What is this word structuralism? It’s been quoted in medical journals both in favour and against, but I’ll attempt to nutshell it with regard to clinicians and clients.  It’s thought to be an extreme focus among AHP’s that structural imbalances and asymmetry in the body can result in painful musculoskeletal conditions. In this model, the imbalances and asymmetries increase the abnormal mechanical / physical stresses imposed on the musculoskeletal system. This may lead to recurrent injury or the development of chronic conditions through a gradual process of wear and tear.

One of the most deeply held beliefs in MSK with AHP’s is that osteoarthritis is a “wear and tear” condition, that years of activity, sports, occupation, weakness / imbalance,  have manifested into joint degradation due to perceived overuse. This is rather a narrow mechanical view of arthritis and directly suggests that the longer we live and/or the heavier we are, that this has increased our predisposition to joint issues.

The model then manifests clinically in the form of postural, structural and biomechanical  assessments (PSB) in order to deliver manual conservative treatments and exercises that aim to correct these structural factors. It can wear a different hat each year; we’ve seen neural tension, tissue stress and fascia, kinematic chains – you name it!  I do believe PSB to be clinically significant, but we must consider all other factors.

The prevalence of osteoarthritis has roughly doubled in the 20th century and that number didn’t change when weight and age were factored out. The study by Wallace et al using long-term historical and evolutionary data looked at the skeletal remains of older people with a well-documented body mass index from the last two centuries alongside  prehistoric knees.

The implications are clear – loading and longer lifespans are almost certainly not the main cause.  The unconfirmed, but likely candidates are the surge in recent lifestyle diseases: metabolic syndrome, diabetes and heart disease (see Kluzek et al or Jiang). These are reassuringly treatable. We can accept that biomechanically knee osteoarthritis “wear-and-tear” problem can be aggravated by weight and age, but recent studies show with great statistical significance that we have a bigger factor that must be contributing to its prevalence in our ageing population, likely biological with genes and heritability coming into play. So what Orthotics services are currently feeling or noticing, is possibly more referrals for OA knee bracing.  Certainly this is something I have felt in the last decade, with a notable increase in Tri – compartment.

As an adjunct, Battié et al found with twins that as much as 47%–66% of spinal degeneration is due to hereditary and shared environmental factors, whereas only 2%–10% of the degeneration can be explained by physical stresses imposed by strenuous occupations or sporting activities.

In contrast to best practice guidelines for knee OA, findings from several different healthcare settings have identified that nonsurgical treatments are underused and TKA is overused. Empirical evidence and qualitative observations suggest that patients’ willingness to accept nonsurgical interventions for knee OA is also at an all time low. Qualitative investigation of why patients may feel that such non surgical interventions are of little value has been an important step toward increasing conservative treatment of knee OA.

I think we can all agree that there is no doubt in cases of excessive asymmetry / imbalance it is unlikely that manual therapies or conservative treatment can substantially lower a VAS pain score.  The difficulty as always is being able to quantify the impact of conservative treatments on an individual with minor / moderate imbalance, or wear and tear. With any joint condition it depends on the individual biological and psychological threshold to reserve capacity to allow for asymmetry and imperfections to exist without symptoms.

Lederman has an excellent paper on this with LBP, with regard to structuralism that equally resonates with an OA knee; we didn’t really nutshell it but let’s just leave it at pathomechanics do not determine symptomatology.

Now back to structuralism – this one of the biggest challenges to the Orthotist treating these OA knees.  Studies have illustrated quite well that patients’ beliefs in a biomechanical model of progressive joint degradation often appeared to originate within earlier clinical encounters and from literal interpretation of the term ‘wear and tear’. These beliefs led to uncertainty regarding interpretation of daily symptoms and participants’ ability to influence the rate of decline and certainty that joint replacement surgery represented the only effective solution to fix the damaged knee.  I witness this weekly in clinic, as clients simply feel they are going through the tick box hurdles before being considered for partial or full TKA and we really need to get them to change this mindset.

