will have sufficient grasp performance to support these activities. This is often estimated by measuring the interaction force at the contact interface. However, this requires a prototyping step and limits the practicality of comparing several concepts in an early design stage. Alternatively, this study presents and compares basic static and dynamic models to numerically estimate grasp performance. This was applied on an exemplary concept for a hydraulically operated hand orthosis grasping a circular object. The models were validated with an experimental set-up that does not require sensors at the contact interface. Static and dynamic model results were almost identical, where the static model could be around 10 times faster and is generally more robust to a high contact stiffness. Both models were unable to make accurate quantitative predictions, which is believed to be due to differences in used contact stiffness. However, the models were able to make correct qualitative comparisons, making it a valid method to compare and choose concepts in an early design stage.

People with Duchenne muscular dystrophy are currently in need of assistive robotics to improve their hand function and have a better quality of life. However, none of the available active hand orthoses is able to address to their specific needs. In this study, the use of hydraulic technology is proposed in the design of an active hand orthosis. Commercially available components were used to identify where customization is necessary for a new electrohydraulic hand orthosis. The presented prototype was able to move four finger modules with a single actuator. The finger modules were separable and had a total mass of only 150 g, whereas the valve manifold added another 250 g. Results revealed that the prototype was able to function well with full flexion/extension cycles up to 2 Hz, but with hysteretic losses between 37-81% of the total input energy. Specialized valves and slave cylinders are required to increase efficiency at higher speeds and to obtain more robust sealing performance.

To design an underactuated wrist prosthesis, a preliminary study has been conducted to identify the relationship between the Degrees of Freedom (DoFs) of the wrist during the execution of tasks of daily living. After the identification of the principal orientations of the wrist describing the tasks, polynomial functions were used to define a synergetic relationship between the DoFs. The latter can be implemented in a prosthetic wrist featuring one actuator to obtain motion along three DoFs, with the purpose of reducing compensatory movements.

Background: Body-powered prosthesis users frequently complain about the poor cosmesis and comfort of the traditional shoulder harness. The Ipsilateral Scapular Cutaneous Anchor System offers an alternative, but it remains unclear to what extent it affects the perception and control of cable operation forces compared to the traditional shoulder harness.
Objective: To compare cable force perception and control with the figure-of-nine harness versus the Ipsilateral Scapular Cutaneous Anchor System and to investigate force perception and control at different force levels.
Study design: Experimental trial.
Methods: Ten male able-bodied subjects completed a cable force reproduction task at four force levels in the range of 10–40 N using the figure-of-nine harness and the Anchor System. Perception and control of cable operating forces were quantified by the force reproduction error and the force variability.
Results: In terms of force reproduction error and force variability, the subjects did not behave differently when using the two systems. The smallest force reproduction error and force variability were found at the smallest target force level of 10 N.
Conclusion: The Anchor System performs no differently than the traditional figure-of-nine harness in terms of force perception and control, making it a viable alternative. Furthermore, users perceive and control low operation forces
better than high forces.

Background: Body-powered prostheses require cable operation forces between 33 and 131 N. The accepted upper limit for fatigue-free long-duration operation is 20% of a users’ maximum cable operation force. However, no information is available on users’ maximum force. Objectives: To quantify users’ maximum cable operation force and to relate this to the fatigue-free force range for the use of body-powered prostheses. Study design: Experimental trial. Methods: In total, 23 subjects with trans-radial deficiencies used a bypass prosthesis to exert maximum cable force three times during 3 s and reported discomfort or pain on a body map. Additionally, subjects’ anthropometric measures were taken to relate to maximum force. Results: Subjects generated forces ranging from 87 to 538 N. Of the 23 subjects, 12 generated insufficient maximum cable force to operate 8 of the 10 body-powered prostheses fatigue free. Discomfort or pain did not correlate with the magnitude of maximum force achieved by the subjects. Nine subjects indicated discomfort or pain. No relationships between anthropometry and maximal forces were found except for maximum cable forces and the affected upper-arm circumference for females. Conclusion: For a majority of subjects, the maximal cable force was lower than acceptable for fatigue-free prosthesis use. Discomfort or pain occurred in ~40% of the subjects, suggesting a suboptimal force transmission mechanism. Clinical relevance: The physical strength of users determines whether a body-powered prosthesis is suitable for comfortable, fatigue-free long-duration use on a daily basis. High cable operation forces can provoke discomfort and pain for some users, mainly in the armpit. Prediction of the users’ strength by anthropometric measures might assist the choice of a suitable prosthesis.

