EBM Terrorism

Ok. True, false, all of the above, none of the above!

 

Robert Stated:
Q1

There is a horrible and fatal disease which affects 1 in 10,000 people. I have designed a test for this disease which is 99% accurate.

I test you and you test positive.

What is the probability you have the disease?

Q2

I have 4 cards. Each has a letter on one side and a number on the other. I lay them before you thus.

A F 3 7

Dennis Reples:
I've been with my grandkids and children sorry. We all need to unplug once in a while.
Please, please keep those illustrations coming. While they are just as spot on as the verbal slime (which I realize are instructive as well) they break the ice and give one thought as to how much our personal arrogance can obscure the topic.

#1.

My answer is:
I have a very short period of time to live and I can either figure out exactly how long or how many other people have this scurge or I can spend every bit of my remaining energy to find a cure. Get me to my clinic, not my abicus.

Question #2:
Four Cards
A/3 A/3 F/& F/7
Dennis

 

Dave Stated:
Now you've got the anger out of your system, have you got anything relevant or interesting to add to this discussion or do you just want to rake over old ground that really only adds to your chagrin.

Regards Dave

Dennis Replies:
This is not anger sir, I do not even know who you are and I don't regard you important enough to generate anger within me.
I am simply trying to point out that in your case, I will not tolerate a double standard where you hold my comments to be full of unproven and anecdotal air while you go about blazing hot hot air in your own private world.
I feel the same of Simon with his infantile articles and references that are lauded on The Arena, with Craig who researches pet notions of things from the past that he wishes to blow away as myths while eliminating viable new ideas before researching them, with Eric who repeats questions to me that are answerable in the literature and on record that he will simply not put any energy into in order to gain knowledge, to Sam who in his youth lets testosterone rule his brain instead of utilizing humility and respect of his elders, etc.
The Arena has taught me much and will continue to do so. It has even shown me that my closest colleague in theory is the dreaded Dr. Glaser who although I feel his paradigm falls short has taken Root STJ Neutral casting to greater heights from which we look down at the rest of all you flat blokes
Gentlemen, to paraphrase the pervasive question of Columbus' day:
Is The Vault of the Foot Flat or is The Vault of the Foot Round?
Time will tell which of us is right and I haven't fallen of The Arena edge yet.
DrSha/Mr. Hyde

 

Glad to see that you are in such good company, Dennis.

 

Originally Posted by drsha
It has even shown me that my closest colleague in theory is the dreaded Dr. Glaser who although I feel his paradigm falls short has taken Root STJ Neutral casting to greater heights from which we look down at the rest of all you flat blokes

Kevin Immaturely States:
Glad to see that you are in such good company, Dennis.

Dennis Replies:
Colleagues make strange company.
Witness your coauthor, Simon Spooner’s statement on a thread meant to give Dr. Root props.
Simon said:
To me, Rootian biomechanics as published by Merton and Colleagues is more analogous in evolutionary terms to the dinosaurs; a side branch that flourished for a while and then died out. Think crocodiles and sharks....... bit's still remain, but other aspects have "died out" and been superseded, for good reason. Survival of the fittest.

You choose your company and I’ll choose mine.
BUT in the end, WE are still all colleagues.
:drinks
Dennis

 

How true.

Thanks for having a go at those questions dennis ;-) I've pm'd you some stuff to mull.

Dave, you're excused, like you say I've played these games with you before.

Glad you enjoy the pictures dennis. One tries to inject levity. There is always a risk we take ourselves to seriously.

You can't tell but I'm trying to de fuse this threads tension by pulling faces at dave even now!

Regards
Robert

 

Robert


A7 and 100:1 (if you test 10000)

Fainites

LoL Dave

 

