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Dave: If by clinical biomechanics you mean physiology and anatomy then I would agree. A good engineer does not automatically make a good clinician. However the clinician with engineering knowledge in terms of biomechanics is better than the one without it".
Robert, take over.
If I had a terrible clinician with engineering knowledge and one with great clinical experience and success practicing next door to each other, whihc would I tale my children to.
There is somethoing circular (or another tautolostic or heuristic reason that flaws your argument.).
I want to practice next to that practitioner/engineer and would make my living explaining to patients and our medical community that he is brilliant but not clinically focused or interested in them understanding his beliefsa but instead is waiting for you to learn his language.DrSha
DrSha
I don't think there is any thing circular in that arguments but: In my statement above I should have been more clear, I meant for the same clinician that has the extra knowledge. However if the 2 clinicians are using mechanical interventions and one has no knowledge of mechanics then how does he expect his intervention to work. If he does understand mechanics intuitively but cannot communicate because of language barriers then how can he improve his knowledge? One way would be to rely on his own experimentation, without reference to any external work, and make conclusions based on his experimental results. This would might be fine if he had plenty of time and large sample populations and rigorous experimental methods, however two problems occur:
1) The investigation of each variable from a huge range of possible variables would render little time for clinical work, which is kind of self defeating.
2) Considering experimental evidence, without reference to outside work and scrutiny by peers, will very likely result in bias errors and more importantly there may be fundamental errors in the underlying concept or axiom underpinning the research that has gone unnoticed either by pure accident or because to acknowledge this deficit would invalidate all the experimental work.
It is within human nature to conveniently ignore or miss this limitation and carry on regardless, since the system appears to work and to acknowledge the fundamental error would mean starting all over again. In some cases all that time and personal effort would equal just a wasted lifetime.
From my fairly recent experience, change can be hard to accept and once accepted hard to deal with as one concept fights another for supremacy but once changed the real learning can begin.
Regards Dave
__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
You have become ever more shrill and spiteful, peaking on the postmodern deconstruction thread. Since that point I have no more respect for you, nor desire or inclination to pander to you delusions of adequacy. As I tell my children when they misbehave, an apology is noble and appropriate but does not lessen my dissappointment with them, nor you.
You have nothing new to say, no new or valid points to make. You simply continue to try to prove through irrational argument, and the occasional tantrum, that we should all work within YOUR limitations. Like many inadequate people, you strive to believe and convince others that your shortcomings are in fact virtues, that the things you have never learned are not worth knowing.
Nobody is buying.
It was an amusing sideshow, now its just dull, repetative and mildly embarrassing. There is nothing new or interesting and you are amazingly, even alarmingly impervious to logic. I shall therefor leave you to those of my colleagues with more patience than me to try in vain to educate you or talk sense to you. I wish them luck, without optimism.
I am assuming that in your family, for your children, there is a sense of family values and and an environment that contains flexibility, an acceptance of opposing views and communication that suports its members as we all have faults.
The Arena is mean and dysfunctional to those with opposing views and I doubt that you would allow others to treat your children or that you treat your children as you do me.
I'm sorry that you have not responded to the evidence I presented as requested, I was looking forward to your thoights.
"Go up close to your friend, but do not go over to him! We should also respect the enemy in our friend".
Friedrich Nietzsche
The Arena is mean and dysfunctional to those with opposing views and I doubt that you would allow others to treat your children or that you treat your children as you do me.
I'm sorry that you have not responded to the evidence I presented as requested, I was looking forward to your thoights.
With Respect Dennis, I have relatively alternative views, maybe not apposing, but never the less different than say Robert, Simon, Kevin et al. However, despite the odd slip up in terminology and understanding, usually on my behalf, when you demonstrate at least a comprehension of the research and principals being discussed the Arena is far from "mean and dysfunctional".
This is an academic forum from which I have contributed some and learnt much. Robert and others HAVE responded to the evidence you have presented. It is without foundation and support. Accept this or not, I am sure you will evangelically continue to market your "product" regardless.
Way to go Dennis, now go away!
Regards
__________________
Graham Curryer
None of us know what we are doing, but some of us know more about what we are not doing than others!::
The Following User Says Thank You to Graham For This Useful Post:
With Respect Dennis, I have relatively alternative views, maybe not apposing, but never the less different than say Robert, Simon, Kevin et al. However, despite the odd slip up in terminology and understanding, usually on my behalf, when you demonstrate at least a comprehension of the research and principals being discussed the Arena is far from "mean and dysfunctional".
This is an academic forum from which I have contributed some and learnt much. Robert and others HAVE responded to the evidence you have presented. It is without foundation and support. Accept this or not, I am sure you will evangelically continue to market your "product" regardless.
