The researcher vs the clincian

Dear Admin

Could it be that, to misquote Simon Spooer (from 5 Great fallacies), "scientific research deal in probabilities" and those probabilities can be subjective.

And so researchers often base their conclusions on the statistical significance
and clinicians base thier conclusions on clinical significance these two criteria are often not mutually conclusive.

Researchers may understand but very rarely indicate the limitations, errors and shortcomings of thier research. The clinician may have no idea about these limiting factors and so each disipline will have a different perception about the meaning of the stated results and conclusions.

Limitations and error have a very important role to play in data evaluation and in my opinion should be discussed more within a paper.



Cheers Dave Smith

 

Craig and Dave:

Here are a few of the many problems with the researcher vs clinician lack of communication/understanding regarding foot orthosis research:

1. Most clinicians don't know much about research protocols, statistical methods and kinetic and kinematic analysis.

2. Most clinicians are not familiar with the existing literature on foot orthoses.

3. Most clinicians wouldn't know a good research project from a bad research project by reading the research paper.

4. Most researchers don't have a clue on how to examine a foot, or establish good foot orthosis prescription protocols for research.

5. Most researchers don't understand that foot orthoses can have a near infinite set of design parameters that will affect foot function and patient comfort.

6. Most researchers don't understand the importance of proper shoe design and fit along with the orthosis in order to optimize patient results.

There are more, but I need to get back to work.

 

Me both clinician and researcher. I say:
VESTED INTEREST
On all sides.......

 

Nice series of papers here (Sorry only abstracts- would be helpful to link to full papers if that's possible Craig?). As I recall, the last in this series explores the problems of clinical versus statistical significance

http://www.apodc.com.au/AJPM/Contents/Full text/Vol33/abstracts/Vol33 3 77-84abstract.pdf

http://www.apodc.com.au/AJPM/Contents/Full text/Vol34/abstracts/Vol34 1 5-14abstract.pdf

http://www.apodc.com.au/AJPM/Contents/Full text/Vol34/abstracts/Vol 34 4 125-131abstract.pdf

 

I've said it before (most recently here:http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=4116), and (unfortunately) I'll have to say it again... read the thread, I can't be bothered.

Here's an analogy to think about: if I reported on a drugs trial to treat syphilis where n =6000000, but each subject had received a different drug, what would your reactions be to my research design?

Lets go on a stage, lets say I found no positive outcomes:
should I conclude:
This study found no evidence to justify the use of drugs in the management of syphilis.

Or:
This study found no evidence to justify the specific drugs tested in the management of syphilis in the subjects that these individual drugs were tested in.

Or:
This study found no statistically significant differences in the outcomes measured in the subjects that these individual drugs were tested in.
????

Go ponder.

P.S. In the tabloid world in which we live, which of the above three conclusions appears the more "sensational" and likely to draw "fame" for the researcher?

Vested interest. Hmmmmmmmmm.

 

Simon

"VESTED INTEREST"

Agreed, bias can be very difficult to erradicate even if unintentional.

BTW I have a vested interest

I am very interested in Vests
In Vests I invested heavily
My bank account relies
primarily
That my investment in vestments are not
contrarily
viewed.


I thank you Danny

 

QUOTE Simon Spooner
"Here's an analogy to think about: if I reported on a drugs trial to treat syphilis where n =6000000, but each subject had received a different drug, what would your reactions be to my research design?

No control, No statistical power, the inter and intra variability of each group (of one subject) could be attributable to chance or real effect but it would not be posible to show.

Lets go on a stage, lets say I found no positive outcomes:
should I conclude:
This study found no evidence to justify the use of drugs in the management of syphilis.

This conclusion cannot be extrapolated from the results

Or:
This study found no evidence to justify the specific drugs tested in the management of syphilis in the subjects that these individual drugs were tested in.

One could make this statement but the statistical evidence is very weak, Clinical eveidence may be stronger if there were a control and there was no significant diffrence between controls and experimental groups.
However the significance of any conclusions must be weak
Or:
This study found no statistically significant differences in the outcomes measured in the subjects that these individual drugs were tested in.
????

This is a true statement. Because the design was poor the statistical significance had to be low oe zero. It is not a very useful statement however even tho it is true and might appear sensational

Go ponder.

