Review Reports - The Technological and Psychological Aspects of Upper Limb Prostheses Abandonment: A Narrative Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, congratulations for the research work undertaken in conceiving the study entitled "The technological and social aspects of upper limb prostheses abandonment: A Review", aiming to discuss technological and social aspects of upper limb prosthesis abandonment.

Notwithstanding the paper identify relevant factors contributing to upper limb prosthesis abandonment, in the review report attached, there are some issues I would like to call your attention for that hamper, in my opinion, its overall quality, due to a lack of a more robust systematic methodology, as well as some unsubstantiated claims in the introduction, which ended up to influence the way your results were discussed.

I would like to enhance my comments serve the only purpose of contributing for the improvement of your paper.

Wish you all the best!
Regards,

Comments for author File: Comments.pdf

Author Response

Please see the attachment.

I would like to enhance my comments to serve the only purpose of contributing to the improvement of your paper.

Wish you all the best!

Regards,

We sincerely thank the reviewer for their thoroughness and dedication during these revisions. We greatly appreciate the comments and believe they have enhanced the quality of the article. We have updated the title and abstract to better align with the content, expanded the bibliography, and clarified some previously unexplored aspects.

Below are our detailed responses to each point.

Comments

(lines 14-16): "The low level of embodiment, overly high user expectations, and poor psychological support are among the main factors contributing to this problem.". The paper claims that 'low level of embodiment, overly high user expectations, and poor psychological support' are among the main factors contributing to abandonment. While these are plausible factors, presenting them as 'main factors' without immediate supporting evidence or a brief explanation in the introduction itself (before the detailed analysis) can be seen as an unsubstantiated assertion at this stage.

We thank the reviewer for the comment. The abstract was modified as follow:

The loss of a limb is an event that significantly affects an individual's quality of life, with implications not only for autonomy in daily activities but also for the ability to interact with others. At the same time, current prostheses often fail to meet the user's needs, resulting in high drop-out rates. In this review, we investigated the primary causes of prosthesis abandonment and analyzed them by highlighting the technological and psychological aspects associated with current devices. Technological issues due to reliability, functionality and comfort, together with psychological issues related to anxiety and depression are among the main factors contributing to prosthesis rejection. Social aspects, sport, and community activities play a crucial role in improving the sense of belonging and acceptance of prosthesis users.

Although research has often prioritized functionality, prosthesis development should follow patient-centered models that address the individual needs and requirements of patients, emphasizing psychological, rehabilitative, and technological support.

(lines 27-30): "It has been estimated that in the United States, there are approximately 2 million people living with limb loss [4], and those numbers are estimated to double by 2050 due to the aging of the population and the higher incidence of vascular diseases and diabetes [4,5].". While it mentions high drop-out rates and failure to meet user needs, the introduction does not quantify the extent of the abandonment problem for upper limb prostheses specifically, instead citing general limb loss statistics. A more precise statement of the problem's magnitude for upper limb devices would strengthen the paper's foundation.

The introduction was modified as follows, including more precise data on upper limb problem:

It has been estimated that in the United States, there are approximately 2 million people living with limb loss [4], and those numbers are estimated to double by 2050 due to the aging of the population and the higher incidence of vascular diseases and diabetes [4,5]. The leading causes of amputations are trauma-related and, most commonly, due to work-related accidents, traffic accidents, and falls. [5–16]. According to Raspopovich et al. [17] 15,900 upper limb amputations are performed in the USA each year, while 6311 in the European Union (data averaged from [17–20] Prostheses rejection rates remain high (30–80%) due to a lack of user needs [21–26].

