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Foot orthoses: how much customisation is necessary?
Menz HB.
J Foot Ankle Res. 2009 Jul 9;2(1):23.

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I can see the merit in this , however the degree of correction and durability of many off the shelf devices is questionable. Monitoring the progress of each patient provided with a modified off shelf device is warranted.
A more cost effective method for patients with off shelf orthotics would be welcome in my practice if the method actually works.

Same old issues...if people only came in 10 types and sizes with 10 types of problems then a packet device of the right combination of features and dimensions would be adequate, but until they do there are plenty who need something made to suit. Same old dive to the lowest common denominator....it's OK not to have the skills to make them yourself, it's OK not to put in the time and effort required to actually be good at it.....because it takes some real time and effort......and we can't have that can we? God help us, it might cost some money and need some time and expertise to teach it??
regards Phill Carter

What do others think of this statement extracted from Hylton's paper??

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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
**************************************************

I agree that there will always be people who require some degree of customisation. However, we need to work out how to identify these people, and what type of modifications are necessary and effective.

Not sure what you mean by this. If prefabs are effective (and the evidence suggests that they are for some conditions in some individuals), then using this approach where appropriate could hardly be considered the "lowest common denominator".

Rather than discussing a single sentence taken from the commentary in isolation, it would be more useful to discuss the main message, ie: the need to develop consensus guidelines for the prescription of customised orthoses, so they can be evaluated to everyone's satisfaction in future research studies. Podiatry Arena would be an excellent forum to initiate such a process.

Hi Hylton,
As staff at Latrobe have said they would happily give the whole manufacturing thing away to P&O, probably without consulting the profession or considering the commercial implications of this policy to the profession. If we turn out baby pods who can only do less things the result is less choice in the workplace, less respect from other professions (which is already a problem in this country) and fewer ways to earn a dollar. The fact that wound stuff is taking up so much curriculum time is questionable in that wound care of significance is really only happening in podiatry in public health hospitals, where they have the budget for the dressings and the patient does not have to pay for them, there are very few jobs of that type in the state. Basically I think the tail is wagging the dog. Out in reality land if a patient has a wound that needs dressing frequently with expensive dressings it will not be done much in private practice, and if it is the patient is being misled into paying for something they otherwise would not have to.
regards Phill Carter

Hylton:

Honestly, in reading your paper, I got the distinct impression that your goal was not to "develop consensus guidelines for the prescription of customised orthoses, so they can be evaluated to everyone's satisfaction in future research studies." Rather, I got the impression that your goal was to emphasize the positives of over-the-counter foot orthoses and de-emphasize the many positive therapeutic effects of custom foot orthoses.

I have treated thousands of patients with custom foot orthoses that have already tried over-the-counter foot orthoses and these custom foot orthoses that I have specifically designed for my patients have significantly and positively changed their lives, whereas the over-the-counter foot orthoses have failed. I'm sure that many of the others here on Podiatry Arena have had similar experiences with their patients. I don't understand why a podiatrist would want to not emphasize the positives of custom foot orthoses in a paper they are submitting for publication, unless they are trying to please a governmental authority or health maintenance organizatinon by doing so.

Why not change the sentence in your abstract from "Although there is currently insufficient evidence to reach definitive conclusions, a growing body of research literature suggests that prefabricated foot orthoses may produce equivalent clinical outcomes to customised foot orthoses for some conditions" to "Although there is currently insufficient evidence to reach definitive conclusions, a growing body of research literature suggests that customised foot orthoses may produce significantly different kinetic, kinematic and therapeutic effects from prefabricated foot orthoses for some conditions"??

__________________
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
**************************************************

I don't work in the podiatry department, so can't make any comment on the issues you have raised about the curriculum at La Trobe.

However, your post implies that I am suggesting that the profession stops making customised orthoses, which is not true. As stated in my previous post, the main message of the commentary (apart from a critique of the Redmond et al paper), is that we need to develop consensus guidelines for orthotic prescription, in order to evaluate them more thoroughly and avoid the "that's not how I make them" criticism of clinical trials. I'm sure there are enough expert clinicians on Podiatry Arena to get this moving.

A more provacative statement is hard to imagine.

