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Rothbarts insoles

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Apr 26, 2006.

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  1. Craig Payne

    Craig Payne Moderator

    Articles:
    6

    Members do not see these Ads. Sign Up.
    Occasionly I pop around and check out other forums. I was amused this morning to see at thatfootsite the comments on Rothbarts "proprioceptive" insoles, especially comments by several anonymous posters and the blind faith put in the approach by others. I thought I would raise it here

    Brian Rothbart is well known around emailing lists and forums for his self promotional posts. He has joined here twice (aganist the rules) and has posted 3 self promotional messages (again, aganist the rules - two of which have been deleted, leaving one for view). Those on the podiatry mailbase email list are familiar with his self promotional messages and failure to respond to or skirt around questions when asked.

    My views on his approach are well documented. Anyone can check the podiatry mailbase archives to read the comments by many others and the lack of or inadequacy of the response.

    Here is my letter-to-the-editor published in 2002:
     
  2. Craig

    I read the topic on thatfootsite with much interest as a couple of weeks back I attended a talk from one of my colleagues in the UK who I have a great deal of time for - Alex Catto - who uses and promotes these insoles. From what Alex says, many patients report unqualified success with these devices and I have no reason to doubt his claims. I have to say when I read the various topics where Brian Rothbart had contributed I came away with a distinct feeling that snake oil had been liberally applied, but the evidence from patients may perhaps suggest otherwise.

    Anecdotal I know, but recently I saw a patient with long-standing knee pain that had been prescribed a pair of orthoses by a renown UK podiatrist who contributes on this forum and others. I was delighted to note that since taking delivery of the devices his knee pain has resolved completely and that he was now asymptomatic. What surprised me however, was that when I looked at the orthoses, I discovered he was wearing them in the wrong shoe - i.e. the right orthoses in the left shoe and vice-versa - and had been since the day he collected them. Strange but true and perhaps biomechanics is not quite the exact science that it is so often portrayed to be by some in the established podiatric community..

    Mark Russell
     
    Last edited: Apr 27, 2006
  3. PF 3

    PF 3 Active Member

    What are these rothbarts innersoles? It sounds like they are full length devices with a relatively big forefoot varus wedge? If they are, a guy out of Adelaide produces something similar. Big bulky devices but it seems that he does have quite a following. From what i have seen and heard, they do seem to work quite well (at the expense of a 1st MPJ). My thought is that they offer more support (due to the large forefoot varus wedge) then alot of devices i see pods producing unfortunately, and therefore they get better immediate results.

    Mark, Have to also admit that i have seen plantar fasciitis cured with a set of orthotics placed in the opposite....Big guy, very conservatively arched orthotic, pain gone....!
     
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Thats exactly how they are being promoted and it amazes me the blind faith put into them by many in this profession. Its easy to dismiss the theory behind it (see above). The published evidence shows that insoles of the design advocated will pronate a foot more. Rothbart claims the opposite, but contniually fails to provide any data.
    Just look at the unqualified success of the "placebo" orthotics in control groups of the randomised controlled trials!!! Anyone can probably claim "unquaified success" with their orthotics. The world has moved on and these kinds of claims are not acceptable in the current environment.

    Based on all the data and evidence available today, I would not want to try and stand up in a court of law and defend the use of massive forefoot varus posts.

    Its exactly because of this kind of crap that is part of the reason 'podiatry' orthotics get a bad rap .... the blind faith in whatever is currently "hot" will make others keep looking on us as snake oil salespersons.

    I will be the first to change my mind when there is some sound theory (rather than voodoo theory) and good data (rather than unsubstantiated claims). Until then it stays in the snake oil basket.
     
  5. PF 3

    PF 3 Active Member

    Craig,

    I agree with you completely. But how do you explain to the average joe that the X hundred dollars they just spent were on their new whiz bang orthotics (which happened to get rid of their pain) was based on voodoo theory and BS, when we the qualified podiatrists arn't too sure whether some $30 over the counter orthotics or a pair of custom made devices would have achieved the same result (I'm not saying this is always the case )? I would think Average Joe would opt for confident sounding snake oil salesperson nearly every time.

    I don't think there is any easy way around this?
     
  6. Gosh Craig, do I take it you're not an avid fan of Professor Rothbart's devices? I wonder what he needs to do before you become a convert! I can't really make any comment as I haven't evaluated any patients who have worn these insoles, but I have no reason to disbelieve what Alex Catto has to say. I would find it difficult to accept that such an experienced and well know clinician would gamble with his reputation if he wasn't convinced there were beneficial outcomes for his patients. Perhaps Alex - who is a member here - can give his view?

    As for established orthotic therapy I have to say that I am still unconvinced after 25 years, that the profession and/or industry fully understand lower limb biomechanics sufficiently enough to be able to manufacture and supply devices that do what the prescribers often claim they will do. Like many colleagues, I read Kevin's recent submissions on functional mechanics (Thought Experiments) with much interest, not to say a little frustration in the puzzle solving process. What comes as no surprise is that the established principles of STJN theory are being challenged and for many clinicians that will shake the fundamental platform they have used for many years in their approach to clinical biomechanics. Which makes me think we are still some way from being able to say with any confidence that accepted podiatric orthoses are not liberally coated in the skitey stuff as well.

    Mark Russell
     
    Last edited: Apr 27, 2006
  7. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    I am in the middle of the series of lectures to the 2nd yr students on the different biomechanical theories of foot function and foot orthoses. As an educator I have a responsibility to expose the students to the different approaches (I also cover the various approaches in seminars). The approach advocated by Rothbart (and disciples) is not even on the radar scope as an alternative theory and does not even get a mention. I do not know a single podiatry school in the world that includes it (dosen't that say something?). We spend a lot of time rigourously analysing the theoretical coherence and biological plausibility of different theories/approaches (Rothbarts approach fails on both points - see my letter above).

    I am not an avid fan of any approach that does not have sound underpinnings (and there are several out there). I am even more contemptous of approaches that are treated like a religion and followed like a blind faith, let alone having the audacity to name a foot type after oneself.
    I welcome anyone to give a point by point refute of the points I made in the letter to the editor above.

