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| What is the professional training
of the dispenser/provider of the orthotics? | Is
a prescriber required? | Can I go through my extended
health care insurance coverage? | Are the measuring
and casting techniques important? | Are the construction
techniques and materials important? | What kind
of footwear will they work in? | What are the charges?
| Are there any warranties? | What
is the delivery time? | Is there an adaption period?
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At present the government does not regulate the making of orthotic
devices meaning that any individual can sell orthoses. Therefore,
it is important that you choose an appropriate facility for your
needs.
1) What is the professional training of the dispenser/provider
of the orthotics?
The most common professions that dispense foot orthoses are Chiropodists,
Master Craftsman Shoe Makers, Orthotists, Pedorthists, and Podiatrists.
Osteopaths, chiropractors, occupational and physical therapists,
shoe repairers and sports stores sometimes also dispense orthoses.
Pedorthists are medical professionals
educated in the design, fit, manufacture, and modification
of footwear and foot orthoses (orthotics).
Today, training to become a Canadian Certified
Pedorthist (C Ped (C)) requires a degree in the Health
Sciences Field, completion of an intense course in pedorthics offered
through the University of Western Ontario and an internship in a
clinical laboratory and footwear setting. There is training in lower
limb biomechanics, gait analysis, manufacturing and fitting of foot
appliances, and fitting and modification of footwear. All must occur
in order to be eligible to write the certification exams. All Certified
Pedorthists in Canada are members of the Pedorthic Association of
Canada (add link here) and the College of Pedorthics of Canada (add
link here). Our code of ethics requires a prescription from an authorized
prescriber before fitting custom orthoses. It is very reassuring
for the physician, as well as the patient, to know that the person
doing their biomechanical assessment is also the person responsible
for fabricating, fitting and doing the fine-tuning of the device
prior to dispensing it.
A Certified Orthotist is a
designation awarded by the Canadian Association of Prosthetists
and Orthotists. The function of a Certified Orthotist involves the
design, fabrication and fitting of orthoses (braces or splints)
intended to prevent or correct deformities, protect a painful part
of the body or improve the function of a weakened extremity. This
may include anything from custom fabricated arch supports to braces
for the knee, back, shoulder or arm.
Chiropodists and Podiatrists
are trained and educated foot specialists including its anatomy,
pathology, medical and surgical treatment, etc. regulated by the
same body, the College of Chiropodists of Ontario. This means that
both Chiropodists and Podiatrists have the same scope of practice
in the province of Ontario.
A Chiropodist is Canadian trained. A Podiatrist is an American
or over-seas trained.
A chiropodist provides assessment
of the foot and the treatment and prevention of diseases or disorders
of the foot by therapeutic, orthotic and palliative means.
A Doctor of Podiatric Medicine (D.P.M.)
is a specialist in care of the feet concerned with the
examination, diagnosis and prevention of foot disorders by
mechanical, surgical and other means of treatment (Ontario
Podiatric Medical Association, 2001). Podiatrists are one of six
primary care professions, authorized by Ontario Law to communicate
their diagnosis to patients. The podiatric physician receives conventional
medical training, plus special training on the foot, ankle, and
lower leg. Podiatric physicians provide treatment for 82 percent
of corn and callus problems, 65 percent of toenail problems, 63
percent of bunion problems, 46 percent of flat feet or fallen arches
problems, and 43 percent of toe/joint deformities.
The seven colleges of podiatric medicine all have entrance requirements
which, like institutions granting MD (medical doctor) and DO (doctor
of osteopathy) degrees, usually consider those with an undergraduate
degree, but will consider candidates who show unusual promise and
have completed a minimum of 90 semester hours at accredited undergraduate
colleges or universities. All 50 states, the District of Columbia,
and Puerto Rico require that they pass rigorous state board examinations
before they are licensed, and most require continuing education
programs for regular license renewal.
Most facilities can be checked out for their credibility through
their professional associations and their local BBB.
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2) Is a prescriber required?
Most 3rd party claims require proof that there is a medical necessity
for the orthoses. See insurance below. Some insurance companies
require the prescription to be written on the prescriber's own prescription
pad.
Most reputable providers of orthotics will require a medical prescription
from your family doctor or general practitioner, medical specialist
(rheumatologist, orthopaedic surgeon, endocrinologist) or foot doctor
(chiropodist, podiatrist) prior to designing orthotics for you.
The reason behind this is that these specialists are able to eliminate
other medical causes of your symptoms that are not related to mechanical
alignment. You can still have a pedorthist assess and evaluate your
foot and leg mechanics, but you will also need to see your medical
specialist as required by the Canadian "code of ethics".
Doctors are responsible for diagnosing a person's condition and
referring you to a pedorthist for treatment. The referral should
include a "diagnosis" and recommendation for "custom
foot orthoses".
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3) Can I go through my extended health care insurance
coverage?
The claimant usually knows if they are seeking out WSIB (Workers
Safety and Insurance Board), Social Assistance programs, personal
accident insurance, Native Indian Affairs, and the ADP (Assistive
Devices Program). Each funding program has its own prerequisites
on how to proceed to be eligible for a claim.
