Instability Footwear - Pedorthic Association of Canada

Instability Footwear
FALL 2012
03
President’s Message
04
OPREG – The regulation of
pedorthists in Ontario
04
Walking in Unstable Footwear –
A Critical Review
07
Living Without the Gift of Pain:
A Peer-led Educational Program
for Preventing Diabetic Foot Ulcers
11
Instability Footwear and Orthoses
Interaction
13
Are you ready to rock?
Contraindications and indications
of stable vs. unstable rocker
bottom shoes
15
Rocker Soles in the Lab
16
Member Profiles
A Periodical of the Pedorthic Association of Canada
A Periodical of the Pedorthic Association of Canada
fall 2012
President’s Message
ryan robinson, C. Ped Tech (C), C. Ped (C)
Throughout this year’s Summer Olympics, I noticed a number of
Pedorthic related items. There were the various types of shoes
the athletes were wearing (or not wearing in the case of beach
Publisher Information
Pedorthics Quarterly
A Periodical of the Pedorthic Association of Canada
volleyball), Kinesiotaping, various knee and ankle braces, and talk
of the various conditions that the athletes were suffering from.
One of the most inspiring parts of the Olympic games is how
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hopeful that the international community would begin to see Rwanda in a more positive light.
Pedorthic Association of Canada
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The Games gave Adrien the opportunity to share not only his individual spirit but also the
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the athletes from different countries and different backgrounds come together and the
opportunities the games provide everyone. From this year’s games, the story of 25-yearold Adrien Niyonshuti, a mountain biker from Rwanda was particularly inspiring. Forty of
Adrien’s family members were killed in the 1994 genocide including 6 brothers and sisters.
He carried the flag in the opening ceremony and despite finishing in second last place, he was
pride he has in his country.
This fall Jonathan Strauss and myself attended the International Association of Orthopaedic
Footwear (IVO) conference in France on behalf of PAC. IVO is an international group of foot
Communications Committee
experts from around the world and PAC became members of this group last year. Member
Chair
countries include Germany, the Netherlands, Australia, Japan, USA, and many more. PAC
Nancy Kelly, C. Ped Tech (C), C. Ped (C)
gained membership with IVO to share with and gain knowledge from those practicing pedorthics
throughout the world. PAC has seen many benefits of partnering with our sister organizations
the US and in Australia, including joint conferences and educational opportunities, knowledge
Vice Chair
Amy Guest, C. Ped (C)
sharing with a broader base of professionals in both individual practice techniques, and on a
Committee Members
larger scale, promoting the profession nationally and internationally.
Alex Whyte, C. Ped (C)
Crystallee Ripak, C. Ped (C)
Grace Boutilier, C. Ped Tech (C), C. Ped (C)
Jim Pattison, C. Ped (C)
Michael Ryan, C. Ped (C), PHD
Tavish Lahay-Decker, C. Ped (C)
A major reason for attending the conference was to support our bid to host the 2018 IVO
Congress here in Canada and I am proud to say we were successful. This will be like hosting
the Olympics for foot specialists! (okay, okay maybe I’m getting a little carried away). However,
hosting the 2018 IVO Congress will give our members access to a prestigious conference and
educational opportunities close to home. For more information on past IVO conferences, I
encourage you to visit the 2012 Conference Page, www.ivo2012.org.au. I am excited about
the prospect of putting a spotlight on Pedorthics in Canada, and the opportunity to show the
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world how we do things here in our home and native land.
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3
Ontario Pedorthic Regulation
Exploratory Group (OPREG) –
The regulation of pedorthists
in Ontario
matthew quattrociocchi, C. Ped (C), OPREG Chair
Walking in Unstable Footwear –
A Critical Review
Derek Kivi, Ph.D
In recent years, unstable footwear has become popular and highly
marketable for shoe manufacturers.
Also known and “toning” or
“physiological” footwear, they have a distinct rounded sole with a
2012 has been a very slow year for OPREG in its pursuit of legislated
compressible rearfoot section which promotes instability during gait.
health regulation for pedorthists in Ontario.
The formal regulatory
These design characteristics attempt to simulate an unstable surface, such
process through the Ministry of Health and Long Term Care has become
as walking barefoot or on sand. Theoretically, this instability increases the
completely stagnant with, seemingly, no movement in site for a few years.
level of muscular contraction in various muscle groups while standing,
However, with 2013 quickly approaching there are a few glimmers of hope
on the horizon in the pursuit of legislated health regulation for Ontario’s
walking, or performing other activities which will improve posture and
gait, and enhance energy expenditure (Romkes et al., 2006).
pedorthists. OPREG has been diligent in maintaining political ties with
Masai Barefoot Technology (MBT) of Switzerland originally developed
some key groups, including, the Ontario Association of Prosthetists &
this type of footwear in 1996. More recently, other shoe manufacturers
Orthotists (OAPO), the College of Chiropodists of Ontario (COCOO) and
(Sketchers, Reebok, New Balance, etc.) introduced their own versions.
their political consultant Mr. Don Gracey, and the Transitional Council of
Because of their high marketability, many claims have been made
the College of Kinesiologists of Ontario (TCCKO) in an effort to maintain
regarding the purported benefits, both scientific and anecdotal.
open lines of communication and not miss potential opportunities to work
footwear practitioners, it is important to have an understanding of the
together with these groups in achieving regulation.
benefits of this type of footwear during gait as proven through empirical
In early September OPREG had a meeting with the registrar of the
TCCKO, Brenda Kritzer, to discuss potential collaborative relationships
that would see pedorthists regulated through some extension of the
College of Kinesiologists of Ontario. The meeting was very productive as
we discussed different scenarios for pedorthists in Ontario. Ultimately,
however, we need to give the TCCKO time to finish its transitional
mandates before real action can be taken into investigating a relationship
between the pedorthists and the Kin college in the future.
For
research, as well as the changes in the lower extremity kinematics and
kinetics that result from their use. This article will review the scientific
literature on unstable footwear and their effects on gait, including
kinematics, kinetics, muscle activation, and physiological response.
