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Background: Prosthetists and orthotists (POs) are essential members of the health care workforce and one of the United Kingdom's (UK's) allied health professions. There is a paucity of information on their demographics, which is essential for the development of the profession. To fill this void, this study has attempted to comprehensively explore the sociodemographics and work-related characteristics of the entire workforce., Methods: Data were collected in 2022 through multiple sources, including surveys of POs, private companies employing POs, and freedom of information requests to National Health Service Trusts/Health Boards and higher education institutes offering programs leading to registration as a prosthetist/orthotist., Results: The workforce survey had 641 respondents (74% response rate). The estimated national ratio of POs per million population was 13, with all bar of the 12 regions below the World Health Organization minimum recommendation of 15 POs per million population. Most of the survey respondents were female (47.6%) and younger than male respondents, were British (75.8%), and in the White ethnic group (74.3%). Most of them were employed by private companies (59.9% vs. 31.4% employed by the National Health Service) and had clinical duties (94%), permanent contracts (90%), worked full-time (75%), and treated a wide range of clinical conditions., Conclusions: The national UK prosthetist and orthotist ratio falls below the recommended international standards. The versatility and broad skill set of POs highlight their crucial role in multidisciplinary teams. Establishing a centralized prosthetist and orthotist workforce database system is recommended for data-driven strategic planning., (Copyright © 2024 International Society for Prosthetics and Orthotics.)

Background: An ankle foot orthosis (AFO) which is prescribed to be rigid should only deform a small amount to achieve its clinical goals. Material thickness and the design of reinforcing features can significantly affect AFO rigidity, but their selection remains based on anecdotal evidence., Objectives: To quantify the effect of these parameters on AFO stiffness and to set the basis for quantitative guidelines for the design optimisation of rigid AFOs., Study Design: Experimental and computational study., Methods: A polypropylene AFO was produced according to UK standard practice and its stiffness was experimentally measured for 30Nm of dorsiflexion. Its geometry and mechanical characteristics were utilised to create a finite element (FE) model of a typical AFO prescribed to be rigid. Following validation, the model was used to quantify the effect of material thickness and reinforcement design (i.e., reinforcement placement, length) on stiffness. A final set of AFO samples was produced to experimentally confirm key findings., Results and Conclusions: For a specific AFO geometry and loading magnitude, there is a thickness threshold below which the AFO cannot effectively resist flexion and buckles. FE modelling showed that stiffness is maximised when reinforcements are placed at the anterior-most position possible. This key finding was also experimentally confirmed. The stiffness of an AFO reinforced according to standard practice with lateral and medial ribbing was 4.4 ± 0.1 Nm/degree. Instructing the orthotic technician to move the ribbings anteriorly increased stiffness by 22%. Further stiffening is achieved by ensuring the reinforcements extend from the footplate to at least two-thirds of the AFO's total height., (Copyright © 2023 International Society for Prosthetics and Orthotics.)

Objective: The purpose of this study was to investigate rigid ankle-foot orthosis (AFO) prescription practices for adult men among UK orthotists., Design: A cross-sectional study using a survey was distributed online to UK orthotists by the British Association of Prosthetists and Orthotists to its members and through social media and orthotic networks. The survey was completed between November 1, 2020, and November 29, 2020., Main Outcome Measures: Descriptive statistics of survey results include information related to the material used, the thickness of the material, positive cast rectification, AFO reinforcement, footplate design, padding, strapping system, and height of AFO., Results: One hundred participants completed the survey, which equates to a response rate of 30.5% of the British Association of Prosthetists and Orthotists members targeted. A clear consensus emerged on the design of a bespoke rigid AFO for the hypothetical patient in this study, which is detailed as follows: 1) 4.5 mm copolymer polypropylene, 2) no additional reinforcement, 3) full-length footplate with mediolateral trimlines terminating behind the metatarsal heads, 4) 3-point correction with parallel sides, 5) padded VELCRO straps with D-rings at the calf and heel, 6) no forefoot or other additional strapping, 7) 3-mm PORON (international Ltd) padding at the malleoli, and 8) AFO height that finishes 2 cm below the fibular head., Conclusions: This study has highlighted a consensus on AFO prescription/design among UK orthotists surveyed, based on the hypothetical patient described in this study., (Copyright © 2022 International Society for Prosthetics and Orthotics.)

