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Would anyone be prepared to share their biomechanical exam forms (if you use one). We are going through a re-writing of our practice policies & procedures as part of the Podiatry Assistants Course my wife is doing. There seems to be a suggestion that not to far down the track all practices will need to be accredited (similar to new requirements coming in for Podiatrists). It is an incredibly time-consuming process & we are required to basically review EVERY thing we do & have it documented & hence we are reviewing our biomechanical assessment form (or the lack of one in my case). I have tended not to follow a form but note what is relevant. I can see the limitations in this & how using a standard form/process has it's benefits. Any input appreciated.

markleigh

Most of the biomechanical forms I have run across appear to have similar format. Non digital data collection formats have one major drawback and that relates to a general lack of space to record data. Computer systems do have greater flexibiliy but most (in may opinion) reflect the faults of paper collection with the program potential very much underused.

From an educator's perspective the history of podiatric data collection reflects more the teaching of the subject rather than a practitioner problem orientated approach. We all become comfortable with the familiar format(s) but rarely question its logic.

I think there are two fundamentally different approaches to collecting bio-physical data.

The first is where you are profile everything; and the other where you are trying to eliminate the need to proceed to complex care.

In the former you can either take an 'head to toe' or alternatively 'toe to head' approach. For the purpose of health and safety you may sub divide the collection in weightbearing and non weightbearing examination. In the elimination approach you start with the contra-indications and if these criteria suggest further examination then refer back to the first form.

Standardising data collection based on anedotal best practice is a mine field. This in no small part is due to the lack of evidence based practice to support the practice of foot orthoses. Consequently whatever would be recommended as a stndard format would be open to criticism and if ever challenged, found wanting.

netizens
As a foot note: Something which is not held so dear by contemporary foot biomechanists is the containdication to foot orthoses (as outlined in the early Californian Biomechanics). This must beg the question, Why and what have we learned or what are we deliberately ignoring ?

What say you?
toeslayer

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Hi Cameron,

I am curious. What kind of containdications to foot orthoses were outlined?

And pointing this on this site is a suicide bomb...

Regards,

Javier

javier

>I am curious. What kind of containdications to foot orthoses were outlined?

Contra-indications would include poor quality, range and direction of joint motion i.e. presence of osteo-arthrosis; and or subluxation. Age in the sense of a physiological inability to realign joint surfaces was considered a contra-indicational to functional foot control. eg traumatic arthroses. I believe we lose this ability through the third and fourth decade onwards.

> And pointing this on this site is a suicide bomb...
I disagree. If the statement is true (which I believe it is and is certainly supported by the literature) then there is real need for this community to accept we do not know enough yet to be so prescriptive.

Footnote
I have been a critic of Californian biomechanics for several decades and like many of my colleagues with similar convictions had a fare share of death threats and cold shoulder treatments but that does not change the facts. All rather sad but there you go.

Anyway off to the bunker to watch the Bill
toeslayer

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Javier:

Those that say that there is a "lack of evidence based practice to support the practice of foot orthoses" obviously have not read the scientific literature on the therapeutic, kinetic and kinematic effectiveness of foot orthoses.

And, Cameron, don't worry, you won't get any death threats from me.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin et al

There is definately plenty anecdotal stuff but much lacking on the independent studies which provide the true scientific measure. No question it would be lovely to think there was scientific foundation for podiatric biomechanics but there is none. At best you have an educated guess.

toeslayer

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Cameron:

More than an "educated guess", as you say. As I said earlier, there is not only plenty of scientific evidence that foot orthoses are therapeutic, but also there is pleny of scientific evidence that foot orthoses have the mechanical ability to change both the kinematics of gait and the kinetics of gait. These are independent studies, done in a scientific manner, with new studies being published nearly every month. Those who are current with the scientific literature would not still be saying that the evidence for foot orthoses is only "anecdotal".

Scientific articles that show foot orthoses are therapeutic:

Blake RL, Denton JA: Functional foot orthoses for athletic injuries: A retrospective study. J. Am. Pod. Med. Assoc., 75:359-362, 1985.

Donnatelli R, Hurlbert C, et al: Biomechanical foot orthotics: A retrospective study. J Ortho Sp Phys Ther, 10:205-212, 1988.

Gross ML, Davlin LB, Evanski PM: Effectiveness of orthotic shoe inserts in the long distance runner. Am. J. Sports Med., 19:409-412, 1991.

Saxena A, Haddad J: The effect of foot orthoses on patellofemoral pain syndrome. JAPMA, 93:264-271, 2003.

Moraros J, Hodge W: Orthotic survey: Preliminary results. JAPMA, 83:139-148, 1993.

