The Pedorthist: a health care and footwear professional
Footwear is part of the essentials in life in many cultures. It protects the foot from the environment, is a fashion statement, a status symbol and can be a cultural expression or of religious use. Those factors make footwear at times a very emotional item. Little is understood about the medical application of footwear/pedorthics as an orthotic/therapeutic device and therefore an assistive technology. The best comparison could be made with orthotic devices of the foot but also the foot and ankle.
Foot orthotic-services as well as foot and ankle orthotic-services are offered by a number of health care professionals. It may be argued that the most complex level of non-surgical lower limb health care orthotic services are fully custom-made medical grade footwear (CMGF), also known as custom made orthopaedic or pedorthic footwear with integrated custom orthoses supporting the foot and ankle. Custom made footwear as assistive technology is far more complex in its provisions than generally assumed. An overlooked complexity is that the patient cannot see and comment on the appearance of the footwear prior to it being fitted. Acceptance by the patient may vary as emotions about the footwear can have a strong influence.
The appearance and cultural aspect is an important, if not the key issue, for the patient, while for the health care practitioner there is a range of factors to consider achieving a desired outcome. Typically, CMGF is only provided after the other options have already been explored and therefore is generally for the most challenging foot shapes and medical and biomechanical issues.
Custom-made medical grade footwear: an orthotic in its own right
Yet CMGF may at times be the best or only solution to a foot as well as foot and ankle problem. Modern technologies make it possible to create footwear that is more pleasing and therefore has a higher social acceptance. Scanning technology and the use of a lab service can make the provision of high-quality custom-made footwear services accessible including in areas away from the metropolitan sprawl. However, the practitioner’s clinical involvement is critical and ultimately influences the outcome of the service.
CMGF is an orthosis in its own right. It may have multiple orthotic features built within that are camouflaged for increased acceptance. Those may include the obvious foot orthoses, but also ankle supporting orthotic elements. Those ankle supporting elements maybe of a flexible or rigid nature or have a jointed function depending upon the need of the individual. In pedorthics a heel height is not a random or only cosmetic feature, but a tool to help position the foot and, in particular, the ankle joint. The available ankle joint range of motion influences the heel height posting.
To give the patient, or user of our services, the best outcome the Pedorthist needs a sound understanding of the medical, health, orthotic and footwear issues. Education and research are the keys to developing a secure service provision for those needing the service. A 3D scanner is not a substitute for a good clinically trained Pedorthist but a tool for a better outcome, if used wisely.
Custom footwear is part of the WHO-list
CMGF is the key competency of Pedorthics. Due to its complexity it is often misunderstood and undervalued. Therapeutic diabetic, neuropathic, orthopaedic footwear is part of the recently published WHO list of 50 essential assistive technologies. It features strongly in the Pedorthic Bachelor Program at Southern Cross University (SCU) and research at SCU. Pedorthics is the only health care profession with key competency in footwear, health care and orthoses. The SCU bachelor program prepares students for a challenging career in Pedorthics. It is currently run over 3 years and is also available as a 4-year double degree with Podiatry. There is an option to develop one’s skill and knowledge further, do research and obtain a PhD in Pedorthics.
How to become a Bachelor of Pedorthics
Here is an overview of the program over the 3 years full time Bachelor of Pedorthics. The program has 24 units spread over 3 years. The first year the units are shared with other allied health care students. Those first year units include Human Anatomy, Psychology and Sociology for Health Sciences, Human Physiology, Functional Anatomy of the Lower Limb and Foot and Ankle and also Research and Analysis in Health to help the student to understand and implement research data in patient care.
There is a unit on psychology and sociology to give the student the theoretical underpinning required to achieve understanding of the dynamics of human behaviour and the structure of the social world. The understanding of all those human factors that could influence health outcomes is very important in pedorthics as footwear has so many cultural aspects to it.
In the second year studies become more specific with Lower Limb Medicine 1 and 2 as well as Lower Limb Assessment. There is a unit on biomechanics of gait allowing the student to recognise normal gait versus pathological changes. The student needs to learn how to assess a patient and develop a treatment plan that meets the patient’s health care and personal needs.
Furthermore, in the second year the student gets the first contact with orthotic and bracing aspects. Students also develop knowledge of the mechanics of abnormal foot function and methods of intervention, management and control, to optimise gait and mobility. The unit has a practical hands-on laboratory component in which the students are exposed to creating initially simple orthotic devices that get more complex over time. These include concepts of foot and ankle orthoses. Pedorthics has two discrete units in year 2.
In the first of those units the students learn about footwear construction principles, design, history as well as fitting. This includes considerations for special purpose footwear like work health and safety footwear or sports footwear. The students learn about footwear modifications and start to take shoes apart in practical laboratory sessions. SCU has a state of the art pedorthic laboratory set up by Jos America/Otto Bock. The students have access to the lab in and outside class times to practise their skills. Industry is generous in donating material and footwear for students to practise their skills.
The variations of different footwear modifications are discussed and put in context of health care. Then the students practise footwear modifications in the lab. We have multiple types of footwear available for the student to cut apart, modify and reassemble to gain practical skills. The concept of a pedorthic specific assessment is taught and practised. Globally, Diabetes related foot and footwear problems are a large and ever-growing issue. The students learn about diabetic specific footwear management and plantar pressure offloading.
