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Orthotics and the inner ear - The Propriocetive effect

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Alex Adam, Sep 16, 2010.

  1. Alex Adam

    Alex Adam Active Member

    Members do not see these Ads. Sign Up.
    This thread has been broken off from The Method of Casting is not important thread

    Correct casting technique is essential as we need to have a reference point in the initial cast to allow the laboratory to continue the reference point throughout the pours, posting and correction techniques prior to pressing of the device.
    Adding all the 'lumps and bumps' after the plates are pressed are counter productive as we can't determine the correct physics behind the process.
    The cast must reflect the needs of the skeletal system and not just the foot.
    This is determined by the Podiatrist in their examination and history.
    Non weight bearing supine for standard soft tissue restraining and prone for cases of ligamentous laxiety. In both cases the pelvis and lower limb is in the position determined by the Podiatrist.
    It is about the physics behind the gait pattern and realising we only have milli seconds to allow 'normal' propulsion. Understanding the proprioceptive response to everything we do, and ensuring the body is not just compensating somewhere else in the body, no point in fixing one problem and producing another.
  2. Re: The Method of Casting is Not Important?

    I think he took your comment about wiping of specks as a death threat Simon.

    Hey Alex

    Interesting post.

    Interesting idea. How does one understand the proprioceptive response to everything we do (by which I assume you mean the orthotic) when we do not fully understand the kinematic effect of everything we do?

    For eg. If you give a casted insole, you cannot accurately predict the kinematic effect (much less model the internal kinetics). Since proprioception is based on internal muscular tendon and articular information, how can we fully understand the proprioceptive response to our devices?

    You seem very certain of the "right way". Upon what do you base this?

  3. Re: The Method of Casting is Not Important?

    Some articles in his garage that he went looking for to post up about 8 months ago - when I asked a similar question . But no articles as yet.

    So I´m really not sure there are any.

    But maybe you will get an answer, as I remember it was the day I dropped coffee all over my desk at work.

    Alex tried to explain something about effecting the inner ear with orthotics as well , but these research papers were in the garage as well as I remember.
  4. Re: The Method of Casting is Not Important?

    Oh yeah, I'd forgotten.

  5. Alex Adam

    Alex Adam Active Member

    Re: The Method of Casting is Not Important?

    Inner ear and orthotics Michael, you hit the nail on the head. I could regress off the topic so I will simply say when the primary responses are over riden by the secondary redponses at around 18 months of age the propriocetive nature of the locomotory system develops with the head as the primary reference point. Bear end nerves are identified and programed to the position of the structure they are in and balance is fully developed, hence why some children toe walk, late walkers and intoed gait, this is somewhat simplistic however for this discussion will surfice.
    One of the princilpes of orthotic therapy is compliance and if a device is too large for a patients footwear then compliance is nil and so a device must be slim enough to allow compliance. Orhotics that are externally modified tend to be bulky and hard to fit footwear.
    A cast that is done holding the foot as close as possible to the position the Podiatrist desires allows for a slim unintrusive device that controlls the pathalogical motion/momentum within the lower limb.
  6. Re: The Method of Casting is Not Important?

    This is worthy of anothe thread as alex says. I wonder if a kindly passing admin might transplant the relevant posts...
  7. Re: The Method of Casting is Not Important?

    There you go Sir.
  8. we have had a quick loo at this earlier as I suggested ....

    Heres some of this discussion - some of the quotes maybe missing, but it should make sense.

  9. Jenene Lovell

    Jenene Lovell Active Member


    I am a first year podiatrist and havent used podiatry arena for very long. I do have a quick question though...

    Is it better to internally or externally modify an orthotic? I personally feel more confident with externally modified orthotics, however they do tend to be more bulky and harder to fit (in the sense of heel slippage mainly) in footwear.

    Alex said:
    One of the princilpes of orthotic therapy is compliance and if a device is too large for a patients footwear then compliance is nil and so a device must be slim enough to allow compliance. Orhotics that are externally modified tend to be bulky and hard to fit footwear.

    the other question that I have is why would you consider making a device that is too large for the patients footwear?

    Surely the shell of the device is from heel to just proximal to the MTPJs, does it really matter the length of the device? Can't you just cut the top cover back to "fit" the shoes... So far I havent encountered this problem, but I just want to know a reasonable answer before I do.

    Or did you mean the heel cup? and it being too wide to fit into shoes...

    I am just confused as to why that was added into the discussion.
  10. Thanks Mike. You're a legend.

    I'd sort of forgotten this thread. Be good to pick it up again.

    Hey Jenene. Welcome back.

