Orthoses Materials... - Pedorthic Association of Canada

03 President’s Message
04 Effect of insole material on lower
limb kinematics and plantar pressures
during treadmill walking
04 A Classification Scheme for
Contemporary Foot Orthoses
08 Review of the PAC Hands-On PD Event
in Toronto
11 A Comparison of Top Cover Material
Choices
12 PAC Symposium Recap
14 Simple Lab Tools You May Not Know
You’re Missing
16 A Comparison of Foot Orthoses Shell
Material Choices
18 Member Profiles
Orthoses Materials...
SUMMER 2012
A Periodical of the Pedorthic Association of Canada
OPENI
JULY 2 NG
Royal B 012!
ank
Plaza
Walking Mobility Clinics is pleased to announce the opening
of our newest downtown Toronto clinic located at:
Royal Bank Plaza
200 Bay St., Lower Concourse Level
Toronto, Ontario
This will be our 12th clinic and we are very excited about this
location. We are located in the lower concourse level of Royal
Bank Plaza within MCI-The Doctor’s Office and we trust this
will better serve those living and working in the downtown core.
This will be a full-service, multi-disciplinary clinic providing
pedorthic, chiropody and medical services.
Career Opportunities
With 12 clinics and growing, Walking Mobility Clinics is always
looking for highly skilled and qualified Pedorthists who would
enjoy managing a new corporate clinic or owning a Walking
Mobility Clinic of their own.
Our focus is clinically 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, Director of Operations
Walking Mobility Clinics
[email protected]
Toronto | North York | Markham | Scarborough | Etobicoke | Richmond Hill | Mississauga (2 locations) | Pickering | Barrie | Ottawa
www.walkingmobilityclinics.com
A Periodical of the Pedorthic Association of Canada
SUMMER 2012
President’s Message
Ryan Robinson, C. Ped Tech (C), C. Ped (C)
Happy summer everyone! The air is warm, the birds are chirping, the
kids are outside playing…and people are hobbling in off the street
with sore feet because of all the walking they are now doing that they
haven’t done in months!
It was great to see so many familiar faces and meet so many new
ones at our annual symposium in Whistler. I always come away from
the conference reinvigorated regarding my chosen profession of pedorthics. I know from the
feedback from many of you that you feel the same way that I do.
This year I sat down and tried to analyze what was it about this conference and others before
it that energizes me so. The list that I came up with included things like open sharing of ideas,
research-based learning opportunities, and the general sense of community one gets from
attending these events.
This year also featured the launch of our new Clinical Practice Guidelines (CPG) textbook. This is
already becoming a much-coveted piece of learning material and we have received high praise
from different organizations across the world including footcare professionals in Australia,
Germany, The Netherlands and the United States. Everyone involved in the development of this
important piece of literature should be commended.
This leads me to what I have come to realize is the ultimate reason why I enjoy these conferences.
Through my interaction with many of you, I have come to view pedorthists as “doers”. On the
whole, we, as a group, are people who like to get things done..I like that. I recently read a book
titled Execute or be Executed and I think we all know that there is some wisdom in that title.
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
Winnipeg, Manitoba R3C 3R6
Toll Free: 1-888-268-4404
Fax: 1-877-947-9767
Email: [email protected]
Printed by Unigraphics
Communications Committee
Chair
Nancy Kelly, C. Ped Tech (C), C. Ped (C)
Vice Chair
Amy Guest, C. Ped (C)
Committee Members
Grace Boutilier, C. Ped Tech (C), C. Ped (C)
Jim Pattison, C. Ped (C)
Michael Ryan, C. Ped (C), PHD
Subscriptions: $199 per year in Canada
If we, as an organization, are not pushing forward with new and inventive ideas to improve,
promote and distinguish the profession of Pedorthics, then we will very quickly be left behind.
Thankfully, with initiatives such as the CPG book, I don’t ever see that happening with this group.
Thanks again everyone for helping make pedorthics in Canada what it is today. Now get out there
and cut your lawn!
PQ Feedback
All articles published in Pedorthics Quarterly are the property of
the Pedorthic Association of Canada. Copyright ©2012 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.
Alternatives to Standard Adhesives - Spring 2012 Issue
Help Us Be Green!
The article on glue in the recent pedorthics quaterly was interesting. I would like to try
a water-based contact cement.
If you would like to receive Pedorthics Quarterly
Could I be sent some information on the two products listed in the article?
I don’t use much glue as I’m not a lab, but would be interested to share.
contact the PAC office at [email protected].
Thanks,
Lee MacKenzie, B.Sc Kin, C. Ped (C), CAT(C), West Toronto Foot and Ankle Clinic
Authors’ Response
Thank you for your interest in the water-based glue/adhesive.
The contact with the first company is Dr. Genaro La Garza in Mexico. The water-based contact cements
developed in Mexico are sold under the brand name Helmitin. They can be contacted through their
website at http://bit.ly/PQS12Helmitin.
The other company is Henkel Adhesives in Germany. The expert that I spoke with from there is
Dr. Dieter Dausmann. Dr. Dausmann said they are eager to have their products sold in Canada, but the
demand for them has not yet been seen. There is a minimum order noted on the website and I have
not established what volume of glue a “drum” is. Henkel Adhesives catalogue can be found online at
http://bit.ly/PQS12Glue. Questions may also be directed to their customer or technical service numbers
found in the catalogue.
electronically instead of the paper version,
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.
We would appreciate your feedback on the PQ and
its articles. Your ideas and thoughts are important
to us. Let us know what you think.
E-mail your letter (referencing the article title and
PQ edition) to: [email protected]. Please include
‘PQ - Feedback’ in the subject line.
PAC also invites you to comment about articles in
the PQ via our Linked-In page.
