Podiatry Review July/August 2012

ISSN 1756-3291

Podiatry Review

Volume 69 No.4. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal July / August 2012

• Article on Orthosis • Conference News and Views • Diabetic Footcare in Kenya

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The Institute of Chiropodists and Podiatrists Editor Mr. W. J. Liggins FInstChP, FPodA, BSc(Hons) Academic Editor Robert Sullivan Dip.Pod.Med., BSc (Hons), PGCert, LA., PGCert.

PODIATRY REVIEW

Contents

Pom's., PGCert N&Skin Surg., PGDip. Pod. Surg., FIChPA., SARSM., MInstChP.

Annual Conference and Trade Exhibition ..........................2

Editorial Assistant Bernadette Willey bernie@iocp.org.uk

Editorial .............................................................................3

Editorial Committee Mrs. F. H. Bailey MInstChP Mr. W. J. Liggins FInstChP, FPodA, BSc (Hons) Mrs. J. A. Drane MInstChP Advertising Please contact Julie Aspinwall secretary@iocp.org.uk Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport Merseyside PR9 0TL 01704 546141

Foot orthosis to improve foot pain in patients with rheumatoid arthritis Robert Sullivan and Derek Santos....................................4 Diabetic Foot Care in Kenya Joanne Sweeney ...............................................................8 Podiatry As a Profession Part 5 Deirdre O’Flynn...............................................................14 Chairman’s Address.........................................................16 President’s Address .........................................................18 Conference Postbag ........................................................20

www.iocp.org.uk

Trade Show Information..................................................26

follow us on twitter http://twitter.com/#!/iocp_chiropody

Arthritis Research UK News.............................................28

Printed by Mitchell & Wright Printers Ltd, The Print Works, Banastre Road, Southport PR8 5AL 01704 535529

ISSN 1756-3291 Annual Subscription

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© The Institute of Chiropodists and Podiatrists.

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.

Conditions Corner: Achilles Tendonitis Michael Hooper, The Langer Group ...............................29 Diabetes News.................................................................30 Branch Profile South Wales ....................................................................32 Rambling Roads...............................................................33 Diary of Events ................................................................34

EXECUTIVE COMMITTEE L-R Julie Dillon, Colette Johnston, Joanne Casey, Martin Harvey, Heather Bailey, Bill Liggins, Jacquie Drane, Robert Sullivan, David Crew, Valerie Dunsworth, Michele Allison, Ann Yorke page | 01

Insttitute of Chiropodists and Podiatrists Book June 7th to 9th in your 2013 diary now!

ANNUAL Following the very successful 2012 Conference and AGM, the Institute has arranged to hold both the 2013 and 2014 events in the same prestigious Conference Centre in Southport.

The 4 star Ramada Hotel is attached to the Centre and overlooks the attractive Southport waterfront. Special discounts will be arranged with the Ramada Hotel , and as a cost-effective alternative, a Premier Travel Inn is located just a few minutes’ walk from the Conference Centre.

If you wish to attend before the beginning of the Conference or stay afterwards, there are many attractions to enjoy at Southport. However, if you live locally, then very advantageous day rates will be negotiated on your behalf.

AND TRADE EXHIBITION Friday 7th to Sunday 9th June 2013 27 Wright Street

In 2012, the CPD workshops were for many

Southport

members, the highlight of the weekend. In

Merseyside

2013 these will be expanded both in terms of the number and breadth, with live audio visual feed to the lecture rooms so that many more members can take part in this enjoyable and fulfilling method of learning.

Following last year’s success, a large Trade Exhibition will be situated just outside the lecture rooms and more new products and equipment will be available for both viewing and testing.

As always, the prestigious black tie awards dinner dance will be held on the Saturday night and we are promised some very unusual but worthwhile entertainment which at least two members of the Executive Committee are looking forward to with some degree of trepidation. Remember, the Institute is the ‘friendly one’!

The Conference is open to any member of any organisation which represents the profession, as well as members of the medical and AHP professions. You will not find high quality CPD of this kind at such a reasonable fee anywhere else and it is tailored for you, the member. We all need to justify our CPD but contact with your colleagues both nationally and internationally is also very important, so come and network!

