"The Orthotic Professions"

Members do not see these Ads. Sign Up.

On another thread, Dr. Wedemeyer referred to the "standards and accepted practices (of biomechanics) in podiatry and the orthotic professions"

I submit that the following internet site and video claiming to have dispensed thousands of custom foot orthotics using subtalar joint neutral casting is the standard accepted practice of biomechanics in that more orthotics are dispensed using its paradigm as any of the others combined by an amorphous group of practitioners, shopkeepers and scanners that defy consensus.

Not the tissue stress, pathology specific, foot centering, MASS or sagittal plane block theories.

http://www.customorthotics.com/ is the url and the video works on that page.

Tell me what standard of care it represents?

I submit, this is the standard of care that we are all working to improve in our own ways as (mostly) Podiatrists looking for Consensus For a Standard of Care for Biomechanics,

Can we start by listing "The Orthotic Professions" as in:
members of a given profession with inherit ability to dispense Custom Foot Orthotics based on the EBM that custom foot orthotics work.

Dr Sha

 

The trained professions are DPM, CO, C.Ped Dr. Shavelson. Prescribing and dispensing though is within the license of DC's and PT's.

Prescribing is limited by state I believe and CO's and Cped's are supposed to obtain a script to dispense custom devices (medical necessity) as well. There may be others I am not certain at the moment.

Since when is MASSSS a theory?

The term orthotic is very broad language, a popsicle stick taped to the phalanges post sprain can be an orthotic. Dr. Scholls and Costco sell 'orthotics' right? With this ambiguity in language in place it is no wonder that custom no longer means custom and that patients do not understand the difference.

 

Sheeeesh. That is poor by any standard!

 

Further.

I think that it is difficult to state what the "majority" of podiatrists are doing. There is the Root protocol, but I would say that almost nobody uses this any more. How many pods, as a straw pole, could name all 8 criteria for normalcy on demand? I would venture almost none. I'm not sure I could. How many people DON'T use the talar head method?

"neutral casting" seems to have become like a mantra. A label which people apply to the mish mash of post root and pseudo-rootian methods and beliefs to give respectability to what they do. Leave alone the absurd inaccuracy of the measurements, I can't remember seeing anyone find STJ neutral by the 2/3rds method in clinic. Always it was the talar head congruence method and that can be an entirely different position.

Also, Foam was unknown as a casting medium in the days of Root and Foam gives quite a different shape cast to POP.

So no, I don't think this can be said to be representative of the majority.

I don't know if "pronation = bad, Supination = Good" has a name as a paradigm, but it seems to be how many people think. The different connotations of neutral people cast in have little in common other than that they are more supinated than RSCP. To call them a single paradigm would be a mistake. Its not Root. Its not any one single paradigm. About the only thing which defines it is the LACK of a coherent system. I suppose as a paradigm it would be classed as "the rest".

 

So does that mean that DPM's like Dr. Bowden and those that Dr. Kirby, I and other academicians with a passion for biomechanics feel lack appropriate biomechanical experience, education, evidenciary knowledge and passion are using their Podiatry credentials unfairly when marketing and serving the public with orthotics that dilute The Standard?

So does that mean that the poorly educated, clinically inept, poorly trained professionals like CO's and C.peds without evidenciary knowledge (unlike you) and a license to diagnose or develop a treatment plan for biomechanical complaints are using their credentials unfairly and being misleading when marketing and serving the public with orthotics that dilute The Standard?

So does that mean that we agree that unless DC's or PT's that do not gain additional education and "training" and follow the evidence (like you) at some level, are prescribing and dispensing CFO's at a low level and using their professional credentials unfairly and being misleading when marketing and serving the public with orthotics that dilute The Standard

I am not even discussing the shoe stores, ski shops, athletic trainers and kiosk foamers and casters as well as the "Custom Fit" pharmacy scanners that have gained a piece of the orthotic marketplace totally without any credentials, education or evidenciary weight are unfair and misleading when marketing and serving the public with orthotics that dilute The Standard?

