EBM and Sacketts Empiricism

In your illustration, this foot would be weighted on the medial tarsus excessively The patient wuld complain of PTTD, navicular and hallux IP pain. etc.
The patient would have a lethargic gait and walk slowly and take small steps.
He would have a flat foot. He would have little to no muscular function, tubular legs and atrophy that would be reflected up the posture such as medial ankle pain and low back problems.

He would be a poor shock absorber, a poor mobile adaptor and a poor morpher.
He would have excessive lateral heel and sole wear on the heels and soles of his shoes.
His x-rays would reflect a closed sinus tarsi, a low CIA, a high TC Angle, etc.

others of his kind would share many of these characteristics although they would differ as to be unique, each requiring specific care if one had the training and experience to separate those within this subgroup. Ageed or not?

Treatments, such as a valgus rearfoot post or a varus producing dwyer could be performed to these feet that would be harmful to other subgroups.
and
A civil discussion as has existed here could be had regarding the subgroup without diversion and with everyone understanding the discussion.
(I'm leaving out the commercial).

To add to the discussion:
Not to say that your physics isn't correct with regard to incresed external or internal moments at the STJ (where I am admittedly once again to be on shaky ground) but wouldn't there be tissue stress in other parts of the system?
I believe the addition of a valgus heel wedge would reduce the tissue stress under the navicular, the hallux IP Joint, the medial ankle area and if the material was shock absorbing, it would summate to buffer the entire posture positively.

My question is shouldn't we test this valgus wedge clinically to see if its positive effects outweigh the negative which you are uncovering and reduce the import of the frontal plane of the subtalar joint?
DrSha

 

DrSha

When posting this foot type with a lateral rear foot post are you taking into account position of the STJ and the talo crural joint, and how lax it is in the frontal plane, relative to the CoP in stance phase and also the relative positions of the CoP in stance phase and the knee joint? Do you take into account foot placement in stance phase or hip function and torsional position or is it just this foot type = this rearfoot valgus post? What other considerations do you make beside FFT to make a reasoned decision about orthosis design?

Dave

 

We can always test clinically, but what negative things do you see me as uncovering? I'm assuming a simple frontal plane model that might support your proposition about rear foot valgus posting, so it would seem that the frontal plane kinetics are a important consideration.

I'm a bit lost with your reply but perhaps your next will reveal your meaning.

Cheers Dave

 

Sorry I'm taking this thread away from the OP question

 

David:
I am too diverting the OP but in addition, I am speaking french on a spanish speaking thread where I have had two years of high school spanish.

Are you saying that on an Fscan, this foot would not light up under the lateral heel, sub navicular and sub IP hallux?

Since I have not witnessed the evolved flat/flat type (a very flexible foot type that has been overused to the point of breakdown and wolf.s and davis's laws contracting it to an endpoint near fusion of flatness (think like the progression of RA).

So let's go with the valgus dwyer foot.

It was lets say 2 degreesvarus STJ preop and 4 degrees Valgus STJ postop.

In cases of a flexible forefoot foot type, (usually the type that would lead to the surgeons choice of a dwyer, postop, the first, second and third ray would dorsiflex and the foot would eventually weightbear under the navicular (it is touching or approaching the ground) with collapse, causing PTTD. As the foot fuses and there is no motioin left, the PT would eventually fail, slack and stay unloaded.
In the early phase PTTD is a complaint. Later, as you say, the PT is totally assymptomatic and the subnavicular type pain ensues as in your diagram (I theorize).
So at the time of your model, I will guess that the PTTD (the CoP) is at the pain free stage.

The question I raise is whether the placement of the lateral wedge in these cases will shift the Fscan picture laterally, therefore taking pressure from under the navicular and the hallux IP Joint.

David:
Does my clinical experience which has me working with a different clinical mindset for all feet once subgrouped have any impact on treatment since I would assume, there are exceptions to your newtonion laws when applied to life (BIO-Newtonian Physics or BNP)?

Example:
I have a three year old toewalker "Prancer's Syndrome" and she is not touching the heel to the ground in gait.
I place a set of 3 degree heel lifts attached to form a 6 degree lift and then the child starts wieghting into the lift and now I cleeve off 2 degrees and with time, she weights into 4 degfrees, then I cleeve two more, she weights the heel into 2 degress and when I remove the last two degrees, she eventuallyweights into the ground CURED.

Yet on evidence (and maybe CoP law?) you would not place a 6 degree heel wedge under a dropped foot to heal it as it would foster the drop, would you? So you wo0uld not consider that care or this case.

