Current Insights On The Benefits Of Custom Orthoses And AFOs

Author(s): 
Guest Clinical Editor: Bijan Najafi, PhD

   As Dr. Mirkin notes, excessive movement, impact, tension or pressure are bound to cause trouble. Orthotics change all of those factors depending on the degree of support (varus/valgus), the type of materials used (rigid, semi-rigid or flexible) and what kind of accommodative padding one places on top, according to Dr. Mirkin. He says one can choose those materials to limit painful joint motion, lessen the pull on damaged or strained tendons and ligaments, and direct force/pressure and shear away from areas or skin that are painful or break down.

   Dr. Landorf emphasizes that the biomechanical effects of foot orthoses are of interest but patient outcomes are the most important issue when evaluating foot orthoses. That said, Dr. Landorf notes it is clear that foot orthoses offer small changes in kinematics and muscle activity although the changes are quite variable in patients so it is somewhat difficult to explain.

Q:

What are the most important outcomes that one should consider when designing foot orthoses for older adults?

A:

Getting rid of pain or a pressure sore and preventing injury are the ultimate successes when it comes to orthoses, says Dr. Mirkin. Since we heal slower as we age, he suggests fostering an understanding that orthotics are part of a healing process that takes time and that patients should expect longer break-in periods. He says although rigid orthotics may seem biomechanically necessary, older adults may not tolerate them well.

   As Dr. Najafi points out, among older adults, falls and a fear of falling could cause a dramatic reduction in mobility, which he says impacts one’s quality of life, independence, frailty, and leads to a further increase in the risk of falling. Dr. Najafi feels the main focuses of foot orthosis design should be reducing the fear of falling as well as the risk of falling. He says many recent studies addressing the benefit of foot orthoses in older adults often neglect the importance of fear of falling, which he says is even more important than the risk of falling.

   For instance, Dr. Najafi says if an appropriately designed AFO may enhance the self-confidence of an elderly patient to be more active, it could also reduce the risk of falling in the long term via the enhancement of lower extremity muscles and vascularity, both of which are key to enhance balance during walking. Accordingly, he says along with assessing the benefits of foot orthoses on gait and balance in older adults, one should also consider fear of falling and changes in spontaneous daily physical activities as primary or at least secondary outcomes.

   Dr. Landorf asserts that the number one goal of orthoses is their benefit to the patient and that one should assess these benefits through appropriate patient-reported outcome measures. He notes that some form of empirical evaluation using a valid and reliable outcome measure will ensure proper follow-up of patients receiving foot orthoses. Prior to this, appropriate biomechanical effects (e.g. redistribution of plantar pressure) and comfort of the orthoses are significant factors that he says physicians need to address. While trying to gain maximum biomechanical effects may seem a worthy goal, he emphasizes that comfort of the orthoses is just as important.

   Finally, Dr. Landorf says shoe fit is also a key factor when providing foot orthoses for older adults so a fundamental consideration is having good quality, appropriate shoes to begin the whole process of prescribing orthoses. Dr. Mirkin also advocates considering the shoe in which the patient is going to use the devices. He says the orthosis may be perfect but won’t work if the patient can’t fit it into the shoe.

   Another consideration for older adults is enhancing the form factor for everyday applications, according to Dr. Najafi. For instance, he points out that most walking in older adults is happening indoors while most of the current designs of foot orthoses are for outdoor shoes.

   “A better form factor design is required to enhance gait and balance in indoor walking including house shoes as well as custom socks with a component of foot orthoses,” argues Dr. Najafi.

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