P.S. In the tabloid world in which we live, which of the above three conclusions appears the more "sensational" and likely to draw "fame" for the researcher?

Vested interest. Hmmmmmmmmm."

 

I think the issues are deeper than statistical vs clinical significance. Take a look at the thread we had on Extracorporeal Shock Wave Therapy and the length that supporters of ESWT go to in an attempt to discredit the publications that show its not effective, yet are not prepared to hold the same publications that show it is effective up to the same standards of evaluation.

To those without a vested financial interest in ESWT, it is the studies that show it not to be effective that have the soundest methodologies.

We are all intelligent people with University degrees, why can be be so blind?

 

I keep thinking of the "in my hands, this is really effective" argument. What we really need is clinician batting averages. Once that orthosis leaves your office how often does it really work. You can't go by the patient never came back. You could go by how often the patient asks for a second pair, but that's not enough. What we need is someone to pay to do the research on success rates for those who pay attention to their protocols versus those take a cast and use lab "discretion" on their prescription.

Kevin's point about orthotic modifications is a good one. There are a lot of times where the patient comes back and a simple modification to the orthosis makes a succesful outcome out of an unsuccesful outcome. Modifications should be included in the grading of a protocol.

cheers,

Eric Fuller

 

The problem with audit type research is that it does not isolate the effects of foot orthoses from other concurrent treatments. Personally, I rarely use foot orthoses in isolation in my management of patient's complaints.

 

Re: The researcher vs the clinician

Craig et al,

The following quote neatly sums up the dichotomy:

Researchers: learn more and more about less and less until they know everything about nothing.

Clinicians: learn less and less about more and more until they know nothing about everything.​

The basic misunderstanding, particularly with regard to assessing the efficacy of treatments, is that clinicians have to deal with multiple variables in individual patients, whereas researchers must manipulate a single variable (or small number of variables) in large samples of participants. Subsequently, we regularly see clinicians criticising orthotic studies because they haven't "customised" the devices as they would in practice, eg:

...and:

This would all be OK if there were widely agreed-upon guidelines for orthotic prescription and "tweaking". There isn't, and probably never will be. This leads to another basic misunderstanding on behalf of some clinicians - that any favourable response to their treatment must have been due to what they did. This can't be substantiated - the patient may have got better without any treatment at all, or they may have got better with any number of interventions or modifications. That's why you need a control group.

I don't agree with Simon's suggestion that vested interest plays an equivalent role in influencing the activities of both clinicians and researchers. Although there may be a small number of "controversialist" researchers who go out of their way to be provocative, on the whole I would argue that the majority of researchers simply want to do good research, whatever the results turn out to be. I'm sure that most researchers would prefer to be praised by the profession for publishing a favourable study rather than be criticised by the profession for publishing a negative finding.

While these issues will continue to create tensions between clinicians and researchers, I think that it is essential that clinicians approach all new study results with an open mind, and critique the results in a rational manner. It's been pretty obvious in recent postings that some clinicians have no intention of giving unfavourable studies a fair hearing.

Everyone has the right to their own set of opinions, but no-one has the right to their own set of facts.

Cheers,

Hylton

 

Re: The researcher vs the clinician

I didn't say anything about it being equivalent; these are your words not mine. None of us is free from bias nor vested interest. Are you suggesting that a researcher has no vested interest in the paper that they have put forward for publication?

Yeh, just like this chap:
http://news.bbc.co.uk/1/hi/health/6289166.stm

& all the others who carry out research on a product for which (coincidentally) they have financial or other forms of backing from the company that manufactures it and/ or have vested interest in that company.

Think about it, which studies are memorable and have created the greatest number of letters to the Editor and discussion from peers? When was the last time you wrote to a Journal to praise the author? Controversy gives coverage; favourable results rarely make the news nor stir the responders.

I'm not saying it's right, but I don't think it should be swept under the carpet either.

 

Re: The researcher vs the clinician

I think that it is essential that researchers don't draw sweeping conclusions which extrapolate beyond the data such as:

"This study found no evidence to justify the use of in-shoe orthoses in the management of flexible excess foot pronation in children"

I also think it is essential that researchers don't become segregated from clinicians by becoming overly defensive when their work is critiqued as occurred here:
http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=2527

 

Hi all,

This discussion has been prompted by Craig after seeing a recent thread about an unfavourable research paper going down a familiar path.