3
Article Review:
What is interesting about this study is how many questions remain with
Effect of insole material on lower
limb kinematics and plantar
pressures during treadmill
walking
one after reading it. Most notably, there is very little explanation as to
Healy A, Dunning D, Chockalingam N. (2012).
context of pressure cannot be the only quality applied to determine
Prosthetics and Orthotics International. 36: 53-62.
appropriate shell material. Properties such as memory, shear rating, and
Grace Boutilier, MSc., C. Ped Tech (C), C. Ped (C)
with respect to a specific pathology such as diabetes. Without a clinical
why the flat insole and custom orthoses conditions were not compared.
Given that this topic receives considerable interest in previous research,
it appears remiss not to include commentary on the additional analysis
that is likely to have been performed. Extrapolating findings from healthy
populations to those with pathologies such as diabetes contains some
inherent limitations. Furthermore, as clinicians, we appreciate that the
correction among others must be considered in material selection, even
At present, there is a dearth of published research advocating the
assessment it is impossible for the reader to understand what, in fact,
importance of shell material selection in custom orthoses provision.
makes this population healthy and with no description of kinematic marker
While some literature has examined the effectiveness of orthoses in
location placement, to assume anything about the sample of participants,
preventing ulceration in people with diabetes1-4, little conclusive evidence
which was quite small and thus challenging to interpret with confidence.
exists to aid the clinical decision-making process with respect to the type
Finally, the authors argued that minimalistic footwear was employed to
of orthoses to be prescribed, nor to impart suitable material selections in
limit the effect of footwear on gait. Conventional wisdom dictates that
constructing orthoses for different patient requirements5.
the supportive platform of the shoe-orthotic interface improves the
In an attempt to gain a greater understanding of the characteristics of
orthotics materials and how they affect normal gait, Healy and colleagues
(2012) performed a repeated measures study analyzing kinematics and
plantar pressures of 10 healthy participants while walking on a treadmill
in various conditions, including shoes only, shoes with 4 types of flat
insoles and 4 types of custom orthoses. The material properties for both
custom and non-custom insert conditions included one of each of:
1.Low density polyurethane (PU) (Shore A hardness 20-25),
2. Medium density PU (Shore A hardness 55 ±3),
3.Low density ethyl vinyl acetate (EVA) (Shore A hardness 25) and
4. Medium density EVA (Shore hardness 50).
These materials were selected based on a previous survey6 which
indicated these were commonly prescribed in orthoses for individuals with
diabetes. The four flat insoles were 3mm thick in one of each durometer.
The custom orthoses were constructed from foam box impressions by a
single clinician, and created with a 4° medial extrinsic rearfoot posting
and forefoot balanced to rearfoot vertical. The footwear utilized was a
standard plimsoll shoe (a minimalistic athletic shoes with a canvas upper
and a rubber sole) with windows cut in the upper to allow placement of
effectiveness of the orthosis device, so this novel suggestion requires
further investigation.
References
1. Spencer S. (2000). Pressure relieving interventions for preventing and treating
diabetic foot ulcers. Cochrane Database Syst Rev. 3: CD002302.
2. Bus SA, Valk GD, vanDeursen RW, et al. (2008). The effectiveness of footwear and
offloading interventions to prevent and heal foot ulcers and reduce plantar pressure
in diabetes: a systematic review. Diabetes Metab Res Rev. 24:S162-S180.
3. Paton J, Bruce G, Jones R, Stenhouse E. (2011). Effectiveness of insoles used for
the prevention of ulcersation in the neuropathic diabetic foot: a systematic review.
J Diabetes Complications. 25:52-62.
4. Mason J, O’Keeffe C, Hutchinson A, McIntosh A, Young R, Booth A. (1999). A
systematic review of foot ulcers in patients with Type 2 diabetes mellitus . II:
treatment. Diabet Med. 16:889-909.
5. Healy A, Dunning DN, Chockalingam N. (2010). Materials used for footwear orthoses:
a review. Footwear Sci. 2:93-110.
6. Healy A, Dunning DN, Chockalingam N, Naemi R. (2010). An investigation in to the
prescription procedures and material choice involved in the provision of bespoke
foot orthoses for diabetic patients. Presented to the 8th Staffordshire Conference
on Clinical Biomechanics. Stoke on Trent, UK.
kinematic markers over anatomical landmarks. Heel contact and toe off
events during a gait cycle were identified using in-shoe pressure sensors
(FScan, Tekscan, Boston, USA).
Two testing sessions were performed, with five conditions each:
participants walking first in shod-only condition, followed by each of the
A Classification Scheme for
Contemporary Foot Orthoses
four flat insoles. Next they walked in the custom orthoses of different
Michael Ryan, C. Ped (C), PhD
densities. Testing sessions were randomized for order.
From a classification standpoint, foot orthoses (FO) are broadly classified
Results for the flat insoles indicated that medium density EVA produced
into custom-made devices versus off-the-shelf (OTS). A survey of 82
the greatest peak pressure. Low and medium density PU were most
recreational, high school and elite caliber runners reported that 69%
effective at increasing average contact area and reducing the pressure-
of the runners that use an FO choose custom-made versus OTS1. Care
time interval. In the custom orthoses category there were no significant
should be taken in differentiating a device that is truly custom-made for
differences when compared to the shoe only condition, but medium
someone (i.e., made from a 3-dimensional volumetric impression of the
density PU increased the average contact area by a greater percentage
foot) versus a product that is otherwise mass-produced but may have
than the other materials. The authors concluded that medium density PU
one or more elements of its design customized. Complicating matters is a
may have a different loading characteristic than the others, indicating it to
number of manufacturers who claim (and market extensively) to provide
be most suitable for patient with diminished plantar pressure sensitivities.
custom-made devices, but in fact sell customized pre-fabricated orthoses.