Kinematics
When walking in unstable footwear, Romkes et al. (2006) reported changes
in various temporal parameters, with cadence, walking speed, and step
length all decreasing significantly as compared to regular footwear.
One strong recommendation from the TCCKO was that all pedorthists in
The authors also found that stride time and single support significantly
Ontario that are Kinesiology graduates become members of the Ontario
increased for the unstable footwear condition. In comparison, Demura
Kinesiology Association (Certified Kinesiology designation) and eventually
et al. (2012), who compared gait characteristics when walking in unstable
the College of Kinesiologists of Ontario. Having a strong contingent of
footwear, flat-bottomed footwear and barefoot, found no differences
members from within the college will give our group a much stronger
in cadence, walking speed, and step length between the two footwear
voice when working to find an avenue for regulation.
conditions. When barefoot, the participants walked with a slower speed,
OPREG and its members are available to assist any of you if you have any
questions or concerns. Please email us from our “Contact” page at www.
opreg.ca.
faster cadence, and with shorter steps than with the two types of footwear.
The differences seen between these two studies may be explained
by the fact that Romkes et al. used MBT footwear and provided their
participants with a 1 hour session with an MBT-certified trainer to ensure
proper MBT walking technique. This was followed by at least 4 weeks of
walking with the footwear prior to data collection. Conversely, Demura
et al. utilized “Stretch Walker” unstable footwear, and without providing
any instruction, allowed their participants 10 minutes in each footwear
condition to familiarize themselves prior to data collection. The footwear,
instruction, and/or familiarization period may have all contributed to the
changes seen in the temporal gait parameters.
When examining the kinematics at the ankle, increased dorsiflexion has
been reported during the initial portion of the stance phase wearing
unstable footwear (Nigg et al., 2006; Romkes et al., 2006). Taniguchi et
al. (2012) also found increased dorsiflexion in terminal stance. These
changes to the sagittal plane movements at the ankle can be attributed
to the rounded sole shape. One important kinematic gait variable that
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is notably absent from the scientific literature is the measure of subtalar
range of motion (inversion and eversion angle) when walking in unstable
footwear. Considering this footwear is designed to promote instability
not only in the sagittal plane but also the frontal plane, this omission is
4
A Periodical of the Pedorthic Association of Canada
fall 2012
significant. Research completed in our lab and presented at the 2012
change muscle activity compared to a
PAC symposium in Whistler (Kivi, 2012) showed that eversion angle is
regular shoe, and that walking barefoot
significantly greater when wearing unstable footwear as compared to
increased muscle activation to a greater
barefoot walking, with no differences seen in inversion angle. The result
extent than when wearing unstable footwear. Again, the methodological
was a significantly greater total range of motion. Further research into this
differences among these articles may explain the results. Although all
important gait parameter is required.
three studies used the same type of footwear (MBT), Sacco et al. (2012)
The research is inconclusive regarding the kinematics at the hip and knee
when walking with unstable footwear. Nigg et al. (2006) reported no
changes in the kinematics at the hip and knee, however, Taniguchi et al.
(2012) found a significant decrease in knee extension angle in the early
part of the stance phase and a decrease in the angle of hip extension.
Similarly, Romkes et al. (2012) reported that the range of motion at both
the hip and knee was reduced when walking with the unstable footwear.
These results may be related to the decreased step length reported by
Romkes et al. MBT promotes a specific technique for walking in their
footwear. Considering these three of these studies involved the use of
MBT footwear and the participants were all instructed in proper technique
by an MBT instructor, it is interesting that only two found kinematic
changes at the hip and knee.
did not provide instruction to their participants. The other two studies
did offer instruction on MBT technique. Romkes et al. (2012) suggested
that the increase in muscle activity found in the gastrocnemius and tibialis
anterior muscles could provide stability and therefore cold be used to
strengthen the leg muscles. Nigg (2009) stated this type of shoe should
be considered a training device. Considering the lack of consistent results
regarding muscular activity during gait when wearing unstable footwear,
these recommendations may not be substantiated.
Physiological Response
The energy requirements during gait while wearing unstable footwear
has been the focus of a limited number of studies. Gjovaag et al. (2011)
examined oxygen uptake and energy expenditure during treadmill walking
while wearing unstable footwear and jogging shoes. Comparisons were
made between self-selected and fast walking speeds, and at zero and
Kinetics
Similar to the kinematics, there is little agreement within the research
regarding the lower extremity kinetics. Walking in unstable footwear has
been shown to reduce the joint moments at the hip, knee, and ankle in the
sagittal plane (Vernon et al., 2004), however, Nigg et al. (2006) reported no
significant differences in the angular impulses at the hip, knee, or ankle
between the unstable and stable shoe conditions. Nigg (2009) speculated
that the inherent instability of the footwear results in muscle activity
which is constantly alternating, which may function to reduce the joint
loading due to muscular co-contraction. He noted, however, that there is
no direct empirical evidence to support this.
Sacco et al. (2012) found that walking in unstable footwear resulted in
higher vertical ground reaction forces as compared to walking with a
standard shoe or barefoot. This was seen in a larger first vertical peak and
weight acceptance rate. In comparison, Taniguchi et al. (2012) reported
10% inclination. No differences were seen in the physiological measures
between the two types of footwear when walking on the flat inclination
at either speeds, however, the unstable footwear was found to increase
oxygen consumption by approximately 5% and energy consumption
by 6% during fast uphill walking. These increases were found to be
significant, however, the researchers noted that the clinical relevance of
the findings may be negligible when related to body weight regulation or
reducing body fat. More recently, Demura and Demura (2012) examined
the physiological effects of treadmill walking with two different brands
of unstable footwear (MBT and Stretch Walkers), with comparisons to
regular footwear. Oxygen consumption was found to be largest when
wearing the regular footwear, and no significant differences were seen
in heart rate and rating of perceived exertion among the three test
conditions.
that there is a reduction in the ground reaction forces for unstable
Summary
footwear, particularly in the early stance phase. These authors suggested
The lack of agreement among the various studies indicates that more
that the footwear may be effective in shock absorption, but this statement
research is needed before recommendations should be made regarding
is not supported by the results of both studies.
the use of this type of footwear. In many cases there are too many
The in-shoe pressure distribution when walking in unstable and flatbottomed footwear has been examined (Stewart et al., 2007).
