Satisfaction and long-term use of orthopedic shoes in people with chronic stroke

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Satisfaction and long-term use of orthopedic shoes in

people with chronic stroke

Marjorie Kerzoncuf, Mathias Jaouen, Julien Mancini, Alain Delarque, Laurent

Bensoussan, Jean Michel Viton

To cite this version:

Marjorie Kerzoncuf, Mathias Jaouen, Julien Mancini, Alain Delarque, Laurent Bensoussan, et al..

Satisfaction and long-term use of orthopedic shoes in people with chronic stroke. Annals of Physical

and Rehabilitation Medicine, Elsevier Masson, 2018, 61 (3), pp.180-182. �10.1016/j.rehab.2018.02.002�.

�inserm-02560422�

Letter

to

the

editor

Satisfactionandlong-termuseoforthopedicshoesin peoplewithchronicstroke

DearEditor,

The most common impairment caused by stroke is motor impairment,whichaffectsabout80%ofstrokesurvivors[1].About two-thirdsofsuchindividualshavegaitimpairmentsduringthe earlyphaseafterstroke.At6monthsafterstroke,30%cannotwalk independently [2]. Foot and ankle deficiencies such as spastic equinovarusfootcanleadtofootdragandankleinstabilitywitha riskoffalls.Therapeuticoptionsforthesedisordersare physio-therapy,local treatment ofspasticity, equipmentsuch asankle orthosisororthopedicshoes,andsurgery.

Orthopedicshoeshavebeenfoundhelpfulfortemporaryuse during the subacute phase of stroke [3]: they can improve functionalandquantitativegaitparameters.After stroke, ortho-pedicshoesareoftenprescribedtoreducefootdrag,improvehind footstability,andcompensateforfootabnormalities(clawtoesor halluxclaw,halluxerectus).

However,whenorthopedicshoesareprescribed,theyarenot alwayswornforalongtime[4],soitseemsimportanttofocuson users’satisfaction, which affects adherence. To the best of our knowledge,no studieshave focused on orthopedic shoesin an ambulatorychronicpost-strokepopulation.Theaimofthepresent studywastoassesssatisfactionwithwearingorthopedicshoesin peopleafterstroke.

We conducted a retrospective, monocentric study in a departmentofphysicalandrehabilitationmedicine.Peoplewith chronicstrokewearingtheirfirstorthopedicshoeswererecruited. The orthopedic shoes were made by the same podo-orthosist betweenDecember2010and December2012.Inclusioncriteria werepost-strokehemiplegia,aminimumof12monthssincethe stroke,andage>18years.Exclusioncriteriawereotherdiseases responsible for gait or balance deficiency, cognitive or phasic disorders, and use of an orthotic device. People we could not contactwereexcluded.Participantswereincludedintheprotocol after providing informed consent as required by the Helsinki Declaration(1975).InaccordancewithFrenchlaw,atthetimeof thestudy,thisretrospectivestudydidnotrequiretheapprovalof anethicscommittee.

Thefollowingdatawerecollectedfromthemedicalrecordsfor allparticipants:demographicandclinicaldata(sex,age,typeof stroke,timesincestroke,spasticityonthemodifiedAshworthscale [range0–5], rangeofmotion),and specificationsfororthopedic shoes.Participantswerecontactedbyphone,andinformationwas collectedbyonephysicalandrehabilitationmedicinespecialist.

Theprimaryendpointwassatisfactionwiththeeffectofthe orthopedicshoesonwalkingasmeasuredbya hetero-question-nairedevelopedbyTysonetal.[5]andusedbyEckhardtetal.

[3].Secondaryendpointsweretheuseoforthopedicshoes(how

often,howlong),satisfactionontheQuebecUserEvaluationof SatisfactionwithassistiveTechnology(QUEST)questionnaire[6], andanobjectivefunctionalassessmentofwalkingperformance (based on the modified Functional Ambulation Classification scale)[7].

Thescoresforthescalesarepresentedasmedian(interquartile range [IQR]) and continuousdata are presented as mean (SD). StatisticalanalysisinvolvedusingSPSSv20.0(SPSSIBMInc.,New York,USA).

Weincluded36peoplewhohadastroke(Fig.1).Demographic andclinicaldataaresummarizedinTable1.Excludedparticipants didnotdiffersignificantlyfromthestudypopulation.

Thespecificationsmostfrequentlyaskedofthepodo-orthosist weretoraisetheforefoot(n=31participants,86.1%),stabilizethe hindfoot(n=29,80.6%),andadapttheshoetoaclawtoe(n=26, 72.2%),halluxclaw(n=21,58.3%),orhalluxerectus(n=3,8.3%). Thequestionaboutrateofshoewearingwasaskedatameanof 2years(median24.41months[IQR14–33])aftertheshoeswere delivered;34participants(94.5%)werestillwearingtheirshoes, and 2 were not (5.5%). Overall, 22 participants (61.1%) were wearingtheshoesdailyduringtheday,6(16.7%)werewearing themdailyforonlyoutsideactivity,and6(16.7%)werewearing them3–4days/weekforonlyoutsideactivity.

