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What are peoples' views on impression box casting? Do people find it to be less accurate than POP neutral suspension casting or does the ability to easily modify the negative make up for the weight bearing complication. Is it a lazy shortcut for people who have a nice carpet in their clinics and don't want it ruined or is it a valid and easy way to do the same job?
The crucial question I ask about any method of negative model production is "can you manipulate the foot segments into the position you want them to be in?". Different methods of negative model production allow you to do different things.
Some points:
1. There is NO evidence of any different outcomes of one method being better than another.
2. There is some evidence (ie McLay et al) on slight differences in shapes between 3 methods of negative model production (plaster cast, foam box and optical scan), but that did not show one method to be "better" than another
3. We have published two studies and I am aware of a couple of others on casting variability/repeatability. The methods that are weightbearing are more repeatable/ less variable than the non-weightbearing methods (but we have no evidence if that variability is important or not, but could assume it should be).
There is a lot of passion in the discussion with some being very aggressive in arguing what they do is better, but we simply have no evidence. I have seen people argue that the semi-weight bearing methods (ie foam impression; semi-weightbearing plaster cast; FAS system; Amfit) are better because they compress the soft tissues somewhat. I have seen people argue that the non-weightbearing (ie plaster cast; optical scan) are better because they do not compress the soft tissues .... I actually have no idea if that is important or not, but love provoking the proponents to see what arguments they use when I ask things like "how do you know its important?"
It all comes down to personal preference of what position you want the different foot segments to be in and the method that you use allows you to do it.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
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Thanks for that. I tend to agree that its all about whether you can get the foot in the position YOU want it (rather than the position it falls into or that gravity forces it into) when you cast. I use both techniques but i tend to get better results using the boxes in most cases. Taking a cast with the patient sitting generally allows me to hold the ST / MT joints where i want them and applying downward force on the knee rather than asking the patient to weight bear means there is not so much force that i lose control of the foot.
My personal and very unscientific view is that when casting some GRF to put the soft tissues somewhat nearer to their weight bearing conformation would allow closer control of the skeletal tissues beneath. Anyone else got a view on this?
Robert
I have found that using foam box's with flexible feet is usually very difficult to get good results. I think this may be due to different levels of stiffness within the segements of the foot reacting differently to the GRF. i.e. a flexible 1st ray may dorsiflex more than the lesser rays resulting in a inaccurate 'image' of the foot being captured. This may not be a problem if it is then well corrected when making the positive model.
I am playing with a non-contact digital image capture system at the moment that allows semi to full weight bearing images to be taken. I will hopefully then compare these to foam impressions (I am going to scan the box's and compare both files in a piece of CAD software) done in the same manner to try and ascertain if the GRF from the foam is influential. I have a gut instinct that the cutaneous feedback from the foam causes the foot to react - either positively or negatively.
I don't tend to use foam in kids as the above factors and many others make it too difficult.
You can screw both methods up. I like to compare my cast to the shape of the foot in the position that it is casted in. You cannot do that with the foam box. Although, if you don't check your plaster cast versus the foot, then this is not at advantage for plaster. I've seen foam box impressions where the patient stepped down with their heel and then pushed down with their forefoot and created an abnormally high arched cast. You cannot compare this mistake to the foot, but it can be obiously visable upon inspection. The redo sure takes much less time. However, this mistake can be avoided by paying attention as you put the foot into the foam.
I did a study on fat pad expansion upon weight bearing and found that it was not predictable for individual patients. Therefore I measure the heel width, weightbearing and make sure the orthotic is that wide before dispensing. This means that the lab has to add varying amounts of expansion plaster around the heel to match the width of heel that is asked for. This is a degree of complexity that some may shy from.
You can add a medial or lateral heel skive and intrinsic or extrinsic wedging to devices made from both casts. I believe this a lot of what makes the orthosis work. So, you don't have to cast in neutral position to get a device that works. I decide what my forefoot to rearfoot relationship in the orhotic should be based on the maximum eversion heigt test. (Standing, ask the patient to evert and estimate the height of the lateral column off of the ground.) No wedge if they cannot lift of the ground 0-5mm the height of the wedge at the 5th met head is the same as in the test. Above 5mm consider shoe internal height. Again this can be done in either type of casting method.