I submit that these groups are dispensing most of the orthotics to the foot and postural suffering public and that they are closer to Dr. Bowden than you or I and by volume, ARE The Standard

Furthermore, can we admit in open debate that we (you or I or kevin or ed or craig) have no right to claim that our CFO's (yours, mine, kevin's, ed's, craigs,etc) are The Standard as you are doing in your posts.

Dr Sha

 

Thank you Dennis for bringing up this subject. The problem as I see it, it there are no standards that are accepted across the world. As also pointed out, almost anyone can claim to be an expert on biomechanics and orthotics. Shoe salesman, running stores and almost anyone is now getting in on orthotics. The question is how to we develop those standards? Should we be meeting with the international biomechanics groups perhaps as a commission? Should we try to come to some common standards on this forum? There are times we can't get along on this forum, how are we going to put aside egos and come to some common standards that would benefit our patients? The American Foot and Ankle Society (orthopaedic) developed a pain index using the pain level and faces similar to those used in psychology and that is now a standard. It is going to be difficult but some standard would benefit our patients and the public. There are common grounds on all school of thoughts (since we do not want to call them theories) that is the basics for foot orthotics.

The other thing we need to do is develop fellowships in biomechanics and orthotics. Another topic I suppose.

 

It was started but for some reason nothing was reported from a "meeting" at a conference to kick start the project (which may not even have happened ?)- http://www.podiatry-arena.com/podiatry-forum/forumdisplay.php?f=85

 

This reminds me. Recently I had to move my clinic due to renovations being carried out in the building I was in. A local Chiropractor heard about my predicament through a mutual patient & thus called me to offer a couple of rooms where he was.

After checking over the rooms, he advised me that he also prescribed orthotics (I knew this as I noticed the advertisement in the waiting room regarding "custom orthotics"). He advised me he uses Foot Levelers... & they are good because they are "flexible"... not "hard". Being that I had not long been through a legal issue with the company Foot Levelers on account of what I wrote about their product, I advised him of this fact & subsequently what I thought of them. I thought I be open & upfront as he would undoubtedly find out sooner or later of my views. This didn't seem to phase him too much & offered to show me what he did (amazed by this, I thought this was an opportunity too good to pass by), thus I agreed.

He showed me a box with a glass window top deck which the patient stood on. A photo/image was taken from underneath to reveal the contour of the footprint... these images were then emailed to the U.S, where based on these images the foot was assessed & an appropriate/corresponding orthotic (or is it insole) was issued/fabricated (not sure to what extent) & then returned. Putting the nature of the assessment & fabrication issues aside...

He then showed me some Foot Leveler orthotic/insole samples which were on his desk. I already knew what these looked like due to patients coming to me with unresolved issues (of which have kept or taken photos of). However, there was one orthotic in particular I was interested in. This particular one had a rearfoot valgus wedge. I said... "hmmm, this looks interesting... an orthotic with a rearfoot valgus wedge". Not intending to put him on the spot, I just out of curiosity of the moment asked... "do you know what this is used for?" He noticed that this particular rearfoot wedge was opposite to the others, which he never noticed before but didn't know the implications/clinical use for it. I described the significance of it & in what circumstances/conditions it is useful for. He then quizzed me on what I thought Chiropractors do (which I thought interesting) of which I gave a "spot on" answer to... we then shortly parted company.

However, I left pondering on the differences of our assessments with regard to orthotic therapy & his limited knowledge of the basic principles of orthotic therapy (we didn’t even get into the biomechanics aspect). I have had patients come to me due to unresolved issues & their subsequent poor experience with “orthotics”, of which has included the Foot Leveler variety; which entail has made my job that much harder to advise that not all orthotic devices are the same... & that there is an effective treatment for your condition.

