The effects of biomechanically optimised ankle-foot orthoses-footwear combinations on the gait of children with cerebral palsy

The purpose of this study was to investigate the effects of the biomechanical optimisation of ankle-foot orthoses and footwear combinations (AFO-FCs) on the gait and energy expenditure of children with cerebral palsy (CP). The child's perception and compliance of wearing AFO-FCs were also investigated. Additional aims were to examine common clinical practice regarding AFO-FC tuning in the UK and to study the validity of using the static shank to vertical angle (SVA) to measure the dynamic SVA during gait. The study included five children with CP. Outcome measurements included sagittal plane kinematics and kinetics derived using 3D motion analysis, physical examination, heart rate (HR), energy expenditure, speed, distance, energy expenditure index (EEI), static SVA and dynamic SVA and an after study questionnaire. When studying children with CP, beneficial effects of biomechanically optimised AFO-FCs on gait parameters were evident; the results identified improvements to knee, hip and pelvic kinematics, particularly in cases where the principal gait deviation was hyperextension of the knee in stance. There were also beneficial effects on energy expenditure with the study highlighting a reduction in energy expenditure, and an increase in self-selected speed and distance covered, when walking in a biomechanically optimised AFO-FC compared to a non-tuned AFO-FC. The study demonstrated validity in using the static measurement of the SVA to estimate the dynamic SVA during temporal mid-stance (TMST). The importance of cosmesis and social inclusion was also highlighted as being important for disabled children who are asked to wear adapted footwear and AFOs. However, the results of this study indicated that when there is an improvement in physical function and activities of daily living, children will choose to comply with what they perceive to be uncosmetic orthoses. It was concluded that biomechanically optimised AFO-FCs have the potential to improve the kinematics and kinetics of gait, energy expenditure, speed and distance covered for children with CP, and that tuning the AFO-FC should be mandatory

Do research papers provide enough information on design and material used in Ankle Foot Orthoses (AFO) for children with cerebral palsy (CP)? : A systematic review.

Objectives The purpose of this article is to determine how many of the current peer-reviewed studies of ankle foot or-thoses (AFOs) on children with cerebral palsy (CP) have included adequate details of the design and material of the AFO, to enable the study to be reproduced and outcomes clearly understood. Methods A thorough search of studies published in English was conducted in March 2015, with no restriction on dates, within all major databases using relevant phrases. These searches were then supplemented by tracking all key references from the appropriate articles identified. Study selection The inclusion criteria were as follows: (1) population - children with CP; (2) intervention - AFOs; and (3) outcome measure. One reviewer extracted data regarding the characteristics of the included studies, with the extracted data checked for accuracy and completeness by a second reviewer. None of the studies reviewed gave adequate details of the AFOs. Only 3.6% (n = 2) of papers tested the stiffness. Many studies (54.5%) did not describe the material used nor the material thickness (72.7 %). None of them gave any clinical justification for the chosen design of AFO. Conclusions There is a clear paucity of detail regarding the design and material used in AFOs on studies involving children with CP. Such a lack of detail has the potential to affect the validity of the reported outcomes, the ability to reproduce the studies and may misinform clinical practice

Cross-sectional survey of orthotic service provision in the UK: does where you live affect the service you receive?

