The Instute of Chiropodists and Podiatrists
Vol. 68 No. 1 - January/February 2011
Introducing Peer Review as a new direction for the Institute of Chiropodists and Podiatrists
Features within this Issue: • • • •
Foot Mobilisation Course Peer Reviewed Articles CPD 2011 A.G.M. Information
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January/February 2011 Podiatry Review
Contents 1. Editorial
The Institute of Chiropodists and Podiatrists Podiatry Review Editor Roger Henry F.Inst.Ch.P. DChM firstname.lastname@example.org Sub-Editor Robert Sullivan M.Inst.Ch.P. BSc(Hons)Pod, PG Dip. TP Surg.
2. Algeos Launches New Foot Pressure Platform Diabetes News 5. Onychomycosis – PinPointeTM FootLaserTM treatment 9. Mobilisation and Manipulation Courses 12. Part 4 - ‘The Implications of Variable Anatomical Traits of the Foot’ 14. Personal Profile
Editorial Assistant Bernadette Willey email@example.com Editorial Committee Mrs. F. H. Bailey M.Inst.Ch.P Mr. R. Beattie Hon.F.Inst.Ch.P., LCh., HChD Mr. S. Gardiner M.Inst.Ch.P BSc(Hons) PGDip Mr. W. J. Liggins F.Inst.Ch.P, FpodA, BSc(Hons) Mrs. A. Yorke, M.Inst.Ch.P Mr. J. W. Patterson, M.Inst.Ch.P., BSc(Hons)
Advertising Please contact the Editor for all matters pertaining to advertising firstname.lastname@example.org Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Tel: 01704 546141
15. Welcome to Our Review and CPD section 16. A History of Closed Methods of Treating Talipes Equinovarus Centre CPD Article Ultrasonic Therapy in Chiropodial/Podiatric Practice 19. Long-Pulsed Nd:YAG Laser Treatment of Warts: Report on a Series of 369 Cases 24. Medical Detection Dogs 26. Branch News 29. Obituary 32. Letter from the President 33. Diary of Events
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34. Classified Adverts 35. CPD © The Editor and The Institute of Chiropodists and Podiatrists accept no responsibility for any opinions expressed in the articles published in the Journal; and they do not accept responsibility for any discrepancies in the information published. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior written permission of the Publishers.
Dear Reader Happy New Year. Welcome to our new look Podiatry Review. New Year - New ideas - New beginnings! I try to bring you, the reader, new ideas for example the Pinpointe Foot Laser for treating onychomycosis. I found that an interesting article [see page 5]. The Elftman Foot pressure pad is another example of modern day technology [see page 2]. We welcome to our editorial team Robert Sullivan, who has been given the task of being responsible for peer reviewed articles. These are ‘A History of closed methods of treating Talipes Equinovarus’ and ‘Laser treatment of warts’. Congratulations to those people who received their City and Guilds Higher Diploma in Foot Health Care and Practice, and to those people who received their degrees B.Sc Pod. I see that Midland Area Council in Leicester and North West Area Council at the University of Central Lancashire in Preston held successful seminars. There are reports of the Irish Area Council continuous professional development meeting at St. James Hospital Dublin and the West of Scotland CPD day in Stirling just to show that the Institute is very much alive and kicking! Preliminary notice of our National A.G.M., seminars, Dinner Dance and Trade Show. This will be held on Thursday12th May 2011 to Saturday 14th May 2011 at Beaumont House Windsor. If it’s as good as Nottingham last year, a good time will be had by all. Best wishes, happy New Year Roger Henry, Editor Podiatry Review
Algeos Launches New Foot Pressure Platform
lgeos are proud to introduce the new Podotech Elftman Foot Pressure Platform, the latest addition to Algeos’ comprehensive Podotech range. Innovative, versatile and cost-effective, the Podotech Elftman is an essential tool when working in any fast-paced clinical environment. The Podotech Elftman utilises state of the art pressure mat technology and electronic sensors to provide extensive analysis options and the static, dynamic and postural modes enable patients to be scanned whilst standing, walking or running. Superior visual analysis is provided via 2D or 3D scans, graphs and reports that enable immediate interpretation of data and encourage patient interaction.
Key Features: l Captures 100 images per second l Matrix homogeneity provided by 1600 equallymeasuring sensors l Thin pressure mat encourages natural gait l Sensor life time of over 1 million uses l Highly durable, permanent mat surface l CE certification provides quality assurance l No product calibration required l Can be walked on with and without footwear Benefits Offered: l User-friendly software guides clinicians through patient consultations l Visual impact reinforces patient education and orthotic recommendation l Immediate analysis and interpretation of data via comprehensive reports l Achieve better CAD/CAM foot orthotic outcomes by combining the Elftman image at design stage l Enables comparisons with a patient’s previous scan or ideal mechanics l Generates PDF and Bitmap files for computerised records l Highly sensitive mat enables analysis of children’s gait and posture l Lightweight, portable and easy to store where space is limited Heidi Meckler, Business Development Executive and biomechanics specialist at Algeos noted: “The Podotech Elftman is very cost-effective compared to competitor systems. It’s a highly versatile platform that offers the clinician with an array of analysis options, and the visual
impact of the scans is great for patient education. Reports are quick and easy to generate, and can be saved to patient files or emailed to colleagues.” The Podotech Elftman offers three scan types: Static Scan: (see accompanying image) l Scan the patient whilst standing to identify plantar pressure distribution l Valuable when assessing orthotic efficiency and detecting leg length discrepancies l Extensive analysis options in 2D and 3D and numerous measuring possibilities l Produces annotatable reports that can be saved and emailed in PDF format Dynamic Scan: (see accompanying image) l Assess the foot in motion whilst walking or running l Video mode allows frame by frame viewing l Gait line display, calculations and curves l Actual size print capacity l Static mapping 3D visualization Postural Scan: (see accompanying image) l Identifies deviations in the musculoskeletal balance l Visually observe Three scan types: Static postural movement over time l Centre of pressure displacement (with zoom) Further information on the Podotech Elftman can be viewed online at www.algeos.com or contact Algeos to request a free brochure. The Podotech Elftman will be a regular feature on the Algeos exhibition stands, so visit the Algeos website to see where demonstrations will be taking place.
Photographs Podotech Elftman Foot Pressure Platform
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Onychomycosis â€“ PinPointeTM FootLaserTM treatment provides a safe and effective alternative Mrs. Martine Abrahams BSc(Hons) MChS and Mr. Michael Abrahams BSc(Hons) MChS, Podiatrists, The London Nail Laser Clinic, 10 Harley Street, London, W1G 9PF
his article describes a new treatment modality using a Nd:YAG laser for the treatment of onychomycosis, a common condition to the Podiatrist. The prevalence of onychomycosis in the UK is estimated between 3% and 22% . Mycotic infection accounts for half of nail conditions  with over half of the cases being seen in the toe nails . Podiatrists are all too familiar with the challenges of treating - either symptomatically or curatively - mycotic nails. This includes inability to self care, embarrassment, discomfort, infection, onychophosis and onychodystrophy.
various non-prescription over the counter medicaments is sparse. Amorolfine lacquer (CuranailTM), indicated for mild to moderate infection of up to two nails has a background of a prescription medication and has typical clinical effectiveness of 30% .
If left untreated the nail infection can spread to the skin as well as other toe nails with subsequent nail dystrophy. There have been several studies [4,5] demonstrating the psychological impact and reduced quality of life. The association with cellulitis for those at risk , together with primary tinea pedis and secondary bacterial infections, which, in the at-risk patient may compromise tissue viability.
Oral treatments are not free from potential side effects. Commonly headache, pruritis and taste disturbance have been reported. Cutaneous, hepatic and haematological effects are severe in 1 in 2000 patients . Although terbinafine is generally safe, many patients and doctors are reluctant to take this route. Some Primary Care Trusts have non-treatment directives towards onychomycosis as well as reluctance by GPs to prescribe. There are no NICE guidelines relating to fungal treatments.
The aetiology of onychomycosis is primarily invasion of opportunistic dermatophytes into and under the nail plate. Trichophyton rubrum and Trichophyton mentagrophytes accounting for about 90% of the infections. Yeasts - Candida and moulds for example Aspergillus syndowii and Scytalidium hyalinum are also detected. The British Medical Journal listed occlusion as the biggest risk factor in the development of mycotic disease and the dark, warm, moist environment facilitated by general poor hygiene of the foot. The pathogenesis is typically invasion of skin followed by invasion of the nail unit, typically via the hyponycium. The resulting subungal hyperkeratosis and onycholysis provide further ingress with the potential to invade the entire nail with resulting dystrophy. Diagnosis of onychomycosis can be difficult and an experienced Podiatrist would be familiar with it's various presentations. Laboratory diagnosis is not conclusive. The presence of plantar desquamation or interdigital tinea improves confidence in clinical diagnosis . Medicine has been quick to embrace laser technology. Dermatology is one medical field that has especially benefited from the high-powered thermal lasers. Laser irradiation can be highly selective by targeting specific pathogens. Variation of the laser wavelength, energy density, timing parameters and treatment procedure will all influence the clinical outcome. The laser parameters for treatment of onychomycosis have been optimised through years of research and are set on the FootLaser to theses specific settings (a class IV neodymium YAG laser). The PinPointeTM FootLaserTM uses the two principles of photothermal ablation and near infrared inactivation. The PinPointe FootLaser has been cleared for the treatment of onychomycosis by the FDA in America and has a CE mark for this use within Europe. The treatment of onychomycosis can be symptomatic, topical, oral, surgical and now laser. Published data on the efficiency of
Terbinafine has been the oral drug of choice for many practitioners with over 20 years availability. The three-month cure rates range from 37.5% to 65% [9, 10, 11]. Itraconazole is 27% to 41% [9, 10, 12]. A combination of oral and topical treatment has achieved a reported 72% to 93% success [11,13].
The PinPointe FootLaser achieved an 88% efficacy in a pilot study conducted by Brian McDowell, DPM in California . Since it's first use in America in 2008, the treatment has been improved and modified by providers. Recent retrospective analyses of private practice data have shown a range in efficacy from 60 to over 90%. The PinPointe FootLaser is FDA-cleared as being safe based on clinical data submitted to the agency. It has been demonstrated that the photo-thermal temperatures achieved are below the range of potential physiologic damage (44 degrees). Local analgesia is contraindicated during the procedure to enable feedback regarding sensation and heat. Following treatment, topical antifungal medication is applied and preventative methods and risk factors are discussed. Toenail growth is estimated at 1.62 mm per month with the hallux nail growing at a faster rate than lesser nails . It may be several months before clinical clearance of the nail is noted. Delayed clinical cure has been reported in several studies. In one , mycological cure following oral terbinafine was achieved in 82% patients compared to a 68% clinical cure (the placebo group achieving a 12% mycological cure, compared to zero clinically). The benefits of the PinPointe FootLaser are clear. The treatment is safe, can be effective in a single treatment episode, there is no oral medication to take and there is no requirement to monitor blood chemistry. There are no specific patient groups whereby treatment is contraindicated but those with peripheral neuropathy or significant peripheral vascular disease may be more sensitive to the photo thermal effects so a restrained technique should be employed. Treatment with the PinPointe FootLaser consists of aggressive debridement, cleansing and application of the PinPointe FootLaser. This 1-2mm diameter spot of pulsed laser light is applied to the surface of the nails and surrounding tissue including the proximal germinal matrix. At least 3 passes over the infected nails are carried out, although all nails are treated twice as a minimum. Topical terbinafine 1% is prescribed and
patient instructed to use twice daily for a week to treat underlying mycotic skin infection. The average time for combined consultation and treatment is approximately two hours for extensive cases. The nails are reviewed after 6-8 months after which approximately 6-8mm nail growth may have occurred and progress is monitored via photographic comparison. A second treatment to infected nails can be applied if required to eliminate any residual areas of mycosis or suspicion. A preliminary review of retrospective patient data for The London Nail Laser Clinic, London, showed encouraging results and provided a foundation for future research. All patients attending for a review consultation between May 2010 and July 2010 were analysed. Of this group, 63 patients demonstrated hallux infection with pre and post treatment comparable photographs in this sequential, retrospective study. Digitised images were analysed by blinded photo-raters for percentage clear nail changes. Mean increase in clear nail was progressive over the 12 month follow up interval. Statistical comparisons (p<0.001) were highly significant at six and nine months where the sample size was adequate - 64% of treated toenails showed improvement at six months and 96% at nine months. At twelve months, 70% of nails had improved.
EXAMPLES OF TREATED NAILS WITH TIME DIFFERENCE BETWEEN TREATMENT AND REVIEW LISTED
The London Nail Laser Clinic
The London Nail Laser Clinic
The London Nail Laser Clinic
A retrospective study of 71 patients treated by Dr. Michael Uro, Foot Doctor Laser Center, Sacramento showed that 65% patients showed statistically significant clinical improvement at six months. More extensive infection (greater than 70% mycotic involvement) within the nail exhibited a superior clearance with 79% of these patients showing increase in clear nail at six months. A conglomerate of data obtained by Podiatrists at three clinics during 2010 (Abrahams & Abrahams, London, Uro & Uro, Sacramento and Grzywacz, Las Vegas) involving 321 hallux nails demonstrated an efficacy range of 60-90% throughout a 12 month period with an increase of effectiveness with increased mycotic involvement. No adverse events were reported within the 197 patients included.