It would seem companies like Foot Leveler & The Orthotic Group (who I have also had close association with) are exploiting this non-regulated area via targeting anyone in a profession of diagnosis & treatment (particularly the Chiropractic field) who have very limited background knowledge on the associated biomechanics & virtually no knowledge on orthotic therapy itself... to then prescribe orthotics themselves (however, I’m sure there are some who have studied in this area). Now we have many more orthotic devices out there through the use of their systems (i.e. TOG footscan) which dumbify the assessment process in order for a virtual prefab of sorts be dispensed at an inflated price due to the fact it has “custom” associated with it & that it was prescribed from a health care professional (regardless of knowledge in this particular area). Foot Levelers & The Orthotic Group (TOG) are primarily the main players in this type of practice with interest in one thing – pushing more orthotic revenue through their prescribers (for obvious financial reasons). I’ve seen it through The Orthotic Group (TOG) with their marketing hype & encouragement to asses every client who walks through the door regardless.

I have it on solid word that TOG does not fabricate orthotics from scratch based on whatever assessment was done (including impression mould or casting of foot)... I was told they are prefabs after specific questioning on the topic... which is hardly custom as is advertised in their literature & promotion material to the practitioner. What’s the bet that the orthotic practices in question in this thread (i.e. http://www.customorthotics.com/) is of a similar nature. Albeit, the word “custom” with association with orthotics is another aspect regarding orthotic therapy that needs to be defined as it is a rather loose term & subject to subjectivity.

I have no doubt the Chiropractor I visited is very good at what he had been trained to do... in fact, I have heard this to be the case; but I seriously question his orthotic therapy knowledge/treatment of which he has “custom made flexible orthotics” advertised in his newsletter & waiting room. I am also not stating that the area of orthotic therapy is the sole domain of the Podiatry profession but there certainly needs to be something done to the regulating of the practice... before it develops an undue reputation of a sham.

 

The man has a point.

Of course it all depends on how you define standard.

By "average", the "hold the foot in the ideal sub talar neutral position" model probably represents the apex of the Gaussian curve, with the Worse still at one extreme and the top level clinicians on the other.

Of course if we take the "authority" line then we need to agree on the authority...

 

Don't forget about footmax orthotics. You email the gait scan to toronto and they tell you whether or not the patient needs orthotics and they then select the type.

One of my patients went to a D.C., C.Ped. Who gained his CPed from his "experience" peddling TOG prefab custom selected "orthotics", she was told she didn't need them because she wasn't over-pronating. She has anterior cavus deformity with heavy loading of metatarsals and related corns and callus. Fortunately she did opt for some truly custom ones from me and should be on her way to relieving her corns. Of course her orthotics are not based on SALRE rather accommodation of the forefoot plantarflexion deformity.

Another favorite question is "are these going to be those big block orthotics that are so hard to get in your shoe?" aka one type fits all AMFITs.

Sarah

 

Btw way to devalue orthotics, Retired Dr. Bowden. We pay for service, assessment follow-up etc. A neutral shell doesn't work for everyone.

Stores have to pay rent electric employees etc hence retail mark-up. We have to pay for similar and student loans and liability/registration fees hence professional fees.

Perhaps he's also one of the (I shall not say it) who helped flush the profession down the toilet by offering to undercut his peers to become preferred amongst insurance companies. They don't control the costs for us, they should not be able to dictate prices.

S

 

Hmmm. Perhaps it would be well to wait for the improvement to actually happen before you congratulate yourself TOO much

Careful. The ice you are on is creaking.

One of the things which does our profession little credit is how willing some people are to roll their eyes heavenward at other peoples "mistakes". Firstly, remember that whatever you do with such a patient has the benefit of hindsight. Secondly, remember that as sure as eggs are eggs somebody, somewhere, will be removing your best efforts from a shoe and tutting at them. Lastly remember that satisfied customers rarely seek second opinions. You will only ever see other peoples failiures. Thats not representative of their whole practice.

We all do it sometimes. We should probably do it less.