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Ziegler-Graham, K.; MacKenzie, E.J.; Ephraim, P.L.; Travison, T.G.; Brookmeyer, R. Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050. Arch Phys Med Rehabil 2008, 89, 422–429, doi:10.1016/j.apmr.2007.11.005.
Segura, D.; Romero, E.; Abarca, V.E.; Elias, D.A. Upper Limb Prostheses by the Level of Amputation: A Systematic Review. Prosthesis 2024, 6, 277–300.
Qadir, R.; Sidhu, S.; Romine, L.; Meyer, M.S.; Duncan, S.F.M. Interscapulothoracic (Forequarter) Amputation for Malignant Tumors Involving the Upper Extremity: Surgical Technique and Case Series. J Shoulder Elbow Surg 2014, 23, doi:10.1016/j.jse.2013.09.007.
Armed Forces Health Surveillance Center (AFHSC) Amputations of Upper and Lower Extremities, Active and Reserve Components Approved for Public Release; Distribution Unlimited. MSMR 2012, 6, 2–6.
Cancio, L.C.; Jimenez-Reyna, J.F.; Barillo, D.J.; Walker, S.C.; McManus, A.T.; Vaughan, G.M. One Hundred Ninety-Five Cases of High-Voltage Electric Injury. Journal of Burn Care and Rehabilitation 2005, 26, 331–340.
Mitchell, S.L.; Hayda, R.; Chen, A.T.; Carlini, A.R.; Ficke, J.R.; Mackenzie, E.J. The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma. Journal of Bone and Joint Surgery - American Volume 2019, 101, 1470–1478, doi:10.2106/JBJS.18.00970.
Varma, P.; Stineman, M.G.; Dillingham, T.R. Epidemiology of Limb Loss. Phys Med Rehabil Clin N Am 2014, 25, 1–8.
Freeland AE, P.R. Traumatic Below-Elbow Amputations. Orthopedics. Orthopedics 2007, 30, 120–126.
Dillingham TR, P.L.M.EJ. Limb Amputation and Limb Deficiency: Epidemiology and Recent Trends in the United States. South Med J. 2002, 95, 875–883.
Flinn, S.R.; Goodman, G. Effective Assessments to Identify Overuse Injuries in Unaffected Limbs of Persons with Unilateral Upper Limb Amputations. Journal of Hand Therapy 2021, 34, 298–308, doi:10.1016/j.jht.2021.05.006.
Das De, S.; Liang, Z.C.; Cheah, A.E.J.; Puhaindran, M.E.; Lee, E.Y.; Lim, A.Y.T.; Chong, A.K.S. Emergency Hand and Reconstructive Microsurgery in the COVID-19–Positive Patient. Journal of Hand Surgery 2020, 45, 869–875.
Resnik, L.; Ekerholm, S.; Borgia, M.; Clark, M.A. A National Study of Veterans with Major Upper Limb Amputation: Survey Methods, Participants, and Summary Findings. PLoS One 2019, 14, doi:10.1371/journal.pone.0213578.
Raspopovic, S.; Valle, G.; Petrini, F.M. Sensory Feedback for Limb Prostheses in Amputees. Nat Mater 2021, 20, 925–939.
Winkler, S.L.H. CARE OF THE COMBAT AMPUTEE. In; (eds Pasquina, P.F. et al. 2009), Ed.; Office of The Surgeon General Department of the Army, United States of America and US Army Medical Department Center and School Fort Sam Houston, Texas, 2009; Vol. XLI, pp. 597–605.
INAIL. Sanità Solo Il 5 Di Amputazioni è Legata a Infortuni Sul Lavoro. Available online: https:// www.inail.it/cs/internet/comunicazione/news-ed-eventi/news/p1780018061_ sanita_solo_il_5_di_amputazi.html (accessed on 26 November 2025).
Atroshi I, R.HE. Epidemiology of Amputations and Severe Injuries of the Hand. Hand Clin. 2001, 17, 343–350.
Resnik, L.; Borgia, M.; Clark, M. Function and Quality of Life of Unilateral Major Upper Limb Amputees: Effect of Prosthesis Use and Type. Arch Phys Med Rehabil 2020, 101, 1396–1406, doi:10.1016/j.apmr.2020.04.003.
Tintle, S.M.; Baechler, M.F.; Nanos, G.P.; Forsberg, J.A.; Potter, B.K. Traumatic and Trauma-Related Amputations: Part II: Upper Extremity and Future Directions. Journal of Bone and Joint Surgery 2010, 92, 2934–2945.
Biddiss, E.A.; Chau, T.T. Multivariate Prediction of Upper Limb Prosthesis Acceptance or Rejection. Disabil Rehabil Assist Technol 2008, 3, 181–192, doi:10.1080/17483100701869826.
Apagüeño, B.; Munkwitz, S.E.; Mata, N. V.; Alessia, C.; Nayak, V.V.; Coelho, P.G.; Fullerton, N. Optimal Sites for Upper Extremity Amputation: Comparison Between Surgeons and Prosthetists. Bioengineering 2025, 12.
Biddiss, E.; Chau, T. Upper Limb Prosthesis Use and Abandonment: A Survey of the Last 25 Years. Prosthet Orthot Int 2007, 31, 236–257.
Wright, T.W.; Hagen, A.D.; Wood, M.B. Prosthetic Usage in Major Upper Extremity Amputations;
Borsook, D.; Becerra, L. Emotional Pain without Sensory Pain-Dream On? Neuron 2009, 61, 153–155.

(lines 32-36): "Limb amputation is certainly a delicate moment that forces the individual to deal with various changes in their life [17,18], such as the difficulty in continuing their work, the loss of autonomy in various daily tasks, the emotional adjustment to the new condition [19,20], the physical pain following the operation, and, in some cases, the phantom limb pain [21].". Although there is still a lack of psychiatric understanding for patients with amputation, studies have found depressive symptoms are common in the first 2 years after amputation, and depression and anxiety may increase again during adjustment to daily life after discharge (Horgan & MacLachlan,2004; Singh et al., 2009). However, the timelapse for the emergence of this symptoms seems to vary, as a previous study on patients with traumatic amputation found depression and anxiety were experienced by 35% and 60% of the sample, respectively, in the first 6 months after amputation (Melcer et al., 2010).

We thank the reviewer for the suggestions and corrections. We included the revisions as follow:

Limb amputation is certainly a delicate moment that forces the individual to deal with various changes in their life [27,28], such as the difficulty in continuing their work, the loss of autonomy in various daily tasks, the emotional adjustment to the new condition [29,30], the physical pain following the operation, and, in some cases, the phantom limb pain [31]. According to Horgan & MacLachlan [32], depression and anxiety are common in the first two years after amputation, even if, as shown by Singh et al [33] level of anxiety and depression are not constant during the two years. Anxiety and depression result in higher levels during hospitalization, following a drop and then increasing again. Mckechnie and John [34], estimated 20.6-63% of depression and 25.45-57% of anxiety incidence after traumatic amputation.

