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Instability Footwear FALL 2012 03 President’s Message 04 OPREG – The regulation of pedorthists in Ontario 04 Walking in Unstable Footwear – A Critical Review…
Instability Footwear FALL 2012 03 President’s Message 04 OPREG – The regulation of pedorthists in Ontario 04 Walking in Unstable Footwear – A Critical Review 07 Living Without the Gift of Pain: A Peer-led Educational Program for Preventing Diabetic Foot Ulcers 11 Instability Footwear and Orthoses Interaction 13 Are you ready to rock? Contraindications and indications of stable vs. unstable rocker bottom shoes 15 Rocker Soles in the Lab 16 Member Profiles A Periodical of the Pedorthic Association of Canada A Periodical of the Pedorthic Association of Canada fall 2012 President’s Message ryan robinson, C. Ped Tech (C), C. Ped (C) Throughout this year’s Summer Olympics, I noticed a number of Pedorthic related items. There were the various types of shoes the athletes were wearing (or not wearing in the case of beach Publisher Information Pedorthics Quarterly A Periodical of the Pedorthic Association of Canada volleyball), Kinesiotaping, various knee and ankle braces, and talk of the various conditions that the athletes were suffering from. One of the most inspiring parts of the Olympic games is how Pedorthics Quarterly is published by: hopeful that the international community would begin to see Rwanda in a more positive light. Pedorthic Association of Canada Suite 503 – 386 Broadway Winnipeg, Manitoba R3C 3R6 Toll Free: 1-888-268-4404 Fax: 1-866-947-9767 Email: a class= __cf_email__ href= /cdn-cgi/l/email-protection data-cfemail= 7b12151d143b0b1e1f14090f13121855181a [email protected] /a script data-cfhash='f9e31' type= text/javascript /* ![CDATA[ */!function(t,e,r,n,c,a,p){try{t=document.currentScript||function(){for(t=document.getElementsByTagName('script'),e=t.length;e--;)if(t[e].getAttribute('data-cfhash'))return t[e]}();if(t&&(c=t.previousSibling)){p=t.parentNode;if(a=c.getAttribute('data-cfemail')){for(e='',r='0x'+a.substr(0,2)|0,n=2;a.length-n;n+=2)e+='%'+('0'+('0x'+a.substr(n,2)^r).toString(16)).slice(-2);p.replaceChild(document.createTextNode(decodeURIComponent(e)),c)}p.removeChild(t)}}catch(u){}}()/* ]] */ /script The Games gave Adrien the opportunity to share not only his individual spirit but also the Printed by Unigraphics the athletes from different countries and different backgrounds come together and the opportunities the games provide everyone. From this year’s games, the story of 25-yearold Adrien Niyonshuti, a mountain biker from Rwanda was particularly inspiring. Forty of Adrien’s family members were killed in the 1994 genocide including 6 brothers and sisters. He carried the flag in the opening ceremony and despite finishing in second last place, he was pride he has in his country. This fall Jonathan Strauss and myself attended the International Association of Orthopaedic Footwear (IVO) conference in France on behalf of PAC. IVO is an international group of foot Communications Committee experts from around the world and PAC became members of this group last year. Member Chair countries include Germany, the Netherlands, Australia, Japan, USA, and many more. PAC Nancy Kelly, C. Ped Tech (C), C. Ped (C) gained membership with IVO to share with and gain knowledge from those practicing pedorthics throughout the world. PAC has seen many benefits of partnering with our sister organizations the US and in Australia, including joint conferences and educational opportunities, knowledge Vice Chair Amy Guest, C. Ped (C) sharing with a broader base of professionals in both individual practice techniques, and on a Committee Members larger scale, promoting the profession nationally and internationally. Alex Whyte, C. Ped (C) Crystallee Ripak, C. Ped (C) Grace Boutilier, C. Ped Tech (C), C. Ped (C) Jim Pattison, C. Ped (C) Michael Ryan, C. Ped (C), PHD Tavish Lahay-Decker, C. Ped (C) A major reason for attending the conference was to support our bid to host the 2018 IVO Congress here in Canada and I am proud to say we were successful. This will be like hosting the Olympics for foot specialists! (okay, okay maybe I’m getting a little carried away). However, hosting the 2018 IVO Congress will give our members access to a prestigious conference and educational opportunities close to home. For more information on past IVO conferences, I encourage you to visit the 2012 Conference Page, I am excited about the prospect of putting a spotlight on Pedorthics in Canada, and the opportunity to show the Subscriptions: $199 per year in Canada world how we do things here in our home and native land. PQ Feedback We would appreciate your feedback on the PQ and its articles. Your ideas and thoughts are important to us. Let us know what you think. E-mail your letter (referencing the article title and PQ edition) to: a class= __cf_email__ href= /cdn-cgi/l/email-protection data-cfemail= 9ef7f0f8f1deeefbfaf1eceaf6f7fdb0fdffb0 [email protected] /a script