In cases where a high amount of accuracy is needed to redistribute plantar
4
A Periodical of the Pedorthic Association of Canada
SUMMER 2012
pressure, such as the idiopathic cavus foot, treatment effectiveness from
Within each of these arms they may be further
the orthosis is largely conditional on how well the congruity of the molded
separated into three broad categories: rigid,
base matches the plantar aspect of the foot. Only in cases where a device
semi-rigid, and accommodative devices
is fabricated from a volumetric impression of the foot and all elements
(Figure 1). These classifications are general in nature and serve more to
of the FO’s design may be considered (from posting, to base materials,
overview different FOs uses than be a strict guide for prescription.
to additions and extensions) can an FO be considered custom-made. On
an individual patient basis this autonomy of design greatly increases the
capabilities of the clinician to address specific features of a patient’s gait
or anatomy. Surprisingly, there is only limited evidence that providing a
custom-made FO is superior clinically to a pre-fabricated (OTS) insole2,
although Trotter et al.3 reported a significantly greater reduction in pain,
even after cross-over, in patients with lower limb and foot injuries with
custom versus prefabricated FOs.
Rigid FOs, as their name suggests, have a base material that is highly
resilient to deformation. Often constructed using inflexible acrylic, carboncomposite or thick thermoplastic materials, rigid FOs are best suited to
patients that have a high tolerance for foot pressure, have a higher than
average body weight, and/or require a high durability of wear. Almost all
rigid FOs are custom made as there is a high probability of intolerance to
the device if it is not fabricated for a specific foot shape.
The majority of custom FOs today would be considered semi-rigid as
this FO classification serves the best compromise between support
and comfort. The base for a semi-rigid FO is typically a thermoplastic
(typically 3-4mm for a 130-200lbs person); however, some thinner (2 –
2.5mm) composite materials can make an excellent low-profile semi-rigid
device. Some OTS FOs are semi-rigid, such as the standard insole from
Superfeet®.
Accommodative FOs derive their name from the fact that their primary
function is to evenly redistribute plantar pressure of the foot with a lesser
amount of direct support to specific joints in the foot and ankle. FOs in
this category are rarely made with thermoplastics or carbon-composites,
instead the base of an accommodative FO is usually a combination of
various light to medium density foams or cork materials. The top cover
to an accommodative FO is often soft and highly conforming to the
plantar surface of the foot optimizing this category’s ability to redistribute
pressure away from painful or pressure sensitive areas. Accommodative
FOs may be either OTS or custom made.
In consideration of this classification scheme it is essential to know that
a FO’s placement into one of these categories is highly dependent on a
patient’s body weight, and to a lesser extent, activity type. A semi-rigid FO
made with a 5mm thick base of polypropylene for a 230lbs construction
worker would be a rigid FO for a 150lbs distance runner. Most FO
manufacturers will provide tables of base thickness that will correspond
to particular rigidity that help the clinician determine an appropriate base
Figure 1 - Classification scheme for foot orthoses (FO). FOs are broadly divided into
off-the-shelf (OTS) and custom made (Cust). Each of these FO types may in turn be
sub-divided into rigid, semi-rigid (semi), and accommodative (Accom).
material and thickness. More simply, on many order forms for custom
FOs (assuming the clinician does not fabricate their own devices), a
clinician need only indicate a patient’s weight together with the intended
rigidity or application and the fabricating laboratory will incorporate the
OTS FOs have advanced substantially over the last decade. There are
necessary design aspects (base thickness, top cover material and length
now OTS devices tailored to virtually every type of athletic footwear and
and sometimes pre-specified posting levels).
arch height. OTS FOs are also increasingly resilient to body weight. In
References
fact, some brands of OTS may be too aggressive for some individuals. As
with footwear, it is imperative that every runner be fit with several OTS
FO models to ensure not only proper support level, but that it is sitting
properly inside of the shoe. The OTS FO should not negatively affect the
fit of the shoe. In particular the heel should not slip from the heel counter
nor should the overall tightness in the shoe fit increase substantially. An
OTS can in some cases be as aggressive in controlling motion of the foot
and ankle as a custom device; therefore, runners are recommended to
1. Ryan, M., M. Harris, and J. Taunton, A survey of foot orthosis usage patterns with
basketball, soccer and running athletes. J Footwear Sci, 2011. 3(S1): p. S140-141.
2. Kripke, C., Custom vs. prefabricated orthoses for foot pain. Am Fam Physician, 2009.
79(9): p. 758-9.
3. Trotter, L. and M. Perrynowski, The short-term effectiveness of full-contact
custom-made foot orthoses and prefabricated shoe inserts on lower-extremity
musculoskeletal pain: a randomized clinical trial. J Am Podiatr Med Assoc, 2008.
98(5): p. 357-63.
progressively increase (i.e., alternate FO use every other run) the use of
any FO with their running, regardless if it is OTS or custom.
5
Update
Over the past year The College of Pedorthics of Canada (CPC) has
been working on revitalizing the Scope of Practice for the Certified
Pedorthic Technician Canada (C. Ped Tech (C)).
CPC would like to announce the following Scope of Practice for the
C Ped Tech (C) - Certified Pedorthic Technician Canada.
These practitioners provide:
• Shoe fitting;
• Shoe modification and orthotic fabrication (from laboratory prescriptions
provided by foot care professionals with the scope of practice to assess);
• Orthotic fabrication;
• Shoe modifications;
• May perform duties of a clinical pedorthist under the direct supervision of
a Canadian Certified Pedorthist. See the supervisory statement for further
details;
• A C. Ped Tech (C) cannot independently manage patients.
6
A Periodical of the Pedorthic Association of Canada
SUMMER 2012
CPC Position Statement: Supervision of PAC Members Working towards Certification
(i.e. Pedorthic Interns) and Other Non-Certified Personnel
This document outlines the supervisory relationship and responsibility of C. Ped(C)s and C. Ped
MCs overseeing Pedorthic Interns, and other non-certified pedorthic personnel, that interact with
patients.