Background: COVID-19 has had a significant impact on the National Health Service in the United Kingdom (UK)., Objective: This study aimed to determine the impact of COVID-19 on orthotic services in the United Kingdom., Study Design: Cross sectional survey., Methods: An online survey was distributed to UK orthotists approximately 6 months after the first peak of COVID-19. Descriptive statistics of results related to appointment waiting times, disruption of services, introduction of telehealth appointments, and clinicians' opinions on the impact of COVID-19 was completed., Results: Seventy-seven orthotists completed the survey, with many reporting that their service was closed or open only to inpatients/urgent patients at some point during the pandemic. There were substantial variation in appointment waiting times, time allocated per appointment, and increases in lead times for orthotic products across services. Over 90% reported using telehealth appointments. Results were comparable with previous research showing long appointment waiting times and indicated that the pandemic has added to this issue., Conclusions: The pandemic has had a significant impact on orthotic services with face-to-face appointments largely reserved for urgent patients and inpatients, and services going through stages of closing and reopening, alongside the introduction of telehealth to ensure less urgent patients could continue to access orthotic care. Future service evaluation studies are required to further assess how orthotic services have been affected by the pandemic and the effectiveness of recovery plans., (Copyright © 2021 International Society for Prosthetics and Orthotics.)

Background: Relatively little is known about spine during gait compared to movement analysis of the lower extremities. The trunk is often regarded and analysed as a single rigid segment and there is a paucity of information on inter-segmental movement within the spine and its relationship to pelvis and lower limbs., Objectives: To develop and validate a new multi-segment kinematic model to assess regional three-dimensional movement of the lumbar, lower thoracic and upper thoracic spine during gait., Study Design: Observational study., Methods: The study was conducted in two parts: (1) to provide validation measures on the kinematic model built in commercially available software and (2) to apply the marker configuration to the spine at T3, T8 and L3 during gait analysis on 10 healthy male volunteers., Results: Proposed model revealed excellent concurrent validation measures between an applied input angle to the recorded output angle from the kinematic model. A high reliability was observed during gait analysis, both during a single session and between sessions for all participants., Conclusion: The thoracic region of the spine should not be modelled as a single rigid segment and the proposed three-dimensional cluster is reliable and repeatable to assess the inter-segmental movement of the spine., Clinical Relevance: Reliable kinematic data can be collected using the three-dimensional cluster technique, thus, allowing researchers to accurately distinguish between movement patterns of healthy individuals to those with a clinical condition, and provide confidence in data acquisition during the monitoring process of an implemented rehabilitation intervention programme., (© The International Society for Prosthetics and Orthotics 2015.)

Background: There is a paucity of evidence regarding the design of children's footwear in relation to musculoskeletal structure., Objectives: The aim was to gain consensus regarding where flexibility and support should be given on a school shoe for the 6- to 10-year-olds., Study Design: Delphi Questionnaire., Methods: Recruitment of 10 Allied Health Professionals yielded a consensus group. Those recruited had dedicated experience in paediatrics and foot health. Rounds of questions were delivered to investigate the basis of the opinions made by the group on the location of support and flexibility in a school shoe for the age range identified., Results: Six themes were generated. Four themes gained 100% consensus regarding footwear allowing normal foot movement, footwear allowing normal forefoot function, footwear providing a stable base and the foot being secure in the shoe. Fleiss' kappa calculations revealed 'poor agreement' for the remaining two themes regarding clinical intervention and the purpose of footwear design in the midfoot in both the upper and sole of the shoe., Conclusion: The qualitative data generated through discussion have highlighted areas where more understanding and research are required, particularly in understanding how, in the long term, shoe design can affect the developing foot., Clinical Relevance: Children's footwear advice is often delivered from experience and personal belief. This article questions current understanding and opinion from clinical experts in the field of paediatric footwear and highlights that there is a lack of knowledge and confidence into the effects of children's footwear. There is a strong requirement for further empirical research to be completed on children's footwear to allow clinicians to formulate relevant and appropriate footwear advice., (© The International Society for Prosthetics and Orthotics 2014.)