data-cfhash='f9e31' type= text/javascript /* ![CDATA[ */!function(t,e,r,n,c,a,p){try{t=document.currentScript||function(){for(t=document.getElementsByTagName('script'),e=t.length;e--;)if(t[e].getAttribute('data-cfhash'))return t[e]}();if(t&&(c=t.previousSibling)){p=t.parentNode;if(a=c.getAttribute('data-cfemail')){for(e='',r='0x'+a.substr(0,2)|0,n=2;a.length-n;n+=2)e+='%'+('0'+('0x'+a.substr(n,2)^r).toString(16)).slice(-2);p.replaceChild(document.createTextNode(decodeURIComponent(e)),c)}p.removeChild(t)}}catch(u){}}()/* ]] */ /script All articles published in Pedorthics Quarterly are the property of the Pedorthic Association of Canada. Copyright ©2012 Pedorthics Canada All rights reserved. Reproduction in whole or in part is permitted only with the prior written consent of the Pedorthic Association of Canada. Address all requests to the PAC office. Trademarks and Registered. Trademarks used in this publication are the property of their respective owners and are used only for the purpose of information. Please include ‘PQ - Letter to the Editor’ in the subject line. PAC also invites you to comment about articles in the PQ via our Linked-In page. Help Us Be Green! If you would like to receive Pedorthics Quarterly If you are interested in contributing articles for the PQ, contact a class= __cf_email__ href= /cdn-cgi/l/email-protection data-cfemail= 2940474f4669594c4d465b5d41404a074a4807 [email protected] /a script data-cfhash='f9e31' type= text/javascript /* ![CDATA[ */!function(t,e,r,n,c,a,p){try{t=document.currentScript||function(){for(t=document.getElementsByTagName('script'),e=t.length;e--;)if(t[e].getAttribute('data-cfhash'))return t[e]}();if(t&&(c=t.previousSibling)){p=t.parentNode;if(a=c.getAttribute('data-cfemail')){for(e='',r='0x'+a.substr(0,2)|0,n=2;a.length-n;n+=2)e+='%'+('0'+('0x'+a.substr(n,2)^r).toString(16)).slice(-2);p.replaceChild(document.createTextNode(decodeURIComponent(e)),c)}p.removeChild(t)}}catch(u){}}()/* ]] */ /script electronically instead of the paper version, contact the PAC office at a class= __cf_email__ href= /cdn-cgi/l/email-protection data-cfemail= 274e494148675742434855534f4e4409444609 [email protected] /a script data-cfhash='f9e31' type= text/javascript /* ![CDATA[ */!function(t,e,r,n,c,a,p){try{t=document.currentScript||function(){for(t=document.getElementsByTagName('script'),e=t.length;e--;)if(t[e].getAttribute('data-cfhash'))return t[e]}();if(t&&(c=t.previousSibling)){p=t.parentNode;if(a=c.getAttribute('data-cfemail')){for(e='',r='0x'+a.substr(0,2)|0,n=2;a.length-n;n+=2)e+='%'+('0'+('0x'+a.substr(n,2)^r).toString(16)).slice(-2);p.replaceChild(document.createTextNode(decodeURIComponent(e)),c)}p.removeChild(t)}}catch(u){}}()/* ]] */ /script To those of you who are already receiving the online version, thank you for helping us be green! Did you know you can read past issues of the Pedorthic Association of Canada quarterly publication online? Go to and log in to your member record. 3 Ontario Pedorthic Regulation Exploratory Group (OPREG) – The regulation of pedorthists in Ontario matthew quattrociocchi, C. Ped (C), OPREG Chair Walking in Unstable Footwear – A Critical Review Derek Kivi, Ph.D In recent years, unstable footwear has become popular and highly marketable for shoe manufacturers. Also known and “toning” or “physiological” footwear, they have a distinct rounded sole with a 2012 has been a very slow year for OPREG in its pursuit of legislated compressible rearfoot section which promotes instability during gait. health regulation for pedorthists in Ontario. The formal regulatory These design characteristics attempt to simulate an unstable surface, such process through the Ministry of Health and Long Term Care has become as walking barefoot or on sand. Theoretically, this instability increases the completely stagnant with, seemingly, no movement in site for a few years. level of muscular contraction in various muscle groups while standing, However, with 2013 quickly approaching there are a few glimmers of hope on the horizon in the pursuit of legislated health regulation for Ontario’s walking, or performing other activities which will improve posture and gait, and enhance energy expenditure (Romkes et al., 2006). pedorthists. OPREG has been diligent in maintaining political ties with Masai Barefoot Technology (MBT) of Switzerland originally developed some key groups, including, the Ontario Association of Prosthetists & this type of footwear in 1996. More recently, other shoe manufacturers Orthotists (OAPO), the College of Chiropodists of Ontario (COCOO) and (Sketchers, Reebok, New Balance, etc.) introduced their own versions. their political consultant Mr. Don Gracey, and the Transitional Council of Because of their high marketability, many claims have been made the College of Kinesiologists of Ontario (TCCKO) in an effort to maintain regarding the purported benefits, both scientific and anecdotal. open lines of communication and not miss potential opportunities to work footwear practitioners, it is