Out of a total of 6247 studies, 19 studies were included in the meta-synthesis ( ; S2 Table ). Seven of the included studies had a mixed methods design [ 9 , 12 , 19 , 23 , 40 – 42 ]; seven included participants of whom more than 25% did not fit the target population but in which the relevant population was analyzed separately [ 9 , 13 , 20 , 21 , 42 – 44 ]; and one contained data of using a prosthesis in both home and laboratory environment [ 45 ]. Of these studies, only the relevant parts were included. In three studies insufficient information was available to check if the included participants completely met the inclusion criteria [ 9 , 21 , 40 ]. However, since this was very likely the case, these were included. The agreement between both reviewers, calculated with Cohen’s kappa coefficient, was 0.60, which can be interpreted as a moderate level of agreement [ 46 ].
Most used data collection techniques were semi-structured interviews (conducted by phone or face-to-face), focus groups and questionnaires with open-ended questions. Furthermore, a case-report and a commentary were included [ 19 , 20 ]. Data analysis methods mainly concerned qualitative content analysis and thematic analysis ( ).
In total 479 participants from eight countries (United States, India, United Kingdom, Switzerland, Sweden, Netherlands, Canada and Italy) were included ( ). Study sample sizes varied between one and 145. Four studies only included men [ 19 , 23 , 42 , 47 ], and two only women [ 11 , 20 ]. In eight studies participants who did not fit the target population were included and not separately analyzed: three studies included participants younger than 18 years [ 12 , 40 , 44 ]; five studies included participants with bilateral upper limb loss [ 22 , 24 , 42 , 43 , 45 ]; two studies included participants with upper limb loss distal from the wrist [ 22 , 43 ]. In all of these studies, this involved less than 25% of the included participants.
CASP criteria are presented if they were unmet, which was the case when a question was answered with ‘no’. Two of the included studies did not have any unmet CASP criteria [ 22 , 44 ], seven studies had one unmet criterion [ 9 , 41 – 43 , 47 – 49 ], one study had two unmet criteria [ 13 ] and seven studies had three or more unmet criteria [ 11 , 12 , 21 , 23 , 24 , 40 , 45 ]. Two studies could not be assessed with the CASP, since one was a case report and the other a commentary [ 19 , 20 ].
The meta-synthesis of literature resulted in six main themes containing 65 subthemes (S1 Table). The main theme ‘rehabilitation’ did not cover all the contents of the included data within this theme. Therefore, this main theme was changed into: ‘Rehabilitation, costs and prosthetist services’. Below the results of most quoted subthemes are described.
Theme 1: Physical. The theme ‘physical’ included all subthemes that were directly related to the body of a person (e.g. physiological functions of the body, gender, age). Reasons to choose a prosthesis in relation to physical problems were often related to ‘overuse symptoms’: to relief already existing overuse complaints or to prevent getting overuse complaints [9,19,20,23,24,41,44,47–49]. Contradictory opinions on MHPs with regard to overuse complaints were found: in one study participants using an MHP experienced more relief of shoulder burden compared to an SHP, while in another the participant experienced more overuse complaints with an MHP in comparison to a body-powered prosthesis [19,23]. Next to the different types of prostheses involved in both studies, these contradictory opinions could be explained by the differences in employment, since the participant in the study of Schweitzer et al. (2018) had a physically demanding work environment and the participants of the study of Luchetti et al. (2015) did not [19,23].
‘I do it [activity of daily living] in a more natural manner.... The movements are normal movements.... I do not block the wrist because I can do like this [leans prosthetic hand on leg]. Now, the shoulder is in a normal position.’–Quote of a current MHP-user, with experience in using an SHP [23].
Another recurrent subtheme in the data was the relation between ‘phantom limb pain/sensations' and prosthesis choice [23,42,43,49]. Some persons indicated that phantom limb pain increased when wearing a prosthesis [42,49]. However, this was not always the case [23,42,49]. In one study it was suggested that interactions, both positive and negative, between the prosthesis and phantom limb pain/sensations was more common in myoelectric compared to body-powered prostheses [42].
