Telehealth

“There are decades where nothing happens; and there are weeks where decades happen.”

Vladimir Ilyich Lenin

Telehealth has been around for a long time (basically, as long as people have had telephones). But, in March of 2020, its popularity skyrocketed. COVID-19 caused this spike for two different reasons.

Across the nation, stay at home orders turned living rooms and spare bedrooms into offices, schools, and clinics. We realized that a lot of things could be done remotely. Even after travel restrictions were lifted, new levels of caution caused people to view waiting rooms as potentially dangerous places. Everybody had the same thought – why take the risk when you could talk to your doctor from the comfort and privacy of your own home? **Side note: waiting rooms have always been full of strangers with various germs sitting too close to each other in uncomfortable chairs and touching the same outdated magazines. There is nothing like a global pandemic to make people notice how awful they have been all along.**

But the sudden popularity of telehealth was not just due to our social-distancing precautions. A fundamentally important second factor was at play – the reimbursement rules had been changed. Although the technology has been available to conduct telehealth for decades, it was viewed as an alternative method, best suited to rural and hard to reach areas. One reason it was not more widespread was because health insurance payments for virtual visits were a bit tricky. Healthcare providers had to use a specific set of billing codes and modifiers to describe their telehealth services (as shown in this now quaint article from 2019). The complex system made it hard to get paid adequately for telehealth.

Suddenly in March, the Centers for Medicare and Medicaid Services (CMS) made an announcement that health care providers could use their regular office procedure billing codes to get paid for the telehealth visits that they conducted. What’s more, they could use any system in order to conduct these visits – Skype/Zoom/Facetime: any and all of the above. With the lifting of these restrictions, telehealth suddenly became very viable. In fact, everyone sort of realized all at the same time, that it had been a good option all along.

There is no going back now. Papers are being written about how telehealth helps to remove access barriers, thus addressing socioeconomic disparities. Economic analyses are being conducted on the savings realized when no-show rates and waiting times are reduced. It has already been announced that some of the payment policy changes will be made permanent. On Thursday, CMS Administrator Seema Verma called this telehealth boom a “seismic shift, initiating a new era of healthcare delivery in America”

A9279

The “internet of things” has exploded in recent years. We now have Bluetooth toasters, smart toilets, and WiFi-enabled light bulbs that can be controlled by Alexa. The trend has also penetrated the medical device market and armies of engineers have been busily developing new ways to integrate sensors and processors into every step of the therapeutic pathway. 

Something that has been a little slower (actually, downright glacial) to advance is the medical insurance coverage of these new technologies. 

There are huge advantages to the new “smart device” revolution that is sweeping the medical technology world.  Including but not limited to: 

• The evolution of personalized and optimized treatments from the vast collections of available data. 
• Efficacy research that can be conducted in real-time and in real world environments. 
• The enhancement of provider and patient communication with the use of dashboards, portals, video conferencing, and messaging. 

The last few months of COVID craziness has emphasized the value of telehealthcare, and highlighted new ways to leverage these connected medical device technologies to improve access to care while protecting vulnerable patient groups. Smart healthcare devices are probably here to stay. But there is a major sticking point yet to be satisfactorily solved. Who is going to pay for all this? Technology is expensive!

The Centers for Medicaid and Medicare (CMS) tend to set the tone for medical insurance payments in the United States. In 2019 and 2020, CMS has made it clear that they will pay medical providers for their time spent evaluating and treating via telehealth and remote patient monitoring. That is encouraging news. But it doesn’t solve the entire payment problem. When insurance pays the physician for remote patient monitoring, they are paying for the time it takes to provide these services, but the cost of the gadgets that enable the remote services is still not accounted for. It’s possible that the healthcare provider can find the generosity in their hearts to take a portion of their own payment to pay for the “smart” devices. But (not surprisingly) there are lots of situations where this doesn’t happen and the cost of the equipment is passed directly on to the patient, increasing the out-of-pocket cost of care. 

The CMS reimbursement system uses a series of codes to represent the various medical items and services that a patient will encounter throughout the healthcare system. These codes (called Healthcare Common Procedural Codes – or HCPCs) are essentially a shorthand to standardize and abbreviate reimbursement communication. Each HCPCs code is tied to a predetermined payment amount and coverage policy. HCPCs can be quite specific. For example: 

• E1130 – Standard wheelchair, fixed full-length arms, swing-away detachable footrest. 

• E1140 – Standard wheelchair, detachable arms, swing-away detachable footrest

But when it comes to describing smart medical devices, that careful specificity flies out the window. 

CMS has only 1 code to describe anything with a sensor in it: 

• A9279 – Monitoring feature/device, stand alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified. 

So, this one little code is expected to be used for everything from a sleep apnea mask to a thermometer to a pressure-sensing cane. As long as the device in question contains a sensor or a monitoring feature, it falls under the classification of A9279. You can clearly see the problem here. Not all of these smart devices are created equal, and they shouldn’t all be referred to by the same name. 

That is like my very non-Italian grandfather on my father’s side driving my very Italian mother up the wall by referring to all pasta (no matter the size, shape, or ingredients) as “noodles”. It could be any dish from fettuccine alfredo to lasagna and it would all just be “noodles” to him. This limited vocabulary obscures communication and it is very frustrating! Imagine a restaurant menu that used this system. Chaos would ensue. 

 

This imprecision and confusion is not the only problem with A9279. In CMS’ own words: “claims for A9279 are denied as statutorily non-covered”. This means that CMS has decided that no-way, no-how is it ever going to pay for devices with this code. In fact, it would take an act of congress to change their minds. That is a pretty firm “no”. 

For years, enterprising medical device companies have been applying to CMS to add new HCPCs codes that will better describe their new technology, with the hope that these new codes could lead to insurance coverage. But, time and again, CMS has denied these requests and stated that an appropriate code already exists – A9279. 

CMS occasionally issues corrective statements about the use of its HCPCs codes (most often when people have been using them incorrectly). A new statement about A9279 was issued this month, reiterating the broad nature of this code:

Code A9279 (MONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED) describes any type of monitoring technology. Code A9279 is all-inclusive, and is to be used whether the monitoring technology is incorporated as part of a base item, supplied as an add-on module or is a stand-alone item.

This is really starting to get ridiculous. Back in 2007, when this code was created, it might have been adequate to describe the small number of smart medical devices that were available. After all, at the time, the internet of things was just a far-fetched concept and Steve Jobs was just announcing the first Iphone. 

The future of medical tech is here, but many of the most impressive innovations are unattainable in real life because of insurance payment issues. It would be really great if CMS could help to lead adoption of new technology, instead of clinging blindly to the past. An excellent way to start would be with a system of HCPCs codes that can appropriately handle the new generation of medical equipment. And while we are at it, maybe we should see about updating the definition of what constitutes medical equipment from the confines of the Social Security Act. In technology terms, those definitions are ancient history. Innovation is accelerating. We need the US reimbursement system to reflect this reality. 

References:

https://www.dmepdac.com/palmetto/PDAC.nsf/DID/MZI98M11U6

https://www.dmepdac.com/palmetto/PDAC.nsf/DID/E6IJ1IZCZW

Figure 15 image: https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-lshc-medtech-iomt-brochure.pdf

Dirty hands

The internet is currently crammed with people talking about handwashing. This was something that we were all confident in our ability to do a few months ago, but suddenly there are videos demonstrating proper techniques and playlists of songs with 20 second choruses to hum to yourself to make sure you aren’t rushing the job. It’s important, and I glad that people are doing it…but, it has become just another thing to worry about.

 

I can offer you a simple antidote. Not to the virus (I wish!)… but at least to the cycle of obsessing about scrubbing away at an invisible threat with terminally dry skin being the only tangible result. My suggestion is to try some dirt-therapy. Here’s two examples of what that looks like for me:

Example 1): I’m an apartment-dweller these days. But I have a little back porch “garden” with a few flowerpots. Today was the day that I wanted to get it all out and ready for planting. Truth be told, there are still a few patches of snow on the ground up here in New England, so I will have a to wait a few more weeks to plant the seedlings. But I took advantage of a sunny afternoon to get set up. There was some…problem-solving involved. My porch only gets sunlight at one end and I wanted to maximize that area, so I had to devise a sort of railing-suspended double-decker plant pot arrangement. It involves a couple of plastic containers, a wire shelf that I found next to the dumpster last year, and some shoelaces. It is exactly as glamorous as it sounds.

I had only about 1/2 the potting soil that I needed, and I wasn’t about to risk the plague to go pay money for dirt, so I took a bucket and dug up some loamy soil from the woods. There followed about an extended session of hand-mixing that looked like a baking show gone wrong. It took me right back to childhood and it was surprisingly fun.

Example 2): The other messy thing I have been doing lately is pottery. This is not new, it is something I have done off and on for about 10 years. But this is the first time I have enjoyed the luxury of having my own pottery wheel in my own apartment. In January, I ordered a little wheel from the internet and turned a utility closet about the size of a phone booth into a tiny pottery studio.

Since then, I have been gradually getting back into throwing mugs and bowls. One of the funny things about making pottery in my own home “studio” (closet), is that I can get creative about what tools I use to shape the clay. The other day, I took a newly-made mug out into my kitchen and made a random pattern of dents on it by thumping it with the handle of a butter knife. I’m hoping that this will look charmingly artisan once the piece comes out of the kiln with glaze on it. It’s a risk. It could just look like someone didn’t know what they were doing. Only time will tell.

