November/December 2010 Vol. 67 No. 6 ISSN 1756-3291
The Principles and Philosophy of Health Care Treatment of Dry Heel Fissures 2011 A.G.M. Information The Institute of Chiropodists and Podiatrists Abductor digiti minimi
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Contacts Editor: Mr. R. H. S. Henry Email: email@example.com Sub-Editor: Mr. R. Sullivan Email: firstname.lastname@example.org Press & Public Relations Officer: Mr. F. Beaumont Telephone: 0191 297 0464 Published by: The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Telephone: 01704 546141 or 08700 110305 Fax: 01704 500477 Email: email@example.com Web: www.iocp.org.uk
Contents 1. Editorial 2. Diabetes News 3. Subscription and Insurance Notice 4. Article- The Principles and Philosophy of Health Care 8. Article - Part 3 Epigenetics 10. Article - The Treatment of Dry Heel Fissures 14. Safe and Healthy 16. Personal Profile 17. HPC – Focus on record keeping Centre CPD Article Osteomyelitis 20. Back to Base 22. 2011 A.G.M. News 23. Branch News 30. CPD 33. Classified Adverts 34. Diary of Events 35. Achilles Christmas Quiz
Dear Reader What makes a good journal? It must be interesting and informative, eye catching and upto-date. Podiatry Review must appeal to the whole spectrum of Membership of the Institute of Chiropodists and Podiatrists. From the Foot Care Assistant right up to the Consultant Podiatric Surgeon and all the chiropodists/podiatrists in between. No mean feat (if you will pardon the pun). What have we of interest and note in this Christmas edition of Podiatry Review? We have an article on the Principles and Philosophy of Health Care by Chris Maggs BSc (Hons). We have a treatise by our old friend Greg Quinn FCPodS Podiatric Surgeon. ‘What is meant by ideal foot function?’ This is the third part of his lecture given earlier this year at our A.G.M. in Nottingham. I have included in this issue a research item entitled “The treatment of dry heel fissues using cyanoacrylate tissue adhesive (glue) a review of 18 cases” by Belinda Longhurst, private practitioner, Elisabeth Allan private practitioner and Ivan Bristow, Lecturer, University of Southampton UK. I found it a very interesting article and I hope you do too.
Our personal profile is fom Claire Todd BSc M Inst Ch P. who has just obtained her BSc in podiatric Medicine. Our congratulations go out to her. To quote her words “Our profession is continuing to change, and we believe that by keeping up with our continued professional development ,we will keep at the forefront.” Our middle page pull out CPD is about Osteomyelitis. Once again we thank Judith Barbaro Brown MSc PGDIP, BSc (Hons) PGCE MChS.for sharing her extensive knowledge with us. I have included notices of Seminars of both branches and area councils. As Christmas is fast approaching I have included a Christmas Quizz just for fun (test your knowledge). It only remains for me to thank Mrs. Bernie Willey in the office for all her help with the planning of Podiatry Review and to wish all our readers a very happy Christmas and a prosperous and above all a healthy New Year Roger Henry, Editor Podiatry Review
Annual Subscription: £25.00 Single Copy: £5.00 Including Postage & Packing ISSN 1756-3291
© 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.
News News News News News News News News
Lilly withdraws old pre-filled insulin pens Lilly UK is discontinuing its old pre-filled insulin pens from March 31 2011 following approval to make both Humulin and Humalog insulins available in its KwikPen insulin device. These pens now contain the same range of Humulin and Humalog insulins previously found in the old pre-filled insulin pens. Lilly UK says that the KwikPen is simple to teach, easy to use and has enhanced colour coding for identification. There are 20,000 people with diabetes in the UK who currently use the old pre-filled pen for insulin. Following authorization from Medicine and Healthcare products Regulatory Agency (MHRA), Lilly can now make their insulin available in its KwikPen.
Awareness Cathy Moulton, Clinical Advisor at Diabetes UK, said: "We are keen to ensure that people with diabetes are aware that Lilly’s old prefilled insulin pens will no longer be available from March 31 2011. "Diabetes UK would like to reassure people with diabetes that no insulins are being withdrawn and that Lilly are discontinuing the old insulin pens to ensure continuity and insulin safety. "All healthcare teams have been notified of the withdrawals and so will be able to help with how to use the new pens. We would advise anyone who has concerns to contact Lilly’s freephone helpline on 0800 783 6764." The transition from the older prefilled pens to the KwikPen has already taken place in France, Spain and Italy with minimal reported impact on people with diabetes using those pens.
European Medicines Agency decides to suspend Avandia The European Medicines Agency (EMA) has announced a recommendation to suspend all forms of Avandia (rosiglitazone) from the European market this afternoon following a review into the safety of the drug. Diabetes UK is advising anyone currently taking Avandia to consult their healthcare team without delay to discuss switching onto an alternative treatment that is best suited to their needs.
Why has it been withdrawn?
Research has suggested that people with diabetes who take Avandia have an increased risk of cardiovascular disease. A panel of experts at the EMA then met this week to review the risks and benefits of Avandia and announced this afternoon that they no longer deemed it to be a safe and effective drug for people with diabetes. At the same time as the EMA announcement, regulators in the US have confirmed tougher restrictions over the drug's use.
Diabetes UK advice
“The EMA (European Medicines Agency) no longer believe that Avandia (rosiglitazone) is a safe treatment. We are
therefore recommending that people with diabetes currently taking Avandia get in touch with their healthcare team as a matter of urgency to discuss their treatment options,” said Simon O’Neill, Director of Care, Information and Advocacy at Diabetes UK. “We would not advise them to stop taking their medication in the meantime unless they are experiencing adverse side effects (such as swollen ankles or breathlessness) as it is very important that people with diabetes keep their blood glucose under control to prevent short and long term complications. “People with diabetes should be given information about the risks and benefits of all the alternative treatment options available to them so that they can reach an informed decision about their best option with their healthcare team.
Patient safety is paramount “Patient safety is paramount, so we welcome that a decision has been made about Avandia so people can now be supported to change onto an alternative treatment. We would urge the EMA to make swifter decisions in the future to ensure patient safety.”
The Principles and Philosophy of Health Care by Chris Maggs, BSc (Hons) Introduction This paper is a case study of Mr T who has type 2 diabetes mellitus. It follows the foot health care treatment of Mr T since diagnosis through to current day treatment, where I continue to treat him. It will demonstrate the reasons why care is needed from a traditional biomedical basis and progress to show how models of health can help understand the patient’s needs, as opposed to treating the condition in isolation. Finally it will examine how effectively Social Policy meet the foot Health Care needs of this individual.
The Patient Mr T is a 64 year old white male who is fully ambulant; he was diagnosed with the condition in 2007. Other than type 2 diabetes and being overweight Mr T is in good health for a man of his age. Mr T developed a plantar ulceration on the first metatarsal head of his right foot. At inception he showed classic signs of patient denial producing late to his GP. As a result of this secondary condition Mr T was tested for diabetes by his GP and placed under the treatment of the Practice Nurse for bi-weekly dressing changes and two months later to myself in the role of an NHS Podiatrist. Initially I saw Mr T on a weekly basis to monitor the recovery of the wound and assist with off loading the pressure through dressing, education and an orthopaedic boot. Once the ulcer had recovered I continue to see him 6 weekly, for basic chiropody. My treatment includes an annual diabetic foot assessment, continuous monitoring of circulation, skin condition and neuropathy of the lower limb, the cutting of nails, removal of callus with care and caution. As well as treating Mr T on a purely biomedical basis ‘...getting the sick back to work. .’(Brown 2010, p42) I will demonstrate the evolution of NHS Government Health Care on how I have tried to educate him on his condition and work in partnership in a biophychosocial way.
Pathophysiology Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia),’ (World Health Organisation 2010, p1) Type 2 diabetes is the most common form of diabetes and can be developed at any age, however it is more evident in people over the age of 40, South Asians and Afro-Caribbean’s. Most diabetics are obese; onset usually begins with insulin resistance, leading onto ’...impaired regulation of hepatic glucose production and declining Bcell function, eventually leading to B-cell failure’ (Mahler & Adler 1999). In general terms, it is an insulin deficiency as opposed to an absolute absence, (Foster 2006). Fortunately for Mr T he developed a secondary condition to that of the otherwise undetected diabetes. This almost certainly saved him from more serious consequences had the diabetes gone undetected.