Objective To investigate the quantity and quality of orthotic service provision within the UK. Design Cross-sectional survey obtained through freedom of information request in 2017. Setting National Health Service (NHS) Trusts/Health Boards (HBs) across the UK. Main Outcome Measures Descriptive statistics of survey results, including information related to finance, volume of appointments, patients and orthotic products, waiting times, staffing, complaints, outcome measures and key performance indicators. Results Responses were received from 61% (119/196) of contacted Trusts/HBs; 86% response rate from Scotland (12/14) and Wales (6/7), 60% (3/5) from Northern Ireland and 58% (98/170) from England. An in-house service was provided by 32% (35/110) of responses and 68% (74/110) were funded by a block contract. Long waiting times for appointments and lead times for footwear/orthoses, and large variations in patient entitlements for orthotic products across Trusts/HBs were evident. Variations in the length of appointment times were also evident between regions of the UK and between contracted and in-house services, with all appointment times relatively short. There was evidence of improvements in service provision; ability for direct GP referral and orthotic services included within multidisciplinary clinics. However, this was not found in all Trusts/HBs. Conclusions The aim to provide a complete UK picture of orthotic service provision was hindered by the low response rate and limited information provided in some responses, with greater ability of Trusts/HBs to answer questions related to quantity of service than those that reflect quality. However, results highlight the large discrepancies in service provision between Trusts/HBs, the gaps in data capture and the need for the UK NHS to establish appropriate processes to record the quantity and quality of orthotic service provision. In addition to standardising appointment times across the NHS, guidelines on product entitlements for patients and their lead times should be prescribed to promote equity. Keywords: Orthotic Devices; Foot Orthoses; Assistive Technology; Self-Help Devices; Outcome Measures; National Health Services; Health Care Survey; Rehabilitation Medicin

Does user perception affect adherence when wearing biomechanically optimised ankle foot orthosis – footwear combinations: a pilot study

Study Design: Pilot study Background: Ankle foot orthoses (AFOs) and footwear combination (FC) is a commonly prescribed medical device given to children with cerebral palsy (CP) in an attempt to improve their gait. Biomechanically optimising the AFO-FC often requires large adaptations to the sole of the user’s footwear. There is currently a dearth of literature regarding the user’s perception of wearing biomechanically optimised AFOs and adapted footwear and whether their perception affects their adherence to orthotic treatment. Objective: This study aimed to investigate perception and adherence to wearing an AFO and FC the participants were asked to wear as part of their orthotic prescription. In particular, whether the visibly modified footwear affected the user’s adherence to the orthotic treatment. Methods: Questionnaire devised for the purpose of this study Results: All five participants responded to the questionnaire; reporting a high number of positive responses in relation to function, including; an improvement in the way they walked, improved balance and fewer falls. Conversely, there was a high level of negative responses regarding aesthetics, with all participants reporting they did not like the cosmesis of their AFO-FCs. They were conscious that the modification to their footwear was noticeable and therefore different from their peers, yet they adhered to the treatment and in some cases increased the wearing time. Conclusions: This pilot set of questions indicated that cosmesis is an important factor for children who wear AFOs and adapted footwear. It can be concluded that the impact of the adapted AFO-FC on the participants’ function outweighed their opinion on the cosmesis of the device. Clinical Relevance: It is vital to understand how orthotic prescriptions affect user adherence. Orthotic prescriptions which are not utilised by the user result in a failed treatment intervention, regardless of the scientific application underpinning them

Shank – to – Vertical - Angle in AFOs: Static versus dynamic assessment in a series of cases.

Background Tuning of ankle-foot orthosis footwear combinations (AFO-FC) has been shown to be effective in aligning the ground reaction force (GRF) closer to the joint rotation center of the lower limbs. The notion of “tuning” the AFO-FC is largely dependent on the shank-to-vertical angle (SVA), which is measured while the subject is static but is meant to represent the SVA in mid-stance. Objectives The aim of this study was to compare the SVA measured in standing position with the SVA at temporal mid-stance (TMST) in a series of cases. Study Design This study is a case series. Methods Four participants had their AFO-FC tuned to optimum SVA using video-based gait analysis with GRF overlay. Initially, the SVA was measured with the subject standing in relaxed stance on the force plate with approximately equal weight on both feet. The SVA was then assessed at TMST. Results The measurement of the SVA of the AFO-FC in relaxed stance seems to be the same as the measurement of the SVA in TMST. Conclusions Measuring the SVA of the AFO-FC in relaxed stance is an accurate way of determining the SVA at TMST. Clinical Relevance Ankle-foot orthosis footwear combination tuning is considered an essential aspect of AFO prescriptions. The SVA is a key principle of AFO-FC tuning. The method for determining the SVA has yet to be tested to ensure that the static measurement correlates to the dynamic measurement during gait

