Point-Counterpoint: Do AFOs Have A Role In Fall Prevention?

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Author(s): 
Jeffrey C. Christensen, DPM, FACFAS, and Douglas Richie Jr., DPM, FACFAS

Yes.

This author has found that custom dynamic ankle-foot orthotics (AFOs) can be helpful in addressing underlying proprioceptive deficits in patients at risk for falls and identifies key factors in assessing and treating these patients.

By Jeffrey C. Christensen, DPM, FACFAS

Falls in the elderly pose a significant public health burden and annually affect one-third of people over the age of 65.1-3 Approximately 20 percent of falls result in serious injury, including hip fractures and death.4,5 In addition to age-related sensorimotor decline, a myriad of underlying etiological factors can contribute to imbalance. These include: polypharmacy; chronic neurological disease (i.e. post-stroke hemiparesis, multiple sclerosis, diabetes and Parkinson’s disease); cognitive impairment; visual or vestibular impairments; arthritis; lower extremity disabilities; and gait disorders.6-9

   Fall risk in the elderly increases, especially during dynamic conditions, as the body center of mass during single limb support projects external to the base of support. In this compromised group, reduced gait speed, stride length, cadence and joint movements are evident. Specific balance impairments include increased postural sway in quiet stance, delayed response to postural perturbations and reduced ability to move toward their limits of stability.6,10 A delayed response to loss of balance can make balance recovery difficult, potentially leading to a fall. Treatment interventions can address and modify many of these deficiencies.

   In general, I favor using ankle-foot orthoses (AFO) for elderly patients with specific lower extremity balance deficiencies. For my patients, I incorporate a targeted balance rehabilitation program, which often includes lightweight AFO devices with stable shoes, to address underlying proprioceptive deficits with the goals of reducing fall risk and improving functional gait.

Keys To Identifying And Treating Patients At Risk For Falls

Along with a working understanding of balance dysfunction, evaluation and management of this patient segment, treatment requires a rational, methodical and multidisciplinary approach.11 Physical and occupational therapists, primary care physicians and podiatrists should be part of the treatment team that actively engages their at-risk patients. Asking about recent falls or near falls is necessary since independent seniors may be fearful about disclosing their missteps to their medical providers for fear of repercussions.

   Podiatric assessment is critical in patients with balance disorders. A study of 1,000 random community dwellers over 65 years old found that 36 percent of the group had significant foot and leg problems, and compromise in balance function.12 A recent Australian-based, randomized controlled trial further confirmed this, showing that active podiatric management can reduce fall risk in the elderly.13 Other investigations have linked significant measurable fall risks with foot and ankle problems. These foot and ankle conditions include: digital deformities, hallux valgus, muscle weakness, ankle instability/malalignments, tendon contractures, adult-acquired flatfoot and peripheral neuropathy.4,5,11,14-22

   Documentation of fall frequency and a fall risk assessment can happen through simple balance screening and focused podiatric treatment. Evaluating patients with multiple and variable disease expressions can be confusing as patients with age-related muscle weakness, lack of coordination or joint instability can still have falls. It is best to identify and focus on pathophysiological and mechanical deficiencies, irrespective of diseases that may or may not be present.23

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Timothy K. CPO, FAAOPsays: October 3, 2013 at 4:51 pm

Dr. Christensen,

I am confused. You state that practitioners should "never prescribe custom braces in a prophylactic manner to prevent falls." Yet your entire article is advocating this practice?

Furthermore, are you saying that when a patient fails the Timed Up and Go test, they qualify for a custom AFO according to Medicare guidelines? I have read the Medicare guidelines for medical necessity and there is nothing about balance disorders, peripheral neuropathy or arthropathy which you state are valid diagnoses for AFO reimbursement from Medicare.

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Douglas Richie DPM FACFASsays: October 30, 2013 at 11:52 pm

Jeff,
I have waited patiently for your reply to this valid challenge to your position in prescribing and billing Medicare for "Falls Prevention AFOs". Can you provide your insight and experience with billing Medicare for these devices when the medical necessity of this treatment is not justified, according to current Medicare guidelines?

Thanks,
Doug

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