Manipulation vs Orthotic Therapy

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I have been receiving a number of enquiries about manipulation and its role with orthotic therapy.

It is my view that Foot Mob/Manip Therapies (FMT) can reduce resistance to supination forces from orthotic therapy (by releasing connective tissue restrictions) and that this would lead to improved clinical outcomes for cases treated with orthotic therapy.

The attached article from 2004 is from podiatry & chiropractic authors.

I look forward to the academic researchers casting their opinions on this article.

Yours clinically,
Ted

 

Ted,

While I think studies like this are long overdue, the sample size, lack of inclusion criteria and choice of combination therapy in group 1 and orthotics only in group 2 leave me wanting better designed studies.

Your thoughts?

 

Touche David!

This is why I'm a clinician and rely on academics to refine the rigour of such studies.

I am currently working with Aaron Wholohan at QUT on researching the effects of a Foot Mobilisation protocol (Aaron is the Academic, I am the Clinician) but this is not a study on comparing different interventions.

Alas, an overdue 'comparative study' is on the 'to do' list!

Cheers,
Ted

 

Agreed that the study is off too small a scale to show anything very much. Also, has rather too many elements involved for my taste.

There have been several studies carried out using rigs to quantify supination resistance. Why not get hold of one of those (or build one) and gather some data on your courses. You have a cohort of about 20 people who are well and truly fmt'd by the end of the 2 days. Measure supination resistance in each at the start of day one and the end of day two. That would give you some preliminary data, and be a good teaching tool as well.

 

I can't speak for Ted but using such a weekends training and devising and introducing measuring systems to ascertain statistical outcomes of supination resistance test (SRT)pre and post mob or manipulation in a manner that accounts for the variables (of say, the differing axes between individuals) is more than a weekend can realistically manage. Especially as people want that time to gain a skill. It would be of interest to people there, no doubt.

Perhaps if such weekends were run in an environment where people could be assessed by others pre and post the work is an option (test equipment on hand), but again, I think there are a lot of variables between individuals foot and ankle function that need to be taken into account.

 

I fell it begs the question:

Why Manipulation Versus Orthotic therapy?

Why not Manipulation and Orthoses

Dave

 

I think you are right Dave as I do not see them as diametrically opposed, rather both may be significant to the over all aim of rehabilitating the structure. I guess it is just the question the researchers were wanting to explore.

 

No need to account for variables. You're just looking at a before / after for the same subjects. Granted diurnal variation would be an issue, but otherwise, the other variables would be similar.

 

The problem with 'measuring' supination resistance is there is not yet a machine which does so with sufficient reliability to allow any meaningful conclusions of data collected.

 

There is that Ian, and thanks for the info. For me, when it comes to mobilising the foot and ankle (which would include soft tissue as well), altering supination resistance is not the goal. That said, interestingly and anecdotally, I would suggest there have been occasions when there are changes in a persons foot and ankle function that might indicate a change in axial function. Equally it might mean that joint function under the existing axis position is just improved.

However I do not want to drift away from Ted OP.

 

Hi Ian I know ot but there are some issues with what you have written.

Axial function ? Not sure what you mean by this, a joint axis is an imaginary line which represents the mid point of equal and opposite forces. An axis will be in a different position if there is motion of that joint.

So if there is a change in motion there will be a change in the axial position when compared to original .

The last sentence I am not sure what you mean by function , but any change in motion will also mean axial position has changed

 

Anthony, if you replace the term variables with confounding factors then there are many not considered in this study e.g.

1) Placebo effect:

Every person was treated with something but nobody given a sham treatment thinking they were having real treatment and nobody was given no treatment at all.

No treatment recovery rate would have been a good baseline reference but it's not there.

Maybe the people who received manual manipulation had an enhanced placebo effect compared to the people who were just given something to put in their shoes.

2) Reliability of data collection:

The orthotic group outcomes relied on self reported compliance far more than the manipulation group.

Cohort expectation of outcome for each mode may influence their answers in terms of reduced pain. E.g. if a patient gets a £20 insole and gets a 50% relief of pain then he will report a brilliant outcome and his report of pain will reflect this.
If he has paid £400 for a pair of orthoses and gets 80% pain relief he will still be disappointed if, because of relative cost, he expected 100% relief and his answer will reflect this too.

Standardised treatment modes:

If each patient got the same prescription orthosis for heel pain and the same mobilisation and stretching regime then, for obvious reasons, this will result in poorer outcomes for the orthosis group.