CONFERENCE

PR9 0TL Tel: 01704 546141

EDITORIAL

Editorial All legally constituted companies are required to hold an Annual General Meeting (A.G.M.) once a year and traditionally the Institute has held a concurrent conference. The A.G.M. is a formal meeting which acts as a review of the year’s activities of the Institute and allows the members to elect officers and review the annual accounts. Although it is a formal meeting, it is also be a good opportunity to communicate with other members. However, the A.G.M. has tended to be regarded by some members as just an A.G.M. and not a conference. Over the past few years more and more time has been spent on the latter aspects although not to the detriment of the former. A new innovation at the Southport conference instituted by Malcolm Holmes and his colleagues was the use of workshops. These turned out to be very popular and have been praised by a number of members who have taken the trouble to write letters published in this number of the journal. It is worth reflecting on why, and how, the Institute runs its A.G.M. and the conference and why, despite its democratic structure which is the envy of other, similar bodies, it is important for as many members as possible to attend.

The venue is decided by the Executive Committee. In 2012 the A.G.M. was to take place in Liverpool; however, due to late changes by the hotel involved, it was decided to change to Southport. This had the advantage that it was relatively easy to access; a superb venue was available with helpful staff and all the necessary facilities for lectures and trade exhibition, there was an adjacent hotel and another less costly hotel was within easy walking distance.

The A.G.M. itself which is conducted by the President consists of: Apologies Apologies from branch representatives who have been unable to attend are read out and recorded.

Minutes / Matters Arising The minutes of the previous A.G.M. having been previously circulated and read to branch members are formally adopted by a proposer and a seconder, whose names are recorded.

Presentation of the President’s Report This gives give an overview of the main achievements of the year.

Presentation of Accounts The accounts are presented by the Treasurer and the company Accountant having been previously circulated. The Treasurer highlights some of the figures in the accounts, explaining any that need explanation, and gives a general overview of the financial position of the organisation. The accounts are audited.

Appointment of Auditors If an organisation is happy with the performance of its auditors it is usual to move for adoption of the existing auditors and such was the case with the Institute.

Election of Officers In the Institute’s constitution the elected officers consist of the President, the Chair of the Executive Committee, The Vice-Chair of the Executive Committee, the Honorary Treasurer, The Chair of Ethics, the Chair of the Faculty of Education the Vice-Chair of the Faculty of Education. In addition there are two members elected to the Standing Orders Committee who have knowledge of the constitution and procedure. Each individual wishing to stand needs to have at least one proposer and seconder from the branches. The remaining members of the Executive Committee are made up of regional representatives elected by the branch representatives to the regional committees. In this way, every individual member can have their views put forward to the Executive Committee.

Voting Procedure Voting for officers actually takes place via the branches by post although the results are scrutinised by the Standing Orders Committee.

In the unlikely event of a tie, the President of the Institute has a casting vote. Casual vacancies (due to sickness, decease or retirement for example) are filled by vote of the Executive Committee.

Motions to be put to the A.G.M. Motions to be put to an A.G.M. are received from the branches by the organisation at an agreed time before the A.G.M., so that they can be included with the papers sent out to those attending. The constitution of the Institute does not allow motions to be put at the A.G.M. on the spur of the moment. Voting is by show of hands.

Amendments Any proposed amendments to the constitution are also discussed at the A.G.M. and are presented as a motion by the Executive Committee.

These have usually been discussed by the present committee and the President will take a few moments to explain why the Committee believe that the change is needed. Amendments are often made to update the constitution in the light of new legislation or new circumstances and are not usually contentious. When the motion or amendment has been presented a vote will take place by show of hands.

Conclusion of Business The meeting is formally brought to a close by the President.

That deals with the formal aspects of how the Institute conducts its business. However, in recent years an informal ‘question time’ has been inserted following the formal section. This allows any member to ask any question of the officers and Executive members and receive an answer there and then. If necessary, more time is allowed on the day following the A.G.M. For convenience, the conference immediately follows the A.G.M. and largely consists of lectures, workshops and the trade exhibition. A great deal of trouble is taken to find high quality speakers who provide illustrated lectures on subjects pertinent to the membership. The workshops in 2012 consisted of demonstrations of nail surgery, padding and strapping, local anaesthetic and hyfrecation of verrucae. These were enormously popular, with some members being forced to stand in order to obtain a view. Because of the acclamation received, they will be expanded upon and repeated at the 2013 conference. The Institute enjoys excellent relationships with the suppliers who are unstinting in their support, and all of whom appreciated the large room adjacent to the lecture rooms to feature their materials. However, they are in business and in turn they appreciate as many members as possible to look at the new instrumentation, equipment and materials they have available.