    In another thread, Simon said something very relevant. It was to the effect that there are only 2 elements to consider with an orthotic. The Geometry (shape) of the top surface, the bit in contact with the foot, and the load deformation characteristics, viz, how it behaves when you load it (does it bend / spread / squidge).

    Personnally I would add the friction characteristics of the top cover as well. :rolleyes:

    The point, and this applies equally to your and Alex's post, is that everything up to that point in the manufacture, the casting position, the casting method, the cast modifications and how they are done, all leads to a final "shape". Geometry. Morphology. Whatever you want to call it.

    There are no inherently superior methods for getting to that final shape. The final insole does not care how the cast took its shape, merely that it did.

    So for the POP vs foam debate as an example. POP is generally taken non weight bearing and then plaster is added for medial and lateral spread of the soft tissue of the heel. Foam, if taken semi weight bearing, will have the tissue spread when the foot is being cast. But if the amount of plaster added is the same as the semi WB shape of the heel the end result will be exactly the same.

    So it is a bit misleading to think in terms of whether intrinsic or extrinsic posting is "better". Its the shape of the end result which defines "better" and we have no data I know of comparing outcomes from the two types.

    My advice would be to find a good ole fashioned orthotics lab and ask if you can spend a day with them. If you can see the process of going from a negative cast to an orthotic, especially if you can see it with several methods, you will have a much better idea of the differences. I've had a few people visit me and I think they go away much clearer about the process.

    Intrinsic and extrinsic postings are different things which create different surface geometries.

    By the by, I find that when working in foam the biggest cause of heel slippage is when the foot enters the foam at a forward angle, shifting the heel cup forward. Easily rectified by squaring the posterior aspect of the heel in the foam.
  11. Alex

    Look forward to your reply to my point re proprioception. But I had to raise this one as well...

    Eyebrows raised a bit on this one. I work almost entirely in Paeds these days. The causes of, for EG, late walking are complex and varied. I'd have to say that the single biggest predictor I've found is gross hypermobility which in turn seems to be either genetic or caused by some ante or perinatal trauma or complication. There are also issues around core strength which in turn is linked to activity which in its own turn is linked to environmental circumstances, sibling and parental influence and other things.

    I do test balance and gross propriception where possible and although it is significant in some cases I'd say its a significant minority!

    Perhaps some of my colleagues in Paediatrics might have a view. Sally, are you out there?
  12. Alex Adam

    Alex Adam Active Member

    Robert I totally agree, my experience in Paeds varies from severe/moderate CP children, muscular dystrophy children through to developmental alignment in perm and late birth babies.
    Ligamentous laxiety is problematic and I have found there is a higher % in C section children when the hip/femur fails to go through anteversion whe they go through the birth canal.
    Perm babies that are 4-6 weeks early show signs of a high ala in the knee and shalow patelas.
    I treat severe cases however usually start a home treatment regime of strengthening and the lower limb and core stability.
    Depending on the pathology presenting will use a good Paeds physio and the use of a soft triplaner wedge to stabilise the rearfoot and this reduces the need for the forefoot compensation.
  13. Alex Adam

    Alex Adam Active Member

    As in regards to propriocetive response, most of the info I use comes directly from personal communication with anatomists, Physios and a couple of very talented OT's in the field of CP patients. Believe me when you are trying to stabilise a CP patients you have to get it right LOL had plenty of failures in my early days. Have to avoid the 'shunting reflex'.
  14. That can´t be it, Alex you have made posts in more than 1 thread about Propriocetive responses from orthotics and the importance of the inner ear.

    If you use these in your treatment plans you must have worked out what response you will most likely see with what device.

    I guess this all starts with an assessment of sorts.

    The floor is yours - Whats your views on assessment and mechanical explanation of the propriocetive responses and the importance of the inner ear.

    Ps Roberts has also asked a few questions as well.
  15. Sally Smillie

    Sally Smillie Active Member

    Better late than never, but I heed your call. For what it's worth, here my 2p worth

    I'd have to agree entirely with your assessment above regarding gross hypermobility, which is the single biggest predictor of late walking. Of course we assess children and take a thorough history,screening to exclude any developmental delay etc. In true dev delay these children will be delayed in other areas. Naturally it is imperative in paeds to know your developmental milestones, all of them (speech, cognitive, social, physical). Excluding these (which is rare), what you are left with is good ol' hypermobility. I'd recommend using the Lower Hypermobility Score (Ferrari et al), it is a 12 point score focussed on the lower limb and so useful for assessing littles.
    Just a note too, walking is not considered late until after 18/12 (at the Multi Disc Childrens' Therapy Team we generally don't accept referrals below that age). Then you need to look at what stage they're at, if they're cruising (ie the stage just before walking) and progressing well we might just look at supportive footwear and core stability work (via play, or basic core exercises if they have the attention span and body awareness- Robert, spot on on that one. But I don't think it's environmental. Environmental issues would be: parent or older sibling bringing everything to the child rather than leaving them with the motivation to ambulate, or if parents fail to implement tummy time for play.

