Keys To Prescribing AFOs For Senior Patients

Jonathan Moore, DPM, MS

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


In his zeal to promote his "Falls Prevention Brace," Dr. Moore cites literature which has no relevance to the patient population targeted in his article. The only studies that demonstrate improved balance with AFO devices were performed on patients with cerebral palsy and hemiplegia after stroke. This was clearly stipulated in the review article published by Ramstrand et al, which Dr. Moore cites.1

Furthermore, this excellent systematic review by Ramstrand et al also concluded that there is no evidence that any design of AFO can improve proprioception. The only devices thus far that have demonstrated improved proprioception are Air Cast(R) stirrup ankle braces, and these studies were performed on younger athletes with and without chronic ankle instability.

This begs the question: Can Dr. Moore provide any evidence that his device or any AFO device has demonstrated improved proprioception, balance and reduced falls in elderly patients who do not have hemiplegia or cerebral palsy?

Ramstrand N, Ramstrand S. AAOP state-of-the-science evidence report: the effect of ankle-foot orthoses on balance — a systematic review. J Prosthet Orthot. 2010;22:P4–P23.

It is important for the readers of this article to be aware of the misrepresentation of the facts of the scientific articles quoted by Dr. Moore. For example, Dr. Moore states, "In a 2006 article, Huang and colleagues reported that a solid gauntlet style AFO is the best option (over an articulated style) for those with ankle osteoarthritis arising from ankle motion.13" Yet Huang et al., did not study any type of gauntlet braces and the device which was recommended was only a simple shell brace, not a rigid gauntlet style AFO. This simple shell brace recommended by Huang et al., barely covered any portion of the foot — only the calcaneus — and was secured on the leg by a simple velcro strap.

Moore cites the study by Rao et al., to substantiate his claim that flexible AFOs improve balance and proprioception yet scrutiny of this study reveals that the single patient wore bilateral SOLID AFO devices, which are the very devices that Moore condemns for use in patients at risk for falls.

Authors should strive to present published research in an accurate and unbiased manner. Since Dr. Moore did not disclose the nature of his relationship with Arizona AFO and Langer, readers may actually believe that leather gauntlet braces are superior to all other types of AFOs as suggested in this article. I would invite any reader to review the scientific articles cited in this piece and make their own conclusions about the presentation of facts versus promotion of specific products.

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