Biomechanics Clinics

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Hi all,

My PCT is looking at further developing its biomechanics service. There will be funding available.

My questions are:
1)In an ideal world what equipment would you find most useful and why?
2)What equipment would you need and why?
3)What equipment would you want and why?
4)What equipment do you find useless / worthless and why?
5)What size room would you like to work in and why?

I appreciate everyone will have different views and look forward to your responses.

Why am I asking the questions? Our current service is under review prior to possible expansion. Not having had much experience working with technology it would be good to find out how others work and with what so we can objectively look at new 'stuff', that has been tried and tested in the real life work place. This way hopefully we won't re invent the wheel.

Thanks in advance

Nikki

 

IMHO In an ideal world all you need is

1) a bucket,

2) some warm water

3) some plaster of paris sheets (not rolls)

4) a digital camera and a colour laser printer.

Obviously 1-3 for making plaster casts. 4 because then you can photograph lots of angles print them out, add them to your patient records and later decide on your prescription when the patient has gone home. This gives you more time.

5) a good lab i.e. allied OSI labs. Because they produce nice orthotics and are reasonably quick.

Foot scanners seem to work on templates and need training to use effectively. Also they do not necessarily pick up odd foot problems such as talocalcaneal coalition where the whole foot does not contact the ground durinmg gait (Giacomozzi et al. 2006, pp.107-115). Patients need to be shown how to use the foot plate therefore repeatability is an issue (Payne 2002, p.316).


There are no standardised protocols for analysing, collecting and interpreting computer generated measurements (Curran and Dananberg 2005, pp.130-142) thus a wide range of companies produce equipment for this, each with their own protocols. So the podiatrists need to ensure that particular systems considered for use match their requirements. So why make it harder than it needs to be?


The casting method is cheaper and quite accurate and gives a 3d representation of the foot. PoP sheets are much easier to use than rolls.

Cheers,

Robin.

And yes I have written an essay on this
I'm now off to add this to my HPC CPD log :wacko:

References:

Curran. S.A. and Dananberg, H.J., 2005. Future of Gait Analysis. A Podiatric Medical Perspective. Journal of the American Podiatric Medical Association, 95 (2), pp.130-142.

Giacomozzi, C., Benedetti, M.G., Leardini, A., Madellari, V. and Giannini, S., 2006. Gait Analysis with an Integrated System for Functional Assessment of Talocalcaneal Coalition. Journal of the American Podiatric Medical Association, 96 (2), pp.107-115.

Payne, C., 2002. Methods of analysing gait. In: Merriman, L.M. and Turner, W. eds., 2002. Assessment of the Lower Limb. 2nd ed. London: Churchill Livingstone. p.315-316.

 

I would say equipment wise in an ideal world

A goniometer
Casting stuff (POP bowl etc)
Casting boxes (impression foam)
Digital video camera and laptop (also does stills)
A pelvic level
Some size templates, and indelible pencil / eyeliner for "simple" insoles
Platform for patient to stand on.
A corridor or room at least 6 m long for gait analysis.
Some strips of vitrathene or similar and a stanley knife with a curved blade for taking casts to above malleolus (for smafo's if you are so inclined).

Some scotchcast for making those cool little pressure releif slipper things.


If you have money to burn an in shoe pressure measurement system will be useful for research.

If you can get your own orthotics lab it saves a LOT of money in the long run and gives you far more flexibility in what you produce so i would push for that while the money is there. Grinding machine, vacuum former, 2* small ovens, fume extraction unit, sink, glue and a selection of materials and you're off!

I've probably forgotten a few things but thats a start.

Regards
Robert

This BTW is all very debateable (and has been ad nauseum) POP may be cheaper than a foam box material wise but have you factored in the amount of your time (which has a quantifiable value) it takes to do? What does ten minutes of your time cost? . The accuracy of foam vs POP has been oft debated and never decided and what you find easier is a personal thing.

 

We have;

• 3 consulting rooms one of which is large enough for F-Scan analysis
• 1 Plaster room which has grinder for orthoses/splint adjustment
• Blocks in 2mm increments to put under the foot to balance the pelvis in LLD
• store cupboard for splint, orthoses, POP bandage, and footwear modifications
• waiting room with pt WC
• Staff WCs male and female
• Matscan
• F-Scan
• PCs in each consulting room for email/internet/X-rays
• Office for Secretaries
• Office for Senior Clincians (inc yours truly)
• Office for Head of Service (she who must be obeyed)

We don't go over the top for "toys" but have a couple of goniometers, percussion hammers, tuning forks, 10gm filament, 2 point discriminator, equinus raises of varying pitch, foam boxes ( for the occ. TCI)

Overall if you have a blank canvas, make a nice environment for yourself to work in and for your patients to visit, and you will be both be happy.

