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VOLUME 4, ISSUE 1 

 2021 

 

LITERATURE  REVIEW 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 

1, No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

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1 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

 

 

 
LITERATURE  REVIEW 

 

THE IMPACT OF ANKLE-FOOT ORTHOSES ON BALANCE IN OLDER ADULTS: A SCOPING 

REVIEW 

Laidler J.L* 
 

Department of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, Canada. 
 
 

 

 

 

  

 

 

 

 

 

 

 

 

 
 

INTRODUCTION   

Falls are the leading cause of injury among older adults in 

Canada and are the third leading cause of death after 

cancer and heart disease.1 One in three adults over age 

65,2 and one in two adults over age 80,3 experience at least 

one fall annually. Falls are associated with high morbidity 

and mortality, and poor health outcomes.4,5 Older adults 

experience more falls and have a high susceptibility to 

injury, making falls a significant public health issue. Age-

related physiological changes coupled with a higher 

prevalence of comorbidities6,7 can result in older adults 

experiencing fractures, hospitalization, or early admission to 

a long-term care facility.8 Greater than 70% of falls in the 

community occur in the home, due to both predisposing and 

situational risk factors.5 With increasing numbers of older 

adults wishing to stay in their homes and ‘age-in-place’, falls 

are of increasing concern.   

Issues in balance control have been identified as a strong 

risk factor for falls.4 Age-related sensory and 

musculoskeletal changes play a large role in affecting 

balance in older adults.5,8,9 Decreased muscle mass is 

notable in aging and can lead to weakness resulting in 

inactivity, decreased balance control, gait deviations and 

instability during ambulation, and a lessened quality of 

life.7,10-12 Age-related physiological changes can co-occur 

 
OPEN  ACCESS Volume 4, Issue 1, Article No.1. 2021 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

BACKGROUND: Balance impairment is a contributing factor to falls. Falls are a leading cause of injury 

and death in older adults. An ankle-foot orthosis (AFO) is a device that can be prescribed as an 

intervention to help individuals with compromised balance to ambulate safely.  

OBJECTIVE: The purpose of this review was to investigate the role ankle-foot orthoses have in affecting 

balance in community-dwelling older adults.  

METHODOLOGY: A scoping review was conducted searching MEDLINE, CINAHL, EMBASE, and 

REHABDATA databases to obtain the appropriate literature to meet the following criteria: 1) quantitative 

research design; 2) studies with participants over age 65; 3) studies with participants with drop-foot or 

sensory deficits in the lower extremity; 4) the treatment intervention was unilateral or bilateral AFOs; 5) 

the outcome measure was balance or stability. The retrieved articles were assessed based on the internal 

validity, external validity, objectivity, and reliability of the study design and the interpretation of results.   

FINDINGS: 11 articles were identified that met the inclusion criteria. Four major themes emerged in the 

analysis about the impact that ankle-foot orthoses have on balance in older adults: (1) AFOs improved 

lateral stability, (2) AFOs improved balance under static conditions, (3) AFOs provided a reduction in 

postural sway and (4) AFOs increased walking speed in community-dwelling older adults.  

CONCLUSIONS: The evidence from the findings of the review indicate that ankle-foot orthoses have a 

generally positive affect on balance in older adults. Clinicians can consider the ankle-foot orthosis an 

effective intervention that can improve balance in some older adult patient populations. 

ARTICLE INFO 

Received: November 22, 2020 

Accepted: December 28, 2020 

Published: January 4, 2021 

CITATION 

Laidler J.L. The impact of ankle-

foot orthoses on balance in older 

adults: A scoping review. 

Canadian Prosthetics & 

Orthotics Journal. 2021;Volume 

4, Issue 1, No.1. 

https://doi.org/10.33137/cpoj.v4i

1.35132 

KEYWORDS 

Ankle-Foot Orthosis, AFO, Older 

Adult, Aged, Balance, Postural 

Balance, Orthosis, Scoping 

Review, Fall 

 

* CORRESPONDING AUTHOR: 

Jenna Laidler, 

Aging and Health Program, School of Rehabilitation Therapy, 
Queen’s University, Kingston, Canada. 

E-mail: j.laidler@queensu.ca 

ORCID: https://orcid.org/0000-0002-9875-6054 

 

https://doi.org/10.33137/cpoj.v4i1.35132
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i1.35132
https://doi.org/10.33137/cpoj.v4i1.35132
mailto:j.laidler@queensu.ca


 

2 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
with the development of chronic condition(s), further 

compromising balance depending on underlying issues, 

and the strategies used to help manage them. Ankle-foot 

orthoses (AFOs) are often prescribed for managing 

pathologies that affect typical functioning of the ankle joint 

in stability, positioning, and pressure distribution.13 An 

ankle-foot orthosis is a brace worn on the lower leg to hold 

the foot and ankle in position, defined by the International 

Society for Prosthetics and Orthotics as an “externally 

applied device used to modify the structural and functional 

characteristics of the neuromuscular and skeletal system.”14 

AFOs have been accepted as a treatment to address 

balance impairment, proper gait parameters, and safe 

ambulation for people with conditions such as stroke, 

peripheral neuropathy, multiple sclerosis, cerebral palsy 

and others.13 Evidence exists to support the use of AFOs to 

improve ambulation and joint alignment, the next step is to 

determine what evidence exists regarding the effect of 

AFOs on balance.  

The objective of this review is to investigate the influence of 

AFOs during static and dynamic balance in older adults. The 

research question will be: What role do ankle-foot orthoses 

play in affecting balance in community-dwelling older 

adults?  

METHODOLOGY 

A scoping review was conducted to identify the existing 

relevant literature available on the subject and to evaluate 

the research findings. Scoping reviews examine the range 

and nature of research literature in a specific subject area, 

and commonly aim to identify gaps in the existing literature 

to determine the value of undertaking a full systematic 

review.15 The research question used to guide the review 

was “What role do ankle-foot orthoses play in affecting 

balance in community-dwelling older adults?” The definition 

of an older adult was men or women aged 65 or older. 

Community-dwelling older adults were considered as those 

living in their own homes, not in institutions such as 

hospitals or long-term care. 

Search strategy 

An electronic database search was conducted using four 

databases: MEDLINE, CINAHL, EMBASE, and 

REHABDATA. These databases were selected because 

they contain literature pertaining to the health sciences, and 

they index the main journals that contain information related 

to healthcare and rehabilitation. To supplement these 

searches, a hand search of reference lists of retrieved 

articles was also conducted to identify potentially relevant 

studies.  

A combination of keywords and MeSH terms were used to 

conduct the search. The search terms were as follows: 

orthotic device/orthotic brace/ankle-foot orthotic/AFO; 

balance/postural balance; aged/older adults. MeSH terms 

and corresponding keywords were combined in searches 

with ‘AND’ or ‘OR’ to ensure the articles retrieved contained 

all relevant terms. Figure 1 illustrates the search strategy 

undertaken in each database (Appendix (A)) for detailed 

database searches). Literature from January 1990 to 

February 2020 were included in the search based on 

discussions with professionals in the field, as well as 

through database searches, which determined that limited 

literature existed on this topic prior to 1990.  

 

 

 

 

 

 

 

 

Figure 1: Example database search strategy. 
Each number represents the database search performed and the results retrieved for 

each MeSH term and keyword (1-6), the searches combining the corresponding MeSH 

term and keyword (7,8,9), and the final search results combining all of the terms involved. 