I disagree, taken at face value alone - custom foot orthoses dont just support the "arch" and may be even designed to specifically not do so. I actually question how a Podiatrist can really write that statement. Perhaps it was with a sense of irony and to create debate?? Maybe but what fun it will be to sit through lecture after lecture by individuals outside (and inside) the Podiatric community with that line quoted endlessly on powerpoint slides.

Regarding the paper in general, custom devices are not superior in every case we all know this. I think most Podiatrists have moved on from the "custom vs pre-fabricated" debate to a "custom either/or prefabricated?"debate. I don't see how this paper advances the debate. Rather than a call for debate the feeling I come away with is of an agenda with an attempt at using the literature for support. The citation of the Redmond et al paper is a clear example. That study was a piece of research that investigated the efficacy of foot orthoses prescribed in the manner least likely to be successful in affecting plantar pressure. What exactly does that prove except the authors own lack of clinical knowledge and a poor editorial reviewing process?

I question a paper that in my opinion is a one-sided commentary in a journal that is called the Journal of Foot and Ankle Research. Especially one that went through the "review" process in about a month. Maybe I'm over-racting, perhaps there is another paper in the pipeline that puts forward an opposing view???

Anyone have any constructive ideas on a way forward?

Thing is, I don't know of any studies comparing custom orthotics to pre fabs.

I know plenty comparing a root neutral cast with a pre fab, and they all have informative value. However I don't know of any which compare a truly custom device, with the prescribers choice from the and the prescribers choice of material and casting method against a single pre fab. And were a study to be carried out it would be meaningless because it would only compare THAT CLINICIANS custom to a pre fab.

The other thing which struck me was this comment

Which presumes that a customized orthotic can only be made of contoured thermoplastic. What of the many and varied materials and laminates available?

Regards
Robert

Lawrence,

I think you've misinterpreted the sentence, or have at least placed too much emphasis on it. By saying that it would take a brave individual to make such a comment, the point I am making is that people hold very passionate views about foot orthoses, not that I personally believe this statement to be completely true (which I think is made clear in the rest of the paper).

There's no "agenda" - merely a call for the profession to develop consensus guidelines for the prescription of foot orthoses, which would be of great benefit for planning of future research studies. The major issue researchers currently have is that when designing an orthotic trial, there's no basis upon which to select the prescription variables to be used. As a result, any negative finding is immediately dismissed by the criticism that the orthoses were not appropriately prescribed (although interestingly, no-one seems to question the prescriptions used in trials with positive outcomes). This will continue ad infinitum until there's a process undertaken to reach some level of agreement that everyone is happy with. This will be difficult, but it is certainly possible, as previous Delphi studies in other fields have shown.

Unlike research papers, commentary papers undergo editorial review, not external peer review. There's nothing stopping anyone from submitting a paper with an opposing view - in fact, I'm sure the editorial team would welcome this.

This is exactly the point. However, if there was some consensus as to how prescribe foot orthoses (or at least some agreement on general principles), then we would be able to design studies with results that could be generalised beyond an individual clinician. If we don't think this is possible, then we might as well give up researching custom orthoses altogether. I would hope that none of us think this is the best way forward.

Touché - you win (but it's a minor point).

Anyway, can I suggest that we take a break from the forensic analysis of the commentary and do something more productive. One way of reaching consensus is the Delphi technique (see Wikipedia entry here). As mentioned in the paper, the technique involves a facilitator recruiting a panel of experts, who, through an interative process, provide feedback on an issue which is shared between the group until opinions converge and a consensus is eventually reached. I'm a complete novice at this, but there are lots of examples in the medical literature, and I know that Prof Wes Vernon in the UK has done quite a lot of Delphi studies.

The first step would be to determine the eligibility criteria to be included as an "expert" on the panel. How would this be done? As the issue being addressed is one of clinical proficiency, years of clinical experience in prescription of foot orthoses would have to be a key consideration, along with some indication of peer recognition.

The next step would be a 2-stage process - consensus agreement on clinical assessment techniques, followed by consensus agreement on how these assessment findings are translated into an orthotic prescription. This would be the difficult bit and would require a skilled moderator, as there's lots of parameters to cover.

I'm sure there's a research student who would love to tackle this, and no shortage of clinicians in this forum who have something to offer.

Hylton,

Well said and needs to be said. We as Podiatry Academics spend much time waffling the merits of our theories with little clinical evidence for their application except clinical outcomes, which the OTC devices have also.

