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Adaptation period to orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bvanderzwaard, Nov 9, 2009.

  1. bvanderzwaard

    bvanderzwaard Welcome New Poster

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    Dear Colleagues,

    I am lecturer at a Dutch university for the podiatry department; I am not a podiatrist myself. I’m also starting a research project on forefoot problems with elderly, a comparison of standardised shoe advice versus podiatatry. I have a question I hope somebody can help me with.

    I’m trying to find out if there is any scientific base for the length time a person / foot needs to adapt to foot orthotics. In the Netherlands podiatrists see their patients again after 6 to 8 weeks since they received their orthotics. Is this similar in other countries? And does anybody know if there is any scientific base for this period?


    Babette van der Zwaard MSc
  2. Re: Addaptation period to orthotics

    I see mine after 4 weeks and then again normally after 8 weeks. No scientific reason thats what the place I 1st worked at did and it seems to work for most, but it is flexiable.
  3. Re: Addaptation period to orthotics

    Babette :welcome: I think this is an excellent question. When when look at published orthoses research, 6 weeks appears to be commonly chosen as a review period for their effects. Thus, we have the potential to argue that if we are following an evidenced based path, the review period of six weeks should be followed since this is what the evidence did. However, this argument very much has the potential for self-perpetuation of an arbitrary length of time. Personally, I'd always made the assumption that it was a reasonable length of time to allow adaptation and to see some healing response and a change in symptoms. In reality, I vary my review period on a case by case basis, depending on their circumstances. Although I would be lying If I said I don't book some to return at six weeks post-dispensation. I also give all patients an open invite to call me if they are experiencing any problems.
  4. Arjen

    Arjen Active Member

    Re: Addaptation period to orthotics

    Simon highlights an excellent rule of thumb. We dispense tens of thousands of custom F/Os annually. We provide the following guidance to those dispensing the device:

    "Typically patients will need to adjust to the corrective effect of the orthotic. May factors will effect the time required. These include the magnitude of the biomechanical adjustment, mobility of the patient's foot, any other outstanding pathology (like a healing process) and the amount of ambulation the patient will be experiencing during this time. Expect to follow up with the patient after 2 weeks and again after 6-8 weeks, depending on your clinical judgment and the patient's feedback at the initial follow up."

    Hope this helps. It would be interesting to do a formal study of follow up guidance. Good topic.
  5. Re: Addaptation period to orthotics

    I always use the analogy of the fairy tale story of the princess and the pea http://en.wikipedia.org/wiki/The_Princess_and_the_Pea
    Some patients are more sensitive than others, some will take longer to habituate to foot orthoses than others: http://en.wikipedia.org/wiki/Habituation

    What I tell them is to build up their wear time gradually, to use their judgement and that I don't know whether they are princesses or not, but experience dictates that those that have problems in the first couple of weeks are those that try to wear the devices for too long too soon. Phone me if you are having any problems at all!

    With runners, I try to get them used to walking about in them before running in them. Often these patients require rest anyway so I use the orthoses habituation as one of their replacement activities- this isn't always an option. In this group, I generally start them with Prof. Kirby's regime of 10 mins (1 mile) and build in 10 minute increments- forgive me if I've miss-quoted you Kevin.
  6. Re: Addaptation period to orthotics

    P.S. 6 weeks (or any time period) sitting at a desk, is not the same as 6 weeks standing, walking, running etc.
  7. Craig Payne

    Craig Payne Moderator

    Re: Addaptation period to orthotics

    The Australasian Podiatry Council has a remommendation in its foot orthotic clinical guidelines that there be a review at 4 weeks (link)

    I have alway advised pateints re adaptation etc etc etc. and that the orthotics will be initially uncomfortable etc etc etc.