Wow. Interesting.
A lot of posts. A lot of words. Everyone thinks they are correct, but can that be possible?
Yes. EBM is absolutely necessary and valuable. And can be dangerous. I see this argument from both sides- I work at a large, inner-city medical center, and I work in private practice. For the average, healthy patient, with situational, temporary pathology, either treatment realm is great. A patient with complex, systemic disease is often better-suited to a large, inter-disciplinary medical system. When a practitioner is in private practice, he or she must have positive results, with an eye on cost-containment for patients, while staying current and simultaneously using experience and knowledge from the past. Curing bad, chronic tinea with free sample topicals and vinegar soaks for a patient will make patients happy and therefore bring more patients, versus using expensive, investigational or new topicals or expensive oral meds. In a large medical center, on the other hand, academics have more freedom to use new, expensive treatment regimens. I do. There are millions of dollars in grants, funding hundreds of studies, and this is where we will learn about the future of successful outcomes while minimizing risks. Some studies are good and valuable, and some are not. I know of a huge research study, claiming that poorly-controlled diabetics with less podiatric visits will have higher amputation rates than well-controlled diabetics receiving frequent, preventative footcare. DUH! Of course. Money tends to corrupt people, and that is obviously a problem. And we all have bias, based on our training and experience. Because of my training and experience, I tend to agree with Kevin Kirby's posts... but I read all posts and all points of view, and respect everyone. Chances are, if you are spending time on a forum such as this, you are dedicated to your profession and to your patients. The corrupt money-motivated aren't here, but they do exist. Like my granny used to say, "be nice, try your best, and help whenever you can..."

And if this doesn't seem to work, listen to the posts from the US. (Just kidding, sort of)
May the force be with you-

 

Gibby:
Your posting summarizes this thread perfectly and should reverberate in all of us as we pass judgement on others claims and theories.

If it is possible to end a thread...
This would be a perfect moment
:good::drinks

 

Thanks for your contribution but with respect Gibby I think you are missing the point.

The OP from DrSha was entitled 'EBM terrorism' which I assumed poses the inferred question is 'EBM being used as a weapon to undermine the intrinsic intuitive skills of the Doctor or clinician'?
Dr Sha eluded to the existence of two seperate and and possibly mutually exclusive protocols of EBM and medical Art. To determine that first we had to define what was meant by Evidence Based Medicine and what was defined as medical Art. We should also define what is the correct or reasonable process of decision making, I'm not sure that we have done that up till now.

Since Medical Art is proposed to be seperate from EBM then the real proposition is that medical art contains no evidence since to do so would bring it within the realm of evidence based medicine.

Therefore we must first define what is evidence and why art contains none.

I think that evidence can be summed up as a sign of truthfulness that can be accepted by most reasonable people. This allows the rule that the more people that believe in a sign of truth the more probability of its truthfulness there is (both in reality and in the abstractness of cognitive thought e.g. reality V's Heureristic perception ) and the less people that believe a sign of truth the less probability of truthfulness there is. This does not however mean that the truth is always contained in the former or that the latter is always false.

Continuing; if art contains no evidence then how can it be used to make decisions?

It was suggested that doctors have the supreme ability to be free thinkers and are therefore free from dogma, protocol, axiom, or convention in their decision making processes.

The argument against this was that nobody can be free from life experience in terms of the construction of deterministic thought. (Only God has the ability to be free thinking since he knows and experienced everything that has been, is and will be.)

Your argument takes the view that common inexpensive treatments and expensive exclusive or trialled medications are diametrically opposed in terms of some scale where medical art is at one end and EBM at the other. Also that expensive trials that have conclusions that were previously common knowledge were a waste of time.

DrSah states

Neither of these arguments are reasonable or valid. Like others in the discussion you take the emotional non formal argument and apply it to the formal argument protocol. In other words what you feel about how things are are not necessarily how they are and that, in a nutshell, is what this whole discussion is about.

Just because DrSha feels that diagnostic or theraputic modalities are not EBM does not mean that this is true and I would take the opposite opinion in many cases.

Some feel that EBM is used against them when they support a more intuitive stance in their medical decision making protocol. However I, and other propose that EBM takes a much wider stance than just that of inductive reasoning (research of the scientific method). Deductive reasoning and intuitive reasoning are forms of presenting evidence to back a theory or judgement. The art comes in deciding just which of these is the more probable in terms of a sign of the truth. Which, takes me nicely back to the first rule (of the truthfulness of evidence) that I outlined earlier.

Decision making is a cognitive process leading one to select a course of action.

Cognitive:- concerned with acquisition of knowledge: relating to the process of acquiring knowledge by the use of reasoning, intuition, or perception. (Encarta dictionary)

How then are Decisions made in the medical scenario? surely they do not come from thin air, just a wild guess. This would not be art, just sheer stupidity or arrogance. Surely a decision is the result of a conclusion and a conclusion, even the most simple, can only come from the consideration of evidence. Here is the art, and it is deciding how reliable the evidence is.

Gibby You wrote

This doesn't mean to say you have to be nice and agree with every statement and thread you ever read just for the sake of harmonious cordiality as you appear to be suggesting here.