When doing a mobilisation this treatment is directed at treating the diagnosed pathological tissue of interest. But very often an orthosis is prescribed based on achieving some arbitrary definition of normal position rather than addressing a reduction of tissue stress objective -

None of these things have been shown to have been considered in the short write up of the research in the paper above (maybe they were but its not written about)

The manipulation group had in effect two treatments modes because they had stretching exercises as well, the orthotic group did not. So it is not possible to tell if the stretching was the reason for improved results or if the manipulation or a combination of both. So maybe there should have been a just stretches group!?

Statistics:
I'm no statitics wizz (so Simon S please feel free to comment here, not htat you need my permission) but it seems to me that considering and stating homogeneity for the groups is a little spurious considering there are many uncontrolled variables.

Homogeneity is the condition in which all the variables in a sequence have the same finite, or limited, variance. When homogeneity of variance is determined to hold true for a statistical model, a simpler statistical or computational approach to analyzing the data may be used due to a low level of uncertainty in the data. Does this does this research model have a low level of uncertainty variance? It doesn't seem like it does, so whatever analysis of variance was done will be completely skewed and invalidated by a highly uncertain baseline variance.

In other words you can't state what the effect of changing a variable is if you haven't controlled or accounted for what other things might also cause a variation in the outcome.

please help out here Simon

Dave

 

Good lord not me you meant I hope Ted, I am merely a clinician myself!

Agreed

Precisely my line of reasoning. Thus too many variables to come to a reliable conclusion and a poorly designed study IMO. Orthotics + Manipulation vs Orthotics alone for a common pathology, say acute plantar fasciitis I feel would be a better design since we already know that orthotics are beneficial in acute PF. My assumption here is they are trying to prove/disprove manipulation is beneficial but they're comparing apples to oranges. Correct?

 

Thank you David S. David W., Ian L., Ian G., Anthony & Mike,

A dearth of great suggestions and recommendations.

I have had direct discussions with a number of you on many of these matters and every time it is the weaknesses of practical studies that we are all trying to address. We are yet to come up with the best option. This is why I am currently actively involved with researchers at QUT to ensure a high level of rigour is applied.

A difficulty in running a study with subjects who have just learnt some techniques in a weekend training is the consistency and skill level across 20+ students.

Personally, I believe that combining FMT with orthotic therapy delivers the best clinical outcomes [because of reduced resistance to supinatory forces from orthoses] but this is nigh on impossible to conduct in a research study due to the number of variables and interventions.

Supination Resistance? I'm still holding out to conduct a blinded study with Boot Camp Master PFC Payne utilising his experience and reliability of measuring Sup Resistance and delivering one standard FMT protocol and one sham protocol. Our discussions/plans are yet to yield fruit...

Please stay tuned or offer suggestions.

Cheers,
Ted

 

Mike
I'm full on with stuff today and then away leading a course until Sunday night. I will try to respond to you question today but if not then by Monday.

 

Um...
Do you mean dearth?!

 

Dave, I'm not entirely sure what they have been up to here with regard to data analysis. I'll give fuller reply later as typing on my iPhone is a pain.

 

Yes that was my initial confusion too!

Dave

 

Hi Mike,

"Axial function ? Not sure what you mean by this, a joint axis is an imaginary line which represents the mid point of equal and opposite forces. An axis will be in a different position if there is motion of that joint."

I agree with your statement and I think my brevity of answer was not helpful, so my apologies on that. Hope the following makes it a bit clearer.

When rehabbing a low leg, foot and ankle issue, where ever it is, one thing I try to do is imagine what the foot structure (functional and passive assessment of joint and tissue) is suggesting about functional activity around the 3 axes of the ankle joint complex (AJC) in gait, one aspect being the impact upon arthrokinematic glide in the complex.

For example, the supinated foot may well suggest a more laterally deviated STJ axis of function etc. I will note that and may try to visualise its impact upon how arthrokinematic function is occurring around the 3 axes of the AJC (I may of course be wrong in my imagination of it). I may well mobilise the structures of concern hoping to improve articular glide and maybe aid, for example, in allowing an increase for pronation capacity.

Post mobilisation they may have more articular glide motion than before yet still operate on a more supinated manner, their symptoms have reduced but their functional axes within the AJC has not markedly changed. Indeed a manual supination resistance test may only register a very subtle change, in this case a subtle increase in resistance. In this sense your comment:

So if there is a change in motion there will be a change in the axial position when compared to original .

is correct, yet my perspective of the foot and ankle functioning around the axes is that the STJ axis change, in this instance, is very minimal.

Does this help explain my brief comment above?

 

Hi Ted,
I think from the original study weight and the axis location in the transverse plane accounted for about a 1/3 each of the variability in force required to resupinate. So if MT is not likely to change either of these variables, how will it alter SRT forces? I do think MT can alter tone (and possibly stiffness), at least in the short term- do those factors account for the remaining 1/3??
Jason.