    HOWEVER, in two studies, comfort at orthotic issue has predicted a more positive outcome (one was in one of Beno Nigg's studies - sorry no have ref as to which one it was and their was this one on foot orthotics and patellofemoral pain - but they no published that data yet)

    So, it could well be that those who orthotics are uncomfortable at issue and we give them the spin about adapting to them, might mean a less positive outcome ?????
  8. Re: Addaptation period to orthotics

    Why 4 weeks, Craig? (sorry if the answer is in the link, but I started reading it and got bored). I found a bit that said, "a review appointment should be booked within four weeks", but no rationale appeared to be given. Struck me a bit like: 10 degrees of ankle joint dorsiflexion is needed for normal gait- OK.

    I agree: Comfort is King.
  9. Craig Payne

    Craig Payne Moderator

    Re: Addaptation period to orthotics

    The document was put together in 1997 - 98 by a consensus panel type process. From what I understand, they thought 4 weeks was a good idea.
  10. Re: Addaptation period to orthotics

    OK, so think of a number. Biggest voice/ personality/ego say's four weeks- rest say yeah that sounds good:wacko:

    "Waltzing Matilda whipped out her wallet
    The sexy boy smiled in dismay
    She took out four twenties 'cause she liked round figures
    Everybody's queen for a day" -Street Hassle Lou Reed

    Round figures, don't you just love 'em? It was never going to be four and half weeks was it? Or 11.5 degrees of dorsiflexion?
  11. Craig Payne

    Craig Payne Moderator

    Re: Addaptation period to orthotics

    In fairness to those who worked on the document --- it was developed becasue of an increasing number of complaints about foot orthotics from patients to the Association's--- one common theme in the complaints was the lack of a review or follow up, so they had to come up with a number .... '4' obviously seemed reasonable at the time and most of those involved must have agreed with it.
  12. Re: Addaptation period to orthotics

    Craig, don't read me wrong, some countries don't even have such a document, let alone implement it.
  13. Admin2

    Admin2 Administrator Staff Member

  14. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi All
    I review all my orthotic patient at 4-5 weeks but they have an open invitation to call me if they have any problems between the fitting and review appointments.
    I am curious to know why Craig Payne advises patients that their orthoses will be uncomfortable initially. I always understood that the patient will have an awareness of their orthoses under their feet but that awareness shouldn't be uncomfortable unless they wear the devices for too long in the first week or two.
    I always tell the patient that they will be aware of their orthoses but they shouldn't be uncomfortable. I am aware of wearing my in-soles after 5 years but have never been uncomfortable.
  15. Craig Payne

    Craig Payne Moderator

    "Uncomfortable" was probably a poor choice of words. Usually I set them up to take time to adapt to them --- especially if they had a large supinatus I casted out....for a few that may be "uncomfortable" .... but the evidence (as limited as it is) tells us that this is likely to be a poorer outcome.
  16. pgcarter

    pgcarter Well-Known Member

    There are people with seriously odd anatomy that have walked around almost on their naviculars for years that you can wedge/lever/derotate right back up to somewhere near neutral over time, to the massive relief of their knees, hips and back.....these kinds of things take much longer and usually more than one prescription over 2 to 3 years.....no science just perseverance and attention to detail....and an unwillingness to settle for half a job.
    Simon the princess and pea story earns it's keep with me also, have used it ever since I graduated.
    regards Phill Carter
  17. Jeff Root

    Jeff Root Well-Known Member

    When I dispense orthoses I never say anything to influence the patient in advance of them wearing their new devices. I want to get their honest first impression. I first put the foot in the casting position and then place the orthosis against the foot to check for accuracy of fit (i.e. length, heel width, arch conformity, etc). I then place the devices in the shoes and inspect fit in the shoes. I then have the patient put their shoes on and I ask them to stand. I then ask "How do they feel?". I get feedback. Depending on the feedback, I have the patient walk and then again ask them how they feel.

    Patients often say things like: they feel different, they feel weird, the feel good, I feel pressure in the arch, I feel a little pressure her or there (I usually have them point to the spot), etc. Only after I get direct feedback from the patient do I then tell them what they might experience and the range of possible reactions. My response depends on the patient’s initial reaction, but I usually say that it is not unusual for the devices to feel different or unusual, but they should never be uncomfortable or painful. I then give them their break-in instructions of increasing wear by one hour per day. I always recommend that patients wear their orthoses one hour the first day, two hours the second day, three hours the third, and so on until they get to 8 hours and then they can wear them full time. I tell them that if they get to a point where they start to feel uncomfortable, that they should not wear the devices beyond that point. So if they get to four hours, they can wear them four hours the next day if they start to get uncomfortable again. I instruct them not to push the break-in.

