Foot orthoses: how much customisation is necessary?

Craig,

So currently the variables we use in our clinical decisions are at best educated assumptions.

So what variables and why?

Agreed. But our assessment of outcomes has to be more than just improvement in pain. Have we done something that in the long run will cause pain else where?

Agreed. So how do we do this?

Regards

 

You have to come to a Boot Camp to find out :butcher:

Its not that different to what we do now. I am just arguing for a reconceptulisation of the process. Too many clinicians start with a preconception of what device they going to use and what negative model method they going to use (I include 'eyeballing' as the negative model produiction method for prefabs). I am just saying we need to set aside that precenception and come up with the list of variables that are needed, then (and only then) should the decision be made as to how to deilver those variables.

For eg the clinical tests that give us prescription variables could include: supination resistance; windlass force and timing; pressure mapping; ankle range of motion; first MP range of motion; FnHL test; midfoot stiffness; lunge test; navicular drift and drop; etc; etc; etc .... not a lot of difference to what we do now.

I just think we need to refocus ...

 

:good: :good: :good: :good: I only quoting this so that no one misses it.

 

Craig,

Agreed.

I tried but you cancelled out on me:boohoo:

When is the next Canadian leg of the tour?

Regards

 

Fair point, although (i) the paper does state that the distinction has become somewhat blurred in recent years, and (ii) as JFAR has an audience beyond the podiatry profession, such a distinction probably still holds true in a broader sense, ie: a lot of physios would be exclusively using prefabs. Still, I think we're in general agreement that some consensus needs to be developed with regard to prescription of orthoses.

The approach you are using in the Boot Camps sounds sensible and rational, but as it hasn't been published in any form, it can't yet be used by anyone designing a clinical trial.

 

Nope. Sounds like English but I don't understand a word!

The hurt is due to tissue damage. Force causes tissue damage, Moments are a measure of rotational force. Apart from force, what do YOU suggest causes tissue damage / pain?

Erm. No. this was where you lost me. Which joint? Which moments?

And I've not found you here! Do you mean what causes moments (in which case you should know) or what makes force pathological (in which case its "when it reaches sufficient levels to damage tissue). And I have no idea what you mean by the space time continuum.

Agreed! Sometimes the requires prescription variables may be BETTER served by a pre fab, other times not. Depends on the available pre fabs and the available customs. But either way, studies which measure one against the other without reference to the patients individual mechanical function can't tell us.

Nobody yet has used this phrase in this thread...

N = 1. No more. Therefore I don't beleive we will, can, or should ever reach a concensus as to whether a certain orthotic / prescription will "best deliver the variables needed" because they will behave differently depending upon who is wearing them. F-scam or not does not matter. Its not an issue of how we measure the outcome, its an issue of the outcome being individually case specific.

IMO anyway.

Regards
Robert

Regards
Robert

 

Robert,

Arn't you saying here that N=1 is enough with only our studied belief as to the effect of devices being enough as long as they appear to work.

Shouldn't we be looking at variables that are measurable, repeatable and Valid which can atleast give us a glimps as to what we are actually affecting other than resolution of pain.

Take a "moment" to think about it!

regards

 

If pain is occurring in the individual due to some type of mechanical overload, then, by definition the forces or moments that caused that mechanical overload are pathological. Now, Graham, let's see you disprove it that statement.

The theories I offer are only blind to those who don't understand the principles of basic Newtonian mechanics.

 

Kevin,

If

I agree. Where we differ is in our perception as to how and why these forces are being generated.

Understanding Newtonian mechanics is one thing. "Knowing",rather than believing, what you have done,other than relieve pain, when you apply the theory through a foot orthoses is another.

Regards

 

What do you know Graham that the rest of us do not?

Is this the same old "sagittal plane" stuff ? Use an F-scan and suddenly you will see all! Are you a consultant for Tekscan as well as Howard ?

