Golding-Day, Miriam
(2025)
What are the optimal ways of working in delivering orthotic interventions to enhance rehabilitation outcomes and reduce complications for stroke survivors?: establishing National Statements of Best Practice.
PhD thesis, University of Nottingham.
Abstract
Background
Stroke is the leading cause of adult disability in the UK with two thirds of stroke survivors leaving hospital with ongoing functional deficit. For many stroke survivors regaining mobility is a key aim in their rehabilitation, and orthotics have a crucial role to play in achieving this. There are up to two million orthotic users in the UK and with the predicted increase in prevalence of stroke by 60% in the next 10 years, this number is also expected to rise significantly.
Currently there is no evidence for the optimal ways of working when delivering orthotic interventions following a stroke and no guidelines of best practice to inform clinicians, for services to adhere to, and for patients to use to advocate for their care. This contributes to poor consistency in the delivery of orthotic intervention for stroke survivors across the UK.
Aim
The aim of this PhD was to establish the optimal ways of working in the delivery of orthotic intervention after stroke, in order to enhance rehabilitation outcomes and reduce complications for stroke survivors.
Methods
This mixed methods PhD was completed through a five-stage process. Stage one of the PhD programme of work comprised a systematic review of the literature. This provided a comprehensive synthesis of relevant evidence in the field, and a detailed foundation of existing knowledge before undertaking further research. The second stage consisted of a national professional cross-sectional survey designed to provide a baseline of data in the post-covid landscape of how orthotists perceive their role and confidence to inform stroke rehabilitation outcomes. The third stage involved the completion of stakeholder focus groups to determine the perspectives of multi-disciplinary expert clinicians, stroke survivors and carers on the role of orthotics in stroke rehabilitation. Within this, they also explored the similarities and differences to the perceptions identified by orthotists within the cross-sectional survey. The findings from these three studies were converged through a triangulation exercise in the fourth stage of the PhD programme, where the synthesised results were formed into themes from which proposed statements of best practice were developed. The fifth and final stage was to refine and finalise the statements of best practice through expert orthotist agreement via a national professional eDelphi consensus study.
Following the internationally adopted Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach, the studies were conducted systematically to produce the first national clinical guidelines for orthotic intervention after stroke in the UK. Additional preparatory studies of a Multi-Disciplinary Team (MDT) professional survey and clinical observations were conducted to supplement the substantive work packages within the PhD and offer additional context to the developed statements of best practice.
Results
The preparatory MDT survey laid a foundation for the PhD programme and indicated the perceived importance of timing and means of orthotic delivery after stroke. The clinical observation inquiry provided context for which the subsequent studies were developed and delivered, with a key finding on the importance of the inter-professional relationships within stroke rehabilitation. The systematic review identified six evaluative studies assessing the impact of timing of lower limb orthotic delivery which were all derived from a single trial, and no studies exploring the specific role of the orthotist. The national professional cross-sectional survey received 56 responses, representative of 10% of the UK registered orthotic workforce. It found that multidisciplinary care was not typical, with 46% of respondents reported ‘rarely’ seeing stroke patients in joint assessment with another clinician. However, confidence in managing lower limb gait difficulties was high, with 89% of respondents feeling able to recommend a lower limb orthotic treatment. Ninety-eight percent (n=55) of respondents agreed that orthotic assessment should be an essential element of gait re-education after stroke, however, they reported limited involvement within early stroke rehabilitation currently.
The stakeholder focus group study was the first to explore the collective perspectives of stroke rehabilitation clinicians, stroke survivors, and carers on their perception of optimum orthotic intervention after stroke. Three focus groups were completed. Following a framework analysis of the focus group transcripts, eight core themes were identified: four foundation themes, a further two centred on the person and two on the wider service structure, and a final two overarching themes. The four foundation themes each represent an aspect of orthotic intervention which is not direct but influential to its implementation. Orthotists need to determine best practice; Biomechanics – The Debate; Visibility and knowledge about orthotics and the profession; Different ways of working. Two further themes relating to the person were identified: Home; Independence, and two relating to the service structure: MDT; Accessibility. These themes are directly associated with orthotic intervention in the way it is delivered and the effect it can have on the stroke survivor. Finally, two overarching themes inform the other themes: Acceptability and fidelity of orthotic intervention after stroke; Timeliness, impact of delays and secondary complications.
A triangulation exercise synthesised the findings of these three studies systematically into five themes of within which the proposed statements of best practice were developed. These themes were: The Orthotist; The Orthoses; The Patient; The Orthotic Service; Ways of Working. Finalised statements were then refined and agreed through professional consensus via an eDelphi exercise with expert orthotists from across the UK. Thirty-two responses were received with a retention rate of 87.5% across the two rounds. Ninety percent (n=29) of participants reported being qualified for six years or more indicating a high level of expertise. Sixty-four statements reached consensus agreement across the two-rounds of the eDelphi with an average consensus of 94.31%.
Conclusions
The first national clinical statements of best practice encompass different elements which inform optimum the ways of working when delivering orthotic intervention for stroke survivors. The 64 finalised statements of best practice have been developed systematically following the GRADE approach and from the findings of this five-stage mixed methods study. The statements were constructed directly from the themes and recommendations identified within the results of the concluding national eDelphi exercise which returned a high level of professional consensus, with participants representative of approximately 5% of the national orthotic expert workforce within the UK.
The developed statements of best practice address a paucity of guidance for the therapeutic use of orthotic intervention within mobility rehabilitation post-stroke. The effectiveness and acceptability of these statements within the applied healthcare setting should now be tested in a future evaluative trial.
Actions (Archive Staff Only)
 |
Edit View |
Tools
Tools