Background: Ankle foot orthoses are used to treat a wide variety of gait pathologies. Ankle foot orthosis-footwear combination tuning should be routine clinical practice when prescribing an ankle foot orthosis. Current research suggests that failure to tune ankle foot orthosis-footwear combinations can lead to immediate detrimental effect on function, and in the longer term, it may actually contribute to deterioration., Objectives: The purpose of this preliminary study was to identify the current level of knowledge clinicians have in the United Kingdom regarding ankle foot orthosis-footwear combination tuning and to investigate common clinical practice regarding ankle foot orthosis-footwear combination tuning among UK orthotists., Study Design: Cross-sectional survey., Methods: A prospective study employing a multi-item questionnaire was sent out to registered orthotists and uploaded on to the official website of British Association of Prosthetists and Orthotists to be accessed by their members., Results: A total of 41 completed questionnaires were received. The results demonstrate that only 50% of participants use ankle foot orthosis-footwear combination tuning as standard clinical practice. The most prevalent factors preventing participants from carrying out ankle foot orthosis-footwear combination tuning are a lack of access to three-dimensional gait analysis equipment (37%) and a lack of time available in their clinics (27%)., Clinical Relevance: Although, ankle foot orthosis-footwear combination tuning has been identified as an essential aspect of the prescription of ankle foot orthoses, the results of this study show a lack of understanding of the key principles behind ankle foot orthosis-footwear combination tuning., (© The International Society for Prosthetics and Orthotics 2014.)

Background: Unstable shoes, which have recently become popular, claim to provide additional physiological and biomechanical advantages to people who wear them. Alterations in postural stability have been shown when using the shoe after training. However, the immediate effect on muscle activity when walking in unstable shoes for the first time has not been investigated., Objective: To evaluate muscle activity and temporal parameters of gait when wearing Masai Barefoot Technology shoes(®) for the first time compared to the subject's own regular trainer shoes., Study Design: A pilot repeated-measures quasi control trial., Method: Electromyographic measurements of lower leg muscles (soleus, medial gastrocnemius, lateral gastrocnemius, tibialis anterior, peroneus longus, rectus femoris, biceps femoris and gluteus medius) were measured in 15 healthy participants using Masai Barefoot Technology shoes and trainer shoes over a 10-m walkway. Muscle activity of the third and sixth steps was used to study the difference in behaviour of the muscles under the two shoe conditions. Temporal parameters were captured with footswitches to highlight heel strike, heel lift and toe off. Paired samples t-test was completed to compare mean muscle activity for Masai Barefoot Technology and trainer shoes., Results: Indicated that the use of Masai Barefoot Technology shoes increased the intensity of the magnitude of muscle activity. While this increase in the activity was not significant across the subjects, there were inter-individual differences in muscle activity. This variance between the participants demonstrates that some subjects do alter muscle behaviour while wearing such shoes., Conclusion: A more rigorous and specific assessment is required when advising patients to purchase the Masai Barefoot Technology shoe. Not all subjects respond positively to using unstable shoes, and the point in time when muscle behaviour can change is variable., Clinical Relevance: Use of Masai Barefoot Technology shoe in patient management should be monitored closely as the individual muscle changes and the point in time when changes occur vary between subjects, and evaluation of how a subject responds is not yet clear.