On the Saturday night of the conference the whole meeting culminates in the President’s reception and the annual dinner. In 2012 this was, as is usual, graced by the presence of the Mayor and Lady Mayoress and is a ‘black tie’ occasion. Following the dinner itself, the annual awards are made and those colleagues who have done so much over the years for the membership are presented with the formal appreciation of the Institute. They and the students who receive their prizes for their hard work really do appreciate as many members as possible being present to congratulate them. Dancing far into the night, follows a speech by the guest of honour and the toasts. In all, the opportunity to learn so much, to see so much, to meet so many colleagues, to ask questions, to put your view forward and to have a wonderfully enjoyable time is unrivalled. The 2013 conference will be very special. Please put the dates in your diary now.

W. J. Liggins

page | 03

ARTICLE

A critical review of the evidence to support the use of foot orthosis to improve foot pain in patients with rheumatoid arthritis Mr. Robert Sullivan1, Dr. Derek Santos2 *Correspondence to: Robert Sullivan robert.sullivan@iocp.org.uk or Dr. Derek Santos, dsantos@qmu.ac.uk 1 Robert Sullivan, Faculty of Education, Institute of Chiropodists and Podiatrists, 27 Wright Street, SOUTHPORT, Merseyside, PR9 0TL, UK. 2 Dr. Derek Santos, School of Health Sciences, Queen Margaret University, Edinburgh, EH21 6UU, Scotland.

This is the summary of a dissertation paper submitted by the author, under the supervision of Dr. Derek Santos, in part fulfillment of the award of the degree of Master of Science in Theory Podiatric Surgery in November 2011.

Abstract Rheumatoid arthritis is an auto-immune mediated inflammatory disease that often affects the foot with often debilitating consequences. The aim of this critical review is to investigate the effectiveness of foot orthosis in the management of rheumatoid arthritis. An extensive literature search was carried out and Randomised Controlled Trials (RCT), Randomised Crossover Studies, and Crossover Studies were selected and reviewed. In total, three RCT’s, one crossover study and one randomised crossover study were selected.

All of the studies discussed in this review involved custom foot orthosis as well as over-the-counter foot orthotic devices. All of the RCT’s and studies used were concerned with different types of rheumatoid foot pain, i.e. metatarsal pain (16 participants), rear foot or ankle joint complex pain (100 participants), and pain due to pressure lesions (42 participants). Comparison to custom-made foot orthosis; over-the-counter devices, no intervention, and a combination of adapted footwear with orthosis were not given. Non-custom foot orthosis were also used in one of the crossover studies. Follow ups ranged from 12 to 30 months.

In conclusion, although their were various issues with regards to the quality of the evidence, it appears that foot orthosis has some degree of success and benefit to Rheumatoid Arthritis patients with regards to pain reduction. Custom-made and over-the-counter foot orthoses devices appear to be equally effective.

Introduction Rheumatoid Arthritis (RA), according to Kumar and Clark (2008), is a chronic auto-immune mediated inflammatory poly-arthritis of unexplained cause. The disorder presents with a symmetrical distribution, initially affecting small joints 04 | page

of hands and/or feet as well as larger joints later on in the disease process. The condition generally leads to destruction of the cartilage and bone. The reported prevalence of foot problems with this disease is as high as 50% - 90% (Chambers et al. 2000; Conrad, Budiman-Mark, and Roach 1996; Michelson et al. 1994; Shi et al. 1994). Shrader (1999), cites proliferative synovitis as being primarily responsible for the development of pathomechanics in the foot, occurring particularly at the metatarsophalangeal joint, but also at the talonavicular and subtalar joints (Shrader 1999). This is caused as a result of joint inflammation leading to joints capsules and ligamentous structures being hyper-stretched, causing joint instability and leading to pathomechanical changes. Cho et al (2009) are in agreement with Shrader (1999), and Michelson (1994) in saying that rheumatoid arthritis frequently affects the metatarsophalangeal joints, leading to dislocation, clawed and hammered toes, hallux valgus, forefoot supinatus and hind foot valgus deformities (Cho et al. 2009; Michelson et al.

