Koalaa designs lightweight and usable prosthetics for people with limb difference. Their goal is to make prosthetics that are affordable, comfortable and readily available. Koalaa’s focus, from its start, has been to find out what people with limb difference really want and need by actually talking to and working with them. ABILITY’s George Kaplan met with Koalaa’s founder, Nate Macabuag, and consultant, Natalie Grazian, to talk about Koalaa’s history, innovations and what’s coming next. Grazian, an occupational therapist with below the arm limb difference, shares her experience of doing yoga and consulting with Koalaa on the prosthesis she uses.
George Kaplan: What inspired the need for Koalaa [Soft Prosthetics]?
Nate Macabuag: Oh, gosh! It generally was a complete accident. It was not the plan to start a company. I wanted an easy life, George. (laughter)
I was in uni (university) doing a mechanical engineering degree. And as per your degree, you get into a team of students, and you work on a project for a whole year. We basically got rejected for the projects we applied for as a team of students. So, we had a choice. We could either pick the dregs of the projects no one else wanted to pick, or we could compose our own one. I went, “This is a great opportunity to basically get the uni to pay us,”–because you get a thousand pounds funding– “to do whatever the hell we want for a year. Let’s just build an ironman suit and trick them into doing that, and that’ll be great.”
So, we go into it on a whim. But my supervisor had the foresight to introduce me to another student, Alex Lewis, who’s an amputee and he’s also a designer. So, we could talk on that level about robotic prosthetics. He used prosthetics. He lost both his arms and both his legs. Surprisingly, he wasn’t the bionic man. He wasn’t walking in on bionic legs. He didn’t have these singing and dancing hands. He was in a wheelchair. He had a very simple look and he had nothing on his left-hand side.
What he was asking for was so different to what I thought, as an outsider, than what I think the industry seemed to think was needed from prosthetics. He wasn’t asking for higher tech or more exotic materials or stuff like that. He was just like, “I just wear these to make me really comfy. Make them really easy to use, don’t have to train for months to just do simple things. And just make them easy to get, so I don’t have to fundraise or beg my clinician to give me the ones I want.”
We thought that sounded really simple. That made sense. We started doing that, looking at them like other things that we wear that are functional, like clothes and shoes. We were like “We can use these things to make a prosthetic.” We didn’t know how to make proper ones. We got to the end of the project and had this terrible, really, really bad prototype, and Alex went, “I love this. This is really cool.” We were like, man, four students can do something that’s even a little bit useful. We fell in love with that, trying to make stuff that people actually can use in life and actually can do stuff with, fell in love with Alex, fell in love with the community, wanted to carry on doing it. We need more resources; we need a plan. That’s how our company was formed. We fell into it. And thus, Koalaa was born.
George: That’s great! So, Natalie, you discovered Koalaa. How did you find out about them? How did you end up joining and helping work on one of their newer prostheses?
Natalie Grazian: So, I found out about Koala on Instagram. At the time, I had been pursuing getting a traditional workout prosthesis for about a year, and that was going to be made from an old passive prosthesis with the hand cut off so that I had the socket remaining. Oh, I was born with a limb difference, by the way. It’s the right-hand, below elbow limb difference. So this was taking a long time. It was going to be more expensive than I had initially thought. Activity specific prostheses are not covered by insurance. I wanted one because I’ve always loved movement. I’ve always loved working out, and I found my own ways to do them. But I knew that I was probably doing something that wasn’t great for my body in the process. When I wasn’t able to bear weight evenly on both sides of my shoulder, I would find ways to do these moves but getting a little wonky on the right side. And we can go down that tangent. Anyways, I was on Instagram. I was frustrated with the process of going through a clinic, and I saw this company that just seemed to be such a fresh slate almost.
It was new. It was really centered on the users and was looking at prostheses in a new way that I hadn’t seen them being looked at before, without the baggage of the traditional model. For example, they’re made of really lightweight material, not plastic, not silicone, but something that’s really lightweight and breathable. That was kind of revolutionary, that it could be comfortable. Yeah, there it is. I have mine right here. It’s super-lightweight.
