The Why, When and How of Orthotic Reassessment
By Mark Charrette, DC
While flexible, custom-made stabilizing orthotics are beneficial for many chiropractic patients, over time they can decrease in effectiveness if not regularly evaluated. Because of exposure to variable biomechanical and environmental stresses, an orthotic's lifespan differs from patient to patient. Orthotics selected for a marathon runner will likely have a different lifespan than those designed for a sedentary octogenarian. Body chemistry and sweat production can also reduce the supportive qualities of some orthotics over time. In addition, some patients need to have new models or types of orthotics, but often don't know what is available.
These are all valid reasons to request a reassessment of the orthotics you have recommended. The frequency of orthotic re-exams will vary according to patient needs, but should definitely not exceed a year. Experience dictates that developing a system to schedule annual orthotic reassessments works best for most patients and practices.
Tracking and Patient Notification
Some form of tracking system is necessary since time passes quickly and we often can't remember exactly who received orthotics and when. Historically, the doctor's assistant would set up a "tickler file" composed of file cards with the patient's name and the date they received their orthotics. Each card would be filed in the appropriate month, and monthly file checks would determine who had been fitted with orthotics in previous years.
Today, many patient-tracking computer programs can perform this function. Some orthotic labs provide monthly lists of patients who need re-checks; this can be a tremendous help to the office staff.
Patient notification can be done with reminder letters, e-mails or a telephone call. It's usually a good idea to use all three, since patients often appreciate the personal contact and some respond more to phone calls than to mailers. They are thrilled to know that someone is keeping track of their health needs. Upon their return visit, many patients will express an interest in new or different pairs of orthotics, or possibly some custom-fitted shoes or sandals when they see samples and literature.
Why Reassessment Matters
If orthotics are not addressing a patient's musculoskeletal problems, they need to be re-evaluated. Sometimes they are not the correct style for the shoes being worn. Occasionally they need to be modified or further customized. And sometimes the patient's needs or physical condition has changed.
Occasionally, there is a wearing down of the orthotic materials, to the point that previous support and control are diminished. In such cases, modification of the current orthotics or provision of a newer or more suitable style of orthotic is needed.
In many cases, the orthotics have been functioning well, but a reassessment still finds a need for additional orthotics. In fact, most patients who are happy with their orthotics are interested in being fitted with additional pairs for their other shoes, or would like a pair of custom-fitted shoes or sandals with an orthotic included. With some professional orthotics labs, if the new orthotics are being ordered within a year or two, there is usually no need to recast the patient. This allows the doctor to discount these repeat purchases, providing further incentive to their patients.
Start by looking at the patient's shoes. Identify any unusual or asymmetrical wear patterns. Check the fit of the shoes very carefully; many orthotic problems are actually shoe-fit problems. This is particularly true in women, who frequently force their feet into shoes that are too small or don't update their shoe size as they age.1
Children's orthotics should be reassessed more frequently (about every six months) because their feet are growing and their shoe sizes can change rapidly.2-4 Also, obese children should be given special attention, as excess body mass appears to have a significant effect on their foot structure.5
Next, examine the feet for calluses, subluxations, and any tender or symptomatic areas. These are all indicators of persisting biomechanical problems that are not being adequately addressed by the orthotics. Also check for sweating or dampness (hyperhidrosis); orthotics using newer materials that wick away moisture may be indicated.
Then remove the orthotics and inspect them carefully. Is there any noticeable pattern of excessive wearing of any of the materials? Are any of the original characteristics (shock absorption, flexibility, arch support) weakening? Is there any evidence of damage from moisture or use? When any of these factors is present, new orthotics (and possibly a different style) are indicated.
Finally, evaluate the effect of the orthotics on the spine and pelvis. Have the patient's spinal symptoms and recurrent subluxations been reduced or controlled as expected? Is there any indication of more spinal stress during standing and walking? Is relaxed gait performed with smoothness and coordination? Do other tests during weight-bearing (such as manual muscle testing) demonstrate good function? If not, consideration of modification of the current orthotics or use of a different style is appropriate.
Provide a Higher Level of Care
An annual reassessment of patients' orthotics provides an opportunity to check the response and the functionality of the orthotics. It also provides an opportunity to review patients' needs and to offer additional styles of orthotics (e.g., for their sport shoes), and to suggest the use of custom-fitted shoes and sandals.
Patients appreciate doctors who follow-up; this demonstrates a level of caring that is not commonly found in busy health care professionals today. By developing some simple office procedures for a regular orthotics reassessment, you can provide a more comprehensive service for many of your patients.
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