Podiatry Review

32491_Chirop_May/June_2011_17416_Chirop_Jan_Feb_08 27/04/2011 10:05 Page A

The Ins tute of Chiropodists and Podiatrists

ISSN 1756-3291

Vol. 68 No. 3 - May/June 2011

2011 A.G.M. - Royal Windsor

Independence

Initiative

Individualism

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May/June 2011 Podiatry Review

Contents 1. Editorial

The Institute of Chiropodists and Podiatrists Podiatry Review

3. Diabetes UK News

Editor Roger Henry F.Inst.Ch.P. DChM editor@iocp.org.uk

6. Clinical guidelines for the

Sub-Editor Robert Sullivan M.Inst.Ch.P. BSc(Hons)Pod, PG Dip. TP Surg.

Subeditor@iocp.org.uk Press and Public Relations Officer Fred Beaumont Hon.F.Inst.Ch.P., D.Ch.M Tel: 0191 297 0464 Editorial Assistant Bernadette Willey bernie@iocp.org.uk

4. Skin Cancer

recognition of melanoma of the foot and nail unit 11. Personal Profile 12. A.G.M. Booking Form 13. A.G.M. Timetable 14. Letter from the President 15. Peer Review Section Centre CPD Article Biomechanics, Myths and Legends - Robert Isaacs, BSc(Hons) MChS Cert. KCHyp

Editorial Committee Mrs. F. H. Bailey M.Inst.Ch.P Mr. R. Beattie Hon.F.Inst.Ch.P., LCh., HChD 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)

DChM, MSc

Advertising Please contact the Editor for all matters pertaining to advertising editor@iocp.org.uk Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Tel: 01704 546141 Printed by Mitchell & Wright Printers Ltd., The Print Works, Banastre Road, Southport PR8 5AL Telephone: (01704) 535529

ISSN 1756-3291 Annual Subscription £25.00 Single Copy £5.00 incl P & P

19. Peer Review Section (cont.)

23. Branch News 24. CPD - 2011 27. The Institute of Chiropodists and Podiatrists – Code of Ethics 29. Rambling Roads 30. West Middlesex branch seminar 31. Sheffield branch seminar 32. Coffee Break Crossword 33. Classified Adverts 34. Diary of Events IBC National Officers

© 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 What have we of interest and note in this spring edition of Podiatry Review?

We thank our friend Ivan Bristow from the School of Health Sciences, University of Southampton and colleagues, have contributed a treatise entitled “Clinical guidelines for the recognition of melanoma of the foot and nail unit”.

We as chiropodists and podiatrists, could be the first health care professionals to encounter a melanoma on the foot, so it is vital we recognise and be aware of the condition. To tie in with the melanoma treatise I have included an article on skin cancer.

We congratulate Linda Pearson on obtaining her BSc Pod Med degree and congratulations also to Richard Peppitt who successfully passed his City and Guilds course at the Sheffield training centre, a level 4 Higher Professional Diploma in Foot Health Care and Practice. We thank Robert Isaacs for his contribution to continuing professional development entitled “Biomechanics, Myths and Legends”.

The peer-reviewed articles are Talipes Equinovarus Part III by Janet McGroggan and Clinical Audit of Foot Problems in Patients with Rheumatoid Arthritis in New Zealand by Keith Rome and colleagues, University of Auckland, New Zealand.

Finally, I look forward to seeing friends old and new at our A.G.M., lectures, chiropody trade exhibition and dinner dance on Friday and Saturday 13th and 14th May at Beaumont House, Burfield Road, Old Windsor.

There is still time to book. Please phone head office on 01704 564141.

Enjoy the springtime, Roger Henry Editor, Podiatry Review

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Research into a new insulin for people with Type 2 diabetes has shown its effectiveness for blood glucose management when used three times a week

T

rials of the insulin, degludec, were carried out over 16 weeks in participants with Type 2 diabetes from the USA, Canada, India and South Africa. The participants were divided into three groups, one treated with insulin glargine (an insulin already on the market and used by people with Type 2 diabetes), a second treated with degludec once a day, with a third group treated with degludec three times a week.

Similar effectiveness Results showed blood glucose levels were much the same across the three groups. In addition, fewer people experienced hypoglycaemia in the once-daily degludec group. In response to the article, Dr. Iain Frame, Director of Research at Diabetes UK, said: “This is an incremental step forward in the treatment of Type 2 diabetes only. The research shows that degludec has the same effectiveness on blood glucose management as an insulin already on the market.

Additional benefits suggested “However, the study does suggest some additional benefits.

For people with Type 2 diabetes who use insulin and find daily insulin injections unpleasant, degludec could reduce the number of injections to three times a week. However, there are trials currently taking place testing weekly and oral therapies which have the potential of offering much more freedom. “The study also suggests that degludec could reduce the frequency of hypos, a serious short term complication that can be debilitating and impact on a person’s quality of life. “This work is still in its infancy and more trials are still needed to prove its effectiveness and safety as a routine treatment for people with Type 2 diabetes.�

The research is published in The Lancet 10/3/11

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Skin Cancer

Other rare possible causes are over exposure to certain chemicals at work, including coal, tar, soot, pitch, asphalt, creosotes, paraffin waxes, petroleum derivatives, hair dyes, cutting oils and arsenic. You should wear protective clothing if you are handling these substances frequently.

Some people with rare hereditary conditions have a higher risk of developing skin cancer. However, non-melanoma skin cancers are not caused by inherited faulty genes that can be passed on to other family members and so other members of your family are not at a higher risk of developing skin cancer.

Lots of people have moles or dark patches on the skin that are flat or slightly raised. Usually these will remain harmless throughout life, but moles or patches of normal skin that change in size, shape or colour over weeks or months in adult life need investigation.

Other signs of skin cancer • a new growth or sore that won’t heal • A spot, mole or sore that itches or hurts • a mole or growth that bleeds, crusts or scabs

Types of Skin Cancer The skin has many purposes. It protects the body from injury and infection. It also helps to regulate body temperature and gets rid of waste substances through the sweat glands. The skin is divided into two main layers. The layer nearest the surface is known as the epidermis and the layer underneath is known as the dermis.

The epidermis contains three types of cells. On the surface are flat cells, known as squamous cells. Under the layer of squamous cells are rounder cells called basal cells. In between the basal cells are the melanocytes. Melanocytes are cells that produce the pigment melanin. It is this pigment that gives skin its colour variations.

Ultraviolet light from the sun is the main cause of skin cancer.

Skin cancer is becoming more common and there are several possible reasons for this. People are living longer (and so their lifetime sun exposure is greater). They often have more time and money for outdoor recreation and holidays in sunny climates and many people still consider suntans to be healthy and attractive. It is likely that most skin damage from ultraviolet radiation occurs before the age of 20. It is thought that a build-up of over exposure to the sun over a period of several years can lead to the development of basal cell and squamous cell skin cancers.

Black or brown skinned people have a very low risk of developing skin cancer because the malanin pigment in their skin gives them protection. A fair-skinned person who tends to go red or freckle in the sun will be most at risk. Children and young adults who have been over exposed to the sun have an increased risk of developing some form of skin cancer. This will not show up until later on in life - usually after about age 40, and often not until the 60’s or 70’s. The regular use of sunlamps and sunbeds increases the risk of developing skin cancer.

Areas of skin that have been badly burned, or have long-term inflammation have an increased risk of squamous cell carcinoma.

Radiotherapy given to treat other conditions can sometimes cause skin cancers in the treatment area later in life.

People who have to take drugs which lower their immunity (immunosupressants) - for example, after a kidney transplant are also at increased risk of getting skin cancer.

4

Non-melanoma Skin Cancer Non-melanoma skin cancer is the most common and easily treated type of cancer. More than nine out of ten skin cancers are this type. There are over 65,000 new cases reported each year in the U.K.

The ABCD Rule Asymmetry The two halves of the mole do not look the same

Border The edges of mole are irregular, blurred or jagged

Colour The colour of mole is uneven with more than one shade

Diameter The mole is wider than 6mm in diameter (the size of a pencil eraser)

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There are two main sorts, both of which tend to affect older people. These cancers are most common on areas of skin frequently exposed to the sun such as the head, neck, hands and forearms.

Basal cell Basal cell cancer is the most common non-melanoma skin cancer.

It grows quite slowly and usually starts as a small round or flattened lump. The lump may be red, pale, or pearly in colour.

Sometimes it appears as a scaly, eczema-like patch on the skin.

Squamous cell Squamous cell cancer is more serious than basal cell cancer as it can spread to other parts of the body if left untreated. Squamous cell cancers appear as persistent red scaly spots, lumps, sores or ulcers, which may bleed easily.

Malignant melanoma Malignant melanoma, also known as melanoma, is the most serious type of skin cancer. It usually develops in cells in the outer layer of the skin. The first visible signs of this may be a change in the normal look or feel of a mole.

Melanoma affects adults of all ages. It is one of the few cancers to affect young adults and is the third most common cancer amongst 15-39 year olds. The risk increases with age.

More women than men develop malignant melanoma. Melanomas in women are most common on the legs and in men they are most common on the back. This is shown in the diagram. (Two Diagrams of man and woman)

Radiotherapy may be used instead of surgery, or may be given after surgery if there is a risk that some cancer cells may still be present. Radiotherapy can be a very effective alternative to surgery for basal and squamous cell carcinomas in areas of the face where surgery might cause scarring. It is also sometimes used for tumours that have grown into the deeper layers of the skin. Radiotherapy treats cancer by using high-energy rays which destroy the cancer cells whilst doing as little harm as possible to normal cells. Often only a single treatment is needed but sometimes several doses of treatment are necessary and these are given over a period of one or more weeks.

Chemotherapy is not often used to treat skin cancers. If it is used, it is usually as a cream that is applied directly to the cancer.

Chemotherapy is the use of anticancer (cytotoxic) drugs to destroy cancer cells.

Occasionally chemotherapy for squamous cell cancer may be given in the rare situation where the cancer has spread to other parts of the body. The chemotherapy is given by injection (intravenously) so that the drugs are carried round the body in the blood and reach cancer cells wherever they are.

Cryotherapy can be used to remove small skin cancers.

Liquid nitrogen is sprayed on to the cancer to freeze it. Within a day or so the area blisters and is left covered with a dressing until a scab forms. It usually takes a month for the scab to drop off and the tumour should have cleared. Occasionally, more than one cryotherapy treatment is needed to get rid of the tumour completely.

Photodynamic therapy (PDT) is a new treatment for several types of cancer, including skin cancer. PDT uses laser, or other light sources, combined with a light-sensitive drug (sometimes called a photosensitising agent) to destroy cancer cells. Again usually only one treatment is sufficient but occasionally it may have to be repeated two or three times.

Prevention - Do’s and Don’ts • Do Wear clothing made of cotton or natural fibres which are closely woven and offer good protection against sun.

When melanoma is caught early it can be treated successfully.

However, if a malignant melanoma is left it can spread to other parts of the body and may be fatal. Any changes to moles or previously normal skin must be checked out.

More than nine out of ten people (90%) with basal cell and squamous cell carcinomas are completely cured. In may cases the only treatment needed is removal of the suspect lump.

Treatment is planned by taking into consideration a number of factors including age, general health, type and size of the cancer, the position of the cancer on the body and what the cells actually look like under the microscope. Treatment is tailored to the patients particular situation, (Occasionally people may be asked to take part in a clinical trial for a new treatment)

Surgery is an important treatment for many skin cancers. This can be performed in a variety of ways. Small cancers can usually be removed under local anaesthetic. When larger tumours are removed, skin grafts are sometimes needed to replace the removed skin. A skin graft is a thin layer of healthy skin taken from another part of the body. This is done under general anaesthetic.

• Do Protect face and neck with a wide-brimmed hat.

• Do wear sunglasses in strong sunlight.

• Do use high-factor sunscreen (SDF 30 or above) whenever exposed to sun, apply frequently particularly after swimming.

• Do stay out of the sun during the hottest part of the day • • • •

(usually between 11am and 3pm) Do use fake tanning lotions or sprays.

Don’t allow skin to burn Don’t sit exposed in the sun Don’t use a sunbed.

Acknowledgement: Grateful thanks in compiling this article go to: Cancer Research U.K. www.cancerresearchuk.org/sunsmart Cancerbackup www.cancerbackup.org.uk and Professor Brian Diffey, Clinical Director, Medical Physics Department Newcastle General Hospital.

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Clinical guidelines for the recognition of melanoma of the foot and nail unit Part One Ivan R Bristow1 David AR de Berker2, Katharine M Acland3, Richard J Turner4 and Jonathan Bowling4 1 School of Health Sciences, University of Southampton, SO17 1BJ, UK 2 Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol, BS2 8HW, UK 3 St. Johns Institute of Dermatology, St. Thomasâ&#x20AC;&#x2122; Hospital, London, SE1 7EH, UK 4 Department of Dermatology, Oxford Radcliffe Hospital, Oxford, OX3 7LJ, UK

Abstract

What is a melanoma and how common is it?

Malignant melanoma is a life threatening skin tumour which may arise on the foot. The prognosis for the condition is good when lesions are diagnosed and treated early. However, lesions arising on the soles and within the nail unit can be difficult to recognise leading to delays in diagnosis. These guidelines have been drafted to alert health care practitioners to the early signs of the disease so an early diagnosis can be sought.

A melanoma is a malignant tumour (cancer) arising from the pigment producing cell of the skin, the melanocyte. The number of cases of malignant melanoma worldwide is increasing faster than any other form of cancer amongst Caucasians [5]. When compared to other forms of skin cancer, the disease is relatively uncommon [6]. However in the UK, like much of the world, the incidence of cutaneous melanoma continues to rise accounting for the majority of skin cancer deaths. It has been calculated that the lifetime risk for an individual developing the disease is 1:120 for men and 1:95 for women [1]. Currently there are around 8500 new cases annually in the UK with around 1800 melanoma related deaths [7]. Cutaneous melanoma can develop on any skin and mucosal surface. The lower limb is the location of around 30% of all primary cutaneous melanomas, with women are more highly represented in this group, and foot and ankle lesions representing around 3-15% of all cutaneous melanomas [8].

Overview and scope of the guidelines Melanoma is a life threatening but potentially treatable form of cancer if diagnosed and managed at an early stage. Guidelines have been published to assist healthcare workers in the recognition of malignant melanoma of the skin [1]. However, early melanoma arising on the foot, particularly within the nail unit and on the plantar surface, can be difficult to recognise.

Consequently, this can lead to delays in diagnosis. Melanoma arising on the foot carries a particularly poor prognosis when compared to melanoma arising at other body sites [2-4]. As there are no consistent features of an early melanoma, these guidelines have been drafted to alert health care workers to the signs which may suggest melanoma and therefore warrant a specialist referral. A melanoma recognised and diagnosed at an early stage can dramatically increase a patient's chances of survival.

This guide has been produced as a reference for health care professionals who may be confronted with pigmented and amelanotic lesions on the foot. It has been split into two sections-melanoma on the skin of the foot and melanoma in the nail. The paper is designed to act as a guide in deciding whether a presenting lesion should be referred on. It is not designed to be a diagnostic tool-confirmation of diagnosis can only be secured though appropriate biopsy, histological examination and specialist interpretation. Furthermore, it is appreciated that melanoma is not the only malignant skin tumour arising on the foot. However, these guidelines should alert practitioners to any skin lesions of the foot exhibiting unusual features. If there is any doubt, a second opinion should be sought. At a local level, foot clinics may wish to establish links with their local dermatology and oncology services to facilitate rapid referral pathways.