Natalie: You don’t have to be fit for one. You do some measurements at home, almost like you’re getting some custom tennis shoes. You send them your measurements and they send back a small, medium, or large and you can make some adjustments from there and tighten it up with Velcro. The results seemed just as good as what I was going to get through this long and expensive process. And I could return it if I didn’t like it. I felt like a human, like any customer out there. I loved the process. I could go on.
George: I understood that. I’m an amputee myself, so I understand how suffocating traditional prostheses can be. This sounds very interesting, an interesting take on a prosthesis.
Natalie: And something else, it comes with the social support that is missing in a prosthetic clinic. They have limb buddies, somebody with a limb difference or amputation. They check in on you. I don’t know if you’ve been able to connect with—of course you are, you work at ABILITY Magazine! I think I came to the community a little bit late in my life, so it was really—I was just kind of and still am starved for interactions with other people who look like me and have that same experience and can really truly get it. That’s such a breath of fresh air.
Nate: It’s interesting what you said, like a fresh take of prosthetics. I should be clear, it wasn’t my idea. Actually, it’s just an exemplary example of that, but it all came from talking to Alex. I went to Imperial College, which fancies itself—don’t tell them I’d say this—but it would fancy itself one of the world’s preeminent institutions for prosthetics, you know, breaking ground, leading the forefront. If I had gone and asked, which I did, my supervisors, leaders in their field, “How do I make a better prosthetic? What do people need?” They would have said, “You need better sensors to control the limbs. You need more sophisticated composite materials to make the hand lighter,” and all these kinds of things. I went to ask Alex, who wore prosthetics, and he said, “I don’t want a hand. I don’t need a hand. I’m a designer. I just want to draw, to hold a pen.” And he was saying things that were so different, dimensionally different from what I was hearing from TV, if I Googled it, from asking those in the field. It was kind of like, when we spoke to people, especially like prosthetists, who’d been doing it the same way for a long time and were heavily trained and highly skilled, they’d say, “What you’re suggesting doesn’t make sense, it’s not right.”
I was always like, “I believe you, because you’ve been doing this longer than I’ve been alive.” But I keep hearing, “We’ve just got to keep trying,” and we kept trying, and it just kept not working. And so it’s funny that if you just listen to what people are asking for, you get these interesting things that shouldn’t be novel. More companies should just do that. That shouldn’t be a unique take on thing, should it? But it’s fun to uncover these things and this one’s no exception.
George: Yeah, it’s like, people expect us to want something that’s one-to-one, something for us to fit in when we just want something that’s practical, that works.
Nate: That’s the thing. It depends where you get people in their journey. I’m was on a call earlier with people who are designing a project in Uganda. There the function that people want is, they just want to be able to go outside without being literally verbally and sometimes physically attacked by the community. They just want cosmetics. It still has function, ultimately it took them a long time to get out of the mindset of the traditional “replace the limb” into the mindset of “it’s a tool to do stuff.” That’s how we connected. We had a tool that was for surfing, and then I started hearing that someone seemed to have been using it for yoga. I went, “That’s mad!” I didn’t even know who it was. “That’s cool!” And then they came across you, Natalie, doing all these cool things and we had the opportunity to go to Seattle and meet. We just chatted all day and decided there was something here we could do together. Because you’re so into it. It makes our job quite simple. We just need to listen to what you say or what you like, and I know we’ll get something really cool, and I think we have.
Natalie: Yeah, yeah. Like what you said, just wanting something useful. And I agree, it’s totally contextual. That’s so interesting because in Uganda, that’s a time and place where there needs are different than my needs. Culture demands fitting in. That’s so interesting. And I saw that you actually did help create some prosthetics to help with that. Where I was, in this time and place where I was living, I didn’t want something that approximated a hand. Something like, we’re not there yet to create something that looks like a hand and actually functions like a hand. So, when it comes to—and I don’t think that everyone understands that. I do have a myoelectronic hand that I use for a lot of stuff. But even friends who I knew very well assumed that I use that for yoga, which is just laughable. No, it does really specific things, and it has specific grips. That’s not going to do anything for yoga.