Dear All,
There is some evidence on outcomes between different impression techniques:
Guldemond NA, Leffers P, Sanders AP, Emmen H, Schaper NC, Walenkamp GHIM. Casting methods and plantar pressure: effects of custom-made foot orthoses on dynamic plantar pressure distribution. Journal of the American Podiatric Medical Association 2006; 96: 9-18.
Abstract:
Foot orthoses are widely used to treat various foot problems. A literature search revealed no publications on differences in plantar pressure distribution resulting from casting methods for foot orthoses. Four casting methods were used for construction of orthoses. Two foam box techniques were used: accommodative full weightbearing method (A) and functional semiweightbearing method (B). Also, two suspension plaster casting techniques were used: accommodative casting (C) and functional subtalar joint neutral position (Root) method (D). Their effects on contact area, plantar pressure, and walking convenience were evaluated. All orthoses increased the total contact area (mean, 17.4%) compared with shoes without orthoses. Differences in contact areas between orthoses for total plantar surface were statistically significant. Peak pressures for the total plantar surface were lower with orthoses than without orthoses (mean, 22.8%). Among orthoses, only the difference between orthoses A and B was statistically significant. Differences between orthoses for the forefoot were small and not statistically significant. The gait lines of the shoe without an insole and of the accommodative orthoses are more medially located than those of functional orthoses. Walking convenience in the shoe was better rated than that with orthoses. There were no differences in perception of walking convenience between orthoses A, B, and C. Orthosis D had the lowest convenience rating. The four casting methods resulted in differences between orthoses with respect to contact areas and walking convenience but only slight differences in peak pressures.
There is of course a need to look at health-related, quality of life outcomes between impression techniques.
Joshua Burns PhD, B App Sc (Pod) Hons
NHMRC Australian Clinical Research Fellow
Institute for Neuromuscular Research
The Children's Hospital at Westmead
Josh - you right on that evidence, that there are some differences in the plantar pressure pattern between different methods of negative model production, but which is the the most appropriate change for better clinical outcomes? We just don't know ....(....but we getting closer to getting an understanding of which changes are predictive or better clinical outcomes) ie
Quote:
There is of course a need to look at health-related, quality of life outcomes between impression techniques.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
What are peoples' views on impression box casting? Do people find it to be less accurate than POP neutral suspension casting or does the ability to easily modify the negative make up for the weight bearing complication. Is it a lazy shortcut for people who have a nice carpet in their clinics and don't want it ruined or is it a valid and easy way to do the same job?
Any thoughts?
Robert Isaacs
Robert:
I have tinkered with foam box casting many years ago but, like Eric Fuller, have not been impressed with my ability to compare the resulting imprint within the foam box to the plantar foot when using a foam box. For this reason, I have always gone back to what I know best, supine negative casting technique with plaster splints (of which I use many variations).
I am sure that as long one understands the principles of negative casting, orthosis manufacture, and foot and lower extremity biomechanics, nearly any technique which captures a three-dimensional impression of the plantar foot can be used to make effective and therapeutic custom foot orthoses. I would imagine that one would likely need to modify the positive cast preparation technique and possibly the orthosis materials and construction technique when changing from one casting method to another due to the changes in foot shape that may occur with each impression casting method.
One must remember that the negative casting technique is only "one of the links of the chain" that allow optimum orthosis manufacture. Here are the other links of the chain that allows optimum orthosis manufacture. It is must be remembered that the chain that produces optimum custom foot orthoses, as a whole, is only as strong as its weakest link.
Quote:
Chain for Optimum Custom Foot Orthosis Production
1. Properly evaluate patient's structure, functional capacity and gait function.
2. Perform accurate negative casting specific to the intended optimum orthosis design.
3. Write specific orthosis prescription in order to design optimum orthoses for patient's symptoms and/or gait pathology.
4. Make certain that the orthosis lab manufactures the orthosis accurately to prescription.
5. Fit orthoses to patient's foot to ensure intended conformity of device to plantar foot.
6. Fit orthoses to patient's shoes to ensure proper orthosis-shoe fit and function.
7. Examine patient's gait with orthoses in shoes and gather initial subjective information of orthosis comfort from patient.