For more extensive cases with long term infection, research has suggested the combination of oral and topical treatments improve outcomes. At the very least, the combination of the PinPointe FootLaser together with oral terbinafine in some cases should improve results and this is an area of research to explore.
The development of the only new treatment for onychomycosis for over two decades is an exciting development to the Podiatrist and the medical community. The provision of a skilful but essentially simple direct treatment approach targeted towards the Podiatrist, is to be embraced by the profession. Whilst onychodystrophy cannot be treated, the underlying infected nail, associated tinea pedis and general quality and condition of the nails and feet can be improved. Simple onychomycosis with associated yellow, orange and white discolouration due to fungal spores without dystrophy responds very well in the authors experience and as shown in photographic analysis.
The PinPointe FootLaser is not available for sale, but PinPointe USA provides what could be described as a partnership plan. Pioneered in the USA, providers are now in the UK, Turkey, Germany and Australia as well as most States in America. The fungal nail industry is worth millions of pounds with pharmaceutical companies Novartis (LamasilTM) and Galderma (CuranailTM) as well as various non pharmacy/prescription companies such as Diaderm (ClearZalTM), Tea Tree Oil and a plethora of potions on the Internet promoting their products to those that suffer with this embarrassing and often distressing problem. Patients are keen to resolve their infection and struggle with the plethora of ineffective or time-consuming treatments. Nd:YAG lasers cost upwards of ÂŁ50,000 and are used in various fields. The PinPointe FootLaser is unique â€“ designed and built specifically for onychomycosis. It is the only laser system for toenails cleared by the FDA in America with over 3 years clinical
experience. Awareness of the treatment is essential both to existing patients as well as locally to general practitioners and the wider community. Availability of appointment capacity to conduct consultations, treat patients and discuss the treatment is required. The provision of a new treatment, sought after by patients can provide a financial boost to the private practitioner keen to promote it and diversify.
With continued research, careful and meticulous treatment and good diagnosis, the PinPointe FootLaser provides an exciting step forward in onychomycosis treatment in the UK and specifically to Podiatrists who are expertly placed to provide this treatment. With careful thought and planning the discerning Podiatrist would embrace this treatment modality.
REFERENCES  Hay R. The future of onychomycosis therapy may involve a combination of approaches Br J Dermatol 2001;145(S60):3  Williams H. The epidemiology of onychomycosis in Britain. Br J Dermatol 1993;129:101-109  Summerbell RC et al. Onychomycosis, yinea pedis and tinea manuum caused by non-dermatophyte filamentous fungi. Mycoses 1989;32:609-619.  Drake et al. Effect of onychomycosis on quality of life. J Am Acad DermatolI 1998;38:702-704  Lubeck, D et al. Quality of life of persons with onychomycosis. Quality of Life Research. 1993;2:341-348  Dupoy A, et al. Risk factors for erysipelas of the leg (cellulites): case-control study. BMJ 1999;318(7198):1591-1594  Garcia-Doval et al. Clinical diagnosis of toenail onychomycosis is possible in some patients: cross sectional diagnostic study and development of a diagnostic rule. Br J Dermatol 2010;163(4):743-751  Prescrire Int 2009;18(99):26-30  Heikkila H, Stubb S. Long term results of patients with onychomycosis treated with itraonazole. Acta Dermatol Venereol 1997;77:70-71
 Evans E, Sigurgeirson B, for the Lion Study group. Double blind randomized controlled study of continuous terbinafine compared with intermittent itraconazole on the treatment of toenail onychomycosis. BMJ 1999;318:1031-1035  Baran et al. A ramdomized trial of amorolfine 5% solution nail lacquer combined with oral terbinafine compared with terbnafine alone in the treatment of dermatophytic toenail onychomycosis affecting the matrix region. Br J Dermatol 2000;142:1177-1183  Lecha M. Amorolfine and itraconazole combination for severe toenail onychomycosis: results of an open randomized trial in Spain. Br J Dermatol 2001;145(Suppl 60):21-26  Hoffman H, et al. Treatment of toenail onychomycosis: a randomized controlled study with terbinafine and griseofulvin. Arch Dermatol 1995;131:919-92  Harris et al. Laser treatment for toenail fungus. SPIE 2009; 7161:1-7  Yaemsiri S et al. Growth rate of human fingernails and toenail in healthy America young adults. J Eur Acad Dermatol Venereol. 2010;24:420-423  Goodfield, et al, Short Term treatment of dermatophyte onychomycosis with terbinafine. BMJ. 1992;304:1151-1154 DISCLAIMER: PinPointe USA contributed towards the cost of data collation by The London Nail Laser Clinic.
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Mobilisation and Manipulation Courses
for members of the The Institute of Chiropodists and Podiatrists
Introduction Having a qualification such as BSc(Hons) is a method of assuring the medical community and the public that a person is qualified by knowledge and skills to practise within a particular profession. After initial certification, advanced technology, improved techniques or changing job responsibilities may require a practitioner to upgrade their knowledge and skill. Continuing Professional Development (CPD) provides a way to fulfill their responsibilities to maintain competence and prevent professional obsolescence. Participation in CPD also demonstrates accountability to peers, medical colleagues, healthcare facilities and the public. The overall result is improved quality of healthcare for the patient and enhancement of the participant's profession.
Standards of Practice Statutory regulators such as the Health Professions Council (HPC) impose standards for CPD. Registrants must seek to ensure that their CPD has contributed to the quality of their practice and service delivery;1 The key word quality comes from the statutory duty imposed under the National Health Service Act 19992. It is a duty imposed on the National Health Service (NHS) and therefore its employees. It includes improving standards of quality and at the same time minimising the risks. Because it applies to the public service it doesn't mean it shouldn't apply to the private sector.
Current Practice There are over one thousand physiotherapists, who have some training in mobilisation and manipulation techniques in the UK. The total number of regulated professionals with mobilisation and manipulation training is over seven thousand with over two thousand unregulated. There are forty two graduates of Brett's Part I course – The Foot to the Knee, who are qualified and regulated podiatrists. The bulk of the podiatry profession in the NHS and in the private sector does not have the capacity to adjust the musculoskeletal system for the benefit of the patient.
Is the introduction of mobilisation and manipulation techniques into the podiatry profession going to help the private practitioner? Yes; because it will help the podiatrist to compete in the high street. Furthermore the private practitioner is more mobile in adopting new products and styles of service delivery than the NHS counterpart. The establishment of a UK wide network of podiatrists with training in mobilisation and manipulation skills with reviews on thermoformable orthotics products should establish the private practitioner in pole position. Competitiveness would be not only on choice of the FO but also on screening, which would include assessment for manual therapy and the judicious application of manual therapy techniques with an overall possibility of choice in whether or not to supply and fit FO’s based on the corrected structural deformity.
Brett's Part I Course, The Foot to the Knee – the key therapeutic principle The key therapeutic principle employed in the Part I Course is the adjustment of a correctable structural deformity and where necessary maintain the skeletal integrity by the use of a functional orthotic (FO). The majority of podiatrists do not have formal training in musculo-skeletal adjustment techniques. It is questionable without formal training in mobilisation or manipulation whether podiatrists would be aware of the need to refer to another qualified health professional. The FO’s used after adjustment need to give adequate support and for that reason the use of chiropody felt and similar modalities has been replaced with a thermoformable device, which is fitted before load bearing and used in accordance with the tissue rest model of McPoil and Hunt3. Over one hundred adjustments have been done since the start of the pilot study, which have needed a instant fit orthotic. This has established a standard of care, which in the event of a negligence case involving FO’s the defendant may not be able to rely on Bolam4 as the defence. The therapeutic model, now established, is: The joints of the limb are evaluated, correctable structural deformities are adjusted and the foot is supported appropriately.
Economic benefits Current situation regarding the provision of functional orthotics (FO’s) The provision of FO’s is a key component of foot care and the effects of poor biomechanical function in the foot, which may affect higher structures such as the knee, hip and spine. It is also economically beneficial for the professional. There are forty two graduates of Brett’s Part I course – The Foot to the Knee, who are qualified and regulated podiatrists. They are capable of adjusting displaced bones in the lower limb and, after fitting an FO, are supporting a structure that has had its integrity restored. Such is the case in examples of cuboid displacement, which can produce mid-foot locking and inefficient action of the peroneus longus muscle. Not to correct a displaced bone and fit an FO results in actually reinforcing a correctable structural deformity.
The prime economic advantage of implementing mobilisation and manipulation into the podiatrist’s scope of practice is that they will be able to screen for correctable structural deformities without the cost of trial and error temporary FO’s or permanent FO’s, which reinforce or even amplify a correctable structural deformity.
The aims and objectives in providing courses in mobilisation and manipulation l
To increase the course participant’s skill range with a view to confer benefit on patients, health care providers and the podiatry profession in general.
To introduce the thermoformable insole as an adjunct to appropriate mobilisation and manipulation of the foot to the knee in the Part I Course.
To add a significant skill base to podiatrists' existing skills.
To qualify course participants in mobilisation and manipulation techniques.
To train course participants to a level that the level of skill attainment, appraisal and safety awareness merits professional insurance cover.
To train course participants to a skill and attainment level that allows graduates to assess whether a joint is suitable for mobilisation or manipulation and when to use an instant fit orthotic followed by a patient regime to alleviate tissue stress, which follows the tissue rest model of McPoil and Hunt.
To train course participants to correct a structurally correctable deformity prior to prescribing and fitting an FO.
To make the qualified manipulator aware of the limitation of the mobilisation and manipulation skills and the safety issues involved.
Support members to comply with Health Professions Council's CPD requirements.
Stimulate standardised recording of assessments and outcomes with a view to obtaining clinical audits and research data.
The stimulation to prepare risk assessments in the form of risk/benefit ratios, ie. mathematical statements rather than verbal descriptors.
To instigate podiatry led randomised clinical trials into mobilisation, manipulative and thermoformable FO supporting techniques.
To train graduates to train others and eventually qualify them as independent course providers.
Access to images, which relate to technique and pathology. Constant reflection on learning outcomes. Safety in application of techniques is checked by the questions put in pages 23 and 40 of the Portfolio. Ongoing appraisal in the form of tick boxes and self appraisal. The Aims and Participant outcomes are detailed at the various stages in the Portfolio. Participants are required to list questions at the end of every demonstration in order to clarify any questions relating to technique as soon as possible after they arise. Directed steps to progress clinical and professional skills in the form of risk assessment, peer reviews, case studies, submitting articles for publication, training to be a manipulation teacher, etc.
Future research Two general models appear to be viable at the present from the results of clinical observations and audit: Increase of ankle dorsiflexion by correction of tibia, fibula and talus skeletal misalignment or malfunction in their interconnecting relationships. Foot length correction by adjustment of the cuboid and adjoining bones with an appropriate thermoformable supporting orthotic.
HPC website. Standards of continuing professional development. Available from http://www.hpcuk.org/aboutregistration/standards/cpd/
Learning outcomes are achieved by:
National Health Service Act 1999 s18 ss1, s51.
Directed intellectual learning by use of the Protocol, Manipulation for Podiatrists, Reciprocal Inhibition Exercises, Arches of the Foot, which are issued to all participants prior to the course.
McPoil T G, Hunt G C (1995) Evaluation and management of foot and ankle disorders. : Present Problems and Future Directions. P 385. J Orthopaedic Sports Physical Therapy. 21. 6. P 381 â€“ 388. June 1995.
Bolam v Friern Hospital Management Committee  1 WLR 583.
Participant communication to stimulate the production of 'good questions', which are questions for inclusion into a closed learning forum. The questions are selected to provide a direction to the participant's study and stimulate intellectual interaction. This exercise is done on email. Demonstration of manipulation techniques, which form the basis of all modern manipulation systems. These demonstrations are unique to Brett's Courses and involve the participants in order for them to appreciate how vector change can create movement of body mass with minimum, if any, force. Demonstration of techniques on Day 1 of the Part 1 Course to allow participants to apply efficient vector orientation to joints and skeletal structures. These techniques are also for the safety of the participants and involve among other things application of techniques with the bones adjoining the wrists of the course participant's being kept in a straight line. Demonstration of technique by the mirror method, where the course participant uses feedback from the patient in relation to eg. the left limb regarding their pressure or positioning in comparison to the pressure and positioning on the right limb by the course provider. The mirror method, is unique to Brett's Courses.
