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Signs of gait improvement with foot orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ian Linane, Jul 26, 2006.

  1. Ian Linane

    Ian Linane Well-Known Member


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    In another thread Ed has said:

    If the patient’s gait looks the same when they walk in without the orthotics as when they walked out, and we have made no visible positive effect on gait, then even if symptoms are masked there will be no long range change in function or form.

    Elsewhere similar thoughts have been expressed.

    Firstly:

    I would be interested, from a visual gait analysis point of view, what others look for to determin if they think there is an improvement in the gait (meaning whole body involvement and not just feet).

    Secondly:

    how many of their senses people use to determin if they feel a persons gait has altered positively (i.e. sight / hearing etc)

    For me, the actions of the feet, post orthosis fitting, play a part but, if i'm honest, a secondary one.

    Ian
     
  2. javier

    javier Senior Member

    Visual gait analysis

    Ian,

    Regarding your questions:

    Visual gait analysis is an unreliable system for biomechanics assessment, it just gives qualitative data. If you want to see an improvement you will see it. It is a classical clinical assessment that gives you some guidelines about what the problem is.



    Sometime ago, after reading some posts on Podiatry Jiscmail mainly from Kevin Kirby and articles on different journals, I realise that kinematic approach to biomechanics assessment have lots of limitations. It is much better to think about moments instead of position.
     
  3. Craig Payne

    Craig Payne Moderator

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    I think visual gait analysis for measureing effectiveness of orthoses is not that important as we now know that it is an alteration of force/kinetic parameters that are associated with symptom reduction. So observing any movement/kinematic change does not necessarily mean anything.

    I am not yet prepared to agree with Ed (I may or may not agree in the future) - we just have no evidence yet as to what is optimal kinematic/movement is and if there is an optimum and we achieve it with foot orthoses, is that associated with symptom reduction. ... it may or may not be. We do know that an alteration in the kinetic parameters are associated with symptom reduction.

    Previously (and until very recently) I used to preach that a visual gait analysis only had one purpose: To look for any abnormal function that may be responsible for the symptoms that the patient has. The problem now is that we know its the force/kinetic parameters that are associated with symptoms, so you can not see these forces in a gait analysis without technology .... let alone know if we have modifed them in the right direction with foot orthoses.

    More recently I have looked at some things that can be seen in a visual gait analysis using a digital video into computer that might correlate to some of the force parameters. We use SiliconCoach. There does appear to be 2 things that do correlate to force/time parameters measured by technology and, more importantly, do influence my orthotic prescirption decision making:
    1. The position of the first met head during propulsion (see this thread)
    2. The symmtry in timing of heel lift

    As for gait analysis on issue of orthoses. IMHO, its a waste of time, unless technology (ie inshoe pressure measurement) is used to measure changes or not in the force time parameters with and withut the foot orthoses (and make final adjustments to the orthoses using this information).

    CP
     
  4. I disagree here, Craig. Observing a change in kinematics in a patient also always indicates a change in kinetics since accelerations/decelerations cannot occur without a concomitant change in forces and/or moments. These changes in motion patterns of the foot and/or lower extremity with a foot orthosis may be due to one or both of the following factors:

    1. The foot orthosis has altered the magnitudes, plantar locations, vectoral directions and temporal patterns of ground reaction force (GRF) that has, in turn, caused a direct change in kinetics across the joint axes of the foot and lower extremity during gait.

    2. The foot orthosis has altered the magnitudes, plantar locations, vectoral directions and temporal patterns from GRF that has, in turn, caused an indirect change in kinetics due to the central nervous system changing the magnitude, temporal pattern and muscular recruitment pattern within one or all the muscles that mechanically affect the lower extremities.

    I do agree with Dr. Ed Glaser on this point: changes in the kinematics of gait are an important part of what we should be doing with our foot orthoses in many patients. Abnormal gait kinematics can cause injury simply due to the simple physics principle that a mass with a linear or rotational velocity has a kinetic energy (KE = 1/2 mv^2). If that body segment is moving too fast, or in the wrong direction at the wrong time, it also then has the energetic capability to cause injury to one of the structural components of the foot and/or lower extremity that is acting to absorb that energy of that abnormal motion.