Don't sell yourself short and cram every useless piece of kit into a tiny space. We don't bulk buy much stuff either. If someone needs silipos heel cups, we order them in. In the meantime, I will give the pt some exercises to do, such as calf stretches, and icing Rx. Then I will fit and supply the heel cups when I review how the pt is doing following the stretching/icing regime.
Environment is important.

 

I have said this before in other threads .... I can never understand this about the UK. Why is 'biomechanics' so special? Why is it given such a special status?

In USA, Australia, NZ, South Africa, Canada ... etc .... biomechanics is just part of what we do. It underpins everything we do. Everyone is set up for it (though a few have more advanced gait analysis equipment).

 

Robin, Robert, and Peter,

Thanks for your replys.

We currently run three sessions (soon to be four) for adults and one for paeds per week. Appointments made via choose and book, letters typed by our secretaries.

We have no 'toys' other than the usual 10g mono filament, tuning fork, and goniometer. We use POP and foam impression boxes, (personally I am beginning to favour the latter) and have PC's with access to x-ray, U/S results. There are three or four of us providing the service. Two of us can directly request x-rays and U/S, administer steroids if needed and also list for surgery with our Pod Surgeon, as our service sits within a Primary Care Orthopaedic Service. Gait is observed along a corridor.

We are also fortunate enough to have our very own lab, use some preform orthoses, and have the materials to manufacture chairside orthoses if required. For footwear requirements (but only if patients cannot get commercial footwear to fit)we can refer directly into secondary care.

I am beginning to feel quite spoiled.

Craig,
I agree entirely with you that biomechanics is 'nothing special', and definately underpins everything Podiatry. My own impression as to why it is given 'special status' is partly the way it is taught as a separate subject at Uni (or so it seems according to the students we have on placement) Our Community Pods complain on the one hand that they 'never get to do Biomechanics', but on the other say 'that patient should be referred to Biomechanics' if they get any one who remotley needs an orthosis.
Our PCT is willing to fund as a separate service, so who am I to argue?

As there is funding available I asked the question in the first place to find out how we can improve our service, with 'better' equipment if there is such a thing, using the esteemed knowledge found on this forum

I for one am not happy about walking patients up and down a public corridor, hence the reference to room size. I know the views about gait analysis on treadmills is somewhat mixed, personally I think that unless someone is 'trained' to walk on one properly the results may not be too good, as the patient has to walk at a everso slightly different speed to their norm, also balance would be altered, etc etc. I am prepared to be shot down over this one.

A digital camera is something I have been pondering over for some time, but also with video capability. A colour printer I hadn't thought of but makes sense so pics are in the notes.

We have already put in a business plan for CAD /CAM equipment, and this is being considered. The service redesign is a separate budget (Don't you just love the NHS)

As it would seem from the replies so far the redesign costs aren't going to be too large, bigger room, camera and printer.......................perhaps I could ask for a cut of the savings then?

Thanks again

Nikki

 

We teach it first year and start of second year as a basic science - it underpins the rest of the course (diabetes; paediatrics; surgery; sports; etc etc)

When they say that they probably mean they are just not understanding or seeing the biomechanics behind the problem they are treating.

 

I agree whole heartedly with what you are saying!

I sometimes wonder if they are looking at all

 

They should not need to refer for biomechanics --- its what Podiatrists do! ---at least everywhere else except the UK .... thats what intrigues me has to how it developed that way.

 

IMHO I think it may be due to the UK desire to encourage specialisms within Podiatry, along the lines of Diabetes, Rheumatology, Orthopadics etc.

Whatever happened to the good all rounder?

My concern for the future is that if the 'non specialists' aren't too careful they will lose all their remaining skills. The establishment has started by the refusal to cut non pathalogical nails (but I don't want to get into that debate here)

We are trying to encourage our staff to treat allcomers rather than refer on. One of the problems is the famous 'entitlement' to teatment. If you haven't got diabetes, PVD, or a rheumatological condition the GP's here won't refer you to the generalists. If you have flat feet they will refer you to biomechanics:bang:.

