Pedorthics - Pedorthic Association of Canada
Transcription
Pedorthics - Pedorthic Association of Canada
A Periodical of the Pedorthic Association of Canada A Periodical of the Pedorthic Association of Canada Quarterly Fall 2010 Pedorthics Focus on Casting... In this Issue... President’s Message 3 Board Updates 4 Executive Director’s Report 7 Pedorthic Association of Canada’s Position Statement on Casting Techniques for Custom Foot Orthoses 8 Overview of casting techniques 10 Casting Definitions 13 Article Review: A Comparison of Four Methods of Obtaining a Negative Impression of the Foot 14 Member Profile: Casey Bjorgum 15 Member Profile: Vanessa Carnovale 16 How proactively are you building your reputation capital? 17 The newest Mississauga clinic located at 2000 Credit Valley Road has seen tremendous success since it opened it’s doors on March 1, 2010. A special “Thank You” goes out to PAC for their help in getting the word out to it’s members. Career Opportunities With ten clinics and growing, Walking Mobility Clinics is looking for Pedorthists who would enjoy managing a new corporate clinic or owning a Walking Mobility Clinic of their own. Our focus is clinically based (not retail based) and staffed with a dynamic team of Pedorthists, Physicians and Chiropodists. If you are interested in joining our comprehensive team approach and would like to discuss a new opportunity with Walking Mobility Clinics, please contact: Ryan Robinson, Pedorthic Director Walking Mobility Clinics [email protected] www.walkingmobilityclinics.com A Periodical of the Pedorthic Association of Canada President’s Message Fall 2010 The world of footwear, foot care and foot orthotics is constantly changing. I like to think that pedorthists drive a lot of this change as we are the only profession that specializes in both foot orthotics and footwear. Change can be beneficial to us and our patients and it can be By Graham Archer, frustrating. I cannot count how many patients I have seen finally C. Ped Tech (C), C. Ped (C) find a pair of shoes that fit, only to have that shoe model change the following season. One thing is certain though - as manufacturers seek an edge over competitors, as consumers demand innovation and increased performance from their shoes and foot gear and as retailers seek the “next best thing”, there will always be change. Change is going to happen, with or without involvement from us as pedorthists. It is up to all of us to be aware of developments that affect our business practices, assessment techniques, manufacturing techniques or patient care. When I first started in pedorthics, manufacturing orthotics using a CAD/CAM system was cutting edge; now it is common place. This development has allowed manufacturing labs turn product quicker, keep manufacturing costs under control and allowed for storage of patient’s positives on a simple digital storage device. The result: quicker turn around for the patient and efficiency for the practitioner. Many innovations we take for granted. Where would we all be without our computerized point of sale or accounting tools? Some innovations get over used. Ever send an email when a phone call is more appropriate? However we look at it though, not many of us would willingly give up our cell phones, computers, PDAs or email. As professionals providing a service to the public we must all embrace change, get educated and use it to appropriately further our practices and services. I have been involved in many passionate conversations about changes in the running and footwear world. Visit any online running or biomechanics forum and there will surely be a lengthy and sometimes heated discussion on barefoot running. You will see educated professionals arguing for it and others arguing against it. You will see lay people saying it is the best thing they have done and others saying it is the worst thing they have done. Does a forefoot strike that is seen in barefoot running overload the forefoot while trying to reduce HF impact? Does it cause too much eccentric strain on the achilles complex? Shoes are being designed to mimic barefoot running. Does this mean that barefoot running on its own is not appropriate? Fitness shoes have grown incredibly in the market place. Old staples such as Earth shoes and MBT are being joined by New Balance, Reebok, Xsensible, Skechers, Easy Spirit and many others. Massive marketing campaigns are in place to tell the consumer why they need to buy these shoes. You will hear words such as toning, fitness, anti-gravity, minimalist and instability when referring to this type of footwear. Pedorthists are looked on as the professionals for footwear choice and fitting and as such we all need to be aware of what is out there so we are able to communicate any shoes appropriateness for our patients. Talk to your local shoe reps, retailers and colleagues about new changes in footwear, be aware and be prepared to communicate your thoughts to your patients. I realize I have asked more questions in this message that provided answers. It is not up to any one of us to have all the answers, it is up to all of us to know where to find them and to generate and opinion. Hope to see you all in Orlando! Help Us Be Green! If you would like to receive Pedorthics Quarterly electronically instead of the paper version, contact the PAC office at [email protected]. To those of you who are already receiving the online version, thank you for helping us be green! Did you know you can read past issues of the Pedorthic Association of Canada quarterly publication online? Go to www.pedorthic.ca and log in to your member record. Publisher Information Pedorthics Quarterly A Periodical of the Pedorthic Association of Canada Pedorthics Quarterly is published by: Pedorthic Association of Canada Suite 503 – 386 Broadway Avenue Winnipeg, Manitoba R3C 3R6 Toll Free: 1-888-268-4404 Fax: (204) 947-9767 Email: [email protected] Printed by Kendrick Printing ISSN 1922-9429 Communications Committee Co-Chairs Linda Deschamps, C. Ped (C) Nancy Kelly, C. Ped Tech (C), C. Ped (C) Committee Members Doug Benoit, C. Ped Tech (C) Grace Boutilier, C. Ped Tech (C), C. Ped (C) Jim Pattison, C. Ped (C) Michael Ryan, C. Ped Tech (C), C. Ped (C) Subscriptions: $199 per year in Canada All articles published in Pedorthics Quarterly are the property of the Pedorthic Association of Canada. Copyright ©2010 Pedorthics Canada All rights reserved. Reproduction in whole or in part is permitted only with the prior written consent of the Pedorthic Association of Canada. Address all requests to the PAC office. Trademarks and Registered. Trademarks used in this publication are the property of their respective owners and are used only for the purpose of information. 3 Quarterly Pedorthics Board Updates Communications Chair – Linda Deschamps, The Communications Committee continues to provide research/ C. Ped (C) scientific-based articles of interest Vice-Chair – Nancy Kelly, to PAC members. We are always C. Ped Tech (C), C. Ped (C) looking for new and interesting ideas for articles and themes for PQ. Please submit any ideas for themes for future issues to Linda Deschamps at ldeschamps000@ sympatico.ca. We would like to thank committee members and contributors for their continued efforts and support in PQ. Education Chair – Lisa Irish, The main goal of the education committee is to support Vice-Chair – Ryan Robinson, the Diploma in Pedorthics program at the University C. Ped Tech (C), C. Ped (C) of Western Ontario. Ryan Robinson, Jonathan Strauss and myself recently met with Chris Thompson, the new program coordinator at Continuing Studies and the outgoing coordinator to discuss the program. It was a very productive meeting and I look forward to keeping you apprised of the outcomes of that meeting as they come to fruition. In order to meet the demand for certified pedorthists we must continue to aggressively promote the Diploma in Pedorthics program at UWO. The education committee recruits members to attend