    For example, during running, if the patients foot strikes on the posterior-lateral border of the running shoe, with the center of pressure being lateral to the STJ axis at the instant of heel contact, this creates a STJ pronation moment that will tend to cause an internal rotation acceleration of the shank and thigh. After the initial impulse of GRF has occurred and the STJ pronation moments have been applied and the thigh and shank has accelerated with an increased internal rotation velocity, then this transfer of kinetic energy in the limb from a downward direction prior to heel contact to an internal rotational direction after heel contact must be absorbed and then transferred to energy elsewhere in the body by a set of anatomical structures. If, for example, the posterior tibial muscle is one of the primary structures used for absorbing this energy, and it is mechanically disadvantaged by short STJ axis moment arms or by being intrinsically weak, then it may be more likely to be injured by the repetitive absorption of kinetic energy caused by the STJ pronation moments that have caused the internal rotation kinetic energy of the shank and thigh segments. We should not assume the motion patterns of gait are not important for the simple reason that gait energetics are directly determined by motion patterns of the foot segments, lower extremity segments and other segments of the body. In other words, it is not all about kinetics!

    I cannot agree with you here, Craig. In my opinion, visual gait is only a waste of time if the clinician does not know how to properly perform a visual gait examination. I have been teaching visual gait examinations for over 20 years and for the busy clinician, it is absolutely indispensable. I perform about 20-25 visual gait examinations a day in my clinic and even though some of them tell me nothing, many of them allow me to determine the most likely cause of the patients mechanical/neurological problem and how I may best fix the symptoms and/or gait pathology that results from that problem.

    Rather than going over the many points that I cover when I give my workshops on visual gait examination, I will attach a handout that I prepared for Ray Anthony's Biomechanics Summer School at Heythrop Park, England in the summer of 2004. I hope that proper visual gait examination techniques continue to be taught at podiatry schools around the world since it is the quickest, most efficient and least expensive method to analyze the kinematic effects of foot orthoses and shoes (and therefore also give a better idea as to the kinetic effects of foot orthoses and shoes) on the movements of the segments of the body during walking and running gait.

     
    Last edited: Jul 27, 2006
  5. Craig Payne

    Craig Payne Moderator

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    You are right in that observing a change in gait will indicate that kinetics have changed. The point I am trying to make is that if you observe a change in gait with foot orthoses or not, then there is no relationship between that and if they respond clinically or not.

    We do teach the students gait anlaysis, but also challenge with the question of what do you actually do with the information - very little of it is actually useful for deriving a foot orthoses prescription.
     
  6. Atlas

    Atlas Well-Known Member

    Craig. The evidence suggests as you have pointed out, that orthotics don't change static measures etc. Am I right in saying that skin markers were used? Has anything been done radiologically? For instance xray with and without device?

    Ron
     
  7. It is incorrect to say that the research evidence shows that orthoses do not change the kinematics of gait. There is research evidence that orthoses do significantly change the kinematics of gait. However, if I were lecturing today on the subject, I would say that foot orthoses always change the kinetics of gait but often may produce immeasurable changes in the kinematics of gait.

    Just because our instrumentation and measurement methods are not sophisticated and accurate enough to measure the motion changes that are occurring within the joints of the foot, doesn't mean it is not happening. Once we can reliably increase our measurement accuracy of the movement of the foot skeleton segments to within a fraction of a degree, then I predict we will be changing our tune and saying that foot orthoses do normally change the kinematics of gait.
     
  8. javier

    javier Senior Member

    If I am not wrong, the original question was related to visual gait analysis (I understand this assessment as a clinician watching a patient walking without any tool a part from his/her eyes) for assessing foot orthotics outcomes.

    I am with Craig about the poor reliability from this system for evaluating outcomes although it is an inexpensive system for achieving some qualitative data from patient's gait.

    Nigg B. Humble N. Stefanyshyn D. Orthotic Confort is related to Kinematics, Kinetics, and EMG in Recreational Runners. Med. Sci. Sports Exerc .2003, 35 (10) 1710–1719 8.

    Thinking again about this question and after reading Kevin's In-Office Gait Evaluation , I would response: gait asymmetries.
     
  9. Thanks for this reference, Javier.

    Here are a few more scientific studies that show that foot orthoses do affect the kinematics of gait.

