Questions, Answers & Commentaries About AFOs

By Dr. Jennifaye V. Brown

This month, the column is reserved to answer questions and respond to commentaries that correspond to the articles written. The following 3 articles were written in the first quarter:

1. Is Neutral Enough for Ankle Dorsiflexion?
2. Sensory Input is Needed for Motor Output–The Foot of the Matter
3. Sensory Input is Needed for Motor Output: The Type of Self-Work for the Best Foot Work Matters

I will address the following comment:

I am so happy that we have such a knowledgeable physical therapist clinician who really considers the individuals functional context in addition to their pathophysiology. It is not often that clinicians consider social determinants of health and the ICF model so fluidly in practice when designing AFOs.

I would like to thank the reader for acknowledging my expertise. I want to reiterate that the literature supports functional context as a focus of rehabilitation as opposed to just impairment-based interventions.¹ We must treat the person as a whole entity (person: mental, emotional, physical, spiritual, intellectual) of who they are in their lived spaces (environment) and what they do in that space (tasks).^2-9

I focus on developing a relationship with the patient/client and their caregiver which begins with an introduction and flows into the subjective history by asking open-ended questions that gives me a picture of who that person was, is, and has the potential to be. The subjective portion of the examination sets the agenda for how I will conduct the objective portion of the examination and furthermore, sets the agenda for shared decision-making for the plan of care and goal setting.^10-11 I have built trust in the relationship and the patient/client and caregiver will trust the process by adhering to a plan that is reflective of their lifestyle.^12-14 For example, if the patient/client does not have a bed and sleeps on the floor, movement analysis begins with moving from the chair to the floor and doing the range of motion, manual muscle and or sensory test starting in the chair and finishing on the floor as warranted. Then, I can assess fall recovery from floor to stand using the chair. This exemplifies the task-oriented approach and sets the agenda for the plan of care.^15-16 The demonstrated movement requires variability in range of motion and strength/force generation: isometric, eccentric and concentric. I can develop exercises/activities as appropriate at the body-structure function level (hip abduction in supine) and at the activity level (side stepping with knee straight targeting stance phase stability in the frontal plane) and last, the participation level (side stepping in a modified squat position to take a seat in the pew at church).

This scenario aligns with the framework established by the World Health Organization known as the International Classification of Functioning, Disability and Health (ICF).¹⁷ Atkinson & Nixon-Cave illustrate the use of this framework as a tool for patient management. Through its use, the practitioner is guided to address the health disease status by identifying impairments associated with body structures and functions, activities, and participation in societal roles. The patient/client is integrated in the framework under the context of environment described by internal identifiers such as behaviors, roles and habits but who is also impacted by external factors identified as for example, family and insurance.¹⁸  The environment portion of this framework aligns with the social determinants of health which should be uncovered during the chart review and subjective portion of the examination.^19-20 Acknowledging and appropriately integrating those social determinants will refine and focus the plan of care into achievable goals. The American Board of Physical Therapy Specialties of the American Physical Therapy Association uses the content of the Atkinson & Nixon-Cave article as a template to demonstrate clinical reasoning, critical thinking and clinical decision-making for those applying for board recertification. This tool for patient management serves as a foundation to a systematic approach I take when examining clients/patients and thereafter, evaluating the data to create and address goals established through shared decision-making which leads to excellence in practice as the normative model in all that I strive to do.^11,21-24 I continue to consider patient/client values and the evidence (practice- and research -based) to assure person-centered care and always keeping the focus on function.

Jennifaye V. Brown, PT, MSPT, PhD, NCS, CAPS is an American Physical Therapy Association 4-time 10-year board certified neurologic physical therapist in Charleston, South Carolina, specializing in stroke rehabilitation, specifically gait analysis and treatment, AFO design, and the redesign of lived spaces allowing individuals with disAbilities to age in place. She is the author of the book, Brace Yourself: Everything You Need to Know About AFOs After Stroke.