Perhaps if you apply your CoP to met adductus casting which we all understand works, it would educate me deeper into your BIO-Newtonian theory.

More and more I am feeling that the only thing practicing on a very clinical plane has done for me is that it has exposed me to all the possible exceptions to your BIO-Newtonian rules and so I do not put as much weight on it as you do and hencxe our two schools of thought.

Fot instance, if I had a three year old who couldn;t get up on her toes, I would put her in heel lifts whether she had a torn or intact tendo achilles even though I would assume the CoP to be different in both cases where you might have different treatments for each.

Soory for the rant, I'm just searching.

 

I've reached the point where those still on thread are stating things that I feel exactly the same about with respect to them.

We appear arrogant and biased and unwaivering to the other and we both feel justified in our thoughts and conduct.

Perhaps one day you will recognize that what you take for meaness is actually the best education money can't buy. Enjoy breakfast, I'm going to work

How do we end this banter?
I know, I can say you're right, I could stop my work and I can joint the team, right?

DrSha

 

Dr’s. Weber. Isaacs, Kirby, Spooner et al:

I am going to try to prove that we are both armed with weak evidence and although I state it out loud and you say it when stagnated in your search (such as a concensus, treatment patterns and agreement on about anything) by posting these quotes from Arena threads and until you have reflected and commented on them, I will keep them anonymous since I believe outsiders would not know which camp they came from.

I believe that they support us considering a consensus that strong enough evidence does not exist for any theory including foot centering, Root, MASS or bio-newtonian. This rejects The Arena consensus that me not being able to produce evidence (admitttedly) constitutes a license to fire your collective cannons at me and claim victory as bullies.

Bio-Newtonian Science has no evidence of value in making clinical decisions any more then any other because when you apply engineering, physics or architecture to human closed chain function, the variables destroy the evidence.

We all go to sleep wishing and waiting for evidence to support our work but alas, at the end of the day, our work is faith based and we are arguing beliefs.


1. “After years of reading conflicting posts on this website (perhaps the definitive source of debate on orthoses anywhere), I think we can safely say there are only some basic concepts that some people and the research agree on.

What is also clear to me, is that for decades thousands of podiatrists, physio's and orthotists etc use have used foot orthoses daily with reasonable levels of clinical success. Some evidence supports this, some is lacking, some conflicts with this.

There are various hypotheses, various theories but no exact single mechanism of action that is agreed upon.

We can keep going in circles, on we can start moving on and accept there are some limitations in our understanding. This needn't be a barrier to not start producing lots more meaningful outcomes studies, or indeed treating foot conditions at the coal face with incompletely understood non-surgical methods such as foot orthoses.

If the pharmaceutical industry worked in this way people would still be dying of AIDS rather than living productive lives, and the 5 year survival rate for most cancers would still be appalling”.

2. “As I´ve increased my knowledge of different biomechanical theories I´m comming the realisiation that we know next to nothing about how the device that we issue to patients works”.

3. “foot orthoses do seem to consistently reduce the internal inversion moment what we don't necessarily know yet are the details of why. We're working on it”.

4. “Acupuncture is a good example. There is some pretty compelling evidence that it can be effective for certain things, but also huge rafts of studies in which it performs no better than a placebo. Because we do not understand how it works it is very hard to work out why some studies show one thing and others something different, and also to tell the things it can treat effectively from those it can't”.

5. “we don't have evidence that we have changed the position of the STJ. We know that we are trying to, but we don't know that we have. Even if we have changed the position of the STJ, we may not have changed it enough to significantly move the STJ axis”.

