Phil Stevens

Despite their use as treatment for a variety of issues, from sports
injuries to orthopedic conditions, ankle-foot orthoses (AFOs) may not always
facilitate inherent benefits to patients’ balance, according to the
results of the American Academy of Orthotists and Prosthetists’ 10th
State-of-the-Science Conference.

This 3-day conference examined the available literature, as well as
current views and expert opinion from various professionals within the health
care sector. Phil Stevens, MEd, CPO, FAAOP, currently in private practice in
Salt Lake City, served as conference chair and editor of the official findings
of the conference.

Lack of literature

In addition to a
multidisciplinary approach — with participants ranging
from orthotists and physical therapists to biomechanists, educators and
researchers — the conference received input from across the global
spectrum as well, including participants from Australia, Sweden and Russia,
Stevens said.

	Bryan S. Malas

After poring over a broad base of different design types, with a wide
range of different patient populations and across multiple outcome measures,
researchers found less than 20 articles looking at balance implications of
traditional
AFOs — not including items like Aircast ankle stirrups,
gauntlets and things of that nature, he said.

“It’s challenging to draw any sort of defined conclusions from
the literature review,” he said. “Recognizing that our industry is
still young, the best available published evidence is rarely sufficient to
answer the clinical questions.”

Historically, practitioners’ focus has been more on gait — and
using AFOs as a tool to optimize gait — and has only secondarily
considered factors like static and dynamic stability, Stevens told
O&P Business News. Balance almost seems to have fallen off the
radar.

	Mark D. Geil

“As an industry, I don’t know if we’ve given balance the
attention it deserves,” he said.

Treatment plan

Bryan S. Malas, MHPE, CO, CPed, director of the orthotics/prosthetics
department and the Moira Tobin Wickes Orthotics Program at Children’s
Memorial Hospital in Chicago, led a clinical consideration discussion to
examine the various aspects that practitioners should consider when developing
a treatment plan that involves an AFO. Several elements of patient assessment
are key to the treatment plan and device design, and ultimately affect the
patient’s outcomes: manual muscle testing, sensation/proprioception, range
of motion and gait evaluation, as well as the patient’s activity level and
needs, and
balance and fatigue considerations, Malas said.

The patient’s activity level is often overlooked, but it may play a
significant role in the design, material selection and alignment of the
AFO,” he said. “Frequently the AFO is the primary factor for
improving a person’s activity level. Many practitioners would agree they
have seen individuals progress from household ambulators to community
ambulators with the use of an AFO.”

	This high-activity patient required an AFO that would allow some motion, but enough resistance to dorsiflexion that it did not compromise stability and balance.
	Image: Bryan S. Malas

Reimbursement levels also play a role in the treatment plan for AFOs,
Malas said. Since practitioners often have to use one AFO for several different
purposes, it is important that they broaden the scope of the AFO’s
usefulness.

“For instance we may have a patient wear one set of shoes for one
task and a different set of shoes for another task,” he said. “The
varying heel-sole differentials change the alignment of the AFO in the shoes
and facilitate the person’s task specific needs.”

It is not enough to focus exclusively on the joint segment in question,
Stevens added.

“We need to zoom out in the treatment room and, in addition to
examining what effect that device has on the ankle and perhaps the knee, to
look more broadly and see what effect the device is having on the overall
alignment of the individual and their ability to keep their center of mass over
their base of support,” he said.

Another point he mentioned is that many patients who are incapable of
“normal gait” develop a host of compensatory movements out of
necessity that allow them to function actively in society. Practitioners often
need to work with this “optimal gait,” instead of trying to change
it, and help the patient to further optimize these movements.

Effect on balance

“I think the biggest take-home message from this conference is that
it’s not reasonable to assume that an AFO will inherently have a positive
influence on balance. It’s just not the case,” Stevens said.

In fact, he added, “there are several instances in the published
literature where a poorly designed AFO has ultimately had a negative impact on
that patient.”

Laboratory assessment is an invaluable tool when treating these
patients, as they often have balance issues that are not visible through brief
clinical observation, Mark D. Geil, PhD, associate professor of the graduate
faculty at Georgia State University and O&P Business News
Practitioner Advisory Council member, said. A force platform is an important
measure of the location and direction of the ground reaction force, which are
the crux of a patient’s balance.

“When those coordinates are plotted, the seemingly random
‘squiggle’ is actually quite revealing. It might reveal larger sway
in the anterior-posterior direction, or more weight centered on one leg,”
Geil said. “There are dozens and dozens of ways to analyze the coordinates
of the center of pressure, and though some are mathematically complex to
perform, the results are generally easy to understand.”

Further assessment includes tests like motion analysis and computerized
dynamic posturography. This equipment, however, typically is not available for
individual patient assessment.

Stevens advised practitioners to take the time necessary to determine if
their patients have any current balance issues that need to be addressed, as
well as to evaluate how the prescribed orthoses affects that level of balance.

“On the one hand, a properly designed device for someone with a
treatable presentation enables us to have a significant impact for good on the
balance of that individual,” he said. “However, the corollary
argument is that if the balance is already compromised, we can make it worse if
we’re not intentional about what we do.”

This issue comes back to the real challenge, Stevens said, which is to
stop treating the ankle in isolation.

“We look at an ankle and we can say based on what I’m seeing
here, we need to assist this motion and block that motion to restore a more
normal ankle motion,” he said. “But we need to step back and make
sure we understand the impact that those decisions have on the entire body of
the individual.” — by Stephanie Z. Pavlou

Disclosure: Phil Stevens, MEd, CPO,
FAAOP, Bryan S. Malas, MHPE, CO, CPed, and Mark D. Geil, PhD, do not have any
relevant disclosures.

The recent look into the lack of research regarding the “Effects of
AFOs on Balance” brings up many valuable points of interest for
orthotists. Balance is complex and can be affected by a multitude of factors,
such as base of support, muscle weakness and compensation, joint instability,
neuropathy, vertigo, and more. As orthotists, we often see only a snap shot of
the patient rather than the full picture. In particular, the gait evaluation in
a standard clinical practice typically takes place on a flat surface and in a
straight line. Unfortunately, this is rarely representative of all environments
or situations in which a patient may be required to use their AFO.

It is important as orthotists that we combine our assessments, as
described by Malas, with a complete medical history and communication with
other health professionals involved, such as physical therapists and
physicians, and then take of all these factors into consideration when
designing an optimal AFO. More importantly is the fitting and adjustment
process. It is one thing to have a well-fitting AFO, but if the orthosis does
not function to achieve the desired goals, then it needs to be reassessed and
adjusted to do so.

Furthermore, additional research is needed to investigate the effects of
the various types of AFOs on balance and eventually develop a more standardized
and simple way to assess balance in a clinical setting so patients can receive
optimal treatments and outcomes.

— Bridget M. Lawler, CPO
Westcoast Brace
& Limb Inc.