career fairs so that prospective students have active pedorthists that can give them a better understanding of what a career in pedorthics involves. If you are interested in manning a booth at a career fair to encourage students to pursue a career in pedorthics then contact the education committee and we will keep you on our list for opportunities in your area. We are also looking for committed certified pedorthists to act as practicum supervisors for the pedorthic program. It is through supervised placements that pedorthic students truly learn to apply their course work to real people. It is so important that we have excellent placement opportunities for students so they are well prepared to enter the pedorthic industry upon graduation. If you feel you could supervise a student for a placement opportunity or need more information then contact UWO for information on the necessary requirements for a placement location and supervisor. This fall there are 18 students registered for the Diploma in Pedorthics Program. We wish them every success in their studies this year. I would also like to extend my appreciation to the instructors and the placement supervisors in this program who work hard to provide a good pedorthic foundation for the students. Have a great academic year! C. Ped (C) 4 Fall 2010 Ethics Chair – Vanessa Carnovale, There are no new cases or concerns before the ethics C. Ped Tech (C), C. Ped (C) committee. We encourage Vice-Chair – Nancy Kelly, everyone to remain familiar with C. Ped Tech (C), C. Ped (C) the Code of Ethics, available through the PAC office. Insurance and Government Relations Chair – Brad Gibbs, In the spring of 2010, PAC learned that BC’s Ministry of Housing and Social C. Ped (C) Development (MHSD) had changed their coverage for foot care and were only covering foot orthoses for those individuals that were in immediate risk of full or partial foot amputations. Graham Archer sent a letter to the Minister of MHSD, Rich Coleman, explaining how this did a disservice to those who need orthotics for long-term daily mobility. In June, we received a response from the Minister explaining that at the present time there will be no change to their policy. That is, that the province’s financial situation predicates the provision for foot orthoses only if the person is at risk for partial or full foot amputation. In response to Graham’s offer to have the PAC participate in the development of future guidelines, Canadian Certified Pedorthists are now formally listed as recognized providers of orthoses and footwear. Of note, our profession is a valued partner in servicing the clients dependent on funding from the BC government. Another issue that began this past spring is the PAC’s application to WCB Alberta to be recognized as contracted providers of foot orthotics. Some members’ claims were being rejected due to the fact C. Ped (C)s are not contracted services providers of orthoses. We received a response to our application indicating that WCB Alberta is not open to including pedorthists as CFO providers at this time. Their numbers reflect a very small percentage of claimants needing custom orthoses and until they can be convinced that there is value to adding additional suppliers, they are happy with Certified Orthotists being the sole supplier. WCB Alberta will continue with the status quo of including C. Ped (C)s as footwear and footwear modifications suppliers, with C. Ped MCs as suppliers of custom footwear. Sun Life recently released a statement indicating that a written recommendation for orthoses or orthopaedic shoes, including diagnosis, fully-paid receipt, date of service and a detailed lab invoice will be required. They took this measure to try to combat an increase in fraudulent claims. Additionally, Sun Life will also be requesting a description of the casting technique and raw materials used in fabrication of the orthoses. We have heard from many members concerned about the requirement of a lab invoice as many PAC members manufacture their own products and lab invoices do not reflect the cost of service component from the provider for either orthoses or custom footwear. With the help of IGR committee member Kim Rau, I have been in contact with officials at Sun Life about this concern. As per the recent communication to members sent out about this, Sun Life will accept receipts with blacked out fees. In summary, with respect to foot orthoses claims, provide the client with:diagnosis from referring practitioner as well as conditions apparent, the casting technique, a list of raw materials used in the fabrication of the orthoses, a brief description of the manufacturing process, the dispensing date and your certification number from The College of Pedorthics of Canada. With respect to custom footwear claims, include the following: the lab invoice, costs blacked out, the casting technique, the dispensing date, and your certification number from The College of Pedorthics of Canada The claims department at Johnson Group has also been inundated with claims for modified footwear and orthoses and needs help clarifying the legitimate from fraudulent claims. They have asked Jonathan Strauss and Brian Scharfstein to help with this. Jonathan and Brian met with officials at Johnston Group in mid-July bringing a variety of samples to help them with the terminology and to get a visual of what modifications and materials look like, as well as non-custom and custom orthoses. Membership Chair – Ryan Robinson, PAC membership continues to increase. There has been a lot of activity in the “Candidate Membership” C. Ped Tech (C), C. Ped (C) class due to the upcoming fall exams. As you may know, in order to be eligible to write the exams, candidates must have obtained this membership in this category for a minimum of 30 days prior to writing the exam. Our current membership in the Candidate class stands at 50 members. Other current membership numbers: Certified members: Non-Practicing members: On-Leave members: Sustaining members: 475 12 11 18 Total membership 566 One of the main goals of the current PAC board is to increase our membership numbers across all categories. We are working very closely with the University of Western Ontario to increase enrolment in the Pedorthic Program offered through the university. There are a number of interesting and exciting ideas currently being discussed to help in this cause. The Pedorthics profession has made tremendous progress in establishing itself as a legitimate health care field. It is essential that we have a strong educational platform to allow for continued growth in this area. Having a direct link to a university of the calibre of UWO is not something that should be taken lightly. We need to ensure that we, as a membership, are doing everything possible to support the university. Professional Development The professional development committee has just seen two new members approved C. Ped Tech (C), C. Ped (C) by the board of directors, and is in the early Vice-chair – Vanessa Carnovale, planning stages for the 2011 PD events. As C. Ped Tech (C), C. Ped (C) the existing committee had strong Ontario representation, we have just included one member from Nova Scotia and one from BC. The committee members will soon be contacted in order to start discussing ideas and roles for the upcoming term. The new members are Benoit Boyer from Kintec and Terry Laurence from the Nova Scotia Rehabilitation Centre. Chair – Patrick Bergevin, 5 6 A Periodical of the Pedorthic Association of Canada Executive Director’s Report “We should be driven by ethics as principles, not rules to exploit for what you can or cannot get away with.” The above quote is from an advertisement that the CFA Institute has been running in Canadian magazines over the last two years. This quote should be applied to all Jonathan N. Strauss professionals, not just Chartered Financial Analysts. When members ask my opinion if something they are doing or want to do is “right” or “wrong” I often think of this statement. The way pedorthists practice should be driven by principals of ethics and not what is specifically written in the Code of Ethics (I in no way mean to suggest to ignore the Code; it is the authority) from The College of Pedorthics of Canada. If pedorthists and all other providers of healthcare services followed this statement I would not have spent the last couples of days representing the PAC at the annual conference of the Canadian Healthcare Anti-Fraud Association. Your success is defined in many ways by the ethics of your fellow pedorthists. All pedorthists need to follow ethical principals in order to ensure that the profession continues to be seen positively by referrers and insurers. If you don’t view the Code of Ethics in the way the quote described, I urge you to reconsider for your own benefit and for the benefit of your fellow pedorthists. The CFA Institute ad goes on to say: “A financial advisor who is a CFA charterholder has devoted years to intensive study, completed at least four years of relevant work experience, and passed three rigorous examinations. The designation represents a commitment to manage a client’s interests with integrity, a willingness to set for realistic expectations that are attainable, and a fundamental belief that principles are a not a luxury. They are everything”. The first sentence of the quote is very similar to the description we use for pedorthists. I hope that all pedorthists can confidently describe their work and the work of fellow pedorthists in the way the second half of the above quote does. For the profession to continue to prosper and grow pedorthists need to be seen as qualified and ethical and need to put the patient’s care first. I hope you will reflect on these quotes and discuss them with your colleagues. It is together that we will continue to cement pedorthists as the top choice for the services that you provide. I look forward to seeing all of you in Orlando! 7 Quarterly Pedorthics Pedorthic Association of Canada’s Position Statement on Casting Techniques for Custom Foot Orthoses Custom Foot Orthoses (CFO’s) are an essential element used by Pedorthists to relieve foot pain related to biomechanical misalignment of the feet and lower limbs. Orthoses can also accommodate foot deformities and redistribute forces applied to the foot. The aim of this position statement is to help clarify some of the rationale that may be used in choosing one casting technique over another. It is widely accepted in both the research and clinical literature that a three-dimensional model of the foot is required to fabricate a truly custom made device. Debate continues as to which three-dimensional casting technique is most effective. More specifically, each technique has its own merits and the casting technique chosen by a trained and certified clinician is but one component in a comprehensive treatment protocol. To choose one specific casting technique as the “Standard” is to ignore the expertise of the clinician and the needs of the patient. It is the opinion of the Pedorthic Association of Canada that it should be the judgement of the clinician as to when to use a specific threedimensional casting technique. Foam box casting requires a great deal of skill to be performed successfully and reliably and it is necessary for a trained clinician to be involved for casting and manufacture of an appropriate device. Contact Digitizing The use of contact digitizing employs the mechanical placement of many small pins to capture the plantar contour of the patient’s foot. When done correctly, the “Subtalar Neutral Position” or NCSP is maintained while the client’s foot is scanned into the software program where all modifications to the image of the foot are executed. This technique uses a milling machine to carve a foot orthosis from the corrected image. As with plaster casting and foam box casting, reliability is improved with education and practice. Laser Scanning Recent innovations in the use of optical laser scanning techniques have shown great promise. Combining the techniques employed in Plaster of Paris slipper casting with the functionality of computer modeling is designed to eliminate the reliance on messy plaster as well as speed turn around times by removing the need to modify models by hand prior to orthosis fabrication. At this time the accuracy of laser scanning has been shown to be equal to the other techniques, and can be prone to human errors if not completed by a properly trained clinician. Casting Techniques Our Position Slipper Casting (Plaster of Paris, Foot Impression Wax, STS Casting Sock) The use of a slipper cast has been employed for many years in the provision of CFO’s. Maintaining a “Subtalar Neutral” or Neutral Calcaneal Stance Position (NCSP) during the casting technique, the clinician is able to reproduce the position typically used to assess foot alignment. A negative cast is taken with either plaster, wax, or a polyurethane embedded sock. This is then used to yield a positive mould for further correction or modification before fabrication. This method works well in capturing the plantar contour of the foot, as well as the forefoot-to-rearfoot relationship. It does require a great deal of skill, and requires considerable training and practice to obtain reliable results from patient to patient. While some organizations may be attempting to limit the type of casting techniques used by clinicians and manufacturers of these custom made medical devices, doing so would put a limit on the skills and treatment palette available to the health care provider. It is the position of the Pedorthic Association of Canada that the limiting of accepted providers to those groups that exclusively dispense orthotic devices in conjunction with a referring practitioner would be a far more effective means of ensuring quality care and in controlling the provision of these devices. This would ensure the treatment of patients by professionals who retain a formal education in foot mechanics, pathology and treatment, and would eliminate the conflict of interest that can arise when the individual prescribing the device is also the individual providing the device. Semi-Weight Bearing Foam Box Casting The use of a semi-weight bearing casting technique, employing a low density foam block for capturing the three-dimensional contour of the foot is widely utilized by many foot care practitioners. It also employs the “Subtalar Neutral Position” or NCSP during the capture of the foot contour. This technique requires less cast dressing prior to manufacture of the foot orthosis, and is also useful when the patient requires an accommodative device, or is unable to maintain a prone or supine position due to injury or medical condition. 8 Fall 2010 The Position Statement on Casting is available online at www.pedorthic.ca Designed to limit stress at the areas of the foot most susceptible to pain, Ambulator Biomechanical Footwear provides unsurpassed comfort and protection with unique features such as SmartGrip™ slip-resistant polyurethane soles, state-of-the-art removable comfort orthotics and soft leather linings. Recently updated with eye-catching styles, Ambulator Biomechanical Footwear is often recommended for diabetes, arthritis or for those seeking a shoe that provides maximum comfort, stability and added protection. STOP BY AETREX PFA BOOTH 1303 AND MEET YOUR LOCAL CANADIAN REPRESENTATIVE New Mens/Woms O&P Amb Ad.indd 1 9/23/10 12:17 PM Quarterly Pedorthics Overview of casting techniques As pedorthists, we know that a BSc (Kin), C. Ped Tech (C), C. Ped (C) cast’s quality determines how successful the foot orthosis will be in alleviating the client’s symptoms. It has been determined that intra-caster reliabilities (using two different casting techniques) are better than inter-caster reliabilities.1 This means it is easier for a trained clinician to reproduce the same cast, while two clinicians are hard-pressed to achieve