    The vast majority of patients do very well and have no significant issues with orthoses. The conservative break-in comes with a strong warning that a small percentage of individuals have issues with break-in so we use a conservative approach with everyone because we can't predict who might have problems adapting to full time, immediate wear. I tell the patient to contact me immediately if they have any significant problems with the break-in. I tell them to be aware of any new symptoms or any existing symptoms that seem to be aggravated by their orthoses.

    If you give the patient good instructions, I don't think it really matters if they see you back in four or six weeks since they should notify you (your office) if they have any significant problem. They should be told that if they experience any significant problem they should discontinue use until their follow-up appointment. Orthoses can create plantar fibromas or other pathology so the patient needs to be made aware of potential complications.

  18. bvanderzwaard

    bvanderzwaard Welcome New Poster

    Thank you all very much for your responses.

    The reason i asked this question is because i have to decide at what point patients in my control group (e.g. standardised shoe advice) have tried their ‘therapy’ long enough without any result and can then be advised to go see a podiatrist.

    So looking at your responses, if I set this point at 8 weeks, it would be at the safe side but acceptable for some change / adaptation to have taken place.

    Thanks again!
  19. Babette:

    Didn't we meet in Ghent??

    If by "adaptation", you mean that the patient is able to walk all day without having irritation or problems with the orthosis, then this can range anywhere from 1 day to 3-4 months. I estimate I have dispensed around 15,000 pairs of orthoses in my career and probably would say, that your 8 week adaptation period is very safe in that over 90% of the subjects will be "adapted" by 8 weeks, with 80% being adapted by 6 weeks and with over 70% adapting over 4 weeks post-dispensing. These are simply estimates based on my 24+ years of clinical experience of having a busy foot orthosis practice. For you information, I see patients at 3 weeks post-dispensing since this is generally adequate time for the patient to know if the orthosis is working therapeutically for them and then I will see them again at 5-6 weeks post-dispensing if they are having difficulty adjusting to the foot orthoses. There is no generally accepted pattern for these orthosis follow-ups, but certainly by eight weeks, most of your subjects will have adapted to the orthoses as long as they have been seen at 3-4 weeks post dispensing to see if a fine-tuning adjustment of the orthosis is required to optimize the comfort and function of the orthoses.

    Hope this helps.
  20. Graham

    Graham RIP

    When dispensing a sagittal device I advise that they will feel different but at no point uncomfortable. They may develop some stiffness in the front of the hips and glute's but should have no pain.

    I see them at a six week follow up. They are advised should they be uncomfortable to wear or create "pain" elsewhere to come back immediately.

    My best results seem to be putting a sagittal device in where a "conventional" device used to be. Or, sometimes just cutting an FHL/First ray into an existing "conventional" device makes a big +ve difference.
  21. bvanderzwaard

    bvanderzwaard Welcome New Poster

    Dear Kevin,

    We did indeed meet in Ghent, good memory! I have moved a bit away from full-time lecturing and managing the part time course to doing research. I’m an old PhD student now 4 days a week ;) and a lecturer 1 day a week.

    Your information does help. I will propose to have the subjects adjust to their new orthotics or new shoes 8 weeks (where orthotics can be slightly adjusted) before it is decided that the treatment doesn’t work.

    Babette van der Zwaard
  22. Jeff Root

    Jeff Root Well-Known Member

    In the real world, eight weeks is a long time for a patient with severe symptoms to go before seeking other treatment options. So while eight weeks might be a good general rule for most cases, in reality the practitioner must look at the individual patient to determine a course of action that is appropriate given their individual medical history. We are treating individuals, not averages.