Background: The assessment of the maximum ankle dorsiflexion angle is an important clinical examination procedure. Evidence shows that the traditional goniometer is highly unreliable, and various designs of goniometers to measure the maximum ankle dorsiflexion angle rely on the application of a known force to obtain reliable results. Hence, an innovative ankle dorsiflexion measurement device was designed to make this measurement more reliable by holding the foot in a selected posture without the application of a known moment., Objectives: To report on the comprehensive validity and reliability testing carried out on the new device., Methods: Following validity testing, four different trials to test reliability of the ankle dorsiflexion measurement device were performed. These trials included inter-rater and intra-rater testings with a controlled moment, intra-rater reliability testing with knees flexed and extended without a controlled moment, intra-rater testing with a patient population, and inter-rater reliability testing between four raters of varying experience without controlling moment. All raters were blinded., Study Design: A series of trials to test intra-rater and inter-rater reliabilities., Results: Intra-rater reliability intraclass correlation coefficient was 0.98 and inter-rater reliability intraclass correlation coefficient (2,1) was 0.953 with a controlled moment. With uncontrolled moment, very high reliability for intra-tester was also achieved (intraclass correlation coefficient = 0.94 with knees extended and intraclass correlation coefficient = 0.95 with knees flexed). For the trial investigating test-retest reliability with actual patients, intraclass correlation coefficient of 0.99 was obtained. In the trial investigating four different raters with uncontrolled moment, intraclass correlation coefficient of 0.91 was achieved., Conclusions: The new ankle dorsiflexion measurement device is a valid and reliable device for measuring ankle dorsiflexion in both healthy subjects and patients, with both controlled and uncontrolled moments, even by multiple raters of varying experience when the foot is dorsiflexed to its end of range of motion., Clinical Relevance: An ankle dorsiflexion measuring device has been designed to increase the reliability of ankle dorsiflexion measurement and replace the traditional goniometer. While the majority of similar devices rely on application of a known moment to perform this measurement, it has been shown that this is not required with the new ankle dorsiflexion measurement device and, rather, foot posture should be taken into consideration as this affects the maximum ankle dorsiflexion angle.

Background: There are a wide variety of ankle foot orthoses used in clinical practice which are characterised by their design, the material used and the stiffness of that material. Changing any of these three components will alter the effect of the ankle foot orthosis on gait., Objectives: The purpose of this article is to provide an overview on the available research on ankle foot orthosis-footwear combination tuning on the gait characteristics of children with cerebral palsy through a structured review., Study Design: Literature review., Methods: A thorough search of previous studies published in English was conducted within all major databases using relevant phrases without any limits for the dates. These searches were then supplemented by tracking all key references from the appropriate articles identified including hand searching of published books where relevant., Results: To date, there are 947 papers in the literature pertaining to the study of ankle foot orthosis. Of these, 153 investigated the use of ankle foot orthosis for children with cerebral palsy. All the studies included in this review were of a within-subjects design and the evidence levels were generally low., Conclusions: The overall results suggested that ankle foot orthosis-footwear combination tuning has the potential to improve the kinematics and kinetics of gait in children with cerebral palsy. However, the review highlights a lack of well-designed and adequately powered studies. Clinical relevance While the research described in this article indicates an improvement in the gait of children with cerebral palsy following tuning of their ankle foot orthosis-footwear combination, there is still a paucity of research with quantitative data on the effects of kinematics and kinetics of ankle foot orthosis-footwear combination tuning, comparing untuned ankle foot orthosis-footwear combinations with tuned ankle foot orthosis-footwear combination. Furthermore, current research does not identify the effect of tuning on energy efficiency.

