Keys To Prescribing AFOs For Senior Patients

Author(s): 
Jonathan Moore, DPM, MS

   However, despite the high prevalence of foot problems and the significant impact these impairments have on older people, they often go unreported because many older people consider foot and ankle pain an inevitable consequence of aging rather than a medical condition.10,11

Pertinent AFO Considerations For Foot and Ankle Osteoarthritis

Clinicians have utilized AFOs for many years to stabilize osteoarthritic joints with the goals of reducing motion and minimizing ground reactive forces to the involved joint. Without question, a gauntlet style AFO is the best fit for these purposes.

   Although articulated devices have been proposed and can offer some benefit, custom gauntlet style solid ankle AFOs perform better for pain reduction and biomechanical control.12 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

   However, clinicians must take care to choose accommodations that will benefit the senior patient’s needs. Although some have deemed gauntlet style AFOs as less advantageous because of the absence of a functional foot orthosis (FFO), most quality labs can incorporate a good FFO into a gauntlet style AFO. For those with isolated subtalar joint osteoarthritis, an articulated style of gauntlet AFO may be of benefit so as not to lock normal ankle joint range of motion.

   Additionally, one must assess the trim lines of the AFO you are prescribing. Most quality AFO manufacturers such as Arizona AFO, Langer Biomechanics and others can offer at least one style of AFO (the Arizona Standard AFO) with specific trim lines designed to control both the ankle and subtalar joint. These companies also offer an AFO style with trim lines that will lock the ankle while leaving the subtalar joint free. An example of this would be the AZ Sporty. Choosing the right trim line for your gauntlet style AFO can be critical for patient adherence and success.

   While the “standard” style gauntlet AFO is very familiar to the podiatric physician, this trim line style may not always be necessary if the patient does not have osteoarthritis in the subtalar joint. The photo above at left and the next two photos below demonstrate three common types of trim lines available for the osteoathritic patient in order to maximize normal motion while offloading the affected joint effectively.

   The most common issue in prescribing a gauntlet style AFO for senior patients is getting them to fit into an acceptable shoe.

Comments

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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