To conclude; I propose that contrary to the feelings of DrSha and the supporters of his argument, EBM can be extrapolated to all realms of reasoning and experience i.e. deduction, induction and intuition. Therefore all reasonable decision making is evidence based. This becomes a tautological argument since if the judgement is not evidence based then it is not reasonable and should not be considered a sign of any truth to anyone accept the proposer of such an argument. The Art is deciding what is a reasonable point at which to discount or disabuse yourself of a certain point of view that has a low probability of being true.

All the best Dave Smith

 

Dave,

You've got to stop reading all those philosophy books and do some biomechanics research, so you can get your PhD

 

Ahh! PhD, motivation and cash, I'm lacking in both at this juncture.

I have thought about a professional doctorate at Brighton tho. igs: But then again I really like the easy life, Judo, Jujitsu, Curry, beer, telly, free time

LoL Dave

 

Yeah, don't ask me my opinion of these. I got my title the real way.

 

David:
This leads me back to the terrorism concept where you (or another expert in EBM and reality and cognitive thought), or an insurance company, can with prejudice and bias and self serving motive select those treatment entities or new theories or services or modalities clinically being used or tested to prove them "experimental, unproven, not necessary, not effective and defer recognition or payment for years beyond their acceptance in the medical community.

Since you are not God, I for one cannot believe that you personally inspect your own treatment patterns and life events or the heureristic theories presented by those you intuitively favor with the same microscope that you are selectively viewing mine.
I further believe that insurance companies push their red flag EBM buttons on any treatment that will be costly and utilized, no matter what its patient facing benefits are.
and
David, you have proven to me that you are not purely profit motivated because having tasted your argumentative skills, you could make a fortune working for Aetna, Cigna or Oxford.
Dennis

 

Dave,
I think you probably are God, and I for one believe that you are more than capable of personally inspecting your own treatment patterns, life events and the heureristic theories presented by those you intuitively favor with the same microscope that you are selectively viewing Dennis.

The Cud Band: ART!

"This song hasn't got any words,
That's 'cos we've not got much to say,
But I'm not talking for this filthy lot,
Just you try and shut my mouth,
Art!

Oh, this song hasn't got any words,
Just you try and decipher them,
Wha wha where we're burrer whim,
You could never try and catch my mouth,
Art!"

 

Theoretical arguments aside for a minute (How many angels can stand on a pin?).

There seem to be two problems with the misuse of EBM.

1. Where it assumes some sort of authority over clinical knowledge, often with poorly devised studies or models. I'm not talking about new treatments at all, but for instance studies that show a generic arch support, or a new running shoe to be just as good or maybe better than a prescription orthotic. At seminars I've heard papers presented that basically purport that orthotics don't work at all!

These studies are used to sell cheapo arch supports or new shoes, or by HMO's or government health agencies to refuse payment for treatment.

2. Where doctors are expected to follow the treatments"proven" by these studies. We are doctors, we have taken the Hippocratic Oath, we have sworn to practice to the best of our ability and judgement. Our judgment, not someone elses. As doctors we have no superiors. We have peers. This doesn't mean we are free thinkers at all. It simply means that we have all the responsibility. If a doctors is uncomfortable with this, he should probably work where he can simply take orders.

Managed care wants to tell us what to do, but why would we want to willingly give up this judgement responsibility? We decide if a study makes sense.

Cheers

Frederick

"There are lies, damn lies, and statistics." Harry Truman

 

Fred:

I tend to agree with your analysis. Even though I realize that EBM is the inevitable future for the podiatry and medical profession, like you, I see EBM also being used as a vehicle by which governmental authorities or health maintenance organizations continually deny necessary treatments to many patients who are suffering from painful or debilitating conditions.

I believe that the image of an ethical and intelligent clinician that bases his or her treatment decisions purely on what will work best for their patient with the least risk of harm, and bases their treatment decisions without regard to their own personal or monetary gain, should be the universal model that we all use when we treat our own patients.

 

Dear DrSha

You always seem to feel that I ( and almost everyone else) have some personal vendetta against you. This is not so and in this particular thread I agree with your sentiment but not with your argument. I assume that you started this thread for the sake of discussion and not just to air your grievance, make a statement and let is pass or even be agreed with ad hoc.

Thank you for your praise regarding my skills in argument, these are indeed skills and can be learned and improved with study just like any other discipline. In science formal argument is the basis of research and in more informal or casual interactions such as this forum it can be useful (if sometimes a little to verbose or effusive).