Article screening and selection process 

Titles and abstracts of retrieved articles were screened for 

relevance to the research question based on the following 

criteria: 1) studies had a quantitative design; 2) participants 

were older adults over the age of 65; 3) participants had 

some degree of drop-foot or a sensory deficit in their lower 

extremity; 4) the treatment intervention was unilateral or 

bilateral ankle-foot orthoses; 5) the outcome measure was 

that of balance or stability. The full text of the remaining 

studies that were identified as relevant were screened for 

eligibility based on inclusion and exclusion criteria.  

Studies were included if they met the following inclusion 

criteria: 1) participants were community-dwelling older 

adults, aged 65 and over; 2) study incorporated the use of 

unilateral or bilateral AFOs, regardless of design or 

fabrication material; 3) study described the effect of the 

AFO(s) on balance; 4) study was written in English. Studies 

were excluded from consideration if 1) the AFO(s) had a 

mechanical/electrical component; 2) patients had partial 

foot amputations; 3) participants were in hospital or long-

term care. These criteria were selected to ensure that the 

most appropriate patient population and study conditions 

were included in the analysis to address the research 

question. Where possible, in studies with mixed-aged 

samples of participants under the age of 65, only data from 

those 65 and over were considered. Each article was 

AFO 

MeSH 

OR 

Search 

Results 

Keyword 

1 

2 

7 

Balance 

Older 

Adults 

MeSH 

OR 

Keyword 

3 

4 

8 

MeSH 

OR 

Keyword 

5 

6 

9 

https://doi.org/10.33137/cpoj.v4i1.35132


 

3 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
screened for eligibility based on whether it met these 

criteria, and whether the title and abstract contained the 

relevant content to address the research question to 

warrant full-text review. The reference management 

software EndNote version X9.2 (EndNote, Clarivate 

Analytics, PA, USA), was used to manage the citations of 

the retrieved articles. 

Data extraction and analysis  

Articles were selected based on their focus on the affect that 

AFOs have on balance in the older adult population. The full 

text of each article was examined by the reviewer and was 

assessed based on the internal validity, external validity, 

objectivity, and reliability of the study design and the 

authors’ interpretation of the results. Key information was 

extracted and organized into a table to display the main 

ideas and characteristics of each study including study aim 

and findings, sample characteristics, study design, AFO 

characteristics, balance metrics utilized, and strengths and 

limitations.  

The quality of each of the selected articles was also critically 

evaluated using a series of quality appraisal questions 

based on a combination of appraisal tools developed by 

CASP16 and McMaster University.17 Quality was 

determined by using these questions to evaluate the 

methodological vigour of the study design and the 

soundness of the interpretation of findings presented in 

each article. Based on the determined quality, a grade was 

assigned (from 1-low to 3-high) to each study, and a quality 

matrix was developed based on the quality rating to 

determine the weight of the evidence presented in each 

study (Appendix (B)). Higher quality evidence was weighted 

greater when considering its value in addressing the 

research question.  

Articles were analyzed based on the similarities of subject 

characteristics and diagnoses, balance metrics recorded, 

and study design. The findings of each article were 

examined and compared for relevancy to answering the 

research question, and for emergent patterns on the effects 

AFOs produce on balance in older adults. 

RESULTS 

A total of 285 studies were retrieved from the database 

searches, 108 of which were duplicates and were 

disregarded. The titles and abstracts of 177 articles were 

screened for relevancy to answering the research question, 

producing 62 articles for full-text review. After the inclusion 

and exclusion criteria were applied, 11 articles remained for 

inclusion in the scoping review (Figure 2). Hand searches of 

reference lists yielded only duplicate or irrelevant studies, 

thus did not add to the search results.  

The emergent trends in the findings of each article were 

identified as the core themes existing in the current research 

literature and were the themes that were examined to help 

address the research question. The 11 articles included 

were selected because they focused on the affect that AFOs 

have on balance in the older adult population. Through the 

quality appraisal and data analysis of each article, four 

major themes emerged: AFOs improved lateral stability, 

static balance and walking speed, and provided increased 

postural control. The quality matrix (Appendix (B)) 

summarizes the quality rating and weighting of the evidence 

presented in each article. The summary of the main 

thematic ideas identified regarding ankle-foot orthoses’ 

affect on balance in older adults are found in Table 1. The 

quality rating was inputted into the final column of the 

thematic summary table (Table 1) and the data extraction 

table (Appendix (C)). 

General overview of study characteristics 

The included studies were conducted in the 

Netherlands,18,19 Taiwan,20-23 Turkey,24,25 and the United 

States.26-28 Nine studies used a randomized pre-test/post-

test design, in which the AFO condition was compared with 

the no AFO condition, and the order of the testing with and 

without the AFO was randomized. Two studies that were 

included were randomized control trials (RCTs).18,27 

Records were searched from 1990 to present, and only one 

study was retrieved prior to 2005.21  

Sample sizes ranged from 1226 to 10322 subjects. The 

studies included a sample of participants in which forty-two 

percent were female, while fifty-eight percent were male. 

The ages ranged from twenty-six to eighty-four years, with 

the average age being 65. Eight of the eleven included 

studies had patients who were recruited from outpatient 

rehabilitation hospital settings.18-25 The remaining studies 

recruited patients from community medical clinics or seniors 

support groups.26-28 The studies that recruited subjects from 

outpatient rehabilitation used samples of hemiplegic stroke 

patients as their subjects, and the three studies who 

recruited from the community setting included subjects with 

peripheral neuropathy or diabetes,26,28 or non-pathological 

subjects.27  

The style of AFOs that were used varied across studies, as 

well as in the duration of time subjects had getting used to 

using them. AFO designs utilized in the studies included 

thermoplastic posterior leaf-spring,18,22-24 thermoplastic 

anterior leaf-spring,20,21,27,28 anterior-shell carbon 

composite,26 thermoplastic hinged,25 or varying types.19 

Studies included both custom and prefabricated AFOs, with 

the majority of studies utilizing prefabricated versions. Six 

studies tested the immediate balance effects of AFOs on 

subjects who had no prior experience using one,20,22,23,26-28 

and five studies included subjects who had sufficient 

practice (>4 days) or used their own AFO at study 

outset.18,19,21,24,25 Eight of the eleven studies had their 

https://doi.org/10.33137/cpoj.v4i1.35132


 

4 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
subjects wear an AFO on a single side (unilaterally),18-25 

and three studies required their subjects to wear AFOs on 

both sides (bilaterally).26-28 

Themes 

Lateral Stability 

Improved lateral stability with AFO wear emerged as a 

theme throughout the literature. Six studies included 

findings that lateral stability was improved while wearing an 

AFO.21-23,26-28 It was found that AFO wearers were able to 

shift their center of mass (COM) more toward the AFO side 

and therefore increase the lateral stability on this affected 

side. Anterior/posterior balance was also measured with 

varying affects found on whether balance was affected due 

to AFO wear. Some studies observed limitations to 

anterior/posterior balance and suggested that the AFO 

restricted natural ankle movement.21-23,26 Chen et al.21 

evaluated the effects of AFOs on postural stability in 

hemiplegic patients during weight shifting using force 

sensors and found significant improvements in lateral 

weight shifting and weight bearing on the AFO side, with no 

improvement observed in the anterior/posterior direction. 

They attributed this to the ankle’s range of motion being 

restricted while wearing the AFO. Wang et al.23 found that 

in their study of assessing changes in balance and gait of 

hemiplegic subjects wearing AFOs, it was demonstrated 

that though AFOs restricted ankle movement, the presence 

or absence of wearing an AFO did not significantly impact 

anterior/posterior balance measures during leaning tasks. 

All of the studies that found a positive relationship between 

AFOs and increased lateral stability, found this improve-

ment in a static condition.  