Fabrication of complex and multi-articulated mechanisms is often seen as a time consuming and demanding process. The development of functional multi-articulated mechanisms that could be fabricated in a single step without the need for post-manufacturing assembly is therefore very attractive. Additive manufacturing (AM) has been pointed out as a feasible solution due to its numerous advantages and high versatility in comparison to other manufacturing techniques. Nevertheless, AM techniques also present different shortcomings that limit the complexity of the mechanism for single step fabrication. Here, we review the applications of AM techniques in fabrication of non-assembly multi-articulated mechanisms and highlight the involved challenges, thereby providing a perspective regarding the advantages and limitations of current AM techniques for production of complex mechanical devices. The paper starts off with basic joint elements in rigid-body and compliant configurations and proceeds with presenting an overview of multiple arrangements of joints and assemblies with embedded mechanical components. For every case of non-assembly fabrication, the limitations of the applicable AM processes are presented and further discussed. This work concludes with a discussion of the major shortcomings found in current non-assembly mechanisms fabricated by AM and recommending alternative techniques and future developments on AM.

Background It is generally asserted that reliable and intuitive control of upper-limb prostheses requires adequate feedback of prosthetic finger positions and pinch forces applied to objects. Bodypowered prostheses (BPPs) provide the user with direct proprioceptive feedback. Currently available BPPs often require high cable operation forces, which complicates control of the forces at the terminal device. The aim of this study is to quantify the influence of high cable forces on object manipulation with voluntary-closing prostheses. Method Able-bodied male subjects were fitted with a bypass-prosthesis with low and high cable force settings for the prehensor. Subjects were requested to grasp and transfer a collapsible object as fast as they could without dropping or breaking it. The object had a low and a high breaking force setting. Results Subjects conducted significantly more successful manipulations with the low cable force setting, both for the low (33% more) and high (50%) object's breaking force. The time to complete the task was not different between settings during successful manipulation trials. Conclusion High cable forces lead to reduced pinch force control during object manipulation. This implies that low cable operation forces should be a key design requirement for voluntaryclosing BPPs.

The group of passive prostheses consists of prosthetic hands and prosthetic tools. These can either be static or adjustable. Limited research and development on passive prostheses has been performed although many people use these prosthesis types. Although some publications describe passive prostheses, no recent review of the peer-reviewed literature on passive prostheses is available.

State of art upper limb prostheses lack several degrees of freedom (DoF) and force the individuals to compensate for them by changing the motions of their arms and body. Such movements often yield to articulation injuries, nonetheless these could be prevented by adding DoFs, for instance, an articulated passive wrist. Available stiff or compliant wrists with passive flexion/extension and/or
radial/ulnar deviation are sub-optimal solutions. Indeed, stiff wrists induce the individuals wearing them to perform exaggerated compensatory movements during the reaching phase while compliant wrists proved to be unpractical while
manipulating heavy objects. Here we present a wrist capable of combining the benefits of stiff and compliant wrists. It is provided with two switchable levels of passive compliance that are automatically selected. The prototype was integrated in a body-powered hydraulic hand prosthesis and actuated using the same hydraulic circuit of the hand. Detailed analysis of the parameters that affect the compliance, the critical load and the performance of the prosthesis are presented.

