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Evidence for the review of foot orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by John Bickerstaffe, Apr 28, 2015.


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    Hi

    We are being asked by our management to provide evidence to support the review of foot orthoses after they are fitted.

    This is a practice I have been carrying out for 30 years since being taught to do so, to check the effects of the treatment I have put in place (as with any treatment) and is not one I wish to end.

    To date I have been unable to find any research to indicate the value or necessity of reviewing orthoses but am well aware of the issues that can occur following orthotic fitting.

    Can anyone offer any idea of where to look for evidence to support the review of foot orthoses post fitting as there appears to currently be sparse evidence in this area.

    I have looked in all the usual areas and have contacted two Professors of biomechanics nationally who support the review of orthoses.

    Many thanks for your help.

    John Bickerstaffe MSc
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    There is no evidence!

    Effectively what the question is that are the outcomes better if there is a review after orthotic issue versus there being no review? We assume that they are better, but we do not know and they may well not be.

    If there was a consensus of expert opinion done, I pretty sure that this would support a review.

    Pretty much every health professional schedules reviews to check on progress after an intervention is used - how many of them have evidence for that?
     
  3. efuller

    efuller MVP

    I wish I got all my orthotics perfect the first time. You ought to have them back just to see if they put them in the right shoes. If you wanted to be stingy, you could have them call for another appointment if the symptoms were not resolved.

    Eric
     
  4. daisyboi

    daisyboi Active Member

    Would it be possible to agree a clinical audit to see how many reviews performed so far resulted in changes to treatment intervention. that would go some way toward a definitive answer and would also make an interesting publication. I think they are asking a fair question as I would suggest that (off the top of my head) I adjust less than 10% of my devices after the initial prescription. Perhaps reviewing everyone is a massive waste of resources and a simple open appointment system might be more efficient.

    Just my tuppence worth

    Dave
     
  5. Hi

    Many thanks to Craig, Eric and Dave for your responses.

    I would agree with Craig entirely, “the question is that are the outcomes better if there is a review after orthotic issue versus there being no review”.

    In the absence of research we currently have only expert opinion to look for guidance.

    Those I have contacted so far agree review is warranted as you simply don’t know how the patient will compensate following the fitting of orthoses, ie whether they are in the correct shoe etc.

    Whilst trying to keep the size of audit down we are considering an audit involving:

    Clinician / not patient recorded outcomes
    A measure of function- this should vary according to the area being treated I am advised
    % of those that are altered at review following fitting
    % of those orthoses that are being worn
    % of those orthoses that are being worn correctly
    % being worn in the footwear they were designed for

    Many thanks again to you all

    Regards
    John Bickerstaffe
     
  6. Griff

    Griff Moderator

    Playing devils advocate here John, but I'm not sure the review being warranted on the grounds you state is that valid.

    What do you mean by those who are altered following review? Pain levels?
    Having a review will only tell you what % of orthoses are being worn (and in what shoe they are being worn) on that day. Bold to assume that extrapolates to the period of time they are not infront of you.
     
  7. John:

    Not to be cynical, but it all comes down to whether your management's treatment goal is to:

    1) Provide the minimum of services to the patient at a minimum of cost and minimum of time to the clinician with the hopes that some patients will improve.

    2) Provide the optimum services to the patient to ensure optimum therapeutic outcome to the patient so that the highest percentage of patients will improve.

    If your goal is #1, then do no review. However, if your goal is #2, then a review is necessary.

    Ask your management first what their goal of orthosis treatment is, either #1 or #2. After they provide their answer to you, then you will be able to easily answer their question on the spot.
     
  8. daisyboi

    daisyboi Active Member

    I think it is being slightly unfair to the manager by citing the situation as being a choice of two polar opposites. If I were the manager I would suggest that my goal is to provide the best service possible TO THE MOST PEOPLE POSSIBLE (probably with an impossibly small budget). This means that review could possibly be done in a different way to the current process, reducing the number of appointments per person and therefore allowing the service to help more people. I would suggest the audit is potentially very valuable, it may tell you that 90% of reviews result in no action and that the remaining 10% are predictable based on previously known criteria. For example you may find that RA patients should all be reviewed or that recreational sports players tend to benefit from a review while others do not. On the other hand you may find that such a high number of changes occur at review that they system should continue to review every client.
    As regards "you simply don’t know how the patient will compensate following the fitting of orthoses"
    If we suggest that without a review we do not know what is going to happen to ANY FOOT I think we are opening ourselves up for considerable flak. I believe it is also reasonable to credit our patients with a bit of savy about their own body. Last time I got a filling at the dentists he didn't need to review to be sure he had done his job properly but I knew I could return if I felt something wasn't right. In any case, if you do the audit you have the data to defend the decisions you make. Without the data you position is not terribly strong. I agree with Griff that you must be careful which conclusions you draw from an audit but I still think it would be a valuable and worthwhile exercise, which would either result in a well informed change to your service or would offer you a robust defence of your current practice which may help to safeguard your service both now and in the future.

    regards

    Dave
     
  9. Dennis Kiper

    Dennis Kiper Active Member

    As long as orthotic technology is unable to produce a quantifiable precription orthosis, predicated on and backed by scientific principles, scientific data to provide evidence that supports orthoses treatment, will remain unreliable and only anecdotal.
     
