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Why do orthotic labs need to know the patients age for?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Oct 10, 2006.

  1. Craig Payne

    Craig Payne Moderator


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    This one has bugged me for a while. I was just going over a whole lot of different orthotic lab script forms and its still puzzles me.

    Why do labs need to know the age of the patient?

    I assume its to do with orthotic tolerance (ie older persons less tolerent of more rigid material), but surely the intelligent podiatrist asks for a more flexible shell if the person is less likely to tolerate the orthotic, so why also put down the age?

    What say you?
  2. Donna

    Donna Active Member

    Maybe it's used as extra info to help identify the patient when duplicate orthoses are ordered from the same set of casts? :confused: Who knows? :eek:
  3. Amanda

    Amanda Member

    I think most of the time it is for the purposes of identifying which set of casts belongs to which patient. In a busy practice writing the names or initials of the patient on the casts can be easily forgotten. The lab may asssume (rightly or wrongly) that the shorter casts belong to the 6 year old girl rather than the 16 year old boy.

    I would assume most of the time it would be to assess patient tolerance to an orthotic. As Craig said older people are less tolerant of rigid materials but this shouldnt be left to lab discretion, the podiatrist should allocate shell thickness. From this perspective they should not need to know the patients age.

  4. Craig Payne

    Craig Payne Moderator

    But even when we leave it to lab discretion do they really take age into account?, or do they just pretend its important for things like tolerance and shell thickness.

    I do not buy the identification argument .... date-of-birth is commonly used as a secondary identification on medical records .... but orthotic prescriptions :rolleyes:
  5. Amanda

    Amanda Member

    Hi Craig,

    The lab probably doesnt actually take age into account when they chose shell thickness, but I'm sure they like us to think they do!

    I myself never leave shell thickness up to lab discretion as they arent aware of all the factors to be considered when deciding shell thickess eg, weight, sports and excercise, presence of arthritis etc

    It could also be as simple as when they plug a patients details and records into the old computer and there are 5 'Joan Browns' , one can be distinguished from the other by age?

    who knows. maybe they are just collecting as much personal information as possible to sell to telstra!!!
  6. Phil Wells

    Phil Wells Active Member


    I have recently designed a new prescription form that does not include patients age. It does ask for shoe size, symptoms and most importantly the patients weight.
    The shell properties are heavily dependant on patient weight, posting style (Intrinsic v's extrinsic), prescription variables such a PF grooves, medial skives and most importantly arch shape and height.

    Not really sure of the relevance of age as this is the practitioners responsibility to let me know what they want the orthotic to do. I am not prepared to second guess them and prescribe the device for them.

  7. Craig,
    At my lab the only reason why I have the patient's DOB is, as Donna has indicated, for identification purposes. If a podiatrist calls me up and says I need a 2nd pair for John Smith I have a check that it is the right John Smith born on 1 Jan 1950... and not John Smith 25th Feb 1975. I do however have a couple of other checks though!

    But this whole discussion brings up a couple of interesting questions. If a podiatrist is prescibing an orthotic device what general prescription factors are needed?

    I know with the prescriptions that come through to me I will always require a shell thickness. I (and Amanda) am probably of the opinion that this should be done by the podiatrist if they are going to send off to a lab. If you are going to make the device yourself this might change the scenario slightly, as you have the patient in mind and may use weight of the patient as an indicator. But I like to think of the lab as making whatever is on the prescription form and having little to no interpretation. Or as Phil Wells puts it "practitioners responsibility to let me know what they want the orthotic to do."

    This is pretty evident at the moment for a few of my students. The 4th year students at times have to manufacture devices that the 3rd yr stuents have casted and prescribed. We often have discussions as to why the 3rd yrs prescibed in the manner they did. The student manufacturing the orthoses have to trust the pod/3rd yr student who saw the patient and the decisions they made for the presciption. You get into a bit of trouble if you turn this around and leave some or all of the responsibility with the manufacturer (student/lab) to come up with decisions based on limited information.

    I see hundreds of prescriptions per week and I think that the thickness of shell is a very variable value between practitioners (especially with the introduction of CAD-CAM manufacture - with different thickness within the one device). Having seen Craig lecture over the years it was interesting to hear him say this year that he believes that shell thickness is getting thinner (ie. more flexible) for orthotic devices. If the lab is only provided with the weight of the patient are you going to get back what you want?