    We have done some testing of the orthoses advocated by Rothbart (analysis not yet complete), but early results showed they appear to decrease rearfoot pronation during initial contact (a good thing), but increased in late stance pronation (a bad thing) and delayed forward progression of the CoP (a very bad thing) - based on that I would not use them.
     
  8. Donna

    Donna Active Member

    Hi All, :)

    I had never heard of Rothbart's insoles until CP mentioned them above...and being the curious cat that I am, I had to check out the Rothbart website to see what type of "snake oil" was being sold. :cool:

    There is a link on the website named "Become a Provider", and you select from a list of "Professional Specialties" to indicate who you are. I was quite amused to see that you could be a Dentist, Orthodontist or Naturopath and be qualified to provide these insoles. My dentist has never done a biomechanical examination to assess if I "hyperpronate" or not...could that be because insoles are not required to improve dental health and prevent cavities :confused: or can they? :p

    And in the section comparing "PCIs vs. Orthotics", it is obvious that Professor Rothbart (or whoever wrote the blurb on the website) has not read up on his Thought Experiments, Subtalar Rotational Equilibrium or Tissue Stress Theories...
    All I can say is :eek: what the?

    Regards

    Donna
     
  9. davidh

    davidh Podiatry Arena Veteran

    Hi Mark,
    Done it myself too :eek: !

    Cheers,
    davidh
     
  10. From the same website:

     
  11. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Some of our more recent work as been looking at the roll of lateral column support in facilitating function (esp in the context of Bojsen-Moller's high gear/low gear axes concept) .... wearing orthotics in the wrong shoe probably elevates the lateral column and facilitates the transfer to the BJ's transverse axis (a very good thing), so I do not think that voodoo is necessarily involved when a theoretically coherent and biologically plausible concept explains the results.
     
  12. Phil Wells

    Phil Wells Active Member

    I personally believe that the Rothbart Insoles work by maintaining an acquired forefoot supinatus. Instant relief for the patient but the long term effects on lower limb mechanics may create a viscious circle - more forefoot supinatus etc. Also if dynamic function is attempted - running etc - then the negtaive effect on sagital plane mechanics may cause significant pathologies.
    I work for an orthotic lab and see thousands of FFO's, TCI's and simple insoles a year. Each practitioner has a completely different approach to orthotic prescribing but one fundamental approach is adhered to - make sure the medial column can function as close to the patient ideal as possible. This means that where a non-fixed 1st Mpj is present, allow it to function. I will even contact practitioners who break this 'rule' to ensure that they realise the consequences.
    Experience has shown me that where a Rothbart type insole has been used, 1st MPj dysfunction has occured and the devices have been returned for adjustment or re-make. A collegue of mine who used to prescribe orthotics with medial column jamming posts joked that 10 years on these devices had resulted in a very affluent surgical practice treating Hallux rigidus.
    We still don't know how orthoses work but as Craig alluded to, we can be fairly sure that if they 'jam' normal function then the old adage of '1st do no harm' will be broken.

    Phil
     
  13. David Smith

    David Smith Well-Known Member

    Dear all

    Am I right or wrong here?
    If a foot stj is maximally pronated then the f/foot will be supinated by GRF.
    The person with a foot like this may have medail band Plantar faciitis. Traditionally the rearfoot is posted towards STJ neutral and the first ray cut out to enable plantar flexion and windlass action. This releases tension on the plantar facia and hopefully it gets better.
    What if instead the rearfoot and f/foot is lateraly posted. This would increase GRF on the lateral aspects, the CoP moves toward the lateral and therfore, GRF being a constant, reduces GRF on the medial. Reducing medial GRF will allow 1st mpj to dorsiflex more easiliy and so release tension on the plantar facia medial band. Hopefully it gets better.(Shame about the sinus tarsi next year, just like wearing the orthoses in the wrong feet)
    Same outcome (initially) oppsosite treatment protocol.

    Cheers Dave Smith
     

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  14. davidh

    davidh Podiatry Arena Veteran

    Phil,
    The orthoses I prescribe, and I teach this method also, are simply an approximate interface between the ground and the foot. They allow the foot to work a little more around STJ neutral.
    This simple system requires only a small leap of faith if we can accept 2 things:
    1) That joints work most effectively around their neutral position, and that includes the STJ (common sense, surely?).
    2) We have not evolved for life on a hard and flat surface (or an approximation of, which is what we live on in the West). Bear in mind that there is absolutely no scientific evidence (just a huge assumption) to show that we have evolved for living on hard and flat surfaces, while there is plenty of fossil evidence to show that we have had similar lower limb anatomy for at least 1.6 million years (do a Google on the Turkana Boy fossil).

    Stick pretty much any feet in STJ neutral and you have an inverted foot.
    Can't be right, surely?
    The Rootian STJ-neutral theory was flawed, but I believe only partly. The "normal" model propounded by Root et al, if it exists at all, is only present in a very few individuals - and therein lies the flaw. But that the STJ works around neutral, and by casting in neutral we capture the FF to RF relationship is not flawed.
    Looked at in the context of an unshod foot, an inverted (and I consider this is normal when the foot is in an approximation of STJ neutral) foot is probably more effective on uneven terrain (which is what the foot developed for).

    I don't think it gets much more complicated than that.
    I think most will agree that for various reasons (diurnal variation, the fact that our terrain is not absolutely hard or flat, the fact that orthoses sink into shoes, which themselves are not uniform - either in heel height or interior rigidity - pick any two you are happy with) it is impossible to work accurately in degree-based increments when prescribing orthoses.

    This is not the same as manufacturing orthoses in a lab, where it is perfectly possible to work in degree-based increments during the manufacturing process. However, that carefully machined 3 or 4 degree post becomes an unquantified wedge when pressed into the innards of a shoe, which is then worn over a slightly less-than-true hard and flat surface.

    Regards,
    davidh
     
  15. Craig and Colleagues:

    I have used varus forefoot extensions on foot orthoses in many athletes and in a few patients who are non-athletes who just want to walk comfortably. I can remember using a varus forefoot extension on an orthosis a few years ago in a patient with posterior tibial dysfunction with a large inverted forefoot deformity that functioned much better and with less pain with the varus wedge attached to the orthosis.

