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Post by samrandall on May 16, 2009 3:41:26 GMT
Hi Guys, Greetings from sings.. Still sweating here and got my first gig tonight with my new band (theprojectsg.com).. gonna soundcheck the V song.. even though I might get arrested for it! Been a while but hope you are all well... I've been recently chatting with an American shoe maker (lady who trained as an engineer then moved into childrens shoe making) see: www.scooterbees.comWe have been discussing what makes the Ideal kids shoe and just thought I'd open that discussion up a little. Obviously each child's needs may differ from one to another, but in a "normal child" (i.e. no great hypermobility, abnormal planal dominance, abnormal development etc) of say the 18 month to 6 year bracket, I have been toying with the idea that the prefect shoe could be one that effectively mimics barefoot. Soft sole, not too much support good sensory feedback from the insole. The idea being that the intrinsic muscles are stimulated to work. Obviously needs to protect the foot from sharp objects etc. There, of course, is the hard flat surface argument that could oppose this idea, and it is one that I am quite a fan of.. With this in mind how then would something like the Nike Free perform in your opinion (it's designed to mimic the plantar pressures of being barefoot on grass, and they have some truely special research that shows it "works" but all credit to them, they do say it should be a shoe to train the muscles of the feet, not something you go into and just run normally in..) I'd be very interested in what your thoughts are?? Kindest regards to all! Sam
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Post by Admin on May 16, 2009 6:24:17 GMT
d There, of course, is the hard flat surface argument that could oppose this idea, and it is one that I am quite a fan of.. Yaaay! ;D
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Post by davidsmith on May 16, 2009 19:08:48 GMT
Sam So, you are a fan of the hard flat surface argument eh! I take it that's David H's argument that feet have not evolved for hard flat surfaces yet we use reference normals that suggest we have. Now, you categorise a normal child's foot posture as that which does not fall outside those reference normals as apply in the statement above. So aren't these two definitions mutually exclusive i.e. If they have not evolved to walk on hard surfaces then surely it is 'normal' to have a foot posture that adapts to that hard surface by adopting a posture that is outside the reference normal. If for some strange reason it was normal to regularly bounce babies on hard concrete surfaces, would the normal ones be those that broke or those that did not break? It may have been that thousands of years ago it was ok to bounce babies off soft surface like grass and sand and they would be OK. Now that we have mostly hard surfaces and, like feet and hard surfaces, babies have not evolved to bounce without breaking on hard surfaces, strangely we categories babies that do bounce without breaking as 'normal'. Hmmm! the confusion is almost palpable No, but what I'm saying is 1) Are you wanting to have your cake AND eat it? 2) Are the broken children the normal ones and the non pathological one are supra normal. Now to solve the problem of breaking bouncing babies you might want to wrap then in bubble wrap (assuming that we can't stop bouncing them). Trouble is how do we know which ones won't break before we bounce them? We don't! So does this mean we must wrap all babies in bubble wrap? Hey! I don't know if there are any answers there or if it is even helpful but at least it something to think about. LoL Dave
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Post by samrandall on May 18, 2009 4:40:51 GMT
Thanks for the response Dave(s)... You have brought up some good points and it will be nigh on impossible to take a defensible counter argument position due to the lack of evidence on the topic. But let me try anyway.. With regards to the point on "normality".. I guess "normal" could be classed as "most commonly occuring" of any given population (i.e. the middle section of a bell curve). The increased levels of pathology as seen in shod populations vs unshod populations may move the mean towards higher prevalence of foot pathology, perhaps in a similar way that coal miners had higher levels of lung pathology vs the rest of the population. But is this normal? Am I confusing normal with ideal? I think what I am asking aswell (as this was much more a post asking questions and opinions as it was making statements of suggested truth) is... We often put children into shoes. Do these shoes help or hinder? Working under the theoretical assumptino that it is possible: how could a shoe be made to help a child develop with a lower risk of pathology? There is an argument, I think, that if we can produce a childrens shoe which closely mimics the forces, surfaces and sensory feedback that a childs bare foot would experience during development in an unshod population, that their foot may develop "better" (ok shoot me down for using bad terminology, but I hope you can see what I'm trying to say) What would be your ideal shoe for a child? I find this topic increasingly interesting at the moment as i currently live in Hardflatsurfaceland.. and there are alot of kids and teens here (more than I think I saw at home.. but got no way of quantifying that) with really flat feet and I see quite a high number of the kids on national service who have super flat feet, medially deviated STJ axis and tib post/nav process pain/pathology. I wonder if there is a combination of factors going on and so far think these might include: Surface the subject developed on, footwear worn whilst developing, foot type/stj location, level of hypermobility, activity level, genetic diversity/idiosyncracies.. just thoughts..
