Prosthetics through the ages | NIH MedlinePlus Magazine

Millions of people in the United States are currently living with limb loss. This number is expected to grow as the population ages and rates of diseases such as diabetes that can cause dysvascularity (poor blood circulation in the legs) increase.

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For people with limb loss, prosthetic devices improve quality of life by providing movement and independence. Early prosthetics were uncomfortable to wear, but they may have helped people return to work and feel accepted in their daily lives. We&#;ll explore how these devices have changed over time, from clunky, early designs and materials to modern innovations&#;some of which NIH-supported researchers are developing.

When were prosthetics invented, and what were they used for?

Historians don&#;t know for certain if the first prosthetics were functional or for appearances. According to Katherine Ott, Ph.D., curator for the Division of Medicine and Science at the Smithsonian Institution&#;s National Museum of American History, this is partly because different cultures have their own ideas about what makes a person whole.

The oldest known prosthetics are two different artificial toes from ancient Egypt. One prosthetic toe, known as the &#;Greville Chester toe,&#; was made from cartonnage, which is a kind of papier-mâché made from glue, linen, and plaster. It is thought to be between 2,600 and 3,400 years old, though its exact age is unknown. Because it doesn&#;t bend, researchers believe it was cosmetic.

The other prosthetic, a wooden and leather toe known as the &#;Cairo toe,&#; is estimated to be between 2,700 and 3,000 years old. It is thought to be the earliest known practical artificial limb due to its flexibility and because it was refitted for the wearer multiple times.

Approximately 300 years later&#;300 B.C.&#;in Italy, an ancient Roman nobleman used a prosthetic leg known as the &#;Capua leg.&#; The leg was made of bronze and hollowed-out wood and was held up with leather straps.

Other known early prosthetics include artificial feet from Switzerland and Germany, crafted between the 5th and 8th centuries. These were made from wood, iron, or bronze and may have been strapped to the amputee&#;s remaining limb.

 A wood and aluminum prosthetic arm invented by William Robert Grossmith in the mid-19th century.

How war&#;and the U.S. military&#;inspired prosthetic advances

Soldiers who lost their limbs in battle often used early artificial limbs made of wood or iron. For example, about 2,200 years ago, the Roman general Marcus Sergius Silus lost his right hand during the Second Punic War. He had it replaced with an iron one that was designed to hold his shield. Knights of the Middle Ages sometimes used wooden limbs for battle or to ride a horse. And in the 16th century, the French surgeon Ambroise Paré designed some of the first purely functional prosthetics for soldiers coming off the battlefield. He also published the earliest written reference to prosthetics.

Then came the American Civil War in . The record number of amputees from the war caused the number of patents for prosthetics to almost quadruple. One of these patents was for a wooden leg called the &#;Hanger limb.&#; It was the first to use rubber in the ankle and cushioning in the heel, showing that inventors understood they needed to make prosthetics less painful for amputees to wear.

 An artificial leg from the American Civil War.

Today, the U.S. Department of Veterans Affairs is a major provider of prosthetics and a leader in rehabilitation treatments for veterans who lose their limbs during their service. These patients are at risk for polytrauma, meaning they have injuries on multiple body parts, usually from blast-related events.

When this happens, these veterans need multifaceted clinical care and a support network. The Rehabilitation Medicine division at the NIH Clinical Center and the National Center for Medical Rehabilitation Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development help treat prosthetic users and conduct research about limb loss.

Improvements in design

While prosthetics were still made of combinations of wood, metal, glue, and leather even up to the 20th century, they were becoming more functional. From the late 15th century to the 19th century, France and Switzerland were making artificial limbs that could rotate and bend using cables, gears, cranks, and springs. However, these devices still needed to be adjusted manually. For example, an artificial hand could be cranked shut around a fork, but the person still needed another hand to operate the crank.

During the s, manufacturers started to build more functional prosthetics by swapping wood and leather for plastics and other artificial materials. Still, some of the best prosthetics were out of reach for most people, including veterans. Many of these devices were only designed for specific tasks such as piano playing. They would not become more accessible to veterans until World War I, when prosthetic manufacturing for soldiers with limb loss increased in Great Britain. According to Jeffrey S. Reznick, Ph.D., Chief of the National Library of Medicine History of Medicine Division, such wartime manufacturing (and repair) sometimes occurred in military hospitals. Soldiers recovering in those facilities were fitted with artificial limbs as part of their care.

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Today&#;s prosthetics look and work very differently from those made before the late 20th century. More lightweight and durable materials such as plastic, aluminum, titanium, and silicone are common in today&#;s prosthetic devices. They also fit closer to the user&#;s remaining limb. The Walter Reed National Military Medical Center will even tattoo service members&#; prosthetics to help them look and feel more natural.