    Even though I occasionally use varus forefoot extensions on foot orthoses, I do have a problem with Brian Rothbart's forefoot varus extension orthoses for walking activities for a few very good reasons:

    1. Varus forefoot extensions will tend to cause increased incidence of functional hallux limitus.
    2. Varus forefoot extensions will tend to cause late midstance pronation.
    3. Varus forefoot extensions will tend to cause a more apropulsive gait with less ankle plantarflexion during propulsion.
    4. Varus forefoot extesions will tend to cause subtalar joint supination instability in the latter half of stance phase.

    I don't really like the information that Brian Rothbart puts out on his website or puts within his posts to discussion lists such as the podiatry mailbase because I believe it is based on faulty logic. As far as I know, the product that is being promoted is being marketed to many individuals with a minimum of foot biomechanics training which tends to worry me that these insoles may be used by "specialists" who wouldn't know late midstance pronation from an abductory twist. Of course, the "foot levelers" used by most chiropractors here in the States are in the same boat, as far as I'm concerned, when it comes to foot orthosis quality...in my opinion.

    Additionally, I don't have a problem with Brian Rothbart putting his name on his product or attaching his name to a condition if he so desires. That is well within his rights to call it any name he wants. For example, here in the States, a well-known lecturer, Doug Richie, DPM, http://www.richiebrace.com/ made the choice to put his name on a series of braces he invented and that his company markets. Therefore, I don't see much difference between the what Brian Rothbart has chosen to do with his name and what Doug Ritchie has also done in regards to promoting either a product or a condition.

    Personally, I am uncomfortable with naming something after myself and have chosen, instead, to use generic descriptive names for the techniques, tests and devices that I have invented over the years. However, not every inventor thinks the way I do, and I see no problem with an inventor putting his name on a product, technique or condition that he or she has initially described, as long as he or she feels comfortable with it.
     
  16. alex catto

    alex catto Member

    Dear All...I had no idea this debate was going on until my email and phone started going this morning. So let me explain how I got involved. But I must say that I have a great sense of Deja Vu here, as I've been here before 20 years ago when I and several others advocated using homoeopathy in Podiatry. The charges of "Voodoo" theories were levelled then, as was the "lack" of creditable evidence,and the fact that only one researcher (Taufiq Kahn) had written the only available research papers.

    The uncomfortable fact was however that the patients got better. I said it then, and I'll say it again.....I got results that I couldn't have got using traditional podiatry techniques. It's not the answer to the universe, but it solved a lot of problems (and still does!)

    I digress....but I remember the lively debate in 2002 when Brian Rothbart published his paper. So when I saw he was holding a workshop in England last year....I went along with an open mind. The deciding factor was the fact that I had seen so many patients with pl. fascitis that weren't getting better. I freely admit that I find this a difficult problem to treat, and having attended the Heel Pain Roadshow in Reading, where just about every Pod in the room had a different treatment modality, and not fancing the idea of dispensing several 100£s worth of rigid devices in the hope that they'd help.......I went to hear what Rothbart had to say.

    Interestingly, not many Pods attended, but a lot of chiropractors/osteopaths/musculo skeletal therapists of all shades. Over 2 days I learned a lot about their views on Pods and orthotics.

    What Brian said made enough sense for me to send off to the States for a starter pack. After 35odd (very odd sometimes) years in practice I've got an open mind regarding treatment modalities, and I'll try most things.
    So, I started to dispense Posture Control Insoles to the "worst" patients I had at the time eg. 21 stone karate black belt guy with heel pain for 2 years, unable to wear shoes. 4 DAYS LATER HE PHONES TO SAY HEEL PAIN GONE.3WEEKS LATER HE ARRIVES FOR FOLLOW UP WITH BOTTLE OF 20 YEAR MALT UNDER ONE ARM, AND NO PAIN. In the world of the High Street generalist practitioner, that's my idea of evidence based medicine ( BringingThe Scotch that is!)

    And it went on like that. It's years since I've seen patients so enthusiastic. They were coming in and phoning up (unasked) to tell me how delighted they were.

    Now, as far as I'm concerned, Brian's theories on Bx, are as valid as any others. NO ONE HAS YET CONVINCED ME AS TO HOW ORTHOTICS WORK. Root's theory is flawed, yet a multi million pound industry was founded on it, and when it appeared the profession was desperate to follow it with blind faith as the best thing yet discovered to give us some scientific credability.
    Remember all those non wt bearing measurements we took with precision accuracy. and we all took perfect casts of course.

    Now Rothbarts theory may be flawed as well........but I've had better results than I ever had with traditional orthotics.
    PLUS THE DEVICES WILL FIT INTO EVERYDAY SHOES.
    PLUS THEY ARE COMFORTABLE

    I don't get where this "massive "forefoot post idea is coming from. Have any of you seen these devices? The posts are 3.5/6.00/9.00mm and 80% of my patients are in 3.5mm ones. 9.00mm I don't advocate using at all unless you're treating the patient in conjunction with a chiropractor/osteopath.

    I don't understand the gait instability comment. I have several patients who say they are more stable, and have stopped lurching into their partners when walking along.




    I would rather fight my case in court with a Bx theory that a lay jury could understand, together with a soft device with a 3.5mm post, rather than a rigid device. And how would you stand up in court when you're prescription is found to have the "lab discretion" box ticked?

    The "crap" that brings Bx into disrepute with the public is the issuing of overpriced uncomfortable devices that the patient is condescendingly told they'll have to go and buy bigger shoes for. That plus the fact that when it doesn't work, very few refunds seem to be forthcoming. And before we get all saintly and say this doesn't happen.......a recent patient was referred to me after paying £1660 for 3 pairs of devices, none of which would fit her shoes (or trainers).

    ALL ROTHBARTS INSOLES COME WITH A 90DAY MONEY BACK GUARANTEE.
    I'VE ISSUED OVER 100 PAIRS OF THESE DEVICES AND GIVEN ONE PATIENT A REFUND. I'VE ALSO ISSUED NUMEROUS PAIRS ON A TRY IT AND SEE BASIS......EVERY ONE HAS PAID UP. If this is snake oil selling then there's not going to be much money in it with that guarantee

    Now, if you've stayed with me this long, I'm sorry if this doesn't satisfy the intelectual argument, but I'm afraid that I earn my living in the real world, where patients pay by results. The above paragraph is the evidence base I'm working to at this point in time.
     