Did you intend to propose that EBM and medical art are very different at two ends of a scale or were you just annoyed that insurance companies dictate more and more which type of medical intervention you should using economic efficiency hiding under the umbrella rationale of EBM as an tool to pervert the hippocratic aspirations of the medic.

If the latter was your intention then surely my argument supports the intutive nature in which you wish to practice medicine in that it supports the argument that EBM is not solely related to evidence of inductive research i.e. the scientific method. Therefore you are at all times using EBM where the evidence is drawn from experience, logical reason, intuition and perception and this is how you can make cognitive decisions that rationally support your treatment protocol.

Therefore you will see that I actually support you both in sentiment and argument by clarifying the argument in more formal and logical terms.

All the best Dave

PS blame Prof Kevin Kirby for my increasing pedantisism, he taught me to be precise and clear in my writing, perhaps I've taken it a little to far, perhaps I enjoy it a little to much, who knows?

 

Kevin:
Dr. Georges posting and your reply to it summarize the tightrope that we tread as practitioners. EBM Terrorism is the fruit of our need to police our peers being misguided or misused.

As comments, I think we must add a small slice of being a patient advocate and proactively as individuals and organizations, we should be fighting against the corporate and governmental policies that are against their health and our ability to provide for it.
Secondly, when you say "without regard to their own personal or monetary gain" are you actually saying that I should not be able to profit from Medicine? That I should not be able to draw a salary and take care of my family? That someone else should decide what my pay scale or comfort level should be?
I ask a question of my patients for the last decade+ whenever they question fees or insurance policies.
I ask "the day before your foot surgery or podiatry visit, whom do you want to have a great nights sleep, Your doctor or The CEO of Your insurance company?

I cannot fathom that you and your family do not live comfortably and that at the end of the week, you do not put money in your pocket.
So, if possible, please revisit this one thought so that it fits our day to day lives.
Cheers,
Dennis

 

Dave:
The Arena is an elite and challenging group and although I doubt it, I hope I am paying it back even a little for the education and perspective that lives on its pages for my benefit.

Podiatry has precise protocols and dictums to which we all aspire and shoot for as goals.
Witness Dr. Kirby's I believe that the image of an ethical and intelligent clinician that bases his or her treatment decisions purely on what will work best for their patient with the least risk of harm, and bases their treatment decisions without regard to their own personal or monetary gain, should be the universal model that we all use when we treat our own patients.
But in reality, we have a colloquial language that redefines (albeit perverted) terms and dictums and this is where we have much unneseccary debate redefining terms leading to personalizations since I live more in the streets and you guys live in academia and research.
In day to day Podiatry:
1. pronation is collapse of the rearfoot in the contact phase of gait.
2. EBM represents the researched and proven methods of diagnostic and treatment protocols.

The unfortunate reality is that these definitions are the same that are being used to educate most podiatrists, the foot suffering public and the medical community and not the ones we know to be more accurate.

Over time, listening to The Arena, I am finding neoteric ways to translate academia into mainstream.
Sorry for deflecting the true debate of this thread for a moment.
Dennis

 

I rather like this as a concept. There must be some form of check on what we claim else we would never have moved beyond hanging dog poo around our necks and issueing homeopathic remedies in leiu of anti malaria drugs. However, like a police force, it must avoid becoming a tool of the state to crush those behaviours which are bad for the state (rather than the spirit of the law).

For me, if I were an EBM cop, I would rarely feel any desire to "pull over" an individual clinician who was trying out something new, and asking to see their papers. However if that person is trying to introduce that behaviour in others, being shouty and argumentative about what they are doing and claiming that they are right and everyone else is wrong then i'm afraid its license, registration and step out of the paradigm please sir.

"Is this your model? Had it long? Do you know how fast and loose you were traveling with the facts there? "

And who knows...

"I'm arresting you on suspicion of postulating under the influence of profit. You do not have to say anything but it may harm your defense if you do not mention, when questioned, vested interest which may later be revealed in court. Anything you DO say may be taken down and examined scrupulously for logical coherance and rationality."

Regards
Det Robert Isaacs

 

Robert:
For the first time, I truly see your point and that of many of the Arena members.
Please allow me to absorb it and try to modify my behavior.

Sorry for being so defensive and high and mighty.
Your post cut me down to a smaller size
and
Can I have my one phonecall!!
I want to call my mother.

