A call to action : providing better footwear and foot orthoses for people with rheumatoid arthritis

Rheumatoid arthritis is a chronic, disabling condition in which the body’s immune system attacks the joints. As the disease progresses, feet become more damaged and deformed. Research produced for this report shows widespread dissatisfaction with all types of therapeutic footwear, and patients have raised concerns around poor fit, appearance, weight of shoe and comfort. Nine out of ten rheumatoid arthritis patients complain of foot pain Seven out of ten having difficulty walking Eighty per cent report problems with their footwear. High street and therapeutic footwear designers and manufacturers do not fully embrace the therapeutic needs of the patient. These factors have an impact on patient quality of life and well-being. The report makes a series of observations and recommendations for the current service, which has been failing for the past two decades to provide accessible podiatric and orthotic services at a time of growing demand from an ageing population

Recent developments in healthcare for cerebral palsy

Recent developments in the conceptualisation of disability (1), definition and classification of cerebral palsy (CP), treatment goals, and research on the effectiveness of interventions require synthesis for AHPs in clinical practice. A multidisciplinary consensus conference which included an international group of 24 clinicians and researchers was convened by the International Society for Prosthetics and Orthotics to consider research and contemporary thinking on the management of CP

A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO

The effect of prefabricated wrist-hand orthoses on performing activities of daily living

Wrist-hand orthoses (WHOs) are commonly prescribed to manage the functional deficit associated with the wrist as a result of rheumatoid changes. The common presentation of the wrist is one of flexion and radial deviation with ulnar deviation of the fingers. This wrist position Results in altered biomechanics compromising hand function during activities of daily living (ADL). A paucity of evidence exists which suggests that improvements in ADL with WHO use are very task specific. Using normal subjects, and thus in the absence of pain as a limiting factor, the impact of ten WHOs on performing five ADLs tasks was investigated. The tasks were selected to represent common grip patterns and tests were performed with and without WHOs by right-handed, females, aged 20-50 years over a ten week period. The time taken to complete each task was recorded and a wrist goniometer, elbow goniometer and a forearm torsiometer were used to measure joint motion. Results show that, although orthoses may restrict the motion required to perform a task, participants do not use the full range of motion which the orthoses permit. The altered wrist position measured may be attributable to a modified method of performing the task or to a necessary change in grip pattern, resulting in an increased time in task performance. The effect of WHO use on ADL is task specific and may initially impede function. This could have an effect on WHO compliance if there appears to be no immediate benefits. This orthotic effect may be related to restriction of wrist motion or an inability to achieve the necessary grip patterns due to the designs of the orthoses

The effect of prefabricated wrist-hand orthoses on grip strength

Prefabricated wrist-hand orthoses (WHOs) are commonly prescribed to manage the functional deficit and compromised grip strength as a result of rheumatoid changes. It is thought that an orthosis which improves wrist extension, reduces synovitis and increases the mechanical advantage of the flexor muscles will improve hand function. Previous studies report an initial reduction in grip strength with WHO use which may increase following prolonged use. Using normal subjects, and thus in the absence of pain as a limiting factor, the impact of ten WHOs on grip strength was measured using a Jamar dynamometer. Tests were performed with and without WHOs by right-handed, female subjects, aged 20-50 years over a ten week period. During each test, a wrist goniometer and a forearm torsiometer were used to measure wrist joint position when maximum grip strength was achieved. The majority of participants achieved maximum grip strength with no orthosis at 30° extension. All the orthoses reduced initial grip strength but surprisingly the restriction of wrist extension did not appear to contribute in a significant way to this. Reduction in grip must therefore also be attributable to WHO design characteristics or the quality of fit. The authors recognize the need for research into the long term effect of WHOs on grip strength. However if grip is initially adversely affected, patients may be unlikely to persevere with treatment thereby negating all therapeutic benefits. In studies investigating patient opinions on WHO use, it was a stable wrist rather than a stronger grip reported to have facilitated task performance. This may explain why orthoses that interfere with maximum grip strength can improve functional task performance. Therefore while it is important to measure grip strength, it is only one factor to be considered when evaluating the efficacy of WHOs

Orthotic management of cerebral palsy : recommendations from a consensus conference

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

Use of stance control knee-ankle-foot orthoses : a review of the literature

The use of stance control orthotic knee joints are becoming increasingly popular as unlike locked knee-ankle-foot orthoses, these joints allow the limb to swing freely in swing phase while providing stance phase stability, thus aiming to promote a more physiological and energy efficient gait. It is of paramount importance that all aspects of this technology is monitored and evaluated as the demand for evidence based practice and cost effective rehabilitation increases. A robust and thorough literature review was conducted to retrieve all articles which evaluated the use of stance control orthotic knee joints. All relevant databases were searched, including The Knowledge Network, ProQuest, Web of Knowledge, RECAL Legacy, PubMed and Engineering Village. Papers were selected for review if they addressed the use and effectiveness of commercially available stance control orthotic knee joints and included participant(s) trialling the SCKAFO. A total of 11 publications were reviewed and the following questions were developed and answered according to the best available evidence: 1. The effect SCKAFO (stance control knee-ankle-foot orthoses) systems have on kinetic and kinematic gait parameters 2. The effect SCKAFO systems have on the temporal and spatial parameters of gait 3. The effect SCKAFO systems have on the cardiopulmonary and metabolic cost of walking. 4. The effect SCKAFO systems have on muscle power/generation 5. Patient’s perceptions/ compliance of SCKAFO systems Although current research is limited and lacks in methodological quality the evidence available does, on a whole, indicate a positive benefit in the use of SCKAFOs. This is with respect to increased knee flexion during swing phase resulting in sufficient ground clearance, decreased compensatory movements to facilitate swing phase clearance and improved temporal and spatial gait parameters. With the right methodological approach, the benefits of using a SCKAFO system can be evidenced and the research more effectively converted into clinical practice

A comparative study of efficacy and functionality of ten commercially available wrist-hand orthoses in healthy females:Wrist range of motion and grip strength analysis

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 ten 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 practice and the prescription of these devices. These findings justify the need to re-design WHOs with the goal of meeting users’ needs

Development of a best practice statement on the use of ankle-foot orthoses following stroke in Scotland

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 in the development of the BPS as part of a working group that included practitioners from the fields of orthotics, physiotherapy, stroke nursing and bioengineering, and 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. At 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

A comparative study of the efficacy and functionality of 10 commercially available wrist-hand orthoses in healthy females during activities of daily living

Objective: Optimal 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. Design: Randomised comparative functional study of the wrist/hand with and without WHOs. Participants: Ten 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 measures: The 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. Results: At 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 15° for a significant amount of time (p  Conclusion: The 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