June 2017

Out on a limb: Valuable testimony

By Jordana Bieze Foster, Editor

A person’s testimony doesn’t always agree with objective evidence—that’s why some defense attorneys won’t allow their clients to take the stand during a trial, even in their own defense. Similarly, as most clinicians know, patient-reported outcomes aren’t always consistent with objective measures of function.

But that doesn’t necessarily mean subjective patient information should be discounted. In fact, the most effective patient care may require consideration of both types of outcome measures.

Lower extremity clinicians working with patients who wear ankle foot orthoses (AFOs) to improve balance and mobility are familiar with this type of dichotomy, as illustrated by a presentation in May at the 2017 International Society of Prosthetics & Orthotics (ISPO) World Congress in Cape Town, South Africa (see “Next level thinking in O&P: Coverage of the 2017 ISPO World Congress,” page 27).

A growing body of research—as well as clinical experience—supports the concept of “tuning” AFOs, in combination with a patient’s footwear, to customize device alignment for each patient in ways that will optimize balance and mobility.

Patient testimony isn’t necessarily part of a good legal strategy. But it can help make a good AFO tuning strategy even better.

So, it’s not surprising that when researchers from the Philippines analyzed the effects of tuned and untuned rigid AFOs in 14 patients who were at least six months poststroke, patients’ scores on the Berg Balance Scale and Timed Up and Go test were significantly better with AFOs than with shoes only in the tuned group, but not in the untuned group.

It would seem logical that the improvement in static and dynamic balance associated with the tuned AFOs would translate to improved balance confidence. But patient-reported scores on the Activity-specific Balance Confidence (ABC) scale told a different story: ABC scores were significantly better with AFOs than with shoes only for the untuned group, but not the tuned group. Mean ABC scores with AFOs were also higher for the untuned group than the tuned group, though that difference was not statistically significant.

Granted, this was a pilot study, with a small number of participants, and it was not designed to look at within-subject differences between the tuned and untuned AFO conditions. But it’s also not entirely surprising that self-reported balance confidence improved more with the untuned AFOs, even though static balance and dynamic balance were improved to a greater extent with the tuned AFOs.

As LER has reported, other studies—not to mention clinicians’ experience—also suggest that patients may be uncomfortable in tuned devices even if their balance and function are significantly improved (see “AFO tuning: Balancing function and satisfaction,” August 2014, page 27). And patients who aren’t comfortable in tuned AFOs aren’t likely to wear them, regardless of the potential biomechanical advantages.

Such patients may be reluctant to voluntarily mention any device-related discomfort; it may be easier for them to express those concerns in a questionnaire. That’s why doing both subjective and objective assessments can help clinicians recognize patients who may need a little more time or assistance in adjusting to tuned AFOs.

Patient testimony may not necessarily be part of a good legal defense strategy. But it can help make a good clinical strategy even better.

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