  17. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Alex - the exact same success rate that you are claiming can be seen in the "placebo orthotic" in the control group of orthotic randomised controlled trials. Anyone and everyone can claim success!!

    3.5/6/9 mm are massive when no forefoot varus is present and easy to demonstrate the interference they have in windlass mechanics and how the make first MPJ dorsiflexion more difficult. .... just do Jacks test with and without the extension.

    Can you refute point by point the issues I raised in the letter to the editor (see above) and published in JBMT?


    Kevin - I do not have a problem with people naming commerical products after themselves (ie the Richie Brace; Cluffy Wedge), its just the agorance of naming a foot type after oneself (Morton never came up with the name "Morton's foot"; Mert Root never used the term "Root Theory) - these along with other names (eg Kirby skive; Blake inverted orthotic) these terms were attributed by the community of peers and not by the individual who's work they are based on ---- most likely as a sign of respect.
    ...to avoid the peer review process and scrutiny of journal publication.
     
    Last edited: Apr 27, 2006
  18. William Fowler

    William Fowler Active Member

    I just wish I knew more to contribute to this discussion. I also wish I had Craig as a teacher, if this is the level of thinking being imposed on students!!

    I just wanted to say, that this level of discussion and debate, rather than what is seen elsewhere is impressive - keep it up.

    Alex:
    I do not mean this with any disrespect, but the way you have said most of what you say is just the way and uses language in the same way as the "snake oil" salesmen talked. That immediately puts me off.

    William
     
  19. Donna

    Donna Active Member

    When a podiatrist prescribes orthoses for a patient (in Australia), they are required to explain to the patient why they are prescribing and how they are going to work (obviously in lay terms so the patient can understand). This forms part of the Clinical Guidelines for Orthoses published by the Australian Podiatry Association... :cool:

    Now, when "prescribing" the Rothbart's insoles, how do you explain to the patient their function? And can these things be modified/customised for different patients? And how do you treat patients with a supinated foot? On the website it says that these insoles are not indicated for supinated feet...what happens when a "supinator" walks through your door with symptoms? :eek:

    I still find it very hard to see how these insoles work and why such a wide range of "providers" such as dentists would be prescribing them also. :confused:

    Regards

    Donna
     
  20. As I said in my last posting, one of the problems I have with patients that have had too much (or any) forefoot varus posting added to their orthoses is the following: Varus forefoot extesions will tend to cause subtalar joint supination instability in the latter half of stance phase.

    I didn't say that all patient's experience this outcome, since I'm sure that some patients may benefit from varus forefoot extensions as I also mentioned. In my posting I stated that I will use this orthosis feature in the occasional patient for walking.

    In Brian Rothbart's website http://www.rothbartsfoot.bravehost.com/ he describes what he calls:


    Rothbart’s Foot Structure (Primus Metatarsus Supinatus)

    In 2002 Dr. Brian A. Rothbart published a paper (Journal Bodyworks and Movement Therapy) describing a previously unreported embryological foot type (technically referred to as the Primus Metatarsus Supinatus Foot), which he linked to the failed or incomplete torsional development of the talus. This foot type is thought to be responsible for poor posture in children and chronic musculoskeletal problems (foot to jaw) in the adult. Frequently it can be identified by its deep first web space.



    And here are only a few of the maladies that his magic insoles may treat (also from his website):



    Proprioceptive Stimulation Can Help You

    Proprioceptive Stimulation affects the body in many positive ways.

    Foot, Knee, Back, Neck, Jaw Pain

    Proprioceptive stimulation repositions the posture into a more correct alignment (see Figure Right). This reduces the stress on the muscles, which allows them to heal (Rothbart and Esterbrook 1988, Rothbart and Yerratt 1995).

    Respiratory

    By straightening the shoulders, the ribcage is opened and pressure is taken off the lungs. This allows for easier breathing.

    Intestinal and Bowel

    Proprioceptive stimulation reverses the anterior rotation of the innominates (hips), which in turn, positionally decompresses the intestines and colon. Waste products pass through the colon more quickly and efficiently, eliminating the pain associated with gastro-intestinal distress.

    Chronic Fatigue Syndrome

    Proprioceptive stimulation improves posture, which in turn, reduces hypertonicity (tightness and strain) within the postural muscles. Lactic acid is reduced. The body has more energy. (Rothbart B. Pressure Plate Analysis of Medial Column Insoles. Journal of Sportsmedicine)

    Diabetic Ulcers

    With improved postural positioning of the foot, blood flow into the foot is greatly enhanced. This allows the diabetic ulcer to heal, reducing the likelihood of a partial or complete foot amputation (Case Studies, Group Health Hospital, Department of Orthopedics, Tacoma Washington 1996).

    Infertility

    Proprioceptive stimulation reverses the anterior (forward) rotation of the pelvis. This decreases the possibility of a blockage (Isthmus Block) between the ovaries and the fallopian (uterine) tubule, where conception normally occurs (See Animated Model below). The egg passes more freely from the ovaries into the fallopian tubule. Impregnation is facilitated (chances of becoming pregnant are improved).


    Menstruation

    By reducing the forward rotation of the pelvis, the blockage between the uterus and the vagina is reduced. This allows the waste materials, generated by menstruation, to be passed out of the body more efficiently. This in turn, diminishes or greatly reduces menstrual pain (and low back pain). (Bellevue Study 1993-95)


    Headaches

    Many headaches arise from tension in the neck muscles. By positioning the head over the spine, the neck muscles relax. Headaches become less frequent and less intense (Rothbart, Hansen and Liley 1994).


    Fibromyalgia


    Many patients with Rothbart's Foot Structure have pain symptoms, foot to jaw. It is not uncommon for these patients to be diagnosed as having Fibromyalgia. One specialist in Chicago talks about her experiences using proprioceptive insoles in their Fibromyalgic Clinic and the results they have seen over the past two years.


    A Profound Effect

    Proprioceptive Stimulation, as you can see has a profound effect on the body, solving so many chronic body problems, that in the past were considered unsolvable. This is done naturally, without the use or need of surgery or drugs. It just makes good sense to treat your body in a kind and respectful way, allowing it to heal itself naturally.