the same final product. Studies such as McPoil and Hunt2 have also indicated that finding subtalar neutral is less important than what we had originally anticipated. From the research we can summarize that it is the clinician’s job to master a few casting techniques to provide the desired level of care for their clients, whether that be in subtalar neutral or not, using full-weight bearing, semi-weight bearing, or a non-weight bearing casting method. The type of weight-bearing casting method (full, semi, non) is in large part easier to break down the casting techniques as opposed to what medium is being used. The different mediums being direct mould, foam box, wax and sand, computer-generated contact digitizer, plaster casting, plaster sock and computer-generated laser foot scan. In this article, I review the different methods and the mediums of foot orthoses casting. Each has pros and cons. It is up to the clinician to decide which of these techniques best suit their clientele and to master them. By Kim Nicoll, Full-weight bearing and semi-weight bearing casting Full-weight bearing casting is achieved in a standing position with the client using their own body weight to produce the cast. This method produces a fully compensated, closed kinetic chain cast impression in which the foot is not in subtalar neutral. It is used when cushioning is the goal and motion control is not of much concern. Examples of when this method could be chosen are a client with diabetes who has a Charcot Joint or a client with severe rheumatoid arthritis. Semi-weight bearing casting is achieved in a seated position with the hip, knee, and ankle all at 90° angles. This is still a closed kinetic chain, semi-compensated position. The most common method is to cast the foot in subtalar neutral. This is achieved by the clinician holding subtalar neutral by using one hand to landmark while the other hand externally rotates the client’s tibia. Semi-weight bearing casting allows the clinician more control in the foot positioning, which allows for an orthosis with more components of motion control. Semi-weight bearing casting has been used for clientele where the amount of correction has to do more with foot position, shell material selection, and posting principles. To capture both a full- and semi-weight bearing cast, a direct mould, foam box, wax and sand or computer-generated contact digitizer can be used; which medium a clinician uses depends on the criteria. 10 Fall 2010 Direct mould casting In the direct mould process, the heat-mouldable material used to cast the foot becomes the shell of the orthosis. The weight-bearing client may wear an insulated sock to protect the foot from the heat. The material is heated and placed on a foam block or in some sort of footwear. The client holds the foot in the same position until the material has cooled. For semi-weight bearing direct moulding, the big difference is that the clinician compresses the cast/shell material into the desired shape. This is more labour intensive and has a greater margin of error for optimal foot positioning. Options of making a more controlling shell are very limited due to the nature of the heat-mouldable materials that can be heated directly against the skin. Higher durometer materials need to be heated at too high of a temperature to allow direct molding against the foot. Moreover, common posting materials would be also be too high of a durometer to be used in conjunction with the materials used to make a direct mould cast/shell. This technique is used extensively in the retail industry, such as in ski shops. Advantages of direct mould •Quick method of orthotic manufacturing. •Good technique if a flexible device is required. •Very clean cast; not as messy as plaster. •Fewer supplies are required. •Can still work with the shell when it comes off the foot. •Inexpensive. Disadvantages of direct mould •Plantar pressure of the foam tends to supinate the foot around the longitudinal mid-tarsal joint axis, elevating the first and exaggerating a forefoot varus. •First and fifth rays can both “float” if the casting foam is too rigid. •Difficult to get the material tight to the foot, allowing too much tissue expansion. •Difficult to know if the mid-foot is locked and subtalar neutral has been obtained. •Must be aware of the temperature of the material before placing against foot. Foam box casting The foam box medium is one of the most common casting mediums in pedorthic clinics. When the clinician uses foam box in a full-weight bearing cast, the client places a foot lightly on top of the foam and slowly applies weight as the foot sinks into the foam. The clinician attempts to hold subtalar neutral in this process; however, this is difficult to achieve due to lack of strength to hold the desired position while the client is applying pressure. The full-weight bearing foam box method works great for rigid foot structures. Semi-weight bearing foam box is the more common of the two weightbearing techniques. Even though it takes the strength of the clinician A Periodical of the Pedorthic Association of Canada to push the foot into the foam, they can use different techniques to achieve their desired cast results. One of these techniques is the gait referenced casting, which was developed by Edward Glaser, DPM.3 For both weight-bearing methods, it is common to use “foam art” to modify the cast. For example, the clinician uses a finger to take away foam from an area of a bony prominence to increase offloading. Advantages of foam box casting •Fast and clean. •Easily transportable. •Adequate soft tissue displacement. •Good pressure from the foam helps load the lateral column. •Allows soft tissue expansion to occur. •Client can remain in chair for casting and does not have to get on a plinth. Disadvantages of foam box casting •Any positioning is usually lost with even partial weight bearing. •Force of foam can distort hyper-mobile forefoot alignment. •Poor visual confirmation of the foot position. •Too much help from the patient can distort the impression. Sand and wax casting The wax and sand medium is used in some pedorthic clinics. A thin sheet of wax is heated in water and placed on a metal tray that holds levelled sand. The client then stands or sits in front of the casting box and places the foot in the box until the wax has cooled. Once the wax hardens and becomes brittle, the cast is removed from the sand box and the client’s foot.4 This is a form of direct moulding. Advantages of sand and wax casting •Allows soft tissue expansion to occur. •Yields a positive that is extremely clean. •No clean-up on the patient. Disadvantages of wax and sand casting •Can be time-consuming. •Requires storage of the sand box and materials. •Clean-up is needed for any spilt sand. •Any positioning is usually lost with partial weight bearing. •Poor visual confirmation of the foot position. Contact digitizer casting The computer-generated contact digitizer is the technologically advanced casting method for full- and semi-weight bearing. This technique uses CAD/CAM software to obtain the three-dimensional cast. With the contact digitizer, the client stands on or sits in front of the unit and the digitizer elevates numerous pistons that contact the foot’s plantar surface. The 3-D image is then transferred electronically and viewed on a computer, where the image can be modified on the screen. This system is commonly used in pedorthic clinics. Advantages of contact digitizer casting •Accurate plantar contour measurement. •On-screen cast modifications with software. •No distortion by operator or materials between scan and fabrication of orthosis device. •Quick and clean scanning and manufacturing. •Cast storage and duplicate orthoses greatly simplified using available software. •Positive perception by client of the procedure. Disadvantages of contact digitzer casting •What you cast is what is manufactured; a poor cast is a poor orthosis. •Systems are quite heavy, making mobility