Borsook, D.; Becerra, L. Emotional Pain without Sensory Pain-Dream On? Neuron 2009, 61, 153–155.
Cotigă, A.C.; Zivari, M.; Cursaru, A.; Aliuş, C.; Ivan, C. Amputation, Psychological Consequences, and Quality of Life among Romanian Patients. Romanian Journal of Orthopaedic Surgery and Traumatology 2020, 3, 29–40, doi:10.2478/rojost-2020-0006.
Jo, S.-H.; Kang, S.-H.; Seo, W.-S.; Koo, B.-H.; Kim, H.-G.; Yun, S.-H. Psychiatric Understanding and Treatment of Patients with Amputations. Yeungnam Univ J Med 2021, 38, 194–201, doi:10.12701/yujm.2021.00990.
Perkins, Z.B.; De’Ath, H.D.; Sharp, G.; Tai, N.R.M. Factors Affecting Outcome after Traumatic Limb Amputation. British Journal of Surgery 2012, 99, 75–86.
Flor, H. Phantom-Limb Pain: Characteristics, Causes, and Treatment. Lancet Neurology 2002, 1, 182–189.
Horgan, O.; MacLachlan, M. Psychosocial Adjustment to Lower-Limb Amputation: A Review. Disabil Rehabil 2004, 26, 837–850.
Singh, R.; Ripley, D.; Pentland, B.; Todd, I.; Hunter, J.; Hutton, L.; Philip, A. Depression and Anxiety Symptoms after Lower Limb Amputation: The Rise and Fall. Clin Rehabil 2009, 23, 281–286, doi:10.1177/0269215508094710.
Mckechnie, P.S.; John, A. Anxiety and Depression Following Traumatic Limb Amputation: A Systematic Review. Injury 2014, 45, 1859–1866.

(lines 44-46): "These stressors challenge individuals' ability to maintain emotional well-being, which can lead to maladaptive reactions and poor psychosocial adjustment [23,24].".Although the emotional reactions subsequent to amputation vary significantly among individuals, influenced by factors such as the underlying cause of the amputation, aspects of personal circumstances, the socio-historical context, the virulence of the disease, the individual’s perception of the symptoms, and /or the self-concept as altered and frequently diminished in comparison to the pre-amputation phase, may elicit detrimental cognitions linked to catastrophizing concerning future functionality and adaptation, which typically leads to intensified negative emotional states including anger, hostility, or suicidal thoughts (Beck et al., 2005; Senra et al., 2012).

We thank the reviewer for the suggestions and corrections. We included the revisions as follow:

Senra et al.[38], demonstrated how depressive symptoms, phantom limb pain, and anxiety influence self-perception and adjustments after amputation. The amputation affects the integrity of the body, and in this way also the skills and talents of the individual[39]. As a consequence, the individual may start perceiving himself as inferior because of the amputation, eliciting detrimental cognitions linked to catastrophizing concerning future functionality and adaptation, often leading to maladaptive behaviors [40] and negative emotional states including anger, hostility, or suicidal thoughts [41].

Senra, H.; Oliveira, R.A.; Leal, I.; Vieira, C. Beyond the Body Image: A Qualitative Study on How Adults Experience Lower Limb Amputation. Clin Rehabil 2012, 26, 180–191, doi:10.1177/0269215511410731.
Roșca, A.C.; Baciu, C.C.; Burtăverde, V.; Mateizer, A. Psychological Consequences in Patients With Amputation of a Limb. An Interpretative-Phenomenological Analysis. Front Psychol 2021, 12, doi:10.3389/fpsyg.2021.537493.
Beck, A.T., E.G., & G.R.L. Anxiety Disorders and Phobias: A Cognitive Perspective.; Basic Books/Hachette Book Group., Ed.; Basic Books/Hachette Book Group.: New York, NY, US, 2005;
Judith S. Beck CognitiCognitive Behavior Therapy: Basics and Beyond; The Guilford Press (A Division of Guilford Publications, Inc.): New York, NY, 2011;

(lines 71-74): "This review aims to gather and discuss the key factors contributing to prosthetic abandonment, analyzing them by prosthesis type. It explores both technical aspects of prosthetics and psychological factors that impact device acceptance and long-term use, including motivation, cognition, and behavior.". These objectives are not aligned with the title, which propose to review the technological and social aspects of upper limb prostheses abandonment.

We thank the reviewer for the comment. We corrected the title of the manuscript in “The technological and psychological aspects of upper limb prostheses abandonment: A Narrative Review”, as our main aim is the one expressed in lines 71-74. Moreover the section was modified as follow:

This review aims to identify and discuss key factors that lead to prosthetic abandonment, analyzing them by prosthesis type. It examines both technical aspects of prosthetics and psychological factors influencing device acceptance and long-term use, including motivation, cognition, and behavior. The goal is to provide a comprehensive, evidence-based perspective that can guide future upper-limb prosthetic design and clinical strategies to reduce prosthetic abandonment. This narrative review includes articles found through a non-systematic search in Google Scholar, PubMed, and Scopus. The selection focused on relevance to the review's topics (technological and psychosocial) without applying formal inclusion/exclusion criteria or systematic screening.

(lines 77-196): "2 Technological challenges: Upper limb Prosthetic Devices (...)".In terms of the pros and cons associated with each type of prosthesis described in the text, it is suggested that this information be conveyed using a schematic representation, in line with Figures 1 and 2, which illustrate, respectively, critical factors related to the abandonment of prosthesis use and the reasons given by their users, from an evolutionary perspective,

for this same abandonment, reducing supplementary information to a maximum of one paragraph per typology. This suggested representation would allow readers, in a very objective way, to understand what differentiates each type of prosthesis from the others, thus avoiding distraction from the main objective of the article, which, I remind you, still needs clarification given the inconsistency found between the article title and the presentation of the objectives (previous comment).