Has anyone ever produced any evidence that any of the F-scan pictures actually demonstrate anything about foot function? Anyone ever shown that the pressure patterns due to FnHL correalated to hip extension for instance? Anyone ever shown that increasing pressure under the 1st met with an orthotic decreases FnHL or increases hip exension?

What do you "know" and what do you "believe"?

L

 

Lawrence,

Very little if anything. I do know how to train Chessapeak Bay Retrievers for Hunt Tests and field trials, Do you?

What I know is that the parameters Howard says you can look at with F-Scan and change with a foot orthoses can be looked at and changed. What I believe is that we need to do as Hylton suggests and really look at measurable "parametes". Do the reliability and validity stuff and then see how these parameters are altered with various approaches.

Regards

 

No. Do you follow at all what i'm talking about when i talk about N=1

Ask the patients.
"well mrs P I have good news! your pressure track is in the right place. Your patterns are all as my computer says they should be. The insoles have done everything they were meant to"

"But my foot still hurts"

"thats not important."

And you did not answer my question

And you did not clarify your previous statement

Regards
Robert

 

Graham,
What do you mean by parameters that you can look at with the F-scan. Are you just looking at the roll over process? Or are you actually doing something with the numbers provided by the F-scan? Do you actually calculate speed of progression of the center of pressure path. Looking at computer screen is analogous to looking at a slow motion video. It may look a little different between trials, but unless you compare numbers you don't know that it is different.

Then, once you know there is a difference in the numbers, you can do the pain relief study compared to those numbers.

Cheers,
Eric

 

Robert,

Yes.

You previously wrote:

Looks like an N=1.

As said to Kevin:

Seems pretty clear toe: Probably should have said "Tissue" instead of Joint.

 

Eric,

I haven't used F-Scan for a few years. You know what Howard and Bruce look at. I agree that numbers are requ9red for true comparisons but not sure how this can be acheived by F-SCAN today.

I am just throwing out some idea's as to mull around Hylton's suggestion. The problem is many seem to get defensive because someone disagrees with them. We need to park the ego's and start looking at this from all points of views. Can we make this happen or do we just fall back to the old theoretical debates with no attempt at proof!

In other words, arn't we just selling a different smelling snake oil than Dennis et al?

Regards

 

A clipfrom the discussions we had in 1998. I guess not much has changed!

Subject: Re: Normal testable parametres and Normal Clinicalobservations
From: Fullerpod <[log in to unmask]>
Reply-To: [log in to unmask]
Date: Mon, 30 Mar 1998 01:00:44 EST
Content-Type: text/plain
Parts/Attachments:
Parts/Attachments

text/plain (57 lines)

In a message dated 98-03-26 08:07:43 EST, Graham wrote

>
> We have to make a diferention between normal testable parameters, ie
> timing of events, force moments, muscle activity etc and what we have
> been trying to describe clinically as normal, for example pronation and
> supination.
>
> The first are measurable and defined and if not defined but measurable
> can be reasearched effectively. The second has proven dificult to
> assess and we have as yet to demonstrate a definative causation link
> with these to symptomatology. We have assumed they are contributing
> to the pathology simply because they are there and we can see them.
>
>
>

I agree, and if the measurements do correlate with pathology that still does
not imply causation.

On the where to proceed debate I would recommend the following article. Nigg
BM. Bobbert M. On the potential of various approaches in load analysis to
reduce the frequency of sports injuries. Journal of Biomechanics. 23 Suppl
1:3 12, 1990.

To summarize, the authors of that article describe two fundamental approaches.
An empirical approach and a modeling approach. In the empirical approach you
find a measurable parameter that correlates, prospectively, with a pathology
and then you alter that parameter and the pathology improves then you have
found something. The modeling approach requires that you create a model of
the structures that are injured and then analyze how the forces on that
structure can be altered. the modeling approach tries to predict stress in a
structure from external measurements. These methods can be combined. The
modeling approach may help you find the parameter that you use in the
empirical approach. It will also help provide the rationale for the
parameter. I also talk about this in my chapter on computer gait analysis in
Valmassey's text.