Anyway. That’s my suggestion for a little quarantine pick-me-up. Take a break from being so clean. I doubt that you will have to construct a double-decker porch garden or a closet pottery studio, but I am sure that there is something else that you can make or do. It only counts if it’s messy. Get up to your elbows in the kind of dirt that will get stuck under your fingernails. Change the oil in your car, build something in the workshop, bake some cookies, create a finger-painted masterpiece. When you are done, and you are scrubbing up at the sink, watch the cloudy water run down the drain. I’m sure that it will take you more than 20 seconds to get your hands clean and the whole time you will be thinking about how nice it was to fill your mind with something else for a while.

Stay well!

Life-space

It’s been a weird month. March is always kind of uncomfortable anyway, with winter dragging on and the mud season before spring. But COVID-19 has really distinguished March 2020 from all the rest. As the threat of the virus has escalated over the past weeks, strange stress-cracks began to show in our daily lives. Consider the unprecedented uptick in attention to toilet paper….pause to reflect on the fact that people who were thought to be unreasonable germaphobes now seem moderate and sensible…and take a minute to appreciate the introverts who have been training for voluntary social distancing all of their lives. 

I have been working from home this week and I realize what a privileged position I am in to be able to do so. My job (as a project leader for the TREAT Center at a medical device engineering firm called Simbex) consists of a lot of web meetings and phone calls with clients, and online research and writing. It is actually the perfect job to do remotely, so the transition has been pretty smooth. 

Yesterday, as I was taking my lunch break in my own kitchen (that part is still weird), I got an email from Dropbox saying that I needed to login to my account to keep it active. I haven’t really used that account since grad school, but I figured that there were some files I would want to keep, so I logged in. It was a trip down memory lane! Most of the files were related to my gig as a research assistant on a project focused on the community mobility of older adults. That project heavily referenced a concept called “life-space”, which is the theme of this post and is oddly poignant during this strange March. 

Life-space is a way to describe mobility (or, if you are an academic, you might call it a “conceptual framework”). There are five potential levels of life-space, shown in this image below. 

In normal circumstances, healthy, active people at Life-Space 5 essentially have no limitations on their mobility. They are free to go wherever they would like to go. In contrast, aging or disability reduces life-space in concentrically smaller circles until, at Life-Space 1, the person may be entirely confined to their home. 

Before this month, I would have said that I thoroughly understood the concept of life-space. I had observed it in my patients and elderly relatives, I had conducted Life-Space Assessments on study participants, I had written papers about it, I had even done a poster presentation about it in grad school.

But, as they say…”you don’t know what you’ve got till its gone”. This March, the concept of life-space limitations is playing out across society. A few months ago, Life-Space 5 seemed like business as usual. We could have flown anywhere and gone on any cruise we chose. Those were the days! As precautions are increasing and travel restrictions have been enacted, our life-spaces are shrinking and it chafes because we are used to such freedom. 

In my case, the daily commute has shrunk down from a 20-minute drive to the office and back, to a short walk across my apartment. I have spent about 40 hours this week sitting on the right hand side of my living room couch. I think this is more hours that I have sat on that couch since I got it last year. 

My daily walks have also subtly changed. I typically take a stroll around town in the evenings, usually passing a few fellow walkers on the trails and sidewalks. But now, the whole town is out walking their dogs, carefully staying more than 6 feet apart and shouting back and forth to each other, intentionally stretching their life-space as far as they can. Here is a picture taken of the sunset last night. It was pretty, but not spectacular. It probably wouldn’t have occurred to me to take that picture if I hadn’t been so focused on enjoying every moment out and about. 

It turns out that the coronavirus pandemic is the perfect opportunity to empathize with people who experience life-space limitations. In the months to come, I predict a bloom of new technologies to help overcome the limitations of proximity. This innovation will be a direct result of the temporary restrictions, but hopefully will have a lasting effect in improving quality of life for people who don’t have the luxury of unlimited mobility. I am looking forward to seeing what we all come up with. In the meantime, if you find yourself with time on your hands, and you want to read about life-space straight from the source, here is the link to the excellent 2005 research article by Dr. Claire Peel and colleagues at the University of Alabama at Birmingham.  https://academic.oup.com/ptj/article/85/10/1008/2804989

 

Now, more than ever – stay well! 

 

Changes and TREAT

2019 is only a few months old and it has already been full of changes. In January, after graduating from the University of Buffalo with my PhD,  I packed up my belongings and moved to New England.

Book-Tetris action shot from the moving process. Something wonderful about Galileo being next to Winnie the Pooh.

I am now working as an entrepreneurial fellow at the TREAT Center. TREAT stands for “Translation of Rehabilitation Engineering Advances and Technology”.  It is an NIH-funded center that helps with the commercialization process of new ideas in the world of rehabilitation and assistive technology. 

I am enjoying this opportunity to see “behind the scenes” of how new products and inventions actually make it into everyday healthcare practice. Researchers, engineers, healthcare professionals, and everyday people submit their product ideas to TREAT, and we provide guidance to help them at every stage from idea to implementation.

TREAT’s Commercialization Process

TREAT is a partnership of several organizations, one of which is an engineering firm called Simbex. The engineers are often called in as consultants for TREAT clients, along with experts from Dartmouth and clinicians from various branches of medicine. A great perk of my fellowship position is that I get to listen and learn throughout the whole process.

Like many of the TREAT clients, I didn’t get a lot of business training during my education, so one of the biggest things I am learning is what makes an entrepreneur’s business sink or swim. There are so many considerations beyond the initial idea, especially because of the complicated layers that surround the healthcare industry. I now have an even stronger appreciation for how difficult it is to make disruptive changes to current practice.

The gap between cutting edge technology and what we can actually use with patients is something I have been complaining about for years. There is record of my complaints in the past (gasp) eight years that I have had this blog. I even wrote an article for the TREAT newsletter this month, talking about how the orthotics and prosthetics world is resistant to change. Now that I am working with TREAT, I feel like I am actually able to contribute to innovation, rather than just bemoaning the lack of it. What an opportunity!

One last note: you may have noticed that I gave the blog a bit of a face-lift today. I also updated the “About walkwellstaywell” page. It was about time and it seems fitting within the theme of changes happening in 2019.

Walk well!

Bracing for change

I haven’t posted in over a year…but I have a good excuse: I have been working on my dissertation. Soon (hopefully) I will be wrapping up my PhD at the University at Buffalo. If you are curious about the Biomechanics Lab where I do my research, check out these pictures: https://www.instagram.com/p/BlOKn_YgKTL/?utm_source=ig_web_copy_link

I just got back from SciComCon at Cornell University, a science communication conference for graduate students. It was a great experience and got me thinking about how important it is to tell people about research. Part of the conference included writing a piece about our particular area of expertise. I chose to write about the struggle to bring bracing into the modern era. I realized that I hadn’t really discussed this on my blog, so I am sharing it here.

(Warning: members of the orthotics and prosthetics community – you might not like this very much. For one thing, I didn’t use the term “orthoses”…I also criticize the L-code system and point out the lack of scholarly research. Tough words, but these are things that have to change in order to ensure that our field survives in the future. Feel free to comment on this post to start a dialogue).

______

For hundreds of years, braces consisted of rigid metal bars and hinges held on to the body with leather straps or strips of cloth. They were made for each individual patient by craftsmen such as armorers, tinkers, blacksmiths and cobblers. The advancement of plastics in the mid 20th century led to cosmetic upgrades, but the metal components of braces remained largely unchanged. (Picture 1: antique leg brace, Picture 2: modern leg brace)

In the 1980s, brace makers formalized the profession and established a list of acceptable types of braces in order to ease the prescription and insurance process. Braces were fabricated to include the components described on the list, special emphasis was placed on the specific type of hinges that would be used in leg braces. This system was important to ensure standardized care for patients. The problem is, we are still using the same list. The field is stuck in a time warp, where only the types of braces that existed in the 1980’s are considered to be legitimate medical devices today.

In recent years, prefabricated braces have become widely available. Braces now come in sizes just like T-shirts, with handy velcro straps that allow for fine-tuned adjustments. Gone is the muss and fuss of making each individual brace from scratch, but bracing innovation continues to be limited by the constraints of the list from the 1980’s. Prefabricated braces have bars and hinges that have been reverse-engineered so that they meet the specifications of the list. However, these elements are removable, or made out of lightweight plastic so that the patient can have a comfortable brace which they are likely to actually wear. This is as ridiculous as an iphone being packaged with an optional rotary dial in order to be classified as a telephone. (Picture 3: a knee brace with removable hinges, Picture 4: a knee brace with very minimal hinges)

 

There is another troubling fact about braces: we are not exactly sure what they do. In the days of more primitive orthopedic treatment, braces were needed to mechanically support limbs that were weakened or twisted by trauma or disease. These days, braces are likely to be worn for more mild complaints, such as after a sprain or to cope with arthritis pain.

Those of us who provide braces operate on the theory that they help to improve alignment, reduce pathological movement, provide support, or prevent further injury. But, when we are asked for the evidence base of our practice, there is an alarmingly scant number of studies about the effects of braces. Bracing studies that do exist often have very small numbers of subjects or lack objectivity because they are sponsored by the brace manufacturers. Top quality studies, such as randomized control trials, are virtually non-existent.

After a few years of working in the bracing profession, I became frustrated with fulfilling the requirements of a list that had been established before I was born.  I was also bothered by uncertainties about the effectiveness of bracing. I no longer felt sure that my work was helping people. My patients claimed to feel better when they wore their new braces, but I wasn’t willing to take this anecdotal evidence as proof. I wasn’t satisfied, so I went back to grad school to do some research of my own.