We thank the reviewer for the suggestion the following picture was included in the manuscript to summarized main pros and cons extrapolated from literature

(lines 218-220): "Analyzing and collecting information from past reviews and the literature, we identified some recurring motivations, as shown in Table 1 and Figure 1.". Yet not being a systematic review, there should be provided a brief description on methodology undertaken to search the studies included in the review. Which databases were searched? Which keywords were used? Based on what criterion were the included studies selected? Which data from each study were extracted? No matter the type of review undertaken, these data grant others researchers interested in this theme to realize the search process and might get to the same results.

The review carried out is a narrative review. The literature search was not conducted systematically, although the articles retrieved were searched through the main databases (Scopus, Scholar, PubMed). We have clarified this aspect in the text:

(lines 222-223): "Table 1. Table of articles from 1993 to 2025 used to evaluate the main reasons for prosthetic abandonment.". The paper states that Table 1 includes articles from '1993 to 2025', yet the earliest entry in the table is from 1993, and the latest is 2019, with a placeholder for 2024. This inconsistency between the stated timeframe and the actual content of the table is misleading.

Table was updated and corrected.

(lines 265-268): "A lack of proper support from rehabilitation specialists or poor user participation in rehabilitation can pose major challenges, leading to dissatisfaction and the abandonment of the prosthesis [76,82,83].". For many amputees, insurance coverage restrictions may also impact the prosthetic rehabilitation process, as some insurance policies limit coverage by classifying prostheses as durable medical equipment, subject to the same annual cap as those items. Therefore, the number of visits patients can make to a prosthetist covered by the insurance may be limited, which therefore may be related to whether fit problems with the prosthesis are resolved enough (Nielsen et al., 1989). Ideally, patients should be given the opportunity to try several types of sockets, harnesses, prostheses, and terminal devices before choosing their permanent device (Brenner & Brenner, 2008).

Cain et al. [118] identified critical boundaries in the individual journey after limb loss, revealing inequities, including inadequate assistance, delays in prosthetic delivery (over 10 months), and financial barriers. Resnik et al. [103] conducted a study involving 727 upper-limb amputees, showing that 20% of those who ever used a prosthesis paid out-of-pocket costs, while up to 25% of individuals who never used a prosthesis or abandoned it reported being unable to repair or afford the prosthetic device. Even in countries with national coverage systems, there is no guarantee that the national health system will cover the costs of the most modern and sophisticated devices [119]. In medical insurance-based states such as the USA, access to prosthetic devices depends on the rules of the health insurance company, which often don’t cover all types of prosthetic terminals, including microprocessor-based prostheses [118], thus limiting the opportunity of amputees to try several types of sockets, harnesses, prostheses, and terminal devices before choosing their permanent device, as should ideally happen [120].

Resnik, L.J. 1, 2; B.M.C.M.A. 2, 3; N.P. Out-of-Pocket Costs and Affordability of Upper Limb Prostheses. Prosthetics and Orthotics International 2024, 48, 108–114.
Cain, J.; Earley, E.J.; Potter, B.K.; Grover, P.; Thomas, P.; Stark, G.; White, A. Innovations in Amputee Care in the United States: Access, Ethics, and Equity. Prosthesis 2025, 7, 153, doi:10.3390/prosthesis7060153.
Kannenberg, A.; Seidinger, S. Health Economics in the Field of Prosthetics and Orthotics: A Global Perspective. Canadian Prosthetics and Orthotics Journal 2021, 4.
Brenner, C.D.; Brenner, J.K. The Use of Preparatory/Evaluation/Training Prostheses in Developing Evidenced-Based Practice in Upper Limb Prosthetics. JPO Journal of Prosthetics and Orthotics 2008, 20.

(lines 289-290): "According to [114–116], amputees are mostly interested in improving the dexterity and durability of prosthetic options.". The Authors to whom the statement “amputees are mostly interested in improving the dexterity and durability of prosthetic options" is according with should be identified the respective names and then followed by the respective reference list numbers within the squared brackets.

Reported lines were corrected according to reviewer suggestions.

According to Engdahl et al. [136,137] and Zheng, J.Y et al. [138], amputees are mostly interested in improving the dexterity and durability of prosthetic options.

(lines 419-423): "Myoelectric systems offer improved functionality and a more lifelike appearance but are still especially vulnerable to rejection. Factors such as a steep learning curve, sensitivity of surface electrodes, limited battery life, and lack of intuitive sensory feedback often discourage prolonged use [156] particularly among unilateral amputees who may prefer using only their intact limb.". Besides the factors mentioned, it would be important to detail biomedical issues related to myoelectric prostheses that might also explain prothesis abandonment, like the critical role of electrodes' placement and contact with the skin for the device to react properly with regard to the user's intentions. Prosthetic design may impede a direct contact of the electrode with the skin, as plastic wall encloses the electrode where the stump is fitted and the device wobble within the stump make electrodes to move from the EMG sites, when wearers move or encounter forces and weights while performing daily activities. These two instances may bring crosstalk of neighboring muscles, which contributes to the unpredictability of the transduction of the proper EMG signals to the prosthesis, resulting in uncertainty for the user, who doesn't know when the prosthesis will react according to his or her intentions (Chadwell et al., 2021).

We really appreciated the reviewer's comment. We corrected and updated the section with the following discussion:

Control is among the most critical issues in this type of prosthesis. The control chain of a myoelectric prosthesis is based on three key aspects: the generation of the electromyographic signal, the ability to acquire the electromyographic signal, and finally, the ability of the terminal to respond to the command [177]. No matter how good the signal generation is, if the interface between the electrodes and the skin fails to provide accurate and reliable signal transfer, the user will struggle to control the device. If the socket is too loose, the arm may move within it, causing electrodes to lose contact with the skin. This can result in signal artifacts or failure to activate the hand [177,178]. Furthermore, the skin-electrode interface varies throughout the day because of socket fit issues, which can be worsened by sweat, rain, or humidity [179,180]. Below the socket, changes in arm posture during muscle contraction may lead to alteration of the EMG features[181,182]. Due to this alteration, a sensor can receive different signals for the same intended movement, leading to an unpredictable movement of the terminal device [177].