Four
regions of the foot were measured: toes, forefoot, midfoot, and hindfoot.
The results showed a 21% reduction in peak pressure under the midfoot
and an 11% reduction in pressure under the heel. A 76% increase in
pressure was seen under the toes. This suggests that unstable footwear
may be appropriate when there is a need to reduce the pressure in the mid
and hindfoot, however, they should not be recommended when reducing
forefoot and toe pressure is required.
Muscle Activity
Increased muscle activity in the lower extremity has been purported as
being one of the benefits of unstable footwear. Nigg et al. (2006) did not
find significant increases in muscle activity during gait when comparing
unstable footwear to a stable control shoe, although “trends” of increased
muscular activity were noted. Romkes et al. (2006) reported increases in
the activity in the tibialis anterior and gastrocnemius muscles, however,
methodological inconsistencies, including differences in the brands of
unstable footwear used, whether or not instruction was provided on
“proper” walking technique, or the duration of the familiarization period
provided prior to testing, which makes it difficult to directly compare the
research and formulate conclusions. Most of the studies completed to
date have involved the Masai Barefoot Technology (MBT) shoes, as the
company has provided footwear and/or financial support for much of the
research. This company should be recognized for this, however, further
independent research is also required. Future research should include an
examination of the long-term implications of the use of unstable footwear
and their effects on gait.
References
Demura, T. & Demura, S. (2012). Physiological responses during treadmill walking at a
constant speed while wearing shoes with a rounded soft sole in the anterior–posterior
direction – oxygen intake, heart rate, and ratings of perceived exertion. Footwear
Science, 4(1), 45-49.
Sacco et al. (2012) found that walking in an unstable footwear did not
5
Demura, T., Demura, S., Yamaji, S., Yamada, T. & Kitabayashi, T. (2012). Gait
characteristics when walking with rounded soft sole shoes. The Foot, 22(1), 18-23.
Gjøvaag, T., Dahlen, I., Sandvik, H. & Mirtaheri, P. (2011). Oxygen Uptake and Energy
Expenditure during Treadmill Walking with Masai Barefoot Technology (MBT) Shoes.
Journal of Physical Therapy Science, 23(1), 149-153.
Kivi, D.M.R. (2012). The effects of physiological footwear on the kinematics and kinetics
of gait and static balance. Presentation at the 2012 PAC Symposium, Whistler, BC.
Nigg B.M. (2009). Biomechanical considerations on barefoot movement and barefoot
shoe concepts. Footwear Science, 1(2), 73-79.
Nigg B.M, Hintzen, S. & Ferber R. (2006). Effect of an unstable shoe construction on
lower extremity gait characteristics. Clinical Biomechanics, 21(1), 82-88.
Romkes, J., Rudmann, C. & Brunner, R. (2006). Changes in gait and EMG when walking
with the Masai Barefoot Technique. Clinical Biomechanics, 21(1), 75-81.
Sacco, I.C., Sartor, C.D., Cacciari, L.P., Onodera, A.N., Dinato, R.C., Pantaleão, E.,
Matias, A,B,, Cezáriom F,G,, Tonicelli, L.M., Martins, M.C., Yokota, M., Marques, P.E.
& Costa, P.H. (2012). Effect of a rocker non-heeled shoe on EMG and ground reaction
forces during gait without previous training. Gait and Posture, 36(2), 312-5.
Stewart, L., Gibson, J.N. & Thomson, C.E. (2007). In-shoe pressure distribution in
“unstable” (MBT) shoes and flat-bottomed training shoes: a comparative study. Gait
and Posture, 25(4), 648-651.
Taniguchi, M., Tateuchi, H., Takeoka, T. & Ichihashi, N. (2012). Kinematic and kinetic
characteristics of Masai Barefoot Technology footwear. Gait and Posture, 35(4), 56772.
Vernon, T., Wheat, J., Naik, R. & Pettit G. (2004). Changes in gait characteristics of a
normal, healthy population due to an unstable shoe construction. The Centre for Sport
and Exercise Science. Sheffield Hallam University, UK.
6
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This work-to-own opportunity is a great way for a responsible, experienced
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We will also entertain offers to purchase.
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please fax a letter of introduction to (519) 579-8469
or by email: [email protected]
A Periodical of the Pedorthic Association of Canada
fall 2012
E D U C A T I O N A L
P R O G R A M S
Reprinted with permission from: Botros M, et al. Living without the gift of pain: A peer-led educational program for
preventing diabetic foot ulcers. Wound Care Canada. 2012;10(3):16-18. © Canadian Association of Wound Care.
