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Over on this this thread we were discussing Laser v´s casting.
I said this:
Quote:
Quote:
Originally Posted by m weber
In My Option the machine that goes ping and when the systems are there to capture a 3D foot shape at a price that people can afford will be the norm.
Although the 1st step maybe to capture the foot shape. The use of computer added and CAD systems will make for a faster turn around, more specific device and give greater control to the Person who prescribes the device ( the next question is if this is a good thing or not for another thread perhaps).
With this systems there will be less waste, faster turn around, less middle-person handelling. The problem is that it requires more from the prescriber which maybe an issue maybe not.
I´m still looking but the technology is at what I can work not quite there and the cost is quite high. I´m hoping time will increase one and decrease the other.
I sound like a broken record but Bloody Volcano.
Robert answered
Quote:
Originally Posted by Robertisaacs
Oooooooo. Is greater clinician control a good thing? Now THERE is a question with far reaching consequences!! Are outcomes improved or damaged by the "homogenising" which goes on at the lab?
BIG thread.
and then Simon said
Quote:
Originally Posted by Simon Spooner
Too right. Firstly, can anyone point to a study of clinical outcomes in which custom devices performed better in reducing pathological symptoms than prefabricated devices... Josh Burns?
So if the future were CAD/CAM system in every practice it would mean the manufactor responsibillty would be on the practice or individual is this a good thing ?
Re: Would greater clinician control be a good thing in Orthotic manufactor?
I guess the problem is that I´ve not come across a study where individual persons needs were issued an orthtoic compaired to an off the shelf model. Most studies Ive read compair one device to another and call one custom because it´s casted. Correct me If I´m wrong.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Quote:
Originally Posted by Simon Spooner
Yep, that's what I currently do- so me biased. Question:, why I have I chosen to do that?
I´ve also chosen and had it decided for me in the last 4 years after moving to the Podiatry desert of Sweden, no labs. But the experience has been great for my "knowledge" of orthotic mechanics. The questions Ive found myself asking myself about arch height shell flex etc have What I believe has lead to a greater understanding of the process. There has been some manufactor problems but my referral from friend box is the most ticked every month so something must be working.
I make mine the old cast + plaster + pressing method but can see real advantage in the CAD/CAM systems. One for finish and two for exact prescription values.
So I´m biased also. I don´t beleive I would go back to the lab system because (and I think this is the same answer you have Simon). I now want complete control over the product design.
Milling at an external lab no stress but design no.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
From personal experience, having greater control over your orthotic manufacture is a superb way of improving your understanding of material properties/capabilities and prescription variables.
It is also a great way,in my opinion of realising that manufacuring orthotics is very time consuming and challenging
Most orthotics I prescribe are CADCAM from cast/impressions depending on the device type. They are from 3 different labs and what the process offers is
1. Ability to finely tune prescriptions based on feedback from patients. All other variables remain largely the same whilst changing only one element if desired
2. Being able to alter heel pitch for different footwear types
3. Accurate posting values. Not that I think that I can measure the difference between 3 and 4 degrees, but to have consistency when requesting to minimise remedial work to get correction desired
4. Matching shell shape to a particular pair of shoes
I would like to learn how to do the CADCAM modifications to have greater control but I think there would be a considerable length of time to learn all of the capabilies. Time available is also an issue.
Do I want to do it all myself, theoretically get it right 100% and see 5 patients per day or do I want to have someone else do the work, get it right 80% of the time and see 25 patients per day?
Regards,
Robin
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Re: Would greater clinician control be a good thing in Orthotic manufactor?
I have visited a lot of labs and one thing that always jumps out at me is the general really bad casts that the labs get .... should those people have more control over ther process?
Something, like the Amfit give you full control over the process.
There is one system I know that is/was in development attached to a scanner that does give clinicians more control. The software was a dumbed down version of the CAD system used by the lab. Rather than send the foot scan to the lab, you had a choice of sending that scan for CAD & CAM or sending the CAD designed orthotic that you designed to the lab for the CAM.
__________________ Craig Payne
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Re: Would greater clinician control be a good thing in Orthotic manufactor?
Some inherit full control. Some acheive full control, and some have full control thrust upon them. The people who work for me have to do all their own manufacture, like it or no.
I find the following.
It makes them better biomechanists (theory wise)
it helps them think outside the box with prescription.
They mostly hate it... At first.
Some never get the hang of it and produce dross.
Once they get a taste for control (ooo err mrs) they often don't want to let go.
Sam Randall, my proudest acheivement, went from lab, to full controll to half and half. He has a good perspective on this, I'll give him a prod.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Quote:
Originally Posted by Craig Payne
I have visited a lot of labs and one thing that always jumps out at me is the general really bad casts that the labs get .... should those people have more control over ther process?
And there we have it, the cat it out of the bag.
There was a discussion around here using the UK system and NHS and nail cutting. Should the NHS be doing nail cutting or something like that, anyway a point was made should the NHS be doing biomechanics. Is the general level of biomechancial knowledge high enough in the profession ?
When we were at school near the end of our orthotics program in 3rd year. A tutor would discuss our orthtoics manufactor. Most got told to send it to a lab, 2 of us were told with more work and time we could manufactor our own devices if we want.
But if you are to design your own device, everything is on you. All mistakes big and small.
It would put a larger onus on Schools to produce a higher understanding of orthoic manufactor, process and biomechancial consequences which maybe a good thing.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
All labs get truly awful casts and stupid prescriptions and they turn out a product that more often or not looks nice, fits the shoes and works.
