AFO compliance responses

AFO compliance responses

Angela Smalley

7/8/2020

Hello List,

 Last week I posted asking the following questions:

“How do you tell if adult patients are wearing their AFOs appropriately?
How do you improve their compliance levels? Do you view compliance levels
as a reflection of the quality of your work?”

I received excellent responses, which are shared below. Please feel free to
continue the conversation if these answers spark any additional thoughts.

Thanks,

 Angela Smalley PhD, BOCPD, COF

TREAT Center Simbex

_______Responses [separated by numbered brackets]_______

[#1] This is an interesting question and likely doesn't have a simple
answer. Patients have a large variety of reasons for decreased compliance
including (and probably not limited to) comfort, aesthetic, perceived
improvement of gait, and efficiency of donning/use. Certainly clinical
competency is important in making the proper device selection (including
materials, thickness, stiffness, trim lines, joints, etc), what an
acceptable fit is and a need/opportunity for patient's to follow-up and
advocate for the adjustments. Unfortunately many Orthotists are not
connected to the result with little to no follow-up on the care they have
provided.

I would also say that there is a significant gap between what physician's
knowledge on different styles of AFO's to meet patient needs, how problems
can be addressed and when to prescribe AFO's is a significant gap in the
medical community.


[#2] We have used iButtons in the past for compliance


[#3] You have dust ring under the heel, it's all solid covered in pet hair,
the plastic turns yellowish, straps are dirty, they come back for repairs.
I do my best to convince them to use the device. Normally, they are
consenting adults. I can't impose anything onto them. Though, usually,
braces help them so much that they are dedicated.


[#4a] Absolutely, It reflects on the quality of my work.

I stress to patients that I expect my orthosis will meet the goal we have
set and be comfortable to wear. In fact I guarantee it. Anything short of
making them pleased with the device, is not acceptable and I am eager to
make it better.

Then all clients get a survey. Any negative comment suggests a level of
resignation about the device that needs to be addressed. Many clients may
come in with an expectation of failure, especially if the condition is
chronic. That expectation needs to be changed before they leave with the
orthosis. It is only too easy to convince them that they were correct.

[#4b - in answer to the follow-up question: do you measure your patients’
compliance in any way, and do document it/ report on it to the referring
physician?] I haven't figured out how to accomplish that. I do make some
follow-up calls for selected patients (difficult, either mechanically or
attitude). And my docs know I take care of any problem. So, if there is
someone with a problem who hasn't reached out to me, usually the doctor
follow-up will take care of the majority of the rest. I haven't come up
with a comprehensive quality measurement form, either. Though I have tried.


[#5] AFO compliance. This is truly a patient management thing, but with
some complexities.

---What if the patient develops contractures? Compliance will change.

---What if the patient is post-CVA, but progresses? Then the orthosis may
be counterproductive. In that case, compliance may be moot.

---It's not a homogeneous group. You have serious post-CVA folks who are
dependent. You have pediatric CP (those need compliance directed to parents
who enable the kiddos). You have chronic ankle instability (think Arizona
AFO) who are independent but can be only occasional users (like hiking or
working out). You can have isolated dropfoot from post total knee
replacement. Perhaps that's only after 2pm when they fatigue, perhaps it's
optional... And then I assume you have your grab bag of all the rest.

---They aren't wearing their orthosis properly if wear appears in the wrong
spot... or if it's dusty in the wrong spot (because a sock will remove
dust).

---You get compliance by knowing your patient and not over-bracing. Less is
more and quality certainly has an impact, but quantifying this is tough.

---Are you looking at developing a metric that requires a constant metric
for monitoring compliance? If so, how do you account for occasional users
who are fully compliant when using the brace is warranted only part-time?


[#6] I do not work with adults, but I have been involved extensively with
the electronic monitoring of orthosis wear. I have a few comments:

  I feel that we need to drop the term “compliance.” This connotes a
paternalistic relationship, whereby we tell the patient what to do and they
comply or not. The term “adherence” is an improvement.

Even in pediatrics, few of our orthoses actually change the natural history
of conditions. We use the electronic monitors only for those few
conditions where we hope to change natural history. Therefore, in adults I
wouldn’t be very concerned with hours of wear, except in fracture orthoses
or some other acute condition.

Inspecting the skin condition and orthosis condition will give you a rough
idea of the wear of an orthosis. If the straps don’t have lint in the
Velcro, it isn’t being worn.

In most situations, an orthosis exists to improve function. If it is not
improving function, it shouldn’t be used. The highest quality orthosis, as
far as fit and finish, is worthless if it doesn’t improve someone’s QOL.
Conversely, we have seen many people with duct taped together, terrible,
orthoses who rely on them daily.

An orthosis is not primarily a piece of plastic. It is primarily about
providing a professional service to improve people’s lives. The psychologic
and interpersonal aspects of providing orthotic care can outweigh the
technical aspects of forming plastic. We need to be sure that we are
providing what is best for a person, not just filling a script. This is
where the “psychologic and interpersonal” aspects come in. Convincing
someone to use a device for their own safety can be very difficult. I could
see a situation where a wear monitor is used as part of a reward system, if
there is someone who is following up closely. Perhaps an adult child visits
and checks the wear monitor weekly. At some threshold of wear they will do
something special.