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Occasionly I pop around and check out other forums. I was amused this morning to see at thatfootsite the comments on Rothbarts "proprioceptive" insoles, especially comments by several anonymous posters and the blind faith put in the approach by others. I thought I would raise it here
Brian Rothbart is well known around emailing lists and forums for his self promotional posts. He has joined here twice (aganist the rules) and has posted 3 self promotional messages (again, aganist the rules - two of which have been deleted, leaving one for view). Those on the podiatry mailbase email list are familiar with his self promotional messages and failure to respond to or skirt around questions when asked.
My views on his approach are well documented. Anyone can check the podiatry mailbase archives to read the comments by many others and the lack of or inadequacy of the response.
Here is my letter-to-the-editor published in 2002:
Quote:
The Editor
Journal of Bodywork and Movement Therapies
Dear sir
Re: Rothbart BA: Medial column foot systems: an innovative tool for improving posture. JBMT January 2002
It was disappointing to read this paper in the journal. Many of the statements and claims made by the author are not supported by evidence and should not have been allowed to be made. Many of the references cited by the author are very old and/or often do not support the claims made by the author. In my opinion, this paper was not academically rigorous enough to warrant publication. I will restrict my evaluation to only 4 aspects of the paper.
Retention of “talar supinatus” as an embryological cause of an elevated first metatarsal:
The talar head is widely believed to go through the changes described by the author, but some of the work of Straus (1927) that this is based on has been questioned (Kidd, 1997; Lisowski, 1967). It is possible that the normal embryological development of the talus does stop prematurely, leaving the head in a supinatus postion. The author claims that this is the cause of a foot structure that he has chosen to name after himself – the “Rothbart Foot Structure”. There is no evidence that the talar supinatus influences forefoot or first metatarsal position as merely stated by the author, or in the references he cites to support the claim. Hypothetically, if the head of the talus is in supinatus, the navicular may be influenced into a more inverted position and influence the angle of the forefoot or position first metatarsal, but as the talonavicular joint has a range of motion, this is not entirely clear. In contrast to the claims made by the author, McPoil et al (1987) have shown that there is NO relationship between the position of the head and neck of the talus and the forefoot, suggesting that the author is wrong in the claims he makes.
The elevated first metatarsal as a cause of hyperpronation of the foot:
The author claims that the elevated first metatarsal is the cause of hyperpronation of the rearfoot. However, he ignores the possibility of the opposite. If the rearfoot hyperpronates for any number of reasons, the medial column of the foot (especially first metatarsal) will be relatively elevated due to ground reaction forces. Over time, the soft tissues will adapt to this postion, so that when the rearfoot is placed in a neutral position, the medial column will be elevated. This is widely considered to be the cause of what the author claims is the primary cause of hyperpronation, when it is actually more likely to be secondary to the hyperpronation (Roy & Shearer, 1986).
The use of medial column support to treat the elevated first metatarsal:
The author advocates the use of medial column support, the height of which is determined by microwedges, to treat the hyperpronation (and the related postural symptoms). A number of references are cited to support the claims, most of which have not been published in academic journals for peer scrutiny or are studies that are in the lower levels of the hierarchy of quality of evidence, due to the lack of a control group, unvalidated outcome measures, poor (or no) description of selection of subjects, significant potential for biases in the measurement of the response variables etc.
It is widely documented that the first metatarsal must be able to plantarflex for the first metatarsophalangeal joint to dorsiflex to allow the body to move over the foot late in the stance phase (Roukis et al, 1996). The use of medial column support, as advocated by the author, would inhibit the first metatarsal from plantarflexing and this would restrict first metatarsophalangeal joint dorsiflexion. This will prevent the windlass mechanism of the plantar fascia from working, resulting in a very unstable foot during propulsion. Mosheyev et al (2002) in a 3-d kinematic study have recently shown that medial column support, as advocated by the author, actually increased hyperpronation and that rearfoot support, which the author strongly asserts “does not decrease walking hyperpronation”, actually decreased rearfoot hyperpronation.
If medial column support is to prevent hyperpronation of the rearfoot, it must first dorsiflex the first metatarsal to its end range of motion before affecting the midfoot joints. The midfoot joints must invert to end range of motion before it can affect rearfoot hyperpronation. Surely moving these joints to function at the end of there range of motion could be pathologic? The author counters this by claiming only 30% of the measured height of the first metatarsal is used to affect a 70% change in hyperpronation and that this due to a proprioceptive feedback loop. While it is entirely possible that any sort of plantar foot support or orthoses has some effects on proprioception, there is absolutely no evidence yet to support this and such unsupported claims should not have been allowed to be made. Even though proprioceptive effects for foot orthoses are claimed by the author (again without evidence), they are more likely to be exteroceptive effects due to alterations in pressure and sensory input on the plantar mechano-receptors by the foot orthoses (this is not proprioception). The author supports his claim by citing an unpublished reference from GRD BioTech Inc. This data appears to be based on visual gait analysis, which for research has been shown to be unreliable (Keenan & Bach, 1996). No other information on this research is presented by the author. It has not been published for any sort of peer scrutiny and appears to be from a company in which the author has a financial interest for the marketing of support systems based on the claims by the author. This financial conflict of interest is not declared by the author.