    Alex, maybe you can also provide us information on whether the Rothbart insoles that you have correctly prescribed have helped improve the "efficiency" of the menstrual cycle of your female patients. Sure sounds like snake-oil to me. :rolleyes:
     

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  21. All,

    I have just returned from a lecture series in Madrid and was surprised to see the return of Rothbart when I got back. From my experiences in Madrid and elsewhere it is clear that there is a world-wide obsession with the windlass mechanism currently.

    One or two of my spare Euro's in to the pot:

    Rearfoot posts reduce 1st MTPJ dorsiflexion too (Smith C., Spooner S.K., Fletton J.A.: The Effect of 5-Degree Valgus and Varus Rearfoot Wedging on Peak Hallux Dorsiflexion During Gait. J Am Podiatr Med Assoc 2004 94: 558-564), but I don't see anyone advocating that we stop using them in case we "block the windlass."

    Windlass action is not dichotomous, that is it is not an all or nothing event. How much though, is enough?

    How do we measure change in plantarfascial tension with and without the effect of the windlass mechanism in dynamic, shod walking? And, control for other factors which may influence plantarfascial tension- In other words, which research has demonstrated the effect that foot orthoses has on the windlass mechanism during walking? Indeed, which research has demonstrated the effect that shoes have on the windlass mechanism during walking; which research has demonstrated the effect that the windlass mechanism has on plantarfasical tension during shod walking?

    I just think too many people are placing too much significance on something we know too little about. Tell me I'm wrong.........

    Craig mentioned Bojsen-Moller. I have written many times in other forums on the problems I perceive with Bosjen Moller's high/ low gear theory; to re-cap the principle points: I believe that a transfer to the high gear axis from low gear is accompanied by a medial shift in the STJ axis, in other words the foot must pronate to achieve this. The greater the length differential between the longer second metatarsal and the shorter first metatarsal the greater the medial shift in STJ axis (Spooner S.K. The subtalar joint axis locator. PFOLA conference presentation, Montreal 2002). This is true whenever the 1st met is shorter than the second. In other experiments carried out we have demonstrated that the "selection" of high or low gear seems to be random, varying from step to step. Sometimes one axis is used, sometimes the other.

    I especially like the low gear axis portrayed in Bojsen Mollers articles which shows it extending through the 5th MTPJ when studies of shear force demonstrate that the 5th MTPJ has no roll in propulsion.


    Do you think that the peroneous longus would fire longer and/or harder in this situation? Perhaps plantarflexing the 1st met, reducing the supinatus and "improving" the windlass in an analogous fashion to the effect of valgus forefoot posts and gastrocnemius?

    One final point, we seem to assume that the foot is fixed on top of an orthoses- it's not.
     
  22. Is this correct?
     
  23. Craig Payne

    Craig Payne Moderator

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    Just look at all the "control" groups in the studies that compare prefabs to custom made etc etc and most patients get better --> implication is that these prefabs which are not designed to do too much are getting the same success rate that Alex is claiming. I probably mis-used the term "placebo" and should have said prefab group in the trials.

    Even in my clinical practice, I offer 100% money back no questions asked and have not refunded any in the last few 100 orthotics.
     
  24. Phil Wells

    Phil Wells Active Member

    David
    I am going to stick my neck out here as I believe the need to make the foot function around STF neutral is a generalisation at best and a poor algorythm at its worst. My reasoning behind this is that foot orthoses should attepmt to change the pathology inducing forces created by GRF (and others) and not try to place the foot in a positional panacea.
    I am also not sure of the relevance of the evolution discussion (I have read the previous postings on this topic) as do not take this into consideration when treating my patient. Do I need to?
    I do agree with your point about orthoses accuracy - as soon as it gets into the shoe, the fibro fatty pad movement, translation of the foot over it etc, then its mecahnics cannot accuratley be measured.
    The point I would make re the Rothbart design is that seem to work by creating a shoulder type sling effect ( post clavicle fracture to immobilse the joint) on the pf - ie. they immobilse the foot. Great for getting of symptoms but not addressing the causative mechanism - what ever that is.

    Phil
     
  25. I'm not sure that fee refunds are truly indicative of clinical success, but of course they are important when you're in the business of private practice. Just as an aside, and not wishing to divert this discussion, what is the success ratio between prefabs and custom made devices?
     
  26. Craig Payne

    Craig Payne Moderator

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    equal
     
  27. Am I missing something here? If prefabs and custom orthoses have equal outcomes, and prefabs and Rothbart's also have the same outcomes (according to Alex's observations), are you saying Rothbart's proprioceptive devices are just as effective as custom made orthoses? Or have I completely fallen off the log?
     
  28. Lawrence Bevan

    Lawrence Bevan Active Member

    One thing that should be said is "well done" to Alex for sticking his neck out on such a touchy subject.

    However I think we would all agree that for a lot of people if you put something in their shoe they will say they "feel" better.

    Plus the "money back guarantee" is a well known means of engendering customer confidence. Many people can be very dissatisfied but still not return to claim their refund. Also customer confidence = enhanced placebo effect does it not?

    Alex, I too have only recently created a miracle cure with orthotics in severe plantar fasciitis. This was bilateral, 5 years duration and has necessitated the use of crutches and he has had everything under the Sun. I got a 75% reduction in 1.5 weeks with the "RIGID" orthotics you prefer not to use. No he didnt ring to tell me but he did immediately refer another pt - his GP! Does this prove anything. No

    Incidentally I took a "neutral" cast, used forefoot balancing and they had a polypropelene rearfoot post. Does this mean they were prescribed with the "flawed" Root concepts in mind. Nope, the Newton's laws of mechanics + an understanding of stress/strain and material properties were employed. Oh and they fitted his shoes.

    Does this mean that the next pt gets the same thing. No
    The same Rx. No
    The same material. No

    Things have moved on since "Root". Prescriptions, materials can all be changed to suit the circumstances. Can the same be said of the "rothbart" approach? I think the worst results of the so-called "Root" approach was the misapplication of its concepts and giving all pt's the same devices. To me the "rothbart" approach is doing the same.

