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

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

25. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community (Review). Cochrane Database of Systematic Reviews. 2012; 12(9):1-408.
26. Tinnetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. NEJM. 1994; 331(13):821-827.
27. Tyson S, Sadeghi-Demneh E, Nester C. A systematic review and meta-analysis of the effect of an ankle-foot orthosis on gait biomechanics after stroke. Clin Rehabil 2013; epub ahead of print.
28. Zissimopoulos A, Fatone S, Gard S. The effect of ankle–foot orthoses on self-reported balance confidence in persons with chronic poststroke hemiplegia. Prosthet Orthot Int 2013; epub ahead of print.
29. Schmid A, Duncan P, Studenski S, et al. Improvements in speed-based gait classifications are meaningful. Stroke. 2007; 38(7):2096-2100.
30. Cameron MH, Lord S. Postural control in multiple sclerosis: implications for fall prevention. Curr Neurol Neurosci Rep. 2010; 10(5):407-412.
31. Cattaneo D, Mearazzini F, Crippa A, Cardini R. Do static or dynamic AFOs improve balance? Clinical Rehabilitation. 2002; 16(8):894–899.
32. Mueller K, Cornwall M, McPoil T, Mueller D, Barnwell J. Effect of a tone-inhibiting dynamic ankle-foot orthosis on the foot-loading pattern of a hemiplegic adult: a preliminary study. J Prosthetics Orthotics. 1991; 4:86-92.
33. Panwalkar NA. Role of Ankle Foot Orthoses in the Outcome of Clinical Tests of Balance: Rehabilitation Sciences, University of Illinois at Chicago, 2010.
34. Pohl M, Mehrholz J. Immediate effects of an individually designed functional ankle-foot orthosis on stance and gait in hemiparetic patients. Clin Rehabil 2006; 20(4):324-330.
35. Menz HB, Lord S, Fitzpatrick RC. A tactile stimulus applied to the leg improves postural stability in young, old and neuropathic subjects. Neuroscience Letters. 2006; 406(1-2):23-26.

   For further reading, see “Keys To Prescribing AFOs For Senior Patients” in the August 2012 issue of Podiatry Today, “Troubleshooting AFOs” in the April 2005 issue, “Key Pearls For Prescribing AFOs” in the February 2003 issue or “How To Address And Prevent Complications With AFOs” in the September 2009 issue.

No.

Citing a lack of credible evidence on the merits of AFOs for fall prevention, this author notes that AFOs do not treat the underlying conditions that put patients at risk for falls and that the devices can actually increase fall risk.

By Douglas Richie Jr., DPM, FACFAS

The answer to this question is quite clear. Yes, ankle-foot orthoses (AFOs) do play a role in falls prevention as they can potentially increase the risk of traumatic falls in elderly patients. In terms of preventing catastrophic falls, there is no credible evidence in the scientific literature to support the notion that any type of ankle-foot orthosis will reduce the rate of falls in non-neurologic impaired elderly patients.

   The latest Cochrane Review of falls prevention evaluated 4,967 studies published in the scientific literature.1 This review found some strong statistical evidence for certain interventions for fall prevention. These included group exercise, home safety modification and withdrawal of psychotropic medication. In this gold standard, systematic review, there is no evidence supporting the notion that ankle-foot orthoses will prevent falls in non-neurologic impaired people. Need we go any further?

   This begs the question: Why are we even debating this issue? What started purely as a commercial venture has now somehow become a controversy in the podiatric profession. My colleagues need to step back and evaluate the facts behind this commercial venture and realize the ramifications of implementing a therapy based upon profit motive, which could potentially harm the end user, a vulnerable elderly patient.

Comments

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.

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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