There have been great advances that have come from logic, science, circular reasoning, mistakes, dreams and dare I say it, evangelicals.
Darwin led to Hitler!
God led to the Crusades!
i can live and learn from you.
Why can't you live and learn from me?
Dennis, I have tried to learn from you. I tried to get you to define your terms in relation to anatomy and you wouldn't (couldn't?).
Quote:
Originally Posted by drsha
End of Round Eight (you know what I mean)
We go to the score cards.
Still Standing!
Still standing = still able to post on the forum. However, a better measure might be what other people think of you and your postings. Would you be happy to direct your clients/ patients to the forum to read your postings and those of others on the forum?
Within the somewhat esoteric (often semantic) arguments made by DrSha, there lurks a fundamental misunderstanding of how it is that Newtonian mechanics relate to the body, its movement and the causality of symptoms:
The understanding of mechanical laws (specifically qualified by Kirby above) is essential to understand how it is that the internal and external environment of the foot interact during function or delivery of its biological purpose. This is not simply to clarify a shared language with other specialties who share our interest (although very important) but also to introduce legitimate physical laws that can be employed to qualify and quantify such forces. That such forces cannot always be readily measured directly does not diminish their relevance or significance in planning orthotic (or indeed surgical) interventions. It is the lack of functional equilibrium between these environments that tends towards what we recognise as symptoms or physical manifestations of stress. That is to say, it is forces or their relative imbalance that produces a sequence of internal events that lead to pain, along with frequently observed patterns of dysfunction.
The suggestion that any biomedical system is not exposed to such laws, especially when movement of mass is the prime purpose, is clearly an intellectual folly. However, DrSha seems to suggest that rather than this, it is the individual, idiosyncratic variability of a multi-system interaction that obfuscates such physical laws which thereby renders them irrelevant. This is a medical misconstruction that reflects a discontinuous thought process.
The morphological, neuromuscular and biochemical processes that characterise individual phenotypes demonstrate increasingly understood interactions that collectively can be configured to describe functional traits. Furthermore, dissimilarities within each studied population are likely to demonstrate continous variation of such traits as they are likely to be strongly influenced by polyepigenetic processes. To regard this biomedical complexity as a justification to ignore laws that WILL apply to any moving object (inaminate or otherwise) is to 'stick one's head in the sand'. We should instead engage with the fundamental aspects of science that are understood and seek improved understanding of how qualified laws interact with other biological systems to produce the individual entropic responses with which we are confronted.
The Following 5 Users Say Thank You to Greg Quinn For This Useful Post:
Within the somewhat esoteric (often semantic) arguments made by DrSha, there lurks a fundamental misunderstanding of how it is that Newtonian mechanics relate to the body, its movement and the causality of symptoms:
The understanding of mechanical laws (specifically qualified by Kirby above) is essential to understand how it is that the internal and external environment of the foot interact during function or delivery of its biological purpose. This is not simply to clarify a shared language with other specialties who share our interest (although very important) but also to introduce legitimate physical laws that can be employed to qualify and quantify such forces. That such forces cannot always be readily measured directly does not diminish their relevance or significance in planning orthotic (orindeed surgical) interventions. It is the lack of functional equilibrium between these environments that tends towards what we recognise as symptoms or physical manifestations of stress. That is to say, it is forces or their relative imbalance that produces a sequence of internal events that lead to pain, along with frequently observed patterns of dysfunction.
The suggestion that any biomedical system is not exposed to such laws, especially when movement of mass is the prime purpose, is clearly an intellectual folly. However, DrSha seems to suggest that rather than this, it is the individual, idiosyncratic variability of a multi-system interaction that obfuscates such physical laws which thereby renders them irrelevant. This is a medical misconstruction that reflects a discontinuous thought process.
The morphological, neuromuscular and biochemical processes that characterise individual phenotypes demonstrate increasingly understood interactions that collectively can be configured to describe functional traits. Furthermore, dissimilarities within each studied population are likely to demonstrate continous variation of such traits as they are likely to be strongly influenced by polyepigenetic processes. To regard this biomedical complexity as a justification to ignore laws that WILL apply to any moving object (inaminate or otherwise) is to 'stick one's head in the sand'. We should instead engage with the fundamental aspects of science that are understood and seek improved understanding of how qualified laws interact with other biological systems to produce the individual entropic responses with which we are confronted.
Dr. Quinn:
Your swarthy and condescending attitude reflects your bias.
You are obviously a debauchee of The Arena.
My work reverberates The Laws of Newton. Regrettably for you, it has habitually found that the pertinence of these laws to produce analytical awards when making clinical decisions over questions that arise in disengaged functioning subjects is greatly truncated when compared to the inexorable appliance of these same laws in exanimate subjects.