    Why then the poor core stability? I suspect it fails to develop in the same way in hypermobiles because of the hypermobility. If you notice, they tend to adopt inactive postures sitting (eg W sitting) and standing (eg ant tilt of pelvis, lumbar lordosis, genu-recurvatum) that use end-range, 'hanging off their ligaments'. It would make sense that they do this for a few reasons; it increases joint position sense and reduces the amount of muscular energy required to maintain these postures. In hypermobility, up to three times the muscle energy is required to perform the same movements as a less hypermobile child, as muscle energy is required to stabilise joints as well as move them. We use lots of soft play and other activities to increase muscular endurance and improved sensory feedback.
    I'd love to hear Jill Ferarri's opinion, being the guru in this area.

    So, I believe that proprioception is implicated but much more so in the sense above. As for inner ear... We do work on vestibular development (which is centred in the inner ear) in children with sensory processing disorders as it manifests in poor balance. The OT's and portage workers in my team work this sense using single plane rotational activities. Although I've done a 40 hour course training in this area, but I would leave that stuff to people more qualified in this area than myself (OT's/portage workers) - it is a huge and complex area and I realise I've just got the tip of the iceburg. I don't think that these are the same kids we're talking about above. It has been very valuable being aware of this though.

    My colleagues Jill, Stewart and I have done some research work in kids with DCD (age 6 and above) and the effect of orthoses in terms of falls and endurance in gait. We've only just finished data collection (last week), so no results or analysis yet. I suspect the improvement may be due to high-sided UCBL devices improving feedback on foot position and structural stability (reducing excess movement due to hypermobility). But it's just guesswork at this point. It needs loads more research to investigate this further.

    However, as for the connections: orthoses and inner ear... I can't see the connection. Balance and inner ear, definately (evidence based). Balance and orthoses again yes (evidence suggests it is so). But my opinion suspects the relationships may be global in the former, local in the latter and not necessarily linked.

    Have I confused or helped the topic? Hopefully the latter.
  16. Thanks Sally. A considered and helpful response.
  17. Alex Adam

    Alex Adam Active Member

    The relationship with regards the inner ear is simply that the body needs a frame of reference with regards the development of bare end nerve programming and this is achieved via the eyes and inner ear, eyes being the horizonal or horizon and the inner ear the balance. This is part of the learned secondary response that over rides the primary response at birth. One of the reasons that in stoke patients the proprioceptive responses are lost and there is a reversal to primary responses.Seen in upper motor neuron lesions and to a some what lesser extent in lower motor lesions.
    Sally's discussion is very valuable and I find this style of investigation should be taught at our Univerities.
  18. Alex Adam

    Alex Adam Active Member

    [Whats your views on assessment and mechanical explanation of the propriocetive responses and the importance of the inner ear.]
    The bare end nerve response is via the spinal reflex, hand on a hot plate, response is to lift the hand, When we do an inversion sprain the programming sees the instant response due to the fact the ligamanet is previously programmed, this produces a mechanical change in position to produce rapid eversion via the peroneals and this can cause damage to the deltoid lig is agressive enough. At this stage the nerve response in the ligament needs reprogramming and this is done via Physio and wobble borad work, once again through the inner ear response and eye horizon.
    Failure to reprogram leads to an unstable joint.
    Orthotics must not interfer with this response and so must be properly balanced controlling the triplane forces in the foot.
  19. I was moderately with you there alex, up to this point
    Sounds all very holistic and sciencey. I'm afraid I don't know what it means though. Perhaps I'm having a slow day (it is sunday after all). Here's why.

    Properly balanced means what? Forefoot rearfoot? As in, the forefoot of the orthotic must be perpendicular to a highly inaccurate line drawn on the heel then extrapolated (with yet more oppertunity for inaccuracy) onto a positive upon which a lab tech arbitarily decides the contours of the arch? to get the forefoot down?

    Remembering that a rearfoot bisection perpendicular to a forefoot is highly unusual in an asymptomatic population...

    And then that is moulded / milled into a shell upon which the foot may move freely, which may incline considerably within the shoe if it sinks into the soft lining, within which it may well more medially and laterally, which may be unevenly worn, and which walks upon irregular terrain?

    OR ELSE the orthotic will interfere with the proprioceptive response?! But if it is shaped JUST SO then it won't?!

    Come now.

    Sorry, you're going to have to elucidate on this as well.