But then we have this, which is so elegant because I looks like—I mean, it looks like a hoof, but you can rock back into downward dog with it, and you can do push-ups and there’s rocking back from side to side. There’s this compression on the bottom so you can do things like burpees and more high-impact things and mountain climbers. It’s very human-centered, with all the engineering know-how behind it. I was super-flattered and honored to be able to be part of this. I never expected to be part of creating something that could potentially go to people all over the world. I got to be part of it alongside other folks with limb differences here in the U.S. and the UK and I think even in Scotland. We all have slightly different anatomy, different limb differences. There’s such a broad range.
With all of our input, Koalaa was able to create something that could work for as many people as possible. That’s such a beautiful thing. We were brought together by the shared interest in yoga and, of course, limb difference. I’ve really enjoyed it.
George: That’s great! As you were suggesting, having a limb difference or being an amputee, either of those, is not a monolith. There’s not one way to be one.
George: And there are so many different ways. I know I’m different from a lot of other amputees. I know you must have a lot of different experiences than a lot of others with limb difference. Could I ask, what’s the model you use and you have worked with on?
Natalie: This guy? (gesturing to her prosthesis) This is the Nicole Pro.
George: How does the Nicole address the problems that amputees face when doing yoga? How would you say that?
Natalie: I would say that we need to have a wide base of support on this side, something that approximates a hand on the other side, so a wide-curved base really helps. It also needed to have this oval shape because some other products on the market, to be specific, have more of a circular, all-the-way-around-similar shape, which could present a problem if you’re going down on your elbows. It would push up—it’s hard to explain, but it would push up the distal part of the hand and put pressure on the elbow. Essentially, what we need is to be able to bear weight evenly on both sides and to keep the shoulder in alignment with the other shoulder. I think that kind of gets to your question a little bit more. And I think about that a lot because we’re already at a much higher risk of getting these muscular-skeletal injuries and overuse syndrome over time. Something like yoga is supposed to help strengthen our joints, keep us as symmetrical as possible, stay flexible and strong, which helps us in everyday activities. But if the yoga, itself, is hurting us in a way because we’re twisting ourselves out of alignment, that’s a bigger problem. So, creating something that is keeping us in alignment as we’re trying to keep our joints healthy. That’s where it solves some problems.
Nate: I don’t know if it’s helpful, George. Have you seen the full sleeve at all?
George: I haven’t, no.
Nate: It’s basically in a nutshell—we have different—they’re all soft prosthetics. They’re all built like shoes. They’ve got the structural rigidity to support weight and distribute loads, but they’re flexible, ultimately. So, you can tighten them on like an item of clothing, which just seems to make sense because you wear them. And we have ones with different areas of limb difference, but this one that’s really popular is the ALX. So, the whole thing is the ALX. And it’s essentially modular. So, what Natalie talked about is the fact that this tool on the end is called the Nicole Pro. You can have lots of different ones that clip in and clip out. And that’s the fun part because all these ideas come from people. But you were very humble about that point about the ovalness. That wasn’t obvious. When we were talking about it and you sketched it out, actually, when it’s symmetrical, it’d be better if it’s like this so I could get down. It also makes it look nice. We never would have come up with that. But the fact that you used it and you said, “That would make sense.” That was where the beauty came from.
So, you get these designs; they can clip on. We had different covers. This is what locks you into the sleeve, and this is the blank sleeve itself. It opens up and your arm goes in there. These covers, our original ones, weren’t strong enough to keep you in when you were weight-bearing. Your arm would slip out. We developed these extra sports bands, which I know you’ve got a bunch of.
Natalie: I do. I’m not going anywhere. (laughs)
Nate: No, they’re cool. So I like that. It’s like a skelaton, right? That’s how I would have it. I think it’s quite cool. So we had to develop those. And the other thing we had to do was we have internal foam, which supports your limbs, like a foam mattress. Which actually, funny enough, you know a lot about as well. And when we came to your house, you’ve been experimenting with different foams.
