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Comparison of foot orthoses made by podiatrists, pedorthists and orthotists

Discussion in 'General Issues and Discussion Forum' started by Hylton Menz, Dec 21, 2005.

  1. Hylton Menz

    Hylton Menz Guest

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    From BMC Musculoskeletal Disorders:

    Comparison of foot orthoses made by podiatrists, pedorthists and orthotists regarding plantar pressure reduction

    Nick A Guldemond, Pieter Leffers, Nicolaas C Schaper, Antal P Sanders, Fred HM Nieman and Geert HIM Walenkamp


    There is a need for evidence of clinical effectiveness of foot orthosis therapy. This study evaluated the effect of foot orthoses made by ten podiatrists, ten pedorthists and eleven orthotists on plantar pressure and walking convenience for three patients with metatarsalgia. Aims were to assess differences and variability between and within the disciplines. The relationship between the importance of pressure reduction and the effect on peak pressure was also evaluated.


    Each therapist examined all three patients and was asked to rate the 'importance of pressure reduction' through a visual analogue scale. The orthoses were evaluated twice in two sessions while the patient walked on a treadmill. Plantar pressures were recorded with an in-sole measuring system. Patients scored walking convenience per orthosis. The effects of the orthoses on peak pressure reduction were calculated for the whole plantar surface of the forefoot and six regions: big toe and metatarsal one to five.


    Within each discipline there was an extensive variation in construction of the orthoses and achieved peak pressure reductions. Pedorthists and orthotists achieved greater maximal peak pressure reductions calculated over the whole forefoot than podiatrists: 960, 1020 and 750 kPa, respectively (p< .001). This was also true for the effect in the regions with the highest baseline peak pressures and walking convenience rated by patients A and B. There was a weak relationship between the 'importance of pressure reduction' and the achieved pressure reduction for orthotists, but no relationship for podiatrists and orthotists.


    The large variation for various aspects of foot orthoses therapy raises questions about a consistent use of concepts for pressures management within the professional groups. ​

    All BMC journals are open access, so you can download the fulltext papers for free.
  2. admin

    admin Administrator Staff Member

    Thanks Hylton
    What is good about publications at BMC is you can access the pre-publication reviewers comments on the panel on the left of the page at the link above. One of the reviewers was Professor Rome :)

    The first author, Nick Guldemond, is a member here, so hopefully he is willing to respond to questions.
  3. Craig Payne

    Craig Payne Moderator

    Nick, if you are around...

    Congrats on the study.

    The only real issue I have with the paper was what was commented on by one of the reviewers and is this sentence in the paper "All podiatrists constructed thin insoles out of rubber, leather and cork" .... I do not know of any Podiatrists in Australia and most other countries that make foot orthoses that way (there must be a few), so must be quite unique to the training of Podiatrists in the Netherlands to make them that way.
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    My god...is this the state of play when a podiatrist says they are making a "foot orthosis" in The Netherlands? How can anything remotely approach the requirements for meaningful plantar pressure reduction without being casted or at least using a reliable pre-fabricated heat-mouldable device? What a joke! :eek:

    Perhaps another wasted opportunity in orthotic research to be ignored by the masses in our profession around the globe?

  5. Guldemond

    Guldemond Member

    Dear all,

    Excuse me for my late reply.
    I was quite busy with setting up a new study.

    The type of foot orthoses made by the Dutch podiatrist, is also provided in Spain, France, and Belgium. The concepts for construction are based on the principals described by the Frenchmen ‘Lelièvre’, ‘Bourdiol’ and ‘Lavigne’ (see for an impression www.posturologie.asso.fr , www.guy-capron.com).
    Although I think these type of insoles are not optimal for local stress reduction, a few podiatric insoles had a better result than some orthoses made according to the ACFAOM practice guidelines.

    We had planned a randomised clinical trial to compare orthoses made podiatrists versus orthoses made by orthotists for treatment of patients with metatarsalgia. In the preparation of this study the representatives of these disciplines had defined a general treatment concept (In the Netherlands the clinical viewpoints of these disciplines on treatment of foot disorders are quite different). After the consultation of the formal representatives, we also visit some companies and workshops for a second opinion. After that, our impression was that the treatment concepts were not so consistent as what was previously suggested by the formal representatives. We worried about whether the study results of our planned RCT could ever be generalized to a larger population of podiatrists or orthotists. If the podiatrists and orthotist (who ought to construct the orthoses for the RCT) work very different from their fellow-workers, a RCT would make no sense. If effectiveness is dependent on individual skills and experience, the concerned therapist could not be a representative for his colleagues and consequently the generalisation of conclusions would be problematic. So, ‘a priori’ we decided to perform a study on variation between and within professional groups concerned with foot care in the Netherlands.

    Truly, we didn’t know what to expect. Based on a few visits and interviews we had some ground to expect a large variation for several aspects of foot care, but on the other hand we never arranged meeting of several therapists around a ‘live’ clinical case. I think we’ve had expected some variation in details.

    I do think that the variation found is not unique for the Dutch situation. Several studies in other countries evaluated variation for different aspects of orthoses therapy like: casting, goniometry and prescription habits. The results of these studies showed a wide variability between foot care specialists.

    A conclusive evidence based theoretical and practical framework is still to be established. The existing guidelines are predominantly based on empirical information. Which is not necessarily wrong, but further research is needed to differentiate which elements of physical examination, clinical reasoning and construction of foot orthoses are relevant for clinical effectiveness. Future fundamental and clinical research as well as available evidence (i.e. literature) is to be integrated in algorithms for daily practice. A practical research approach would be to start with the evaluation of existing guidelines.
    As an example, we examined also the three disciplines regarding their ability to identify locations with elevated plantar pressures. We saw important discrepancies between quantitative measurements (golden standard) and ratings of the therapists. In this case the first step should be an inventory of possible valid methods for plantar pressure screening. Second, a detailed study has to be performed to find a clinical method or a combination of methods and techniques, which can most accurately identify locations with elevated pressure. Third, after validation and standardisation the best method should be implemented as a standard guideline.

    …for my appreciated colleague LuckyLisfranc:
    Without any scientific evidence for many aspects of foot orthoses therapy, I think it is inappropriate to be so convinced about the efficacy of casted or reliable pre-fabricated heat-mouldable devices for plantar pressure reduction. (what’s in a name: Lisfranc was not a popular person, his bellicose manners making any close friendships between him and his colleagues impossible…what a joke).

    Till soon,

    Nick Guldemond
  6. IvoFlipse

    IvoFlipse Welcome New Poster

    Well Nick I liked the idea of your research, but off course had some points of comment as I told you n Munich.

    I know about the methodological problems it would cause, but shouldn't the patients/persons wear the insoles for a longer period and get the upportunity to adapt to it or at least get used to it? I gave a similar comment on your latest research on the insole shapes, but I still believe it's (as you state yourself) no so easy to compare insoles based on a couple of trials.

    Furthermore I thought it was too bad you only looked at pressure reduction, because the idea with for instance the Lavigne type of insoles is to maintain the foot mobility and only correcting it. In that case it perhaps doesn't give an overall peak pressure reduction, but it still could have a possitive efect on the pathology.

    But perhaps that would be something interesting for the future! Good luck with your next research!

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