difficult. •Expensive, especially if equipment fails. Misconceptions •Office scanners provide diagnostic information. •Result is more exact because it’s done with computers. •Technology replaces the skill of the practitioner. •CAD/CAM technology is only for large institutions due to cost. Non-weight bearing casting Non-weight bearing casting is achieved with the client lying prone, supine or in a seated position. Whatever position is used, the most common method is to cast in a subtalar neutral position. This is an open kinetic chain, in an uncompensated position. To achieve subtalar neutral, the clinician places their thumb between the sustentaculum tali and the medial malleolus with the index finger in the sinus tarsi cavity on the lateral portion of the talus. The thumb of the other hand locks the calcaneocuboid joint by applying a dorsiflexion force to the fourth and fifth metatarsal heads until resistance is felt in the ankle joint. When the client lies in a prone position, the clinician is best able to see the forefoot and rear foot position. However, prone position is harder for the client to manoeuvre into. The other method of casting in non-weight bearing is the hang technique,5 which is not used very often. With this method, the client lies supine or prone and the cast is taken with no loading of the forefoot, and subtalar neutral positioning does not occur. All types of orthoses can be produced from non-weight bearing casts. This method of casting is most used when motion control is the primary objective. Plaster casting Along with foam box casting, plaster casting is the other most common casting medium in pedorthic clinics and the medium used in the pedorthic certification exam. It requires the most skill in how to apply and position the foot in the desired alignment. Plaster casting allows a lot of control and flexibility in making the negative cast. 11 Quarterly Pedorthics Advanced casting techniques are commonly used that mimic what occurs with intrinsic posting. An example of this is pressing the medial calcaneus with the fleshy part of the palm while the plaster is drying, thus mimicking the Kirby Skive technique in rear foot intrinsic posting. Clinicians will commonly add pressure to the forefoot to obtain a tripod with the first, fifth and heel when the client has a flexible forefoot varus. Plaster casts are either a full-length slipper cast that covers the toes and will hold plaster to do a manual positive cast or a three-quarter slipper cast that is not as deep and does not include the toes. The three-quarter slipper cast is often done when a cast laser scanner is going to be used to make a computer-generated positive cast or shell. To achieve good and workable casts, training and time for the clinician are required. Advantages of plaster casting •Easy to manipulate the subtalar joint into a neutral position. •Can load the lateral column and neutralize longitudinal axis to provide good mid-foot and forefoot stability. •Good visual confirmation of foot position. Disadvantages of plaster casting •Need to modify positive model of cast to compensate for soft tissue expansion during weight bearing. 12 Fall 2010 •Requires water and creates a mess. •Can be time consuming. Common errors •Poor positioning of the subtalar joint: either too much pronation or too much supination. •Insufficient or excessive loading of the lateral column. •Allowing the metatarsal heads to elevate (and the toes to sag), which distorts the position of the first ray. Plaster sock casting The plaster sock medium is very similar in pros and cons to plaster casting. The plaster sock is one unit where the clinician matches the client’s foot size to the sock size. During the drying process, the plaster sock heats up and requires a plastic bag to act as a barrier between the foot and the cast. A plastic tube is inserted in the dorsal aspect of the foot and acts as a vacuum, taking away any air pockets. Once the cast dries, the clinician cuts the cast, usually where the channel tube was inserted, which allows the cast to come off easily. The socks come in many different heights. the most common used for orthosis being the slipper sock, which ends below the malleoli and covers the toes. Casting with the sock requires less manipulation of the wet plaster than with the strips, which allows for a tidy end A Periodical of the Pedorthic Association of Canada product. Once the clinician becomes familiar with the medium, this technique is very fast. Like plaster casting, the clinician can use advanced casting techniques and use a laser cast scanner after the negative is off the foot. Advantages of plaster sock casting •Easy to manipulate the subtalar joint into a neutral position. •Can load the lateral column and neutralize longitudinal axis to provide good mid-foot and forefoot stability. •Good visual confirmation of foot position. •Cast is one unit, less manipulation of wet plaster. Disadvantages of plaster sock casting •Need to modify positive model of cast to compensate for soft tissue expansion during weight bearing. •Requires water and creates a mess. •Storage required for casting materials due to different cast foot sizes. Common errors •Poor positioning of the subtalar joint: either too much pronation or too much supination. •Insufficient or excessive loading of the lateral column. •Allowing the metatarsal heads to elevate (and the toes to sag), which distorts the position of the first ray. Laser foot scanner casting Computer-generated laser foot scanner is the technologically advanced medium for casting in non-weight bearing. This technique also uses CAD/CAM software to obtain the 3-D cast. With any laser scanner, the clinician produces a digital image of the foot/cast using laser or white light. The laser foot scanner is not used regularly in pedorthic clinics. The pedorthist must either give up a hand to hold the device or work around a bulky piece of equipment to hold the foot in position. Most commonly, a cast laser scanner is used in lieu of the laser foot scanner. Advantages of laser foot scanner casting •Accurate plantar contour measurement. •On-screen cast modifications with software. •No distortion by operator or materials between scan and fabrication of orthosis device. •Quick and clean scanning and manufacturing. •Cast storage and duplicate orthoses greatly simplified using available software. •Positive perception by client of the procedure. Disadvantages of laser foot scanner casting •What you cast is what is manufactured; a poor cast is a poor orthosis. •Expensive, especially if equipment fails. Misconceptions •Office scanners provide diagnostic information. •Result is more exact because it’s done with computers. •Technology replaces the skill of the practitioner. •CAD/CAM technology is only for large institutions due to cost. As you can see, there are many different options of casting. Most pedorthists become great at casting either a semi-weight bearing or a non-weight bearing cast. Then they become good at the other weight-bearing methods. This way, the clinician can achieve any result they and their client like. Research indicates that introducing an orthosis will not necessarily change foot alignment to the degree we had originally thought, and that the use of an orthoses, is mainly to provide comfort to the client.6 So it is the client’s comfort level, which they associate with alleviation of pain, that determines if a pedorthist is doing his or her job well. The first step in orthosis fabrication is a great cast! References Trotter LC, Pierrynowski MR: “Ability of foot care professionals to cast feet using the non-weight bearing plaster and the gait-referenced foam casting techniques.” JAPMA 98: 1, 2008. McPoil TG, Hunt GC: “Evaluation and management of foot and ankle disorders: present problems and future directions.” JOSPT 21: 6, 1995. Decker W, Albert S (2002) Contemporary Pedorthics. Seattle, Washington: Elton-Wolf Publishing. Michaud, T.C. (1993) Foot Orthoses and Other Forms of Conservative Foot Care. Baltimore, Maryland: Williams & Wilkins. Nigg BM: “Impact forces and movement control - Two new paradigms.” PAC Conference April 15–17, 2005. Nicoll KD: PEDS 6012 Advanced Orthosis Systems. University of Western Ontario, 2010. Casting Definitions •Casting – The act or process of taking a 3-D impression of the foot. This can be done in a number of ways, e.g. off-weight-bearing slipper casts, semi-weight-bearing impression foam. •Subtalar Joint Neutral – The point at which one feels congruity of the medial and lateral edges of the talus to the calcaneus. •Lateral Column – Consisting of the calcaneus, cuboid, fourth and fifth metatarsal bones and the joints formed by these bones. When plaster casting we lock the lateral column to simulate the ideal stance foot alignment. •Negative Impression/Mould – The actual 3-D impression of the foot. This is used to produce a positive mould. •Positive Mould – The cast or mould made from the negative impression. This may be modified. This is the cast on which the orthotic shell material is formed to obtain the shape of the shell. 