There are two issues here. Diagnosis and treatment. I don't feel that these
parameters are going to be useful for diagnosis. We will never know if the
pain causes the gait or the gait causes the pain. I feel that establishing
normal values is not necessary, for treatment, in this approach. All you
have to do is identify the structure that is injured and then know in which
direction to "push" the foot to decrease stress on that structure. I believe
someone commented that the activity level of the patient should be taken into
account. I agree. Normal values of stress in abnormal circumstances may
cause pathology. We need to know how to push the foot away from pathology and
not necessarily toward normal or average.

Eric Fuller, DPM
Associate Professor of Podiatric Medicine
California College of Podiatric Medicine

 

I dont know what a Chessapeak Bay Retriever is! So that's one to you :drinks


Bottom line from our current knowledge base, consensus on treatment has to be outcome driven and the accepted medical model is one of measuring success on the presence or absence of symptoms. Surely to get to a consensus on that would be a big step?

I agree with other posters that what is lacking from current research is "real world" treatment. I dont post every orthotic the same, give everyone a heel skive or thick anterior shell or forefoot pad. My patients orthotics at the end of their treatment may be very different to the one they started with. If I did give everyone the same prescription and never did any alterations I would expect there would be every likelyhood that the "custom" devices would be no better and possibly worse than a pre-fabricated device such as a Vasyli.

Any trial that gives every patient the same prescription, even one based on a poll of the "average prescription of the average podiatrist" (whatever that is and who would believe such a poll??), is pointless. This should be at the heart of any commentary on orthotic therapy research.

 

Lawrence:

Excellent statement!:good:

These are the best thoughts so far in this thread. Good job.:drinks

 

Kevin and Lawrence,

You are missing the point. Hylton is suggesting we come to a concensus with regard to clinical measures that we use to come up with the prescription in the first place. Of course each patient will have individual requirements but how do we decide what these are?

Regards

 

Graham:

I don't believe that I am missing the point. I'll let Lawrence speak for himself.

I agree with Hylton that something needs to be done in regard to having some standards for custom foot orthosis therapy so that some good studies may be performed regarding the therapeutic effectiveness of prefabricated versus custom foot orthoses. Unfortunately, if I were asked to come up with a set of standards for what I measure, what I look for and then what exact type of orthosis I would prescribe for each patient with each foot and/or lower extremity pathology, this would create great difficulty for me. The point is that 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 I have gained from my professors and my years of treating patients. I have written three books on these types of subjects and I still haven't described 2/3rds of the techniques and "tricks" I use when treating patients in order to optimize their custom foot orthosis therapy.

That being said, I will happily take the time and work with anyone to try and help improve our collective knowledge towards the goals that Hylton is working towards. I am volunteering my expertise, if it is wanted or necessary in order to make this important and long-overdue project be successfully completed.

 

Fantastic, the level of enthusiasm is wonderful.
Lots of great ideas, plenty of them with merit. But after all the theory and research when you go to the clinic and see patients there is a variable that we can't control or allow for, which is individual patient tolerance. We all know this is a huge variable, and even if we have an established and accepted protocol for arriving at a series of orthosis design parameters for a particular problem in a particular individual, if they can't tolerate that, then you do what they can tolerate. I look forward to having the "UNIFIED FIELD THEORY OF HUMAN FOOT FUNCTION" and the "UNIVERSAL TREATMENT ALGORYTHM" but even when you guys provide me with it, it will be feedback from my patient that is driving what goes on with my treatment.
regards Phill Carter

 

There is no reason why "tolerance" is not part of the systematic assessment protocol that derives design parameters for the "tolerance"issues. Once ALL of the prescription variables are determined, of which tolerance issues is just one, the decision on how to deliver that variables via orthotics design parameters can be made

I know of several people currently working on 'tolerance' issues and look forward to incorporating it in a more systematic way when it becomes available.