Dennis

 

Dennis,

You still haven't quite got to grips with what pronation is have you??... this is at least the second thread you've demonstrated this. Whichever paradigm one subscribes to or whichever terminology/language one speaks surely this is a concept that should be understood by someone who has patented a new biomechanical model?

Ian

 

Ian:
I am sorry I worded my post so poorly or you just didn't get my point.

No matter what we agree to be the definition of EBM or Pronation the point of service and how it is defined and used most often by podiatry and the foot suffering public is not the same.

Trying to be deductive, if most people believe that the definition is one thing and the few believe it to be another, whose defintion is the correct one?

To me since 1977 Root, we have done a very poor job of explaining FLEB.

orthotic
pronation
rearfoot

all come up misspellings on word spellcheck.

Just as Root STL neutral needs upgrading our language needs upgrading as well.

Summarizing:

EBM includes research, proven evidence as well as the body of clinical, anecdotal information but it is percieved to be research based only in the public domain.
Pronation is a movement but it is percieved to be an actual collapse of the reafoot in the contact phase of gaut in the public domain.
Dennis

 

This is relativism. The idea that truth is a relative concept based on perception. Schrodingers pussy will be along in a minute (or not. Or maybe it will be both here and not here. Its hard to be sure.)

Sorry, can't have that. Up is up. Down is down. Inversion is inversion. Flexion is flexion. Pronation is what it is regardless of whether the GU and / or poorly informed clinicians might think it is. Its a movement not a pathology. We don't redefine the terminology to fit what people THINK it means.

By this token of definition by democracy how would FFT be defined?

Kind regards
Robert

 

Dennis:

:good: Thank you for such a nicely reasoned posting and reply.

Of course, I want to be paid for what I do and I believe clinicians should be paid well for what they provide for the healthcare of the general public. My statement of

was meant to highlight the fact that we should, as clinicians, not make treatment decisions for our patients based on what is the most profitable for us, but rather should make treatment decisions based on what is the most therapeutic and safe for our patients.

 

Kevin, well said. I couldn't agree with you more.

That is where the job satisfaction, the fun, comes from.

I was retired for awhile, and missed that direct appreciation that we get from patients we have helped. That's all that matters.

Now I have fun every day at the clinic, and do free work at the Charity Hospital.

Good to hear your thoughts.

Cheers

Frederick

 

Robert Stated:
We don't redefine the terminology to fit what people THINK it means.

Dennis Replies:
So how do we go about changing the redefined or modified terminology so that discussions between camps make more sense.

As a relative example here.

Dr. Roots original theory involved STJ Neutral but also involved Rearfoot/Forefoot relationships and forefoot pathology. He looked at the foot as a whole but always began in the STJ Neutral position when diagnosing and treating. Now that is the default and his legacy (although The Arena knows better).

I am not sure if it is folkloric or not but anecdotally, Dr. Root's original theory was that once put in "the healthiest" position, the bones of the foot would support themselves, end of discussion.
He stopped his publishing when he realized that this was not the case and there was a kinesiologic piece where the musculotendonous units were needed to act with power and in pahse throughout the gait cycle. This part of his theory has been reduced, if not eliminated over time.

There are so many terms and definitions that have become unclear.
Consider these language translations:
The rigid rearfoot type should have a STJ Axis that is laterally deviated.
The flexible rearfoot type should have a STJ Axis that is medially deviated.
The stable rearfoot type should have a STJ Axis that is STJ Neutral or not deviated.
The flat rearfoot type should have a STJ Axis that is maximally medially deviated.
Biomechanics is a Tower of Babel and we are debating our nationalistic tendencies.

Dennis

 

Dr. Root thought the foot had an "osseous restraining mechanism". They stopped writing the book to test his theory. They loaded a cadaver and began to cut the plantar ligaments and discovered that the foot eventually collapsed under load, so the concept of an osseous restraining mechanism (independent osseous structural integrity) was proved to be false. It proved the fact that the foot's structural integrity relied on osseous compression resulting from tensile forces in plantar tissue structure of the loaded foot. While this seems obvious now, apparently it wasn't at the time.

Respectfully,
Jeff
www.root-lab.com

 

Eh? We don't modify the terminology! All the "camps" learn the correct terminiology!

Biomechanics is NOT a tower of babel. There is accurate terminology which we should always strive toward.

Name 3. I'm sure someone can clarify them.

