March 2018

Function meets fashion in modern therapeutic devices

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Unattractive therapeutic devices do not benefit patients if they won’t wear them. Leading practitioners discuss how, over the past decade, manufacturers have made significant strides in turning the solely functional into the truly fabulous.

By Jill R. Dorson

You probably think that “fashionable therapeutic device” is an oxymoron. After all, the extra depth needed for a good diabetic shoe is sure to ruin the elegant line of high heels. And there’s nothing good looking about medical-grade compression stockings. When talking about orthotic and prosthetic devices, well, the goal is to walk, not look good, right?

Some practitioners would take issue with the idea that a person can’t both feel good and look good, or that fashion and therapeutic devices are mutually exclusive. Sure, it’s tough to make that clunky brace look cool, but physicians, academics, and pedorthists are trying.

The intersection of fashion, form, and function

“Most people are not aware of more stylish options,” said Peter Morcom CPed[C], president of the Pedorthic Association of Canada and manager of a footwear and orthotics venue in Vancouver, BC. “There is [an] overarching fear of this large, clunky orthopedic shoe.” Today, however, most patients don’t require that type of footwear.

Not only are shoe companies and custom shoe manufacturers offering a wider range of therapeutic devices, Morcom added, but the materials and methods of fabrication have also improved over the past 5 or 10 years. The result is that fashion, form, and function are becoming better integrated.

Making shoes, stockings, and other devices more fashionable isn’t just about looking good. It’s about patient adherence.

More options, it turns out, also means better options. Roy H. Lidtke, DPM, CPed, FACFAOM, of the Department of Physical Science and Rehab at St. Luke’s Hospital in Cedar Rapids, IA, and an assistant professor of internal medicine, at Rush University Medical Center in Chicago, is at the forefront of bringing fashion to diabetic footwear. Lidtke’s research demonstrated a 200% reduction in forefoot pressure when women wore a modified—and stylish—heeled shoe.1 The study enrolled only 10 women, and none with foot deformities, but Lidtke said the results were compelling.

Image courtesy of Cascade DAFO

He and his team conducted the study because of the natural skepticism around high-heeled shoes for the diabetic population. “It just doesn’t make biomechanic sense. But I like a good challenge, so we looked at what parts of the shoe we could modify.” The researchers found the forefoot pressure could be decreased, even in those subjects with diabetes.

The shoe, a modified patent-leather, Mary Jane style, was tested against a more standard heeled shoe. The modifications included an elevated midsole, a metatarsal bar, anterior rock, and several cut-out areas. The result was a comfortable shoe that provided a more dressed-up, high-heeled option for those women who wear diabetic shoes.

Aesthetic improvements in the past 10 years

There is little research on the aesthetics of therapeutic devices, but practitioners say they’ve seen an improvement in everything from diabetic shoes to compression stockings to orthotic and prosthetic devices in the past decade.

Making shoes, stockings, and other devices more fashionable isn’t just about looking good. It’s about patient adherence. In fact, studies2,3 have shown that many patients wear their prescribed footwear less than 60% of the time during daylight hours. Practitioners admit the onus is on them to talk with patients about what footwear is available, why they should use it, and the consequences – which vary widely – of not adhering. That conversation often begins with the first office visit.

Image courtesy of Sigvaris

“I’m very aware that people want to look nice,” said Milwaukee-based Alex Kor, DPM, MS, immediate past president of the American Academy of Podiatric Sports Medicine. “For women who favor a 3-inch heel and a narrow toe box, I suggest a 1 ½-inch heel and a wider toe box. I try to give them an idea of what to look for. They need to be satisfied and have less pain and be happy when they look down at their feet.”

Although Lidtke embraced the challenge of creating a more stylish diabetic high-heeled shoe, Morcom said that overall, therapeutic shoes are better looking and more comfortable now because the materials are better, softer, and more functional. In fact, Morcom pointed to several running shoe companies that incorporate a stiff front rocker, which according to a 2017 study,4 alleviates stress on the forefoot and can create subtle changes in gait. Morcom said that feature used to be exclusive to specialty shoes but now can be found in some off-the-shelf running shoes and dress shoes, which allows patients to get relief at lower cost and without “clunkiness.”

Compression stockings have not caught up

Advances in style have not necessarily made their way into other therapeutic aids. For example, medical-grade compression stockings still look like, well, medical-grade compression stockings worn with shorts or skirts that expose the legs. Practitioners say that lighter and more advanced materials have made the stockings more comfortable and less likely to bunch up and create discomfort, but few advances have been made in terms of fashion.

Compression stockings used to improve peripheral circulation for patients with any of a number of conditions, including diabetes and peripheral vascular disease, may also be used temporarily to help prevent blood clots after a surgical procedure.

