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Need assistance in comprehending physiotherapy opinion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markjohconley, Oct 1, 2014.

  1. markjohconley

    markjohconley Well-Known Member


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    Goodaye all,
    A second physiotherapist, i was talking to today, reiterated the belief that 'foot orthoses' can only assist short-term, that "muscle re-training" is needed for long-term benefits. Any opinions appreciated; not knowing enough to dispute this, I would've thought that foot orthoses by altering the joint moments 'do re-train muscles'.
    Not related, I was emailed today from my boss, querying my (over-)use of 'frontal plane' wedges; I was a tad angry, then a touch sad, but walking home from work I realised that she wasn't a reader of PA and as such hasn't had the benefits that i have had in the last 10 years'ish. If she doesn't comprehend surely one of the most basic (and beautiful) principles(?), STJRE, then ......
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    They just showing their ignorance and total lack of understanding of foot orthotics and lower limb biomechanics, which is dangerous if that is how they are treating patients. Would you not expect that anyone who has an opinion on something would demonstrate that they actually understand the issue before forming an opinion on it? ... esp if they making clinical decisions that affect other people!

    Gait retraining and muscle reeducation will work brilliantly if it was the cause of the problem - they are showing their ignorance by assuming that this is the problem in all cases, which of course it is not.

    Ask them how they plan on retraining someone with an osseous forefoot varus? How the f... are they planning on getting the medial side of the forefoot down to the ground without "overpronation"? (a soft tissue forefoot supinatus is a different issue and might be amenable to some re-education;- do they even know the difference between the two? Yet they are making clinical decisions in patients with it ... go figure!)

    What are they planning on doing in someone with a massively medial STJ axis; high supination resistance and early stage post tib dysfunction??? By the time they realize that the gait retraining and muscle reeducation has failed, the post tib dysfunction would have progressed beyond stage 2 and need some reconstructive surgery with poorer outcome for the patient!

    On the other hand if there is an issue with the gluts and this is causing the problems, then yes orthotics will result in a fix today and glut retraining will do away with the need for the orthotics in the medium term.

    Also, in many overuse injuries, orthotics can do a brilliant job at reducing the load in the short term and then you can use progressive resistance and tissue adaptation to build up the tissue in the medium and longer term so orthotics not needed longer term if
    1) there is no issue preventing tissue adaptation (eg genetics)
    2) the patient actually complies long term (ie a piece of plastic in the shoe is a helluva-lot easier than relying on long term compliance to an exercise program)
    3) the magnitude of the forces are so high that the tissues can not adapt (in which case orthotics are a long term option)

    Give the patient the options and let them decide in the context of their being no long term adverse outcomes with foot orthotic use (ie they do not weaken the muscles; etc)

    Also ask the physio if they believe in evidence based practice - the evidence for foot orthotics is much stronger than the evidence for gait retraining and muscle re-education!
     
  3. markjohconley

    markjohconley Well-Known Member

    Thanks Craig, wow i feel better after that......one of my remaining wishes is to pay you to come to canberra and talk to the AIS physio's, some non-believers in their heirachy i hear. Excellent post, mark
     
  4. Ian Linane

    Ian Linane Well-Known Member

    Tend to think that in these things it is rarely "either/or" but quite often "both/and". That said, I use an aweful lot less devices than I use to, probably just more circumspect with them in conjunction with the other skills than suggesting one is better than the other.
     
  5. efuller

    efuller MVP

    To add to Craig's excellent comments.

    The problem in posterior tibial tendon dysfunction is that when there is a medially deviated STJ axis, that muscle already has to work harder than the muscle in a foot with an average axis. The problem is that it is overworked. When it starts to fail, working it harder to strengthen it is not going to help. An orthosis with a medial heel skive will reduce the muscles workload, hopefully enough so that it can heal.

    Eric
     
  6. Dananberg

    Dananberg Active Member

    I used the patient’s history as the major way to determine whether they would require long or short term foot orthotic management.

    If they were athletic, or worked in a supermarket, for instance, and were always on their feet, and only began to have difficulties following some sort of accident (a fall, sprained ankle, etc.), then it seemed to me that their biomechanics was fairly stable. The use of FO was then a short term solution while they healed their particular injury.

    If however, they had chronic lower back, leg, knee, and/or foot pain when they were on their feet for even shorter periods of time, or if a runner and could never break the 10-15 mile/week barrier without symptoms, it was highly likely that long term FO treatment was likely.