Clinical outcomes
The author cites several of his own publications for the clinical outcomes of the approach he is advocating, of which half are ‘posterboard’ conference presentations and are not published in any accessible form for critical appraisal of the claims by readers. Most journals do not accept the use of such references. Most of what the authors claims as supporting his approach are at the lower level of the hierarchy of evidence with the methods and results sections being extremely poorly documented and are generally unacceptable due to the lack of control groups, unvalidated outcome measures etc. None of the papers have of the author’s approach are considered to have a rigorous methodology (eg Rothbart & Yarrett, 1994) for inclusion in subsequent literature reviews or systematic analyses of the topic area.
In a uncontrolled outcome study on chronic low back pain, Dananberg & Guiliano (1999), using foot supports practically the opposite of what the author is claiming should be used, reported a good success rate in the management of chronic low back pain. The theoretical rationale proposed by these authors for this approach is considerably more soundly based than that proposed by Rothbart.
Conclusion
In conclusion, the approach advocated by Rothbart is not coherent theoretically, is not consistent with the published evidence, is not supported by the references given by the author. The clinical approach proposed by the author may even be detrimental.
Kind Regards
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I read the topic on thatfootsite with much interest as a couple of weeks back I attended a talk from one of my colleagues in the UK who I have a great deal of time for - Alex Catto - who uses and promotes these insoles. From what Alex says, many patients report unqualified success with these devices and I have no reason to doubt his claims. I have to say when I read the various topics where Brian Rothbart had contributed I came away with a distinct feeling that snake oil had been liberally applied, but the evidence from patients may perhaps suggest otherwise.
Anecdotal I know, but recently I saw a patient with long-standing knee pain that had been prescribed a pair of orthoses by a renown UK podiatrist who contributes on this forum and others. I was delighted to note that since taking delivery of the devices his knee pain has resolved completely and that he was now asymptomatic. What surprised me however, was that when I looked at the orthoses, I discovered he was wearing them in the wrong shoe - i.e. the right orthoses in the left shoe and vice-versa - and had been since the day he collected them. Strange but true and perhaps biomechanics is not quite the exact science that it is so often portrayed to be by some in the established podiatric community..
Mark Russell
__________________
"citing an indisposition due to special circumstances"
What are these rothbarts innersoles? It sounds like they are full length devices with a relatively big forefoot varus wedge? If they are, a guy out of Adelaide produces something similar. Big bulky devices but it seems that he does have quite a following. From what i have seen and heard, they do seem to work quite well (at the expense of a 1st MPJ). My thought is that they offer more support (due to the large forefoot varus wedge) then alot of devices i see pods producing unfortunately, and therefore they get better immediate results.
Mark, Have to also admit that i have seen plantar fasciitis cured with a set of orthotics placed in the opposite....Big guy, very conservatively arched orthotic, pain gone....!
distinct feeling that snake oil had been liberally applied,
Thats exactly how they are being promoted and it amazes me the blind faith put into them by many in this profession. Its easy to dismiss the theory behind it (see above). The published evidence shows that insoles of the design advocated will pronate a foot more. Rothbart claims the opposite, but contniually fails to provide any data.
Quote:
many patients report unqualified success with these devices
Quote:
he does have quite a following
Just look at the unqualified success of the "placebo" orthotics in control groups of the randomised controlled trials!!! Anyone can probably claim "unquaified success" with their orthotics. The world has moved on and these kinds of claims are not acceptable in the current environment.
Based on all the data and evidence available today, I would not want to try and stand up in a court of law and defend the use of massive forefoot varus posts.
Its exactly because of this kind of crap that is part of the reason 'podiatry' orthotics get a bad rap .... the blind faith in whatever is currently "hot" will make others keep looking on us as snake oil salespersons.
I will be the first to change my mind when there is some sound theory (rather than voodoo theory) and good data (rather than unsubstantiated claims). Until then it stays in the snake oil basket.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I agree with you completely. But how do you explain to the average joe that the X hundred dollars they just spent were on their new whiz bang orthotics (which happened to get rid of their pain) was based on voodoo theory and BS, when we the qualified podiatrists arn't too sure whether some $30 over the counter orthotics or a pair of custom made devices would have achieved the same result (I'm not saying this is always the case )? I would think Average Joe would opt for confident sounding snake oil salesperson nearly every time.
Gosh Craig, do I take it you're not an avid fan of Professor Rothbart's devices? I wonder what he needs to do before you become a convert! I can't really make any comment as I haven't evaluated any patients who have worn these insoles, but I have no reason to disbelieve what Alex Catto has to say. I would find it difficult to accept that such an experienced and well know clinician would gamble with his reputation if he wasn't convinced there were beneficial outcomes for his patients. Perhaps Alex - who is a member here - can give his view?
As for established orthotic therapy I have to say that I am still unconvinced after 25 years, that the profession and/or industry fully understand lower limb biomechanics sufficiently enough to be able to manufacture and supply devices that do what the prescribers often claim they will do. Like many colleagues, I read Kevin's recent submissions on functional mechanics (Thought Experiments) with much interest, not to say a little frustration in the puzzle solving process. What comes as no surprise is that the established principles of STJN theory are being challenged and for many clinicians that will shake the fundamental platform they have used for many years in their approach to clinical biomechanics. Which makes me think we are still some way from being able to say with any confidence that accepted podiatric orthoses are not liberally coated in the skitey stuff as well.
Mark Russell
__________________
"citing an indisposition due to special circumstances"
I am in the middle of the series of lectures to the 2nd yr students on the different biomechanical theories of foot function and foot orthoses. As an educator I have a responsibility to expose the students to the different approaches (I also cover the various approaches in seminars). The approach advocated by Rothbart (and disciples) is not even on the radar scope as an alternative theory and does not even get a mention. I do not know a single podiatry school in the world that includes it (dosen't that say something?). We spend a lot of time rigourously analysing the theoretical coherence and biological plausibility of different theories/approaches (Rothbarts approach fails on both points - see my letter above).
