Pedorthic certification can bring a chiropractic practice more business and reimbursement, but also—and most importantly—improved patient care.
Most of us learn to walk by the time we are 2 years old, and barring accident or illness, most of us continue to walk throughout our lifetimes. But not all of us walk correctly. The reason could lie in those first few steps. New walkers typically received a heap of praise (and often hugs and kisses) rather than a critique of form. Chances are the adult didn't even think about form. Many adults are walking incorrectly themselves.
Improper walking form can be a response to pain or a cause of it. Problems can be related to disease, congenital defect, overuse, or injury.
Common associated ailments include plantar fasciitis and heel spurs, lumbar pain, bunions, acute strains, sprains, arthritis, hammer toes, and metatarsal injuries. David G. Wedemeyer, DC, CPed, of Wedemeyer Chiropractic and Orthotics in Costa Mesa, Calif, sees a wide range of ailments and adds to the list drop foot; Charcot foot; severe pes planus (pronation); tibilais tendinitis; posterior tibial tendon dysfunction (PTTD); ankle, subtalar, and midtarsal trauma; moderate to severe chronic ankle sprains; rheumatoid and degenerative arthritis; and diabetic ulcers.
"Ninety percent of the devices I provide treat foot dysfunction," Wedemeyer says. To provide the best treatment for that dysfunction, orthoses require specific knowledge and expertise, often beyond the general education of the chiropractor. Goal setting, device selection, and outcomes are optimized when orthotics are designed and fit by a specialist.
"If [an orthotic] is not casted or evaluated correctly, the patient will not benefit to their fullest capability and [the treatment] can actually cause more pain and/or damage," says Amy L. Palladino, DC, CPed, with ALP Chiropractic & Orthotic Center in Sarasota, Fla.
Both Palladino and Wedemeyer have completed pedorthic certification programs to expand their knowledge of the foot. Currently, The American Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABC), Alexandria, Va, and The Board for Orthotist/Prosthetist Certification (BOC), Owings Mills, Md, provide this service in the United States.
"The pedorthic profession involves the design, fit, and modification of shoes and related foot devices to alleviate foot pathology caused by disease, overuse, or injury," according to Wedemeyer's Web site. Certified pedorthists have completed a fixed number of educational hours, passed an examination, and continued to meet continuing education requirements.
Both the ABC and the BOC define the pedorthist's scope of practice as broad. BOC breaks the responsibilities into four groups: pedorthic assessment (information gathering, foot assessment, footwear examination, and expectation determination), implementation (device selection, model creation, and orthoses fabrication), practice management (documentation, communication, and compliance), and professional development and responsibility (adherence to legal and ethical codes).
ABC describes the scope of a pedorthist as "the practice, pursuant to a written order/prescription when addressing a medical condition, of evaluating, treatment planning, patient managing, measuring, designing, fabricating, assembling, fitting, adjusting, or servicing, necessary to accomplish the application of a pedorthic device for the prevention or amelioration of painful and/or disabling conditions of the foot and ankle."1
Essentially, both organizations expound the same thing: knowledgeable experts to deliver appropriate treatment. "I feel that lower-extremity evaluation and treatment is lacking in our training at the school level. Many chiropractors don't have a clear idea why they are providing orthotics and are not treating foot dysfunction," Wedemeyer says. Palladino concurs, saying, "We as chiropractors have very little, if any, training in foot orthotics."
Podiatry- and orthotic-focused seminars are often the best options to obtain the most useful information on the foot and ankle, even for the chiropractor, Wedemeyer suggests. "They bridge the gap between the chiropractor who hands out accommodative orthotics and one with a better understanding of how the foot functions and the goals for that patient's treatment," Wedemeyer says.
Cast in a Different Mold
Being able to bridge that gap can be good for business. Wedemeyer finds he works more closely with medical doctors and podiatrists, drawing more business from referrals than he would attract with advertising. The practice is building a lab on-site to accommodate the volume.
Simply knowing how to take a proper cast can help improve the effectiveness of the device. "You are changing a patient's foundation—it needs to be done correctly. You will make your patients happiest if you have someone who works with feet on a daily basis—such as the CPed—cast and evaluate," Palladino says.
Casting is not as easy as it may seem. Many factors should play a role. Wedemeyer notes that too often a weight-bearing cast is taken instead of a more appropriate version. "This is wholly inadequate for a functional device, and a distinction between accommodative and functional devices needs to be understood," Wedemeyer says.
For instance, "with diabetics, you want to capture their feet semiweight-bearing in foam so that you capture part of the deformity and know what to offload. For a truly custom functional device, you are trying to get not just an image of the foot but also a reference point from which to make modifications," Wedemeyer says.