6

Who is likely to develop melanoma?

There is a relationship between ultra-violet (UV) exposure and the development of melanoma on sun exposed sites. Data has demonstrated that in particular that irregular and intense exposure to sunlight significantly increases the risk of melanoma [9]. However, the relevance of UV light on nonexposed areas such as the plantar surface of the foot the role is not so clear.

Melanoma is a rare occurrence before puberty, but shows a gradual increase in incidence from the age of fifteen, peaking at around the age of fifty. Around 80% of lesions occur between the ages of 20-74 years [10]. White populations have a much greater risk of developing the disease than Hispanics, Asians and Afro-Caribbeans. Although non-white races overall have a much lower rate of the disease, they are most likely to develop melanoma in acral locations such as the palmar, plantar surfaces and nail bed [11-15].

Melanoma can arise in a pre-existing naevus (mole) or develop de novo on the skin. The risk of developing melanoma can be correlated to the number of naevi (moles) an individual has.

The greater the number-the higher the risk. Dysplastic naevi are atypical moles which are generally larger than ordinary

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“lentiginous”. The term “acral” defines the location which is of the extremities, namely the skin of the hands and feet, including the nail unit. ALM is the only type of MM which arises equally across all skin types and is frequently observed in darker skin types and represents about half of the melanoma occurring on the hands and feet. In the early stages, the clinical symptoms for this type of melanoma maybe very subtle such as an ill defined macule or patch of light brown or grey discolouration of the skin.

Nodular melanoma (NM) Nodular melanoma is characterised by a prominent vertical component to the invasion of the tumour when viewed under the microscope. This typically corresponds to a pigmented lesion which may appear nodular to the naked eye. This lesion is more often seen in older patients.

Superficial spreading melanoma (SSM) is the most common of the four types so called because of its radial growth phrase (lateral spread) before becoming invasive. It may arise de novo or in a pre-existing mole. This type has been most frequently reported arising on the dorsum of the foot [16].

naevi and tend to have an irregular and indistinct border and irregular colours. Patients with dysplastic naevi are also at a greater risk of developing melanoma. Recognised risk factors are listed in Table 1.

Lentigo maligna (LM) is a type of in situ melanoma, found almost exclusively on the face and neck of older adults in the setting of sun damage. Lentigo maligna may progress to lentigo maligna melanoma which is a lentigo maligna with an area of dermal invasion. A small but significant proportion of melanoma lack pigmentation and are hence labelled amelanotic melanoma. Such lesions are more likely to arise on acral areas such as the feet and be misdiagnosed as other skin disorders as they maybe fleshy in colour (Figure 2).

Table 2 The ABCDE acronym A Asymmetry. One half of the lesion is not identical to the other.

B

Border. A lesion with an irregular, ragged or indistinct border.

C Lesion has more than one Colour present within it.

Types of melanoma There are four main types of melanoma although not all can be specifically classified as one particular type (Figure 1).

D Diameter. The lesion has a diameter of greater than 6 mm.

E

Evolution. Any change in the lesion in terms of size, shape or colour.

Acral lentiginous melanoma (ALM)

Bristow et al. Journal of Foot and Ankle Research 2010, 3:25

This type of melanoma is characterised by having an extensive component running as a layer of malignant melanocytes within the basal layer of the epidermis, giving rise to the term

http://www.jfootankleres.com/content/3/1/25 Page 4 of 13

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A large proportion of melanoma are discovered by patients and relatives [17]. Unfortunately, for many patients, the foot is difficult to see and is seldom checked. Consequently, changes may not be readily observed or noted by the patient.

Chiropodists/Podiatrists can play an important role in screening the foot and leg.

The prognosis for melanoma corresponds to the histological (Breslow) thickness of the excised tumour. This represents a measure of depth of invasion of the tumour into the dermis.

For example, a < 1 mm thick lesion has a five year survival rate of 95%, whilst a > 4 mm thickness holds a 50% chance of survival at five years. As depth of tumour is partly related to its age early identification of suspect lesions is paramount [18].

Assessment It is suggested that at an initial appointment details of any pigmented or solitary lesion arising on the feet is recorded in the patient's notes with a description including location, size, colour and shape. Inclusion of accurate measurements can be more objective. The examination must be comprehensive and include interdigital areas and the plantar surface.

When assessing lesions, a history of trauma should not exclude the possibility of a melanoma. Evidence suggests many cases of melanoma are brought to the attention of the patient by coincidental trauma and injury. The role of trauma in the aetiology of melanoma remains controversial, but it may bring the patient's attention to an existing lesion. The use of the simple acronym ABCDE [19] is a useful tool in remembering the main clinical signs of a potential melanoma (See Table 2) but may miss amelanotic or smaller lesions [20]. Any mole or 8

solitary vascular lesion whether new or pre-existing which is growing or changing shape or colour should be referred for a specialist opinion.

The utility of the standard ABCDE system for plantar and nail lesions has been questioned owing to the variation in presentation on the plantar surface and within the nail unit compared to other areas of the skin [21-23]. Moreover, data has highlighted how melanoma on the foot holds a poorer prognosis than melanoma elsewhere due to delays in presentation and misdiagnosis of the condition [23-25] particularly so when located in the periungual areas, beneath or around the nails [26]. Lack of pigmentation in suspect pedal lesions can compound the problem. Many misdiagnoses are made in favour of more benign conditions such as: l Ingrowing toe nail l Foot ulcer l Wart/verrucae l Tinea Pedis/Onychomycosis l Bruising l Foreign body l Sub-ungual haematoma l Pyogenic granuloma l Poroma l Hyperkeratosis-corns/callus l Necrosis l Paronychia l Ganglion

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Table 3 The “CUBED” acronym for foot melanoma

1.

Bishop JN, Bataille V, Gavin A, Lens M, Marsden J, Mathews T, Wheelhouse C: The prevention, diagnosis, referral and management of melanoma of the skin: concise guidelines. Clinical Medicine, Journal of the Royal College of Physicians 2007, 7:283-290.

2.

Hsueh E, Lucci A, Qi K, Morton D: Survival of patients with mealnoma of the lower extremity decreases with distance from the trunk. Cancer Causes Control 1998, 85:383-388.

3.

Talley LI, Soong S-j, Harrison RA, McCarthy WH, Urist MM, Balch CM: Clinical Outcomes of Localized Melanoma of the Foot: A Case-Control Study. J Clin Epidemiol 1998, 51:853-857.

4.

Walsh SM, Fisher SG, Sage RA: Survival of patients with primary pedal melanoma. J Foot Ankle Surg 2003, 42:193-198.

5.

Lens MB, Dawes M: Global perspectives of contemporary epidemiological trends of cutaneous malignant melanoma. Br J Dermatol 2004, 150:179-185

6.

Diepgen TL, Mahler V: The epidemiology of skin cancer. Br J Dermatol 2002, 146:1-6.

7.

UK Skin Cancer mortality statistics [http://info.cancerresearchuk.org/cancerstats/types/skin/mortality/]

8.

Soong SJ, Shaw HM, Balch CM, McCarthy WH, Urist MM, Lee JY: Predicting survival and recurrence in localized melanoma: a multivariate approach. World J Surg 1992, 16:191-195.

9.

Gandini S, Sera F, Cattaruzza MS, Pasquini P, Picconi O, Boyle P, Melchi CF: Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 2005, 41:45-60.

10.

Ries LA, Wingo PA, Miller DS, Howe HL, Weir HK, Rosenberg HM, Vernon SW, Cronin K, Edwards BK: The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000, 88:2398-2424.

11.

Chang JW, Yeh KY, Wang CH, Yang TS, Chiang HF, Wei FC, Kuo TT, Yang CH: Malignant melanoma in Taiwan: a prognostic study of 181 cases. Melanoma Res 2004, 14:537-541.

12.

Ishihara K, Saida T, Yamamoto A: Updated statistical data for malignant melanoma in Japan.

Int J Clin Oncol 2001, 6:109-116.

13.

Al-Maghrabi JA, Al-Ghamdi AS, Elhakeem HA: Pattern of skin cancer in Southwestern Saudi Arabia. Saudi Med J 2004, 25:776-779.

14.

Muchmore JH, Mizuguchi RS, Lee C: Malignant melanoma in American black females: an unusual distribution of primary sites. J Am Coll Surg 1996, 183:457-465.

15.

Bellows CF, Belafsky P, Fortgang IS, Beech DJ: Melanoma in African-Americans: Trends in biological behavior and clinical characteristics over two decades. J Surg Oncol 2001, 78:1016.

16.

Barnes B, Seigler H, Saxby T, Kocher M, Harrelson J: Melanoma of the foot. J Bone Joint Surg Am 1994, 76:892-898.

17.

Hamidi R, Cockburn MG, Peng DH: Prevalence and predictors of skin self-examination: prospects for melanoma prevention and early detection. Int J Dermatol 2008, 47:993-1003.

18.

Büttner P, Garbe C, Bertz J, Burg G, D'Hoedt B, Drepper H, Guggenmoos-Holzmann I, Lechner W, Lippold A, Orfanos CE, et al.: Primary cutaneous melanoma. Optimized cutoff points of tumor thickness and importance of clark’s level for prognostic classification. Cancer 1995, 75:2499-2506.

19.

Malignant Melanoma [http://www.aad.org/public/publications/pamphlets/sun_malignant.html]

20.

Strayer S: Diagnosing skin malignancy: Assessment of predictive clinical criteria and risk factors. J Fam Pract 2003, 52:210-218.

21.

Albreski D, Sloan SB: Melanoma of the feet: misdiagnosed and misunderstood. Clin Dermatol 2009, 27:556-563.

22.

Bristow I, Acland K: Acral lentiginous melanoma of the foot: a review of 27 cases. J Foot Ankle Res 2008, 1:11.

23.

Metzger S, Ellwanger U, Stroebel W, Schiebel U, Rassner G, Fierlbeck G: Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 1998, 8:181-186.

C Coloured lesions where any part is not skin colour.

U Uncertain diagnosis. Any lesion that does not have a definite diagnosis.

B

E B

Bleeding lesions on the foot or under the nail, whether the bleeding is direct bleeding or oozing of fluid. This includes chronic “granulation tissue”.

Enlargement or deterioration of a lesion or ulcer despite therapy.

Delay in healing of any lesion beyond 2 months.

Refer when any two features apply.

As many of the benign conditions are very common, identifying a rare occurrence of melanoma amongst them can be challenging. In view of the additional difficulties the authors offer an alternative acronym to highlight potential melanoma on the foot using the acronym “CUBED” (Table 3).

Table 3. The “CUBED” acronym for foot melanoma Clinical judgement should identify lesions which appear “unusual” in their form or have atypical features. For example, the appearance of a suspicious foot ulcer in a patient without the normal risk factors (neuropathy, diabetes etc) should raise concerns as to the correct diagnosis. Furthermore, when individual skin lesions don't respond to a treatment in the normal, timely manner the original diagnosis should be reconsidered.

Dermoscopy has been demonstrated to be a useful adjunct in the visual assessment of pigmented lesions to detect potential melanoma on acral skin [27] however, such equipment requires training and knowledge before use. Readers are referred to the article by Bristow and Bowling [28].

Nail unit melanoma Like elsewhere on the foot, melanoma of the nail unit (NUM) is typically diagnosed at a later stage in its evolution than melanoma at most other body sites. Accordingly, the tumours are thicker and there is a worse prognosis than for other melanoma. A large UK survey of 4 regions demonstrated that NUM represented 1.4% of melanoma over a 10 year period, giving an incidence of 1 per million of population per year.

The 5 year survival of this group was 51%, where those with a Breslow thickness of less than 2.5mm had a 5 year survival of 88% and those for which the thickness was 2.5mm or greater, had a 44% 5 year survival rate [29].

24.

Bennett DR, Wasson D, MacArthur JD, McMillen MA: The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot. J Am Coll Surg 1994, 179:279-284.

25.

Soon SL, Solomon AR Jr, Papadopoulos D, Murray DR, McAlpine B, Washington CV: Acral lentiginous melanoma mimicking benign disease: the Emory experience. J Am Acad Dermatol 2003, 48:183-188.

26.

De Giorgi V, Sestini S, Massi D, Panelos J, Papi F, Dini M, Lotti T: Subungual melanoma: a particularly invasive "onychomycosis". J Am Geriatr Soc 2007, 55:2094-2096.

27.

Saida T, Miyazaki A, Oguchi S, Ishihara Y, Yamazaki Y, Murase S, Yoshikawa S, Tsuchida T, Kawabata Y, Tamaki K: Significance of dermoscopic patterns in detecting malignant melanoma on acral volar skin: results of a multicenter study in Japan. Arch Dermatol 2004, 140:12331238.

Presentation of melanoma in the nail unit

28.

Bristow IR, Bowling J: Dermoscopy as a technique for the early identification of foot melanoma: a review. J Foot Ankle Res 2009, 2:

29.

Banfield CC, Redburn JC, Dawber RP: The incidence and prognosis of nail apparatus melanoma. A retrospective study of 105 patients in four English regions. Br J Dermatol 1998, 139:276-279.

There are 2 main patterns of nail unit melanoma (NUM); longitudinal melanonychia and amelanotic tumours (Figure 3).

The first may be associated with alteration of nail plate anatomy in more advanced cases. The latter is almost always associated with nail plate change. Some NUM may present with features common to both patterns.

First published in the Journal of Foot and Ankle Research The electronic version of this article is the complete one and can be found online at: http://www.jfootankleres.com/content/3/1/25 © 2010 Bristow et al; licensee BioMed Central Ltd.

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Personal Profile Linda Pearson M.Inst.Ch.P., BSc, Pod.Med Having been accepted to partake in the BSc. course in September 2009 at New College Durham, I was equally pleased to find out that my friend and colleague for many years Denise Willis was also enrolled on the same course.

Due to the Monday being a bank holiday we all received an even more “Intensive induction week!” During the week we all met the tutors relevant to our particular module choices. I chose Pharmacology, Phsycology and Sports and Biomechanics.

I also met new friends and colleagues Debbie and Tony, plus others. There seemed to be a great sense of comradeship, probably due to the fact that most of us had been out of the school type learning environment for 20+ years.

There were quite a few laughs (mainly hysterics on my part, as I can kill a computer at 20 paces!) I am sure our Statistics tutor John Barnes (Not the footballer) believed, perhaps, we weren’t taking the subject seriously (I didn’t like to tell him my brain had short-circuited on day two!!!!)

All of my modules were challenging but I enjoyed working on them and by the end of my assignments I could see how the core modules enhanced the subject in question.

I would definitely recommend this course to other colleagues, as it opens your mind to analyse things in a slightly different manner giving you a wider perspective. There is a lot of work involved in drafting, redrafting etc. and you should ideally allow at least one to two clear days a week to fully concentrate on what is required.

On 27th November 2010 despite the two foot of snow, I graduated. It also happened to be on the same day our team, F C United of Manchester, were playing Brighton away in the 2nd round of the FA Cup. Naturally I was gutted being the opposite end of the country, but Mum and Martin (my son) kept me up to date with the match scores. The magic of modern mobiles with earphones! however, Martin did advise me that if I heard a cheer it was probably because FC had scored a goal! (Thanks for that mate!). Final score 1 all and a replay at Gigg Lane, so I didn’t miss it entirely after all.