1994; Shrader 1999). The predominant problems with the foot in rheumatoid arthritis are caused by a loss in the range of movement at the ankle joint (Platto et al 1991). Also when joint destruction occurs in the subtalar and mid foot it leads to pes plano valgus, dysfunction and pain (Michelson et al.

1994; Platto et al. 1991).

The use of foot orthosis in the management of pain associated with the rheumatoid foot is relatively common practice within podiatry. However clinicians need to be informed of the research evidence to support the use of these orthotic devices. The aim of this review is to investigate foot pain in patients diagnosed with rheumatoid arthritis, and the ability of foot orthotic devices, as termed by this review, to render relief.

ARTICLE Literature search The following electronic databases were searched from 1999 – 2011. Medline, Cinahl, Pub Med, Cochrane.

Papers by, Woodburn et al (2002), Woodburn et al (2003), Cho et al (2009), Hodge et al (1999) and Mejjad (2004) were selected as suitable for review. Hand searches were also carried out and primary reference sources were approached for sight of any unpublished works, which may have been presented at professional gatherings. Scherer (2003) suggests that 60% of randomised or controlled clinical trials presented as summaries or abstracts at professional events are never published in peer review journals (Scherer 2003). Thus, there is a risk that eligible trials were not identified or included; this can threaten the validity of this review.

Inclusion criteria for studies Analysis in this review is based on principles of intention to treat rheumatoid foot pain with orthotical interventions where the study had been carried out on or around the subject of foot orthosis and pain management with a primary interest in RA. Limitations of included trials There are methodological limitations in all of the included randomized controlled trials (RCT) and controlled clinical trials (CCT); as a result, this review shows the findings to have a high risk of bias. The only unmet criterion by all the included studies was intervention provider blinding. It is difficult, in a therapy that uses orthotical devices, to meet this criterion, as it is standard clinical practice for the practitioner who ordered the device to check it for best fit.

In these trials and studies it is accepted that a practitioner can tell the difference between a sham device and a custom device, this may bias the practitioner as they may already have a conviction that a custom device is preferable to a sham device. There exists in all these studies the possibility that the provider of the intervention may have intentionally or unintentionally influenced participants with their perceived expectations of the effectiveness of the device used as the intervention. Thus, studies used a single blind design. This is a limitation of current studies and one that is difficult to resolve with regards to RCTs using foot orthotics as interventions.

Limitations of this review There is lack of interdisciplinary and international consensus on the definition of foot orthosis and foot orthotical devices. Because of this lack of definition, the actual definition of foot orthosis as used in this review may be different from that used by other healthcare professions.

Scope of this review ‘Korda and Balint (2004) state that, ‘Podiatrists are experts on foot disorders: both patients and rheumatologists can profit from the involvement of a podiatrist' (Korda and Balint, 2004). However the podiatrist must be informed in order to offer best practice. It is hoped that this summary review will assist podiatrists in informing their clinical evidenced based practice.

Theories about how orthotics might work The precise mechanism with regards to how orthotics may affect pain is unknown. A number of potential theories have been proposed, with foot orthosis leading to a more re-aligned foot improving foot posture. According to the theories, this may allow for more normalized motion at joints; reduction and redistribution of plantar foot pressure; reduction in pressure time integral; altering muscle activity; and altering proprioceptive feedback (Tomaro, 1993; Cornwall, 1997; Nigg, 1998; Redmond, 2000; Nawoczenski, 2004). However, it is more likely that a combination of more than one theory is more likely and that different theories may affect pain through more than one pathway.

Description of studies reviewed Woodburn et al (2002) This RCT has a two parallel-group design. The study looks at painful correctable valgus deformity of the rear foot in RA patients. Participants were recruited from a hospital outpatient clinic. Inclusion in the study necessitated that subjects satisfied the revised 1987 American College of Rheumatology criteria. Participants were required to have a full normal range of motion at the ankle, subtalar and midtarsal joint. In total 98 patients took part in the trial.