I am not an avid fan of any approach that does not have sound underpinnings (and there are several out there). I am even more contemptous of approaches that are treated like a religion and followed like a blind faith, let alone having the audacity to name a foot type after oneself.
Quote:
I take it you're not an avid fan of Professor Rothbart's devices? I wonder what he needs to do before you become a convert!
I welcome anyone to give a point by point refute of the points I made in the letter to the editor above.
We have done some testing of the orthoses advocated by Rothbart (analysis not yet complete), but early results showed they appear to decrease rearfoot pronation during initial contact (a good thing), but increased in late stance pronation (a bad thing) and delayed forward progression of the CoP (a very bad thing) - based on that I would not use them.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I had never heard of Rothbart's insoles until CP mentioned them above...and being the curious cat that I am, I had to check out the Rothbart website to see what type of "snake oil" was being sold.
There is a link on the website named "Become a Provider", and you select from a list of "Professional Specialties" to indicate who you are. I was quite amused to see that you could be a Dentist, Orthodontist or Naturopath and be qualified to provide these insoles. My dentist has never done a biomechanical examination to assess if I "hyperpronate" or not...could that be because insoles are not required to improve dental health and prevent cavities or can they? :p
And in the section comparing "PCIs vs. Orthotics", it is obvious that Professor Rothbart (or whoever wrote the blurb on the website) has not read up on his Thought Experiments, Subtalar Rotational Equilibrium or Tissue Stress Theories...
Quote:
Conventional wisdom professes that you can control hyperpronation by supporting the arch with an arch support and reduce hypermobility of the heel by placing it in a heel cup.This works quite well so long as you stand still, and that’s the problem. They don’t work nearly as well for active people. Active people walk and run; they bend and are on their toes. When your weight is on your forefoot or when you are on your toes, your weight is not on the orthotic.
Anecdotal I know, but recently I saw a patient with long-standing knee pain that had been prescribed a pair of orthoses by a renown UK podiatrist who contributes on this forum and others. I was delighted to note that since taking delivery of the devices his knee pain has resolved completely and that he was now asymptomatic. What surprised me however, was that when I looked at the orthoses, I discovered he was wearing them in the wrong shoe - i.e. the right orthoses in the left shoe and vice-versa - and had been since the day he collected them. Strange but true and perhaps biomechanics is not quite the exact science that it is so often portrayed to be by some in the established podiatric community..
I was quite amused to see that you could be a Dentist, Orthodontist or Naturopath and be qualified to provide these insoles. My dentist has never done a biomechanical examination to assess if I "hyperpronate" or not...could that be because insoles are not required to improve dental health and prevent cavities or can they?
From the same website:
Quote:
In my private practice, approximately 40% of the postural distortions I see come from the feet, 45-50% are mixed (feet and jaw, feet and teeth, etc) and the remaining 10-15% come from the bite or teeth alone. These may require a proprioceptive guide (oral night splint) or orthodontic treatment. However, before orthodontic therapy is initiated, the head must be positioned over the spine (e.g., bioimplosion, if present, must be reversed).
__________________
"citing an indisposition due to special circumstances"
Some of our more recent work as been looking at the roll of lateral column support in facilitating function (esp in the context of Bojsen-Moller's high gear/low gear axes concept) .... wearing orthotics in the wrong shoe probably elevates the lateral column and facilitates the transfer to the BJ's transverse axis (a very good thing), so I do not think that voodoo is necessarily involved when a theoretically coherent and biologically plausible concept explains the results.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I personally believe that the Rothbart Insoles work by maintaining an acquired forefoot supinatus. Instant relief for the patient but the long term effects on lower limb mechanics may create a viscious circle - more forefoot supinatus etc. Also if dynamic function is attempted - running etc - then the negtaive effect on sagital plane mechanics may cause significant pathologies.
I work for an orthotic lab and see thousands of FFO's, TCI's and simple insoles a year. Each practitioner has a completely different approach to orthotic prescribing but one fundamental approach is adhered to - make sure the medial column can function as close to the patient ideal as possible. This means that where a non-fixed 1st Mpj is present, allow it to function. I will even contact practitioners who break this 'rule' to ensure that they realise the consequences.
Experience has shown me that where a Rothbart type insole has been used, 1st MPj dysfunction has occured and the devices have been returned for adjustment or re-make. A collegue of mine who used to prescribe orthotics with medial column jamming posts joked that 10 years on these devices had resulted in a very affluent surgical practice treating Hallux rigidus.
We still don't know how orthoses work but as Craig alluded to, we can be fairly sure that if they 'jam' normal function then the old adage of '1st do no harm' will be broken.
Am I right or wrong here?
If a foot stj is maximally pronated then the f/foot will be supinated by GRF.
The person with a foot like this may have medail band Plantar faciitis. Traditionally the rearfoot is posted towards STJ neutral and the first ray cut out to enable plantar flexion and windlass action. This releases tension on the plantar facia and hopefully it gets better.
What if instead the rearfoot and f/foot is lateraly posted. This would increase GRF on the lateral aspects, the CoP moves toward the lateral and therfore, GRF being a constant, reduces GRF on the medial. Reducing medial GRF will allow 1st mpj to dorsiflex more easiliy and so release tension on the plantar facia medial band. Hopefully it gets better.(Shame about the sinus tarsi next year, just like wearing the orthoses in the wrong feet)
Same outcome (initially) oppsosite treatment protocol.
