Are Gauntlets A Universal Solution For AFO Intervention?

I often lecture on the topic of clinical indications for ankle-foot orthotic (AFO) therapy. Through interactions with many colleagues around the country, I am amazed at the number of practitioners who favor the use of gauntlet-style AFO devices for bracing the lower extremity. My suspicion is that the handsome reimbursement for these devices may supersede better judgment about patient adherence and improved clinical outcomes.

As the owner of a company that manufactures AFOs, I could be accused of a bias in favor of certain braces. However, my company makes several styles of gauntlet braces in addition to a wide range of articulated, dynamic braces. My preference for selecting certain styles of AFO devices is based upon simple biomechanics and restoration of normal lower extremity function.

Gauntlet-style devices contain a solid shell AFO combined with a leather lacer enclosure, which envelops the foot, ankle and lower leg. This brace has the best capacity to limit all motion of the ankle, hindfoot and midfoot. When there is serious degenerative arthritis in any or all of these joints, this comprehensive limitation of motion is not a bad thing. When arthritis is mild and restoration of mobility is the primary treatment goal, solid-shell non-articulated AFO devices and rigid gauntlet braces have several negative shortcomings.

The biggest challenge with gauntlet braces is patient adherence. Donning these bulky devices and fitting them in shoes is a challenge for anybody, particularly an elderly patient and patients with limited mobility of the hands and fingers.

Most people who use a gauntlet or solid AFO are unable to drive a car if the device is on the right foot. The challenge of removing the brace in order to drive a car often causes the user to avoid wearing the device altogether.

An important issue with all non-articulated ankle-foot orthoses is their significant potential to compromise balance and potentially increase the risk of falling. Several studies have demonstrated this.1-2 It has also been the subject of several blogs I have written in the past.3-5 When ankle motion is inhibited with any non-articulated AFO, we compromise key proprioceptive feedback from the muscle stretch receptors. This also inhibits avoidance strategies during recovery from falls.

The most popular application of AFO devices in podiatric medicine is in the treatment of adult-acquired flatfoot or posterior tibial tendon dysfunction (PTTD). Neville and Houck published an interesting study comparing the biomechanical effects of different AFO designs for the treatment of PTTD.6 The kinematic studies showed that articulated AFO improved arch height and corrected forefoot abduction better than the solid AFO. More importantly, the researchers point out:

“Ankle plantarflexion weakness may account for functional impairments and gait disturbances reported by patients with PTTD. Orthoses that restrict ankle motion (solid AFO), while very popular, may induce plantarflexor weakness and increase dependence on the orthosis for support.”6

There is definitely a place for rigid gauntlets when practitioners implement AFO devices for challenging lower extremity pathologies. One can best treat severe, end-stage, adult-acquired flatfoot as well as advanced degenerative arthritis of the hindfoot with rigid immobilization provided by gauntlet AFOs.

On the other hand, the majority of conditions presenting to podiatric clinicians are not at this level of severity. These conditions would greatly benefit from interventions that preserve ankle and hindfoot motion to ensure better adherence and better patient outcomes.

References
1. Cattaneo D, Marazzini F, Crippa A, Cardini R. Do static or dynamic AFOs improve balance? Clinical Rehabilitation. 2002; 16(8):894-899.
2. Ramstrand N, Ramstrand S. AAOP state-of-the-science evidence report: the effect of ankle-foot orthoses on balance-a systematic review. SSC Proceedings. 2010; 10:4-23.
3. Richie Jr. D. New research warns of negative effects of AFOs on balance. Podiatry Today. Available at http://www.podiatrytoday.com/blogged/new-research-warns-negative-effects... . Published April 23, 2013. Accessed Oct. 22, 2013.
4. Richie Jr. D. The truth about AFOs and fall prevention. Podiatry Today. Available at http://www.podiatrytoday.com/blogged/truth-about-afos-and-fall-prevention . Published Feb. 24, 2012. Accessed Oct. 23, 3013.
5. Richie Jr. D. Still looking for documentation that AFOs effectively prevent falls. Podiatry Today. Available at http://www.podiatrytoday.com/blogged/still-looking-documentation-afos-ef... . Published June 25, 2012. Accessed Oct. 23, 2013.
6. Neville C, Houck J. Choosing among 3 ankle-foot orthoses for a patient with stage II posterior tibial tendon dysfunction. J Orthop Sports Phys Ther. 2009; 39(11):816–824.



Timothy K. CPO, FAAOPsays: October 26, 2013 at 12:57 pm

As a clinical practitioner in O&P for many years prior to the invention of the Richie Brace and Arizona AFO, I can honestly say that the majority of DPMs DO NOT have an understanding of when to prescribe a Richie style brace vs. an Arizona style (leather) gauntlet. I also feel that in podiatry, the reimbursement of leather gauntlets supercedes judgement about patient adherence and improved clinical outcomes.

When a doctor tells me he likes the "Richie brace better" or the "Arizona AFO better," this statement tells me that the doctor DOES NOT have a true understanding of the clinical indications for lower extremity AFO therapy. Most podiatrists are not even aware that a leather gauntlet can be made articulating with tamarack joints.

With that being said, the majority of patients braced by podiatrists in leather gauntlets ARE NOT end-stage PTTD and/or DJD. And these patients are being put in a leather gauntlet fixed at ninety degrees. Never take away range of motion for the mild to moderate patient with PTTD and/or DJD.

Thank you Dr. Richie for clarifying this misunderstanding of clinical AFO therapy.

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Ron Raducanu, DPMsays: October 29, 2013 at 5:47 pm

Timothy,

I absolutely agree with your assessment.

In my practice now, we focus much more on conservative treatment, bracing and orthotics, and rehabilitation. I find many patients who do indeed get the "right" brace for their condition do extremely well, and also avoid the "cripple" of some of these end-stage surgical procedures that are so common now.

Sadly, residents have to count how many of these procedures they've done rather than how many they can manage to prevent.

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