I focused my research on measuring the effects of leg braces. To narrow the question even further, I picked the one component that all types of leg braces have in common – the straps. Straps were considered so basic that they were not even mentioned in the list from the 1980’s. But, straps are important, every brace has to be held on somehow. (Look back at all four of the braces pictured previously and notice that they all have a strap just below the knee. This is the area that I had my subjects wear the straps around their legs.) Modern brace straps are made out of padded velcro. I could imitate this in the biomechanics lab for a few dollars. Because I was committed to starting basic, I decided to look at the effects of wearing brace straps on standing – reasoning that you have to stand before you can walk.

My experiments showed that people were aware of a sense of compression around their muscles when wearing brace straps on their legs. The subjects in my studies showed improvement in their balance when wearing the straps. These results suggest that the sensation of wearing velcro straps around the leg contributes some form of sensory aid which improves neuromuscular control.

Other researchers have had similar findings, where subjects were helped with use of flexible types of leg braces. It appears that when it comes to bracing, sometimes less is more.  Minimalist braces may have an effect, without including the bars and hinges that were traditionally considered fundamental components of braces. This possibility was not considered in the early days of the bracing industry, so non-rigid braces were not categorized as medical devices. I think our definitions of what constitutes a brace should change – it is about time to seriously amend the brace list.

There is so much research left to be done, which makes this an exciting and challenging field. Opportunities abound for collaboration between biomechanists, engineers, practitioners, and patients. New technology that could be used to create better bracing is constantly developing. A backlog of wearable devices and robotic exoskeletons is waiting to join the mainstream bracing offerings, if we can find a way to eliminate the bottleneck of historic regulations.  The possibilities are endless – I am excited about the future, but in order to get there, we have to overcome the limitations of the past.

Walking

Today I did something unusual. I left early. It’s near the end of the semester. This is the time of year when everything is due at once, but it is also the time of year when the sun comes out for the first time in months. I looked out the window at the blue sky and I decided that the PowerPoint I was making could wait. So I went for a walk. I followed a surprisingly empty bike path near the river. I successfully passed by two joggers, one biker, and an entire women’s rowing team without having to talk to anyone. I brought my camera along and got a few pictures of the evidence that spring is spreading.

As I walked, my mind kept returning to the presentation that I had been putting together, which was on the topic of gait and balance. I have been fascinated by the way people stand and walk ever since I was a kid, this interest is what got me into sports medicine, and then into the field of orthotics and prosthetics and now into my PhD research. This semester, I am collecting data on a project that measures people’s balance when they are standing in various conditions. I am also the TA for an undergraduate biomechanics class. The presentation I am putting together is for a class lecture that will hopefully help the students think about ways to apply their newly acquired understanding of biomechanics to their future careers in rehabilitation science. I thought talking about walking would a good way to do this.

“I just want to be able to walk  ________”  Fill in the blank.  Some patients say again, some say without pain, some say for the first time, or down the aisle at my wedding, to the mailbox, or up a mountain. I have heard variations of that sentence hundreds of times. For many people, the line between disability and normality is drawn at the ability to walk. If walking is unavailable, we will settle for alternate forms of transport – like wheelchairs or mobility scooters. But walking does seem to be the preferred method. Last year I had the opportunity to participate in a research project about mobility of the elderly within the home environment. We interviewed the participants about how well they were able they were to move around their homes, we measured their walking ability and we measured their homes. Mobility is a result of two different factors – the person’s physical abilities and the challenge of their environment. This becomes clear if you consider two extreme scenarios:

1)   A rock climber can use his extraordinary fitness and skill to conquer a cliff face.

2) An old woman uses all of her strength to reach the top of a flight of stairs.

The amount of effort might be similar in both situations. In both cases, the individual is pushed to the limit to overcome a barrier. The only differences are the size of the barrier, and the extent of the physical limitations. This afternoon as I was walking along a smoothly paved bike path, I was well within my mobility “comfort zone”. I was able to enjoy the scenery and let my mind wander without having to struggle through each step. It’s a privilege to be able to do that.

In 2015, the Center for Disease Control estimated that limited mobility was the most common form of disability in the United States, impacting about 13% of adults. The National Health Interview Survey found similar results, stating that about 18.2 million adults in the US are unable to walk even 1/4 of a mile.

There were mile markers on the trail that I was walking along, placed every quarter of a mile. Each time I passed one I was reminded of these statistics. Besides feeling fortunate to have the ability to walk, I was also feeling excited to have picked such an intriguing area of research and clinical practice. Gait and balance impact so many aspects of a person’s life, these abilities can be threatened by myriad conditions and restored via many therapeutic interventions. This means job security and ample opportunity to make a positive difference. Tomorrow I will go back to preparing the PowerPoint. I will turn these rambling thoughts into tidy bullet points, and then I will deliver them to a hall full of sleepy students. Maybe I can change the way that some of them think about walking.

 

Walk well!

 

ICD-10

Don’t panic

Do you remember the Y2K scare? When the calendar year turned over from 1999 to 2000 there was widespread fear that our computer-driven society would suffer some sort of mass meltdown and that apocalyptic-style crisis would ensue. It didn’t. 1/1/2000 was a day much like every other. All those stocks of canned goods and bottled water went unused, nothing exploded, no missiles launched – and we all breathed a sigh of relief.

Well, tomorrow (10/1/15) marks the first day of a new era in the medical world. The beginning of the ICD-10 diagnosis code system. It is a big, scary change; everybody hopes it goes smoothly, but if it doesn’t – it could be Y2K 2.0. The change-over has been put off for the last several years because of the huge amount of preparation it takes to ready the medical software and billing systems for the transition.

Keep calm and …

For those of you unfamiliar with diagnosis codes, here is a little look behind the curtain. When you go to your doctor for an appointment, you describe your symptoms, the doctor examines you and eventually comes up with a diagnosis. The doctor then writes an office note about your visit, recording any significant findings and maybe a line or two about the symptoms you described. The note is as short as possible since the doctor has to move on quickly to the next patient. This note is then made a part of your medical record and can be accessed in the future to verify what happened at that day’s appointment. One important component of your office note is the diagnosis code. This is a short sequence of numbers that describes what injury or illness you have.

This diagnosis code is included on a prescription that is then sent on to your pharmacy, any therapist who will be giving you treatment or anyone who might be fitting you for a brace or medical appliance. The diagnosis code is the only information that we (your Pharmacist, Therapist… in my case, Pedorthist) have about your condition unless we request a copy of the chart notes from the doctor. The diagnosis code is also the only information your insurance company has about your doctor’s appointment.

Follow the money

In an effort to be as profitable as possible, insurance companies do their best to avoid payment for what they deem to be unnecessary treatment. As a result, insurance companies check to make sure the diagnosis code matches a list of approved codes before agreeing to pay for any treatment. For example, if your doctor has prescribed that you wear a knee brace, your diagnosis code must be for a knee injury. The brace might be denied as “not medically necessary” if you just have a diagnosis for a knee bruise, since a bruise is not considered a serious enough injury to require a brace.

Usually this system works pretty well, the insurance companies save money by not paying for unnecessary things. The patients feel vaguely that their insurance coverage is not what it was cracked up to be, but they can’t do anything about it so they pay their bills and move on. Everybody (by which I mean the insurance company and the doctor) is happy. However, this already somewhat dysfunctional system is about to turned on its head.

Old vs. New

The old diagnosis code system was called ICD-9. It contained about 17,000 codes for your doctor to select. Most of the time, it was pretty easy to find a code that somewhat described your problem. If you only had 1 thing wrong with you, you might only have 1 diagnosis code, if you had multiple issues the doctor might use a combination of codes to describe your condition. ICD-9 codes also contained handy “catch-all” codes like this one (my personal favorite) 729.5 which means “pain in unspecified limb”. Ha ha. That’s like saying “Doctor, my leg hurts” and having him say “yes, that’s because your leg hurts…that’ll be $75 please”. But, I digress…

The new ICD-10 system contains 69,000 codes. This means that the physician must be much more specific about what exactly is wrong with his patient. Which is a good thing, it means that each patient’s medical record will now be more complete and contain a lot more information. No more lazy diagnoses, the codes now indicate if this is a new or old condition, how it occurred, and a lot more details about what exactly is wrong. There is a code for everything, this is an actual, real code:  W59.22XA = Struck by a turtle, initial examination. How does that even happen?

What does this mean for you?

Unless you are in the healthcare industry, you don’t have to change much about your daily routine after tomorrow. You may not even notice the transition from ICD-9 to ICD-10. But if (as I suspect) the change-over is a little bumpy, you may notice a snafu or two. For one thing, it will now be easier for an incorrect diagnosis code to be applied to your chart. The physician choosing the code is most likely working with software that helps him choose from a list of possible diagnoses, these lists are long and confusing. It is very easy to click the wrong code and next thing you know you have been diagnosed with an injury from a turtle strike.

You, as the patient, should always know what your medical record says. You can help ensure continuity of care by being well-informed. Remember, you are one of many patients being seen in a busy office and it is very easy for mistakes to be made. You are in charge of yourself. Be your own advocate and make sure a simple data entry error isn’t getting in the way of your treatment. You can google your ICD-10 codes to make sure that they make sense. If you have a question, don’t be afraid to ask. (But as a tip, be cognizant of the fact that your doctor is probably in a hurry – be brief, be courteous).

The other thing you need to know is that insurance approvals might take a little bit more time than usual in the next few weeks. This is because they are busy checking everybody’s new codes to make sure that the treatment is still “medically necessary”. With these new, more complicated codes there is much more information to sift through.