History, Signs and Symptoms Prior to diagnosis Mr T showed some but not all of classic symptoms of this condition. He experienced unexplained weight loss, excessive thirst, polyuria and neuropathy, in feet and fingers. Mr T did not exercise regularly and is clinically obese. There is no proven family
history of the condition although his father died young after the onset of more than one stroke which is linked with this condition. “If diagnosed late, left untreated or poorly managed; it can lead to devastating complications such as heart disease, strokes and blindness.” (Castle 2010, p3) Other signs and symptoms not present or importantly not disclosed by Mr T include: renal failure, blindness, erectile dysfunction, arterial disease, coronary artery disease, excessive bowel movements and lethargy/chronic fatigue, (Mahler & Adler 1999).
Physical Assessment and Treatment Initially Mr T was treated by his GP attempting to control the primary condition through diet. He condensed the intake of fats and sugars and although his blood sugar level readings reduced, they did not decline at a desired rate so he was issued with the following medication; Aspirin 75mg, Ramipril 10mg, Avandia 4mg and Metformin 500mg. As a result of the medication his blood sugar readings had declined from an alarming 23 to a now manageable normal 6-7. Because of Mr T’s primary condition and neuropathy he is susceptible to developing further ulcers. In short, the overall aim of my treatment of Mr T is to detect problems, educate him on the condition/solutions and constantly review my treatment so he achieves optimum health. In more detail I use the following 6 stage approach (Foster 2006). 1) Mechanical control, this includes examination of the patient’s feet and footwear. Particularly looking for abnormalities on the feet that may be related to wearing unsuitable or no footwear, or particular wear to the shoe which would indicate particular points of pressure. 2) Dialogue with my patient regarding suitable footwear and methods used to off load pressure in both short and long term situations. Metabolic control, the patient’s history with his GP, blood pressure, BMI, smoking history, etc. 3) Microbiological control, comparison of both feet searching for signs and symptoms of infection. If conditions present, what are the changes in size, colour, discharge, odour, pain, swelling, fever, wider and so on. If problems are located, samples need to be taken and sent for analysis. Appropriate treatment can then be sought. 4) Vascular control. Is the foot ischaemic? If so, to what degree? Does the patient need to be referred to the vascular team? 5) Wound control. Is the wound suitably debrided and dressed appropriately? Is a competent person changing the dressing and is the wound in improvement or decline? 6) Education control, (remembering always Ley’s model of compliance, 1989) the patient’s knowledge of their condition, perceived risk, day to day responsibilities to minimize complications.
Psychosocial Models of Health As I am limited in words for this assignment in order to understand the foot health care needs of Mr T I am going to examine two of the more widely known psychosocial models of health. Other models such as Attribution theory (Heilder 1958), Transtheoretical Model (Prochaska & DiClemente 1977), Unrealistic Optimism (Weinstein
1983), Protection Motivation Theory (Rogers 1975), Theory of Planned Behaviour (Ajzen & Fishbein 1980), Health Action Process Approach (Schwarzer 1992) and Self Efficacy (Bandura 1977) are available in appendix A-G. It must be remember that when dealing with all of these models we do not have the availability of the vacuum effect and evaluation of all of the models as is difficult. It must never be forgotten we are dealing with complex characters living in an evolving world, so a control specimen in purely scientific purposes is impossible.
Health Belief Model (HBM) The Health Belief model originates from the 1950’s by Hochbaum, Rosenstock and Kegels working in the U.S. It was developed by Rosenstock (1966) and further again by Becker et al (1977). The model is based on the following principles; a person will take health related action if they feel a negative health condition is avoidable, by taking that action they will avoid/negate the condition,they can successfully take that action. Initially the model was based on four basic principles, the first two concentrate on the illness itself and the later two on courses of action to managing the risk or severity of the disease. 1) Susceptibility of illness (chances of getting it), 2) Severity of illness (evaluation/consequences of developing the condition), 3) Benefits of a health behaviour (i.e. prevention through examination), 4) Costs/barriers to carrying out that behaviour, i.e. time and money. The fifth “Cues to action” added later by Becker and once triggered promotes a revisiting of the model and further evaluation. The sixth self-efficiency is the confidence in the ability to successfully perform an action. ‘This concept was added by Rosenstock and others in 1988 to help the HBM better fit the challenges of changing habitual unhealthy behaviours.’ (University of Twente 2010, p1).
Relating the Model to the Case Study In the case of Mr T qualitative research interviews (assuming honest cooperation) have indicated that as a healthy person he never envisaged developing this condition. Even when the symptoms of the diabetes started, they appeared gradually and were dismissed as aging. Although Mr T does not openly admit the seriousness of the condition it is difficult to establish if he feels differently in private. I am certain he sees the benefits of self examination but does not do it any where near the recommended daily advice. From treating Mr T over a period of 3 years I am confident he would seek help if a further ulceration developed, but again I expect he would produce late. As Mr T’s condition is chronic there are no direct financial costs to him, as NHS treatment is free. However as he is a self employed business man the indirect cost of time for examination and lost work time through making appointments are definitely factors in the decision making process. Developing the ulcer was in fact a wake up call and it had the desired effect in the principle of the model making him re-evaluate and seek help. The sixth stage self-effiicancy can be viewed two fold, some adaptation to this condition would be easier (six weekly podiatry appointment) than others (fundamental change of diet).
Evaluation of the Model Results from studies are inconsistent (Brown 2010), people’s feelings and opinions change overtime, with moods so Mr T may show positively one day and anxiety the next. Unfortunately to make matters even more complicated depression is a symptom of the condition and therefore affects the evaluation process. Other critics of this model point to many unanswered questions. Can we truly make such rational decisions about matters relating to our health when we are not well and could be in shock and denial? Are the components of the model related? If so how? Or do they purely work in isolation? Returning this model specifically to Mr T, his wife (a complicated other) has driven his improvement often making appointments for him and attending with him, So it must be remembered, regardless of the patient’s
behaviour a complicated other may help or hinder progress, (food preparation etc). We must not forget other human factors such as race, religion, class and of course “good intentions” but poor results. Schwarzers model of Health Action Process Approach pays particular attention to this in appendix F.
Health Locus of Control (HLOC) Health Locus of Control (Rotter 1975) was considered a revolutionary way of looking at causation. This model is very similar to attribution theory, however attribution concentrates on what has happened as opposed to looking at the future as this model does. The foundation of this model is that individuals based on previous experience either have an internal locus of control (basically they decide their fate) or they have an external locus of control (destiny and luck decides their fate). Wallston et al (1976) applied this model to health forming the Multidimensional Heath locus of control. This model has three key dimensions. Health is controlled by: 1) The individual (internal) 2) Chance (external) 3) Powerful others (Doctors etc).
Relating the Model to the Case Study This time ignoring the primary condition and focusing on the ulcer, if Mr T demonstrated an internal locus of control he would believe that if he takes care of himself and is careful, he should avoid getting another foot ulcer. However if his view is external, his view would be that no matter what he does, destiny will decide if he is going to get another ulcer. The third vital element is that of the powerful other, whatever happens I was just following the ‘Doctors orders.’ Correlation here between point two and three locus’ are therefore obvious.
Evaluation of the Model Again unfortunately evaluation of this model remains inconclusive. However if patient T has an internal locus of control and places value in medical opinion then by working together further problems can be limited. Again criticism is offered, in that do individuals always view matters internally or externally? (Hewstone & Stroebe 2001). Humans are complex characters and changes in mood and opinions can shift focus from one to the other. Again taking Mr T as the example, having worked hard in conjunction with a medical team to treat and heel his ulcer, patient T may feel matters are somewhat under his control. However should a second ulcer appear, will he be thinking the same way or will he become defeatist and shift to an external locus in that there is nothing he can do to effect matters? Finally by seeking medical assistance, are patients being internal or external? One could argue that by seeking help Mr T is trying to reduce his chances of further problems or conversely, that he is abdicating all responsibility leaving it the powerful other and allowing fate to decide.