 

Dr. Shavelson your questions are excellent, as are the responses from others above. I won’t pick at Dr. Bowden but I will say that he is not the only colleague of yours that I have encountered who has marketed via the internet a “custom orthotic”. Clearly the term orthotic is a generic one and the meaning of custom has lost its value along the way. Would you agree? Is it best practice to offer devices in this way? I believe we would all say no, at least not for pathology.

On that subject you have suggested that “wellness” is the new paradigm shift for custom orthoses and it is not the standard by which the majority of your profession practices, prescribes and dispenses is it? The great majority of CFO’s dispensed by DPM’s are for pathology are they not? What you see out of most DC and many PT offices is in fact based on this wellness paradigm.

You made the statement that CO’s and CPed’s are “poorly educated, clinically inept, poorly trained professionals”. I don’t take offense to that personally because I am confident in my own clinical skills but that is a very derisive admonition dart. Those professions are required to obtain a script from a duly licensed professional (MD, DO, DPM, DC) prior to dispensing; allegedly anyway. They are the professions that often manufacture and fit those devices for physicians and they make evaluations and follow the treatment plan of that physician, or should. My point is there is no reason to deride other professions, there is a great deal of overlap and licensure regulating certain practices and prescribing rights amongst the health professions to limit this to qualified professions exists in a paltry number of states in the U.S. You don’t have to agree with it but it is the reality and that is why the chain pedorthic stores have flourished; zero control over the industry.

I would have to agree that much of what is offered by DC’s and PT’s without additional training is substandard. At the same time would you disagree that with an upgrade in training that either of these professions is unqualified to prescribe and dispense CFO’s? I’m not holding myself out there as any sort of authority or expert but clearly I have studied the subject like few others in my profession, gained additional licensure, served Medicare as a supplier for the diabetic community, receive the bulk of what I dispense on referral from physicians and now endeavor to improve the skills of my colleagues open to improving their skill set. You may never accept me as a distant colleague Dr. Shavelson and that is fine but my goals are really no different in some respects to your own; improving and promoting the best care that we can afford our patients despite my primary license.

Dr. Nunan’s comments are excellent:

“It is going to be difficult but some standard would benefit our patients and the public. There are common grounds on all school of thoughts (since we do not want to call them theories) that is the basics for foot orthotics. The other thing we need to do is develop fellowships in biomechanics and orthotics”

Well stated Dr. Nunan and precisely the point that I was trying to make with Dr. Shavelson on the other thread. There exists a common basis for the methods used to mediate pathology with CFO's.

Wellness though is not taught within these standards in the professions with any level of training but many professions sure have found methods to exploit the concept and make a buck. I would term that type of dispensing an orthotic or generic device.

 

Are you sure about that Sarah, the CPed program in Canada to my knowledge is a baccalaureate degree and TOG does not offer a CPed program? There really would be no point in that because TOG employs a 2D pressure pad and lacks a volumetric cast, therefore it cannot be a custom device.

 

Matthew don't get me started on Foot Levelers!

 

As A C.O. who has worked in the field of orthotics for the last 25 years I feel I should chime in even though I see that my chosen path is looked at in a somewhat derogatory manner by this board. For those who wish to bash another profession's education is subjective at best unless you have attended the same classes and continuing education that we do. There are good and bad in every field of endevour and to say one is "superior" or "better than" another is not a good argument. There are many aspects of my work that you would know nothing about in that it would involve a move of the discussion to a place where it is not all about foot and ankle. Just as you say you have seen the errors in other's work you should know we see your errors as well. None are immune to this and if you feel that you are confident in what you do then hey, that's the least your patient's deserve is it not?

Try not to pigeon hole other professions because it puts you in a precarious position of comming off as arrogant.

 

Dear Sir:

If I added to my comments that referred to other professions like mine (American Podiatrist) words like:
"So does that mean that DPM's like Dr. Bowden and those that Dr. Kirby, I and other academicians with a passion for biomechanics feel lack appropriate biomechanical experience, education, evidenciary knowledge and passion are using their Podiatry credentials unfairly when marketing and serving the public with orthotics that dilute The Standard?"