Living Without the Gift of Pain:
A Peer-led Educational Program
for Preventing Diabetic Foot Ulcers
“God’s greatest gift to mankind is pain. Insensitive feet have lost the warning signal that ordinarily
brings a person to their doctor.” – Paul Brand MD, orthopedic surgeon1
BY
MARIAM BOTROS
DCH IIWCC
M. GAIL WOODBURY
PHD BSCPT
JANET KUHNKE BSN
MS ET
MARC DESPATIS MD
MSC FRCS
ANDREA MARTIN
Mariam Botros,
Foot Specialist, Clinical
Coordinator, Wound
Healing Clinic, Women’s
College Hospital,
Toronto, Ontario
Introduction
iabetic foot ulcers represent a significant
medical and financial burden to the
healthcare system. It is estimated that
15–20% of people with diabetes will
develop a foot ulcer during their lifetime.2
Additionally, foot complications account for longer
hospital stays than any other complication of diabetes.2 Furthermore, diabetes is the most common
cause of non-traumatic lower-limb amputation,
occurring in approximately 20% of people with diabetic foot ulcers.3
D
Foot ulcers and educational programs
Education for people with diabetes regarding proper
foot care, especially for those who are at high risk, may
help prevent diabetic foot ulcers and amputations.6
Education has been shown to
improve people’s foot care knowlFIGURE 1
edge
and behaviours, although
Process of teaching people to manage their diabetes9
more research is required to
determine whether these improvements are sustained over the long
term. In addition, the best type of
educational format – with respect
to effectiveness and sustainability –
has yet to be determined in this
high-risk group.7
M. Gail Woodbury,
Toronto, Ontario
Janet Kuhnke,
Kingston, Ontario
Marc Despatis,
Vascular Surgeon,
Centre Hospitalier
Universitaire
de Sherbrooke,
Sherbrooke, Quebec
Andrea Martin,
Coordinator,
Diabetes, Healthy Feet
and You Project, CAWC,
Toronto, Ontario
16
Neuropathy and foot ulcers
Approximately 40–50% of people who have had
diabetes for 10 years or more are affected by sensorimotor polyneuropathy.4 This condition causes
decreased sensation, and is associated with an
increased risk for complications such as diabetic foot
ulcers and lower-limb amputation.5
Wound Care Canada / Volume 10, Number 3
Self-management education
and diabetes
There is a growing utilization of
self-management education in
chronic diseases in general and in
diabetes specifically.8 The aim of
self-management education is to
increase individuals’ self-confidence and foster their motivation
to control their disease.
Empowerment is an essential
cornerstone of the self-management educational model, as it
allows participants to feel accepted
Soins des plaies Canada / Volume 10, numéro 3
7
and explore further aspects of their disease management. In addition, self-management facilitates the
active involvement of all parties (e.g. patients and
healthcare professionals) in the education process.
Educational approaches that increase individuals’
participation and collaboration in decision-making
regarding their care have been shown to be more
effective when face-to-face delivery, cognitive reframing teaching methods and practical application of
the teaching lessons are involved. Figure 1 shows the
steps involved in teaching people to self-manage
their diabetes.9 Recognition and prevention of diabetic
foot ulcers, as well as amputation prevention, are also
important self-management issues.
Support systems that include family members and
caregivers in self-management educational interventions have been found to be beneficial in improving
patients’ diabetes-related knowledge, as well as
their ability to cope with the disease.10,11 Moreover, selfmanagement education programs led by peer leaders
and supported by health professionals foster self-care
for people with chronic conditions such as diabetes.
Indeed, these programs have demonstrated short-term
improvements in patients’ confidence to manage their
chronic condition.10
Lay peer educators can enrich the delivery and
depth of the self-management education by sharing
their personal journeys and commitment to change
with participants. They are able to empower and
motivate participants because there are no boundaries
between them (as there sometimes are between
clinicians and patients) and they can relate to each
other’s stories and experiences. Peer-led programs are
also an economical intervention that can provide a
valuable link between people with diabetes and healthcare professionals in the healthcare delivery system
(Figure 2).10–12
According to a recent World Health Organization
report, several randomized controlled trials have
demonstrated improved glycemic control, quality of
life and self-efficacy among patients with diabetes
who take part in peer-led educational programs.
Peer-led, face-to-face self-management programs
have also demonstrated short-term improvements in
participants’ self-rated health, cognitive symptoms
and diabetes self-management. Even so, more
research is needed to determine the optimal program
settings and types – specifically, how peer-support
programs can be integrated into clinical and outreach
services over the long term.11,13
The strength of evidence varies across peer-led educational programs; at this time, no peer-led diabetes foot
care program has been developed that specifically
8Wound Care Canada / Volume 10, Number 3
“Peer leaders are charged with rolling out the program
in the community. I believe that the ripples created
so far will create waves of awareness and reduce
lower-limb and foot complications.”
– Axel Rohrmann BSc Pod Med;
PEP Talk healthcare practitioner and workshop leader
focuses on the prevention of foot complications
and diabetic foot ulcers. Still, the success of peer-led
programs is attributed to the leadership from and
support of a person who has experienced the challenges
of living with a similar condition, in this case diabetic
neuropathy and its complications.10,11
Our commitment to preventing
diabetic foot ulcers
The CAWC is committed to reducing the number of
diabetes-related foot ulcers and other potential neuropathic foot complications that can lead to lower-limb
amputation. In 2010, the CAWC, in partnership with
the Public Health Agency of Canada, launched the
Diabetes, Healthy Feet and You interactive educational
program and website for persons living with diabetes.
In Phase 1 of the program, a variety of selfmanagement educational tools were developed in
collaboration with people with diabetes, with the aim
of motivating people living with the disease to prevent
diabetic foot ulcers. Some of the educational materials
developed through this program have been translated
into 17 languages. For more information, visit
http://www.cawc.net/diabetesandhealthyfeet.
Phase 2 of the Diabetes, Healthy Feet and You initiative involves a series of peer-led self-management
workshops that will empower people with diabetes to
FIGURE 2
The chronic care model13
Soins des plaies Canada / Volume 10, numéro 3
17
A Periodical of the Pedorthic Association of Canada
“Neuropathy is like no other health indicator.
There is no pain or discomfort. It is the absence
of symptoms. That means our body’s early-warning
signals are useless. We have to think and not feel!”
– Douglas Cowling; person with diabetes living with neuropathy
understand and apply proper daily foot care practices.
The overarching goal of the program is to train community leaders from each province and territory to facilitate
community-based workshops in partnership with healthcare professionals, thereby empowering people living
with diabetes to “discover and use their own innate
abilities to gain mastery of their diabetes” and foot care.14
fall 2012
education alone may not always result in the
necessary behaviour changes, particularly when people
with diabetes may already have a loss of protective
sensation. The PEP Talk program offers support to
people with diabetes who are living without “the gift
of pain.” Peer leaders can share their experiences with
the aim of educating other people with diabetes
about: the hidden dangers of living with a lack of
protective sensation; the risk of forming ulcerations;
and the risk of potential ulcer complications that can
lead to amputation. Program participants are more
likely to reflect on the information that is shared in
the program because they can truly say that the peer
leader has walked in their shoes.