Background: Participation in sport and exercise training, while aiding in the reintegration and confidence building of wounded service personnel, also has potential to prepare them for elite sport competition. It is this encouragement of the war injured to use sport and recreational physical activity as a means of rehabilitation back into civilian life, which has become the worldwide phenomenon of Paralympic sport., Objectives: This paper evaluates existing research relating to the incidence of types of war injuries and the use of sport within the rehabilitation process., Study Design: Literature review., Methods: Initial searches were conducted in the electronic databases EBSCOHost, ScienceDirect and Pubmed using the keywords 'veterans' and 'sport' or 'physical activity'. These searches were then supplemented by tracking all key references from the appropriate articles identified. A narrative literature review methodology was employed., Results: Although it is clear from the reported literature that further development of available rehabilitation services is necessary to provide the required level of care for the types of mental and physical injuries and the concept of 'therapeutic recreation' is becoming popular, there is still a need for the development of specific protocols to identify individuals who can participate and excel in a specific sport at an elite level., Conclusions: Drawing on the US military experience it can be argued that sport in the UK and other parts of the world should be more widely recognized as a component of rehabilitation. This is not just for the role that sport can play as a tool for rehabilitation but also for the intrinsic and extrinsic benefits that participation in elite sport can offer.

Background: Currently there is a paucity of research providing recommendations on the type of orthotic or material used in its construction for different patient requirements., Objectives: To gain a greater understanding of the characteristics of orthotic materials and how they affect gait so to enhance the clinical decision-making process., Study Design: Repeated measures., Methods: Plantar pressures and kinematics were evaluated for 10 participants while walking on a treadmill under various conditions which included, shoes only and shoes with four different flat insoles and custom devices created in each of two densities of two materials., Results: For the flat insoles, medium density ethyl vinyl acetate was found to produce greater peak pressures than at least one of the other material conditions and low and medium density polyurethane were most effective at increasing average contact area and at reducing pressure time integral. For the custom devices, while no significant differences were evident, when compared to the shoe only condition, medium density polyurethane increased average contact area by a greater percentage than the other materials., Conclusions: Results for medium density polyurethane suggest a possible difference in loading characteristics, indicating a potential material suitability for patients with a compromised ability to deal with pressure.

Background: Measurement of ankle joint dorsiflexion is an essential examination technique that needs to be performed prior to prescription of foot orthoses since the presence or absence of ankle equinus will affect the design of such devices. The purpose of this study was to investigate the effect of foot posture on sagittal plane kinematics of various foot segments during passive dorsiflexion., Study Design: Comparative repeated measures design., Objectives: To determine the effect of foot posture on inter segmental kinematics during passive dorsiflexion., Methods: An optoelectronic movement analysis system was employed to collect kinematic data. A validated marker set (Oxford Foot Model) was applied to 16 subjects (12 males, 4 females) with a mean age of 35.5 years (range 20-56 years), who provided informed consent. An upward force was applied to the forefoot until maximum resistance. Sagittal movement of the hindfoot and forefoot segments along with the whole foot movement were analyzed in the pronated, neutral and supinated foot postures., Results: While maximum foot dorsiflexion angle showed a significant difference between the three postures (p = 0.000) the actual recorded difference between the neutral and supinated postures was only 2.49°. For the hindfoot and forefoot segments, mean angle range of movement for the pronated foot posture was significantly higher than the other foot postures. The forefoot to hindfoot angle demonstrated a significant (p = 0.005) increase during dorsiflexion between the pronated and supinated postures. These results indicate that during passive dorsiflexion, the forefoot travels through a greater degree of movement than the hindfoot., Conclusions: While the maximum foot dorsiflexion angle differs significantly between the pronated and supinated foot postures, hindfoot movement also varies significantly between foot postures. Furthermore, the forefoot to tibia angle travels through a greater range than the hindfoot to tibia angle, in all three foot postures. The hindfoot to forefoot angle does not remain constant during passive dorsiflexion, but increases upon application of a dorsiflexing force, indicating that the forefoot movement cannot be eliminated completely by placing the foot in any particular posture.