If you have any kind of doctor’s appointment tomorrow, bring a treat for your physician and especially for the office staff. It is going to be a long and hectic Thursday. Expect delays. Hopefully this new system will lead to better quality care in the long run. Only time will tell.

Walk well!

Plantarflexion Contactures

A contracture happens whenever a muscle gets stuck in its shortened position- making the joint have less motion than it should. In the case of a Plantarflexion contracture, the joint in question is the ankle. The muscles on the back of your calf are called the Plantarflexors. Here is a picture of those muscles:

The plantarflexor muscles are anchored behind the knee and are responsible for pulling up on the back of the heel, which makes the toes point downwards. This is called a plantarflexed position.

When the muscles in the back of the calf are in contracture, it means that the person is unable to move his or her foot into normal position. (The opposite of plantarflexion is a motion called dorsiflexion, which means bringing your toes up. See the picture below). Dorsiflexion can only happen if the muscles in the back of the calf are able to be stretched.

The yellow line in both pictures represents the “neutral” position of the foot. In order to walk normally, you have to be able to move your foot a few degrees beyond this line. This becomes impossible if the plantarflexor muscles are contracted.

Moderate to severe Plantarflexion contractures occur very frequently in people who have been born with Cerebral Palsy, had a stroke or suffered some sort of injury. More mild versions of a Plantarflexion contracture can happen to anyone. As you can see in the picture above, the mildest form of Plantarflexion contractures just means that you are unable to pull the front of your foot up towards you past the neutral position.

I have found that VERY MANY people who complain of foot pain have a mild case of Plantarflexion contracture. There are two reasons for this high correlation:

1. If you have really tight Plantarflexor muscles you probably also have a very tight Plantar fascia. This is because the two are very closely related. See this previous post about the topic of a tight fascia and tight calves. https://walkwellstaywell.wordpress.com/2012/09/05/plantar-fasciitis-a-real-pain-in-the-arch/

 

2. If you have a Plantarflexion contracture you are probably spending a bit more time walking on the front part of your foot since you are already in “tip-toe” position. This means that instead of distributing your body weight over the entire foot, a lot of stress is concentrated at the front your foot (The metatarsal region).

 

 

 

Walking with a Plantarflexion contracture is not only bad for your feet, it can also effect the rest of your body – especially the hips, back and knees.

                                       

People with Plantarflexion contractures tend to compensate by moving their knees into bad alignment when walking or standing. This causes stress to the knee joint because if forces the knee to be in an unnatural position. The hamstrings then get sore and tight, they pull on the hip which then puts extra strain on the back. The net effect is to make the person’s feet, legs and back feel sore and tired.

Now when someone with a Plantarflexion contracture comes to me for treatment, I am faced with two options:

I can make them feel better

Or

2. I can help them actually get better

 

In order to make someone with a Plantarflexion contracture feel better, all I have to do is put a wedge underneath their heel inside of their shoe. (Or instruct them to wear a shoe with an elevated heel). This solution essentially brings the floor up to the foot – It makes up for the fact that the person cannot get his or her foot into the neural position. In fact, it encourages the foot to remain in a nice relaxed Plantarflexed position. So what’s the problem with that? Well, it’s fine as long as the person can always have a wedge under their heel. But it means that they will no longer be comfortable walking without their shoes on. They are now dependent on the heel elevation to be able to walk without pain. This position becomes their new “normal”. If maintained long enough, the foot loses its ability to dorsiflex even to the neutral position. The patient has now moved to a more severe level of Plantarflexion contracture.

In order to actually chose option #2 and recover from a Plantarflexion contracture, the patient needs to be encouraged to do just what the foot doesn’t want to do – Dorsiflex. In other words, they need to stretch. Aggressively! The plantarflexor muscles are very tough and strong and they are not going to give up without a fight. Research suggests that if you are stretching to overcome a Plantarflexion contracture, you will need to stretch for at least 30 minutes per day. You can read more about the topic of calf stretching in this blog post from a few years ago. https://walkwellstaywell.wordpress.com/2012/10/03/silly-putty-stretching-for-plantar-fasciitis/

Now you know! Plantarflexion contractures happen all the time. And they are really bothersome once they are established. You can fight this problem by being diligent about your calf stretching. Pass the knowledge on:  Watch for anyone walking on their tip-toes or standing with hyperextended knees. Be alert for signs of achy foot pain in yourself and your family members. Direct them towards this blog for some further reading. That’s all for now – go and stretch your Plantarflexors….

 

Walk well!

Collaboration

A fellow blogger named David and I worked together to write an article about teamwork and cooperation in healthcare.

You can read our post here:

http://blog.davidbendell.com/2014/improved-interdisciplinary-collaboration-for-better-patient-safety/

It has been my experience that small, private healthcare practices, such as those in the field of Orthotics and Prosthetics, tend to operate very independently. Interactions with other members of the healthcare community are often limited to self-promotion aimed at referral sources and the occasional round-table discussion at annual conferences. This may have been an acceptable practice previously, but the world has changed. Information is now able to be exchanged at increasingly rapid rates, we no longer have the excuse that it is difficult to contact our colleagues. Patients benefit when their caregivers maintain open and clear communication.

What should you do? 

1. If you are a patient: You should not assume that your various caregivers are communicating adequately. Be sure that you have copies of all relevant documentation. Keep a set for yourself and bring your paperwork to your appointment. Take notes about what each caregiver is telling you. Be able to refer to these notes in case you seem to be getting confusing or conflicting information from different practitioners. This extra caution will ensure that you don’t fall through the cracks. Your doctors should never intentionally mislead or incorrectly treat you, but everyone makes mistakes… Even people who wear white coats.

2. If you are a practitioner: Reach out to your colleagues. Get to know the other practitioners in town. Don’t just view them as competition or as a referral source. Think of them as a fount of information that you can use to better treat your mutual patients.  Even those who vary drastically from you in terms of discipline type and education level possess specific skill sets and knowledge bases from which you can learn. Your patients will benefit from your willingness to collaborate with their other caregivers.

Walk well!

Varus and Valgus

This blog is about two of my favorite medical terms: Varus and Valgus. These words come from Latin and they basically are ways to refer to something that is crooked. Most of the time when I use “varus” or “valgus” I am referring to different types of crooked legs. Almost nobody has perfect legs – so most of us fit into the category of either varus or valgus leg alignment.

One of the first things I do when evaluating a new patient is to decide if their legs are varus or valgus.  I use these categories as very loose guidelines to help me quickly decide what types of injuries the person might be experiencing. It is not too surprising that people with similar body types often develop similar injuries.  Of course there are exceptions to every rule, and there also degrees of severity. Not everyone fits neatly into a category, but I find that this is as good a starting place as any.  Here is a brief overview of the Varus, Valgus and “Good” alignment groups.

Before we get too far into this, I need to stop for a disclaimer: Please excuse the poorly hand drawn pictures that resemble happily dancing robots. I am no Picasso. Or maybe I am too much of a Picasso (if you have seen some his cubist paintings).

Good alignment

Legs are considered to be in good alignment if a straight line can be drawn from the hip, through the knee to the second toe. Here is a guy with good alignment:

Although this figure looks very smug about his perfect legs, you can’t always assume that people with good leg alignment will be injury free. Legs that are very straight sometimes have a hard time absorbing shock. Because all the bones are aligned exactly on top of each other, every step can send shock waves up into the rest of the body. This shock is often absorbed in the pelvis or spine, resulting in injuries of the back or even the neck.

 

Varus

A person with Varus alignment of their legs looks something like this:

Varus alignment can also be called “Bow legged”. A person with varus alignment has legs that curve outward, with the knee being further out than the foot. The curving shape can happen at either the knee joint itself or because the actual bones of the lower leg are bent outward.

If you have trouble remembering the meaning of varus, remember that that R stands for Rounded.

Varus legs are susceptible to the following injuries:

–          Osteoarthritis of the knee

–          Shin splints

–          IT band pain at the hip or knee

–          Chronic ankle sprains

The most common issue I see with people who have varus legs is knee pain. The varus leg shape is bad for both the medial (part on the big toe side) and lateral (part on the pinky toe side) areas of the knee. Because of the curved shape of the leg, all of the structures on the medial side of the knee are squished together and all of the things on the lateral side get stretched apart.

To make matters worse for the varus leg group, it is very common for someone with a varus knee to also have a varus foot alignment. This is also called having a supinated foot. Supinated feet look like this:

There is a whole list of additional problems that comes with having supinated feet. It will be the subject of its own blog post in the future. For now it is enough to say that people with supinated feet are more likely to sprain their ankles, since they put most of their body weight on the outsides of their feet.

 

Valgus

Valgus leg alignment is much more common that varus leg alignment. Someone with valgus legs stands with their knees close together, in a “knock knee” position.

You can remember the term valgus because the leg forms an angle like the letter L

Valgus leg shapes can lead to the following injuries:

–          Knee caps that dislocate

–          Medial knee pain

–          Patella/femoral syndrome (also called jumper’s knee)

–          Foot and arch pain

–          Low back pain

People with valgus leg alignment almost always have pronated feet.

This means that the weight of the body causes the arch of the foot to collapse and the person then stands with more weight on the inside portion of the foot.

Valgus knee alignment (not surprisingly) puts exactly the opposite stresses on the knee as varus alignment does. The lateral side of the knee is squished and the medial side of the knee is stretched.

People with valgus leg alignment often have pain in the front and the inside of their knees. This is because the angle of the leg causes an uneven pull on the kneecap. It is slightly more common for females to have a valgus leg shape because they tend to have wider hips.

