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

   Unlike ordinary AFOs intended to treat neurologic and musculoskeletal conditions, a new “fall prevention AFO” promises to prevent a medical event.2 Never before in any branch of medicine has a single device been promoted and promised to prevent a traumatic fall, an event that carries as much public health importance as a heart attack or stroke.

   Yet, even more astounding is that thousands of senior citizens received this device before any valid research could determine if the lofty expectation of fall prevention could ever occur. Furthermore, the notion of prescribing bilateral, non-articulated AFO devices runs contrary to customary practice of ankle-foot orthotic therapy in this country.3 The safety of this practice has yet to have testing or validation.

A Closer Look At The Paucity Of Research On AFOs In Relation To Fall Prevention

Recently, I wrote in my Podiatry Today blog about new published research showing the negative effects of bilateral solid shell, non-articulated AFOs on balance and functional tasks.4 This study investigated the effects of semi-rigid, non-articulated AFO devices during several tests of balance in patients wearing AFOs bilaterally.5 In terms of clinical implications, this research revealed that semi-rigid non-articulated AFO devices negatively affected the ability to move, lean or reach. The authors concluded that bilateral, non-articulated AFO devices could affect functional tasks such as picking up an object from a shelf, initiation of gait and other essential activities. They point out how restricting ankle joint motion can compromise essential proprioceptive feedback from the ligaments, tendons and muscles around the ankle joint.

   Hadadi and colleagues have validated this notion in another study that measured a continuous decline in postural control when comparing soft ankle braces to a more restrictive semi-rigid brace.6 Despite how thin or flexible the plastic material, a non-articulating AFO will restrict motion more than the non-braced condition. There is convincing evidence that a solid shell, non-articulated AFO will compromise proprioception and balance, particularly in those populations already at risk for falling.7

   The proclamation that a new device could prevent a catastrophic event would normally be predicated upon a breakthrough study published in a peer-reviewed scientific publication. No credible physician would implement a new treatment protocol for such an important public health initiative such as fall prevention without examining the quality of research that supports the intervention.

   Yet this appears to be happening in the podiatric profession where many are not concerned about scientific evidence and might be focusing on Medicare reimbursement, which can be handsome for certain AFO products. Today, evidence-based medicine appears to have been ignored as a growing number of practitioners are implementing AFO therapy to prevent falls without any proof that this treatment really works. This begs the question: Why hasn’t the prescription of bilateral “fall prevention” AFO devices become mainstream amongst our MD colleagues?

   Early on, I raised concern about the promotion of so-called fall prevention AFOs in my blog in Podiatry Today.8 The response to my blog from the primary spokesperson of this intervention quoted studies that supposedly validate the notion that AFOs will prevent falls. However, scrutiny of these studies shows each and every time that the research cited has nothing to do with fall prevention in non-neurologically impaired senior citizens, who are the target of this marketing campaign. Falls brace advocates, who focus on severely impaired stroke patients, have cited laboratory studies on postural control and gait. In response to my blog, a spokesperson quoted other research, actually composed of studies of sport ankle braces on healthy athletes.8

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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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