Static Balance 

Improvements in static balance as a result of wearing an 

AFO was the most commonly observed theme in the 

reviewed studies.20-24,26-28 Static balance was improved 

while wearing AFO(s) in each of these studies and was 

more significant than measured improvements in tests of 

dynamic balance. Many studies conducted trials primarily 

using static measures of balance, while only some included 

dynamic walking test conditions. All of these studies used a 

computer-based devices and software to attain their 

balance measures. 

Cakar and colleagues24 investigated the relative effect of 

AFOs on balance and fall risk by comparing balance 

measurement outcomes within a group of stroke patients 

with spasticity to determine that AFOs improved balance, 

though they used exclusively static testing conditions. 

Similarly, the studies by Chen et al.,20 who evaluated the 

effects of an AFO on postural stability in stroke patients with 

hemiplegia, and Wang et al.,27 who investigated the 

effectiveness of AFOs on balance in older adults, also found 

improvements in balance while only testing in static 

conditions using force plate posturography and balance 

sensors, respectively.  

 

Figure 2: Flowchart diagram of the literature search, screen and selection process 

 

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In

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d

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E

lig
ib

ili
ty

 

Records screened 

(n = 177) 
Records excluded after 

title/abstract screen 
(n = 115) 

Full-text articles assessed for 
eligibility 
(n = 62) 

Full-text articles 
excluded 

(n = 51 did not meet 
inclusion criteria) 

Studies included for full 
analysis (n = 11) 

Records after duplicates removed (n = 177) 

Records identified in 
MEDLINE 
(n = 103) 

Records identified in 
REHABDATA 

(n = 41) 

Records identified in 
EMBASE 
(n = 34) 

Records identified in 
CINAHL 
(n = 107) 

https://doi.org/10.33137/cpoj.v4i1.35132


 

5 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 

Postural Control 

Seven studies found a reduction in postural sway as a result 

of AFO wear.18,20,23,25-28 Postural sway, or postural control, 

was a variable measured to some capacity in all reviewed 

studies. In their investigation to determine the immediate 

effect of AFO wear on balance and functional reach in older 

adults, Yalla et al.28 found that AFOs decreased postural 

sway. Bigelow & Jackson26 found similar results in their 

investigation on the immediate effects of AFOs on balance 

and gait using force plates and clinical tests to produce 

findings that postural sway was reduced in static conditions, 

though the improvements in postural control in dynamic 

balance and walking conditions were more varied.  

Doğan et al.25 and Nikamp et al.18 were two studies with 

weaker evidence to support the AFOs ability to better 

control postural sway. Doğan et al.25 investigated whether 

AFOs had an effect on stair climbing, balance, and mobility 

Table 1: Summary of the main ideas about the affect ankle-foot orthoses have on balance in older adults. 

Author, 
Year 

Sample/ 
Study Design 

Aim of study Main Themes 
Quality 
Rating 

   
Lateral 
stability 

Static 
balance 

Postural 
Control 

Walking 
speed 

 

Bigelow & 
Jackson, 

201426  

 

n=12  
subjects with peripheral 
neuropathy; 
Pre-/post-test  
Quantitative 
Within-subjects comparison 

To observe the immediate 
effects of AFOs on balance and 
gait in individuals with peripheral 
neuropathy. 

 
x 

 
x 

 
x 

 
 
3 

Cakar et al., 

201024  

 

n=25 subjects with post-stroke 
hemiplegia with spasticity;  
Pre-/post-test Quantitative  
Within-subjects comparison 

To investigate the relative effect 
of AFOs on balance and fall risk. 

 
 
x 

  
 
1 

Chen et al., 

200820 

 
 

n=21 subjects with new onset 
stroke hemiplegia + 10 healthy 
subjects; 
Pre-/ post-test; 
Quantitative  
Cross sectional + control 
group comparison 

To evaluate the effects of an 
AFO on postural stability in 
stroke patients with hemiplegia. 

 
 
x 

 
x 

 
 
3 

Chen et al., 

199921  

n=24 hemiplegic subjects;  
Pre-/ post-test Quantitative  
Within-subjects 
comparison 

To evaluate the effects of an 
AFO on static and dynamic 
postural stability in hemiplegic 
patients.  

 
x 

 
x 

  
 
1 

Doğan et 

al., 201125  

n=51 subjects with post-stroke 
hemiplegia; 
Pre-/post-test Quantitative  
Within-subjects comparison  

To investigate whether AFOs 
have an effect on stair climbing, 
balance and mobility while 
improving walking parameters. 

  
 
x 

 
x 

 
1 

Nikamp et 

al., 201718  

n=33 subjects with post-stroke 
hemiplegia;  
RCT 6-month follow-up  
Quantitative  
Parallel group comparison 
 

To study the 6-month effects of 
early or late provision of AFOs in 
stroke patients; To look at 
differences between groups and 
functional improvement 
overtime.  

  
 
x 

 
x 

 
2 

Simons et 

al., 200919 

n=20 post-stroke subjects with 
hemiplegia; 
Pre-/ post-test Quantitative  
Within-subjects comparison 
with washout period 

To examine effects of AFOs on 
functional balance, static and 
dynamic weight bearing 
asymmetry, and dynamic 
balance control. 

 
 

  
 
x 

 
2 

Wang et al., 

201927  

n=44 
non-pathologic subjects  
RCT 
Quantitative Longitudinal (6-
month follow-up) 

To investigate effectiveness of 
AFOs on balance, fear of falling, 
and physical activity in older 
adults.  

 
x 

 
x 

 
x 

 
 
3 

Wang et al., 

200522  

n=103 subjects with post-
stroke hemiplegia;  
Pre-/ post-test 
Quantitative 
between group comparison 

To examine the effects of AFOs 
on balance in patients with short 
and long duration hemiparesis. 

 
x 

 
x 

 
 
x 

 
2 

Wang et al., 

200723  

 

n=58 subjects with post-stroke 
hemiplegia; 
Pre-/ post-test 
Quantitative 
Within-subjects comparison  

To assess changes in balance, 
and improvement in gait of 
hemiplegic subjects as a result 
of wearing an AFO. 

 
x 

 
x 

 
x 

 
x 

 
2 

Yalla et al., 

201428  

 

n=30 subjects with 
diabetes and/or peripheral 
neuropathy; 
Pre-/ post-test 
Quantitative 
Within-subjects comparison 

To determine the immediate 
effect of AFOs on balance and 
functional reach distance in older 
adults. 

 
x 

 
x 

 
x 

 
 
2 

 

https://doi.org/10.33137/cpoj.v4i1.35132


 

6 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
using functional measurement methods for which two of 

three functional tests showed a decrease in postural sway, 

and the third showed no effect. Nikamp et al.18 conducted a 

six-month follow up to their previous RCT to evaluate the 

effects of early or late provision of an AFO for stroke 

patients and to observe the differences in functional 

improvements overtime between groups. They observed 

the trend that postural balance improved overtime and did 

not differ between groups. The remaining studies that did 

not show a reduction in postural sway, did not find a 

negative impact of AFOs on postural sway or balance 

control.19,21,22,24 

Walking Speed 

Five studies showed AFOs produced an effect on walking 

speed.18,19,22,23,25,26 With the exception of Bigelow & 

Jackson,26 who found that AFOs decreased walking speed, 

the remaining studies found that AFOs increased walking 

speed, with effects reported on improved gait parameters 

as well.22,23 In examining the effects of AFOs on balance in 

patients with short- and long-duration hemiplegia, Wang et 

al.22 found that in addition to gait speed improving, cadence 

was also improved while wearing an AFO in their clinical 

tests involving gait trials.  