    If you are not sure what to do when initiating treatment, go back and take more history.

    Howard
     
  7. Mark:

    Sorry I didn't see your question sooner.

    This appears to me to be a case of the physiotherapist, and your boss, being unfamiliar and/or ignorant of the large body of research that clearly demonstrates that not only do foot orthoses have a fairly amazing ability to improve pain, increase function, increase healing, and improve balance but also can alter the kinetics and kinematics of gait. I have attached a book chapter that is available online that I wrote a few years ago that goes through some of the foot orthosis research that is important for all podiatrists to be aware of (Kirby KA: "Evolution of Foot Orthoses in Sports", in Werd MB and Knight EL (eds), Athletic Footwear and Orthoses in Sports Medicine. Springer, New York, 2010).

    As an aside, here are some of the things that foot orthoses have been shown to do for patients by peer reviewed research papers:

    1. Positively affect foot and lower extremity kinetics.
    2. Positively affect foot and lower extremity kinematics.
    3. Reduces pain and disability in RA and JIA.
    4. Reduces pain and disability in knee OA.
    5. Reduces pain and disability from ankle bleeds in hemophilia A.
    6. Reduce pain from patellofemoral pain syndrome.
    7. Reduce pain from plantar fasciitis.
    8. Reduces plantar pressures in neuropathic diabetic feet.
    9. Reduces plantar pressure and pain from "metatarsalgia".
    10. Prevents stress fractures in metatarsals and femur.
    11. Improve balance and reduce pain and disability in elderly women.
    12. Improve balance in single leg and bipedal standing.

    I don't have a lot of patience for these type of people who are ignorant of foot orthosis research and because of their ignorance, just start making things up. Their comments are then spread around by other like-thinking members of their profession who also are ignorant of the research and have an agenda. From this passing of mythological beliefs from one individual to another in lectures and over the internet, it is not uncommon for such idiotic ideas to become common beliefs. This is what I believe is happening in your situation. The origin of the idea that properly-prescribed foot orthoses cause weakness or other types negative side effects over time is very similar to what happened during the barefoot running fad: people made things up, wrote them on the internet, this was then accepted as fact by others and then it is believed to be true by those that want to believe it is true. However, in reality, in the case of the barefoot running fad and all the things that were accepted to be fact by some people, these were not facts, they were myths propagated by ignorant individuals who had a desire for these myths to be true.

    From what I can tell, this belief that foot orthoses should only be used short term seems to be something that is being talked about mostly by physiotherapists, (e.g Blaise Dubois said something like this here on Podiatry Arena a few years ago). However, I have also even heard Irene Davis, PhD (who is a physical therapist) say the same thing. This is just a case of wishful thinking by a group of professionals who really don't have a clue about how effective foot orthoses can be for patients when prescribed by someone who is well-trained in their use. They want to be doing "gait retraining" and "muscle reeducation" on everyone, even though, like Craig said, there is less evidence about the long-term effectiveness of gait retraining than there is on the effectiveness of foot orthosis therapy.

    What is really sad about these people is that they have not a shred of research evidence to show that long term use of foot orthoses is detrimental in any way. Foot orthoses have not been shown to weaken feet. Foot orthoses have not been shown to cause other pathologies. And, in fact, from what I have seen over the past three decades of making over 15,000 pairs of orthoses for patients is that foot orthoses seem to strengthen feet indirectly by allowing individuals to stay more physically active and thus strengthen their foot and lower extremity by increased activity. I have never, in any of those 15,000 individuals that I have treated with foot orthoses see a single one of them develop "foot weakness" from wearing foot orthoses. Where is the evidence that foot orthoses cause foot weakness? Answer, there is none!

    Would these same physiotherapists recommend only short term use of prescription eye glasses or contact lenses since they believe that individuals that wear eyeglasses or contact lenses will develop weak eyes and therefore, instead of long term prescription eyeglass or contact lens use, these individuals must start doing daily eye-muscle strengthening exercises? I hope not.