The mean age of participants is 54 years with 68% being female and a diagnosis duration of 3 years calculated using an Influential Relationship Questionnaire. The nonintervention group have a mean age of 53 with the females making up 53% of the group; disease duration (IRQ) being 3 years.

The orthosis used in this study were constructed of carbon graphite with a deep heel cup and a contoured medial arch. Devices were custom made for each participant using casting with the subtalar joint in neutral.

All devices were covered with 6mm cushioning material extended to the toe sulcus. The non intervention group was not given orthosis at baseline, however over the course of the study (30 months) orthosis were given if there was a clinical need.

Outcomes were measured using Foot Function Index pain scale, activity limitation scale and disability scale. The reported wear time was 6.3 (SD 3.5) hours a day and 6.1 (SD 1.9) days per week. page | 05

ARTICLE Woodburn et al (2003) This is a prospective RCT which investigates the use of custom orthosis of RA patients with localized rear foot pain and deformity. Patients were identified and randomized to an orthotical intervention. In this trial 3D kinematics were measured at the ankle joint complex. This was a 30 month study where the kinematics were repeatedly measured over the period.

foot and second metatarsal head. Four types of orthosis; prefabricated, standard custom molded, custom with a met bar, custom with a met dome, were compared to shoe only control. Outcomes were measured using a digital system to assess plantar pressure during repeat trials of comfortable cadence walking and standing for each intervention and shoe only.

The criteria for inclusion were that the subjects satisfied the revised 1987 American College of Rheumatology for diagnosis of RA and that they had bilateral arthritis of the peritalar joint complex and a valgus deformity of the heel.

Mejjad et al (2004) A prospective, randomized crossover study to evaluate the possible decrease in foot pain in RA patients. The objective of the study is the relief of pain but not the possible improvement in gait.

There were 98 participants involved in this study, 50 patients were assigned to the intervention group. The mean age was 51.8 and 58% of the intervention group were female.

Orthosis were constructed of carbon-graphite from neutral casts of each foot. All devices had a deep heel cup and a contoured arch, other adaptations were made where necessary.

Outcomes were measured using an electromagnetic tracking system (EMT) to record 3D joint motion at the AJC Cho et al (2009) This is an RCT which investigates the varying effects of insoles combined with specialized shoes. It is a singleblinded RCT. The study took 42 patients attending an outpatient clinic for physical medicine and rehabilitation.

Criteria for inclusion were that participants had RA foot pathology. They had stable disease activity and were receiving a pharmacologic intervention. Participants were able to walk independently without assistive devices and understood the study procedure and participated voluntarily. Patients were assigned randomly to two different groups for orthotical intervention. Patients were given extra deep forefoot rocker type shoes and either a custom made semi-rigid orthotic or a ready made simple insole. The combination of footware and orthosis were worn every day for at least 3 hours.

Primary outcome measures were foot pain, using a visual analogue scale (VAS) and (FFI). Results were gathered over 6 months.

Hodge et al (1999) This is a repeated measures study in which the independent variable was orthosis design.

The aim of the study was to investigate the effectiveness of foot orthosis in the management of plantar pressure in the RA patient. Inclusion criteria was active RA pain to the 06 | page

Inclusion criteria for this study was that subjects should be between the ages of 18 and 80 and had only RA related forefoot pain with no hind or mid foot involvement.

Orthosis were made from a semi-flexible 10mm thick podofaam; all devices were made using a patient imprinting technique. The devices were all palliative and no corrections were added. Outcome were measured using VAS. Summary of current evidence There are many types of foot orthosis prescribed for patients with rheumatoid arthritis, ranging from prescription (of which there are many variations), to overthe-counter devices. All of the reviewed trials and studies reported a degree of success. Some evidence suggests that custom-made devices may help in reducing rear foot pain in patients diagnosed with rheumatoid arthritis. However overall, custom prescriptions and over-the-counter devices seem to be equally effective in the management of RA foot pain. Custom prescription devices with a met dome were considered a safe intervention for RA foot pain. Similarly, this may apply for over the counter devices. However, the trials and studies informing this review all presented some level of methodological bias so their conclusions should be interpreted with caution.

