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Orthopedic footwear and foot orthoses prescription

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Petcu Daniel, Jan 10, 2017.

  1. Petcu Daniel

    Petcu Daniel Active Member

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    Dear Members,

    Having to document the subject of orthopedic footwear and foot orthoses prescription I kindly ask for your support:
    -what exactly "prescription" means from the point of view of orthopedic footwear and foot orthoses?
    -which are the practitioners who has the legal right to prescribe orthopedic footwear and/or foot orthoses?

    Any reference will be appreciated,
  2. Craig Payne

    Craig Payne Moderator

    1. In pretty much every country anyone (qualified or not) can technically "prescribe" or sell them
    2. However, it varies from country to country who can actually "prescribe" and who can "provide" to get 3rd party reimbursements (from Govt, insurance and employers)
  3. Boots n all

    Boots n all Well-Known Member

    Morning Daniel, Craig is right every country is different.

    One thing that should apply in every country, is you can be either a prescribe or a provider not both, that line has been blurred when it comes to orthoses in Australia.
    Here, mostly registered prescribes for different funding systems are Podiatrist and P&O, otherwise anyone can refer/prescribe for those privately funded including Doctors, Osteopaths and so on.
    A prescription can vary, depending on the writer and the department guide lines funding the device.
    Some prescriptions l get simply read "David make a pair of boots for Mr Smith he has a Charcot foot"
    Others a little more detailed asking for certain aspects to be focused on, "Velcro closure" "Rigid rocker sole" "Extended medial support" but the truth is most writing the prescriptions leave it up to us, the Pedorthist.
    More clinical notes should come from the prescribe.

    If you are creating a system, my wish list would be to say all relevant clinical notes should be included with a prescription, including and not limited to Xrays and client history.
    We dont get them at all here.

    Here are a few links from DVA, a Government department.

  4. Petcu Daniel

    Petcu Daniel Active Member

    Thank you Craig and David!
    I found a similar approach from the above quote in some answers which I've received from different countries with a developed prescribing system. In my understanding this means that the Pedorthist act as a "prescriber" because he is deciding "prescribing parameters". Or, in the list of assessors from www.dva.gov.au/sites/default/.../MGF_powerpoints_assessinghealth_providers.ppt we have: "Approved assessing health providers for MGF are podiatrists or medical specialists i.e. Vascular Surgeon, Orthopaedic Surgeon, Rehabilitation Specialist or Rheumatologist". On the other hand an incomplete prescription means that the prescriber didn't made completely its job for which is paid!.
    Yesterday I found a good definition of the medical prescriprion on: https://en.wikipedia.org/wiki/Medical_prescription : "a health-care program implemented by a physician or other qualified health care practitioner in the form of instructions that govern the plan of care for an individual patient". What means "other qualified health care practitioner" ?
    I've to think at this!
  5. Petcu Daniel

    Petcu Daniel Active Member

    I think this is a more reactive than proactive affirmation which is not reflecting my thoughts! I found an old article "The Orthotic Prescription Derived from a Concept of Basic Orthotic Functions" http://www.rehab.research.va.gov/jour/69/6/1/89.pdf which I found to be very actual in relation with prescription procedure because I think it is proposing a "basis for meaningful and precise communication between the physician, the orthotist and the therapist by describing clearly the essential medical and biomechanical aspects of disability as they are related to the prescription of a device". The procedure the authors are proposing it takes into account in a correct way the role and competences of each specialist implied in this proces.
    Any thoughts ?
  6. Boots n all

    Boots n all Well-Known Member

    lnteresting the problem is in many coutnries, l think the lack of prescription detail, handing over the client history and detail goes deeper.

    Is it they feel they have ownership? Is it lack of respect for the "Team" approach whatever the reason if we, the "Team:Allied health" want better outcomes, we need to better support each other to support the client, this means a detailed prescription should include a full client history.
  7. Boots n all

    Boots n all Well-Known Member

    Thats a good article Daniel.
    It clearly states the prescribe doesnt have to know the device but rather a prescription states the desired outcome, brilliant.
    l feel a prescription should be a communication tool more than a directive. As it says for the more complex a consult between prescribe and provider may be needed.
    This encourages a real team approach as apposed to "us" and "them".