As clinicians it is paramount that when treating with nonsurgical interventions you consider exploring and targeting patient held misconceptions about, causes, consequences, timeline, and treatment of knee OA to influence the above mindset. These misconceptions about knee OA treatment influence patients acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. The author would suggest that once diagnosed with “bone-on-bone” changes, we deliver this with more information on how the joint may of reached this point and that with hindsight there was likely nothing the client could of done differently with the knee. Disseminating up to date clinical evidence on effectiveness of conservative management to prevent many disregarding an exercise based or bracing intervention further damaging their joint or feeling it, is merely futile. It’s time to challenge and be honest about structuralism and get our clients on board with compliance.

#orthotics #osteoarthritis #knee #oa #oaknee

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Evidence based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. The current state of EBP within orthotics I feel is summarised quite well by the Latin phrase below, coined by the 17th century philosopher John Lockes.

‘Argumentum ad ignorantiam’ – Argument from ignorance / appeal to a lack of contrary evidence.

It asserts that a theory is true if it has not yet been proven false, or a theory is false because it has not yet been proven true. I’m probably a little unfair and that the above statement is in fact a false dichotomy, in that it excludes the possibility that maybe we had a flawed trial to prove that the theory is either true or false, which is the majority of our professions research. Evidence is rarely persuasive, or highly controlled, with susceptibility to false positive / negatives. Therefore a possibility is that the answer is unknowable, knowable in the future, or neither completely true nor completely false and possibly somewhere between the two; the dreaded grey area. It is this grey area I’m afraid that doesn’t sit very well with evidence based practice, and relies upon the Orthotists own interpretation.

Rightly or wrongly Orthotists often think that issuing an orthosis for treatment may well be ‘worth a try’. I just want to help! But wasted orthoses in our current environment can be a reckless use of our dwindling NHS resources and budget. Additionally an ineffective orthosis can waste patients’ time and in some cases cause harm.

Processes for policy and protocol development and revision are now based on the inclusion of best evidence, clinician expertise, patient values or preference and updated when new evidence justifies a revision. Once disseminated it will facilitate staff adherence to new practices, which we see within our BAPO Debop and MSK courses recently.

Good clinical practice is shifting from a practice based on historical tradition, expert opinion, subjective clinical experience and intuition, to practice based on examinations and interventions that are supported with robust patient centered research.

What hurdles do we need to overcome?

The biggest is often funding barriers. When competing with research proposals evaluating interventions that might save children’s lives, the latter outcome can be given higher value than a orthoses to improve gait for example.

Orthotists value EBP research as a means of improving clinical practice, but they are faced with a number of practical barriers in performing it. Primary factors of time constraints, workload, department demands, lack of mentorship, gaps in skills and knowledge required to perform EBP are all regularly given. This has a damaging cumulative effect of propagating negative attitudes toward EBP.

Adoption of EBP varies from Orthotist to Orthotist. Age, experience, degree level held and percentage of clinical contact have been shown to have little influence through a study of physio colleagues in the USA. So if personal characteristics don’t predict the propensity to adopt EBP, then all we have is the workplace environment and its social system.

From experience the CPD opportunities in the NHS and private companies are poorly structured. If fortunate enough to be offered, then CPD it is rarely protected and sickness / holiday cover often trumps an employer’s CPD time due to the employers financial constraints. Teamed with a lack of support, energy and motivation, transport, child care, faulty remote computer access, it becomes often little more than a convenient bit of down time to catch up on everything else at work. Additionally CPD time can be often used for personal reflection, although a useful skill and requirement we have to make the distinction that this is only a small part of EBP. In absence of workplace support then we must strive for self-directed learning, or in more extreme cases a more favourable work environment all together.

Orthotics services are small but critical and EBP can be a critical part of a fulfilling career to those already in the workforce, whilst maintaining a workforce that is appropriately trained whilst meeting the needs of the service. We are acutely aware of current issues in orthotics of recruitment and retention, therefore factors that can influence retention are mentorship schemes and formal supervision, which should consequently be seen as a necessity.

How do we navigate grey areas currently?

I’m not suggesting that all clinical reasoning is fallacious, but currently we will need to conduct a frank discussion about the pros and cons of different orthotic treatment options in the absence of strong evidence. In this way the decision is biased towards relying on clinical experience and patient preferences, whilst acknowledging evidence if any. I really hope in the future we have infrastructure and funding to support clinical trials, so that the current obvious acknowledgement of uncertainty around our treatments can become clearer.

