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08/22/2015 Stephen Peslar, BSc, DCh
Are We Still
In the commentary written by Dr. Shavelson, the article that he links to is disturbing for three reasons.
First, the author mentions that a CPed or CO spends hundreds (?) of hours studying foot anatomy, biomechanics & related pathologies but the author does not mention that current board certified DPMs do an undergrad bachelor's degree, 4 years of study at a podiatry school and then a 3 year residency.
The second reason is that podiatry students did manufacture their own orthoses for patients back in 1983. We used Rhoadur back then and unfortunately it cracked quite often. When I took a course at CCPM back in 1987, a prof there said his preferred choice was Rhoadur because of the level of control he was able to obtain from it. I assume podiatry students today still manufacture orthoses (both accommodative & corrective) from newer and better materials than Rhoadur.
The third reason is the most disturbing because the article was written in British Columbia, Canada. In BC, podiatrists are registered & licensed to practice by the College of Podiatric Surgeons. Does the public there feel comfortable going to a podiatric surgeon for orthotics? When was the last time you referred a patient to an orthopaedic surgeon for an AFO? Furthermore, since the podiatrists in BC seem to focus on podiatric surgery, Footcare Nurses of Greater Vancouver Association has formed. See http://footcarenurses.ca the home page states,
"We are a group of Independent Footcare Nurses, from the Greater Vancouver Area and throughout British Columbia..." Also, "Standard foot care treatment protocol involves the care of the foot and nails, including mobility [does this include orthotic/AFO assessment, casting and dispensing?], health assessment and physical trimming of nails, reducing calluses and thickened nails including client teaching."
From the Services/Prices page, "Prices for home visits range from $35-$45 per person per visit and additional fees [for orthotics/AFOs?] may be charged in special circumstances."
The questions that come to mind are, have the podiatrists in BC practice only foot surgery and therefore call themselves podiatric surgeons? Has this opened the door for CPeds & COs to be the primary foot orthoses providers for the residents in BC? Also since podiatric surgeons seem to mainly practise foot surgery, has this enabled independent footcare nurses to provide conservative foot care? Finally, is this phenomenon concurrent in other jurisdictions in Canada & the USA.
Stephen Peslar, BSc, DCh, Toronto, Ontario
Other messages in this thread:
09/01/2015 Stephen Peslar, BSc, DCh
Are We Still "Kings" of Orthotics? (Elliot Udell, DPM)
I have been reading the opinions from podiatrists and to date, no podiatrist has discussed the insurance companies' strategy to maximize profits by reducing payouts for prescribed medical appliances. This is why Dr. Udell is incorrect when he wrote insurance companies, "want to see current, well-written research papers." These companies only want to see profits and they do this by reducing payouts.
I remember 25 years ago, perusing patients' insurance benefits booklets and the benefits covered: prescription orthotics, $400; orthpaedic shoes, $400; braces, $400; trusses, $400; prescription eye glasses, $400. Today, some insurance companies pay $100 for prescription orthotics, $400 for custom made orthopaedic shoes and $100 for prescription eye glasses per calendar year. Why? Locally, in Toronto, I've seen podiatrists, chiropractors, physiotherapists and even massage therapists cast and dispense orthotics.
We've all seen the growth of LensCrafters and other fashion boutique eyeglass optician dispensers. I was perturbed when I saw patients spending $500 each year for eyeglasses when they got $400 per year coverage for them but they used the same orthotics for 5+ years even when the top cover came off.
Well today, due to over prescribing, many insurance companies are providing $100 for orthotics and $100 for eyeglasses. Also there is only $400 coverage for custom hand made orthopaedic shoes. Locally, they cost $1,500+ per pair and the patients wearing them can't wear extra depth nice looking "orthopaedic" shoes with custom made orthotics.
How many studies prove the effectiveness of eyeglasses? How many of us depend on eyeglasses? I see patients who can't walk 10' without orthopaedic shoes. Despite this, insurance companies keep the payouts low and unfortunately will not increase them even if there are 100 scientific, well-researched studies that prove the effectiveness of custom made orthotics.
Stephen Peslar, BSc, DCh, Toronto, Ontario
08/31/2015 Don Peacock DPM, MS
Are We Still "Kings" of Orthotics? (Elliot Udell, DPM)
All of Dr. Udell's comments are correct and his philosophical stance toward the purveyors of theoretical concepts is a cause for us to have natural skeptical attitudes. Science and art definitely coexist in the field of medicine and to a great degree in the implementation of orthotic design. Where I disagree with Dr. Udell is the notion that this intermingling is a bad thing. Of course, differing concepts and opinions will surface and that's completely natural.
The theoretical prophets all make up their theories and they do this through the creative imagination. These artist/scientist are a gift to us. I find it fascinating when someone challenges an accepted dogma despite its ingrained followers. Wrobel has an interesting conclusion.