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Post by davidsmith on May 18, 2009 11:52:43 GMT
Sam
Not considering the ethical issues of predictive intervention - treat or not to treat, which have been discussed at length before, or the sensory changes that might occur but are not well known - then:
You wrote
I assume you mean a massed produced generic shoe that would fulfil your criteria for every child. Does this seem a reasonable expectation? Would you expect that we could have one style of orthosis (FFO) that would do the same? Effectively, in very loose terms, the shoe is an orthosis, in that it is an appliance that interfaces and changes the applied forces acting on the foot, when compared to the barefoot.
How ever the Greek root of orthosis is orthos, meaning straight and literally means a straightening device, hardly appropriate in todays terms don't you think.
The Free Dictionary
Orthosis /or·tho·sis/ (or-tho´sis) pl. ortho´ses [Gr.] an orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve function of movable parts of the body.
Dynamic orthosis a support or protective apparatus for the hand or other body part which also aids in initiating, performing, and reacting to motion.
Halo orthosis a cervical orthosis consisting of a stiff halo attached to the upper skull and to a rigid jacket on the chest, providing maximal rigidity.
Dorland Medical Dictionary
Orthosis An external orthopedic appliance that prevents or assists the movement of the spine or limbs.
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.
Orthosis A force system designed to control or correct or compensate for a bone deformity, deforming forces, or forces absent from the body. Mentioned in: Cervical Spondylosis, Congenital Hip Dysplasia
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.
orthosis [ôrthō′sis] Etymology: Gk, orthos, straight a force system designed to control, correct, or compensate for a bone deformity, deforming forces, or forces absent from the body. Orthosis often involves the use of special braces. orthotic, adj., n.
Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.
Orthosis pl. orthoses [Gr.] an orthopedic appliance or apparatus used to support, align, prevent or correct deformities or to improve function of movable parts of the body.
Saunders Comprehensive Veterinary Dictionary,
Orthosis plural, orthoses Orthopedics The straightening of a deformity; an external device–eg, a cast, brace, or splint used to stabilize, reinforce or immobilize an extremity, ↓ sensory input to an extremity, prevent stretch weakness, ↓ contractures, functionally assist weak muscles, protect a limb with pressure sores, provide a mechanical block to prevent undesired movement Types Orthoses are available for spine, hip, foot, knee. See Foot orthotics, Scapular reaction.
Do these descriptions suit your criteria for a shoe action upon the foot. I think the last one probably comes the closest eh?
What is it you want to do with the childrens feet?
Two more questions come to mind if you wanted a shoe to fulfil your criteria. And assuming we must wear shoes of course.
1) What are the forces, or the nature of the forces, acting on the foot in the modern environment that can be classified as potentially pathological.
2) How can these forces be changed by the use of some interface into those forces which are not potentially pathological.
And reiterating my earlier queries
3) Can we expect that we could design such an interface that could do this for all children with just one mass produced prescription?
4) What is it you want to do with the childrens feet in terms of a shoe / orthotic intervention
5) Ok five, name five things the Romans ever did for us
In the OP you wrote
If we consider or make the assumption that bare feet on natural surfaces propagate forces that are not potentially pathological.(Quite an assumption I would say but anyway) and agree (for the sake of argument) that the foot has not evolved for hard flat modern surfaces then can we then say that it is better to walk on hard flat surfaces in bare feet, which is exactly the implied conclusion you made by the supporting the design of shoes that mimic barefoot walking. Does it make sense to do this?
