Tag Archives: peer review

The APMA are taking some heat for this advice on childrens shoes and its hard to defend

On the website of the American Podiatric Medical Association, is this advice regarding children’s footwear with this graphic provided by the children’s shoe manufacturer, StrideRite.
children's shoes
It is not too dissimilar to the advice that I have seen being widely given for the use of children’s shoes. Where a problem arises is that I periodically come across comments in social media calling out the APMA on what they are advising, asking how robust the advice is and what is the evidence supporting the advice that they are given. I have yet to ever see the APMA respond. Here the most recent couple that I have seen:

The onus on any professional body giving advice or guideline is to ensure that that advice and guidelines are consistent with the latest preponderance of evidence and not underpinned by any commercial bias. What evidence is underpinning the above recommendations? There is none. There is no evidence that a children’s shoe should have a stiff heel. There is no evidence that a children’s shoe should only bend at the toes. There is no evidence that the midsole should be rigid. It is on that basis that the APMA is being called out in social media for this advice.

The cynic could simply respond superficially by saying, do those who are criticizing the APMA have any evidence that the claims are wrong? They don’t. However, the ‘burden of proof’ fallacy is that the burden is on those making claims to support and defend them. So you can’t just twist it around to get the critics to provide evidence of the opposite by deflecting the burden of proof to the negative.

What sort of issues does this raise?

  • What are the responsibility of professional representative organizations to issue advice and guidelines that are evidence-based? (surely the answer to that is obvious!)
  • If you follow some comments in social media, the commercial bias and imperative is often raised. In this case, the graphic on that APMA page that is posted above is provided by a commercial manufacturer. I do not have a problem with commercial sponsorship and support for professional organizations as the money is typically used to fund the goals of the organization, but they should not dictate or influence any policies or guidelines of the organization. In this case, StrideRite has a ‘seal of approval‘ from the APMA which they would have had to pay for. This certainly opens the APMA to criticism in giving non-evidence-based advice on a product that is giving them money. As money is involved, this increases the scrutiny as to the quality and robustness of the advice being given
  • Why is the APMA not responding to the call outs in social media to defend what they are advising?

So what advice should be given for children’s shoes?
I would have thought that the most appropriate logical and intuitive advice on shoes for kids, in the absence of any evidence to intervene, would be to use shoes that have design features that do not interfere with the developing foot. That contradicts with some of the advice being given by the APMA.

This is, of course, assuming that there are no problems present that need intervention. We can have a debate on the evidence for that another day.


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JAPMA lets us down again: Shock wave for mortons neuroma

Back in 2009, the Journal of the American Podiatric Medical Association (JAPMA) published this impressively titled study: Extracorporeal Shockwave Therapy for Interdigital Neuroma: A Randomized, Placebo-Controlled, Double-Blind Trial that found:

The treatment group showed a significant difference before and after extracorporeal shockwave therapy (P < .0001). The sham group did not have a significant difference after 12 weeks (P = .1218).

and as such concluded

Conclusions: Extracorporeal shockwave therapy is a possible alternative to surgical excision for Morton’s neuroma

Given that impressively sounding title and the p values you could not help but be impressed, except that the way the results are stated in that quote above should have let off a huge alarm bell that the JAPMA editorial and peer review process had failed. The whole point of having a control group is that you do a statistical test comparing the outcomes between the intervention and control groups (ie a between groups analysis). What this study did was a within groups analysis which is not how you analyse a trial comparing two (or more) groups.

The study actually posted all the raw data in table, so I reanalyzed their data using the right analysis and published that as a letter to the editor of JAPMA. Others (here and here) also expressed the concerns about how the study was analysed. It turns out that the authors own data actually showed that shock wave therapy did not work for mortons neuroma!

JAPMA did not do the right ethical thing and retract the publication. They should have. They did not even link the abstract or paper on the website to the letters-to-the editor pointing out about the wrong analysis. They should have. If you read that paper and do not know about the issues of between groups vs within groups analysis, then without going quite a way out of your way to find the letters-to-the editor, you would believe that shock wave works for mortons neuroma. That is a problem.

Now fast forward to 2016 and this paper on the same topic, but different authors, appears in JAPMA: Extracorporeal Shockwave Therapy in Patients with Morton’s Neuroma: A Randomized, Placebo-Controlled Trial, again with a pretty impressive sounding title, that concluded:

These results suggest that ESWT may reduce pain in patients with Morton’s neuroma.

Guess what? JAPMA’s peer review and editorial processes let us down again
Guess what? The authors did a within groups analysis rather than the correct between groups analysis (the exact same wrong analysis as the 2009 paper above)
Guess what? They did not actually publish the mean and standard deviations of the outcome values in the paper (another failure of the editorial and peer review process to not get the authors to include that), but if you look at the outcomes in figure 3 (if you have access to the paper), notice that if you compare them between the two groups, they are about the same (you can only guess what the values are from the graph as they did not publish them).
Guess what? This study’s own data actually showed that shock wave therapy for mortons neuroma does not work, which is the opposite of what they conclude.

You think they would have learnt from the first one above, wouldn’t you?, but, no they repeated the same error again in the second one.

Am I going to write to the Journal another letter to the editor? No, can’t be bothered. The first example above shows that it does not work.
JAPMA should have retracted the first paper and now it should retract this second paper.

This is a serious ethical issue and JAPMA editorial staff would do no worse than appraise themselves on publication ethics. Anyone not familiar with the between groups vs within groups analysis will mistakenly believe the conclusions of these studies, when both studies show that shock wave therapy does not work for neuroma’s. What is the ethics of using shock wave therapy on neuromas based on these two papers that should not have made it through the editorial and peer review processes?

I have made no secret of my views on the editorial and peer review processes at JAPMA and have previously called them on another publication on my other blog on running. Guess what: one of the issues was the same as above, ie within group vs between group analysis. JAPMA’s Impact Factor has been languishing around 0.5 for a while now while all other foot and podiatry related journals have gone up. There is a reason for that.

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