    I think the podiatrist needs an understanding of how the lab they are using operates and what each box on the lab's prescription form means. The better the relationship you have with your lab the more likely you will get back what you have requested.

    Sorry to get off the topic of patient age and orthotic prescription.

  8. Craig Payne

    Craig Payne Moderator

    I probably looked at over ~40 prescription forms from different labs this PM (including yours, but not Phil's) - most asked for age, with only a few asking for DOB .... don't figure :rolleyes:

    Totally agree with your other point.

  9. At Precision Intricast, we have four boxes on the prescription order form (age, sex, weight, and activity) for the podiatrists who want to include that information on the patient. [I never fill them out when I order orthoses from the lab.] However, some podiatrists include these tidbits of information on the patient so that the lab personnel can help them out with the prescription. The boxes allow the ordering podiatrist to conveniently communicate that information to the lab.

    Age, sex, weight and activity level are a few of the parameters that determine the specific design of the optimum orthosis for the patient. Most knowledgeable podiatrists will factor all of those parameters into their final orthosis prescription order to the lab so that they don't need to fill in the boxes. However, for the less knowledgable podiatrists, every bit of information that they can convey to the lab will help the lab personnel advise them toward a better orthosis for that patient's specific biomechanical needs.

    In the perfect world, these boxes should not be necessary on the order form. However, since most podiatrists are not experts in biomechanics and orthosis therapy, anything that the orthosis lab can offer toward helping the less knowledgable podiatrist order better orthoses for their patients is greatly appreciated by the podiatrist. In addition, making sure that orthoses are designed more intelligently in the first place also makes the lab's life much easier in the long run.
    Last edited: Oct 10, 2006
  10. Phil Wells

    Phil Wells Active Member


    I understand the thought process behind offering help or a safety net to the less experience pods but only if it is done correctly i.e. if the prescription is to be modified or changed, then the lab should talk this through in person with the pod and not just 'do it'. I always offer this courtesy and am always happy to see that the next time the pod has the same problem, then they will use the new mod or ask for me to ring them.
    There is nothing more frustrating than receiving an ortho back from the lab and not knowing what has been.

  11. In addition to what has previously been noted, there are of course age related changes to gait that may, or may not, be significant in orthoses design.

    The main thing I note with regard to age is that often the older the individual is, the less suitable the footwear is to accommodate orthoses- especially a certain group of ladies which I like to describe as: "mutton dressed up as mutton", you know the ones: well dressed, too much bling, too much perfume and oedema "flowing" over the top of their court shoes. Bless 'em
  12. Craig Payne

    Craig Payne Moderator

    I agree totally, but should it not be the prescribers responsibility to prescribe those alterations to the orthoses design because of that rather than write the age on the prescription form and let the lab guess based on the age if these factors are or are not present ...... thats why it puzzles me why they want to know the age.
  13. Absolutely. My favourite box on lab forms is the "labs discretion" box, when all the lab has is the cast- love it. This is the basis of the 4 degree/ 4 degree device aka Morgan's meat pie- play it safe and no-one gets hurt -right?. The bottom line is- too many people prescribe devices who haven't got the faintest idea of what they are doing- but the labs support this = Too many people in it for the money.
  14. DaFlip

    DaFlip Active Member

    Champion, the labs run a business and the aim is profit. The 'Flip' does no go to work as a charity either. The 'Flip' likes money and wants to add much more money. The 'Flip' cannot get all the ladies with no money, so uses a cheap little orthoses lab to maximise profit. But...the 'Flip' does have some idea on orthoses prescription based on a a very rigorous self analysis.

    The question the 'Flip' raises is legal. The practioner sends casts with prescription. Lab makes them. Sends them back. Patient has problem and takes legal action. Lab may not have any issues as made to prescription of practitioner. However if practitioner sends with lab discretion 'Flip' thinks lab may have some legal isses coming their way. DaFlip suggests practitioners don't use this because in court they will look like clowns with NFI. The lab will be guilty based on not knowing what the patient even presents with and making orthoses for an unknown/unseen/unevaluated patient.