    "...The physician can state his objectives clearly without considering the details of brace ... It is important to list not only what is desired at each joint or segment but also what is not desired. Once the specific orthotic objectives have been defined in this manner, the physician is able to assign priorities to them....
    In complex problems, the physician may find it necessary to consult with the orthotist or other members of the medical and paramedical team to arrive at an effective and practical orthotic treatment program. In this instance, the functional description provides a basis for precise communication between the physician and the paramedical personnel since it clearly states the physician's orthotic objectives
  8. footpower

    footpower Active Member

    In Germany the Pedorthist (Orthopaedic Shoemaker Meister) is a health care professional covered by the “Gesetz zur Ordnung des Handwerks (Handwerksordnung)” Law to regulate the trades. This is the same for other health care trades like Optometrists and Prosthetist Orthotists. Only those that are registered with the relevant authorities are allowed to provide custom made orthopaedic footwear regardless of who funds them. Foot orthoses are not so tightly regulated and therefore for example sport shops can provide them to those that pay privately.
    Source however only in German https://www.gesetze-im-internet.de/hwo/BJNR014110953.html
    About the right to prescribe in Germany. The OSM can provide all his / her services to a person that privately funds directly. However as just about everybody is covered by a health insurance or funding body for orthopaedic footwear and orthoses, the funding agencies usually require a prescription from a medical Doctor preferably a specialist. Allied Health are not eligible to prescribe for the funding agency process. Prescriptions are usually not very detailed but of a general nature and then do focus on the aim and the general prescription of the product like “needs custom made footwear to reduce plantar pressure DX Diabetic foot syndrome”
    Here some references unfortunately all in German:
    Funding agencies want the prescriber to be more specific in an effort to reduce costs. After receiving Doctor’s prescription, then the OSM does an assessment and submits a quote with detailed list of items. That quote is the closet to an actual prescription as the item and their function is defined. Funding agencies may question the prescription or may approve it. Funding agencies have an obligation to fund necessary items. At times there is a debate on what is necessary. Below is a list of what is covered in regards to footwear and foot orthoses.
    If you want an overview on what assistive technology is covered:
  9. Petcu Daniel

    Petcu Daniel Active Member

    Thank you Karl!
    Even if "funding" is essential I think it should be separated by "prescription"!
    Pedorthists and orthotists/prosthetists are "allied health professions" ( https://en.wikipedia.org/wiki/Allied_health_professions ). If we consider an official definition of "custom-made device": "‘custom-made device’ means any device specifically made in accordance with a duly qualified medical practitioner's written prescription which gives, under his responsibility, specific design characteristics and is intended for the sole use of a particular patient." (quote from COUNCIL DIRECTIVE 93/42/EECcof 14 June 1993 concerning medical devices) we see 3 interrelated elements: prescription - responsibility - specific design characteristics. The "quote with detalied list of items" means "specific design characteristics", isn't it? Or this is the Doctor's "responsibility"! Why the OSM/Pedorthists are assuming responsibilities for which, as Allied Health, are not eligible? The answer is simple, I think: because the OSM/pedorthist has some specific technical knowledge (prescription parameters) which very probable the majority of eligible prescribers doesn't have and is not absolutely necessarily to have! The solution which I see comes from the same document which states "The above mentioned prescription may also be made out by any other person authorized by virtue of his professional qualifications to do so." One solution is making the OSM/pedorthist eiligible "by virtue of his professional qualification" and sharing the prescription responsibility between the "qualified medical practitioner" ( "functional description" and possibly but not imperativley "specific design characteristics") and OSM/Pedorthist (only "specific design charactersitics").
    For example “custom made footwear to reduce plantar pressure DX Diabetic foot syndrome” is a "functional description"! How much to reduce plantar pressure is another question!
    What do you think?

  10. Petcu Daniel

    Petcu Daniel Active Member

    Can you imagine on National Geographic Channel a "Foot&Shoe Crash Investigation" after "Air Crash Investigation" ( http://www.natgeotv.com/uk/shows/natgeo/air-crash-investigation )?
    I think it is only a problem of proactive communication between specialists!
  11. Boots n all

    Boots n all Well-Known Member

    l would rather one on the prevention of... How do we better communicate with each other and the client, the benefits of what a team can achieve.

    Those that received CMfootwear and orthoses, with reviews, have a reduced rate of ulcer recurrence from 72% down to 25%
    Those that are pressure mapped, have similar results of reduced recurrence, the evidence is there to support this sort of approach, that prevention is the right direction.

    But the prescription and referral are the first step in that journey and very important and underestimated.

    https://www.ncbi.nlm.nih.gov/pubmed/?term=rizzo structured shoes
  12. footpower

    footpower Active Member

    I agree with you funding should be a different discussion. Therefore the OSM/pedorthist is eligible "by virtue of his professional qualification”. That is that the Pedorthist and the OSM are allowed to operate their profession on their own in German and in Australia for that matter. In Germany the HWO regulates who is qualified to provide the services of the OSM/Pedorthist and only those that are registered are allowed to operate a (Gewerbebetrieb) commercial operation. Relevant here is that the commercial operation completely encompasses the profession/ trade or at least the core of the profession.
    In Australia it is common place that allied health prescribe custom made orthotic devices including footwear. That includes the certified Pedorthist, Podiatrist, Prosthetist / Orthotist. Traditionally like many allied health, Pedorthic training was in the vocational education sector and even then the national training package medical grade footwear acknowledged that the profession can provide all services on his /her own. Source: Textiles Clothing and Footwear Training Package LMT00 Version 3, Volume 17: Medical Grade Footwear. Since that time Pedorthic training has moved into University sector with a Bachelor training program at Southern Cross University. http://courses.scu.edu.au/courses/bachelor-of-pedorthics/2017
    Therefor by "by virtue of his professional qualification” allied health including certified Pedorthists are qualified to prescribe custom made assistive technology in this case orthoses and footwear.
  13. footpower