Phil,
The orthoses I prescribe, and I teach this method also, are simply an approximate interface between the ground and the foot. They allow the foot to work a little more around STJ neutral.
This simple system requires only a small leap of faith if we can accept 2 things:
1) That joints work most effectively around their neutral position, and that includes the STJ (common sense, surely?).
2) We have not evolved for life on a hard and flat surface (or an approximation of, which is what we live on in the West). Bear in mind that there is absolutely no scientific evidence (just a huge assumption) to show that we have evolved for living on hard and flat surfaces, while there is plenty of fossil evidence to show that we have had similar lower limb anatomy for at least 1.6 million years (do a Google on the Turkana Boy fossil).
Stick pretty much any feet in STJ neutral and you have an inverted foot.
Can't be right, surely?
The Rootian STJ-neutral theory was flawed, but I believe only partly. The "normal" model propounded by Root et al, if it exists at all, is only present in a very few individuals - and therein lies the flaw. But that the STJ works around neutral, and by casting in neutral we capture the FF to RF relationship is not flawed.
Looked at in the context of an unshod foot, an inverted (and I consider this is normal when the foot is in an approximation of STJ neutral) foot is probably more effective on uneven terrain (which is what the foot developed for).
I don't think it gets much more complicated than that.
I think most will agree that for various reasons (diurnal variation, the fact that our terrain is not absolutely hard or flat, the fact that orthoses sink into shoes, which themselves are not uniform - either in heel height or interior rigidity - pick any two you are happy with) it is impossible to work accurately in degree-based increments when prescribing orthoses.
This is not the same as manufacturing orthoses in a lab, where it is perfectly possible to work in degree-based increments during the manufacturing process. However, that carefully machined 3 or 4 degree post becomes an unquantified wedge when pressed into the innards of a shoe, which is then worn over a slightly less-than-true hard and flat surface.
I am in the middle of the series of lectures to the 2nd yr students on the different biomechanical theories of foot function and foot orthoses. As an educator I have a responsibility to expose the students to the different approaches (I also cover the various approaches in seminars). The approach advocated by Rothbart (and disciples) is not even on the radar scope as an alternative theory and does not even get a mention. I do not know a single podiatry school in the world that includes it (dosen't that say something?). We spend a lot of time rigourously analysing the theoretical coherence and biological plausibility of different theories/approaches (Rothbarts approach fails on both points - see my letter above).
I am not an avid fan of any approach that does not have sound underpinnings (and there are several out there). I am even more contemptous of approaches that are treated like a religion and followed like a blind faith, let alone having the audacity to name a foot type after oneself.I welcome anyone to give a point by point refute of the points I made in the letter to the editor above.
We have done some testing of the orthoses advocated by Rothbart (analysis not yet complete), but early results showed they appear to decrease rearfoot pronation during initial contact (a good thing), but increased in late stance pronation (a bad thing) and delayed forward progression of the CoP (a very bad thing) - based on that I would not use them.
Craig and Colleagues:
I have used varus forefoot extensions on foot orthoses in many athletes and in a few patients who are non-athletes who just want to walk comfortably. I can remember using a varus forefoot extension on an orthosis a few years ago in a patient with posterior tibial dysfunction with a large inverted forefoot deformity that functioned much better and with less pain with the varus wedge attached to the orthosis.
Even though I occasionally use varus forefoot extensions on foot orthoses, I do have a problem with Brian Rothbart's forefoot varus extension orthoses for walking activities for a few very good reasons:
1. Varus forefoot extensions will tend to cause increased incidence of functional hallux limitus.
2. Varus forefoot extensions will tend to cause late midstance pronation.
3. Varus forefoot extensions will tend to cause a more apropulsive gait with less ankle plantarflexion during propulsion.
4. Varus forefoot extesions will tend to cause subtalar joint supination instability in the latter half of stance phase.
I don't really like the information that Brian Rothbart puts out on his website or puts within his posts to discussion lists such as the podiatry mailbase because I believe it is based on faulty logic. As far as I know, the product that is being promoted is being marketed to many individuals with a minimum of foot biomechanics training which tends to worry me that these insoles may be used by "specialists" who wouldn't know late midstance pronation from an abductory twist. Of course, the "foot levelers" used by most chiropractors here in the States are in the same boat, as far as I'm concerned, when it comes to foot orthosis quality...in my opinion.
Additionally, I don't have a problem with Brian Rothbart putting his name on his product or attaching his name to a condition if he so desires. That is well within his rights to call it any name he wants. For example, here in the States, a well-known lecturer, Doug Richie, DPM, http://www.richiebrace.com/ made the choice to put his name on a series of braces he invented and that his company markets. Therefore, I don't see much difference between the what Brian Rothbart has chosen to do with his name and what Doug Ritchie has also done in regards to promoting either a product or a condition.
Personally, I am uncomfortable with naming something after myself and have chosen, instead, to use generic descriptive names for the techniques, tests and devices that I have invented over the years. However, not every inventor thinks the way I do, and I see no problem with an inventor putting his name on a product, technique or condition that he or she has initially described, as long as he or she feels comfortable with it.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Dear All...I had no idea this debate was going on until my email and phone started going this morning. So let me explain how I got involved. But I must say that I have a great sense of Deja Vu here, as I've been here before 20 years ago when I and several others advocated using homoeopathy in Podiatry. The charges of "Voodoo" theories were levelled then, as was the "lack" of creditable evidence,and the fact that only one researcher (Taufiq Kahn) had written the only available research papers.