For more information on the PEP Talk program
specifically, or diabetic foot health in general, visit
www.diabetespeptalk.ca.
References
1. Brand P, Yancey P. Pain: The Gift Nobody Wants. Zondervan; 1993.
2. Public Health Agency of Canada. Report from the National
Diabetes Surveillance System: Diabetes in Canada, 2009. Ottawa,
ON: Public Health Agency of Canada; 2009. Available at:
www.phac-aspc.gc.ca/publicat/2009/ndssdic-snsddac-09/2eng.php. Accessed May 23, 2012.
3. Dang CN, Boulton AJ. Changing perspectives in diabetic foot ulcer
management. Int J Low Extrem Wounds. 2003;2:4-12.
PEP Talk participants proudly display their certificates
of learning.
PEP (Peer Education Program) Talk: Diabetes,
Healthy Feet and You consists of workshops that
are co-led by volunteer peer leaders who are living
with diabetes and neuropathy and volunteer healthcare
professionals committed to improving the lives of
people with diabetes. The self-management program
incorporates multiple educational strategies, including
social activities, interactive presentations, goal setting,
problem solving, group activities and other motivational
strategies that empower and motivate participants to
adopt an approach to preventative foot care.9
PEP Talk: Diabetes, Healthy Feet and You encourages people with diabetes and their family members
to attend a self-management educational workshop.
The program’s aim is to influence positive behaviour
change in participants by increasing their knowledge
of the risk factors for foot ulcers. Peers leaders can
also offer individuals the support and resources needed
to prevent and treat foot ulcers, and link them to
available community resources with the same focus.
Educational programs that help people with diabetes
to recognize and manage foot complications in a timely
fashion are the cornerstone of preventing diabetic
foot ulcers and amputations.6,15 The challenge is that
18
Wound Care Canada / Volume 10, Number 3
4. Canadian Diabetes Association. Building Competency in Diabetes
Education: The Essentials. Toronto, ON: Canadian Diabetes
Association; 2010.
5. National Institute for Health and Clinical Excellence. NICE Clinical
Guideline 119: Diabetic Foot – Inpatient Management of
Diabetic Foot Problems. London, UK: National Institute for
Health and Clinical Excellence; 2011. Available at: www.nice.org.uk/
guideline/CG119. Accessed May 23, 2012.
6. Registered Nurses’ Association of Ontario. Nursing Best Practice
Guideline: Reducing Foot Complications for People with Diabetes.
Toronto, ON: Registered Nurses’ Association of Ontario; 2007.
7. Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane Database
Syst Rev. 2010;5:CD001488.
8. Registered Nurses’ Association of Ontario. Strategies to Support
Self-management in Chronic Conditions: Collaboration with Clients.
Toronto, ON: Registered Nurses’ Association of Ontario; 2010.
9. Canadian Diabetes Association. Clinical practice guidelines for the
management of diabetes in Canada. Can J Diabetes.
2008;31(Suppl. 1):S1-S201.
10. Heisler M. Self-management and clinical outcomes. Diabetes
Spectr. 2007;20:214-220.
11. Fu D, Fu H, McGowan P, Shen Y, Zhu L, Yang H, et al. Implementation
and quantitative evaluation of chronic disease self-management
programme in Shanghai, China: Randomized controlled trial.
Bull World Health Organ. 2003;81:174-182.
12. Improving Chronic Illness Care website. The Chronic Care Model.
Available at: www.improvingchroniccare.org/index.php?p=Chronic
+Care+Model&s=124. Accessed May 23, 2012.
13. World Health Organization. Peer Support Programmes in Diabetes.
Available at: www.who.int/diabetes/publications/Diabetes_final_
13_6.pdf. Accessed May 23, 2012.
14. Funnell MM. Patient empowerment. Critical Care Nursing Q.
2004;27:201-204.
15. Driver VR, Fabbi M, Lavery LA, Gibbons L. The costs of diabetic foot:
The economic case for the limb salvage team. J Vasc Surg.
2010;52(3 Suppl.):S17-S22.
Soins des plaies Canada / Volume 10, numéro 3
9
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Instability Footwear and Orthoses
Interaction
• The rigidity of the sole comes from a
shank, constructed of TPU (thermoplastic
polyurethane) mixed with short glass
fibers to create an impact-resistant material with a high degree of
stiffness.
Chris Hope, C. Ped (C) & Alex WhYte, C. Ped (C)
Instability footwear can be classified in two categories, stable and unstable.
Stable is defined as having a firm midsole from heel to toe and these
provide more medial and lateral stability than their unstable counterparts.
Footwear in the unstable category are defined by having a soft midsole;
specifically at the heel. There are many various shoes which are marketed
in these general categories; Reebok Easy Tone, Congent, Earthshoe, Fit
Flops, Orthaheel, Chung Shi, Finn Comfort Finnamic to mention a few.
In this article we will focus on 4 common models of instability footwear:
MBT, Ryn, Sketchers Shape Ups and Mephisto Sano.
• MBTs also have a very soft heel area built into the midsole called the
Masai Sensor. This soft polyurethane Masai Sensor is the heart of
MBT technology, claiming to create the specific functionality (sink-in
movement) of the sole.
• The remainder of the midsole is made from firm polyurethane.
Unstable - SKETCHERS SHAPE UPS
• Sketchers are an American shoe company, founded in 1992. Sketchers
makes an effort to maintain a trendy and stylish brand image by using
celebrity-driven advertising.
Unstable - MBT
• The design of the Shape Ups mimics the MBT in syle and function.
• Founded in 1996 and pioneered by Swiss engineer Karl Muller, MBT
(Masai Barefoot Technology) is marketed as the first physiological
footwear.
• They claim to provide a natural soft surface that allows muscles to
make balancing movements, relieving pressure on joints and providing
a beneficial system of exercise.
• MBT’s come in various styles such as walking, dress casual and sandals.
All styles, with the exception of the sandals have removable sock liners.
• The sole is rigid with an aggressive rearfoot and forefoot rocker. There
is a balancing area underneath the metatarsus.