These findings highlight the urgent need for device-specific improvements to lower abandonment rates and increase user satisfaction. For myoelectric prostheses, greater attention must be paid to the design of the socket and the optimisation of the electrode-skin interface, in order to ensure durability and reliability throughout the day. Recently, epidermal electronics have demonstrated the ability, in controlled environments, to enable both the acquisition of biopotentials [183–186] and electrical stimulation for sensory feedback [187], through the use of tattoo technology, which, thanks to its mechanical properties, can optimise adhesion to the skin and maximise the contact surface [188,189]. Although tattoo electrodes represent an interesting technological solution, their use in real-world conditions still needs to be demonstrated.

For BP prosthesis, design priorities should be moved towards the fulfilment of user requirements, prioritizing and investigating new design approaches and solutions capable of reducing the number of harnesses and facilitating the control. Particular attention should be given to innovative designs, such as the “Self-Grasping Hand” [190–192], which represents a passive hand with a grasping mechanism. Another option is the “Wilmer Elbow Control,' a harness-free, elbow-controlled body-powered prosthesis that uses the elbow's flexion and extension movements as control inputs instead of a traditional harness [193]. Finally, the Breathing-Powered UL prosthesis proposed by Nagaraja et al. [194,195] may overcome some of the limitations of current BP technology in cabled systems, including limited operational space and user discomfort from the harness to which the cables are affixed.

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Nagaraja, V.H.; Moulic, S.G.; D’Souza, J. V.; Limesh, M.; Walters, P.; Bergmann, J.H.M. A Novel Respiratory Control and Actuation System for Upper-Limb Prosthesis Users: Clinical Evaluation Study. IEEE Access 2022, 10, 128764–128778, doi:10.1109/ACCESS.2022.3226697.
Nagaraja, V.H.; da Ponte Lopes, J.; Bergmann, J.H.M. Reimagining Prosthetic Control: A Novel Body-Powered Prosthetic System for Simultaneous Control and Actuation. Prosthesis 2022, 4, 394–413.

(lines 423-425): "These findings highlight the urgent need for device-specific improvements to lower abandonment rates and increase user satisfaction.". From the earliest documented instance of a body-powered prosthesis, known as the ‘Ballif arm’, which can be traced back to the year 1818 (Borchardt et al., 1919; Meier, 2004; Muilenburg & LeBlanc, 1989), the design priorities and requirements of individuals utilizing body-powered prostheses have remained largely consistent over several decades (LeBlanc, 1985; Nagaraja et al., 2016), and insufficient attention has been directed towards expanding the range of design alternatives accessible to this population. The facilitation of control and the complete abolition of the harness remains an aspiration for individuals utilizing body-powered devices (LeBlanc, 1985). The “Self-Grasping Hand” was conceived to fulfill the requirement for an entirely mechanical apparatus that obviates the necessity for harnessing. Nonetheless, the Self-Grasping Hand represents a passive-adjustable mechanism that fails to afford users with continuous regulation over grasping maneuvers in comparison to active upper-limb prostheses. An additional alternative is the “Wilmer Elbow Control,” which is a harness-free, elbow-controlled body-powered prosthesis, as it employs the flexion-extension motions of the elbow as a control input rather than relying on a conventional harness (Plettenburg, 1998). Recently, Nagaraja and colleagues' investigation presents an innovative body-powered framework capable of addressing specific drawbacks associated with existing cabled systems, including a limited operational space and user discomfort resulting from the harness to which the cables are affixed (Nagaraja et al., 2025). A novel breathing-powered apparatus has been introduced to grant users comprehensive control over hand movements in a three-dimensional environment. Users are able to modulate their respiratory patterns, and this controllable airflow is subsequently harnessed to energize a diminutive Tesla turbine, which can precisely regulate the movements of the prosthetic fingers. The breathing-powered device offers a groundbreaking prosthetic alternative that facilitates unrestricted body movements for the user.

We really appreciated reviewer’s suggestions. To include the correction we modified the manuscript as follows:

Body-powered prosthesis section

Although the first information and examples of BP prostheses can be dated around 1812 [68] the design priorities and requirements of users still seem to have remained consistent over the past decades, with main concerns about harness discomfort and control [69,70].

Muilenburg, A.L.; Leblanc, M.A. Body-Powered Upper-Limb Components. In Atkins, D.J., Meier, R.H. (eds) Comprehensive Management of the Upper-Limb Amputee.; Springer, New York, NY., 1989.
Leblanc, M.A.M.E. Innovation and Improvement of Body-Powered Arm Prostheses: A First Step. Clin Prosthet Orthot 1985, 9, 13–16.
Nagaraja, V.H.; Bergmann, J.H.M.; Sen, D.; Thompson, M.S. Examining the Needs of Affordable Upper Limb Prosthetic Users in India: A Questionnairebased Survey. Technol Disabil 2016, 28, 101–110.

