Patient communication = patient satisfaction

Patient compliance is one of the most difficult challenges we face as health professionals. It's easy for us to see the benefits of a product or an exercise, and we can be confident explaining to our patients why we are asking them to follow certain protocols. Some patients greet those suggestions eagerly and can't wait to start following our directives.

Yet, more often than not, after leaving your office a patient will fail to comply with your regimens.

According to the American Medical Association, of the two billion prescriptions meted out to patients, more than half of those prescriptions are taken improperly against medical advice. If taking a pill at the right time every day is difficult, then getting patients to adhere to chiropractic wellness modalities can be a trial.

One particular area that's a true test of your compliance mettle is in prescribing orthotics.

You already know that custom-made orthotics make a significant difference in the lives of your patients. But, did you know the way you issue them could affect both your success and that of your patients?

Due to the intense biomechanical changes that the orthotics will create in the patient's body, getting the person to wear them often enough, in the right shoes, and to endure the biomechanical changes collectively can be a Herculean endeavor.

For years, I've stood behind what I call the "WTSE Principle." WTSE stands for "Wear," "Test," "Shoe," and "Exercise" -- and it's the most practical and beneficial way to provide patients with orthotics. In essence, WTSE is face-to-face, hands-on communication between a doctor and a patient. Its purpose is to bring the highest level of satisfaction to your patients, which will help expand your practice.

As health care professionals, we realize that our patients are going to be most successful if they comply with our treatment plan. Like anybody else, if patients lack the understanding of why they should follow instructions, the chances of them doing so are slim. Patient compliance is highest when they understand why.

The saying, "Patients comply when they know why," could not be more accurate. Our job is not just to outline a plan of treatment for our patients, but also to communicate the importance of our plan and why we've selected it for their needs.

The WTSE Principle will enable you to equip your patients with the understanding and knowledge they need to successfully follow your orthotics treatment. If you follow this simple, four-step process, you can expect to achieve optimal success, patient satisfaction, and an increase in patient referrals.

WTSE begins when patients come to the office to receive their custom orthotics from you.

1. Remove the orthotics from the package and show them to your patient. Demonstrate how to insert the orthotics into his or her shoes, stressing the heel of the orthotic needs to fit snugly against the counter of the shoe. Also, explain how the support can change from one pair of shoes to another.

2. Stress to patients the importance of wearing their new orthotics. Explain that to reap the benefits of orthotics they must be worn all the time. Any new treatment requires the body to go through a period of adjusting to the improvements being made. As with a pair of new shoes, there is a break-in period for the new orthotics. Patients must understand that during the break-in period, not only is it "okay" to wear the new orthotics, it's critical they do so!

This adjustment period varies patient to patient. Some people adapt immediately while others require as long as four weeks to adjust to their new orthotics.

Supporting the feet affects the whole body. In the beginning, it's not uncommon for your patients to experience mild -- but temporary -- discomfort as the knees, hips, pelvis and spine adjust to the improvements. [1] Instruct patients that if discomfort occurs, the orthotics should be removed from the shoes for about a half hour and then re-inserted.

You've determined your patient needs orthotics and fit him or her accordingly, but don't stop there. Continue to evaluate your patient. Schedule additional visits during the first few weeks to help the individual adjust to his or her new orthotics. Include manual muscle testing in these visits.

Manual muscle testing is one of the most valuable procedures in chiropractic practice. It reveals to you, the health care professional, pertinent information about your patients' postural integrity that is necessary to plan their care. Kendall and Kendall describe muscle testing in their textbook and state, "Manual muscle testing is the tool of choice to determine the extent of imbalance." [2]

Muscle testing will allow you to get immediate objective feedback from patients. It is based on the fact that joints, ligaments, and tendons have mechanoreceptors, which are constantly modulating neuromuscular tonus and reactivity.

Equally as important, muscle testing demonstrates to your patients that you're incorporating that knowledge to improve their overall well being. Patients are much more receptive when a health care professional takes the time to explain how specific testing measures can lead to improved care.

Perform the following manual muscle tests before patients leave your office with their custom orthotics:

*** TEST bilaterally the iliopsoas, gluteus medius/minimus and quadriceps muscles. Note the relative strength of each. (Fig. 1)

(Fig 1 -- Click on image for large graphic)

*** ADJUST bilaterally the navicular (medial arch), cuboid (lateral arch), and metatarsal heads (transverse arch). (Fig. 2)

(Fig 2 -- Click on image for large graphic)

*** RE-TEST the muscles as above (Fig. 1). Note the increase of the relative strength.

Help your patients understand that wearing their custom orthotics throughout the day will help maintain the pedal foundation in better balance, which improves overall structural stability.