I'm only a minnow in the research arena with moderate appreciation of some aspects and close to zero retained skills in understanding the statistical testing.

Nevertheless, I took exception in that previous thread to the researchers stating a conclusion that to me had no VALIDITY whatsoever. They absolutely, cannot conclude that from their study 'customised orthoses are ineffective in treating flexible pes planus ' in children. They can say that the methodology they used was ineffective and no one could argue with that.

I do appreciate that researches need to minimise the number of variables to reduce confounding elements in their projects but then they cannot then use a broad brush to describe what they did. As Hylton said

And so they need to be very specific about saying that the results apply to the 'cut' they took and not to everything.

I also appreciate that clinicians are seriously hampered by holding on to belief systems that are not prooven in any way. This then limits options in the resolution of clinical problems. In all probability the stronger the belief system the more limited is the approach.

A couple of other topics for another paragraph could be on "intention to treat" being a requisite of such research projects and being honoured.
"Peer review" also relates to experts in that exact field and also needs to be honoured.

Cheers
Shane

 

Re: The researcher vs the clinician

Perhaps they should have stated
"This study using the outcome measures we used found no evidence to justify the use of in-shoe orthoses of the type we used in the management of flexible excess foot pronation in children"

 

Re: The researcher vs the clinician

Simon:

"Vested interest on all sides" sounds a lot like equivalence to me, but you're splitting hairs here.

Conflict of interest in relation to industry-funded trials is a different issue worthy of a separate discussion. You were suggesting (I think) that some researchers have a vested interest in that they benefit from publishing controversial studies. I agreed, but argued that this sort of activity is not common. Your highly atypical example of Dr Wakefield illustrates this point. Also, I would probably argue that in the longer term, there would be a greater vested interest in producing studies with favourable outcomes. After all, who would pay money to attend a seminar in which a researcher tells the audience that what they do doesn't work?

The manner in which the media (tabloid or otherwise) presents the results of research findings is also a separate issue, and I don't think that researchers can always be held completely responsible for how their work is presented in the media. There's countless examples of researchers being misquoted, and while a small number may enjoy the attention associated with this, most would feel very uncomfortable about it.

I completely agree, and if I reviewed this paper, I probably would have suggested that this sentence be reworded. However, the inclusion of this over-reaching sentence doesn't automatically invalidate their results. Please note that I am not defending this particular paper, as I haven't read it yet (the full paper, that is).

Researchers in the allied health professions have a much closer relationship to clinicians than researchers in other fields. Most of our researchers were originally clinicians (or still are). This is very different to the medical sciences where a lot of research work is done in labs by people who may never have had any patient contact. So relatively speaking, I think the "divide" between researchers and clinicians in allied health in general (and podiatry in particular) is quite small.

Of course, if a clinician wants to refute the findings of a paper which they consider to be unfavourable, it's very easy to pull out the old "ivory tower/real world/how many patients do they see" slight to discredit the researcher. This is a classic example of "playing the man rather than playing the ball". Shane's reference to the "crappy academic", along with some members regularly citing the number of patients they have "successfully treated" are a symptom of this. Clinical experience is obviously valuable, but it can be wrong, and it sits much lower on the evidence hierarchy than a well-designed randomised controlled trial.

Ideally, researchers should be conducting research that is clinically relevant, and clinicians should base their practice on the best available evidence. I don't mind if clinicians choose not to do this, but if this choice is made, the consequences (ie: joining the ranks of the many other alternative / complementary therapy professions) need to be carefully considered.

Cheers,

Hylton

 

Re: The researcher vs the clinician

Hylton and Colleagues:

For the patient, clinical experience is not only very valuable, it is sometimes life-changing.

For myself, being primarily a clinician that has done some research (but has read very much research), my concern with foot orthosis research is that there seems to be very little attempt to make a true patient-specific custom foot orthosis for a patient in these research projects other than the researchers take a negative cast of the foot, choosing a plate type (with or without a rearfoot post), use a shallow heel cup, put on a generic topcover without any forefoot extensions and then balance all the subjects' orthoses vertically. If I made all my foot orthoses like that for my patients, I would probably be out of business by now due to their low success rate.

