Excuse me for my late reply.
I was quite busy with setting up a new study.
The type of foot orthoses made by the Dutch podiatrist, is also provided in Spain, France, and Belgium. The concepts for construction are based on the principals described by the Frenchmen ‘Lelièvre’, ‘Bourdiol’ and ‘Lavigne’ (see for an impression www.posturologie.asso.fr
Although I think these type of insoles are not optimal for local stress reduction, a few podiatric insoles had a better result than some orthoses made according to the ACFAOM practice guidelines.
We had planned a randomised clinical trial to compare orthoses made podiatrists versus orthoses made by orthotists for treatment of patients with metatarsalgia. In the preparation of this study the representatives of these disciplines had defined a general treatment concept (In the Netherlands the clinical viewpoints of these disciplines on treatment of foot disorders are quite different). After the consultation of the formal representatives, we also visit some companies and workshops for a second opinion. After that, our impression was that the treatment concepts were not so consistent as what was previously suggested by the formal representatives. We worried about whether the study results of our planned RCT could ever be generalized to a larger population of podiatrists or orthotists. If the podiatrists and orthotist (who ought to construct the orthoses for the RCT) work very different from their fellow-workers, a RCT would make no sense. If effectiveness is dependent on individual skills and experience, the concerned therapist could not be a representative for his colleagues and consequently the generalisation of conclusions would be problematic. So, ‘a priori’ we decided to perform a study on variation between and within professional groups concerned with foot care in the Netherlands.
Truly, we didn’t know what to expect. Based on a few visits and interviews we had some ground to expect a large variation for several aspects of foot care, but on the other hand we never arranged meeting of several therapists around a ‘live’ clinical case. I think we’ve had expected some variation in details.
I do think that the variation found is not unique for the Dutch situation. Several studies in other countries evaluated variation for different aspects of orthoses therapy like: casting, goniometry and prescription habits. The results of these studies showed a wide variability between foot care specialists.
A conclusive evidence based theoretical and practical framework is still to be established. The existing guidelines are predominantly based on empirical information. Which is not necessarily wrong, but further research is needed to differentiate which elements of physical examination, clinical reasoning and construction of foot orthoses are relevant for clinical effectiveness. Future fundamental and clinical research as well as available evidence (i.e. literature) is to be integrated in algorithms for daily practice. A practical research approach would be to start with the evaluation of existing guidelines.
As an example, we examined also the three disciplines regarding their ability to identify locations with elevated plantar pressures. We saw important discrepancies between quantitative measurements (golden standard) and ratings of the therapists. In this case the first step should be an inventory of possible valid methods for plantar pressure screening. Second, a detailed study has to be performed to find a clinical method or a combination of methods and techniques, which can most accurately identify locations with elevated pressure. Third, after validation and standardisation the best method should be implemented as a standard guideline.
…for my appreciated colleague LuckyLisfranc:
Without any scientific evidence for many aspects of foot orthoses therapy, I think it is inappropriate to be so convinced about the efficacy of casted or reliable pre-fabricated heat-mouldable devices for plantar pressure reduction. (what’s in a name: Lisfranc was not a popular person, his bellicose manners making any close friendships between him and his colleagues impossible…what a joke).