Some may read this conclusion to mean that a custom orthotic is no better than an off the shelf. It could also mean that the way we make orthotics needs improving, etc. Also, it could mean that certain foot types respond and some do not et etc. Similar research has shown the ineffectiveness of NSAIDs, injections, physical medicine, surgery chronic plantar fasciitis.
The most interesting research for me in this area that fractures the concept that the fascial band is inflamed. Dr. Harvey Lemont showed in histological studies that the plantar fascial band is not inflamed. Is the name plantar fasciopathy more appropriate?
Recently, Dr. Stephen Barrett has given us a way to stage plantar fasciopathy via ultrasound and its relation to fascial band thickness in the 3 known zones. If you want a better knowledge of when conservative care is likely to work look at this concept of staging. If you want a biomechanics theory that you can put to the test and get great results try Dennis Shavelson's foot typing.
We are the Kings and we are still in need of a tutor. All I know is I have a lot to learn.
Don Peacock DPM, MS, Whiteville, NC
08/31/2015 Stephen Albert, DPM
Are We Still "Kings" of Orthotics? (Elliot Udell, DPM)
Reading PM News exchanges from Drs. Richie, Udell, Kesselman, and Phillips, I am compelled to join them as President of the American College of Foot and Ankle Orthopedics and Medicine (ACFAOM). I wish to do so in a broader context rather than just Dr. Wrobel’s article. By the way, James Wrobel, an acquaintance of mine, is an excellent podiatric researcher.
ACFAOM believes that biomechanics and medicine are the cornerstones of contemporary podiatric practice. With that in mind I wish to underscore the educational avenues available to practitioners and those still in training available from not only ACFAOM but other sources as well and also address a couple of other issues mentioned before.
Acknowledging the comments of Drs. Richie, Kesselman and Phillips and using Dr Udell’s comments as a segue, I will comment upon the 3 areas underlined below.
“Up until now, education in biomechanics has been, by and large, in the domain of self- declared experts. They occupy bully pulpits at conventions where they espouse their own theories of how an orthotic should be made and why it works. The obvious problem is that if you attend five lectures by five different individuals on this topic, you will hear five different sets of conflicting theories and recommendations. This is because the information given by these speakers has not stood up to the scrutiny of solid university-based research.”
1) Regarding education in biomechanics, perhaps some readers are not aware that ACFAOM offers yearly educational conferences. We pride ourselves in offering conferences that are case based, evidence based and interactive. Our last Annual Conference was in conjunction with the APMA National in Orlando and our next is scheduled to be in Savannah, GA June 24-26, 2016.
Admittedly, I have a bias, but the lecturers over last few years have been presenting a more consistent EBM view on biomechanics. And Drs. Richie, Philips among others have presented in the past. A video sampling of the recent Orlando conference will soon be available at the ACFAOM website.
2) ACFAOM also has on its website a Live Learning Center (acfaom.org) featuring biomechanics education. Both videos and text with an expert opinion of how to properly bill for your biomechanical exam. Also not to be missed is the reference and link to “The 4 Peer-Reviewed Journal Articles Every Podiatrist Should Read.” This article points to the importance of biomechanics to conditions podiatrist encounter every day in their practices.
3) ACFAOM also offers a booklet on Prescription Custom Foot Orthoses Practice Guidelines
4) And lastly we offer a Review Text in Podiatric Orthopedics & Primary Podiatric Medicine, currently under revision to reflect the latest in EBM.
I should mention that outside of ACFAOM
1) There is no arguing that more research in biomechanics and foot orthoses is needed by podiatrists. Yet we must not ignore other sources outside of our profession for today that is where much of the “solid university-based research” is found. Presentations at the International Foot and Ankle Biomechanics Community (iFAB.org) meetings include solid university-based research. They are an international group admittedly not all clinically oriented nor DPM’s for that matter. North American meetings occur periodically interspersed with international ones.
2) A website I suspect rarely frequented by the surgically-focused DPM is Podiatry Arena (podiatry-arena.com). Hosted by podiatrists, down-under, in Australia. It has a forum for all podiatrists worldwide. If you are a “self- declared biomechanics expert” and post to the forum you will be challenged to prove your “expertise” with evidence.
I wish to credit podiatry-arena.org for the following graphic comparing The Scientific method vs. Faith-based Methodology in biomechanics. 3) Recently, two biomechanics book reviews appeared in The Journal of the American Podiatric Medical Association May 2015 issue. Drs. Spooner and Shapiro provide excellent reviews and acknowledge the engineering principles and tissue stress concepts that are underpinnings of our current biomechanical knowledge of foot and lower limb function. Each book provides numerous references to current biomechanical research. For full disclosure and a disclaimer, I played a co-editor role in one of the books.
Perhaps my comments have shed some light as to the available resources for those interested in foot and ankle biomechanics in a broader sense than just custom vs. pre-fab foot orthoses. And by the way, that was a topic at a recent ACFAOM conference.