Its simple really corns equals Community Pods, flat feet equals Biomechanics, at least in the eyes of our referrers (is that the right word?). Never mind other foot problems.

Also partly patients are to blame. They still seem to think there is a difference between a 'schiropodist' and a Podiatrist. Often they turn up after seeing a private practitioner saying 'my 'schiropodist' said I needed to see a Podiatrist for some insoles. (let me apologise to all those private practitioners who don't do this, and I know there are many of you, I'm just saying how it is as I see it)

We educate all our GP's then the rules change, GP's become fund holders, then they don't, PCTS are developed, then the structure changes, then they merge, then they divide into commissioning PCT and provider PCT.

I'm sure Robert and Simon will add to this and also correct me if they feel I am 'over reacting'. I'll get off my soap box as I do get very frustrated by the long waits for people to be assessed in the specialist clinics, when they could have their treatment started sooner in Community Clinics which are invariably closer to their homes.

I just want the best possible treatments for my patients

Nikki

 

Therein lies the difference. Biomechanics is not seen as a specialism in the rest of the world as its a fundamental part of those other specialisms. .... ie its a basic science, not a speciality.

BTW - I recall a diabetes specialist physician telling me a long time ago that he would hate to be a GP as you have to know so much

 

Hi Craig

Perhaps what can underly some of these "Referals" is that in the UK we still make biomechanical intervention more complicated than it needs to be, in many cases, terrifying the learner and even the practitioner. There will be some that test the brain and rational but many need not and the practical intervention can be simpler than feared.

Equally perhaps there is a history of too much emphasis upon the effect an orthosis can have upon the foot ( i have heard people lecture in the past and say it needs to be right or a leg may be broken)

Ian

 

You are probably right; vested financial interests and egos want to make it more complicated than it is.

 

Hi Ian,

You are right of course. This state of affairs has existed in the UK for over 25 years (and is still going on:bang:.

Cheers,

 

Back on topic..............

Nikki,

I like vertical loading gait analysis systems (Tekscan and similar).

I don't buy into everything the manufacturer says they're capable of, but they are useful for instantly recording some aspects of gait (early heel-lift, ad/abduction angles etc). A Tekscan system is currently around the £6000.00 mark I believe.

IMO the limitations of these systems are outweighed by the fact that data is easy to collect and store (movies and stills), and you/they don't need a huge amount of room to collect it.
I use one quite successfully with a bottom of the range laptop in a standard hospital consulting room.

Cheers,

 

Craig et al

In my experiance the reason bimechanics is often treated as "separate" stems from how it is covered (or not) in the undergrad syllabus. It is not given anywhere near the emphasis it gets in La trobe. Many of the students we get from our local uni have very little idea of any of the basic principles much less the more advanced stuff. I managed to graduate (admittedly quite a few years ago however i have seen no indications that it has improved) without anyone telling me what a moment was! I'd never heard of gait plates or mortons extensions and i had no idea that there was a difference between ff varus and ff supinatus. It was just not a part of the course. The only biomechanics exam i ever had was one 15 minute station on an OSCE.

As such most of the training takes place after graduation and as such many people (who specialise in other things) simply don't do it! One simply cannot rely on all podiatrists knowing all the fundamentals.

This is the undergrad syllabus for brighton

You see even one module on biomechanics? I don't. I'm sure its woven into the others but it is not covered in any depth.

Looking at your learrning centre here http://www.latrobe.edu.au/podiatry/learningcentre.html

It looks like biomechanics makes up 1/4 of your 1st and third year and 1/6 of the second! Not a surprise that after doing that you can expect all of them to know a bit about it.

This might be only my local experiance, perhaps it gets better coverage in other schools. But thats my theory.

Regards
Robert

 

Agree with Craig's points. I think musculo-skeletal is the specialist area, not biomechanics, but I'm sure this is contentious too. One bug-bear point re: orthoses = biomechanics. Orthoses have mechanical properties, not biomechanical.

In terms of equipment required: personally I'd start with enthusiatic, skilled clinicians. But I also find a treadmill and video system very useful.

 

Hi All

But corns are in many cases symptoms of an underlying biomechanical problem are they not ??

Not EVERYWHERE in the UK Craig I see and treat as I find and the biomechanical problems seem to be overtaking all else in my practice by referral or initial presentation.

