OTC Orthoses

[TimVS]

From time to time, I get patients who for various reasons don't want to go down the road of full prescription orthoses, and so I usually use a Vasyli. There is some research out there indicating OTC orthoses are just as effective as prescription devices. So do any of you use OTC devices, and if so, which do you find to be the best? Or would you spit on the ground they walk on

Cheers,

Tim

[Admin]

Hi Tim,

I suspect an artificially strong case has been made for OTC orthoses, largely driven by pricing. I have absolutely no proof of this BTW .

I saw several pts today who had OTC devices fitted. Each still had their symptoms. In one case the pt had a letter from the Orthopaedic Surgeon his GP had referred him to (but no face to face appointment) stating that he was being referred to the orthotic department, but "it would take several months for his appointment to come through".
He brought the letter in to show me.
Would the orthotic department be prescribing custom devices?
Highly unlikely in this particular cash-strapped Trust .

Personally, I don't think OTC devices work particularly well, and if by chance they do, they are expensive.
Custom devices = around the £250-mark. Good custom devices last for life (my personal devices are now 30+ years old).
OTCs, even from Boots or other High St outlet = £20+. They last one. perhaps two years at most.

There was some myth put out a few years ago, probably by orthosis manufacturers, that most if not all pts needed to be re-cast every two years. Of course there is absolutely no proof to show that this is the case.

I reiterate - IMO custom devices are much more effective than OTCs. They are certainly way less expensive than OTCs for the long-term wearer.

Cheers,

[dtt]

Hi Davidh

Custom devices = around the £250-mark. Good custom devices last for life (my personal devices are now 30+ years old).

I think that statement has to be viewed against a patients lifestyle

If a Pt is 20 stone and plays rugby or runs marathons, no orthotic in the world is going to last more than a couple of years (and please don't try to tell me it will ) ;D

Top covers,postings and paddings will need replacing albeit the orthotic shell may remain intact for a longer period.

Is that not like "trigger" out of "only fools and horses" when asked about his broom which he claimed he had swept the streets with the same one for 30 years.

When asked he stated "yes the same one all this time I have replaced the head 20 times and the handle 10 times" ;D

One problem I do have is Rx-ing custom O's for kids because of the growth element. they can work out very expensive for the parents so I do try ( EVER so hard) to get the NHS involved.

Frankly the now regular scenario of "we will send you to the surgical fitter" who draws a line on paper around the foot and provides a device that is about as much good as wearing a pack of chewing gum in the shoe is not a practice I pursue any longer.

The other is all patients being referred to the paediatric podiatrist must got via an orthopedic consultant.

I am also fed up with sending kids in great pain with obvious foot problems and after waiting some considerable time, the parents being told "oh this will sort itself out in time and if not when they are 18 we will correct it surgically"

I have had enough of returning distraught parents and kids, so expensive it will be , with an explanation and the option of continuing / trying their luck with the NHS

I still think as a profession the main problem with Custom "O's" is we are frightened of charging that amount of money to Pt's as we have always worked for peanuts

This monkey gives a fair service at a fair price take it or leave it

For you average Pt I tend to agree that custom "O's" are cheaper in the long run.

Cheers
Derek

[TimVS]

Try to answer these points in turn from my limited experience thus far
No question IMO that FPO orthoses are the best and most effective option clinically. Not entirely sure if the available research backs that up, but that's one to mull over over the next 2 years.....

That said, I take the view that 'it is better to do something than nothing', so I try to work with the patient and within their budget, if they are insistent that FPO devices are outside of their means. In practice I find that once the options are outlined, they tend to choose FPO devices with no further prompting from me.

As to kids, this is one area where I more or less insist on FPOs, unless there are dire finacial circumstances, in which case I will offer a payment plan to help them out. Why? Because I have yet to find an OTC device which matches the specialised needs of children, not to mention the stresses and strains they put on the devices. - I see a lot of kids in my practice! - PlUS, and this is the biggy, my FPOS, (OSI) come with outgrowth insurance that also covers loss and damage. It's a win win situation. I don't refer to the NHS, it's a complete waste of time round my way, and frankly a disgrace the way children are treated, or not, in fact. Ahem. (Climbs off hobby horse).
So in summary, I am adolf hitler when it comes to prescribing for kids, no arguments, and the results I am getting vindicate my approach, I think, but with adults I can afford to be a bit more touchy feely. SO I will usually use an FPO, but might lob a Vasyli in if I'm in the mood, that is after I've utterly mullered their plantar fascia with my dodgy massage techniques ;D

[Admin]

dtt said:

If a Pt is 20 stone and plays rugby or runs marathons, no orthotic in the world is going to last more than a couple of years (and please don't try to tell me it will ) ;D

Top covers,postings and paddings will need replacing albeit the orthotic shell may remain intact for a longer period.