The materiality of Newton's Laws is not in question in my armamentarium of medicine but I raise weighty doubts on their constancy when correlated to EBP.
DrSha
To respond to your ridculous statement that I bolded: These forces which we all know exist (and I do not deny or look to reduce in import) have reduced relevancy and applicability when applied to a human, functioning subject at the clinical level when making orthotics or decisions on the very kinetics and kinematics that they define (for me).
FYI:
The Thesaurus which I used to create this response (I am impressed if you did not use one) has NO THESAURUS RESULTS FOR:
Biomechanics
Bioengineering
BioArchitecture or
BioNewtonian
The transfer of the incontrovertable scientific and mathematical homogenious nature of the principles and practice of
Mechanics
Engineering
Architecture
or
Newtons Laws
applicability to ZOETIC SUBJECTS
with regards to any of their BIO equivilants is APOCRYPHAL and unwarrented and because of your skills and credentials borders on malevolent when applied to those with cross-purposes like me.
Summarily:
Your premise that Newton's Laws apply equally to apples and cats in motion is the basis for my heresy and will be the basis that will eventually expose you all as mercenary CHARLATANS.
Goodness me. What on earth provoked that response? Unfortunately, one of the very type that has dissuaded me from posting before very recently. Malevolence coupled with debauchery are not characteristics with which I have been associated before. The implication that I would require a thesaurus to construct a coherent discussion point I shall ignore.
It is my contention that efforts to integrate scientific knowledge in our chosen field are fairly new. Additionally, I am attempting to point out that physical laws are subject to a complex and concomitant interaction with other biological systems to deliver an ultimate biological purpose. That this might resonate with what you are trying to say and perhaps move the discussion forwards was perhaps a forlorn hope. I would like to clarify however for other readers, that it was well intentioned.
FYI:
The Thesaurus which I used to create this response (I am impressed if you did not use one) has NO THESAURUS RESULTS FOR:
Biomechanics
Bioengineering
BioArchitecture or
BioNewtonian
The transfer of the incontrovertable scientific and mathematical homogenious nature of the principles and practice of
Mechanics
Engineering
Architecture
or
Newtons Laws
applicability to ZOETIC SUBJECTS
with regards to any of their BIO equivilants is APOCRYPHAL and unwarrented and because of your skills and credentials borders on malevolent when applied to those with cross-purposes like me.
Summarily:
Your premise that Newton's Laws apply equally to apples and cats in motion is the basis for my heresy and will be the basis that will eventually expose you all as mercenary CHARLATANS.
The Biomechanical Engineering (BME) Group offers research and teaching programs that focus on the application of mechanical engineering principles to biology and medicine. Biomechanical Engineering at Stanford has maintained a leadership position in the field by defining itself at multiple length scales including: the cell, tissue, organ, and the physiological systems level. A key element of the program is that research and education approaches are motivated by clinical applications of fundamental principles. Thus the group fosters a multidisciplinary approach that includes strong interactions with the school of medicine as well as other engineering disciplines. The BME Group has particularly strong research interactions with the Mechanics and Computation Group and the Design Group in the Mechanical Engineering Department as well as the Departments of Bioengineering, Orthopaedic Surgery, Surgery, Medicine, and Radiology, and the Biodesign Program in the School of Medicine.
Topics of studies include the mechanics and mechanobiology of cells and tissues, tissue engineering and the pathogenesis and treatment of diseases using methods including cell and culture, tissue mechanics, imaging, microscale biosensor fabrication, biofluidics, human motion capture and computational methods. Design and evaluation of medical implants, devices, and procedures are also important aspects of the BME program. Student research projects reflect the overall research program of the BME Group.
BME is one of five groups in the Department of Mechanical Engineering. BME originated as the Biomechanical Engineering Program within the Design division. The BME Program was formed in 1991 and underwent a rapid expansion. In December 1995, the Program became an independent division (now group) within Mechanical Engineering, and the group and faculty are experiencing ongoing growth.
The research activities of the Soft Tissue Biomechanics Laboratory focus on the function, degeneration and regeneration of articular cartilage and fibrocartilage, with an emphasis on understanding the complex interactions between biophysical and biochemical cues in controlling cell behavior. Our approach combines contemporary approaches from a variety of disciplines including experimental and theoretical mechanics, cell and tissue culture, imaging, biochemistry and molecular biology.
Mechanobiology of skeletal tissues lies at the heart of two of the most common skeletal diseases in the elderly...osteoarthritis and osteoporosis. Due to our aging population, the prevalence of these diseases is increasing each year and motivates much of our research.