Conclusions Although there is little quality research evidence (that is, RCTs and CCTs) to support the use of foot orthosis in the management of rheumatoid foot pain there is a wealth of other research evidence to support their use. Possibly one reason for this is that conducting RCTs and CCTs using foot orthosis is methodological challenging for the researcher and extending the trial beyond single-blinding may be impossible. Thus, top level evidence may be impossible to attain. However, further research into the use of foot orthosis in the management of RA foot pain is still required to support current evidence.

ARTICLE

References Chambers, A., Busby, C., Goyert, J., Potter, B. and Shulzer, M. 2000. Metatarsalgia and rheumatoid arthritis - a randomised, single bline, sequential trial comparing 2 types of foot orthosis and supportive shoes. Journal of Rheumatology, 27 pp.1643-1647.

Mejjad, O., Vittecoq, O., Ouplin, S., Rassin-Delyle, L., Weber, J., Le Lort, X. and Groupe de Recherche, s. l. H. d. L. 2004. Foot orthosis decrease pain but do not improve gait in rheumatoid arthritis patients. Joint Bone Spine, 71 pp.542-545.

Cho, N. S., Hwang, J. H., Chang, H. J., Koh, E. M. and Park, H. S. 2009. Randomized controlled trial for clinical effects of varying types of insoles combined with specialized shoes in patients with rheumatoid arthritis of the foot. Clinical Rehabilitation, 23 (6), pp.512-521.

Michelson, J., Easley, M., Wiglry, F. and Hellmann, D. 1994. Foot and ankle problems in rheumatoid arthritis. Foot and Ankle International, 15 pp.608-613.

Conrad, K., Budiman-Mark, E. and Roach, K. e. a. 1996. Impact of foot orthosis on pain and disability in rheumatoid arthritis. Clinical Epidemiology, 49 pp.1-7.

Cornwall, M. W., McPoil T. G. 1997. Effect of foot orthotic on the initiation of plantar surface loading. The Foot. 7, pp. 148-152.

Higgins, J. P. T. and Green, S. 2006. Cochrane Handbook for Systematic Reviews of Interventions.

Nawoczenski, D. A., Janisse, D. J. 2004. Foot orthosis in rehabilitation – what’s new?

Clinical Sports Medicine. 23 pp.157-167.

Nigg, B. M., Khan, A., Fisher, V., Stefanyshyn, D. 1998. Effect of shoe insert construction on foot and leg movement. Medicine and Science in Ports and Exercise. 30 (4) pp.550-555.

Platto, M., O'Connell, P., Hicks, J. and Gerber, L. 1991. The relationship of pain and deformity of the rheumatoid foot to gait and an index of functional ambulation. Journal of Rheumatology, 18 pp.38-43.

Hodge, MC., Bach, TM. and Carter, GM. 1999. Orthotic management of plantar pressure and pain in rheumatoid arthritis. Clinical Biomechanics, (14), pp.567-575.

Redmond, A., Lumb, P. S., Landorf, K. B., Stickel, W. L. 2000. Effect of cast and noncast foot orthosis on plantar pressures and force during normal gait. Journal of the American Podiatric Medical Association. 9 pp.441-449.

Kavlak, Y., Uygur, F., Korkmaz, C. and Bel, N. 2003. Outcome of orthosis intervention in the rheumatoid foot. Foot and Ankle International, 24 pp.494-499. Korda J, Bálint GP: When to consult the podiatrist. Best Pract Res Clin Rheumatol 2004,18:587-611.

Shrader, JA. 1999. Nonsurgical management of the foot and ankle affected by rheumatoid arthritis. J Orthop Sports Phys Ther, 29 pp.703-717.

Kumar, P. and Clark, M.2008. Arthropathies. Clinical Medicine. Sixth Edition ed.

Edinburugh: Elsevier, pp. 555-556.

Tomaro, J., Burdett, R. G., 1993. The effect of foot orthotics on the EMG activity of selected leg muscles during gait. Orthopaedic Sports Physical Therapy. 18 (4), pp.532-536.