 

Hi Phil,

I'm not sure who at La Trobe University said this, but it is blatantly untrue. I know no-one here that would want to give orthotic manufacturing away to the profession of Prosthetics and Orthotics. Phil, this is a public forum and you must get your facts right, and if you write material like this you must have proof to back up your statements.

We do, however, have a constant discussion, and it has been going on now for 15 years, about the merits of teaching manufacturing skills to undergraduate students; however we still teach them, and probably will still teach them for many years to come. We also have an external advisory committee that meets a few times every year, which includes valued members of the profession (both from the public and private sector) that help us shape the course that we teach.

Over the past few years we have also focused more on teaching better prescription habits to students. I think we would love to be able to one day stop teaching manufacturing skills to undergraduate students because of the expense and time it takes, but that day has not arrived yet. Hopefully, with the advent of scanners and cad-cam technology we might soon be able to direct more attention to the prescription of orthoses rather than the manufacturing process. I'm sure anyone that has manufactured lots of orthoses themselves (and that includes me for those who suggest otherwise!) would agree that if the technology allows us to produce devices that are the same, or even better than if we made them ourselves, then that has to be a good thing.

Cheers,

Karl Landorf
Acting Head of the Department of Podiatry

 

Hi Everyone,

While I am interested in some of this discussion can I remind contributors that this is a public forum - unmeasured and rude comments about colleagues are not appropriate, and definitely add nothing to the debate. Some of the comments posted early in this thread border on being defamatory, so could I politely request that people stick to the point of discussion, and resist from making personal jibes.

Some of the following postings are particularly distasteful:

LL and K, I am surprised by these comments and hope that they do not reflect where we are heading as a profession.

Karl

 

The thing I struggle with is that to truly measure X vs Y, X needs to always be X and Y needs to always be Y.. When you measure custom orthoses (X) against OTC orthoses (Y) for a given pathology doesn't X now change with every different prescription, method of casting, material used etc.. So X is an ever changing variable.. and isn't that impossible to then standardise and measure?

Thus to truely measure it you need to give the same prescription for each patient in the customised orthoses group. Does this not then take away the customisation part?

 

Your physio coleague is 100% correct.

Accordingly, the sad truth is, that despite its intentions, such volumes of research has been to the detriment of how your average physio approaches back pain.

"Non-specific-back-pain" was the lazy manifestation of the convenience of a large pidgeon-hole. An 8 year old can come up with such a diagnosis without one test.

We have lost a generation without the meticulous assessment skills. Core stability exercises was THE answer for all back pain. (According to the GP, it was walking) When you have one solution, no need to assess.


With all the research, with all the modern medicine, it is paradoxical at where we are today.



Having said all this, I think this OTC v. custom question has merit from a cost-effective viewpoint. I find it intriguing that so many of my customs look the same?


Ron
Physiotherapist (Masters) & Podiatrist

 

Karl:

My goal, as a podiatrist, with a quarter century of teaching biomechanics and foot orthosis therapy to students and clinicians, is to improve the podiatric profession internationally and improve the ability of podiatrists to make the best foot orthoses for their patients so that people around the world with sore feet and lower extremities due to mechanically-based foot and lower extremity pathology are more happy and healthy. I would like to see both podiatric researchers and clinicians striving toward that same goal. However, I also strongly believe that custom foot orthoses are vastly superior to prefabricated foot orthoses. Therefore, I will continue to do what ever I can during my lifetime to make certain that the wonderful therapeutic benefits of this most valuable treatment modality are not shortchanged or dismissed as being somehow equivalent or equal to prefabricated foot orthoses. I hope all of us here on Podiatry Arena share this common goal so that all our patients can have more productive, healthy and fulfilling lives.

 

You've got it!

You could break it down one level further. If you make x the effect of the orthotic then x will be variable even within the same prescription and casting protocol!

That's why, IMO, trying to reach a concensus as to what customization works best for what is futile.

