Craig Payne

University lecturer, runner, researcher, skeptic, woo basher, clinician

Jan 13, 2018
Published on:
2 min read

I often enjoy playing the provocateur and can frequently make statements to have that effect. They are not done to be mischevious but are typically done to encourage critical self-reflection, mostly in the context questioning one’s own clinical practice and reflecting on improving that. There is always a context and a purpose. Often those comments can be a bit extremist, but the purpose is to encourage that self-reflection on one’s own views and own practice. However, sometimes some of those comments can be taken out of context and portray a meaning that was not intended.

On Facebook, Kettlebell Physio posted a comment that I have frequently made, this time from one of the PodChatLive interviews that I do with Ian Griffiths. The comment is something I frequently make as part of my clinical biomechanics boot camps. I have no problems with what they posted:

It gives me an opportunity to litigate the issues and provide some context to what I am talking about.

The big picture issue is what is the ethics of doing any clinical test or clinical investigation if the outcome of the test or investigation has no potential to alter the intervention? A typical example would be the use of plain x-rays at the initial consultation for a plantar heel pain that all clinical signs point to one obvious thing. What is the ethics of that x-ray (in the context of the minuscule amount of ionizing radiation exposure and the financial cost to the patient)? What is the potential for the outcome of the x-ray to alter the treatment? Probably none. (I am not talking about the 1 in a million chance of it being a bone tumour; the ethics of PYBM (‘protect your butt medicine‘) is a separate ethics issue). The recent consensus document from ACFAS supported not doing that initial x-ray. That does not mean that you do not do the x-ray (and/or other investigations) down the track if the condition is not responding how it should – but at that stage, the potential of the x-ray to alter the treatment is greater as you reached the stage of ruling out and looking for the ‘zebras'(1).

Hopefully, that principle makes sense with that example: ie what is the potential of the test or investigation to alter the intervention? That then leads to the question of what is the ethics of doing that clinical test if it has no potential to alter the intervention?

So what about a gait analysis? This is widely and commonly done as part of a clinical assessment of many types of patients and conditions, as well as at the retail level for the “prescribing” of running shoes. What is the potential of the gait analysis to alter the intervention? What is the ethics of doing a gait analysis if it has no potential to alter the intervention? (By intervention, I mean different foot orthotic design features; a change to the running technique; or different running shoe; or exercises; etc).

I used to teach gait analysis to the students. I used to use it routinely (visual down the corridor and on a treadmill with and without a video; and in-shoe plantar pressure systems). I used to be a big advocate of it. However, I went through a stage in my own clinical practice where I would assess someone, check them out, consider the history, etc and pretty much make a decision on what I consider needs to be done before doing the gait analysis. I eventually came to the realization that the gait analysis was adding nothing to my clinical decision-making process. I was only doing the gait analysis because that is what you are supposed to do. That troubled me. That raises ethical issues of charging for a service that was not helping me make a clinical decision. That troubled me. It did, however, make it easier for me to convince people to part with money as it looked as I knew more about what I was doing as I had done the gait analysis. That troubled me. (Hence, the quote of mine above that KettleBell Physio made form the PodChatLive discussion).

So you could imagine the critical self-reflection that I went through at the time trying to resolve that cognitive dissonance. Hence, in the courses I teach I do tend to take a bit of an extremist view and ask people to think about their own clinical decision-making process and how much the information that they were getting from the gait analysis (and other tests and interventions) that was actually altering the intervention that they used. A hallmark of any good health professional is those critical self-reflective skills and that is often not easy and can be painful. Its all about moving people outside their comfort zone, hopefully to make better clinicians. This also has to be done in the context of the evidence.

Having said all that, I still do use a gait analysis clinically and still do advocate its use. However, that process I went through has changed my practice (which is what it is supposed to do). The gait analysis is now focused on looking specifically for things that I do know will change my clinical decision-making process if they are present and not wasting time looking at those things that do not have the potential to change the process. It is not about impressing the patient that I know what I am doing (though, yes, I do want to do that), it’s about focusing on what information is needed to make clinical decisions as to the recommended intervention.

There are lots of gait systems that come with all sorts of ‘bells and whistles’ and produce pretty pictures that can really impress people. If another health professional down the road from you has one of those, their patients are probably going to be more impressed than your patients. That is going to put you at a competitive disadvantage and puts them in a position to convince people to more easily part with money for whatever intervention they are recommending. This still comes down to ethics. Was their clinical decision-making process as to the intervention altered by the ‘bell and whistles’? Probably not. I am sure you can see the ethical issue.

What about video gait analysis at the running shoe retail level? Same principles. Firstly, a running shoe store that does a gait analysis is trusted by runners (see this study), despite some data that you are at increased risk for injury if you got running shoes following a video gait analysis. Secondly, a running shoe store is at a competitive disadvantage if they do not have a gait analysis as runners have come to expect it. The question then is, is the recommendation as to what shoe is better altered as a result of that gait analysis? Think about that. Would the same recommendation be made without the gait analysis if other things were considered to decide on the design features that should be recommended for that runner? I not saying yes or no. I just saying reflect on it.

As always, I go where the evidence takes me until convinced otherwise …. and all the above has to be done in the context of the best available evidence.

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(1) There is an old wise clinical saying that when you hear hoofbeats, think of the obvious when all the signs point to it probably being only one thing – horses. Later you can consider that it might be zebras.