Hi dtt,
If a custom orthosis is only going to last two years, how long will an OTC device last ?

My orthoses are one-piece (no covers or separate posts) machined from a solid piece of polyprop - so no stress points from being heated and pressed. They are about 30 years old.

The lab I use can provide one-piece devices too.
They also provide a pt-lifetime warranty against breakage, and best of all, keep cast information electronically so that when and if an orthosis breaks, it can be replaced with a telephone call or email.

I can puportedly obtain this service in the UK, but I've never been really happy with it, so I use a USA lab.

I think Tim makes the case for kids devices very well.

Take your point about pricing, and agree completely!

Cheers,
david

[dtt]

Hi Tim

PlUS, and this is the biggy, my FPOS, (OSI) come with outgrowth insurance that also covers loss and damage

Could you PM the details of that to me please ??

Ta

I am adolf hitler when it comes to prescribing for kids

Oh as kind as that ;D

My family tell me my whole attitude is exactly the same as "Doc Martin" on the TV. (I'm not sure if that's a compliment or not )

So I don't get too much nonsense from anyone but I do get results. I also know how hard it is to bring up a family on a low wage ( as in our previous life) so for that reason alone when dealing with kids I try to keep the cost to a minimum.

I

don't refer to the NHS, it's a complete waste of time round my way, and frankly a disgrace the way children are treated, or not, in fact. Ahem. (Climbs off hobby horse).

The paediatric podiatry services are virtually non existent in my area as well along with a host of other services so I am coming round to your way of thinking.

I keep a few reserve Vasyli's for pts returning for replacements with no further clinical symptoms.
I'm still a great believer in "if it ain't broke don't fix it"

Cheers
Derek

[TimVS]

Only today I was chatting with a cricketer who pulled out his orthoses to show me. They were full length EVA with bits stuck on the bottom and he got them for the keen price of £600 for two pairs :oSo really, I'm undercharging Still, they did cure his shin splints.

[dtt]

Hi Tim
thanx for the PM.

They were full length EVA with bits stuck on the bottom and he got them for the keen price of £600 for two pairs

Don't forget I have P***sh & B*ll in my area who charge over £1000 a time for theirs ( same lab as you I believe) so you know the mark up.

I was talking to an Osteopath that knows the person behind the company and his main boast is how he sold SEVEN pairs to one patient for SEVEN types of shoe in one go

So price wise.......... You tell me who's undercharging

Cheers Fella
Derek

[paulm]

Hi all
spoke to guy from P****h & B**l today re article in times paper, i was straight up front and said who i was and that i was interested in the bit that said unique orthotic system... somehow very quickly got round to him sending me his book, how the hell did that happen lol .......wish i had a packet to spend on that kind of advertising

getting back to original thread of tims....i rarely use OTC..If i do its a slimline neutral shell all 1 piece...you can heat up as well...i recently tried a new type for a child...i must admit i was a wee bit disappointed with them when they arrived as i could fold them up and put in my pocket but according to literature they have proved to be quite good...so i will see....the other interesting thing to note was a facia grove in all sizes....claims to enhance the windlass mech.....my understanding of this grove in a prefabricated device (again just my opinion from what i have learnt)is it makes the device more comfortable accross the board when incorporating a high medial arch on a prefab device.....

life span of orthotics(prescription).....i tell my patients the device should last a lifetime..unless the dog gets to it, not sure why but i have had to refurb quite a few devices where dog has chewed the neoprene used for heel posts...it may be a glue thing...but like ddt says top covers need to be replaced..more so if forefoot extensions applied due the flexible area at point of shell finish and top cover extension (usually see cracks in this area if using a vynal top cover)

regards

[TimVS]

When the dog approaches the orthotic.....that's when your hammer comes in handy Paul ;D


Sorry, I've had such a sh***y day, it's so nice to have a laugh !

