The researcher vs the clincian

Don't forget to pack your wellies.

 

Dear Shane

While I respect your treatment protocol I cannot agree with it.

If a patient who had a severely arthtitic knee was told by his orthopaedic consultant that, he was going to treat him as a single case study and said, "you might need a new knee joint but first I'm just going to tape this stick to your leg and see how you get on. If it does not improve your knee significantly then I will not be fitting a knee joint as obviously it would be a waste of time".
How ridiculous would that be. Is this not the same as your protocol? You are going to use an inferior intervention to trial a superior intervention and make an invalid and unreliable extrapolation of data as a conclusion to your decision making process??? And if you customise a preformed orthosis so that it works then this is a custom orthotic (it is not bespoke tho) but a cheap one that won't last long.

This logic is flawed. Use your best option first.

Cheers Dave Smith

 

netizens

Podiatry is not alone with nearly all the clinical disciplines scratching for A class evidence based practice to support their current clinical practice.


Informed enquiry (research) needs to have a purpose which is bigger than personal interest if it is to meet, an altruistic ideal. For the reasons previously stated clincal surveys are more common place in clinical practice than true blue research.

An interesting development in the UK regarding diabetes care and podiatry competencies has come about because there is a total absence of A class evidence based practice. A more pragmatic path has now been taken which involves revaluing best 'known' practice. This is because there is significant anecdotal evidence to support clinical intervention but there is also a total absence of A class research to support it.

The paradigm shift does not abandon scientific approach but mearly changes the parameters of treatment assessment. Nor does it condone unquestioned continuance based on personal experience. Far from it, clinical pathways follow known (and predicted) outcomes. Some practitioners may see this as a constraint on their scope of practice whereas others view this as liberating.

Interesting times

What say you?

toeslayer

 

David et al

>If a patient who had a severely arthtitic knee was told by his orthopaedic consultant that, he was going to treat him as a single case study and said.......................

I think it is the principal of a working diagnosis (clinical hypothesis) followed by evaluation of feedback (cue acquisition) that forms the basis of a single case control, here. Taking your example the orthopaedic consultant is only accessed after all other avenues have been explored with the clinical options more clearly confined to their expertise. This scenario may not be so clear in general podiatry.

>You are going to use an inferior intervention to trial a superior intervention and make an invalid and unreliable extrapolation of data as a conclusion to your decision making process???

Bearing in mind clients rarely present without co-moribund complications which are uncomplicated a thorough history of the complaint is as revealing as detailed biophysical data.

Podiatric biomechanics swank aside, Newton's Rules determine you can either lift, tilt or wedge bits of the foot and in truth it matters not a jot what you do it with (from the armoury of podiatric materials), if as a result, painful symptoms associated with underlying pathologies subside then that is a very valuable clue to the clinician and justification to extrapolate. To do otherwise might constitute experimentation without informed consent. A "Try this and see how you go," approach in the full knowledge a practitioner cannot predict with any confidence the likely outcomes (good or bad) could be construed as unethical. Since there are no ethics in podiatry then this might be seen as bad practice.

>And if you customise a preformed orthosis so that it works then this is a custom orthotic (it is not bespoke tho) but a cheap one that won't last long.

Semantically 'custom' and 'bespoke' mean the same thing. However you do bring up an interesting point with the phrase "won't last long".

To be analytical for a moment (no criticism intended to the author), to put a value on the device's longevity would raise several questions.

Pathology
Is the condition life long and therefore requires life long care?

Prophylaxis
Is the condition transient (will respond to short term intervention) and if so what purpose does the foot orthosis serve after symptoms subside?

Aesthetic
Does a quality product equate to quality care ?
Will the client receive a rebate if the condition does not improve?

toeslayer

 

Wellies....?......translation please.

 

http://en.wikipedia.org/wiki/Wellington_boot

Oxfordshire and Gloucestershire suffered heavy flooding at the weekend-
http://news.bbc.co.uk/1/hi/uk/6912650.stm

 

Yes I can confirm that gloucestershire has already had major flooding.

So far 10,000 people have been evacuated from their homes, 45,000 have been without electricity and 350,000 will be without water for at least the next week with businesses, healthcare centres and other places of work closing due to lack of running water. The power station that supplies electricity for the 500000 inhabitants of the whole county is under threat I believe the River Severn is within 1 inch of the top of the emergency barrier that is holding the water back from the perimeter of the station. There has already been vandalism, looting and rioting. We all hope that they can re-start the water soon.

Oxfordshire has had major flooding and the Thames is at breaking point and could well overflow in the next 24hrs.