They do this by hitting the "DEFAULT" button. ie slap on some cast dressing, straighten it up, smooth it out, ignore all the silly requests that wont fii the shoes ie reduce postings to 0-3 degrees.
If suddenly everyone had full control and actually added all the bell and whistles there would be a far higher reject rate.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Quote:
Originally Posted by Lawrence Bevan
All labs get truly awful casts and stupid prescriptions and they turn out a product that more often or not looks nice, fits the shoes and works.
They do this by hitting the "DEFAULT" button. ie slap on some cast dressing, straighten it up, smooth it out, ignore all the silly requests that wont fii the shoes ie reduce postings to 0-3 degrees.
If suddenly everyone had full control and actually added all the bell and whistles there would be a far higher reject rate.
"and works" is key, THIS despite the fact that as you say the lab has "slapped" on the additions to make a "default" device. Begging the question i posed at the top of this thread.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Quote:
Yep, that's what I currently do- so me biased. Question:, why I have I chosen to do that?
Ah c'mon simon. I know you like to ask difficult questions to make us think, but asking US why YOU do something... thats a bit tricky!
Ok, so, not presuming to know whats in your mind, I also like complete control so I'm also biased. So I'll answer that question for me, why have I chosen to do that.
1. Because I think I can do a better job at things like posting height, material selection, prescription etc than someone who has not seen the patient.
2. Because I have, in the last 10 years, made LOADS of mistakes. But I try not to make the same ones twice.
3. Because The reason I do an assessment is to work out what I think will work best. If I allow what I do to be homogenised there is little point in an assessment.
4. Because many of the patients I see (NHS remember) have feet which are as far from "standard" as it is possible to get. Put THEM in a standardised device they'd not make it out the building.
Here's the thing. If I was to send a patient to a still green podiatrist, or one I knew to be rubbish at prescription or manufacture, I would expect best outcome from a nicely standard homogenised device. If I were to send one to you Simon, or Kevin, or Mike, or any of the podiatrists who have amazed me with their clinical insight and ability over the years, I would want them in complete control.
However. How do great clinicians start? As brand new, rubbish ones. And without letting them learn, we would never be any better than the people in scholl handing out metaflexes to all and sundry. I can remember being roundly whipped for giving out horrible, ugly orthotics. Those patients would have been better off with a pre fab. But we move on, and now I often see patients who have problems even with standard devices, who improve with truly custom ones.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Quote:
Originally Posted by Robertisaacs
Ah c'mon simon. I know you like to ask difficult questions to make us think, but asking US why YOU do something... thats a bit tricky!
Ok, so, not presuming to know whats in your mind, I also like complete control so I'm also biased. So I'll answer that question for me, why have I chosen to do that.
1. Because I think I can do a better job at things like posting height, material selection, prescription etc than someone who has not seen the patient.
2. Because I have, in the last 10 years, made LOADS of mistakes. But I try not to make the same ones twice.
3. Because The reason I do an assessment is to work out what I think will work best. If I allow what I do to be homogenised there is little point in an assessment.
4. Because many of the patients I see (NHS remember) have feet which are as far from "standard" as it is possible to get. Put THEM in a standardised device they'd not make it out the building.
Here's the thing. If I was to send a patient to a still green podiatrist, or one I knew to be rubbish at prescription or manufacture, I would expect best outcome from a nicely standard homogenised device. If I were to send one to you Simon, or Kevin, or Mike, or any of the podiatrists who have amazed me with their clinical insight and ability over the years, I would want them in complete control.
However. How do great clinicians start? As brand new, rubbish ones. And without letting them learn, we would never be any better than the people in scholl handing out metaflexes to all and sundry. I can remember being roundly whipped for giving out horrible, ugly orthotics. Those patients would have been better off with a pre fab. But we move on, and now I often see patients who have problems even with standard devices, who improve with truly custom ones.
They're my reasons. What are yours?
Regards
Robert
Pretty much in line with yours, and after 20 years and making thousands of them, I still enjoy it and continue to learn from my mistakes and successes.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Lawrence
You got it 100% right with the only caveat being that the lab has to know the customer really well to do this.
If a new customer uses us for the 1st time, they will get phone calls/emails to clarify what they need based on the casts sent in.
People do send in poor casts but sometimes they are a true reflection of the foot - e.g. the question being does the patient really have a fore foot varus?
Without giving the lab a critique of your casts ('I know the cast is rubbish can you do your best to make a device?) we really are p$%^ing in the dark.
In my experience of using CAD to design 1000+ pairs of orthoses a month, the most important thing to reduce returned orthoses is for the practitioner to both review the cast and to measure the inner dimension of the shoes they are going into. Combine these two and returns can be non-existent.
Re: Would greater clinician control be a good thing in Orthotic manufactor?
Quote:
Originally Posted by m weber
So if the future were CAD/CAM system in every practice it would mean the manufactor responsibillty would be on the practice or individual is this a good thing ?
I fully expected that my client systems would be a glorified replacement for fedex and ups for casts. Few have exceeded that expectation. For the greater majority of client systems, the users depend on the laboratory they're working with for actual design work, although both systems have equal capabilities and service levels (Free technical support and training) There are 3 basic levels a client system can operate:
1) scan
2) Orthotic design
3) Scheduling or nesting onto a workpiece.
Option 1 is simply a replacement for plaster and biofoam.
Options 2 and 3 implies training and places responsibility onto the the lab only to meet material thickness and alignment tolerances.
Most practitioners would prefer to see more clients and the greatest time saver is to replace plaster and biofoam.
Would greater clinician control be a good thing in foot orthotic manufacture?
Hybrid Mode