    It doesnt surprise me that there were lots of Chiropractors at the meeting - they can cure deafness with spinal manipulation you know. They can also prescribe custom orthotics by post just by letting you take one step on their clever pressure mats!

    Quick question Alex, were you a big prescriber of thermoplastic custom foot orthotics before you started using "rothbart" orthotics?
     
  29. Felicity Prentice

    Felicity Prentice Active Member

    Did you know that recently Scientists (people in lab coats) discovered that Bernouilli's equation does not in fact adequately explain how the shape of airplane wings actually generates lift in flight. Sure, there are differences in pressure and such, but there are also significant holes in the theory proposed by Bernouilli.

    This was only discovered recently. And on the day it was discovered, not a single jumbo jet fell out of the sky due to the lack of theoretical support.

    Now, I will agree with Craig (he's bigger than me for a start) that we shouldn't be racing off chasing anecdotes; and I know nothing about Prof/Mr Rothbart's products....and to be honest I dislike a snake-oil sakes approach as much as the next person. But I think we need to recognise where we are in the scheme of the theoretical/practical junction.

    Sooner or later we will have a clearer picture of WHY orthotic devices have the effects they do - and thanks be to the researchers who will lead us there. And sooner or later we will figure out how jumbo jets fly.

    cheers,

    Felicity
     
  30. David Smith

    David Smith Well-Known Member

    Dear All

    I’ve reworked and paraphrased some of this but what do you think of the following theories? (stick with it it makes sense by the end I Hope!)
    Theorem One
    1=2
    Proof
    Suppose a=b and neither is zero or 2=2.

    Then if,
    a²-b²=(a-b)(a+b) or 4 – 4 = (2-2) x( 2 + 2) =>0

    Also,
    a²-b²=a²-ab or 4-4 = 4-4 => 0

    So,
    a²-ab=(a-b)(a+b) or 4 – 4 = 0 x 4 => 0
    a(a-b)=(a-b)(a+b)or 2 x 0 = 0 x 2 => 0
    a=a+b or 2=2+2? 2 =4??
    a=a+a or if a=b and a = a+ b then a = a + a
    a=2a
    2=4 so 1=2

    Intuitively you know 1 does not = 2. But it appears by transposition that a =2a but that is because one assumes that ‘a or b’ = a number, which they do not, they are just a or b. a = 2a by the rules of algebra but are not / cannot be proved by the rules of arithmetic.
    Theorem Two
    Movement is impossible!
    Proof
    This is a proof by contradiction. Assume that movement is possible and derive a contradiciton, thereby proving movement to be impossible.
    So suppose movement is possible. A runs 10 times faster than B. In a race B starts 10metres ahead of A. A can run 10mtrs / sec. The race starts, after 1 sec B goes 1mtr to position B2, A goes 10mtrs to position A2 but B is still ahead. In the next fraction of a sec A moves to position B2 but B moves to position B3 so B is still ahead. A moves to position B3 but B moves to position B4 and is till ahead of A. A cannot catch up or over take B. So by this logic after racing for infinity A could not move but infinity is in less than 2 seconds. So What if B starts (0.1mm x 10 to the power of minus infinity) ahead of A. Movement is impossible

    This is again algebra comparing A in relation to B but contained within the rules of their own parameters in which time and space does not exist (but it intuitively exists to the reader) and not in relation to the real world where time does exist.
    ………………………………………………………………………………………………………………………..

    In the early years of the twentieth century, two English philosophers, Bertrand Russel and Alfred Whitehead, adopted the black-and-white view. They tried to formalize all of mathematics by carefully spelling out all axioms, (Statements which are true (within the parameters of the criteria of the rules for the statement,which is all truths)) and then deducing every possible true statement, all of mathematics. During the course of this project, Russel came up with a famous paradox which bears his name.
    Russel's paradox goes like this:
    Divide all possible sets into two groups: the group of sets which contain themselves and the group of sets which do not contain themselves. Into which group does the set of sets which do not contain themselves go?

    Indeed, the goal of proving all possible true statements turned out to be an impossibility. This was proved by Kurt Gödel, an Austrian philosopher mathematician. He showed that in any consistent system which was reasonably complicated (on the level, say, of arithmetic) it was possible to write down in the language of that system a statement that basically meant this statement is true but unfortunately not provably so. The consistency of the system necessitates the statement's being true (can you see why?) -- but that means you can't prove its

    I take this to mean that it is possible to prove that a statement, made about a certain system, is true by using the criteria of the rules for that system. It is impossible to prove that statement wrong without using criteria outside of the rules of the original system, which make the counter proof invalid which, by the same logic, also means it is impossible to prove the original theory.

    One could say then that this leads to a paradox such as the argument in this thread about Rothbarts insoles. One can only disprove his system by using rules of another system which are not valid for analysis of the original Rothbart system.

    Touchee!!. Makes you think doesn't it.

    Cheers Dave Smith
     
  31. Mhmm, Dave...and on a Friday night too! ;)

    I know where you're trying to go, and the thing is, if you do it without the numbers, it would be less complicated, the numbers are confusing and take you away from the main error of thinking.

    The mistake you made though is that you go from a(a-b) = (a+b)(a-b) to a=a+b. This however means that you divide both sides of the equation by (a-b). Because a=b, that means you divide by zero, which is mathematically impossible. And there-in lies the mistake of your proof, so your conclusion is faulty. Sorry!

    Your movement thing was explained in a very difficult way. If you do the same thing and apply it to the story of the turtle and the hare, it's much easier to explain, and for others to understand. There is another one with an arrow and a second arrow being fired afterwards…but I’m sure you know that already.

    Say the hare moves twice as fast as the turtle. Which means that if the hare arrives at point A, the turtle will have only arrived at point A/2(which is half the length at the same size).

    To make the competition a bit more fair, they give the turtle a head start, and the hare only leaves when the turtle is already at point A. When the hare arrives at point A, the turtle is at point A+A/2. when the hare arrives at point A+A/2, the turtle is at point A+A/2+A/4 and so it goes on, the hare can never catch up with the turtle.