13 Quarterly Pedorthics Article Review: A Comparison of Four Methods of Obtaining a Negative Impression of the Foot By Michael Ryan PhD, C. Ped (C), Research Associate, University of Wisconsin Department of Orthopedics and Rehabilitation Original article by Laughton C, Davis IM, Williams DS. Journal of the American Podiatric Medical Association 2002; 92(5):261-268. The method a clinician uses to capture the foot for the provision of a functional foot orthosis has obvious importance. Clearly the shape of the orthosis to the foot with which it is matched must be similar; a failure of congruity can result in poor device performance, discomfort or injury. The pedorthic profession has maintained that three-dimensional (3-D) volumetric impressions are the gold standard in obtaining a negative of a client’s foot shape. However, there is some debate as to which 3-D impression method is best. For that matter, what defines “best” is itself subject to scrutiny. Do the best methods most accurately replicate a positive of the foot, or result in the best clinical outcomes? The long standing implication here is that the former will lead to the latter, but this has yet to be proven. Laughton’s robust study provides useful insights into these questions with their comparison of four different 3-D impression methods: plaster 14 Fall 2010 cast; partial weight bearing foam box; and partial- and non-weight bearing laser scans. Thirty feet from 15 subjects (12 women, 3 men) between the ages of 20 and 34 were used in their sample. The same physiotherapist performed initial clinical measurements of forefoot and rear foot width, and forefoot to rearfoot angle, using metric calipers with the subject lying prone - with impressive intra-tester reliability (r values not lower than 0.93). Each foot then underwent the four different negative impression methods after Velcro markers indicated the head of the first and fifth metatarsal bones and the bisection of the calcaneus. As their names suggest, laser scans were performed with the subjects either in a long-leg sitting position (with knees extended and ankles dorsiflexed) for the non-weight bearing scan, or sitting on a stool with hips, knees and ankles flexed to 90° for the partial weight bearing scan. The foam box impression was taken with the subject sitting on a stool with their lower extremity in the same flexed position while the tester applied a downward force on the knee and foot holding the subtalar joint position constant. The plaster cast was taken with the A Periodical of the Pedorthic Association of Canada subject lying prone with the examiner loading the mid-tarsal joint after the plaster of Paris splints had been applied. The subtalar joint was palpated while the cast was drying. All of the impressions were uploaded into an Automated Orthotic Manufacturing System (AOMS) software program (Sharpshape) which processed a 3-D graphical image of each foot’s contour. Numerical values were given for the same measures taken clinically (forefoot and rearfoot width, and the forefoot to rearfoot angle). Statistics were performed to determine: a) whether any of the respective values from each of the impression methods differed from each other, b) how reliable each measure was when captured from each impression method, and c) how closely the measures from each impression method were compared to those measures taken clinically (a test of validity). The results certainly have a bearing on clinical practice. The major findings were: •All impression methods significantly overestimated (by as much as 9mm) the “true” rearfoot width (i.e. the measure taken clinically using calipers), except the plaster cast which underestimated it (by on average 1.9mm). •The plaster cast, foam box and non-weight bearing laser scan all significantly overestimated forefoot width (by as little as 1.7mm for the laser scan and as much as 3.4mm for the foam box) relative to the clinical measure. •NONE of the impression methods differed significantly from each other, or relative to the clinical measure, for the forefoot to rearfoot angle. •All methods had excellent reliability in capturing rearfoot and forefoot width. •Only plaster and partial weight bearing laser scans had excellent reliability capturing the rearfoot to forefoot angle, and only these two methods had good reliability in capturing arch height. At its most basic level, a negative impression should do two things: accurately capture the shape of the foot (to minimizing device discomfort) and accurately capture the relationship between the forefoot and the rearfoot (to maximize device effectiveness at addressing foot malalignment). Based on the results from Laughton’s study, all of the impression methods have their limitations when it comes to replicating foot shape, particularly at critical areas such as forefoot and heel width. The authors had predicted that the plaster impression method would produce smaller width values as the tissue is being compressed upon application. While none of the impression methods differed statistically in their ability to produce accurate forefoot to rearfoot angles, values from the plaster cast method had the closest agreement with those derived from clinical measurement. Based on this strong forefoot to rearfoot angle agreement and robust reliability in capturing rearfoot and forefoot widths, the authors recommended plaster casting as the most valid and reliable method of taking an impression of a foot in the design of a functional orthosis. It is worth mentioning limitations within Laughton’s study to put the outcomes in perspective. As the authors themselves acknowledge, it would have been beneficial to take the impressions one step further and construct a device taken from each method. Subject-centered evaluation of the support and comfort from the device could then be included, without which we are left to make assumptions of the clinical effectiveness stemming from high scores in each of the parameters in this study. In addition, this study assumes that caliper-based measurement of the non-weight bearing foot is accurate for estimating the validity of a device that is used in a weight bearing context. Nevertheless, the outcomes from Laughton’s paper serve as an effective reference for the global limitations that may be experienced with each of the four impression methods used. Of course, as impression methods evolve to make use of better laser and optical scanning technologies, updated research in this area will most certainly be needed. Member Profile Becoming a pedorthist was, quite literally, in Casey Bjorgum’s blood, as her family has now been in the industry for three generations. After studying Kinesiology at the University of British Columbia, Casey moved fully into a career at Generation 2 Orthotics, which was a family-owned business before it was purchased by Össur. The company had