DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY

2021, VOL. 16, NO. 6, 609–613

[Link]

ORIGINAL RESEARCH

Orthotic care needs in a cohort of neurological rehabilitation inpatients

Joshua Younga and Cameron Mossb
a
Orthotic Service, St George’s University Hospitals NHS Foundation Trust, London, UK; bWolfson Neurorehabilitation Centre, St George’s
University Hospitals NHS Foundation Trust, London, UK

ABSTRACT ARTICLE HISTORY

Aim: Orthotic management is frequently part of the rehabilitation of various neurological conditions in Received 9 October 2018
adults such as stroke, peripheral neuropathies, spinal cord injuries and multiple sclerosis. Despite this, Accepted 22 October 2019
there are limited data available on the implementation of orthotic care in practice. The primary aim of
KEYWORDS
this study is to establish the proportion of inpatients in a mixed neurorehabilitation cohort which receive
Orthotics; orthoses;
orthotic assessment and treatment. The secondary aim was to document the overall care pathway. neurorehabilitation; stroke
Methods: Existing data were reviewed retrospectively. Data gathered included patient demographics
such as age, gender and diagnosis, type of orthoses prescribed, number of orthotic treatment sessions
required and outcome measures used. The paper was prepared in accordance with the STROBE statement
for observational studies.
Results: During a 6 month period, 54 patients were admitted as inpatients. Of these, 25 (46%) were
referred to the orthotic service for assessment, with 23 (43%) receiving a lower limb orthosis and 19
(35%) subsequently being discharged using either an ankle-foot orthosis or knee-ankle-foot orthosis. The
conditions most commonly seen were stroke (40%), incomplete spinal cord injuries (28%) and peripheral
neuropathies (16%). Significant improvements were recorded at discharge using the Functional
Independence Measure (FIM) and Functional Assessment Measure (FAM). Various aspects of the orthotic
care process are described.
Conclusions: This study suggests that orthotic treatment is needed with high frequency in a mixed
inpatient neurorehabilitation cohort. In terms of service planning, these data support existing the recom-
mendation that neurological rehabilitation centres should have good access to orthotic services.

ä IMPLICATIONS FOR REHABILITATION

Custom orthoses such as AFOs and KAFOs are frequently needed by neurological rehabilita-
tion inpatients.

Orthoses may facilitate standing and walking at an earlier stage during rehabilitation.

Those responsible for neurological rehabilitation services should ensure appropriate access to orthotic
services.

Background the established use of orthoses in adults with neurological condi-

tions (AwNCs), there are limited data available on the implemen-
Orthotists are part of the multidisciplinary team involved in the
tation of orthotic care in practice; it is unclear what proportion of
rehabilitation of long-term neurological conditions [1]. Orthotic
management is commonly part of the rehabilitation of neuro- AwNC are prescribed orthoses and what types of orthoses are
logical conditions including stroke, peripheral neuropathies, spinal used. This is reflected by the varying recommendations made on
cord injuries and multiple sclerosis. Orthoses may improve gait the use of AFOs in stroke [14–16].
kinematics and kinetics, walking speed, energy expenditure and
reduce risk of falls [2–7]. In addition to being considered as a Aim
device worn by the user to achieve a functional benefit, orthoses
may also be considered as a therapeutic tool or an adjunct to The primary aim of this study is to establish the proportion of
therapy [8,9]. One study has suggested that functional recovery in inpatients in a mixed neurological rehabilitation cohort at a single
stroke is improved by the prescription of an ankle-foot orthosis centre which receive orthotic assessment and treatment. The sec-
(AFO) [10], although prescription within six weeks of stroke does ondary aim was to document the overall pathway including
not improve short-term kinematic and spatiotemporal gait out- patient characteristics, nature of care provided (i.e., orthoses pre-
comes versus later provision [11]. Use of orthoses may be associ- scribed), functional status of patients at assessment and dis-
ated with some negative effects including discomfort, pain and charge, and whether prescribed orthoses were still being used at
difficulty in using footwear together with orthoses [12,13]. Despite (a) discharge and (b) 3 month review.