Theme 2: Activities and participation. The theme ‘Activities and participation’ included all subthemes that referred to tasks and activities executed by a person as well as subthemes that referred to a person’s involvement in life situations. The subtheme ‘work/school’ appeared frequently in the data. The majority of the persons wore their prosthesis in the occupational/school setting, it enabled them to perform more ‘work/school’ related activities [9,11,19,20,23,24,42,44,47,49]. Myoelectric prostheses in general seemed to be less suitable for physically demanding work because they appeared to break easily and were not water- and dirt resistant [19,43]. Specifically regarding MHPs experiences differed, which seems to be person- and job-dependent: one participant said that the possibility to perform a lateral grip allowed him to do more work-related activities [23], while another person said he preferred the body-powered prosthesis over the MHP for his also physically demanding work, because he experienced the body-powered prosthesis as more reliable, comfortable, powerful, light-weight and cost-effective service with less maintenance [19]. In contrast, one DEKA-arm user, who also had an MHP, preferred to wear the MHP at work because of the more realistic look [11].
‘… it looks realistic and for me, at work, having something that looks realistic is crucial, so I couldn’t really wear the DEKA Arm.’–Quote of a DEKA-arm user, who also uses an MHP [11].
Many persons experienced their prosthesis useful for ‘leisure activities’ [9,23,24,41,44,47–49], although some persons could not perform all leisure activities they liked with their prosthesis [21,47,48]. As a consequence, they often did not enjoy those activities anymore and avoided them.
A part of the MHP-users experienced ‘grabbing, picking up and holding objects’ as more natural and more precisely using an MHP compared to an SHP [23]. However, one person experienced more frequent drops and skin problems when grabbing or lifting objects with an MHP compared to a body-powered prosthesis [19]. So the experiences with the MHP differ across persons, which seem to be person- and job dependent.
Theme 3: Mental. The theme mental included all subthemes that were related to someone’s thinking or feelings. ‘Coping’ strategies varied across people and could influence prosthesis choice and usage in both a positive and negative way [11,13,20–24,43,47,48]. For example, one participant said she felt miserable when the socket got sweaty, while another was not bothered by sweatiness, illustrating different types of coping styles [48]. Additionally, data emphasized that a prosthesis should fit someone’s ‘self-image’ or identity [11,20,21,23,47–49].
‘… There were some days at school when I was younger, when I couldn’t use the prosthesis and it was terrible… ‘–Quote of a prosthesis user, unknown which type [49].
Whereas some persons saw their prosthesis more as a clothing or fashion item, others saw their prosthesis as a part of their body and did not feel ‘complete’ without it [23,24,45,47–49]. This ‘embodiment’ was described by persons using an MHP [23], as well as by persons using an SHP and unknown prosthesis types [23,24,47–49]. The prosthesis seemed to have a positive influence on self-confidence [13,21,23,44,47,49]. With regard to MHPs, the influence seemed to differ per person: one participant felt more confident wearing an MHP because it felt more human, while another did not feel confident at all with an MHP [23]. This lack of confidence was probably caused by temporary failure of the MHP.
Theme 4: Social. The theme ‘social’ included all subthemes that relate to someone’s social relations and functioning in society. ‘Fitting in’ appeared to be a dominant subtheme [9,11,49,13,20,22,23,40,44,47,48]. People often had the desire to fit in and feel like everybody else. ‘Fitting in’ seemed to be closely related to the subtheme ‘reactions in public’ [9,11,20,23,40,44,47–49]. Most persons with ULD gain unwanted attention by people staring at their prosthesis or amputated arm. For some persons this was the reason to choose for a cosmetic prosthesis [49], but also for persons with other types of prostheses this often determined their prosthesis choice [9,11,20,23,40,44,47–49]. Participants with an MHP felt more normal with their prosthesis, because they could assume more natural postures and move more natural [23]. Furthermore, the MHP may facilitate social integration [23].
‘I was at a buffet… and, a glass of wine… I held a stem glass [with the Michelangelo prosthetic hand]!… Before, I had to take a plate from the buffet and find a table to eat, not now! Now, I can also walk… I mean… the fact that I have to sit at a table, it was something that isolated me from others.... Instead, now it is normal… wonderful!’–Quote of a current MHP-user, with experience in using an SHP [23].