originally been owned by Casey’s grandfather and father, and even before Casey Bjorgum she had completed her studies, she seemed destined to continue in the family practice. “I was doing knee-bracing and odd jobs through university, and then as soon as I was done, I started training for pedorthics,” she says. “I was always around it. It always looked very interesting to me.” Her path began simply enough by job shadowing and as she began to take a more active role at Generation 2, she felt confident enough that this was her destined career. Rather than take physiotherapy, she continued in what she describes as an apprenticeship before pursuing certification in pedorthics. Working with family, as anyone who has gone on such a career path, can be strenuous at times as attitudes can change from when a son or daughter is a helping hand to being a fully-certified professional. Casey comments that this wasn’t the case at all, however, working with her father. “I don’t think he looked at me any differently at all,” she says with a laugh. “He was always pushed me quite a bit, which was good, and he was always there if I had any questions.” That dynamic changed, however, when the family business was bought out. No longer having her father with her in the company meant that she would be going forward, in essence, on her own; but rather than shy away from her new surroundings, Casey embraced the change. “It was quite different when Össur bought out G2,” she says. “It was 15 Quarterly Pedorthics a little bit different not having him there, but I think it was good because I gained my independence. It was a different transition but it has been positive for me.” Despite the change in company, Casey has found that the two companies have similar goals, in that they are both very patient driven – committed to ensure that their clients have successful outcomes, ensuring that patients leave her care happy. Another element that hasn’t changed is her location. Throughout her career, Casey, who was recently married, has stayed close to home (admitting that a major factor in her decision to do her training at UBC was the proximity), and for several reasons, has chosen to stay on the west coast. “To be quite honest I consider myself very lucky to live in what I consider to be one of the most beautiful cities in the world,” she says. “I would be crazy to leave a city where I can ski on Saturday and golf on Sunday. How great is that?” Being in B.C. also gave Casey a once-in-a-lifetime opportunity this past winter, as Össur worked with several athletes during the 2010 Winter Olympic and Paralympic games. “It was a great challenge to work with such high caliber athletes who take such an active interest in their bodies and their overall health,” she says. “It was a hugely positive and motivating experience for me!” Member Profile As a student at the University of Western Ontario, Vanessa Carnovale had no idea that her career would turn out the way it has. Young Vanessa, however, can hardly be blamed for this. After all, the success that she has now enjoyed with BioPed is an amazing feat. In actuality, Vanessa seemed destined for a career in chiropractics when she caught sight of a booth about pedorthics at a job Vanessa Carnovale fair UWO was hosting. “There was someone there from Pedorthic Services who was discussing the new pedorthic program that was going to be available at Western, and it was through that discussion that I decided to apply to the program,” she recalls. Despite already being registered for chiropractic college (a program that she went on to complete), Vanessa spent that summer in the pedorthics program, and upon completion of her in-class time in the chiropractics program, she did her clinical hours in pedorthics. After completing her studies at UWO (based in London), Vanessa moved back to her hometown of Etobicoke, and immediately began working with the same company she is with today. “There was a job opening at the BioPed Scarborough location. One of the employees had gone on maternity leave,” she recounts. “Once I had stopped filling in I decided to stay.” 16 Fall 2010 Vanessa would continue at the Scarborough location for two-anda-half years before the company came with the call for her to move to BioPed’s head office in Oakville. The position now brought on a new dynamic to Vanessa’s career, one that hadn’t crossed her mind. “If you’re in university you always think there’s a career path for yourself that’s very specific, and then once you’re actually out in the workforce, you tend to realize there’s other things that also interest you,” she explains. “This is a good way to incorporate the clinical as well as what I would now consider to be an interest in business.” Of course, with the shift in her career, so too has the composition of her daily life in pedorthics. What was once a fairly regular schedule now sees Vanessa assuming various duties in any given week. “I’d say no two days are alike,” she says. “Originally I was doing allclinical work and managing a centre, but now I’m doing everything from medical education to conducting a large number of seminars on a yearly basis for family physicians as well as other referring professionals. “I’ve spent a lot of my days supervising medical representatives and I’ve spent other days training a lot of our pedorthists in new processes and providing them with further clinical education.” But is there one segment of her portfolio that sticks out to more than others? “The one I probably enjoy the most is working with our franchisees and sharing ideas of best practices,” she remarks. The franchisees she refers to are primarily across Ontario, but there are also BioPed outlets in Surrey, B.C., Bedford, Nova Scotia and Moncton, New Brunswick. This has meant that Vanessa has added another aspect to her job – travel, which takes her out of BioPed headquarters for the majority of the work week. “I could be anywhere from Oakville to B.C.” she says. “Whenever a centre requests that I come out and assist them or provide a presentation to their physicians, they’re booked into my calendar and off I go.” When she does have spare time, Vanessa enjoys spending time with her family and friends, travelling and salsa dancing. Stocking Your Pedorthic Toolbox Pedorthic Symposium The PAC Symposium is returning to Ottawa, Ontario, March 25 – 27, 2011! This year’s Symposium, Stocking Your Pedorthic Toolbox, will provide attendees with knowledge that can be taken home and immediately applied in their everyday practice. The theme will focus on current concepts, footwear, business development, multidisciplinary approaches, and new clinical research. A Periodical of the Pedorthic Association of Canada How proactively are you building your reputation capital? By David Nour, Author – Relationship Economics and Keynote Speaker at the 2010 North American Pedorthic Congress Keynote Speaker Reputation: 1a: overall quality or character as seen or judged by people in general b: recognition by other people of some characteristic or ability or 2: a place in public esteem or regard: good name. Merriam-Webster Dictionary When it comes to business relationships, one of the foundational components to elasticity in your success is your reputation capital: the quantifiable and strategic significance of the value you’ve promised and delivered, consistently over a period of time. By the way, this isn’t speed dating! By definition, the development, nurturing, and protection of this reputation – in essence, the building of your reputation capital – is an investment of time, effort and resources (human and capital). It also has comparable value as your reputation is often compared to those of others at equal or greater business stature. I equate this to building a house. Few will recognize the painstaking labor of love dedicated to the intricate details and investments you make in beams and supporting infrastructure, or the long-term viability, sustainability and protection you expect for