The uncomfortable fact was however that the patients got better. I said it then, and I'll say it again.....I got results that I couldn't have got using traditional podiatry techniques. It's not the answer to the universe, but it solved a lot of problems (and still does!)
I digress....but I remember the lively debate in 2002 when Brian Rothbart published his paper. So when I saw he was holding a workshop in England last year....I went along with an open mind. The deciding factor was the fact that I had seen so many patients with pl. fascitis that weren't getting better. I freely admit that I find this a difficult problem to treat, and having attended the Heel Pain Roadshow in Reading, where just about every Pod in the room had a different treatment modality, and not fancing the idea of dispensing several 100£s worth of rigid devices in the hope that they'd help.......I went to hear what Rothbart had to say.
Interestingly, not many Pods attended, but a lot of chiropractors/osteopaths/musculo skeletal therapists of all shades. Over 2 days I learned a lot about their views on Pods and orthotics.
What Brian said made enough sense for me to send off to the States for a starter pack. After 35odd (very odd sometimes) years in practice I've got an open mind regarding treatment modalities, and I'll try most things.
So, I started to dispense Posture Control Insoles to the "worst" patients I had at the time eg. 21 stone karate black belt guy with heel pain for 2 years, unable to wear shoes. 4 DAYS LATER HE PHONES TO SAY HEEL PAIN GONE.3WEEKS LATER HE ARRIVES FOR FOLLOW UP WITH BOTTLE OF 20 YEAR MALT UNDER ONE ARM, AND NO PAIN. In the world of the High Street generalist practitioner, that's my idea of evidence based medicine ( BringingThe Scotch that is!)
And it went on like that. It's years since I've seen patients so enthusiastic. They were coming in and phoning up (unasked) to tell me how delighted they were.
Now, as far as I'm concerned, Brian's theories on Bx, are as valid as any others. NO ONE HAS YET CONVINCED ME AS TO HOW ORTHOTICS WORK. Root's theory is flawed, yet a multi million pound industry was founded on it, and when it appeared the profession was desperate to follow it with blind faith as the best thing yet discovered to give us some scientific credability.
Remember all those non wt bearing measurements we took with precision accuracy. and we all took perfect casts of course.
Now Rothbarts theory may be flawed as well........but I've had better results than I ever had with traditional orthotics.
PLUS THE DEVICES WILL FIT INTO EVERYDAY SHOES.
PLUS THEY ARE COMFORTABLE
I don't get where this "massive "forefoot post idea is coming from. Have any of you seen these devices? The posts are 3.5/6.00/9.00mm and 80% of my patients are in 3.5mm ones. 9.00mm I don't advocate using at all unless you're treating the patient in conjunction with a chiropractor/osteopath.
I don't understand the gait instability comment. I have several patients who say they are more stable, and have stopped lurching into their partners when walking along.
I would rather fight my case in court with a Bx theory that a lay jury could understand, together with a soft device with a 3.5mm post, rather than a rigid device. And how would you stand up in court when you're prescription is found to have the "lab discretion" box ticked?
The "crap" that brings Bx into disrepute with the public is the issuing of overpriced uncomfortable devices that the patient is condescendingly told they'll have to go and buy bigger shoes for. That plus the fact that when it doesn't work, very few refunds seem to be forthcoming. And before we get all saintly and say this doesn't happen.......a recent patient was referred to me after paying £1660 for 3 pairs of devices, none of which would fit her shoes (or trainers).
ALL ROTHBARTS INSOLES COME WITH A 90DAY MONEY BACK GUARANTEE.
I'VE ISSUED OVER 100 PAIRS OF THESE DEVICES AND GIVEN ONE PATIENT A REFUND. I'VE ALSO ISSUED NUMEROUS PAIRS ON A TRY IT AND SEE BASIS......EVERY ONE HAS PAID UP. If this is snake oil selling then there's not going to be much money in it with that guarantee
Now, if you've stayed with me this long, I'm sorry if this doesn't satisfy the intelectual argument, but I'm afraid that I earn my living in the real world, where patients pay by results. The above paragraph is the evidence base I'm working to at this point in time.
Alex - the exact same success rate that you are claiming can be seen in the "placebo orthotic" in the control group of orthotic randomised controlled trials. Anyone and everyone can claim success!!
3.5/6/9 mm are massive when no forefoot varus is present and easy to demonstrate the interference they have in windlass mechanics and how the make first MPJ dorsiflexion more difficult. .... just do Jacks test with and without the extension.
Can you refute point by point the issues I raised in the letter to the editor (see above) and published in JBMT?
Kevin - I do not have a problem with people naming commerical products after themselves (ie the Richie Brace; Cluffy Wedge), its just the agorance of naming a foot type after oneself (Morton never came up with the name "Morton's foot"; Mert Root never used the term "Root Theory) - these along with other names (eg Kirby skive; Blake inverted orthotic) these terms were attributed by the community of peers and not by the individual who's work they are based on ---- most likely as a sign of respect.
Quote:
I don't really like the information that Brian Rothbart puts out on his website
...to avoid the peer review process and scrutiny of journal publication.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Last edited by Craig Payne : 27th April 2006 at 01:53 PM.
I just wish I knew more to contribute to this discussion. I also wish I had Craig as a teacher, if this is the level of thinking being imposed on students!!
I just wanted to say, that this level of discussion and debate, rather than what is seen elsewhere is impressive - keep it up.
