Keys To Prescribing AFOs For Senior Patients

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Author(s): 
Jonathan Moore, DPM, MS

   Many common AFO designs often actually worsen the pain at this area because of the trim lines of the AFO. In most gauntlet style AFOs commonly prescribed for PTTD/talonavicular joint collapse, the medial flange wraps around the foot’s medial arch, forcing the prominent navicular into the orthotic plate and causing even more pain. While sweet spots, padding and proper casting have all received discussion in regard to addressing this problem, I have had the best success with a “pocket” style AFO with an extrinsic post to offload the talonavicular joint. This dynamic pocket style AFO will be commercially available in the near future.

   While many with PTTD may not need such a modification, this modification can be extremely valuable for those with prominent and chronically painful talonavicular joints, especially on or around the navicular. However, no pocket style AFO can work without some extrinsic posting to “suspend” the painful joint complex off the ground. Accordingly, there is a need for a dynamic pocket style AFO with extrinsic posting to hold the medial column off the ground.

   Here are some key pearls for prescribing AFOs for patients who have PTTD and talonavicular collapse.
• It is critical to cast these patients in such a way to capture the dynamic state of the patient’s deformity. Semi-weightbearing casting often does not capture the location of the talonavicular joint in a dynamic natural state of standing or walking. This can lead to accommodations that do not adequately fit the patient’s anatomy.
• The dynamic pocket style AFO not only supports the medial ankle but also suspends and pockets the prominent talonavicular joint or accessory navicular. An additional layer of Plastazote can even further reduce pain and make these devices much more comfortable.
• An extended full foot plate with Plastazote lining can be very comfortable and reduce pain, but will also make this much more difficult to shoe. Keep this in mind when ordering a full foot plate with or without a Plastazote orthosis.
• A gauntlet style AFO is essential to fully control ankle motion in these severely pronated patients but also keep in mind the possibility of a more open ankle trim line that allows more ankle joint range of motion.
• An extrinsic post below the pocket works great in the clinical setting if one ensures proper casting and marking of the cast.
• These patients often need a Lycra style shoe that can stretch or a larger size shoe.
• Velcro is essential and it is often preferable to leave the AFO in the shoe for donning.

Final Notes

In summary, our ever growing senior patient population has unique needs that we as podiatric physicians can meet with the right tools and education.

   As with any job, practice makes perfect and there is no better way to learn about AFO styles and casting than visiting a lab or attending an educational seminar.

   There is no single “go to” AFO for every condition and you certainly cannot get away with the same style of AFO for every condition. Learning the available trim lines and being familiar with different AFO accommodations and topcover materials can make a big difference.

   However, the biggest challenge in enhancing AFO outcomes is learning what shoes work well with specific styles of AFOs. Having the right AFO is only half the battle if you do not prepare the patient for the possible requirement of a different style or type of shoe. Preparing the patient and setting the right expectations are critical to achieve optimal results.

   Dr. Moore is board-certified by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. He is the Fellowship Director of the Central Kentucky Diabetes Management program, serves as adjunct faculty at the Kent State University College of Podiatric Medicine and serves on the Board of Trustees of the American Academy of Podiatric Practice Management. Dr. Moore is a managing partner of Cumberland Foot and Ankle Centers of Kentucky.

   Dr. Moore has disclosed that he is the developer of the Moore Balance Brace.

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Doug Richie D.P.M. FACFASsays: August 2, 2012 at 11:33 am

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.

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Doug Richie DPM FACFASsays: August 6, 2012 at 11:35 am

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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