The long-term effects of wearing and Ankle Foot Orthosis: the

experiences of stroke survivors

Dr Anne Taylor; Ms Gill Alexander; Ms Nicola Munroe; Ms Karen Kerr

Background

• Small clinical audit by one of the co-applicants (GA) found that only one patient attending her clinic could put their AFO on independently.

• All patients (N=5) reported long term problems with standing, transferring or mobilising when not wearing their AFO.

• All patients reported a history of falls due to instability in bare feet especially when going to the toilet overnight.

Background

• A scoping review of the literature identified a lack of studies exploring the long-term effects of AFO use, particularly in relation to bare foot activities.

• The literature was found to concentrate on • the long-term effect of gait (Hung et al, 2011; Meadows et al, 2008; Pavlik et al, 2008),

• effect on balance (Stevens 2010; Wang et al, 2007; Wang et al, 2003)

• muscle tone (Kobayashi et al 2011; Ibuki et al, 2010; Edwards, 2002).

• SIGN 118 (2010) highlighting that the aim of using an AFO is to improve mobility and quality of life, improve and facilitate increased independence of stroke survivors.

Aim

• To explore the experiences of wearing an AFO with stroke survivors

• Research Questions

1. What proportion of stroke survivors prescribed an AFO still use it after 1 year?

2. What are the key characteristics of people who use/not use an AFO?

3. What are the main reasons stroke survivors give for continuing/ceasing to use an AFO?

4. What are the experiences of stroke survivors who continue/cease to use an AFO?

The Study

• A mixed methods study where a questionnaire was developed & used to gather a range of views from stroke survivors on wearing and using an AFO, with telephone interviews used with a sub-sample of participants to explore their experiences in more depth.

• The Primary Care Local Enhanced Service database was searched for stroke survivors discharged from hospitals across NHS Greater Glasgow and Clyde (NHSGGC) in the last 1 to 5 years.

• The sample identified was then cross referenced against the NHSGGC Orthotic Database to identify all stroke survivors prescribed an AFO in the same time frame

Questionnaire

• Four broad areas explored:

• Length of time wearing AFO

• Appearance of AFO

• Functionality of AFO

• Follow up

Data Collection Methods

• A random sample of 500 stroke survivors lettered by a member of the orthotic team about the study and invited to participate.

• From the letter response rate (approx. 125-150) a sample of 100 stroke survivors will be contacted and asked to participate in the study and sent the questionnaire.*

• A sub sample of stroke survivors (n=20) who agreed to be contacted will be purposively sampled (gender, years post stroke, use of AFO) and invited to participate in a telephone interview. This interview will explore the questionnaire responses in more detail and in the context of their own experiences.

• Ethical approval will be sought from the West of Scotland Research Ethics Committee prior to the study starting.

Questionnaire Findings • 493 letters of invite posted to stroke survivors from merged databases

• 55 agreements to be contacted were returned • 7 informed no longer wear an AFO due to: short-term use/other comorbidities/preferred

other appliance ( FES)

• 1 could not participate due to time commitments

• 34 were contacted and agreed to complete questionnaire

• 24 returned questionnaire and signed consent form • 19 males & 5 females

RQ1. What proportion of stroke

survivors prescribed an AFO still use it after 1 year?

Out of the 24 respondents 16 (70%) reported wearing their foot

splint at some point with majority (54%) reporting

everyday

How many hours do you wear AFO?

Of those who reported wearing the foot splint, 50% of

participants require to wear the foot splint all of the time when

they are out of bed

Easy to get AFO on and off

54% reporting that they found their foot splint easy to get on

and off but there was a reasonable number of

participants who also reported having difficulties (38%)

Walking is steadier

The majority (83%) of participants reported that their

walking is steadier with their AFO on

Walking without AFO

67% of the participants reported that they do walk without the

foot splint

Falls with and without AFO

Interestingly there were similar response from participants

reported falling with and without AFO on.

Shown how to walk

46% reported being taught how to walk without an AFO however

over 50% of participants reported no or did not respond to

the question

RQ3. What are the main reasons

stroke survivors give for ceasing to use an AFO?

Too awkward to put on with Left sided weakness

I wore my splint every day until sores developed behind it - since

then I have been wearing walking boots

My legs requires bandages and have done for the past 2 years due

to an ongoing condition

I only wore it for about em … let’s think, probably about a month,

three or four weeks

Need for Review

When asked about follow up the majority of respondents (57%)

reported that they would like an annual review.

Telephone Interviews

• 17 participants agreed to a telephone interview (12 males & 5 females) • I interview failed

• I participant declined on the day

• Carried out by NM & GA

• Interviews audio-recorded and transcribed verbatim

• Analysis • Descriptive & thematic

RQ4 What are the experiences of stroke

survivors who continue/cease to use an AFO?

you got your foot splint when you were in the stroke unit …

Yeah, that's right

… and have you worn it every day since then?

Yes, I'm on the fourth one now (P002)

I: I wear it every day

R: Can you tell me why that is?

I: I've no idea, I was told to wear it and that was it (P008)

R: are you still wearing the splint just now, or are you wearing your shoes?

I: Nah, I can'nae get it on

R: How long did you wear it for then, to begin with?

I: About a year but stopped wearing it cause it was rubbing (009)

Wearing the foot splint

RQ4 What are the experiences of

stroke survivors who continue/cease to use an AFO?

I: the carers put it on and the only time I don’t wear it is a night when the carers get me ready for bed (P008)

I:need help to get it on? I can't sort of bend my foot the right way to get it in, and I can do it eventually by lying the thing on the floor and sort of gradually slipping my foot in and then the foot has to bend to go in the shoe , but which time I'm exhausted (P010)

Getting AFO on and off

RQ4 What are the experiences of

stroke survivors who continue/cease to use an

AFO? • Well I feel as if my knee juts out a wee bit without the splint when I walk, and that in turn em makes my foot jut out as well to the right but if I've got the splint on it keeps it straight forward more but I feel as if my knee’s immobilised, I can't move my knee (P009) Walking steadier

RQ4 What are the experiences of

stroke survivors who continue/cease to use an

AFO?

• I've fallen a couple o' times with the splint, but … I think maybe once, eh four times in two years. Just maybe tripped up or something like that. Oh it's always at home, aye (P008)

• I think it was partly the pavement and partly my lack of concentration …It was a trip. I just went straight down on my face and that was it …the next thing I know was, on the ground, I didn’t really have time to think about it, it was quite fast. Sometimes it's maybe me stopping concentrating on what I'm doing and maybe looking at something because you've got to almost think about every step you're taking, but if there was suddenly a noise or something, or something happens to the side of you and you turn to have a look that's when I feel as though I get unsteady (P005)

Falling with or without AFO

To date……

• Interview Analysis is ongoing

• Report due to CHSS by end of July

• Aim for publication towards end of the year

Thank you

Any questions?