Alex:
I do not mean this with any disrespect, but the way you have said most of what you say is just the way and uses language in the same way as the "snake oil" salesmen talked. That immediately puts me off.
Originally posted by Alex Catto: Now, as far as I'm concerned, Brian's theories on Bx, are as valid as any others. NO ONE HAS YET CONVINCED ME AS TO HOW ORTHOTICS WORK. Root's theory is flawed, yet a multi million pound industry was founded on it, and when it appeared the profession was desperate to follow it with blind faith as the best thing yet discovered to give us some scientific credability.
When a podiatrist prescribes orthoses for a patient (in Australia), they are required to explain to the patient why they are prescribing and how they are going to work (obviously in lay terms so the patient can understand). This forms part of the Clinical Guidelines for Orthoses published by the Australian Podiatry Association...
Now, when "prescribing" the Rothbart's insoles, how do you explain to the patient their function? And can these things be modified/customised for different patients? And how do you treat patients with a supinated foot? On the website it says that these insoles are not indicated for supinated feet...what happens when a "supinator" walks through your door with symptoms?
I still find it very hard to see how these insoles work and why such a wide range of "providers" such as dentists would be prescribing them also.
I don't understand the gait instability comment. I have several patients who say they are more stable, and have stopped lurching into their partners when walking along.
As I said in my last posting, one of the problems I have with patients that have had too much (or any) forefoot varus posting added to their orthoses is the following: Varus forefoot extesions will tend to cause subtalar joint supination instability in the latter half of stance phase.
I didn't say that all patient's experience this outcome, since I'm sure that some patients may benefit from varus forefoot extensions as I also mentioned. In my posting I stated that I will use this orthosis feature in the occasional patient for walking.
In 2002 Dr. Brian A. Rothbart published a paper (Journal Bodyworks and Movement Therapy) describing a previously unreported embryological foot type (technically referred to as the Primus Metatarsus Supinatus Foot), which he linked to the failed or incomplete torsional development of the talus. This foot type is thought to be responsible for poor posture in children and chronic musculoskeletal problems (foot to jaw) in the adult. Frequently it can be identified by its deep first web space.
And here are only a few of the maladies that his magic insoles may treat (also from his website):
Proprioceptive Stimulation Can Help You
Proprioceptive Stimulation affects the body in many positive ways.
Foot, Knee, Back, Neck, Jaw Pain
Proprioceptive stimulation repositions the posture into a more correct alignment (see Figure Right). This reduces the stress on the muscles, which allows them to heal (Rothbart and Esterbrook 1988, Rothbart and Yerratt 1995).
Respiratory
By straightening the shoulders, the ribcage is opened and pressure is taken off the lungs. This allows for easier breathing.
Intestinal and Bowel
Proprioceptive stimulation reverses the anterior rotation of the innominates (hips), which in turn, positionally decompresses the intestines and colon. Waste products pass through the colon more quickly and efficiently, eliminating the pain associated with gastro-intestinal distress.
Chronic Fatigue Syndrome
Proprioceptive stimulation improves posture, which in turn, reduces hypertonicity (tightness and strain) within the postural muscles. Lactic acid is reduced. The body has more energy. (Rothbart B. Pressure Plate Analysis of Medial Column Insoles. Journal of Sportsmedicine)
Diabetic Ulcers
With improved postural positioning of the foot, blood flow into the foot is greatly enhanced. This allows the diabetic ulcer to heal, reducing the likelihood of a partial or complete foot amputation (Case Studies, Group Health Hospital, Department of Orthopedics, Tacoma Washington 1996).
Infertility
Proprioceptive stimulation reverses the anterior (forward) rotation of the pelvis. This decreases the possibility of a blockage (Isthmus Block) between the ovaries and the fallopian (uterine) tubule, where conception normally occurs (See Animated Model below). The egg passes more freely from the ovaries into the fallopian tubule. Impregnation is facilitated (chances of becoming pregnant are improved).
Menstruation
By reducing the forward rotation of the pelvis, the blockage between the uterus and the vagina is reduced. This allows the waste materials, generated by menstruation, to be passed out of the body more efficiently. This in turn, diminishes or greatly reduces menstrual pain (and low back pain). (Bellevue Study 1993-95)
Headaches
Many headaches arise from tension in the neck muscles. By positioning the head over the spine, the neck muscles relax. Headaches become less frequent and less intense (Rothbart, Hansen and Liley 1994).
Fibromyalgia
Many patients with Rothbart's Foot Structure have pain symptoms, foot to jaw. It is not uncommon for these patients to be diagnosed as having Fibromyalgia. One specialist in Chicago talks about her experiences using proprioceptive insoles in their Fibromyalgic Clinic and the results they have seen over the past two years.
A Profound Effect
Proprioceptive Stimulation, as you can see has a profound effect on the body, solving so many chronic body problems, that in the past were considered unsolvable. This is done naturally, without the use or need of surgery or drugs. It just makes good sense to treat your body in a kind and respectful way, allowing it to heal itself naturally.
Alex, maybe you can also provide us information on whether the Rothbart insoles that you have correctly prescribed have helped improve the "efficiency" of the menstrual cycle of your female patients. Sure sounds like snake-oil to me.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
I have just returned from a lecture series in Madrid and was surprised to see the return of Rothbart when I got back. From my experiences in Madrid and elsewhere it is clear that there is a world-wide obsession with the windlass mechanism currently.