    Specifically what forces, in what structures, at what times and in what way are they controlled? For eg, lets say the pre device stress in the deltoid is 10 %, 50% and 100% at heel strike, mid stance and heel lift. You wish to control this force, what prescription will reduce it to 7%, 30% and 60%?

    I'm being slightly facetious here to make a point. The wording of your last comment implies that one can controll forces, which we can't see, using orthoses, which exert a very complex effect. I suggest that until we know the "formula" to control position, the crudest and most visible manefestation of forces in the foot, we certainly can't claim to control forces, a much more complex and sensitive proposition!

    Orthotics are bits of bent plastic which push. They don't hold and they certainly cannot control in any but the crudest and most unilateral sense. I find the proposition that an orthotic can be calibrated to the point that "correctly balanced" it will enhance proprioception but "incorrectly balanced" it won't, a bit silly, especially considering the myriad and manifold inaccuracies inherent in the casting and manufacture process! It sounds good, but I can't see that it has any basis in reality!
  20. Alex Adam

    Alex Adam Active Member

    Robert this has not been expanded on as it is not part of this topic and has been beaten to death in other threads.
    [Inaccurate lines drawn on the heel area]
    Well the article that presented that was bias when written, I was present at the examinations and well lets say it wasn't the best article written, poor methodology and there was unclear nomenclature used.
    [Orthotics must not interfer with this response and so must be properly balanced ]

    the forces that the orthotic produces must bring the skeleton into balance otherwise the resultant proprioceptive response can be damaging as seen in MBT shoes, yes they help the lumbar region of the spine but we are seeing a thorasic overload at T8 T9 regions with the compession of the disc.
  21. What is "to bring the skeleton into balance"? What does that mean?

    You just can't be that vague alex! Let's say I want to emulate your work. What am I trying to do if I am trying to bring the skeleton into balance? Stop it falling over?! What is a balanced skeleton? Is this a position? A functional range? What?

    And which study showing inaccuracy did you mean? There have been several!

    Is bring the skeleton into balance the same as balancing a cast? You did not clarify what you meant there either!
  22. Alex Adam

    Alex Adam Active Member

    Vague LOL I have been called that after a couple of scotches. How can I bring 25yrs of reading, dissection and research into a very succinct discussion.
    Firstly let us address the line marking, the original article was based on taking podiatry students by a profesional not familiar with the method used by myself and a number of my Australian colleagues. The students were given instructions to carryout a process that returned poor results. However with correct teaching and with practice over their study period the results become more accurate. I am not saying these measurements can be used for scientific assessment but it is a tool to allow the profesional to determine if some form of compensation is producing the presenting pathology. As a test I constantly revisit the measurements on my patients and over a five year period I am about to confirm the original lines.

    As for the balanced skeleton, well that's a very large area for discussion and if we start then we digress from the thread first presented. To say the least we aim to remove the need for the skeleton to compensate for alignment issues of the foot by balancing the foot structure in a position that does not fire off muscle contractures out of phase. This allows the normal phasic contracture of all muscle groups in gait.
    We have been able to achieve this by a comprehensive biomechanicl assessment together with a orthotic device that is made from a cast that mimics the foot at foot flat with the body fully over the weight bearing foot. This reference point is then taken through to pouring and correction stage prior to pressing making every device unique in it's own right. Having used this model to perscribe and manufacture over 6000 pairs of successful devices I am confident with the model especially as I offer money back guarantee.
    I use an exclusive laboratory in Australia
  23. Lets :drinks

    Perhaps we should be specific about which study (s) we are talking about.

    Lets start with these

    Stephan J. LaPointe, DPM, PhD*, Charles Peebles, DPM, Aprajita Nakra, DPM and Howard Hillstrom, PhD§ The Reliability of Clinical and Caliper-Based Calcaneal Bisection Measurements This Article Journal of the American Podiatric Medical Association Volume 91 Number 3 121-126 2001

    ELVERU RA, ROTHSTEIN JM, LAMB RL, ET AL: Methods for taking subtalar joint measurements: a clinical report. Phys Ther 68: 678, 1988.

    PICCIANO AM, MEGAN SR, WORRELL T: Reliability of open and closed kinetic chain subtalar joint neutral positions and navicular drop test. J Orthop Sports Phys Ther 18: 553, 1993.[Medline]

    SMITH-ORICCHIO K, HARRIS B: Interrater reliability of subtalar neutral, calcaneal inversion and eversion. J Orthop Sports Phys Ther 12: 10, 1990.

    PIERRYNOWSKI MR, SMITH SB, MLYNARCZYK JH: Proficiency of foot care specialists to place the rearfoot at subtalar neutral. JAPMA 86: 217, 1996.

