I guess I would call this a continuation of Paul's previous post "Should We." I find this question interesting because I am a board certified and licensed Occupational Therapy Assistant and work with Physical Therapists and other Rehabilitation professionals all the time. I of course do not know the exact context that the debate took place in but I find it interesting that the argument came about. I have also thought about the Prescriptive -vs- Preventative idea although from a little different perspective than the one Paul presents but my overall conclusions seem to be in line with what Paul discussed in his Should we post.
The fact that putting a wedge in someone's shoe is prescriptive medicine is a little far reaching, if indeed that is the exact verbiage which was used. Really to be prescriptive, at least the way I understand it, one of two things have to be true. Either the thing being "prescribed" has to have some kind of control which is placed on it, usually by the government, which makes it illegal to have without a prescription from a licensed professional. The other way is a baby aspirin or a cane can be prescribed by a medical professional and then insurance will many times cover it, which would be prescriptive medicine. The fact that a medical professional told you to use this for a medical need makes it prescriptive. Since wedges are not regulated and presumablely a bike shop employee is not a medical professional you do not have any prescribing of anything going on. Now I would believe that if this Physical Therapist is doing a fitting as a Physical Therapist and tells a client they need a wedge for a specific issue the client is having, such as pain, then it probably just became prescriptive. I won't even guess if it would be prescriptive if the same Physical Therapist did a fit outside of the therapy setting and said they need a wedge. Would that or would that not be prescriptive? I really don't know but I personally error on the side of it would be.
I have to keep all kinds of insurance for myself and my fitting business because I have more knowledge of the human body and medicine which makes me more liable if something I would do as a fitter, weather or not I am in a therapy setting, has a negative impact on the client. I would also suggest that each fitter even without a similar background as mine look into some insurance coverages as nothing can stop someone from at least saying that what you did made something worse. However, that does not make anything a fitter does prescriptive. It is also why fitters without a high degree of knowledge and confidence should be at least aware of this fact. And have some contact with medical professionals so if they see something that makes them uneasy or that they are not completely competent in they can direct their client on for a "second opinion" so to speak. This is also why during training Paul tells student to be careful when people are coming to you with pain and have not consulted with a medical professional to identify the source of the pain. You should encourage them to seek medical advice before doing the fit and always document everything. This can do nothing but make your client even more confident in your services and knowledge weather or not something is actually found as a problem by the medical professional.
On this same note, every situation is different and I myself have to be somewhat careful about this. If a fitter is working with a client and telling them that they have all kinds of issues with different anatomy of their body. Then sells them products and advice on how to fix these issues they had better have a really good background in what they are talking about, and the insurance to back that up. Reason being if that client later has issues and they go to a medical professional for help and that medical professional starts discounting or contradicting what was done then there is likely going to be, at the very least, a very unhappy client and at worst legal issues to deal with. That is why USA cycling coaches, personal trainers, medical professionals, and the like; have insurance, ongoing training, and certifications to back up what they say they know. The phrase "above all, do no Harm" from the Hippocratic Oath which most medical professionals recite during graduation comes to mind. I doubt anyone is out to knowingly make a person worse on purpose, but they need to know when they are outside their knowledge base; which is why people contact Paul for training in the first place. Trying to prevent a problem is a good thing but can be harder to prove since no problem ever happens. Maybe the phrase should be "Above all, do no Harm and if you see a potential problem fix it."
Along this same vein, I am a Certified Strength and Training Specialist. When I am working with a client and they are lifting heavy weights, or light weight for that matter, I will often have them wear a lifting belt and even wrist support to "prevent" injury. Do they have to wear it to perform the lift, Nope? In most cases they could lift fine for a long time without it but it is there to prevent injury. It is also there to remind them to tighten their ABS, keep their back straight, keep their wrists straight, it's a reminder. Yes, they do provide support and maybe even correct some issues but mostly they are preventative. I do not feel that I should wait until an injury occurs to use them because that is too late. If you read the article "Footloose" by Steve Hogg which Paul has in his Articles Section on the website Steve talks about foot wedges providing tactile feedback to our brains which creates an awareness that helps us better coordinate movements and prevent overuse injuries. The same thing is true when I use the belt and wrist supports. The fact that the client can feel them provides feedback so they remember to lift correctly and prevent injury. These are not in my opinion prescriptive items.
With all of this said I agree with Paul that what most fitters are doing when wedging a foot is not prescriptive, and is preventative, and carries with it little liability. Hell when I went in to buy running shoes someone looked at my foot and made a recommendation on what shoe I should buy based on how much I pronated. This was preventative, I don't have any issues at this time but I could if a started running 100 miles a week without the proper shoes. If they would have done nothing about the pronation and I did start running a lot then I wouldn't have been happy with the shoes and that is bad for their business. By knowing what over pronation is and addressing it preventatively they are keeping a customer happy, good business move.
My other point woven into this whole thing is I think fitters need to understand that they are incurring an amount of risk when doing a fit. There is a chance that if they choose to wedge or not wedge a person things could get worse. I do not believe the risk is large and I think that if the fitter is running their business correctly they will know about a negative issue before anything bad comes about, but the risk is always there and a fitter should be prepared for it.
Michael Irwin
This frontal view depicts very well what 10 degrees of Varus do to the pedaling mechanics.
The legendary John Howard spent over an hour visiting and talking with customers.
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