The former of these are all definitions you have invented. Which, of course, means you have a perfect right to define them as you like. I can define a foot with a medially deviated axis, a long first toe and an ingrowing toenail as the "Isaacs" foot type (I just did). But that does'nt mean I can expect everyone else to adopt / respect that terminology or even to understand it.

And what I CAN'T do is redefine functional HL as structural HL or a fiberous corn as a VP because thats what some podiatrists / members of the public they are. :craig:

And in that example I don't know what you mean by "should" have a certain axial position. Do you mean that you tend to find that they do? And what is a maximally deviated axis???? And what is an axis which is STJ neutral?! And what have they to do with terminolgy?

Please tell me you are not saying that these are different names for the same thing!

Regards
Robert

 

Good example. Take a foot in wb and put it in STJ neutral. Then measure the distance from the 1st MPJ and the ground.

One Prof Rothbart says that if this distance is between 10 and 25 mm from the ground this is pathgnomic of "rothbarts foot type".

Most of the rest of the world, however, still call this forefoot varus, supinatus or invertus. Just because he thinks otherwise does not mean we all switch to HIS terminology or chance what "supinatus" means.

Robert

http://rothbartsfoot.info/RFS.html

 

Moreover, how can you have an axis that is "not deviated"? Dennis, I admire your tenacity but postings like this merely demonstrate your ignorance.

 

Simon States:
Dennis, I admire your tenacity but postings like this merely demonstrate your ignorance

Dennis replies:
Dictionary
Ignorance is the state in which a person lacks knowledge and is unaware of something. This should not be confused with being unintelligent, as one's level of intelligence and level of education or general awareness are not the same. The word "Ignorant" is an adjective describing a person in the state of being unaware. (e.g. "One can be an expert in math, and totally ignorant of history.")
I have admitted my ignorance. Why don't you find two subjects on The Arena and test them for ignorance and compare levels of ignorance and then call them twats.
Mr. Hyde

 

I thought it might be interesting to post the first two pages of Biomechanical Examination of the Foot (Root, Orien, Weed, Hughes)
Jeff
www.root-lab.com

FOREWORD

The purpose of this manual is to provide you with a concise, well illustrated, and clinically practical method for biomechanical examination of the foot and lower extremity.

Examination is an art. Any art requires understanding of certain basic principles followed by the continued practice of technique. Generally, a greater understanding of basics leads to a more thorough examination and interpretation of findings, but this premise is only true when the examiner has perfected the techniques to the extent of clinical reliability. Inconsistent technique will lead to false conclusions and treatment failure; therefore,
one should practice the described techniques until he feels confident that the performance of those techniques provides him a degree of reliability, which is clinically effective.

The intent of this manual does not permit a broad discussion of basics. It is designed, rather, to provide a comprehensive, yet simple, description of techniques in common usage for biomechanical examination of the lower extremity. The techniques herein described have been time tested for ease of performance and dependability of findings.

This manual should be most useful and effective, in conjunction with classroom presentation of the described techniques by an experienced instructor. For those who are unable to attend courses designed to teach examination technique, it is the hope of the authors that you will find the descriptions sufficiently detailed and illustrated; so that with practice, your examination of the foot will be rewarded with more meaningful and reliable information.


MERTON L. ROOT, D.P.M.

INTRODUCTION TO TERMINOLOGY

Biomechanics is a science. As a science, its terminology must be exact and consistent.

Orthopedics is a medical discipline. Its basis, in the future, will be biomechanics. Former orthopedic terminology, as applied to the lower extremity, is not exact and, therefore, inconsistent.

Biomechanical terminology must become orthopedic terminology, for the future development of clinical understanding and communication relating to the lower extremity.

To understand the foot, one must have terms which accurately describe motion of one part to another, and of a part to the floor. Furthermore, structural abnormalities place certain parts in positions which cannot be attained by any motion in a normal foot.
Therefore, three sets of terms are necessary. They are:

1. Terms to describe motion.
2. Terms to describe position.
3. Terms to describe bone deformity.


The terms, as defined by the authors in this manual, are in common orthopedic usage, but each term has been provided a strict scientific definition.

Advancement of clinical treatment and knowledge of the foot have been seriously impaired by a lack of specifically defined and commonly accepted terminology. That inter-professional communication barrier has been successfully broken by those
practitioners who have learned and applied the definition of terms described in this chapter. Categorically, it can be stated that no science can be understood or applied without concise understanding of terminology applicable to that science. Biomechanics cannot be understood, or used as a basis of practice, until you speak the language!