We get back to what tools do we have Clinically which can also be used in research to determine the most appropriate prescription for a foot orthoses. I know most in this arena don't use F-Scan, but until we start using this tool to compare prescriptions from various theories and OTC's we will never come to any concencus. We need to use something that is within the reach of most podiatrists. This may lead to further questions that can be researched in the Labs with more "suitable" research tools.

But perhaps the insurance industry will only cover OTC devices! As they seem to have equivalent outcome measures as custom devices!

Until then I will use custom devices with insured clients, as insurances do not cover OTC devices, and I will use what I regard as the most appropriate OTC device for anyone not insured.

We should not feel threatened by these suggestions but should embrace the research community for their continued involvement and "suggestions".

Thanks you Hylton.

regards

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Kevin
Howard
Simon
Craig

Perhaps a good start. Too many, as in this arena, is unlikely to succeed!

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Kevin,


Comes across as protectionism Kevin. It is quite clear as to the sugestions made by Hylton.

But why?

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Lawrence,


The question Hylton is asking is how can we develop a prescription concensus as to when and why to use a specific Rx or an OTC.

So how do we?

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Super. F-scans for everyone.

Can't help feeling we've been here before.

How does f-scan determine the most appropriate prescription?

I submit that f-scan cannot be used to compare prescriptions from various theories because this presumes that feet are uniform and homogenous. In other words orthotic A will produce outcome X with one foot and outcome Y with another.

If we take a study of 1000 feet with orthotics A, B and C and find that orthotic B produces (on average) the most pleasing pretty colours and lines we may be tempted to reach the concensus that orthotic B is superior.

But this would be a mistake. Because the average will not take account of the subject specific responses. 500 of the patients might have had wildly abberent force tracks which, when averaged, produce a nice one. 50 of them might do really badly (would have been better with C) but be lost in the statistical process.


I would offer that outcome studies are, if anything, more useful than 3 dimensional kinetic data from an f-scan because patients do not care if their pictures look good or if their patterns fit an arbitary "norm". They care about whether they get better or not. So should we. Else we truly are just "waffling academics".

Regards
Robert

Probably because I never used an F-Scan???

__________________
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
**************************************************

Robert,
Ask Howard and Bruce - It's a start!

Isn't this what we assume our theories will allow us to do. At least with F-Scan you have temporal data to add to the assumption.

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Kevin,

Probably because you aren't prepared to justify what you may find out!

We can talk theory but are you wiling to test it? apparently not. Using the "in my 25yrs of experience" is like me saying "In MY 25yrs of experience". whoopdy doo!

Hylton has made an extremely important observation and suggestion. To rule it out because we are happy with our "outcomes" without truly understanding why they occur is suggesting that we may talk evidence and science, but we are obviously not prepared to put it to an objective test.

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Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Tell me, Graham, how does an F-scan system determine whether or not pathological levels of moments are occurring about the joint axes of the foot and lower extremity? In addition, how does an F-scan determine the three-dimensional location of the ground reaction force vector?

And, by the way, I have not ruled out Hylton's suggestion since I appreciate him at least trying to come up with ways to do more research on the question of prefabricated versus custom foot orthoses and their therapeutic efficacy. I also appreciate that Hylton has taken the time to write and publish a paper that has stimulated a discussion such as this.

Maybe, Graham, you should also consider writing and publishing some since you obviously don't think that just saying "25 years of clinical experience" quite cuts the mustard anymore. All it takes is a lot of time with no monetary reward.

__________________
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,

Tell me Kevin, how moments occuring about a joint axis are determined to be pathological? You can't can you. You can hypothesise but offer no proof to the assumption.

F-SCAN does not offer any 3D data. However, it's temporal information, which we have all discussed with Howard and Bruce, does offer some interesting information to discuss against the application of various theoretical models.

Sure sounded like it!

M Because I'm not a researcher. But in MY 25yrs of practice I find using an approach that has at least attempted to demonstrate changes clinically in temporal and pressure data from what appears to be abnormal to a more "normal" situation to hold more credibity than Blind Theory.

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Kevin and all,

I have made my own suggestion as to how to take up Hylton's challenge. And yes I think we should. I have also made a suggestion as to who should be in a "working group" as suggested by Hylton. This also includes Kevin, as I respect his knowledge, if not agree with his assumptions.

