07/31/2024    Jonathan Moore, DPM, PhD, MS

Balance Braces

In 2009, I introduced the Moore Balance Brace,
which was initially manufactured by Arizona AFO.
Following OHI's acquisition of Arizona AFO, I
began a long-standing collaboration with OHI,
primarily through the leadership of Jason Kraus,
OHI’s former CEO. Under Jason’s guidance, numerous
studies were conducted using my design, including
biomechanical, clinical, and peer-reviewed
research published in journals such as Geriatrics
and JAPMA.

From the beginning, I advocated for a
multidisciplinary fall prevention program. As the
AFO gained widespread clinical use and
demonstrated significant success, many DME
companies started copying my basic design to
replicate its clinical benefits and financial
rewards. To differentiate the Moore Balance Brace
from these imitations, I withdrew my intellectual
property and involvement from OHI and once again
collaborated with Orthotica’s CEO, Jason Kraus.
Our goal was to create a better AFO with enhanced
features to improve balance, reduce postural sway,
and offer a comfortable, sleek design that fits
into a shoe.

Together with Orthotica’s partners, Jason and I
developed the first lower extremity fall risk
management program, "Life in Balance," based on
the CDC’s STEADI document. This program helps
podiatric physicians recognize at-risk individuals
and implement an evidence-based algorithm,
starting with a standardized, reimbursable fall
risk assessment.

Jason and I also introduced podiatry’s first
reimbursable web/app-based platform that not only
identifies patient risk factors but also supports
clinical intervention pathways, including physical
therapy/exercise, AFO/DME, and additional
procedures to improve patient functional
independence.

An AFO designed to enhance balance should not be
used as a stand-alone approach to fall prevention.
The Life in Balance Fall Risk Management program
aims to make fall risk reduction evidence-based
and clinically effective. Moreover, not all AFOs
marketed as Balance AFOs possess the necessary
design features for effective biomechanical
control and balance enhancement. An appropriately
designed Balance AFO should not restrict sagittal
plane motion but should allow normal sagittal
movement. The design, incorporating a posterior
leaf spring, supports the arch, prevents
shuffling, and addresses sagittal plane weakness
if present. The Moore Balance Brace (MBB) permits
normal sagittal plane motion, preventing seniors
from dragging or shuffling their feet, thereby
reducing the risk of forward falls.

Jonathan Moore, DPM, PhD, MS, Somerset, KY

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04/24/2019    Paul Kesselman, DPM

Balance Braces for Elderly Patients (Fall Prevention) (Dennis Shavelson, DPM)

From a purely utilization standpoint, those who
dispense bilateral AFOs on the same date of
service, stand out on the right end of the bell
curve. Now mind you, being on the right side of
the bell curve or being an "outlier" is not
necessarily a bad thing. But if you are going to
be a "pioneer" be prepared for lots of potential
negative push back from carriers, simply because
you are not in step with your peers. And by your
peers, I mean all providers of AFOs, not just
podiatrists. Currently, the data simply is not in
line with bilateral dispensing of AFOs.

As for the time period mentioned by Dr.
Shavelson, I believe he was referring to the Same
or Similar issue, which somewhat precludes a new
AFO within a 5 year (not 3-5 as mentioned in his
LTE). While the Same or Similar period can be
overcome through appealing to your DMEMAC and
meeting the requirements stipulated in the LCD
(new diagnosis, change in anatomy, physiology,
etc.), it's no slam dunk to a successful appeal.
If your appeal fails, you may get stuck paying
for an expensive brace without reimbursement.

As for the clinical efficacy of external or
internal bracing for fall prevention, we are a
far cry from any verdict on any of this. There
are a few recent papers which I was fortunate to
review, which do provide some positive feedback
regarding the use of balance bracing and fall
prevention. These papers suggest some evidence
that AFOs prevent falls, but there still is a
wide gap between suggestion, preliminary data and
clear evidence-based medicine (EBM) to stipulate
that AFOs prevent falls. Simply put, there are so
many etiologies for falls in the elderly, it will
take quite a bit of studies to draw any positive
conclusion that balance bracing can prevent falls
due to each and every fall etiology.

From the perspective of external AFOs vs.
internal AFOs, external (E) AFOs do offer quite a
number of advantages. Most are light weight and
one I've become familiar with can easily be
removed from one shoe and placed on another.
Others are more limited to use on one shoe. Easy
removal and donning is no doubt a great advantage
for the elderly, as is not taking up any room in
the shoe, thus allowing patients to wear a more
normal appearing shoe. Unfortunately many EAFOs
also have fewer clinical applications than their
internal counterparts.

From a reimbursement perspective, there are very
few preventative programs in Medicare available
for the podiatrist to provide. The ones most
recognizable to podiatrists include routine foot
care, LOPS and Therapeutic Shoe Program for
Patients with Diabetes. AFOs used when the
primary intent is for fall prevention are
currently not a covered service. Disguising
claims for fall prevention devices with other
diagnosis, in particular when dispensed
bilaterally, is ill advised.

Paul Kesselman, DPM, Woodside, NY