Legal Notice: The material contained in this Document is the intellectual property of Tom Brett. The Institute of Chiropodists and Podiatrists is allowed to download a copy for the express purpose of publication in the Podiatry Review. Readers: You are expressly prohibited from sharing the content in this Document in whole or in part with person(s) or organisation(s) not contractually engaged with or directly owned by Tom Brett. Should you wish to reproduce part of this Document 10% is the allowable percentage by law. You are permitted to quote parts of this Document providing that a formal acknowledgement is made and that permission by Tom Brett has been forthcoming for the use thereof. The material contained in this Document is protected by international copyright laws including the copyright laws of the United Kingdom. No part of this Document may be reproduced in any form or by any means - graphic, electronic or mechanical including recording, photocopying or by any other information storage or retrieval system whatsoever. Any breach or violation of the said copyright laws or the said Terms and Conditions will be prosecuted under the laws prevailing in the Country in which this Document was first issued or in the Country in which any such breach or violation occurs. Copyright 2010 Tom Brett (Brett's Reports). All rights reserved.
The Institute of Chiropodists and Podiatrists CPD *New Venue* The Peel Hospital, Tamworth Close to the M42/M6
“Foot Manipulation – the Adjustment of the Lower Limb” Two Day Course
06.03.2011 and 03.04.2011 Lecturer/Course Leader Tom Brett BSc(Hons), LL.M Course to Include: Pre-Course Study Anatomy Revision
Manipulation/Mobilisation –terms Demonstrations Therapeutic Principles Treatment – Examination and Mobilisation Includes lunch, morning coffee and a
Course fee £300.00 for both days. Includes lunch, morning coffee and afternoon tea together with extensive documentation. Please telephone Head Office 01704 546141 or send cheque for £300 to The Secretary, Institute of Chiropodists and Podiatrists, 27 Wright Street, Southport, PR9 0TL 11
Part 4 - ‘The Implications of Variable Anatomical Traits of the Foot’ Greg Quinn, FCPodS, Podiatric Surgeon “The materials of action are variable, but the use we make of them should be constant”. Epictetus
umans have evolved as upright bipedal apes and this requires our species to share particular physical traits that allow us to do this e.g. the sub-talar joint translates leg rotation into the foot during contact pronation. This ability is passed on because we inherit the many genes that govern development from our parents. The complex interplay of developmental growth factors continues for life as our feet are used to deliver their purpose i.e. to carry us forward in an efficient and pain free manner. As growth continues, we hope to ideally acquire an ability to deliver a foot function that matches the perfect exploitation of our inherited traits. There are three things that can work against this: Firstly, we may inherit physical traits in the foot that make this process more difficult to achieve; secondly we require an adaptability of our muscles, ligaments, bones and joints that can alter their make-up to match our individual movement patterns; and thirdly, our environment may alter to challenge the foots ability to function normally. Any of these three issues can result in anatomical or functional differences that stress the tissues of the foot, induce malfunction and ultimately produce the signs and symptoms that go with it.
Genetic factors It is widely appreciated that to one extent or another, familial resemblance can be very striking between generations and this is true for any aspect of our biology. Morphology, physiology and even behaviours can and have been genetically linked and this is also true for our feet. Whilst detailed genetic mapping studies are not yet available, foot problems have been recently implicated as an inherited trait1. Higher arched feet will demonstrate a more limited range of ankle joint extension and are more likely to have less range of motion at the sub-talar joint2. Conversely, low arched feet are more likely to demonstrate greater eversion of the heel as they pronate. Furthermore, the relative length of the first metatarsal is linked to population differences (themselves genetic in origin) and this is significant in that longer 1st toes are more prone to hallux valgus and hallux rigidus. The calcaneo-cuboid joint that is vital to the time sensitive change in stability of the mid-tarsus, also demonstrates differences between ape species and individual humans, which strongly implies differences in the timing, duration and specificity of genetically controlled bone growth. Changes that induce a less stable configuration of the opposing joint surfaces will produce a less stable arch, and this is unhelpful if the arch and heel are to lift together as the foot approaches the propulsive phase of ideal walking (see part 3).
Adaptive plasticity This term does not refer to the physical plasticity of the foot’s structures but rather to the ability of the foot to change its physiology to reduce the impact of potentially damaging forces. All biological systems have some measure of adaptive plasticity, either physical or physiological, and this ability is very useful to survival in a changing environment. E.g. the plantar skin has a variable ability to respond to high ground reaction forces to produce hyperkeratosis. However this protective ability whilst helpful, presents a potential problem: If the forces continue to be
high, cornification of the skin can proceed at a faster rate, ultimately producing parakeratosis at the point of highest pressure i.e. plantar corn instead of protective callus. This can give rise to an underlying inflammatory response and pain. These are local physiological expressions of an inherent genetically controlled process and gives rise to a broader issue: adaptive plasticity is something of a double-edged sword. All musculo-skeletal tissues possess adaptive plasticity. They are physiologically in tune with the forces generated within and outside of the body. When the internal or external environment changes beyond the range of physiological normal values, the body adapts to minimise this effect. The sub-talar joint has been shown to be adaptively plastic during our early lives, changing shape to respond to increasing body weight3. When muscles are stimulated through continued exertion over a period of time, muscle size and strength increase. When not employed, they may atrophy and weaken and so save on valuable resources that can be used elsewhere. As forces change across the 1st MTP joint, the sub-articular bone will be strengthened or weakened according to Wolff’s law. This adaptively plastic response can create an abnormal joint angle i.e. hallux valgus. However, should forces be too high or occur over too short a time period for the physiological response to occur, then traumatic injury will occur e.g. metatarsal stress fracture. Within the musculo-skeletal system, pathological change is perhaps too often regarded as a separate change or different entity from what is regarded as physiologically normal. In actuality, there is only a quantitative change in expression of the body’s ability to respond to forces. At a particular and often arbitrary point, biological function is compromised and beyond that an individual body’s ability to cope is exhausted and pain results. The foot will demonstrate key common anatomical structures that create an ability to deliver a common purpose. Therefore, it is our shared genetic and adaptive responses that characterise our feet. These processes not only give rise to what we have in common, but also explain our individuality. It is not what position our bones and joints must be in at a particular point in time e.g. sub-talar neutral that matters, but the avoidance of exceeding the limits of tolerable forces and the body’s response that counts. I referred to three things that work against the ideal foot. The last of these, the environment and how it can challenge the function of the foot will form the basis of the 5th and final part of my article in the next issue of the journal. References 1. Hannan. Hallux valgus and Pes Cavus are highly heritable in older men and women: The Framingham Foot Study. American College of Rheumatology Annual Scientific Meeting, Atlanta, 2010. 2. Bruckner J: Variations in the Human Subtalar Joint. J Orthop Sports Phys Ther 8(10): 489-494, 1987. 3. Hellier CA, Jeffrey N: Morphological Plasticity in the Juvenile Talus. J Foot Ankle Surg 12: 139-147, 2006.
Greg Quinn, Sheffield email@example.com
the foot as a
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More Congratulations Despite horrendous weather conditions three of our second cohort battled through the snow to Sheffield on Friday, 3rd December to receive their City and Guilds Higher Diploma in Foot Health Care and Practice Very well done to Grace Fraser, Louise Rudyk and Joy Tyldesley
Personal Profile Denise Willis B.Sc. M.Inst.Ch. P I had always worked in administration since I left school. I was a shorthand typist for a large building organisation in Liverpool. After getting married in 1986, I moved near to Chester and started working in a major finance house. We had always wanted to start a family and 6 years later I fell pregnant. The prospect of becoming a parent was exciting but also daunting. Unfortunately 3 months into the pregnancy I lost my baby through an ectopic pregnancy. It was the most awful feeling in the world to lose a baby. I had time off work to recuperate and when I returned my department had moved to Warrington. I wanted to stay closer to home initially as driving was difficult. I was unable to do so. After a couple of months I had had enough. After working at several jobs I started working within the Job Centre, cold calling local companies to advertise their job vacancies, and also setting up a database. This was only temporary. I did find myself a job working for a general manager in one of the largest hotels in Chester. I loved working there. After a few years I found I was pregnant again. At the time the laws on returning to work did not allow the employer to keep your job open, so I knew once I had my daughter I would have to find another job. I am a great believer that things happen for a reason and I knew that this was my chance to start a new career. My podiatry career started in 1997. I qualified from the Scholl chiropody course in Southport and joined the Institute. On the course I was given lots of help and guidance and made some good friends. My tutors were Jill and Cathy. They made the whole course so interesting. I knew I had made the right choice and couldn’t wait to get started. I have built up a busy domiciliary business. I have also worked in two clinics in which I have gained more knowledge as I worked with other health professionals. You never stop learning in this job. I have attended many CPD courses and I attend G.P. lectures and training on other subjects related to the body as a whole. I have lots of patients, all with a variety of different ailments, conditions and disabilities. I feel as a health professional we need to know more about the body as a whole and not just the feet. I decided that it was time to look at more professional qualifications and enrolled on the BSc Podiatry Medicine degree course at Durham. I was astonished to find I had been accepted. I am not normally a nervous person, but I had butterflies in my stomach whilst driving up to Durham with my friend and colleague Linda Pearson. A week of statistics filled me with dread. I had not done any kind of maths since leaving school back in the seventies, so we were not sure what to expect. The induction week was busy. Learning statistics was one of the hardest things I have ever done and took me out of my comfort zone. One day the tutor said that we had done the equivalent to an A level in 4 days! I honestly believed that he was right.
The modules that I chose were Podogerontology, Pharmacology and Psychology. The college also popped a couple of research method modules in there as well, so there was plenty to do. Personally I enjoyed the studying, but it did take a lot of time and you do need to be committed. I did leave 2 days to do the study and most evenings. I found that I worked better in the morning so did all my writing then and left the research for the afternoon. It is well worth doing. My husband proof read all my assignments. I knew what I wanted to say but occasionally it did not come out that way. I would like to say a big thank you to him for running the cleaner round the house and doing a bit of ironing when required. It is a great help when you have support at home whilst you are involved on the course. I also got plenty of help from other cohorts who were on the course. We have swapped many e-mails with information, help and advice. I would like to say a thank you to them also. We keep in touch regularly and I have made many friends. The course has given me confidence to question new ideas and to think ‘outside the box’. I passed in June 2010 and now have a BSc., not bad for a girl who left school with no qualifications. I am secretary for the Chester, North Wales, Staffs and Shrops branch, a job in which I enjoy immensely. Training and learning plays an important role at our branch and I feel proud I am able to prepare good presentations for our members so they can get the most out of the meetings. Outside of work I like to paint. I like watercolour painting and love nothing more that to sketch something out and paint it. I love architecture and light so most of my drawings are of Paris. We visit there every year. I am from Liverpool and my family were involved in the building of the Anglican Cathedral. With this heritage in mind I have done a painting of the cathedral. I am very pleased with the result. One day I will get it framed! I am not sure where our profession will go. Learning is a daily part of our job, whether it be studying for additional qualifications or being able to communicate with patients. We as podiatrists have to be good thinkers, good practitioners and good listeners. It is important that patients feel confident that you can do the best job for them. I have made a lot of friends who originally were patients. I have been to weddings, invited to a wedding in France, and offered the use of a villa in Spain for any holidays. This is the best job I have ever done and I don’t regret taking the plunge.
Peer Review Section
Welcome to Our Review and CPD section It gives me great pleasure to introduce my self to you as the Review’s sub-editor responsible for the academic articles along with the peer review concept. My name is Robert Sullivan, and for those of you who don’t know me, here is a little about my background in podiatry. I qualified in 1998 from one of the UK private training providers with a Certificate in Chiropody/Podiatry. Over the next few years I went on to complete courses in Cryosurgery, Bio-Mechanics and Electrotherapy, resulting in the award of a Diploma in Podiatric Medicine. As recognition for my work I was awarded a fellowship of the College of Surgical Chiropody/Podiatry in 2003. In 2003, while I was completing these studies I trained with the Institutes Irish Area Council for a Certificate in Nail and Skin Surgery which I received in 2003. In 2004 I was honoured by the Irish Chiropody and Podiatry Association with the award of a life fellowship in recognition of the work I have done for the furtherment of the profession in Ireland. In 2004 I commenced distance learning with Anglia Ruskin University on a 4-year programme to attain an Honours Degree in Health care practice (Podiatry), which I was awarded in 2008. As I am a glutton for punishment, I enrolled on a Masters in Theory Podiatric Surgery which is a joint degree run by Glasgow Caledonian University and Queen Margaret University Edinburgh, in September 2008. I earned a post graduate certificate and in 2009 a post graduate diploma in 2010. I am now completing my MSc in Podiatric Surgery and hope to complete this early 2011. I have extensive experience in lecturing on various podiatry subjects at university and Continual Professional Development events in Ireland, the UK and further a field. On a side note all university courses are available to HPC and DOH registered podiatrists
What is peer review? Peer Review is a process used by professional journals such as ours, to ensure that the articles we publish are representative of the best scholarship currently available. When an article is sent to us it is sends it out to be read by recognised scholars in the same field or who would have a special interest in the subject area. These other scholars are people such as university lecturers, Podiatrists, Doctors, Surgeons and other recognised professionals working in various disciplines. These reviewers give their opinion of the article, based on scholarship, quality, relevance to the chosen field, and supporting material sited in compiling the article. They also comment on the articles appropriateness for publication in the authors chosen journal. The following are appropriate for peer review: Articles relevant to Podiatry Research Proposals Research Papers Protocols Systematic Reviews Related Subjects
If you would be interested in joining our peer review panel than please send in your résumé and we will be happy to consider your application.