One or two of my spare Euro's in to the pot:
Rearfoot posts reduce 1st MTPJ dorsiflexion too (Smith C., Spooner S.K., Fletton J.A.: The Effect of 5-Degree Valgus and Varus Rearfoot Wedging on Peak Hallux Dorsiflexion During Gait. J Am Podiatr Med Assoc 2004 94: 558-564), but I don't see anyone advocating that we stop using them in case we "block the windlass."
Windlass action is not dichotomous, that is it is not an all or nothing event. How much though, is enough?
How do we measure change in plantarfascial tension with and without the effect of the windlass mechanism in dynamic, shod walking? And, control for other factors which may influence plantarfascial tension- In other words, which research has demonstrated the effect that foot orthoses has on the windlass mechanism during walking? Indeed, which research has demonstrated the effect that shoes have on the windlass mechanism during walking; which research has demonstrated the effect that the windlass mechanism has on plantarfasical tension during shod walking?
I just think too many people are placing too much significance on something we know too little about. Tell me I'm wrong.........
Craig mentioned Bojsen-Moller. I have written many times in other forums on the problems I perceive with Bosjen Moller's high/ low gear theory; to re-cap the principle points: I believe that a transfer to the high gear axis from low gear is accompanied by a medial shift in the STJ axis, in other words the foot must pronate to achieve this. The greater the length differential between the longer second metatarsal and the shorter first metatarsal the greater the medial shift in STJ axis (Spooner S.K. The subtalar joint axis locator. PFOLA conference presentation, Montreal 2002). This is true whenever the 1st met is shorter than the second. In other experiments carried out we have demonstrated that the "selection" of high or low gear seems to be random, varying from step to step. Sometimes one axis is used, sometimes the other.
I especially like the low gear axis portrayed in Bojsen Mollers articles which shows it extending through the 5th MTPJ when studies of shear force demonstrate that the 5th MTPJ has no roll in propulsion.
Quote:
Originally Posted by Kevin Kirby
As I said in my last posting, one of the problems I have with patients that have had too much (or any) forefoot varus posting added to their orthoses is the following: Varus forefoot extesions will tend to cause subtalar joint supination instability in the latter half of stance phase.
Do you think that the peroneous longus would fire longer and/or harder in this situation? Perhaps plantarflexing the 1st met, reducing the supinatus and "improving" the windlass in an analogous fashion to the effect of valgus forefoot posts and gastrocnemius?
One final point, we seem to assume that the foot is fixed on top of an orthoses- it's not.
__________________ Science is the antidote to the poison of enthusiasm and superstition
I'VE ISSUED OVER 100 PAIRS OF THESE DEVICES AND GIVEN ONE PATIENT A REFUND. I'VE ALSO ISSUED NUMEROUS PAIRS ON A TRY IT AND SEE BASIS......EVERY ONE HAS PAID UP
Quote:
Originally Posted by craig payne
Alex - the exact same success rate that you are claiming can be seen in the "placebo orthotic" in the control group of orthotic randomised controlled trials.
Is this correct?
__________________
"citing an indisposition due to special circumstances"
Just look at all the "control" groups in the studies that compare prefabs to custom made etc etc and most patients get better --> implication is that these prefabs which are not designed to do too much are getting the same success rate that Alex is claiming. I probably mis-used the term "placebo" and should have said prefab group in the trials.
Even in my clinical practice, I offer 100% money back no questions asked and have not refunded any in the last few 100 orthotics.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
David
I am going to stick my neck out here as I believe the need to make the foot function around STF neutral is a generalisation at best and a poor algorythm at its worst. My reasoning behind this is that foot orthoses should attepmt to change the pathology inducing forces created by GRF (and others) and not try to place the foot in a positional panacea.
I am also not sure of the relevance of the evolution discussion (I have read the previous postings on this topic) as do not take this into consideration when treating my patient. Do I need to?
I do agree with your point about orthoses accuracy - as soon as it gets into the shoe, the fibro fatty pad movement, translation of the foot over it etc, then its mecahnics cannot accuratley be measured.
The point I would make re the Rothbart design is that seem to work by creating a shoulder type sling effect ( post clavicle fracture to immobilse the joint) on the pf - ie. they immobilse the foot. Great for getting of symptoms but not addressing the causative mechanism - what ever that is.
Just look at all the "control" groups in the studies that compare prefabs to custom made etc etc and most patients get better --> implication is that these prefabs which are not designed to do too much are getting the same success rate that Alex is claiming. I probably mis-used the term "placebo" and should have said prefab group in the trials.
I'm not sure that fee refunds are truly indicative of clinical success, but of course they are important when you're in the business of private practice. Just as an aside, and not wishing to divert this discussion, what is the success ratio between prefabs and custom made devices?
__________________
"citing an indisposition due to special circumstances"
Am I missing something here? If prefabs and custom orthoses have equal outcomes, and prefabs and Rothbart's also have the same outcomes (according to Alex's observations), are you saying Rothbart's proprioceptive devices are just as effective as custom made orthoses? Or have I completely fallen off the log?
__________________
"citing an indisposition due to special circumstances"
One thing that should be said is "well done" to Alex for sticking his neck out on such a touchy subject.
However I think we would all agree that for a lot of people if you put something in their shoe they will say they "feel" better.
Plus the "money back guarantee" is a well known means of engendering customer confidence. Many people can be very dissatisfied but still not return to claim their refund. Also customer confidence = enhanced placebo effect does it not?