1. Explain that orthotics are custom-made for the patient, but shoes are not. Orthotics that don't appear to fit correctly in "store-bought" shoes is usually a good indication that the shoe size isn't correct.

According to The Brannock Device Company, shoe sizes and foot sizes are not the same. [3] It's important that the foot has enough room in the shoe for comfort and performance.

Proper fitting shoes are a must.

Therefore, I recommend that my patients have their feet measured for length and width at least once a year, using the Brannock Device. If patients have experienced significant fluctuations in weight, then more frequent measurements may be necessary.

2. Old, worn shoes and custom-made orthotics are not a good combination. Shoes that are too soft and broken down can't provide the support the foot needs to bear the weight of the spine. Investigators have found that "Alteration of normal foot mechanics can adversely influence the normal functions of the ankle, knee, hip, and even the back." [4]

Inadequate support from patients' shoes will cause the spine to be exposed to abnormal stresses and strains that eventually result in recurrent subluxations and interference with chiropractic correction. The corrections a new orthotic prescription provides are so important that recommending a new shoe to accompany the orthotic is essential.

3. Different shoes need different orthotics. The basics are simple:

A. Shoes with laces = full-length orthotics.

B. Shoes without laces = 3/4-length orthotics.

It might also indicate that, because the patient wears different styles of shoes during the day (a slip-on at work and an athletic shoe at home, for example), a second style of custom orthotics might be necessary to achieve all-day support.

Which leads us to another point.

Fashionable shoes are not functional. High heels are almost impossible to fit with orthotics. Additionally, wearing heels concentrates abnormal forces on the ankle and rear foot, relative to the forefoot. The tibiotalar joint "is a tightly interlocked joint exposed to extreme mechanical conditions during single limb support" and susceptible to repetitive, traumatic forces. [5]

4. If the orthotic appears to be too wide, explain to the patient that, after wearing the orthotic for a few days, it will take on a concave appearance and -- to a degree -- mold to the shoe. Consequently, it will slip in and out of the shoes more easily after several days of wear.

I recommend several exercises to help patients get through the adaptation process and experience a more rapid improvement in symptoms.

The following "golf ball exercise" should be done in the mornings and evenings to break up any fixation in the foot which may slow the adaptation process. This exercise has proved to be very successful with athletes. It hastens the break-in time and, as a result, athletes wear their orthotics for competition much sooner.

The "golf ball exercise." Ask the patient to sit in a chair, drop a golf ball on the floor (a Coke bottle could be used, as well as any round object), and place a foot on it. For about five minutes, rotate the foot on the ball with as much pressure as is comfortable. Have the patient repeat the process with the other foot.

The following toe crunch exercise helps patients strengthen weak muscles in their feet, and should be performed six times a day.

Toe crunches. Have the patient sit barefoot in a chair. Lay a towel or similar cloth flat on the floor and instruct the person to "scrunch" up the towel -- first, with the toes of his or her right foot, then with the left foot.

Ankle/calf stretch. For this exercise, instruct the patient to stand facing the wall, left foot forward. Keeping the right leg straight and in place, have him or her bend the left knee, put hands on the wall, and lean forward slowly. Leg positions are then reversed and the exercise is repeated.

WTSE will help you get your patients through the adaptation process, so they can experience the many benefits of custom-made orthotics. When their symptoms improve and adjustments hold better, they'll appreciate the orthotic treatment plan you prescribed for them. And ultimately, their satisfaction will result in your success.

1. Olsen, Jeffrey. "Adaptation for a Comfortable Fit." Orthopedic Notes.

2. Kendall FP, McCreary EK, Provance PG. "Muscles: testing and function." 4th ed. Baltimore: Williams & Wilkins; 1993. p. 270.

3. www.brannock.com

4. Katoh Y, et al. "Biomechanical analysis of foot function during gait and clinical applications." Clin Orthop Rel Res 1983; 177:23-33.

5. Kapandji IA: "The physiology of the joints." 5th ed. Churchill Livingstone Inc. 1989: 148-206.