 

Dennis:

I have made it very clear over the past 2+ decades in my papers, books, internet writing, collaborative research and lectures on subtalar joint (STJ) axis spatial location about what determining STJ axis spatial location can tell us about the specific biomechanics of a patient's foot. Unfortunately, in reading your reply above, it seems that you have either not read these works at all or have somehow misunderstood what I have written. In other words, none of what you say above is true and is a total misrepresentation of the subtalar joint axis location/rotational equilibrium theory of foot function that I have worked so hard to present in a logical and scientific manner to the podiatric profession over the last 20+ years of my life.

Here is a list of my publications on the topic so you can become more familiar with the biomechanics of STJ axis spatial location and rotational equilibrium about the STJ.

Kirby KA: Methods for determination of positional variations in the subtalar joint axis. JAPMA, 77: 228-234, 1987.

Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989.

Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992.

Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992.

Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997.

Kirby KA.: Biomechanics and the treatment of flexible flatfoot deformity in children. PBG Focus, J. Podiatric Biomechanics Group, 7:10-11, 1999.

Kirby KA: Biomechanics of the normal and abnormal foot. JAPMA, 90:30-34, 2000.

Kirby KA: Conservative treatment of posterior tibial dysfunction. Podiatry Management, 19:73-82, 2000.

Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001.

Kirby KA: Foot and Lower Extremity Biomechanics II: Precision Intricast Newsletters, 1997-2002. Precision Intricast, Inc., Payson, AZ, 2002.

Lewis GS, Kirby KA, Piazza SJ: Determination of subtalar joint axis location by restriction of talocrural joint motion. Gait and Posture. 25:63-69, 2007.

Lewis GS, Cohen TL, Seisler AR, Kirby KA, Sheehan FT, Piazza SJ: In vivo tests of an improved method for functional location of the subtalar joint axis. J Biomechanics, 42:146-151, 2009.

Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009.

 

Already found my subjects, tested them and guess what... Dennis, the more you write here, the more concrete my opinion of you becomes. I don't need a "double-blonde" trial.

 

Dennis

Here's a recent publication that may interest you


Not Enough Evidence for Evidence-Based Guidelines?

The ACC/AHA guidelines have continued to expand, yet a new study suggests that the evidence to support most recommendations has declined.
The American College of Cardiology and the American Heart Association currently use a dual grading scheme for guideline recommendations. The class (I through III) indicates the strength of the recommendation, and the level of evidence (LOE; A through C) characterizes the supportive research data, including expert consensus opinion.
These investigators examined changes to recommendations in ACC/AHA cardiovascular guidelines over time and evaluated the LOEs supporting the recommendations. Fifty-three ACC/AHA practice guidelines published from 1984 through September 2008 were included in the study. The guidelines covered 22 topics and included a total of 7196 recommendations.
In the guidelines that were revised at least once during the period assessed, the total number of recommendations increased significantly by 48%. The content of revised guidelines shifted toward more Class II recommendations and fewer Class III recommendations; the proportion of Class I recommendations remained constant. Of 2711 recommendations with reported LOEs, 314 had an LOE of A (median per guideline, 11%), and 1246 had an LOE of C (median per guideline, 48%). Among the 1305 Class I recommendations, only 245 had an LOE of A (median per guideline, 19%), whereas 481 (median per guideline, 36%) had an LOE of C.
Comment: A large proportion of ACC/AHA Class I recommendations rely on low levels of evidence or expert opinion only. The authors of a related editorial conclude that "clinicians and policy makers must reject calls for adherence to guidelines." To me, this seems to throw the baby out with the bathwater. Despite concerns about the evidence base, adherence to guidelines has improved outcomes. These findings should not result in an abandonment of guidelines; rather, they reaffirm the need for more research to address the gaps in our knowledge.
— JoAnne M. Foody, MD
Published in Journal Watch Cardiology April 1, 2009
CITATION(S):
Tricoci P et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009 Feb 25; 301:831.
• Original article (Subscription may be required)
• Medline abstract (Free)
Shaneyfelt TM and Centor RM. Reassessment of clinical practice guidelines: Go gently into that good night. JAMA 2009 Feb 25; 301:868.
• Original article (Subscription may be required)
• Medline abstract (Free)

Dave

 

Kevin Stated:
it seems that you have either not read these works at all or have somehow misunderstood what I have written
Dennis Replies:
ditto

Kevin Stated:
it seems that you have either not read these works at all or have somehow misunderstood what I have written.