A big thanks to the friends who proof-read my work and my family for their continued support and endless supply of cups of tea!

The Institute wishes to congratulate Linda on gaining her BSc in Podiatry

Congratulations also go to…

Richard Peppitt who successfully passed the final practical examination of the City & Guilds Course in February at the Sheffield Training School.

Richard was really focussed on the work to be done and has been awarded a Level 4 Higher Professional Diploma in Foot Health Care and Practice.

Well done Richard… hard work but all worth it.

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THE INSTITUTE OF CHIROPODISTS AND PODIATRISTS HOTEL ACCOMMODATION APPLICATION FORM

2011 Conference - Beaumont House, Old Windsor ALL HOTEL ACCOMMODATION AND THE DINNER/DANCE MUST BE BOOKED ON THIS FORM PLEASE COMPLETE THE FORM IN BLOCK LETTERS

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Institute of Chiropodists and Podiatrists 2011 Annual Conference and A.G.M.

Beaumont House, Beaumont Estate, Burfield Road, Old Windsor Timetable Thursday 12th May 2011 1:00 p.m.

National Officers Meeting 2:00 p.m.

Arrival of Delegates 2:30 p.m.

Executive Committee Meeting 5:00 p.m.

Standing Orders Committee 6:30 p.m.

TH1 Lecture - Silicones and their use in Podiatry (Max 30) 8:00 p.m.

Evening Meal: Dining Room Friday 13th May 2011 9:00 a.m. - 5:00 p.m. Medical Trade Exhibition: Hanover Suite 1 and Hanover Lounge 8:30 a.m.

Credential Officers and Scrutineers Briefing: Hanover Suite 3 9:30 a.m. - 5:00 p.m. Assembly – All Delegates to be present: Hanover Suite 3 9:30 a.m.

Mayoral Tour of the Trade Exhibition 9:45 a.m.

Opening of Conference: Hanover Suite 3 10:00 a.m.

26th Annual General Meeting of The Members Emergency Benevolent Fund: Hanover Suite 3 10:00 a.m.

F2 Workshop 1 – Practical Use of Silicones: Hanover Suite 2 10:15 a.m.

Annual General Meeting: Hanover Suite 3 11:00 a.m.

Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 11:30 a.m.

Annual General Meeting: Hanover Suite 3 11:30 a.m.

F3 Workshop 2 – Use of Liquid Nitrogen and New Regulations: Hanover Suite 2 12:30 p.m.

Lunch Restaurant and Medical Trade Exhibition: Hanover Suite 1 2:00 p.m.

Annual General Meeting Continues: Hanover Suite 3 2:00 p.m.

F4 Workshop 3 – Lasers, Their use in Podiatry: Hanover Suite 2 3:00 p.m.

Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 3:30 p.m.

Annual General Meeting: Hanover Suite 3 followed by Question Time 3:30 p.m.

F5 Workshop 4 – Vascular Assessments using Dopplers: Hanover Suite 2 6:30 p.m. - 7:15 p.m. Presidents Drinks Reception: Hanover Suite 1 and Lounge SPONSORED BY CANONBURY 7:15 p.m.

Presentation Ceremony (whilst seated at Dinner Tables): Hanover Suites 2 and 3 7:30 p.m.

Annual Dinner and Dance: Hanover Suites 2 and 3 Saturday 14th May 2011 9:00-5:00 p.m.

Medical Trade Exhibition: Hanover Suite 1 and Hanover Lounge 9:30 a.m.

S6 Lecture 1 “Treatment of mild to moderate osteoarthritis of the knee with visco supplement injections

by Podiatrists” Martin Harvey, MInstChP, PGCE, BSc – Hanover Suite 3 9:30 a.m.

S7 Workshop 1 – Use of Liquid Nitrogen and New Regulations: Hanover Suite 2 10:30 a.m.

Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 11:30 a.m.

S8 Lecture 2 “Inter Profession Dissonance” Judith Barbaro-Brown, MSc, BSc (Hons), PGCE, DPodM, MChS – Hanover Suite 3 11:30 a.m.

S9 Workshop 2 – Lasers, Their use in Podiatry: Hanover Suite 2 12:30 p.m.

Lunch: Restaurant and Trade Exhibition: Hanover Suite 1 2:00 p.m.

S10 Lecture 3 “Dementia, How to Interact with Patients” Patricia Pope, RGN Hanover Suite 3 2:00 p.m.

S11 Workshop 3 – Cryosurgery using a Cryo Alfa unit: Hanover Suite 2 3:00 p.m.

Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 3:30 p.m.

S12 Lecture 4 “Dementia, Effects on Practice” Patricia Pope, RGN – Hanover Suite 3 3:30 p.m.

S13 Workshop 4 – Practical Paddings and Strappings: Hanover Suite 2 4:30 p.m.

CLOSE OF CONFERENCE

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Letter from the President As a private practitioner I have always respected the freedom my patients have to choose who they select for their treatment and the area in which I work has a number of practitioners. Are we in competition for business? Yes, of course. Competition “keeps me on my toes” and encourages me to review the service I offer my patients; is my training and CPD up to date, am I cognisant of all current regulations? As I plan my year I take account of replacing and renewing equipment and investing in CPD, which has a cost in time lost from the surgery and family as well as outlay for the training. I also check that my patient record cards are audited and our own Clinical Standards read regularly to continually improve my practice. See the Clinical Standards and Audit of Patient Records documents in the Documents section of the Members Area of the web site.

I dislike the term “refurbishment” which is often used as improvements should be continuous because a business that rests on its laurels is a business that is not improving. To move out of your “comfort zone” is exciting and satisfying when the results come to fruition.

My colleagues on the E.C. are also in business and give their skills to good effect in improving the services offered to you by the IOCP. I think it is true to say that all of us have found a knowledge of modern communications to be a necessity recently as we action the requirements put upon your organisation: Membership Benefits – are the services you receive what you need?

Training – do you upgrade your skills? Do we provide the courses that you want?

CPD – what type and level do you require, where do you want to go for it and how much are you prepared to pay? Your feedback is important here.

Voice your comments at your branch meetings, these will be added to comments from Area Council and the A.G.M. and then actioned by the E.C. Acting on previous motions and comments we are taking a different format for the A.G.M. in May at Windsor, the work in putting this together has been exciting; we have high quality lectures, and workshops at a cost that will be hard to beat.

The venue is an ideal location with the attractions of Windsor Castle, Safari Park and Lego land to entertain the family while you catch up with your CPD and colleagues.

Your branch delegate will take part in the democratic process of running your organisation, a process which is unique to the IOCP, on the Friday and voting for the National Officers who you select to carry out your wishes during next year. Please come along and use the opportunity to speak to the National Officers, we really do want to hear your views.

The IOCP stand will be in Birmingham on May 25th and 26th, and at Kettering on June 21st and 22nd. See the online CPD Diary at http://www.iocp.org.uk/node/78 for details.

Under the Board of Ethics I draw you attention to the revised Code of Ethics on the web site at http://www.iocp.org.uk/node/359 Also for those members who are not registered with the HPC you need to be aware that it is illegal for you to use the protected titles of Chiropodist/ Podiatrist and Chiropody/Podiatry, there is a logo for you to use, contact Head Office to receive a copy of this by email.

The designatory letters that you may use are A.M.Inst.

The present and the incoming members of the Board of Education have been working together for new ways that you can take part in CPD, which will be made public at this years A.G.M., where I look forward to seeing both familiar and new faces.

Heather Bailey, May 2011

The Institute of Chiropodists and Podiatrists Training Centre, Sheffield

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Peer Review Section

PEER REVIEW SECTION Robert Sullivan BSc (Hons), Dip.Pod.Med, PgC .L.A, PgD.Pod.Serg, FSSChP, FIChPA, MRSM, M.Inst.ChP.

P

ublication deadlines seem to come and go with increasing speed, and winter becomes, and early summer approaches. It’s great so see colour seeping back into the day, and the longer evening for walks and clean air.

Next months peer review include a systematic review style paper from a new author who is in her final months at university in Edinburgh. It is great so see students taking an interest in writing for our journal. We wish her and all examination students a clear head and steady hands.

This peer review section sees the final article by Janet McGroggan. Personally I think that she as given us all much food for thought. Her articles show the enjoyment we can all have from expanding our education and skills. I have received a number of letters and email about here articles, whilst all these letters were great to receive, one sticks in my mind, the writer said “sections in the journal like Ms McGroggans really make one realise that podiatry is only mundane if we become stagnant”. An interesting thought are stagnant?

If Iyou canbecoming write so can you. It is Dr. Martin Gregor has review all of the articles that Janet McGroggan submitted to date, here is what he had to say this time.

Wethree on the peer review “The articles present a good overview of the possible nonsurgical method of treatment for a condition that in the past has almost totally relied on surgical interventions. I would like to congratulate the author on an engaging matter of fact writing style, a style which makes a complex subject entirely readable”. t

This issue see our first rheumatology article. This article is a clinical audit of foot problems in New Zealand. For any one with an interest in rheumatology this article will reflect their own finding and confirm of suspicions. This is an excellent shows the value of research, and This isarticle whatwhich he said:how we as professionals can apply that information in our

o

everyday practice. This article was reviewed by Mr. Mark Phelenson a consultant rheumatologist in Iceland. This is what he had to say about it.

“I find this article very interesting, as I, and my clinical practice are on the other side of the world.

Many of my patients have problems in walking due to joint instability; this instability can be very restrictive to the client. The multidisciplinary approach to client care is one of our best available tools as practitioners; we need to become expert communicators as well as practitioners. My clients, as I am sure yours are, could have been the clients that were the object of this study. The results of this audit show the importance of podiatry and communication between specialities as well as helpful suggestions in the management of foot pressure lesions. I would agree with the conclusions of this study; multidisciplinary rheumatology teams better serve the RA patient with foot problems”.

I appreciate you views and comments on any articles published in the journal, and would like to publish some of them in future issues as such comments promote debate.

Your views are important to me and this section of you journal. You can contact me through the email address in the front of the review or by contacting Head Office who will pass your comments and suggestions on.

There is an extract from an email I received. What do you think?

‘Robert I have problems with the treatment some of my Her of contribution patients, especially with verrucae, I am sure others have similar problems to. Can we have a discussion forum in the Review where we can talk about things like this? We could let each other know what works for us and pass it on’.

Any body want to let us know what they find helps with the good old hpv? or share some treatment gems. Emails Look out for some of these reviewed articles in please.

15

r I am looking forward to the next article, and

“enjoy these articles, and

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What is the podiatrist’s role in the modern day treatment of Talipes Equinovarus?

The third in a series of three articles by Janet McGroggan, joint winner of the Cosyfeet Podiatry Award 2009 Abstract In two previous articles I introduced the work of Dr. Ponseti in the non-surgical correction of talipes equinovarus and described the methodology of the treatment.

This article will summarize the second day of the Ponseti Workshop I attended in Manchester on the 11th October 2010.

I will then go on to discuss recent literature pertaining to gait analysis of corrected feet and what we may expect to see in podiatry gait labs in the future as a result of these findings. Further to this I will describe the structure of a Ponseti clinic and the implications for podiatrists in such clinics. Finally I will refer to current literature in all aspects of the Ponseti method and bring us up to date on the topic.

The second day of the Ponseti Method Workshop in Manchester’s Chancellor’s Hotel and Conference Centre was an ‘Advanced Course’ and was attended by many experienced practitioners eager to revise their skills and catch up with current research. Following a history of the Life and Work of Dr Ponseti,1 a recap on the technique2 and a plastering master class, Naomi Davis reviewed a number of case studies in which the patients had kindly come, or been brought, along.

These varied from a mother who described her experience of antenatal advice, to a baby currently undergoing treatment.

Also present was a young boy who had mismanaged complex clubfoot plus a knee pathology, and a young girl who had been through several failed surgical corrections.

Miss Davis3 then presented a talk on treating the complex foot, also known as the atypical clubfoot. The atypical clubfoot is tight posteriorly and on the plantar aspect rather than medially as expected. It is not necessarily obvious at the initiation of treatment that the foot is atypical, but if during manipulation the anterior process of the calcaneus comes out from underneath the talus early, and correcting the equinus and plantaris is difficult, then this is an indication that something is unusual. The result will be an over abducted foot with a lateral crease. Continuing on with treatment can result in the foot swelling, causing constant cast slippage. As the child gets older and stronger the foot can get stuck in cavus and equinus. Failure to stop treatment at this point can result in a break of the mid foot. When recognized, the foot can be treated using a modified Ponseti technique.

By removing the casts and allowing swelling to reduce, the deformity can revert to its original form and the modified technique can begin. Abducting gently to no more than 30° the cavus and equinus is addressed early by extending all the metatarsals simultaneously with both thumbs and casting.

Good moulding around the heel will help prevent slippage, as will keeping the knee at 90° and taking the plaster high on the thigh. In this treatment technique the practitioner will feel the anterior process of the calcaneus moving out from beneath the talus around the third cast. When this happens and the foot is in marked equinus and cavus then the practitioner must actively manipulate the foot into dorsiflexion. The tenotomy may need to be repeated in such cases and further 16

dorsiflexion can take place in the boots. Walking will improve the rear foot but the feet must be carefully monitored for recurrence so this can be treated immediately.

Following this talk, Stephanie Bohm4, an orthopaedic surgeon from Basel, Switzerland, with a particular interest in research associated with the Ponseti method, presented case studies where talipes was associated with other conditions such as Spina Bifida and Arthrogryposis. The Ponseti method was successfully used in these cases. Guy Atherton5 then discussed Congenital Vertical Talus, a condition which he has successfully treated with a combination of surgical and modified Ponseti method. Other conditions which have also been treated via the Ponseti method but using fewer casts are metatarsus adductus and positional clubfoot. Details of these were presented by Denise Watson,6 a physiotherapist from Chelsea and Westminster Hospital.

Jennifer McCahill,7 from the Oxford Gait Laboratory, presented her research on the correlation between plantar pressure (using a prototype piezoresistive pressure plate) and Oxford Foot Model (OFM) kinematics in clubfoot. The kinematic data was collected with a 12 camera Vicon 612

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Peer Review Section

system. Using visual markers in conjunction with pressure plates the researchers superimposed anatomical landmarks onto pressure footprints. This allowed them to divide the foot into five sub-sections based on the anatomical landmarks and correlate the peak force from each sub-section with clinically relevant variables from the OFM. McCahill reported that by dividing the pressure footprint into medial and lateral forefoot, medial and lateral rear foot and midfoot they found an inverse correlation between forefoot supination in relation to the rear foot and medial/lateral heel force. This indicates forefoot pronation compensating for rear foot varus. Midfoot force was significantly higher in affected limbs when compared to a normal control group. The research concluded that rear foot loading influenced forefoot positioning.

I managed to chat with Jennifer McCahill over coffee, explaining that I was trying not only to involve podiatrists in the Ponseti treatment but in the long term aftercare. She was very encouraging and recognized that podiatrists are well trained and well placed to undertake such work. She also pointed out that research into midfoot pressures was needed and saw this area as one in which podiatrists could perhaps assist. She later emailed me two articles pertaining specifically to midfoot pressures.