Simons and colleagues19 examined the effects that AFOs 

have on functional balance, and static and dynamic weight 

bearing asymmetry using posturographic and functional 

clinical tests with stroke patients wearing various AFO 

designs. They found that walking speed was increased in all 

patients regardless of the style of AFO worn. There was no 

consistent AFO fabrication style or design used in the trials 

of other studies that demonstrated an increase in walking 

speed, only that they were all worn unilaterally. Custom-

made versus prefabricated devices also had no apparent 

role on the balance outcomes of older adults in the included 

studies. 

Quality of the evidence 

The articles deemed to be of the highest quality20,26,27 were 

found to have strong objectivity and reliability, while the 

articles found to be of the lowest quality21,24,25 were found 

to have poor external validity. The evidence presented in 

the examined articles was generally found to be of moderate 

quality. Randomized control trials were considered to be at 

the top of the hierarchy of evidence,29 though only two were 

found to meet the inclusion criteria for the review.18,27 Most 

authors randomized the orthotic conditions during pre-

test/post-test trials so that the participants could act as their 

own control, while only three studies actually included 

distinct comparison groups.18,20,27 The Nikamp and 

colleagues18 study was an extension of their previous RCT 

involving inpatients, to investigate the six-month effects of 

their intervention. Though this study had elements of the 

strength of an RCT, it was not considered to be as high 

quality in its ability to answer this review’s research 

question. The sample sizes in the reviewed studies were 

small, and all studies had under 60 participants except for 

one.22  

Through the quality appraisal procedure, the studies by 

Wang et al.,27 Chen et al.,20 and Bigelow & Jackson26 were 

considered to have the most procedurally sound designs 

and be the highest quality of the studies reviewed. These 

studies found that AFOs had an effect on balance by 

decreasing postural sway and improving balance under 

static conditions. In addition to balance improvements in 

these two areas, Bigelow & Jackson26 and Wang et al.27 

also found significant improvements in lateral stability as a 

result of wearing an AFO. The trend that AFOs increase 

walking speed came from articles that were identified as 

moderate or low quality.  

DISCUSSION  

The aim of this scoping review was to investigate the role 

ankle-foot orthoses play in affecting balance in community-

dwelling older adults. Most studies found that with AFO 

wear postural control was improved, especially in the lateral 

direction. It was also demonstrated that AFOs improved 

static standing stability, that did not necessarily transfer into 

improved stability in dynamic conditions, such as walking.  

The trends observed from the findings of these articles 

provided some insight into the role that AFOs play on 

affecting balance in older adults.  

Main findings 

Improved Lateral Stability 

Lateral stability was widely found to improve amongst AFO 

wearers in this review. The findings by Wang et al.22 

confirmed earlier findings by Chen et al.,21 that through the 

use of an AFO, the body’s limit of lateral stability is 

increased, and subjects were able to bear more weight 

through their hemiplegic side. Wang et al.23 reconfirmed this 

finding in their 2007 investigation on changes in balance 

while wearing an AFO, which again showed the AFOs ability 

to improve balance through increasing lateral stability.  

Age-related declines in reaction time and physical strength 

can lead to impaired postural control in mobility. In a study 

on age-related differences in lateral stability, King, Akula, & 

Luchies30 found that compared to younger subjects, older 

individuals generated a larger force to recover balance to 

account for reduced lateral stability. Age-related muscle 

weakness can affect an older adult’s ability to produce this 

response for balance recovery. Impairments in balance 

control leave older adults more susceptible to falls, which 

are a major health issue, and a cause for injury and loss of 

independence in this population.31  

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7 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
Many of the reviewed studies acknowledge the lack of 

anterior/posterior balance improvement with AFO wear and 

attribute it to restrictions imposed on the ankle by the 

AFO.21-23,26 Rigid AFOs decrease ankle range of motion, 

which Yalla and colleagues28 speculate could increase risk 

for falling. However, Wang et al.23 report that though the 

AFO did restrict ankle movement, it did not significantly 

impact balance. This is supported by the investigation by 

Chen et al.,20 on ankle strategies in balance responses, 

which found that despite the rigid ankle, patients were still 

able to elicit ankle strategies to maintain postural control 

while wearing AFOs. Further investigation on the role AFO 

ankle rigidity plays on balance is necessary.   

Improved Static Balance 

Improved balance during static standing conditions was the 

most commonly observed theme in the literature in this 

review. Wang et al.22 examined stroke patients wearing 

AFOs under static standing conditions and found that 

balance improved. In reaching during static standing, Yalla 

et al.28 found that the AFOs improved static balance. In 

interpreting these findings, it is important to take into 

account that many studies in the review only measured an 

AFOs affect on balance during static, rather than dynamic 

conditions.  Cakar et al.,24 for example, found that AFOs 

improved balance in spastic stroke patients under static 

conditions, however they did not include dynamic measures 

of balance in their study.  

Dynamic balance was investigated in a study by Shearin, 

Smith, Querry, & McCain32 to assess individuals’ ability to 

attend to external demands requiring modifications to 

balance while walking. The results of this study found that 

dynamic balance was improved in individuals wearing an 

AFO. This finding was not validated in this review, and only 

one study23 demonstrated positive effects of AFOs on 

balance in a dynamic situation. As well, Simons et al.19 

found that the AFO had no effect on either static or dynamic 

balance. Further investigation is required to determine the 

AFOs role during dynamic balance. 

Improved Postural Control 

AFOs were shown to affect postural control in this review. 

To maintain stability during standing, the body’s center of 

mass (COM) must be positioned over the feet - the base of 

support (BOS).33 Even during quiet standing in healthy 

individuals, the COM experiences sway, though it is 

minimized when balance is proficient.34 Moving the COM 

outside of the BOS leads to instability, which when 

combined with age-related changes in strength and reaction 

times,31 can cause an increased frequency of falls.35  

Stability and balance are significantly impacted when 

proprioception is impaired. Multiple studies indicated the 

role that AFOs play in augmenting proprioceptive feedback 

on the lower leg and foot when deficits exist.20-22,26-28 In an 

investigation on the AFOs ability to provide sensory cues, 

Aruin & Rao36 found that AFOs can substitute for the lack of 

proprioceptive feedback in sensation impaired limbs to 

improve the postural responses. Yalla et al.28 suggested 

that wearing an AFO promotes proprioceptive feedback 

through stimulating cutaneous receptors. This is especially 

important for patients with peripheral neuropathy, and other 

pathologies that impair sensation. Malas37 points to the 

important considerations this requires from orthotists when 

fitting an AFO to ensure that pressure is properly distributed, 

enabling feedback to optimize stability.  

Increased Walking Speed 

In the present review, all studies that reported improved 

walking speed contained a sample of hemiplegic stroke 

patients. Since walking speed and cadence usually 

decrease in hemiparetic gait patterns,38 this finding 

suggests that the AFO has a regulating effect on the gait 

patterns in this population. Wang et al.23 attribute the 

increased walking speed to improved balance control in the 

affected leg that occurs as a result of wearing an AFO.  

In a study on the impact AFO design has on gait parameters 

in stroke patients, Tyson & Thorton39 reported that hinged-

AFOs better improved walking speed. Pardo, Galen, 

Gahimer, & Goldberg40 found similar results in their 

examination of hinged-AFOs effect on walking speed. In this 

review, only Doğan et al.25 used a hinged-AFO design, so 

this cannot explain the improvements observed. The 

studies that found improvements in walking speed with 

AFOs were of moderate quality, so further investigation into 

this effect is required. 