    Running research:

    Decrease in maximum rearfoot eversion angle (Bates et al., 1979; Smith et al, 1986; MacLean et al., 2005)

    Decrease in maximum rearfoot eversion velocity (Smith et al., 1986; MacLean et al., 2005)

    Decrease in maximum ankle dorsiflexion angle (MacLean et al., 2005)

    Decrease in maximum internal tibial rotation (Nawoczenski et al., 1995; Williams et al., 2003)

    Decrease in internal rotation and adduction of the knee (Stackhouse et al., 2004)

    Walking research:

    Decreased in rearfoot pronation and decreased rearfoot pronation velocity with varus wedged orthoses and increased rearfoot pronation with valgus wedged orthoses (Nester et al., 2001; Nester et al., 2003).

    Decrease in rearfoot eversion during stance and decrease in internal tibial rotation after 12 months of wearing the orthoses in patients with rheumatoid arthritis (Woodburn et al., 2003).

    References:
    Bates BT, Osternig LR, Mason B, James LS: Foot orthotic devices to modify selected aspects of lower extremity mechanics. Am J Sp Med, 7:328-31, 1979.

    MacLean CL, Hamill J: Short and long-term influence of a custom foot orthotic intervention on lower extremity dynamics in injured runners. Annual ISB Meeting, Cleveland, September 2005.

    Nester CJ, Hutchins S, Bowker P: Effect of foot orthoses on rearfoot complex kinematics during walking gait. Foot Ankle Intl, 22:133-139, 2001.

    Nester CJ, Van Der Linden ML, Bowker P: Effect of foot orthoses on the kinematics and kinetics of normal walking gait. Gait Posture, 17:180-187, 2003.

    Nawoczenski DA, Cook TM, Saltzman CL: The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Ortho Sp Phys Ther, 21:317-327, 1995.

    Smith LS, Clarke TE, Hamill CL, Santopietro F: The effects of soft and semi-rigid orthoses upon rearfoot movement in running. JAPMA, 76:227-232, 1986.

    Stackhouse CL, Davis IM, Hamill J: Orthotic intervention in forefoot and rearfoot strike running patterns. Clin Biomech, 19:64-70, 2004.

    Williams DS, McClay-Davis I, Baitch SP: Effect of inverted orthoses on lower extremity mechanics in runners. Med. Sci. Sports Exerc. 35:2060-2068, 2003.

    Woodburn J, Helliwell PS, Barker S: Changes in 3D joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. J Rheum, 30:2356-2364, 2003.
     
  10. Craig Payne

    Craig Payne Moderator

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    The evidence is that some studies show they do change kinematics and other studies show they don't. I recently had a physio student in my office waving one of the studies showing they don't change kinematics, claiming orthotics don't work (....duh?) ---- the problem with all the kinematic studies is that regardless of the changes measured, none of them correlated that to symptomatic changes (we have the first one that does this in press at JAPMA).

    There have been two studies that have measured x-ray changes while standing on foot orthoses and they showed changes ---- thats all well and good, but we do not know if the changes they measured are actually asscociated with better clinical outcomes or not. Most of the radiographic changes measured are linked to changes in arch height, but how desirable are those changes?

    Another eg, its one thing to say that orthotic X reduced calcaneal eversion by 7 degrees and peak inversion moment by .14 Nm/bw.ht whereas orthotic Y reduced calcaneal eversion by 3 degrees and peak inversion moment by .24 Nm/bw.ht ---- what does that actually mean? which one is better? which change is associated with symptomatic improvement? .... we simply to not know.
     
  11. David Smith

    David Smith Well-Known Member

    Atlas

    Reinschmidt C. Three Dimensional Tibiocalcaneal and Tibiofemoral Kinematics During Human Locomotion Measured with External and Bone Markers.PhD dissertation Pge 2, University of Calgary, Dept Medical Science. 1996.

    Concluded that skin surface markers over estimate change of position when compared to bone located marker pins.

    Dave
     
  12. javier

    javier Senior Member

    It makes sense, although skin markers are widely used for biomechanical assessment. For instance, Kevin Kirby and Simon Spooner used dots on the skin to identify the point at which the least amount of skin motion occurred:

    Simon K. Spooner and Kevin A. Kirby. The Subtalar Joint Axis Locator: A Preliminary Report J Am Podiatr Med Assoc 2006 96: 212-219

    Perhaps, they could explain more about the reliability from this system.

    Regards,
     
  13. EdGlaser

    EdGlaser Active Member

    Very interesting thread,

    This thread is concentrating on the value of gait analysis. There are many important points to look at here, a few of which are.