Mostparticipantsreportedthattheshoeshadpositiveeffects on satisfaction(medianscore>3)in termsofwalkingdistance, improvementin swingphase,weightbearingduringthestance phase,self-confidence,andsafety.Mostparticipantsreportedthat walkingvelocityhadnotchanged.

ThemediantotalsatisfactionscoreontheQUESTwas50[49– 52].Satisfactionwaspositive(totalscore>36)for34participants

AnnalsofPhysicalandRehabilitationMedicine61(2018)180–182

Fig.1.Flowofparticipantsinthestudy.

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https://doi.org/10.1016/j.rehab.2018.02.002

(94.5%)butwasnegativeorneutral(totalscore36)for2(5.5%) (Table 2). A median score of 4 or 5, corresponding to ‘‘quite satisfied’’ or ‘‘very satisfied’’ was obtained for all items except repair services. Items on which most of the participants were satisfiedweretherobustnessoftheshoes,theireaseofuse,quality oftheprofessionalservicesprovidedandqualityoffollow-up,size of the shoes, ease of adjustment, and efficiency in terms of objectives.The item for which the participantswere the most dissatisfiedwastheweightoftheshoes.

The2participantswithanegativeQUESTscorewerethesame 2whohadabandonedtheirshoes;theirglobalQUESTscorewas lowerthanfortheotherparticipants( 13.8to 16.8,P<0.001). Participantswhoworetheirshoesdailyandthosewhousedthem occasionally did not differ in total QUEST score ( 2.7 to 7.2, P=0.32),nordidparticipantswhoworetheirshoesalldayand thosewhoworethemonlyoutside( 0.9to5.7,P=0.17).

The modified Functional Ambulation Classification score was significantly improved for participants who wore their shoes versus went barefoot: median 6 versus 4 (P<0.001) (Table3).

Theself-reportedqualitativeimprovementingaitafterwearing orthopedicshoesfocusedonwalkingdistance,improvementinthe swing phase, weight bearing during the stance phase, self-confidence when walking, and safety. A study also using this scale found similar results [3]: more than 90% of participants reportedimprovedwalkingdistance,self-confidence,andsafety. Concerningsecondaryendpointsinourstudy,overallsatisfaction with the orthopedic shoes was very good: the global median QUESTscorewas50.Overall,94.5%oftheparticipantshadatotal QUESTscore>36,correspondingtopositivesatisfaction. Partici-pantsweremostdissatisfiedwiththeweightoftheshoes,whichis known in our clinical practice to be a recurring reason for dissatisfaction,despitetheprogressinmakingmaterialslighter. Mostparticipantswere‘‘moreorlesssatisfied’’withthequalityof therepairservices,simplybecausetheyhadnotneededtheirshoes repaired.VanNettenetal.[4,8]studiedparticipants’satisfaction withorthopedicshoesbutgavenodetailsaboutthespecifications orthelimits.Satisfactionwasestimatedonthebasisoftheshoe design(whichwasnotincludedintheQUESTscore):theoverall scorewas54/100;thequalityoftheprofessionalserviceswas82/ 100 in terms ofcommunication withthe doctorand 84/100 in terms ofcommunication withthepodo-orthosist. Theseresults agree with our findings on participants’ satisfaction with the

Table3

Participants’qualitativeassessmentoftheirowngaitwhenwearingorthopedicshoesbasedonthemodifiedFunctionalAmbulationClassificationscale.

Medianscore Positiveeffect Noeffect Negativeeffect

Walkingdistance 4 28(77.8) 6(16.7) 2(5.5)

Gaitspeed 3 14(36.1) 21(61.1) 1(2.8)

Footlifting 3 17(47.3) 15(41.7) 2(5.5)

Swingphase 4 25(69.4) 11(30.6) 0

Weightbearingduringstancephase 4 31(86.1) 5(13.9) 0

Selfconfidence 4 33(91.7) 1(2.8) 2(5.5)

Safety 4 25(69.4) 11(30.6) 0

Dataaren(%). Table2

SatisfactionwithwearingorthopedicshoesontheQuebecUserEvaluationofSatisfactionwithassistiveTechnology(QUEST)questionnaire. Medianscore Satisfaction

Positive(score>3) Neutral(score=3) Negative(score<3) Technologicalaspectsofshoes

Size 4 31(86.1) 0 5(13.9) Weight 4 23(63.9) 2(5.5) 11(30.6) Easytoadjust 4 31(86.1) 3(8.4) 2(5.5) Safetowear 5 25(69.4) 11(30.6) 0 Robustness 5 32(89) 2(5.5) 2(5.5) Easytouse 4 32(89) 2(5.5) 2(5.5) Comfort 4 29(80.6) 5(13.9) 2(5.5) Efficiency 5 31(86.1) 5(13.9) 0 Servicesprovided Prescriptionprocedure 4 30(83.3) 3(8.4) 3(8.4) Repairservices 3 14(38.9) 22(61.1) 0 Professionalservices 5 32(89) 0 4(11) Qualityoffollow-up 4 32(89) 4(11) 0 Dataaren(%). Table1

Demographicdataforparticipantswithstrokeincludedandexcludedinthestudy ofwearingorthopedicshoes.