The claimant should find out in advance if their insurance provider
needs:
- A pre-estimate to be sent in;
- A particular prescriber's credentials;
- An approved provider's credentials;
- Any warranty coverage;
- To know what usage they are required for;
- Other manufacturing information such as casting techniques,
materials used, gait and biomechanical evaluation;
The claimant may find it helpful to know if their insurance has:
- A coverage amount (i.e. deductibles, maximums, %ages, quantity
of pairs);
- A time-line of the coverage (once/calendar year, purchase-to-purchase
date).
Due the radical increase of orthotic dispensing and abuse from
outside health care practitioners the major insurance companies
in Canada have implemented a plan of action to protect their insured
from improper dispensing of orthotics and orthopedic shoes. The
plan states that orthotics can only be dispensed/provided
by one of the following professionals: Chiropodist, Podiatrist,
Pedorthist or Orthotist. Green Shield has taken this a step further;
to dispense orthotics under their plan, the dispensing professional
must also be registered under contract with Green Shield as a preferred
provider. These professions have associations that self-govern their
conduct so that the client is getting professional and ethical treatment.
Be wary of facilities that charge your purchase based on what
the insurance coverage may entail.
The majority of insurers also request that an eligible prescriber
submit the prescription before reimbursement is provided.
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4) Are the measuring and casting techniques important?
The method of casting is critical to the success of the orthotics.
Casting methods have advantages and disadvantages and your pedorthist
will determine the best method for you. Some techniques can be performed
in full, semi or non-weight bearing, static (still) or dynamic (moving).
The foot type determines which system may be better. Determining
factors may be: if there a rigid or flexible foot; a rigid forefoot
deformity. Non-weight bearing casts usually create a more corrective
type of orthotic whereas weight-bearing a more accommodative type.
Some of the most common techniques are: Plaster cast; polyester
cast; heat moldable foam or wax; foam box impression; 3-dimensional
computer scan; 2-D pressure plate computer, and inkblots. The last
two casting techniques only obtain a 2-D image of a foot. At Sole
Decisions are two main methods are: plaster
or polyester slipper casting and foam
box impressions.
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Foam box
involves pushing the foot into a foam box. This
can be a non- or weight bearing technique often used if someone
cannot get on a table for plaster casting or if a less aggressive
(corrective) shell shape is desired.
Plaster slipper casting
involves applying plaster directly to the foot in order to
capture the contours and shape of your foot. The casting will
be done with you lying down on your stomach or back. This
is a non- weight bearing technique and takes 5-7 minutes.
Semi-weight bearing while seated can give a more accommodative
shell but is rarely used.
Advantages of slipper casting in non-weight bearing are:
- The non-weight bearing foot does not capture its structural
defects; for example if the arch flattens excessively (hyperpronation,
pes planus) then this occurs when the weight is on the foot.
This is why most of us believe that our arches are fine
- we look at them when there is very little weight on them,
for example when we are sitting.
- Precise positioning of the foot by the pedorthist can
hold the joints including the ankle, subtalar (below the
ankle), midtarsal (bones in the middle portion) and the
forefoot. Positioning the forefoot up or down can increase
or decrease the height of the arch and the overall correction
of the foot. Most other casting methods cannot provide this
degree of flexibility of intrinsic (internal) cast correction.
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Computer systems use contact
data as an image of your foot from which to fabricate the orthotic.
Dynamic cast orthoses are usually produced
from the information produced when you walk across a pressure sensitive
pad. This means that the images are taken in a weight bearing position
and therefore captures an image of your foot when it is already
compromised in function - already pronated or supinated - the position
that may be contributing to your symptoms. Ultimately this is a
2 dimensional image derived from where you foot makes contact with
the mat. The computer uses algorithms to best estimate the actual
shape of your foot. It does not in fact know whether the arch of
your foot is 1mm or 10mm off the ground. At Sole Decisions, our
techniques used and required by the Association capture an accurate
3 dimensional model of your foot, and the orthotic is designed from
this.
Another static system such as Amfit uses Computer Aided Design
and Manufacturing (CAD-CAM) to take a 3-D imprint from pegs rising
up to the foot surface to take a mold. It can adjust the final product
with corrective intrinsic pieces prior to and after scanning the
foot. It is somewhat limited in its use of materials able to be
ground out by the mill that produces the orthotic.
The use of multiple lasers
to create an electronic 3-D image is evolving and will likely be
capable of equaling the flexibility of slipper casting in the coming
years. Once the negative impression (plaster cast or foam box) of
the foot is taken, it is scanned by a 3-D laser scanner which converts
it to a digital file. CAD/CAM equipment then uses the digital file
to produce a positive mold.
Inkblots done at Home Shows
or mail-in orders for orthotics may well help alleviate mild symptoms
and feel generally comfortable. But you should be cautioned on the
expense of these devices as they are not a truly custom molded device
and may have the same therapeutic affect as a much less expensive
off-the-shelf arch support. These types of arch supports are generally
made of a fairly flexible rubber-like material and claim to be custom
to your feet. They are however, massed produced products providing
little more support or benefit than a non-custom insole.