    1. Compare data from motion analysis to that gathered by the human eye.
    a. The frame rate is better with motion analysis or high speed camera, and for research can be measured later to do statistical analysis and asses significance.
    b. The human eye is free and you have it with you. The frame rate is about 15fps. Focus and depth of field are variable within biological limits.
    2. The accuracy deemed necessary in any measuring device is proportional to the size of the changes being measured. Plus or minus a hammer handle is dead on when measuring the cosmos and absurd when measuring quantum effects.
    a. In the past kinematic changes have been either small or nothing. The effect of orthoses on symptoms is being attributed to tissue stress changes. Certainly with great 3D motion analysis systems these changes are visible. The small changes being desired to be measured will require an equally accurate system to measure them. If you are measuring millimeters, you need a system that has a very small tolerance of error.
    b. When I talked about changes is the gait cycle, I was talking about changes that are often dramatic and therefore easily visualized with the naked eye. In other words, where the eye is a perfectly unreliable instrument to measure kinematic changes with many cast corrected posted and skived orthoses, the eye does become a reliable indicator when changes reach a certain magnitude.
    c. Certainly each patient will change their kinematics to a different degree. In other words, some changes in gait cycle, even with the most aggressive positional changes will appear to change little.
    d. The smaller the change in gait cycle therefore, the less suitable the human eye is to measure them.
    3. Conclusion:
    a. For evaluation of orthoses whose primary action is to reduce tissue stresses and not change kinematics much, a very accurate system is necessary. Then do not trust visual gait analysis.
    b. For evaluation of orthoses whose primary function is to change the kinematics of gait so that the foot never reaches the end of its ROM in the direction of pronation (where tissue stresses ocurr), which radically changes the COP in relation to the STJ axis by placing the foot in supination, the human eye is more suitable as a measurement tool.

    But, what is it that you are looking for? Kevin did a good job in his outline. These are excellent visible parameters. I especially like the importance placed on symmetry. In fact I think that these would be very easily seen with a simple video camera which has a slightly higher frame rate than the eye but nowhere near that of a high speed camera. In fact this is an easy research study. (...hint...hint...)

    BTW, we have a demo coming up of a high speed camera in the 6K range. Does anyone have one that they recommend?

    I disagree with Craig on this point. Craig, you are still using alleviation of symptoms as the gold standard of success. I think not. I suggest a new standard: Restore Function because "form follows function". We need to reset the bar a little higher.
    Bring the patient from their current gait cycle to as close to an ideal gait cycle as is possible with their anatomy. More ideal gait, in my observation leads not only to reduction in pain, but also to improvement or even reversal of many deformities.

    Simon asked, what is ideal? I think that the Goals of Biomechanics that Don Bursch recommended in this post as follows is an excellent start.


    Ed
     
  14. Craig Payne

    Craig Payne Moderator

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    I do not think we necessarily disagree...I just do not think we know what is the "ideal" function to restore people to is. Don's goals of
    may or may not be correct (from a theoretical standpoint, they sound OK), but we just do not know that if you do restore people to this theoretical norm, that outcomes (short and long term) are any better than if we did not restore them ....I think that is our point of difference. You may be right (or wrong) - there is just no data .....yet.
     
  15. Craig Payne

    Craig Payne Moderator

    Articles:
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    Thats nothing compared to what we are preparing for publication. We measured the kinematic and kinetic changes to foot orthoses (for the purpose of using supination resistance as a predictor) .... as a side exercise we used difference reference frames (ie lab axis; foot axis; tibial axis; distal axis) and analysed the results seperately 4 times --- WE GOT A DIFFERENT RESULT DEPENDING ON WHICH AXIS WE USED ... ie we could pick one of the reference frames we used for publication to give us the result we most liked!!! - this puts a question mark over all previous studies, in that the choice of reference frame may have predetermined the resul!!!! :eek:
     
  16. Nicely done, Ed. I agree with your statements above. In a previous Precision Intricast Newsletter from February 1999, (Kirby KA: Foot and Lower Extremity Biomechanics: Precision Intricast Newsletters 1997-2002. Precision Intricast, Inc. Payson AZ, 2002, pp. 3-4) I did a newsletter on the goals of foot orthoses. http://www.dpmlab.com/html/newsletter02.html

    Here are my recommmendations from over 7 years ago that I still use today in my lectures on foot orthosis therapy:

    I agree with you, Ed. We, as foot-health specialists, should not stop short of only getting rid of the patient's symptoms when we make custom foot orthoses. We must also seek to optimize the gait function of our patients with our foot orthoses so that our patients will be able to derive maximum therapeutic benefit without having any new injuries or symptoms occur from our "foot orthosis gait optimization process".
     