So, if F-Scan isn't even a little bit a part of the answer. What is?

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Hi all,

I agree with Hylton's point about creating a protocol for determining who gets the custom devices. I'd like to throw in a few observations.

I've seen many patients with bags full of custom and OTC devices who come to me with symptoms that have not resolved their complaints. Many of these I have made devices that have relieved their symptoms.

Once, I had a patient call me up and say that the prefab from a source I suggested relieved her symptoms whereas my custom one did not. I'd bet there were others, but she was only the one nice enough to call.

I've worn prefabs that caused pain in my feet. However, those prefabs, after modification, were able to relieve my symptoms. My custom devices are more comfortable than those prefabs. That won't necessarily be true for all people.

I've seen patients get better with prefabs. The literature supports this.

There are many different types of prefabs. It would be great to know which prefab works best in a particular situation. Just as it would be great to know which prescription variable for a custom device works best in a particular situation.

I'm quite confident that STJ axis position, in the transverse plane, will help in deciding whether a varus, valgus or no wedge would be best for a patient. There is an elegant theoretical base for this, but we need to be able to show that we can reproduce accurately STJ axis transverse plane position.

I'm also confident that eversion range of motion will be helpful in predicting whether a forefoot valgus wedge will be effective. (That is why my prefab hurt. It had more forefoot vagus wedge than my foot could handle.)


To be able to use the F-Scan we need a published protocol that we can test. We need a recipe that anyone with an F-scan can follow. If you see a particular pattern on the f-scan consistently, what orthotic modification do you make. Looking at a rollover process of an F-scan measurement is no different than looking at a slow motion video in the following sense. The F-Scan measurment is a visual representation of the forces applied to the bottom of the foot during a step. Unless you do something with the numbers provided in the F-scan data, it is analogous to saying that a foot looks pronated on video. How do you compare from on video/ F-scan to the next? For example if you say that the CoP path tracks laterally that is analogous to saying that the heel is everted. Unless you put a line on the calcaneus and measure some angle, or you measure the position of the CoP relative to total foot width, your measurement is subjective.

Cheers,
Eric

Robert

Couldn't agree more. Since I graduated 15 years ago, the majority of waffle I have seen surrounds how to measure feet in terms of function, with relatively little directed towards outcomes studies.

Do you think drug trials are designed to understand *exactly* how a drug works. The majority of the time the researchers just have a vauge theory about the pharmacodynamics of a given drug. The true test is to find if a given drug works for a given condition. Not as easy with the many variables of a custom orthosis, but some of you boffins should have the expertise to work that out.

Move on!

In terms of a clinicians perception of Hyltons comments, I can understand and indeed share the frustration of those who have commented on this post so far. My initial reaction was very negative towards the paper also.

I will tell you why.

When I graduated from my Australian undergraduate podiatry degree in the early/mid 1990's, the majority of my class were virtually indoctrinated into the belief that custom orthoses were just a means for certain podiatrists to make bag fulls of money, and that there was *no evidence* to support their use.

Then I had to leave the cloistered halls of university and actually fix people who had already tried various types of orthoses. They had quite strange and remarkable conditions such as Stage 3 posterior tibial tendon dysfunction, tarsal coalitions, isolated calcaneo-cuboid osteoarthritis, neurological ankle varus...in fact just about all the things OTHER than plantar fasciitis, which we hear about endlessly.

It became pretty clear and apparent within a couple of years that I was fed a heap of horsesh*t at uni, and that there were pretty bloody firm and clear reasons why I needed to use custom devices. All of the 'research' that kept coming out over subsequent years, particularly from Australia, led me to suspect there was either some pretty serious investigator bias against custom orthoses in academia, or these people hadnt actually been required to *fix* too many patients...I would also look at the patients being fitted with all manner of devices by orthotists, often to remarkable effect, and lament the lack of instruction given to me as an undergraduate. Since then I have retrained myself in the prescription and design of both prefab's (as a rough template) and custom orthoses.

The *research* has been virtually ignored by myself, and most of my colleagues.

We stopped listening long ago. It just didnt gel with reality.

Anyway, can we just move on from these circular arguments. Please. Before the health insurance companies start to think that custom devices are no better than prefabs for 'everything', and my non-plantar fasciitis patients have to pay through the nose for the most appropriate intervention. Or should we just send them all to foot surgeons and be done with the whole lot of it?