 

The Combo:

It is also possible to have any combination of leg alignments:

One leg could be valgus while the other leg is straight, one leg could be varus with the other leg is straight, or you could even have one of each! These combo arrangements often happen either as the result of a serious injury (like a fracture that didn’t heal well) or because one leg is significantly longer than the other.

 

So what should you do if you have varus or valgus legs?

–          Loose the extra weight. If you have varus or valgus leg alignment, the best thing you can do for yourself is to maintain a healthy body weight. Additional pounds can make a mild alignment issue much worse. Our legs have to work really hard to support us, even under the best of circumstances. People who naturally have excellent body alignment can often get away with being a bit heavier, but anyone who has varus or valgus legs should be very cautions not to make the issue more severe by gaining too much weight.

 

–          Do low impact exercises and activities. The stress associated with long distance running and other such repetitive activities can really prove damaging to people who have severe varus or valgus alignments.  Cross training and alternative exercise programs are a great way to overcome this. Try swimming or biking for your cardio workouts. You can still do some running, just keep it in moderation.

 

–          You might be able to somewhat improve your alignment by doing specially targeted stretching and strengthening exercises. Find yourself a physical therapist or fitness specialist who can help you set up a routine.

 

–          Sometimes the alignment issue is severe enough that a brace must be used on that leg. “Unloading” knee braces apply force to the side of the knee in an effort to reduce the angle of the joint.

 

–          Foot orthotics can correct the issue from the ground up – this can often reduce the amount of varus or valgus in the rest of the leg.

 

–          Remember that poor body alignment can lead to chronic injuries. Be careful with yourself! If you do develop one of these injuries, be sure that you treat it and allow it to fully heal so that it won’t come back to haunt you. Sometimes this means changing your usual activities… I’m looking at you, distance runners!

 

–          If the alignment problem is severe enough you will probably be referred to see an orthopedic surgeon. The orthopedic surgeon might tell you that a knee replacement surgery is in your future.

** Remember that surgeons make their living by doing surgeries – it is always ok to get a second opinion from someone who doesn’t stand to benefit from performing an operation on you. **

 

Walk well!

Patient Centered Care

I accidentally majored in Therapeutic Recreation in college. It was not my first plan- in fact, I think it was “plan C”. I was originally all set to major in Athletic Training, but the program was cut down to a minor just before I was qualified to begin. Then I set my cap on an Exercise Science major only to have it morph into a Physical Education Teaching track, which did not thrill me at all. By this time I had accumulated a strange assortment of classes under my belt and I went where the wind took me. Which was in the direction of Therapeutic Recreation (also called TR). I wasn’t happy about it.

All the other TR majors were equestrian types who wanted to work at youth ranches and summer camps for troubled teenagers. I wanted to work in a clinical setting and treat patients who were recovering from orthopedic injuries. I was a snob about it. I thought to myself “These people don’t have any place in the world of Medicine” (Capital M to make it seem more important). “What am I doing here”, “This is beneath me”. Snobbery of the worst kind.

But, in spite of myself, I began to absorb things in my TR classes. In fact, I learned a lot of really useful theories, many of which I use on a regular basis now that I work at my clinical job.  The main point that was hammered home to me again and again was the concept of “Patient centered care”.

Patient centered care is all about putting the needs of the patient first. This seems like it would be a basic concept, but it turns out that it is not. All too often in medicine we spend our time treating the problems instead of taking care of the people.  This is the difference between putting a brace on a mildly sprained Left wrist and treating Doug, a mailman who slipped on the ice and sprained his wrist last week.

It doesn’t actually change the treatment at all. The same brace gets used for the same injury whether the wrist belongs to a mailman or rocket scientist. It doesn’t matter to the clinic, we get paid the same amount for the brace either way. But it does matter to Doug. He knows that I am conscious of the fact that he as a person is attached to his sprained Left wrist. We exchange a few words of genuine human conversation. I made a weak joke, he snickers slightly. He walks out with his wrist feeling better and his human dignity intact.

Patient centered care is actually really hard to do in real life. This is because medicine is a business. Businesses are all about efficiency. In order to reach maximum efficiency, facts are reduced to numbers and figures.

–          This is my 7^th patient this afternoon

–          She is 65 years old

–          ICD9 824.4

–          His insurance will only cover 80% of the cost

–          5’5”, 195lbs

–          We are running 10 minutes behind schedule

–          Right TKA 3 months ago

–          L4360

–          15” calf circumference

Somewhere in the cloud of numerical facts, the practitioner has to find the time and presence of mind to actually talk to the patient as a person. And people are messy. They tell you their entire life story when you are just trying to get the history of the injury, they cough without covering their mouths, they smell bad. Last week I asked an elderly patient if she had any pain while I was evaluating her knee injury. She responded with “I don’t drink. Never touch the stuff”. Thankfully she was too deaf to hear me snort with laughter. I bellowed back at her “Neither do I”. She seemed satisfied.

I saw this picture on the internet on Monday. Window washers at a children’s hospital in North Carolina don superhero costumes while reppelling down the side of the building to clean the glass. How unnecessary and wonderful! I’m sure that this action doesn’t boost the productivity of the window washers. Imagine how annoying it would be to wear a cape and/or helmet when you are dangling from a harness 15 floors above the ground. It doesn’t make a whole lot of sense from a business perspective. But to the sick and injured kids in the hospital beds, this little extra act of kindness is a big deal.

Even though the patient centered care processes can sometimes be a challenge, it matters.  Talking to the patient, getting to know them slightly and going the extra mile to help them feel that they are valuable and important is a huge part of successful treatment.  Even though it may seem less efficient, this type of approach often garners superior results. This is because people’s feelings very much effect their health. Good feelings = feeling good.

For a more in-depth look at patient centered care, I recommend this article:

http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/

 

Walk well.

AFOs for Foot Drop

My last blog entry served as a bit of an introduction into the topic of AFOs. (If you didn’t read it, here is your chance). By way of quick review, AFO is an abbreviation that stands for “Ankle Foot Orthosis”.  Orthosis is the more formal term for a brace.

The number 1 most common reason for someone to wear an AFO is because they have a condition known as “Foot drop (or drop foot)”. Foot drop happens when there is weakness in a muscle group called the “Dorsiflexors”. These muscles run along the front of your lower leg and ankle. They are responsible for the action of lifting your toes up. The muscles in the Dorsiflexor group include the Anterior Tibialis, the Peroneus Tertius and the Extensors of the Toes.

Sometimes when a person has foot drop, the Dorsiflexor muscles themselves are weak, but most frequently it is actually the nerve that runs to these muscles that isn’t functioning properly. Because it is so often a nerve problem, foot drop occurs many times in people who have had a stroke, brain injury or multiple sclerosis. It also common in people who are born with cerebral palsy, muscular dystrophy, CMT, or many other conditions. Foot drop can also be the result of a back or leg injury.

All of these Dorsiflexor muscles are controlled by a nerve called the “Common Peroneal Nerve”. This nerve is actually an extension of the Sciatic nerve which branches off the spinal cord at the lower back and runs all the way down through the leg. If this nerve is damaged at any point, there is a very good chance that the signals will be disrupted and some leg and ankle weakness will occur as a result.

Drop foot can range from mild weakness to complete paralysis of the effected muscle groups. People with mild foot drop sometimes only notice it when they are tired at the end of a long day. Many times mild cases of drop foot go unnoticed until the person begins to realize that they are tripping and falling more frequently than usual, especially on uneven surfaces.

Those with more severe drop foot usually walk with a very distinctive gait called a “steppage gait”. This is where the person picks their knees up especially high in order to allow their foot to swing forward without snagging on the ground. When the foot is placed down on the ground it usually hits with a slapping noise as the toes uncontrollably flap onto the floor.

Here is a little video demonstration:

 

 

The job of an AFO for someone with drop foot is to keep the toes from dragging while the person walks, and also to slow down the slapping motion as the foot is planted on the ground. A whole multitude of devices have been invented to do this task.

Very mild drop foot can be treated with devices like this:

More complicated cases of drop foot sometimes require custom molded AFOs with a variety of features. Here is a little photo gallery of typical drop foot AFOs:

Custom foot drop AFOs like these are made by Orthotists and Pedorthists. They are typically made from a cast of the patient’s leg. The AFO is then designed and fabricated exactly to the specifications of each individual patient. Custom AFOs usually work very well (if the person making it did a good job), but they have several draw-backs: It takes a long time to make them, they are super expensive and because they are made so precisely, they have to be adjusted and fine-tuned frequently to ensure that they fit correctly. If the AFO was made for a child, constant changes have to be made to accommodate growth. Even adults tend to lose and gain weight over the course of the years. These changes can jeopardize the fit of the AFO. A poorly fitting AFO is not as effective as it should be and it can even be dangerous because it could lead to falls or it could cause a sore on the skin.

Because of these complications, new solutions to foot drop are beginning to flood into the market. My personal favorite development is carbon graphite AFOs. These AFOs are lightweight and strong. They are low profile because they don’t have to include bulky joints like the old fashioned plastic AFOs. Many models of this type of AFO can be purchased completely ready to wear. This eliminates the long process of taking molds of the patient’s feet and making the AFOs from scratch. Many patients use a custom foot orthotic in addition to the carbon graphite AFOs in order to ensure total comfort and appropriate support.