In conclusion, I will repeat, not only does ACFAOM believe that biomechanics and medicine are the cornerstones of contemporary podiatric practice we view our role primarily as educators in biomechanics and podiatric medicine.
Stephen Albert, DPM, President, ACFAOM
08/28/2015 Robert D. Phillips, DPM
Are We Still "Kings" of Orthotics? (Doug Richie, DPM, Elliot Udell, DPM)
I note the never-ending debate on the value of pre-fabricated orthotics vs. custom-made orthotics, with everyone holding dear to their position by citing their favorite research article. This is indeed a most superficial debate and shows failure of those who engage in it to dig down into basic biomechanics and basic mechanical science. If anyone who really studies these basic sciences uses a term such as “moment of inertia” or “stress-strain curve”, or even “direction cosines” we find a vast majority of clinicians who shut the mental blinders, believing that they don’t need to understand math or physics – after all they are “real surgeons.” While I could make a whole lecture on the subject of why pre-fab orthotics work or don’t work, I would like to make just a few points in this correspondence.
1. When we prescribe a custom made orthotic, what are we really selling? A piece of plastic or leather to go into our shoe? I would maintain that what we should be selling is expertise. If we don’t take any measurements, if we don’t do muscle testing, or gait analysis, and we let nurses take our impressions, and we don’t do careful follow-up and have the ability to make small changes in our offices, then what are we really selling? I notice an interesting statement in the PM News from the other day, ““You can’t manage what you can’t measure.”
2. If we dig down just a little into the basic science, the simple fact is that if an orthotic is contacting that foot when it is in its “ideal position” [I’m not going to get into what that position should be] then it may be able resist deformation of the foot from that ideal position. The less the orthotic deforms from that ideal shape when the body weight is placed on it, the less the foot will deform from the ideal position. I see people at trade shows pick up an orthotic, try to bend it with their hands, and decide whether the orthotic is too rigid. Such is fallacy as I know no one that can bend an orthotic with their hands with the same force a foot will try to bend it with body weight. Such a person may want to test the effectiveness of their car springs by putting a 20 pound bag of sugar on the springs.
3. Many pre-fab orthotics have a 3D contour that is close to an individual’s ideal foot shape contour. With the wide variety of pre-fabs on the market, it is possible to find among the myriads, at least one that has a contour that fits any specific foot. Therefore it doesn’t matter if the form is prefabbed or custom made, it has to have the right contour.
Custom-made is usually a much easier and faster process than sorting through the numerous pre-fab devices to find the right one. One particular prominent orthotic laboratory has a large library that he can fit a great majority of foot shapes. Such a library bridges the pre-fab and true- custom made market. None of the studies that have compared pre-fab and custom made orthotics have given us any data as to how close the shape of the pre-fab is to the shape of the custom-made orthotic.
4. You do not need to have “full control” of foot motions to alleviate plantar fasciitis. You just need to relieve the tension of the tissues enough to get them out of the plastic region, into the elastic region of the stress-strain curve. I am very surprised that Dr. Udell has to use so many additional anti-inflammatory measures in addition to the orthotics. It would be of great interest to study the practice techniques and orthotic techniques of those who have low percentage of patients responding to only orthotic therapy versus those who have a high percentage. This is the true Evidence Based Medicine Study that needs to be done. Robert D. Phillips, DPM, Orlando, FL
08/28/2015 Paul Kesselman, DPM
Are We Still "Kings" of Orthotics? (Doug Richie, DPM, Elliot Udell, DPM)
I have read the paper referenced by my two esteemed colleagues as well as their comments. This is in fact an excellent start for evidence- based medicine (EBM) papers which podiatry desperately needs. When my colleagues meet with insurance executives the paucity of these types of papers are often the most obvious hurdles we have to overcome to convince medical directors that orthotics are worth paying for (or continue) to pay for.
Say what we want how custom foot orthotics save money by avoiding costly surgery and post- operative complications, they want to see peer review studies proving our contentions. So while the flaws and positive outcomes of this study have been pointed out by Drs. Richie and Udell, no study is perfect. And has also been pointed out, this is an excellent start, but more papers like this are needed, especially those by podiatric authors.
Some of my colleagues may be correct in their opinions where they would rather see custom fabricated orthotics (CFO) not covered at all; with decreasing or very limited reimbursements for them, I can't say they are entirely incorrect. However, this study could be the start of a trend where reimbursement strategies for CFO change. Also, since many patients simply cannot afford them nor do the pre-fabricated types of devices work for them, this may allow those set of patients access to CFO.
Regardless of which side of the fence you are on with respect to reimbursements from third-party payers, the podiatry profession needs more EBM papers on the efficacy of CFO and many of the other treatments we regularly advocate. Thanks to Drs. Richie and Udell for a job well done in bringing this attention to those of us who regularly have to negotiate these issues with insurance carriers.
Paul Kesselman, DPM, Woodside, NY
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