Keys To Prescribing AFOs For Senior Patients

Author(s): 
Jonathan Moore, DPM, MS

   Cakar and colleagues stated that a flexible style AFO can reduce fall risk while several studies have highlighted the fact that an AFO can not only improve postural stability but also proprioception around the foot and ankle through enhancement of somatosensory feedback.17,18

   Researchers used bilateral AFOs to assess balance in a patient with severe neuropathy and a history of frequent falling. The study showed the use of AFOs significantly improved overall balance test performance. Without the AFOs, the patient had falls performing most of the tests.19

   Clinicians have used AFOs for decades for those at the highest risk for falling but only in the last few years have we seen an AFO style designed for the senior patient in mind. The Moore Balance Brace, which I developed in 2010, has become another useful tool for the podiatric physician, physical therapist and the orthotics and prosthetics specialist in an effort to impact the risk factors for falling among our senior patients. The brace’s lightweight design and flexible trim lines along with its unique posting have made this thermoplastic posterior leaf style AFO (hinged and standard) a significant and impactful tool for those treating the at-risk senior patient.

   The following additional considerations are vital in order to select the right style of AFO for those seniors at risk for falling.
• First and foremost, one must perform a biomechanical fall risk assessment to identify the specific risk factors involved. As I noted earlier, weakness, balance deficits and gait deficits are reportedly among the top causes of falling among seniors.15,16
• Senior patients who already have risk factors for falling (i.e. history of falling, weakness, joint instability) must have symmetrical treatment for the best outcome. Thus, bilateral AFO bracing is critical when addressing a severe ataxic, unstable gait.
• Any AFO used for balance must be lightweight and easy to don. While this is true for all AFOs discussed in this article, it is critical to make sure the patient receives proper training on how to put on and take off the AFO. This can make or break the success of any AFO among seniors.
• In addition to being lightweight, a balance AFO must be flexible so as to stabilize the ankle and improve postural stability, but not so solid as to limit the normal range of motion still available.

• A flexible or hinged gauntlet style AFO, like the Moore Balance Brace, is critical to maximize somatosensory contact, thereby improving proprioception around the foot and ankle. In my experience, most patients have more than ample flexibility with the non-hinged standard Moore Balance Brace, but there are some who will benefit more from the hinged version (i.e. those who need more stability but more sagittal plane flexibility).
• Lightweight, balanced footwear is critical to the success of any AFO used for the improvement of balance. This one point is probably what prevents more success when utilizing a balance AFO.
• Easy donning and doffing is critical for any AFO designed for a senior. However, ordering Velcro attachments for these patients with no loops or strings can be an easy way to improve adherence. Strings, loops and hooks, while very valuable in many styles of AFOs, can create more difficulty for a senior.

Essential Insights On Utilizing AFOs For Drop Foot

While utilizing AFOs for drop foot patients has been widely accepted and understood for decades, clinicians must carefully consider a few important factors when ordering the right style for more senior patients.

   While not a disease in and of itself, drop foot is a symptom of an underlying pathology that can include a stroke, a traumatic brain or spinal cord injury, spinal stenosis, multiple sclerosis or a peroneal nerve injury.

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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