SLR - March 2016 - Robert Craig

Title: Compliance of Patients Wearing an Orthotic Device or Orthopedic Shoes: A Systematic Review

Reference: Swinnen E, Kerckhofs E. Compliance of Patients Wearing an Orthotic Device or Orthopedic Shoes: A Systematic Review. J Bodyw Mov Ther. 2015 Oct; 19(4):759-70.

Scientific Literature Review

Reviewed By: Robert Craig, DPM
Residency Program: The Christ Hospital

Podiatric Relevance: Orthopaedic devices including shoes, AFOs and others are used to provide many functional services to patients including protection from ulceration, increasing mobility and decreasing pain. They are designed to be worn when the patient is ambulating.  However, as with any medical treatments, compliance with DMEs can be an issue. There are many issues for compliance failure including patient’s functional expectations, practicality of use where patients may believe it is too cumbersome, and it may not be aesthetically pleasing. If the patients are non-compliant with these devices and wear them once a week, once a month or not at all they are not receiving the benefit for which they were created. This study was designed to see what the rate for non-compliance of orthopedic devices was and investigate the reasoning why patients were being non-complaint and if patients used certain devices less than others.

Methods: The researchers used four different databases including PubMed, Web of Science, Pedro and Cochrane Library. They used key-words to discover potential articles relating to orthopaedic devices and patient compliance. The researchers reviewed the article title and if they felt it relevant investigated the abstract to see if it would satisfy their inclusion criteria. Only papers written in French, Dutch and English were included.

Results: The researchers discovered 117 articles initially, and eventually narrowed it down to 10 studies. All studies used were either cohort or cross sectional. Out of the 10 studies, 1576 patients were included, six studies involved orthopaedic shoes, two with AFOs, two with a dropped foot simulator and one with a mix of devices. These studies involved patients with numerous pathologies including rheumatoid arthritis, stroke, osteoarthritis, Charcot-Marie-Tooth (CMT) and cerebral palsy. In regard to the studies on orthopaedic shoes, non-compliance rates ranged from 4.8 to 20 percent. The majority of reasons for not wearing the shoes were either the cosmetic appearance or the discomfort/pain involved with using them. The AFO study with patients with CMT showed non-compliance to be 80 percent. Similar to the orthopaedic shoes, AFO compliance was mainly divided into discomfort and aesthetics. The foot drop simulator displayed a non-compliance of near 50 percent. Aesthetics held low reasoning for the drop foot simulator for non-compliance, instead focusing on no longer needing the device due to improvement in mobility.

Conclusion: The study concluded that there is a wide range of non-compliance when dealing with an assortment of orthopaedic devices, some as low as 6 percent and others as high as 80 percent. They determined that this leads to a high cost on the patients, device manufacturers and insurance companies, especially when a device is created custom and is not used based on discomfort or aesthetics. The study suggests that a questionnaire could be created to screen for potential non-compliance. I feel that a questionnaire could be beneficial to determining possible compliance of patient with device, however it is possible that realizing they are being evaluated the patients may not answer honestly. Instead, it may be more beneficial for the doctor to use their subjective judgment on whether they think the individual patient will comply. This study certainly affects the way I handle patents with deformities that will benefit from production of these devices. I will be more diligent in examining not only their physical deformity but also their mental state to determine if they will use the device, especially AFOs as they had a very high rate of non-compliance. It will also lead me to explain the reasoning behind the device in better detail and why it benefits the patient to wear it at all times so that the patient is better informed about expectations.

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