The style of AFOs worn in the different studies in this review 

were variable, with no consistent observations made on 

AFO style and balance. Pardo et al.40 investigated the 

outcomes of balance tasks in individuals wearing custom 

and non-custom (prefabricated) AFOs. The results 

indicated there was no difference in balance outcomes 

between custom-made and prefabricated devices. These 

findings complement the observation in this review, that 

outcomes on balance were not linked to custom-fabricated 

devices.  

Limitations 

The primary limitation of this review was that only one 

author was involved in the quality appraisal process of the 

included studies. This may have introduced some reporting 

bias, and could have been strengthened had additional 

reviewers been involved in the process. The small number 

of studies included in the review and that all of the studies 

had small homogenous samples containing largely stroke 

patients, affects the confidence in the validity of the findings 

and limits their generalizability. It was found to be difficult to 

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8 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
obtain relevant literature with all participants over age 65. 

Therefore, studies were included that had participants 

under age 65, if the majority of subjects were over age 65. 

A strength of this review was that studies were included 

from three different continents and found generally similar 

results on the effects AFOs have on balance in the older 

adult population. This provides reasonable confidence in 

the external validity of the findings within a specific 

population of patients.  

Recommendations and implications for practice 

The findings of this scoping review generally support that 

AFOs affect balance in older adults in a positive way. The 

observation that though restrictions to the natural 

movement of the ankle can occur through wearing AFOs, 

the AFOs effect on improving proprioception appeared to 

remedy any potential deficit. This is an important clinical 

consideration when prescribing AFOs to patients who may 

have sensory deficits, to ensure the AFO does not 

negatively impact the limitations their pathology imposes. 

This is pertinent information for healthcare providers who 

prescribe AFOs or work with AFO wearing individuals, and 

the evidence derived from this review indicates the 

relevance of a more in-depth examination of literature in this 

subject area.  

This review did not display better balance outcomes for 

individuals wearing custom fabricated AFOs, suggesting 

that off-the-shelf, prefabricated AFOs may work sufficiently 

for certain patient populations. Custom AFOs are 

substantially more expensive than their prefabricated 

counterparts, so healthcare providers must give 

consideration to appropriate use of the healthcare 

resources available when prescribing AFOs.   

The patient populations examined in this review were small 

samples of hemiplegic stroke and peripheral neuropathy 

patients. Investigation into the effects AFOs have on other 

older adult populations with more diverse pathologies is an 

important area for future study to help substantiate the 

evidence found to support the AFOs affect on balance in 

these two specific patient groups. Studies conducted with 

larger sample sizes in more diverse setting would aid in 

validating the findings of this review.   

CONCLUSION 

The purpose of this review was to investigate the role AFOs 

play in affecting balance in community-dwelling older adults. 

Given the many dimensions that comprise the ability to 

balance, evidence was examined for consistencies 

amongst findings for which aspects of balance were most 

impacted by AFOs. The AFO was found to increase lateral 

stability, improve balance under static conditions, better 

control postural sway, and increase walking speed. The 

findings indicate that the AFO has a generally positive affect 

on balance in older adults with hemiplegia and peripheral 

neuropathy, and supports the use of AFOs in patient 

populations with sensory impairments to improve balance 

and walking speed. Investigation into the affects of AFOs on 

the balance of other pathologic patient populations and on 

balance during dynamic conditions warrants further 

research.   

ACKNOWLEDGEMENTS 

The author of this article would like to express appreciation to Dr. 

Marcia Finlayson, Queen’s University, Canada, for her assistance 

in preparing the current manuscript for publication.  

DECLARATION OF CONFLICTING 

INTERESTS 

The author has no conflicts of interest to declare.   

SOURCES OF SUPPORT 

No funding was provided for this review. 

ETHICAL APPROVAL 

Ethical approval was not needed for this study. 

REFERENCES 

1.Statistics Canada. Causes of death, 2017; [Internet].2019 [cited 2020 

June 1]. Available from: https://www150.statcan.gc.ca/n1/daily-

quotidien/190530/dq190530c-eng.htm 

 

2.Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk 

in community-living older adults: a 1-year prospective study. Arch 

Phys Med Rehabil. 2001;82(8):1050–1056. DOI: 

10.1053/apmr.2001.24893 

 

3.Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital 

falls, and unintended consequences. N Engl J Med. 

2009;360(23):2390–2393. DOI: 10.1056/NEJMp0900963 

 

4.Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric 

syndromes: clinical, research, and policy implications of a core 

geriatric concept. J Am Geriatr Soc. 2007;55(5):780-791. DOI: 

10.1111/j.1532-5415.2007.01156.x 

 

5.Soriano TA, DeCherrie LV, Thomas DC. Falls in the community-

dwelling older adult: a review for primary-care providers. Clin Interv 

Aging. 2007;2(4):545-553. DOI: 10.2147/CIA.S1080 

 

6.Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among 

older adults: a review of the literature. Maturitas. 2013;75(1):51-61. 

DOI: 10.1016/j.maturitas.2013.02.009 

 

7.Eibling D. Balance disorders in older adults. Clin Geriatr Med. 

2018;34(2):175-181. DOI: 10.1016/j.cger.2018.01.002 

 

8.Mulasso A, Roppolo M, Gobbens RJ, Rabaglietti E. Mobility, 

balance and frailty in community‐dwelling older adults: what is the 

best 1‐year predictor of falls? Geriatr Gerontol Int. 

2016;17(10):1463-1469. DOI: 10.1111/ggi.12893 

 

9.Perry SD. Evaluation of age-related plantar-surface insensitivity 

and onset age of advanced insensitivity in older adults using 

https://doi.org/10.33137/cpoj.v4i1.35132


 

9 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
vibratory and touch sensation tests. Neurosci Lett. 2006;392(1-

2):62-67. DOI: 10.1016/j.neulet.2005.08.060 

 

10.Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle 

weakness and falls in older adults: a systematic review and meta-

analysis. J Am Geriatr Soc. 2004;52(7):1121-1129. DOI: 

10.1111/j.1532-5415.2004.52310.x 

 

11.Vieira ER, Berean C, Paches D, Costa L, Décombas-

Deschamps N, Caveny P, et al. Risks and suggestions to prevent 

falls in geriatric rehabilitation: a participatory approach. BMJ Qual 

Saf. 2011;20(5):440-448. DOI: 10.1136/bmjqs.2010.042382 

 

12.Waterval NFJ, Nollet F, Harlaar J, Brehm M. Precision orthotics: 

optimising ankle foot orthoses to improve gait in patients with 

neuromuscular diseases; protocol of the PROOF-AFO study, a 

prospective intervention study. BMJ Open. 2017;7(2):1-9. DOI: 

10.1136/bmjopen-2016-013342 

 

13.Ramstand N, Ramstrand S. AAOP state-of-the-science 

evidence report: The effect of ankle-foot orthoses on balance – A 

systematic review. J Prosthet Orthot. 2010;22(10):4-23. DOI: 

10.1097/jpo.0b013e3181f379b7 

 

14.International Society for Prosthetics and Orthotics. Prosthetic 

and Orthotic Services; [Internet]. [cited 2020 February 20]; 

Available from: https://www.ispoint.org/page/POservices 

 

15.Arksey H, O’Malley L. Scoping studies: toward a methodological 

framework. Int J Soc Res Methodol. 2005;8(1):19-32. DOI: 

10.1080/1364557032000119616 

 

16.CASP UK. CASP quantitative studies checklist [Internet]. 