Elsewhere, the CPC has defined the scope of practice for Certified Pedorthic Technician [C. Ped
Tech (C)], Certified Pedorthist (Canada) [C. Ped (C)], and Certified Pedorthist Master Craftsman
[C. Ped MC]. The practices of these individuals are governed by the College of Pedorthics.
The CPC supports the training of Pedorthic Interns seeking certification as C. Ped (C). The CPC
also acknowledges the need to supervise and interact with other “non-certified pedorthic
personnel” in the delivery of pedorthic services to enhance the effectiveness of fabrication,
modification and overall pedorthic treatment.
“Non-certified pedorthic personnel” may include: Pedorthic Interns, Technical Apprentices, C.
Ped Tech (C)’s, office assistants, or any individual that is providing services related to pedorthics
on behest or as a result of working with a C. Ped (C) or C. Ped MC.
Pedorthic Interns working towards C. Ped (C) certification have a requirement to fulfill work
experience hours supervised by a C. Ped (C) or C. Ped MC (a “supervisor”). Appropriate
supervision is crucial to ensure the quality of client services. The supervisor of the Pedorthic
Intern must provide supervision that meets these criteria:
• A supervisor may only supervise up to 2 interns at a given time irrespective of
whether the intern is working full-time hours or not
• A supervisor may only co-sign clinical paperwork for an intern for a limited time
of 36 months (consistent with PAC membership);
• The supervisor must be onsite (in the same building) as the intern for a minimum
of 55% of hours worked.
• A supervisor must review, discuss and confirm the appropriateness of work
performed by the intern, this work includes:
o Analyses of the presenting problem
o Recommended treatment plan
o Design of the device or modification
• The supervisor must co-sign all written documentation by the intern including
both in clinic chart notes and any external correspondence to referring parties or
agencies.
C. Ped (C)’s and C. Ped MC’s are ultimately responsible for all work completed by non-certified
pedorthic personnel. In the event of a complaint or clinical problem identified with non-certified
pedorthic personnel, the College will investigate the supervising certified member as they are
identified as having ultimate responsibility for the quality of service.
January 2012
7
Review of the PAC Hands-On PD
Event in Toronto – May 26, 2012
Richard May, C. Ped (C), C. Ped Tech (C)
On May 26, 2012 the PAC Hands on Professional Development Event was
attended by pedorthists and attendees from Manitoba and Ontario to
full capacity. This was the first time for Toronto’s Sunnybrook Hospital
at the Health Sciences centre to host the one day program. It opened
with an overview of the 3 courses and introduction of the instructors:
Jay Paul, C. Ped (C), C. Ped Tech (C), Kevin Fraser, C.Ped (C), C. Ped Tech (C),
and Bill Meanwell, C.Ped.
Jay Paul covered the measuring, casting and our criteria for orthopaedic
footwear. Kevin Fraser presented on OTC footwear modifications and
Bill Meanwell showed us three valuable Harris Mat (ink pad) impression
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A Periodical of the Pedorthic Association of Canada
SUMMER 2012
The two footwear segments provided the attendees to manually apply
what was first theoretically explained and presented by Jay and Kevin.
To quote from anatomy author Arthur Dalley,” you remember almost
all of what you experience and understand fully”, we can all agree
in our profession we learn by doing. While doing our hands on work
each instructor was readily available to critique and provide valuable
feedback. This interactive teaching environment fostered a great learning
atmosphere where we would learn from the instructor and from each
other. This really benefitted those of us who work independently or with a
small group of pedorthists.
Highlights for me included: learning a systematic approach for measuring
and casting for orthopaedic footwear. Also the usefulness of the Harris
Mat foot impression outlines and how the markings act as a template for
the rocker sole modifications. I highly recommend this learning format to
those who couldn’t make it. Mark it on your calendar for next time!!
9
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A Periodical of the Pedorthic Association of Canada
A Comparison of Top Cover
Material Choices
SUMMER 2012
Microcell Puff
This is a material with good wear resistance
and shock absorption. It tends to bottom
out when put under sore and pressure
Jim Pattison, C. Ped (C)
Top covers make an orthotic comfortable and prolong the time that an
orthotic can be used. There are a wide variety of top covers available and
it can be a challenge to select the correct one. Here is a brief consideration
of the materials that have been advocated as top covers.
Leather
This is a natural product and is a good choice if a person is allergic to
producing areas. It does not absorb sweat but is easily cleaned. There are
two thicknesses commonly available -1/16” and 1/8”.
Pink Plastazote
This is a material that is commonly used for people with diabetes and
arthritis. This is good for shock absorption and it bottoms out underneath
pressure areas to provide uniform pressure distribution across the foot. It
is easy to clean with water and mild soap. synthetic materials. This is not a commonly found group, but it is growing
Frequently, this material is a cover for other shock absorbing materials like
and knowledge about using hypoallergenic leather to help people will
PPT. This layering of materials increases the usable life of the top cover.
make a difference. There have been some people with environmental
There are several thicknesses available, ranging from 1mm to 6mm.
illness that have come to me telling me that they are allergic to glues.
When a person with an autoimmune disorder tells me that their feet
Cloth coverings
burn when other top covers are used, I often will use leather to deal with
Cloth provides a durable cover that is absorbent, comfortable, and has
this issue.
limited slipperiness however, by itself it has limited shock absorption. This
Leather absorbs moisture and helps keep the foot cool. The downside
of leather is that some types do stretch easily. For example, cattle and
stingray leather can’t readily be stretched and glued in at the same time.
material is easily cleaned by water and mild soap. Often cloth has other
materials like PPT, slow recovery poron or other materials underneath it
for shock absorption.