Gross MT et al: The impact of custom semi-rigid foot orthotics on pain and disability for individuals with plantar fasciitis. J Ortho Sp Phys Ther, 32:149-157, 2002.

Walter JH, Ng G, Stoitz JJ: A patient satisfaction survey on prescription custom-molded foot orthoses. JAPMA, 94:363-367, 2004.

Eggold JF: Orthotics in the prevention of runner’s overuse injuries. Phys. Sports Med., 9:181-185, 1981.

D’Ambrosia RD: Orthotic devices in running injuries. Clin. Sports Med., 4:611-618, 1985.

Dugan RC, D’Ambrosia RD: The effect of orthotics on the treatment of selected running injuries. Foot Ankle, 6:313, 1986.

Kilmartin TE, Wallace WA: The scientific basis for the use of biomechanical foot orthoses in the treatment of lower limb sports injuries-a review of the literature. Br. J. Sports Med., 28:180-184, 1994.

Kusomoto A, Suzuki T, Yoshida H, Kwon J: Intervention study to improve quality of life and health problems of community-living elderly women in Japan by shoe fitting and custom-made insoles. Gerontology, 22:110-118, 2007.


Scientific research showing that foot orthoses alter the kinematics of the foot and lower extremity:

Bates BT, Osternig LR, Mason B, James LS: Foot orthotic devices to modify selected aspects of lower extremity mechanics. Am J Sp Med, 7:328-31, 1979.

Fong DTP, Lam MH, Lao MLM, et al: Effect of medial arch-heel support in inserts on reducing ankle eversion: a biomechanical study. J Ortho Surg Res, 3:7-13, 2008.

Johanson MA, Donatelli R, Wooden MJ, Andrew PD, Cummings GS: Effects of three different posting methods on controlling abnormal subtalar pronation. Phys Ther, 74:149-158, 1994.

MacLean C, Davis IM, Hamill J: Influence of a custom foot intervention on lower extremity dynamics in healthy runners. Clin Biomech, 21:621-630, 2006.

MacLean CL, Davis IS, Hamill J: Short and long-term influences of a custom foot orthotic intervention on lower extremity dynamics. Clin J Sport Med, 18:338-343, 2008.

Nester CJ, Hutchins S, Bowker P: Effect of foot orthoses on rearfoot complex kinematics during walking gait. Foot Ankle Intl, 22:133-139, 2001.

Nester CJ, Van Der Linden ML, Bowker P: Effect of foot orthoses on the kinematics and kinetics of normal walking gait. Gait Posture, 17:180-187, 2003.

Smith LS, Clarke TE, Hamill CL, Santopietro F: The effects of soft and semi-rigid orthoses upon rearfoot movement in running. JAPMA, 76:227-232, 1986.

Nawoczenski DA, Cook TM, Saltzman CL: The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Ortho Sp Phys Ther, 21:317-327, 1995.

Williams DS, McClay-Davis I, Baitch SP: Effect of inverted orthoses on lower extremity mechanics in runners. Med. Sci. Sports Exerc. 35:2060-2068, 2003.

Woodburn J, Helliwell PS, Barker S: Changes in 3D joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. J Rheum, 30:2356-2364, 2003.

Stackhouse CL, Davis IM, Hamill J: Orthotic intervention in forefoot and rearfoot strike running patterns. Clin Biomech, 19:64-70, 2004.


Scientific research showing that foot orthoses alter the kinetics of the foot and lower extremity:

Williams DS, McClay-Davis I, Baitch SP: Effect of inverted orthoses on lower extremity mechanics in runners. Med. Sci. Sports Exerc. 35:2060-2068, 2003.

MacLean C, Davis IM, Hamill J: Influence of a custom foot intervention on lower extremity dynamics in healthy runners. Clin Biomech, 21:621-630, 2006.

MacLean CL, Davis IS, Hamill J: Short and long-term influences of a custom foot orthotic intervention on lower extremity dynamics. Clin J Sport Med, 18:338-343, 2008.

Mundermann A, Nigg BM, Humble RN, Stefanyshyn DJ. Foot orthoses affect lower extremity kinematics and kinetics during running. Clin Biomech, 18:254-262, 2003.