Oxford: CASP UK; 2018 [cited 2020 March 2]. Available from: 

https://casp-uk.net/wp-content/uploads/2018/03/CASP-

Qualitative-Checklist-2018_fillable_form.pdf 

 

17.McMaster University. Qualitative studies - critical review form 

(version 2.0); [Internet]. 2007 [cited 2020 March 2]. Available from: 

https://healthsci.mcmaster.ca/docs/librariesprovider130/default-

document-library/critical-review-form-qualitative-studies-version-2-

1.pdf?sfvrsn=6723c450_2 

 

18.Nikamp CDM, Buurke JH, van der Palen J, Hermens HJ, 

Rietman JS. Six-month effects of early or delayed provision of an 

ankle-foot orthosis in patients with sub(acute) stroke: a randomized 

controlled trial. Clin Rehabil. 2017;31(12):1616–1624. DOI: 

10.1177/0269215517709052 

 

19.Simons CDM, van Asseldonk EHF, van der Kooij H, Geurts 

ACH, Buurke JH. Ankle-foot orthoses in stroke: effects on 

functional balance, weight-bearing asymmetry and the contribution 

of each lower limb to balance control. Clin Biomech. 

2009;24(9):769-775. DOI: 10.1016/j.clinbiomech.2009.07.006 

 

20.Chen CK, Hong W, Chu N, Lau Y, Lew H, Tang S. Effects of an 

anterior ankle-foot orthosis on postural stability in stroke patients 

with hemiplegia. Am J Phys Med Rehabil. 2008;87(10):815-820. 

DOI: 10.1097/PHM.0b013e31817c150e 

 

21.Chen CL, Yeung K, Wang C, Chu H, Yeh C. Anterior ankle-foot 

orthosis effects on postural stability in hemiplegic patients. Arch 

Phys Med Rehabil. 1999;80(12):1587-1592. DOI: 10.1016/s0003-

9993(99)90335-0 

 

22.Wang R, Yen L, Lee C, Lin P, Wang M, Yang Y. Effects of an 

ankle-foot orthosis on balance performance in patients with 

hemiparesis of different durations. Clin Rehabil. 2005;19(1):37-44. 

DOI: 10.1I91/0269215505cr797oa 

 

23.Wang R, Lin P, Lee C, Yang Y. Gait and balance performance 

improvements attributable to ankle-foot orthosis in subjects with 

hemiparesis. Am J Phys Med Rehabil. 2007;86(7):556-562. DOI: 

10.1097/PHM.0b013e31806dd0d 

 

24.Cakar E, Durmus O, Tekin L, Dincer U, Kiralp MZ. The ankle-

foot orthosis improves balance and reduces fall risk of chronic 

spastic hemiparetic patients. Eur J Phys Rehabil Med. 

2010;46(3):363-368. 

 

25.Doğan A, Mengüllüoğlu M, Özgirgin N. Evaluation of the effect 

of ankle-foot orthosis use on balance and mobility in hemiparetic 

stroke patients. Disabil Rehabil. 2011;33(15-16):1433-1439. DOI: 

10.3109/09638288.2010.533243 

 

26.Bigelow K, Jackson K. Immediate influence of carbon composite 

ankle-foot orthoses on balance and gait in individuals with 

peripheral neuropathy: A pilot study. J Prosthet Orthot. 

2014;26(4):220-227. DOI: 10.1097/JPO.0000000000000040 

 

27.Wang C, Goel R, Rahemi H, Zhang Q, Lepow B, Najafi B. 

Effectiveness of daily use of bilateral custom-made ankle-foot 

orthoses on balance, fear of falling, and physical activity in older 

adults: A randomized controlled trial. Gerontology. 2019;65:299-

307. DOI: 10.1159/000494114 

 

28.Yalla SV, Crews RT, Fleischer AE, Grewal G, Ortiz J, Najafi B. 

An immediate effect of custom-made ankle foot orthoses on 

postural stability in older adults. Clin Biomech. 2014;29(10):1081-

1088. DOI: 10.1016/j.clinbiomech.2014.10.007 

 

29.Aveyard H. Doing a literature review in health and social care: a 

practical guide. 3rd ed. New York: McGraw-Hill Ryerson; 2014.      

 

30.King GW, Akula CK, Luchies CW. Age-related differences in 

kinetic measures of landing phase lateral stability during a balance-

restoring forward step. Gait Posture. 2012;35(1):440-445. DOI: 

10.1016/j.gaitpost.2011.11.004 

 

31.Maki BE, Sibley KM, Jaglal SB, Bayley M, Brooks D, Fernie GR, 

et al. Reducing fall risk by improving balance control: development, 

evaluation and knowledge-translation of new approaches. J Safety 

Res. 2011;42(6):473-485. DOI: 10.1016/j.jsr.2011.02.002 

 

32.Shearin SM, Smith P, Querry R, McCain K. Bracing for persons 

with Parkinson Disease: a case series with clinical reasoning. J 

Prosthet Orthot. 2015;27(3):95-102. DOI: 

10.1097/JPO.0000000000000065 

 

33.Perry SD, Radtke A, McIlroy WE, Fernie GR, Maki BE. Efficacy 

and effectiveness of a balance-enhancing insole. J Gerontol A Biol 

Sci Med Sci. 2008;63A(6):595-602. DOI: 10.1093/gerona/63.6.595 

 

34.Yamamoto T, Smith CE, Suzuki Y, Kiyono K, Tanahashi T, 

Sakoda S, et al. Universal and individual characteristics of postural 

sway during quiet standing in healthy young adults. Physiol Rep. 

2015;3(3):1-24. DOI: 10.14814/phy2.12329 

 

35.Conradsson D, Paquette C, Franze E. Medio-lateral stability 

during walking turns in older adults. PLoS ONE. 2018;13(6):1-12. 

DOI:10.1371/journal.pone.0198455 

 

36.Aruin AS, Rao N. Ankle-foot orthoses: proprioceptive inputs and 

balance implications. J Prosthet Orthot. 2010;22(4 Suppl):34-37. 

 

https://doi.org/10.33137/cpoj.v4i1.35132


 

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No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
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37.Malas BS. The effect of ankle-foot orthoses on balance: a 

clinical perspective. Phys Med Rehabil. 2010;10:24-33. DOI: 

10.1097/JPO.0b013e3181f4c1cb 

 

38.Hill KD, Goldie PA, Baker PA, Greenwood KM. Retest reliability 

of the temporal and distance characteristics of hemiplegic gait 

using a footswitch system. Arch Phys Med Rehabil. 1994;75(5): 

577-583. 