Social Policy Traditional Social Policy has seen a shift from the biomedical model towards the bio psychosocial model. The biomedical model was originally the prominent health care model in the Western world since the mid nineteenth century and was the basis of the NHS. ‘.. The biomedical model is considered the epitome of scientific, objective and reproducible medicine, the actual delivery of health care may be somewhat different in practice.’ (Brown 2010, p49) It is in its idealistic form its aim is efficient fitness, without disease (Jones 2004). However the bio psychosocial model is seen as having all of the above with the bolt on of ‘Social, psycochlogical and emotional factors in diagnosis and treatment.’ (Brown 2010, p51). This new Social Policy in its idealistic form is more expensive than its predecessor particularly in the short term as it looks past treatment alone in clinical terms and to that of prevention. Even though we are in a global recession and have had a new coalition Government, the likes of which we have not seen for many years, it is considered by experts (Liggins 2010) that we will not see a return to the past in the race for short term financial gain.
Mr T receives free NHS treatment in line with Government Policy on managing chronic conditions and it has to be said that he as a patient he is reasonably well catered for in his PCT. Although it must be remembered that in a society of devolved budgets a post code lottery exists as different areas run there spin on National Policy, (Foster 2006). Mr T from inception to recovery/stabilisation has received treatment from a multidisciplinary team including GP, Diabetic Nurse and myself (Podiatrist). His medication, orthopaedic insoles and basic chiropody treatment are all at no cost to him and the only cost/barrier to treatment, (Becker et al 1977) is that of his personal time. In an economic utopia Mr T should have been referred to me at an earlier stage and everything he needed from an orthopaedic point of view should have been ready yesterday, but this will never be the case. Even in privately paid treatment there are delays as someone has to physically make the boot/support. More should be done on the education of the condition through the National media and this is something that “Diabetes UK” is continually campaigning for. Their aim is to receive on a more comparable basis investment through National media campaigns similar to obesity, smoking, substance abuse and more recently strokes, interestingly most of which have links with diabetes!
Conclusion This assignment set out to illustrate why foot health care is needed through the experience of Mr T in a biomedical way of returning him to ‘functional fitness’. It developed to show how psychosocial models of health can help
References Source: Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, p. 179-211, (on line) http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communica tion/theory_planned_behavior.doc/ (Accessed 26/5/10) Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopaedia of human behaviour (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopaedia of mental health. San Diego: Academic Press, 1998), (on line) http://www.des.emory.edu/mfp/BanEncy.html (Accessed 27/05/10) Becker, M H, Maiman L A, Kircht J P, Haefer D P & Drackman R H (1977) The health belief model and prediction of dietary compliance. A field experiment. Journal of Health and Social Behaviour. 18: 348-66 Brown J. B (2010) Principles and Philosophy of Health care Course Notes [Lecture] Unit 2, Sheffield Training School (18/4/2010)
understand the needs and thinking of the patient and why treatment is needed but cannot always be successful. Finally this paper assesses how adequately Social Policy and Health Care meet the needs of Mr T.
In Summary It must be remembered that success varies patient to patient based on numerous reasons stemming from the Health Belief of themselves or the Powerful other treating them. Other factors include patient cooperation/non adherence (either deliberately, financially, lack of understanding or because the patient is confused over instructions/poor explanation). Patients of different age, sex, race, religion or social class often make these decisions based on their socialisation (see appendix G). Other prevailing factors include the type, seriousness and duration of the illness.
The Future The prognosis for Mr T, providing he follows the advice of the multidisciplinary team, is good. He will never be cured due to the chronic nature of his condition and unfortunately over time with poor circulation and increased neuropathy of the lower limb sensation is likely to decrease with age. However on a positive note with good patient and multidisciplinary cooperation any future ulceration should receive much faster detection and treatment.
Rogers R W (1975) A Protection Motivation theory of fear appeals and attitude change. Journal of psychology 91, 93-114 Rosenstock I M (1966) Why people use health services. Millbank Memorial Fund Quarterly 44, 94-124 Rotter J B (1975) Some Problems and Misconceptions related to the construct of internal verses external control of reinforcement. Journal of Consulting and Clinical Psychology, 43, 56-67 Salmela S, Poskiparta M, Kasila K, Vähäsarja K, Vanhala M. Transtheoretical modelbased dietary interventions in primary care: a review of the evidence in diabetes. Health Education Resources 2009 Apr; 24(2):237-52. (on line). http://www.enotes.com/topic/Transtheoretical Model (Accessed 26/05/10). Schwarzer R (2002) Modeling Heath Behaviour Change, The Health Action Process Approach (HAPA) (on line) http://web.fu-berlin.de/gesund/publicat/ehps_cd/health/hapa.htm (Accessed on 27/05/10)
Cancer Prevention Research Centre Transtheoretical Model (on line)
Sutton S. (2002) Health Behaviour; Psychosocial Theories University of Cambridge UK
http://www.uri.edu/research/cprc/TTM/efficacy.htm (accessed on 27/05/10)
University of Twente (2010) Health Belief Model (on line) http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communica tion/Health_Belief_Model.doc/ (Accessed on 12/04/2010)
Castle D. (2010) [Public Affairs Manager at Diabetes UK] Podiatry Review May/June 2010 Vol 67 No 3. Epstein O.,Perkin D. G., Cookson J & De Bono D. P (2004) Pocket guide to Clinical examination, Third edition, Edinburgh, Mosby. Foster A.V.M (2006) Podiatric Assessment and Management of the Diabetic Foot, Edinburgh, Churchill Livingstone.
University of Twentee (2010) Theory of Planned Behaviour Model (on line) http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communica tion/theory_planned_behavior.doc/ (Accessed on 27/05/10)
Haralambos M. & Holborn M. (1991) Sociology Themes and Perspectives, Third Edition, London, Collins
Wallston B S, Wallston K A, Kaplan G & Maides S (1976), Development & validation of the Health Locus of Control (HLC) Scale. Journal of Consulting & Clinical Psychology, 44, 580-585
Heilder, F (1958) The Psychology of Interpersonal Relations. New York, John Wiley & Sons
Weinstein (1983) Reducing unrealistic optimism about illness susceptibility Health Psychology, V 3 431-457
Hewstone M. (Ed) & Stroebe W. (Ed) (2001) Introduction to Social Psychology, Third Edition, Oxford, Blackwell.