Wholeheartedly agree with David here I use one myself ( Gait Scan) and as an aid to diagnosis and patient education tool I would never be without it now.

Just my thoughts
Cheers
Derek

 

Not to worry, Robert. I never was taught what a moment was during my six years of podiatric education as podiatry student, surgery resident and biomechanics fellow. I had to learn this one from my physics-biomechanics textbooks on my own. There are a whole lot of podiatric surgeons out there who still don't know what a moment is because this would mean they would have to go to something other than a surgery seminar!!

 

Re-assuring

I bet they never taught you about the SALRE model either.

 

Hi,

we have a similar monitoring pressure system which is similar to F-scan and it costs less than F-scan, do you have any interests to have a look?

 

I have oft thought there should be no specific Bio service, or even wound care specialists/diabetes specialists. We should all be doing that stuff, all the time.

Trouble is, you come out of uni, keen to do some Bio but the PCT has that as a seperate dept. You then express an interest in doing some Bio clinics after a few months of getting in the groove with the generic stuff, but you can't get in for whatever reason (it's not in your PDP you see). So you end up on the treadmill and a few years later you’re deskilled and unmotivated to deviate from what becomes a normal day at work.

 

I would have thought that the reason for the difference in UK vs other countries is simple. In all the other countries Podiatry is a business and therefore a practioner cannot afford to de-skill and turn patients away. As Craig says all Podiatrists in Australia would consider orthotic therapy part of their skills. Whether that means they are good at it is another question...

In the UK, Podiatry has a large public sector and many Podiatrists within it do not want to do anything percieved as complicated.

 

You could also replace the word want with need to make things more accurate.

 

Ok correction : neither wanted nor needed to do anything more complicated!

Historically some UK public sector staff have wanted to and thus accumulated a mechanical therapy case-load and this lead to de facto "specialised" clinics and "specialised" clinicians. Its not a case of the UK regarding "biomechanics" as separate its just evolved that way as some practioners wanted to and others were only to glad not to do mechanical therapy with no financial penalty.

 

Craig I understand and agree with your point in the second paragraph but how can you not understand why biomechanics is special or needs specialists when at La Trobe you have Podiatric Biomechanics modules, you run a Special Biomechanics Boot Camp and research specialities include biomechanics. Surely the tutors teaching these courses and modules must have specialist knowledge. Or are you saying that any teacher, tutor, graduate or professor of La Trobe podiatry dept has the same level of knowledge in all areas.

I believe you are saying a Podiatrist must include biomechanics in his everyday practice and I agree with that. But some people will have greater knowledge in that area and so can specialise.

Fitting a pressure relieving felt pad is biomechanics but is also a far cry from using a whole range of clinical, kinetic and kinematic data to design a new type of custom ankle and knee brace for a specific customer with CP for instance..

Not every private clinic has a gait lab and a orthotics workshop and many podiatrists wouldn't have the skill to use them to their best advantage even if they did..

So where does the basic biomechanics skill give way to a specialist practitioner with useful skills in all or some areas of the above. Can these practitioners then have enough time to say they specialise in other areas. I don't think so otherwise there would be no need for dermatologists, wound care, diabetes and vascular specialists etc. (plus all their machines that go Ping)

While there may be some top practitioners who can do all these things well, I don't believe this is the norm. There's only a few like you and Kevin et al, who have been in podiatry since the dawn of time, who have had the time and motivation to learn all thiese things Some of us are mere mortals who exist in the constraints of time.

We who are not worthy salute you:santa:

Dave

 

I think the difference is one of philosophy - we teach pod biomechanics as a basic science (like biochemistry) in 2nd yr that underpins what is taught in subsequent yrs (ie paediatrics, diabetes, sports, etc). Its not taught as something "seperate" as a speciality. It is taught as something that underpins the other specialities. I make it clear to the students that they do not have an option of being interested in this subject or not - they have to "get it" or they will not survive 3rd and 4th yr

 

And when I teach biomechanics to the 2nd and 3rd year podiatry students at the California School of Podiatric Medicine, they fully understand that biomechanics forms the basis for the decision making process not only for orthoses, braces and other conservative measures, but also for all types of foot and ankle surgery. They are taught that biomechanics is not an option, but rather is an integral part of understanding how to most effectively treat the only weightbearing organ of the human body.