8. Perform followup of patient within one month to ensure optimum orthosis fit, function and therapeutic effect.
9. Perform any orthosis and/or shoe adjustments as necessary to improve orthosis fit, function and therapeutic effect.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Thanks all. It seems as always there is a spectrum of opinions with some very sound reasoning on all sides. I think the esteemed Mr Kirby summed it up best with
"Perform accurate negative casting specific to the intended optimum orthosis design."
So long as the cast is accurate and specific to the intended orthosis design the rest is probably moot.
Regards
Robert
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Measure outcomes with each method you employ; consider time & $ involved with each method; add to your preference of practise and patient wow factor = best method for you to use in clinic
:) I recommend foam casting at this time. Similar to Phil we are researching new mediums both analog and digital.
When choosing a medium or technology of casting I would ask:
(for each question, I will give you my reasoning, why I do what I do)
What position do you want to put the foot in? I personally recommend MASS position over neutral. MASS position is simply the maximum amount of arch possible at midstance when the heel and forefoot are in full contact with the supporting surface.
Is there a frame of reference in the casting technique making repeatability possible? There is relatively little for plaster. A difficult proposition to control 26 bones out in space as the plaster is drying. I like Craig’s article Jan. 2003 JAPMA, Variability of Neutral Position Casting of the Foot. Most techniques of using foam also lack frame of reference. This can be achieved in foam however by bottoming out every step of the technique…you will always push them to the floor….never through the floor.
How meaningful us the final shape of the cast to the final shape of the orthotic? Cast correction or modification on a gradient scale divorces the shape of the orthotic from the shape of the foot held in the desired position. A full contact device must be shaped like the bottom of the foot when it is held in the desired position. Shape becomes critical as does repeatability.
Will manufacturing match casting? If the casting technique places the forefoot on the ground while the rearfoot is in some degree of supination, it would make sense to then “read” the rearfoot off of the forefoot.
Will the lab be able to reliably interpret the data you send them and translate that into a meaningful device? Or Will the lab be able to “trust” your cast? How does the lab assure itself that casts it is receiving are cast using the same technique or level of aptitude? We attempt (not always successfully) to train every new provider that is allowed to use our technology.
Can the cast be QC’d as Eric points out? We use the pen test: since a pen us usually a cone shaped object (what we call in the US a BIC Pen), the deeper it is impressed in the foam, the wider the hole. At the end of casting we recommend every cast is stuck with the cone shaped point of the pen in the center of the first, fifth mets and heel. Three equal size holes indicates that these three points are on the same plane.
Is soft tissue compression desirable? I think yes. The shape of the final orthoses, when full contact is desired should be the shape that the foot will assume when plantar pressures are applied evenly over the plantar surface which will necessitate a compression force during casting. Foam applies an even force and is rated often between 1.75 and 2.5 psi.
Most important however is not medium but technique. I will submit to you our technique here for consideration: right foot
1. Patient keeps socks on and pulled up to avoid wrinkles. (Socks are not excessively thick unless that is what the patient regularly wears or has a specific use for this orthosis involving these socks). This mimics actual use, smoothes skin lines and reduces the moisture “fissuring the foam”.
2. Patient is seated on the edge of the chair…knees free to move up and down.
3. Foot centered in the foam front to back with slightly more room on the lateral side.
4. Box is positioned so that the knee is comfortably directly over the ankle. Mimics midstance and takes care of sagittal and frontal plane leg position.
5. A finger is placed on the second metatarsal and the box is rotated in the transverse plane until the finger is visually in line with a “knife hand” bisecting the thigh.
6. The right hand is placed across the right knee using the fingers on the lateral side of the knee to prevent knee abduction.
7. The left thumb is then placed under the neck of the first metatarsal and the forefoot is maximally inverted.
a. This places the rearfoot in supination
b. Levels the anterior facet and moves the head of the talus onto this facet, preventing sagittal plane rotation around the posterior facet.
c. Externally rotates the tibia
8. A vertical shoulder thrust is then applied to the hand on the knee with the right shoulder in contact with the knee. The heel is thus bottomed out.
9. The tips of all eight fingers are then placed along the lateral side of the foot between the fourth and fifth metatarsal shafts and a vertical pressure is applied to lower the lateral column. For some patients there is still a considerable lateral arch but most patients, the styloid process barely touches bottom.