Palladino offers classes and training for chiropractors seeking to improve their mold-making skills. "The results show. A good evaluation and casting make it much easier for the lab to make a great product," Palladino says.
Wedemeyer suggests there is no shortage of good labs, and he works with more than one. "There are so many different designs, materials, and labs. I don't use just one lab. Some do things better than others, and once you learn how to prescribe the device, there are so many that do a good job," Wedemeyer says.
Still, many doctors will—and should—properly evaluate the products they prescribe. Palladino, whose practice features a full in-house orthotic laboratory, has many doctor clients who order a pair of orthotics before prescribing the device to get a better feel for how the product looks, feels, and works.
Generally, a custom orthotic will be more effective but also more expensive. Wedemeyer estimates custom devices generally range from $300 to $500, but can run as high as $700 for some brands. When cost is an issue, over-the-counter devices are an option, but very often the patient will pay for the custom piece. "Very rarely do I encounter a patient without the insurance to cover it who won't pay out of pocket," Wedemeyer says.
When insurance does pay, both Wedemeyer and Palladino receive higher reimbursement than the average chiropractor because of their pedorthist certification. "I've been paid by Medicare [for orthotic services] under my pedorthic license. As a chiropractor, the reimbursement is terrible and frequently denied," Wedemeyer says.
Wedemeyer estimates about 30% to 40% of his regular established chiropractic patients have been prescribed an orthotic; about half of Palladino's patients use orthotics. "That may be higher because I own my own lab and manufacture them on-site with a quick turnaround time," Palladino says. The devices are completely custom-made, from the plaster casting to the melting or heating of material to each foot.
The goals of an orthotic are usually multiple. "My typical goals are to provide a solid foundation, so as a chiropractor everything I do to the body stays in line and balanced, allowing the body to perform at its optimum," Palladino says.
Objectives can include the reduction of pain, the offloading of tissue under stress, and improved body mechanics. "[Orthotic devices are] like eyeglasses. As long as you are wearing them, they will change how the foot functions, which will have more global effects, especially on gait function," Wedemeyer says.
Though custom products are often preferred, heat-moldable and over-the-counter products can achieve the orthotic objectives with some success, particularly if the problem is minor. "If someone comes in with a minor problem, I won't sell them a $400 to $500 orthotic," Wedemeyer says.
Orthoses are medically necessary devices and often referred by an outside physician. Semirigid over-the-counter orthotics can also indicate whether a more expensive custom will work. "If we notice an improvement, it's a good indicator that a custom device will do an even better job," Wedemeyer says.
Brands he has worked with include Superfeet Worldwide Inc, Ferndale, Va ("for good off-the-shelf models," Wedemeyer says); Powerstep from Stable Step Inc, Cincinnati, which bills itself as affordable, first-line therapy for heel and arch pain; and Vasyli Medical, a company with US headquarters in San Rafael, Calif, that offers a range of heat-moldable custom orthotics.
"The majority of devices I provide are more functional and often use semirigid materials such as polypropylene, Carboblast, or TL2100—a blend of graphite and fiberglass," Wedemeyer says.
Choice, Compliance, and Consequence
When selecting an orthotic, it's important to consider all impacting factors, such as the age of the patient, his or her activity level, body weight, and the morphology and flexibility of the foot. "Pronators will require a different type of orthosis than supinators," Wedemeyer says.
Choosing the right device is often the biggest challenge. Patients tend to be compliant, in part because the orthotic achieves some or all of the intended objectives, such as the reduction of pain.
"My patients are very compliant. I make sure it is a joint decision, and I do not force the purchase on anyone. Nor will I agree to make a pair if they are not willing to change their shoe style if that is a factor in causing the problems," Palladino says.
For some, fashion before function is an actual motto, and subsequently, believers can walk improperly in response to the pain of their pretty shoes. Others might find they have pain no matter how sensible their shoes are. Orthotics can help to ensure that our last steps are as pain free as our first, and perhaps better in form.
Renee DiIulio is a contributing writer to Chiropractic Products. For more information, contact .
- America Board for Certification in Orthotics, Prosthetics, and Pedorthics inc. Scope of practice for certified pedorthists. March 17, 2003. www.abcop.org/Credentialing_Pedorthists.asp. Accessed October 21, 2008.
If the Orthotic Fits …
Whether off-the-shelf or custom created in the lab, orthotics play an important role in keeping patients well-balanced. Patient needs and what your practice provides can help determine the right mix of orthotic products to offer.
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