[paulm]

no problemo m8
i see you saw through my disguise, hell im not sure iv'e spelt disguise correct.........age thing

[TimVS]

I've given up spelling - can't find the research to back it up

[robertisaacs]

Hey tim

As to kids, this is one area where I more or less insist on FPOs, unless there are dire finacial circumstances, in which case I will offer a payment plan to help them out. Why? Because I have yet to find an OTC device which matches the specialised needs of children, not to mention the stresses and strains they put on the devices. - I see a lot of kids in my practice! - PlUS, and this is the biggy, my FPOS, (OSI) come with outgrowth insurance that also covers loss and damage. It's a win win situation. I don't refer to the NHS, it's a complete waste of time round my way, and frankly a disgrace the way children are treated, or not, in fact. Ahem. (Climbs off hobby horse).

few questions

What specialised needs are you referring to?
What problems have you had with stresses and strains in kids?
I'm guessing from the above that you are an advocate of treating Asymptomatic paed flat feet. Why? If not, why not?

I agree with you on most of what you said but i'm curious to know how you reached your views. Might stimulate an interesting debate.

regards
Robert Isaacs

[TimVS]

Hi neighbour! (Not sure where you are in Kent)

Anyway. To try and answer your questions:-

What specialised needs are you referring to?

In comparison to adults, the fact they have growing feet, and will therefore outgrow. Also their changing anatomy in terms of bony alignment plus bone growth and density, vulnerability of growth plates, etc. Also, and this ties in with q2, the fact that they are generally more physically active and thereby arguably put more stresses and strain on footwear, orthoses included. Of course this is balanced by the fact they are less heavy than adults.

What problems have you had with stresses and strains in kids?

I have had two pairs of polyprolene heel stabilisers break in half in the past year. In both cases the children were netball players, and the devices broke when jumping high for the ball. I have since learnt to include more detailed questioning as to activity levels and type into my initial exam! Incidentally new devices were supplied free of charge and arrived within a fortnight from the US, all covered by the insurance.
I just find, clinically, that it is much harder to get a comfortable and durable fit with OTC devices. I once fitted a pair of Vasylis to, I think, a 13 or 14 year old rugby player. They were completely trashed in under 6 months

I'm guessing from the above that you are an advocate of treating Asymptomatic paed flat feet. Why? If not, why not?

I am in most cases, but usually only after about age 6, where rotational changes in the lower limb are complete.

In no particular order, in the absence of symptoms, I look at family history, evidence of clumsiness, lack of co-ordination, getting tired easily, lack of interest in sport. Then in terms of the exam checking for lig. laxity, degree of pronation and joint misalignment, variations in gait which could be improved with orthoses, muscle balance and strength, and so on. Is their posture and gait likely to lead to problems in the future if untreated? Could it be affecting their physical performance now, despite lack of pain type symptoms ? My treatment aims broadly are to improve efficiency in gait and hopefully prevent future problems caused by stresses and strains on the lower limb structures. I admit my reasoning is clinically, not research based, but there it is.
As I'm moving more into sports therapy, I'm becoming much more interested in the physical performance aspects of the equation to be honest, so spend as much of my time doing stretches, muscle balance work and exercise modification as prescribing orthoses.

Look forward to your comments.

Regards,

Tim

[dtt]

Hi Tim , Robert et al

I'm guessing from the above that you are an advocate of treating Asymptomatic paed flat feet. Why? If not, why not?

in the absence of symptoms, I look at family history, evidence of clumsiness, lack of co-ordination, getting tired easily, lack of interest in sport.

I think ANY Paed that turns up in my / Tim's situation has symptoms of some description or they would not be there in the first place!!

I think Tim has given several symptoms in the above all of which affect the child's quality of life and so in my view are worth a look and provision of orthoses as required.

I get many from parents that have been to see me with a biomx problem and after treating them and explaining the problems to them and how they are / can be familial its surprising how many requests I get to check the kids.

I use a scanning (pressure plate) system and during that I do a comparison scan of an "optimal sample" with the Pt scan.

I sometimes compare the parents with the child's scan. At times the similarity is amazing.

I agree totally with Tim on the destructive power of kids on OTC's and top covers etc and also the fitting issues are much less with custom O's especially in sport footwear.

To get a Paed into see a Biomx pod in my area has to be done via a consultant orthopedic surgeon.
I must confess to being heartily sickened by the amount of kids waiting ages for the appt, being in pain ( unable to walk to school,play sport etc) who become withdrawn, unhappy,school work suffering . Being told to stand on a bit of paper someone drawing a line around their feet and then supplying sorbathane /Eva type insole with no follow up and no change in the kids condition

I therefore have given up trying to integrate the NHS in kids treatments for O's and give the parents the option to try to arrange themselves or pay the price of my treatments.
Cheers
Derek