Adherence Among Users of Orthopedic Footwear and Lower-limb Orthoses
August 2016 Issue
During my orthotic residency, a physical therapist and I were discussing orthotic options for a patient with post-stroke hemiparesis. The therapist had concerns about the KAFO I was recommending and advocated for an AFO. As I explained the rationale for the KAFO, she leaned in and said, "Here's a dirty little secret-most of these things end up in the closet." As the discussion continued, it was obvious that her comment was intended as a statement about patient compliance, and not related to the quality of the devices provided. Whether the therapist was right or not in her general appraisal of KAFOs and compliance, many practitioners would affirm that use of the devices they provide often does not match their recommendations or expectations. In many cases we consider this nonuse a significant detriment to the patient's health and function. Our impressions of the frequency and causes of noncompliance based on our past experience often influence our clinical decisions and recommendations. This article reviews themes found in a number of recent studies about patients' compliance when using assistive devices, orthopedic footwear, and lower-limb orthoses.
Compliance and Adherence
The terms we use to discuss the phenomenon of a patient not using a prescribed device can represent different perspectives about the roles of the patient and medical provider. According to Wessels et al., "(Non-) compliance relates to how well the patient obeys (or complies with) the doctor's orders. The patient is perceived as a passive receiver of instructions.... Nonadherence, on the other hand, relates to the willingness and the possibility of a patient to develop his own health plan. Adherence has to do with commitment. The patient is perceived as someone who has the right to make choices, guided by the professional."1 The term abandonment "suggests a somewhat active (or at least conscious) choice not to use something" while the term nonuse "is a more neutral description of the phenomenon."1
More precise definitions of nonuse are required to better understand published literature on this subject and apply it to a patient's situation. Abandonment is a more absolute term, usually indicating that a device is no longer used at all, and describes only a small percentage of cases. Noncompliance is used frequently in the O&P profession and usually implies that the patient is not doing something, such as wearing a device, that the clinician believes he or she ought to be doing. As we'll see later in this article, this view may not sufficiently address the nuances of the patient's situation or the role that the clinician plays in the patient's appropriate device usage. Because of its neutrality, the term nonuse will be used throughout this article, although it may not adequately address the varied clinical presentations of the phenomenon.
Table 1 shows the factors identified by Wessels et al. that relate to nonuse of assistive technology and nonadherence with other medical interventions.1 Knowledge of these factors may increase clinicians' appreciation of the variety of factors that impact the decision to use or not use a device.
Definitions of Nonuse
One of the challenges in determining rates of use and nonuse is that a variety of definitions are used in the literature. According to Dijcks et al., the definition of nonuse may include "no use at all, no full-time use, nonuse at the time of the study, no frequent use, low average use, no correct use, nonuse for the activities it was prescribed for."2 Some researchers use "frequency of use, duration of use per day, use at any point post-discharge, average use, used at least three times since prescription" or "the device is being used correctly, the device is being used incorrectly, and the device is not being used," to identify various levels of usage in their studies.1
Asking about device use at a particular point in time may mask the nuances related to device usage. For example, a patient may discontinue use of one device because he or she began using a different type of device due to changes in function. We often expect, and even recommend, different patterns of use based on differing short- or long-term goals. Task-specific devices are intended only for specific activities. Other devices, such as cranial remolding orthoses and TLSOs to treat scoliosis, are intended to be used for extended periods of time each day over a prolonged span of time. Koyuncu et al. exemplify a common distinction between various levels of acceptable use in a study of patients with spinal cord injuries (SCIs) using lower-limb orthoses when they described "verticalization is correct ambulation in parallel bars" as "therapeutic ambulation," and "mobilization using an orthosis to implement daily life activities inside or outside of the house" as "functional ambulation."3 Clinicians often use such terms to distinguish between various levels or types of acceptable device use.
General Rates of Nonuse
Multiple researchers report that between 25 and 30 percent of assistive devices are not used as intended.1,2 Swinnen and Kerckhofs reviewed ten studies, involving over 1,500 patients, that examined the rate of lower-limb orthotic device and shoe nonuse, and reported a wide range of nonuse rates (6-80 percent).4 This broad range is due to the variety of devices included in the studies. The percentage of nonuse was lower for orthopedic shoes and highest for "AFOs in severe bilateral foot drop due to CMT [Charcot-Marie-Tooth disease]."4 Arts et al. report only 22-36 percent of patients with diabetes "use their footwear frequently (> 80 percent of daytime, i.e. time out of bed)," and their research shows that 58 percent of patients wore "their prescription footwear for less than 60 percent of daytime hours."5 Koyunco's research on the use of orthoses after SCIs reveals that "at least one out of four patients with SCI do not use the recommended lower-extremity orthosis."3 In a 2015 study of neurological patients and their lower-limb orthoses, Swinnen et al. report that out of 33 patients, most of whom wore an AFO, "21 patients (64 percent) were wearing their devices every day, while the other 12 patients (36 percent) were wearing [them] several times a week but not every day."6
Patient Expectations and Communication With Providers
Orthotic usage is significantly affected by clients' expectations of themselves and their assistive devices, as well as the expectations of their performance with those devices from people in their social circles.1 In 2010, van Netten et al. investigated the relationship between 339 patients' expectations upon receiving their first pairs of orthopedic shoes and their use of those shoes. The researchers found that "the expectations of patients who frequently used their orthopedic shoes were in concordance with their experiences, whereas the expectations of patients who did not use their orthopedic shoes were much higher than their experiences.... An orthopedic shoe that is technically perfect, yet does not meet the patients' expectations, will most likely not be used."7