EBP should be prioritised within the profession, as well as initiating cultural change needs to support clinicians in incorporating research findings into their daily practice. Additionally Orthotists will need to become more active in generating research rather than relying on other professionals. We still see many cases of orthoses being issued when we have clear evidence against it, and it’s simply unethical and negligent. Who’s at fault? Clinician or workplace for not disseminating the information?

Unsure of whether an intervention is effective? Then structure a question around the patient-intervention-comparison-outcome (PICO) format. Once you have an answerable question you can look for evidence efficiently in several journal resources and critically appraise it.

How do you see EBP within orthotics currently?

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Automation and new technology is here and it is thought that in the next 15 years over 10 million workers jobs will be directly affected in the UK, of which 7.5% are in the manufacturing industries. The idea that a job is for life is not true for most of us and our industry is certainly not immune to this.

I suggest you give the independent Future of Work Commission a read, led by Tom Watson MP it details how the UK will deal with the new technological revolution. ‘Automation and Artificial Intelligence will create as many jobs as they destroy?’ I am largely apprehensive of this statement and we have seen little in policy or reform to set these doubts aside.

The principles of work are valuable. Work should provide dignity, should offer security, should promote autonomy, and work should be available to everyone. I will not get into the real politics of this, or the wider impact of the broadening separation and vulnerability of the low skilled vs high skilled manual worker, but the reality is innovations in digitisation, computing, artificial intelligence and robotics are already transforming our economy and labour market. The scope and pace of the current technological revolution is likely to surpass anything that has gone before.

Recent advances make it possible to automate a much greater range of tasks than those enabled by previous developments. This means that the current wave of automation will reach into sections of our economy that have traditionally been considered “safe”, including high skilled jobs which involve complex cognitive / analytic tasks alongside manual labour skills. Therefore all our P&O Technicians are at some point going to be vulnerable, but the one role that logically seems most at risk is the Technician.

Plaster work or more accurately the treatment of the negative to positive cast, is not always traditionally the work of the Technician, often In-house Orthotists and nearly all Prosthetists oversee the treatment and rectification of their own cast. In some manufacturing P&O clinicians have had the ability to scan, rectify digitally and have a carver produce the positive mould, leaving the Technician to only mould over, trim, finish and final assembly. The latter in some countries is still the domain and job requirement of the clinician, from cast to final assembly. I think that in some cases (mainly Paediatrics) we will need to cast by hand for a while, but often companies will then still scan the negative cast.

At present the main threat is largely going to be 3D printing, as this completely removes a large percentage if not all traditional manufacturing time, whilst running all night to produce an arguably more architecturally advanced, lighter product; reducing the Technician input to clean up of holding tabs and assembly. More recently however and with advances in 3D printers, the level of finish requires little if any clean up from removal off the printer before assembly. With the ability of 24h unmanned manufacture, delivering less waste and quicker production, it makes sense from a business standpoint to adopt 3D printing and leapfrog the Technician straight to clinician. Geographically hard to reach locations could easily have a single clinician running assessment, manufacture and supply.

Looking at this with a wider lens however; the ease at which devices can now be manufactured means an explosion of viral videos showing parents producing orthoses for their own children and overnight being deemed an expert!? Expert at what? Technician, Clinician? I do think we need to take ownership of this now and before it runs away from our industry.

A possible light at the end of the tunnel is an interesting hybrid, like that of the Create O&P company, where the client scan is then rectified with tools through the use of VR headsets. The Technician will actively rectify the render with a VR headset, a virtual surform if you like and then print. I am not entirely convinced by this workflow, but it may keep our Technicians in a job and could technically be deemed to still have a ‘hands on approach’. Useful maybe as a training platform and the plaster room would undoubtedly be cleaner.

I think however the future is more likely to resemble SME’s like 3D LifePrints who are embedded into the NHS with their 3D printing hubs. This allows multiple clinicians from varying specialities to utilise the printers on site.  This coal face production is likely to yield better results and promote creative thinking amongst all professionals. We can often be blinkered and seeing how other professionals are using this 3D printing technology  in a hub is likely to expand the horizons of what we are capable of producing, whilst problem solving as a collective.

So the question is, from the initial scan who is going to take ownership of the rectification to final assembly? Will we still see it being at the hands of the Technicians with re-training, cross industry technicians in SME embedded hubs, or the P & O Department? How does the next 15 years look for you? Share this with a friend or colleague

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