Discussion section

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Smit, G.; Maat, B.; Plettenburg, D.; Breedveld, P. A SELF-GRASPING HAND PROSTHESIS. In Proceedings of the Proceedings of the Myoelectric Controls and Upper Limb; Prosthetics Symposium, Fredericton, NB, Canada, August 15 2017.
O’Brien, L.; Montesano, E.; Chadwell, A.; Kenney, L.; Smit, G. Real-World Testing of the Self Grasping Hand, a Novel Adjustable Passive Prosthesis: A Single Group Pilot Study. Prosthesis 2022, 4, 48–59, doi:10.3390/prosthesis4010006.
Chadwell, A.; Chinn, N.; Kenney, L.; Karthaus, Z.J.; Mos, D.; Smit, G. An Evaluation of Contralateral Hand Involvement in the Operation of the Delft Self-Grasping Hand, an Adjustable Passive Prosthesis. PLoS One 2021, 16, doi:10.1371/journal.pone.0252870.
Plettenburg, D.H. BASIC REQUIREMENTS FOR UPPER EXTREMITY PROSTHESES: THE WILMER APPROACH. In Proceedings of the Proceedings of the 20th Annual International Conference of the IEEE Engineering in Medicine and Biology Society. Vol.20. Biomedical Engineering Towards the Year 2000 and Beyond. (Cat. No.98CH36286); Hong Kong, China, 1998; Vol. 20, pp. 2276–2281.
Nagaraja, V.H.; Moulic, S.G.; D’Souza, J. V.; Limesh, M.; Walters, P.; Bergmann, J.H.M. A Novel Respiratory Control and Actuation System for Upper-Limb Prosthesis Users: Clinical Evaluation Study. IEEE Access 2022, 10, 128764–128778, doi:10.1109/ACCESS.2022.3226697.
Nagaraja, V.H.; da Ponte Lopes, J.; Bergmann, J.H.M. Reimagining Prosthetic Control: A Novel Body-Powered Prosthetic System for Simultaneous Control and Actuation. Prosthesis 2022, 4, 394–413.

(lines 425-426): "A recurring theme in the literature is the gap between users’ expectations and the actual performance of commercial devices.". The paper presents various factors contributing to abandonment but does not always critically analyze or reconcile potentially conflicting findings or the strength of evidence for each factor. For instance, it mentions that 'functionality has often become the primary focus of research, the comfort of prostheses should not be neglected', but the discussion does not fully explore how these two aspects might be balanced or prioritized based on user needs.

(lines 430-434): "Several technological priorities have emerged as critical for improving upper-limb prostheses. The prosthetic socket represents the most critical part. Improving fitting and reducing the weight of prostheses must be a priority for designers. New materials should be explored, and 3D printing technology must be investigated more thoroughly to reduce costs and enhance prosthetic personalization.". While the discussion touches on 'technological priorities' and 'social and psychological factors' for improvement, these are presented as a list rather than an integrated vision. The paper lacks a cohesive framework for how these diverse factors should be addressed in future research and clinical practice to truly reduce abandonment rates.

We modified the discussion section including also a Future Direction subsection, were we included the following lines:

The resolution of the problem of prosthetic abandonment requires a complex effort involving legislative bodies, orthotics and prosthetics specialists, rehabilitation personnel, and engineers. As seen throughout this article, while from a technological perspective the issue of abandonment is related to functional problems, comfort, or reliability, the causes of abandonment can also stem from psychological and social aspects. Social inequality can disadvantage certain groups, which, as such, may not receive the appropriate psychological support before and after amputation, thereby delaying the process of psychological acceptance and adaptation. Poor healthcare coverage may also fail to ensure the pursuit of the best prosthetic device. It is essential to develop new patient-centered care models, ensuring that the entire “prosthetic journey” meets the patient's needs, as auspicated by Cain et al. [118].

Cain, J.; Earley, E.J.; Potter, B.K.; Grover, P.; Thomas, P.; Stark, G.; White, A. Innovations in Amputee Care in the United States: Access, Ethics, and Equity. Prosthesis 2025, 7, 153, doi:10.3390/prosthesis7060153.

(lines 470-472): "Standardized protocols, combined with qualitative research into lived experiences, would yield a more nuanced understanding of success and failure.". Effective strategies addressing users’ prosthetic needs require a comprehensive clinical assessment that provides a holistic understanding of the individual’s symptoms, health, function, and environmental barriers and facilitators (Schaffalitzky et al., 2012; Walton et al., 2015). Restructuring educational curricula variables for orthotics and prosthetics students (Spaulding et al., 2019), and prosthetists interactive training in tests administration (Gaunaurd et al., 2014) are among the few initiatives that have been taken in recent years to promote and support the use of outcome measures in clinical prosthetics settings. However, the lack of standardized assessments in prosthetics and orthotics services has been reported in various developed countries (Hall et al., 2020; Morgan et al., 2022; Ostler et al., 2021). To fulfill this gap, efforts have been made to develop an online interactive platform for clinical assessment and follow-up in prosthetic service settings. Through a three-round electronic Delphi method, Dupuis and colleagues undertook three independent focus group with prosthetists, prosthesis users, and decision makers to identify all relevant elements that should be included in the clinical assessment of prosthetic services in lower-limb amputees (Dupuis et al., 2025). A total of 78 elements were identified as crucial for the evaluation of prosthetic service provision and classified into various domains, encompassing the acquisition of personal and medical data, contextual information pertaining to the environment, technical aspects (including prosthetic components, usage, comfort, and user satisfaction), as well as the physical health status of the prosthesis recipient (pain and clinical evaluation, which includes mobility assessments both with and without the prosthesis). This framework possesses the capability to enhance the quality of clinical assessments, inform therapeutic interventions, and promote the overall well-being of adults who have undergone lower limb amputation.