Projects that are currently underway include the following:
Jeff's note: the following are links to research and can be found at :http://starlab.stanford.edu/research.html
bone strength, structure & remodeling
knee meniscectomy & osteoarthritis biomechanics
periosteum biomechanics
tissue engineering
mechanical properties of cartilage
patellofemoral pain mechanism & cartilage modeling
Dennis, to suggest that your work is cross purposed is fine, but you said it in a way that implies that the work of others is not. Nothing could be further from the truth. I posted the information from Stanford's website to demonstrate the pragmatic nature and application of biomechanical education and research that is being conducted at just one of many prestigious educational institutions.
It would be impossible for man to ambulate without friction. Friction can be explained by applying the laws of physics. You seem to be dismissing or devaluing the application of the laws of physics to gait, gait related pathology and ultimately to foot orthotic therapy. You claim to have an EBM practice, but you offer no scientific evidence to support your claims and you seem to snub the scientific community because you don't believe we can apply the laws of physics to biological (“zoetic”) subjects. How else can any of it be explained? The flaw in your logic is this: Our absence of knowledge doesn't make our existing facts invalid. The fact that there are variables or factors that can’t be measured doesn't invalidate the factors we can measure. Any valid model of foot function and orthotic therapy must be consistent with the existing laws of science. The burden is on those who claim that these laws can’t be applied to living structures to prove why these laws are inapplicable or invalid and ideally, to supply some other plausible explanation. Until then, scientists will use the existing facts, including Newton’s laws to conduct their research can create models. What other option is there other than to stop looking for answers?
Within the somewhat esoteric (often semantic) arguments made by DrSha, there lurks a fundamental misunderstanding of how it is that Newtonian mechanics relate to the body, its movement and the causality of symptoms:
The understanding of mechanical laws (specifically qualified by Kirby above) is essential to understand how it is that the internal and external environment of the foot interact during function or delivery of its biological purpose. This is not simply to clarify a shared language with other specialties who share our interest (although very important) but also to introduce legitimate physical laws that can be employed to qualify and quantify such forces. That such forces cannot always be readily measured directly does not diminish their relevance or significance in planning orthotic (or indeed surgical) interventions. It is the lack of functional equilibrium between these environments that tends towards what we recognise as symptoms or physical manifestations of stress. That is to say, it is forces or their relative imbalance that produces a sequence of internal events that lead to pain, along with frequently observed patterns of dysfunction.
The suggestion that any biomedical system is not exposed to such laws, especially when movement of mass is the prime purpose, is clearly an intellectual folly. However, DrSha seems to suggest that rather than this, it is the individual, idiosyncratic variability of a multi-system interaction that obfuscates such physical laws which thereby renders them irrelevant. This is a medical misconstruction that reflects a discontinuous thought process.
The morphological, neuromuscular and biochemical processes that characterise individual phenotypes demonstrate increasingly understood interactions that collectively can be configured to describe functional traits. Furthermore, dissimilarities within each studied population are likely to demonstrate continous variation of such traits as they are likely to be strongly influenced by polyepigenetic processes. To regard this biomedical complexity as a justification to ignore laws that WILL apply to any moving object (inaminate or otherwise) is to 'stick one's head in the sand'. We should instead engage with the fundamental aspects of science that are understood and seek improved understanding of how qualified laws interact with other biological systems to produce the individual entropic responses with which we are confronted.
Elegant, eloquent, and right on the money.
Got to be one for quote of the year.
Regards Dave Smith
__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
The morphological, neuromuscular and biochemical processes that characterise individual phenotypes demonstrate increasingly understood interactions that collectively can be configured to describe functional traits. Furthermore, dissimilarities within each studied population are likely to demonstrate continous variation of such traits as they are likely to be strongly influenced by polyepigenetic processes. To regard this biomedical complexity as a justification to ignore laws that WILL apply to any moving object (inaminate or otherwise) is to 'stick one's head in the sand'. We should instead engage with the fundamental aspects of science that are understood and seek improved understanding of how qualified laws interact with other biological systems to produce the individual entropic responses with which we are confronted.
Greg Stated:
Malevolence coupled with debauchery are not characteristics with which I have been associated before
DrSha replies:
Welcome to the club. I have never been accused of or called the things that I have on The Arena either.
The fact that bioengineering is young and is the future of where our science is going is very clear and comfortable to me.
My complaint is the posture taken on this site as if the science is already mature, proven and totally capable of answering every clinical question that arises.
I have stated that I understand physics, Newton's Laws and their importance but I do not understand fizzics and it has been demanded of me to learn the fizzics, do my own research and obey the dictums being taught here without question.
It sounds like the BioEngineering Dept at Stanford is acting in a manner more fitting as it associates with the clinical areas at Stanford Med. They seem to be fostering relationships rather then demanding conversion.
