Podiatry Update

Just an update on the previous post on Parish and Bell and all the disatisfied "patients" that were left in no-mans-land with the bankruptcy and no one was held accountable for the duty-of-care. Well, it turns out the owner, Les Bailey has reinvented himself (this time claiming to have a Phd) and has started a new company to peddle more of the same: Foot Pain Pioneers

(Added: Also posted here on ThatFootSite about it)

Labels: parish and bell

In the most recent issue of the Journal of the American Podiatric Medical Association is this paper: Robert Fridman, Jarrett D. Cain, and Lowell Weil, Jr: Extracorporeal Shockwave Therapy for Interdigital Neuroma: A Randomized, Placebo-Controlled, Double-Blind Trial. J Am Podiatr Med Assoc 2009 99: 191-193. This was a randomised controlled trial comparing shockwave therapy for mortons neuroma to a placebo.

The purpose of a RCT is to determine how much more effective an intervention is compared to a placebo. To do this the correct way to analyse a RCT is to compare the outcomes BETWEEN the intervention and placebo groups (I could cite some references here, but every book on clinical tials says that, so take your pick).

The authors in this study did a WITHIN groups analysis which is the wrong way! They found a statistically significant difference between baseline and outcome in the shockwave group and no difference in the placebo group. Doing a WITHIN groups comparison, you have no way of knowing how much of the change in the shockwave group was due to the placebo effect which is why you do a BETWEEN groups comparison. On the basis of the analysis that the authors did, they concluded that: “Extracorporeal shockwave therapy is a possible alternative to surgical excision for Morton’s neuroma” and made recommendations for its use.

In the paper the authors tabulated the individual results for each participant. I put those numbers into a stats program and did a BETWEEN groups comparison and got a p value for the difference of 0.27 – not even close to being statistically significantly different! The authors actually showed that shockwave therapy for neuromas was no better than a placebo! – the opposite of what they claimed!

Not to mention that this research was also very underpowered and there were dropouts in the placebo group that should have been included in the analysis (look up ‘intention to treat’).

I seriously question how this publication made it past the journal’s review process. Comments here: Shockwave therapy for Morton's neuroma.

Labels: neuroma, research

Two things caught my eye today.

First there was this blog post from Podiatrists.com:
"the Internet’s leading online directory of podiatrists is now ranked on page one organically on the worlds leading search engine Google as well as; Yahoo.com, MSN.com and AOL.com under the key search queries ”Find a Podiatrist”, “Podiatrist”, Podiatrists” and “Find a Foot Doctor”. Elysium Internet CEO Scott Gallagher commented, ” We’re pleased to deliver our members page one access to search engines that cover 97.3% of all online searches in the US "

and then there was this newsletter from Podiatry Exchange:
"pleased to announce to its readers and vendors that the Exchange is listed as #1 on GOOGLE key word search PODIATRY CLASSIFIEDS. PODIATRY EXCHANGE ranking on GOOGLE key word search under PODIATRYPODIATRY CLASSIFEDS) #1 out of 50,300 listed in that category(PODIATRY CODES) #3 out of 157,000 Listed in that category"

So I did a bit of looking around. According to Overture and Wordtracker (who measure what terms users put into search engines when searching for stuff), no one actually uses the terms "Find a Podiatrist", "Podiatry Classifieds", or "Podiatry Codes". However, from what I understand, a few people will probably use these terms, but it so few that it does not register at Overture or Wordtracker.

The claims made by these two sites are right - they do rank well for these terms, but what is the point in ranking well for them if no one actually searches using the terms! Are they making the claims to impress potential advertisers? Hope none of them fall for it.

Labels: search engines

Tea Tree Oil is an 'alternative' medicine. Its seems to be popular amoung Podiatrists in the UK and some in Australia and NZ, but not used widely in the USA (why is that?). It has been shown to be no better than a placebo for the treatment of onychomycosis, yet so many still use it (why is that?). The EU have expressed safety concerns about it, yet many still use it (why is that?) (see: Tea tree oil faces ban over health fear). See these discussions:
Whats your Gold Standard for onychomycosis?
Is there a place for tea tree oil in foot care?
I just can not understand the rationale of those that use it (...there is always the argument that "I used it and got some good results" -- BUT, according to the evidence, a placebo would have got the same results).