In this edition We are presenting two peer reviewed articles; the first is by Janet McGroggan, Janet qualified as a podiatrist in 2003 from the University of Ulster, Northern Ireland. She then worked in private practice for four years before embarking on her part time distance learning MSc. in Podiatry via Queen Margaret University, Edinburgh. She became interested in the Ponseti method of treating talipes during her MSc and as a result decided to investigate the podiatrist’s role in this treatment. Janet visited clinics and met with eminent people in the field prior to her training in the method. She hopes to help podiatrists become aware of the Ponseti method, and to explore the possibility that podiatrists may in the future undertake this treatment on talipes patients, along with any necessary followup therapy that these patients may require in adulthood.
What our reviewers said: The first by Janet McGroggan has been reviewed by Dr. Martin Gregor, who is a graduate of the University of Queensland with a major in anatomy and physiology, having completed further studies in Chiropractic Medicine at Macquarie University in Sydney he graduated with a Master of Chiropractic. Having gained many years of clinical experience Martins special interests include non-invasive interventions for musculoskeletal issues. The following are his comments. “The author has presents an interesting and, in my opinion, enlightened article on the history and development of closed methods of treating Talipes Equinovarus. The information gathered can be of great use to a range of therapists in raising the awareness of the importance of early intervention. She demonstrates that minimal invasiveness, and a structured and consistent program of care and parental compliance are of considerable benefit. This approach should, in my opinion, be the primary method of intervention for this condition as opposed to surgical intervention, and its inherent risks, after all surgery is not always the best option.” The second article by Tae Young Han et al, has been reviewed by Dr. St.Clare who is a consulting dermatologist. She has many years of experience in her field. Here is a little of her background. “I am Anna Marie St.Clare and I work as a dermatologist in Paris. After completing my medical studied in Trinity College Dublin in 1980, I went to Paris where I specialized in the integumentary system. My special interests are basal and squamous cell carcinoma and HPV. In the course of a year I review many articles for publication in my own association’s publication, it is rare to find such a good article as this. The study size, method and discussion provide lots of food for thought. The results also speak for themselves. For podiatrists this study presents potential foe extended scope and practice development. For me as a dermatologist it too supports an argument for up skilling. Until Robert Sullivan, your academic editor asked me to review this article I did not realize the scope of practice contained within the discipline of podiatry. I recommend this article to you.”
Peer Review Section
A History of Closed Methods of Treating Talipes Equinovarus The first in a series of three articles by Janet McGroggan, joint winner of the Cosyfeet Podiatry Award 2009 Abstract Inspiration comes from far flung places and for me this was in my living room watching Super Doctors, a series of programmes detailing the work of doctors who had gone over and above the call of duty, mavericks you might say. This particular episode covered the work of Stephen Mannion an orthopaedic surgeon who was treating Talipes Equinovarus (TEV) in Malawi using the Ponseti method of treatment. I had never heard of this method nor, in my ignorance, of any non-surgical treatment of TEV. Either I was off that day or we did not cover it (I graduated in 2003). It seemed so simple that it was unbelievable and I wanted to know more. This series of three articles will take you from the history of closed TEV correction methods through the Ponseti method of treatment and my training and conclude with the question â€“ Where are Podiatrists in all of this? The anatomy and pathophysiology of talipes equinovarus is fascinating and the aetiology an enigma. Around the sixth to eighth week of gestation all foetal feet are turned inwards and the forefoot is in an inverted position. Throughout normal development the leg externally rotates and the foot everts into a normal foot. This usually occurs during months three or four of gestation although it has been observed as late as month seven.1 As yet the aetiology of talipes is still uncertain however it is generally accepted that normal development is interrupted at some point typically before the 20 week scan and the congenital musculoskeletal abnormality results.2 There is still speculation as to whether this interruption is genetic, neurological, vascular, developmental or positional.3 In the talipes foot the calcaneus decreases in size depending on the severity of the deformity, it is forced into a plantarflexed position under the talus which is also smaller. The talar neck is shifted medially and downwards and the navicular is also orientated medially and downwards however the cuboid is largely unchanged.3 The cuneiforms are smaller and increasingly adducted in relation to the severity of the deformity. As the deformity increases in severity, the long axis of the first and second metatarsals decreases.3,4 As a consequence of these positional anomalies the related articular surfaces are altered accordingly and a congruent subtalar joint is not possible.5 There is also whole limb involvement in reduced tibial torsion and internal femoral rotation.
In their study of foetal talipes anatomy in 2006 Windisch et al dissected seven affected feet of aborted foetuses and compared them to normal feet of similarly developed foetuses. They looked particularly at articular surfaces, shapes and angles of bones and their skeletal relationships and concluded that the tarsal bones, mainly the calcaneus, are the primary fault.3 However in other research4 the talus has been identified as the linchpin of the deformity and Bensahel6 targets the midtarsal joint in the development of his treatment method. In spite of disputed origins within the foot Windisch et al in a further study1 concluded that soft tissue development was secondary to bony deformity. They identified fibrotic, retracted, short medial tissues with altered orientations. Laterally, tibialis posterior formed a thickened mass which divided off to its usual insertions and the calcaneofibular ligament was distorted depending on the severity of the deformity. Typically the foot presents with ankle equinus, heel varus, mid foot cavus and forefoot adduction and if left untreated will cause deformity, stiffness, pain on walking, footwear difficulties and the likelihood of ulceration on pressure points caused by the deformity.7
Peer Review Section blocks adduction of the calcaneus under the talus frequently causing â€˜rocker bottom deformityâ€™ and consequently up to 75% of patients required open surgery.10,11
As it affects 1.2 of every 1,000 live births, is bilateral in 50% of cases and has been depicted in ancient Egyptian and Indian art7 it is no surprise that treatment has varied over the decades and from country to country. However it may be surprising that it is only in the last couple of decades and due to our increasing understanding of mechanical properties, anatomy and biomechanics that non-surgical methods of treating talipes have become a successful and acceptable alternative to surgery. In the 1800s the Thomas Wrench was used to forcibly correct talipes non-surgically. It was used on the mature limb and literally wrenched the foot into an abducted position tearing bone and tissue in the process. The device was modified by Starr in 1901. Starr appears to have a certain understanding of some of the elements of the deformity but not the mechanics of the foot as a functioning unit. This wrench was a steel device which attempted to correct the entire deformity with one outwards swing often tearing limbs or flesh.8 In 1928 Telson described a wrench he had devised in an attempt to provide a less brutal form of closed treatment. (See Figure 1) Telson was correct in theorising that in open surgery the surgeon must cut through tissues that are not part of the deformity in order to get to the bones and ligaments that need correction. This wrench, he felt, would reduce the forefoot varus allowing for the removal of the sub-astrangular wedge in open surgery to correct the rearfoot varus. He felt that the wrench would produce a better shaped foot and in his research his team did in fact find that they needed to perform less mid-tarsal wedgectomies.9 The device produced a stiff painful foot was aesthetically acceptable.10
The low success rates of closed methods of talipes correction and the introduction of anaesthesia and aseptic techniques meant that surgical correction of talipes became the mainstay. Surgeons began to set aside osteotomies in favour of extensive soft tissue releases in the 1970s such as a medial release of the subtalar joint, ankle and talonavicular joint. Procedures have varied through the decades however the complexity of the deformity means that there is not a single procedure which will correct all aspects of it, for example the medial release mentioned does not address the rearfoot valgus.11,12 Long term results are frequently unfavourable and the feet produced are typically weak and stiff with large amounts of scar tissue which hinder further surgeries.13 The quest for a successful closed method of treatment continued and in the 1950s in Paris a quite brutal technique of forceful manipulation and taping feet into splints was used which was relatively unsuccessful unless the original deformity was mild. Henri Bensahel, an orthopaedic surgeon, saw that recurrences were common and the method was deemed harmful and scrapped. Bensahel went on to develop the Functional Method also known as the French Functional Method or the Physiotherapy Method of treating talipes in the 1970s.6 This method concentrates on the midtarsal joint and involves daily gentle manipulations of the affected tissues in the foot to stretch and strengthen the muscles. The limb is then taped and splinted. The majority of correction will happen within three months with full correction expected by five months. Parents continue the treatment at home until walking age and splints are worn until the child is three.14 This method has been used worldwide since the 1990s with varying success rates. Parental compliance has been cited as one reason for the varying success rates due to the commitment to daily treatments and home treatment regime.11
Whilst Telson did correctly identify the complexities of talipes surgery his approach of using a mechanical device capable of fracturing bones has unsurprisingly fallen by the wayside over the years.8
Meanwhile in Iowa Dr. Ignatio Ponseti an orthopaedic surgeon became frustrated with the results of the surgical treatment of talipes.13 Between 1948 and 1956 he treated patients using what became known as the Ponseti method. The method requires an in depth knowledge of functional anatomy and details a specific sequential manipulation method followed by serial casting (see Box 1).15,16
It was Kite who sowed the seeds for a gentler method of treatment in 1939. He detailed a manipulation and serial casting method which corrected the varus and equinus deformities separately rather than the foot as a whole. He recommended abduction of the forefoot against the calcaneocuboid joint to correct the heel varus and at the time quoted an 85% success rate. However the sequence actually
A key feature of the method is that it addresses the cavus deformity in the initial casts and this aligns the midfoot. The adductus and varus deformity of the heel is then corrected with progressive abduction of the forefoot using the talar head as a fulcrum. When these deformities are fully corrected a tenotomy performed under local anaesthetic may be necessary to correct the equinus.17
Peer Review Section a long term follow up of many of Ponseti’s original subjects. The successful long term results and the increased use of the internet, which allowed parents to research treatments available to their children, threw the treatment into the limelight. Ponseti believed that many orthopaedic surgeons did not understand the concept of the deformity as triplaner and this is why it took so long for the treatment to be accepted.
Around six casts will be required and treatment is weekly (See Figure 2). The casts consist of a thin layer of plaster of paris applied in two sections, from the toes to just below the knee allowing the foot to be held in the corrected position and then, holding the knee at right angles, the leg is gently rotated outwards to correct tibial torsion and plaster of paris applied from below the knee up to the top of the thigh.14 Ponseti and Smoley reported the results in the Journal of Bone and Joint Surgery in 1963. 67 patients totalling 94 feet were evaluated reporting 71% (n=67) as good, 28% (n=26) as acceptable and 1% (n=1) as poor. All feet treated presented initially as severe and rigid talipes equinovarus. 74 of the 94 reported feet underwent a tenotomy. Following the final cast, which if a tenotomy has been carried out will stay on for three weeks, the patient will wear a DenisBrown splint full time for three months and then only at night and nap time until the child is four years old (see figure 3). This phase is known as the boots and bar phase and is essential to prevent recurrence. Ponseti recognised the importance of parent education in the success of his method. In general recurrence of the deformity shortly after successful casting was as a result of parental non compliance during the boots and bar phase of the treatment.14 The Ponseti method has emerged as the gold standard of treatment for talipes in the UK and is used even in cases where some surgery will still be required as it will reduce the complexity of the surgical procedure.7 One factor in its success is early intervention. Most children will be treated within the first two weeks of life. At this point in skeletal development the bones in the foot consist largely of anlage, a cartilage. Anlage continues to ossify post natally leaving only a thin layer of cartilage at articular surfaces. If manipulation is carried out early enough the tarsal ‘bones’ are malleable enough to manipulate and congruent articular surfaces will develop post treatment.2,15
The French Functional Method is also used today although it is less common in the UK due to the daily treatment routine and the lower success rates. There are complexities to offering a closed method of treatment for TEV for example the long miles families have to travel weekly to clinics, family education and compliance. Research has been carried out to address these problems and will be discussed in article 3. In my next article I will be discussing my training in the Ponseti Method and going into detail as to what the treatment entails. Acknowledgments The author wishes to thank Cosyfeet for their support in writing this article, global-HELP.org for their permission to use images and words. Please address any correspondence to: email@example.com
Windisch G, Anderhuber F, Haldi-Brändle V & Exner GU. Anatomical study for an updated comprehension of clubfoot. Part II: Ligaments, tendons and muscles. The Journal of Childrens Orthopaedics 2007 1:79-85.
Mahmoodian R, Leasure J, Gadikota H, Capaldi, F & Siegler S. Mechanical properties of human fetal talus. Clin Orthop Relat Res 2009 467:1186-1194.
Windisch G, Anderhuber F, Haldi-Brändle V & Exner GU. Anatomical study for an updated comprehension of clubfoot. Part I: Bones and joints. The Journal of Childrens Orthopaedics 2007 1:69-77.
Hata M, Nango A, Niki H, Hayafune Y & Kato A. Volume of tarsal bones in congenital clubfoot. Journal of Orthopaedic Science 1997 2:3-9.
Howlett JO, Vincent SM, Bjornson K. The association between idiopathic clubfoot and increased internal hip rotation. Clinical Orthopaedic Related Research 2009 467:1231-1237.
Bensahel H, Bienayme B and Jehanno. History of the functional method for conservative treatment of clubfoot. Journal of Childrens Orthopaedics 2007 1:175-176.