Furthermore, and correct me if I am wrong, biomedical newtonian theory has not yet produced any viable, clinically applicable level I evidence (other than medial knee OA using a wedge that would be harmful to many feet and postures).
I argue that that leaves room to look at other theories not blow them out of the water as is routinely done here.
Finally, if feet vary so much as a bell curve in toto, why not subgroup them for purposes of clinical exam and care and research in order to have less error and more focused care and results. What's so crazy about that?
My complaint is the posture taken on this site as if the science is already mature, proven and totally capable of answering every clinical question that arises.
I have stated that I understand physics, Newton's Laws and their importance but I do not understand fizzics and it has been demanded of me to learn the fizzics, do my own research and obey the dictums being taught here without question.
What is fizzics? We all have to do our own research Dennis, unless we can pay someone to do it for us.
Quote:
Originally Posted by drsha
Furthermore, and correct me if I am wrong, biomedical newtonian theory has not yet produced any viable, clinically applicable level I evidence (other than medial knee OA using a wedge that would be harmful to many feet and postures).
Firstly, your foot-typing approach has produced what level 1 evidence? Secondly, show me the level 1 evidence that valgus wedging is harmful to many feet and postures...
Quote:
Originally Posted by drsha
I argue that that leaves room to look at other theories not blow them out of the water as is routinely done here.
From an excellent paper I read today:
"To be scientifically useful, a theory
must be prescriptive and make predictions
that then should be tested. If
the theory survives a series of falsifying
tests, it may gain credence."
Kuo Arthur D; Donelan J Maxwell: Dynamic principles of gait and their clinical implications. Physical therapy 2010;90(2):157-74
By presenting your theories here in the absence of experimental data to support your contentions, then the falsifying tests can only begin with the asking of questions. If you had published your theories in a peer -reviewed journal, the paper would be questioned by your peers in much the same way. If anyone had the time, money and inclination they could perform physical experiments to test you hypotheses. But to be honest, if the theory doesn't appear water-tight in the first place, why go to that time and expense?
Quote:
Originally Posted by drsha
Finally, if feet vary so much as a bell curve in toto, why not subgroup them for purposes of clinical exam and care and research in order to have less error and more focused care and results. What's so crazy about that?
You can sub-group data, but you first need to demonstrate that the probability that a member of one sub-group could also belong to a another sub-group is not too great. Statistical processes, Dennis. But, that is not what you want or what you are talking about. You want us to accept your method of foot-typing as valid, so first you must demonstrate the validity... Then we need to see if it is better than another method of sub-grouping the data, for example using the foot posture index which has demonstrable validity and reliability through published research.
Then we need to see if it is better than another method of sub-grouping the data, for example using the foot posture index which has demonstrable validity and reliability through published research.
Originally Posted by drsha
Furthermore, and correct me if I am wrong, biomedical newtonian theory has not yet produced any viable, clinically applicable level I evidence (other than medial knee OA using a wedge that would be harmful to many feet and postures).
Firstly, your foot-typing approach has produced what level 1 evidence? Secondly, show me the level 1 evidence that valgus wedging is harmful to many feet and postures...
if we can agree that neither of us has proven our theory with level I evidence?
I for one, have not
if we can agree that neither of us has proven our theory with level I evidence?
I for one, have not
DrSha
No we can't agree on that! Since, the theory based on physics and Newtonian principles does have level 1 evidence (as you pointed out); while your theory does not (a fact which you concede above). The fact that I, personally, did not generate that evidence is neither here nor there to this discussion.
“I been silent so long now it's gonna roar out of me like floodwaters and you think the guy telling this is ranting and raving my God; you think this is too horrible to have really happened, this is too awful to be the truth! But, please. It's still hard for me to have a clear mind thinking on it. But it's the truth even if it didn't happen”
No we can't agree on that! Since, the theory based on physics and Newtonian principles does have level 1 evidence (as you pointed out); while your theory does not (a fact which you concede above). The fact that I, personally, did not generate that evidence is neither here nor there to this discussion.
Dr. Spooner:
As I am interested in the amount of Level I Evidence BioNewtonian Theory has produced to this date and as I wish to have a starting point from which to continue to grow my work, if you could list those Level I EBM additions to the literature so that I may examine them, I can then state that my work has none and yours has ......
Thus creating a beginning for the state of Level I Evidence in biomechanics. Other theorists could then list their level of data and we will have "The Current State of Biomechanics Level I EBM".
DrSha
Dr. Spooner:
As I am interested in the amount of Level I Evidence BioNewtonian Theory has produced to this date and as I wish to have a starting point from which to continue to grow my work, if you could list those Level I EBM additions to the literature so that I may examine them, I can then state that my work has none and yours has ......