As an example, at least a few times a week in my practice, a take a pair of foot orthoses made by another practitioner, I adjust it in the office in a few minutes, make the orthosis go from being uncomfortable to comfortable and the patient then goes from being skeptical of orthoses to being happy that they found a clinician that "knows orthotics". These sort of experiences, repeated time and again, for the past 20+ years tells me that one custom foot orthosis is not the same as another custom foot orthosis and that there are nearly limitless design permutations of foot orthoses that can be used to achieve optimum therapeutic results. This also leads me to suspect that the generic, non-specific casted orthoses used by so many researchers in their studies are not truly patient-specific custom foot orthoses, but rather are non-specific casted orthosis designs that have allowed the reseachers to simplify their research sufficiently to attain statistical significance one way or another. Is this the best researchers can do? I know it isn't.

Ethical clinicians base their practice on getting patients better, resolving their pain, and improving their lives, hoping that there is "any evidence" and sometimes regardless of what the "best available evidence" says. Even though I understand the concept of "evidence based medicine", the evidence for effective treatment of many podiatric pathologies is simply not there for many patients who suffer daily with foot and lower extremity pain and disability. Because of this fact, I am happy to join the ranks of the alternative/complementary therapy professions if this means that my patients are getting better, are happier and are leading fuller lives than those clinicians who handcuff themselves in practice by solely by using the "best availalble evidence".

For example, where is the evidence for the therapeutic efficacy for the medial heel skive technique? There is none. I have been using the medial heel skive on orthoses for over 17 years (and many other podiatrists around the world have also used the technique) to treat literally thousands of patients with symptoms related to abnormal magnitudes of subtalar pronation moments. In the world of evidence based medicine, the medial heel skive technique is certainly one of the lowest forms of evidence to the worshipers of evidence-based practice. Funny, but my patients who have gotten better from the judicious use of the medial heel skive technique along with other specific orthosis techniques certainly don't seem to mind one bit that their pain went away and/or didn't need surgery and/or can still walk with their spouses in the evenings without pain. But, hey, what do these people know, they are only human beings with feelings and lives......they don't even have a research degree!!

Certainly clinicians are as much at fault in this discussion as are researchers since many clinicians make orthoses that are worthless for their patients. I could go on and on about poor orthosis design from clinicians much longer than I could go on about poor orthosis design by researchers. However, if researchers want to see what custom foot orthoses can really do for patients, then they need to treat their research subjects with truly patient-specific custom foot orthoses, not non-specific generic casted orthoses.

Good discussion, Craig. Keep 'em coming......

 

Re: The researcher vs the clinician

Good one, Simon. I still very well remember that episode where I was trying to be funny about plantar fasciitis research and then had my comments deleted by one of the moderators. Guess, he didn't like my sense of humor in regard to one of his departmental colleagues. However, JISCmail did seem to become quite active for a full month or two after that incident on Podiatry Arena.

 

Kevin,

With all due respect, this statement suggests that you may not fully understand the concept of evidence-based medicine. It doesn't mean doing nothing if there are no published RCTs available. What it means is basing treatment decisions on the best evidence that is currently available. Depending on the condition and intervention in question, the best available evidence might be a systematic review of randomised controlled trials, or, at the other end of the scale, expert opinion. A clinician would be practicing evidence-based medicine if they gave more credence to the former than the latter when making a treatment decision. This can hardly be called "handcuffing".

According to what criteria - the Kirby approach? The Payne approach? The Spooner approach?, etc, etc.

Here's a challenge for those who strongly believe in the custom orthoses paradigm: develop a consensus document on the indications for the plethora of orthoses prescription variables (as well as indications for orthosis "tweaking") that are used in practice, and I'm sure that there will be several researchers who would be more than happy to compare this approach to a generic device. I hope to be proven wrong, but I suspect that no consensus will ever be reached. If this is the case, we might as well stop the discussion now, as there's no point continuing with a "my orthoses are better than yours" argument.

One final point to ponder - why do these discussions always end up focused on orthoses? Why are there no clinicians arguing that their own concoction for treating onychomycosis is more effective than terbinafine?

Cheers,

Hylton

 

I understand and you make a good point, Hylton. However I do get tired of researchers and other evidence-based advocates implying that clinicians that use treatment methods that have not yet had randomized clinical trials performed on that treatment method are not practicing the best medicine available for the patient.

