Factors that influence prescription of foot orthoses

Despite foot orthoses being one of the main interventions for foot pathology, there is a lack of knowledge about current orthotic practice and the use of technology within it.

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‘Current orthotic practice is variable and does not embrace technology, as it is perceived as being not fit for purpose in the clinical environment. However, practitioners do have a desire for technology that is usable and enhances patient focussed assessment, the interventions, the clinical outcomes and the patient’s engagement throughout these processes’. Williams, et al. 2016

Anita Ellen Williams, Ana Martinez-Santos, Jane McAdam and Christopher James Nester, School of Health Science, University of Salford, Journal of Foot and Ankle Research.

Foot orthoses are used to manage a plethora of foot and lower limb conditions, including those associated with diabetes and rheumatoid arthritis. They are advocated in several practice guidelines with the standards being defined by the emerging evidence base. However, these guidelines fall short of detailing precisely the type of orthosis, how to derive its shape or what materials should be used. Therefore, what an individual practitioner chooses to provide for each patient may be based on personal preference and hence may result in variable practice.

In relation to underpinning theory and protocols to assess patient suitability for orthoses, we assume practitioners follow the widely held Root model of orthotic practice since this was likely to be the foundation for their initial training. However, Jarvis et al. found evidence that practitioners adapt elements of the model as they gain experience and decide for themselves which parts of the assessment protocols are most valuable. Alternative approaches to foot assessment, such as the Foot Posture Index might also inform clinical decisions related to orthosis prescription.

Whilst these and other approaches to patient assessment might provide a general approach to orthotic prescription, the final choice to use a customised or prefabricated orthosis, the choice of orthotic material, and nature and scope of advice provided to patients, lies with individual practitioners. These decisions may also be affected by factors specific to the patient (e.g. footwear choices, expected time scale, prior experiences of orthotic use) or practice context (e.g. cost of orthoses and clinical appointments, time available). Freedom to decide the details of the orthotic prescription allows a suitable level of autonomy that places the requirements of the patient first.

Equally, however, it might allow such freedom that standardisation of best practice is difficult to achieve. Whilst the theoretical foundations for the use of foot orthoses might be relatively consistent, actual practices and therefore the experience of patients is likely to be less so. Furthermore, the factors that affect the decisions that individual practitioners make about individual patients have not been explored. Thus, the way in which clinical experience and local constraints interact with knowledge from formative training in orthotic practice is not understood.

custom-foot-orthotics-mfgOther factors that should influence orthotic practice include the policies that encourage greater adoption of technology in practice and the generally improved availability of technologies. In terms of foot assessment for example, 3D foot scanning has been shown to more reliable than plaster of Paris and foam impression boxes. However, whilst not a new technology, anecdotally, it does not seem to have found favour in the majority of health care settings.

Also, the drive for ever more quantitative evidence of outcomes from practice should mean that there will be a role for measurement tools that quantify changes due to foot orthoses, such as a change in plantar pressure. However, in shoe pressure measurement tools appear limited to the research rather than clinical domain, and clinical outcome measures seem routed to more subjective tools such as the Manchester Foot Pain and Disability Index possibly due to ease of administration and being less time consuming. Thus, there is a disconnection between health technology policy, what technology can do to enhance practice and the adoption of the apparently useful technology.

Despite foot orthoses being one of the main interventions for foot pathology, there is a lack of knowledge about current orthotic practice and the use of technology within it. To date, there has been little published work investigating prescribing practices, with the focus being describing practice trends rather than explaining the factors that influence decisions. This is the first study that has the primary aim of gaining insight into what constitutes current foot orthotic practice, the factors that affect this area of practice and how technology has or may play some role in future orthotic practice.

The purpose of this work was to better understand the context within which future innovations in practice might be introduced. Accordingly, this study set out to explore such issues as, alternative methods for assessing patients and their feet (e.g. 3D and 4D scanning), use of new orthotic materials (e.g. additive manufacturing), and adoption of technologies that might enhance clinical processes, patient experiences and evaluation of outcomes (e.g. mobile and web technologies).

The practice of providing foot orthoses varies considerably between practitioners reflecting the integration of formal education with local factors influencing their personal practice style. The influence of research on practice was less evident.

Measurement of outcomes from orthotic practice is a priority but there are no current norms for achieving this. There have been attempts by practitioners to integrate technology into their practice, but with largely negative experiences. The process of technology development needs to improve and have a more practice rather than technology focus. Further, more information on current orthotic practice is needed.

‘Trial and error…’, ‘…happy patients’ and ‘…an old toy in the cupboard’: a qualitative investigation of factors that influence practitioners in their prescription of foot orthoses, Anita Ellen Williams, Ana Martinez-Santos, Jane McAdam and Christopher James Nester. Journal of Foot and Ankle Research 2016.9:11 DOI:  10.1186/s13047-016-0142-9

Also see
Comparison of foot orthoses made by podiatrists, pedorthists and orthotists regarding plantar pressure reduction in The Netherlands in BMC Musculoskeletal Disorders
Biomechanics Education Blog in Langer Group UK
Prescribing Orthoses: Has Tissue Stress Theory Supplanted Root Theory? in Podiatry Today

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