Try using google with key words such a valgus wedge knee etc, sooner or later Dennis you are going to have to start doing some research for yourself; research includes finding the evidence.
Embarrassingly I'm not exactly sure. I think its honiton. Possibly exeter. I'll find out for sure. What can I say, I'm an educational ho. I just go where i'm sent and do what i'm told.
Try using google with key words such a valgus wedge knee etc, sooner or later Dennis you a going to have to start doing some research for yourself; research includes finding the evidence.
I know you could have accomodated my request if you wanted to as I have seen you spew out articles when requested by others.
I have learned alot from you when it comes to building walls in a relationship and how to live a biased and tunnelled visioned academic life.
Now I finally have gotten some valuable information from you. When someone asks me for the evidence for Neoteric Biomechanics, I will simply reply: Simon, you a going to have to start doing some research for yourself; research includes finding the evidence.
which includes:
Foot orthotics are considered medically necessary for members who meet all of the following selection criteria:
1.
Member has any of the following conditions:
1.
Adults (skeletally mature feet):
1.
Acute plantar fasciitis
2.
Calcaneal spurs (heel spurs)
3.
Calcaneal bursitis (acute or chronic)
4.
Neurologically impaired feet (including: neuroma; tarsal tunnel syndrome; ganglionic cyst; and neuropathies involving the feet, including those associated with peripheral vascular disease, diabetes, carcinoma, drugs, toxins, and chronic renal disease)
5.
Inflammatory conditions (i.e., sesamoiditis; submetatarsal bursitis; synovitis; tenosynovitis; synovial cyst; osteomyelitis; and plantar fascial fibromatosis)
6.
Acute sport-related injuries (including: diagnoses related to inflammatory problems; e.g., bursitis, tendonitis)
7.
Musculoskeletal/arthropathic deformities (including: deformities of the joint or skeleton that impairs walking in a normal shoe; e.g. bunions, hallux valgus, talipes deformities, pes deformities, anomalies of toes)
8.
Medial osteoarthritis of the knee (lateral wedge insoles)
9.
Vascular conditions (including: ulceration, poor circulation, peripheral vascular disease, Buerger's disease (thromboangiitis obliterans), chronic thrombophlebitis)
10.
Conditions related to diabetes (see section above on therapeutic shoes for diabetes for a complete list of medically necessary diagnoses).
Foot orthotics have no proven value for back pain, knee pain (other than medial osteoarthritis), pes planus (flat feet), pronation, corns and calluses, hammertoes, hip osteoarthritis, and lower leg injuries.
2.
Children (skeletally immature feet):
1.
Torsional conditions (e.g., metatarsus adductus, tibial torsion, femoral torsion)
2.
Structural deformities (e.g., tarsal coalitions)
3.
Hallux valgus deformities
4.
In-toe or out-toe gait
5.
Musculoskeletal weakness (e.g., pronation, pes planus);
and (for both adults and children)
2.
The member must have symptoms associated with the particular foot condition (foot orthotics are not considered medically necessary when the foot condition does not cause symptoms); and
3.
The member has failed to respond to a course of appropriate conservative treatment (e.g., physical therapy, injections, strapping, anti-inflammatory medications). (Orthotics should not be considered first line therapy.)
Foot orthotics are considered experimental and investigational when these criteria are not met.
Please advise if you have any Level I Evidence to refute Aetna's Policy?
and
Here's another, somewhat more promising but nothing that would convince me to alter my EBP protocol for treating plantar fascitis.
Stretching the Achilles tendon is generally included in most treatment plans for plantar fasciitis. Pfeffer and colleagues[8] looked at stretching as the only treatment: 72% of patients assigned to stretching alone noted improvement of symptoms compared with 88% of patients who utilized prefabricated splints along with stretching exercises. The study's main weakness was the lack of an observational control group to evaluate the effectiveness of the stretching program alone. DiGiovanni and colleagues[9] noted improvement of symptoms if the program utilized dorsiflexion of the forefoot and toes, as opposed to Achilles tendon stretching alone.
Recommendation. Achilles tendon stretching may be helpful, but there are few studies to support its practice.
Level of Evidence. Expert opinion; recommended in most treatment guidelines; no randomized controlled trials (RCTs) to confirm effectiveness over simple rest.
Rest
No randomized trials were identified that evaluated rest as an intervention for treatment of plantar fasciitis. There were 2 retrospective studies (514 patients) noted that asked patients to evaluate different therapies. Rest ranked third, behind casting and injection, among 11 other modalities examined in the study.[10,11]
Recommendation. Although rest is likely to be helpful, there is minimal support for this approach in evidence-based literature. Of note, most patients usually experience a decrease in pain within the first 6 months, independent of the initial treatment selected.