  17. EdGlaser

    EdGlaser Active Member

    Craig,

    Great point. Lets do the research. This year we are stepping up our research efforts considerably. We now have 5 cPeds on staff that are seeing patients and 80 employees we can measure. What I am most excited about is having Kinematic studies performed at an outside University comparing the various theories in all aspects and outcome measurements. Please suggest a design for the study at La Trobe and we will fund it, supply the Sole Supports and stay completely neutral in the evaluation of the data. Any other company or individual wishing to test their technology is more than welcome to participate by supplying thier product and hopefully some of the funding.

    Thanks,
    Ed
     
  18. Atlas

    Atlas Well-Known Member


    Disagree Ed and Kevin.

    Alleviation of symptoms should be the platinum standard.
     
  19. javier

    javier Senior Member

    Can you explain further this statement, please?

    Regards,
     
  20. David Smith

    David Smith Well-Known Member

    Craig,

    when you say different, can you say in what terms the results differed.

    When investigating the limitations and errors of 3D Motion analysis I found that analysing the raw data in terms of varying axes would give less or more reliable output data.
    This was because of the way that the camera system saw the limb markers relative to each other and the limb or joint of interest. Selecting the appropriate markers for the joint of interest and formulating the appropriate equations for analysis of the data would give the most reliable characterisation of the limb or joint motion.

    Therefore analysis results can vary depending on the algebraic formulation used to manipulate the raw data and while one formulation gives reliable characterisation for a certain aspect it may not be so for a different aspect. So if the same processing is used for different reference frames then it may be that one would expect to have variable output data.

    I use the word reliable because although the output data maybe accurate, and probably will be in terms of mathematical processing, it may not reliably characterise the joint motion in terms that are clear or useful to the clinician.


    Cheers Dave Smith
     
  21. Craig Payne

    Craig Payne Moderator

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    David - the details and mathematics of this are beyond me -- I leave that to the wiz I work with....this is his most recent email to me:
     
  22. David Smith

    David Smith Well-Known Member

    Craig

    I'll try and give an example of what I mean.

    A ball dropped from a speeding train is seen by three people, one on the train 'A', the other two, B and C, on the ground but either side of the train .
    A fourth 'D' party asks about the motion of the ball. A says it flew backwards toward B. B says it flew away from me. C says what ball?.

    Imagine that A B and C are cameras looking at the marker Ball. You would have to write a formula so that the imformation given by the cameras would give a reliable characterisation of the motion of the ball. This would probably be in terms of a common reference point. Camera C, however would still give no infomation about the Ball. So you only use A and B's information to formulate the characterisation of the ball motion

    Now drop the ball from the other side of the train and now the same formula has no information from B and does not use C therefore the data although accurate may not usefully characterise the motion of the ball and the characterisation may differ between the former and the latter.

    Obviously this is very over simplified but I think it gives agood idea of the difficulties that may be experienced. The more sophisticated the collection and analysis system is the less these variations occurr.

    However when changing reference frames, ie from a global frame of the lab to the local frame of the Femur, Then you have the problem of accurately locating the axis of the Femur. If you decide to reference from distal to proximal, ie from the foot axis to the shank axis then from the shank axis to the thigh axis etc, then each time there will be errors in terms of defining relative location of axis aswell as location of each axis in space. It would seem inevitable therefore that there may be considerable variation in output data when comparing two individual systems of reference.

    Therefore your biomechanist may be saying the same in his/her report and it may be that great care should be taken when comparing these results in absolute terms.


    Dave
     
  23. David Smith

    David Smith Well-Known Member

    Craig

    Quite interested in this bit;

    When changing the analysis from global to local there will usually be a change in the internal moments since the extenal moments act about different lever arms. With regard to the STJ the invertor / evertor moments of the local axis in my limited experience they will usually be lower when comparing to global axis and in some cases will change direction. This should be independent of orthoses.

    Did your analyst mean this or something else?
     