    BOONE DC, AZEN SP, LIN C-M, ET AL: Reliability of goniometric measurements. Phys Ther 58: 1355, 1978.

    ELVERU RA, ROTHSTEIN JM, LAMB RL: Goniometric reliability in a clinical setting: subtalar and ankle joint measurements. Phys Ther 68: 672, 1988.

    SELL KC, VERITY TM, WORRELL TW, ET AL: Two measurement techniques for assessing subtalar joint position: a reliability study. J Orthop Sports Phys Ther 19: 162, 1994.

    PIERRYNOWSKI MR, SMITH SB: Rear foot inversion/eversion during gait relative to the subtalar joint neutral position. Foot Ankle Int 17: 406, 1996.

    We are not talking about one dodgy study, with inept students being shown bad techniques. The data is pretty unequivocal. With all respect to you Alex, I struggle to believe that where all the data points to this method being unreliable / unrepeatable, that YOU can do it accurately. And even if I believed this, how can I believe on this basis that I can do likewise?

    With respect, it is KEY to this topic. If this is unreliable then all else is moot.

    Which position might that be? :rolleyes: Do you mean

    Are you talking about a fully weight bearing cast?! Say it ain't so! And, as another BTW, if this is the position of the cast regardless, whats the point of the complex biomechanical assessment?!

    So when you say "balance the foot structure in a position" do you mean "hold the foot in a position?" then? Because again, as I've said before, the evidence shows we cannot do this (please don't make me go find another list of references on that).

    And, out of interest, how do you know if a certain "position" fires of muscle contractures out of phase? Done EMG studies with different prescriptions? Or are you presuming.
  24. Alex I really don´t care how long you have been in practice or how many orthotics you have prescribed - It really gets under my skin when people say that - Who cares there maybe a new grad who understands more about biomechanics than the rest of us.

    For you to prescribe using the inner ear and propriocetive effect you must have some idea of whats going to occur when you add a new force the orthotic reaction force.

    Tell us about it or just say I´ve got no idea , holding back information to me is the same as saying I´m making this up and Ive got not idea.

    I am very intersted in the CNS - muscle tuning - leg stiffness regulation I do beleive that this is going to be very important in our understaning of biomechanics in the future. So maybe you have something here - but I´m not going to trust you or learn anything or dismiss anything until I get info - If I get no info then it must be dismissed as it says to me that your just making it up to impress patients to sell orthotics to make money.

    I admit my knowledge of the inner ear is this - it controls balance, 3 words thats it.
    and I´m still waiting for someone to explain the proprioceptive effect of orthtoics - and how they have some understanding of the outcome from introducing an orthotic.

    So hit me with it Alex.
  25. Alex Adam

    Alex Adam Active Member

    Robert with all due respect I will go and read all the above references, the last one I remeber reading some time ago and I found it flawed however will dig it out gain so I can be more specific.
    As for casting technique, the simplest is the best in my experience, non weightbearing using the a specific technique that incorporates holding the arm in a presise position and maintaining that position thoughout the process, killer on the anterior and medial deltoids of the shoulder. It's all about loading the foot while countering the forces holding the foot. This allows for easy replication of results and once learnt transferable between practioners.
    The biomechanical assessment allow the practioner to determine if the foot can reach the perpendicular (calcaneous) and if it passes through this position into valgus or remains perpendicular or stays varus even with total range of pronation being used. Hence comensated, partially or uncompensated.

    As I indicated before I am not saying the technique is of pure science, the variability aspect does not allow thi, however as a Clinical Podiatrist I have developed tools to allow the diagnosis of the presenting pathology. Having passed these techniques to other practioners we have been able to replicate results.
    Proprioception and the study of movement in CP children, together with the anatomy of the nervous system, mainly parasympathetics, allows the understanding of muscle response to osseous and soft tissue restraining mechanism.
    I am sure my colleagues who seek the pure science behind skeletal balance and muscle response would disagree with my observations and research but that's what the forum is about, the what if's
    Many articles fail on one main level and that is the clarification of nomenclature, one thing I have found in my readings is that jargon between close profesions differ so much and so clarity is essential. eg Podiatrists see pronation as triplaner while anatomists see it part of eversion.
  26. And the Exteroceptive effect. Lets not forget that.
    After all, if a cast is taken at the position in which the foot is close to maximally pronated, its pretty unlikely to make much change to the position of the foot through gait since Mc Poil and Cornwall (2005) showed this position to be highly predictive of the dynamic arch height as well.

    So, for EG, an arch which is taken fully WB with leg over the foot which is 2cms high will go into an insole which applies to a foot which bottoms out at about 2cms. Super.

