To whom should an Ankle-Foot Orthosis (AFO) prescription be sent?

AFO Prescription Process: Where to Send It

AFO prescriptions should be sent to a specialized orthotist who can properly fit, customize, and fabricate the device based on the patient's specific needs and the prescriber's specifications. 1

Prescription Pathway

1. Initial Prescription:

   • Complete a detailed prescription form specifying:
     • Type of AFO needed (standard, custom, hinged, solid)
     • Material requirements
     • Specific biomechanical goals (ankle stability, dorsiflexion assistance)
     • Patient's diagnosis and functional limitations

2. Send To:

   • Orthotist: A certified professional specializing in orthotic devices
   • Located in:
     • Orthotic and prosthetic clinics
     • Rehabilitation centers
     • Some hospital outpatient departments
     • Specialized orthotic companies

3. Assessment Process:

   • The orthotist will:
     • Evaluate the patient's gait and mobility needs
     • Take measurements and/or molds of the patient's foot and ankle
     • Discuss functional goals with the patient
     • Create a custom-fitted device or modify a prefabricated one

Evidence-Based Considerations

Type Selection

• For stroke patients with ankle instability or dorsiflexor weakness, AFOs are strongly recommended (Level I, Evidence B) 1
• Initially, prefabricated braces may be used, with customized orthoses reserved for patients demonstrating long-term need 1
• For patients with deformity or joint instability, below-knee customized devices should be used for optimal plantar pressure distribution 1

Prescription Details

• UK orthotists commonly prescribe rigid AFOs using 4.5 mm copolymer polypropylene with full-length footplates and trimlines behind the metatarsal heads 2
• The posterior upright width significantly affects resistance to dorsi- and plantar-flexion movements, allowing for customization based on patient needs 3

Common Pitfalls to Avoid

1. Inadequate Specification:

   • Failing to specify biomechanical goals can result in inappropriate orthotic design
   • Always include diagnosis, functional limitations, and specific goals

2. Bypassing the Orthotist:

   • Sending prescriptions directly to manufacturers without orthotist involvement
   • The orthotist's expertise is crucial for proper fitting and customization

3. Poor Timing:

   • Delaying referral to an orthotist can lead to development of compensatory movements
   • Early prescription is recommended, especially for stroke patients

4. Insufficient Follow-up:

   • AFOs require adjustment periods and may need modifications
   • Schedule follow-up appointments to assess fit, function, and patient compliance

Special Considerations

• For patients with Charcot neuro-osteoarthropathy, custom-made footwear and orthoses that accommodate foot shape are strongly recommended 1
• For thumb base osteoarthritis, orthoses should be custom-made by specialized health professionals to improve compliance and long-term use 1
• For powered wheelchairs, a face-to-face examination by the prescribing physician and detailed documentation of mobility limitations are required 4

Remember that proper orthotic prescription and fitting can significantly improve mobility, safety, and quality of life for patients with various neurological and musculoskeletal conditions.