Regards
Robert

 

This has become an excellent thread.

I have heard this also through a Physio colleague of mine here who specialises in LBP. He used this study-
Ferreira et al- 'Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial'- Pain. 2007 Sep;131(1-2):31-7.
...as an example where no differrence was found between treatment modalities. I understand that the design was very robust, but it has received much criticism from practitioners who point out that the treatment was not directed- all non-specific LBP received the same treatment- without looking at the finer mechanisms.
I am sure Ron knows this paper an can probably expand in this if necessary...

When I saw this, I could not help but see the similarity with Karl's Plantar Fasciitis paper comparing the Pre-forms and Customs- robust study design, but practitioners dismiss it as they feel that it is not reflective of what a skilled practitioner does in practice. It is not directed treatment.

CP picks up on another very real issue with this- the line is extremely blurry between custom and prefab- and probably more than many realise.
I have been looking at many manufacturing systems to try and improve efficiency- most CADCAM systems I have seen only use the scan to give the dimensions of the orthotic. They are sold and prescribed as a bespoke custom device. You certainly can make all sort of modifications to the base model, but is this a true bespoke device if it does not recognise the morphological nuances of the foot? Does this matter?
Labs that use plaster models also are guilty of producing very generic devices even though they are using the direct model- it is all about how the plaster additions are done...
For many patients it probably doesn't matter with respect to their symptomology, but perhaps it affects other aspects of what the orthosis does... such as comfort, feedback from the ground etc.

Perhaps we could look at this in another way-
If you have an orthotic 'failure', what is it about the orthotic that did not achieve the desired effect? (assuming that you can pinpoint that the orthotic was not up to scratch- obviously there are many aspects to treatment).

 

A thought that I just had was, would it be possible to use a CADCAM Type 3d scanner a bit like a force plate.. get the patient to walk over the scanner, analyse how the foot is operating during stance phase and then specifically tailor a design based on the Dynamic measurements of the foot and your assessment.. i guess we kinda do that already but not seen a scanner used in such a way.. I bet you could get some pretty interesting data on exactly how the foot is operating. It'd kinda be a cross between the F-Scan and video gait analysis but building a model in 3d on the computer taken from the plantar aspect. Can it be/is it being done?

Just thinking out loud..

 

Hi Karl,
I am not reporting hearsay, I was there and heard it said myself 3 years ago. Strangely enough a Latrobe student I was speaking to lately repeated the comment almost word for word in the past few months. At that time there was discussion of taking orthoses out of the curriculum and making it a post grad ticket, maybe this idea has died since?
Hi Craig,
I be very glad to find out how you can test in advance how somebody might or might not tolerate the shape of a particular device in advance, without putting that device under them in order to find out. It will save problems to be able to do that for sure, at this stage that whole thing is experienced guesstimation and as far as I have observed this problem tends to cause labs to make easily tolerated shapes and presription variables that offer minimal functional change. Which obviously works fine for some folks. Its the ones that are further from average that seem to continue to have trouble.
regards Phill

 

There are people working on issues like testing different shell flexibilities and see what predicts "tolerance" - using things like sensitivity tests; planal dominance and joint stiffness .... if it can be made somewhat predictable, then altering shell flexibility will be a design parameter coming out of clinical assessments of these things.

I even have in some notes I wrote at a conference a very long time ago that I just relooked at - it was about a tolerance test prior to use of orthotics. The test was to have patient stand and rotate their pelvis maximally to the left and to the right; then observe how much the arch comes up during the movement ---> apparently the less the arch move the less tolerant patients are of more rigid orthotics. I have no idea of the validity of the test as I have never tried it. I did make a note at the conference to follow this up with the speaker, but didn't. ... but I did see him last week, so will now follow up with them to see if I got the understanding right.

Its tests like this (assuming it pans out) that will go into the "systematic assessment to derive prescription variables" that I keep talking about.