Alex, I too have only recently created a miracle cure with orthotics in severe plantar fasciitis. This was bilateral, 5 years duration and has necessitated the use of crutches and he has had everything under the Sun. I got a 75% reduction in 1.5 weeks with the "RIGID" orthotics you prefer not to use. No he didnt ring to tell me but he did immediately refer another pt - his GP! Does this prove anything. No
Incidentally I took a "neutral" cast, used forefoot balancing and they had a polypropelene rearfoot post. Does this mean they were prescribed with the "flawed" Root concepts in mind. Nope, the Newton's laws of mechanics + an understanding of stress/strain and material properties were employed. Oh and they fitted his shoes.
Does this mean that the next pt gets the same thing. No
The same Rx. No
The same material. No
Things have moved on since "Root". Prescriptions, materials can all be changed to suit the circumstances. Can the same be said of the "rothbart" approach? I think the worst results of the so-called "Root" approach was the misapplication of its concepts and giving all pt's the same devices. To me the "rothbart" approach is doing the same.
It doesnt surprise me that there were lots of Chiropractors at the meeting - they can cure deafness with spinal manipulation you know. They can also prescribe custom orthotics by post just by letting you take one step on their clever pressure mats!
Quick question Alex, were you a big prescriber of thermoplastic custom foot orthotics before you started using "rothbart" orthotics?
Did you know that recently Scientists (people in lab coats) discovered that Bernouilli's equation does not in fact adequately explain how the shape of airplane wings actually generates lift in flight. Sure, there are differences in pressure and such, but there are also significant holes in the theory proposed by Bernouilli.
This was only discovered recently. And on the day it was discovered, not a single jumbo jet fell out of the sky due to the lack of theoretical support.
Now, I will agree with Craig (he's bigger than me for a start) that we shouldn't be racing off chasing anecdotes; and I know nothing about Prof/Mr Rothbart's products....and to be honest I dislike a snake-oil sakes approach as much as the next person. But I think we need to recognise where we are in the scheme of the theoretical/practical junction.
Sooner or later we will have a clearer picture of WHY orthotic devices have the effects they do - and thanks be to the researchers who will lead us there. And sooner or later we will figure out how jumbo jets fly.
I’ve reworked and paraphrased some of this but what do you think of the following theories? (stick with it it makes sense by the end I Hope!)
Theorem One
1=2
Proof
Suppose a=b and neither is zero or 2=2.
Then if,
a²-b²=(a-b)(a+b) or 4 – 4 = (2-2) x( 2 + 2) =>0
Also,
a²-b²=a²-ab or 4-4 = 4-4 => 0
So,
a²-ab=(a-b)(a+b) or 4 – 4 = 0 x 4 => 0
a(a-b)=(a-b)(a+b)or 2 x 0 = 0 x 2 => 0
a=a+b or 2=2+2? 2 =4??
a=a+a or if a=b and a = a+ b then a = a + a
a=2a
2=4 so 1=2
Intuitively you know 1 does not = 2. But it appears by transposition that a =2a but that is because one assumes that ‘a or b’ = a number, which they do not, they are just a or b. a = 2a by the rules of algebra but are not / cannot be proved by the rules of arithmetic.
Theorem Two
Movement is impossible!
Proof
This is a proof by contradiction. Assume that movement is possible and derive a contradiciton, thereby proving movement to be impossible.
So suppose movement is possible. A runs 10 times faster than B. In a race B starts 10metres ahead of A. A can run 10mtrs / sec. The race starts, after 1 sec B goes 1mtr to position B2, A goes 10mtrs to position A2 but B is still ahead. In the next fraction of a sec A moves to position B2 but B moves to position B3 so B is still ahead. A moves to position B3 but B moves to position B4 and is till ahead of A. A cannot catch up or over take B. So by this logic after racing for infinity A could not move but infinity is in less than 2 seconds. So What if B starts (0.1mm x 10 to the power of minus infinity) ahead of A. Movement is impossible
This is again algebra comparing A in relation to B but contained within the rules of their own parameters in which time and space does not exist (but it intuitively exists to the reader) and not in relation to the real world where time does exist.
………………………………………………………………………………………………………………………..
In the early years of the twentieth century, two English philosophers, Bertrand Russel and Alfred Whitehead, adopted the black-and-white view. They tried to formalize all of mathematics by carefully spelling out all axioms, (Statements which are true (within the parameters of the criteria of the rules for the statement,which is all truths)) and then deducing every possible true statement, all of mathematics. During the course of this project, Russel came up with a famous paradox which bears his name.
Russel's paradox goes like this:
Divide all possible sets into two groups: the group of sets which contain themselves and the group of sets which do not contain themselves. Into which group does the set of sets which do not contain themselves go?
Indeed, the goal of proving all possible true statements turned out to be an impossibility. This was proved by Kurt Gödel, an Austrian philosopher mathematician. He showed that in any consistent system which was reasonably complicated (on the level, say, of arithmetic) it was possible to write down in the language of that system a statement that basically meant this statement is true but unfortunately not provably so. The consistency of the system necessitates the statement's being true (can you see why?) -- but that means you can't prove its
I take this to mean that it is possible to prove that a statement, made about a certain system, is true by using the criteria of the rules for that system. It is impossible to prove that statement wrong without using criteria outside of the rules of the original system, which make the counter proof invalid which, by the same logic, also means it is impossible to prove the original theory.
One could say then that this leads to a paradox such as the argument in this thread about Rothbarts insoles. One can only disprove his system by using rules of another system which are not valid for analysis of the original Rothbart system.
Rothbarts insoles
or can they? :p
what the?
Linear Mode