    More importantly my experience suggests the ladies prefer a well educated man with money, one who is big enough and good enough looking to write his own prescriptios, one such as DaFlip ;)
  15. Craig Payne

    Craig Payne Moderator

    If I was a judge, this is what I would rule:
    1) If the clinician filled out the prescription form and the lab makes it exact to that prescription, then the clinician is legally liable
    2) If the clinician fills out 'lab discretion' and the lab has a series of 'defaults' for each prescription variable that they use in this situation and the clinician is aware of these, then the clinician is legally liable
    3) If the clinician fills out 'lab discretion' and the lab makes descions based on supplied information (eg age :eek: ), then they are making clinical decisions and the lab should be legally liable jointly with the clinician.
  16. DaVinci

    DaVinci Well-Known Member

    Surely this a bad. It encourages clinicians to be lazy and incompentent and gives them an out when things go wrong. They can claim as a defence "its the labs fault". !!!
  17. Cameron

    Cameron Well-Known Member


    Standard collection of normative data would enhance client identification (as has been previously stated). Potentially the labs could then use this information for further internal audit and service anlaysis to their clients eg at what age the patient started with prescribed foot orthoses, how frequently they were these reviewed, was the same client ever serviced by different pracitioners, was there a significant difference in practitioner prescription. All valuable information and provided the lab had computer facilities then this would be comparatively simple to program and a standard for any of today's service industries.

    A brief review of prescipion forms for the last thirty years strongly favours a "history and practice" approach where "cut and paste" behaviour has prevailed based annoyingly on the maxim "Why reinvent the wheel," when thinking through from first principles might be more appropriate (I would assume that is what Craig has done). Formal guidelines on collection of data have subsequently been adopted but all too frequently the "same old , same old " has not been dumped from the original forms.

    Change is a challenge and managing change more so, with maintaining the status quo often the primary goal of the silent majority. Altering one form without the agreement of the foot orthotic industry (which is different in different countries) and the overall adoption by practitioners is unlikely to effect change. Starting with one centre of education and working with subsequent cohorts of students is as much as can be done but unlikely to lead to major change.

    Here in the West, the presciption services are small businesses which have started by servicing a small number of users ( like minds), this is a highly competative "cottage industry" with fierce rivalry which sharpens the service to the practitioner but at the same time favours certain approaches which are not universal to the podiatry population or the bigger industry. Practitioners tend to be loyal to their lab and labs have become the determinant factor on the prescription ranges they are prepared to make available. For example a new influx of practitioners favouring "neutral shells" have problems finding a lab prepared to supply them.

    But I digress. However I think it does highlight the resistance to change which is witnessed in this industry.

    Two further comments

    I would have hoped by now practitioners would tealise it is not the thickness of the shell that matters but the materials resitance to torque which determines its usefulness for support. Polymers are that sophisitcated now as to have have the strength in any thickness. You just have to choose the appropriate material which is not always availaible to the lab.

    Secondly, from perpsonal conversations with lab managers in the US and UK one of the main problems they constantly come across with disturbibg regularity is the poor casting technique of practitioners that use their services.

    Me I prefer "off the peg" stuff

    But hey, what do I know?

  18. Cameron

    Cameron Well-Known Member

    Craig et al


    That is a difficult one.

    In the case of a miscare of a client under any circumstances whilst they remain in your charge, then the clinician is liable. In the same way as legal responsibility lies with the end user, as seen in pharmacy use. Diagnosis carries duty of care and should always have a predicted outcome (shared with the client). Technically to add in any intervention without being able to predict outcome would be to practice without ethics. Bespoke foot orthoses should first meet the clinician's scrutiny before being supplied to the client.

    However many practitioners operate on the understanding the contract is between the supplier of the orthoses and the client. Like mail order if you have a problem take it back to the company ( and not the local representative). Most labs will have money back gauarentee backups which sensibly releases them from legal liability. The responsibility for intervenion outcomes remains with the practitioner.

    It would be interesting to learn of any legal precedents where a practitioner and lab have come to court about prescriptions (I would doubt whether there are any). However good business practice would suggest a clause in the labs contract which allows " prescription modification without consultation with the practioner carries no liability." This would seem only sensible since foot casts supplied vary with accuracy.

    At the risk of not having any Christmas cards this year (again) I would suggest the "flips", "skives" and "extensions" make no significant measurable difference, and hence the absense of objective data make a legal ruling, impossible.

    What say you?


    1) If the clinician filled out the prescription form and the lab makes it exact to that prescription, then the clinician is legally liable
    2) If the clinician fills out 'lab discretion' and the lab has a series of 'defaults' for each prescription variable that they use in this situation and the clinician is aware of these, then the clinician is legally liable
    3) If the clinician fills out 'lab discretion' and the lab makes descions based on supplied information (eg age ), then they are making clinical decisions and the lab should be legally liable jointly with the clinician.

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