6. “There are so many variables that I look at that it would be very difficult for me to tell another clinician how to perform the exam, cast the foot, order the orthosis, advise the proper shoe and adjust the orthosis after dispensing without having them train with me for at least a few months so that I could impart the clinical knowledge
7. “Of all the therapies you provide to your patients, including the obvious multiple orthosis modifications you make for your patients, what percentage of these many types of therapies, would you estimate, to be supported by Grade A (levels 1A-1C) evidence?”. REPLY: “Not a lot. For obvious reasons that sort of evidence is hard to come by”.
8. “since so much of what I do in practice, including custom foot orthoses and foot surgery, can not be practically researched using experimental controls that the patient is blinded to, then I have found that those that want to discredit the effectiveness of foot orthoses or foot surgery use EBM concepts in order to minimize the importance of much of what I can do for my patients”
9. “many others use a method of evidence gathering that uses universal statements, extrapolated from a generally accepted axioms, that can be applied to the singular problem by the way of logical reasoning. So while there may not be direct research that is applicable to the singular problem, deductive reasoning based on generally accepted concepts or axioms does allow one to apply universal results of scientific research to the singular problem. This in my opinion is how evidence based medicine works best”.
10. “I have never categorized or itemzed a list of the evidence that I have utilized to adjust my practice over the years. I have been influenced by many.
Robert: I assume you have such a list at your fingertips (care to share?).
I am reviewing and catagorizing evidence from the following places which seem to have many titles that I am familiar with along with ones needing research.
Kirby's list on orthotics (on The Arena)
Larry Huppin DPM's list on his practic weebsite under evidence based medicine and EBM Stuff http://www.sciencebasedmedicine.org/?p=558
I also enjoy and trust the EBM dictums, debates and writings of
Michael Turlik, DPM going back to 2001
11. ” If you were a regular on the forum or had read previous discussions such as the Barefoot Running thread you would see that we (the Podiatry Arena community) demand a far more rigorous level of evidence to suggest causality".

I’ll stop here.
Please all join in.

HINT: The only quote that is DrSha is #10

Dr Sha

 

1ST Dennis as Ive said before No PHD for me so no Dr, If and When I get a PHD you can still call me Michael or Mike.

The rest of the post I´ll leave alone, So to paraphrase Newtonian physics holds true for everything else in the world except for feet Mechanics.

Dennis if a bone pin study shows that wedges can change the STJ axis and alter joint motion, what would you say then?

Heres why I find you biomechancis theory lacking, the 6 Billion people who live on Earth have 8* foot types and should all be treated according to these Functional foot Types.:bang:

where by using physic´s we can try an explain why the individual has specific symptoms and therefore construct a treatment approach to change the forces on the tissue under stress to releive symptoms. ie 1 person 1 mechancial make-up 1 specific treatment approach make more sense to me. But I´m still learning more and more everyday on how it all works.


* or however many you have in your system.

 

DrSha

I will get back to answering your last queries about heel posting in different scenarios in a different post. For now I will say that even if our two systems dictate that we give the same treatment for a particular pathology scenario it does not mean that they are equally valid. As Robert explained earlier successful outcomes do not validate evidence. We need to make the right decision based on the correct evidence. The system of the right decision validated by the wrong/false evidence is destined to fail at some point. I see this is reflected in papers I've read recently regarding the evidence gathered to make surgical decisions.

Cheers Dave

 

Dennis:

I have been following your debates with Robert, Simon, Dave Smith and others for some time now and have been staying out of them since you tend to be repeating yourself, not saying anything new and not making good biomechanical sense. Honestly, to me, you seem to be just like a old vinyl record, with the stylus slipping repeatedly into the same groove, over and over and over and over again.

Just now having returned from the Italian orthopedic-podiatric biomechanics-surgery seminar, and seeing the great enthusiasm in that country for ideas based on simple Newtonian mechanics, STJ axis location, moment arms, ground reaction force vectors, stress-strain, elastic deformation, plastic deformation, stiffness, compliance, etc, I just wanted to publicly point out that since your ideas are not based on sound biomechanical principles, they are (unfortunately for you, fortunately for us) ideas with no future for our profession.

Yes, I give it that you are passionate, persistent and are probably a very good podiatrist. In addition, I truly believe that you think that your ideas are the best ideas for your patients and other podiatrist's patients. However, as far as the future direction of podiatric-orthopedic biomechanics in the next 50 years, your ideas are a dead-end, that will likely be, once you are no longer around to tirelessly promote them, remembered only for your enthusiastic marketing of them, not for their substance or their worthiness for our profession.

My advice to you, Dennis, if you truly want to change this likely future situation, is that you actualy take the time and publish some of your ideas in a peer-reviewed podiatric journal so that your ideas can be analyzed by a larger audience and hopefully gain greater respect from your peers, and give you more respect within the international podiatric biomechanics community. Until then, it is unlikely that "Foot Centrings" or "Functional Foot Typing" will have any significant future for the podiatric profession in the coming decades.:drinks

 

Kevin:

Thanks for your frank opininon.

Time will tell where I land but I will have had fun trying.

Dennis

PS: Is that why you haven't returned my calls into your office?