Natalie: (laughs) Yeah. Denser foams because I was finding that, even when I should be even, I was sinking into the foam. And so, you can really go down a foam rabbit hole. And I actually worked at a mattress company for a while. There’re so many foams. There’s density and pressure relieving. My husband and I actually created a little cylindrical support of really dense foam made of the stuff that’s like wall insulation, and that worked really well. And then for some more pressure relieving, we popped on a little thing that Koalaa sent, a little coin of foam on top of that so that I could have the pressure relief, but also the support and density. But that was before they created the new one.
Nate: And that was our starting point, from what you had. How could we recreate that? I went through thousands of foam. We had to tweak the internal density of the foam. Essentially it’s like a package that’s modular. You can use each individually. You can tweak the density there and do all these kinds of things. I think it’s so—the process I thought was quite fun. As an engineer, I quite enjoyed it, working with you to try this, tweak this. And you end up on something that’s a little bit unique and has a personality because the people behind it are not in a lab somewhere. It’s actually got a heart.
Natalie: I like that! (laughter) It does have a heart!
Nate: I like it!
George Kaplan: That’s pretty cool. Has Koalaa always been foam-based? Were there other attempts you worked through, like suction, other kinds of ways to get into Koalaa?
Nate: All of the above. Two things. I’m a very simple person. I’m not super-smart, so I have to try things over and over to iterate something. We also realized really early on that I don’t wear prosthetics, so my opinion just doesn’t really matter. You just have to make prototypes and give them to someone to use and just listen humbly to the feedback. And most of the time, the longest time, the feedback was, “This is crap. It just doesn’t work.” And that’s fine, that’s fun because you get to iterate it. We went through all kinds of things.
At first, we didn’t make arms longer than someone’s arm. We always ended the sleeve where someone’s arms ended because we thought that gave you better control over whatever you were doing. Then when we were faced with yoga, you have to be balanced. How will we do that? We had to extend the sleeve. And if we extend it, what will we fill it with? We tried rigid stuff that’s uncomfortable. We tried soft stuff, but then it’s too squishy. We had to try all kinds of things. We’ve never properly done suction, yet, because it’s fabric. We have tried with those kind of suction liners, the ones you roll on. We’ve tried with those. They have the pin locks in the end. But because this is kind of fabric-y itself, it kind of in a way acts as its own liner. So, we’re always trying stuff. We’re always iterating. If you check back in a year, it will be different. (laughs) It’ll be a little bit better.
George: So, you’re always trying to work on it. What are the plans for the future of Koalaa?
Nate: Basically, what we’ve realized is that around the world, there are about 21 million people with upper limb differences of some sort. And 93% of those people get nothing at all. They don’t get something and then decide it sucks, they just get nothing. So, there’s a massive challenge to just make as many of these available to as many people as possible. Not to prescribe them, not to make them necessary, but to make them available so if they want to engage in an activity, they can. It’s about scale and reaching as many people as possible. This is why generally it’s really helpful to ask for all of us together. It’s awareness of letting people know we exist because for a very long time prosthetics have been a stigmatized medical device. I think we think it’d be nicer if it moved into something that’s more like—well, actually like this. It’s just part of your gym equipment. It’s just a thing that you wear to do a certain thing, to move into a sort of health fitness kind of space. So, that’s what we’re going to do. We’re going to be doing loads more sports, loads more activities, and in loads more parts of the world. And we want to work with anyone and everyone, including you, George, to just do that because there’s a lot of opportunity to make neat little things out there.
George: I’m a leg amputee, and if you ever extend to that, let me know.
Nate: Maybe! I can neither confirm nor deny it. When we first started ALX, it was designed just for holding a pen, very lightweight stuff. It was designed like a slipper, more like your traditional dress shoe, for example. But as the community grew and there were more and more people using it, we suddenly had people saying, “Oh, yeah, I’m just weight-bearing on it, it’s fine.” So you realize it can actually do a lot of stuff. I see no reason why we couldn’t do all areas of limb difference, eventually. I heard you, George. I will be taking you up on that. If you want to try some, I’ll work with you.