  10. podcare

    podcare Active Member

    Reminds me of a patient I reviewed many years ago following the dispense of orthotic appliances. I noticed the patient had their orthoses in the wrong shoes (i.e. left orthosis in right shoe and vice versa). I asked the patient how they went ajusting to the orthotics and the response was "fine, no problems". After further examination I noticed a significant indentation and callus formation in the lateral plantar aspect of both feet as a result of pressure applied from the medial aspect of both orthotics. I'm glad the patient returned because he had Type 2 Diabetes and there was a real possibility of long term ulceration not to mention any other musculoskeletal issues had this not been rectified at their review.

    Over the years, I have seen many children and some adults place orthotics in the wrong shoes, misinterpret instructions, misunderstand complementary exercise programs etc., etc. The review is an essential part of any orthotic therapy.

    When you're dispensing any device or appliance which redirects forces - you have an obligation to ensure any changes you are making are beneficial and not more harmful. If they do make the patient worse and you decided not to review them just to save them or management a few dollars... my thoughts are - Good luck in court! Medicolegally, I could see lawyers having a field day with this.
     
  11. Dr. Steven King

    Dr. Steven King Well-Known Member

    Aloha Jon,

    It would be really cool if we could better quantify-test our treatment modalities. During this follow up visit you could perform some type of gait or footwear system analysis that would quantifiably reflect the effects of the treatment.

    I agree with the wisdom of Craig which kind of echoes that of Dr. Benno Nigg.
    "Effectively what the question is that are the outcomes better if there is a review after orthotic issue versus there being no review? We assume that they are better, but we do not know and they may well not be."

    A Hui Hou,
    Steve
     
  12. Dr. Steven King

    Dr. Steven King Well-Known Member

    Aloha Jon,

    We are starting in medicine to develop more wearable smart technologies. Much like wearable insulin pumps and blood sugar readers that allow capture downloadable data for the patient's health professional's to review and make further treatment corrections.


    Mahalo,
    Steve
     
  13. Hi

    Many thanks to everyone who has replied to my question, I realy appreciate all your answers and your time:

    To answer Griff firstly-

    Q What do you mean by those who are altered following review? Pain levels?
    Sorry – typo- this should read those orthoses that are altered following review.

    Yes due to it being an audit it is open to great interpretation.

    Kevin

    I think your answer is very perceptive as it hits at the crux of the issue.

    Dave

    We will be going ahead with an audit however this will have to be within the confines of our existing computer stats to make it workable allowing reports to be run on a monthly basis with the minimum of clinician input.
    We are looking at perhaps reviewing in a different way however my concern is that this might influence the quality of our care.

    “You simply don’t know how the patient will compensate following the fitting of orthoses”- in the vast majority of cases we know how a patient will react to an orthosis however there are always going to be patients who don’t behave as predicted and hence the need for review / access to backup is needed. (We need to know the outcome of an intervention and if not the expected outcome we need to refine our treatment plan or refer elsewhere).

    We do need to be careful in what we audit how we interpret it.

    Potentially this could become a huge study which I am not able to embark on in the absence of further investment at present. We will continue to monitor pain, FPI (or other area specific index) pre and post orthotic fitting however this alone could become a huge piece of work as our existing stats package has no means of collecting this so we would have to revert to Excel.


    I put the same question re: review / follow to our lead physiotherapist who said “the need for review and reassessment is crucial to the clinical reasoning process in order to prove or disprove the initial working diagnosis”. This justifies the” important need for ongoing review to solve any clinical indeterminacies or misattributions on initial presentation”. Selfe and Greenhalgh (2010).
    If we abandon follow up assessments this could sadly lead to the misconception of more serious pathology- ie if heel pain was still evident following treatment how long would it be before they had their heel x rayed and an osteoid osteoma or other pathology was found and further action was taken without review occurring?

    We will be setting ourselves up for the inevitable increase in the litigation process in a blame and claim society unless we continue to review.

    References:

    Selfe and Greenhalgh (2006) Red Flags: A Guide to Identifying Serious Pathology of the Spine.

    Regards

    John Bickerstaffe
     
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