An international multidisciplinary group of healthcare professionals and researchers participated in a consensus conference on the management of cerebral palsy, convened by the International Society for Prosthetics and Orthotics. Participants reviewed the evidence and considered contemporary thinking on a range of treatment options including physical and occupational therapy, and medical, surgical and orthotic interventions. The quality of many of the reviewed papers was compromised by inadequate reporting and lack of transparency, in particular regarding the types of patients and the design of the interventions being evaluated. Substantial evidence suggests that ankle-foot orthoses (AFOs) that control the foot and ankle in stance and swing phases can improve gait efficiency in ambulant children (GMFCS levels I-III). By contrast, little high quality evidence exists to support the use of orthoses for the hip, spine or upper limb. Where the evidence for orthosis use was not compelling consensus was reached on recommendations for orthotic intervention. Subsequent group discussions identified recommendations for future research. The evidence to support using orthoses is generally limited by the brevity of follow-up periods in research studies; hence the extent to which orthoses may prevent deformities developing over time remains unclear. The full report of the conference can be accessed free of charge at www.ispoint.org.

A National Health Service Quality Improvement Scotland (NHS QIS) scoping exercise in 2007 identified the use of ankle-foot orthoses (AFOs) following stroke as a clinical improvement priority, leading to the development of a best practice statement (BPS) on AFO use after stroke. This paper outlines the development process of the BPS which is available from NHS QIS. The authors were involved as part of a working group that included practitioners from the fields of orthotics, physiotherapy, stroke nursing and bioengineering, staff of NHS QIS and a patient representative. In consultation with an NHS QIS health services researcher, the authors undertook a systematic literature review to evidence where possible the recommendations made in the BPS. Where evidence was unavailable, consensus was reached by the expert working group. As the BPS was designed for the non-specialist and non-orthotic practitioner the authors also developed educational resources which were included within the BPS to aid the understanding of the principles underpinning orthotic design and prescription. The BPS has been widely distributed throughout the health service in Scotland and is available electronically at no cost via the NHS QIS website. As part of an ongoing evaluation of the impact of the BPS on the quality of orthotic provision, NHS QIS has invited feedback regarding successes and challenges to implementation.

Objective: Wrist-hand orthoses (WHOs) are prescribed for a range of musculoskeletal/neurological conditions to optimise wrist/hand position at rest and enhance performance by controlling its range of motion (ROM), improving alignment, reducing pain, and optimising grip strength. The objective of this research was to study the efficacy and functionality of ten commercially available WHOs on wrist ROM and grip strength.Design: Randomised comparative functional study of the wrist/hand with and without WHOs.Participants: Ten right-handed female participants presenting with no underlying condition nor pain affecting the wrist/hand which could influence motion or grip strength. Each participant randomly tested ten WHOs; one per week, for 10 weeks.Main outcome measures: The primary outcome was to ascertain the impact of WHOs on wrist resting position and flexion, extension, radial, and ulnar deviation. A secondary outcome was the impact of the WHOs on maximum grip strength and associated wrist position when this was attained.Results: From the 2,400 tests performed it was clear that no WHO performed effectively or consistently across participants. The optimally performing WHO for flexion control was #3 restricting 86.7%, #4 restricting 76.7% of extension, #9 restricting 83.5% of radial deviation, and #4 maximally restricting ulnar deviation. A grip strength reduction was observed with all WHOs, and ranged from 1.7% (#6) to 34.2% (#4).Conclusion: WHOs did not limit movement sufficiently to successfully manage any condition requiring motion restriction associated with pain relief. The array of motion control recorded might be a contributing factor for the current conflicting evidence of efficacy for WHOs. Any detrimental impact on grip strength will influence the types of activities undertaken by the wearer. The design aspects impacting wrist motion and grip strength are multifactorial, including: WHO geometry; the presence of a volar bar; material of construction; strap design; and quality of fit. This study raises questions regarding the efficacy of current designs of prefabricated WHOs which have remained unchanged for several decades but continue to be used globally without a robust evidence-base to inform clinical practise and the prescription of these devices. These findings justify the need to re-design WHOs with the goal of meeting users' needs.

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ObjectiveOptimal wrist/hand function facilitates the performance of activities of daily living (ADL), which are associated with independent living and increased quality of life. Rheumatological, musculoskeletal, and neurological conditions or injuries can negatively impact hand/wrist function, with wrist-hand orthoses (WHOs) being prescribed to control motion and improve wrist alignment whilst enhancing hand/wrist functionality. The objective of this follow-up study was to quantify and assess the efficacy and functionality of 10 commercially available WHOs during five ADLs.DesignRandomised comparative functional study of the wrist/hand with and without WHOs.ParticipantsTen right-handed healthy female participants with no underlying condition or pain affecting the wrist/hand that could influence their ability to undertake ADLs.Main outcome measuresThe primary outcome was ascertaining the impact of each WHO during five ADLs. Movement was quantified in sagittal, coronal, and transverse planes with and without WHO use. The resting position, maximum mean flexion, extension, pronation, supination, and radial and ulnar deviation attained were quantified, with the time spent in wrist flexion, wrist flexion and ulnar deviation, wrist extension >15°, and radial deviation recorded. Finally, the time to complete each task was compared between conditions.ResultsAt rest, four WHOs maintained the desired sagittal plane wrist position, with only one preventing radial deviation with variation observed in the transverse plane. All WHOs reduced mean maximum flexion, with only 10 out of 50 tests (20%) showing a successful restriction of flexion (p < 0.05) and 14 out of 50 (28%) showing a reduction of the time spent in flexion (p < 0.05). In 42 out of 50 tests (84%), the wrist was extended >15° for a significant amount of time (p < 0.05), with the wrist in radial deviation in 98% for a significant amount of time (p < 0.001). The wrist was flexed and in ulnar deviation for a significant time for 6 out of 50 tests (12%, p < 0.05), whilst all WHOs impacted transverse movement, with 27% reducing it significantly, and all tasks took a longer time to complete, with 46% taking a significantly longer time (p < 0.05).ConclusionThe WHOs did not control movement sufficiently to successfully manage any condition requiring motion restriction associated with pain relief and were found to increase the time to complete the ADLs. Multifactorial design aspects influenced functionality, and there is a clear need for WHO redesign.