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

   The promotion of AFOs for fall prevention has relied on misrepresentation of published articles that have no relevance to the prevention of falls in non-neurologic impaired senior citizens. I encourage the reader to read each and every study quoted by the fall brace advocates. It is disturbing to see that many times the results have been reported in a distorted fashion.

   I am aware that the fall prevention brace company has sponsored research showing changes in postural control with its devices. Only when this research is peer reviewed and published in a respected medical journal can we really begin to evaluate the findings. Furthermore, studies on postural control do not in any way prove that an intervention will prevent falls in elderly people. Improving postural control is not a valid medical indication for prescribing AFO devices, according to Medicare guidelines.

   To conform to Medicare guidelines, the fall prevention brace advertisements advocate identifying common musculoskeletal conditions normally treated with AFOs, which can justify the prescription of a fall prevention brace. Not only is this practice deceptive and potentially illegal, there is no validity to the notion that treating musculoskeletal conditions will prevent catastrophic falls.

Why The Argument About Treating Risk Factors Doesn’t Hold Up To Scrutiny

Let’s look at this argument that by treating known musculoskeletal risk factors, AFO devices will reduce the risk of falling in elderly patients. The fallacy of this argument is the fact that there is no evidence that AFO devices actually “treat” these risk factors in a way that the devices will actually prevent falls. It is well known in epidemiologic research that, while we can identify risk factors, treating the risk factors does not always ensure the prevention of the event or disease. Implementing AFO devices for osteoarthritis, muscle weakness or gait abnormality may improve the symptoms of these conditions but does not automatically translate into a lower rate of falling.

   For example, while osteoarthritis is a known risk factor for falling, one must ask: How does an AFO device change or modify osteoarthritis so it actually prevents falls? If AFO devices improved arthritis and prevented fall risk, studies would be available to prove this cause/effect relationship. Thus far, there are no such studies showing that treating arthritis with AFO devices will prevent falls.1 Similarly, there are no studies showing that when one uses AFO devices to treat muscle weakness, limited joint motion or gait abnormality, a significant reduction in the risk of falls will occur.8

Final Notes

There is better evidence that foot orthoses, not ankle-foot orthoses, will improve balance and reduce fall risk in elderly patients.9 One must ask: Why are podiatric physicians not implementing bilateral foot orthotic therapy to prevent falls in elderly patients rather than AFO devices? The answer may be the fact that Medicare does not cover custom foot orthoses but reimburses handsomely for custom AFO devices. One has to question the role that financial incentive is playing in this new, unproven intervention for fall prevention.

   Finally, one has to step back and realize that this whole controversy about prescribing bilateral solid shell AFO devices on elderly patients obscures the many positive aspects of fall prevention in podiatric practice. Last year, I wrote an article in Podiatry Today describing the positive role that podiatric physicians can play in identifying fall risk and implementing certain valid, proven interventions.10 One cannot let a commercial interest blur the significant and positive effects of valid fall prevention treatments implemented by the podiatric profession.

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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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