Six, name six things that the Romans ever did for us ;D
I'll let you consider these problems and get back later
Cheers Dave
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Post by samrandall on May 19, 2009 1:10:11 GMT
Hi Dave, thanks for playing.. ;-) I'm not talking about a shoe for all children and stated as much in my first post.. I am arguing the point that a child who starts their development without gross deformity may benefit for a shoe that will mimic the forces and textures of a natural surface. I think perhaps I would like to invert this point slightly and say: Am i safe in the assumption that there is a large of children in the developed world living on a hard flat surface, whos parents will, no doubt, place them into shoes? If so, theoretically, what would be the shoe that gives them the least chance of developing pathology. Would a shoe that tries to mimic some of the forces and textures encountered whilst unshod be this shoe? If you look at Orthosis as a word it is an inapproriate term, as is Tendonitis, and is no more useful than shin splints and metatarsalgia. But I think that if you ask the majority of people what an orthotic is they will reply "something that goes into a shoe". I would view the shoe as an interface between the floor and the foot. The foot needs to be protected from the floor, but what else does the shoe need to do?? Support the foot?? stop the foot from rolling around as much..? maybe all this support is the problem! Anecdotally, last year in the UK I saw a lady in her mid twenties who was placed into solid boots and rigid insoles at an early age due to "flat feet". She came to me with fairly diffuse foot pain after any level of activity, no real abnormalities structurally in her feet, although she did score quite highly on the beighton score. She was seeing a physio who was working on exercises for the intrinsic muscles of the foot, which she said were helping with her pain. I looked at giving her some fairly flexible insoles just to aid foot position (slow speed of pronation) and allow the muscles to work, albeit under a slightly lesser load than they would have and the patient tolerated them well, continued with her exercises and the plan was to get her out of insoles when (if) the foot muscles were able to cope on their own. How would she haved developed differently given an alternative intervention? (of course we will never know) Also, a point that I was particularly keen to explore is the Neurological feedback component. I have heard of (although not seen) some idiopathic toewalkers (with other learning difficulties too I believe) who just stopped toe walking when a rough texture was placed under the heel inside the shoe. I am unaware of any research done and would greatly like to be enlightened with any anecdotal/researched or any other information. I feel that perhaps this area (especially in paeds) is underlooked in our field because we can get tied into the mechanics of it all too much (myself included). Now, to get to your questions: 1) I believe the hard flat argument goes as such: the fact that the hard flat surface give you (roughly) the same force coming from the same angle landing on the same part of the foot with each step you take. As opposed to "natural"/less articifial surfaces (unless you live on a frozen lake) which give you slight undulations, and a need to use different muscles to stabilise the foot with each step. 2) some material that compresses and allows the foot a slight instability. Also if the material compresses and allows a loading pattern on the plantar aspect of the foot to mimic landing on a softer surface you may be able to reduce excessive levels of ground reaction force on the lateral heel, thus reducing the pronatory moments and thus the speed with which the foot pronates. You may not change the amount that the foot pronates, but if you can reduce the speed you may be able to reduce pronatory related pathology. 3) I have absolutely no idea! 4) I believe i have covered this above.. not sure tho.. 5) Aqueducts, wine, safe to walk the streets at night, education, sanitation. Lastly.. the shoe that I am proposing Mimics barefoot walking on grass.. so you manufacture a sole that works on the hard flat surface and gives you a similar energy return, instability and, for lack of a better word (it is only 8.30am here!): "feel" to grass. And strangely enough it seems: Stinging nettles www.schoolhistory.co.uk/year7links/doneforuse.shtmlOk I haven't read over this and my boss is gonna kill me if I don't start seeing patients (sound familiar robert??) S
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Post by samrandall on May 19, 2009 1:42:58 GMT
"maybe all this support is the problem!"
Actually meant to take that bit out..
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Post by davidsmith on May 19, 2009 15:20:08 GMT
Sam
Sounds like your talking about MBT's
Dave
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Post by samrandall on May 20, 2009 1:10:34 GMT
Hi Dave,
No, I'm pretty sure I'm not.
What I am trying to do, is ask for info.
What would YOUR idea of a good shoe for paeds be???
I'm really not trying to put forward this as an idea, I'm not DrSha.. I'm trying to ask questions and stimulate debate in an area I'm interested in.
I'm quite surprised Robert hasn't said anything.. I'm interested in his point of view.