Theme 5: Rehabilitation, costs and prosthetist services. The theme ‘rehabilitation, costs and prosthetist services’ included all subthemes that were directly related to training, guidance, prosthesis maintenance, reimbursement procedures and other services provided by either the rehabilitation team or the prosthetist. Most quoted subtheme in relation to this main theme was ‘professional maintenance of prosthesis’ [9,11,19,40,42–44,47]. The frequency in which professional maintenance was needed was experienced as a disadvantage of prostheses. No differences between prosthesis types were mentioned. The ‘costs of a new prosthesis and repairs’ were experienced high by most participants [9,19,40,43]. As a consequence, not all prosthesis options were financially accessible for everyone [9]. Possibly, users of a body-powered prosthesis considered costs more important than users of cosmetic or myoelectric prostheses [9].
‘The overall cost of the prosthesis needs to be lower. Most “insurances” pay 80%, but the other 20% is brutal.’–Quote of a prosthesis user, unknown which type [9].
‘A number of the farmers interviewed reported traveling long distances to see a prosthetist with the expertise they needed, which further increased their out-of-pocket cost. Some drove over 3 h one way, some traveled out of state, and some even traveled by air to see their prosthetist!’–Text from included study [43].
Theme 6: Prosthesis related factors. The theme ‘prosthesis related factors’ included all subthemes that were directly related to (properties of) the prosthesis. The overall most quoted subtheme was ‘functionality’ [9,11,41–45,47–49,12,13,19,20,22–24,40]. Repeatedly, it was mentioned that the prosthesis should be ‘functional’ and should have an added value relative to not having a prosthesis. For some this added value was indeed the function of the prosthesis, while for others a life-like appearance was more important. For some a prosthesis did not have any added value and they therefore chose to not use one [9,11,49,13,20,21,23,44,45,47,48]. Most MHP-users indicated that the prosthesis had more functions and resulted in an increased dexterity [23]. However, users also indicated the device was less robust and noisier [23].
The importance of a ‘life-like appearance’ of the prosthesis for persons differed [9,11,41,44,47–49,12,13,20–24,40]. For some persons a life like appearance did not matter at all, while for others this was the main reason to choose a particular prosthesis.
‘You’re very conscious of the fact that…I mean, me and my wife don’t find it off-putting but I think other people would. I won’t even wear a short-sleeved shirt because I’ve only got one arm showing and I’m obviously disabled.’–Quote of a prosthesis user, unknown which type [47].
A recurrent complaint about the appearance of the prosthesis, especially from females, was the relatively big size of some prosthetic hands [9,11,12,23,24,48]. Due to the size of the hand, and also the socket, not all clothes could be worn. Sometimes the prosthesis was too big to get into a sleeve. With regard to MHPs, it was mentioned that the MHP was slightly bigger compared to SHPs [23]. However, despite this difference, users said the MHP looked more life-like [23].
‘Wearing comfort’ was frequently experienced as a drawback of prostheses [9,11,41,42,44,47–49,12,13,19,20,22–24,40]. For body-powered prosthesis users, the harness was the main cause of discomfort, while for myoelectric prosthesis users the socket was [9,20,48]. In case of myoelectric prostheses, some persons said this was due to a poor socket fit in combination with sweating, that could cause slipping off the prosthesis. Cold weather was also designated as a cause of discomfort, since the socket of the myoelectric prosthesis conducts the cold. A part of the MHP wearers indicated pain or tiredness of the stump due to friction and the heavy weight of MHPs [19,23].
‘Reliability of a prosthesis’ was of great importance for most users [9,11,44,47–49,12,13,19,20,23,40,41,43]. The experienced reliability varied across different types of prostheses. While cosmetic prostheses were experienced as reliable [13], this was not always the case for MHPs, where unexpected movements could occur or an intention to move resulted in no movement [19,23]. ‘Durability’ was also seen as a major drawback of the current prostheses [9,12,49,13,19,20,22,41,43,45,47]. Durability of the body-powered prosthesis was experienced as better compared to the myoelectric [20,43]. For some persons, this was the main reason to not use a myoelectric prosthesis.
‘Control cables and wrists were identified as the “weak links” in body-powered upper-limb prostheses. Concern for durability was the main reason farmers with amputations gave for not utilizing myoelectric devices.’–Text of included study [43].
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