My understanding is this was just an option on the table like many other options. Like all teaching we do, its constantly under review and discussion.

 

One final posting from me re these statements:

Each of these statements is heading toward the territory occupied by the manual therapy/alternative therapy professions, ie: that clinical practice is so complex and patient-specific that it is "unresearchable". For example, a recent paper in International Musculoskeletal Medicine (link) titled "Why myofascial release will never be evidence-based" essentially concludes that patients are so variable, and responses to treatment so heavily influenced by clinical experience, that there is no point conducting any further trials of this treatment.

I don't accept this argument. Surely patients with multiple comorbidities (eg: diabetes, hypertension, osteoarthritis) being managed by their GP are equally, if not more complex to treat, yet the medical profession manages to do pretty well by implementing treatments based on consensus guidelines and informed by clinical experience. I'd be worried if my GP starting mixing up some strange concoction of drugs during a consultation rather than following a treatment protocol recommended by an expert panel of clinicians and researchers based on the best available evidence. Granted, it's not a perfect analogy, but you get my point.

Although I don't accept the argument made in this paper, I actually have a lot of respect for the author, as he has made a fairly bold decision to align himself with this alternative view. If some of the contributors to the current discussion took the same approach, I'd have the same level of respect. However, there does seem to be some degree of having it both ways, in that studies where custom orthoses are found to be effective are warmly embraced (even though the orthoses weren't prescribed, manufactured or adjusted by them personally), while those that have a less favourable conclusion are reflexly criticised.

I guess the bottom line is that the profession needs make a decision that (i) foot orthoses are researchable, or (ii) they are not. If the former, then we need to get on with the business of some level of consensus and standardisation in order to make progress. If the latter, then we need to be bold enough to accept the consequences, ie: that foot orthoses can only be considered to be an alternative or complementary form of therapy.

I hope that, despite the mudslinging that many Podiatry Arena discussions unfortunately descend to, the discussion prompted by my commentary eventually has some positive outcome.

Time for me to retreat from the harsh "real" world to the cloistered safety and comfort of my ivory tower ....

 

Karl

"Nevertheless, it would take a very brave individual to claim that foot orthoses are nothing more than rebranded arch supports, particularly when an entire industry is sustained by the premise that modern foot orthoses are somehow different."

rebranded = deliberately trying to change the image of orthotics from arch support into something more valuble even when it does not have have a greater value by an "industry" sustained by that increase in value.

I think this is also potentially defammatory and I don't think the postings in this thread have been defensive, they have been people upset by this statement and others. I'm not missing the point that there is insufficient research but can I not raise objections about what I saw as headline-grabbing phrasing?

I sense that a big hand is looming over the thread shut down button, so otherwise may I say "well done!" to Hylton for obviously generating passionate debate!!

Current research lacks specificity - same orthotic, different subjects = poor outcome, unreflective of practice. Future trials need to be along the lines of the LBP study outline earlier with subjects with condition x being split into foot types - for want of a better word - each of these receiveing an orthotic prescription relevent to their structure. Perhaps also a protocol for orthotic modification post fitting needs to be built in to the study.

As Hylton says maybe the way to decide on "the foot types", the prescriptions and the possible post-fitting modifications and their indications could be decided by consensus polling of experts.

 

Ooooo, you scamp

Perish the very thought.

I think that biomechanics is absolutly researchable. It just depends on how one considers research.

Let us consider, for example, the idea of a reverse mortons extension for the tx of FnHL. This is at the top of my mind because it was being discussed on another thread in context of which prescription and whether top covers affect the function. So what research could we do there?

Well, we could start with the hypothesis that the orthotic I tend to favour (a simple) can improve FnHl. So we look at the null, that this orthotic CAN'T.

We know the mechanism for FnHL, the situation where the internal planterflexion MOMENTS (Graham) exceed the external dorsiflexion moments.