Research that Stephanie Bohm was involved in8,9 showed significantly higher maximum force, contact area and impulse moment in the midfoot region compared to normal values and stated that the increased contact area was not easily understood. Conversely, the midfoot plantar pressures showed no significant differences to normal values.

However, the rear foot plantar pressures were reduced in affected feet. This was attributed to the delayed development of muscular activity. (The average age of subjects was three years). They also observed significantly higher plantar pressure values in the whole foot in the non-affected limbs in unilateral cases.

orthopaedic consultants’ time and are convenient for families, preventing long weekly journeys to specialist hospitals and reducing in-clinic waiting times. The families attend the ‘hub’ for the tenotomy and brace fitting, and the ‘spoke’ for serial manipulation and casting (see chart 1)15.

Trials showed that providing treatment in secondary care clinics results in fewer tenotomys, most likely as a result of earlier intervention. This clinic design also reported that the use of a number of trained clinical specialists reduced the effect of absenteeism through holidays and sickness.

It is interesting that podiatrists are not currently involved in the provision of treatment for talipes as it is a lower limb complaint and we are lower limb specialists. Our knowledge of functional anatomy and biomechanics makes podiatrists the ideal health profession to provide the Ponseti method of treatment.

In a recent article, Donald Lorimer16 considered the future of podiatry, whose evolution into a science has often been hindered by financial constraints within the NHS. He pointed out that we do not want to shift away from general podiatry, but that as a profession we must embrace new skills that allow us to be regarded as foot and lower-limb specialists. Lorimer predicts a sea change within podiatry where assistant practitioners are managed by podiatrists as dental hygienists are managed by dentists. This allows the practitioner to develop specialist interests without ostracising our core skills.

We are trained to work both independently and as part of a team and we demonstrate professional autonomy. Autonomy allows us to have influence and freedom within our specialism.

For me, this was the area of the course that I had been waiting for. What residual anomalies pertaining to gait and deformity will we be presented within our clinics as the children treated using the Ponseti method mature? Podiatrists will need to be prepared for patients who have been treated using the Ponseti method presenting once skeletal maturity has been reached or as the aging process causes pathological gait changes. Research has shown excessive internal tibial torsion can be problematic in such patients10, 11 and the significance of the subtalar joint as an interface between the leg and foot should not be underestimated when treating associated pathologies.

There is also evidence that vascular and neurological conditions12,13 exist as a result of the original deformity that cannot be corrected by manipulation or a single surgical procedure. This research is still in its infancy and in the future it may become evident that the podiatrist is not only required to monitor the gait of patients born with talipes on a regular basis but carry out vascular and neurological assessments also.

The Ponseti method is currently provided in the NHS in a ‘hub and spoke’ form14. The ‘hub’ clinic is in a hospital and the ‘spoke’ clinics are a number of secondary care clinics in the community. These physiotherapist-led clinics free up 17

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This is a privilege not afforded to all health professions and we should value this and use it to enhance our professional status17.

Due to the long term studies which demonstrate the effectiveness of the Ponseti method, the incidence of surgical correction of talipes is declining18. Research is now turning to gait analysis,8,9,10,11,19 classification systems20 and using the method to treat more complex cases such as untreated adults and children with associated pathologies4,5,6.

Epidemiologists in Denmark21 and Sweden22 have reported an increase in the incidence of talipes. As the cause of talipes is still unknown the researchers could only speculate on the reasons for this. If, as some evidence suggests, there is a genetic aetiology, immigration has been proposed as a link as there is a higher incidence of talipes in the Far East and South Africa. The Danish study concluded that the rise is associated with an increase in population density and cited exogenous factors such as environmental stress, substance abuse and potential exposure to infection. These factors are more common in a dense population. The Danish study also pointed out that fewer foetuses with talipes are being aborted and therefore the statistics show an increase in live births with talipes. Whatever the aetiology, this fact indicates that the UK could have a significant increase in talipes patients in the future as the condition is de-stigmatised.

I was the only podiatrist on this course and chatting to physiotherapists I felt that our involvement would be welcomed. One lady actually said that she wished they had a podiatrist on their team as our biomechanical knowledge is superior to that of the orthotists they use.

It is important that we are trained in the Ponseti technique even if we use this information only to enhance our understanding of the condition and the corrected limb. The majority of treated patients in the UK at the moment are children. One study actually recommended that it would be best if these patients were advised to adopt sedentary careers to maintain long term correction23. I feel that podiatrists are critical to allowing treated talipes patients to lead a full life, choosing whatever career and hobbies they wish through the use of gait analysis, orthotics, vascular and neurological assessments. Long term correction may be maintained through a long term relationship with a podiatrist.

For a FREE DVD called ‘How to do “The Ponseti Method” Including Atypical Club Foot’ please email Stella Morris at stella@c-prodirect.co.uk or go to www.cprodirect.co.uk For a FREE DVD called ‘Parents Guide to Clubfoot. The Ponseti Method’ please contact www.steps-charity.org.uk You can also stream this film from http://www.stepscharity.org.uk/links/4-14-clubfoot_or_talipes.php Acknowledgments The author wishes to thank Cosyfeet for their support in writing this article and global-HELP.org for their permission to use images and words. Please address any correspondence to janetmcgroggan@hotmail.co.uk 18

References 1. Hulme, A. 2010. The Ponseti Method Workshop. The Life and Work of Dr. Ponseti. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

2. DeKiewiet, G. 2010. The Ponseti Method Workshop. Recap – The Ponseti Technique. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

3. Davis, N. 2010. The Ponseti Method Workshop. Treating the Complex foot. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

4. Bohm, S. 2010. The Ponseti Method Workshop. Spina Bifida and Arthrogryposis. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

5. Atherton, G. 2010. The Ponseti Method Workshop. Congenital Vertical Talus. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

6. Watson, D. 2010. The Ponseti Method Workshop. Protocols for Metatarsus Adductus and Positional Clubfoot. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

7. McCahill, J. 2010. The Ponseti Method Workshop. Outcome Tools and Gait Analysis. [lecture] October 11. Manchester: The Chancellor’s Hotel and Conference Centre.

8. Bosch, K., Bohm, S., Sinclair, M.F. & Rosenbaum, D. 2008. Foot loading patterns in children after Ponseti clubfoot treatment. Clinical Biomechanics. 23 pp665-666.

9. Sinclair, M.F., Bosch, K., Rosenbaum, D. & Bohm, S. 2009. Pedobarographic analysis following Ponseti treatment for congenital clubfoot. Clin Orthop Relat Res. 467 pp1223-1230.

10. El-Hawary, R., Karol, L.A., Jeans, K.A. & Richards, B.S. 2008. Gait analysis of children treated with physical therapy or the Ponseti cast technique. J Bone Joint Surg Am. 90pp1508-1516.

11. Gottschalk, H.P., Karol, L.A. & Jeans, K.A. 2010. Gait analysis of children treated for moderate clubfoot with physical therapy versus the Ponseti cast technique. J Pediatr Orthop. 30(3)pp235-9.

12. Dobbs, M.B., Gordon, J.E. & Schoenecker, P.L. 2004. Absent posterior tibial artery associated with idiopathic clubfoot. J Bone Joint Surg Am. 86pp599-602.

13. Klychkova IJ. 2008. Clinical and physiological examination of congenital clubfoot (principles and results). In: Bensahel H, Kuo KN, Lehman. Fifth Annual Clubfoot Congress IFPOS & ICFSG, August 27-28, Hong Kong. Journal of Childrens Orthopaedics 3:67-83, 2009.

14. Waite, J. 2010. The Ponseti Method Workshop. Setting up a Clinic in the UK. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre.

15. Kampa, R., Binks, K., Dunkley, M. & Coates, C. 2008. Multidisciplinary management of clubfeet using the Ponseti method in a district general hospital setting. J Child Orthop. 2 pp463-467.

16. Lorimer, D. 2009. The scope of podiatry – use it or lose it. Podiatry as a science.

Podiatry Now. January. pp22-23.

17. Mandy, P. 2008. Demons and slaves: autonomy and status in professional practice.

Podiatry Now. May. pp 23-25.

18. Bridgens, J. & Kiely, N. 2010. Clinical review. BMJ. 340:c355.

19. Nabeshima, Y., Mori, H., Fujii, H., Ozaki, A., Mitani, M. & Fujioka, H. 2009. Ankle valgus and subtalar varus in treated clubfoot. J Foot Ankle Surg. 48(6)pp615-9.

20. Chu, A., Labar, A.S., Sala, D.A., van Bosse, H.J. & Lehman, W.B. 2010. Clubfoot classification: correlation with Ponseti cast treatment. J Pediatr Orthop. 30.

21. Krogsgaard, M.R., Jensen, P.K., Kjaer, I., Husted, H., Lorentzen, J., HvassChristensen, B., Christensen, S.B., Larsen, K. & Sonne-Holm, S. 2006. Increasing incidence of club foot with higher population density. Acta Orthopaedica.

77(6)pp839-846.

22. Engesaeter, L.B. 2006. Increasign incidence of clubfoot. Changes in the genes or the environment? Acta Orthopaedica. 77(6)pp837-838.

23. Cooper, D.M., & Dietz, F.R. Treatment of idiopathic clubfoot. A thirty-year followup note. J Bone Joint Surg Am. 1995. 77pp1477-1489.

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Continued ProfessionalDevelopment

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.

Biomechanics, Myths and Legends Robert Isaacs BSc(Hons)MChS Cert. KCHyp

A

s a wise man once said, “many of the truths we cling to depend greatly on our point of view.” Biomechanics is a wonderfully challenging specialism for the clinician and theorist alike. In the last 40 years since Root, Orien and Weed published their model of biomechanical assessment and prescription, the science has made great strides, mostly in the wrong directions (though a few in the right ones).

Biomechanics is as a great stew in which we fish for the meat of knowledge and the potato of clinical effectiveness amidst the oily film of bias, the unidentifiable wobbly bits of myth and the indigestible gristle of presumptions. And we must be ever alert for the cockroach of deliberate, profit driven error which can all too often scuttle in un-regarded.

If you will, dear reader, follow me now through some of the pieces which have the superficial appearance of wholesomeness, but which in truth may well cause you a day on the metaphorical lavatory if you swallow them.

Myth 1 - The foot should function/functions best in sub talar neutral This one is born of a misinterpretation of Root’s original work.

Root never actually stated that the foot should be in Sub Talar Neutral throughout gait. Indeed he describes a pattern of pronation and supination through gait which closely resembles the more recent data we have.1,2 Sheldon Langer, in his book “A practical manual for a basic approach to foot biomechanics” states that: “In the ideal person, when the subtalar joint is in neutral position, a line bisecting the posterior aspect of the calcaneus will be vertical… This is true both on and off weight bearing”3 This is neither clinically reproducible, nor logically consistent.

Firstly, as Langer’s book states elsewhere, pronation is a necessary movement to absorb shock. If the foot is “held” in sub talar neutral it cannot fulfil this essential function. Merton Root wrote: A functional orthosis does not support the arch of the foot. A functional orthosis does not “balance” a foot. A functional orthosis does not hold a foot in any position.

Orthoses do NOT hold the foot in neutral.

Secondly, for the foot to be in sub talar neutral in relaxed stance the body must expend considerable muscular effort. Try it yourself, it’s tiring! It is not logical for the position of rest to demand so much of the body.

Thirdly we have copious dynamic data which shows that the sub talar joint in a normal, healthy individual works through a pretty broad range during gait.2 It certainly does not stay in a single position, why should it? What would be the point of having a joint which does not move?

Myth 2 - Insoles hold the foot in sub talar neutral This one is born partly of a desire to fit in with myth 1. There exists still the quaint notion that if you cast the foot in a certain position, that the insole will hold the foot in that same position.

That would be true if the insole was screwed directly to the bones of the foot, however almost no orthotics have this feature.

Studies show us that there is considerable variation in the effect of orthotics on rearfoot position4-7. There has NEVER been a study which showed a 1:1 ratio, that is that a 5 degree heel wedge will incline the foot by 5 degrees. There is just too much “slop” of the foot on top of the orthotic. Further, the effect of an insole on foot position is impossible to predict.

Unless it wraps around the foot or ankle (like a SMAFO or some UCBLs) or unless it has the aforementioned screws, orthotics cannot “hold” anything. They can push, but that’s all.

The idea that whatever shape the foot is in when you cast it is the shape the insole will hold the foot in the shoe is arrant nonsense.

Myth 3 - Pronation is bad This is another frequent misquote of Rootian Biomechanics.

Pronation is a rather useful and vital movement. It allows for adaptation to terrain. It allows for shock absorption. It allows for “smoothing” of motion over the stance leg so that there is less bobbing up and down. If you see a patient who has no pronation during gait, worry! They are probably in all kinds of trouble.

And yet, when you stand a patient with a pain in front of a medic, a physio, or even a podiatrist, they will almost certainly nod owlishly and say something along the lines of “Egad, you’re pronating. That’ll be the problem right there.”

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Before and After - The picture which sold a thousand insoles, but is it fact or fallacy?

Pronation is much maligned. Think of it as the shock absorber of the foot (in the same way as the shock absorber of a car) and you’d not be far from the truth.

Sometimes of course, the structures involved in controlling / decelerating pronation can become pathological. The plantar fascia, the tibialis muscles, the deltoid ligaments, the sinus tarsi are all susceptible to damage. But the fact that the structures can be damaged does not mean the function which caused the damage is a bad thing. An orthopaedic surgeon faced with an arthritic knee will not declare that it was caused by the knee bending and fuse it. A podiatric surgeon faced with a 1st met which has become painful to bend would not state it was because the big toe should never bend and that the “ideal” position of the toe is straight and rigid. A mechanic faced with wobbly shock absorbers would not roll his eyes and declare that the function the shock absorbers were carrying out (before they broke) was abnormal or a design flaw. So why should we, when faced with a foot in which a structure involved with pronation has started hurting, say that it’s because pronation is a bad thing?

Pronation is a good thing! Cut it some slack!

May/June11CPD

Myth 4 - Ok, but OVERpronation is bad So what is OVERpronation? Is it pronation beyond a certain point? At a certain speed? At an incorrect time during the gait cycle? Is it to do with degree? Stiffness? Axial location? Residual moment?

It could be any of those things. But let’s be honest, we have NO evidence to show us where all those “certain points” lie. No consensus either, peoples idea for the “correct” position for an orthotic to operate range from almost flat to as supinated as the foot can achieve (MASS position). And in the absence of evidence that’s ALL they are, opinions. I can say that pronation beyond 7.34 degrees is abnormal but that is just a number I’ve plucked from the air.

Consider the typical Afro-Caribbean foot. Almost without exception they are much floppier and flatter than European feet and will sit in a much more pronated position in relaxed stance.

Are they, to a one, “overpronated”? The disproportionate representation of Afro Caribbeans in elite running (especially in sprint races) would seem to suggest that the generally more pronated foot posture of that race does not necessarily equate to poorer or less efficient function.

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Continued ProfessionalDevelopment Like most joints there IS a range at which the joints sublux and become less efficient or pathological. This, I suppose, could be loosely termed as overpronation. But let’s be honest the majority of people given this label are not in that range.

Step two. Say what that structure does in the foot. For example the plantar fascia operates the windlass which supinates the foot.

The deltoid ligament limits the range of pronation in the foot. The peroneus brevis pronates the foot.