Labels: onychomycosis, tea tree oil

Parish and Bell are a foot orthotic clinic in the UK that advertise nationally, apparently use high pressure sales and marketing techniques as well as charge what appear to be extortionist prices for foot orthotics. They recently went bust leaving a lot of disgruntled patients and numerous threads on a number of forums. The one on Podiatry Arena is most interesting as Les Bailey from Parish and Bell tried to rationalise what happen by blaming everyone else for their demise and claiming that the criticism were just Podiatrists being jealous. See the Parish and Bell thread and see the reactions from Podiatrists and patients -- judge for yourself.

Labels: parish and bell

What to blog about today (especially when not feeling well)?

Maybe go and have a read of this:
Best Podiatry Arena Quotes for 2008 (it really sums up just how gullible and blind with blinkers some people can be!)

All the best to all for the holiday season.

Within the discipline of Critical Thinking, all the strategies that can be used to make arguments are well researched and documented. The fallacies of logic are clear. One of the false types of agruments is know as the straw man argument in which you define your opponents position as something that its not and then argue against that position. Wikipedia defines it as:

A straw man argument is an informal fallacy based on misrepresentation of an opponent's position. To "set up a straw man," one describes a position that superficially resembles an opponent's actual view, yet is easier to refute. Then, one attributes that position to the opponent. For example, someone might deliberately overstate the opponent's position. While a straw man argument may work as a rhetorical technique—and succeed in persuading people—it carries little or no real evidential weight, since the opponent's actual argument has not been refuted.

Here a some Podiatry Arena threads:
Challenging MASS
Challenging SALRE
Claims of Foot Orthoses Superiority

Have a read of them. Guess what? Spot the straw man arguments!

All this sums up the point that Steve the Footman made about Podiatry Arena: "What other profession has a forum that gives its members access to its most significant researchers and clinicians? You can ask any question you want and get informed and experienced replys that include links to multiple research papers. New research is discussed and critically appraised immediately. It is like having a blowtorch applied to the cherished beliefs of the profession. It is like having an academic review panel of 8000 people at your fingertips.And I think it is the major development in sports podiatry in 2008."

During gait, in a number of patients, just as the heel comes off the ground, the foot often abducts. There is no doubt this happens and its called an abductory twist.

What is interesting about it, is that two different biologically plausible and theoretically coherent theories can be used to explain it:

1. Foot pronates beyond midstance--> internal rotation moment to leg; the opposite leg is swinging forward and rotating the pelvis --> externally rotation moment to leg on ground --> conflict between proximal external rotation and distal internal rotation moments -- initially the pronated foot causing the internal rotation moment wins the battle and foot does not resupinate to accommodate that proximal external rotation moment ..... eventually as heel comes off ground, friction between the ground and foot can no longer no longer resist the external rotation moment coming from above --> abductory twist

2. As heel starts to come off the ground a functional hallux limitus kicks in (for whatever reason); as the body has to move forward over the first MPJ, it can do so by a number of mechanisms; one of these is to abduct the foot to roll off the medial side of the blocked first MPJ --> abductory twist

This is a classic example of how a fact (the presence of an abductory twist during gait) can be explained by two competing theories (this is what make clinical biomechanics fun).

Lets wee what others think on the abductory twist.

Labels: biomechanics

Advising runners what shoe to use is always difficult. Shoes change frequently and what suits one runners does not necessarily suit another, even if they appear to have similar needs. Keeping on top of who needs what and what company makes what is always difficult. This grid is a good step in the right direction to pick up what shoes models fit into what category of running shoe.

Labels: running shoes

I use this quote (not sure where I got it from) during lectures to students to suggest just how painful gout is: “Screw up the vise as tightly as possible - you have rheumatism; give it another turn, and it is gout” - Anonymous

Here are a couple of good threads at Podiatry Arena on Gout:

The latest on gout (this one has all the very latest news)

Reason for gout in more peripheral joints (this one looks at reasons why the first MPJ is the most common site for gout.

For this interested in magical cures; or what people with gout are reading; or want some good dietary advice, there are these eBooks:

Cure Gout Now

Gout Natural Remedy Report

The Ultimate Instant Gout Relief Report

Cure Gout Cookbook

Labels: gout