    As a case in point, I recently saw a 13 y.o. female soccer player with no known history of injury but who complained of pain on the plantar aspect of her foot in the area of the cuboid and 5th met. and pain up the anterior, lateral leg with swelling on the dorsum of the foot at the ankle. On exam she had significant peroneal spasm and pain limited any STJ or MTJ motion. I referred her to a podiatrist. X-rays were negative for 5th met fracture. She was treated with a boot to immobilize her foot. Her symptoms worsened. She then had an MRI that revealed evidence of trauma to the lateral wall of talus and calcaneus. She was then diagnosed with RSD and treated with a nerve block. She was casted and placed in orthoses but there is a question as to whether she might need to be casted to better immobilize her foot.

    The point is, you can't give this type of patient her orthoses and say see me in eight weeks for a follow-up appointment because it is a very dynamic situation.

    Jeff Root
  23. Kenva

    Kenva Active Member


    I was thought that it was minimum about 4/6 weeks because that should be the time you generally need to adapt neuromusculary (if that is a word...) to a new physical situation...

  24. Interesting range of view.

    With Kevin's ideas on neuromotor effects of orthoses and Brians claims for proprioceptive (by which he means Exteroceptive) effects of orthotics it raises another interesting question, that is, how do the effects of the orthoses change over time? Do they create a different effect when the person is "used to them" and is this to our advantage or not?

    I wonder if peoples expectations of their orthotics, based on how they feel initially, how they are issued etc, would make an observable kinamatic difference...

  25. Excellent point, Robert. As I recall, experiments using tone inhibiting orthoses that act via Duncan's reflex stimulation have a short lived effect as habituation to the stimulus they produce negates their effect over time. I suspect that similar changes will be noted in all foot orthoses. That is the stimulus from the foot orthoses immediately post dispensation will create a given neuromotor effect but as the habituation process continues, that neuromotor effect will change.
  26. But as the ground shape changes and feet move on top of the orthoses during gait in different patterns are we not getting a constant flow of new neurological responses ? Therefore there would be less habituation.
  27. Griff

    Griff Moderator


    Is it fair to assume that if an individual does exhibit visual/kinematic changes when using an orthotic device that these changes will also change over time (in line with the neuromotor changes)?

  28. Only if the kinematic changes are driven by neuromotor effects and not by direct kinetic effects of the foot orthoses.

    Michael what you are saying would mean that there is no habituation to foot orthoses, I'm not sure that this is true
  29. I think we must be careful of our terms here and make sure we all mean the same thing during this interesting discusstion. Habituation is a known central nervous system response pattern in animals whereby a constant peripheral nervous system sensory stimulus causes decreased awareness of that stimulus over time. For example, we don't feel our clothes on our body during the day since we are habituated to the clothing stimulus.

    Adaptation is a more loosely defined term and I am not sure we are all talking about the same thing here. Anyone care to offer a definition of adaptation, in regards its specific meaning of becoming adapted to the direct mechanical and neuromotor influences of foot orthoses?
  30. Here's the wikipedia on habituation:

    Note that neural adaptation is part of habituation

    Here's a definition of physiological adaptation:

    This should provide a reasonable starting point.
  31. Jeff Root

    Jeff Root Well-Known Member

    Perhaps the term "accustomed to" is better. See #3 below.

    ac·cus·tomed (-kstmd)
    1. Frequently practiced, used, or experienced; customary: answered with his accustomed modesty. See Synonyms at usual.
    2. Being in the habit of: I am accustomed to sleeping late.
    3. Having been adapted to the existing environment and conditions: eyes not accustomed to desert sun.

  32. Having said this, on reflection if we see soft tissue adaptation in response to the direct effects of foot orthoses, then it is also quite possible that kinematic effects will vary with time. Indeed, when we put on our shoes plus orthoses afresh each day the immediate neuromotor stimulus and response is probably not the same as that at the end of the day; levels of fatigue of patient and orthoses may also be significant.
  33. Jeff:

    Accustomed may not be the best term due to the meaning of accustomization such as in foot orthosis accustomization:


    Accustomization: The process of learning the techniques of living with a minimum of discomfort in an extreme or new environment.

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