Wild S., Roglic G., Green A., Sicree R., & King H (2004) Global prevalence of diabetes: Estimates for the year 200 and projections for 2030, Diabetes Care 27, 1047-1053World Health Organisation (on line) http://www.who.int/en/diabetes/en/ (Accessed on 12/4/2010)
Healthy Lifestyles Unrealistic Optimism (on line) http://www.healthierlifestyle.info/unrealistic-optimism/ (Accessed 27/05/10) Hogg M.A & Vaughan G. M (2002) Social Psychology, Third Edition, Edinburgh, Prentice Hall.Jones L.J (1994) The Social Context of Health and Heath Care, Basingstoke, Macmillan Ley P (1989) Improving patients’ understanding, recall, satisfaction and compliance in A K Broome (Ed) Health Psychology Processes and Applications London: Chapman and Hall Birdwhistell R (1970) Kinese and context. University of Pennsylvania Press, Phildelphia Learning Theories, Attribution Theories (on line) http://www.uri.edu/research/cprc/TTM/efficacy.htm (accessed on 27/05/10) Liggins W. (2010) History of the Institute Course Notes [Lecture] Induction day, Sheffield Training School, 24/3/2010 Mahler R.J & Alder M.L (1999) Type 2 diabetes Mellitus: Update on diagnosis, pathophysiology and treatment. The Journal of Clinical Endocrinology & Metabolism Vol 84 No 4 1165-1171. (on line) http://jcom.endjournals.org/cgi/content/full/84/4/1165 (Accessed 26/05/10) Prochaska J O & DiClemente C C (2005) The Transtheorectical approach in Norcross J C. Goldfield M R (Ed) Handbook of Psychotherapy integration 2nd Ed. New York, Oxford University Press, 147-171
Bibliography Annandale (1998) The sociology of Health and Medicine: A critical Introduction, Polity Press Argyle M. (1994) The Psychology of Interpersonal Behaviour. Fifth Edition, London, Penguin. Models of health care delivery: the bio psychosocial model 2010 (on line) available fromhttp://openlearn.open.ac.uk/mod/resource/view.php?id=278225 (accessed 08/04/2010) Models of health care delivery: the biomedical model 2010 (on line) available fromhttp://openlearn.open.ac.uk/mod/resource/view.php?id=278223 (accessed 08/04/2010) NHS website foot health for people with Diabetics (2009) available from http://www.nhs.uk/livewell/foothealth/pages/diabetesandfeet.aspx (accessed 03/05/2010)
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Part 3 - What is meant by ideal foot function? Greg Quinn, FCPodS, Podiatric Surgeon “The attainment of an ideal is often the beginning of a disillusion” Stanley Baldwin
t is possible to analyse the behaviour of any body system in a number of ways by using physiological, biochemical or physical levels of analysis. All approaches to the analysis are equally legitimate, and useful analysis at one level does not prevent the usefulness of others. The key issue is how differences in one type of analysis relate to those in others. When we are confronted with patients suffering from painful symptoms we strive to consider the etiological cause. If the problem is diagnosed to be of biomechanical origin, physical examination and analysis is clearly the appropriate process to be adopted. In so doing, we use a theoretical model to compare what we might expect to find with our examination findings. In the past, this would have been done using the model of subtalar neutral positioning to connect alignment with function. This is now largely discredited as an unreliable process. The understanding that anatomical features of the foot will vary but collectively deliver a common purpose is fundamental to understanding how symptoms arise and planning treatment intervention. The human foot evolved through the acquisition of retained genetic mutations that define our common structures although these vary between individuals. A succinct way to describe this might be that whilst our bones, joints, ligaments etc. vary in size and exact position, they are arranged within an identical skeleton i.e. the broad proportions and general shapes remain the same for us all. As a consequence, walking on our feet tends to be carried out in a broadly similar way within each environment. The physical processes involved will tend to utilise common features to deliver the foot’s purpose. Working as an integrated ‘unit’, the foot accepts the forces of loading body weight (as the knee flexes or bends) prior to acting as a propulsive lever to push us forwards as we extend (straighten) the knee and hip. As we learn to walk, the leg and foot are inverted (tilted inward) relative to a vertical midline of the body. In striking the ground weight bearing occurs first on the lateral border. The force of body weight is resisted by an equal ground reaction force acting through the lateral foot structures. Rather than bear weight on only the lateral border, the force acts through the rearfoot joints to produce rotation. The inherent orientation of the sub-talar joint provides least resistance to this force and as a consequence, the head of the talus moves medially and downwards onto the navicular which itself is pushed lower to the ground with a slight medial drift. The legs will twist inwards slightly and the heel moves into a less inverted position. The consequence of this movement (which we describe as pronation) is to place the foot flat to the ground, providing a more stable platform of support. The medial column of the foot has been loaded. In so doing the arch structure (e.g. calcaneocuboid joint) will lose some stability. The medial loading process requires guiding and supporting ligament action (including the plantar fascia) to prevent excessive arch instability. Muscle action (e.g. tibialis posterior) medial to the sub-talar joint serves to decelerate and control this process as the ground reaction force is gradually spread across the sole of the foot.
During this entire initial phase, the foot’s skeleton and associated structures, work in concert to withstand these normal stresses. A compromised performance in one structure will create greater stresses or strains within it or transfer damaging forces into other tissues. Loading of the medial column of the foot brings the 1st metatarsal head in contact with the ground. This is articulated proximally with the medial cuneiform (collectively described as the 1st ray). The 1st Ray has a variable but inherent stiffness that will resist ground reaction force, but will elevate slightly as the overall shape of the medial arch deforms naturally. Having dissipated the forces of loading within the lower limb, pressure is gradually shifted towards the forefoot as the body moves over the now fully weight bearing foot. The initial internal leg twist is now reversed as the supporting limb externally rotates. This is translated through the rearfoot and the calcaneocuboid joint assumes a more stable position. As the foot moves into a propulsive phase the ankle joint plantarflexes as the heel leaves the ground. To assist with this, the peroneus longus muscle contracts. This also serves to lift the cuboid and consequently the arch and heel lift together. This is a uniquely human trait. The shorter lateral metatarsals and toes progressively (lateral to medial) lift from the ground resulting in a maximum extension of the 1st MTP joint. Through the ‘windlass effect’ of the plantar fascia, the arch is supported and the heel inverted. This supports external rotation of the supporting limb. The 1st and 2nd toes are the last structures to leave the ground as the thrusting force of propulsion is imposed against it. The maximum heel lift, created by the arch lifting with it, optimises the capacity of the propulsive thrust to generate knee, hip and lower spine joint extension. This process returns energy efficiently back into the body, minimises energy expenditure and increases stride length. I began this article by explaining how different analyses can be used to specify malfunctions in a body system. Foot, or more accurately, lower limb biomechanics has an increasing number of behavioral models to employ to help normalise gait kinetics (forces) and kinematics (movement) e.g. Morphology, plantar pressure mapping and gait analysis. What is essential to bear in mind here, is that for each model, there should be a corresponding correlation of findings with each other’s legitimate levels of investigation. The findings from each investigative assessment or examination must also make reference to the fundamentals of biological purpose. Furthermore, the findings from one patient may only be broadly extrapolated for another if anatomical and functional traits are closely matched. As we have discovered, from Evolution and Natural Selection has emerged a foot that is marked by a relative variability of its structural and functional properties. Greg Quinn, Sheffield. firstname.lastname@example.org
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The treatment of dry heel fissures using cyanoacrylate tissue adhesive (glue): a review of 18 case Belinda Longhurst, Private practitioner, Winchester, Hants, UK, Elisabeth Allan, Private practitioner, Hants, UK, Ivan Bristow, Lecturer, University of Southampton, UK Summary Topical tissue adhesives have been used widely in healthcare for the closure of wounds and lacerations (Beam 2008). A recent Cochrane review (Coulthard et al 2009) has indicated the benefit of this modality over other more traditional types of closure. However, little investigation has been undertaken into the potential applications of tissue adhesives in podiatry, such as closure of dry heel fissures which often cause pain and offer a challenge for podiatrists to manage effectively (Singh 1996). A case series is presented reporting the use of glue in the management of dry heel fissures. A review of 18 patients treated with Octyl-Blend10™ tissue adhesive (MedLogic Global Ltd®, Plymouth, UK) was undertaken across four private practices in Hampshire. Each patient underwent administration of tissue adhesive by the podiatrist and was followed up for a minimum of three weeks. Outcomes were measured using a patient/practitioner evaluation and feedback form and digital photographs of the lesions before, during, immediately after and three weeks post treatment. Overall the response was positive from patients and practitioners alike with regard to ease of application, aesthetics and patient comfort. During the study period, 94% (17 patients) of lesions healed with no adverse events. Instant and lasting pain relief following application was reported by the majority of patients. Dehiscence of the fissure occurred in only 1 subject. This exploratory work suggests that cyanoacrylates, and the Octyl-Blend10™ tissue adhesive in particular, may have a place in the management of painful heel fissures.
Cyanoacrylate topical skin adhesives
Fissures are splits in the epidermis which can extend to and involve the dermis. These are usually found at sites where the skin is under tensile stress e.g. around the heel margin, being associated with hyperkeratosis and anhidrosis (Penzer 2005). The main symptoms for patients are pain, itching, bleeding and embarrassment. Discomfort can make walking and weight bearing difficult, whilst the embarrassment of thick, callused heel fissures can psychologically affect a person (Beltraminelli & Itin 2008). Moreover, such lesions can act as a portal of entry for secondary infection. Systemic and peripheral states that affect skin quality can render some people more prone to the condition than others, such as patients with diabetes, peripheral vascular disease, rheumatoid arthritis, pregnancy, obesity, systemic sclerosis, dermatitis, ichthyosis, palmoplantar keratoderma, psoriasis and tinea pedis for example (Lucke et al 2002).