The alcohol leather stretching solution is applied to the leather until
The material that comprises the cloth can be infused with Silver Nitrate
it is wet which can impair the adhesion of the leather to the shell and
or Copper salts to introduce antibacterial qualities to the orthotic. This is
materials below. More flexible forms like pig, horse and sheep leather
something that has been advocated for people who are susceptible to
can be stretched and glued simultaneously. Cleaning is done with saddle
circulation compromise to the feet and reduced ability to fight infections.
soap and leather conditioners. There is a limited number of thicknesses
Another practice is to introduce nanostructural compounds into the cloth.
available. Since leather is softer than some of the other top covers, it
This means particles of a product are made that are smaller than have
needs to be inspected for wear and replaced more frequently than some
currently been used and the net effect is that nanostructural compounds
other top covers.
make the product lighter while retaining the original qualities of the
Vinyl
product. Nanostructural products are being introduced into other areas of
Generally the most popular material due to its cost, durability and its
ability to stretch. It is billed also as non-absorbent and easy to clean with
water or with mild soap. The down side is that this makes people whose
feet sweat uncomfortable. Although it is durable, it also tends to crack
at the flex points and can cause injury to the plantar surface of the foot.
Some have found this to be slippery and can increase the shear forces on
some areas of the foot. There are a limited number of thicknesses - 1/16”
the shoe and it is an area to watch.
Nanostructural bamboo is one of several materials introduced in the
material for almost unparalleled sweat absorption and moisture wicking.
The reason for this is the surface area of the bamboo particles is much
larger than any other preparation. This allows the bamboo to be much
more effective in its work of wicking up the sweat and other moisture from
the foot. The downside is we have observed decreased wear resistance
is the most common.
when nanostructural bamboo is included in insoles.
Vinyl covers can have shock absorbing layers like polypropylene
Cloth coverings are very thin - about 1/32” to 1/16”. When the cloth cover
thermoplastics (PPT) included underneath them. PPT is a material that
has other materials included under it, they range from 1 to 3 mm.
has limited shear resistance and does not stand up as a top cover.
EVA
This material gives good wear resistance with less slip and shear forces.
There are a number of different durometers available and there is shock
absorption available. It remains flexible over its life unlike vinyl. There are
a good variety of thicknesses available ranging from 1mm to 25cm and
this material is easily cleaned with water and mild soaps. However, this
material tends to bottom out over the years. Advertise in the
Pedorthics Quarterly
The PQ is distributed to 550+ members of the Pedorthic Association
of Canada in January, April, July and October. To advertise
There are a lot of different forms of this on the market from a number
in the PQ, contact Chantal Champagne at 1.888.268.4404 or
of different suppliers. NORA products like Lunacell and Lunasoft are a
[email protected].
couple of products in this class. Nickelplast and its derivatives are other
examples.
This is a great way to connect with the industry!
11
2012 Symposium Recap
C
ongratulations and a heart-felt “Thank You” to the staff of
the Pedorthic Association for another successful conference.
The Westin Hotel at Whistler was a fantastic venue for this
conference and it was the perfect opportunity to take in the sights
and sounds of Whistler Village. It makes one proud to be a Canadian
when we are surrounded by such beauty in our own backyard!
The hotel accommodations, meals and conference rooms, provided
by the Westin Hotel, were excellent and the quality of speakers were
very good.
It was also great to meet many new vendors displaying their
product lines in the exhibit hall, as well as seeing our ongoing
vendor support from those that we deal with on a regular basis.
It will be hard to top this conference but I am confident it will be
done for 2013.
Thanks again,
Liana Ellis, Director of Sales and Marketing, Walking Mobility Clinics
S
A Periodical of the Pedorthic Association of Canada
tarting a new job is always nerve wracking, but
SUMMER 2012
taking those first steps in your career is something
else altogether. This April, the annual PAC
conference in Whistler was my first conference as a C
Ped (C). I had attended other conferences in the past, but
always as a student. I was nervous to say the least, as this
was the first time I was attending a conference as a peer.
Whistler was breathtaking, and PAC could not have
chosen a better place to hold a conference. Having never
been to British Columbia, I arrived early, to take the
opportunity to enjoy Whistler as much as possible before
the Conference began. I was speechless at the beautiful
surroundings in Whistler.
The content of the conference sessions and lectures
themselves were fantastic this year. It was inspiring to
hear about the research being done in our field and the
plans for future research. I have a keen interest in the
Diabetic foot and therefore found Dr. David Armstrong’s
lecture particularly enthralling. He was a highly engaging
speaker with such a wealth of knowledge. His lecture was
the highlight of the conference for me.
All in all, I was able to take something away from every
session I attended, and managed to speak with numerous
exhibitors, speakers and fellow Pedorthists. Although I
still felt like a little fish in a big pond, I had a really positive
experience at this year’s conference and am looking
forward to the next. See you all In Montreal!
Kathleen Klement, C. Ped (C)
Clinic Owners’ Retreat
Sunday, October 21 to Tuesday, October 23, 2012
White Oaks Resort, Niagara-on-the-Lake, Ontario
Being a great clinician does not guarantee that you are prepared to be a great business owner. Back by popular demand, the Clinic Owners’ Retreat
(COR) is a forum for pedorthists to learn, share and grow as business owners and to help prepare you for the next stage in your career.
Open only to pedorthists who own an equity position in one or more clinics, the COR will be a facilitated peer learning forum. This retreat is for
those who are prepared to share as much as they listen.
You will find that this is not a typical conference where a
speaker talks at you. This is a forum where the facilitator
will lead the group through a number of questions.
Cost to register: $675 plus HST per person.
Note that accommodations are not included in this fee.
Space is limited.
Visit www.pedorthic.ca to Register.