important to have an understanding of the together with these groups in achieving regulation. benefits of this type of footwear during gait as proven through empirical In early September OPREG had a meeting with the registrar of the TCCKO, Brenda Kritzer, to discuss potential collaborative relationships that would see pedorthists regulated through some extension of the College of Kinesiologists of Ontario. The meeting was very productive as we discussed different scenarios for pedorthists in Ontario. Ultimately, however, we need to give the TCCKO time to finish its transitional mandates before real action can be taken into investigating a relationship between the pedorthists and the Kin college in the future. For research, as well as the changes in the lower extremity kinematics and kinetics that result from their use. This article will review the scientific literature on unstable footwear and their effects on gait, including kinematics, kinetics, muscle activation, and physiological response. Kinematics When walking in unstable footwear, Romkes et al. (2006) reported changes in various temporal parameters, with cadence, walking speed, and step length all decreasing significantly as compared to regular footwear. One strong recommendation from the TCCKO was that all pedorthists in The authors also found that stride time and single support significantly Ontario that are Kinesiology graduates become members of the Ontario increased for the unstable footwear condition. In comparison, Demura Kinesiology Association (Certified Kinesiology designation) and eventually et al. (2012), who compared gait characteristics when walking in unstable the College of Kinesiologists of Ontario. Having a strong contingent of footwear, flat-bottomed footwear and barefoot, found no differences members from within the college will give our group a much stronger in cadence, walking speed, and step length between the two footwear voice when working to find an avenue for regulation. conditions. When barefoot, the participants walked with a slower speed, OPREG and its members are available to assist any of you if you have any questions or concerns. Please email us from our “Contact” page at www. faster cadence, and with shorter steps than with the two types of footwear. The differences seen between these two studies may be explained by the fact that Romkes et al. used MBT footwear and provided their participants with a 1 hour session with an MBT-certified trainer to ensure proper MBT walking technique. This was followed by at least 4 weeks of walking with the footwear prior to data collection. Conversely, Demura et al. utilized “Stretch Walker” unstable footwear, and without providing any instruction, allowed their participants 10 minutes in each footwear condition to familiarize themselves prior to data collection. The footwear, instruction, and/or familiarization period may have all contributed to the changes seen in the temporal gait parameters. When examining the kinematics at the ankle, increased dorsiflexion has been reported during the initial portion of the stance phase wearing unstable footwear (Nigg et al., 2006; Romkes et al., 2006). Taniguchi et al. (2012) also found increased dorsiflexion in terminal stance. These changes to the sagittal plane movements at the ankle can be attributed to the rounded sole shape. One important kinematic gait variable that is notably absent from the scientific literature is the measure of subtalar range of motion (inversion and eversion angle) when walking in unstable footwear. Considering this footwear is designed to promote instability not only in the sagittal plane but also the frontal plane, this omission is 4 A Periodical of the Pedorthic Association of Canada fall 2012 significant. Research completed in our lab and presented at the 2012 change muscle activity compared to a PAC symposium in Whistler (Kivi, 2012) showed that eversion angle is regular shoe, and that walking barefoot significantly greater when wearing unstable footwear as compared to increased muscle activation to a greater barefoot walking, with no differences seen in inversion angle. The result extent than when wearing unstable footwear. Again, the methodological was a significantly greater total range of motion. Further research into this differences among these articles may explain the results. Although all important gait parameter is required. three studies used the same type of footwear (MBT), Sacco et al. (2012) The research is inconclusive regarding the kinematics at the hip and knee when walking with unstable footwear. Nigg et al. (2006) reported no changes in the kinematics at the hip and knee, however, Taniguchi et al. (2012) found a significant decrease in knee extension angle in the early part of the stance phase and a decrease in the angle of hip extension. Similarly, Romkes et al. (2012) reported that the range of motion at both the hip and knee was reduced when walking with the unstable footwear. These results may be related to the decreased