CONTACT Joshua Young joshua.young1@[Link] Orthotic Service, Queen Mary’s Hospital, St George’s University Hospitals NHS Foundation Trust, SW15 5PN
London, UK
Supplemental data for this article can be accessed here.
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
610 J. YOUNG AND C. MOSS

Methods Use of orthoses at discharge and review

Data were collected at the level 1 Wolfson neurorehabilitation By discharge, all 23 patients initially prescribed an orthosis or
centre, which provides multidisciplinary inpatient neurorehabilita- orthoses were still using the device(s). At 3 months, one patient
tion led by neuropsychiatry, neurology and rehabilitation consul- was lost to follow up, one was deceased, one ceased KAFO use
tants. Orthotic treatment for inpatients is provided by an on-site due to terminal illness, and one ceased foot orthosis use due to
orthotics service and workshop. Other services available on-site lack of benefit. A further patient progressed from using their
include a spasticity clinic, functional electrical stimulation clinic KAFO to an AFO. The remaining 18 patients who were reviewed
and gait laboratory. The service has 26 inpatient beds for AwNC; at 3 months were still using their orthoses as initially prescribed.
patients are referred from an acute services within the same trust Of the initial cohort of 54 inpatients, 23 (43%) were discharged
or from acute, sub-acute or community services nationwide. A using a lower limb orthosis. Of the initial cohort, three (6%) were
discharged with prefabricated lower limb orthoses; 20 (37%) were
weekly clinic for these inpatients is conducted by an orthotist
discharged with custom lower limb orthoses; 19 (35%) were dis-
with experience in neurology, supported by a highly specialized
charged using either an AFO or KAFO. 9/23 (39%) stroke patients
physiotherapist from the inpatient team. Referrals to this clinic are
were discharged with an AFO or KAFO and 10/31 (32%) of those
made by the physiotherapy team, based on clinical observation
with all other diagnoses.
during therapy sessions by a highly specialized physiotherapist.
Data for patients admitted during a 6 month period in 2017
were included. Electronic and paper records were reviewed retro- Outcome measures and functional status at assessment
spectively. Data were gathered for all patients referred to and discharge
orthotics including demographics such as age, gender and diag- During treatment within the orthotic clinic, the 10 metre walk test
nosis, type of orthoses prescribed, number of orthotic treatment (10MWT) or timed up and go (TUG) test were used with 68% of
sessions required and outcome measures (OMs). Orthoses are patients at some stage during the treatment pathway. A numeric
described based on terminology from the International Standards rating scale for pain was also used with one patient (4%). Use of
Organization (ISO) such as “ankle-foot orthosis” (AFO) and “knee- OMs varied meaning that comparison values with and without
ankle-foot orthosis” (KAFO) [17]. Functional Independence orthoses at each stage was not always available. At assessment in
Measure (FIM), Functional Assessment Measure (FAM) and orthotic clinic, 12 patients (48%) were recorded as being unable
Neurological Impairment Set (NIS) version 9.3 data [18] were to complete a TUG or 10MWT without physical assistance, even if
tested for normality using a one sample Kolmogorov–Smirnov walking aids such as sticks and frames were allowed. Thirteen
test and compared using a paired t-test with significance (52%) were able to complete a TUG or 10MWT, using temporary
at <0.05. orthoses (such a pre-fabricated AFO or soft and scotch devices)
Written confirmation was gained from the trust’s research gov- and walking aids as necessary. At fitting stage, three patients pre-
ernance office confirming that the study did not require formal viously unable to complete OMs were able to complete OMs (two
ethical approval. The paper was prepared with reference to the completed TUG, one completed 10MWT) only while using their
STROBE statement for observational studies [19]. orthoses (two KAFOs, one rigid AFO). At inpatient review
2–4 weeks later, a further two patients previously unable to com-
plete OMs were able to complete a TUG only while using a rigid
Results AFO. At discharge, 20 (87%) in the group treated with orthoses
were able to walk with the use of orthoses and walking aids as
During the period, 54 patients were admitted as inpatients. Of necessary, although formal OMs were not used in each case, while
these, 25/54 (46%) were referred to an orthotist for assessment the remaining three patients were using ankle foot orthoses for
during their stay. Mean length of stay was 11.08 weeks (SD 3.05, therapeutic standing only.
range 3–16) with a median of 12 weeks. 9/23 (39%) stroke Functional Independence Measure, FAM and NIS scores were
patients were referred to orthotics and 16/31 (52%) of those with assessed at admission and discharge 3 months later. Total
all other diagnoses. See Figure 1 for patient flow through the FIM þ FAM scores increased from mean 176 at admission to 223
care pathway. Patient characteristics, diagnoses and orthotic pre- at discharge which was significant using a paired t-test
scriptions are indicated in Table 1. Mean age was 56.8 (SD 16.31, (p ¼ <.0001). Mean NIS scores decreased from 16.24 at assessment
range 20–86) and 60% were male, 40% were female. The most to 13.13 at discharge (p ¼ .0012).
common diagnoses were stroke, incomplete spinal cord injury
and peripheral neuropathy. Discussion
In this study, 46% of all AwNC admitted for neurorehabilitation
Orthotic prescription and clinical time were referred for assessment by an orthotist during their stay,
with 35% discharged using an AFO or KAFO. This suggests that
Twenty-three out of 25 patients referred to the orthotic clinic orthotic treatment is needed with relatively high frequency in this
were provided with a lower limb orthosis (see Table 1). For details mixed group. High frequency of AFO use (65%) has previously
of orthotic prescriptions by diagnosis, see Table 2. In stroke, spinal been reported in Charcot–Marie–Tooth among adults attending
cord injury and brain injury patients, the most common prescrip- an outpatient clinic [20]. Studies looking at inpatient rehabilitation
tion was a custom rigid AFO (including unilateral or bilateral use) found that 22% [21] and 30.7% [10] of patients with stroke were
ranging in frequency from 43% to 100%. However in peripheral discharged with an AFO, which is lower than the 39% reported in
neuropathies, custom rigid and hinged AFOs were used with this study. A study of lower limb orthosis use by patients with spi-
equal frequency (25%). KAFOs were most commonly used in spi- nal cord injury found a frequency of use of 25% [22]. Variables
nal cord injury (29%). Patients required between 1 and 5 treat- affecting referral to orthotics may include referrer’s beliefs and
ment sessions (mean 3.4, SD 1.26). practice, and patient presentation. Practice may vary in different
 ORTHOTIC CARE NEEDS IN NEURO REHAB INPATIENTS 611