The students create diabetic foot orthoses and footwear modifications, such as patient specific rocker soles, to achieve optimal plantar pressure redistribution. The students use an in-shoe plantar pressure device to evaluate their work and depending upon the outcome, further enhance it to get the desired outcome. The concept of evidence based pedorthic treatment is practised based on van Netten et al. “Diabetic Foot Australia guideline on footwear for people with diabetes”.
In the second semester of year 2 in the pedorthic unit students learn how to make a pair of shoes and a bracing boot for themselves. The lectures cover the whole process of the custom footwear provision. The practical aspect part starts with an assessment process, establishing a profile drawing, creating a treatment plan, the taking of measurements and continues to casting of the foot and ankle in the prior determined position. The students then learn how to turn the cast negative into a cast positive or last, suitable for bracing boot manufacture.
Concurrently the students learn how to take a pre-existing oversized last blank and turn it into a last that is suitable to make a pair of shoes for themselves. Once both the cast positive and the last are advanced, a clear fitting plastic socket is produced and the students conduct a fitting test to see how their cast/last actually measures up to the foot, for the shoe, and the foot and ankle for the bracing boot. Depending upon the outcome, the student may need to do adjustments. Typically, the process is repeated several times until a working outcome is achieved. This is followed by the construction of a foot orthotic element for the shoe as well as the ankle foot bracing element for the boot. Upon completion, another round of diagnostic trial fitting and adjustments maybe conducted.
Upper design, pattern cutting, and all steps required in manufacture to complete an upper comes next. It culminates in the students hand making the shoe and bracing boot. Once finished, fitting takes place. At this review assessment, the treatment plan and the actual outcome are analysed, and discrepancies discussed.
If all goes well, the shoe is worn and students walk around the neighbourhood of the university to test out their creations.
The third and final year includes a unit on Small Business and Entrepreneurship for Allied Health, Fitness and Sport as there is a reasonable expectation that the future Pedorthist will open their own pedorthic clinic or perhaps work in a management role in a larger organisation. The Diabetes related high risk foot is a very important scenario for the aspiring Pedorthist and, as such, here is a dedicated unit concentrated on this global health issue. Students learn to deal with the at-risk foot including wound management.
Placements provide practical experience
There are three double weighted pedorthic specific placement units in year 3. Each of those is 280 hours. The placements take place at approved pedorthic clinics as well as the SCU student clinic and are arguably the most valuable components of the course in terms of preparing the students for the workforce. The participation and contributions of Pedorthists are critical in giving the students opportunities to understand and participate in real world cases.
Their mentoring and experience are invaluable. During these placements the students gain exposure to different patient and pedorthic management situations. The student is involved in the day to day operations of a pedorthic facility. A key element of the placement is that the student has to complete a project. This includes a complete service provision from first assessment, to casting, to creating all components, to making the actual footwear with orthotic features, fitting and review of a real patient.
The complexity of the patients increases from placement to placement. Here are the key elements that are covered in the placement unit. They are divided into 3 areas: clinical, professional and communication.
Clinical
- To take a comprehensive, skillful and in-depth health history from a patient
- To provide biomechanical assessments (sports, neurological and muscular impairment, skeletal deformities)
- To review and interpret medical reports, including radiology results
- To provide clinical assessments (including, but limited to, range of motion checks, skin condition, muscular ability, hands-on manual examination) and treatment plan for the lower limb
- To do a clinical assessment specific to the at risk or high-risk neuropathic foot for example a diabetes related foot
- To take a three-dimensional foot and ankle model (casting and scanning) for clients
- To apply skills in the manufacture and/or modification of pedorthic appliances
- To provide client treatment, and review progress and make appropriate adjustments to the treatment
- Overall, to demonstrate a developing level of clinical skills
Professional
- To safely and competently determine the limitations of pedorthic practice
- To demonstrate professional competence, attitudes and standards appropriate for practice
- To competently determine the appropriate point for referral to other health care professionals
- To demonstrate developed interpersonal skills, workplace professionalism and teamwork
- To demonstrate professional, medico-legal and ethical principles pertaining to clinical practice
- At all times to observe workplace health and safety regulations and infection control
Communication
- To competently present oral and written case studies
- To professionally communicate by written and oral means with clients, peers, staff and other health care professionals
The graduate will have spent about 1200 hours in clinical time in different clinics. About 840 of those are purely pedorthic related while the other hours are with other units. The Bachelor of Pedorthics is focused on real life outcome and a great science back ground. This leads to career opportunities in private Pedorthic practices, public health appointments, or roles in larger organisations. Some of those roles are not accessible without a university degree. It prepares the graduate to take on further studies and venture into research and higher degrees. We have one Pedorthic PhD student at this point in time doing pedorthic focused research.
The authors:
Karl-Heinz Schott, C Ped CM, Australia, OSM, staatlich gepr. Podiatrist, Germany, Adjunct Professional Fellow in the School of Health and Human Sciences at Southern Cross University
Adam Smith BPed, is self employed, working as an orthotic technician for a number of years before completing the Bachelor of Pedorthics degree at Southern Cross University.
Adam Jorgensen, BSc, BAppSc(Podiatry), BPed.
He is a recent graduate of the SCU Pedorthics programme. He has previously qualified as a Podiatrist in 1994, and has worked in both the public and private Podiatry sectors.
Adress for the authors:
Karl-Heinz Schott
Suite 11, 818 Pittwater Road
Dee Why NSW 2099
Australia