Clinicians should take the time to discuss each patient's expectations regarding the recommended device and treatment plan, and discuss differences between those expectations and the device they are recommending.7 "When the relationship between the patient and the clinicians is seen as a partnership in order to achieve well-being, patients will feel taken into account and will have confidence in their clinicians."8 In van Netten et al.'s 2010 study, "around one-quarter of the patients reported that there was no communication of their expectations with the medical specialist or the orthopedic shoe technician."7
Wessels et al. state that "communication between client and counselor is of strong influence to the degree of adherence."1 Good communication includes taking into account what is important to each patient, considering the opinions of the patient in the device selection process, and learning the patient's preferences and priorities, all of which can positively affect usage.1,2,5,8 Further, good communication has a number of connections with patient satisfaction, including a positive effect on patients' decisions to use their orthopedic shoes and increases in the likelihood that patients follow up with their practitioners when they encounter problems, have their concerns addressed, and continue using their devices.7
The Importance of Function
Adherence is closely related to usability, which is "the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use," according to van Netten et al.7 Dijcks et al. report, not surprisingly, that "persons who stated that the problem their assistive device was provided for was (largely) solved, and persons who were satisfied with their device and the services, reported nonuse less frequently."2 This puts responsibility on the practitioner to perform a thorough assessment and provide a device that effectively meets each patient's needs, as well as to foster a close relationship with the patient that allows for constructive strategies to address patient problems and complaints.2
Swinnen et al.'s published data relates to neurological patients' acceptance of and satisfaction with their lower-limb orthoses-most of which were AFOs for patients post-stroke or with multiple sclerosis-and found patients' perceived functional improvement as the main advantage and reason for continued device usage.6 While participants in this study reported the lowest satisfaction in areas related to aesthetic concerns, less than one-fourth of the patients had negative comments about the visual aspects and the ability to hide their orthotic devices.6 The researchers summarize that function and comfort were more important to patients than the aesthetic, design, and psychological aspects of an orthosis. "The majority of the patients would consider continuing using their OD [orthopedic device] even if the visual aspects were not good...if they felt disabled... or if they had the feeling that others saw them as disabled."6
van Netten et al.'s study on the use of orthopedic shoes found that "an improvement of walking was indicated as the most important factor of usability. The importance of other factors (cosmetic appearance and ease of use) was determined by reaching a compromise between these factors and an improvement of walking."8 Arts et al.'s study of 153 patients with diabetes found that the determining factor for footwear use was "the perceived benefit of wearing prescription footwear at home."5 They recommend "educating patients more effectively about the therapeutic value of custom-made footwear."5
It is important to remember that "nonuse of assistive technology does not always indicate a problem."2 We do our best to make recommendations that are in our clients' best interests and recognize that, as the end-users of the devices, they may have a better sense of what is necessary, manageable, useful, and appropriate. Their decisions do not occur in a vacuum and often involve complicated calculations about the roles the devices play in their lives.
Swinnen and Kerckhofs conclude in their 2015 systematic review that "if the walking function or mobility is not improved enough or if it is still possible to manage without them, this could lead to not using the assistive device."4 Taking the time to listen, help clarify expectations, and provide clear instructions will allow us to distinguish between nonuse that is detrimental to the patient's well-being and a use pattern that is simply different from our expectations and goals for the patient. These strategies will also help us address patient concerns more effectively and increase the likelihood that the device is used as designed and intended.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
- Wessels, R., B. P. Dijcks, M. Soede, G. J. Gelderblom, and L. P. De Witte. 2003. Nonuse of provided assistive technology devices, a literature overview. Technology and Disability 15(4):231-8.
- Dijcks, B. P., L. P. De Witte, G. J. Gelderblom, R. D. Wessels, and M. Soede. 2006. Nonuse of assistive technology in The Netherlands: A nonissue? Disability and Rehabilitation Assistive Technology 1(1-2):97-102.
- Koyuncu, E., G. N. Yüzer, P. Çam, and N. Özgirgin. 2016. Investigating the status of using lower extremity orthoses recommended to patients with spinal cord injury. Spinal Cord doi:10.1038/sc.2016.39.
- Swinnen, E., and E. Kerckhofs. 2015. Compliance of patients wearing an orthotic device or orthopedic shoes: A systematic review. Journal of Bodywork and Movement Therapies 19(4):759-70.
- Arts, M. L., M. de Haart, S. A. Bus, J. P. J. Bakker, H. G. A. Hacking, and F. Nollet. 2014. Perceived usability and use of custom-made footwear in diabetic patients at high risk for foot ulceration. Journal of Rehabilitation Medicine 46(4):357-62.
- Swinnen, E., C. Lafosse, J. Van Nieuwenhoven, S. Ilsbroukx, D. Beckwée, and E. Kerckhofs. 2015. Neurological patients and their lower limb orthotics: An observational pilot study about acceptance and satisfaction. Prosthetics and Orthotics International doi:0309364615592696.
- van Netten, J. J., M. J. Jannink, J. M. Hijmans, J. H. Geertzen, and K. Postema. 2010. Patients' expectations and actual use of custom-made orthopaedic shoes. Clinical Rehabilitation 24(10):919-27.
- van Netten, J. J., P. U. Dijkstra, J. H. Geertzen, and K. Postema. 2012. What influences a patient's decision to use custom-made orthopedic shoes? BMC Musculoskeletal Disorders 13(92):1.