Included Excluded n=36 n=4

Sex(M/F) 15/21 2/2

Meanage(years) 62 59

Stroketype(ischemic/hemorrhagic) 29/7 4/0 Strokeside(right/left) 20/16 * Timesincestroke(months),mean 76 60 TimesinceOSdelivery(months),mean 24 * ModifiedAshworthScore(/5)

Gastrocnemii2 6 0 3 21 3 4 7 1 Soleus1 2 0 2 24 3 3 10 1 Tibialisposterior1 34 3 2 2 1

Rangeofmotionoftalocruraldorsiflexion,mean

kneeextended(degree) 0 8

kneeflexed(degree) +10 0

Subtalarjointmobility(normal,limited,augmented) 28/6/2 3/1/0 OS,orthopedicshoes.

quality ofthe professionalservicesand with follow-up,with a medianscoreof4/5.Intermsofadherence,after2yearsof follow-up, 94.5% of the participants were still wearing their shoes regularly.These results agree with Van Netten et al. [4], who reported 86% of participants still wearing their shoes after 1.5 years. However, that study included people with different pathologies.

Aswell,wefoundimprovedmodifiedFunctionalAmbulation Classificationscores:underbarefootconditions,themedianscore was4but6withorthopedicshoes.

Thefirstlimitationofourstudyisthatitwasaretrospective studybyphonesurvey.Itassessedthesatisfactionofpeoplewho hada stroke ‘‘in real life and after a long time’’, which is of importanceforthistypeofdevicebecauseitiswellknownthat onlysatisfactioninducespeopletoweartheequipment.Another limitationisthelack ofcomparison betweenorthopedic shoes and usual shoes. However, there are no exact definitions for normalandfactoryshoes,andthewalkingconditionsarelikelyto varyconsiderablyamongparticipants.Inoureverydaypractice, thegaitofpeoplewhohadastrokeisoftenassessedwhenthey arewearingtheir‘‘usual’’shoes,buttheseshoesdiffer consider-ably:theycanhaveloworhighuppers,openorclosedforeparts, andlow or high heels. Another limitation is that we did not consider the esthetics of orthopedic shoes. Concerning the population,thepeopleincludeddidnothavesevereorthopedic deformationsandhadquite goodautonomy,witha Functional AmbulationClassificationscoreof4beforeputtingontheshoes. People excluded had more severe deformations, and their adaptation to the shoes may have been more difficult and thereforelowersatisfaction.Afurtherprospectivestudywitha largercohortincludingpeoplewhohada strokewiththe first-everorthopedicshoesprescribed,comparingorthopedic shoes, usualshoes, andthebarefoot condition withquantitative gait analysiswouldbeofinterest.

Orthopedicshoesareanefficientmeansofimprovinggaitand correctingimpairmentssuchasfootdrag,hind-footinstability,and foot deformities in people after a stroke. Adherence to and satisfactionwithwearingtheshoesseemtobegood.

Funding

This research received no specific grant from any funding agencyinthepublic,commercialornot-for-profit-sectors.

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest. Acknowledgement

JulieBertolino,podo-orthosist. References

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[3]EckhardtMM,MulderMCB,HoremansHL,vanderWoudeLH,RibbersGM.The effectsofhighcustommadeshoesongaitcharacteristicsandpatient satisfac-tioninhemiplegicgait.GaitPosture2011;34:543–7.

[4]VanNettenJJ,JanninkMJ,HijmansJM,GeertzenJH,PostemaK.Long-termuseof custom-madeorthopedicshoes:a1.5-yearfollow-upstudy.JRehabilResDev 2010;47:643–9.

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[7]Park CS, An SH. Reliability and validity of the modified functional ambulationcategoryscaleinpatients withhemiparalysis. JPhysTherSci 2016;28:2264–7.

[8]vanNettenJJ,GeertzenJH.Useandusabilityofcustom-madeorthopedicshoes. JRehabilResDev2010;47:73.

M.Kerzoncufa,_*,M.Jaouenb_,J.Mancinic_,A.Delarquea_{,L.Bensoussan}a_,

J.-M.Vitona a_{AixMarseilleUniv,APHM,INT,InstNeurosciTimone,CHUTimone,}

PhysicalandRehabilitationMedicineDepartment,13005Marseille, France

b_{AixMarseilleUniv,APHM,CHUTimone,PhysicalandRehabilitation}

MedicineDepartment,13005Marseille,France

c_{AixMarseilleUniversite´,Inserm,IRD,13005Marseille,France}

*Correspondingauthor E-mailaddress:marjorie.kerzoncuf@ap-hm.fr(M.Kerzoncuf). Received24October2017 Accepted9February2018 Availableonlinexxx Lettertotheeditor/AnnalsofPhysicalandRehabilitationMedicine61(2018)180–182