 

39.Tyson SF, Thornton HA. The effect of a hinged ankle foot 

orthosis on hemiplegic gait: objective measures and users’ 

opinions. Clin Rehabil. 2001;15(1):53-58. DOI: 

10.1191/026921501673858908 

 

40.Pardo V, Galen S, Gahimer J, Goldberg A. Effect of custom-

molded and pre-fabricated hinged ankle-foot orthoses on gait 

parameters and functional mobility in adults with hemiplegic: a 

preliminary report. J Prosthet Orthot. 2015;27(1):33-38. DOI: 

10.1097/JPO.0000000000000053 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

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APPENDIX (A) 

 

  

Appendix (A): example database search strategy 

 

MEDLINE Search Strategy (Literature search performed: February 2, 2020) 

1. Orthotic devices/ or braces/ 

2. (AFO or ankle foot ortho*) 

3. exp# Postural balance/ 

4. Balance 

5. exp Aged 

6. older adult* 

7. (Orthotic devices/ or braces/) or (AFO or ankle foot ortho*) 

8. (exp Postural balance/) or (balance) 

9. (exp Aged) or (older adult*) 

10. ((Orthotic devices/ or braces/) or (AFO or ankle foot ortho*)) and ((exp Postural balance/) or (balance)) and ((exp 

Aged) or (older adult*)) 

 

 

CINHAL Search Strategy (Literature search performed: February 2, 2020) 

1. (MH “Orthoses+”) 

2. “ankle foot orthosis or afo or orthotic” 

3. (MH “Balance, Postural”) 

4. “balance” 

5.  (MH “Aged+) 

6. “older adults” 

7.  ((MH “Orthoses+”)) OR (“ankle foot orthosis or afo or orthotic”) 

8.  ((MH “Balance, Postural”)) OR (“balance”) 

9. ((MH “Aged+)) OR (“older adults”) 

10. [((MH “Orthoses+”)) OR (“ankle foot orthosis or afo or orthotic”)] AND  

[((MH “Balance, Postural”)) OR (“balance”)] AND [((MH “Aged+)) OR (“older adults”)] 

 

 

EMBASE Search Strategy (Literature search performed: February 2, 2020) 

1.       exp ankle foot orthosis/ 

2.       (AFO or ankle foot ortho*) 

3.       exp balance impairment/ 

4.       balance 

5.       exp aged/ 

6.       older adults 

7.       (exp ankle foot orthosis/) OR ((AFO or ankle foot ortho*)) 

8.       (exp balance impairment/) OR (balance) 

9.       (exp aged/) OR (older adults) 

10.    [(exp ankle foot orthosis/) OR ((AFO or ankle foot ortho*))] AND [(exp balance 

          impairment/) OR (balance)] AND [(exp aged/) OR (older adults)] 

 

 

REHABDATA Search Strategy (Literature search performed: February 2, 2020) 

 

View Articles, including International Research, containing the exact phrase: '"ankle foot ortho*"', containing at least one of the 

word(s): '"balance"', where Abstract contains: [(older AND adult) OR (ankle AND foot) AND (ortho* AND balance) 

 
# exp= explode - In database searches, the subject heading can be ‘exploded’ to include other more specific terms that are related to the initial 

subject heading in the search results.  

 

 

 

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Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
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ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
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APPENDIX (B) 

 

Appendix (B): Quality appraisal and rating of studies reviewed 

 

 

a - Studies arranged in order of quality rating: 1 = weak; 2 = moderate; 3 = strong 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author, Year 
Neutrality 
Objectivity 

Consistency 
Reliability 

Applicability 
External Validity 

Truth Value 
Internal Validity 

Quality 
Rating a 

Wang et al., 201927 
High 

 
High Moderate Moderate 3 

Chen et al., 200820 
High 

 
High Moderate Moderate 3 

Bigelow & Jackson, 201426 Moderate High Low High 3 

Wang et al., 200522 Moderate High Moderate 
Moderate 

 
2 

Wang, et al., 200723  
Moderate 

 
Moderate Low Moderate 2 

Simons et al., 200919 

 
Moderate  Low Low Moderate 2 

Yalla et al., 201428 

 
Low Moderate Low Moderate 2 

Nikamp et al., 201718 
Moderate  

 
High Moderate  Low 2 

Doğan et al., 201125 Low 
Moderate 

 
Low Moderate 1 

Cakar et al., 201024 Low 
Moderate 

 
Low Moderate 1 

Chen et al., 199921 Moderate 
Low 

 
Low 

 
Low 

 
1 

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Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 
 

 

APPENDIX (C) 

 

Appendix (C):  data extraction table – characteristics of the included studies 

Author, 
Year 

Aim of 
study/paper 

Sample size/ 
characteristics  

Study Design  
AFO type & 

features 
Balance 

measures 
Main findings/ 
conclusions 

Strengths and 
limitations 

Article 
quality 
rating 

Bigelow 
& 
Jackson, 

201426  

 

To observe the 
immediate 
effects of AFOs 
on balance and 
gait in individuals 
with peripheral 
neuropathy. 

n=12 patients 
with peripheral 
neuropathy; 
convenience 
sample 
 
 

Pre-/ post-test  
Quantitative 
Within-
subjects 
comparison 

Anterior shell 
carbon 
composite 
AFOs 
 
Prefabricated 
Bilateral  

Force plate 
posturographya 

• LOS 

• AP/ML sway + 
velocity 

Clinical tests 

• MiniBESTest 

• TUG 

• Gait speed 

AFO has immediate 
improvements in static 
postural control but more 
variable responses during 
dynamic balance and gait. 
AFOs restrict AP LOS. No 
sig. difference in AFO 
conditions for clinical 
balance and gait 
assessments. 

First time AFO wearers, 
given same amount of 
practice time 
Small sample  
Reduced ordering 
effect 
Did not use standard 
measures in dynamic 
balance tests 

 
3 

Cakar et 
al., 

201024  

 

To investigate 
the relative effect 
of AFOs on 
balance and fall 
risk. 

n=25 hemiplegic 
long duration 
stroke patients 
with spasticity  

Pre-/ post-test 
Quantitative 
Within-
subjects 
comparison 

Thermoplastic 
posterior leaf 
spring AFO 
 
Prefabricated 
Unilateral 

BBS 
Postural Stability 
test b 
Fall Risk test b 

AFO improved balance 
and provided fall risk 
reduction in hemiparetic 
patients with 
mild/moderate spasticity; 
no difference in AP/ML 
stability scores. 
 

Used verified & valid 
test measures 
Excluded 2 outliner 
scores 
Distance from 
researcher 
Homogenous group of 
participants 

 
1 

Chen et 
al., 

199921  

 

To evaluate the 
effects of an 
AFO on static 
and dynamic 
postural stability 
in hemiplegic 
patients.  

n=24 hemiplegic 
patients; 
convenience 
sample 

Pre-/ post-test 
Quantitative 
Within-
subjects 
comparison 

Thermoplastic 
anterior leaf-
spring AFO 
 
Prefabricated 
Unilateral 
 
 

Stabiloboardd 
weight-shift AP/ML 
max. balance  
Postural sway & 
symmetry  

Significant improvement 
in lateral weight shift and 
weight bearing through 
affected leg with AFO. No 
difference in postural 
sway, postural symmetry 
or AP max. balance range 
with AFO. 

Poorly described study 
design; hard to 
replicate condition 
Small homogeneous 
convenience sample  
Dynamic postural 
stability was assumed 
Random assignment to 
test condition 

 
1 

Chen et 
al., 

200820  

 
 

To evaluate the 
effects of an 
AFO on postural 
stability in stroke 
patients with 
hemiplegia. 

n=21 patients 
with new onset 
stroke (<3mo.) 
hemiplegia 
+ 10 healthy 
subjects 

Pre-/ post-test 
Quantitative 
Cross 
sectional + 
control group 
comparison  

Thermoplastic 
anterior leaf-
spring AFO 
 
Prefabricated 
Unilateral 

Postural stability c 
- Ankle strategy 
- Max stability 
- COG velocity 
 
 

Anterior AFO may be 
used to assist early stage, 
hemiparetic stroke 
patients improve postural 
stability during stance by 
reducing COG velocity, 
lessening likelihood of 
falls. 

Standardized test 
Conditions random 
Comparison group 
Single, 1-hour session 
of testing 
Only tested in static 
conditions 

 
3 

Doğan et 
al., 

201125  

To investigate 
whether AFOs 
have an effect on 
stair climbing, 
balance and 
mobility while 
improving 
walking 
parameters. 
 

n=51 hemiplegic 
stroke patients  

Pre-/ post-test 
Quantitative 
Within-
subjects 
comparison 

Hinged AFO 
with 90o PF 
stop 
 
Custom made  
Unilateral  
 
 

Ashburn Walking 
and Stair test 
TUG test 
BBS 
STREAM 

AFOs improved balance 
and ambulation activities 
in hemiparetic subjects. 
All subject showed 
improvement in gait 
speed, balance and 
mobility with AFO use. No 
affect on stair climbing. 