In my experience the thing which leads people to be classed as “overpronating” is very simply, that they have a pathology. Which is a wonderful piece of circular logic. Why do we decide that their pronation is in fact OVERpronation? Because they have a pathology. What do we think caused the pathology? The overpronation. And how do we know its OVERpronation not ordinary healthy pronation? Because it caused a pathology. And how do we know its overpronation? Because it caused a pathology. Etc ad infinitum. It makes no sense.

Step three. Design an insole which does the same function as the injured structure.

This logical error is called “tautology”. It occurs when we make two statements which we consider to be true but which rest only upon one another. Why do I think the animal is a cat? Because it has a tail. How do I know it has a tail? Because it’s a cat and cats have tails. And how do I know it’s a cat? Because it has a tail. Etc.

Myth 5 - There is no evidence that Orthotics actually work.

Funny one this, no idea where it came from. There’s plenty!

One should, I suppose, define what we mean by “work”. One could mean either have a measurable effect on the function of the foot or whether they resolve symptoms.

For the former contention many studies have shown changes in joint positions (kinematics) or in forces (kinetics) with the use of orthotics. The latter contention is harder to test as one must always consider the placebo effect. However Blake and Denton (1985)8 surveyed a population of patients and found that 70% of them opined that their devices “defiantly helped”. Donatelli et al (1988)9 surveyed a population and found that 91% were “satisfied” with their orthoses. Mororas & Hodge (1993) 10 surveyed 523 patients and found that 63% had their symptoms completely resolved and 95% at least partially resolved by their orthotics. There is a substantial body of evidence that orthotics can work!

So there we go. A few things floating in the saucepan which on close inspection are somewhat unsavoury. Unfortunately it is rather easier to identify the obvious fallacies than the indisputable truths.

The collective pronoun for biomechanists is a “barny” or “ruck”.

We rarely agree on very much, which makes it hard for you, the coalface clinicians, to know who to believe when we contradict one another. The collective pronoun for podiatrists at a biomechanics conference tends to be a “baffle”. However I would offer you, as a logically consistent and coherent model, the tissue stress paradigm.

This was first proposed by Mcpoil and Hunt 11,12and has been enlarged upon and promoted by others, notable Kevin Kirby and Eric Fuller13,14. It is moderately complex and for the full version you should follow the references provided and read the work of far cleverer men than me. However for those who want a simple summary of a simple and elegant model, It goes like this.

Step one. Diagnosis. Find out which structure hurts. It may be a muscle, ligament, tendon, joint, or any other tissue. This is easiest done by prodding them in turn and noticing where your finger is when the patient says “ow”, or putting tension on the individual muscles / tendons to see which ones hurt.

So if the deltoid ligament limits the range of pronation and is injured, then your insole should limit the end range of pronation.

If the tibialis posterior supinates the foot / decelerates pronation the your insole should supinate the foot / decelerate pronation. If the fibrofatty padding under the ball of the foot distributes plantar pressure then your insole should distribute plantar pressure. If the calcaneofibular ligament limits supination then your insole should also limit supination by pronating the foot.

This is, to be sure, a simplified and crude description of this model, but it is logically consistent, easily clinically applicable, and fairly easy to understand. You will notice the lack of measuring angles, finding norms, or assessing neutral positions in this model. A tissue stress approach has use for these things in its more advanced forms, but at base it is all about making injured structures heal rather than assessing what the foot is doing and assuming that the injury is caused by a function variation.

Sometimes, injury is caused by something other than a gait pattern or functional “abnormality”.

In Conclusion Most conventional biomechanics is oriented around making the foot function “normally” or “correctly”. That is well and good, but it makes several incorrect assumptions. Firstly, that we know what is “normal” or “correct” in a foot. We don’t. There is a video on youtube called “overpronation the truth” 15 which shows the running style of Haille Gebrselassie, the greatest distance runner of all time. His ankles pronate to the point that it looks as if his feet are about to snap off and fly into the crowd. By any conventional measure he is “abnormal”. If someone came to see any one of us with a gait like that I suspect all of us would have him in antipronation trainers and orthoses in a heartbeat, with the warm satisfied glow of correcting a significant “overpronator”.

And we’d be wrong to do so, because this is the running style of the best runner in the world. His gait is not inefficient, nor does it predispose him to injury. He is better at running than anyone with a “normal” level of pronation. So if we don’t know what “normal” or “optimal” looks like, how can we practice biomechanics? Quite simply by stop trying to make people look normal and instead treating the injury which is in front of us. That may well involve supinating the foot. Or it may involve giving an insole to make the foot pronate MORE. There is abundant evidence that laterally posted insoles, which increase pronation, are effective at treating certain types of knee pathology16-19.

This, then, is the great evolution in biomechanics, the next paradigm shift. This evidence, significant in both scope and quality, should forever lay to rest the core biomechanical principle which I, and probably you, learned in training. That is, that biomechanics boils down to Pronation = bad and Supination = good. Once you free yourself from this assumption, a whole world of biomechanics opens before you. To me, it’s a far simpler and more coherent world.

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Continued ProfessionalDevelopment REFERENCES

11. McPoil TG & Hunt GC: Evaluation and Management of Foot and Ankle Disorders:

1. Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot. Clinical Biomechanics Corp., Los Angeles, CA, 1977.

2. MCPOIL T, CORNWALL MW: Relationship between neutral subtalar joint position and pattern of rearfoot motion during walking. Foot Ankle 15: 141, 1994.

3. S. Langer and J. Wernick. A practical manual for a basic approach to foot biomechanics.

3rd ed., Langer Biomechanics Group (U.K.) Ltd. (1989).

4. Blake RL, Ferguson HJ: Effect of extrinsic rearfoot posts on rearfoot position J Am Podiatr Med Assoc 1993 83: 447-456.

5. STELL JF, BUCKLEY JG: Controlling excessive pronation: a comparison of casted and non-casted orthoses. The Foot 8: 210, 1998.

Present Problems and Future Directions. JOSPT 21(6)381-388 1995.

12. McPoil TG & Hunt GC: An Evaluation and Treatment Paradigm for the Future. In Hunt GC & McPoil (eds): Physical Therapy of the Foot and Ankle 2nd Ed 199?

Churchill Livingstone.

13. Fuller, E.A.: Computerized gait evaluation. pp. 179-205, in Valmassy, R.L. (editor), Clinical Biomechanics of the Lower Extremities, Mosby-Year Book, St. Louis, 1996.

14. Kirby, K. A.: What future direction should podiatric biomechanics take? Clinics in Podiatric Medicine and Surgery, 18 (4):719-723, October 2001.

6. GENOVA JM, GROSS MT: Effect of foot orthotics on calcaneal eversion during standing and treadmill walking for subjects with abnormal pronation. J Orthop Sports Phys Ther 30: 664, 2000.[Medline].

15. http://www.youtube.com/watch?v=EAW87NsiGuI

7. Relationship Between Positive Clinical Outcomes of Foot Orthotic Treatment and Changes in Rearfoot Kinematics Gerard V. Zammit, BPod(Hons) * and Craig B. Payne, DipPod, MPH.

17. Effects of disease severity on response to lateral wedged shoe insole for medial

8. Blake RL, Denton JA. (1985) Functional Foot Orthoses for Athletic Injuries: A Retrospective Study. Journal of the American Podiatric Medical Association 75(7): 359-362.

9. Donatelli R, Hurlbert C, Conaway D, St. Pierre R. (1988) Biomechanical Foot Orthotics: A Retrospective Study. The Journal of Orthopaedic and Sports Physical Therapy 10(6): 205-212.

10. Moraros J, Hodge W. (1993) Orthotic Survey: Preliminary Results. Journal of the American Podiatric Medical Association 83(3): 139-148.

16. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004020.

compartment knee osteoarthritis. Arch Phys Med Rehabil. 2006 Nov;87(11):143641 18. Laterally Wedged Insoles in Knee Osteoarthritis: What are their Immediate Clinical and Biomechanical Effects and can they Predict 3-month Clinical Outcome? Rana S Hinman, Kim L Bennell, Craig Payne, Ben R Metcalf 19. The effect of a subject-specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. Butler RJ, Marchesi S, Royer T, Davis IS. J Orthop Res. 2007 Apr 27;

Questions 1. Who said “A functional orthosis does not hold a foot in any position?”

2. What is the most effective position for a foot to function in during gait?

3. What type of knee pathology is effectively treated by pronating the foot with lateral wedging?

4. What are the useful functions of pronation?

5. What feature of Haile Gebrselassie’s gait does he share with Ussain Bolt?

6. Which Ethnic Group has characteristically pronated feet in static weight bearing?

7. To which ethnic group do the five fastest athletes ever, belong?

7. Afro-carribean 6. Afro-carribean 5. Huge pronatory range when running 4. Shock absorbtion, adaptation to terrain 3. Medial Knee osteoarthritis 2. There is no single most effective position, the foot function through a range of positions 1. Merton Root Answers Robert Isaacs - email rissacs@nhs.net May/June11CPD

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Peer Review Section

Clinical audit of foot problems in patients with rheumatoid arthritis treated at Counties Manukau District Health Board, Auckland, New Zealand Keith Rome*1, Peter J. Gow2, Nicola Dalbeth2,3 and Jonathan M. Chapman1 Address:

1 Health and Rehabilitation Research Centre and Discipline of Podiatry, AUT University, Auckland, New Zealand, 2Department of Rheumatology, Counties Manukau District Health Board, Auckland, New Zealand and 3Department of Medicine, University of Auckland, Auckland, New Zealand

Email:

Keith Rome* - krome@aut.ac.nz; Peter J Gow - Peter.Gow@middlemore.co.nz; Nicola Dalbeth - n.dalbeth@auckland.ac.nz; Jonathan M Chapman - hwg3728@aut.ac.nz * Corresponding author First published: 15 May 2009 in Journal of Foot and Ankle Research 2009, 2:16

Abstract Background: At diagnosis, 16% of rheumatoid arthritis (RA) patients may have foot joint involvement, increasing to 90% as disease duration increases. This can lead to joint instability, difficulties in walking and limitation in functional ability that restricts activities of daily living. The podiatrist plays an important role in the multidisciplinary team approach to the management of foot problems. The aim of this study was to undertake a clinical audit of foot problems in patients with RA treated at Counties Manukau District Health Board.

Methods: Patients with RA were identified through rheumatological clinics run within CMDHB. 100 patients were eligible for inclusion. Specific foot outcome tools were used to evaluate pain, disability and function. Observation on foot lesions were noted and previous history of foot assessment, footwear/insoles and foot surgery were evaluated.

Results: The median age of the cohort was 60 (IQR: 51–64) years old with median disease duration of 15 (IQR: 7.3–25) years. Over 85% presented with foot lesions that included corns and callus over the forefoot region and lesser toe deformities. Moderate to high disability was noted. High levels of forefoot structural damage were observed. 76% had not seen a podiatrist and 77% reported no previous formal foot assessment. 40% had been seen at the orthotic centre for specialised footwear and insoles. 27% of RA patients reported previous foot surgery. A large proportion of patients wore inappropriate footwear.

Conclusion: This clinical audit suggests that the majority of RA patients suffer from foot problems. Future recommendations include the provision of a podiatrist within the current CMDHB multidisciplinary rheumatology team to ensure better services for RA patients with foot problems.

Introduction

R

heumatoid arthritis (RA) is the most common type of inflammatory arthritis [1]. The prevalence rate of RA in New Zealand has been reported to be between 0.79–2.6% [2,3]. When untreated, the disease can progress rapidly, causing swelling and damage to cartilage and bone around the joints. Any joint may be affected, but hands, wrists and feet are most often involved [4]. The main symptoms of RA are severe pain, stiffness, fatigue and loss of mobility. 42% of RA patients are registered disabled within 3 yrs of diagnosis [2]. 80% are moderately to severely disabled within 20 yrs. At diagnosis, 16% of RA patients may have foot joint involvement [5] increasing to 90% as disease duration increases [5,6]. This can lead to joint instability, difficulties in walking and limitation in functional ability that restricts activities of daily living [6]. The talonavicular joint is the most commonly affected; subtalar joint involvement shows a similar pattern, with an increase of 25% between 5–10 years of duration [7]. Deformity of the tarsal joints and forefoot also occurs with disease progression [8]. Williams and Bowden [9] reported that the evidence base for dedicated podiatry as part of multidisciplinary foot clinics in diabetes is well established, but that this has yet to be achieved for rheumatology services [10].

However, the role of the podiatrist in the rheumatology team is becoming recognised as a vital component in the integrated care given to patients by the multidisciplinary team [11,12].

Increasingly consultants and their teams are requesting specialist foot care services and it is suggested that the podiatrist is a key

practitioner in the management of patients with musculoskeletal disease [11-13]. It has been recommended that patients should understand the role and have access to a podiatrist [9]. The podiatrist's role is to identify, diagnose and treat disorders, diseases and deformities of the feet and legs and implement appropriate and timely care. Additionally, podiatrists also monitor foot health status, provide education and support in enabling behaviour change in lifestyle, and may be the only health-care professional that the patient sees on a regular basis. Therefore, they may arguably act as gate- keepers to other members of the multi-disciplinary team. This may be provided directly by a podiatrist or in association with other healthcare team members as required by the individual's foot problems [4]. The goal of the podiatry element of rheumatology care is to reduce foot-related pain, maintain/improve foot function and thus mobility, while protecting skin and other tissues from damage [4] Despite this recognition, it is generally perceived that access to podiatry services for patients with rheumatic diseases appears to be varied and in some instances absent, especially in New Zealand.

Podiatrists have a prominent role to play in symptom relief and improving quality of life because involvement of the feet, even to a mild degree, is a significant marker for impaired mobility, functional incapacity and negative psychosocial impact. Foot pathology contributes to difficulty with walking in about 75% of people with RA, and is the main or only cause of walking difficulty in 25% [1]. In the foot, joint pain and stiffness is the most common initial presentation, but a range of other features, including tenosynovitis, nodule formation and tarsal tunnel 19

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Peer Review Section syndrome may also present, reflecting widespread soft-tissue involvement [13,14]. Based upon the Arthritis and Musculoskeletal Alliance (ARMA) Standards of Care for People with Foot Health Problems and Inflammatory Arthritis [15] the purpose of this audit is to provide a benchmark by which podiatric service standards may be evaluated by all stakeholders. Therefore, the aim of this study is to identify the nature of foot problems experienced by patients attending rheumatology outpatient clinics at Counties Manukau District Health Board (CMDHB) and to ascertain the availability of podiatric services for these patients.

Method Patients The clinical audit was conducted over 12 weeks between December 2008 and March 2009. Sample size was determined by a fixed recruitment period for this clinical audit. Ethical approval was obtained from the Northern Regional Ethics Committee. All patients received information regarding the study. A convenience sample of 100 RA patients was recruited from rheumatology outpatient services based at CMDHB, Auckland, New Zealand.

One examiner (JC) interviewed and assessed all patients. Patients were eligible if they had a confirmed diagnosis of RA (satisfying the 1987 American Rheumatism Association revised criteria [16].

Demographic characteristics Age, ethnicity, gender, occupation, disease duration, Health Assessment Questionnaire (HAQ) [17] and current pharmacological management that includes non- steroidal antiinflammatory drugs (NSAIDs), methotrexate, other disease modifying anti-rheumatic drugs (DMARDs), prednisone and biologic therapies were recorded for each patient. Blood results that included erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and the presence of radiographic erosions were recorded from the patient's case notes.