Dennis Replies:
In my case, I have repeatedly admitted that I do not understand your language and therefore the theory that you are trying to convey.

The point you are missing that seems to turn you angry instead of open minded to new theory is that I have total sense that your work is accurate and valuable coming off of a STJ Neutral Shell proven (I think) to be much flawed and inferior to our goals.

Mr. Hyde Replies:
WE NEED A NEW and BETTER SHELL which once existent, would put you in Dr. Root's current place which is as you put it is Dying and therin lies my threat to you.
:empathy:
Dennis Replies:
Other guru's work off the same STJ Neutral Shell (Which Ian states loosely quoted is "The best we have and until something else comes along we must make it do".
Dr's Dananberg, Ritchie, Scherer, Blake and Mr. Root.
I believe their work is accurate and valuable. based on a STJ Neutral Shell Orthotic.

Theoretical Question:
If there were better casting techniques that provided a surperior shell when compared to Root Neutral wouldn't all your current paradigms when built on that shell be updated and expanded and the ability to improve outcomes upgraded as well?

I believe that superior shell will be more vaulted, foot type-specific since there are certain pure foot types such as the flat/flat and the rigid/rigid where Root Neutral remains the standard (These are the poster boy foot types shown by neutral casters, faomers and scanners in marketing, lecturing, etc.
:drinks
Dennis

 

DrSha

This thread is turning back to a discussion of the merits of your casting methods and shell type, however to get it back on the track of the OP - EBM versus Art, (or scientific method versus personal experience and intuition).

You wrote

And Robert Wrote

I previously wrote

These 2 quotes by Dennis and Robert are good examples of my rule of evidence.
2 people who each believe passionately in their respective theories and thousands who do not. Where is the truth more likely to lie?

Of course this does not mean that there is no possibility that the Dennis and Rothbart are correct, just they are more probably wrong. How ever they are both entitled to their theories, just as was Galileo and heliocentric theory and look how wrong he was - ish

Dave

 

Dennis,
This thread may be getting off track slightly, but the question remains one of evidence. If we look at the practice of "Root theory" in say 1970, 1975, 1985, and 2009, you will see that the practice of the theory has evolved considerably. As I suggested to Kevin recently, we do things much differently than we did back in the early days of Root theory. For example, a medial heel skive (Kirby skive) is a modification to the shape of the orthotic shell that did not exist previously. It has a definite mechanical influence on the foot.

Dennis, you are proposing a new system of foot evaluation or classification and are attempting to link the orthotic Rx to this classification system. I would argue that the negative, neutral position cast captures and represents the various anatomical differences that are present in feet. For example, if the patient has a high arch, it is reflected in the cast. So the issue becomes, what evidence or compelling reason (logic?) should motivate someone to switch to your system?

Until one can see evidence, be it anecdotal or otherwise, that your system produces better outcomes for the patient, I don't think they will be motivated to adopt your system. Although there is always room from improvement, the vast majority of practitioners who use my lab seem to get excellent results. I can't see them completely abandoning what has worked very well in order to try an unproven system and method of treatment.

If we attempt to separate the theory from the practice of orthotic therapy and look specifically at the nature of the orthotic shell, you advocate a higher arched device but a more flexible shell. I advocate a lower arch device but a more rigid shell. Until you (we) have evidence which suggests that your higher arched but more flexible shell has a different mechanical influence on the foot than my lower arch but more rigid shell, and until that mechanical influence can be associated with better patient outcomes, I can't see why someone who has experienced excellent results with Root type orthoses would be inclined to change.

I believe that the reason you have experienced so much resistance from the Podiatry Arena contributors is not due to the design or nature of your orthotic device, but rather due to the system that you use to determine the device and the terminology associated with it. The primary reason that I posted the first two pages from Root's book was due to the following quote:

This statement is as true today as it was in 1971 when it was published by Root, Orien, Weed and Hughes. In my opinion, if you have any hope of advancing your theory, I believe you need to overcome the communication barrier that your terminology has created. This lack of clearly defined terminology seems to be a major source of the frustration that is expressed towards you. For the record, I would like to tell the arena members that having met you in person and I believe you are an intelligent and good person. The fact that you have a commercial interest in your theory has nothing to do with whether it is valid or not and I hope we can continue to debate your theory in good spirit.

Respectfully,
Jeff
www.root-lab.com