A Scoping Literature Review of Studies Assessing Effectiveness and Cost-Effectiveness of Prosthetic and Orthotic Interventions

Purpose: Approximately 1.5% of the world’s population (~100 million people) need a prosthesis/orthosis. The objective of the study was to establish an overview of the literature that has examined prosthetic and orthotic interventions with a view to inform policy development. Methods: Fourteen databases were searched from 1995-2015. Studies reporting primary research on the effectiveness or cost-effectiveness of prosthetic and orthotic interventions were examined. Metadata and information on study characteristics were extracted from the included studies. Results: The searches resulted in a total of 28,958 articles, a focus on studies with the words “randomised” OR “randomized” OR “cost” OR “economic” in their citation reduced this total to 2,644. Research has predominantly been conducted in Australia, Canada, Germany, Netherlands, UK and USA. 346 randomised controlled trials were identified, with only four randomised controlled trials examining prosthetic interventions. The majority of research examined lower limb orthoses in the adult population and used a wide range of outcome measures. Conclusions: While various international organisations have highlighted the value of providing prosthetic and orthotic services, both to the user and society as a whole, the availability of scientific research to inform policy is limited. Future structured evaluation of prosthetic and orthotic interventions/services is warranted to inform future policy developments

The effect of tuning ankle foot orthoses-footwear combinations on gait kinematics of children with cerebral palsy: a case series

Study Design: Case series Background: AFOs are a commonly prescribed medical device given to children with cerebral palsy (CP) in an attempt to improve their gait. The current literature is equivocal on the effects AFOs have on the gait of children with CP. The vast majority of AFOs issued are not subject to AFO-FC tuning. There are emerging studies investigating the effects tuning AFO-FCs has on the gait of children with CP. However, the research is limited, and there is a lack of quantitative data. Objective: To compare the kinematics of tuned versus non-tuned gait in children with CP. Methods: Gait analysis assessment of five children aged between 7-11 years with a diagnosis of CP (one hemiplegic and four diplegic participants, two female, three male, with a Gross Motor Functional Classification System (GMFCS) of 2) at a Gait Analysis Laboratory. Results: In comparison to barefoot and non-tuned gait, walking with a tuned AFO-FC produced improvements in several key gait parameters. Including hip flexion and extension, posterior pelvic tilt and knee extension. Results also indicated that the type of gait pattern demonstrated by the participant affected the outcomes of tuning. Conclusions: Tuning the AFO-FC of children with CP has the potential to improve hip function, pelvic function, knee extension in stance phase and knee flexion during swing phase and that an non-tuned AFO-FC can potentially decrease hip function, posterior pelvic tilt and increase knee extension. Clinical Relevance: Whilst AFO-FC tuning has been recommended for routine clinical practice, there still remains a paucity of research on the kinematic effects of using a tuned AFO-FC compared to a non-tuned. This paper provides a comparison of kinematics on children with CP, during barefoot, non-tuned and tuned AFO-FC walking with a view to inform clinical practice

The challenge of service planning and development without adequate data: The case for orthotic services

The UK National Health Service (NHS) employs a group of 14 separate allied health professions. Prosthetics and orthotics are the smallest of these professions. Although small, orthotics is integral to many clinical care pathways and has shown to provide an essential impact on a range of clinical conditions in the health service priority lists. Previous reports acknowledged the lack of data on the UK prosthetic and orthotic workforce, appointment outcomes and cost and the service users accessing such services and thus the challenges that it poses for effective service delivery. There is still a paucity of relevant data or initiatives to support the service provision. The work within this paper has taken the first step to address this gap, presenting a summary of the information relating to appointments and costs, and provides a discussion on the implications of variations across the NHS orthotic services within England in terms of spend, staffing and skill mix for orthotic services and service users and the need for further data on service users and the UK prosthetic and orthotic workforce