Fissures, or cuts in the skin, often need to be closed to ensure rapid and uncomplicated healing. Traditionally, there have been four ways to join tissue together: sutures, staples, tapes and synthetic tissue adhesives. Sutures, staples and tapes work well in non- weight bearing post operative situations (Murtha 2006) but are also associated with a number of surgical complications, including discomfort, infection and inflammation (Farion et al, 2001). Hashimoto (1999) asserts that treatment of lacerations in emergency room situations has shown that cyanoacrylate tissue adhesive is less painful to use and faster than suturing or tape. He also recommended the use of “off-the-shelf Superglue” for the treatment of heel fissures in patients with diabetes. OctylBlend10™ tissue adhesive (MedLogic Global Ltd®, Plymouth, UK) is a CE marked product which is licensed for the closure of skin cuts and abrasions. The product was adopted across four private practices in Hampshire and after an initial period was evaluated for its effectiveness in the management of dry heel fissures.
Historically, management of dry fissures has required removal of the source if possible. For instance, in shoe devices can be used to alter forces on the tissue under stress, the removal of allergens or treatment of tinea pedis, etc, can reduce or eliminate the underlying cause. (O`Donnell 2002) Debridement of hyperkeratotic tissue and optimising epidermal strength is also paramount to assist resolution. This can be achieved in controlling stratum corneum water content, by hydrating anhidrotic skin with an emollient or hydrocolloid dressing (Springett et al 1997). However, anecdotally, dry heel fissures are difficult to heal because of the mechanical stresses brought about by weight bearing. Standard treatments for hyperkeratosis are of little use once a painful fissure develops (Hashimoto 1999). Thus, the requirement to promote healing and, more importantly, instant and lasting pain relief by means of closing the fissure should be explored.
Singer et al (2007) reviewed the structure and function of cyanoacrylate topical tissue adhesives as well as their advantages, indications and clinical application for optimal use. They detailed how the basic cyanoacrylate has been distilled to achieve purity and remove any toxic by-products, resulting in a low viscosity liquid (figure 1). On contact with various anionic substances, such as blood, the cyanoacrylates polymerize into long chains forming a solid film that bridges the wounds and holds the apposed wound edges together. Because the adhesive film generally sloughs off within 5 to 10 days as the epidermis regenerates, there is no need to remove the adhesive.
Of particular importance, Singer et al also highlighted that topical tissue adhesives should be used in conjunction with immobilization in areas of high tension, due to the increased risk of dehiscence. Therefore, it is advisable to take measures to mitigate the tensile stress associated with heel fissures (Dockery 1997) in addition to encouraging hydration of the tissues by regular moisturising and application of tissue adhesives to the fissure. Saxena & Willital (1999) suggest that wounds in areas of high skin tension (hands, feet and over joints) can be successfully treated with tissue adhesive if excessive movement is restricted. This may be achieved through use of heel cups, orthoses and advice should be provided on supportive and accommodative footwear. A recent Cochrane review (2009), to determine the relative effects of various tissue adhesives and conventional skin closure techniques on the healing of surgical wounds, indicated that tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations. Eight randomised controlled trials (630 patients) were reviewed where tissue adhesive, stitches and/or adhesive tape were used for wound closure. No statistically significant differences were found between various tissue adhesives and sutures for dehiscence, infection, satisfaction with cosmetic appearance when assessed by patients` or surgeons` general satisfaction. Nor were differences found between a tissue adhesive and tapes (2 trials) for infection, patient`s assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. However, where tissue adhesive was utilised, they noted the benefits of decreased procedure time, including no requirement for a follow up visit for removal of stitches and less pain was observed in comparison (verified by pain scores) to standard wound closure.
When considering a wound closure device, ideally it should be easy to use, rapidly acting, and painless, resulting in pleasing cosmesis, not require device removal and importantly, be cost effective. Topical cyanoacrylate tissue adhesives offer many of the characteristics of this ideal wound closure device. Studies have clearly demonstrated that a moist environment is best for optimal wound healing (Feldman 1991). Octylcyanoacrylates are reported to create an occlusive wound healing environment and a barrier to microbial penetration (Mertz et al, 2003).
Methods Across four private podiatry practices in Hampshire, a review of cases was undertaken to identify patients receiving treatment of dry heel fissures using the Octyl-Blend10â„˘ tissue adhesive. Eighteen patients presenting in four private practices in Hampshire, with dry fissuring of the heels treated with the modality, were identified. Data from the four locations was pooled for analysis. Across the four practices a standard treatment approach was adopted prior to the evaluation. Before treatment with the adhesive, fissures were measured and photographed. Questionnaires were utilised by the podiatrists to ascertain any underlying systemic pathology that could complicate healing and any previous treatment methods, or products used by the patient. Overall practitioner and patient satisfaction scores were measured according to aesthetics and comfort, in addition to patient pain scales, all of which were documented on the questionnaire on a scale of 1-10. Pain scores were recorded prior to treatment using a 100mm visual analogue scale, immediately after adhesive application and three weeks after the initial application of the adhesive.
Figure 2: Pain scale before and after application of tissue adhesive.
Each patient underwent administration of Octyl-Blend10â„˘ tissue adhesive (MedLogic Global Ltd, Plymouth, UK) following callus reduction by the podiatrist. Wound edges were opposed manually and the Octyl-Blend10â„˘ tissue adhesive was applied in two thin continuous layers allowing 30 seconds to polymerize between layers. It was noted by the authors that due to the low viscosity of the tissue adhesive, care had to be taken to ensure that excessive runoff did not occur, nor to allow it to wick or seep into incompletely opposed edges during application of the tissue adhesive. This was easily avoided by horizontal positioning of the wound surface and careful, controlled expression of the adhesive from the tip of the applicator. Patients were followed up at three weeks to assess results.
Results Fissure size ranged from 0.5mm to 3mm in depth (mean = 1.55mm) and 3mm to 20mm in length (mean =10.55). Improvement in terms of instant and lasting closure of the fissure was achieved in 94% (17) participants along with remarkable immediate and long-term pain relief following application (see figure 2). It was noted that the instant pain relief could be attributed to sharp reduction of the callus alone, however anecdotal responses (not recorded in questionnaire) from patients reported improved immediate pain relief in comparison to previous treatment methods. Dehiscence of the fissure occurred in only one patient. In this case, the practitioner noted that the edges were not easily approximated and the fissure was a high tension wound. Underlying systemic conditions that could potentially complicate healing were noted to be present in 50% (9) of patients; however this was not observed as a poor outcome marker by practitioners. Patient satisfaction was recorded as 78% (14) of participants commenting positively on the convenience of being able to lightly shower the treated area. These also expressed appreciation for not having to wear an unsightly dressing. Practitioner satisfaction was calculated according to ease of use of applicator and strength or quality, of closure obtained. In total, 88.9% (16) cases were reported by podiatrists as having pleasing results.
Limitations The authors acknowledge that this represents a relatively small case series, within a restricted geographical area and timetable. A larger scale investigation, with objective measures using a control intervention, over a longer period of time would provide a more detailed picture of its use and effectiveness. However, this has demonstrated that skin adhesives have the potential to be of benefit in the management of painful, dry heel fissures in the potential applications in podiatry.
Conclusion The introduction of tissue adhesives was received enthusiastically by both patient and practitioner, in this case series. This preliminary investigation indicates that cyanoacrylates and the Octyl-Blend10â„˘ tissue adhesive in particular, may have a place in the successful management of heel fissures. Of greatest significance was the immediate and long term pain relief reported by the majority of patients with painful dry heel fissures. They functioned as an occlusive dressing with a reported microbial barrier, and were aesthetically pleasing to patients. Whilst they are simple to use and present many potential advantages, they are not suitable for all wounds, i.e. areas of high tension, as with major biomechanical anomalies, or where infection is present. A greater understanding of the mechanical properties, advantages and disadvantages of these cyanoacrylates will aid the podiatrist to establish their indication and use.
Declaration: All adhesive samples for this study were supplied by Medlogic (UK) Ltd. Distributed in the UK by Bailey Instruments Ltd.
Murtha AP, Kaplan AL, Paglia MJ, Mills BB, Feldstein ML, Ruff GL. Evaluation of a novel technique for wound closure using a barbed suture. Plastic and Reconstructive Surgery 2006;117(6):1769–80.