The addition of a cosmetic glove to an upper limb prosthesis has a distinct effect on the cosmetic value, but its viscoelastic behaviour adds a substantial amount of stiffness and hysteresis to the system. As a result, the overall usability of the prosthesis is degraded. A novel negative stiffness element is designed to compensate for the cosmetic glove’s stiffness. A combination of linear helical springs and the concept of rolling link mechanisms has resulted in a Rolling Stiffness Compensation Mechanism (RSCM). Results show that the RSCM is capable of exerting a progressive negative stiffness characteristic and can be built small enough to fit inside a 33 mm diameter wrist. Using the RSCM, an otherwise voluntary opening toddler-sized prosthesis is converted into a voluntary closing device, reducing maximum operation forces down to 40 N with a combined efficiency of 52%. Further adjustments to the design are possible to further improve the efficiency of the mechanism. Moreover, changes in geometric relations of the mechanism offers possibilities for a wide range of prostheses and other applications.

This study does not describe a success-story. Instead, it describes an exploratory process and the lessons learned while designing a compliant mechanism for a dynamic hand orthosis. Tools from engineering optimization and rapid prototyping techniques were used, with the goal to design a mechanism to compensate for hypertonic or contracted finger muscles. Results show that the mechanism did not reach its design constraints, mostly because it could not provide for the necessary stiffness and compliance at the same time. Hence, the presented approach is more suited for design problems with either lower forces or less displacement. It was concluded that physiological stiffness models are an important part when modeling hand orthoses. Moreover, further research on compliant mechanisms in dynamic hand orthoses should focus on the feasibility of implementing more complex three-dimensional shapes, i.e., compliant shell mechanisms.

The development of dynamic hand orthoses is a fast-growing field of research and has resulted in many different devices. A large and diverse solution space is formed by the various mechatronic components which are used in these devices. They are the result of making complex design choices within the constraints imposed by the application, the environment and the patient’s individual needs. Several review studies exist that cover the details of specific disciplines which play a part in the developmental cycle. However, a general collection of all endeavors around the world and a structured overview of the solution space which integrates these disciplines is missing. In this study, a total of 165 individual dynamic hand orthoses were collected and their mechatronic components were categorized into a framework with a signal, energy and mechanical domain. Its hierarchical structure allows it to reach out towards the different disciplines while connecting them with common properties. Additionally, available arguments behind design choices were collected and related to the trends in the solution space. As a result, a comprehensive overview of the used mechatronic components in dynamic hand orthoses is presented.

Background: Little is known about action-perception learning processes underlying prosthetic skills in body-powered prosthesis users. Body-powered prostheses are controlled through a harness connected by a cable that might provide for limited proprioceptive feedback. This study aims to test transfer of training basic tasks to functional tasks and to describe the changes over time in kinematics of basic tasks of novice body-powered prosthesis users. Methods: Thirty able-bodied participants and 17 controls participated in the study, using a body-powered prosthetic simulator. Participants in the training group were divided over four groups and practiced during a 2-week-period either direct grasping, indirect grasping, fixation, or a combination of these tasks. Deformable objects with different compliances had to be manipulated while kinematic variables and grip force control were assessed. Functional performance was measured with the Southampton Hand Assessment Procedure (SHAP) prior to and after the training sessions, and after 2 weeks and 3 months retention. The control group only performed the SHAP tests. Results: All four training groups and the control group improved on the SHAP, also after a period of non-use. Type of training had a small but significant influence on the improvements of the SHAP score. On a kinematic level movement times decreased and hook closing velocities increased over time. The indirect grasping group showed significantly shorter plateau times than the other training groups. Grip force control only improved a little over training. Conclusions: Training action-perception couplings of body-powered prosthesis in basic tasks transferred to functional tasks and this lasted after a period of non-use. During training movement times decreased and the indirect grasping group showed advantages. It is advisable to start body-powered training with indirect grasping tasks but also to practice hook-object orientations.