I have been in an evidence based biomechanics practice (EBP) for over thirty years, even though EBM is only 15 years old.

Following the dictums of EBM, I utilize the best available evidence when questions arise, as I treat individual patients.  I integrate the evidence with my clinical diagnostic and treatment skills and foundational knowledge and the patient’s particular needs.  In addition I evaluate my results and modify my practice accordingly and I support biomechanical research.

In 2009, The Redmond Study revealed that STJ Neutral high tech OTC orthotics perform equally well to Subtalar Joint neutral custom casted versions.¹  DPM’s can no longer justify the additional cost of our custom orthotics until we upgrade our evidence to refute his claim, even though this study uses a surrogate outcome rather than a patient centered outcome, which cannot be easily related to patients. 

In his 2009 editorial, Menz concluded that “The development of consensus guidelines for the prescription of custom foot orthoses using such a technique would be a major step forward, and would provide a foundation upon which customised foot orthoses could be evaluated to the satisfaction of both researchers and clinicians.  Over time, further research may indeed reveal that there are subgroups of patients and conditions that respond more favorably to particular types of customised orthoses compared to prefabricated orthoses”.²

As Menz suggests, my EBP has brought me to a level where I profile all feet into subgroups for the purpose of diagnosis, treatment and research with greater predictability and success.  Neoteric Biomechanics through Functional Foot Typing and The Foot Centering Theory represents a teachable, reproducible and useful tool in EBM Biomechanics when examined and it does not require a major change in Rootian Theory, as all testing and casting begins with STJ Neutral, MTJ Locked positioning.³

Kirby’s Skive, Dananberg’s Kinetic Wedge and Glaser's anecdotal MASS Position may be validated when researched using functional foot type-specific theory, because foot typing allows for subgrouping of subjects.

Theoretically, if 1000 subjects were foot typed and 100 of them were selected having the rigid rearfoot, flexible forefoot foot type and its characteristics and they were then tested with a STJ Neutral three degree varus RF Post (as in the Redmond Study) and then a custom device (as in Redmond) with a kinetic wedge, I predict that valid level-one evidence could be produced justifying the kinetic wedge for that foot type. If the same subjects were then tested with the STJ Neutral, varus posted device and a medial Kirby Skive, my prediction would be that no valid evidence would develop toward the use of the medial skive in those same feet.

In podiatry, there are areas of practice that rely heavily on EBM, because they tend to be researchable and have a large foundation of high level evidence to build upon. When it comes to diabetes, arthritis, dermatology, pharmacology and certain aspects of surgery (wound healing, instrumentation and tech advances), level 1 EBM is alive and well as an important practical and teaching tool.

However, there are areas of practice that rely less on EBM because, although there is low level evidence supporting or denying one paradigm or another,^4,5,6 there is a dearth of positive Level I evidence for any of them.  Researching large populations with biomechanical and surgical questions oftentimes produces evidence that is not relevant or applicable to isolated clinical encounters.⁷  Biomechanics EBP uses the best available and applicable research for evidence and commits to develop new mechanisms that will produce higher level useful evidence.

This means that for biomechanics, since evidence remains low level and not always applicable, often times a well designed treatment plan based on a doctor’s clinical foundation and skills and the patient’s presentation remains the basis for EBM care. 

The presumptions and realities of EBM remain debatable and must be resolved in a clinicians mind before committing to EBP (See Table I).

Table I: The Presumptions and Realities of EBM10

Authorities agree that Sackett’s 2002 definition of Evidence Based Medicine (EBM) is the most descriptive."EBM is the integration of clinical expertise, patient values, and the best evidence in decisions for patient care. Clinical expertise reflects the practitioners experience, education and clinical skills. The patient brings his or her personal and unique concerns, expectations, and values. The best evidence is found in clinically relevant research conducted using sound methodology."⁸ Updating to 2010, we must add “After Eliminating Bias."

The EBM Learning Model

An Evidence Based Medicine practice utilizes problem-based learning where patients create the need to explore important information about diagnosis, prognosis, therapy and other health care issues.  EBM targets reading to specific patient problems. EBM "converts the abstract exercise of appraising the literature into the pragmatic process of using the literature to benefit individual patients while simultaneously expanding the clinician's knowledge base." (Bordley DR, 1997).⁹

In an EBM based practice, the doctor is searching for answers to a patient specific diagnostic or treatment question that, once answered with evidence, allows for greater confidence in the decision making process for that patient and future patients by decreasing uncertainly. 

The doctor builds a question central to the case.  He selects appropriate resources and searches for evidence.  He evaluates the truthfulness and applicability as well as the level and quality of the evidence and then modifies the treatment plain based on the evidence.  The doctor then evaluates the outcome and alters practice accordingly.  Finally, the doctor supports new research (see Table 2).

Table 2: The EBM practice module

Authorities agree that Sackett’s 2002 definition of Evidence Based Medicine (EBM) is the most descriptive.
“EBM is the integration of clinical expertise, patient values, and the best evidence in decisions for patient care. Clinical expertise reflects the practitioners experience, education and clinical skills. The patient brings his or her personal and unique concerns, expectations, and values. The best evidence is found in clinically relevant research conducted using sound methodology”.⁸ Updating to 2010, we must add “After Eliminating Bias”.

Scientific Development

Scientific Development is a cyclical progression from pre-science, to normal science, to crisis, to revolutionary science, to paradigm shift, to (new) pre-science, to (new) normal science, to (new) crisis, to (new) revolutionary science, to (new) paradigm shift, etc.

Modern Biomechanics is in the (new) pre-science phase. New schools of thought addressing the same subject matter from mutually incompatible standpoints have developed.   Competition and rivalry between schools exists.

When a consensus is reached by a majority of scientific practitioners, normal science comes into being and currently, a consensus is distant amongst the biomechanics schools, as some of the best minds in international biomechanics have failed to reach a consensus for researching orthotics after almost one year.¹¹  In summary, EBP in biomechanics will remain low level until a mechanism exists that produces valid and applicable Level 1 evidence.

It is my position that Neoteric Biomechanics exists as a low evidence EBP Biomechanics paradigm for inspection, scrutiny and consideration that may lead to a consensus for developing high level evidence enabling the development of the science of biomechanics.

References:

Next Installment: Part II: The Levels of Biomechanical Evidence

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