Figure 1. Patient flow through the care pathway.

centres; a multi-centre study or clinician survey would provide fur- instability or weakness [16]. Recent work has shown that there is
ther information on practice nationally within the UK. a need for further research in this area [24]. The significant
Considering the recorded OMs, it seems significant that five improvements in FIM þ FAM scores indicate that patients using
patients are recorded as being able to walk without physical orthoses improved during their rehabilitation. This does not iso-
assistance of clinicians only while wearing their orthoses. This late the effect of orthoses as other treatments, therapy and nat-
effect has been reported previously [23]. This, combined with the ural recovery may all be reflected by these changes in scores.
observation that three subjects were discharged using their AFOs Some natural recovery is suggested by the significant change in
for therapeutic standing only, points to the fact that both KAFOs NIS score.
and rigid AFOs may be used to stabilize the knee by preventing As patients in the cohort were frequently discharged with cus-
collapse into knee flexion. This is recognized by the NICE guide- tom orthoses, it seems likely that neurological rehabilitation
line which recommends AFO use where there is ankle or knee centres should have good access to orthotic services. This is in
612 J. YOUNG AND C. MOSS

Table 1. Patient characteristics, diagnoses and orthotic prescriptions. high frequency in a mixed inpatient neurological rehabilitation
Number (n ¼ 25), cohort. Further research is needed to determine current prac-
Characteristics frequency [%] tice nationally.
Age (years) – A Supplementary Appendix containing details on orthotic pre-
Mean ± SD ¼ 56.8 ± 16.31 scription details, prescriptions by diagnosis and rehabilitation
Range ¼ 20–86
scores at admission/discharge is available online (doi:10.17605/
Gender
Male 15 [60%] [Link]/MYEUT) or by contacting the lead author.
Female 10 [40%]
Diagnosis
Stroke 10 [40%] Disclosure statement
Incomplete spinal cord injury 7 [28%]
Peripheral neuropathy 4 [16%] At the time of conducting the study, JY was employed by Opcare,
Brain injury 2 [8%] a company which provides subcontracted clinical services within
Multiple sclerosis 1 [4%] the NHS. At the time of publication, JY is employed by John
Functional neurological disorder 1 [4%] Florence Limited, a company which provides subcontracted clin-
Orthotic prescription
Unilateral custom rigid AFO 8 [32%]
ical services within the NHS.
Bilateral custom rigid AFOs 3 [12%]
Unilateral custom KAFO 3 [12%]
Custom foot orthoses 2 [8%] ORCID
Unilateral custom hinged AFO 2 [8%] Joshua Young [Link]
Unilateral pre-fabricated AFO 2 [8%]
No prescription 2 [8%]
Bilateral custom hinged AFOs 1 [4%]
Pre-fabricated foot orthoses 1 [4%] References
Orthotic/orthopaedic footwear 1 [4%]
[1] Turner-Stokes L, Sykes N, Silber E, et al. Long-term neuro-
logical conditions: management at the interface between
neurology, rehabilitation and palliative care. Clin Med.
Table 2. Orthotic prescription by diagnosis. 2008;8(2):186–191.
Diagnosis Orthotic prescription [2] Menotti F, Laudani L, Damiani A, et al. An anterior ankle-
Stroke (n ¼ 10) Unilateral custom rigid AFO – 50% foot orthosis improves walking economy in
Unilateral custom hinged AFO – 20% Charcot–Marie–Tooth type 1A patients. Prosthet Orthot Int.
Unilateral pre-fabricated AFO – 20%
