Orthotic Care After Stroke: Building UK Consensus

Ava

Welcome to the podcast. I’m Ava, and I’m joined by David. Today, we are discussing an important new paper on the delivery of orthotic interventions following stroke. The study addresses a longstanding gap in UK stroke rehabilitation. Although orthotic interventions can support standing, walking, independence and the prevention of secondary complications, there has previously been no UK wide professional consensus describing how orthotists should be involved in stroke rehabilitation services.

David (2)

That is exactly what makes this paper significant. Rather than evaluating a particular orthosis or treatment technique, the researchers focused on how services should work. They asked experienced UK orthotists to agree statements describing best practice for the assessment, prescription and delivery of orthotic interventions after stroke.

Ava

The researchers used a modified electronic Delphi study, often referred to as an eDelphi. This is a structured method for developing professional consensus by asking a group of experts to consider and rate a series of statements over more than one round. Thirty two orthotists participated in the first round, and twenty eight completed the second, giving a retention rate of 87.5 per cent. Participants had at least two years of experience in delivering orthotic interventions within stroke rehabilitation.

David (2)

The initial questionnaire contained 65 proposed statements. These had been developed through earlier research, including a systematic review, professional surveys and consultation with stroke survivors, carers and healthcare professionals. The final framework contains 64 statements organised into five themes: the orthotist, the orthoses, the stroke survivor, the orthotic service and ways of working.

Ava

The level of agreement was striking. The study reported an overall consensus level of 94.31 per cent across the statements. This suggests that, despite variations in service models and clinical settings, there is considerable agreement among orthotists about what good post stroke orthotic care should look like.

David (2)

One statement is particularly interesting because it highlights the difference between defining best practice and delivering it within existing services. The experts agreed that when an orthotist is not embedded within a stroke rehabilitation unit or community team, the orthotist should attend to assess and treat patients at least once a week.

Ava

That statement reached the study’s predetermined consensus threshold of 75 per cent. Clinically, the reasoning is understandable. Regular contact can support timely assessment and treatment, improve communication between orthotists and the wider stroke team, facilitate knowledge exchange and reduce delays in accessing appropriate intervention.

David (2)

Early involvement can be particularly important for stroke survivors experiencing impaired motor control, mobility difficulties, abnormal alignment, tone, spasticity or a risk of contracture. The statements also recognise that orthotic intervention is not simply about supplying a device. It involves specialist biomechanical assessment, collaborative goal setting, appropriate prescription, fitting, tuning, education and ongoing review.

Ava

However, the recommendation for weekly attendance raises an important implementation question. The paper reports that there were 1,187 dual registered prosthetists and orthotists in the UK in March 2023. It estimates that approximately half were practising as orthotists, giving a workforce of around 593 registered orthotists. That is a relatively small workforce responsible for a wide range of services, including neurological rehabilitation, paediatrics, musculoskeletal care, diabetic foot management and many other complex clinical areas.

David (2)

Many orthotists also work across several hospitals, clinics and community settings. In that context, weekly attendance at every stroke unit may be difficult for some services to provide immediately. But it is important to be precise about what the paper is saying. The researchers did not describe these statements as deliberately unachievable, nor did they present them as a criticism of individual clinicians or services. They describe optimal ways of working and provide a professionally agreed picture of best practice.

Ava

That distinction matters. Statements of best practice should not simply reproduce the limitations of existing services. Their purpose is to describe the standard that services should work towards and to support clinicians, commissioners and patients in understanding what high quality care requires.

David (2)

Exactly. A service that cannot currently provide regular orthotist involvement should not interpret the statement as a judgement on its clinicians. Instead, it can use the consensus to examine referral pathways, workforce capacity, multidisciplinary working and commissioning arrangements.

Ava

The wider set of statements reinforces that message. The experts agreed that orthotists should be integral members of the stroke rehabilitation team, involved in multidisciplinary assessments and able to contribute to rehabilitation goals. They also agreed that orthotic services should be planned, commissioned and funded to provide specialist, individualised assessment and treatment for stroke survivors.

David (2)

The paper therefore places responsibility not only on individual practitioners, but also on the systems surrounding them. Best practice depends on appropriate service design, adequate investment, effective referral pathways, collaboration between professions and equitable access across acute, community and longer term rehabilitation settings.

Ava

Another important feature is the focus on the stroke survivor. The statements support timely and equitable assessment, consideration of communication and cognitive difficulties, involvement of carers where appropriate, written and verbal information, follow up appointments and access to reassessment as needs change. They also recognise that orthotic assessment may be valuable for people with severe impairments or those who are not independently mobile, particularly where an orthosis may improve comfort, positioning, transfers or care delivery.

David (2)

There is also a strong emphasis on clinical reasoning. The paper supports orthotist-led prescription based on biomechanical principles, appropriate use of both custom made and prefabricated orthoses, tuning to optimise function, and the use of outcome measures to evaluate the effects of intervention.

Ava

Taken together, these statements provide more than a clinical checklist. They offer a framework for improving pathways, strengthening multidisciplinary relationships, and reducing unwarranted variation in care. They also provide a foundation for future research to investigate how these recommendations can be implemented and whether they improve outcomes for stroke survivors.

David (2)

The key message is that professional consensus can help define what good care should look like, even where services may require additional capacity or redesign to deliver it consistently. Recognising a gap between current provision and best practice is not a reason to lower the standard. It is an opportunity to identify what needs to change.

Ava

We strongly encourage clinicians, service managers, commissioners, researchers and anyone involved in stroke rehabilitation to read the full paper. The complete title is “Professional consensus on UK national statements of best practice for ways of working to deliver orthotic interventions after stroke: an eDelphi study.” It was published in the Journal of Rehabilitation Medicine in 2026, volume 58. The lead author is Miriam Golding Day, from the Centre of Rehabilitation and Ageing Research at the University of Nottingham.

David (2)

Thank you for listening. We hope this discussion encourages further conversation about how orthotic expertise can be integrated more consistently into stroke rehabilitation.