References: Beam JW. Tissue adhesives for simple traumatic lacerations. Journal of Athletic Training. 2008; 43(2):222–4
Mertz PM, Davis SC, Cazzaniga AL. Barrier and antibacterial properties of 2octyl cyanoacrylate-derived wound treatment films. Journal Cutaneous Medicine and Surgery 2003; 7:1-6
Beltraminelli H. Itin P. Skin and psyche – From the surface to the depth of the inner world. Journal der Deutschen Dermatologischen Gesellschaft 2007;6:8-14
O`Donnell M, Lorimer D & Forster M (2002) Clinical therapeutics; in Lorimer D, French G, O’Donnell M, Burrows JG (eds) Neales Disorders of the Foot. London:Churchill Livingstone p433
Coulthard P, Esposito M, Worthington HV, van der Elst M, van Wes OJF, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database of Systematic Reviews 2009; Issue 3. Art No.:CD004287. DOI:10.1002/14651858.CD004287.pub2. Dockery GL. Mechanical Inuries: in Cutaneous Disorders of the Lower Extremity. (1997) Pennsylvania: WB Saunders p242. Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T, Vandermeer B Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database of Systematic Reviews 2001; Issue 4. Art No.;CD003326. DOI: 10.1002/14651858.CD003326. Feldman DL. Which dressing for split-thickness skin graft donor sites? Annals of Plastic Surgery. 1991;27(3):288-291. Hashimoto H (1999) Superglue for the Treatment of Heel Fissures. Journal of the American Podiatric Association 89(8):434-435 Lucke T, Munro C, Ronerts D, Springett K & Thomson J (2002) Dermatological conditions of the foot and leg; in Lorimer D, French G, O’Donnell M, Burrows JG (eds) Neales Disorders of the Foot. London:Churchill Livingstone p211
Penzer R (2005) Emollients: selection and application. Podiatry Now 2005;9 pS1-S8 Saxena AK ,Willital GH. Octylcyanoacrylate tissue adhesive in the repair of pediatric extremity lacerations. Am J Surg 1999;65(5):470-2 Singer AJ, Quinn JV, Hollander JE. The cyanoacrylate topical skin adhesives. American Journal of Emergency Medicine 2007;26:490-496 Singh D, Bentley G & Trevino Callosities, corns and calluses. British Medical Journal 1996 312(6) (7043):1403-1406 Springett K, Deane M, Dancaster P Treatment of corns, calluses and heel fissures with a hydrocolloid dressing. Journal of British Podiatric Medicine. 52(7):102-104 Corresponding author contact details: Belinda Longhurst – firstname.lastname@example.org First published as: Longhurst B, Allan, E, Bristow I. The treatment of dry heel fissures using cyanocrylate tissue adhesive (glue): a review of 18 cases. Podiatry Now 2010 Sept; 13 (9): 11-15. Conflict of Interest: None declared
Safe and Healthy Stephen Gardiner, PGDip, BSc (Hons) Health and Safety Officer for The Institute of Chiropodists and Podiatrists Health and Safety doesn’t have to be a headache. A little planning and simple measures will ensure that your clinic policy passes any health check, and you may even boost productivity and staff morale as a result. Also remember by conducting a Health and Safety audit can be used as part of your CPD. Mention the words health and safety to many people and they might stifle a yawn, but ensuring that you have robust health and safety procedures is a legal requirement for any business with five or more employees, however it is good practice to have a Health and Safety policy in place for those that have less than five employees. Those who fail to protect the health and safety of their staff and other people – such as customers and members of the public – can be fined or even risk being sent to prison. In 2008 to 2009, 29.3 million work days were lost due to health and safety-related issues. Some 24.6 million of these were due to work-related ill health, and 4.7 million were a result of workplace injury, according to the Health and Safety Executive (HSE). Fortunately, setting up a health and safety policy is far less of a trail than some may first expect. All it takes is a little planning and regular reviewing to ensure it is robust and up to date. Having a healthy and safe workplace can even help your bottom line, whether by reducing the cost of your liability insurance, or by reducing worker sick rates and boosting staff productivity and morale.
For starters A good place to start if you’re looking for guidance and a source of information is the HSE, Britain’s national regular for workplace safety and health. Its website – www.hse.gov.uk – gives information including case studies of how different types of businesses have complied with health and safety rules. It also has a ‘myth of the month’ page, in a bid to counter misleading assumptions and press reports about health and safety.
Risk assessment One of the key parts of a health and safety policy is risk assessment. This involves assessing all the potential risks in a workplace, ranging from injuries caused by machinery to slipping on a spilled drink on the stairs. Once they’ve all be identified, you must find ways to either eliminate or control them to ensure healthy and safe conditions are maintained until people reach safety, or the danger is averted.
A lot of businesses get anxious about the whole concept of risk assessment around health and safety; you see it mentioned in the press all the time as a big bugbear, but it’s really quite a straightforward process. A pub’s risk assessment, for example, would include walking around the premises to note any things that might be dangerous or present a potential hazard, checking the accident book for any previous health and safety incidents, and making sure that deliveries of food and drink meet health and safety standards.
Compiling a policy After doing a risk assessment of your business, the next step is to compile a written health and safety policy. This needn’t be a complicated document, and should simply explain to staff and others how you implement and monitor your health and safety controls. This should then be signed by the manager or chief executive, dated and on display. Health and safety legislation is normally reviewed twice a year, so make sure you review your policy at least annually.
Key considerations Another important, but often overlooked, requirement is making sure you have sufficient fire wardens and staff who are trained in first aid. Employers also need to sort out health and safety insurance – employer’s liability insurance – to protect them from any compensation claims from staff that are injured or become ill because of their work. You also have a duty to record any relevant details of workplace accidents in an accident book, and keep them on record for least three years. If an accident occurs, however small, you need to record the full name, address and occupation of the injured person, the date and time of the accident, where it happened, and the cause and nature of any injury. Near misses should also be reported and investigated, since they may have caused injury in slightly different circumstances. Employers ignore health and safety regulations at their peril. Fortunately, there is plenty of advice and support available on the subject, making compliance with rules less of a headache.
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Personal Profile Claire Todd, BSc., M.Inst.Ch.P, Devon and Cornwall Branch Congragulations to Claire Todd on obtaining her BSc in Podiatric Medicine Having moved to Cornwall in September 2008 from London where I had practised for 18 years, I have been gradually building up a new practice. As I had more free time on my hands I decided that this was the best opportunity for me to upgrade my professional qualifications.
It was very beneficial knowing others were there to listen and help when needed.
I applied and was accepted at New College Durham. During my four day induction I wondered what I had let myself in for? The amount of work that we were given was enormous as was the pile of assignments!
I thoroughly enjoyed completing the degree. â€˜Time managementâ€™ was the hardest factor to overcome for me but I set aside two days each week, and with the support of my family I managed to stick to it. There were some very stressful times and I missed my free time but I feel that it was a small price to pay for the overall result.
I made some very good friends during these four days and we kept in touch throughout the year (and continue to do so) helping and encouraging each other as the course progressed. This was a great morale booster as studying alone is not easy.
Our profession is continuing to change and I believe that by keeping up with our continued professional development we will keep at the forefront.
Focus on record keeping
e set standards which our registrants (‘you’) must meet, both to gain entry to the Register and to stay on the Register. This article focuses on what our standards say about record keeping, and is the second in a series covering some of the issues we are frequently asked about. We do not produce specific guidance around record keeping. This is because we recognise that our registrants work in many different types of role with distinct requirements as to how records are created, updated, and stored. While the specific way in which you should keep records is usually set by your employer, our standards of proficiency and standards of conduct, performance and ethics do have standards on record keeping. These standards set out the general principles you should always follow when keeping records. Our standards are written in a broad and non-prescriptive way so that they can apply to all registrants, no matter what profession you belong to or what your role is.
Our standards on record keeping Standard 2b.5 of our standards of proficiency states that you must be able to maintain records appropriately and standard 10 of the standards of conduct, performance and ethics states that you must keep accurate records and store them securely. The standards of conduct, performance and ethics also require you to keep records for everyone you provide services to. You must complete your records promptly, and if you are using paper-based records, they must be clear, easy to read, and each entry should be signed and dated. You can find the full text of our standards on our website at www.hpcuk.org/aboutregistration/standards.