    The reason why this is not applicable in real life and why in real life you can actually catch up with someone is that the space point A takes up on earth or in the universe or whatever has no width, length, depth...it is infinitely small. this means that when the hare and the turtle get to go a few kilometres further, you can't apply this theory anymore as their feet won't be able to actually cross a distance of A/x, because the size of their feet would already be larger than the distance A/x, where x is a big number

    This reasoning actually stems from a paradox which was found earlier, which says that if you try to cross a distance by crossing half each time, you will never get to your destination. Say you decide to go to point A. First you go to point A/2. then to A/2+A/4. Then to A/2+A/4+A/8 and so on and so forth. If you calculate this sum, you will get A(1/2+1/4+1/8+1/16+1/32+...) the sum on it's own will never truly be equal to 1(try it on your calculator if you want), only in its limit, so you will theoretically never arrive at point A.

    The first paradox you mentioned gave lead to start the rule that "a collection of an infinite amount of sets is not a set"

    Russel was not the first to try this, though...to explain everything in maths axiomatically. Before him there was the Bourbaki group, a group of professors at the Sorbonne in Paris. They tried doing it as well in the 19th century, but found that, though it is possible, it makes the proofs often very long and tedious - because it is always the same thing over and over again in an algorythm until you eventually arrive at your destination. However the scholars of the Boubaki movement did find a lot of very interesting things about set theory, a part of mathematics that hadn't really been explored before that.

    An interesting aside, but I’m not sure you can apply the same reasoning to the Rothbart –v- Traditional Bx paradox.

    Mark Russell
     
    Last edited: Apr 28, 2006
  32. Craig Payne

    Craig Payne Moderator

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    That may well be the case. The difference is that the theory underpinning Rothbarts approach is very very flawed - the evidence actually contradicts the theoretical underpinning, whereas aspects of the theoretical underpinning of other approaches may not be supported by evidence, its certainly not contradicted. (I notice no one has yet done a point by point rebuttal of the points I made in message 1). Based on what evidence we have and the potential longer term consequences of using devices like Rothbarts [eg forefoot varus posts pronate feet more (Mosheyev et al, 2002); the restriction of first MPJ dorsiflexion (Roukis et al 1996); etc], you are on very shaky ground if using them. None of the claims made by Rothbart can be substantiated - see the comments in message one re Rothbarts use of unpublished sources of references that can not be obtained; that have not been subject to peer review; provide insufficent information for replication; in most cases do not even provide any evidence for the statements being made; and have not been published in any mainstream or podiatric journal.

    Contrast that with the theoretical need to get a force medial to the STJ axis and get the first ray down - no evidence contradicts that theoretical underpinning. In fact the evidence supports that kind of approach (and different theoretical perspective put a different spin and how and importance of each)
     
  33. David Smith

    David Smith Well-Known Member

    Mark

    "because a=b, that means you divide by zero, which is mathematically impossible. And there-in lies the mistake of your proof, so your conclusion is faulty. Sorry! "

    No need to be sorry Mark, That is the whole point of the argument. You use a mathmatical rule which is valid in your system but not by this equation's set of rules, which do not state that a = number. The numbers are there as an example to see how number could change under the same rule.
    See this ref: Proving Mahavira’s Conjecture (a ÷ 0 = a) roger ploughman 2006.
    You'll probably understand it better than I but the basic premise is that maths is based on counting (computers only add and subtract) nothing more than fancy ways of adding and subtracting. multiplication and addition are addition and subtraction. Therefore Adding or taking away a zero does nothing a +or- 0 = a and so multiplying by Zero does nothing. Therefore a / 0 = a

    But isn't this relevant to the whole argument of the biomechanicals of orthoses and Rothbart in particular. If an argument does not recognise a certain condition that another argument does because they use different criteria then it is impossible for them to agree. For them to agree someones rules must change.

    Personally I read Rothbarts papers a few years ago and tried out the micro wedging thing without much success. Some did work initially, very comfortable, relieved pain, but they returned with problems associated with saggital plane progression blockage. only one pair worked well and the guy has had 2 more pairs since.

    Cheers Dave
     
  34. Dave

    Therein lies the rub: What Rothbart does is challenge a system of beliefs insofar as although his theoretical arguments may seem weak, clinically his argument (through these insoles) appears to have some validity. It is a very common thing - especially with people who have their minds set and who project part of themselves into what they believe - in that listening to others, especially those with good arguments as to why their beliefs might be faulty, is very risky for them, for when they lose their own belief system, sometimes they also lose themselves...


    In any discussion, be it politics, religion, philosophy, science (even within science itself!),... there are always those that don't really listen to others - not really anyway - and I know I have been guilty of that myself in the past (and probably will be in the future). It's just part of human nature, which is why I think it's important to raise questions but not purposefully undermine other folk's belief systems...unless science has clearly and undeniably proven them wrong!

    Who is truly in a position to judge in this instance?

    Have a good weekend.

    Mark Russell
     
    Last edited: Apr 29, 2006
  35. Mark, Dave, Craig and Colleagues:

    I can't really admit that I understand what Dave and Mark are talking about regarding how mathematical proofs relate to the snake oil sales pitch seen on the Proprioceptive Stimulation Insoles website. However, I do know enough about foot and lower extremity biomechanics to know that not all patients respond the same way to the same type of foot orthosis and that foot orthoses can do a lot of things, but improving fertility and menstruation "efficiency" is certainly not included in the list I use.

    Mark, seeing how you answered your posting, I have a few questions for you. If Rothbart had an insole system that was a flat piece of material (such as a piece of cardboard) with no wedging or shape but he claimed that this insole did the same remarkable things that it did with "scientifically proven" concepts, would you still agree that his insoles "challenge a system of beliefs insofar as although his theoretical arguments may seem weak, clinically his argument (through these insoles) appears to have some validity."?? In other words, how far off the mark of known scientific principles does one have to be before you say, this doesn't make sense with our known scientific principles and is hogwash until it becomes supported by some reliable evidence?! Or would you just let him continue preaching in an unchallenged fashion since you didn't want to "purposely undermine other folk's belief systems"?