    All this is very disturbing to me and I think we all need to become more aware of the foot orthosis research so we can respond appropriately when someone makes such claims against a treatment that is such an effective therapy for hundreds of thousands of patients around the world. I would be happy to take anyone of these people on in a one on one debate on why they feel that correctly prescribed foot orthoses are detrimental to patients in any way. Tell them to come onto Podiatry Arena and we will see if they really believe what they are spreading around as being a "truth". I'm at my whetstone, as we speak, getting ready for battle!!:butcher:
     
  8. markjohconley

    markjohconley Well-Known Member

    Excellent Prof Kirby. I will be speaking before a group of multi-discipline clinicians (allied health) next month so will do my best. May I print off and distribute the chapter to the physio's? I will be advertising the Podiatry-Arena website also, thanks, Mark
     
  9. The chapter is actually freely available for download on the internet so you may freely distribute it. You may also want to check out Craig's Running Research Junkie website where he details the few research papers that did look at whether foot orthoses "weaken the foot" since this odd notion seems to be an accepted fact by some of the physiotherapists you are dealing with.

    Let me know if you need any more help. The bottom line, however, is when you are presenting to a group, become as knowledgeable as you can regarding references that you are likely to use in discussions with these people. If you can quote articles supporting your viewpoint from memory, that will generally diffuse things very quickly....and they will need to start changing their tune in order to not sound like idiots.
     
  10. Ian Linane

    Ian Linane Well-Known Member

    "From what I can tell, this belief that foot orthoses should only be used short term seems to be something that is being talked about mostly by physiotherapists"

    Hi Kevin.

    Can't say that my physio friends and colleagues fit that bill entirely. They would tend to see orthoses as fitting along lines such as: in some cases short term, others medium term and in other instances long term/permanent, dependent upon the need presenting and what level of rehabilitation can be achieved.
    Maybe I have good physio friends and colleagues.
     
  11. I have never heard any of my physical therapy friends here in my community either say that "foot orthotics weaken feet" or that "foot orthotics should only be used short term". As I said before, this notion that "foot orthotics weaken feet" and "foot orthotics should only be used short term" seems to be coming only from physiotherapists, but I don't have any idea how widespread this idea is.

    I have been wearing foot orthoses pretty much continually for the past 38 years with no ill effects. I literally see two to three patients a week in my office who have been wearing the orthoses I made for them for well over ten years and are wanting second pairs or replacement pairs since they help them so much. They don't know what they would do without them.

    In fact, at least once a week one of these patients will say something to the effect of: "Dr. Kirby, you aren't going to retire anytime soon are you? You can't retire. Your orthotics have saved my life. Where am I going to go to get my orthotics once you retire?!" [Most of them know I have been practicing for nearly 30 years and I can clearly see my grey hair, bald head and wrinkles so they know I'm not going to be doing this podiatry thing for many more years.]

    Does this sound like a person who wants to wear their foot orthoses short term or who is having "foot weakness" problems from their orthoses? No, it doesn't.

    Therefore, the next time a physiotherapist, or any individual for that matter, says that foot orthoses make the foot weak or that foot orthoses should only be used short term, ask them for the research which supports their conjecture. Since they will have none, then next ask them why they are gait retraining individuals since there are no long term studies that shows that gait retraining is anything more than a temporary fix that will soon be forgotten by patients after they stop visiting the physiotherapist for their gait retraining sessions.

    Don't be nice. Be knowledgeable!
     
  12. gingerphysio

    gingerphysio Member

    As a physiotherapist I have been witness to many occasions where the use of antipronation style inshoe orthotic devices had a positive impact on chronic pain conditions. I used to make fairly flimsy but effective devices myself when working in places where the right help was not available, though I'm glad to not have to sniff glue any longer .
    My impression is that the real benefit of reducing overpronation in many, is to normalise the torques and forces impacting on and reducing normal mobility of the SIJ. In cases where SIJ mobility is reduced by those abnormal forces ,the flow on effect is to induce spinal protective behaviour, which gives rise to many referred and local pain problems.
    My clinical time is spent mostly on reducing and eliminating spinal protective behaviour . It is common to witness significant and lasting benefits to many chronic lower limb pain and dysfunction states with only attention to the spine. Included amongst which are plantar, heel, toe, achilles , calf, knee, lateral thigh and groin problems.
    Not every pronator needs orthotics, the spectrum of abnormality and sensitivity to those perceived abnormalities requires clinical judgement on a case by case basis. Though, broadly, I am in favour of orthotics as a means to overcome altered biomechanical stressors in a well thought out non surgical solution oriented intervention.
    Cheers
     
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