It is being referred to as the worst flooding in the UK in modern history

 

Never rains but it pours. Kevin, good luck in Oxfordshire. BTW couldn't help but notice that you're endorsing the polyprop OTC orthosis from Rx Labs - the Rx Skive - which makes great play of the advantages of the medial heel skive. Looking at the way these devices are marketed and your association with this via the product endorsement, can't help feeling there's a bit of a dichotomy/hypocrisy given your stance vis-a-vis custom -v- OTC devices earlier in this thread....

 

I don't think Rx Labs using references to Kevin's articles amounts to Kevin's endorsement of this product.
http://www.rxlabs.com/acatalog/RX_Skive.html

 

I allowed Ray Anthony to use my photo on the marketing flyer for this product relative to my creations of the medial heel skive technique and the concept that shifting ground reaction force medially on the foot creates increased supination moment. However, I don't think you could call my photo on the flyer and a description of a technique I created 15 years ago a "product endorsement" since I didn't receive any compensation for the use of my photo and he specifically doesn't use any quotes from me endorsing his specific product. If another lab wants to use my photo to discuss the use of the medial heel skive, I'm sure I would have no problems with that either, as long as they aren't tying in my photo to saying that I recommend their product over another.

Also, Mark, I don't really understand your claim that "there's a bit of a dichotomy/hypocrisy" here. When did I ever say that I never used over-the-counter foot orthoses, or that they could sometimes be useful in many types of conditions? I use over-the-counter foot orthoses daily in my practice, but prefer using prescription foot orthoses. What I did say was one does not need to start with over-the-counter orthoses when treating patients, but may start by going directly to prescription foot orthoses. I hope this clears up your confusion.

 

Hadn't seen the photo on the flyer. Is it that same old one of you Kevin in your old suit?

 

Yep.....that's the one... from 1999, I believe, when I had less glare on my forehead. I guess I should get a more recent portrait taken since the newly arrived grey hair on the sides makes me look more "mature".

 

I wish I could be mature as well as macho. If I painted the sides of my hair grey would this help?

 

Funny they claim RX Skive is a EVIDENCE BASED preformed orthosis. Are they referring to Evidence Based Medicine studies? Because I can not recall any RCT involving medial skives. Or perhaps they are referring to level 5 of evidence (http://www.cebm.net/index.aspx?o=1025)? It is curiously linked to the aim of this thread.

Regards,

 

Javier:

I don't know of any studies involving medial heel skive orthoses other than the recent one just published by Paul Scherer and colleagues (Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY: Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. JAPMA, 96:474-281, 2006). I'll be sure to mention your and Mark's comments to Ray Anthony when I lecture at his seminar at Heythrop Park in a few weeks. I never really paid much attention to these details before since I didn't have anything to do with the planning of the brochure or his advertisements for the over-the-counter orthosis his lab is selling.

 

Dear Toeslayer


David et al

>If a patient who had a severely arthtitic knee was told by his orthopaedic consultant that, he was going to treat him as a single case study and said.......................
I think it is the principal of a working diagnosis (clinical hypothesis) followed by evaluation of feedback (cue acquisition) that forms the basis of a single case control, here. Taking your example the orthopaedic consultant is only accessed after all other avenues have been explored with the clinical options more clearly confined to their expertise. This scenario may not be so clear in general podiatry.

Toeslayer, you may be right but how does it help the podiatrist or the patient to prescribe a device that only improves things a bit, with the intention of fitting something else, at a later date, that works better.

>You are going to use an inferior intervention to trial a superior intervention and make an invalid and unreliable extrapolation of data as a conclusion to your decision making process???

Bearing in mind clients rarely present without co-moribund complications which are uncomplicated a thorough history of the complaint is as revealing as detailed biophysical data.

Without Co-moribund complications which are uncomplicated? Moribund - meaning, in a dying condition. I don't understand this half of the paragraph, can you explain.

"a thorough history of the complaint is as revealing as detailed biophysical data."

Yes agreed

Podiatric biomechanics swank aside, Newton's Rules determine you can either lift, tilt or wedge bits of the foot and in truth it matters not a jot what you do it with (from the armoury of podiatric materials),

Yes it does! Material properties are a significant consideration in the prescription and construction of effective orthoses.

if as a result, painful symptoms associated with underlying pathologies subside then that is a very valuable clue to the clinician and justification to extrapolate.

But what if the symptoms do not subside, what can you conclude from that scenario? Orthotics won't work or only the temp orthoses used don't work.
What then, make another temp pair with a different prescription and hope they do the job. And if they do give a clue then why not just use a bespoke orthosis first of all and save the in between bit of waffle. It's just a waste of time and effort. And IMO only suitable for the clinician that is not sure about what they are doing.