    Because, you did say "It's just part of human nature, which is why I think it's important to raise questions but not purposefully undermine other folk's belief systems...unless science has clearly and undeniably proven them wrong!" As you probably know, I have been purposely undermining "other folk's" belief systems for the past two decades by raising questions about the Root system of biomechanical dogma which I was taught in Podiatry school and about the Sagittal Plane Theory. Personally, I think it is healthy to try and undermine other folk's belief systems, since this is the only way to make them think, debate and come up with proof for their belief systems.

    I have always made it a point in my 20+ years of teaching, debating and challlenging others in podiatric biomechanics to adhere closely to Newton's Laws of Motion and other known well-tested engineering and biomechanics principles since I know that this allows me to stand on some very solid ground when I make statements about foot biomechanics and foot orthoses since these statements are underpinned by some very solid scientific principles (as Craig made in his last note).

    However, Mark, how much latitude are you going to give someone to preach their beliefs that has a website like this one http://www.rothbartsfoot.bravehost.com/ when they make "snake-oil-claims" of cure-all health systems such as proprioceptive insoles??? In other words, what would it take for you to take a firm stance, straighten up your back, hold out both arms and say that this person is full of .... and say to others that you should not believe what he says?! If you want to let him say these things and not challenge him because you think he deserves the right to express his opinion, then that is your choice. However, my opinion is that if he really had something that was worthwhile to publish then he would have had it published in a peer-reviewed podiatric or medical journal that was worthwhile (and not on a self-promoting website) and he would be able to use good biomechanical logic to make his case.

    I believe that we have now, as a profession, progressed to a point that we can no longer let just anyone that has a seemingly good idea go unchallenged, because, if we do, then there will be so much useless information in our professional meetings and textbooks, that the medical profession will look at us as a bunch of idiots. This will eventually weaken all the academic gains that we have made as a profession over the past few decades.

    As for me, I will continue to challenge these weak ideas as long as my lungs hold breath within them. I know that my role within the podiatric profession is to help my colleagues with less knowledge and less clinical experience in my field of expertise determine what ideas make good sense and what ideas are full of holes and are being pushed forward for self-serving promotors. Just as others may rely on my opinions, I rely on others within my profession for their thoughts on new ideas and techniques in subjects that I am not as familiar with. These colleagues are very valuable commodoties to me as a health professional since I know that I can rely on them for well-thought-out opinions on subjects that I am interested in but not an expert in.

    Therefore, like Craig, I am not at all impressed by either the claims or products offered on this website http://www.rothbartsfoot.bravehost.com/ and think that the term "snake-oil salesman" really sums up my feelings in this regard.
     
  36. Akbal

    Akbal Active Member

    Rothbart insoles

    Dear All,

    I have to wondewr how many of the participants in this debate have seen these devices.

    Craig and other have described them as 'Massive' forefoot varus posts. I have seen them and even issued 1 or 2 although not overly keen on the theroretical basis on which they are promoted. I think they have some merit.

    Firstly I should decribe them they are a 1st ray (Hallux) Varus post, they are a modified mortons extension that is all. They do not extend beneath the 2nd Met.

    I have issued them is situations where a short 1st met is evident and there is over loading of the 2nd MTPJt, I of course assess if a functional Hallux limitus is present. I don't claim or believe that they are the answer to all foot problems and posture but, as I have used mortons extensions in the past I will use these insoles in the future they are inexpensive and can provide good results.

    If anyone who has not seen them and is going to be at the Stafford conference I will bring with me a couple of pairs and the training DVD (which is interesting to say the least).
     
  37. Ian Linane

    Ian Linane Well-Known Member

    Not wanting to self publicise but on our module two last week people were shown how to achieve the same postural changes, as some of the images on the above website, improve glut max function and stablise forward progression with a simple 3 or 5 mm heel raise.

    Ok, so over time people may want to add to a good maintenance of this through core stability execises but that seems somehow natural and normal.

    Personally I am open to listening to any approach but the questions for me include:

    1. If we do not have a definitive norm for the alignment of and function of the foot then how can we decribe such a subtle type of alignment issue as Rothbarts as being faulty?

    2. Is the reasoning behind his views taking into account a foot that developed for undulating surfaces or is it based upon the flat surface thinking?

    3. the impact of random variable ranges of movement in any given joint during the day and the foots need for this natural function?

    Ian


    It does not have to be rocket science.
     
  38. Craig Payne

    Craig Payne Moderator

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    I was exaggerating when I said "massive", I have seen them and have used them. We did some experiments with them (see earlier) following the exact instructions from Rothbarts website and publication and based on what we found that they do to the foot (let alone the menstrual cycle), will never use them again.
     
  39. Craig Payne

    Craig Payne Moderator

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    BTW - I deliberatly left out the word "proprioceptive" in the title of this thread. I think people need to go and look up what it means before they start using the term.
     
    Last edited by a moderator: Apr 29, 2006
  40. No, of course not. However, if patients and colleagues reported significant improvements in pathomechanical conditions when these insoles were used, and the clinical outcomes were roughly comparable with those of established orthotic therapy, then circumstances would, in my opinion, support my original statement.
    The key word here Kevin is "known". You make the assumption that Rothbart knows and understands what his insoles do. Reading his website I tend to agree with you and I've said so at the beginning of this thread. However, it could be that the insoles work because of scientific principles not yet known or understood by Rothbart, Kirby et al. A bit like an 18 Century snake oil salesman stumbling across penicillin purely by accident I suppose.

    Well, I would give more weight to your argument if the insoles produced no beneficial outcomes whatsoever. Clearly they do work for some patients - perhaps even more effectively than your custom made devices in some instances - and just because you don't know or understand the mechanisms involved - what Dave Smith was illustrating in his post - doesn't give you the right to ridicule the person who believes in them. Challenge the mechanics and science by all means, but I have to say that some of your personal attacks are rather uncharitable and most uncharacteristic of you.

    I haven't seen these insoles or used them, but I do respect the views of colleagues like Alex and Akbal - that's why I opened this enquiry. What has surprised is the rather startling observation that prefabricated orthoses appear just as effective as custom-made devices in randomised clinical trials - and that Rothbart's insoles procure roughly the same values too! The term snake-oil has been used quite liberally these past few days and how appropriate; it's not a can of worms that's been opened here, more like a seething pit of angry vipers! I wonder why?

    Best wishes

    Mark Russell
     
    Last edited: Apr 29, 2006
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