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Effective Orthotic Prescription Writing

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Mar 1, 2006.

  1. admin

    admin Administrator Staff Member


    Members do not see these Ads. Sign Up.
    ProLab have just sent out there latest communique
    Thanks to Larry & Paul for this.
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
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    The approach I take is somewhat different, perhaps driven by a teaching and research agenda with the need to break the prescribing process down to teachable and researchable steps that are explicit and transparent (...and to get rid of the marketing spin and hype that some commerical interests put on different things ;) ).

    Essentially we have:
    1. Characteristics of the foot
    2. Characteristics of the footwear
    3. Characteristics of the environment (eg sport; surface; employment; etc)
    4. Psychosocial issues (eg $'s; third party reimbursement)

    Then we have a number of prescription variables that need to be matched up to the above:
    1. Negative model production variables
    2. Positive model modification variables
    3. Shell variables
    4. Top cover variables

    Prescribing is nothing more than matching the charactistics listed above to the prescription variables - if they match up, the patient gets better. It does not matter if its a prefab or custom or which negative model production method you use ... as long as they match up.... anyone notice how so many claim to have the best method? How can they all be right?

    The main questions I ask when prescribing to match the above two are:
    1. Where do you want the foot to be?
    2. How much force is needed to get it there?
    3. Where does that force need to be applied?
    4. Which body plane is the foot compensating in?
    5. Is sagital plane motion facilitated?
    6. (then there are a huge number of other decisions re "minor" prescription variables).
     
    Last edited by a moderator: Mar 1, 2006
  3. I use a slightly different approach when prescribing foot orthoses for patients that is based on the Subtalar Joint Equilibrium and Tissue Stress Approach to Biomechanical Therapy of the Foot and Lower Extremity:

    1. Determine the structural component(s) that is (are) injured.

    2. Determine the most likely type of force that is causing the abnormal stress to the tissue. In other words, is it a shearing force, tensile force or compression force, or a combination of the above, causing the pathology?

    3. Design the orthosis and/or recommend mechanical therapy and/or recommend shoe design so that the following three goals are accomplished:

    A. The magnitude of pathological stress on the injured structure is reduced so that healing may occur.
    B. The kinematics of gait is optimized so that better gait function results.
    C. Other pathologies are not created in the process of accomplishing goals A and B.

    All the other variables inherent in orthosis/shoe prescription are then based on the above approach and may be accomplished with multiple orthosis/shoe designs, as long as goals A, B and C are all met in the process.
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    Kevin - I don't think what we do is any different to each other, except that the framework in which we use to make decisions is different. What you use is incorporated in what I do (mainly because of the teaching and research agenda) - I just need to expose students to it all in an explicit framework.
     
  5. Atlas

    Atlas Well-Known Member


    Spot on. That is why you understand, and have been capable of tackling pathologies such as peroneal overuse, while the rest of us have been paranoid about stopping/reducing "pronation".


    The thing that I don't get is that symmetry is rare; feet are so different within the individual and obviously between individuals; signs and symptoms are so varied and sometimes multiple in presence; yet most orthotic devices pumped out look identical to the next.

    The question I would add to the orthotic prescription process is "How is this foot different". And if you can't find an answer, just pump out another device that imparts a supination force medial to the axis about the sustentaculum tali region and tell the patient 'to wear them 1 hour today and 2 hours tomorrow...'
     
  6. pgcarter

    pgcarter Well-Known Member

    I would modify the above only by saying that there are cases where the so called ideal parameters of gait are no longer possible (or were never possible) to achieve and that ideal parameters (best efficency, least pain?) for a particular individual are really what you are looking for....which caters to what Atlas has said about the infinite variablity of feet and bodies.
    Regards Phill
     
  7. Phill:

    If you will notice, in my last posting, I have listed the second goal of orthosis therapy as follows:

    B. The kinematics of gait is optimized so that better gait function results.

    In other words, I did not say that we are trying to achieve an ideal or "normal" gait pattern. What I did state is that we should try to optimize the kinematics (i.e. movement patterns) of gait to try and improve an individual's gait pattern. This is very different than making the statement that we should be trying to make an abnormally structured individual function in some ideal or "normal" fashion.

