Keys To Prescribing AFOs For Senior Patients
Given the escalating number of people who will become senior citizens in the years ahead, this author examines the potential of ankle foot orthoses (AFOs) to treat common conditions in this patient population. He also offers several AFO prescribing pearls and key insights on helpful modifications.
In 2011, the oldest baby boomers started turning 65. Every day for the next 19 years, more than 10,000 more will cross that threshold.1 Most changes in gait that occur in older adults are related to underlying medical conditions — particularly as conditions increase in severity — and should not be viewed as merely an inevitable consequence of aging.2-4 Early identification of gait and balance disorders, and appropriate intervention can prevent disability and loss of independence.
Performing activities of daily living while maintaining postural stability and balance requires the interaction of multiple sensory motor systems that include vision, vestibular function and muscle strength. All of these functions decline with age. The bottom line is that ankle flexibility, sensory function and muscle strength are significant independent predictors of balance, functional ability and mortality.5,6
As foot and ankle specialists, we are in the unique position to initiate treatment that can improve strength and flexibility for our senior patients. Moreover, as prescribers and suppliers of footwear, orthotics and ankle foot orthoses (AFOs), we have the opportunity to mitigate further risk in this patient population by correcting gait and balance deficits. These two risk factors are among the top risk factors for falling.
Ankle foot orthoses, functional foot orthotics, diabetic footwear and other durable medical equipment (DME) items all offer our senior patients with foot and ankle deficits efficacious, conservative and noninvasive treatment options that often obviate the need for surgery. Yet in spite of these obvious advantages, there are large numbers of podiatric physicians who still choose not to provide these valuable services.
According to a 2010 CMS report, podiatrists billed the most common HCPS code used for custom gauntlet type AFOs (L1940) an average of 0.7 times per year.7 Yes, that is less than one AFO on average per year.
Medicare policy is clear that patients are covered for custom AFOs if they have documented orthopedic risk factors that often contribute to gait deficits, falls or instability.
Obviously, AFOs are not the only tools we have at our disposal to reduce the incidence of falling, gait deficits and disability among our senior populations. The medical literature is replete with articles highlighting the benefits of physical therapy, exercise, proper footwear, education, orthoses and other assistive devices like canes and walkers.
However, ankle foot orthoses can be of great benefit in treating the following conditions in our senior patient population.
• Foot and ankle osteoarthritis
• Foot and ankle postural instability/imbalance
• Flaccid foot drop
• Posterior tibial tendon dysfunction with a collapsed talonavicular joint/ accessory navicular
Seniors face common challenges that are intrinsically related to aging. The combination of extrinsic factors along with these intrinsic issues can significantly reduce quality of life and can even impact mortality. Osteoarthritis contributes significantly to abnormal gait and postural control.
In a landmark study by Verghese and colleagues, abnormal gait (neurological, non-neurological and a combination of both) predicted a statistically significant increase in institutionalization and death.8
According to Menz and co-workers, foot and ankle problems affect up to 80 percent of “older people” and are associated with impaired mobility and ability to perform common household tasks.9