Development of a Best Practice Statement on the Use of Ankle-Foot Orthoses Following Stroke in Scotland

Abstract

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.

Use of the ICF to investigate impairment, activity limitation and participation restriction in people using ankle-foot orthoses to manage mobility disabilities

“…Psychological outcomes in orthotics are rarely assessed. However an earlier descriptive study has shown that 58% of participants reported that AFO use was linked to reduced distress and 64% reported that the AFO made them feel better about themselves [2].…”

“…While acknowledging that some participants in this sample may also have had cognitive challenges, due to their underlying pathology, and may not have been able to recall recommendations for use, no differences in use were seen between participants whose condition was caused by brain damage and those whose condition was not. When compared with data reported in the Best Practice Statement of 2008 [2], which found that approximately 50% of respondents claimed they did not get any information about the AFO and 40% felt they did not receive clear information, this figure of 27%…”

“…They are used to modify the structure and function of the neuromuscular and skeletal systems [1] and are used to manage mobility disabilities caused by a wide range of conditions such as stroke, cerebral palsy, spina bifida, poliomyelitis and peripheral nerve injury [2][3][4][5][6]. AFOs have been shown to improve timed walking speed, step length and clearance of the toe in the swing phase of gait.…”

“…AFOs have been shown to improve timed walking speed, step length and clearance of the toe in the swing phase of gait. [2,3,5,[7][8][9][10][11][12][13][14]. Whilst these outcome measures are valuable in providing evidence for orthotic intervention, they focus on specific aspects of physical activity that can be measured in a gait laboratory.…”

You’ve heard about outcome measures, so how do you use them? Integrating clinically relevant outcome measures in orthotic management of stroke

“…5 Orthotic management is intended to address lower limb impairments in the post-stroke population, with ankle foot orthoses (AFO) being the most commonly provided orthosis by certified orthotists practicing in the USA. 6 Recent literature reviews on the orthotic management of stroke indicate that AFOs can: (1) improve walking in the poststroke population, especially when plantar flexion motion is restricted by the orthosis 7 ; (2) improve gait kinematics during both stance and swing phases 7 ; (3) directly affect function of the foot and ankle complex and indirectly affect the knee, hip and trunk [7][8][9] ; and (4) may make a positive contribution to quality of life. 8,9 These reviews indicate that a primary goal of orthotic management of stroke is the improvement of mobility.…”