 

Kevin:
As stated previously, ad nausium, I am a podiatrist not a research scientist.
That is why your compliment, proclaiming me a very good podiatrist, fuels me to my goal of mentoring my profession to being better DPM's.
I wonder how many others on these pages you have (or would) proclaim to be a very good podiatrist though admittedly, they destroy me as a biomechanical theorist, in practice, when it comes to biomechanics, as a whole, you and I would both admit they are in diapers, like most of our American brethren in practice. Foam boxers, Scanners, EVAers and STJ Neutral Casters.

I think you will be rememebered as responsible for much of the future evidence in biomechanics but when it comes to leading our profession down its future clinical path, your ideas are a dead-end, that will likely be, once you are no longer around to tirelessly promote them, remembered only for your enthusiastic marketing of them, not for their substance or their worthiness for our profession.

The future will prove which of us is right since you have no place for collaboration in your ego walls and unlike you, I wish you well and I hope more of your dreams become reality.

If I have learned anything about EBM and EBP, it is that until evidence is strong enough to influence a practitioners clinical decisions when treating isolated patients, it must be developed, it must be followed, it must be evaluated for value, level and applicability and sadly, when it comes to the state of current biomechanics evidence (including Bio-Newtonian, and Neoteric) there is little to be applied to practice.

If we went to a play framed back to the time of Newton, as he tried to get his work examined and accepted, I am wondering which of us would be playing the role of Newton?

But I think we would both audition!

My question has no answer and it is, Who would be directing?

However, when I examine our followings on the The Arena, and to use an architectural alliteration (or is it metaphor) and with regards to Columbus, you represent the flat world and I the round (arched).

I have no advice for you but if I did, like me with regards to yours, you wouldn't give it a nanasecond of thought.

DrSha

 

Warning, sarcasm ahead.

S'right. Besides Kevin, I can't think of ANY podiatrists who advocate and promote the tissue stress / Physics based models of biomechanics. Thats why Kevin has had to work so hard on this thread, because he is the ONLY one with these ideas and everyone else thinks they're wrong....

Oh no wait. Strike that. Reverse it.

I have given up on trying to dispute this sort of statement using mere logic, evidence based medicine, bench data, or theory. So, for variety, I shall attempt to dispute it in the same way Dennis disputes other peoples points:-

Actually Dennis, scanned and Milled EVA orthotics (in sub talar neutral) are far superior to any other type and much better than polyprop. They are the only truly functional orthotics, the only ones which hold the foot in an optimal position and allow dynamic and effective function. Its a real shame its taking the profession so long to realise how much more effective they are. You are clinically a child for still issuing polyprop insoles and its a real shame for your patients who are suffering. When Dennis "the theorist" starts to take his patients wellbeing a bit more seriously and opens his mind to the future of biomechanics he will start to have far better outcomes and his practice will be much enhanced. Until proven otherwise however I KNOW I am a far better clinician than him, (or indeed anyone else who does not use scanned EVA insoles. Perhaps were he not so caught up in developing his theories, models and abstract ideas he would focus more on making his patients better, but what can you expect from a pure theorist? While he was obsessing over angles and shapes, the rest of us were seeing patients and focussing on them.

If there was anything there you didn't like Dennis, reflect on this. They are ALL arguments you have used.

So. EVA is better than poly. Scanned are better than casts and you are a theorist who does not get so good results as me, and does not have his patients best interests at heart. You only do this through a spiteful refusal to accept the FACT that EVA is better.

If you were me, Dennis, how would YOU refute these (obviously absurd) contentions? What argument would you offer?

 

As are many others who publish their theories in peer-reviewed journals in order that their theories may be subjected to the scrutiny of their peers and better honed. Why does being a podiatrist prevent you from writing your theories for publication in a peer-reviewed journal? What stands you out from the rest of us in this respect?

The great thing about the English language is that when you miss out a key word within a sentence, the meaning of the sentence changes. What Kevin actually said was:

The key word being "probably"; Kevin did not say you were a very good podiatrist. He said you were probably a very good podiatrist and there is a difference. I'm guessing Kevin has never audited your outcomes nor even watched you at work, so his level of evidence for you being "probably a good podiatrist" is what? Indeed, we could philosophically discuss the meaning of "good podiatrist"... No thanks. Me, I don't know whether you are a good podiatrist or a rubbish one. Moreover, I don't care. However, I do think that your system of foot typing is a back-ward step and is fundamentally flawed, based on the evidence that you have presented in support of it.

Finally, the international podiatry community does not start nor end with DPM's. Although, if by not being a DPM means that I don't have to be subjected to your "mentoring", I thank my lucky stars (and stripes) that I'm not based in the United States of America. Parochial, Dennis. Very parochial. And could be construed as insulting to your international colleagues, Dennis.