A January 2018 web search of medical-grade stockings turned up many stylish options for when the leg is not exposed—patterned knee-high stockings for men and women and pantyhose and tights for women. But when a patient’s leg is exposed, as is often the case in warm weather, the options are few. Regardless of whether a patient’s leg is exposed, weather can have a big effect on the comfort of—and therefore desire to wear—the socks, stockings, or other therapeutic device.

Image courtesy of Anodyne

Kor noted that efforts to make medical-grade stockings more aesthetically pleasing may not be worth it. “I don’t think I’ve ever had a patient tell me that they don’t like compression socks because of the color. …Thickness and ease of application play a role, and some of the newer synthetic materials can be thinner and more comfortable and provide the right compression.” Kor’s experience is backed up by research and thoughts from other practitioners. Sizing can be tricky, and if patients aren’t fitted properly, they may experience pain and not wear the stockings.

For in-shoe inserts, functionality rules

Orthotic and prosthetic devices are another area where aesthetics are changing, although both Kor and Morcom noted that the stylishness of an in-shoe orthotic is not a major concern. “On the orthotic side of things, we make a business-casual insert that matches the inside of the shoe,” Morcom said. “There are better products being made, and they are more attractive.” One insert manufacturer offers 60 to 70 different materials from which to choose.

Kor feels that before taking aesthetics into account, podiatrists must make sure to consider what types of shoes patients will be wearing with orthotics or other therapeutic devices. He said he hears more often from women than men that their orthotics don’t fit their shoes and, in turn, that the patients don’t wear them. Once fit is correct, aesthetics can come into play.

Kids like keeping it cool

Image courtesy of KnitRite.

Practitioners believe making the look of the device “cool” is particularly relevant for kids.  “I’ve seen orthopedic shoes with flashing lights,” Kor said. “There are lots of things you can do with them.” Kid-colored options for ankle-foot orthoses (AFOs) and prosthetics are available, but some young patients may not want to draw attention to their therapeutic device.

Although making a device colorful might seem like a good idea, adding color to the plastic of an AFO can shorten the life of the device. Decals, such as the logo of a favorite sports team, a superhero, or a piece of artwork, applied to the exterior of the device don’t degrade the material.

Although adding color or artwork to devices may seem appealing for children, it is not always the case. Cora Miller, RN, has seen first-hand how hard it can be to get a child to embrace a brace. Her son, Miles, now 6, was born with clubfeet and wore Ponseti braces 23 hours a day for 3 months when he was 1 year old, and at night for more than a year. Over the past 5 years, Miles has endured not only braces but also serial casting, and from December 2017 to January 2018, he wore casts on both legs following Achilles tendon–lengthening surgery.

“He should have worn the braces longer,” Miller said, “but he hated [them].” Miles, however, was able to choose candy-stripe colors for his recent set of casts, which he debuted at Christmas. “For the braces, there wasn’t too much we could do with them.”

Aesthetics continue to make strides

Image courtesy of OHI

Although the aesthetics of therapeutic devices may still be a work in progress, practitioners say that making patients aware of available options is critical. The internet can be used to get this information to patients and presents another avenue for professionals to share that information. “There’s not a day that goes past that I’m not with a patient at the computer, that I am not showing a patient a picture,” said Kor.

That said, while the internet facilitates the sharing of information, Lidtke reminds patients to be aware that not everything on the internet is “good” information. “I do use technology and the internet,” Lidtke said. “But I do think that ‘Dr. Google’ can give you some bad information. I generally try to use it in the office and give patients specific websites to look at.”

Ultimately, whether practitioners can improve the fit and look of a medical device through technology or cutting-edge materials, the end result must be a device that the patient will wear. “People need to have more fashionable options [for therapeutic devices] because people are only going to use them if they fit into their lifestyle,” Morcom said. “It’s important for us to look at what our patient does every day and make sure [what we prescribe] works for them.”

REFERENCES
  1. Lidtke R, O’Reilly B. Evaluation of high heel diabetic shoes. Presented at the American Podiatric Medical Association Conference; July 22-July 24, 2013; Las Vegas, NV. Abstract.
  2. Arts ML, de Haart M, Bus SA, et al. Perceived usability and use of custom-made footwear in diabetic patients at high risk for foot ulceration. J Rehabil Med. 2014;46:357-362.
  3. Waaijman R, Keukenkamp R, de Haart M, et al. Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration. Diabetes Care. 2013;36:1613-1618.
  4. Lin SY, Su PF, Chung CH, Hsia CC, Chang CH. Stiffness effects in rocker-soled shoes: Biomechanical implications. PLoSOne. 2017;12:e0169151.
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