Guess what people. No self respecting foot surgeon will recommend a procedure (eg a hindfoot arthrodesis) unless significant previous efforts have been made in terms of conservative care. In a court of law, this often means an appropriate prescription orthosis.

Hylton, some clinical management guidelines would be a wonderful place to start - perhaps your musculoskeletal research centre might consider it as a project worthy of funding?

LL

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Remember, it's just a foot.

LL,

nobody is saying that outcome measures are not important. However, to demonstrate that podiatry is the profession to be regarded as the forefront of the biomechanical knowledge & application professionals we need to demonstrate something more than the Jo Blow arch support guy in the mall.

Currently we can't.

So how do we?

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

I got limited time to respond (have severe RSI in the arms and have to get off the computer and frantically working on restoring the deleted threads from back up)

Two recent publications have substantially changed my thinking recently. They changed my thinking in such a way that was the opposite effect of the intention of the publications (those who been to a very recent Boot Camp know about this).

The first was: Foot orthoses in lower limb overuse conditions : A systematic review and meta-analysis. COLLINS Natalie ; BISSET Leanne ; MCPOIL Thomas ; VICENZINO Bill ; Foot & ankle International 2007, vol. 28, no3, pp. 396-410

It was not a bad systematic review, but I have on major problem with their conclusion: "There is evidence from pooled data that there is no difference between the use of custom made and prefabricated foot orthoses, inferring that practitioners may use either in the treatment or prevention of lower limb overuse injuries". I am not saying the conclusion is wrong, but I do not believe that it is not yet supported by the data.

When there are enough RCT's done in an area, it is time to do the systematic reviews and meta-analyses. When doing these, there are certain quality criteria that gets applied to the reviewed studies to decide if they should be included. This includes things like randomisation, blinding, etc. ...which is what the above authors applied as the criteria.

HOWEVER, if a meta-analysis or systematic review on foot orthoses is to be done shouldn’t an inclusion criteria for the study also include something like “the orthotics used in the study are of the type and protocol actually used in clinical practice”? If you look at the studies that were used in the above review, almost NONE of them could be defended on this criteria. This means that the authors reached a conclusion from their meta-analysis and systematic review based on the use of studies of foot orthoses used in such a way that almost no one uses them that way in clinical practice!

To explain further, one study used a particular brand of prefabricated foot orthoses -- the orthotic was used as is from the packet with no modifications. During the study no modifications were made to the device. Who actually uses prefabricated orthoses that way? In normal clinical practice, prefabricated devices are usually modified (eg wedges etc added); and if the patient is not responding well, the orthotic is further modified.

One study used custom made orthotics made from a neutral position cast and then balanced so that the rearfoot post held it around STJ neutral. Who actually does that in clinical practice? I do not know about you, but when I use a custom made device, I add a heel raise if the calf muscles are tight; add a first ray cut out if FnHL is present; add a plantar fascial groove if the plantar fascia if tight; more medially wedge the rearfoot if supination resistance is high; etc. Don't you do this? Don't most people use custom made devices this way.

My point is that the research comparing custom made and pre-fabricated devices are comparing and using devices in such a way that they are not normally used in clinical practice. Conclusions are being drawn and systematic reviews and meta-analyses being done on flawed foot orthotics prescription protocols.

I am not for one minute suggesting that there is a different in outcomes between custom made and prefabricated, I am saying we probably do not have enough data to say that at this stage. It may well be that there is no difference if the devices and protocols that get used in studies more closely mimic practice ...or there might be.

Also the distinction between custom made and premade is so artificial to be irrelevant today, especially with the advent of the library systems. The line between the two is even more blurred today than it was yesterday.

The second publication that influenced me a lot recently was: When and how should new therapies become routine clinical practice? Kari Bø and Robert D. Herbert. Physiotherapy Volume 95, Issue 1, March 2009, Pages 51-57

In this paper the authors use egs of how the world currently works in physiotherapy with the implementation of new therapies. They then present an EBM model of how it should work. While the intention of the paper was to argue for the model of how it should work, the impact on me was the realisation that it is never going to happen this way, as good as the model may be. It made we realise that we need an alternative model ... whatever that might be.

My $0.02

__________________
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?

Who cares! It is the application of the knowledge that is the most important to the profession.