 

I'm glad that was not lost on you. Although, I suspect it could be lost on others.

 

Took me awhile but got it

 

Simon:
I don't know whether you are a good podiatrist or a rubbish one. Moreover, I don't care. However, I do think that your Bio-Newtonian system is a back-ward step and is fundamentally flawed, based on the evidence that you have presented in support of it unless you specialize in medial knee pain.

 

I lecture and write interchanging podiatrist and DPM to reduce repitition. I would rather your insecure mind think that I am being offensive to non DPM's than change this part of my style.

 

Finally: (and this is getting sooooooooooooooo tirrrrrrring.
Kevin:
I wonder how many others on these pages you have (or would) proclaim to probably be a very good podiatrist though admittedly, they destroy me as a biomechanical theorist, in practice, when it comes to biomechanics, as a whole, you and I would both admit they are in diapers, like most of our American brethren in practice. Foam boxers, Scanners, EVAers and STJ Neutral Casters (and let's add OTC Orthotic dispensers).

 

The Podiatric biomechancial community as seen through the eyes of some.

 

:good::good:

Robert:
In all sarcasm there lies a modicum of truth.

Your EVA is better than poly argument is not absurd no more than me having dispensed thousands of polypro (or the like) thermoplastics in an aggressive biomechanics EBP without ever dispensing one and with no high level evidence.

You have finally breached the "what do I do clinically button" that all of you have skillfully dodged and avoided by saying that we do other things than STJ Neutral casting when for the most part you don't.
The reason you dodge is that you cannot produce what for a year + you have asked me to (upset that I admit that I cannot provide evidence that we all know doesn't exist) when you cannot produce evidence that your inserts are any better than a placebo in a double blind study either.

EVA (the higher the durometer) is bulky and forces patients make negative lifestyle adjustments and downsize style and type of shoe in order to use them successfully to relieve pain. Thermoplastics have better memory, greater life of shock absorbancy, greater life, period and molds better to positives. They can be modified easier and they, I think, are less labor intense to work with at the lab.
Polypro supports better, controls better, molds better and until proven otherwise, is better (for me).
They look better cosmetically and for me, they represent the future and not the past as plastic research for new and better materials is far greater than EVA research.

Working with EVA allows for a greater margin of error when trying to prevent complications and when combined with low level goals like pain relief of tissue stressed pathology as they apply to gait instead of wellness and quality of life for all activity (i.e. stance, side to side, backward, lifting, up and down movement, dance, etc.), produce competant clinical results (as long as it is not discussed and debated) as long as they are not compared to loftier goals.

DrSha

 

The Evolution of Shavelson's Biomechanics EBP

History:
I wanted to be a research scientist (BS in Biology) but the Vietnam War was in full bloom in 1966and I entered podiatry instead to maintain my deferment as I was against the war.

I was Valedictorian of my NYCPM class at a time when there were 14 Residency Slots for 600 and had my pick of programs but chose Marvin Steinberg, DPM’s Medically oriented program. Dr. Steinberg taught me that I was a closed chain specialist and that was what was unique in our education, practice and teaching. he never published and lived by the term "until proven otherwise" in practice for justifying his protocols.

My 39 year old daughter, eldest of five has never taken an antibiotic. I have been preventive oriented all my life. I rarely use cortisone in the office but I have given hundreds of thousands of therapeutic injections in my career. I became Board Certified ABPS 14 years into practice as I saw the direction of my profession heading in that direction but the center of my practice has been biomechanical both surgically and non operatively.

I was born with one leg short and had lower back problems whe athletic as a young person and podiatry helped me solve my problems and fostered a passion to prevent, solve problems and improve the quality of life and performance of my patients as goals.

Root was taking hold in biomechanics and he presented to me an amazing new box that I thrived in.

For years, I took preceptees from CCPM and drained them of their biomechanical knowledge as I taught them podiatry. I attended CCPM Super Seminars and went out west to learn what wasn’t available in Schuster’s East Coast World summers.

The notion that an orthotic was never going to be enough and that I had to learn kinetics, kinesiology, phasic activity of muscles, the gait cycle, etc, etc. instilled in me by Root became the motto of my practice.
Root Suggested:
The Inherited Nature of Foot and Postural Problems
The fact that as we age, we slow down our lives and lifestyles unnecessarily
The fact that there are types of feet that by examination can be typed (fully compensated rearfoot varus, partially compensated forefoot varus) that gave me a starting point to examine foot sufferers and help explain biomechanics to the medical community, healthy people that will have biomechanical issues in the future and yes, even podiatrists.