Faulks S & Luther B. Changing paradigm for the treatment of clubfeet. Orthopaedic Nursing 2005 24(1):25-30.
Starr CL. A club-foot wrench. The Journal of Foot and Joint Surgery 1901 1(14):197-200.
Telson DR. A clubfoot wrench. The Journal of Foot and Joint Surgery 1926 8:425-426.
10. Kite JH. Non-operative treatment of congenital clubfeet: A review of one hundred cases. Southern Medical Journal 1930 23(4):337-345. 11. Dobbs MB & Gurnett CA. Update on clubfoot: Etiology and treatment. Clin Orthop Relat Res 2009 467:1146-1153. 12. Stabile RJ & Giorgini RJ. A review of talipes equino varus. Podiatry Management 2009 167-174. 13. Ponseti I, Morcuende JA, Mosca V, Pirani S, Dietz F, Herzenberg JE, Weinstein S, Penny N & Steenbeek M. In: Staheli L (Ed) Clubfoot:Ponseti Management, 2nd Edn. Global-HELP Publication 2005. 14. Faulks S & Richards B. Clubfoot treatment. Clin Orthop Relat Res 2009 467:1278-1282.
Conclusion From 1963 when his ‘results of treatment’ article was published until 1995 Ponseti continued to write articles primarily on metatarsus adductus. His revolutionary treatment of TEV had not been accepted by the orthopaedic community. In 1995 Cooper & Dietz published the results of
15. Ponseti I & Smoley E. Congenital club foot: The results of treatment. The Journal of Bone and Joint Surgery 1963 45:261-344. 16. Docker CEJ, Lewthwaite S and Kiely NT. Ponseti treatment in the management of clubfoot deformity – A continuing role for paediatric orthopaedic services in secondary care centres. Annals of the Royal College of Surgeons England 2007 98(5):510-512. 17. Cooper DM & Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. The Journal of Bone and Joint Surgery 1995 77:1477-1489.
The Institute of Chiropodists and Podiatrists
Continuing Professional Development This article is one of a series of educational documents that can be inserted into your portfolio and be a contribution towards your personal CPD learning.
Ultrasonic Therapy in Chiropodial/Podiatric Practice by Carl R. Burrows F.Inst.Ch.P.D.Ch.M When I first commenced practice well over forty years ago I had some experience of physical therapies and particularly that of ultrasound, so decided to purchase an ultrasound machine for use in my practice. This was to prove a decision I never regretted as it paid for itself many times over during the course of the next few years and in addition expanded the parameters of my practice to the benefit of many patients.
perception reduces with age. Therefore the dull thud we spoke of would be in the region of 20 odd Hertz and the high pitched squeak around 18,000 Hz.
Let us consider what ultra-sound actually is. Its therapeutic benefits centre mainly around a physical phenomenon called “micro-massage” which occurs right down at cellular level.
As mentioned above the penetration of ultrasound varies according to the medium through which it travels, examples being:
Firstly, in order to understand this phenomenon we need to focus a little on the physics of what is involved. The definition of sound is:”A periodic disturbance in an elastic medium progressing through air or living tissue at a speed characteristic of that medium” In normal circumstances what we recognise as “sound” is what we hear. Bearing in mind that air is one of the aforementioned “elastic mediums” (sound will NOT travel through a vacuum), when a sound is generated it travels through the air until it meets our eardrums and we perceive the result whether that be a high pitched squeak or a dull thud, depends on the frequency of the generated sound. The range of normal human hearing covers the frequency range from about 20 Hz (Hz = the number of cycles per second) to around 20,000Hz in a young person and that
Therapeutic ultrasound operates in the frequency range of 1 to 3 MHz (megahertz, i.e. millions of cycles per second) which I am sure you can see, is way above that detected by human hearing.
Velocity of Sound in Various Media Sound travelling in metres per second through Air
Moves at 344 m/s
Soft Human Tissue
Thus it can be seen that penetration of ultrasound can vary considerably with the body tissue involved. The other point to consider is that sound waves can be refracted at interfaces and that between periosteum and bone is an important case in point for podiatrists. January/February11CPD
Continued ProfessionalDevelopment The following diagram illustrates the main components of an ultra-sound machine. Sound waves are also attenuated by two main factors 1. Absorption â€“ the intensity decreases as the depth of penetration occurs 2. Scatter â€“ the wave is dissipated as it spreads out in the tissues Both these points are important when calculating dosage.
Coupling Media: It is essential when using ultrasound, that a coupling medium is used between the treatment head and the part of the body being treated. There is a specially formulated gel which is the best for direct contact, and distilled water is most suitable when treating areas that have bony prominences such as the dorsum of the foot and the toes etc. The transmission efficiency varies quite considerably and again must be taken into account re dosage. The percentages are: for Aquasonic Gel 78%, Distilled Water 59% and Liquid Paraffin 19%. The Physiological Effect of Ultrasound: There are basically three effects: 1. Thermal ( causing a local hyperaemia) 2. Micromassage (unique to ultrasound and works by vastly improving fluid exchange at cellular level) 3. Biochemical Effect (improving permeability of cell membranes and producing analgesia. January/February11CPD
The method of administration is either by direct contact via the aforementioned gel or in the case of the dorsum of the foot, around the maleoli etc.is best done under water and a plastic bath of the type used for babies is ideal for this method of administration. Whilst it is best to use distilled water as it contain much less gas than that from the tap, in practice it is often difficult to produce such large quantities so if tap water is used, one needs to watch the build up of bubbles on the sound head and wipe these away swiftly as they occur. It is also very important not to switch on the machine when the transducer is not in contact with a coupling medium because the frequency is such that there will be a rapid build-up of wave in front of the head which will damage it - expensively! There is one other method of administering ultrasound where contours prevent direct contact and immersion in water is contraindicated. That is to fill a well sealed plastic bag with distilled water, from which all air has been excluded and to coat both surfaces generously with gel. The bag will then mould to the contours and the transducer (treatment head) can be manipulated in contact with the opposite side of the bag viz:
Continued ProfessionalDevelopment There is a wide range of indications for treatment in podiatric practice and all, in my experience, benefit from its use, particularly in the treatment of sprains and strains, in which the effects are usually quite dramatic. For example I have seen many cases of sprained ankle where the patients have been comfortably back on their feet in a matter of three or four days, which without such intervention would have taken about the same number of weeks!
Contra-indications to Ultrasound:
Undications for Ultrasonic Therapy in Chiropodial/Podiatric Practice:
4. Malignant Tumours – because of the obvious danger of causing metastases.
1. Recent Soft Tissue Injuries (after 48 hours have elapsed because of possible exacerbation of haemorrhage in the deeper tissues)
It is perhaps worth mentioning here, the difference between a sprain and a strain. In the former case there is a rupture of the connective tissue such as a ligament and in the latter it is stretched beyond its normal limits.
What are the two biochemical effect s of ultrasound?
What is the effect that is unique to ultrasound?
What is a sprain as opposed to a strain?
10. Why should you NOT use ultrasound in the presence of malignancies?
What is the most efficient coupling medium?
1,400 meters per second;
What factors attenuate ultrasound?
They are refracted;
What are the commonly used frequencies of ultrasound?
1 or 3 MHz;
What happens to sound waves at interfaces?
Absorption and Scatter;
How fast does sound travel through muscular tissue?
What does sound NOT travel through?
Improves permeability of cell membranes and
8. Release of Scar Tissue
6. Varicose Ulceration (around the periphery of the ulcer to stimulate circulation, and thus healing potential).
5. Erythema Pernio (treatment needs to be performed prior to the onset of winter as a preventative in susceptible individuals).
There are several models of machine available from the major podiatric supply houses and also from physiotherapy suppliers and detailed instructions are usually supplied with them. There are also physiotherapy textbooks on the subject and information available on the internet.
Actual rupture of a ligament;
4. Sprains, Strains and Contusions
3. Radiotherapy – patients who have received radiotherapy which has been completed in the past nine months should not be treated.
3. Plantar Fasciitis (which ultrasound excels in treating)
2. Acute Sepsis – because of the danger of spreading the infection to surrounding tissues.
10. Danger of causing metastases
2. Non-Infective Inflammatory Conditions (such as arthritis)
1. Vascular conditions; particularly thrombosis – where there is a danger of dislodging a blood clot
The Institute of Chiropodists and Podiatrists Training Centre, Sheffield
Membership of the Institute of Chiropodists and Podiatrists is open to all chiropodists/podiatrists Contact Head Office for details:
The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside. PR9 0TL Telephone: 01704 546141 Email: firstname.lastname@example.org January/February11CPD
Peer Review Section
Long-Pulsed Nd:YAG Laser Treatment of Warts: Report on a Series of 369 Cases Tae Young Han,1 Ji Ho Lee,2 Chang Kyun Lee,2 Ji Young Ahn,3 Seong Jun Seo,1 and Chang Kwun Hong1 1
Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea. Gowoonsesang Dermatology Clinic, Seoul, Korea. 3 Department of Dermatology, National Medical Center, Seoul, Korea. Corresponding author. 2
Address for correspondence: Seong Jun Seo, M.D. Department of Dermatology, College of Medicine, Chung-Ang University, 224-1 Heukseokdong, Dongjak-gu, Seoul 156-755, Korea. Tel: +82.2-6299-1525, Fax: +82.2-823-1049, Email: email@example.com
This article was provided here courtesy of Korean Academy of Medical Sciences
Abstract Various treatment methods have been adopted in the management of warts; however, there is still no consensus on first-line treatment. This study was designed to evaluate the efficacy of long-pulsed Nd:YAG laser in the treatment of warts. Over the course of 1 yr, 369 patients with recalcitrant or untreated warts were exposed to a long-pulsed Nd:YAG laser. The following parameters were used: spot size, 5 mm; pulse duration, 20 msec; and fluence, 200 J/cm2. No concomitant topical treatment was used. In all, 21 patients were lost during follow up; hence, the data for 348 patients were evaluated. The clearance rate was 96% (336 of the 348 treated warts were eradicated). The clearance rate of verruca vulgaris after the first treatment was very high (72.6%), whereas the clearance rate of deep palmopantar warts after the first treatment was low (44.1%). During a median follow-up period of 2.24 months (range, 2-10 months), 11 relapses were seen (recurrence rate, 3.27%). In conclusion, long-pulsed Nd:YAG laser is safe and effective for the removal or reduction of warts and is less dependent on patient compliance than are other treatment options. Keywords: Lasers, Warts Introduction Warts are benign epithelial neoplasms of the skin and mucosa resulting from human papillomavirus (HPV) infection. They are a common dermatologic complaint, with an estimated incidence of 10% in children and young adults (1). Even if disease progression is naturally self-limited, the course of the disease is unpredictable, and treatment may be necessary. Several treatment methods are available for treatment of warts; however, most methods have specific disadvantages and side effects. Invasive methods have the drawbacks of pain and long recovery periods. Topical management requires the application of drugs for long durations and treatment success is, therefore, highly dependent on patient compliance (2). Laser treatment is based on the principle of photodermal or photomechanical destruction of the target tissue. Target structures absorb monochromatic coherent light of specific wavelength and fluence. Light energy gets converted to thermal energy, thus destroying the target structure. Depending on the pulse duration and energy density, this may result in the coagulation (photodermal effect) or blasting
(photomechanical effect) of these structures (2). A wart is a lesion characterized by proliferation and dilation of vessels. Many studies have used 585-nm pulsed dye lasers for the treatment of warts, with the wart blood vessels as the target tissue (1-4). This is because hemoglobin in blood has strong absorption peaks at wavelengths ranging from 585 to 595 nm (5). Moreover, hemoglobin has a significant, albeit more modest, absorption peak between 800 and 1,100 nm. Therefore, it has been postulated that 1,064-nm Nd:YAG lasers could be used in the treatment of telangiectases (5). In addition, since there is decreased light absorption by melanin at this wavelength, there is reduced risk of pigmentary side effects (4). Previous studies have shown that 1,064-nm Nd:YAG lasers used at longer widths can be used to treat telangiectasias of the lower extremities (5), face (6), and venous lake (7). We used a long-pulsed Nd:YAG laser in the treatment of warts, with the wart blood vessels as the target, and evaluated clinical outcomes. Methods and Materials
age, 21 yr; range, 3-67 yr) (Table 1) with recalcitrant or untreated warts were treated with a long-pulsed Nd:YAG laser. Informed written consent was obtained from all participants before inclusion in the study. In all, 21 patients were lost during follow up, and therefore, the data of 348 patients were evaluated. Warts were classified into three types-verruca vulgaris (212 patients), deep palmoplantar warts (68 patients), and periungual warts (68 patients). Prior to the study, photographs of all the lesions were taken and the size of each lesion was recorded. Over the course of 1 yr, 369 patients (mean
Peer Review Section "#$%&'$(&
The study employed a 1,064-nm long-pulsed Nd:YAG laser (Cutera, Inc., Brisbane, CA, U.S.A.). The following parameters were used: spot size, 5 mm; pulse duration, 20 msec; and fluence, 200 J/cm2. Prior to laser treatment, warts were treated with EMLA速 cream or a local lidocaine injection and were peeled with a razor blade. One or two courses of slightly overlapping laser pulses were applied to each wart, covering the wart itself and a 1-mm margin on the surrounding skin. Around the third treatment date, crusts were found to be formed on the treated parts. At 1 to 2 weeks after treatment, the crusts were removed, and the warts were cleared, leaving only a small scar (Figs. 5--7).7). The treatment interval was 4 weeks, with up to four treatment sessions. Clearance was defined as the complete absence of a clinically apparent wart, and treatment failure was defined as a persistent lesion after four treatments.
