Reflections and future directions for psychological science in Prosthetics and Orthotics International

Abstract

In the inaugural edition of Prosthetics and Orthotics International in 1977, Dr Sidney Fishman identified the Psychological Sciences as one of six indispensable areas of skill and knowledge in professional prosthetic–orthotic practice. Since then, there have been substantial changes and developments in the complexity and capabilities of assistive technologies, greater emphasis on understanding the relationships between people and enabling technologies, growing recognition of the importance of the contexts and environments that support their use, and changes in both health care services and the professional development of prosthetists and orthotists. The aim of this narrative review is to reflect on the role of Prosthetics and Orthotics International in shaping the evolving understanding of psychology in prosthetics and orthotics. There remains considerable potential and opportunity for the development and application of psychology in addressing the challenges of disability globally. However, a broad interpretation and application of the principles of rehabilitation psychology are needed if we are to meaningfully incorporate psychological science into the knowledge that informs prosthetic and orthotic practice.

Introduction

In the inaugural edition of Prosthetics and Orthotics International in 1977, Dr Sidney Fishman ¹ identified the Psychological Sciences as one of six indispensable areas of skill and knowledge in professional prosthetic–orthotic practice. Dr Fishman highlighted the importance of the psychologies of, and relationships between, patients and prothetists-orthotists. He emphasized the need to understand and relate to patients when working towards a common goal and articulated an educational curriculum for training in prosthetics and orthotics that included study of psychological science. The intervening 40 or so years since that publication have seen changes and developments in the ways in which services are configured and delivered, and in the professional development of prosthetists and orthotists. Particularly, there have been changes and developments in the range, complexity, and capabilities of assistive technologies, greater emphasis on understanding the relationships between people and enabling technologies, and growing recognition of the importance of the contexts and environments, broadly defined, that support their use.^2–5 Awareness and understanding of psychosocial issues, defined by the American Psychological Associations as ‘the intersection and interaction of social, cultural, and environmental influences on the mind and behaviour’, ⁶ has continued to develop.

Since 2006, more than 180 state parties have ratified the United Nations Convention on the Rights of Persons with Disabilities ⁷ whose provisions entitle all people with disabilities to high-quality, affordable assistive products, including prostheses and orthoses. In parallel, there is an international push to more fully locate people/individual users in the centre of service delivery contexts. For example, through patient- or person-centred care, and a growing democratisation of health policy that increasingly engages consumers in policy processes and research, with the beginnings of disruption in traditional professional–consumer relationships. ³ These developments are profoundly and unequally distributed. ⁸ For example, the World Health Organisation estimates that only 5%–15% of people in low- and middle-income countries who need prostheses or wheelchairs have access to them. ⁹ Much of the research and theorising on psychosocial experiences and needs of assistive technology users is from developed and high-income countries, and grounded in North American and European traditions. In a commentary on the World Report on Disability ⁸ and its implications for rehabilitation psychology, MacLachlan and Mannan ¹⁰ note that the sub-discipline of rehabilitation psychology is most extensively developed in the United States and that psychology as a discipline has had only modest impact in countries where the majority of people with disabilities live. Thus, there remains considerable potential and opportunity for the development and application of psychology, and rehabilitation psychology in particular, in addressing the challenges of disability globally.^10,11 The aim of this article is to reflect on the role of Prosthetics and Orthotics International in shaping the evolving understanding of psychology in prosthetics and orthotics and to consider possible future directions for this clinical specialty.

Psychology in Prosthetics and Orthotics International

As the flagship journal of the International Society for Prosthetics and Orthotics, Prosthetics and Orthotics International plays a key role in shaping and guiding expectations about psychosocial issues in the field of prosthetics and orthotics, as well as disseminating this information to a global multidisciplinary audience. Our 2002 review ¹² of the psychological content in Prosthetics and Orthotics International, over the 25-year period from its inception, identified 21 articles (approx. 3% of published papers), with pronounced variation in the focus and depth of consideration of psychological issues (from a single line in some instances, to entire articles in other cases). We thematically summarised the content under the following headings: (a) body image; (b) coping and adjustment; (c) developmental issues; (d) psychosocial well-being; (e) quality of life; and (f) psychological factors leading to amputation. We repeated the search using the original search terms (which although limited allow for direct comparison with the previous review): psychology; psychosocial; coping; quality of life; and developmental). We searched the period from 2002 to August 2020, during which the Journal published 1040 papers, and 166 articles were returned (approx. 16% of papers published). It is encouraging to see an increase in the percentage of papers referring to psychosocial issues. However, given the considerable diversity in the extent of coverage and specificity of focus on psychosocial issues, there remains a need for continued and expanded efforts in this space to capitalise on the knowledge and understanding that psychological sciences can bring to the field of prosthetics and orthotics, and to ensure that the research evidence is shared by multidisciplinary teams involved in prosthetic and orthotic services and care. The search term ‘quality of life’ yielded the largest number of returns (n = 107) with mention of this term in 10% of papers published. Emphasis on quality of life as a critical patient-reported outcome is paralleled across epidemiological, clinical, health economics, and health services research; however, specific measurement and implementation challenges remain.^13–15

