Adapting AFO parameters to optimise true neuromotor recovery of gait during early phases of rehabilitation following a stroke

Outcomes from the gait rehabilitation of stroke survivors are disappointing with mean walking speeds at discharge - 0.7m/s - that are well below aged matched healthy peers and too slow to safely use a pedestrian crossing. This is despite recovery of walking being a priority for therapists and stroke survivors.
The ability to generate forward propulsion is clearly important for achieving the walking speeds (and changes in speed) necessary for everyday mobility. The positioning of the lower limb plays a key part in creating this forward impulse. It is possible that the prescription of an AFO, during the early phases of stroke rehabilitation, could impede recovery of the natural propulsion mechanisms by constraining the ankle rotation during the terminal phase of stance.
Our recent work from the SWIFTcast study has shed some light on this problem by identifying the tibia to vertical angle as a key correlate of walking speed recovery among sub-acute stroke patients.
The objectives for this PhD are:
Identify the biomechanical, clinical and neural (EMG) variables most closely associated with gait speed recovery. This will be done through a combination of literature review and analysing a large (n=90) database of biomechanical and EMG measurements taken from acute/sub-acute stroke survivors before and after a 6 week rehabilitation programme.
This will be followed by a clinical study prospectively testing tailored AFO prescriptions that account for the variables identified previously and which aim to support recovery of the pre-morbid gait pattern.
This study will consider the clinical, biomechanical and neural outcomes as well as the acceptability to users through a mixed methods approach.
Our intention is to collaborate with the NHS as well as orthotics companies such as Peackocks(?/Buchanans) to progress towards a more tailored approach to prescribing AFOs during the early stages of recovery from a stroke. Without prejudicing the findings of the study there may be outcomes that could be exploited for both AFO design and how they are prescribed.

The CDT students will help create solutions for amputees and people with debilitating conditions such as stroke and diabetes, reducing mortality and enabling them to live more satisfying, productive and fulfilling lives. These solutions, co-created with industry and people living with disabilities, will have direct economic and societal benefits. The principal beneficiaries are industry, P&O service delivery, people who need P&O devices, and society in general.
Industry
The novel methods, devices and processes co-created with users and industry will have a direct economic value to our industry partners (by the creation of IP, new products, and improved industry and academic links). Our CDT graduates will be the natural potential employees of our industry partners and for companies in the wider healthcare technology sector. This will help address the identified critical skills need and shortage leading to improvement in the UK's competitiveness in this rapidly developing and growing global market. The CDT outcomes will help UK businesses spread risk (because new developments are well founded) and more confidently enter new markets with highly skilled employees (CDT graduates).

P&O service delivery
Doctoral engineering graduates with clinical knowledge are needed to improve the deployment of advanced technologies in practice. Our main UK industry partner, Blatchford, stated: "As technology develops it will become easier for the end-user (the patient), but the providers (the clinicians) are going to need to have a higher level of engineering training, ideally to PhD level". The British Association of Prosthetists and Orthotists estimates that no more than ten practising P&O clinicians have a PhD in the UK. Long-term P&O clinical academic leadership will be substantially improved by the CDT supporting a select number of clinically qualified P&O professionals to gain doctorates.

Users
The innovation of devices, use of device and patient monitoring, and innovation approaches in LMIC should not only lead to improved care but also lower healthcare costs. Diabetes UK estimates that the total healthcare expenditure related to foot ulceration and amputation in diabetes was £1billion (2014-15), with 2/3 of this related to foot ulceration. Small innovations could lead to large cost savings if targeted at the right aspects of care (e.g. earlier adoption, and reducing device abandonment).
An ability to work is fundamental to a person's place in society and their sense of purpose and has a significant societal impact in all territories. This is perhaps greatest in LMIC where attitudes towards disability may still be maturing, and appropriate social care infrastructure is not always in place. In these cases, an ability to work is essential for survival.
Improved design approaches will impact on all users regardless of context, since the device solutions will better match local and individual user needs. Addressing issues related to prosthetic/orthotic device abandonment (e.g. cosmesis) and improved adherence should also lead to greater social participation. Improved device solutions will shift focus from what users "cannot do" to what they now "can do", and help progress attitudes towards acceptance of disability.
Societal
The majority of the global P&O users are of working age, and a key economic impact will be keeping users in work. The average age at amputation due to diabetes is just 52 in the USA but much younger in countries with less well-developed health care and trauma services (e.g. 38 in Iran). Diabetes UK reports that 35-50% of people are of working age at diagnosis and that there are around 70,000 foot ulcers in the UK, precursors to amputation. There is a similar concern for stroke survivors around a quarter of whom are of working age and are 2-3 times more likely to be out of work after eight years.