The reason carbon graphite AFOs are so cool is that the material is springy which means that it provides energy return. This allows the person wearing the AFO to walk with a very smooth and natural gait. Some people are even able to run marathons, hike, bike, etc with the use of this type of AFO. Can you tell that I am excited about this technology? Here are some cool videos of people using a few of the more common carbon graphite AFOs:

 

 

before:

 

after:

one more:

 

 

These are just some examples of the new solutions to the problem of foot drop. I think that carbon graphite AFOs are the wave of the future. I am very interested in watching the evolution of the AFO as patients become more thoroughly informed about their treatment choices. Patients now have access to huge amounts of information in all sorts of formats (including possibly, dare we say – this blog). They can then use these facts and concepts to educate their caregivers and voice their opinions and preferences. This is great! It means that more and more people get to take advantage of the cutting-edge technology choices. This process then drives improvements and encourages the development of even newer and better AFOs. How exciting!

Walk well.

From tapes and braces to AFOs

Back in my days as a student athletic trainer, my favorite injury to take care of was a sprained ankle. I enjoyed them because they were a common occurrence and because ankle rehab is very involved and detailed.  My favorite part of the rehab process was when the athlete was ready to return to play and we would decide what sort of ankle support was needed to make sure that they were able to play a game without incurring any additional injury.  Usually our support method of choice was a solid ankle tape. Some of those tape jobs were works of art, incorporating all types of stretchy and supper strong tapes in with the plain white athletic tape. We did heel locks and figure 8s and figure 4s and extra stirrups and horseshoes and basket weaves.  When the tape was done we wanted to sign our names to it and take a picture of our handiwork. Taping was so fun, and it introduced me to the concepts of how to correctly support an injury in order to encourage healing while still allowing function. It was this experience that got me interested in braces.

 

In athletic training, we often fit an athlete with an ankle brace if they show signs of chronic ankle instability. The braces are more convenient for the athlete than getting an ankle tape every day.   Depending on the type of injury, we can choose between several kinds of ankle braces to decide which would provide the best stability and prevent re-injury.

When I was first getting into the field of Orthotics, I thought most of the ankle braces I would be making and fitting would be somewhat like the braces that we used in athletic training. How wrong I was! It turns out that I had failed to take one important consideration into account: Population. Athletic trainers work mostly with athletes (no surprise there).  Most Orthotists spend much of their time focused on patients with chronic conditions or disabilities. The majority of these patients are not going to be playing basketball any time soon.

Every once in an odd while these patients need ankle braces for the same sort of reasons that my athletes need to wear a brace: because they injured their ankle at some point and they need to protect the joint so that the injury doesn’t reoccur. I will categorize this as ligamentous instability. In other words, at some point this person severely sprained a ligament in their ankle and as a result the ankle is unstable. This the type of injury I was used to dealing with in the athletic training world. (And to tell you the truth, it is still my favorite…)

But there is a much bigger category of people with a different sort of ankle instability. This is the group of people with muscular instability. The ankle is a very complicated joint, which relies on an intricate system of small muscle groups to hold the foot in the correct position to allow you to walk and stand. The patients who are being treated by orthotists usually have some sort of weakness in one of these muscle groups. As a result of this deficit, the positioning of their foot and ankle is faulty and they are at risk of tripping and falling if they do not wear a brace. Because muscular weaknesses can lead to some unusual joint alignments, custom braces are often needed to accommodate the patient’s unique ankle structure.

Here is a pretty dramatic video of a guy demonstrating how much better he can walk with the use of his custom ankle braces.

This leads me to another difference between the ankle braces that I was used to in athletic training and the braces from the field of Orthotics. Terminology. In athletic training and rehabilitation, we are content to call a brace a brace. But orthotists call a brace an “Orthosis”. If multiple braces are being spoken of, they are called “Orthoses”.  Therefore, if you hear someone referring to an ankle brace as an “Orthosis” you can bet that the brace was made by an orthotist. It is also a pretty safe bet to assume that the brace was either custom made for that person or at least custom fit to them. Because it is cumbersome and annoying to keep saying “Ankle Orthosis”, the term is commonly shortened to the abbreviation “AFO” (which stands for Ankle, Foot Orthosis).

AFOs can be described as the “bread and butter” of the orthotic industry. They are by far the most common type of orthosis. The AFO category is broad and varied. This makes sense because there is a wide variety of people who need AFOs for many different reasons. My next few posts are going to talk some more about AFOs. Upcoming topics to include:  some of the most common reasons people would need an AFO, types of AFOs, and the history and future of AFOs. I have already started to scratch the surface of this topic in these previous blogs: https://walkwellstaywell.wordpress.com/2013/10/20/creative-problem-solving/   https://walkwellstaywell.wordpress.com/2013/09/22/lace-up-ankle-braces/ . But it’s a big topic and there is plenty more to say on the subject. Stay tuned for more info!

Walk Well

Custom foot orthotics.

Shame on me. I realized that I have been writing this blog for a little over 2 years and I have never once taken the time to show you how I make custom foot orthotics. It’s only the number one thing that I do. I am going to correct that error right now.

In my opinion, foot orthotics are very often the most successful and un-invasive way to correct bad body alignment, allowing patients to recover from and prevent many kinds of overuse injuries.  Custom foot orthotics are made from scratch for each individual patient. The materials and techniques used to make foot orthotics can vary widely depending on the needs of the patient and the skills of the practitioner.

I am going to walk you through the step-by-step process. The pictures in this blog are just snap-shots I took while at work one day – sorry for the low quality.

Step 1:  Take a mold of the patient’s foot.

BioFoam molds

This mold is a box full of crushable foam into which the patient’s foot has been pressed. Another type of mold is made from plaster casting material which is wrapped around the foot (See below).

Plaster cast

This plaster type of mold is messier and takes a little longer, so it is usually only used for more complicated cases.

Step 2: Make a replica of the patient’s foot

Plaster is poured into the footprint or plaster mold and allowed to harden into the shape of the patient’s foot. It is removed from the mold and cleaned up to smooth out all the rough edges. When it is ready it looks like this:

Model of Patient’s Foot

Step 3: Mold material to the model of the foot

The material that foot orthotics are made from comes in large flat sheets of various thicknesses. A blank of suitable material is cut to fit the patient’s foot size.

Cut out a blank

Next, the material is heated in an oven until it becomes soft and pliable. The model of the patient’s foot is placed in a vacuum press which will be used to shape the material around the plaster cast. The hot material is removed from the oven and draped over the cast while a powerful vacuum suctions the rubber membrane of the press against the model. There are no pictures of this step because it is so time sensitive that I couldn’t do it one-handed.

This is a picture of the model of the patient’s foot inside of the vacuum press with the hot material being molded to it. I am using my thumb to smooth out any air bubbles that form underneath the rubber to ensure a good mold.

In the Vacuum Press

Step 4: Finalizing the Orthotic

Once the material has finished cooling in the vacuum press it can be trimmed down to its final shape. The molding process has created wrinkles and left excess material that has to be removed. Here is what it looks like when I take it out of the press.

After the Vacuum Press

Posterior View After Vacuum Press

At this point, the sides of the orthotic material wrap around the mold too far and would create a lot of unnecessary bulk inside the patient’s shoe. It is trimmed down with the use of a grinder. Sorry, there are no pictures of me using the grinder for what I hope are obvious safety-related reasons.

Once it has been ground down it looks like this:

Side View After Trimming

See how the material exactly matches the contour of the patient’s arch?

Here is a view from the heel:

From the heel

Step 5: Fit the orthotic to the patient.

At this point, the patient returns to the office with a pair of appropriate shoes. The final touches are added to the orthotic while the patient is present. This might include attaching a full-length top cover or grinding off additional material to tailor the orthotic exactly to the patient’s needs. It is very important for the practitioner (that’s me) to watch the patient walk with his or her new foot orthotics. This ensures that the foot orthotic can be properly adjusted to the patient’s individual needs. It pays to be very picky at this point. The patient should be able to give feed-back as to how the orthotics feel underfoot. And the practitioner should be able to see a marked improvement in the way the patient is walking. In my office, the patient doesn’t leave their fitting appointment until we are both satisfied that the orthotics are the best they can be.

Things you should know:

Custom foot orthotics are great when they are made well, but they can also be pure torture to the patient if they are made incorrectly. It is a big responsibility. Many offices do not make their foot orthotics themselves; instead, they send all foot orthotic molds out to a central fabrication facility. This means that every time the patient requires some sort of adjustment the orthotics have to be sent back to the fabrication lab. This can be costly, frustrating and time-consuming. I recommend to all patients that if they have complicated foot issues they should get their foot orthotics from someone who makes them in-house.

One other thing to be cautious of is to make sure that if you are paying for custom foot orthotics – they actually are custom foot orthotics. Look back at step 1. If you don’t have a mold of some sort taken of your feet, then you should decline treatment and go somewhere else. FYI: There are some facilities that use a 3D scanner to capture the shape of your feet – this is sort of like taking a mold, it is acceptable. **Note: The little electronic platform that some stores have you stand on only shows the high pressure areas of your feet and does not count as a mold-taking process.** That is just technologically advanced smoke and mirrors. Don’t be too impressed.

My advice is to do your research before you buy any type of foot orthotic. Know how much they cost. If you are wondering, the industry average for a pair of custom made foot orthotics is in the neighborhood of $400. Most insurances do not cover the cost of foot orthotics. For this reason, many people try to purchase off-the-shelf foot orthotics to save money. Sometimes this works. Actually, if you have a pretty average foot shape and your problems aren’t too severe – then I say go ahead and try it. But, if you have unusual feet then I can already tell you that it isn’t going to work.