Simple Lab Tools You May Not
Know You’re Missing
Scalpel
Not just used by surgeons, scalpels are great for slicing through thin
materials. Treat your scalpel like a good pair of sewing scissors, USE
ONLY ON FABRIC! Utility knifes are great for everything around the
Alex Whyte, C. Ped (C)
As pedorthists we are always looking for ways to improve our client’s
experience. First impressions are made during the assessment
appointment, but the lasting impressions are what you do for your client
at the pick up appointment. This involves fitting the orthoses in the
client’s shoes and delivering them a product that performs better than
expected. With many pedorthists outsourcing their foot orthoses to labs,
it’s easy to forget the simple tricks of the trade that come with on the spot
adjustments and quality lab work.
lab, but when precision is needed, the sharpest blade is the safest. A
scalpel can be used for removing the paper backing from polypropylene
thermoplastics (PPT/Poron), cutting through materials a misplaced
metatarsal pad is sandwiched between, and removing the suede top
cover from the jute layer on a Birkenstock modification.
Tip: Have replacement blades on hand at all times and dispose used blades safely in
a sharps box.
Electrical Tape
Having the client’s orthoses glued, cut to the proper size, and ready to
Below is a short list of simple lab tools that you may not know you’re
put in the shoe when they come in is a pedorthist’s ideal situation, but
missing, which can help you deliver a product the client will hopefully
does not always happen. When it’s time to check the fit of the orthoses
rave about.
on the client, or adjustments that need to be done at the future check
Digital Camera
Learning what has worked and what has not worked for the client in the
past is crucial for the success of their future orthoses. Remembering
material types, additions placement, shell shape, length of the orthoses,
thicknesses, previous wear patterns, etc. is a lot to remember and write
down during the initial appointment. Documenting old orthoses with
photos is an accurate way to describe an uncommon recipe for replication.
Having a large screen with which to view the images also makes it easier
to analyze the photos while you recreate them and it saves paper if you
don’t print them off.
Tip: Have a clearly defined ruler in the photo and the clients name in every frame,
this will save confusion when referring to them at a later date.
14
up, electrical tape is a must to have around. Electrical tape has been a
saviour for many pedorthists when it’s time to temporarily attach an
adjustment to an orthoses before or during the appointment. Whether it is
to temporarily attach a metatarsal pad, valgus/varus post, neuroma pad,
2-5 extension, heel raise, arch cookie, or anything else one can think of, it
does the job clean, easily, and fast. The design of electrical tape allows for
a strong hold onto many pedorthic materials while not leaving a residue
or mark behind when it is time to remove it. It’s also important for the
orthoses to maintain a clean superficial look; this keeps it easy to clean
and preserves its professional appearance.
Tip: Be sure to remind the client that this is only for temporary purposes and if the
adjustment is successful the tape will be removed.
A Periodical of the Pedorthic Association of Canada
SUMMER 2012
Alcohol Solution Spray/ Windex
Working with feet can become a smelly and dirty environment. It is
important that we decrease the amount of bad smell, bacteria, and filth
we interact with on a daily basis. A strong alcohol solution spray (or
diluted Windex) works great on orthoses to clean before handling in
an appointment, or to remove the fine dust in the final touches during
fabrication to give them a shine. These products generally do not have
a strong scent nor do they contain irritants to the body, which is great
for those with environmental allergies. These solutions also work well
as an overall cleaner and disinfectant in the lab and examination area.
Tip: Simply cleaning up a client’s old pair of orthotics and giving them a fresh look
is always a nice added touch to your service.
Different Colours of the Same Material
This may sound like an excess amount of inventory to carry, but
it is worth it for the client. The most popular material to have two
colours of is PPT/Poron. Having a minimum of 2 colours in PPT/Poron,
polypropylene, and EVA is ideal if your lab allows for it. The reason for
this is so the client can tell the difference between their multiple sets of
orthoses. This becomes an asset when clients bring in multiple pairs to
have recovered. Clients usually like to have some input on the orthoses
where possible, so this gives them a sense of contribution while not
changing the final product. Also, giving kids multiple colourful top
covers to choose from is always a treat for them.
Tip: On your order sheet specify the colour you want. When looking back in your notes
it’ll be easier to distinguish between the clients 6 year old and 4 year old orthoses.
These are all simple changes a pedorthist can make to their lab process,
at a very low cost, to help improve their lab work. If you are already doing
these on a daily basis, then you’re on the right track. Happy building.
consistently biotech
unique service • fast turnaround • outstanding product
1-888-745-9055
www.biotechorthotics.com
15
A Comparison of Foot Orthoses
Shell Material Choices
orthosis than a polypropylene plastic orthosis made of equal rigidity. This
David Deir, C. Ped (C)
wall, heel cup, and grinding away shell thickness to improve the fit in
As pedorthists, we see nearly an infinite number of combinations of foot
durability. A thinner carbon composite shell will allow for a deeper heel
types, body types, activity levels, footwear choices, and personality traits.
Thankfully, there are almost an equally large number of material choices,
to most appropriately suit your client. Shell materials have a number of
characteristics including rigidity, thickness, durability, weight, and even
colour, that all need to be considered prior to fabrication. Ultimately, The
decision as to which shell material to choose is based on examination
is advantageous in both extreme planus and cavus foot types, as each
have their own fitting challenges. For example, a 5mm polypropylene
shell orthosis for a severe planus foot may require lowering the medial
unmodified standard footwear. This will decrease the shell strength and
cup and a higher, stronger medial wall.
XT Sprint carbon composite is a very user-friendly material. It grinds as
well as thermoplastics and heats faster. Typical heating time, depending
on the thickness, is between 3 and 5 minutes at approximately 4000F. The
major disadvantage of this material is the price. XT sprint costs as high as
skills and treatment goals.
$22.56 per blank, which is significantly higher than a polypropylene blank
This is a review of 3 shell materials (carbon composite thermoplastics,
is best used in circumstances where improved fitting and/or increased
black plastazote, and multi-cork), that are less frequently used in the
pedorthic community. These offer alternatives to more commonly used
of the same size. Considering the large price differential this material
strength and durability are required.
shell materials like ethylene vinyl acetate (EVA) and polypropylene
BLACK PLASTAZOTE
thermoplastics.