10. The tips of the toes are then lowered with the thumbs to release the windlass effect.
11. The metatarsal heads are then bottomed out completely.
12. Recheck the lateral and met heads for vertical compression.
13. Slight trust is applied along the STJ axis to “seat” the heel with the right hand while the left hand applies a vertical force on the head of the first met to prevent rocking back. When pressing on the forefoot there was some rocking so that final thrust seats the heel. Applying force along an axis will usually minimize rotation around that axis because there is no perpendicular distance between force and axis…torque is zero.
We find that this technique is accurate, repeatable, closed chain, full contact and give us the shape of the foot with soft tissues compressed in the MASS position. This process has gone through an evolution as thousands of practitioners have tried it and shown us new and creative ways to screw it up and although it is still not fully fool-proof we have found the repeatability to be adequate for our purposes. Can it get better…always and I appreciate any recommendations.
If you like, this technique can also incorporate plaster by placing plaster splints over the foam while performing the steps above and allowing the plaster to dry with the foot in the foam before removing either.
Casting of the foot is only relevent to the degree that the data gathered in the cast translates into influencing the final shape of the device.
i like to compare the actual orthotic to the patients foot rather than comparing the negative cast. why? because doesn't really matter what the negative cast looks like, its what the orthotic technician does with it. Remember, what you ask for is not always what you get. The tissue expansion after a inversion of the negative cast is estimated by the technicians eye (most of the time).
i personally tend to like the foam box, i haven't any problems so far and when checking the orthotics to the patients foot, i do always find it holds the patient in neutral, the shape of the arch is good and the sizing is good. and that is what is important. and if a podiatrist believe he way of casting does the same, the good for them and the patient.
Those foam boxes are not as good as true plaster casts. I have used those boxes, digital scanners (images sent through the internet to a lab), and the traditional plaster casts. The plaster is simply the best. It is messy, labor-intensive, and old-fashioned, but it is the best.
We had a digital system for a while, and it was a neat toy, and we could make copies of the scans, but the actual orthotics were not as good as doing it the old-fashioned way, with plaster---
-John
__________________
Dr. John G. Fasick II
Clinical Insructor, LSU School of Medicine
Advanced Foot & Ankle Center of East Jefferson footankledoc2@gmail.com
I think the foam box is fine for accomodative orthoses.
I assumed we were talking about corrective devices.
No, true neutral is not possible. Precision is better with an experienced person, but never perfect.
Bisection is an estimate.
True neutral is not needed in an accomodative device.
Foam boxes are good. Plaster casts are better. Since the boxes are cheaper and cleaner, lots of podiatrists use them here. They get good results- better than over-the-counter devices. But for treating the hundreds of diagnoses we see, where STJ neutral and MTJ pronation is sought, plaster is better.
How much better? Who knows? I get plaster in bulk, very cheap, so I can use it. I suppose it depends on the practitioner's circumstances and training---
The differences in efficacy may not justify the difference in time and price---
If you want to discuss further, I'll be back in touch when things are less busy. I am always open to discussion. Maybe there are techniques for casting that are better than the ones I learned in school (Miami) or residency, fellowship (Yale). I will certainly look into it. I also have a bias against those foam boxes they send me. They are made in China. The plaster is from the US and/or Germany...
Here's an article from ACFAOM (American College of Foot and Ankle Orthopedics and Medicine), THANKS -John
The following articles report on research completed, in whole or in part, under a grant from ACFAOM. Thanks to all those whose voluntary contributions to ACFAOM's Research Fund make such grants possible.
Comparing Negative Casting Techniques: Foam versus Plaster of Paris
Richard Berenter, DPM, FACFAOM
Introduction:
This study was undertaken to determine whether there was any difference in the clinical outcomes related to the type of negative casting technique utilized in the manufacture of functional foot orthoses. Those practitioners who favor foam casting blocks argue that the technique is cleaner, faster, more cost effective and just as reliable a method to produce functional foot orthoses versus the plaster of Paris technique. On the other hand, a number of practitioners have argued that the foam block technique is inferior because the foam is incapable of capturing the shape of the foot with the subtalar joint in neutral position and the midtarsal joint maximally pronated thereby leading to an inferior foot orthosis, which will be less effective at reducing patient symptoms.