Across the assistive technology sector broadly, identifying outcomes of importance from the perspectives of users and developing multimodal ways to appropriately assess and monitor these outcomes over time remains a key challenge for needs analysis, meaningful planning, matching needs to solutions, and optimising usage and participation. It is also critical in demonstrating value that different technologies offer, quantifying this impact, and informing funding decisions. ³ The complexity and challenges of robust measurement of patient-reported outcomes are evidenced in papers published in Prosthetics and Orthotics International, most notably in reviews and articles describing psychometric evaluation studies.^13,16–19 Consideration of the development of core outcome sets, agreed-upon standardised sets of outcomes that are measured and reported in cases where there are multiple clinical trials in health or healthcare, ²⁰ have also been featured.^21–23 Internationally, there have been numerous calls for the development of foundational data sets to inform evidence-based practice in product and service delivery, and to quantify investment cases for assistive technologies. ²⁴ MacLachlan and Mannon ¹⁰ highlight psychological expertise in assessment and measurement, training in psychometrics, and fundamental grounding in person-environment dynamics as valuable resources in meeting the challenges and opportunities for improved measurement of person-centred outcomes that can guide intervention at individual, community, or societal levels. ¹¹

Beyond a growing emphasis on quality of life, most of the themes identified in our 2002 review ¹³ continue to receive some coverage both in articles reporting primary data and in literature reviews. The frequency of coverage of these topics in Prosthetics and Orthotics International remains modest. For example, excluding our review, just five papers published between 2002 and August 2020 include the term ‘body image’ in the title or abstract.^22,25–28 In their 2012 review of the literature on motivations and barriers to participation in physical activities, exercise and sport of prosthesis users, Deans et al. ²⁷ identified four themes, based on the 12 articles included articles: components; rehabilitation outcomes; body image; and motivations and barriers to participation. The findings point to the importance of body-image-related self-esteem, sense of mastery, and supportive social relationships and environmental contexts for prosthesis users to maintain physically active lifestyles. ‘Body image’ also appears in the abstracts of a technical note on the redesign of foam cosmeses for people with lower limb absence, ²⁵ a retrospective chart review on factors influencing the delivery of cosmetic covers, ²⁶ a study comparing outcomes for people with unilateral or bilateral amputations, ²⁸ and in an article on the development of core outcome sets. ²²

During the same period, the term ‘coping’ appears in three abstracts and ‘adjustment’ (in the context of psychological adjustment) appears in six abstracts. Collectively these nine articles include two reports of psychometric properties of the Trinity Amputation and Prosthesis Experience Scales;^29,30 a systematic review of the psychosocial literature on Paralympic athletes; ³¹ and six articles reporting primary data.^32–37 Examples of articles reporting primary research data include one by Donovan-Hall et al. ³² examining the effects of the appearance of a prosthesis on social behaviour, social discomfort and psychological well-being in 11 amputees taking delivery of a prosthesis with a silicone cover; one by Bent et al. ³³ that combined interviews and questionnaires to examine health and psychosocial issues among people living with the consequences of thalidomide; and one by Amorelli et al. ³⁴ describing findings from focus groups with people with amputations and healthcare professionals that were designed to shape the content of a peer support programme called Amputees Unanimous.

The term ‘psychosocial wellbeing’ appeared in only one abstract: Jefferies’ et al. ³¹ systematic review of the psychosocial literature on Paralympic athletes. ‘Wellbeing’ appears in 13 abstracts including the aforementioned review, ³¹ but with considerable variation in terms of the extent of focus on wellbeing in the full-text articles. Psychological theory was at the fore in the Callaghan et al’s. ³⁸ study using Leventhal’s Common Sense Model of self-regulation to investigate whether the psychological constructs represented in the model were predictive of prosthesis use and activity limitations among people with lower limb amputations. Washington and Williams ³⁹ adopted an interpretive phenomenological approach ⁴⁰ to explore experiences and impacts on psychological well-being following amputation.

Search of the term ‘developmental’ did not return any abstracts relevant to psychology; however, a 2010 review by Michielsen et al. ⁴¹ considered literature on participation, quality of life and psychosocial functioning in children and adolescents with congenital limb deficiencies and highlighted the general paucity of published research evidence in this domain. On analysis of the 15 included studies, the authors concluded that the available literature provides limited knowledge on quality of life and participation in children with congenital limb deficiencies and called for greater research efforts to address this gap.