    footpower Active Member

    Having said that I do value team work. This includes the input from other allied health and the medical profession. I like to get a referral with a general functional description or description of desired outcome or a question.
  14. Petcu Daniel

    Petcu Daniel Active Member

    I think being eligible (OSM/pedorthist) "by virtue of his professional qualification" doesn't automatically mean that it is an official recognition! Isn't it?
    A prove could be the list "eligible prescribers" from Queensland Government website ( https://www.health.qld.gov.au/mass/prescribe/footwear ):
    "Private orthopaedic surgeons,
    Vascular surgeons,
    Medical specialists in rheumatology, rehabilitation, geriatrics, endocrinology and neurology"

    Why "pedorthists" are not included in the above official list ?
  15. footpower

    footpower Active Member

    Funding is the word.
    That is why the Pedorthist as well as the Podiatrist or P&O are not included. Limiting the number of eligible "prescribers" limits the number of prescriptions. I am not aware that any of the listed medical professionals have any pedorthic training element in their educational process. That may raise the question do they prescribe or rather write a referral to express a need rather than writing a prescription.

    In the State of New South Wales (NSW) we have a state funding body called enable that lists a number of allied health including the Pedorthist as an eligible prescriber of orthoses and footwear. http://www.enable.health.nsw.gov.au/home/forms-and-guidelines/footwear_and_orthotics

  16. Petcu Daniel

    Petcu Daniel Active Member

    I think this is one of the most clearly and detailed system which I've heard about! And is in line with what is written in article "The Orthotic Prescription Derived from a Concept of Basic Orthotic Functions" ! Thanks!
  17. Petcu Daniel

    Petcu Daniel Active Member

    An ISPO document from 2004 ( http://www.ispoint.org/sites/default/files/archives/report.pdf ) is discussing about:
    -"open prescription" - "Their activity is always triggered by a physician’s prescription and so without this prescription, patients cannot apply for refunds. As a rule, the prescription will only stipulate the desired orthopaedic effect (so-called ‘open prescription’), and not the methodical aspects of it such as choice of materials or application methods). Some doctors,however, do specify choice of materials or devices.", pg.20,
    -"medical and technical prescription" - "Need to define the difference between medical and technical prescription....In UK doctor/surgeon make medical and technical prescription. This has changed slowly over time.We have to make clear that the prosthetist/orthotist is responsible for the technical prescription.", pg.39

  18. Boots n all

    Boots n all Well-Known Member

    Why a prosthetist/orthotist should provide Technical prescription escapes me?
    To my knowledge that degree in Australia does not have a footwear component in its syllabus?
  19. Petcu Daniel

    Petcu Daniel Active Member

    Maybe because in some countries there isn't pedorthist and the orthotist has its competencies ?
    See ISPO Standard & Guidelines ( http://www.ispoint.org/standards-guidelines ):
    -Category I (page 9): "orthopaedic footwear and shoe modifications",
    -Category II (page 9): "shoe modifications, shoe inserts/foot orthoses"

    Interesting is that the category II can't "address" the "orthopaedic footwear" !

    In UK, see "Orthothics competency framework for the prevention, treatment and management of diabetic foot disease" ( http://www.diabeteseducationscotlan...mpetency Framework Orthotics Level 6 Only.pdf ), level 6:
    -"Formulate a prescription for footwear considering all risk factors utilising appropriate materials" (page 12).

  20. DougYoung

    DougYoung Member

    Daniel is correct. In the UK we do not have Pedorthist's and the responsibility mainly falls to Orthotist's. We cover footwear prescription and adaptations in our training syllabus.

    A patient may be referred for an assessment from other AHP, GP or Consultant, however the prescription is very much up to us. The biggest problem with prescription FW in the UK is compliance!

    There are some areas in the UK where Podiatrists will take on the responsibility of prescription FW as well.

  21. Petcu Daniel

    Petcu Daniel Active Member

    Thank you Doug!
    Can you detail a little the problem of compliance ?
  22. DougYoung

    DougYoung Member

    The biggest issues are the cosmetic appearance and construction. I can recall walking through the local town and seeing a lady who I had prescribed prescription to because of hammer toe deformities which I thought were not suitable for commercial FW. However she was wearing her old slip ons, which were narrow and poor quality. I believe she probably felt that the prescription FW were too far away from the style of shoes she wanted to wear. This is something I should have established at assessment, however patients will always say they are willing to try something, especially when it doesn't cost them anything.