    So there is unlikely to be much by way of positional change I would think!
  27. Alex Adam

    Alex Adam Active Member

    Michael the simple concept of the pupose of the inner ear can be found in Gray's as for the effect orthotics have on the inner ear is ludicrous, as I have discussed earlier the inner ear and eyes allow for the programming of the upright body and begins at birth through to 3 to 4 yrs of age, primary response being over riden by secondary response, basic anatomy knowledge but I will endevour to find some references for you.
    As for saying I am about $$ and selling devises, I have no problem trying to explain the techniques I use and they are open to discussion but not abuse.

    How do orthotics alter the propriocptive response, well it is what a balanced orthotic doesn't do is the point. All angles within an orthotic will change the position of some structure within the foot and lower limb, by definition of what an orthotic is. As all parts of the body is connected to the brain, sympathetic and parasypathetic networks then there must be a response and if this is not accepted then there is nothing more to say.
    I feel there are three camps in this debate those who don't believe orthotics are biomechanically sound those who do and those in the middle who want pure scientific proof alas the variable that is lacking in most papers I have read is the clear understanding of what the expectations of the orthotic should and can do and the presice way they are manufactured.
  28. Alex Adam

    Alex Adam Active Member

    Arch eight?? I will read the article, thank you.
    In my readings starting with Whitman 1906 where he indicated that the foot was not an arch rather that a structure that responded to proprioceptive response. Wood Jones 1944 cocurred with this describing the tarsal region to be slung off the rear foot, my dessection work in 1996-1998 indicated that the attachment of the P.longus tendon had a number of tendrils moving into the cuneoforms and the anterior and posterior tendons also attached in such a way as to reinforce this thought. C. Oxnard 1980 -1990 described the formation of the calcaneous to allow upright posture due to the changes of the angle of the sustentaculum tali and the resultant forces indicatd that the sling mechanism was accurate.
    The development of the medial process of the cuboid instigates respination through a reverse origin of the P.longus and this sets off the proprioceptive response for muscle contracture producing propulsion phase through the plantaris tendon triggering contracture of the gastrocnemius
  29. No. Sorry.

    BLAKE RL, FERGUSON HJ: Effect of extrinsic rearfoot posts on rearfoot position. JAPMA 83: 447, 1993.

    BROWN GP, DONATELLI R, CATLIN PA: The effects of two types of foot outhouses on rearfoot mechanics. J Orthop Sports Phys Ther 21: 258, 1995

    I think I occupy all three of those.

    I DO beleive orthoses are biomechanically sound in that I beleive they work primarily by altering external forces and thus by altering internal forces.

    I DON'T beleive that we can "control" things to anything like the degree you suggest, nor that measurements taken of the foot can be relevantly applied to like measurement variables on an orthotic, nor that the measured variables on an orthotic extrapolate predictably to alterations of position or force in the foot. So from that point of view, they're not.

    I hold the above view because of data which shows it to be the case.
  30. :D

    Yes. Its connected to the calcaneous and affected by the outhouses.

    No it doesn't.

    As in, that which is asserted without evidence can be dismissed without evidence. Stating anatomy does not constitute evidence that a certain orthoses will alter muscular function in a certain way, nor that the loss of proprioceptive response is the cause of the pathology, nor that a fully weight bearing cast is the correct way to do it.

    Here are some more references for your reading pleasure. Some evidence that altering plantar sensation (exteroception) does not alter position. And I've already given you evidence Re the proprioception.

  31. But your the one who brought it up a few months ago

    And Ive asked and asked and you went looking for references.

    and again Ive asked about the proprieceptive effect - But I´m still waiting.

    So once again if your going to add an orthotic to a patients shoe - how do you know what the Proprieceptive outcome is likely to be ?
  32. Alex Adam

    Alex Adam Active Member

    Well yes it does according to Anatomists Susman 1983, Lewis 1980,Bojsen-Moller 1979, Tobias 1985, Morton 1964, Rao 1966.

    I have been asked to list a email I sent to Michael so excuse the length

    If you say to a patient that this device will have this effect we hope to see. You must be able to explain the concept, you have not explained anything. I am very open to new ideas but I need to see an explanation or reasoning . So I really want to hear what you have got say so I can make my own mind up.[/B

    ]Totally understand where you are coming from but I try to stay in the context of the thread I am discussing. The following is how I determine if a patient treatment regime would include orthotics.