you and your family. It’s a far greater asset than a simple structure; it’s a home you’re proud to call yours. Regardless of the investments you make in building your home, it will always have a comparable value. If the street or neighborhood is perceived to be undesirable, your home will likewise suffer from reputation by association. Similarly, the business relationships you painstakingly invest time, effort and resources in to develop over the years, whether you like it or not, directly contribute to your reputation capital. The employees you attract, the suppliers you utilize, and the customers and investors you serve all contribute to your reputation capital. One of the biggest challenges with reputation capital is that very few executives really know how they are perceived! And you simply can’t do anything about a reputation you’re unaware of. In working with clients such as Disney, Siemens, Assurant, HP and KPMG to name a few, we’re coaching the next generation of leaders in a proactive, systematic, disciplined process to develop, nurture and leverage their reputation capital. They understand that corporate reputations are earned daily by the market’s perception of the value their respective companies delivered from their promises yesterday, and the realistic expectations of what these organizations will deliver tomorrow. So what are the key ingredients of building, validating, and fostering your reputation? 17 Quarterly Pedorthics The image of the industry you work within: Beyond products, services, and even brands, keep the focus of the industry on the overall experience or perception based on a degree of confidence in predictability of behavior (“what you’re going to get”). Also, be aware of guilt by association – missed opportunities to engage and transform typical transactions into memorable relationships. Your corporate image and identity: “Image” is a person’s beliefs about an organization and “identity” is the attributes used to describe the organization. For example, Character describes organizational culture & competitiveness; Ability describes the CEO, employees, and resources; Products & Services are evaluated by quality, value, and range; Behavior is defined by leadership and profit. All of this is based on the individual’s relationship with the organization, its past behavior, and what other people have said about it. Your stakeholders: Values and perceptions vary greatly by how much the organization’s character, respective beliefs and values about appropriate corporate behavior are aligned. Stakeholders are becoming more sophisticated as they look for their expectations to be exceeded, not simply met. Customers are looking for dependable products and services today and an organization to fix them when they are broken tomorrow. Employees are looking for a salary today and skills development and reserved funds for retirement tomorrow. Investors are interested in meeting today’s cash flow requirements while building equity and increased shareholder value tomorrow. Individual reputations are often described in terms of esteem, respect, trust, and confidence (or lack thereof). The outcome of the perception from the above ingredients is inherently simple: Good or Bad. The results of one forming an opinion from this perception is the notion that it’s “safe” to do something with you or your organization such as apply for a job with your firm, buy your products or services, purchase your stock, or invest in your company and not boycott you during times of crisis. According to Professor Thomas J. Kosnik at the Harvard Business School, visibility and credibility are the key components of measuring an organization’s reputation. Similarly, your visibility in the marketplace, measured by the number of quality and diverse stakeholders who are aware of your characteristics and capabilities, as well as your credibility, which is the quality of your reputation amongst those who know it, determines your current market reputation. Recent college graduates often have low visibility and credibility – they simply haven’t had the chance to earn it yet. As such, their reputation is predominately unknown. With increased visibility, your reputation becomes unparalleled. An undesirable scenario is a highly visible role with a diverse group of stakeholders, but low credibility in the perception of your vision or ability to execute. So, when considering an individual, team or organization’s reputation, what are the sources of these reputations and the quantifiable outcomes of reputation capital? An individual’s reputation comes from personal characteristics, (when was the last time you did a personal SWOT – strength, weakness, 18 Fall 2010 opportunities and threats – specifically around your reputation?), professional development efforts, non-working activities, and the company you keep! The quantifiable returns become individual and peer-level recognition, broader appeal and visibility / more interesting and demanding work, personal & professional growth, and personal rewards for performance. A team or group’s reputation is derived from HR practices which determine how the team recruits, develops, rewards, and terminates its employees; clear goals and objectives (KPIs) of the team; a clear understanding of “part” of bigger objectives; and the executioncentric skills of the team leader. Reputation capital dividends include business unit, departmental, or company-wide recognition; current “A Players” attracting other A players; reduced involuntary attrition and cost of position replacement; captured and shared best practices; and strong intra-company relationships that attract resources (both capital & human). The organization derives its reputation largely through the personalities of the senior management, shared corporate values, and the financial stewardship of the organization. Viable examples include Steve Jobs’ consistent knack for innovation at Apple, Johnson & Johnson’s credo, IBM’s values including respect for the individual, customer service and commitment to excellence, and HP’s seven corporate objectives including profit, customers, field of interest, growth, people, management and citizenship. The quantifiable value of reputation capital at an organizational level can manifest itself in preferential access to market opportunities previously deemed improbable, unconditional support in times of business crisis, and lifelines when the bottom falls out of your company. So, I ask you again, how proactively are you building your reputation capital? Join me at the 2010 North American Pedorthic Congress in Orlando, Florida to learn more. http://www.pedorthiccongress.org © 2010 The Nour Group, Inc. All Right Reserved. David Nour is a Keynote Speaker at the upcoming North American Pedorthic Congress in Orlando, Florida. For more information, please visit www.pedorthiccongress.org PAC Membership invoices will be sent out in November. Check your inboxes. Membership payments will be due by January 1, 2011 FINN PAC NOVEMBER 2010.pdf 16/09/2010 5:34:48 PM The Finest Walking Shoes On Earth. Savannah Finn Comfort shoes are meticulously handcrafted in Germany. Renowned for their supreme comfort and unparalleled orthopedic support, Finn Comfort footwear comes highly recommended by leading health professionals worldwide. All Finn Comfort footwear feature removable footbeds for custom orthotics. Pretoria Finnamic’s gentle rocker soles promote natural rolling motion when walking yet provide both stability and comfort when standing. Prevention Footwear by Finn Comfort offers numerous features and benefits which address the problems of tender and pressure sensitive feet. 96103 Exclusive Canadian distributor: Tel: (450) 625-8511 Fax: (450) 625-8895 E-mail: [email protected] Visit our web site: www.serum.ca www.pedorthiccongress.org PEDO R T H I C S & the 2010 North American Pedorthic Congress Thursday, November 18 to Sunday, November 21, 2010 H ilton Walt Disney Wor ld R esor t, Or lando, Flor ida