Here is a picture of that same patient’s foot mold sitting on top of an off-the-shelf foot orthotic:

Off-the Shelf = Poor fit

And just for comparison, here again is the newly made custom orthotic for the same foot:

Side view to show arch shape

See what’s going on here? All that gaping between the patient’s arch and the prefabricated foot orthotic means that the foot will not be getting enough support. Whereas the custom foot orthotic follows the arch of the foot exactly, supporting it evenly and completely. That support can be the difference between sore feet and happy feet.

Well, that concludes this little back-stage glimpse into the magic that happens in an orthotic lab. I hope you have enjoyed it! If you have any questions, feel free to comment below and I will do my best to clear things up for you.

Walk Well!

Creative problem solving

My grandpa fell in love with my grandma because of her creativity. They were in college and they both were attending a dance in a lodge with a fireplace. As soon as the fire was lit, the room began to fill with smoke. Grandpa climbed up on the mantle to investigate the problem and found that the flue wasn’t staying open. He called down into the crowd saying he was sure he could fix the issue if only someone would bring him some string. Soon a girl (Grandma) came over with a small length of white rope. “Will this do?” He saw that it was a string from a mop and he laughed.  It did the trick. He fixed the flue, they danced the night away and the rest is history.

I get really excited about creativity. I guess you could say it’s in my blood. I especially admire innovative problem solving. Albert Einstien famously said: “The definition of insanity is doing the same thing over and over and expecting different results”.

When I think about this quote I remember something that I watched happen while I was on a mission’s trip in the Dominican Republic. Our group was doing some demolition and construction work. Part of this involved using sledge hammers to break up an old cement staircase. We had some big strong guys in our group who were confident that they could handle the job. The biggest guy grabbed the heaviest hammer and swung it as hard as he could. It bounced off the cement without even making a dent. He swung again and again with only blisters on his hands to show for all the effort. Our translator, who was just a skinny little guy, shook his head when he saw what our strong men were doing and picked up a hammer to show how it was supposed to be done. He took one swing and chipped a huge piece off the edge of the top step, he took another and an even bigger chunk cracked away. He explained that cement is resistant to direct blows but if you hit it at an angle it becomes fragile.

I remember this every time I come up against a big obstacle. If at first you don’t succeed…Try the periphery. Walk the borders and look for another way in. Use glancing blows. Harness your creativity. This is what problem solving is all about.

I chose to work in the discipline of Orthotics for several reasons, but one of them was because I saw that it had problems that needed solving. In my undergraduate arrogance I was sure that I could fix the field singlehandedly. I couldn’t wait to get started. Now that I’m actually working in the profession I can still see those flaws, but they seem bigger and more complicated up close. One of the most challenging aspects of the field is its inertia. It’s a lot like an old decrepit concrete staircase that has been sitting around unchanged for the last 50 years.

Here’s an example: Below are 2 pictures of AFOs (Which stands for Ankle Foot Orthosis, “orthosis” means “brace”).  The type of metal brace pictured has been around since the Civil War, and believe it or not, people still wear them today. Can you imagine if all medical technology had not advanced since the Civil War days? We would still be performing operations with rusty old saws and dying from infections without the use of antibiotics. To be fair, that type of AFO is now referred to as the “old style” but “old style” in the same way that bellbottom pants are old style…they are still acceptable, just not considered cutting edge.

pic from: http://www.orthomedics.us/Pages/ankle.aspx

The “New style” AFOs are made out of plastic. This type of AFO began to be used in the late 1960’s -1970s, and it really hasn’t changed since. Once again, just for a little perspective – Star Trek was a hit show when this type of brace was developed…to a young person like me this is ancient history. In the last 5 years the Orthotic industry has started to think about possibly accepting the computer fabrication, 3D printing and CAD CAM methods of making braces. But with characteristic glacial slowness, acceptance of this advanced technology hasn’t become very widespread.

Pic from: http://www.georgelianmd.com/cms/InformationLinks/Braces/tabid/124/Default.aspx

There are, of course, multiple reasons for how “stuck in a rut” the Orthotic field is. For one thing, only a few orthotic training programs exist in the country, and those are run by the old-school practitioners who continue to teach the “time tested” methods of brace making. For another thing, insurance companies use a series of L-Codes to categorize braces and determine how much money they are willing to pay for each type of brace. These L-codes were set up in the same Star Trek, bellbottom era as the plastic AFOs, and the system is limited largely to what was available back then. Practitioners can’t afford to make newer, more elaborate braces if they are still going to get paid 1970’s prices for their work. And that’s just the beginning of the reasons for the profession’s retarded development.

Realizing all of this has been a little daunting. I don’t think I will be able to wave my magic wand and fix this profession as quickly as I had planned. It’s going to take some work. I’m going to have to continue to swing my sledge hammer at the edges of the problem. Fortunately I am young and patient. The demographics of the Orthotics profession is changing, more young people like me are joining up. I hope they bring their creativity with them.

I have plans to pursue a PhD in the near future. This will allow me to do research in and around the Orthotics field. I can study the old methods and think of new solutions. There is only one problem…I’m going to have to be creative about finding a research institution that will equip me with the knowledge and skills I need to move forward. (In case you hadn’t guessed, I can’t exactly find a university with a graduate program tailor-made for problem solving within the Orthotic industry…try googling that. Nothing.)  It’s just another barrier to negotiate around. (Seriously, if you have suggestions on grad schools let me know.) Collaboration and an interdisciplinary approach is the key.

Some people are already coming up with creative solutions. Check out this website:

http://www.silverringsplint.com/about/

Here’s an example of someone taking an old clunky style brace like this:

And making it into something modern and beautiful and functional like this:

That’s creative genius. That’s what I’m talking about.

It’s innovation like this that gets me fired up. We need to take the same imaginative problem solving into the rest of Orthotics. This is important, because if we don’t change our profession we will just continue on in the status quo. Extinct like the dinosaurs. Stuck in a time warp. Doing the same thing over and over again. How insane would that be?

Walk well (and think creatively!).

Lace-up Ankle Braces

The most common type of brace worn is the ankle brace. There are hundreds of varieties of ankle bracing systems in existence…I will probably discuss them all eventually, but today we are going basic.

Very basic.

Right back to the beginning.

When an ankle has been injured, the treatment is to wrap something around it in order to support the joint, give compression to reduce swelling and limit motion. This treatment has been around since the first Egyptian bound some strips of linen around his sandal after he tripped over a rock. (No, really – they have found picture evidence of ancient splinting mixed in with the hieroglyphics in some pharaoh’s tomb).

The truth is, this treatment technology hasn’t really changed much over the years. Modern day athletes have their weak or injured ankles taped by Athletic Trainers. The cloth tape supports the ankle and reinforces it, restricting ankle movement in an attempt to reduce pain and risk of re-injury. This works really well for athletes who have a staff of Athletic Trainers to take care of them. But there are a lot situations when ankle taping is impractical. For example; If the injury is going to need long-term treatment, or if the person does not have access to someone who can tape their ankles. Lace-up ankle braces work very well to approximate the same type of support you would get from a tape job.

The most famous brand of lace-up ankle brace is the Swede-o brace. It looks like this:

http://www.swedeo.com/ankleproducts.htm

If the basic Swede-o brace doesn’t provide enough support for you, I recommend the ASO brace (or something with a similar concept). This type of brace has extra straps that can be wrapped around the ankle to add an additional level of stabilization.

http://www.asoankle.com

These two types of ankle brace are sturdy, low profile and functional. They fit easily into athletic shoes and can be worn while playing sports or during everyday activities.  One draw-back of a lace-up style ankle brace is that it usually takes a bit of time to put them on, what with all the ties and straps.

Both the ASO style and the plain lace-up style ankle braces contain small removable plastic stays on either side of the ankle. When worn with a well-laced shoe the combination of tough fabric and thin pieces of plastic in these braces provide enough stiffness to support most ankles.

Notice I said “most ankles”. I probably should have said “average ankles”. Because as we all know, there are always those people who are not and never will be average. In this case I’m talking about people who either have really whacky ankle alignment or who are in need of serious, big league motion control. But never fear, the lace-up ankle brace category has a big brother…literally. The Arizona brace.

http://www.arizonaafo.com

The Arizona brace works on the same principles as the other lace-up braces, just multiply everything by 10. Instead of small, removable plastic stays, the Arizona has a solid plastic core that is custom molded to fit the patient’s ankle. That’s right. I said custom molded. And because you can’t drape molten plastic over someone’s leg (well, you can – but it is very much not advisable) you have to take a cast of their leg and make a model from that cast and then you can make the brace. Yeah. It’s complicated. I’m sure I will write a blog post about the custom brace making process one of these days. For now, all you need to know is that it takes a lot of skilled labor to make a custom brace.  And skilled labor = $$$$.

Arizona braces are very expensive. But they are tough and strong and boy do they work. The traditional style Arizona braces have a leather covering over the plastic that allows the brace to be laced up like a logging boot or an ice-skate. The Arizona brace is a bit bulky but most people can still fit it into their regular shoes.  Because leather is pretty old-tech and can get gross and smelly, some companies have started making Arizona-style braces out of all synthetic materials. I think this is the way to go. Here’s a picture of what that looks like, in case you are curious.

http://lowerextremityreview.com/products/dynamic-response-gauntlet

Now, it’s not all flowers and butterflies with a lace-up style ankle brace. There are some other things that have to be considered. The Arizona brace pretty much renders the ankle immovable. It’s like an ankle fusion without the surgery. Even the wimpier over-the counter lace-up braces limit the up and down movements of the foot and ankle.

Locking up the ankle can be a bad thing. After all, it was designed to move for a reason. For one thing, the ankle adapts to the angles of uneven terrain to make walking easier. Ankle movement also allows the foot to absorb shock with every step. If this doesn’t happen, the jolt of each footfall is transmitted up the leg until it effects the knees, hips and back. This is why everybody should be sure to have just the right amount of support for their own personal needs. Over-bracing is not a good idea. And that’s coming from someone who makes and sells braces for a living.