Clearly psychological concepts and theories extend to domains beyond content identified in our initial review as articles published in Prosthetics and Orthotics International over the last 18 years evidences new psychosocial content. Although not an exhaustive search, here we highlight some of the articles that resonate with Dr Fishman’s ¹ vision for psychological science in prosthetics and orthotics. First, Dr Fishman observed that ‘since the prosthetist–orthotist creates a product to be worn by a human being, success or failure will be influenced by the opinions, attitudes, feelings, likes and dislikes of that human being’. ¹ In considering patient preferences, Williams and Nester ⁴² investigated perceptions of stock footwear among adults with rheumatoid arthritis or diabetes who required prescription footwear; they noted differences in prioritisation of requirements between the two patient cohorts and suggested that existing footwear ranges do not meet all patients’ requirements. They observed that clinical needs can only be met when patients actually wear the prescribed shoes, and pointed to the importance of integrating patient preferences in the design of footwear. In their research on foam cosmesis for lower limb prosthesis users, Cairns et al. ⁴³ investigated satisfaction with cosmesis and the importance of various attributes of cosmesis design. They reported on a user-centred product design methodology ²⁵ to integrate user needs in the design process.

Second, Dr Fishman articulated the need for the prothetist–orthotist to understand and relate to their patients. Anderson et al. ⁴⁴ used semi-structured interviews and thematic analysis to explore motivations to attend, experiences of participation, and perceptions of benefits among people with limb loss attending a mobility clinic. Findings highlighted the importance of opportunities for peer learning and support, perceptions of challenge in adjustment, adaptation to amputation, and improving mobility. Articles by Ide et al. ⁴⁵ and Areskoug-Josefsson et al. ⁴⁶ addressed issues of sex and sexuality, and prosthetic and orthotic students’ attitudes towards addressing sexual health in their future professional practice, respectively. Areskoug-Josefsson et al. ⁴⁶ reported that students feel unprepared to discuss sexual health and anticipate embarrassment in such discussions. They called for integration of training on sexual health issues in prosthetist–orthotist education. Adopting a phenomenological approach to explore lived experiences of osseointegrated limbs compared to socket suspended prostheses, Lundberg et al.’s ⁴⁷ analysis of in-depth interviews with 13 participants centred on meaning beyond function, transformations in body image, and prosthesis integration or embodiment.

Third, Dr Fishman emphasised working constructively with the individual, ‘rather than at cross-purposes’. ¹ Quigley et al. ⁴⁸ focused on shared decision-making as a process to support patient participation in decision making, and described the process and lessons learned through use of the International Patient Decision Aid Standards to develop shared decision-making resources, using decision making about the level of dysvascular amputation as an illustrative example. Van Netten et al. ⁴⁹ described the importance of clinicians communication with clients in daily practice, and described communication techniques that aimed to support patient acceptance and adherence to prescribed therapeutic footwear.

Finally, Dr Fishman ¹ noted that ‘Patients, peers, professional colleagues, and prosthetist–orthotists themselves must be viewed in psychological terms and dealt with in a similar manner’. Using focus group data, Anderson et al. ⁵⁰ examined physical, psychosocial, and environmental workplace experiences of prosthetists and orthotists across varied organisational settings. Problematic themes identified centred on ‘demands of work practice’, ’impacts on the individual’ and ‘job design’. A lack of understanding of the job role outside the profession was also highlighted. Applying critical psychology, Grobler et al. ⁵¹ described the co-construction and philosophical basis of a psychology of practice module that aimed to integrate theory and practice in a model for the development of a professional identity as an orthotist–prosthetist.

Conclusion

Scherer ⁵² defines rehabilitation psychology as

A specialty area within psychology that focuses on the study and application of psychological knowledge and skills on behalf of individuals with disabilities and chronic health conditions in order to maximize health and welfare, independence and choice, functional abilities, and social role participation across the life span.

In considering a global rehabilitation psychology, Bentley and colleagues ¹¹ summarise the key foundational principles in rehabilitation psychology as:

person-centered care; conceptualizing disability as multidimensional arising from the interaction between the person and environment, use of an interdisciplinary approach, attention to social context, focus on retained abilities and positive psychological factors, and efforts for inclusion of persons with disabilities – to shape health care delivery and health behaviour change initiatives at an international level.

While the enhanced profile of psychological science within prosthetics and orthotics is welcome, psychology and rehabilitation psychology require interpretation and application reflective of this definition and these principles, if we are to meaningfully incorporate these elements into the knowledge that informs prosthetic and orthotic practice. The potential of psychology to complement and advance the field of prosthetics and orthotics is significant, and there is much promise for it to inform topical debates, local to global policy, emerging technology development, and service delivery initiatives in areas such as, but not limited to, the person/technology interface, disruptive technology adoption, acceptance and engagement, behaviour change, cognitive functioning and ageing, lifespan development with a particular focus on children and families, resilience and strengths-based approaches, innovative assessment, and interventions to support psychological wellbeing and empower living in a personally meaningfully way. The benefits of public and patient involvement in research are only beginning to be harnessed in prosthetics and orthotics. ⁵³ This is a call to the prosthetic and orthotic community to be inclusive and creative, and to embrace all of the advantages that a more inclusive understanding of psychological science can bring. In doing so, the field can be truly advanced and Prosthetics and Orthotics International, as the flagship journal, can lead this charge and be the journal of choice for people publishing in this field.