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Discussion in 'Biomechanics, Sports and Foot orthoses' started by scott1, Aug 4, 2011.

  1. scott1

    scott1 Member

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    Hello there,

    I would like some advice re. my current place of work please.
    I work in a predominantly physiotherapy clinic, where the resident podiatrist has been using casted orthosis for the treatment of bio pts which have been referred by a physio or by some other route eg. self referral.
    I recently joined the practice to build upon the routine podiatry side of things. I have some bio pts too which I have successfully treated using non-casting methods. This has perplexed the physios as casting is all they know. I have been trying to educate them to new ways of thinkin with re. treatment of bio pts in the sense that its not all about the casted/moulded orthotic.
    I feel that I am limited in number of bio pts I may recieve as they dont fully appreciate other methods of insole production.
    Any advice re this? Also does the lit more support casted vs non casted methods?
    I really enjoy working in this clinic and the physios are keen to understand my methods but I cant break the "moulded casting" spell.

    Any help would be much appreciated

  2. Scott, I'm reminded of a debate I recently took part in regarding whether prefabricated, library or custom devices were best. I think we all agreed that it was a case of picking the right horse for the right course. There will be cases who will require custom devices; in which you won't be able to get the outcome you seek with the currently available prefabs. The skill is in spotting these. But there will also be a large number of patients who will gain symptomatic relief through prefabricated foot orthoses. As prefabricated devices get more diverse, more patients will be helped via off the shelf devices, this can only be a good thing, provided the cost saving is indeed passed onto the patients. Yet, there will always be those patients that require custom devices, since the range of prefabs is inadequate to meet all of the people all of the time, at least today.

    Certainly in my own practice I find myself prescribing more and more prefabs and less and less custom devices, while still returning efficacious outcomes. This may be a reflection of the economic state of the world, or perhaps a reflection of how much better off the shelf devices have become. Either way, happy patients equal a healthy practice.

    As Craig has pointed out, it's about delivering the prescription variables. If I have a patient that should benefit from say, reduction in external pronation moments, then it matters not whether this reduction is achieved by custom made devices or prefabricated devices so long as it is achieved and reduces the internal supination moments provided by the tissues to a degree which allows the tissues to function within their zones of optimal stress (ZOOS). The foot doesn't care how the device was manufactured only whether the load/deformation, topography and frictional characteristics of the device relieve the stress on the pathological tissue without increasing the stresses in other tissues beyond their ZOOS.
  3. scott1

    scott1 Member

    Hi Simon,

    Thank you for that.
    I was taught to think that way at university, but trying to convey this is proving quite difficult. The clinic is open to change I'm sure, but I think the main problem is the
    utopian idea idea of "custom made" devices, particularly in private practice.
    Would the best approach be; less about evidence more about results?

  4. In private practice there are a number of drivers, certainly the financial one cannot be ignored. Do I make more money from custom devices? Of course I do. However, what I try to do is to have an honest and open discussion regarding the options, the evidence base and what I believe will work best for each individual patient based on experiential learning- they are paying for my skills, experience and moreover, my opinions; what they do with those opinions is up to them. Thus, ultimately the choice remains with the patient, not with me. And sometimes the patient makes the wrong choice, in my opinion.

    Why does "the clinic" have control over your professional practice and decision making?
  5. Craig Payne

    Craig Payne Moderator

  6. RobinP

    RobinP Well-Known Member

    Most physios that i work with, like most of us, are not led by one paradigm of treatment. Most physion will be aware of several different modalities of treatment that will be available to treat a given condition. For example, mechanical low back pain. In NHS hospitals the McKenzie Method or MDT (linky) is commonly used. Yet, in private practice, many physios will tend to favour a more hands on manipulation/mobilisation approach.

    My point being that they make a decision on a course of treatment based on their examination and experience of managing common pathologies. The may well have fairly standard protocols for treatment of certain pathologies, but will deviate to something else on occasion because the presentation demands it.

    What is their selection criteria for one modality over another......usually horses for courses. Experience will tell them that a certain client may require a greater degree of input and a more bespoke pattern of treatment. This is no different to how we operate.

    We decide upon a prescription variable that the patient requires and then find the best way of delivering it. Physios similarly identify an injured structure and decide upon how best to redcue the stress on that structure via strengthening/stretching/mobilisation/manipulation in most cases. The physio may have two people with identical conditions caused via the same mechanism but may decide on two completely different modalities based on something as simple as the job the patient does or the fact that one is 50lbs overweight. Horses for courses.

    It might be worthwhile reading some physio literature and finding something that is analagous to choosing a prefab over a bespoke. Once they appreciate that, you can start to educate them on kinetics versus kinematics because, in my experience, this is something that is poorly understood by physios and they are genuinely surpised when you start to introduce this thinking.

    To paraphrase something that Ian griffiths said last year, "When chatting to a physio colleague, I happened to drop into the conversation that the transverse arch was a myth. He looked at me like i had put my cock in his coffee"

    Hope this helps

  7. scott1

    scott1 Member

    Hey guys,

    Thank you for taking the time to reply! If i wasn't so rubbish at finding related threads I could have saved you some time - so it is much appreciated.
    After reading your comments and the various threads I definately feel more confident in tackling this now.

    Kind Regards


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