This is where I think the 'profession' and 'academia' part ways.

To use my medical analogy again. Most GPs I know dont have a clue how half of their routine drugs work in serious detail - just the broad brush strokes. The academic boffins in the pharmaceutical research labs know all of that detail.

Podiatry is no different. Clinicians really can't be bothered in the main to learn about F-scan intricacies, (contradictory) biomechanical theories, and esoteric biomechanics arguments. They really just want and need appropriate and sound principles for therapeutic interventions, so they can get on with the job of helping people and know they are doing it properly.

The really detailed knowledge can be held onto and fermented by the serious biomechanicists, and wheeled out from time to time for us all to gaze glassy eyed at.

Bring on some long overdue clinical management guidelines, as Hytlon suggested.

LL

__________________
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Remember, it's just a foot.

I loved the posting by LL about his experience with the agenda that seems to be coming from certain professors at some of the Australian podiatry colleges:

My impression that there are academics, who started out as podiatrists, but don't actually have much clinical experience , that have an agenda, for some unknown reason to me, to show that prefabricated orthoses are just as good as custom foot orthoses. Is there some kind of chip on their collective shoulders because they see practicing cliniciains who do not have an advanced degree making more money than they do because they are very good at getting people better with custom foot orthoses and working in a clinical practice?? I don't know, but as a clinician first, and a researcher and academic second, I don't have a whole lot of respect for those academics that claim or suggest that prefabricated foot orthoses are just as good and effective as custom foot orthoses, and don't have enough clinical experience or clinical expertise to even know how to practice effective foot orthosis therapy. Enough said on that.

Now, certainly Eric Fuller and Craig Payne and I share very similar sentiments on this subject. Prefabricated foot orthoses are an important part of my practice. I recommend them every day and I am constantly customizing prefabricated orthoses for my patients in order to achieve my goals of mechanical foot orthosis therapy. In addition, I have a very busy custom foot orthosis practice. I receive referrals for custom foot orthoses from a 100 mile radius from my practice in a large metropolitan area of Northern California, not because I know how to effectively modify prefabricated foot orthoses, but from what my patients tell me that they have heard from others that I get very good results with the custom foot orthoses I make for my patients.

To do the research that is required to really delineate the differences in therapeutic effectiveness between prefabricated and custom foot orthoses, as Craig said, the research should be done using the clinical methods that effective orthosis clinicians use in their own busy practices. I don't just hand out orthoses and see how they work for my patients over a two to three month period without modifying them. I commonly will add heel lifts, grind in plantar fascial modifications, add covers, add forefoot extensions and add medial and lateral arch filler to my custom foot orthoses (as a few examples of post-dispensing modifications) after they have been initially dispensed to the patient because either the symptoms aren't improving fast enough, they are getting other symptoms or their gait function isn't what I want it to be.

I don't know how you would compare my custom foot orthoses to prefabricated foot orthoses other than letting me make custom foot orthoses and adjust them (or not adjust them) as necessary [since this is the way that I, and many others practice effective custom foot orthosis therapy] and comparing the patient's clinical response to just getting a prefabricated foot orthosis that has not been adjusted by an experienced clinician. I don't think that we need any other measure other than a pain scale and functional ability scale pre and post prefabricated and custom foot orthoses to determine orthosis effectiveness. And we certainly don't need an F-scan to get good therapeutic results or to be part of such a study, even though for some clinicians, the F-scan certainly seems to aid them in making their patients better.

Like LL said, let's get on with the research. However, let's also not do research in such a fashion that the wonderful therapeutic benefits of custom foot orthoses are minimized just for the purpose of pleasing the governmental authorities and insurance companies that would love to not pay out any money for mechanical foot treatment, just to keep the bean-counters happy at the expense of the painful and suffering individuals that are their nation's citizens or their paying customers.

__________________
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
**************************************************

Hylton

Just a couple of thoughts:
It is a great idea to suggest guidelines and the use of DELPHI. But if there are so many biomechanical theories, how can one set of orthotic guidelines be constructed?

Perhaps Chris Nester's research may be incorporated into the development of the guidelines. From memory, Chris said at the Australasian Pod Conference that he was going to look at creating a database of feet characteristics from his research. Could that research be used, in part, to facilitate practitioners prescribing a custom-made or prefab?