    By stating the second goal of orthosis therapy as above, then I am including all types of variability in structure and asymmetries that can occur within the human population. Most individuals have asymmetrical foot and lower extremity structure and function. In addition, most individuals don't have a snowball's chance in Hades of functioning in an ideal fashion even with the best foot orthoses available.

    I hope this better clarifies my posting above.
     
  8. Thanks for that Atlas. I believe that I become frustrated at times because I am continually seeing patients who have been made orthoses by local podiatrists that do not work. These same podiatrists then want to do surgery because their orthoses have not worked. Go figure??!!

    Peroneal tendon/muscle pathology is just one of the many pathologies that I routinely treat successfully with pads on insoles or with properly made orthoses (that do not in any way look like the type of orthoses that I was taught to make at CCPM using Root et al ideas) that very few other podiatrists seem to know how to do correctly. I believe that this is because these podiatrists were all taught by instructors who themselves thought they knew more about the biomechanics of the foot and lower extremity than they really did, were taught biomechanical principles that were many times wrong, were taught that the foot functions in a way that it really doesn't, and were taught how to make orthoses in ways that are not the most effective for all types of pathologies.

    I feel sorry for the patients that have needlessly been in pain for the last 1, 2 or more years of their life, have spent sometimes thousands of dollars on their medical care or have had unnecessary surgery. I often think that, in the ideal world, that there should be some way that I could have educated their treating podiatrist(s) so that they could have been able to do the same thing that I routinely do in my practice. In this way, the patient would not have needed to suffer so long and to have spent so much of their hard-earned money in seeking relief of their pain and pathology.

    Even though I have done a my fair share of educating podiatrists, this just doesn't seem to console me to the fact that if the patient had been seen by a more knowledgeable podiatrist, that they would not have been in pain so long. There seems so much more work to do in educating podiatrists, but so very little observable progress being made toward this goal from year to year. As I am entering probably the last 20 years of my professional career, I am beginning to realize that I can only do so much. In the end, when all of this educational work is over for me, I just would like to have the opportunity to be able to look back on my life and feel that I have done something very valuable not only for my patients but also for the patients of my podiatric colleagues.
     
  9. Good point, Craig. In my posting, however, I was just trying to point out the different method of how I organize my thoughts regarding orthosis treatment versus the "five question approach" that Larry Huppin wrote about in his newsletter.
     
  10. Atlas

    Atlas Well-Known Member



    Kevin, IMO, the best health professionals/teachers are not knowledgable. I think the best ones are fallible, but realise their limitaions, and realise that there are other professionals (inter-profession and intra-profession) that could give a second-opinion on a difficult patient condition.

    The underlying problems are 1/more of money, ego, and EBP in its infancy.


    As a physiotherapist, I don't get it right all the time...far from it. But I have learnt faster than most, about which conditions I cant help sooner-rather-than-later, and move them on appropriately. For example, if I have a shoulder that I am not getting right quickly (2-3 sessions), I will send them to a Sally Green (PhD.) for instance. More than a decade of sending "my patients" to other practitioners (inter and intra), my patients have not been the only beneficiaries...I have learnt first hand from experts across the board when dealing with recalcitrant conditions.

    On a related point, it is a pity, that teachers don't get their hands dirty, and get in there, in front of students; as if they are too scared to make a mistake. There is nothing more educational, IMO, than an experienced teacher/expert grappling with and going trial-and-error on a difficult patient condition. 'They' say "we learn more from our mistakes", but the learning environment for me, across the board, is too sanitary. The role of a teacher solely to pass judgement/comment/critique should become anachronistic IMO; simply a waste of experience and a lost opportunity for raw coal-face learning and psuedo-collaboration.


    Is there a place for 'trial and error' in the current EBP environment? I think not. The flip side of EBP (I know that it is necessary) is that it doesn't cater for trail-and-error. Unfortunately, it forces us to walk in a narrow spectrum, with the herd, and in its infancy, asks us to look at most patients in a "textbook" manner. The problem is, when a practitioner has thrown EBP at the condition, he/she is entirely satisfied that that is all that can be done 'conservatively'. Why should the EBP-practitioner bother seeking a second opinion?????? When EBP has failed, and the patient has the 'hide' to seek a 2nd opinion, how should the next practitioner respond? Repeat what has failed? Send them for an immediate triple fusion? Or try something, albeit 'unethically'?
     
    Last edited: Mar 4, 2006
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