Would that reduce your sense that I was pigeon holing yours?

Oh Wait!

I already DID.

Dr Sha

 

Dr. Shavelson what you then said was:

I certainly read it that you feel that podiatry is the sole profession that is appropriately trained, clinically competent and capable of providing CFO's. Is that your contention Dr. Shavelson?

If so why is there such a large base of practitioners, mostly podiatrists eagerly reading this forum? I wonder how didactic training in foot orthoses in podiatric college is weighted amongst the different universities, number of credit hours, is fabrication inclusive etc? I'm sure it outweighs the orthotist and pedorthic programs in credit hours, right? I never thought about this before but calling CO's and CPed's "poorly educated, clinically inept, poorly trained professionals without evidenciary knowledge" does make your statement sound very arrogant Dr. Shavelson.

 

I believe that we agree here Dennis but I still do not quite understand the criteria and methodology for dispensing CFO’s for wellness. What is wellness to you Dennis, prescribing the primary mode of treatment in your tool bag as a preventive measure? I feel all health professions do employ that modus to some degree for patient benefit though I find more often it is for profit. You appear to agree with that so when is it wellness and when is it necessary if there is no presenting complaint?

Again, no argument from me. I’m sure we all see a number of interesting orthotics like these in wander into our offices. Did I recount the tale of the man who was wearing the Theta orthotics I treated recently? I can find no words for the inherent ‘wrongness’ of those devices for his foot. Got them off the internet you know…step in the flower arrangement foam, pay your fee…

Dennis I am truly sorry if you feel that I have not given your work its due. We have had epic disagreements in the past but I do respect you, your education and your intelligence. I also believe that you care about your profession, which has been stated to me by other podiatrists who may not agree with you about FFT btw.

Please send me any material that you would like and I will give your system a very thorough and honest evaluation. If I feel that it can help certain patients I will give it a try if that is your wish? I question everything but if something makes sense and has merit I will use it, I’m an eclectic.

Obviously a DPM degree (and a DC) requires a lot more training than orthotists and pedorthists. My point is that the actual time spent covering orthotic intervention cannot be that disparate. They should not be denigrated and are valuable members of the health care team. Licensure and board examination are only required to meet basic competency in any field, some will strive to do more and some will not but the foundation is there I believe.

This does not make me proud as a DC but a large number of them sell this, probably because no one within the profession has ever taken them on and refuted their marketing and claims or offered to improve upon it. Their hired consultants quote Rothbart at times in articles, what does that say? Their product qualifies as a non custom insole. Period.

Just when we were getting along so well Dennis.

Well I could update my avatar but I’d hardly call those a flat arched device. As I recall the forefoot in those are intrinsically posted but I digress. We have a common ground Dennis; we’re both passionate about the subject and would both like to see an improvement in the nomenclature, standards and practices of dispensing custom foot orthoses. Expect a tidal wave to hit the east coast soon, cats and dogs living together, mayhem and chaos!

It would be very difficult to police the whole of the industry though when there are several professions that have the ability to diagnose (or ‘assess’) and dispense and you can add the nifty couch and wall treatments, obviate the office visit and sell your insoles calling them custom via the internet. It is near impossible when your own profession engages in the above!

Regards

 

The C. Ped ( C ) designation in Canada is a post university designation. You must have BSc from a health science program. After which you may either do a 3 year internship with a Certified Pedorthist (Canada) or, take the University of Western Ontario Pedorthic Stream Diploma Program which is roughly 1.5 years of internship and online course...after either course there is a practical and written exam from the College of Pedorthics Canada. . For more info on both the Pedorthic Association of Canada and the College of Pedorthics Canada , please go to http://www.cpedcs.ca/.

Sincerely,
Freeman Churchill, B Sc., B PE., Certified Pedorthist (Canada,

 

There is no one profession the owns "foot orthotics".