Foot and ankle assessment Foot and ankle assessment were based upon the recommendations from the Standards of Care for People with Musculoskeletal Foot Health Problems [16]. Assessments included: (i) Measures of structure and function; (ii) Lifestyle and social factors; (iii) Footwear suitability; (iv) Tissue viability and skin and nail assessments; (v) Baseline measures of foot impairment; (vi) The impact of any previous interventions, including surgery and foot orthoses.

The musculoskeletal foot examination included documentation of foot and toe deformities, foot type, joint swelling, pain and instability, plantar callus and foot ulceration. Baseline measures of pain, function and health status were also assessed [12,17].

Procedure Fore - and rearfoot deformities were quantified using the Structural Index score [18], which considers hallux valgus, metatarsal phalangeal (MTP) subluxation, 5th MTP exostosis, and claw/hammer toe deformities for the forefoot (range 0–12) and calcaneus valgus/varus angle, ankle range of motion and pes planus/cavus deformities for the rearfoot (range 0–7). Lesser toe deformities (hammer, mallet, and claw toes) were scored one point each, as were hyperkeratotic lesions (corns and calluses).

20

Other abnormal bony prominences, such as Tailor's bunions and exostoses, were also scored one point [19]. Patients were asked if they received professional foot care and what interventions were used (such as palliative care, foot orthoses or specialist footwear).

Similarly those patients who had been provided with foot orthoses by the local orthotic centre were asked about the suitability of the devices and if they had been beneficial in reducing foot pain.

Finally, the assessing podiatrist asked if the patients' had undergone previous foot surgery.

Disease measurement Disease impact was measured using the Leeds Foot Impact Scale [12]. This self completed questionnaire comprises two subscales for impairment/footwear (LFISIF) and activity limitation/participation restriction (LFISAP). The former contains 21 items related to foot pain and joint stiffness as well as footwear related impairments and the latter contains 30 items related to activity limitation and participation restriction [12].

Footwear characteristics An objective assessment of footwear was carried out by the podiatrist, to ascertain the type and appropriateness of the participant's footwear. The assessment included shoe style: selected from a list of 16 basic shoe styles and included the terms sandals, mules and jandals [20]. Sandals are defined as shoes consisting of a sole fastened to the foot by thongs or straps. A mule shoe is a type of shoe that is backless and often closed-toed.

The term jandals, used predominantly in New Zealand and the South Pacific (also known as flip-flops in the UK and US and thongs in Australia) are flat, backless, usually rubber sandal consisting of a flat sole held loosely on the foot by a Y- shaped strap that passes between the first and second toes and around either side of the foot.

Data analysis Data were analysed using SPSS 15.0 for Windows.

Pharmacological management, gender, occupation, ethnicity and general footwear scores were described as percent- ages. All other demographic characteristics were described as the median (inter quartile range – IQR).

Results Participant demographics and disease characteristics One hundred (100) RA patients were recruited into the study with a median age of 60 (IQR: 51–64) years old with 79% being women. The results demonstrated a ratio of 4:1 female: males (Table 1). Fifty-seven patients (57%) were Caucasian with 14% being Maori and 14% Pacific Islanders. The median duration of disease was 15 (IQR: 7.3–25) years which suggests a wellestablished disease with levels of functional disability. In spite of the general prevalence of moderate disease activity, 39% of patients were employed.

Sixteen percent (16%) of patients also had diabetes Sixty- seven percent (67%) of patients presented with erosions on X-rays.

Sixty-four percent (64%) of patients were treated with NSAIDs, 67% specifically with methotrexate, 42% with other DMARDs, 33% with prednisone and 17% with biologic therapies.

Foot impairments Patients in the current study had high-to severe (LFISIF >7 point, LFISAP >10 points) levels of foot impairment and disability on the LFIS subscales (Table 2). The forefoot structural index demonstrated severe structural problems but the rearfoot

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Peer Review Section structural indices demonstrated moderate problems. Over twothirds of patients were observed with hallux valgus (bunions).

Over 85% of patients in the study presented with symptomatic callus under the plantar surface of the foot and/or on the toes.

Podiatric care Concerning podiatric intervention, 24% of RA patients reported they have been seen by a podiatrist and over 40% of patients used the orthotic centre. Because of the absence of a podiatry service at CMDHB for patients other than those with diabetes, no participant in the current study had received podiatric intervention by a qualified podiatrist specialising in the management of rheumatic.

Table 1: Demographic and clinical characteristics Demographic characteristics Value Median (IQR) Age (years) 60 (51-64) % Gender (F:M) 4:1 (79% female.

21% male) % Ethnicity Caucasian: 57% Pacific Islands: 14% Maori: 14% Asian: 11% Non-European: 4% Median (IQR) disease duration (years) 15 (7.3-25) Working: (%) 34% Not working/Beneficiary: (%) 15% Retired: (%) 31% Housewife/homemaker: (%) 15% Clinical characteristics Median (IQR) HAQ Score (0–3) % radiographic erosions

0.9(0.4, 1.3) Yes: 67%; No: 33%

Pharmacological management NSAIDS: n (%) Methotrexate: n (%) Other DMARDS: n (%) Prednisone: n (%) Biologics: n (%)

62 (64%) 65 (67%) 41 (42%) 32 (33%) 17 (17%)

Blood investigations Median (IQR) ESR (mg/hr) Median (IQR) CRP (mm/L)

27.0 (12.0; 42.3) 7.9 (3.8; 7.3)

diseases. 27% of patients reported having foot surgery (Table 2).

The majority of RA patients wore open-type footwear such as sandals (21%), jandals (10%) or mules (10%). Only nine patients wore surgical footwear (Table 3).

Discussion The purpose of this study was to undertake a clinical audit evaluating current RA foot care services in Counties Manukau.

Overall, this study demonstrates that in this particular outpatient clinic, poor foot health and foot pain is highly prevalent in patients with rheumatic diseases. Over 85% of patients with RA had foot involvement ranging from callus, corns and lesser toe deformities.

The study also demonstrated moderate impairment and limited activity using the Leeds Foot Impact Scale [12] suggesting the majority of patients suffer with long-term disability from this chronic condition.

Table 2: Foot & ankle characteristics Foot characteristics Median (IQR) Forefoot Structural Index (range 0–12) Median (IQR) Rearfoot Structural Index (range 0–7) Median (IQR) Leeds Foot Impact Scale impairment/footwear (range 0–21) Median (IQR) Leeds Foot Impact Scale activity limitation/participation restriction (range 22–51) Total Median (IQR) Leeds Foot Impact Scale Median (IQR) Foot Problem Score Hallux Valgus: (%) Number and Frequency of Foot Lesions: n (%) Forefoot Callus: (%) Lesser Toe Deformities: (%) Previous Foot Assessment: n (%) Previous Podiatry: n (%) Previous Foot Surgery: n (%) Previous Orthotics: n (%)

Score 9 (1-14) 2 (2-4) 11 (8-14)

18 (11-23) 29 (20-36) 7 (5-13) 64% 99 (79%) 63% 86% Yes 23%: No 77% Yes 24%: No 76% Yes 27%: No 73% Yes 40%: No 60%

The problem of footwear was highlighted in the audit. The majority of patients were observed wearing footwear that could be described as inappropriate for those patients with severe pain and disability and included sandals, mules and jandals. The lack of support mechanisms, cushioning and protection of toe regions may contribute to pain and disability.

The current clinical audit demonstrated 16% of RA patients presented with diabetes suggesting that patients with autoimmune disorders, and/or taking medication that compromises the immune system should be considered at risk of infection and foot ulceration, due to a lack of protection, especially on the plantar surface of the feet. Likewise, patients with micro-vascular and/or large vessel disease and foot deformity are also at risk of foot trauma, ulceration and subsequent infection [9]. The use of podiatrists and management programmes that includes advice of foot health education, appropriate footwear and prescription of foot orthoses is essential if we are to reduce the impact of foot problems in this patient group.

The results from the current audit are similar to UK audits [3,9].

Recent reports from the UK recommend the need for more consistent provision of specialist care for patients with RA and better implementation of guidance and best practice [4,21].

However, there is no similar data or recommendations for New Zealand, and there are no previous studies of foot problems in New Zealand patients with rheumatic diseases.

The results of this study support the case for a specialist podiatrist to manage patients with rheumatic diseases in this locality, whatever the patient's age or stage of disease. This audit recommends that in order to identify patients with foot problems, their consultant or specialist nurse should question patients about their feet. If foot problems are identified, a referral to the specialist podiatrist should be made. Patients with disabling foot pain, or who are at risk of foot ulceration, should receive priority foot care [9,22].

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Peer Review Section Foot orthoses should be considered for patients recently diagnosed with RA as this intervention has been demonstrated to reduce pain and the effects of abnormal joint function in the foot [23].

The current audit demonstrated that RA patients reported podiatry was "very useful". However, patients perception of the term podiatry was related only to toenail cutting, and corn reduction rather than for structural modifications. The role of the podiatrist within rheumatology involves a range of different assessments and interventions [4]. An assessment of the lower limbs may include the skin, vascular and neurological systems, the musculoskeletal structures and walking. Specialist prescription footwear should also be available for patients who cannot fit into appropriate retail footwear and in this domain; both podiatrists and orthotists should collaborate to achieve the optimal clinical outcome [9]. Working with surgeons, in relation to appropriateness for foot surgery, should also be considered, as this option is often over- looked by podiatrists. This study demonstrates that there is an unmet need for specialist podiatry in patients attending this particular rheumatology out patients clinic.

A mechanism should be put in place whereby everyone with a diagnosis of inflammatory arthritis receives a foot examination within three months of diagnosis [16].

Table 3: General footwear assessment General footwear type Sandal Mule Jandals Walking Shoe Athletic Shoe Moccasin Surgical/Orthotic Shoe Boot High Heel Backless Slipper Court Shoe Oxford Shoe Socks only Slipper Unable to assess footwear

% 21% 13% 10% 10% 9% 9% 9% 6% 4% 2% 2% 2% 1% 1% 1%

Patients with RA should be provided with information and education to enable them to recognise the signs of these variations and understand what to do if variations occur. Increased systemic disease activity can accelerate changes in foot pathology so consideration must be taken of local as well as systemic factors.

A recent study under- taken in the UK using a self-management foot care programme for 30 patients with RA demonstrated that just over 50% of patients were physically able to undertake some aspects of self-managed foot care, including nail clipping and filing, callus filing and daily hygiene and inspection [13]. A clinical audit of 139 rheumatoid patients undertaken in the UK reported that poor foot health and foot pain as being common in patients with rheumatic diseases [9]. The authors highlighted that the lack of foot care could lead to reduction in mobility and in some cases serious complications and recommended that a specialist and dedicated foot care service needs to be provided for these patients [9].

Conclusion

The current study has highlighted patients with RA have an increased need for a range of basic foot care services. There is evidence from the current literature that early intervention for existing or potential foot problems can improve long-term outcomes. Baseline foot examination can identify people with existing or imminent needs and provide a comparator for assessment. Regular assessments that document the rate of structural change can aid treatment decisions and improves 22

outcomes. An annual musculoskeletal, vascular and neurological assessment, which includes an assessment of the lower limbs and feet, will help identify problems early. Future developments may incorporate self-educational programmes and the need for podiatrists to be part of the rheumatological multidisciplinary team. Overall, this study showed that opportunities for innovation and improvement in RA services exist and need to be pursued vigorously including the development of a business case for a combined DHB-academic post in podiatry.

Competing interests The authors declare that they have no competing interests.

Authorsâ&#x20AC;&#x2122; contributions KR, PG and ND conceived and designed the study. JC collected and inputted the data. KR, PG and ND conducted the statistical analysis. KR and JC compiled the data and drafted the manuscript and ND and PG contributed to the drafting of the manuscript. All authors read and approved the final manuscript.

Acknowledgements The authors would like to thank the rheumatology staff at Counties Manu-kau, Auckland, New Zealand and all the patients who took part. The authors also wish to thank the Counties Manukau District Health Board Studentship Research Committee for funding the current study.

References 1. Michelson J, Easley M, Wigley FM, Hellman D: Foot and ankle problems in rheumatoid arthritis. Foot Ankle 1994, 15:608-13.

2. New Zealand Health Survey: A portrait of health Key results of the 2002/03 New Zealand Health Survey. 2004.

3. Redmond A, Redmond AC, Waxman R, Helliwell PS: Provision of foot health services in rheumatology in the UK. Rheumatology 2006, 45:571-6.

4. National Rheumatoid Arthritis Society Website [http://www.prcassoc.org.uk/standards-project] 5. MacSween A, Brydson GJ, Hamilton J: The effect of custom moulded ethyl vinyl acetate foot orthoses on the gait of patients with rheumatoid arthritis. Foot 1999, 9:128-133.

6. Kerry RM, Holt GM, Stockley GI: The foot in chronic rheumatoid arthritis: a continuing problem. Foot 1994, 4:201-203.

7. Bouysset M, Bonvoisin B, Lejeune E, Bouvier M: Flattening of the rheumatoid foot in tarsal arthritis on X-ray. Scand Rheum 1987, 16:127-13.

8. Turner DE, Woodburn J: Characterising the clinical and biomechanical features of severely deformed feet in rheumatoid arthritis. Gait Posture 2008, 28(4):574-80. Epub 2008 May 27 9. Williams AE, Bowden PA: Meeting the challenge for foot health in rheumatic diseases. Foot 2004, 14:154-158.

10. Edmonds ME, Blundell MP, Morris ME, Maelor-Thomas E, Cotton LE, Watkins PJ: Improved survival of the diabetic foot: the role of the specialist foot clinic. Q J Med 1986, 232:763-71.

11. Beeson P: Podiatric perspective: a case study of rheumatoid arthritis and a multidisciplinary approach. Br J Ther Rehabil 1995, 10:566-71.

12. Helliwell PS, Allen N, Gilworth G, Redmond A, Slade A, Tennant A, Woodburn J: Development of a foot impact scale for rheumatoid arthritis. Arthritis Rheum. 2005, 53(3):418-422.

13. Semple R, Newcombe LW, Finlayson GL, Hutchison CR, Forlow JH, Woodburn J: FOOTSTEP self-management foot care pro- gramme: Are rheumatoid arthritis patients physically able to participate? Musculoskeletal Care 2008, 17:57-65.

14. Taylor W, Smeets L, Hall J, McPherson K: The burden of rheu- matic disorders in general practice: consultation rates for rheumatic disease and the relationship to age, ethnicity, and small-area deprivation. New Zealand Medical 2004, 17:1203.

15. Musculoskeletal Alliance (ARMA): Standards of Care for People with Foot Health Problems and Inflammatory Arthritis. 2008.

16. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS: The American Rheumatism Association 1987 revised cri- teria for the classification of rheumatoid arthritis.

Arthritis Rheum 1988, 31:315-324.

17. Bruce B, Fries JF: The Health Assessment Questionnaire. Clin Exp Rheumatol 2005, S39:14-18.

18. Platto MJ, O'Connell PG, Hicks JE, Gerber LH: The relationship of pain and disability of the rheumatoid foot to gait and an index of functional ambulation. J Rheumatol 1991, 18:38-43.