To do otherwise might constitute experimentation without informed consent.

Surely faffing around with trial temp orthoses is experimentation. Am I misunderstanding you?

A "Try this and see how you go," approach in the full knowledge a practitioner cannot predict with any confidence the likely outcomes (good or bad) could be construed as unethical. Since there are no ethics in podiatry then this might be seen as bad practice.

Unethical? it could be, I agree, but I'm not sure which side you are arguing for now. I am pretty confident I can predict the outcome of most of my prescriptions ie they will get better.

>And if you customise a preformed orthosis so that it works then this is a custom orthotic (it is not bespoke tho) but a cheap one that won't last long.

Semantically 'custom' and 'bespoke' mean the same thing. However you do bring up an interesting point with the phrase "won't last long".

By the dictionary you are correct. To me custom or customised means to alter a generic to the customers requirements. Bespoke means to make an original to the customers requirements. If you customise an OTC product so that it is the same in every way as a bespoke product then you can no longer claim that you have fitted an OTC product. And the argument is moot.

To be analytical for a moment (no criticism intended to the author), to put a value on the device's longevity would raise several questions.

Pathology
Is the condition life long and therefore requires life long care?

Prophylaxis
Is the condition transient (will respond to short term intervention) and if so what purpose does the foot orthosis serve after symptoms subside?

The condition may be transient but most often the biomechanical aetiology is permanent. Therefore lifelong use is useful.

Aesthetic
Does a quality product equate to quality care ?
Will the client receive a rebate if the condition does not improve?

I believe a quality product will be better in the long term and enhance the patients perception that they are getting the best care and so will expect the best outcome therefore they will get it. Rebates are a comercial consideration.

If you fit two products that give the same outcome but one lasts longer, looks better and needs less maintanence, which is the better.


Cheers Dave

 

Never suggested anywhere that you said the above.

Product endorsement by association is a useful marketing ploy used by many companies, Kevin. Anyone perusing the flyer from Rx Labs could be forgiven for thinking the Rx Skive is synonymous with Kirby in much the same way that Vasyli OTC devices are synonymous with Danenberg.

Nothing wrong with that - nor is anything wrong with being associated with Rx OTC devices. I use them myself for some patients. But anyone reading your comments over the years could also be forgiven for concluding that you believe custom devices are far superior, not to say more clinically appropriate, than OTC non-specific generic casted orthoses, for any number of foot conditions. Rightly, you made a robust defence of this position on a number of occassions, especially when arguing the point against the likes of Rothbart and Glaser. I don't disagree with you - it makes sense to conclude that patient specific devices will have better outcomes than non specific devices, even though recent studies show otherwise. So why allow your name to be associated with a treatment modality you consider to be inferior?

BTW change the photograph, Kevin - think about Howard's X-rated 'fcuk me, fcuk you' pose for the Vasyli "think tank". Sex sells. Advise Ray to have you photographed naked with only the Rx Skive covering your modesty for the next flyer with the heading..."Medially deviated? Rx can fx you"

 

Please show me where I endorsed the product you speak of, Mark. My name is used in reference to the medial heel skive technique, which this product includes within its design. Many other labs use my name on their prescription order form to describe the medial heel skive technique. Other labs have posters with my name on them in regard to the "Kirby skive" and some have over-the-counter orthoses with "Kirby skives" in their advertising literature. Why are you so worried about this Mark? I have never "endorsed", as you said, any one product from any lab. You make it seem that just because I invented an orthosis technique 17 years ago, never made any money off the technique, never put my name to the technique, never patented the technique, did it for the good of podiatry and their patients, and now am not making any money off of a lab that wants to use my name to describe my technique in their literature for one of their over-the-counter orthosis products, that I am somehow personally doing something wrong?!

If you feel this way, then that is your right, Mark. However, I have no problems whatever with what I have done in this matter and if you have a problem with what RX labs is saying in their literature, then go speak to the RX labs about it. I am done with this discussion.

 

Intention to treat is not an ethical concept - it's a statistical concept:

From Hollis (http://www.bmj.com/cgi/content/full/319/7211/670?ijkey=30f24591e45bfcf352a9c2b1abb90132d7d7fc89):

"Intention to treat" is a strategy for the analysis of randomised controlled trials that compares patients in the groups to which they were originally randomly assigned. This is generally interpreted as including all patients, regardless of whether they actually satisfied the entry criteria, the treatment actually received, and subsequent withdrawal or deviation from the protocol. The intention to treat approach has two main purposes. Firstly, the approach maintains treatment groups that are similar apart from random variation. Secondly, intention to treat analysis allows for non-compliance and deviations from policy by clinicians."