Effective strategies for addressing users’ prosthetic needs require a comprehensive clinical assessment that offers a holistic view of the individual’s symptoms, health, function, and environmental barriers and facilitators [207]. Recent initiatives include restructuring educational curricula for orthotics and prosthetics students [208,209]and providing prosthetists with interactive training in test administration [210]. Despite these efforts, the lack of standardized assessments in prosthetics and orthotics services persists in many developed countries [211–214]To address this gap, Dupuis et al. [215] developed an innovative solution based on an online interactive platform for clinical assessment and follow-up. Dupuis and colleagues used a three-round electronic Delphi method, involving focus groups with prosthetists, prosthesis users, and decision-makers, to identify essential elements for assessing prosthetic services in lower-limb amputees. A total of 78 elements were identified as crucial for the evaluation of prosthetic service provision and classified into various domains, encompassing the acquisition of personal and medical data, contextual information pertaining to the environment, technical aspects (including prosthetic components, usage, comfort, and user satisfaction), as well as the physical health status of the prosthesis recipient (pain and clinical evaluation, which includes mobility assessments both with and without the prosthesis).

Although the study has so far been conducted only in Canada, the potential of the framework proposed by Dupuis and colleagues should be investigated on a broader scale.

Schaffalitzky, E.; Gallagher, P.; MacLachlan, M.; Wegener, S.T. Developing Consensus on Important Factors Associated with Lower Limb Prosthetic Prescription and Use. Disabil Rehabil 2012, 34, 2085–2094, doi:10.3109/09638288.2012.671885.
Spaulding, S.E.; Yamane, A.; McDonald, C.L.; Spaulding, S.A. A Conceptual Framework for Orthotic and Prosthetic Education. Prosthet Orthot Int 2019, 43, 369–381.
Spaulding, S.E.; Kheng, S.; Kapp, S.; Harte, C. Education in Prosthetic and Orthotic Training: Looking Back 50 Years and Moving Forward. Prosthet Orthot Int 2020, 44, 416–426, doi:10.1177/0309364620968644.
Gaunaurd, I.; Spaulding, S.E.; Amtmann, D.; Salem, R.; Gailey, R.; Morgan, S.J.; Hafner, B.J. Use of and Confidence in Administering Outcome Measures among Clinical Prosthetists: Results from a National Survey and Mixed-Methods Training Program. Prosthet Orthot Int 2015, 39, 314–321, doi:10.1177/0309364614532865.
Hall, N.; Parker, D.; Williams, A. An Exploratory Qualitative Study of Health Professional Perspectives on Clinical Outcomes in UK Orthotic Practice. J Foot Ankle Res 2020, 13, doi:10.1186/s13047-020-00416-w.
Morgan, S.J.; Rowe, K.; Fitting, C.C.; Gaunaurd, I.A.; Kristal, A.; Balkman, G.S.; Salem, R.; Bamer, A.M.; Hafner, B.J. Use of Standardized Outcome Measures for People With Lower Limb Amputation: A Survey of Prosthetic Practitioners in the United States. Arch Phys Med Rehabil 2022, 103, 1786–1797, doi:10.1016/j.apmr.2022.03.009.
Ostler, C.; Dickinson, A.; Metcalf, C.; Donovan-Hall, M. Exploring the Patient Experience and Perspectives of Taking Part in Outcome Measurement during Lower Limb Prosthetic Rehabilitation: A Qualitative Study. Disabil Rehabil 2024, 46, 5640–5650, doi:10.1080/09638288.2024.2307384.
Robinson, C.; Fatone, S. You’ve Heard about Outcome Measures, so How Do You Use Them? Integrating Clinically Relevant Outcome Measures in Orthotic Management of Stroke. In Proceedings of the Prosthetics and Orthotics International; SAGE Publications Ltd, February 1 2013; Vol. 37, pp. 30–42.
Dupuis, F.; Pichette, M.; Swaine, B.; Auger, C.; Zidarov, D. Consensus-Based Recommendations for Comprehensive Clinical Assessment in Prosthetic Care: A Delphi Study. Prosthesis 2025, 7, doi:10.3390/prosthesis7040092

Reference #47: "47. Weir, R.F.F. DESIGN OF ARTIFICIAL ARMS AND HANDS FOR PROSTHETIC APPLICATIONS; 2004.". Reference seems to be incomplete.

We checked and corrected the entire bibliography.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a comprehensive review of the major technological, psychological, and social determinants contributing to upper-limb prosthesis abandonment over a wide period, spanning more than three decades. The topic is meaningful, timely, and relevant to clinical practice, prosthetic design, rehabilitation engineering, and policy-related discussions on prosthesis accessibility. While the review is well-written and thorough, some revisions are necessary to enhance the manuscript's quality. Comments are provided below.

Because not every reader is an expert in this field, they may not have a clear understanding of the different types of upper-limb prostheses. I think the authors should add a figure to present the types of upper-limb prostheses mentioned in this manuscript.
Please summarize future research directions for technology developers and rehabilitation clinicians based on the review study. The authors can add a paragraph at the end of the discussions to clearly explain the issues the users care about and to decrease the rate of prosthesis abandonment.

Author Response

Please see the attachment.

We thank the reviewer for the time dedicated to reviewing our article and for the professionalism shown. We greatly appreciated the comments made and the advice received. We believe that the reviewer's work has allowed us to significantly improve the quality of the proposed article. Below, we report the responses and the modifications made.