  24. EdGlaser

    EdGlaser Active Member

    Position vs

    Let me answer Atlas and Javier at the same time. :)

    Look at the knee. The knee is on the sagital plane (approximately) and acts like a hinge joint (a single axis). As the foot pronates, the knee internally rotates and moves mediallywhich increases the Q angle. This causes the Quads to pull laterally. The V shaped patella sitting in the V shaped femoral groove is pulled laterally by Quad contraction and rides up the lateral side of the groove and as it comes down, shears the medial 10-15000x/day and much more when running long distances. The shearing wears in infrapatellar cartillage on the medial side as one would expect.

    Put this patient in posted orthoses and the kinematics are barely changed.
    Put this patient in Sole Supports and the knee is in most cases on the sagital plane (the axis is perpendicular to the sagital plane). The muscle that was the deforming force, the quads, are now pulling the patella smoothly over the groove. Infrapatellar cartillage is replaced and the patient is better. Not just out of pain.

    The standard treatment is strengthening the Vastus Mediallus (sorry about the spelling). This muscle cannot be isolated. You are really strengthening the quads. This in turn pulls the patella into the groove, which prevents it from riding up the lateral side of the joint and shearing the medial. The problem with this is that (and this is a secret)...some patients stop doing the exercises. The condition returns.

    We have an opportunity to cure this condition. 70% of running injuries that stop runners from running are knee injuries and the vast majority are patello-femoral tracking disorder (a much better term than Chondormalacia Patella).

    Can you see how only positional changes will have a real positive effect here. Covering symptoms can be accomplished with drugs. We can just give cortisone body whirlpools (a joke), but that will not change function. Do we just want to mask symptoms or change function? I say the later.

    Ed
     
  25. EdGlaser

    EdGlaser Active Member

    oops, mistake....never mind, I didn't know that I could edit...so I fixed it, Sorry,
    Ed
     
  26. David Smith

    David Smith Well-Known Member

    Javier

    On the contrary I was quite suprised by that. I would have thought that skin would move less than bone and that skin markers would underestimate the change of position.
    Try this experiment. Put a mark on the positon of the apice of the greater trochanter with the hip in the position of reference. Internally rotate the hip and mark the greater trochanter again, externally rotate the hip and mark the apice of the GT again. You should find three different marked positions indicating that the bone traversed under the skin while the skin moved little.

    If you were videoing the hip motion and using the first mark to estimate the position of the hip throughout the gait cycle it would not be possible to characterise its motion very reliably.

    Dave
     
  27. Atlas

    Atlas Well-Known Member


    Ed, I like your thinking, and I too agree that the VMO retraining importance is over-blown. Physios think they have a bit of arsenal here, but its only a pop-gun.

    But you have mis-understood what I mean by the goal of symptom-alleviation. Or rather, the means with which we get there.
    I have placed altering foot mechanics to relieve symptoms at the top of the tree; rather than altering foot mechanics to achieve perfect textbook function.

    Mechanical problems have mechanical solutions. I have never even thought about drugs/cortisone in relation to symptom alleviation.
     
  28. conp

    conp Active Member

    Interesting thread.

    Firstly, I agree that the symptoms are our immediate concerns (mainly because it is the patients), however prevention is a big part of our profession.

    Secondly, if we are looking for a change in gait to or close to an "ideal" gait cycle, what is that ideal? This is the question Craig raises.

    Don's goals below sound good but can they all be seen visually? What is "abnormal compensatory motion " in #2 goal? and so on.
    HTML:
    So here is my list of goals:
    1. Sufficient re-supination of the foot occurs after midstance to stabilize or “lock” the tarsus in the sagittal plane to allow for efficient propulsion.
    2. The forefoot contacts the ground without imposed abnormal compensatory motion proximally or in the transverse, sagittal or frontal planes
    3. The first metatarsal is stably plantarflexed against the ground during forefoot loading
    4. The first metatarsal accepts 60% of forefoot loading force
    5. The first metatarsophalangeal (MTP) joint is free to dorsiflex sufficiently to avoid compensations in foot or lower extremity posture that would otherwise be necessary to allow sufficient dorsiflexion or forward gait progression.
    Although we may not have any data to suggest positive outcomes for a particular "ideal gait" (I take Craig's word for it), would it be too simplistic for me to suggest that in theory the "ideal gait" would be the one that has the joints (whole body) functioning congruently (away from end range)? If a joint continues to function at end range it is more at risk of injury that the joint functioning away from end range.
    Hard to visualise that too!