19. Menz HB, Lord SR: The contribution of foot problems to mobility impairment and falls in community-dwelling older people. J Am Geriatr Soc 2001, 49:1651-55.

20. Menz HB, Sherrington K: The footwear assessment form: a reli- able clinical tool to assess footwear characteristics of rele- vance to postural stability in older adults. Clin Rehab 2000, 14:657-664.

21. National Institute for Clinical Effectiveness (NICE): Rheumatoid Arthritis: The management of rheumatoid arthritis in adults. 2009 [http://www.nice.org.uk/nicemedia/pdf/ CG79NICEGuideline.pdf].

22. Williams AE, Meacher K: Shoes in the cupboard; the fate of pre- scribed footwear? Prosthet Orthot 2001, 25:53-9.

23. Woodburn J, Barker S, Helliwell PS: A randomised controlled trial of foot orthoses in rheumatoid arthritis. J Rheumatol 2002, 29:1377-83. Š2009 Rome et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Area Council News Southern Area Council Spring 2011 Seminar The Southern Area Council (SAC) had great pleasure presenting their spring seminar on the 26th March 2011 at Anglia Ruskin University, Chelmsford in Essex.

This year there was some changes to the usual programme of events, which involved a series of lectures in the morning and two afternoon workshops to keep those with a sleepy constitution after lunch involved, interested and learning. The seminar’s guest speakers were Neil Simmonite from the University of East London, who gave two very interesting lectures in the morning under the seminar’s title of ‘Podiatry & Health’. The topics presented included the many issues of Clinical Governance, health & safety, risk assessments, COSHH, cross infection and an introduction to microbiology.

In addition he covered other aspects that surround our daily practice and if that was not enough he went onto present a very enjoyable workshop in the latter part of the afternoon on ‘Challenging your views as a Podiatrist/ Health Professional’, which had everyone engaged and taking part in the discussions and fun activities. Martin Nunn also presented a very interesting workshop after lunch on Plantar Fasciitis with a practical application of padding and strapping.

The seminar was well attended by some very motivated members, along with three trade stands also in attendance, to which the SAC would like to give our grateful thanks to: Martin at C & P Medical, Heidi from Algeos and Rose from Bailey Instruments for their support of this seminar. Although numbers were down on previous years, which given the current economic factors may have played a part; the seminar was deemed to be a very successful day all around.

The SAC had great pleasure welcoming our President to the seminar as our special guest and who was kind enough to be Martin’s model for his workshop in the afternoon; plus drawing

both the free prize draw and raffle draw at the end of the day.

The raffle monies raised went to support the Helen Rollason Cancer Charity and a further donation of £100 will be given to the Benevolent Fund.

The seminar was very interesting, informative and thought provoking and was very well received. The feedback that delegates kindly submit at the end of the day is always helpful to enable the SAC to organise future seminars and provide a good standard of Continuing Professional Development (CPD) for all its members.

The SAC wish to thank everyone who attended the seminar, and in particular special thanks must go to the lecturers and our President who do so much to support and encourage learning among our members. We look forward to seeing you all again next year.

Kind regards and best wishes Beverley Wright, Chairperson Southern Area Council

Northern Ireland Area Council Long Service Awards The Northern Ireland Area Council wish to extend their deep gratitude to the faithful service and contributions given by the esteemed members awarded certificates of Long service at the NIAC A.G.M. in January. We in Northern Ireland are indebted to their influence and guidance spanning over 50 years. Official branch positions they held range from chairman, secretary, treasurer, auditors, social secretary and conference delegates, in fact ALL are still in full time practice and never miss branch meetings!

Stephen Preston, NIAC Chairman

Back Row (L to R) Colin Craig, May Maxwell, David McDonald Front Row Honor Reay and Patrica Malone

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The Institute of Chiropodists and Podiatrists – Code of Ethics In accordance with the Memorandum and Articles, all Members and Students of the Institute shall in writing undertake to adhere to the following:- (members must note that because an item is not mentioned, it does not mean that it cannot constitute a breach of Ethics). As chiropody/podiatry in the United Kingdom is a legally regulated profession within the scope of the Health Professions Order 2001 (and subsequent amendments) attention is specifically drawn to the provisions of that act and the requirements of the legal entity created for its implementation; the Health Professions Council (HPC). The contents of this document should be read in conjunction with the specific legal obligations and requirements placed upon Chiropodists and Podiatrists as registrants of the HPC. Breaches of such legal requirements would additionally be regarded as breaches of the Institutes own ethical code and be dealt with in the manner laid down for such occurrence.

5.

UK members currently HPC registered as Chiropodists and Podiatrists may utilise, sell and supply those pharmacy-only medicines which are laid out in the amendment to the 1968 Medicines act recognised by the UK Medicines and Healthcare Products Regulations Agency in its guidance published in November 2006 or such amendments, and/or applicable statutory instruments, as may from time to time and for the time being be made and be in force. It is the professional responsibility of registrants to ensure that they are appropriately trained to utilise such medicines and that their knowledge is current and in line with the best practices applying at the time of such use.

6.

Suitably trained Chiropodists and Podiatrists with recognised qualifications who are appropriately registered with the HPC and annotated for local anaesthetics and/or prescription only medicines, may independently upon their own clinical judgement utilise injected local anaesthetics and supply or administer the range of stated exempted prescription-only medicines as defined in accordance with the current legislation applying at any particular time. Additionally, members who are suitably qualified and registered and annotated with the HPC as supplementary prescribers may prescribe any appropriate medicine in line with a clinical management plan agreed between themselves, an independent prescriber (who must be a Doctor or Dentist with the right to prescribe such drugs) and the patient referred to in such a plan. It must be stressed that anaesthetics, exempted medicines and prescribing may only be utilised by registrants currently so annotated on the HPC register and such right of use immediately terminates upon an individual leaving the register for any reason.

7.

Members in practice outside the United Kingdom shall at all times comply with any and all local legislation applying to their professional practice and conduct.

8.

The Institute recognises that an individual’s scope of practice may change due to additional training or qualifications being undertaken. As a democratic organisation committed to the ongoing development of the profession of chiropody/podiatry, it does not seek to arbitrarily define or limit such scope of practice and actively encourages its members to continue learning and personal skills development to the very highest levels throughout their entire professional careers. However, it is both the ethical and legal duty of all members to only practice at any time within the scope of their own competence as defined by training or qualifications recognised by the board of education of the Institute, and within such legislation as may be applicable at such time of practice.

9.

A member has the right to examine, diagnose and treat the conditions for which he/she has been trained and within the scope of the law, without reference to a medical practitioner.

Associates who are not HPC registrants are still bound by the requirements of ethical, decent and lawful behaviour at all times and are subject to the same sanctions of the board of ethics as would apply to an HPC registrant member.

PROFESSIONAL DEFINITION 1.

“Chiropody/Podiatry” means the scientific care of the foot and directly related structures of the lower limb in health and disease in line with the best evidential paradigms existing at the time of such care.

2.

“Chiropodist/Podiatrist” is a protected professional title recognised in law and may only be used by an individual registered with the HPC if that practice is within the United Kingdom. It is a criminal offence for such titles to be used by anyone who is not currently so registered even if they possess qualifications which relate to the titles such as diploma, certificates or degrees in chiropody or podiatry or any variation thereof which could be taken to imply they are currently registered as Chiropodists/Podiatrists. Members in practice outside the United Kingdom must comply with any legislation defining titles and their use that are applicable in their country of operation.

SCOPE OF PROFESSIONAL PRACTICE 3.

All members of the Institute of Chiropodists and Podiatrists agree absolutely to follow the dictum of ‘primum non nocere’ and will at all times seek to ensure to the best of their professional ability and endeavours that in dealing with clients they ‘first do no harm’.

4.

Registered members of the Institute may undertake the surgical and mechanical treatment of the foot and its directly related structures within the lower limb in accordance with their specific training, professional liability insurance cover and experience.

This can include but is not limited to; abnormal nails, superficial excrescences occurring on the feet, corns, callosities and verrucae; the corrective and preventive treatment of congenital or acquired deformities of the feet, and the provision of appropriate appliances, orthoses and prosthetics. Nonprescription medicines which are on the ‘General Sales List’ may be utilised by all members in the course of their professional practice subject to that member having accurate and comprehensive clinical knowledge of such use.

PROFESSIONAL CONDUCT 10. A member shall at all times uphold the dignity and honour of the profession in all their actions, manner and dealings with clients and colleagues alike.

11. A member shall in all cases beyond their scope of practice advise or refer the patient to consult an appropriately qualified colleague, medical practitioner or other healthcare professional.

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12. A member shall not give treatment to any patient, who to his knowledge is under the current care of a medical practitioner, for a specific lower leg or foot problem, without the knowledge of that practitioner.

13. A member shall not for any reason offer treatment and/or advice to any patient known to be under the care of another member of the Institute without the consent of such member.

14. A member having been employed as an assistant by another member, shall not at the termination of such employment, or at any future time attempt to induce any patient to leave the former employer's practice.

15. The friendly relations which exist between professional persons should not be affected if another member should set up in practice nearby, or by a patient changing chiropodist. Institute members are expected to use their discretion in not setting up in close proximity to other members.

16. A member shall not use the Crest of the Institute without the permission of the Institute.

17. A member shall respect absolutely the confidence of their patients, other healthcare professionals and medical practitioners. Members must abide by the requirements of any legislation pertaining to the keeping and use of personal information regarding patients, whether such information is in physical or electronic format 18. A member shall not offer to give tuition in the theory or practice of Chiropody/Podiatry or Foot Health Care unless he is a tutor, a licensed teacher, mentor or instructor of the Institute.

19. All Registered Chiropodists/Podiatrists shall:

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PROFESSIONAL LITERATURE 20. All professional literature utilised by a registrant shall be factual, decent and accurately reflect the qualifications, professional memberships and registrations held by the member. In particular the member should not lay claim to any skills or specialism’s with which they are not competent. Current laws applicable to advertising shall at all times be complied with.

PROFESSIONAL TITLES AND QUALIFICATIONS 21. As previously stated, Chiropodist and Podiatrist are titles that may only be used within the United Kingdom by persons registered with the Health Professions Council whilst such individuals continue to have such registration. Their use in any other way is unlawful.

22. In the context of their professional chiropody/podiatry practice, only such qualifications and designatory letters as are recognised by the Board of Education and Executive Committee may be publicly used by registrants.

23. Associates who are not HPC registered podiatrists and chiropodists shall use only such title or titles as may be approved from time to time by the Boards of Ethics and Education of the Institute and shall in no manner present themselves as, suggest or otherwise imply themselves to be, chiropodists or podiatrists.

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Rambling Roads Much news of interest from ‘Assistive Technologies’ Issue 76 Dec2010/Jan2011. Smith and Nephew have pioneered the ‘Visionaire’ tailor made knee replacements. An Xray and scan of the knee affected by osteo-arthritic degeneration of the joint is computer modelled. Nylon blocks are then cut to match the femoral and tibial components of the joint, sterilised and then used in the replacement procedure. There are only a handful of hospitals offering the technique but it is believed that the procedure has the potential benefits of better outcomes than the standard methods, together with considerable cost savings.

The same journal reports that Age UK in Bristol is launching what it describes as a ‘Foot Care Clinic’. The ‘treatment’ actually consists of a toenail cutting service carried out by volunteers who have undergone some form of training under the auspices of the local NHS devices (sic. presumably services). The recipients of the service are required to purchase a basic foot care kit at a cost of £5.00 and pay £10.00 for each treatment. The article notes that this price is less than half the equivalent private alternatives.

Achilles doubts that any qualified chiropodist/podiatrist/FCP would limit their treatment plan to simply cutting toenails and cannot therefore understand to what equivalent alternative the writer refers. He also notes that Age UK is not a charity but a business and questions whether the volunteers receive the quoted fee in its entirety.

On a happier note, a further article notes that the average woman can stand their new pair of shoes for just 34 minutes before grimacing. Erika Gibbons, podiatrist for shoe insert company Insolia also claimed that after surveying 4,000 women, she discovered that half of all women going out to pubs and clubs have walked home barefoot, rather than in their new shoes. She said “The fact that the nation’s women are resorting to taking a second pair of shoes, and walking home barefoot means that they need to do something so they can get to enjoy nights out and not worry about their feet.”

All members interested in treating sports related problems will be familiar with the name Benno Nigg, the sports scientists who has a great interest in biomechanics. The 5th March 2011 issue of New Scientist has Frank Swain interviewing him. It is clear that he is a modest realist who, despite his involvement in the development of running shoes, is happy to state that running injury patterns over the past 30 years have not changed despite improvements in sports shoe design. He also points out that in buying a pair of running shoes, in-shop video analysis may not help and that comfort seems to be the most reliable criteria. He quotes a study carried out with soldiers in which they were supplied with six different orthoses and let them decide on which, or none, was the most comfortable for the individual. In four months, those with orthoses had 53% fewer injuries than those without. He also notes that some claims made for the Masai ‘barefoot technology’ shoe which he helped design were overstated. He also debunks the recent claims of barefoot runners quoting relevant papers which show an advantage of 3-4% to shod runners.

The Bulletin of the British Healthcare Trades Association reports on the speech made by Karen Middleton, Chief Health Professions Officer for England at the recent BHTA conference held in Birmingham. She spoke of the current government’s White Paper on ‘Liberating the NHS’ with particular reference to

the ‘Personal Budgets’ of patients. She is reported as saying that by ‘handing a patient the money’ and then for the first time having the patient sit with the health commissioner – the GP – “It will be very interesting to see whether the behaviour of the commissioners changes as a result.” Also at that conference Frances Heywood, Honorary Research Fellow at the School for Policy Studies, University of Bristol noted the changing demographic in the U.K. This equated to an extra 1.7 million people over the age of 65 years, but that figure hid the increase in the over 85 year age group which increased by 112% from 660,000 to 1.4 million. It is this age group who are the most likely to fall or require other hospital care.

The implications for the podiatric private practitioner are clear; however, all the indications are that whilst the profession has much to offer, change will not be a straightforward process.

New Scientist 19th March 2011 describes how thousands of years of civilisation have reshaped our bodies – and not always to advantage. Whilst some changes might be due to ‘microevolution’ or genetic changes in action, many are due to lifestyle which – as the author delightfully states – would melt away if we returned to a Stone Age environment. Due to our western calorie rich diet and less active lifestyle we have become generally fatter. This in turn has led to a less muscular body and that in turn to weaker, smaller bones. The femur, for example has shrunken both in diameter and cortex by 15% in the last four thousand years alone. Broken hips – relatively common now, were ‘vanishingly rare’ in archaeological specimens, even accounting for the then shortness of life. Spina bifida has decreased markedly in western countries because of an understanding of the causative factors, and the resulting encouragement of pregnant females to increase folic acid intake. However, spina bifida occulta has increased. Compared to the victims of Vesuvius in Pompeii, who suffered a 90% rate of the condition, today no less than 100% of the population exhibit open sacral 5 vertebrae. However, the evolutionists are not dismayed; body variability is increasing and that might not be detrimental to the species.

New Scientist of 26th March carries an article written by Debora MacKenzie entitled ‘Polio’s last stand’. IN 1998 the World Health Organisation stated that it intended to eradicate the disease by the year 2000. This target date was revised to 2005, but the virus still exists. In fact, the results thus far are impressive.