Level of Evidence. Expert opinion; no RCTs to demonstrate utility vs more active forms of therapy.
Taping
No studies were found evaluating the effectiveness of taping in the treatment of plantar fasciitis. Most taping methods tend to run the length of the longitudinal aspect of the plantar arch. Taping decreases the amount the arch flattens during the active stance phase. This also serves to prevent excessive pronation of the foot (ie, pes planus), which is known to be associated in patients with plantar fasciitis. Although taping is frequently used in the acute care of this ailment, no studies were located examining the effectiveness of taping in this setting.
Recommendation. Because taping has not been adequately studied in the literature, no clear recommendations can be offered in its role for management of plantar fasciitis.
Level of Evidence. None.
Night Splints
Night splints have been used to maintain the foot in dorsiflexion during sleep. The consensus of opinion is that this may allow the fascia to begin to heal with the plantar aponeurosis in full extension, thereby reducing the tension at the origin of the fascia at the calcaneus. In 1991, Wapner and Sharkey[12] described 14 patients with symptomatic plantar fasciitis for greater than 1 year who had not responded to multiple treatments. They were splinted in 5 degrees of dorsiflexion overnight. Eleven patients had no pain, with full relief of symptoms by 4 months.[13] Additional studies have demonstrated similar improvements.[14]
Probe and colleagues[15] in 1999 compared the use of shoe modifications, nonsteroidal anti-inflammatory drugs, and stretching with a similar program utilizing these interventions with the addition of night splints. A total of 116 patients in this study were followed for 3 months with no difference in outcome between the 2 groups. The reason for the outcome of the study is likely related to significant differences in patients in the 2 treatment arms. The group that demonstrated efficacy of night splints enrolled patients who had failed to respond to many modalities for long periods of time. The arm of the study that did not demonstrate a treatment advantage used splints as one of the initial treatment measures. The study is also limited in the small number of patients studied, making it problematic to demonstrate any significant treatment advantage from any modality used in the initial treatment of plantar fasciitis.
Recommendation. Night splints may have some utility in the treatment of persistent plantar fasciitis.
Level of Evidence. Evidence from RCTs (small/moderate).
Heel Pads and Orthotics
A review of various biomechanical studies does not support the use of heel cups in the treatment of plantar fasciitis. Studies that have evaluated heel force impact demonstrate that the heel strike forces in patients with plantar fasciitis are similar in both painful and asymptomatic heels.[5] Another study that examined heel strike impact forces noted similar outcomes, with heel pads only proving useful in patients with localized pain from contusions as opposed to plantar fasciitis.[16] However, custom-made orthotics have been shown to reduce the tension in the plantar aponeurosis, whereas standard orthotics did not produce the same effect.[17] As stated earlier, because tension at the origin of the plantar aponeurosis is the likely etiology of plantar fasciitis, reducing the tension in the plantar aponeurosis would likely reduce pain and aid healing.
Recommendation. Heel pads are not recommended for the treatment of plantar fasciitis but may provide relief for patients with pain due to a heel contusion. Orthotics are recommended in the initial treatment of plantar fasciitis. Custom molded orthotics are more effective than preformed orthotics. The cost of custom-molded orthotics, however, may limit the utility of this treatment option.
Level of Evidence. Small RCTs showed a trend toward benefit.
Steroids
Corticosteroids are frequently used to treat patients with plantar fasciitis. Different prospective RCTs have shown positive effects of using both iontophoresis[18] and percutaneous infiltration[19,20] techniques to reach the plantar fascia with steroid medications. However, all studies have noted the relief to be transient. After 30 days, no significant difference in pain relief was noted between treatment and control subjects. As a limitation, the RCTs have had small numbers of patients.
One risk of using steroid medication on the plantar fascia is the possibility of rupture of the fascia. Acevedo and Beskin[21] examined 765 patients with plantar fasciitis in their 1998 study. Steroid injections were performed in 122 patients overall. Of 51 patients experiencing a rupture of the plantar fascia, 44 of the patients received a steroid injection prior to rupture.
The technique for injection of the plantar fascia may be ultrasound assisted. However, there is no evidence that this technique improves outcome or reduces the incidence of long-term complications. The standard method of injection is the medial approach at the point of maximal tenderness on the medial aspect of the calcaneus. One should avoid the heel pad as a site of injection because this may result in significant discomfort for the patient.
Recommendation. The benefits of steroid injection appear to be transient, although they are commonly used in the initial treatment of plantar fasciitis. Steroids also have the potential to increase the likelihood of rupture of the plantar fascia. Corticosteroids should not be used in the initial treatment of plantar fasciitis due to the potential for harm and lack of a lasting beneficial effect.
Level of Evidence. Evidence from small to moderate RCTs and retrospective studies.