Materials and Methods:
A total of 38 patients were enrolled in the study. All of the patients presented with lower extremity symptoms associated with abnormal lower extremity function as determined by gait evaluation. At the time of the initial visit, each patient signed a consent form and completed the top portion of the data sheet which included both personal information and the amount of pain in each extremity (patients were asked to circle the amount of pain on a scale from 0-10 with 0 being no pain and 10 being the worse pain ever felt).
Upon completion of all paper work, both feet of each patient were casted via the semi-weight bearing foam block technique and by the non-weight bearing supine plaster of Paris method. Both sets of casts were sent to a professional orthotic laboratory with a prescription filled out for an orthotic shell with a medium amount of arch fill, average heel cup depth, normal orthotic width (to the lateral border of the 5th metatarsal and bisection of the 1st metatarsal shaft) and a thickness of polypropylene which would behave in a semi-rigid behavior for the patient's stated weight. A laboratory technician was instructed to randomly select one of the two pairs of negative casts and keep track of which casts were used without the knowledge of the principal investigator. In this way, a double blind study was established since neither the principal investigator nor the patient knew which casts were used to construct the foot orthotics.
Approximately 2-3 weeks following casting, the patient was dispensed a pair of functional foot orthoses and asked to walk around for a minimum of 10 minutes to gauge the comfort level of the orthotics. Each participant was asked to use one of 4 descriptive terms (very comfortable, comfortable, slightly uncomfortable or very uncomfortable) to describe the comfort level of 5 different regions on each foot orthosis corresponding to the heel region, medial arch, lateral arch, middle of the orthosis and distal edge. Patients were then sent home with standardized break-in instructions for the functional foot orthoses and returned to the clinic at intervals of 2 weeks and 4 weeks post-orthotic dispensal.
At each follow-up visit, patients were asked to fill out a data sheet gauging the level of symptoms and comfort level of the orthoses. The data was then compiled and saved in a spread sheet format and upon completion of the study, the laboratory technician was contacted in order to identify which patients belonged to which study group, the foam box or plaster of Paris casting technique.
Results:
The data was compiled and the two study groups separated by casting technique. An independent investigator (non-podiatrist) was contacted and asked to analyze the data to answer the following questions:
1. Does the negative casting technique (foam vs. plaster) make a difference in the ability of the orthotic device to reduce symptoms?
2. Does the negative casting technique (foam vs. plaster) make a difference in how comfortable the orthotic device feels to the patient?
The data was analyzed in a variety of methods such as the mean reduction of pain, Fischer exact test and Chi-square with T-tests. A simple comparison of the average reduction of pain after four weeks of orthotic therapy indicates that the plaster of Paris orthoses achieved a mean decrease of 82.43% of pain versus 61.14% reduction in pain with foam box cast orthoses, with a level of significance p< 0.01. However, further analysis of the data demonstrated that casting technique had no statistical difference in the reduction of pain in patients presenting with high levels of pain, but a significant advantage for plaster of Paris orthotics in reducing moderate amounts of pain.
The difference between the comfort levels of the orthoses from different casting techniques was also extremely interesting. No statistical difference was noted in the comfort level of any of the five regions studied (the heel, medial arch, lateral arch, middle of orthosis and distal edge) at the time the orthotic was dispensed. However, after one month of orthotic wear, the orthoses manufactured from plaster of Paris casts were statistically more comfortable in the medial longitudinal arch and the distal edge regions.
Another analysis performed on comfort level of the orthotic devices compared improvement of comfort level between the orthoses from the two casting techniques. In this analysis, only the medial longitudinal arch was statistically more improved in the plaster of Paris technique versus the foam box method.
Final Thoughts:
The analysis of the data was fascinating in that both casting techniques were able to show some marked reduction in symptoms and reasonably comfortable orthoses. However, there were some statistical advantages of the plaster of Paris orthoses over the foam box devices.
__________________
Dr. John G. Fasick II
Clinical Insructor, LSU School of Medicine
Advanced Foot & Ankle Center of East Jefferson footankledoc2@gmail.com
I teach and demonstrate all types of negative model production. ...its is easy to get the foot into STJ neutral in weightbearing or foam box casting .
Quote:
True neutral is not needed in an accomodative device.
Neutral is not needed for any type of orthotic. Achieving neutral with a negative model method or getting the foot to neutral with a foot orthotioc has nothing to do with clinical outcomes.