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• Sketchers Shape Ups are similar to MBT in the sense that they have
a rigid double rocker sole. A soft area at the heel is also found in this
style to create further instability.
Stable - Ryn
• Ryn have been available to the US market since 2008.
• Ryn’s have a very aggressive rearfoot and forefoot rocker profile with
a rigid sole.
• The shoe’s last is straight.
The23
Ryn
shoe
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has no soft area in the heel, as the MBT or Shape Up’s
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• They claim that the construction of the Ryn is comprised of a 7-piece
unit which is designed to guide the foot correctly through natural heel
strike to toe off. Further technical details of this 7-piece unit were not
available.
• The company stresses quality of construction and durability. The
midsole is made of polyurethane with built in “air bags”.
• Ryn’s are available in walking shoes, sandals, dress shoes and off road
shoes.
• Ryn footwear also offers a line of shoes not in the “instability” category.
Orthotic Interaction
The relationship between an individual’s custom foot orthotic and their
shoe is very important for a successful treatment. A hot topic buzzing
around shoe trends lately has been the controversial discussions about
traditional versus instability shoes, and their purpose in a pedorthic
treatment plan.
The purpose of an orthotic is to the keep an individual’s foot posture in its
ideal position to prevent excess movement or loading at the joints and/or
structures, which may cause pain or discomfort. As explained earlier, an
unstable shoe commonly has a lower durometer midsole, particularly at
Stable - MEPHISTO SANO
the heel. This allows for a compression motion in the sagittal plane, and
• The Mephisto brand has been available in Canada since 1989. The
Sano is their “toning” shoe.
frontal plane. The low durometer midsole allows for greater compression
and a wider range of motion during the contact phase of the gait cycle.
• The Sano’s rocker is not as aggressive at the rearfoot as the Ryn.
If an individual with a severely medially deviated subtalar joint axis walks
• This has an aggressive forefoot rocker with a rigid sole.
in an unstable shoe without orthoses, the medial midsole material is more
• There is no soft area in the heel as with MBT or Sketchers.
likely to compress. This will allow an amplified medial load on the shoe,
• The midsole is approximately 3cm high at the heel.
resulting in the medial column of the lower leg to become overworked.
• Other prominent features of the Mephisto Sano include a 100%
This can cause a greater stress load on the flexors and inverters of the
caoutchouc rubber outsole, cement construction, leather upper and
foot and ankle. On the other hand, if the patient is a severe supinator, the
removable sockliners.
same results would occur to the lateral side of the shoe and lower limbs.
• The midsole has what’s termed by Mephisto as “Soft-Air Technology”
and “Active Suspension” shock absorbing systems.
Wearing an unstable shoe over a prolonged period can increase stress,
causing fatigue and possibly leading to a lower limb injury. Individuals
with unstable joints are more vulnerable to injury in an unstable shoe
compared to individuals with stable joints. It is generally advised that
anyone who experiences balance problems and excess joint motion
should avoid this style of shoe.
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A Periodical of the Pedorthic Association of Canada
Stable rocker shoes are designed to provide much more medial and lateral
support when compared to unstable rocker shoes. This is primarily due to
the fact that it does not have a soft heel area. The high durometer midsole
acts as a stable platform that does not allow frontal plane motion during
fall 2012
Are you ready to rock?
contraindications and indications of stable
vs. unstable rocker bottom shoes
gait. This provides a much more reliable surface of contact for the foot.
There is currently no conclusive evidence on which durometer of midsole
Tavish Lahay-Decker, C. Ped (C)
works best for a specific foot types in a rocker shoe. When designing
There has been a significant amount of buzz surrounding rocker bottom
orthoses, it is important to make sure that the subtalar joint axis is being
shoes, which translates to pedorthists being asked many questions
controlled. There is not a specific design that needs to be taken into
regarding this type of footwear and who should be wearing it.
consideration when building orthoses for this style of shoe.
First, it is important to note that there are two categories of rockered
Landry, Nigg and Tecante (2010) found that if the goal of treatment is to
footwear: stable and unstable. Both categories can be designed with
strengthen the extrinsic muscles of the foot, then unstable (low durometer)
different types of rockers such as: forefoot, rearfoot and full sole. When
shoes have been shown to increase strength by increasing postural sway.
discussing appropriate footwear with clients it is important to convey
Whereas if an individual has a very unstable foot structure and is prone to
how many variables need to be considered when choosing between the
excess motion, a stable (high durometer) shoe would be recommended.
different types of rockered footwear. The choice is not as simple as it
The most important rule when combining orthoses with an unstable or
seems; we cannot all wear them and have fantastic glutes.
stable rocker or ”instability” shoe is to make sure the combination of the
two is comfortable and does not cause the patient any discomfort.
When recommending rockered footwear to clients, knowing which
design of rocker your client will do well in is essential. So what should
In conclusion, it is up to the Pedorthist to determine and recommend
we consider? Before we even get to suggesting rockers, we need to be
which shoe is best for each patient’s individual situation. There is still a
realistic about our client and their capabilities.
large amount of research needed to answer all of the questions regarding
the effects that foot orthoses have when combined with stable and
unstable rocker footwear.
references
Landry S., B. Nigg, and K. Tecante. Standing in an unstable shoe increases postural sway
and muscle activity of selected smaller extrinsic foot muscles. Gait Post, 32:215-19, 2010.
• What type of structure do they have in both feet and lower limb?
• What joint range of motion are they capable of?
• What is their muscular strength like in all intrinisics, extrinsics, glutes,
core and pelvis, in both standing and in single leg stance?
• Does their strength and stability need to be addressed first by another
health care professional?
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• How is their sensory input; vision, vestibular, proprioceptive?
There are different variations to forefoot, rearfoot and full sole rockers, so
• Do they have any neurological or health issues that may be a
choosing the appropriate one should be based on the client’s presentation
contraindication?
and needs.
• Psychologically what type of care is appropriate for them? Do they have
the necessary compliance and motivation to follow through on your
suggestions?