So my starting place for evidence beyond Root was to research walking habits.

I came up with three or four Ph.D’s studying walking.

They were:
Mary Murray, Ph.D (listed works)

Drillis, R,J (listed works)

Walker (no references, help)

and I think Sutherland (no references, help).

References:

Murray, M . Patricia, A. Benjamin Drought, and Ross C . Kory: Walking Patterns of Normal Men . J . Bone & Joint Surg ., 46-A(2) :335-360, 1964.

Murray, M. Patricia, Ross C . Kory, Bertha H . Clarkson, and Susan B . Sepic: Comparison of Free and Fast Speed Walking Patterns of Normal Men . Am. J . Phys . Med ., 45(1) :8-24, 1966.

Murray, M . Patricia and Bertha H. Clarkson : The Vertical Pathways of the Foot During Level Walking . 1xm . Phys. Ther. Assoc ., 46(6) :585-599, 1966.

Murray MP, Kory RC, Sepic SB: Walking patterns of normal women. Archives of Physical Medicine & Rehabilitation. 51:637-650, 1970.

Statham L, Murray MP: Early walking patterns of normal children. Clinical Orthopaedics & Related Research. 79:8-24, 1971.

Murray MP, Kory RC, Clarkson BH: Walking patterns in healthy old men. Journal of Gerontology. 24:169-178, 1969.

Murray MP: Gait as a total pattern of movement. [Review] American Journal of Physical Medicine. 46:290-333, 1967.

Seireg AH, Murray MP, Scholz RC: Method for recording the time, magnitude and orientation of forces applied to walking sticks. American Journal of Physical Medicine.47:307-314, 1968.
.
Murray MP, Sepic SB, Gardner GM, Downs WJ: Walking patterns of men with parkinsonism. American Journal of Physical Medicine. 57:278-294, 1978.

Murray MP, Spurr GB, Sepic SB, Gardner GM, Mollinger LA: Treadmill vs. floor walking: kinematics, electromyogram, and heart rate. Journal of Applied Physiology. 59:87-91, 1985.

Murray MP, Seireg A, Scholz RC (1967) Centre of gravity, centre of pressure and supportive forces during human activities. J Appl. Physiol. 23: 831-838

Murray, M. P. (1967) Gait as a total pattern of movement.
Am. J. phys. Med. 46.290-333.


Drillis, RJ :Objective recording and biomechanics of Pathological gait;Ann.New York Acad od Sciences, 74:86-109, 1958

Drillis, RJ: The Influence of Aging on the Kinematics of Gait; The Geriatric Amputee. National Research Council, Committee on Prosthetics Research and Development. NAS-NRC Publication 919;1961

Drillis RJ, Contini R. Body segment parameters . Technical
Report No . 1166 .03 School of Engineering and Science, New
York University ; 1966 .

Contini R, Drillis RJ, Bluestein M. Determination of Body Segment Parameters. Human Factors. 1963;5:493–504.

In summary, they suggested that as we age, we walk slower and take smaller steps and as we get unhealthy (il) we walk slower and take smaller steps and they suggested that with treatment, that could be reversed.

From them, I decided that when working biomechanically my goal was not just to relieve pain, chief complaint, etc but to get my patients to walk faster and take bigger steps as part of my care insuring them a better qulaity of life. I renamed my practice LifeStyle Podiatry and practice Wellness Biomechaniocs from that time on.


Please react to this and then I’ll go further if there is interest.

Dr Sha

 

http://www1.elsevier.com/homepage/sab/gait/97000295/fulltext.pdf
http://www.ejbjs.org/cgi/reprint/62/3/354
http://www.ejbjs.org/cgi/content/abstract/48/1/66
http://www.ejbjs.org/cgi/reprint/54/4/787

etc.

Exactly how did each of the papers you listed above influence your thought processes and the development of your theories? I've read many of them as antique texts, what precisely did you draw from each of these papers? Moreover, in the context of the current discussion, could you score each of these papers against Sackett's hierarchy of evidence? How many make level 1- hint: none. Food for thought, Dennis?

 

Mary Murray helped develop the gait cycle.
Newton's work is far more antequated. Where are you going.
You are soooooooo biased.

I f you reply to my post with information on how you digested these articcles and decided how they would be of value as evidence and then note whether you have decided to apply them (or not, or to what extent) to your EBP as that will help me decide as to whether to continue answering roberts evidence question,

After that, I will entertain a reply to your question.