Here's a question for you, Hylton. Which of the many foot and lower extremity pathologies that podiatrists commonly treat successfully in their practices have had, what you would determine to be, high level evidence to support the continued use of that treatment for that pathology?

You don't already know my answer to that one??

I think it would be like trying to get a bunch of biomechanics researchers to develop a consensus document on the best method to research foot orthosis therapy.

Possibly because terbinafine treats only onychomycosis, when, in the hands of a skilled clinician, foot orthoses can successfully treat the following:

Plantar fasciitis
Peroneal tendinitis
Intermetatarsal neuroma
Sesamoiditis
Hallux limitus/rigidus
Joplin’s neuroma
2nd metatarsophalangeal joint capsulitis
Abductor hallucis muscle strain
Plantar ligament stress syndrome
Plantar intrinsic stress syndrome
Posterior tibial tendinitis/dysfunction
Dorsal midfoot interosseous compression syndrome
Sinus tarsi syndrome
Anterior tibial tendinitis
Achilles tendinitis
Iliotibial band syndrome
Medial tibial stress syndrome
Patello-femoral syndrome
Pes anserinus bursitis
Postural fatigue of lower extremities
Low back pain
Medial compartment osteoarthritis of knee
Lateral compartment osteoarthritis of knee
Greater trochanteric bursitis/tendinitis
Lateral plantar compression neuropathy
Tarsal tunnel syndrome
Metatarsalgia
Plantar neuropathic ulcers
Osteoarthritis of subtalar joint
Talo-navicular joint osteoarthritis

When you have a treatment method that can effectively treat all these pathologies, and the more skilled you get at it the better results you attain for your patients, you tend to get a little more excited about the treatment and the biomechanics behind the treatment than by simply handing someone a prescription for an antifungal medicine.

 

netizens

In the world of biomagic all things are possible and development in biotechnology should easily see an antimicrobial impregnated orthotic shell, anytime now.

toeslayer

 

Re: The researcher vs the clinician

Kevin asked:

The best place to find this info is in the list of Cochrane reviews collated here:

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=2573

An impressive list, Kevin. Almost as impressive as the list of conditions that can be successfully treated with MBT shoes or Rothbart insoles.

We are, however, getting off track in regard to Craig's initial question. Here's some hopefully constructive suggestions:

1. Clinicians should develop the consensus document I referred to in my previous posting
2. Researchers should develop standardised techniques for assessing orthosis efficacy (this has already started, with the use of VAS, FHSQ, etc)
3. Researchers should consider undertaking factorial RCTs, where combinations of treatments can be compared, rather than single interventions
4. Journals should allow authors sufficient space to fully describe their study design (tight word limits are probably responsible for much of the confusion)
5. Clinicians should hold back from criticising a study until they've actually read it
6. Researchers should resist the temptation to overstate their conclusions, and editors should ensure that this does not happen
7. Clinicians should be prepared to accept that equivalent outcomes of their orthotic therapy may have been achieved through various other approaches
8. We should all be very wary of tabloid media reports of medical research, and instead read the actual paper
9. Clinicians and researchers should remember that each relies on the other

Any other suggestions?

Cheers,

Hylton

 

I wonder if there is a very practical element to this.

In a previous working life it was common to find that it took approximately 20 years for a new idea to filter from inception through to grudging acceptance and then practical application. All the usual reasons applied including vested interest.

Like it or not, given the best EBM there is still the actual aspect of practical application of that EBM to the patient by a possibly bewildered practioner. Given that the said practitioner may have graduated 10 years ago (and done their CPD to an extent) some of what has been discussed relies upon practitioners being able to access adequate practical tution on some of these things.

Accessing this is not always straight forward and must go beyond attending courses where possibly 50 to 100 attendees are present and practical instruction is almost impossible.

So in Kevins example, If the EBM says that reconstructing an orthosis in a certain way in office is the best then many Pods may find this practically difficult to do as many may need to see it done and be led by the hand for the first time.

Given using a tried and trusted and successful method or having to adapt to using a method based upon EBM, that may be outside of a persons experience, then many will naturally and reasonably default to the former.