The average number of treatment sessions required for clearance was 1.49 (range, 1-4 sessions) (Fig. 1). At the end of the first treatment, 64% of warts were cleared, while 96% (336/348) of warts were cleared after the fourth treatment (Fig. 2). Verruca vulgaris responded better than the other types of warts and required fewer treatments for clearance (mean, 1.35 sessions). Deep palmoplantar warts required a mean of 1.95 sessions for clearance (Fig. 1). The clearance rate after the first treatment was also higher in the verruca vulgaris group (72.6%) than 64.7% in the periungual warts group and 44.1% in the deep palmoplantar warts group (Fig. 3). The size of the warts was reduced by an average of 10% based on the diameter. This was observed in 69.1% of the verruca vulgaris warts, 52.5% of the periungual warts, and 27.4% of the deep palmoplantar warts. Histopathologic examination after treatment showed separation of the dermoepidermal junction, epidermal necrosis, and red blood cell (RBC) extravasation. Destroyed blood vessels surrounded by a dense inflammatory infiltrate were also shown in the dermis (Fig. 4). Since most (82%) patients who were anesthetized with EMLA速 cream complained of serious pain during treatment, local lidocaine injections were administered during the second treatment. Other side effects included transient numbness (15%), hemorrhagic bullae (7%), hyperpigmentation (5%), and hypopigmentation (4%). In addition, 2% of patients with periungual warts experienced nail dystrophy. During a median follow-up period of 2.24 months (range, 2-10 months), 11 relapses were seen (recurrence rate, 3.3%).
Fig. 5 (A) Periungual warts (B) Three days post treatment
Fig. 1 Average number of treatments according to subtypes of warts.
Fig. 7 (A) Verruca Vulgaris on the toe (B) After Only treatment
Fig. 2 Cumulative clearance by successive treatments.
Peer Review Section & & & & & & & & & & & & & & & & & Fig. 3 Clearance rates according to number of laser sessions per subtype. Tx treatments
)*+,-++*.(! ! Warts are very common, with an incidence of approximately 10% in children and young adults. An estimated 4-million-patient visits were recorded in 1982 for nonvenereal warts. Approximately 70% of these patients were between 10 and 39 yr of age, and 50% presented to a dermatologist. Peak incidence occurs between the ages of 12 and 16 yr (8). Warts often cause pain and may interfere with function. These complications, along with cosmetic embarrassment and risk of translocation to other areas of the skin, are indications for treatment, which can be challenging. Effective therapy must provide reduction in pain and improvement in quality of life. Many different types of therapy have been used in the treatment of warts (9-13). Commonly used methods of physical destruction include surgical excision, electrodesiccation, cryosurgery, and pulsed dye or carbon dioxide laser therapy. Chemical destruction can be included with salicylic acid, cantharidin, formaldehyde, or glutaraldehyde, among other agents. Chemotherapeutic agents include
Fig. 4 Histopathological findings by H&E staining. (A) Separation of dermo-epidermal junction (!40). (B) Destroyed blood vessels in the dermis surrounded by a dense inflammatory infiltrate (!200).
podophyllin, podophyllotoxin, 5-fluorouracil, and bleomycin. Allergic contact agents used against warts include dinitrochlorobenzene and squaric acid dibutyl ester. More recently, immunomodulators such as interferon, systemic retinoids, cimetidine, and topical imiquimod have been used (14-16). This prospective study evaluated the efficacy of long-pulsed Nd:YAG lasers in the treatment of warts. The results show that long-pulsed Nd:YAG lasers are a safe and effective approach to wart treatment, with clearance rates higher than those achieved with other common therapies. Previous studies of cryotherapy in the treatment of warts report clearance rates ranging from 63% to 69% (10, 17, 18). In a study using imiquimod, 56% of the patients reported total clearance (19). Efficacy studies of cantharidin show success rates of approximately 80% (20). The pooled data from six randomized controlled studies demonstrated a cure rate of 75% in those treated with salicylic acid compared with 48% in the control group (21). One study performed using bleomycin prick method demonstrated complete resolution of warts in 92% of participants (22). Longpulsed Nd:YAG lasers emit a visible light spectrum at 1,064 nm. When a 1,064-nm long-pulsed Nd:YAG laser is used on the skin, a short, strong laser pulse is absorbed by red structures such as cutaneous blood vessels. As a result, blood vessels heat up rapidly and burst. Upon blood vessel rupture, purpura appear, which subside 5 to 7 days later. Vascular lesions become pale with repeat treatment. The mechanism of action of a long-pulsed Nd:YAG laser in the treatment of warts is not fully understood. Dilated vessels in the papillary dermis are a characteristic feature of warts (23). Light microscopic evaluation of treated areas at 7 days after treatment in this study showed separation of the dermoepidermal junction, epidermal necrosis, and RBC extravasation. In addition to these findings, destroyed blood vessels in the dermis were found to be
Peer Review Section prevent normal activity. In conclusion, long-pulsed Nd:YAG lasers are a safe and effective treatment for warts, with response rates higher than those obtained with conventional therapies. No single optimal treatment has been inclicated for warts; therefore, long-pulsed Nd:YAG lasers should be considered a reasonable addition to the therapeutic options available. Future studies examining optimal laser parameters and treatment intervals would expand our knowledge on how best to use long-pulsed Nd:YAG laser therapy in managing warts.
Fig. 6 (A) Deep palmoplantar wart three days after treatment. (B) After one week. (C) After two weeks.
surrounded by a dense inflammatory infiltrate. This destruction may obliterate the nutrient supply to the wart or destroy the rapidly dividing epidermal cells that contain HPV. Minimal destruction of the surrounding tissue is anticipated with long-pulsed Nd:YAG lasers. In our study, the overall clearance rate was 96% (336 of the 348 treated warts were eradicated). The clearance rate of verruca vulgaris after the first treatment was very high (72.6%), whereas the clearance rate of deep palmopantar warts after the first treatment was low (44.1%). Most patients required repeated treatments. The average number of treatments required for clearance was 1.49. During a median follow-up period of 2.24 months (range, 2-10 months), 11 relapses were seen (recurrence rate 3.3%). This low recurrence rate seems to be due to the short follow-up period in this study; therefore, a study with a longer follow-up period and examination of recurrence is needed. The clearance rate after pulsed dye laser treatment, which employs the same mechanism of action as the Nd:YAG laser, has been reported to be 48% to 92% (1-4), while the laser used in the current study showed a higher clearance rate (96%). Therefore, a comparative study between these two types of lasers is required. Side effects noted in our study included transient pain during treatment (82%), posttreatment numbness (15%), hemorrhagic bullae (7%), hyperpigmentation (5%), and hypopigmentation (4%). A crust formed in most patients and was removed within 1 to 2 weeks. Side effects were generally mild and did not
Refernces 1. Robson KJ, Cunningham NM, Kruzan KL, Petal DS, Kreiter CD, O'Donnell MJ, Arpey CJ. Pulsed-dye laser versus conventional therapy in the treatment of warts: a prospective randomized trial. J Am Acad Dermatol. 2000;43:275–280. 2. Kopera D. Verrucae vulgares: flashlamp-pumped pulsed dye laser treatment in 134 patients. Int J Dermatol. 2003;42:905–908. [PubMed] 3. Kenton-Smith J, Tan ST. Pulsed dye laser therapy for viral warts. Br J Plast Surg. 1999;52:554–558. 4. Ross BS, Levine VJ, Nehal K, Tse Y, Ashinoff R. Pulsed dye laser treatment of warts: an update. Dermatol Surg. 1999;25:377–380. 5. Wiess RA, Wiess MA. Early clinical results with a multiple synchronized pulse 1064 NM laser for leg telangiectasias and reticular veins. Dermatol Surg. 1999;25:399–402. 6. Sarradet DM, Hussain M, Goldberg DJ. Millisecond 1064-nm neodymium: YAG laser treatment of facial telangiectases. Dermatol Surg. 2003;29:56–58. 7. Bekhor PS. Long-pulsed Nd:YAG laser treatment of venous lakes: report of a series of 34 cases. Dermatol Surg. 2006;32:1151–1154. 8. Cobb MW. Human papillomavirus infection. J Am Acad Dermatol. 1990;22:547–566. 9. Bunney MH, Nolan MW, Williams DA. An assessment of methods of treating viral warts by comparative treatment trials based on a standard design. Br J Dermatol. 1976;94:667–679. 10. Gibbs RC, Scheiner AM. Long-term follow-up evaluation of patients with electrosurgically treated warts. Cutis. 1978;21:383–384. 11. Shumer SM, O'Keefe EJ. Bleomycin in the treatment of recalcitrant warts. J Am Acad Dermatol. 1983;9:91–96. 12. Street ML, Roenigk RK. Recalcitrant periungual verrucae: the role of carbon dioxide laser vaporization. J Am Acad Dermatol. 1990;23:115–120. 13. Tan OT, Hurwitz RM, Stafford TJ. Pulsed dye laser treatment of recalcitrant verrucae: a preliminary report. Laser Surg Med. 1993;13:127–137. 14. Brodell RT, Bredle DL. The treatment of palmar and plantar warts using natural alpha interferon and a needleless injector. Dermatol Surg. 1995;21:213–218. 15. Yilmaz E, Alpsoy E, Basaran E. Cimetidine therapy for warts: a placebo-controlled, double blind study. J Am Acad Dermatol. 1996;34:1005–1007. 16. Edwards L. Imiquimod in clinical practice. Australas J Dermatol. 1998;39(Suppl 1):S14–S16. 17. Allington HV. Liquid nitrogen in the treatment of skin diseases. Calif Med. 1950;72:153–155. [PMC free article] [PubMed] 18. Zacarian SA. Liquid nitrogen in dermatology. Cutis. 1965;1:237– 242. 19. Hengge UR, Esser S, Schultewolter T, Behrendt C, Meyer T, Stockfleth E, Goos M. Self-administered topical 5% imiquimod for the treatment of common warts and molluscum contagiosum. Br J Dermatol. 2000;143:1026–1031. 20. Coskey RJ. Treatment of plantar warts in children with a salicylic acid-podophyllin-cantharidin product. Pediatr Dermatol. 1984;2:71– 73. 21. Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev. 2003;3:CD001781. 22. Munn SE, Higgins E, Marshall M, Clement M. A new method of intralesional bleomycin therapy in the treatment of recalcitrant warts. Br J Dermatol. 1996;135:969–971 23. Xiaowei X, Erickson LA, Elder DE. Disaese caused by viruses. In: Elder D, Elenitsas R, Johnson B Jr, Murohy GF, editors. Lever's histopathology of the skin. Philadelphia: JB Lippincott; 1997. pp. 651– 679.
Medical Detection Dogs Medical Assistance Dogs are ordinary dogs that have been trained to assist individuals who have to manage complex medical conditions on a day to day basis. The dogs are taught to identify the odour changes that are associated with certain medical events. For example for someone living with diabetes; hypoglycaemia, or the avoidance of it can be a daily problem. This condition is frightening and very distressing, symptoms can vary from confusion, seizures to comas and be life threatening and Medical Assistance Dogs can be invaluable companions. The same applies to someone living with Addisons disease. Addisonâ€™s disease is a chronic condition brought about by the failure of the adrenal glands. The adrenal glands sit at the top of the kidneys, one on each side of the body and have an inner core (the medulla) surrounded by the outer shell (the cortex). The inner medulla produces adrenaline, the Afight or flight stress hormone. While the absence of the adrenal medulla does not cause disease, the cortex is more critical. It produces the steroid hormones that are essential for life: cortisol and aldosterone. Cortisol mobilises nutrients, it enables the body to fight inflammation, it stimulates the liver to produce blood sugar and it also helps control the amount of water in the body. Aldosterone regulates salt and water levels which affect blood volume and blood pressure. The adrenal cortex also produces sex hormones known as adrenal androgens; the most important of these is DHEA. The normal adrenal cortex has an enormous functional reserve. This is called upon by the body especially in times of intense stress, such as surgery, trauma or serious infection. One of the most significant consequences of Addison's disease is, therefore, the body's failure to adapt to such stresses and, in the absence of adequate steroid cover, this may result in a state of shock, known as an Addisonian crisis, which is a medical emergency and requires urgent treatment. Lifelong, continuous treatment with steroid replacement therapy is required and treatment must be sought quickly in an Addisonian Crisis. Medical Assistance Dogs are trained to recognise dangerously low and high blood sugar levels, as these levels give off a different scent compared with blood
sugars that are within the normal range. When outside the normal range the dogs, once trained, can warn and get help before the symptoms are felt. Depending on their ownersâ€™ needs the dogs will alert in a variety of ways e.g. by barking, jumping up, licking or pawing. They will bring their owner any necessary medical supplies such as glucose and blood testing kits and get help when necessary. They can also be trained to push alarm buttons. This greatly assists those individuals who live in daily fear of an unrecognised hypoglycaemic attack. For many individuals with brittle diabetes who get no warning of such an episode these dogs are truly lifesavers. The dogs are also trained to warn when blood sugars become too high and although this is rarely an emergency situation there are numerous very serious and potentially life threatening side effects of hyperglycaemia. Our Assistance Dogs quickly recognise the signs and are taught to bring vital medical supplies and to summon help. Six-year-old Rebecca Farrah had been hospitalised eight times in two years due to her brittle diabetes and unpredictable changes in her blood sugars. Night times were particularly worrying for Rebecca's mother and she wasn't sleeping knowing that her daughter could be taken seriously ill without her realising it. We paired Rebecca with Shirley, a Labrador who had been originally puppy walked as a Guide Dog for the Blind. We were extremely grateful to The Kennel Club Charitable Trust who sponsored Shirley for her training. Within just three weeks following her placement with Rebecca and her mum Claire and family, Shirley was alerting successfully. Shirley has already woken Claire on a number of occasions during the night when Rebecca has been in trouble, meaning prompt action could be taken at home avoiding a trip to hospital. Rebecca used to collapse three of four times a week, unable to feel any change in her sugar levels but since the arrival of Shirley, the fear of collapsing has eased. As a hypo-alert dog trained to sense the change in odour when Rebeccaâ€™s sugar levels drop or increase, Shirley can warn the little girl by licking her hands, sitting on her lap and even dragging a sugar-level testing kit to her side.