Regards :-D
Sam
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Post by davidsmith on May 20, 2009 9:30:10 GMT
Sam
No I know your literally not talking about MBT's but isn't the aim of MBT and your ideal shoe, pretty much the same.
"What would YOUR idea of a good shoe for paeds be???"
I don't know. I do know what might be the best shoe for a particular patient but one shoe for all, in the terms you are suggesting, is a bit difficult.
Cheers Dave
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Post by samrandall on May 21, 2009 2:30:14 GMT
Hi Dave,
Fair enough..
For those that are wondering MBT's propose to: "create a natural instability underfoot, which stimulates and exercises the body's supporting muscle system." Which is, I guess, what I was saying. But I had quite a different shoe design in mind.
Obviously, childrens shoes are mass manufactured and many propose to be the "ideal" shoe for growing kids. We enlightened few know that different feet need different things. I was trying to think about what the least damaging/most stimulating shoe might be for kids.
I really would like to make it very clear that I am not about to embark on a designing/manufacturing campaign with a shoe company, I know I don't know nearly enough.. I do not think that the shoe I am proposing is the best shoe for all children. I dont endorse it. I was taking a corner and trying to fight that corner. I believe I put enough disclaimers into the sentence "..I have been toying with the idea that the prefect shoe could be.." to make this clear and try stimulate a theoretical debate on the topic.
Is there any research on the requirements of neurological stimulation in foot development. Does anyone know, or have they heard anything about this..??
I think this post has all stemmed from the big move towards barefoot technique shoes like the Nike Free and the Vibram Five fingers.. (sounds like a fung fu move.. or a naughty film)http://www.vibramfivefingers.com/ and although initially I was fairly dismissive of barefoot shoes being not so good for you and a bit of a fad, I have started to try and question those beliefs (and others) that were so righteously and rigorously instilled in me at University. Barefoot shoes seem to work really well for some adults, I have met a number of people who swear they are the most comfortable shoes they have ever worn and regularly run 10+km in them (i know this is really really really dependant on foot type). Unshod populations have been proven to have a lower level of foot pathology than shod populations. I was, perhaps in some naivety, trying to extrapolate that down to a paediatric level.. the whole developmental what if? question.
Anyways, keep well all..
S
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Post by davidsmith on May 21, 2009 11:57:38 GMT
Sam
Yes I get that and I wanted to see if you had any design concepts yourself. And I agree that there is an intuitive aim of the ideal shoe, a feeling that there must be a shoe that would be best for most people most of the time. We know what would be detrimental to most feet but the opposite is much more difficult to pin down.
Its a bit like asking what is the ideal bridge design, we know what we want it to do and how we want it done, we know the engineering principles of bridge construction and we know how not to build it, but the actual design and construction of the bridge for a particular site, depends very much on what the topography, geology, load magnitude, dynamics and type, planning and engineering regulation etc etc are going to be.
Even when we have designed a shoe that is bespoke to a certain child, will that shoe be optimal for all of that child's activities.
Is the shoe that was designed for walking to school and such daily activities, still good for trail riding at the weekend or fell walking with the family.
I remember walking up Ben Lomond one year, I had some good Cat walking shoes but when walking over very rough grassland full of little hillocks throughout the deep grass I was continually straining my medial and lateral ankle ligaments and muscles. I took my shoes of and walked in bare feet and this was much better. The reason was the heel of the shoes gave a long lever arm to the STJ and when the CoP was extremely lateral or medial depending on which side of the next hillock my foot fell upon, then this really twisted my ankle over. However I soon had to put my shoes back on when walking on hard stony ground that was relatively flat.
So here is an anecdote that shoes were better for my feet, in terms of less potential pathology, when the ground was flatter.
This brings me to my next point, which is a favourite of Simon Spooner, Go out in the world and see if pavements roads and pathways are actually flat. They are not, so how flat does flat have to be before it becomes pathological to our normal feet that have not adapted to flat ground?
Again I will concede that there is an intuitive feeling that flat, hard ground is damaging to feet because it causes them to pronate in the same way with the same magnitude with each step, but is this true? can you show this by experiment (as a statement for a population not a singular expression for an individual) and again how flat and hard is too flat and hard.