This is not so much a clinician versus researcher issue but one of practical nuturing of application in a practioner. This of course is referring to Orthosis adaptation and does not take into account the many variables already mentioned. Hopefully it illustrates the point.

Ian

 

Re: The researcher vs the clinician

This list covers about 5-10% of what I treat in my practice and none of the Cochrane reviews are specific enough to give a detailed approach of how to accomplish the techniques. So, for the remaining 90-95% of the pathologies I treat in my practice (and to get good clinical results from what the Cochrane reviews do cover), I guess the "best evidence" is my clinical experience, common sense, prior education and the experiences of other talented clinicians. Therefore, this "evidence based medicine" approach that we are all supposed to get excited about hasn't really changed much for me or my patients over my past 22 years of clinical practice other than I now better understand the concepts of "evidence based medicine".

 

Simon

I know this is a little slow of me but I get your previous analogy of statistics used to measure outcomes of orthotic intervention (I think). You wouldn't use a different drug for each patient to test the effectiveness of drugs on cancer but this is effectively what we are doing with bespoke orthoses since each person requires a unique prescription.

BTW I was also Danny KaySmitt, I used another computer and couldn’t remember my password so I registered with a different name. (did you guess?)

Isn’t there always this problem with statistically evaluating clinical or medical interventions even if the intervention is the same inter subject.?

Statistics are different methods of finding means and medians and comparing them.
But it is convenient to ignore outliers. This is fine if we are grading beans or engineering tolerances but those outliers in medicine are real people and the problem is we don’t know who they are pre intervention. Therefore it may be necessary to tailor each persons treatment rather than use standardised interventions that EBM show statistically to be superior over large groups of people. Unfortunately or fortunately we treat individuals and so perhaps for the best outcome we require individual bespoke interventions that cannot be reliably statistically assessed.

Is this what you are saying?


Cheers Dave

 

http://www.algeos.com/cgi-bin/sh000..._PORON__4400__Green__100.html#aOB2173#aOB2173



Keep up!

On the subject of EBM i think much of the dissonance stems from the application of double standards. Nobody expects to need a double blind study to prove that enucleating a HD makes it hurt less so we claim it to be common knowledge, common sense, based on a good rational or based on expert opinion. If however somebody comes along with a product we suspect to be bogus, (mentioning no names

BRIAN​

)
We say "aha, you have no evidence, we sneer at you with scorn" and similar.

Robert

 

Pretty much. At best the large trials are testing the prescription protocol. This, as we know, is subject to measurement reliability issues and the ability for the prescription to be accurately produced within the finished devices. If we take a paper recently discussed on this list in which "experts in the field" (note the plural) produced the prescriptions and said devices I would expect inter-tester reliability to be disclosed within the paper.

 

One of the main problems with orthosis research is that these research papers rarely outline what exact orthosis prescription parameters were used in producing these orthoses. Even something as simple as saying that 4 mm polypropylene plate was used doesn't mean a lot since polypropylene will vary in stiffness with different shapes, foot sizes, orthosis modifications used and with different heating times and temperatures. With Simon's upcoming orthosis FEA lecture at PFOLA in San Diego, I think it is about time we standardized orthosis stiffness/performance issues with material testing machines so that apples can be compared to apples from one research project to another instead of apples always being compared to oranges.

How about it Simon? Any ideas on the best physical parameters to measure with a material testing machine for mechanical characteristics of orthoses??

Here are some starters:

1. Orthosis medial longitudinal arch load vs. deformation curve.

2. Orthosis lateral longitudinal arch load vs. deformation curve.

3. Force required to achieve 5 mm deformation of medial longitudinal arch.

4. Force required to achieve 5 mm deformation of lateral longitudinal arch.

5. Distance from medial edge of orthosis longitudinal arch to corresponding area on foot in non-weightbearing STJ neutral position of foot.

6. Inversion-eversion moment required to produce lifting of orthosis medial-lateral anterior edges.

 

Kevin,

Let me first put on my researcher head...

Surface stiffness is basically = force/ deformation
Which is what you are suggesting measuring above Kevin.