Exploratory investigation into energy expenditure using tuned versus non-tuned ankle foot orthoses- footwear combinations in children with cerebral palsy.

tudy Design: Within-subjects design. Background: Children with cerebral palsy (CP) commonly expend two to three times as much energy to walk as typically developing children. Research shows that the effects of non-tuned ankle-foot orthoses (AFOs) on energy expenditure is inconclusive. Tuning of an ankle-foot orthosis-footwear combination (AFO-FC) has demonstrated an improvement in the kinetics and kinematics of athological gait, particularly knee flexion during stance phase, which are key determinants of an energy efficient gait. Objective: To compare the submaximal energy expenditure via indirect calorimetry, speed and distance walked, of tuned and non-tuned AFO-FCs and barefoot gait, in children with cerebral palsy (CP). Methods: Performance assessment of four children aged between 7-10 years with a diagnosis of CP (one hemiplegic and three diplegic participants, two female, two male, with a Gross Motor Function Classification System (GMFCS) of 2) at a Gait Analysis Laboratory. Results: There was a reduction in gross submaximal energy expenditure and energy efficiency index (EEI) based on O2, in three out of the four participants tested when wearing tuned compared to a non-tuned AFO-FC, the reduction ranged from 9.2% to 33.7%. Speed and distance covered also showed improvement in the tuned condition. Conclusions: Tuning the AFO-FC of children with cerebral palsy has the potential to decrease energy expenditure and increase speed and distance compared to providing a nontuned AFO-FC. Clinical Relevance: There is a lack of research on the effect of using a tuned compared to a non-tuned AFO-FC on energy expenditure. This paper provides a comparison of energy expenditure in children with CP, during Barefoot, Non-tuned and Tuned AFO-FC walking, intending to inform clinical practice

Framework to guide Allied Health Professional telehealth patient consultation guidelines and training

Purpose AHPs make up the third largest healthcare workforce in the UK NHS and with their wide range of skills make a significant contribution to the health and care of people using their services. Current telehealth guidelines and training programmes for AHPs are not sufficiently comprehensive and lack information on key telehealth aspects, meaning AHPs may not be adequately supported in the delivery of remote patient consultations. Therefore, a policy brief to guide the development of AHP telehealth patient consultation guidelines and training was developed to meet the needs of policymakers, AHP professional bodies, and clinical services. The intended purposes of this policy brief are to: (1) present key telehealth domains that should be considered when designing telehealth guidelines for patient consultations, and (2) present areas in which AHPs should be trained prior to providing telehealth consultations. This policy brief aims to provide guidance and facilitate further discussion on the essential components of telehealth guidelines and staff training, it is not an exhaustive list of recommendations. Recognising the diversity of telehealth applications and the differences between and within individual allied health professions, this policy brief is not profession specific and may require adaptation to the context of use and individual circumstances. Policy brief development This policy brief was developed in four phases, which include: (1) a scoping review to synthesise available evidence; (2) a survey to explore the opinions of UK AHP clinicians and service managers on their telehealth service guidelines and training; (3) formulation of the draft policy brief; (4) consultation with stakeholders and formulation of the final policy brief. Patient users of telehealth were not involved in the development of this policy brief. However, the policy brief considers patient users’ suitability, needs and requirements. Audience This policy brief is intended to inform the development of telehealth consultation guidelines and training for AHP patient consultations. Therefore, the target audience includes policymakers, AHP professional bodies, AHP service managers, and professional societies involved in the planning and management of AHP training, clinical and academic staff involved in training AHPs, and independent AHPs requiring support in their telehealth patient consultations. Telehealth definition Telehealth is defined by the World Health Organization (WHO) as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” (1). For this policy brief, telehealth was defined as a telephone or video consultation with a patient