Unstable rockers are just that - they are supposed to simulate walking on
unstable ground. This increases the center of pressure during standing1
and has been noted to minimize ankle joint loading2. Additionally, they
Once you have considered the above, you can decide on a stable or
can decrease plantar pressure at the rearfoot and midfoot while increasing
unstable rockered shoe. When deciding on the category of rocker, you
plantar pressure in the forefoot3. As with any rocker, this can be beneficial
need to know what you want the shoe to function like; do you want
to some, such as clients with heel pain, while detrimental to others, such
walking and standing to be harder (unstable) or easier (stable)? Keeping
as those with a history of forefoot ulcers or other forefoot issues. Unstable
in mind that one of the main functions of the foot is to be a stable base
rockered footwear is designed to roll in the sagittal plane while allowing
it is important to know whether your client is capable of overcoming the
medial/lateral sway, the degree of which can vary between brands. The
shoes inherent instability. By inhibiting this ‘stable base’ we are forcing
medial/lateral instability can also be unpredictable depending on the
our clients to maintain their balance and mechanics through other means.
wearer’s mechanics and the design of the shoe; some can create a large
Is this going to create an injury or worsen a current injury or condition?
pronatory force during late stance into toe off which may exacerbate 1st
Stable rockers are great for a number of clients, however your purpose
for needing a rocker influences whether you should chose a forefoot,
rearfoot or full sole rocker. All stable rockers aid in the sagittal plane or
the movement of the foot from heel to toe during gait. Rearfoot and full
sole rockers can be a fantastic addition for those with a fusion of their
talocrural joint or midfoot, while a forefoot rocker is beneficial for some
clients with painful bunions, corns or other forefoot issues. Essentially
using these rockers decreases the amount of range needed in a particular
joint by having the shoe ‘roll’ rather than having the joint bend, while
trying to maintain a fluid transition from heel strike to toe off. Additionally,
full sole rockers can help with pressure relief or dispersion which may be
important in some cases. For example: a diabetic with a history of ulcers.
metatarso-phalangeal joint issues. As stated previously, it is the wearers’
strength and stability that is meant to overcome the instability of this type
of footwear, so it is important to note that there is a balance between
strengthening the muscle and over use – the body typically chooses
the path of least resistance, so strong muscles tend to get stronger, and
weak muscles get weaker. While some clients may be ideal for this type
of increased demand on the musculature of the lower leg, it is not for
everyone. For example, one study has shown that this type of footwear can
increase activation in tibialis anterior, gastrocnemius, vastus medialis and
vastus lateralis. By activating the musculature on the anterior/posterior
and medial/lateral sides of the knee this increases compression within
the joint and may exacerbate current knee issues in some clients4. All these
variables should be considered before recommending this type of footwear.
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inic
A Periodical of the Pedorthic Association of Canada
As with any type of pedorthic treatment it is important to know all the
advantages and disadvantages prior to making recommendations
regarding stable and unstable rockered footwear. I think the most
important thing we can convey to clients is not to believe the hype
surrounding this category of footwear and to make an informed decision
prior to jumping onto the bandwagon.
references
1. Nigg B., et al., 2006. Clinical Biomechanics 21, 82-88
2. Boyer K. and Andriacchi T., 2009. Clinical Biomechanics 24, 872-876
3. Stewart L., et al., 2007. Gait & Posture 25, 648-651
4. Romkes J., et al., 2006. Clinical Biomechanics 21, 75-81
Rocker Soles in the Lab
jim pattison, C. Ped (C)
There are 2 styles of rocker soles that pedorthists typically deal with. The
first is a regular rocker sole, this adds to the normal toe spring found
in a shoe. The second is a breakpoint rocker sole which has an abrupt
breakpoint to drastically minimalize high pressure areas.
Regular Forefoot Rocker Sole
The case: Someone with multiple phalangeal fractures, with some
fractures crossing the joint space. This causes a lot of pain in the affected
area during heel off through to toe off.
The treatment: A ½” rocker sole was added to the sole with an extended
shank. It exaggerates the toe spring and dramatically decreases the
dorsiflexion required in the phalanges. The EVA added to the sole was
gradually tapered to nothing at the distal end of the shoe. Because the
shoe style is one that has a separate heel, the proximal end of the forefoot
lift was also tapered to make the aesthetics more appealing. To balance
things off the heel had the same lift height added. The forward part of the
heel lift was tapered a bit to keep it from catching.
To perform this shoe modification, one may need to remove a portion of
the existing sole from the footwear being modified. Polyurethane can be
used to prepare the surface of the sole. The new sole material (eg. EVA) is
then added to the footwear. Heating this material can improve flexibility
and allow for better adhesion to the shoe. The material can then be cut
and shaped to the desired style of rocker prior to adding an outsole.
It should be noted that a thicker sole can contribute to lateral instability.
As a result, the medial and lateral borders should not be flared inward for
aesthetics. One must consider the loss of stability with how much height
the patient needs.
It is possible also to remove existing material from the distal end of the
shoe to exaggerate toe spring. This results in a less aggressive a rocker
sole. In the case presented, the modifications promoted healing and
some dorsiflexion was possible without pain.
15
Once extra material is added, just as you would do for a regular rocker sole
modification, you must consider the break point, rather than attempting to
create a smooth transition to feather out the rocker sole. The break point
of the rocker (the Apex) determines where pressure is off weighted from.
For a forefoot breakpoint rocker, this is typically located proximal to the
metatarsal heads, however if you are off weighting an ulcer at the MTH it
should break proximal to the ulcer site. Once the breakpoint is considered,
grind away excess midsole material using a wedge cut out or grinding
a straight angle to the toe to produce a rocker. For a rearfoot breakpoint
rocker sole, there is no material under any part of the calcaneus. Be sure
to consider the angle of the breakpoint and assure it is perpendicular to the
Breakpoint Rocker Sole
patients gait direction.