Unilateral custom KAFO – 10% 2014;38(5):387–392.
Incomplete spinal cord injury (n ¼ 7) Unilateral custom KAFO – 29% [3] Carse B, Bowers R, Meadows BC, et al. The immediate
Bilateral custom rigid AFOs – 29% effects of fitting and tuning solid ankle-foot orthoses in
Unilateral custom rigid AFO – 14% early stroke rehabilitation. Prosthet Orthot Int. 2015;39(6):
Custom foot orthoses – 14%
No prescription – 14%
454–462.
Peripheral neuropathy (n ¼ 4) Bilateral custom rigid AFOs – 25% [4] Daryabor A, Arazpour M, Aminian G. Effect of different
Bilateral custom hinged AFOs – 25% designs of ankle-foot orthoses on gait in patients with
Orthotic/orthopaedic footwear – 25% stroke: a systematic review. Gait Posture. 2018;62:268–279.
No prescription – 25%
[5] Cakar E, Durmus O, Tekin L, et al. The ankle-foot orthosis
Brain injury (n ¼ 2) Unilateral custom rigid AFO – 100%
Multiple sclerosis (n ¼ 1) Custom foot orthoses – 100% improves balance and reduces fall risk of chronic spastic
Functional neurological disorder (n ¼ 1) Pre-fabricated foot orthoses – 100% hemiparetic patients. Eur J Phys Rehabil Med. 2010;46(3):
363–368.
[6] Tyson S, Sadeghi-Demneh E, Nester C. A systematic review
line with existing recommendations [15]. Evidence based practice
and meta-analysis of the effect of an ankle-foot orthosis on
guidelines state that custom orthoses are essential in the pres-
gait biomechanics after stroke. Clin Rehabil. 2013;27(10):
ence of certain indications [14]. 879–891.
Limitations of this study include the retrospective observa- [7] Arazpour M, Tajik HR, Aminian G, et al. Comparison of the
tional design and relatively small sample size. The study reflects effects of solid versus hinged ankle foot orthoses on select
practice in a single centre, limiting generalizability. While multiple temporal gait parameters in patients with incomplete spi-
clinicians are involved in referrals to the orthotic service and in nal cord injury during treadmill walking. Prosthet Orthot
clinical decision making, the results may be influenced by bias as Int. 2013;37(1):70–75.
a result of the authors’ practice. Further work is required to define [8] Bowers R, Dennis J, Lawrie J, et al. Use of ankle foot ortho-
current practice concerning orthotic care provided to AwNC in ses following stroke [Internet]. NHS Quality Improvement
other areas, in both inpatient and outpatient contexts. Scotland; 2009. Available from: [Link]
[Link]/previous_resources/best_practice_state-
Conclusions ment/use_of_ankle-foot_orthoses_fol.aspx
[9] Hou J, Fortson BD, Lovegreen W, et al. Lower limb orthoses
This brief report provides an insight into clinical practice concern- for persons who have had a stroke. In: Webster JB, Murphy
ing orthotic treatment in neurological rehabilitation. In this study, DP, editors. Atlas of orthoses and assistive devices. 5th ed.
a large proportion of AwNC required orthotic assessment and Philadelphia (PA): Elsevier; 2019. p. 289–295.
treatment. Patients significantly improved in functional measures [10] Momosaki R, Abo M, Watanabe S, et al. Effects of ankle-
following rehabilitation including the use of orthoses. While prac- foot orthoses on functional recovery after stroke: a propen-
tice and access to orthotic services may vary around the UK, these sity score analysis based on Japan Rehabilitation Database.
results imply that orthotic treatment is needed with relatively PLoS One. 2015;10(4):e0122688.
 ORTHOTIC CARE NEEDS IN NEURO REHAB INPATIENTS 613