    I just get the feeling that we are not paying enough attention to the whole gait. Yes we are getting great results from foot orthoses (distal correction) but are we ignoring some strong proximal forces. This is why I regularly send patients with orthoses to a physiotherapist who specialises in gait retraining(familiar with Irene Davis's work) and I think (haven't measured) that the"prevention" and the "efficiency of dynamics of the whole body during weightbearing activities" is enhanced.
     
  29. martinharvey

    martinharvey Active Member

    the wider picture

    Conp,
    valid point about whole gait analysis. I believe overall posture has a very important role in evaluation too(which idea of course is not new - 'Gait and Posture' from elsevier has been published for a long time now.)

    Kinematographic analysis lends itself well to wider analysis and I find it a useful tool in reviewing the efficacy of FFO's. ie. has it altered that antalgic hesitation, reduced the tib' rotation, decreased the kyphosis etc etc. I always show Pts the video as well, before and after, explaining what I'm trying to do, and what I think the FFO has accomplished.

    That approach seems to get better compliance from the Pts for FFO's as well, if they have a basic understanding of the therapy and its goals.

    Cheers,

    Martin
     
  30. Ian Linane

    Ian Linane Well-Known Member

    Hi all

    thank you for the replies, very helpful thoughts and interesting.

    I reached a point a while ago when I ceased relying to much on watching the foot to determin if any orthosis intervention I provided altered its function. Rather i have prefered to observe upper body changes in rotations and reciprical arm swing, postural alterations etc. Strangely, by looking more at altering overall gait/posture, whilst being aware of the presenting foot symptoms, I have found a helpful way of observing visually. I have to, for me, say that in most cases symptom resolution and altered gait posture have gone hand in hand (does not make it right of course). If I have got symptom resolution but not much alteration in gait/ posture I am happy anyway but also look to see if more can be done for posture etc.

    It seems to work for me although it is a more gross observation than the fine ones of the foot. But for me it makes sense to take a whole view.

    In this context I would suggest that visual gait analyisis is not dead. Possibly underated as we focus so much on fine movements of the foot?

    Cheers
    Ian

    Thanks for the thoughts
     
  31. Ron:

    Alleviation of symptoms with foot orthoses is the most important goal for us to achieve when prescribing custom foot orthoses for our patients. If you will read my postings very carefully, Ron, I never said that attempting to alleviate symptoms was less important than attempting to optimize gait function.

    I also stated the following:

    Are you now saying that we should not attempt to optimize gait function with foot orthoses, in addition to making them asymptomatic, as a service to our patients?
     
  32. javier

    javier Senior Member

    Hello Ed,

    I wrote:

    You answer:

    I reformulate my questions:

    1. What do you mean for "ideal gait cycle as is possible with their anatomy"?
    2. How do you measure it?
    3. How do you evaluate foot orthotics outcomes?

    Regards,
     
  33. There you go again, Ed. Promoting your company's orthosis product on an academic website meant for exchange of useful information among podiatrists and other health professionals. This site is not for self-promotion of one company's product. Craig, please correct me if I am wrong.

    Ed, your company is not the only one that makes orthoses that can change gait function, there are hundreds of labs that can make such orthoses....this information is not proprietary...it is up to the podiatrist to make certain that this is occurring with the orthoses they prescribe for their patient.

    In other words, quit mentioning "Sole Support" orthoses by name, as if your company's orthoses are the only foot orthoses that can perform the goals of foot orthosis therapy. Until you can prove this with some good research, then I consider it nothing more than a back-handed way of advertising your company and your company's products on an academic health-professional website.

    And I thought you were making some progress toward not making every posting an advertisement for your company.......
     
  34. admin

    admin Administrator Staff Member

    Its a diffcult one. When its blantant and nothing but a promotion of a product, the message is usually deleted before anyone gets to read it (see spam). If its a "promotion" in the context of providing some useful information, then its a fine line that puts me in an awkward position. The forum rules are clear:
    I have to weight up a whole lot of things....mostly I cansider Podiatry Arena visitors intelligent people, so they will see straight through those posts that walk on that fine line and in some cases, its often helpful to leave them there, so visitors can see what is going on in the world and what we think of it (eg thats why Brian Rothbarts self promotion was not deleted).