Rebecca’s mother, Claire explained: “She would regularly collapse and be taken to hospital, sometimes four times a week.” But since Shirley arrived she has had her confidence back and it has been a massive relief to us. Shirley goes everywhere with her. They are soulmates, they get on so well.” Six-year-old Rebecca Farrah had been hospitalised eight times in two years due to her brittle diabetes and unpredictable changes in her Shirley and Rebecca blood sugars. Night times were particularly worrying for Rebecca’s mother and she wasn't sleeping knowing that her daughter could be taken seriously ill without her realising it. We paired Rebecca with Shirley, a Labrador who had been originally puppy walked as a Guide Dog for the Blind. We were extremely grateful to The Kennel Club Charitable Trust who sponsored Shirley for her training. Within just three weeks following her placement with Rebecca and her mum Claire and family, Shirley was alerting successfully. Shirley has already woken Claire on a number of occasions during the night when Rebecca has been in trouble, meaning prompt action could be taken at home avoiding a trip to hospital. Rebecca used to collapse three of four times a week, unable to feel any change in her sugar levels but since the arrival of Shirley, the fear of collapsing has eased. As a hypoalert dog trained to sense the change in odour when Rebecca’s sugar levels drop or increase, Shirley can warn the little girl by licking her hands, sitting on her lap and even dragging a sugar-level testing kit to her side.
University and Endocrinology specialists at Cardiff NHS Trust to try and establish the dogs sensitivity and start to learn exactly what it is the dogs are detecting. We continue to investigate other debilitating and life threatening conditions which our dogs may have the potential to detect. These include, severe pain seizures which lead to collapse and hospitalisation, severe allergic responses and narcolepsy, a malfunction of the sleep/wake regulating system which causes sleep attacks and paralysis. Dogs are donated to the charity from breeders, welfare charities, and other assistance dog charities or just because they need a new home. Dogs are chosen for their ability which allows work with a variety of breeds. They live with volunteer foster families during their training which, can take up to 18 months. To train and support one dog costs in the region of 10,000! All of these dogs have the potential to help and save thousands of lives. For those living with life threatening and disabling health conditions having an Medical Assistance Dog can make all the difference. Not only can they reduce the cost of NHS care and hospital admissions but more importantly give their owners’ a better quality of life, freedom, independence and help reduce the responsibility of care for carers as well. Many thanks for this article to Claire Guest Chief Executive and Director of Operations Medical Detection Dogs.
Rebecca's mother, Claire explained: “She would regularly collapse and be taken to hospital, sometimes four times a week." But since Shirley arrived she has had her confidence back and it has been a massive relief to us. Shirley goes everywhere with her. They are soulmates, they get on so well.”
How to get involved with the Sniff for Life campaign The Sniff for Life campaign is aiming to significantly increase the number of dogs we are able to train, this will help to meet the ever rising demand for an alert dog. We would like to raise enough money to train at least 50 dogs within the next three years and hope to move to a new training centre that will accommodate the predicated growth of Cancer and Bio-detection Dogs.
Claire Guest, Chief Executive of (Medical Detection Dogs Charity) says We are now working with Bristol
Further information can be obtained from http://www.hypoalertdogs.co.uk/about.html
Midland Area Council Seminar 2010 Pamela Osborne, MInstChP
Chiropody/podiatry delegates gathered at the Hilton Hotel, Leicester on 30th October for the annual Midland Area Council (MAC) education seminar. Also in attendance were Institute President, Heather Bailey and Chairman of the Board of Education, Bill Liggins. The day was divided between a morning dedicated to rheumatology revision and update, presented by Judith BarbaroBrown, and an afternoon session of an introduction to injectable silicone therapies with Dr Frank Bowling, courtesy of OsteoTec Ltd. During coffee breaks and luncheon, a comprehensive trade exhibition was well received with contributions from Hilary Supplies, Flexitol Ltd and Heeley Surgical. Valerie Davies, MAC chairperson, introduced Bill Liggins to delegates who, in turn, welcomed Judith Barbaro-Brown. Judith is no stranger to MAC seminars and the delegates had a high expectation of a quality presentation. She did not disappoint. With her customary genial approach she outlined the nature of rheumatic disorders, detailing the classification, epidemiology, aetiology (albeit considered somewhat idiopathic), pathology and relevant clinical features. After a group discussion upon the clinical implications and impact of rheumatic disorders in practice, she continued with an update of current management and potential therapies. In particular she described the possible mechanisms of the recent anti-TNF (Tumour Necrosis Factor) agents, their benefits and possible side effects, comparing and contrasting these exciting, relatively new,drugs with the more established pharmacological products of recent decades. After a lively question and answer session, concluding with a short discussion relating the “dog on the towel” (you really did need to be there!), delegates broke for luncheon. The afternoon session commenced with a lecture delivered by Dr Frank Bowling, introduced by Val Davies. He presented the topic “Silicone Injection Therapy”, a technique to relieve foot pain due to denudement of the natural fibro-fatty padding of the metatarsal heads and plantar calcaneal area. It was clear that he has made a considerable positive contribution to this subject, not only in the UK, but also in Spain and the USA. The procedure was described in full detail, the use of a local anaesthetic being mandatory, together with the need for all
appropriate precautions, particularly in relation to anaphylaxis. He dealt comprehensively with the possible complications, but not in a fashion that would deter delegates from pursuing these therapies. A syringe is filled with the silicone compound and injected into a sub-epidermal void to bulk out the tissue. When pressure is applied to the bulked out area the mobile silicone spreads to offer an cushioned load bearing surface.
Following afternoon refreshments OsteoTec Ltd provided silicone injection kits and suitable media (raw chicken legs!) for a touchy feely (hands on) workshop. This afforded delegates a tactile experience of syringe filling and expulsion into the sub-epidermal tissues under the supervision of Dr Bowling and his colleague. All the delegates approached this with great enthusiasm and there can be no doubt that the quality of the afternoon session matched that of the morning. During questions he explained that the Medical Devices Agency could not authorise pre-filled syringes, hence the need to fill the syringe from a single treatment vial. Appreciation was expressed to the presenters and following the collection of CPD certificates the delegates departed for home, considerably enriched by the day’s experience.
Irish Area Council News The Irish Area Council held a CPD meeting at St James’ Hospital Dublin on Saturday 20th of November 2010. Our fist guest speaker was Dr. Thomas Ahern who is an endocrinologist involved in research. His lecture was about leg ulcers in diabetes patients. He gave a very informative presentation, supported by current literature and research. The lecture enabled everyone so see the evidence to support best clinical practice. His lecture fuelled debate and questions, which were well answered. Dr. Caroline McIntosh who is Head of Podiatry at National University of Ireland Galway delivered our second lecture. She spoke about developments in relation to the supply and administration of local anaesthetics to patients, and other prescription issues. It would appear, that we in Ireland are close to registration, as a result we had to nominate to people for election to the podiatry post on the registration board (CORU). Our nominations are Caroline McIntosh and Andrew Farrell. As the POM is a big issue for us Caroline answered many questions on the subject, and took away with her a number of suggestions. The afternoon was given over to Council business, the meeting was chaired by Chairperson Joan Flannery,
Robert Sullivan informed the membership of matters of interest from the last Executive Meeting and collected comments for the next. Vice Chair Yvonne Geoghan gave a report on CPD in Sheffield, where five members attended the verrucae hyfrecation and cryotherapy workshop. The day was concluded with the award of long service certificates. The date of the Irish A.G.M. has been set for Saturday 29th January 2011. Robert Sullivan, Republic of Ireland
West of Scotland CPD Day Seminar Sunday 14th November 2010 West of Scotland Branch members were delighted to welcome guest speaker Mr. Gareth Hicks of Bailey Instruments to The Holiday Inn, Stirling. The seminar titled “Assessing the Diabetic Foot” consisted of series of lectures, discussion groups and practical sessions, was appropriately held on World Diabetes Day. This also being Remembrance Sunday, Mr. Hicks kindly led the branch in observing a minutes silence at 11:00 a.m. What followed was a very informative lecture accompanied by excellent visual presentations. During the hands on section, members worked in pairs and were encouraged to try out various instruments such as the doppler. monofilaments (10mgs) patella hammers and tuning forks, provoking much laughter! On behalf of the Branch, I would just like to express our thanks to Mr. Hicks for an informative and fun day and for travelling a considerable distance to be with us. Thanks also to our education officer Mr. Stephen Gourlay for organising another successful CPD day. Alisdair Reid, Chairman, West of Scotland Branch
The following obituary was sent in by the family of the late John F. Webster. John wrote it and left instructions to his family for it to be sent to the Institute following the death of Walter, who survived John. Walter was born in Manchester on 4th January 1917; the eldest of four children, two girls and two boys. At the age of eleven his academic prowess earned him a scholarship to William Hulme Grammar School but his father, whose health had been ruined by being gassed in the First World War, had to take a poorly paid job as assistant school caretaker and his mother worked as the school cleaner, so they could not afford to let him attend this prestigious school. On leaving school, Walter was employed for the time at A. V. Roe, aircraft manufacturers where he was carving out a promising career until he was called up for army service five weeks prior to the Second World War. Because of his particular talents, ability and skills, he rose to the rank of Major. Walter was always reluctant to talk of his exploits in the army, but over the years I learned that he had fought at Dunkirk and was one of the many thousands rescued from that desperate battle. On D Day he was in the fist wave of troops (known by many as ‘The Suicide Squad’) to land on the Normandy beaches and he fought his way across Europe, eventually ending up in Germany. After the enemy surrendered he stayed in Germany for some time as part of the occupying forces. Before being called up for military service, Walter was courting the love of his life, but whilst he was away fighting, she met and married someone else and he never fell in love again and remained single. Walter was a man of many talents and when he left the army he became Superintendent of a children’s home. After this he was appointed Personnel Officer for the Severn Trent Water Board. In the late 1950’s Walter had another change of career and trained as a chiropodist. He joined the Institute of Chiropodists and always took an active part at branch, area and national levels, eventually becoming President. He was very perceptive and had the ability to foresee and quickly analyse problems. Walter did not suffer fools gladly and could be abrasive but underneath his ‘crusty shell’ he was a gentle person, ever ready and willing to help those in need. Walter lived very frugally and over the years gave many thousands of pounds to groups and individuals in need often denying himself for the sake of other. He earned the epithet of ‘Good Samaritan’ by many whose lives he enriched. He was a devout Christian Spiritualist. Despite his humble beginnings, Walter triumphed over adversity and will be sadly missed by those who were privileged to have known him. God bless Walter, Requiescat In Pace
Walter was born in 1917 in Hulme Manchester and attended school there; he worked hard at night school as he had always wanted to be a doctor. He had to give up this idea as he felt he had to serve his Country and joined the Army in 1939 as a Private soldier. He was soon promoted and ended the war in 1945 as a Major, a rank which he held for his Service in the Territorials. Walter was well known in the Masonic circles and became the Lodge Chaplain, for he was deeply religious and a spiritualist. He trained and joined the chiropody profession in the 50’s and always supported the Institute, giving his advice and comments in no uncertain terms. Walter had a pleasant and helpful manner and a ready wit. Many chiropodists, including myself, can thank him for his help and advice. We will miss “Our Walter” Bryan Massey, North West Branch