Polyethylene foam is a frequent material choice in the fabrication of an
CARBON COMPOSITE THERMOPLASTICS
One of the newest advances in orthotic fabrication is the addition of
carbon composite thermoplastics. Carbon composites are high strength
carbon and glass fibers, in a polypropylene matrix. XT Sprint, for example,
is a fiber reinforced polypropylene composite material. It offers incredible
strength and durability. Once formed, it will not creep, relax or bottom
orthosis. However, it tends to be used more frequently as cushioning
materials, rather than a shell material. Polyethylene is a closed cell foam
that is easily heat moldable, grindable, hypo-allergenic, and washable.
Black plastazote is a rigid polyethylene foam, with a durometer of 65.
This material is by no means new on the market, but is certainly not as
commonly used as EVA and polypropylene for shell materials.
out. The finished product is a thin, durable orthosis shell.
The major advantage black plastazote has over other shell materials
As with a polypropylene plastic shell, the amount of correction and
of this material makes it very rigid and allows for the fabrication of a
rigidity is determined by thickness. However, the increased strength of
the carbon composite materials allows for a much thinner and lighter
16
is that it is ultra lightweight. Despite the light weight, the high density
corrective orthosis. This makes it an ideal material for elderly clients
A Periodical of the Pedorthic Association of Canada
who are constantly requesting lightweight footwear, but still require a
functional orthosis. Black plastazote also works well for pediatric clients for
the same reasons.
A unique characteristic to polyethylene is its auto-adhesiveness. If two
layers of polyethylene are heated and pressed together they will adhere to
each other with a very strong bond. This makes adding an arch fill, forefoot
post, or rearfoot post very easy even without the use of contact cement.
Closed cell polyethylene materials will bottom out eventually making black
plastazote less durable than other shell materials, however the high density
improves its lifespan. Another disadvantage of this material for an orthosis
shell is that, like EVA, in order to create more rigidity and correction adding
an arch fill is often required. Therefore, for more rigid orthoses there must
be an adequate amount of depth and width in the footwear for a proper fit.
This means that black plastazote would not be a suitable material choice for
a dress orthotic, although can be very effective as a semi-rigid orthosis in
many circumstances.
MULTI-CORK
Cork is a material that historically was used for orthoses before thermoplastics
were readily available. It has lost popularity to the EVAs and plastics that are
lighter, easier to mold, easier to grind and produce a much slimmer end
product. Natural cork cushions and is a long lasting material because it
resists compression well. By itself it is not heat moldable so a substrate is
necessary. Multi-cork is a unique blend of EVA and cork that offers a product
that is tough and easy to grind and is long lasting with good shape retention.
Multi-cork is a 60 durometer material that heats at a temperature of
approximately 3000 F for about 2-4 minutes. It is available in thicknesses
from 2 – 10mm. The combination of cork and EVA makes multi-cork a slightly
lighter and slightly less expensive material than most EVA. However, it is
difficult to make a corrective, rigid orthoses with multi-cork unless it is used
in combination with another material. Deep heel cups are nearly impossible
to create and, like black plastazote and EVA, thicker shells are required for
increased rigidity. However, the light weight and user-friendliness of multicork for fabrication and adjustments can still make it an effective shell
material. It is best utilized as more of an accommodative rather than a rigid
functional orthosis. It can also be used effectively in combination with other
materials as an arch fill or a posting material.
When selecting shell materials it can be easy to get into a habit of using
the same materials over and over again. In some cases extra thought is
required to come up with a shell material or combination of materials that
will be most effective for your client. It is foolish to not take advantage of the
vast number of material choices that are available today. Carbon composite
thermoplastics, black plastazote, and Multi-Cork are three choices that just
may offer a more suitable alternative for your next client.
REFERENCES
Michaud, Thomas C., (1997). Foot Orthoses and other forms of conservative foot care.
Newton Massachusetts, USA: Library of Congress
Palton, J., Jones, R.B., Stenhouse, E., Bruce, G., (2007). The Physical Characteristics of
Materials Used in the Manufacture of Orthoses for Patients with Diabetes. Foot and Ankle
International.
Tong, Jasper W.K., and Ng, Eddie Y.K., (2010). Preliminary investigation on the reduction
of plantar loading pressure with different insole materials (SRP – Slow Recovery Poron®,
P – Poron®, PPF – Poron® + Plastazote, firm and PPS – Poron® + Plastazote, soft). The
Foot 20, 1-6.
Vittoria Phoenix. Materials Guide (2006). Retrieved from http://orthovp.com/
National Shoe Specialties Limited
17
Member Profiles:
Dave Deir, C. Ped (C)
Kimberly Rau, C. Ped (C)
Dave Deir fell into his career in pedorthics, “In
2011 was a milestone year for Kimberly Rau.
high school I played every sport imaginable,
She celebrated 25 years in practice, 20 years
and that’s why I went into Kinesiology.”
in her head office location and 30 years with
Initially attracted to a career with a strong
Pedorthic Services – one of the oldest pedorthic
emphasis on technical skills and hands on
labs in Canada.
training, Dave applied to the orthotics and
prosthetics program at George Brown before
he found out about the Diploma in Pedorthics
program. “It seemed like a good fit and I like the ability to do placements
anywhere across Canada.” He used this flexibility to do placements in
Kingston, not far from Gananoque, ON where he grew up and where his
parents still live.
When Kim Rau was working towards a degree
in Kinesiology, she was unsure of her future
direction as the program content was fairly
broad and while it did not specifically qualify her for one profession, it
provided a valuable foundation opening the doors to many options.