Because not every reader is an expert in this field, they may not have a clear understanding of the different types of upper-limb prostheses. I think the authors should add a figure to present the types of upper-limb prostheses mentioned in this manuscript.

We have created an image illustrating the main prostheses and the parts that constitute them. We thank the reviewer, because we believe that, as suggested, this has made the article more accessible to readers.

Here the picture

Please summarize future research directions for technology developers and rehabilitation clinicians based on the review study. The authors can add a paragraph at the end of the discussions to clearly explain the issues the users care about and to decrease the rate of prosthesis abandonment.

We have proceeded to modify the discussion section and include a subsection titled 'Future Directions”.

Below are some extracts reported respectively at lines 530-541 and 584-603

4.1.1 Future Directions

Effective strategies for addressing users’ prosthetic needs require a comprehensive clinical assessment that offers a holistic view of the individual’s symptoms, health, function, and environmental barriers and facilitators [207]. Recent initiatives include restructuring educational curricula for orthotics and prosthetics students [208,209]and providing prosthetists with interactive training in test administration [210]. Despite these efforts, the lack of standardized assessments in prosthetics and orthotics services persists in many developed countries [211–214]To address this gap, Dupuis et al. [215]developed an innovative solution based on an online interactive platform for clinical assessment and follow-up. Dupuis and colleagues used a three-round electronic Delphi method, involving focus groups with prosthetists, prosthesis users, and decision-makers, to identify essential elements for assessing prosthetic services in lower-limb amputees. A total of 78 elements were identified as crucial for the evaluation of prosthetic service provision and classified into various domains, encompassing the acquisition of personal and medical data, contextual information pertaining to the environment, technical aspects (including prosthetic components, usage, comfort, and user satisfaction), as well as the physical health status of the prosthesis recipient (pain and clinical evaluation, which includes mobility assessments both with and without the prosthesis).

Although the study has so far been conducted only in Canada, the potential of the framework proposed by Dupuis and colleagues should be investigated on a broader scale

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, I appreciate your efforts for improving and get to this revised version of the manuscript "The technological and social aspects of upper limb prostheses abandonment: A Review". While some comments/suggestions made to the first verison were welcomed, others were not and I do understand why they weren't as you might think these could somehow make your research distort from your first thoughts.

However, there are three issues I believe remain unresolved, albeit not likely to jeopardize the publication of your work: search methodology, factors focused, and generalizability. On the first topic, although the review explicitly states that its article selection was conducted through a non-systematic search across Google Scholar, PubMed, and Scopus, thus allowing for broad coverage, not applying formal inclusion/exclusion criteria or systematic screening inherently introduces potential biases and may lead to the omission of relevant studies that a more rigorous, systematic review process would have captured. The absence of predefined criteria for study inclusion and exclusion could affect the reproducibility and thoroughness of the literature selection.

On the specific factor identified and discussed as leading to prosthetic abandonment, both technical and psychological aspects were analyzed, and motivation, cognition, and behavior were emphasized as future guiding principles on the upper-limb prosthetic design and clinical strategies. However, by focusing on these specific aspects, other potentially significant factors influencing abandonment might receive less attention or be overlooked. The narrative nature of the review, while allowing for a broad overview, may not provide the same depth of analysis for each factor compared to a more focused, systematic investigation.

Last, it was highlighted that the framework proposed by Dupuis and colleagues, which focuses on comprehensive clinical assessment, has so far only been conducted in Canada. While suggesting its potential for broader application, the review itself does not provide an extensive analysis of how its findings, particularly those related to psychosocial and contextual factors, might translate across different healthcare systems, cultures, and socioeconomic contexts. This limits the immediate generalizability of some of the implied recommendations derived from the review's synthesis.

While your review provides a valuable overview of the complex interplay between technological, psychological, and social factors in upper limb prostheses abandonment, its non-systematic search methodology and potential limitations in generalizability for certain recommendations are points for consideration in future researches on this theme.

Regards

Author Response

Regards

Response

We sincerely thank the reviewer for their thoroughness and professionalism throughout the review process. The comments and suggestions provided have been extremely helpful in improving the quality, clarity, and overall coherence of the manuscript. In response to the reviewer’s feedback, we have made the following revisions to the text, explicitly addressing the limitations of our approach.

Lines 96-102 were modified as follows:

This narrative review includes articles found through a non-systematic search on Google Scholar, PubMed, and Scopus. An initial literature search was conducted using the research query “("Prostheses" or "Prosthetics") and "upper limb" and ("rejection" or "abandonment")”, which was then expanded without following a systematic approach. The selection was based on relevance to the review's topics (technological and psychosocial) without applying formal inclusion/exclusion criteria or systematic screening.

The following paragraph was added to the section “Study Limitations and Future Directions”

Although this work focused on reviewing the most relevant literature on prosthetic abandonment from technological and psychological perspectives, it is important to highlight some limitations of the study. The research was conducted using the main search platforms (Google Scholar, PubMed, Scopus) without a systematic approach in selecting the inclusion and exclusion criteria. This may have introduced a bias in the definition of the main factors influencing prosthesis abandonment, favoring certain aspects over others. Nonetheless, we believe this work represents a significant step in identifying key psychological and technological factors related to prosthetic abandonment. Many of these aspects will require further analysis to establish guidelines that connect them to cultural and socio-economic contexts. In this work, the technological and psychological aspects of prosthetic abandonment have been examined from a global perspective, without emphasizing the national context and, therefore, socio-cultural factors. We believe that future studies need to analyze in more detail how the factors identified in this work change and evolve from one country to another, depending on different national healthcare systems.

Author Response File: Author Response.pdf