In 2009 there were 741 polio cases in India; in 2010 just 42. In Nigeria the number of genetically distinct types of virus has fallen from 26 in 2008 to 4 in 2011. A problem remains in that the Oral Polio Vaccine currently used consists of weakened but live virus.

This can circulate and mutate into a more dangerous variety which can then lead to increased infections. Because only one infection in two hundred causes the disease it can spread widely before detection. There is an alternative; the Inactivated Polio Vaccine, which is, unfortunately, expensive with the result that richer countries have already made the switch but for poorer countries which need it most, the cost is unsustainable.

Fortunately, research continues, sometimes backed by Trusts and individuals such as Bill Gates; however, with the eradication of the disease so near it would be an indictment of slashing research budgets if we failed to achieve this.

Achilles Helen 29

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WEST MIDDLESEX BRANCH SEMINAR Sunday, 26th June 2011 at Holiday Inn Express, Watford WD17 1UE 19, Bridle Path, St. Albans Road (01923) 28 86 00 PROGRAMME: 10:45

Registration, coffee and biscuits

11:15

A Diabetic Talk – by Gareth Hicks, Podiatrist B.s.c.

12:00

Sandwich buffet

12:45

Practical session on foot assessment using instruments described in the talk

14:00

Coffee and biscuits

14:15

Questions

14:30

Close of Seminar and CPD Certificates

Please complete Booking Form below before 15th May due to limited numbers Enclosing: Cheque for £20 (this includes lunch, tea & coffee) Made payable to: West Middlesex Branch Institute of Chiropodists & Podiatrists Send to:

Eva Hossain, Treasurer 65B Durban Road West, Watford, Hertfordshire WD18 7DR

If you require more details contact: Hyacinth Tyrrell 07873493946

Closing date for applications 15th May Booking Form Name .................................................................................................................................................................................................

Address ............................................................................................................................................................................................. ..................................................................................................................

Post Code: ................................................................

Branch: ....................................................................................................

Tel No:.......................................................................

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SHEFFIELD BRANCH SEMINAR Sunday 23rd October, 2011 10.00 â&#x20AC;&#x201C; 15.00 at

Sheffield Works Department Sports and Social Club Heeley Bank Road, Sheffield S2 3GL

ÂŁ35.00 to include Buffet Lunch

Chiropody Express Trade Stand present throughout the day Infection Prevention & Control in Community Practice Diane Churchill-Hogg Diane is the Infection Prevention & Control Nurse Specialist for Nottinghamshire Community Health

The Prevention of Osteoporosis with Medically Approved Social Exercise Classes Bobbie Drakeford Bobbie is a Fellow & Director of the International Dance Tutors Association, having a degree in Anatomy & Physiology, alongside her dance qualifications has allowed her to devise medically approved exercise programmes at the request of the Metabolic Bone Unit in Sheffield

New Innovations in Diabetic Care Jenny Roby Nurse Practitioner

FOR A PLACE PLEASE CONTACT:

DEBBIE STRAW 01623 452 711

(Closing Date September 30th, 2011) 31

32491_Chirop_May/June_2011_17416_Chirop_Jan_Feb_08 27/04/2011 10:05 Page 32

Coffee break Crossword

Across: 1. Good for broken bones… except shins 5. Neuroma 6. Tarsal Joint 8. The big one!

9. Adduction, plantarflexion and inversion 10. plantar apophysitis 15. Hammer or mallet?

16. You have 14 of these. Probably 17. Long, short or… tert?

18. Root, to his friends Robert Isaacs email: rissacs@nhs.net

32

Down: 2. Its an infarction, but not myocardial 3. Nice pickled. Could be a typo…

4. Sailors tinkers and soldiers don't get bunions like this 7. Joint under this is rather important 11. Fine in horses. Not great for humans though 12. 26? You forgot these!

13. NOT the bottom 14. There's bundles of them in the foot 16. Nice to walk on, very soft 15. Poor little feet, all inverted and plantarflexed Answers will appear in the July/August issue

32491_Chirop_May/June_2011_17416_Chirop_Jan_Feb_08 27/04/2011 10:05 Page 33

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32491_Chirop_May/June_2011_17416_Chirop_Jan_Feb_08 27/04/2011 10:05 Page 34

Diary of Events May 2011

Primary Care Conference 2 day event 25th and 26th May Birmingham NEC The Institute will be appearing at this event in conjunction with Schuco http://www.schuco.co.uk/Further details http://www.thenec.co.uk/whatson/primary-care.

Essex Branch Meeting 22nd May – Education Centre, Southend University Hospital, Carlingford Drive Southend-on-Sea. Tel: 01702 460890

Hants and Dorset Branch Meeting 9th May 7:00 p.m. – The Fish Inn, Ringwood, BH24 2AA Discussions on A.G.M. resolutions and our branch voting. (Food available) Tel: 01202 425568

Institute of Chiropodists and Podiatrists Annual General Meeting, Trade Exhibition and Dinner Dance 12th,13th,14th May – Beaumont House, Windsor - see inside pages for further details.

Tel: 01704 546141

Leicester and Northants Branch Meeting 22nd May 10:00 a.m. – Kilsby Village Hall CPD Lecture on Pharmaceuticals used within practice by local practicing pharmacist tbc. Registration and refreshments at 9:45 a.m.

Tel: Sue 01530 469816

North West Branch First Aid Course 15th May 10:00 a.m. – St. Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR. Tel: 0161 486 9234

Sheffield Branch Meeting 19th May 7:30 p.m. – SWD Sports Club, Heley Bank Road, Sheffield S2 3GL. Tel: 01623 452711

West Middlesex Branch Meeting

Cheshire, North Wales, Staffs and Shrops Branch Meeting 5th June 2011 at 10:00 a.m.

The Dene Hotel, Hoole Road Chester CH2 3ND Presentation by Gareth Hicks, Bailey Instruments Diabetes Assessment.

Tel: 0151 327 6113

Hants and Dorset Branch Meeting 8th June 7:45 p.m. – Crosfield Hall, Broadwater Road, Romsey, SO51 8GL. Lecture: Silicone modelling in practice Heidi Meckler from Algeos.

Tel: 01202 425568

Institute of Chiropodists and Podiatrists Executive Meeting 18th June – Head Office, 27 Wright Street, Southport, PR9 0TL. Tel: 01704 546141

Leeds/Bradford Branch Meeting 5th June 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel: 01924 475338

Midland Area Council 5th June 10:00 a.m.

Kilsby Village Hall, CV23 8XX.

Tel: 01386 47695

North West Branch 12th June Midsummer Luncheon To be arranged.

Tel: 0161 486 9234

Southern Area Council Meeting 4th June 1:00 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 01992 589063

Surrey and Berkshire Branch CPD Meeting 13th June 7:30 p.m.

Pirbright Village Hall.

Tel: 0208 660 2822

Western Branch Meeting

9th May – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

12th June at 12:15 p.m. – Seminar Room 1, The Women’s Hospital Liverpool. Lecture: Plantar Fasciitis, Exercise and Prevention by Cuxson Gerrard plus trade support from Chiropody Express.

Tel: 01745 331827

June 2011

West of Scotland Branch Meeting & CPD Day

Kettering 2 day event 21st & 22nd June 2011

5th June 10:30 a.m. – Presentation by Richard Goodwin - Canonbury on Shoe/footwear and use of Cryopen Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

The Institute will be appearing at this event and be putting on workshops Further details http://www.professionalevents.co.uk

Birmingham Branch Meeting

Wolverhampton Branch Meeting

23rd June 8:00 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

26th June 10:00 a.m. – 4 Selman’s Parade, Selmans Hill, Bloxwich WS3 3RN. Tel: 0121 378 2888

34

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Diary of Events July 2011 West Middlesex Branch Meeting 11th July – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

Surrey and Berkshire Branch Meeting 2nd July at 1:30 p.m.

Greyfriars Centre, Reading.

Tel: 0208 660 2822

Sussex Branch Meeting

West of Scotland Branch Meeting and full CPD Day 11th September 9:30 a.m. – Presentation on the Paediatric Foot and Chemical Treatment of Verrucae Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

West Middlesex Branch Meeting 12th September – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

2nd July – The Bent Arms, Lindfield, West Sussex.

Tel: 01273 890570

October 2011

September 2011

Cheshire, North Wales Staffs and Shrops Branch Meeting

East Anglia Branch Meeting 11th September – Haymarket Day Centre.

Tel: 01603 440828

Essex Branch Meeting 18th September – Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea. Tel: 01702 460890

2nd October at 10:00 a.m. – The Dene Hotel, Hoole Road Chester CH2 3ND. Tel: 01244 321165

Devon and Cornwall Branch Meeting 9th October 10:00 a.m. – Exeter Court Hotel, Kenford, Exeter EX6 7UX. Tel: 01805 603297

Hants and Dorset Branch Meeting

Leeds/Bradford Branch Meeting

14th September 7:45 p.m. – Crosfield Hall, Broadwater Road, Romsey, SO51 8GL. Talk: Tax and the small business - Elise King HMRC. Tel: 01202 425568

6th October 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel 01924 475338

Institute of Chiropodists and Podiatrists Executive Meeting 23rd/24th September – Head Office, 27 Wright Street, Southport, PR9 0TL. Tel: 01704 546141

Leicester and Northants Branch Meeting 4th September 10:00 a.m. – Kilsby Village Hall CPD Lecture on Padding and Strapping by Chris Leech tbc. Registration and refreshments at 9;45 a.m.

Tel: Sue 01530 469816

Midland Area Council 23rd October 10:00 a.m.

Kilsby Village Hall, CV23 8XX.

Tel: 01386 47695

Sheffield Branch Meeting 23rd October – Time to be confirmed SWD Sports Club, Heley Bank Road, Sheffield S2 3GL. Tel: 01623 452711

Surrey and Berkshire Branch Meeting

London Branch Meeting

10th October 7:30 p.m.

Pirbright Village Hall.

7th September 7:30 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

Wolverhampton Branch Meeting

North West Branch Meeting

9th October 10:00 a.m. – 4 Selman’s Parade, Selmans Hill, Bloxwich WS3 3RN. Tel: 0121 378 2888

27th September 7:30 p.m. – St. Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR. Tel: 0161 486 9234

Tel: 0208 660 2822

November 2011

Southern Area Council Meeting

Birmingham Branch Meeting

10th September 1:00 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 01992 589063

17th November 8:00 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

Western Branch Meeting

Essex Branch Meeting

4th September at 12:15 p.m.

Seminar Room 1, The Women’s Hospital Liverpool.

Lecture: tbc Tel: 01745 331827

20th November – Education Centre, Southend University Hospital, Carlingford Drive Southend-on-Sea. Tel: 01702 460890

35

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Diary of Events Hants and Dorset Branch Meeting

Hants and Dorset Branch A.G.M.

18th November 7:45 p.m. – Our usual ‘Social Occasion of the Year’ Dinner out with friends/partners/colleagues.

Venue to be arranged.

Tel: 01202 425568

9th January 2011 – 7:45 p.m. coffee (meeting 8-10 p.m.)

Crosfield Hall, Broadwater Road, Romsey, SO51 8GL. Tel: 01202 425568

Leeds/Bradford Branch Meeting

Leicester and Northants Branch Meeting plus A.G.M.

6th November 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel 01924 475338

Leicester and Northants Branch Seminar Arrangements tbc – Lutterworth Cricket Club LE17 4RB. 10:00 a.m. start. Registration & refreshments at 9:45 a.m.

Autoclave calibration by prior arrangement (Max 12).

Tel: David 01455 550111

London Branch Meeting 16th November 7:30 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

Sussex Branch Meeting 20th November – The Bent Arms, Lindfield, West Sussex.

Tel: 01273 890570

West of Scotland Branch Meeting 6th November at 11:00 a.m.

Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

West Middlesex Branch Meeting 14th November – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

22nd January 10;00 a.m. – Lutterworth Cricket Club LE17 4RB. Registration and refreshments at 9:45 a.m.

Tel: Sue 01530 469816

London Branch A.G.M. 18th January 7:30 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

Midland Area Council A.G.M. 29th January 10:00 a.m. – Kilsby Village Hall, CV23 8XX. Tel: 01386 47695

North West Branch A.G.M. and Meeting 15th January 11:00 a.m. – St. Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR. Tel: 0161 486 9234

Southern Area Council A.G.M. 21st January 1:00 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 01992 589063

Surrey and Berkshire Branch A.G.M. 14th January 1:30 p.m.

Greyfriars Centre, Reading.

Tel: 0208 660 2822

Western Branch A.G.M.

December 2011 Leeds/Bradford Branch Meeting

8th January at 12:15 p.m. Meeting at 1:45 p.m.

Seminar Room 1, The Women’s Hospital Liverpool.

Tel: 01745 331827

4th December 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel: 01924 475338

Scottish Area A.G.M. 22nd January 10:30 a.m. followed by

January 2012

West of Scotland Branch A.G.M.

Birmingham Branch A.G.M.

Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

12th January 7:30 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

East Anglia Branch A.G.M. 29th January – Haymarket Day Centre.

Tel: 01603 440828

Essex Branch Meeting and A.G.M. 29th January – Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea. Tel: 01702 460890

36

Wolverhampton Branch A.G.M. 15th January 10:00 a.m.

4 Selman’s Parade, Selmans Hill, Bloxwich WS3 3RN. Tel: 0121 378 2888

32491_Chirop_May/June_2011_17416_Chirop_Jan_Feb_08 27/04/2011 10:05 Page 37

National Officers

Branch Secretaries

President Mrs. F. H. Bailey M.Inst.Ch.P

Birmingham

Mrs. J. Cowley

01905 454116

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. A. Brown

01603 440828

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Leeds/Bradford

Mr. N. Hodge

01924 475338

Leicester & Northants

Mrs. S. J. Foster

01234 851182

London

Mrs. F. Tenywa

0208 586 9542

North East

Mrs. E. Barwick

0191 490 1234

Standing Orders Committee Mr. M. Hogarth M.Inst.Ch.P. Mrs. L. Pearson M.Inst.Ch.P

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. Massey

0161 486 9234

Secretary Miss A. J. Burnett-Hurst

Northern Ireland Central

Miss G. Sturgess

0289 336 2538

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Republic of Ireland Dublin

Mr. C. Kerans

00353 1285 3150

Republic of Ireland SW

Mr. R. Sullivan

00353 21 4621044

Sheffield

Mrs. D. Straw

01623 452711

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., B.Sc(Hons) Vice-Chairman Board of Education Mr. J. W. Patterson B.Sc(Hons)., M.Sc., M.Inst.Ch.P

Area Council Executive Delegates Midland Area Council Mrs. V. Dunsworth M.Inst.Ch.P. D.Ch.M North West Area Council Mr. M. J. Holmes M.Inst.ChP., D.Ch.M, B.Sc.Pod Republic of Ireland Area Council Mr. R. Sullivan M.Inst.Ch.P BSc.(Hons), Dip. Pod. Med, PGDip,

South Wales & Monmouth Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mrs. J. Drane

01796 473705

Wolverhampton

Mr. D. Collett

0121 378 2888

Yorkshire Library

Mrs. J. Flatt

01909 774989

Cert.L.A, FSSCh, FIChPA, 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.

32491_Chirop_May/June_2011_17416_Chirop_Jan_Feb_08 27/04/2011 10:05 Page 38

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