Employer policies While we expect you to meet the standards we set for record keeping, it is also important that you follow your employer’s record keeping policies. This is because employers often need to set more detailed requirements that are relevant to a specific service context or role. For example, certain records might need to be countersigned in some situations, and policy on how records should be stored may vary. We are sometimes contacted by registrants who are concerned about the record keeping processes of their employer and whether they are compatible with our standards. It is very unlikely that we would have concerns about your record keeping if you follow your employer’s policies in good faith, and act in the best interests of your service users. If you are self-employed, we would recommend that you develop and follow your own record keeping processes. It can also be a good idea to document your policy so that if your record keeping comes into question, you can explain how you keep your records.
Abbreviations We are often asked about the use of abbreviations in record keeping. We do not have an agreed statement or list of abbreviations to be used by you. We also do not say whether or not you should use abbreviations, as the use of abbreviations varies depending on the profession. However, we do recommend that, where used, abbreviations should be easily recognised and understood by other professionals and practitioners.
HPC Registration statistics end September 2010 Route to Application CH
Gender Breakdown CH
Are you Greek or Egyptian? It’s all in the eye’s ... No, make that the feet! n August 2003 the press reported the discovery of the statue of a Roman legionary wearing socks under their sandals, in a Romano-Celtic temple found in London. Romans were blamed for having introduced in Britain what some would say an example of appalling bad taste. According to anatomists three quarters of the population have a so-called Egyptian foot which is characterised by a great toe longer than the second toe, 1/6 of the population have so called Greek foot, where the great toe is shorter than the second toe, while the rest of the population have a square foot where the great toe has the same length as the second. The reference to Egypt is due to the fact that in Egyptian paintings, the great toe appeared longer than the second toe. Greek Gods as a rule were portrayed barefoot even when they wore elaborate dresses. However there were some exceptions: Diana, the huntress goddess, wore proper footwear, and often other gods portrayed while hunting were not barefoot. The presence of snakes maybe influenced the decision of providing both Athena and Aesculapius with a means to tread on them.
Roman Emperors, especially for their eastern subjects, promoted themselves as having a divine nature. Augustus paid a lot of attention to his own iconography. In the same statue shown above, he is portrayed wearing an elaborate cuirass over an even more elaborate toga, but barefoot. To the eyes of some western viewers who perhaps associate being barefoot with being a little uncivilised, the feet of Augustus do not seem to match the rest of the statue. However, walking barefoot was a privilege of the ancient gods, who clearly were not affected by thorns and scratches.
Many ancient relief’s showing fights often portrayed one side barefoot and the other not. In the relief showing a battle between the Greeks (led by Achilles) and the Amazons, nakedness is a sign of superiority, while in relief showing Romans and Germans the superiority of the former is enhanced by their being fully dressed and wearing boots. ( Many thanks to Roberto Piperno for this extract from his article ‘Roman Feet and Sandals’ romeartlover.tripod.com
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.
Judith Barbaro-Brown MSc BSc(Hons) PGCE, DPodM, MChS
Learning Objectives At the end of this module, you should be able to: 1. discuss the differences in the causes of endogenous and exogenous osteomyelitis 2. describe the pathological changes which occur in disease development 3. understand which individuals may be at risk of developing osteomyelitis, and why this is so 4. describe the clinical signs and symptoms of both acute and chronic osteomyelitis 5. give the management strategy for treating osteomyelitis Osteomyelitis is a bone infection usually associated with bacteria, although it should be remembered that fungi, parasites, and viruses also can cause bone infection. It is categorised according to the pathogen’s mode of entry into bone tissue; exogenous osteomyelitis – enters from outside the body, e.g., through open fractures, penetrating wounds, or surgical procedures. The infection spreads from soft tissues into adjacent bone. endogenous (haematogenous) osteomyelitis – pathogens are transported in the blood from sites of infection elsewhere in the body. The infection spreads from bone to adjacent soft tissues, and this is more common in infants, children, and the elderly. In infants, incidence rates of osteomyelitis amongst males and females are equal whereas in children and older adults, males are most commonly affected. Osteomyelitis is also a common complication of sickle cell anaemia, and low oxygen tension. There is a UK incidence of 10-100/100,000 population per year for acute haematogenous osteomyelitis. Prevalence of osteomyelitis after a foot puncture is thought to be as high as 16%, rising to 30-40% in diabetic patients. Risk factors commonly include: l Trauma (orthopaedic surgery or open fracture) l Prosthetic orthopaedic device l Diabetes l Peripheral vascular disease l Chronic joint disease l Alcoholism l Intravenous drug abuse Chronic steroid use l Immunosuppression l Tuberculosis l HIV and AIDS l Sickle cell disease l Presence of catheter-related blood stream infection
This disorder is difficult to treat, and often culminates in extensive physical disability. Several factors contribute to the difficulty in treating bone infection: 1. Bone contains multiple microscopic channels that are impermeable to the cells and substances of the body’s natural defences. Once bacteria gain access to these channels, they are able to proliferate unimpeded. 2. The microcirculation of bone is highly vulnerable to damage and destruction by bacterial toxins. Vessel damage causes local thrombosis of the small vessels, which leads to ischemic bone necrosis. 3. Bone cells have a limited capacity to replace bone destroyed by infections. Initially, osteoclasts are stimulated by infection to resorb bone, which opens up isolated bone channels so that cells of the inflammatory and immune systems can gain access to the infected bone. At the same time, however, resorption weakens the structural integrity of the bone. New bone formation usually lags behind resorption, and the haversian systems in the new bone are frequently incomplete.
Causative organisms Staphylococcus aureus is the usual cause of haematogenous osteomyelitis. Other potential causative agents include group B streptococcus, Haemophilus influenzae, Salmonella, and gramnegative bacteria. Group B streptococcus and H. influenzae tend to infect young children; Salmonella infection is associated with sickle cell anaemia; and gram-negative infections are most common in older adults and immunocompromised individuals with impaired immunity. Mycobacterial, viral, and fungal infections occur in more severely immunocompromised individuals. Cutaneous, sinus, ear, and dental infections are the primary sources of bacteria in haematogenous bone infections. Softtissue infections, disorders of the gastrointestinal tract, infections of the genitourinary system, and respiratory infections are also sources of bacterial contamination. In addition, infections that occur after total joint replacements are sometimes the cause. The vulnerability of specific bone depends on the anatomy of its vascular supply. In adults, haematogenous osteomyelitis is more common in the spine, pelvis, and smaller bones such as those in hands and feet, microorganisms reaching these areas via the vascular and lymphatic system.
Continued ProfessionalDevelopment Exogenous osteomyelitis can be caused by human or animal bites or even traumatic injury to the mouth where mucosal tissues are damaged by the teeth. These injuries inoculate local soft tissue with bacteria that later spread to underlying bone. Deep bites can introduce micro-organisms directly onto bone. The most common infecting organism in human bites is S. aureus, whereas with animal bites the most common infecting organism is Pasteurella multocida, which is part of the normal mouth flora of cats and dogs. Direct contamination of bones with bacteria can also occur in open fractures or dislocations with an overlying skin wound. Intervertebral disk surgery and operative procedures involving implantation of large foreign objects, such as metallic plates or artificial joints, are associated with exogenous osteomyelitis. Local injections and venous punctures are significant causes of exogenous osteomyelitis. Exogenous osteomyelitis of the arm and hand bones tends to occur in those who abuse drugs, and again S. aureus is the most common pathogen.
Lifting of the periosteum also stimulates an intense osteoblastic response, which results in the laying down of new bone around the infected areas, in some cases sealing off the sequestrum. This new layer of bone is known as the involucrum. If the wall of the involucrum is incomplete, then exudate from the sequestrum can escape, and due to the presence of collagenases within the exudate, a sinus track is formed, leading to the skin surface, allowing the discharge of exudate. Involucrum development in adults is less common because the perisoteum is more firmly attached. What is more likely is that the cortex is disrupted and weakened, predisposing to the development of pathological fractures.
These vary depending on the age of the individual, the affected area, the initiating event, and the organism involved.
In general, individuals who are chronically ill, have diabetes or alcoholism, or are receiving large doses of steroids or immunosuppressive drugs are particularly susceptible to exogenous osteomyelitis, or recurring episodes of this disease.