Cheers Dave
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Post by samrandall on Jun 11, 2009 6:07:59 GMT
I have been thinking long and hard (and flat teehee) over this post.
I think the bridge analogy is a very good one.. I might even use it next time I have to present to a bunch of non believers (i.e. singaporean physios and doctors)
I have changed my views perhaps a little over the past few weeks, however I will outline the idea for a shoe that I had:
something thin but hard wearing/nonslip for the outsole. Midsole: a soft compressible material like a low density EVA or similar material that compresses under the higher pressure area of the foot so basically the whole of the plantar aspect of the is in contact with the midsole during weight bearing.. The insole/inlay itself would comprise of something a little rough or bobbly, to allow some sensory feed back for the plantar aspect of the foot. the upper is slightly more flexible designwise, as long as the foot is held onto the shoe.
My idea for this shoe is really in foot that falls into the category I perhaps misguidedly call "Within normal limits".. indeed I hear people shout "what IS normal" and the answer is I cannot give you a figure or series of angles and positions of the foot. For me i guess I am talking about the theoretical "ideal" foot.
"This brings me to my next point, which is a favourite of Simon Sthingyer, Go out in the world and see if pavements roads and pathways are actually flat. They are not, so how flat does flat have to be before it becomes pathological to our normal feet that have not adapted to flat ground?"
I contest this point.. here in Singapore the surfaces are hard and flat.. everywhere you go.. hard flat surfaces.. the pavements are well kept, there is a shopping mall on every street corner, everyone has marble type floors, it is a very modernised city. And to hang out, the singaporeans go to the mall.. or the library (I had 3 18 year old students with my the other day.. I asked them what they did to hang out and i kid you not they said they go to the library with their friend... at that age I could down a pint of lager in 5 seconds holding the glass with just my teeth!!!!!!)
I have nothing to back up this claim at the moment (although I am looking into it) but I see a very high incidence of very flat feet and hypermobility in the chinese population here. I feel there is a link.. it is a hunch, but no more as yet.
I very much like this point also.. "Even when we have designed a shoe that is bespoke to a certain child, will that shoe be optimal for all of that child's activities?"
Dave, thanks again for the insightful and interesting comments..
Sam
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Post by davidsmith on Jun 17, 2009 12:20:44 GMT
Sam
Good to see you have a passion for your vocation.
So from your last post I get a different perspective of the problem at hand. Lets assume that Singapore people who live in city areas do walk on flat hard ground. Lets also state that flat has a precision that within the constraints of the foot print area and the area between two foot prints there are no significant changes in this local topography.
Lets also assume that long term walking on hard flat ground is pathological in terms of foot and lower limb injuries.
The problem perhaps, becomes one of changing the surface contour and not one of making people walk more normally.
So let us ask how can we change this local topography to less hard and flat for an individual or individuals of interest. I.E. we cannot change the surface properties therefore we must change the foot - ground interface properties. This does not attempt to give a normal walking pattern or define the parameters of normal walking. All we try to do is change the foot - ground interface to be more like walking on more rough, softer and variable surfaces.
So the next questions are how do we achieve those objectives
1) Rougher under foot
2) Softer underfoot
3) More variable within each step.
Will the resultant change in kinetic and kinematic action of each modification have beneficial or detrimental effects on the population of interest. What is the net effect of all modification in terms of pathology.
1) Roughness - is there any evidence to show that a rough insole / foot interface is benificial.
2) Softness - Does adding softness or cushioning to a shoe sole really increase force attenuation in the lower limb or is the effect very localised.
Is this soft feel an illusion of comfort that masks the effect of pathological forces i.e. the initial foot contact feels soft so the force attenuation properties of the lower limb action is not ready for the effect of the hard, non compliant ground.
If, as you imply in your shoe specifications, a midsole of some specified density is required what are the optimum material properties for shock attenuation and energy return and kinematic control.
3) Variability. - How can a shoe that interfaces with a regular flat surface have an irregular and variable action on the foot (has MBT already done this or is it just an illusion)
Do we need to consider these if we just want to change the surface /foot interface ? If we agree that surface interface changes are good how much change would become pathological?
Dave
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