Keys To Prescribing AFOs For Senior Patients

Author(s): 
Jonathan Moore, DPM, MS

   Any gauntlet style AFO will naturally take up space in the shoe, often resulting in the need for a different style or size shoe. Choosing footwear that can accommodate the AFO and the patient’s foot without being too bulky, heavy or aesthetically unpleasing can be challenging. Lycra (stretch) styles with extra depth are usually the best options but the length of the AFO footplate and the style of the AFO will determine the best shoe style. Having a stock of shoe styles that fit well with AFOs can be extremely valuable when dispensing and assessing the AFO on the patient.

   First, consider the options available for AFO topcover material. Although the classic leather gauntlet AFO offers greater stability and remains the gold standard for maximum stability and support, one may consider materials that are less bulky and lighter in weight. The Arizona AFO utilizes a more lightweight, breathable synthetic material (AZ Breeze) than leather and can often be a better alternative for seniors or patients with diabetes.

Nine Prescribing Pearls On AFOs For Osteoarthritis In Senior Patients

• Consider a plastic thickness appropriate for the patient’s body size. You can specify this with the central fabrication facility from which you obtain your AFO. Make sure the patient’s body size and weight match the chosen thickness of plastic for the inner shell of the gauntlet.
• Educate your senior patients about the need for proper footwear to use with their AFO in order to achieve the best outcome. We often set ourselves up for failure by not taking the time to set the right expectations for our patients with regard to what they are getting and what will be required of them to achieve the best outcome.
• Keep in mind that anything that limits too much motion in a senior patient can reduce balance and increase the risk for falling. Studies have suggested that a solid style AFO can reduce balance and postural stability in compromised senior patients, and one should avoid this unless other pathologies exist that necessitate a solid style.14

• Adding extrinsic posting to the AFO can be valuable in some cases in which frontal plane deformity exists. However, these accommodations will often require more space in the shoe.
• Increased heel/foot height in a senior patient can reduce postural stability and thus increase the risk of falling. One should ensure careful selection of the proper style of AFO and footwear in order to keep the patient as close to the ground as possible.
• Full-length foot plates are valuable under some circumstances (i.e. a significant forefoot deformity that needs accommodation). However, these modifications can reduce balance and often require a bigger shoe.
• Don’t sacrifice comfort and padding for your senior patients. A thin layer of Plastazote or a pocketed accommodation over at-risk areas around the ankle or foot can add comfort and improve adherence.
• Velcro is always optimal with senior patients.
• For severe osteoarthritis of the ankle, subtalar joint or both, an extended style of AFO can be extremely effective.

Can AFOs Help Address Postural Imbalance And Fall Risk?

According to the most recent studies, the top risk factors for falling among seniors include weakness, balance deficits and gait deficits.15,16 Several articles have clearly demonstrated the link between the benefits of a flexible style AFO for those with postural imbalance/instability.

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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