    Assuming orthotics are indicated
    1] I check the standing posture noting kyphosis, lordosis centre of gravity, symmetry, pelvic position[ both anterior tilt and hip heights L and R side], knee position[varum or valgum] centre line of lower leg in relation to the centre of the tarsal region, base of support through the second ray and resting calcaneous position.
    2] in supine position check leg length, internal and external rotation of the hip with knee in flexed position, check patelas for +ve Clarke's test and tracking of patela and if crepitis is present, malleolar torsion, ankle dorsiflexion [knee extended and flexed] isolate STJ and check if axis is high, low or WNL; isolate MTJ and determine ROM and axis; determine if 1st ray is elevatus or WNL.
    3] in a prone position I dissect the calcaneus ensuring paralex error is observed[this is to indicate the ROM from the lower 1/3 of the leg; holding the STJ in neutral, talus congruent with navicular, the forefoot to rear foot alignment is assessed and 1st ray motion determined.
    4]once these observations are done I examine the gait of the patient and from the mesurements I expect to see the resultant forces and If I don't I look further possibly for a scoliosis.
    5] I then track the resultant forces through the skeleton knowing the proprioceptive responses and if the forces end at the point of pathology we can treat.
    6] If we suspect spinal influence then another practioner is called in to determine if it's structural or functional.
    7] proprioceptive response is at multiple levels from muscle groups of the leg, rotators of the the hips, quad lumborum through to the trapiezius all producing there own pathology in specific area, very holistic I know but we can't take things in isolation.
    8] once I am 100% sure we can alter the alignment to correct the entire stucture then and only then we proceed with the patients full understanding what we are doing, expressed in simple english, the hardest part of the whole exercise.
    9] take a non weight bearing case suspending the foot taking care not to dorsiflex or plantarflex the ankle, knowing the MTJ motion and axis load and lock MTJ as at foot flat the important principle is Physics based and the paralax error os compensated for, the point of reference is to ensure the centre line of the leg is inline with centre line of the foot.
    10] the reference point is taken through to casting and correction and then the final device
    11] the frame of reference ensures the final device supports the foot at the point the profesional wants. Control is via the triplane point of control at the point with the medial aspect of the cuboid process initials resupination in normal gait cycle while balancing the forefoot on a horizonal platform graded down to zero.

    For me to list all the references that have developed my thinking would be too numerous to list however I have have always indicated that it is not the be all end all way and I enjoy reading new ideas and expanding on those ideas, I enjoy the challange of Knowledge.
    Kindest regards
    Alex Adam


  33. Thanks Alex-

    All seems quite Rootian in base from the start expect some of point 2 - re STJ axis.

    Points in the quote below, Im going to have to get you to expand.

    If you can express it in simple English I should be able to get it ..... hit me with it.

    The MTJ locking point I´ll leave alone for now ...........
  34. No it doesn'nt. Show me a quote. Show me a proper reference. Show me where they SHOW that insoles have this effect. They don't. This has never been shown. At best, it may have been hypothesised but there is a million miles between theoretical hypothesis and what is.

    The evidence I have offered to the contrary on the other hand, is pretty solid.

    Also irrelevant. The references which helped you develop your thinking don't really move us forward. Its references to support your claims that I'm interested in!

    If there are none, fair enough. It doesn't make you wrong. Lack of evidence is not evidence of lack. But if thats the case then the two little words "I believe" need to feature rather more strongly.

    Apart from the points which Micheal mentioned, I would make these observations.
    1. This is a fixed casting protocol. Looks a great deal like garden variety root to me. That being the case, if this is what you are planning to do anyway, why bother with 1 through 8? If it won't change what you do it is superfluous.

    As I've pointed out about 300 times now, this line is grossly inaccurate. I've provided copious references to support this. Saying "But it IS accurate" does not change this

    If you mean in the position the professional wants, no it doesn't. I've also provided references which show no kinematic change. I could give many, many more which show a change in position, but a small and unpredicable one.
  35. David Wedemeyer

    David Wedemeyer Well-Known Member

    These should really drive Michael and Robert to frustration:



    and these are worthy of some analysis & comment:



    You'll notice in the pubmed studies a lumbosacral corset was used (which has a specific direct effect via full contact and exerting a force on the lumbopelvic spine, a far cry from an in-shoe device placed beneath the foot) in the first and in the second we find splinting type of devices used vs. taping (which performed horribly).

    Alex, as a practicing chiropractor I have heard both sides of this story numerous times. Most of this proprioception idea is now propagated by a singular insole manufacturer whose audience is the chiropratic profession. It shames me to watch them market this because there is zero credible evidence out there in support of their claims (I have searched for ten years for it). I recall Michael asking me just this question a while back on a thread regarding the STJ/TMJ connection where I couldn’t support that theory based on the lack of evidence either.