Large number of 
exclusion criteria 
Larger sample then 
most other studies 
Ceiling effects for some 
tests used 
Instrumentation effect 
Attrition effect 

 
1 

Nikamp 

et al., 

201718  

 
 
 
 
 

To study 6-
month effects of 
early/late 
provision of 
AFOs in 
(sub)acute 
stroke patients 
To look at group 
differences and 
affects on 
functional 
improvement 
overtime.  

n=33 unilateral 
hemiplegic 
stroke patients 
max. 6 weeks 
post stroke  
Early (wk 1) 
n=16;  
Late (wk 9) n=17 

RCT  
6 mo. f/u  
 
Quantitative  
Parallel group 
comparison 
 
  

3 types of 
non-
articulated 
posterior leaf 
spring 
thermoplastic 
AFOs 
-rigid 
-semi-rigid 
-flexible 
Prefabricated  
Unilateral  

10m walk test 
BBS 
FAC 
6 min walk test 
TUG test  
Stairs test 
Barthel index 
Rivermead Mobility 
index 

No 6-month differences in 
functional outcomes of 
providing AFOs at 
different times in early 
rehab after stroke. In 
general, both groups of 
AFO wearers improved 
over time 

Registered RCT 
Underpowered 
Maturation effect -
natural recovery post-
stroke 
No control group 
Randomly assigned 
groups by 3rd party 
Learning occurred out 
of clinical setting 
Not possible to blind 

 
2 

https://doi.org/10.33137/cpoj.v4i1.35132


 

14 

Laidler J.L. The impact of ankle-foot orthoses on balance in older adults: A scoping review. Canadian Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, 
No.1. https://doi.org/10.33137/cpoj.v4i1.35132 

ISSN: 2561-987X AFO AFFECT ON OLDER ADULT BALANCE     

Laidler J.L. 2021 

 
CPOJ 

 

Simons 
et al., 

200919  

To examine 
effects of AFOs 
on functional 
balance, static 
and dynamic 
weight bearing 
asymmetry, and 
balance control 
in stroke 
patients. 
 

n=20 
hemiparetic 
stroke patients 
(at least 3 mo. 
post-stroke) 

Pre-/ post-test 
Quantitative 
Within-
subjects 
comparison 
with washout 
period 

Various 
flexible and 
rigid AFO 
designs  
Patient had 
own AFO at 
study outset  
Custom 
made+ 
Prefabricated   
Unilateral 

Functional tests 
- BBS  
- TUG  
- 10m walk  
- FAC 
- TBT 
Posturo-graphic 
tests 
- CAREN 

AFO improved 
performance of functional 
tests, but had no effect on 
weight bearing 
asymmetry or dynamic 
balance. 
No effect on postural 
sway. Increased walking 
speed 

Highly sophisticated 

CAREN system 
Washout period 
between trials  
Attrition effect 
Only measured AP not 
ML balance during 
perturbations 

 
2 

Wang et 
al., 

201927  

To investigate 
effectiveness of 
AFOs on 
balance, fear of 
falling, and 
physical activity 
in older adults.  

n=44 
non-pathologic 
patients with fear 
of falling, or 
previous fall 

RCT; 
Quantitative 
Longitudinal 
(6mo f/u) 

Flexible 
anterior 
gauntlet AFO 
 
Custom made 
Bilateral 

TUG 
AST 
 
Postural sway 
(COM, ankle, hip)  

AFO + walking shoes 
improve balance 
compared to walking 
shoes alone and 
significantly reduces fear 
of falling. Increased 
lateral stability 
 

Registered RCT 
Many exclusions 
Non-pathologic 
participants 
Underpowered 
Attrition effect- 25% 
dropout rate 
History effect  

 
3 

Wang et 
al., 

200522  

To examine the 

effects of AFO 
on balance in 
patients with 
short and long 
duration 
hemiplegia. 

n=103 subjects 
with long 
(>12mo)/ 
short(<6mo) 
duration 
unilateral 
hemiparesis  
SD n=42 
LD n=61 
 

Pre-/ post-test 
 
Quantitative 
between 
group 
comparison 

Thermoplastic 
AFO 
 
Prefabricated 
Unilateral  

Standing balance c 

- COG velocity, 
excursion, 
accuracy 

- LOS 
Sit-to-stand BBS 
10m walk test 

AFO improves symmetry 
in static + dynamic 
balance, and increases 
gait speed and cadence 
in subjects with short 
duration hemiparesis. 
Effects not observed for 
long duration subjects. 

Largest sample size in 
data set 

No control group 
Cane used in walking 
trials 
Test sequence random 
Gait assessed by 
independent 
physiotherapist 

 
2 

Wang et 
al., 

200723  

 

To assess 
changes in 
balance, and 
improvement in 
gait of 
hemiplegic 
subjects as a 
result of wearing 
an AFO 

n=58 subjects 
with hemiparesis 
(within 6 mo. 
post-stroke) 

Pre-/ post-test 
 
Quantitative 
Within-
subjects 
comparison 
 

Thermoplastic 
AFO 
 
Prefabricated 
Unilateral 

Standing balance c 
- COG velocity and 
excursion 
- LOS 
Gait parameterse 

(time/distance) 

AFO improved dynamic 
balance and increased 
walking speed in 
hemiparetic subjects. 
Increased lateral weight 
bearing on AFO side 

Random test sequence 
Researcher performed 
tests 
Walking speed much 
faster than previous 
studies’ findings 

 

 
2 

Yalla et 
al., 

201428 

 

To determine the 
immediate effect 
of AFOs on 
balance and 
functional reach 
distance in older 
adults 

n=30 
diabetic/ 
peripheral 
neuropathy 
-excluded 
hemiplegics 

Pre-/ post-test 
Quantitative 
Within-
subjects 
comparison 

Flexible 
anterior 
gauntlet AFO 
 
Bilateral 
Custom made 
 

Postural Swayf 
- COM, ankle, hip 
Forward Reach 
test 
TUG 

Wearing AFO reduced 
postural sway and 
improved lower extremity 
coordination in subjects 
without interfering with 
their ability to perform 
ADLs 
 

Less restricted patient 
population than other 
studies 
Clear/consistent 
protocol  
Instrumentation effects 
- sensors vs. force 
plate used  

 
2 

 

LOS=Limit of stability; TUG=Timed Up and Go; AP= Anterior-posterior; ML=Medial-lateral; BBS=Berg Balance Scale; COG=Centre of gravity; PF=Plantar 

flexion; STREAM=Stroke rehabilitation assessment of movement; FAC=Functional Ambulation Categories; TBT=Timed Balance trial; AST=Alternate-Step Test; 

ADLs=Activities of daily living  
a from BP5050 (Bertec Corporation, Columbus, OH, USA) 
b from Biodex Balance System (Biodex Medical Systems, Shirley, NY, USA) 
c from SMART Balance Master System (NeuroCom International, Inc., Clackamas, OR, USA) 
d from Computer Dyno Graphy system (Market-USA Inc., Severna Park, MD, USA) 
e from GAITRite system (CIR System Inc., Franklin, NJ, USA) 
f from BalanSensTM Sensors (BioSensics LLC, Boston, USA)  

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v4i1.35132