The goal of the orthotic is therefore to reduce the internal planterflexion moments. Simple way to test this, pop the hallux in a sling with a set of fishing scales on the end and yoink (technical term) up on the hallux til it moves to a set angle. The amount of external dorsi moments (look on the scales) will at that point be equal to the internal planter moments (which we're trying to reduce).

So we cut the toes out of a pair of shoes and try the experiment with and then without the orthotic. Hopefully we will disprove the null. If we don't, if its the same, we have not proven that the device CAN'T work, simply that it did'nt that time in that foot.

Research into orthotics. Without which, as you rightly say, all is hearsay and opinion.

BUT. We cannot do a larger comparative study with 2 types of orthotic and try to reach a concensus as to which we should be using because which works best might depend on why the fnHL is there and the biometric and morphological vaguaries of that particular foot. Sometimes I use a casted device with a reverse mortons, depends on the foot. I would'nt say either are better, they're simply different.

So I'd argue that we can research biomechanics and orthotics might be used in that research, however that is not to say we can derive from that research that device A is "best practice" for condition B.

Regards
Robert

 

Robert,

I believe we need to develop a concencus of assessment parameters, which are valid, and repeatable, first. Having a set of measurable parameters which can be compared to an "ideal", an be observed not to be ideal and can be altered, positively or negatively, with a foot orthoses will allow us to then to customise our prescriptions to the individuals we see. And compare OTCs as to their effects on these parameters.

Obviously,in many cases we are dealing with significantly "damaged goods" and we will not be able to bring many clients back to the ideal. We may,however, be able to observe measurable ranges of tolerance that could help gain the most optimum beneficial effect or our clients. This may also educate us as to what and why some techniques work over others.

I'm not saying inshoe measurements are the only way to do this, but as this is the enviroment we work in it is extremely important.

No need to bombard me with the obvious variables of life. This will always be a frustratingly unsolveable point of contention.

Regards

 

Any intelligent podiatrist can determine which way a researcher or clinician leans in the prefabricated versus custom foot orthosis debate when they read what they have written in the past about the subject. Are they being fair and objective, or do they seem to have an agenda or a chip on their shoulder, one way or another? Actions of individuals speak very clearly, in my book, and I can see very clearly what is happening. Therefore, before the governmental authorities and insurance companies remove custom foot orthoses from the treatment options for our ailing patients, we must all, both podiatric researchers and podiatric clinicians, work toward the goal of making certain that the true therapeutic benefits of custom foot orthosis are clearly shown by well-designed research. Please, let us all work together toward that goal for the benefit of our patients and for the future of the podiatric profession worldwide.

 

Groundhog thread.

With respect, I think there IS a need because that is the very crux of this whole debate :bang:.:deadhorse:

You Said

And for the umpteenth time I have to ask:-

What is "Ideal"?

Who decides what is "ideal" and how?

And how can there be a single "ideal" functional concept, whether with f-scan or any other method of observation, which fits a 13 year old boy, a 25 year old sedendary IT consultant, a 30 year old elite sprinter, a 40 year old Playstation junkie weighing 200 kilos and a 70 year old with two plastic hips, a dicky bladder and a zimmer frame? Are you really proposing that we seek to make all of these people function the same?! Is "Ideal" the same for all of them? And if not, how many "ideals" do we need?

This is a fundamental issue in biomechanics. Do we seek, with our devices, to move people TOWARDS a predetermined "normal" (be that a Good ole' Root STJ neutral or a nice looking fscan COP track) or AWAY from the perceived tissue trauma (as per the tissue stress model). That will often be the same direction, but not always!

Regards
Robert
In desparate need of a Robeer

 

Kevin,

This is a two way street:boxing:

 

Robert,

That my friend IS the first question to be asked and validated. Without a concencus on this we can go no further.

The working group suggested by Hylton would make the suggestions as to what can and needs to be measured. The research would hopefully identify ranges within these measurable parameters that are considered to be ideal based on the best information to date.

We have not yet cut the research question down to this basic requirement. Currently our cart is before the horse.

regards