step length reported by Romkes et al. MBT promotes a specific technique for walking in their footwear. Considering these three of these studies involved the use of MBT footwear and the participants were all instructed in proper technique by an MBT instructor, it is interesting that only two found kinematic changes at the hip and knee. did not provide instruction to their participants. The other two studies did offer instruction on MBT technique. Romkes et al. (2012) suggested that the increase in muscle activity found in the gastrocnemius and tibialis anterior muscles could provide stability and therefore cold be used to strengthen the leg muscles. Nigg (2009) stated this type of shoe should be considered a training device. Considering the lack of consistent results regarding muscular activity during gait when wearing unstable footwear, these recommendations may not be substantiated. Physiological Response The energy requirements during gait while wearing unstable footwear has been the focus of a limited number of studies. Gjovaag et al. (2011) examined oxygen uptake and energy expenditure during treadmill walking while wearing unstable footwear and jogging shoes. Comparisons were made between self-selected and fast walking speeds, and at zero and Kinetics Similar to the kinematics, there is little agreement within the research regarding the lower extremity kinetics. Walking in unstable footwear has been shown to reduce the joint moments at the hip, knee, and ankle in the sagittal plane (Vernon et al., 2004), however, Nigg et al. (2006) reported no significant differences in the angular impulses at the hip, knee, or ankle between the unstable and stable shoe conditions. Nigg (2009) speculated that the inherent instability of the footwear results in muscle activity which is constantly alternating, which may function to reduce the joint loading due to muscular co-contraction. He noted, however, that there is no direct empirical evidence to support this. Sacco et al. (2012) found that walking in unstable footwear resulted in higher vertical ground reaction forces as compared to walking with a standard shoe or barefoot. This was seen in a larger first vertical peak and weight acceptance rate. In comparison, Taniguchi et al. (2012) reported 10% inclination. No differences were seen in the physiological measures between the two types of footwear when walking on the flat inclination at either speeds, however, the unstable footwear was found to increase oxygen consumption by approximately 5% and energy consumption by 6% during fast uphill walking. These increases were found to be significant, however, the researchers noted that the clinical relevance of the findings may be negligible when related to body weight regulation or reducing body fat. More recently, Demura and Demura (2012) examined the physiological effects of treadmill walking with two different brands of unstable footwear (MBT and Stretch Walkers), with comparisons to regular footwear. Oxygen consumption was found to be largest when wearing the regular footwear, and no significant differences were seen in heart rate and rating of perceived exertion among the three test conditions. that there is a reduction in the ground reaction forces for unstable Summary footwear, particularly in the early stance phase. These authors suggested The lack of agreement among the various studies indicates that more that the footwear may be effective in shock absorption, but this statement research is needed before recommendations should be made regarding is not supported by the results of both studies. the use of this type of footwear. In many cases there are too many The in-shoe pressure distribution when walking in unstable and flatbottomed footwear has been examined (Stewart et al., 2007). Four regions of the foot were measured: toes, forefoot, midfoot, and hindfoot. The results showed a 21% reduction in peak pressure under the midfoot and an 11% reduction in pressure under the heel. A 76% increase in pressure was seen under the toes. This suggests that unstable footwear may be appropriate when there is a need to reduce the pressure in the mid and hindfoot, however, they should not be recommended when reducing forefoot and toe pressure is required. Muscle Activity Increased muscle activity in the lower extremity has been purported as being one of the benefits of unstable footwear. Nigg et al. (2006) did not find significant increases in muscle activity during gait when comparing unstable footwear to a stable control shoe, although “trends” of increased muscular activity were noted. Romkes et al. (2006) reported increases in the activity in the tibialis anterior and gastrocnemius muscles, however, methodological inconsistencies, including differences in the brands of unstable footwear used, whether or not instruction was provided on “proper” walking technique, or the duration of the familiarization period provided prior to testing, which makes it
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