Physical testing in a material testing machine has to overcome the physical limitations of the loading apparatus i.e. the jig set-up, I think greater potential lies in the application of FEA since we can link with in-shoe pressure plate data and simulate what is really occurring in 4D with "real" loading patterns (You never did send me that data Craig ) and create many virtual orthoses without the need to ever actually manufacture them. Indeed, in the FEA world we are not limited to looking at deformation at discreet areas of the orthoses such as the medial or lateral longitudinal arch, but can look at this in 3D across the whole of the orthoses. Although, for some aspects of the research it may be useful to validate the models through physical testing.

Surface stiffness has been successfully manipulated to decrease injury rates by 50% and improve efficiency in runners (McMahon TA and Greene PR. The influence of track compliance on running. J Biomech 12: 893–904, 1979). It is also a key aspect of Nigg's paradigm (Nigg BM. The role of impact forces and foot pronation: A new paradigm. Clin J Sport Med 2001;11:2-9). So there appears great potential here. Early days though and worth remembering that both the foot and the shoe deform under loading too. Making this much more complicated-

N.B. I have vested interest in this research since I am the one funding it, carrying it out, writing it up and presenting it. And would I prefer it to result in provocative findings? Yes, because provoking a reaction is the aim. That's why we do it

 

Actually, a couple of studies show that debriding hyperkeratotic lesions has the potential to make them worse- so perhaps we do need the research.

 

Yet another perfectly good presumption goes spiraling down in flames. You love doing that to me don't you!

 

Simon said:

If that's why you do research, Simon, that's fine. However, it may not be the reason why many others do research. Research doesn't necessarily need to be provocative or exciting to be good research.

Cheers,

Hylton

 

But it should provoke SOME reaction- and that was my point.

 

To me, there is no sense in doing research if no one finds it useful, enjoys it, learns from it, or answers an important question.

 

Re: The researcher vs the clinician

Kevin:

Of course. My point is that answering an important question doesn't always result in a provocative, exciting result, and researchers shouldn't expect that it will, nor should they select research topics on this basis.

For example, large-scale prevalence studies in podiatry are sorely lacking, but are very important studies to do in order to determine the public health impact of foot disorders. Few clinicians, however, would find such studies "exciting", and many would argue that the resources would be better utilised in answering more "clinically relevant" (exciting?) questions.

The other issue to consider is which questions are going to be considered important enough for the major research funding organisations. Unfortunately, some of the burning questions in clinical practice may be of little interest to these organisations, who need to decide how to distribute funding across projects relating to cancer, diabetes, cardiovascular disease, etc.

Cheers,

Hylton

 

Re: The researcher vs the clinician

Hylton:

I agree. I envy those researchers, like yourself, Hylton, who do have the opportunity to research new areas in foot-related issues. In another life, I would have enjoyed being able to run a research lab to explore the many questions I have about what makes the foot and lower extremity function the way it does. I think I could be very happy in that role. I sincerely appreciate the podiatrist-researchers like yourself, Craig Payne, Karl Landorf, Tony Redmond, Jim Woodburn, Keith Rome, Angela Evans, Josh Burns, Chris Nester, and others since you are all doing what I really wish I could do, but really can't seem to find the time to accomplish in my busy clinical practice.

On another note, I don't necessarily know if I agree with Simon in that research needs to generate a reaction. However, I believe his point is that good research that is answering important clinical questions always generates a reaction due to it being able to change what we do as clinicians. Well-performed research that does not answer an important clinical question may be of interest to other researchers, but doesn't necessarily do anything for the people who it is intended for...the clinician and the patient.

However, one cannot, as a researcher, expect immediate reaction to a published paper since often times the rest of the clinical world is not ready to give a reaction to innovative, landmark research until 5-10 years after it has been published. I know that my paper on STJ axis location from 1987 (that is now 20 years old ) took about 10 years to generate a significant reaction, with some podiatrists still not reacting to it the way I think they should. Such is life....I have learned to just hope for positive feedback from one or two people....and accept the fact that getting a whole profession to think differently about foot biomechanics will probably never happen within my lifetime.

Good discussion.

