Developing an evidence-based instrument to guide transfemoral prosthetic prescription in South Africa
Background: Prosthetic prescription is often based on experiential knowledge. Clinical competence can contribute to adequate prescription; however, choices are neither evidence-based nor transparent. Aim: To develop an evidence-based screening instrument to guide transfemoral prosthetic prescription in South Africa. Objectives: i) To determine evidence-based variables that can be used to guide screening for transfemoral prosthetic prescription through a scoping review of literature from the Global South. ii) To determine the variables used by transfemoral prosthetic service providers in South Africa to screen for transfemoral prosthetic prescription. iii) To collate variables from the two sources and the Guidelines: screening for prosthetic use and through a consensus survey identify variables to be included in a transfemoral prosthetic screening instrument for government services in South Africa. iv) To formulate a transfemoral prosthetic screening instrument for government services in South Africa. Methods: The study was conducted in three phases, starting with a scoping review. Six databases were searched. After screening four studies were included. Thematic analysis was done. In phase 2 qualitative data was collected from 21 service providers. Content analysis was done. Forty service providers completed a consensus survey, administered through Redcap, in phase 3. The survey included 67 statements that were scored on an eight-point Likert scale. Data was analyzed descriptively and mean deviations from the median were determined. Ethical considerations: Approval was granted by Stellenbosch University Health Research Ethics Committee. Permission was obtained from all gatekeepers. Ethical principles of autonomy, beneficence and justice were adhered to. Findings: The scoping review showed limited evidence from the Global South that can be used to develop contextually appropriate lower limb prosthetic prescription guidelines. It highlighted that systems level variables should be considered in addition to physical characteristics of the users. The qualitative findings highlighted the multi-layered nature of prosthetic prescription. Physical ability, muscle strength, joint mobility, and stump condition were identified as important determinants of prosthetic function. The findings also underscored the importance of mental health, user expectations, and systemic factors like pre prosthetic rehabilitation. The consensus survey determined 18 positive predictors, 18 negative predictors, and one contra indicator, while 26 variables were seen as neutral. MDM scores indicated low levels of agreement on positive predictors. The positive predictors were mainly among variables related to physical abilities (10) and environmental factors (4). Variables with high levels of agreement among negative predictors included cognitive problems (0.08), loss of sensation in the residual limb (0.05), instability in joints of the sound limb (0.13 and 0.18), requiring supervision in daily activities (0.08) and obesity (-0.10). Conclusion: Prosthetic prescription comprises multiple interwoven factors related to physical, psychological, and systemic aspects. The complexity and interrelatedness of variables shows that guidelines should be used in combination with empirical knowledge. Draft guidelines for prosthetic prescription in the government sector in South Africa were developed through this study. But they must be finalized and validated before implementation. Furthermore, peri-prosthetic rehabilitation, mental health interventions, peer support and ongoing education on prosthetic prescription must be facilitated in the study setting.
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