    My preference would be those that have a product to promote, that they participate in the forums; answer some questions; get involved in the debates; etc ... they are perfectly entitled to have a link to the website of the product in their signature. Guess which approach they will get more respect for - the more overt or covert one?

    I would just rather no one puts me in the position of having to make a judgement call.
     
    Last edited: Jul 31, 2006
  35. Atlas

    Atlas Well-Known Member


    Kevin.

    You agreed with Ed's post here. In it he essentially disputed the main goal of alleviation of symptoms.


    IMO, it must be the main goal. That is the patient's main concern. We struggle to get health economists just to pay out for symptom relief. Imagine our stuggle to get them to fork out for symptom-free function facilitation.


    What happens when the 2 goals collide? That is, when yourself, ED, and anyone else attempts to restore perfect function...and the patient returns suggesting that now they have pain.

    Surely the goal of symptom reduction takes priority.

    In a perfect world with unlimited resources, (even an imperfect world with limited resources) there is nothing wrong (and potentially big upside) in trying to restore function/symmetry etc.

    The overriding goal, the main priority, the platinum standard though must be to reduce symptoms.


    Ron
     
  36. Ron:

    Thanks for basically restating what I have already stated multiple times in my previous postings on this subject. ;)
     
  37. Thanks for that Craig (oops.....I mean Admin Numero Uno). Thanks again for getting this forum up and going and making it the great resource that it is for all 3,111 of us.

    My only question is......how long will it take you to train those two expected new members of the Payne family to do all the website editing for you?? ;)
     
  38. conp

    conp Active Member

    I must also congratulate Admin for 'their' (feels like many) exceptional efforts in maintaining, referencing, linking, overlooking, screening (hey is that where all my post have gone?! only kidding). Your efforts are recognised. An enjoyable, informative experience.
    Well Done to you and all who make it interesting with their valued posts.

    Hope all goes well with the twins Craig. No discouragement but I am finding it difficult with only one 11 month old girl. (kidding again) she is the best!

    Many Thanks

    Con
     
  39. admin

    admin Administrator Staff Member

    Thats not all they will be doing. Laurence Sidari from Sydney tells me that his 3yr old has already become proficient at doing positive model plaster modifcations ....:)
     
  40. David Smith

    David Smith Well-Known Member

    Hi all

    Today I fitted a pair of Amfit EVA orthoses to a lady who had been referred by an osteopath. She has medial knee and hip pain. In short its a ITB problem with involvement of the Glut med origin.
    She has a internal femoral torsion and a high Q angle, plus about 10dgs of frontal plane RoM in the knee, r/s tibial varum (curved tibia) 10dgs NCSP position.
    Only able to abduct the hip 30dgs. In gait 45dgs of toe out, abduction and circumduction of hip during swing phase, giving a trendelenburgh appearance. In stance phase the knee severely internally rotates and the foot comes round to about 15-20dgs toe out. One can imagine the excessive moments and tissue stress about the knee and hip from GRF.
    I was very pleased when immediately the orthoses where fitted the gait became almost symmetrical with a fairly normal swing and stance phase bilaterally. Q angle much more shallow. The patient reported that the hip felt better straight away.

    The point is that this gross change of gait pattern was what I wanted to achieve so as to reduce external moments and internal tissue stress about the knee and hip and hopefully it will give a good outcome long term.

    However this is not what I want to achieve in most cases. Usually just enough change to relieve foot pain is all that is required and the orthoses are made accordingly.

    I think that making gross changes in the gait pattern when there is no pathology, in terms of pain, in proximal structures may be unwarranted.

    I have seen many 80yr olds with plantargrade feet, unsymmetrical, non textbook stance and gait that have no proximal pain. They have been that way as long as they can remember and are quite happy thank you very much.

    Today the 80yr old presents with post tib syndrome. Should I alter his mechanics just enough to fix his post tib pain or should I make orthoses that force him to walk straight and symmetrical and relieve his pain? I would chose the former.

    I think the ideal gait is the one that best suits the individual and their needs for their lifestyle. So, as they say, if it ain't broke don't fix it.

    Thats the beauty of ZOOS individual treatment designed for individuals, with no pre determined casting positions or dogmatic expectations of 'ideal' gait patterns.

    Cheers Dave Smith
     
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