    I believe that proprioception as a function of normal joint mechanics (lower extremity) is influenced by alterations in normal (injury) that can be impacted by orthoses (as demonstrated by Cornwall and Murrell on injured vs. uninjured subjects) but what this has to do with the inner ear and the effect further up the chain and how that supports orthoses being marketed in this manner I am not understanding?

    I would love to be convinced. The floor is all yours Alex.

  36. Can't access these from work. Which is probably for the best all things considered. My BP is high enough as it is!

    I use lycra in the Multidisciplinery peads clinic all the time. I have certainly seen subjective improvement in function with things like shorts, corsets and similar. Very exciting stuff...

    But as you say David, nothing to do with insoles!

    The second one strikes me as a bit of a gunslinger moment. One could as easily call that study "effects of stabilisation" as "effects of propriception".

    And again, nothing to do with insoles!

    That there is a link between exteroception, proprioception, balance and position, I have no doubt. One cannot simply make the jump from there being "a link" and confidently saying that THIS type of insole improves matters and THAT type won't. As Simon often says, "you can't get there from here".
  37. Alex Adam

    Alex Adam Active Member

    Well the floor is not mine, I am not into banter just exchange of ideas, references are only there for what has been expored. Orthotics effecting the inner ear is WHAT??? The basic developing of secondary response as I have said numerous times is what allows the overall point of reference, basic Physics and Mathmatics, references for this unfortunatley were not given to me in Pod Med 101 or Physics 101 and Mathmatics 101 where a point of reference is esential for any discussion. I'm sorry for assuming that it was general knowledge.

    Yes Robert you have supplied multiple references to counter my ideas congradulations but it doesn't change the simple fact that if a joint is compacted then the proprioceptive change produces both musclar, liganmentous and osseous changes, basic Wolf's and Davis's laws,
    Bleck and Oxnard have investigated these areas and concur.
  38. Thanks David I went to the face book page read , shock my head alot, PM Robert so would not miss out and then went looking for the orginal paper, posted below.

    Which makes for more intersting reading.

    Enjoy Robert ;)
  39. BP, 165 over 110. Thanks for that Mike. This will be the last post on this for a while as I rather think we're all wasting our time here. :deadhorse:

    Thankyou. I note with some annoyance that each time I do, you skip on to another concept rather than either dispute the argument or admit that what you have said is not, in fact, true. You make a claim, I produce evidence which shows it to be implausible, you skip on to the next claim. A familier pattern.

    Firstly, I don't know what a compacted joint is. I just looked it up and google doesn't seem too sure either. Is this a phrase you've just made up?

    It strikes me that unless the Orthotic makes the person lighter (see Keven Kirby's helium balloon beltothotic) the "compaction" in a joint is going to stay pretty much the same. The position of the joint might change the surface area of the joint of course, but thats different isn't it. Or do you mean that different BITS of the articular surface are compacted...

    You can't just say sciency sounding phrases and not either explain them or expect people to challenge them. That works with patients, but not with peers.

    Which you've failed to demonstrate or explain so we don't know what you are talking about...

    Wolffs law

    Davis law

    Proprioception, and the inner ear, is not mentioned.

    Oh you should have said. If they concur then thats different...

    Have they, by any chance written about their concurance? Somewhere we could go read about it? Or shall we just take your word for it that two names I'm dimly familier with agree you, and not me, and thus lend credance to your ideas. Again, you can't just name drop and not expect people to go look for details.

    So, let me sum up.

    1. The lines you say are repeatable, arn't.

    2. The measurements you say are accurate, arn't.

    3. The insoles you say hold the foot in the desired position, don't.

    4. The position you hold the foot in, you've not told us.

    5. Whatever this position is, the foot does not stay there, because it passes through a range of motion through gait. So the whole idea of an "optimum position" during gait is horseradish (as Merton Root knew well and wrote of BTW).

    6. That position has not been validated

    7. No studies have been done which show any of the effects you claim with the devices you discuss.

    8. You have still not told us:-

    -What a balanced skeleton is
    -What forces you are refering to
    -What "balancing them" involves.
    -What "tracking them through the body" involves.

    9. What you are doing looks like standard root biomechanics... except that you are claiming a complex and entirely hypothetical set of outcomes from your orthotics with no shred of evidence to back your claim and ignoring the copious evidence which shows gaping holes in your logic.

    10. In essence therefor, you are asking us to set aside what we DO know and what HAS been shown and beleive instead something entirely unproven, with no references, because you beleive it.

    Alex, if you want to talk about your doings, lets go over those points one by one. If you just flit on to the NEXT unsubstantiated claim, this is going to degenerate into farce.

    Kind regards
  40. and here in lines the problem

    we have proprioception the classic lateral ankle sprain example

    and we have the proprieceptive effect of orthotics which I´m still waiting on an explaination .

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