Extracorporeal Shock-Wave Therapy
Extracorporeal shock-wave therapy (ESWT) has recently been advocated in recalcitrant cases of plantar fasciitis. It has often been viewed as a useful option prior to considering surgical treatment. Impulses of low-energy shock waves through ultrasound guidance are focused at the point of maximal tenderness across the base of the calcaneus in a transverse axis. These waves may help to accelerate the healing process via an unknown mechanism.[22]
There have been 2 small RCTs and 1 medium-sized RCT published in the past decade, but all have major limitations. Two studies by Rompe and colleagues[23,24] in 1996 utilized inconsistent patient selection criteria, and a subsequent investigation by Speed and colleagues[25] in 2000 was rather small with a high drop-out rate in the placebo group (5/15). An intention-to-treat analysis of this data would not have demonstrated any treatment advantage. In fact, due to issues related to cost and minimal evidence supporting use of ESWT, the health ministries of 3 European countries in 2000 put a hold on reimbursement for this procedure until further evidence emerges to support the validity of the treatment.[26]
Additional recent studies have not resolved the controversies over ESWT. A prospective RCT by Rompe and colleagues[27] in 2003 examined 45 runners with persistent heel pain and noted a significant decrease in pain at 6 months and 1 year in patients treated with 3 applications of 2100 impulses of low-energy shock waves.
Theodore and colleagues[28] also reported a beneficial effect from ESWT. However, there were significant limitations from this study. The initial improvement at 3 months was not convincing, with 56% of patients who received ESWT reporting improvement at 3 months, in comparison with 46% of patients receiving a placebo. There was also no long-term follow-up available. In fact, the authors permitted patients to cross over to the active treatment group after the 3-month assessment. In contrast to these studies, many other studies have failed to show benefit from the therapy. Multiple other studies have not demonstrated an advantage of ESWT.[22,29-32]
A Cochrane review of ESWT in 2003 noted that "there is conflicting evidence for the effectiveness of low-energy extracorporeal shock-wave therapy in reducing night pain, resting pain, and pressure pain in the short-term (6 and 12 weeks) and therefore its effectiveness remains controversial."[33]
Recommendation. ESWT may have some utility in the treatment of chronic plantar fasciitis. There are studies that have shown no benefit, while other studies show moderate improvement in a proportion of patients. It remains controversial at this time. There is no evidence of harm from the therapy.
Level of Evidence. RCTs (moderate sized) with systematic reviews.
Surgery
Surgery is generally considered in patients who have not responded to conservative measures over a period of 1 year. In fact, a study by Wolgin and colleagues[11] showed that a large proportion of patients will have a reduction in their symptoms between 6 and 12 months.[11]
Specifically, a plantar fasciotomy is performed along with neurolysis of the nerve to the abductor digiti quinti.[34] Both endoscopic and open fasciotomy have been performed, with both techniques demonstrating similar outcomes seen only in retrospective patient survey data.[35] There are no prospective studies on whether the open or endoscopic technique is associated with better functional outcomes. In multiple studies, between 70% and 90% of patients experienced initial relief after undergoing surgery.[34-38]
However, based on long-term follow-up, the results are not as favorable. Davies and colleagues[38] found that less than 50% of patients (48%) were satisfied with the results, although they initially noted improvement following surgery.[38] Nearly 33% of patients reported continual forefoot and midfoot pain, although they were initially satisfied postoperatively with their outcomes.[34,36]
This may be related to the fact that undergoing a fasciotomy leads to flattening of the longitudinal arch and a redistribution of the peak forces of ambulation from the heel to the midfoot.[37] This shift of forces often leads to pain in the midfoot and forefoot during ambulation. In fact, Yu and colleagues[39] noted recurrent plantar fasciitis, arch instability, and structural failure due to overload on MRIs of patients with persistent or recurrent pain following plantar fasciotomy.
Recommendation. Surgery should be considered for patients with persistent plantar fasciitis who fail to respond to conservative measures. Some patients will take up to 1 year to experience relief of pain using noninvasive approaches. ESWT should be considered prior to considering surgery. Surgery may provide short-term relief, but long-term results are not favorable. Prior to undergoing surgery, patients should be aware of the possibility of problems developing in the midfoot and forefoot secondary to the division of the plantar aponeurosis.
Level of Evidence. No RCTs; cohort studies show improved outcome following surgery.
I review the biomechanics literature above average by my pulse and to date, I have reviewed no level I evidence of Bio Newtonian Theory that convinces me to alter my practice protocols. I have begun to apply more thought as to how I am using Newton's Laws in my EBP but I have not changed it to date.
Re: Bio-Newtonian Theory Quantitative At Best
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:di zzy:
Linear Mode