The second type of rocker sole is a breakpoint rocker sole. With it, there is
This modification must be used with some caution as there is an extreme
no smooth arc to the rocker, seen in the picture below. There is an abrupt
decrease in stability during gait when compared to a regular rocker sole. If
cut off to the sole material. The purpose of this is to prevent or dramatically
a person has balance issues, they may need a cane for improved stability.
minimalize weight bearing on the affected area. This modification is useful
for people who have an ulcer or sore on either the ball of the foot or on
the heel where removing or diminishing weight is needed to heal the sore.
There are many variations to a breakpoint rocker sole, the use of which are
determined by the needs of the patient. It is important to consider the area
of concern when deciding on the material, breakpoint location and angle.
When choosing materials it is important to consider the patients weight,
activity level, medical needs, and how much material is required to reach
the desired rocker. Often shoes do not have a thick enough midsole to
produce a rocker sole, so the pedorthist must add material to increase
midsole thickness. Often EVA is used, although as EVA increases in
durometer it becomes quite dense and heavy. Other options would be
Black Poron or Featherlite EVA.
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A Periodical of the Pedorthic Association of Canada
Member Profiles:
chris hope, C. Ped (C)
“I had the interest without even knowing
it!” A pedorthist at heart, Chris Hope found
his perfect career by a series of fortunate
happenstances. He knew he liked to work with
his hands, he knew he wanted to help people,
and he knew for certain that he loved sports.
“In a sense, it’s like being a detective solving a
problem; the more you know, the more you can
help people.”
After graduating from the University of British Colombia, with a degree in
Human Kinetics and a Bachelors in Exercise Science, he set out to discover
“what the heck to go do” with his degree. After working a few odd jobs,
he fell in with a company called the Sport Med Retail Group where he was
tasked with fitting orthotic braces. While working there, Chris was able to
observe pedorthists as they came in for mini labs a couple days each week.
This exposure, “the reward of being able to walk into a lab and create
something with my hands,” as well as his background in kinesiology
propelled Chris to pursue pedorthics as a career.
“But what really did it for me,” explains Chris, “was when Mike Neugebauer
ripped open a patient’s Birkenstock sandal, added a few things to it, and he
was actually able to help the person walk away more comfortably.” And
fall 2012
out, Sports Med Retail Group’s affiliation
with Paris Orthotics launched Chris into a
formal apprenticeship where he received his
C. Ped Tech (C) in 2006 and his C. Ped (C) in 2007.
Gaining the credential was really part of the natural progression for Chris.
“I love that there are so many things pedorthists can do, and of course
when working with the public, with each person comes a new experience.”
When talking to Chris, his enthusiasm and passion is obvious, and this has
led him to the 2010 Olympics where he participated on the medical team
with athletes from around the globe. Not only is Chris active in training
new apprentices, new C. Ped Tech (C)s, and new C. Ped (C)s, he is nowhere
close to slowing down.
“I just want to give back more. “ Chris explains of his growing involvement
with PAC. “For me when I walk down the street, I want to be able to ask any
old Joe ‘What is a Pedorthist’—and for them to know! The board’s goals
are right in line with this, in fact the folks who volunteer for this are the
reason I have a profession!”
When Chris is not in the lab or with patients, he dedicates his time to his
family, including wife, Mareva, his two daughters, Alora who is 2 and
a half, and Leona, 9 months. And in the few hours between home and
work life, you might find Chris exercising that very love of sports, on the
ski slopes, the tennis court, or playing regional hockey. But for Chris, it’s
hardly work; “I’m lucky, I get paid to do what I love, and not everyone can
say that.”
so he mucked around in the lab learning as much as he could. As it turned
17
kathleen klement, C. Ped (C)
Kathleen Klement is a woman of diverse
interests and experience, and this translates to
her practice of pedorthics. With a ‘foot’ in many
areas of the practice, she embodies the wide
application of the field itself.
“Geographically, the things you see working
in various places are just entirely different,”
she explains. Klement has experience working
intimately with diverse but distinct demographics of patients, from
professional athletes to pregnant mothers to elderly diabetics to farmers.
This kaleidoscope of patient experience gives her a wide perspective on
the importance of pedorthics, and the areas in which she hopes to excel
Kathleen only received her certification in January of 2012, she is already
enrolled in a Masters Program of Clinical Science at the University of
Western Ontario to study the pedorthic application to Wound Healing,
specifically in diabetic patients. Working across disciplines, (most of the
other students are nurses and physical therapists), she will be the first
Pedorthist to complete this program—all while continuing to work fulltime!
In addition to her clinical hours at SoleScience, based in London, Ontario,
and attending university, Kathleen also applies pedorthics outside the
clinic, to yoga. At Moksha Yoga, she volunteers hours, and is currently
setting up a pedorthic practice outside of the studio there. “You could say I
have a passion for hot yoga,” she admits, adding “And that I can combine
that with pedorthics is a great opportunity.”
in the future. “Seeing each groups’ different needs is one of my favorite
In fact Kathleen hopes to take advantage of as many opportunities within
things about the profession—I can make a great impact on many different
the field as she can, including at PAC. “Given my academic involvement,
people’s lives.”
I really hope to participate more in the Pedorthic Research Foundation of
A true student of the trade, Kathleen began her study at the University of
Canada,” she pointed out as a longer-term goal.
Western Ontario with a Bachelor of Arts (honours) in Kinesiology in 2009.
When speaking to Kathleen, it’s apparent her thirst for the field is insatiable.
While at a job fair, she met Jordanna Jones of BioPed London South, who
From yoga to the clinic, Klement is all pedorthics, all the time. “Another
was pivotal in opening Kathleen’s mind to the field. “It was just natural;
thing I’m very excited about is the social media opportunity,” she adds,
a great combination of my skills working with my hands, as well as my
specifically in thinking about working more with PAC. “It’s so fast, we
knowledge of kinesiology—it just made sense.”
could potentially spread awareness to so many new demographics, and
And so she completed her practicum placements and received a diploma
in Pedorthics from Continuing Studies at Western in 2011. And while
18
that’s really what it’s all about.”
A Periodical of the Pedorthic Association of Canada
fall 2012
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