George: That would be awesome! Yeah, I’m super-down! Anything you want to add, Natalie?
Natalie: I could probably talk more about the benefits of yoga for people with limb differences.
George: That’d be great!
Natalie: When we don’t use one side of our body a lot, the bones will get more fragile. If you don’t bear weight or put a load on something, it will deteriorate over time. Yoga is going to strengthen bones and, of course, strengthen muscles. Twisting ourselves out of shape, when it comes to typing or pushing a cart or putting our hair up or tying shoes, all of those things. We’re reaching forward to get uneven in some way. The muscles in the front will shorten, those in the back will lengthen. Essentially, we’re setting ourselves up for a secondary disability. It’s super-common. We need more research on it. We know that we’re twice as likely, upper-limb amputees or people with limb differences will have–– are twice as likely to have musculoskeletal complaints. It will help in a lot of those ways.
There’s also the mental health aspect. I have to say that it’s helped me enormously to put everything aside for an hour and just be out of your head and in your body. I think that’s something everyone should have the opportunity to try if they want to. And I mean, flexibility as well, yoga helps with that. And just in order to do the thing, to operate in a two-handed world–If I’m going to tie my shoes, I have to be flexible. If I lose that, then everyday activities become harder. Strengthening core. When you think about, let’s say you’re on the bus and the bus starts moving before you’re sitting down and you want to reach out and grab something but maybe you’re holding onto something with this hand, essentially you need to use balance a lot more because you don’t have another hand to stabilize with or to grasp hold of something with.
Pushing up from the ground, those kinds of things. It all comes back to your core. Yoga is almost purpose-built to help with these things that limb-different people could benefit from. But unfortunately, it’s inaccessible, even though it’s so accessible as a sport. You’re really encouraged to adapt. It’s a really kind community that welcomes all kinds of bodies and all kinds of differences. But the fact remains that it’s much harder if you don’t have two hands to evenly balance on. I guess Koalaa is bridging that gap for a lot of people.
Nate: I want to follow up on that. You’re kind of in a unique position. Because your studying as an OT, you’ve got a unique perspective.
Natalie: Thank you.
Nate: Which is quite exciting. In terms of as a tool, because OT is a fantastic place to select the right tools to get people to do whatever they want to do, how do you think something like the yoga tools, like the ALX, fit into that system? How should OTs engage with that?
Natalie: OTs will look at the whole person, their body, their mind, their family, their culture, everything about the person, their value and priorities, and the environment they’re in, the things they want to do. We feel that if there’s something that’s preventing them from doing what they want to do, what in the person or in their environment or the thing that they want to do can be changed? If the thing someone wants to do is working out, then there you go. You change something in their environment. You give them a tool that helps them do it. It’s such a neat, simple solution.
And working out and doing yoga, those could also be interventions that an occupational therapist uses for someone because maybe if the fact that they’re not flexibly or they don’t have the core strength or they need help with emotional regulation, those are all things yoga helps with, so the OT can help them integrate that into their life as the intervention itself. And to do that in the case of people with limb differences, it helps to have a tool that lets you will help you do the thing. (laughs) Does that make sense?
Nate: Yeah, I think that’s an interesting place that we haven’t really touched on before because we’ve always done stuff directly with wearers and with users. I think there’s a lot of opportunity to do stuff with clinicians and with the OTs and the physios. I think I just want to do more of that. I think it could be a cool way to bridge that gap we’d like to.
Natalie: I think also we should talk! (laughs)
Nate: Oh, we should talk? Fantastic!
Natalie: I have a cool community of OTs and prosthetists here at University of Washington — I’ve talked about you and they’re interested.
Nate: I recently decided, as in this morning, that Chelsea and I will come over to the West Coast again this year.
Nate: So I’m on my way!
Natalie: Incredible! All right! Let me know when and where!
George: Awesome! Making things happen! All right! If there isn’t any more, it was nice talking to both of you. I think this is a life-changing device.
Natalie: I have to say, it’s been such a fun conversation that it’s easy to forget that we’re doing this for ABILITY Magazine! Exciting! Thank you, George!