  23. Petcu Daniel

    Petcu Daniel Active Member

    On Pedorthic Association of Canada website (http://www.pedorthic.ca/for-health-care-providers/ ) 2 terms are described:
    -"referral": "As part of the Canadian healthcare team, Pedorthists, like other footcare professionals, consult with patients based on referrals from physicians, nurse practitioners and other healthcare professionals." and
    -"prescription": "Once a referral is received, a pedorthist must: (....) write a prescription* for the orthopaedic products indicated (as well as manufacture the products)" where "An orthotic prescription is actually the detailed instructions on how the custom orthotics are to be made. The prescription specifically outlines the parameters of design, materials, composition and fabrication of the orthopaedic product intended to treat each patient’s unique medical needs based on the findings of the foot care professional’s clinical assessment, biomechanical examination and gait analysis."

  24. footpower

    footpower Active Member

    based on the Canadian definition, I have never in my 29 years working in Australia received a prescription. I have received referrals. While working in Germany in the 1980th, I have received many documents called a prescription but based on the above definition, those prescriptions where more like referrals calling for a foot orthoses treating a particular DX. or other service with a specified DX given on the form. However things maybe different in Germany now, after 30 years.
  25. Petcu Daniel

    Petcu Daniel Active Member

    It seems to be only the position of the PAC as in the "claim requirements" the eligible prescriptors are: physician, podiatrist, chiropractor, orthopedic surgeon, nurse practitioner and not the pedorthist (for example http://www.pac.bluecross.ca/pdf-bin/100/OrthopedicShoeClaimingChecklist.pdf ; https://uwaterloo.ca/human-resource.../orthotics_submissionrequirements_pm_2013.pdf ; http://assets.greenshield.ca/greens...pedic shoes communication (Final English).pdf ; https://umanitoba.ca/admin/human_resources/staff_benefits/pdf/bulletin-jan-2013-claim-submission.pdf ) !
    From the lab a "detail of casting technique" is required !
    Maybe this is because not all of the involved entities (PAC, insurers, ...) has the same understanding of the definition of the "prescription"! Interesting, PAC has a special section on their website for insurance industry: http://www.pedorthic.ca/insurance-providers/ !
  26. Petcu Daniel

    Petcu Daniel Active Member

    Interesting quote from Dennis Jannise:
    "For every prescription we receive that reads, "Extra-depth shoes with Velcro closures, heel-to-toe rocker soles, extended steel shanks, custom Plastazote foot orthotics with MTH offloading, and partial foot filler on L," we get ten that read, "Shoes and inserts.""
    followed by:
    "In the case of these vague and open-ended prescriptions, the next step is to contact the physician's office to request a detailed prescription. The method used often depends on the practitioner's comfort level with the physician in question. If the physician is not well known to the practitioner, the best approach may be a phone call to determine whether the physician did indeed have something more specific in mind or would prefer the practitioner simply provide whatever he or she feels is appropriate. If the latter is the case, hopefully the physician is agreeable to signing a new prescription."
    Source: Working with physicians: Footwear prescriptions (September 2013), https://opedge.com/Articles/ViewArticle/2013-09_10
  27. Boots n all

    Boots n all Well-Known Member

    l agree with what Dennis Jannise has said, it is not uncommon to get an email stating
    "Hi David, sending you another client for custom boots"

    It is purely a lack of respect. But its also reflects poorly on them, on their lack of professionalism and care for the client.

    But, to get hold of clinicians in Hospitals or private practise is not so easy or when they return the call your in clinic yourself with a client and cant take the call. Why not just send the prescription in the first place?
  28. Petcu Daniel

    Petcu Daniel Active Member

    Just found an (old ?) article on this topic. Has anyone a copy of it?

    The art of writing the footwear prescription, Lippert , Frederick G. III MD, PhD
    Current Opinion in Orthopaedics: April 2003 - Volume 14 - Issue 2 - pp 88-91
    Ankle and foot
    Informal studies and feedback from pedorthists show that prescription writing practices of referring foot care providers are often incomplete and difficult to understand. This means that footwear providers must spend time clarifying the contents of the prescription as to what is needed, especially if their pedorthic latitude is limited. The PEDS prescription writing approach: P: problems medical, biomechanical, occupational; E: effect of the problems on the foot and ankle; D: desired effect of the footwear/inserts; S: specific directions, insures that the footwear provider understands the patient's problem and what the referring provider wants the footwear to accomplish. In addition, the PEDS format specifies how much leeway the referring provider is granting to establish what will work best for the patient. The result is a new method of communicating with precision between the referring and providing sources.

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