But what if a prosthetic could move without the user consciously controlling it? That is what the next generation of artificial limb technology aims to do.

 An example of a modern bionic prosthetic arm.

NIH-supported innovations in prosthetics

Scientists are developing robotics, 3D printing, artificial intelligence, virtual reality, and motion-sensing technologies for prosthetics. Over the last decade, NIH has funded several projects that harness the brain&#;s electrical activity to move prosthetic limbs using electrodes implanted in a person&#;s remaining muscles. These electrodes send signals to the brain and allow the prosthetic limbs to move more freely.

One example of research funded by the National Institute of Biomedical Imaging and Bioengineering is a robotic lower leg prosthesis that creates a more natural walking motion. Researchers at Vanderbilt University created the device with powered knee and ankle joints and with software that can anticipate how the user wants to move.

In addition to these technological advances, it&#;s also important to track how many people use prosthetics and what treatments work best for these patients. That&#;s why NIH, together with the U.S. Department of Defense and the Mayo Clinic, helped create the Limb Loss and Preservation Registry in . This registry uses electronic health records to measure how many people in the United States have limb loss and understand the costs and treatment outcomes for these patients.

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There is plenty of technological and neurological work yet to be done to make prostheses that feel like natural body parts and that come to be fully integrated into a person&#;s sense of self. Some of today&#;s most advanced prosthetics that stimulate neurons in the brain to mimic real sensations, for example, involve only a small number of the brain&#;s many billions of cells, Hatsopoulos said. We have, in other words, likely only scratched the surface of the kind of sensation that people have in their natural limbs. The goal of full restoration is still a significant way off.

Longevity is another challenge, Hatsopoulos said. Eventually, electrodes and other components wear out and need to be replaced. That raises ethical and philosophical questions. What happens, Valle asks, if you come to view a prosthesis as part of your personal identity and then it, too, breaks?

That&#;s not the only unanswered question raised by rapid advances in prostheses. In a comprehensive review of studies on neuroprostheses, researchers from the Netherlands identified 169 ethical implications (van Velthoven, E. A. M., et al., Journal of Neural Engineering, Vol. 19, No. , ). For instance, implantation of electrodes into the brain carries health risks, and there are long-term uncertainties about safety. Other questions concern autonomy, the relationship between people and machines, and threats to communities, like Deaf culture. In addition, although many studies mention a goal of improving well-being and life satisfaction with neuroprosthetic devices that restore hearing or speech, devices don&#;t always work perfectly, and they can end up causing suffering when results don&#;t match expectations.

Hearing aids, in particular, face barriers to acceptance that include lack of awareness. Even though 1 in 8 U.S. adults has problems with hearing, which affects more than two thirds of people older than 70, more than 90% of people couldn&#;t identify what a normal range of hearing is in a survey of 1,250 adults ages 50 to 80 (Carlson, M. L., et al., Otology & Neurotology, Vol. 43, No. 3, ). Most adults don&#;t know that there are long-term health consequences (such as cognitive decline) to untreated hearing loss or that there are treatments that can help.

As technological advances continue, rehabilitation psychologists remain an essential part of an interdisciplinary team of prosthetists, physical therapists, engineers, and others who can work together to help people learn to use and embody prostheses, Scherer said. Rehab psychologists make good managers of rehabilitation teams, she added, but they are in short supply. Even though APA Division 22 (Rehabilitation Psychology) was formed in , fewer than 1% of psychologists today self-report a specialty in rehabilitation psychology, according to recent APA data, and just 4% hold an American Board of Professional Psychology certification in the specialty.

Many rehabilitation patients get help from psychologists not trained in rehab psychology, found an analysis of postdoctoral rehabilitation psychology training in the United States and Canada (Stiers, W., & Stucky, K., Rehabilitation Psychology, Vol. 67, No. 3, ). Solutions will need to include more outreach and advocacy to expand the pipeline and visibility of the profession, concluded researchers in a report on the state of the field which was the first of its kind (Baker, L. N., et al., Rehabilitation Psychology, Vol. 67, No. 2, ).

&#;A rehabilitation psychologist is focused on coping, adaptation, maximizing functioning, enhancing quality of life, helping people find employment, helping them achieve what they want to do,&#; Scherer said. &#;There are not enough of them.&#;

If prostheses eventually reach the point where they can truly mimic or improve sensation and performance, there will be yet more issues to grapple with, Hatsopoulos said. Should prosthetics be reserved for those with paralysis, for example, or should they become available as performance enhancers for people with ordinary abilities or to make high-performing athletes even more competitive? &#;When the time comes when you can actually enhance people&#;s capabilities, even people without spinal cord injury,&#; he said, &#;there are definitely ethical considerations.&#;

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