A Biopsychosocial Approach To Foot Orthoses: Considering The ‘Other Ways’ They May Work

How much do individual perceptions of pain and preexisting perceptions of modalities factor into reported outcomes with orthoses? These authors assess biopsychosocial research findings from other fields and how they might apply to the use of custom orthoses.

Within the evidence-based medicine framework, one judges therapeutic modalities in terms of their ability to bring about positive clinical outcomes. In regard to foot orthoses, one frequently evaluates the devices by their ability to modify musculoskeletal pain. Due to a historical bias toward a biomedical model, most published work in the field of foot orthoses focuses on the direct and indirect mechanical effects of these devices upon the musculoskeletal system. 

Contemporary understanding dictates that pain is a complex, individual, emergent experience with numerous inputs outside of the purely biomechanical/biomedical domain.¹ It seems appropriate to consider that if an intervention such as a foot orthosis successfully changes this experience, it may be doing so via mechanisms instead of (or in addition to) those that are biomechanical. However, this theory appears to have received scant attention in the literature to date.

Researchers studying whether foot orthoses “work” attempt to neutralize the psychological component of foot orthoses’ efficacy by introducing the concept of sham orthoses into blinded trials.² Such endeavors acknowledge the potential for foot orthoses’ efficacy as being due, in part, to psychosocial influences.²

While researchers rightly attempt to negate confounding variables in their studies, perhaps clinicians should attempt to utilize techniques that might improve the probability of better patient outcomes. Since there is little written on the potential correlation of orthotic therapy and psychosocial domains, let us consider insights from clinical research applied to other therapeutic modalities so one may factor in a potential psychosocial impact with the prescription and dispensation of foot orthoses protocols that could enhance the probability of positive patient outcomes.

The correlation between chronic pain and psychosocial factors is well established.³ Accordingly, when we consider that one of the most common and persistent foot issues patients experience is plantar heel pain, it is surprising to note that many clinicians still view this as a purely mechanical pathology, which only requires mechanical management. 

A recent systematic review highlighted that catastrophization, anxiety, stress and depression all have associations with plantar heel pain.⁴ Moreover, researchers have demonstrated that the greater the presence of these psychological factors, the poorer the outcomes of shockwave therapy.⁴ Despite researchers appearing to address such non-mechanical considerations, this concept does not seem to be as widely accepted among clinicians with respect to the daily management of musculoskeletal complaints and foot orthoses.^5,6

While the vast majority of foot orthoses research is quantitative in nature and focused on mechanical outcomes, Williams and colleagues took a more qualitative approach when they looked the use of foot orthoses for 16 weeks for lower back pain in 25 patients.⁷ The study authors found that if clinicians met the expectations and information needs of their patients, foot orthoses could be successful in the management of lower back pain. This in turn may lead to a change in their beliefs about their therapeutic course. 

Do Patient Beliefs And Expectations Play A Part In Orthotic Therapy Outcomes?

To date, few studies investigate the relationships between the recipient’s beliefs and expectations of foot orthoses and their outcomes.⁸ It is clear that more work is necessary. If we lean on the literature from other treatment modalities for further insight, it is interesting to note that higher outcome expectations on the part of the patient were significantly associated with better improvement of chronic pain with acupuncture.⁹ Positive expectations (set verbally by the clinician) appeared to be effective in reducing shoulder pain with Kinesio Taping.¹⁰

Louw and colleagues provide further evidence that the choice of words at the time of treatment delivery may be important and have the power to alter the efficacy of the treatment.¹¹ These researchers showed that differing levels of “education” about therapeutic ultrasound could immediately influence the clinical findings associated with the straight leg raise in individuals with lower back pain. 

In Conclusion

Polarized clinician opinions about these modalities aside, if we consider acupuncture, Kinesio Tape and therapeutic ultrasound in the treatment of lower extremity musculoskeletal pain, we must acknowledge that most humans are likely to have existing beliefs and experiences regarding such interventions. The research hints that the more positive these patient beliefs are, the better the likelihood of a good outcome. The treating clinician can very much influence this with the words he or she speaks at the time of treatment. Perhaps it is time to give stronger consideration to whether psychosocial perceptions can influence outcomes with foot orthoses.

The human body is a complex, individual biopsychosocial ecosystem and pain is an incredibly complex, individual biopsychosocial experience. Thus, it appears naïve to continue to attribute any successful foot orthoses outcome to their mechanical effects in isolation.  

Future research could begin to evaluate the importance of identifying patient beliefs and expectations regarding foot orthoses prior to utilization and effective methods of positively influencing these beliefs and expectations if appropriate. A clinician dispensing foot orthotic therapy could also find significant value from data suggesting how best to frame the information provided to the patient who is receiving these devices.

Mr. Griffiths is a sports podiatrist in the United Kingdom and Director of Sports Podiatry Info, Ltd.

Dr. Spooner is in private practice at Peninsula Podiatry in Plymouth, United Kingdom. 

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