__________________ Craig Payne
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I teach and demonstrate all types of negative model production. ...its is easy to get the foot into STJ neutral in weightbearing or foam box casting .
Quote:
True neutral is not needed in an accomodative device.
Neutral is not needed for any type of orthotic. Achieving neutral with a negative model method or getting the foot to neutral with a foot orthotioc has nothing to do with clinical outcomes.
Couldn't agree more.
As Kevin's written, it all comes down to ;
Quote:
Chain for Optimum Custom Foot Orthosis Production
1. Properly evaluate patient's structure, functional capacity and gait function.
2. Perform accurate negative casting specific to the intended optimum orthosis design.
3. Write specific orthosis prescription in order to design optimum orthoses for patient's symptoms and/or gait pathology.
4. Make certain that the orthosis lab manufactures the orthosis accurately to prescription.
5. Fit orthoses to patient's foot to ensure intended conformity of device to plantar foot.
6. Fit orthoses to patient's shoes to ensure proper orthosis-shoe fit and function.
7. Examine patient's gait with orthoses in shoes and gather initial subjective information of orthosis comfort from patient.
8. Perform followup of patient within one month to ensure optimum orthosis fit, function and therapeutic effect.
9. Perform any orthosis and/or shoe adjustments as necessary to improve orthosis fit, function and therapeutic effect
I think this comes down to how the clinician is able to understand the reason behind an orthotic prescription so the chain of events that lead though patient assessment and orthotic prescription and and then production. The medium in which this is captured has little to do with the success of your prescribed device it still comes back to why do you recommend an orthotic for the patient. As long as you have that understanding then your orthotic will work. However Personnel preference is not a matter of better or worse just thats what works for you.
I have to say that the local NHS department does a lot of foam impression casts and I make a good living from their mistakes but think it still comes down to understanding. Using a foam box and controling the patient is important.
I find both methods equally useful although POP seems to upset my cleaner and since she is a formidable woman, I tend to use foam boxes for most casts. I cant say that I have had better results from either system. Just anecdotal I know but I personally find very little difference. I think Kevin makes a very valid point in that there are so many links in this chain that contribute to the final outcome. I guess its better to make a half decent foam impression cast than a shody POP one (and visa versa obviously), so using what you are personally more comfortable with should result in the best outcome you can achieve for your patient.
Foam boxes are by far the most inaccurate way of taking a patients cast I shall explain,
The contour of the heel is never I mean never accurate, the plantar surface can be bizarrely shaped, one side of the calcaneus can be lower than the other. The foam causes many discrepancies, it can push the arch higher, if the correct technique (if there really is one) isn’t used it can leave the borders of the positive device flared outwards or inwards. But I’m sure you will know this all.
A foam box is never a good cast!
It may be ok for an EVA full contact device but for a standard functional device they are near to impossible to work with.
Fabricating a functional device through a foam box by hand just isn’t worthwhile nor possible, there are way too many problems to begin trying to achieve the right outcome for the patient, it just wont work!
Well this is my opinion, however now cad cam is widely used and foam boxes are scanned to make the custom device, how custom really is this though another topic for sure
Fabricating a functional device through a foam box by hand just isn’t worthwhile nor possible, there are way too many problems to begin trying to achieve the right outcome for the patient, it just wont work!
This is also absolute drivel
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I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps
Would you be kind to explain how a standard functional device is manufactured through a fox box impression? And if the treatment outcome is as good as a POP cast?
How about taking a foam box impression and a POP cast of the same feet and fabricating a standard functional device using both types of casts (by hand) and let me know if the orthosis were any good, more importantly work for the patient as you imagined? I will answer this for you, you will not receive the same treatment outcomes as you would consistently with POP casts.
The clinician has no way of knowing the rearfoot to forefoot relationship (using my words very carefully) when the feet are inaccurately pushed into the foam box. Is the foot really stable during this method, do you take an accurate cast of the plantar surface of the foot which obviously would help, is the arch contour accurate, if I push down to much at the forefoot what will this cause when a forefoot balance platform is created?
I am not talking about cad-cam, handmade manufacturing techniques using a foam box.
POP casting vs Impression box casting
.... I actually have no idea if that is important or not, but love provoking the proponents to see what arguments they use when I ask things like "how do you know its important?"
I like foam for now
Hybrid Mode