[11] Nikamp CDM, Hobbelink MSH, van der Palen J, et al. A [18] Turner-Stokes L, Nyein K, Turner-Stokes T, et al. The UK
randomized controlled trial on providing ankle-foot ortho- FIM þ FAM: development and evaluation. Functional assess-
ses in patients with (sub-)acute stroke: short-term kine- ment measure. Clin Rehabil. 1999;13(4):277–287.
matic and spatiotemporal effects and effects of timing. [19] Elm E. V, Altman DG, Egger M, et al. Strengthening the
Gait Posture. 2017;55:15–22. reporting of observational studies in epidemiology
[12] Vinci P, Gargiulo P. Poor compliance with ankle-foot-ortho- (STROBE) statement: guidelines for reporting observational
ses in Charcot–Marie–Tooth disease. Eur J Phys Rehabil studies. BMJ. 2007;335(7624):806–808.
Med. 2008;44(1):27–31. [20] Williams S, Singer B, Lamont P. Balance and falls in people
[13] Tyson SF, Vail A, Thomas N, et al. Bespoke versus off-the- with Charcot-Marie-Tooth disease: a cohort survey. Int J
shelf ankle-foot orthosis for people with stroke: random- Ther Rehabil. 2018;25:6–12. Available from: [Link]
ized controlled trial. Clin Rehabil. 2018;32(3):367–376. [Link]/doi/10.12968/ijtr.2018.25.1.6
[14] Bowers R, Ross K. Development of a best practice state- [21] Teasell RW, McRae MP, Foley N, et al. Physical and func-
ment on the use of ankle-foot orthoses following stroke in
tional correlations of ankle-foot orthosis use in the rehabili-
Scotland. Prosthet Orthot Int. 2010;34(3):245–253.
tation of stroke patients. Arch Phys Med Rehabil. 2001;
[15] Bowen A, James M, Young G, et al. National clinical guide-
82(8):1047–1049.
line for stroke [Internet]; 2016; [cited 2018 Jun 29].
[22] Hada T, Momosaki R, Abo M. Impact of orthotic therapy for
Available from: [Link]
improving activities of daily living in individuals with spinal
Documents/Guidelines/2016-National-Clinical-Guideline-for-
Stroke-5t-(1).aspx cord injury: a retrospective cohort study. Spinal Cord. 2018;
[16] The National Institute for Health and Care Excellence. 56(8):790–795.
NICE CG162 stroke rehabilitation in adults [Internet]; 2013; [23] Slijper A, Danielsson A, Willen C. Ambulatory function and
[cited 2018 Jun 19]. Available from: [Link] perception of confidence in persons with stroke with a cus-
guidance/cg162/resources/stroke-rehabilitation-in-adults-pdf- tom-made hinged versus a standard ankle foot orthosis.
35109688408261 Rehabil Res Pract. 2012;2012:206495.
[17] International Standards Organization. ISO 8549-1:1989 – [24] McDaid C, Fayter D, Booth A, et al. Systematic review
prosthetics and orthotics – vocabulary – part 1: general of the evidence on orthotic devices for the manage-
terms for external limb prostheses and external orthoses ment of knee instability related to neuromuscular and
[Internet]; 1989; [cited 2018 Jun 19]. Available from: http:// central nervous system disorders. BMJ Open. 2017;7(9):
[Link]/standard/[Link]?browse=tc e015927.
Copyright of Disability & Rehabilitation: Assistive Technology is the property of Taylor &
Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.