Nigg BM, Stergiou P, Cole G, et al: Effect of shoe inserts on kinematics, center of pressure, and leg joint moments during running. Med. Sci. Sport Exerc., 35:314-319, 2003.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

While I agree that there may be contra-indications for orthoses, one is more apt to find contra-indications for a certain type of orthosis or for a certain orthotic prescription than for orthoses in general. If a foot orthosis is not well tolerated or effective in reducing symptomatology, it doesn't mean that a different device might not be well tolerated and efficacious. Foot orthoses are generally very safe and are classified here in the US by the food and drug administration as class I devices:
Class I - General Controls
Class I devices are subject to the least regulatory control. They present minimal potential for harm to the user and are often simpler in design than Class II or Class III devices. Class I devices are subject to "General Controls" as are Class II and Class III devices.

The insensate foot is probably where the most caution and highest level of monitoring of foot orthoses is required since the perception of "tolerance" is diminished and the consequences of harm are significantly increased.

I doubt anyone who successfully treats adult acquired flatfoot, and there are many of us, would agree with your opinion that orthoses, including functional AFO's, are contra-indicational to functional control. On the contrary, these people with joint subluxations, OA, and significant angular joint deformities are the one who require functional intervention the most! We routinely treat people in their 5th, 6th, 7th, and 8th decade of life and they respond very well, with significant functional repositioning of the joint of the foot possible.

Doug Richie, DPM wrote:
In a recently published study, researchers reported impressive outcomes in the treatment of 20 patients with various stages of AAF.13 Ninety percent of the patients reported statistically significant improvement of symptoms.
The long term results of AFO therapy in patients with Stages II and III AAF have not been reported. Anecdotally, there have been many reports from practitioners stating that up to 30 percent of patients with Stage II AAF only require an AFO for six to 12 months. They note that these patients remain asymptomatic without the AFO for months or years thereafter as long as they wear traditional foot orthoses and proper shoes. For the full l article, see Podiatry Today http://www.podiatrytoday.com/article/2584

I'm not exactly sure who you are including in your broad characterization here, however, there has probably been some educational benefit from those discussions in spite of some of the attempted commercialization. I find all of those contributions to be far more productive and worthy of my time than reading your last posting. I recently asked one critic how the reader might alter their methods of treatment for the better based on their criticism, and I'm still waiting for an answer. It just proves the fact that it's much easier to complain about the problem than it is to offer solutions to the problem. Most people take the easy road.

Respectfully,
Jeff
www.root-lab.com

Amazing how short discussions become when you can offer scientific evidence to support your side of an argument and the other side of the argument can not.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin

I think we need to accept we will never agree. Whilst chewing the fat is good it is not going to get anywehere and probably bores most of the readship.

In the interests of academe however cited studies need to have a consistentcy factor which in this case would require Class A/B type research and that is not evident.

The references you cite are a random goup of rather dated publications from a cross section of journals. Whilst the findings may appeal the range of methodologies and lack of a discipline across the studies themselves makes their findings collectively unreliable as a basis for scientific debate. To ignore this would infer bias.

Jeff
In relation to contra-indications, I was referrering specifically to functional foot orthoses i.e those made with materials capable of realigning GRF through joint surfaces.

cheers
toeslayer

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I'm not complaining but interesting how my request for biomech. forms gets into a discussion on evidence for orthoses.

Sorry Mark,

I do apologise that was me that side tracked into foot orthoses.
You do make a good point however and collecting of biomechanical data maybe quite a separate issue to prescribing foot orthoses.

This does come back to my point of the logic of data collection. For example in the case of a frail ambulant or wheelchair bound client, what would the purpose of a standard weight bearing examination achieve? Very little I would expect.

WJat say you ?

toeslayer

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No need to apologise Cameron. I was just making an observation.

Just to clear up this point... My quote was directed very intentionally at only one person and it was a bit of an in-joke. I, in no way, suggest that it was descriptive of anyone other than that person.

Kind Regards,

Sam

Cameron:

Bias can also prevent someone, when presented with clear scientific evidence, from making rational conclusions regarding the efficacy of a very useful therapeutic modality that helps very many people.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

mark, i think i am more like you, noting relevant things as they arise, more than following a specific "form". i have tried specific templates in the past, yet always seem to end up with the good old lined A4 bit of paper. i guess it would be quite useful in multi-practitioner clinics, enabling a more uniform assessment, especially if the practitioner treating the patient is changed regularly.

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Thanks LCP. My request is mainly because we are documenting EVERYTHING we do. It's not my nature to be so organised & structured but there seems to be a feeling around that practice accreditation will come in & we will all need to have a lot more documented on policies & procedures. I'm only getting in early because my wife is doing a Podiatry assistants course.

define standard weight-bearing examination - they are different for ambulant and wheelchair bound patients
weightbearing examination of a wheelchair bound patient would be very relevant if he had lesions on his feet (or a pain in his arse) - the feet bear weight on the footplates and I have used orthoses to offload the affected areas with success -