Thursday 12th May 2011 - Saturday 14th May 2011
Beaumont House, Burfield Road, Old Windsor, SL4 2JJ
* *CPD Lectures *
Annual General Meeting
Friday and Saturday
Full Programme in the March/April Issue Podiatry Review
Booking Form In this Issue
please book early to avoid disappointment
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Letter from the President January 2011 The start of 2010 saw the country in the midst of the deepest recession since the 1930’s, and this continued throughout the year. At the Annual General Meeting in May 2010 the Honorary Treasurer warned of the likelihood of a shortfall in the I.O.C.P. finances of at least £4,000 by the autumn. The circumstances surrounding the reasons for this will be seen in the audited accounts and will be discussed with members at the A.G.M. in May 2011. Our motto, Concordia Victrix (Achievement through united effort) could not have been more aptly chosen by our founders as the National Officers and Executive Committee members worked long and hard to rectify the situation. Following the May 2010 A.G.M. meetings were held between members of the Executive Committee, Honorary Treasurer, our company accountants and business advisory agents to gain advice and plan for the future. All of the N.O.s and E.C. members, the Secretariat and staff have taken part in the planning workshops resulting in the I.O.C.P. running its finances differently and more clearly from the past. As our financial year ends on December 31st the changes will be not seen in the this year’s published accounts, they have however already made a considerable difference such that there was not a short fall and by continuing to expand our business plan our projected position by the end of 2011 is very healthy. Sacrifices had to be made along the way, including redundancies and a freeze in pay, a hold on our plans for expansion at Sheffield and development of the website. What has not been sacrificed are the services to the membership, in fact they have been improved, one area being member professional insurance, much time has been spent on this, headed by our Company Secretary. Members may be unaware that the I.O.C.P. insurance is non-profit making, all monies collected by Head Office being paid to the insurance agent. The I.O.C.P. is not a broker and does not take a fee from your payment. The purpose of the I.O.C.P. is to source the best cover available for all members and as I.O.C.P. members are regarded as low risk by the insurers this is reflected in the low cost and cover of £5,000,000. Insurance requirements by other chiropody organisations require £10,000,000 indemnity and mandatory autoclave temperature of 134ºC by 31st December 2010. Beware if sourcing your own cover that the cheapest cover does not necessarily provide best value. The I.O.C.P. represents the membership in a number of diverse and political areas, for example the proposed name change of the H.P.C. and the consultation document regarding proposals on post registration qualifications and the implications. Unless you read the www you will be unaware of these. You will have had the Department of Health Engagement Exercise Paper on Independent Prescribing brought to your attention by your branch officers for you to comment on. These and other issues will affect your working practices. The I.O.C.P., through the N.O. and E.C. and co-opted members are active in making sure that your interests and views are represented. January sees elections taking place within branches and area councils, proposals for National Officers and motions to be submitted to the A.G.M. in May. This year David Crew, Vice Chairman of the E.C. and John Patterson, Vice Chairman of the Board of Education will step down Their hard work and wide experience will be missed by us all. Changes should always be made to bring in people with new ideas and enthusiasm to advance both the I.O.C.P. and the profession. Other officers will stand again as they have contributions to make and projects to take further. As for me, this will be the last time I will stand for the office of President. If you are considering being proposed for national office be warned that it is not an easy ride, there is no place for slackers in the E.C. team and no pay either. We do the work not for self aggrandisement but to benefit the I.O.C.P. We must continue to press forward with modernising the I.O.C.P. standing still is not an option; in fact it is a move backwards. The I.O.C.P. has a number of plans in motion. New courses have been sourced by the Board of Education, available to members and non-members and are taking place in Sheffield and other locations, see the Podiatry Review and web site for details. Please make the effort to support your branch and area councils, the officers work hard on your behalf. We are unique in that democracy is at the heart of the I.O.C.P. all of the National Officers are appointed democratically by the members from the membership. Continuing from the changes made to last year’s A.G.M. which proved such a success, this year there will be further changes, the most controversial of these being to move the A.G.M. itself to Friday from Saturday which will allow the opportunity to introduce concurrent workshops. Those attending as branch delegates have their travel, dinner dance, hotel and C.P.D. paid for, other members and non members who attend fund themselves, see http://www.iocp.org.uk/node/455 for details. Much of the costs are deductable from your tax. We continue to develop our ties with the Royal Society of Medicine and have negotiated an exclusive 25% discount on membership for I.O.C.P. members. Free online C.P.D. during the autumn was a benefit available to our members who took advantage of the discounted offer. See http://www.iocp.org.uk/node/11. We have new I.O.C.P. leaflets for your patients which can be seen at http://www.iocp.org.uk/node/402. The Minimum Standards document has been available on the web site since last September (http://www.iocp.org.uk/node/11); we are expecting this to be accepted as a standard by the Department of Health. The City and Guilds course continues to gain approval across the profession; we have eight superb units in academic form and they provide the opportunities for regular elements of handson teaching. Each of the modules has been designed to be standalone so that they can be studied as individual units. We also have eight well qualified tutors who are specialists for their own unit. The units are all set up and ready to go and can be presented anywhere in the UK so if you want a module taught in your branch or area please contact the Board of Education via Head Office. The Podiatry Review, under the editorship of Roger Henry and Sub Editor Robert Sullivan and assisted by Bernadette Willey, has been enhanced by the inclusion of peer reviews to articles. The I.O.C.P. is not the only business to have been hit by the recession but we are coming through the down-turn fitter and stronger.
Diary of Events January 2011
Sheffield Branch A.G.M.
Birmingham Branch A.G.M. 13th January at 7:30 p.m. - Red Cross Centre, Tel: 01905 454116
Vine Street, Evesham
Chester, North Wales Staffs and Shrops Branch A.G.M. and Meeting
Thursday 20th January 2011, 7:30 p.m. Sheffield SWD sports Club, Heeley Bank Road, S2 3GL Tel: 01623 452711
Southern Area Council A.G.M. 15th January at 1:00 p.m. Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 01992 589063
16th January 2011 at 10:00 a.m. - The Dene Hotel, Tel: 01244 321165
Hoole Road Chester CH2 3ND
Surrey & Berkshire Branch A.G.M.
Devon & Cornwall Branch A.G.M. & Lectures
8th January 10:00 a.m. Greyfriars Centre, Reading
23rd January at 11:00 a.m. - Exeter Court Hotel, Kennford, EX6 7UX. Mr. Chris Leech, Cuxson Gerrard
Sussex Branch A.G.M.
Tel: 01805 603297
East Anglia Branch A.G.M. followed by meeting plus CPD - 30th January at 10:00 a.m. Newmarket Day Centre, Fred Archer Way, Tel: 01223 881170
Newmarket CB8 8NT
Tel: 0208 660 2822
15th January at 9:30 a.m. - The Bent Arms, High Street, Lindfield, RH16 2H Tel: 01273 890570
Teesside Branch A.G.M. Sunday 30th January 2:00 p.m. - 4:00 p.m. The Dolphine Centre, in the ‘meeting room’, Darlington Tel: 01287 639042
Essex Branch Meeting and A.G.M.
Western Branch A.G.M. and Branch Meeting
30th January 2:00 p.m. - Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea
9th January 12 noon - Blair Bell Education Centre, Seminar room 1 Tel: 01745 331827
Tel: 01702 460890
Scottish Area A.G.M. 10:30 a.m. followed by West of Scotland Branch A.G.M.
London Branch Meeting 19th January at 7:30 p.m. - Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01895 252361
Leicester & Northants Branch A.G.M. 23rd January A.G.M. plus meeting - Kilsby Village Hall 9:45 a.m. Registration and Refreshment 9:15 a.m. Further details
Tel: Sue 01530 469816
Sunday 16th January at 11.00 a.m. The Express by Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705
March 2011 Wolverhampton Branch A.G.M. Sunday 21st March - 10:00 a.m. - 4 Selman’s Parade, Selman’s Hill, Bloxwich WS3 3RN Tel: 0121 378 2888
Midland Area Council A.G.M. Sunday 30th January 10:00 a.m. - Kilsby Village Hall, Kilsby, CV23 8XX
Tel: 01865 434756
Chester, North Wales Staffs and Shrops Branch Meeting
North West Branch A.G.M. 16th January
Tel: 0161 486 9234
5th June 2011 at 10:00 a.m. - The Dene Hotel, Hoole Road Chester CH2 3ND Tel: 01244 321165
Nottingham Branch A.G.M. 16th January at 10:00 a.m. - The Red Cross Centre, Nottingham MG8 6AT
Tel: 0115 932 8832
Chester, North Wales Staffs and Shrops Branch Meeting
Oxford Branch A.G.M. 15th January at 10:00 a.m. 89 Rose Hill, Oxford OX4 4HT
Tel: 01993 883397
2nd October at 10:00 a.m. - The Dene Hotel, Hoole Road, Chester CH2 3ND Tel: 01244 321165
Membership Membership of the Institute of Chiropodists and Podiatrists is open to chiropodists/podiatrists registered with the Health Professions Council and Foot Health Practitioners who qualify for acceptance.
We offer professional and business support To discuss further about becoming a Member or Associate of the Institute please call us and we would be happy to talk to you.
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To view our website/online store please visit:
The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside, PR9 0TL Telephone 01704 546141 email firstname.lastname@example.org
Recruitment BARNET, NORTH LONDON Independent self employed Chiropodist/Podiatrist wanted. Initially for 1 day a week and Saturday mornings. Patients load already available but MUST be willing to build up own clientele. Private practice experience helpful but not essential. Will suit motivated person. Please send CV to: email@example.com
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BUSINESS CARDS printed 1 side: 1,000 = £40, 10,000 = £96. Appointment Cards printed two sides: 10,000 = £99. Record Cards, Continuations, Sleeves all 8” x 5” x 1,000 = £59. Small Receipts: 2,000 = £48, 4,000 = £68. Des Currie: 01207 505191. BERGMAN UK – For all your Orthotic Requirements 28 High Street Northallerton, North Yorks DL7 8EE. Telephone: 01609 781397 or 07877 986605.
The Institute Strongly advises any applicants seeking employment to obtain a formal “Contract of Employment”
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President Mrs. F. H. Bailey M.Inst.Ch.P
Mrs. J. Cowley
Mr. N. Hodge
Cheshire North Wales
Mrs. D. Willis
0151 327 6113
Devon & Cornwall
Mrs. M. Reay
Mrs. S. Bennett
Mrs. B. Wright
Hants and Dorset
Mrs. J. Doble
Mrs. C. Hughes
Mr. M. Hogarth
Leicester & Northants
Mrs. R. Rose
Mrs. L. Towson-Rodriguez
Standing Orders Committee Mr. M. Hogarth M.Inst.Ch.P Mrs. L. Pearson M.Inst.Ch.P
Mrs. E. Barwick
0191 490 1234
North of Scotland
Mrs. S. Gray
Secretary Miss A. J. Burnett-Hurst
Mr. B. W. Massey
0161 486 9234
Northern Ireland Central
Miss G. Sturgess
0289 336 2538
Northern Ireland Regional
Mrs. T. Patterson
0289 145 6900
Mr. S. Gardiner
0115 932 8832
Mrs. S. Harper
Republic of Ireland
Mr. R. Sullivan
00353 21 462 1044
Mrs. D. Straw
Sth Wales & Monmouth
Mrs. J. Nute
02920 331 927
Surrey and Berkshire
Mrs. M. Macdonald
0208 660 2822
Mrs. V. Probert-Broster
Mr. J. Olivier
Mrs. L. Pearson
Mrs. H. Tyrrell
0208 903 6544
West of Scotland
Mrs. J. Drane
Mr. D. Collett
0121 378 2888
Mrs. J. Flatt
Chairman Executive Committee Mr. R. Beattie Hon. F.Inst.Ch.P Vice-Chairman Executive Committee Mr. D. A. Crew OstJ, F.Inst.Ch.P., DCh.M Chairman Board of Ethics Mrs. C. Johnston M.Inst.Ch.P.,BSc(Hons) Chairman Board of Education Mr. W. J. Liggins F.Inst.Ch.P., F.Pod.A., BSc(Hons) Vice-Chairman Board of Education Mr. J. W. Patterson BSc(Hons)., M.Sc., M.Inst.Ch.P Honorary Treasurer Mr. S. Gardiner M.Inst.Ch.P. BSc(Hons)PGDip
Area Council Executive Delegates Midland Area Council Mrs. V. Dunsworth M.Inst.Ch.P. D.Ch.M Northern Ireland Area Council Mrs. T. Patterson M.Inst.Ch.P North West Area Council Mr. M. J. Holmes M.Inst.ChP., D.Ch.M, BSc.Pod Republic of Ireland Area Council Mr. R. Sullivan M.Inst.Ch.P., BSc(Hons) Dip. Pod. Med. PGDip. Cert LA. FSSCh. FIChA MRSM
Scottish Area Council Mrs. A. Yorke M.Inst.Ch.P Southern Area Council Mrs. M. Newnham M.Inst.Ch.P Yorkshire Area Council Mrs. J. Dillon M.Inst.Ch.P
Podo Lux 30 Dust Extraction Drill
£795 Carry Case half price..
£699 £599 Hampshire Unit
Canonbury Royal Domiciliary Bag
£295 £195 Canonbury Round Saddle Seat Colour options Chart B, E or F.
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