The pathological changes occurring in osteomyelitis are the same whether the source in endogenous or exogenous. The invading pathogen provokes an intense inflammatory response, with increased vascular activity, tissue fluid leakage, oedema, and white cell activity. Once the process has begun the terminal vessels in the bone thrombose, and exudate seals the bone canaliculi. Inflammatory exudate extends into the metaphysis and the marrow cavity and through small metaphyseal foramina into the cortex. In children, exudate that reaches the outer surface of the cortex forms abscesses that lift the periosteum off underlying bone. This disrupts blood vessels that enter bone through the perisoteum, reducing the blood supply to the underlying bone. The end result of this is necrosis and death of the affected area, resulting in a sequestrum, an area of dead bone.
Acute osteomyelitis causes abrupt onset of inflammation. If an acute infection is not completely eliminated, the disease may become sub-acute or chronic. In sub-acute osteomyelitis, signs and symptoms are often indeterminate, whereas in the chronic stage, infection is silent between exacerbations. The microorganisms persist in small abscesses or fragments of necrotic bone, resulting in intermittent episodes of acute osteomyelitis. The progression from acute to sub-acute osteomyelitis may be the result of inadequate or inappropriate therapy, or the development of drug- resistant microorganisms. In the adult, haematogenous (endogenous) osteomyelitis has a slow onset. The symptoms are usually vague and include fever, malaise, anorexia, weight loss, and pain in and around the infected areas. Oedema may or may not be evident. Recent infection (urinary, respiratory, skin) or instrumentation (catheterization, cystoscopy, myelography, diskography) usually precedes onset of symptoms.
Continued ProfessionalDevelopment Single or multiple abscesses (Brodie’s abscesses) characterise sub-acute or chronic osteomyelitis. Brodie’s abscesses are circumscribed lesions usually localised in the ends of long bones and surrounded by dense ossified bone matrix. The abscesses are thought to develop when the infectious microorganism has become less virulent, or the individual’s immune system is resisting the infection somewhat successfully. In exogenous osteomyelitis, the usual signs and symptoms of soft-tissue infection are common. Inflammatory exudate in the soft tissues disrupts muscles and supporting structures and forms abscesses. Low-grade fever, lymphadenopathy, local pain, and swelling usually occur within days of initiation. Radiologically, evidence of acute osteomyelitis is first seen with overlying soft-tissue oedema at 3-5 days after infection. Bony changes are not evident for 2-3 weeks, and initially manifest as periosteal elevation followed by cortical or medullary lucencies (‘thinner’ areas of bone). Approximately 40-50% focal bone loss is necessary to cause detectable lucency on plain films. By 28 days, 90% of patients demonstrate some abnormality.
Cierny-Mader Staging System: Anatomical state of the bone Stage 1: medullary osteomyelitis (infection confined to the bone surface) Stage 2: superficial osteomyelitis (contiguous type of infection) Stage 3: Localised osteomyelitis (full-thickness cortical sequestration which can easily be removed surgically) Stage 4: diffuse osteomyelitis (loss of bone stability, even after surgical debridement)
Patient’s general condition (physiological class) A host: healthy patient B host: there is systemic (Bs) or local (Bl) compromise, or both C host: treatment morbidity outweighs morbidity of disease
Factors affecting immunity, metabolism and local vascularity Systemic factors (Bs): malnutrition, renal or hepatic failure, diabetes mellitus, chronic hypoxia, immune disease, malignancy, extremes of age, immunosuppression or immune deficiency Local factors (Bl): chronic lymphoedema, venous stasis, major vessel compromise (chronic local hypoxia), arteritis (chronic local hypoxia), small vessel disease (chronic local hypoxia), extensive scarring, radiation fibrosis, neuropathy, tobacco abuse. To determine disease stage: anatomical state + physiological class = clinical stage For example- Stage 4Bs osteomyelitis = a diffuse lesion in a systemically compromised patient. With laboratory results, the WBC count may be elevated, but it is more commonly seen as normal. C-reactive protein levels are usually increased but nonspecific, although this is a more useful marker than ESR as this takes longer to show elevation. Culture or aspiration findings in samples of the exudate are normal in 25% of cases, and blood culture results are positive in only 50% of patients with haematogenous osteomyelitis. Diagnosis of osteomyelitis requires 2 of the 4 following criteria: l
Purulent material on aspiration of affected bone
Positive findings of bone tissue or blood culture
Localised classic physical findings of bony tenderness with overlying soft-tissue erythema or oedema
Positive radiological imaging study
The Cierny-Mader staging system is used to determine the status of the disease process regardless of its aetiology, regionality or chronicity. It takes into account the state of the bone, the patient’s overall condition and factors affecting the development of osteomyelitis.
Management Generally, if there is early clinical suspicion, confirmation through imaging and microbiological tests and prompt treatment are the keys to a successful outcome. Analgesia (and limb splinting if a long bone is involved) may be necessary and is an important part of symptom control. Ultimately, surgery may be required to debride the bone and close any defects.
Treatment regimes Empirical therapy in non high-risk patient: l
Flucloxacillin plus benzylpenicillin, plus either fusidic acid or rifampicin depending on the severity of infection.
Empirical therapy in high-risk patient: Flucloxacillin plus either an aminoglycoside (e.g. gentamicin) or a quinolone (e.g. ciprofloxacin) plus either fusidic acid or rifampicin, depending on severity of infection. l
Alternatively: a second-generation cephalosporin (e.g. cefuroxime) plus either fusidic acid or rifampicin depending on severity.
Continued ProfessionalDevelopment Empirical therapy in penicillin-allergic patient: l
Clindamycin plus a quinolone (e.g. ciprofloxacin).
Alternatively: vancomycin plus a quinolone (e.g. ciprofloxacin).
Empirical therapy in MRSA positive suspected patient (also consult microbiology): l
Vancomycin should be used instead of flucloxacillin.
Gentamicin or a quinolone (e.g. ciprofloxacin) can be added subject to local policies and the advice of your microbiologist.
Treatment for acute infection is usually for 4-6 weeks and chronic infection for at least 12 weeks. High doses are required to achieve suitable bone penetration in high enough concentrations in necrotic avascular bone. Intravenous treatment is used initially and also to cover any surgical period, up to two weeks post surgery. The switch to oral therapy may happen once the clinical condition stabilises, the inflammatory markers are going down and there are reliable microbiology results. Although treatment is guided by clinical response and the level of inflammatory markers, an early drop in C-reactive protein levels does not mean that antibiotic therapy should stop. Therapy should be for at least four weeks. Changes on plain Xray lag at least 2 weeks behind normalisation of CRP.
Specifically consult a microbiologist if there is a risk of MRSA or if there is a prosthetic device in situ. Microbiologists will also be able to help in the case of polymicrobial infection. Rifampicin should not be used alone as antimicrobial resistance rapidly develops. With chronic osteomyelitis it is usually appropriate to delay treatment until culture and sensitivity results are obtained, unless the infection is severe, in which case empirical treatment is started (see above). Surgical debridement is the mainstay of treatment in chronic cases as it removes the necrotic tissue and provides an infection-free scaffold for future healing. If surgery is not possible, indefinite antimicrobial therapy may be required but this is generally accepted to be less effective than surgery.
Prognosis This depends on the number of risk factors and the patientâ€™s general condition, hence the use of a staging system during the patient assessment period. Outcomes are improved if treatment is started 3-5 days after onset of the infection. Timely diagnosis and intervention in an otherwise well patient should lead to full recovery, although follow-up over several months will be required to monitor for relapse.
KEY LEARNING POINTS 1. Osteomyelitis is infection of the bone, either from an external or internal source. 2. The commonest causative organism is S.aureus. 3. The physical structure of bone makes osteomyelitis more difficult to treat because of the blocked canaliculi preventing blood flow through bone tissue. 4. Involucrum development is more common in children, whereas in adults the bone is more likely to develop pathological fracture. 5. Acute osteomyelitis has an abrupt onset with the signs of acute inflammation. 6. Chronic osteomyelitis symptoms are slower in onset, and are more non-descript. 7. A staging system is often used to clinically describe the severity of infection. 8. Management requires long-term use of anti-biotics, as well as pain management, and surgery.
Learning Objectives 1. Discuss the differences in the causes of endogenous and exogenous osteomyelitis. 2. Describe the pathological changes which occur in disease development. 3. Understand which individuals may be at risk of developing osteomyelitis and why this is so. 4. Describe the clinical signs and symptoms of both acute and chronic osteomyelitis. 5. Give the management strategy for treating osteomyelitis.
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