So if you are a lace-up ankle brace wearer, do a couple of things for yourself:

–          Talk to a physical therapist (or someone like that) who can give you some ankle strengthening exercises to do. Maybe you can eventually phase out of your brace wearing, or at least step down to a less-restrictive style.

–          Wear your brace when you need it, and don’t wear it when you don’t. This will ensure that your brace lasts longer and that the little stabilizing muscles in your foot and ankle don’t forget how to do their job.

–          Do your homework. Make sure you are wearing the best brace for you.  At the very least do a google search.  You are in charge of your own treatment….just like that Egyptian guy who first wrapped a rag around his ankle. Aaannnd we come full circle.

Walk well!

Suspension

Lately I’ve been fitting a lot of knee braces. Something about the summer time seems to prompt people to jump off things, ride their bicycles too fast and rollerblade on uneven surfaces. When their stunts go awry, these people come to see me to get fit for a brace.

Knee braces come in all shapes and sizes. Here are some examples:

If the patient is going to have knee surgery (such as to repair some torn ligaments) they will be fit with a brace that looks something like this:

http://www.breg.com/products/knee-bracing/post-op/t-scope-post-op-post-operative-knee-brace

If they need continued support after surgery and rehabilitation they may be assigned a functional brace something along these lines:

https://www.djoglobal.com/products/donjoy/legend

If the injury is not bad enough to need surgery but the patient has general soreness and swelling they will probably be given this sort of brace.

http://www.bledsoebrace.com/products/crossover/

I will write a more detailed post another time about the function of each type of knee brace, but right now I want to focus on something that they all have in common. In order for a knee brace to work, it has to stay in the right place. It is really hard to keep a knee brace in the proper position. This is a problem that I never encountered with foot orthotics. You see, foot orthotics stay in place because you stand on top of them. Not so with knee braces. Good old gravity works against even the best brace and tries to pull it down.

In the orthotics world we call the ability of a brace to stay in the right place suspension. This is why knee braces have so many straps.  We are trying to suspend the brace above the ground by anchoring it firmly against the leg.

Gravity is only half the problem however. Most people have conical legs. That is to say, the circumference of their thigh is greater than the circumference of their calf. Think of the shape of an upside-down traffic cone.

Now think this through with me – Let’s say your leg is shaped like that. Even if you were to tighten the straps on your brace down really hard, what is to keep the whole thing from sliding south? Not much. In fact, there is only 1 thing that stops the brace from migrating down around your ankles. It is called the Gastrocnemius and is definitely in my top 10 list of the coolest muscles in the body.

The Gastrocnemius forms a little “shelf” in the back of the calf where the leg is a little bit skinnier just below the knee. This is the place to win the fight against gravity. In order for a knee brace to be suspended effectively it has to grab onto the leg right here. If you look back at the three types of knee braces at the top of this blog, you can see that each model has a strap in this spot. That is no coincidence.

Many knee brace wearers don’t understand this fact. People often over-tighten the straps of their brace and then they just have a really uncomfortable knee brace that still feels like it is going to fall off. This leads to skin irritation and rubbing and general miserableness that causes people to abandon their braces. Knee braces are only effective if they are actually worn. And worn correctly I might add.

If you are a knee brace wearer, don’t let gravity get the better of you. Harness the power of your Gastrocnemius and keep that brace suspended.

Also, enjoy the last of this warm summer weather and try not to hurt yourself doing anything stupid.

Walk well!

More Letters… Nbd…

Two weekends ago I took my Orthotic Fitter Certification test. It took place in a computer testing center in a bank in Rochester NY. Other than the 2 of us taking tests and person administrating the exams the bank was empty and quiet on a Saturday afternoon. The other test taker was on her second attempt at some sort of counseling/ mental health examination. The test administrator asked me what in the world an Orthotic Fitter was. I gave her a brief explanation and she still looked puzzled. After the other test taker and I checked all our belongings into a locked cabinet, We were issued pieces of scrap paper and 2 pencils each and then marched into a tiny cubical of a room with cameras pointing at us from every angle.

I smiled at the camera over my computer monitor, clicked OK, and it took a dorky looking picture of me which was then posted to the top Right corner of the screen. Great. Then I had to answer a bunch of strangely worded multiple choice questions that were designed to trick me into answering incorrectly. Somewhere around question 75 I thought to myself that this sort of exam is really testing to see if you are good at test taking, not necessarily if you thoroughly understand your subject matter. Oh well.

I stuck to my usual test taking strategy, blowing through the easy questions quickly and then going back through to check my work and puzzle about the harder ones. I hadn’t really studied for this test like I usually do, it was hard because the subject matter was broad; how to brace any part of the body for any possible injury. How do you even study for that? I had settled for reading back through my notes from the Orthotic Fitter class I attended and flipping through an old text book that my boss lent me from his days in Orthotist School.

Thankfully I was able to piece together all this info and answer most of the questions without much trouble. After I was sure I had done my best I clicked the STOP button, waved good luck to my fellow test taker and walked out into the hallway. As I exited the room I could hear a little printer on top of the locked cabinet whirring. It spit out a single piece of paper and the test administrator picked it up. She glanced at it before giving it me, said “congratulations” and handed me my purse from inside the cabinet. That was it. Another test over with. No big deal.  Another certification under my belt. A couple more letters behind my name. (Now it is officially Angela Smalley MS, CES, BOCPD, COF).

Now I’m a Certified Orthotic Fitter, which means I can fit any type of prefabricated braces for any part of the body. Yay! So the shape and focus of this blog may change a little now. You might see me writing about knee injuries or elbow braces. But don’t worry. I won’t forget Pedorthics.

Walk well.

P.S. Sorry for the lack of pictures…Here is a link to the BOC’s website explaining what an Orthotic Fitter is in case you are interested:

http://www.bocusa.org/orthotic-fitter-certification-cof

UCBLs / Captive audience

Well, the long awaited laptop has arrived. I can now happily multitask again, reading some nerdy article while typing away in a Word document AT THE SAME TIME! I didn’t think this was a big deal until I couldn’t do it anymore. I tell ya, there are some things an Ipad just won’t do.

Anyway, today’s topic is UCBL style foot orthotics. For the past few weeks I’ve been making them like they are going out of style. The term UCBL stands for University of California Berkley Labs, where the UCBL was first developed.

There is a bit of a debate about what constitutes a UCBL foot orthotic. The definition is shaky. People market a wide variety of foot orthotics as UCBLs. Here are some pictures to give you an idea:

The general consensus is that a UCBL foot orthotic is made out of a rigid material such as plastic or carbon fiber. It is usually molded to a model of the patient’s foot (but it is possible to purchase prefabricated UCBLs). The side of the UCBL are deep, cupping the heel and extending up around the edges of the foot. The UCBL usually ends just before the Metatarsal Heads of the foot. See the green lines in the picture below.

The purpose of a UCBL foot orthotic is to control and aggressively correct the foot. UCBLs are most often used for people who pronate severely, often because of flexible flat foot (also called Pes Planus) or because their Posterior Tibial Tendon is ruptured or damaged.

UCBLs are usually prescribed when nothing else will work. They are bulky and hard to fit into shoes. I’ve been told that they are an absolute bear to break in. They are hard and unforgiving and have to be made absolutely right otherwise they will cause rubbing and blisters and skin irritation. Speaking from a Pedorthist’s point of view, they are a pain in the neck to make.  So why haven’t UCBLs gone extinct with the dinosaur? And furthermore, why have I made so many of them in the past few weeks? Because if they are done right, they work wonders. UCBLs operate under what I like to call the “captive audience” premise.
Have you ever been at a social event and gotten cornered into talking to a really annoying person? You use sophisticated strategies to get out of the situation. At the first possible excuse you put some distance between yourself and the talker, then you rope some other innocent bystander into the conversation. Then you see someone across the room you have to run over and greet. Whew. Disaster averted.

Well, your feet do similar things. Sort of. If you have a really flat or collapsed arch and then you stick an orthotic with an  aggressive arch support underneath it, your foot is just going to slide off to the side in an effort to escape the uncomfortable situation. This leaves your shoes looking like this:

And your arch is no better off than it was before.
A UCBL grabs both sides of your feet, holding your arch against the support with the help of your shoe. This forces your foot to adapt to the shape of the UCBL. Whether it likes it or not. To return to the awkward talker analogy – it’s as if the talker were seated next to you on a long airplane flight. You can’t get away!

I warned you earlier that UCBLs are unpleasant to get used to. (Like an obnoxious conversationalist). But give them time, and your feet will adapt to the situation. If you had bad enough alignment to warrant needing a UCBL in the first place, you will begin to notice an improvement after wearing them for about 1 week. At the end of two weeks, you should be able to forget you are wearing them. And you should be able to see a positive change in the arch, ankle, knee and back pain that first prompted you to ask your doctor for a prescription for foot orthotics.

As for the annoying talker, I’m sorry – there’s nothing I can do about that. At least your feet won’t hurt while you are listening to his long winded story about his latest UFO conspiracy theory.

Picture sources:
http://www.delatorreop.com/orthotic-devices/all-devices/foot-orthotic-orthopedic-ucbl-220/
http://jmorthotics.com/products-childrens.php

http://www.footeducation.com/acquired-adult-flatfoot-deformity-posterior-tibial-tendon-dysfunction

http://www.thequadrastepsystem.com/ls.html