Initially enrolled in the math program at the University of Waterloo with
electives in Kinesiology, Kim soon realized that the diversity of the KIN
“I loved the hands on side of it and I thought it was really practical
program was a better fit as it satisfied her interests in three “p’s” – physics,
because you’re learning from people who’ve been working in the field
psychology and philosophy. Considerations for a future in orthotics/
for years, it really is the best way to learn,” Dave recalls, describing his
prosthetics, medical school or a career in pathology soon became history
placement time with both Linda Deschamps of Stand Your Ground and
as a kinesiology liaison introduced Kim to Howard Feigel of Pedorthic
Meghann Brunet and Mac Graydon at BioPed Kingston. He credits the
Services in 1986. Howard was a pioneer in pedorthics in Canada and one
placement instructors and the other C. Ped (C)s he worked with during his
of the original 7 who brought the profession to Canada in 1981. “Howard’s
placements with offering such strong support while he learned as much
passion for our profession was contagious and his contributions before
as he could about the profession.
his passing in 2004 were infinite”, recalls Kim. Kim has become a leader
After completing the Diploma and gaining his certification in 2010, Dave
accepted a position at BioPed Kingston. The onsite lab at the location
fosters Dave’s love of the hands on aspects of pedorthics. “I really like the
in pedorthics and trained over a dozen C Ped (C)’s. “Howard remains my
number one inspiration through the knowledge, philosophies and values
I learned in our 17 years of practice together”, says Kim.
cases where you have to problem solve. For me, the onsite lab provides a
Kim founded Kimberly Rau & Associates who are a group of pedorthists
great advantage for those cases; it’s great to go from assessment to making
working in 8 multidisciplinary clinics in the Kitchener-Waterloo area.
my own orthotic and working on it every step of the way. Sometimes it
“Working closely with other health care professionals has always made
takes a little trial and error to figure out exactly what material you want to
sense as it offers a phenomenal learning environment, provides an ideal
use to achieve exactly what you want.”
setting for our clients who often need other treatments and creates the
As a weekend warrior himself Dave really likes cases involving runners
and other athletes. He uses these outside interests especially golf, as a
way of connecting with clients. Learning about the whole person helps
him determine the best course of treatment for his clients. Dave says,
“Some patients can’t handle a certain amount of rigidity just based on the
type of person they are despite what their foot dictates. This is something
opportunity for cross referrals and growth as these professionals with
who you develop close personal relationships open additional facilities.
Kim has always identified with the need to “adapt, migrate or perish” and
while this model has always been a win win situation for her practice, she
strongly feels that with the present climate of health care, it is the direction
the profession must go to remain an invaluable part of health care.
you learn as you go along — the more I’ve been doing it the better I’ve
Kim’s passion for the profession continues to grow as “our understanding
been getting at reading the client as well as their actual feet. Trying to
of what we do is in its infancy”. She explains, “We know what we do works
come up with the best overall treatment is the most fun part!”
and we’re forever searching now for the why”. She terrifies some of her
students when she verbalizes her thoughts, “There are times when I feel
like I know nothing – there is so much to learn!”. Her enthusiasm is ignited
by her students – “Being involved in teaching keeps you accountable as
students need explanations and validation. There are things you have
done for years simply because your outcomes are successful and it is
not until a student questions you that you evaluate deeper and finally
understand why,” she laughs.
“’Knowledge speaks, wisdom listens’ is a favourite quote by which I try
to live”, says Kim. We never stop being a student and our profession
Pedorthic Association of Canada
offers an amazing platform for learning. In addition to the obvious formal
education, attending conferences, and keeping current with research, Kim
attributes some of her greatest understanding to the knowledge gained
from her students, other health care professionals, and her patients
whose feedback on successes and failures mold her future treatments.
18
A Periodical of the Pedorthic Association of Canada
SUMMER 2012
If you ask Kim to name her number one key to success in the
profession next to her relationship with Howard Feigel, it would
be her involvement with PAC and the Insurance and Government
Relations Committee. She became involved in the committee
PAC 2012 Corporate Sponsors
gold:
at Howard’s request when he was ill and has never looked back.
Through her involvement, she has developed close personal
relationships with many PAC members as well as members of the
insurance industry with whom she now works as a consultant.
These individuals are a source of boundless information, knowledge
and guidance.
It is evident that Kim values “relationships” above all else and
she attributes her sanity through a very demanding career to her
amazing office staff, but most importantly the endless support of her
husband Bob and son’s Zachary and Harrison who help her to keep
perspective. “If you love what you do, you never have to work a day
in your life.” was a favourite quote shared with Kim by one of her
sons. This is true of pedorthics for Kim, but absolutely everything
in life is about balance so when she is not at the office, she enjoys
running, playing basketball and ultimate, attending her son’s many
musical theatre productions and spending hours baking for both
family and friends. Even referring professionals appreciate the home
Silver:
made sweets at presentations and as a thank you for their loyalty. It
is the tagline for her company. “It just made sense”, says Kim.
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19
“ When making
my decision
of the best
workplace
for me,
www.bioped.com
I searched for an environment
filled with a collegial team of
professionals, an opportunity
for personal growth through
on-going professional
education and a company
that believed in giving back
to the community.”
Lisa Welsh
BioPed - Surrey B.C.
“And I found all this... and more at BioPed.”
My Personal Growth
Career options that can
lead to management,
clinic ownership and
share participation
My Professional Growth
Through professional
education and a best
practices, encouraging,
work environment
My Decision. My Future. My BioPed.
My Independence
Knowing that I have
options of where in the
BioPed network to work,
across the country
My Security
That comes from the
stability of a leader
with over 30 years of
experience in my field
My Contribution
Being part of a caring
culture that gives
back to Canadians
For more information on employment opportunities or to inquire about
owning your own BioPed clinic, call Nancy Ekels at 1 905 829 0505 x231