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5) Are the construction techniques and materials
important?
Construction techniques can vary such as adjusting the molds before
the shell is molded (intrinsic modification) for the final orthotic.
Adjusting the orthotic after the shell is molded is an extrinsic
modification. The effect on the final product can vary dramatically
depending on the amount and time modifications are done.
The size/length of the orthotic devices is dependent on the foot
type/problem and sometimes space available in the footwear. There
are typically 3 lengths: full, ¾ and ½. We have our
own manufacturing facility and we use the best products available
to create your orthotics. The composition of your orthotics
will be determined based on your needs. Some orthotics are made
of rubber-based materials, and others are made of semi-rigid plastics.
They can then be covered with a durable top cover and cushioned
material to provide extra comfort.
Material choices should vary depending on the foot problem and
room available in the footwear and the shoe characteristics such
as shape and support. The following are 3 basic types.
Rigid Orthotics
Made from a wide assortment of thermoplastic materials, rigid orthotics
are generally used when maximum foot control is desired. Because
these devices are not as bulky as those in the other categories,
they are also used when shoe room is a factor. The wide range of
material properties allows the pedorthist to vary the rigidity and
control level of these devices to meet the individual needs of the
patient's feet. Flexibility is increased if the material used is
thinner and the wall heights are lower.
Semi-rigid Orthotics
Semi-rigid orthotics provide a blend of support and cushioning.
Through the lamination of various low, medium, and high-density
foam materials, this type of orthotic provides moderate control
and some cushioning. Firm devices tend to be bulkier than semi-rigid
orthotics, making them more difficult to fit into some footwear.
Soft Orthotics
When bony prominences in the foot cause pressure points, maximum
cushioning and/or accommodation of soft orthotics is required. These
devices provide minimal support and, because of their bulk, generally
require the use of extra-depth footwear.
Some materials have resin stiffening agents added to help create
a new shape. Some materials are molded with time and sheer pressure.
This type generally doesn't last as long though.
Raw materials are usually heated and draped over the positive mold
and vacuum pressed or left for a time to set to their new shape
pulling the material tight to the contours of the mold creating
the orthotic shell. Once the shell is produced the lab finishes
the orthotic to the specifications of the pedorthist based on their
assessment. Depending on the material used and the shape it's molded
into durability and support can vary.
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6) What kind of footwear will they work in?
Can they be used in all your shoes? This is not always possible
due to foot shape changes when wearing different heel heights and
varying depths in footwear that may or may not be able to accommodate
different thicknesses of orthoses. Are they suitable for athletic
footwear? The type of activity they will be used for may make it
necessary to change material types used. Do you have to purchase
more suitable footwear? At times the footwear choice may be the
appropriate style but the wrong fit/size. Your pedorthist is trained
to help you with the correct decision. It's best to purchase the
shoes after receiving your orthotic. The final fit should be assessed
in case any adjustments/trimming are necessary.
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7) What are the charges?
Inquire as to the price range the facility is charging and what
this includes to see that you are getting good value. Does it include
adjustments or repairs? Are multiple pairs discounted since the
cast may be reused?
Since as pedorthists we manufacture our own devices, our prices
are consistently in line with, and generally below, those of practitioners
using external labs.
At Sole Decisions, we are happy to assist our patients with the
financial aspect of their pedorthic care. Our service to our patients
includes help with claim forms, insurance billing where eligible
and a payment plan when needed.
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8) Are there any warranties?
For how long are they covered under warranty? Is natural wear included
or material defects covered? Is there a money back guarantee, in
part or full, and in what time frame? Are repairs or adjustments
covered under warranty? Changes in the condition due to injury or
surgery may mean a reevaluation is necessary.
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9) What is the delivery time?
Are the hours of operation convenient for you? How long will the
appointments take? How soon can you be seen for an appointment?
No one wants to wait a long time when they are pain.
How fast will I get my final product delivered? Most computer-generated
orthotics are fabricated in various facilities across the country.
If you have problems with your orthoses, they must be sent back
to that facility for any changes to be made. In-house labs are usually
quicker. At Sole Decisions, we design and fabricate all of our own
orthoses locally. This allows the pedorthist continued access to
your orthoses during fabrication, and allows us to make modifications
or adjustments quickly. This means that you are not without your
orthotics for a couple weeks while changes are made, and we can
better evaluate the result of a change. Not too many people want
to wait 1 month for an adjustment because the product is mailed
away.
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10) Is there an adaption period?
Will they be uncomfortable or take time to get used to? Generally
they should be comfortable but not create blisters or joint pain.
Some soft tissue (muscle, ligament) ache maybe normal and temporary.
A reasonable break-in period may vary with each case but you should
have an idea of what to expect. Start with shorter periods building
up your time in them to adapt to the new changes. Typically adapting
takes longer when the foot condition is more severe, has been around
for a long time or the person's health or flexibility is poorer.
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www.cbc.ca/marketplace/sole_patrol/
- Link to CBC Marketplace Investigation re: Orthotics and Fradulent
Practices
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