 

Hi Hylton,

You wrote

Very obviously, research happens to improve clinical outcomes for the punters. We started looking at a research project that I think quite outrageously concluded that orthotic therapy(of any sort) was of no value in the treatment of painful 'flexible pes planus' in children.
I was hoping that you as an eminent researcher would have outlined any shortcomings in the research methodology as the average podiatrist cannot do this. This paper has been printed in what is basically an orthopaedic journal and will be happily quoted by orthopods and physios around the world, possibly leading to poorer outcomes. If this was a drug study it would have been abandoned within a few months as there was no change in outcomes and conditions must have been becoming more chronic. This is not how an ethical clinical research methodology is conducted. It shows to me that the researchers and the academic body that oversaw the project do not have a deep understanding of the therapy being used.There is an ethical concept called "intention to treat" and this was not observed. The principle researcher will now be widely quoted and considered an expert. As Kevin said (in his own words) the study did show that if you just take casts and give out standardised orthoses then you are set up to fail which is exactly what happened by the design of the study. This is a finding that needs more power in the podiatric community and would be of some benefit. Meanwhile far better research as you have outlined can be undertaken.
An oversight in this study was that the opinions of eminent clinicians in the discussion and probably in the setting out of the methodology have been given no weight. It is my recollection of clinical research methods that the opinions of eminent practitioners be given a strong weighting. So far the opinions of Kevin and Simon have not been honoured.

Believe me I think that our profession has an immeasurable scope for improvement overall but that study did not help.

Hopefully your advice will be followed as above.

Cheers
Shane

 

Hi Kevin,

I understand your enthusiasm when you wrote :

However I would have liked you to say that the therapy may be helpful in the treatment of these musculoskeletal conditions.
A problem from my perspective with how orthotic therapy is practiced is that pods regard the diagnosis of any musculoskeletal pain as indicating the need for orthotic therapy. I think fair comment then of "biomagic".
Obviously many of these problems are resolved by improved footwear and modification of some activities and perhaps some exercises or release of a couple of trigger points.

So when do we intervene with orthotic therapy as I don't think it is by naming a condition, which I think is a popular approach, and if we do intervene how do we do it (who's method? Hylton would say).

My suggestion is to treat every person as SINGLE CASE STUDY.I do this by using chairside orthoses (full length pre made moulded insoles with various wedges or buildups attached according to what is seen as likely to be helpful in the examination) and used for a trial period. I will not make custom made orthoses if I have not made a significant reduction in symptoms over a few weeks with this method. This gives strong prescribing clues both to magnitude and direction of the interventions. Sometimes the chairside devices remain as the sole intervention and sometimes they become just a diagnostic tool and a spare insole. If the chairside device did not help it may be further modified but nevertheless it needs to be significantly helpful before taking the therapy any further.

If for example a large medial wedge was used in the rearfoot the there are different ways of achieving that with a prescription according to the practitioners skills (and we know how you would do it!)

Cheers
Shane

 

Shane:

My list of diagnoses that are treatable with foot orthoses is not complete but is what I came up with in my ten minutes of thought on the subject. I have treated all of these conditions successfully with custom foot orthoses over the past 22 years.

If musculoskeletal pain is caused by abnormal magnitudes of external forces or pressures, or abnormal magnitudes of internal forces or moments, then foot orthoses have the therapeutic potential to resolve the pain caused by these abnormal forces, pressures, and moments. I don't have a problem with a podiatrist thinking that most musculoskeletal pain in the foot and lower extremities is treatable with foot orthoses, because this is what I believe also. However, I do have a problem with anyone, including researchers who waste their valuable time with poorly designed research, who thinks that a non-specific custom foot orthosis will treat all these conditions, since I know it can't.

Custom foot orthoses must be specifically designed to reduce the magnitudes of abnormal external and internal forces and moments acting on and within the foot and lower extremity in order for the foot orthoses to have maximum therapeutic benefit. The Tissue Stress Approach that Eric Fuller and I will be lecturing on at Biomechanics Summer School 2007 in Oxfordshire,England http://www.rxlabs.com/summer_school.asp in a few weeks (along with Sophie Cox, Emma Cowley and Diane Nichol) involves determining the anatomical structure that is injured, determining what type of abnormal force/moment is producing the abnormal stress/pressure on the tissue that is symptomatic, and, by using modelling techniques, determining how a foot orthosis must specifically be designed to apply the necessary forces to the plantar foot to optimize the healing of the injured structure. It is really as simple as that. This method requires no pre-fab or adjusted temporary orthoses beforehand and produces very predictable clinical results.