Marshall, Catherine & Rossman, Gretchen B. (1995). Designing Qualitative Research (2nd edition). Thousand Oaks, London and New Delhi: Sage Publications. pp 111.

Woodburn, J., Helliwell, P. S. and Barker, S. 2003. Changes in 3D joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. Journal of Rheumatology, 30 (11), pp.2356-2364.

Maxwell, L., Santesso, N., Tugwell, P. S., Wells, G. A., Judd, M. and BuchBinder, R. 2006.

Method Guidelines for Cochrane Musculoskeletal Group Systematic Reviews. Journal of Rheumatology, 33 (11), pp.2305-2311.

Woodburn, J., Barker, S. and Helliwell, P. S. 2002. A randomized controlled trial of foot orthoses in rheumatoid arthritis. Journal of Rheumatology, 29 (7), pp.1377-1383.

page | 07

ARTICLE

Diabetic Foot Care in Kenya

Cosyfeet Podiatry Award winner Jo Sweeney was awarded £1,000 to assist with her travel and living expenses during her voluntary work in Kenya.

Here she reports on her experiences.

In January 2011, in the final year of my B.Sc. (Hons) Podiatry, just home from a pilot trip to Kenya and working towards finishing my degree, I proposed a three month trip to the Coastal Province of Kenya. Here I planned to volunteer as a podiatrist at Coast Provincial General Hospital (CPGH), working within the diabetic team and focusing on diabetic foot disease. The global burden of disease is moving from communicable diseases, such as HIV/AIDS, to non-communicable disease such as diabetes. I hope to guide my career into working with the most vulnerable feet in the developing world, not only at a clinical, but at a policy development level.

With partial funding secured, the trip of a lifetime to Africa had begun.

I had undertaken a short pilot trip in 2010 based in the clinic I proposed for my 2011 trip, and until I began planning my new trip, I had been unaware of the immense value of the pilot trip. It allowed me to assess which resources would be of greatest value to patients, clinicians and to the hospital. Moreover, the pilot trip made real for me the disparity between health care in the West and in the rest of the world. The constraints on public health care in Kenya, and East Africa in general, are considerable - even with NGO work and international aid. Conscious of this, I assembled a list of resources to aid my treatment of patients without additional cost to the hospital or using their limited resources. The items required ranged from basic clinical consumables such as examination gloves to wound dressings and medicaments. My pilot trip had taught me that wound dressings in Kenya were very basic, limited in availability and that those available were often misused, so wound dressings were high priorities.

With my extensive list prepared I had my work cut out. I began writing to companies for charitable donations and organising fundraising activities. I targeted specific companies for specific items and in total approached over 115 companies. Considering the financial climate, I was delighted with the response and achieved a 1:10 uptake offering donations of varying value and descriptions.

I purchased the remaining items to complete the kit, which now weighed in at 250kg. My next hurdle was 08 | page

transporting the kit to Kenya. To pay for transport, I organised a fundraising event at Glasgow Caledonian University, which involved selling 1000 doughnuts in one afternoon!!

Planning the journey was very time-consuming and a little stressful. It turned out the cheapest, fastest and most reliable way to transport the kit was with me. This meant that I had to travel from Glasgow to London by train, fly to Nairobi then drive to Mombasa with 250kg of excess luggage.

I anticipated this would not be an easy journey. I was also acutely aware that each stage of the journey had its own difficulties. For example, would the train company allow me to travel to London with this volume of luggage? Once I arrived in London, would airport security want to search each of the 11 carefully packed and weighed boxes? I expected I would be searched on arrival in Kenya, but would they try to charge me import duty? And lastly, was it safe to drive to Mombasa?

My trip fell at a very difficult time for the country, which had just gone to war with Somalia. There had been two fatal tourist kidnappings within four weeks of my departure, however the Foreign Office only advised against travel to the north of the country. After carefully considering all the security risks, I decided to continue with the project. I departed Glasgow mid-October, bound for Mombasa via London and Nairobi.

The train company was fabulous and allowed me to travel with my additional luggage at no extra cost. I booked a taxi to take me to London Heathrow Airport, where I departed for Nairobi.

Astonishingly, I had no check-in problems or delays due to the luggage - which was booked onto the flight in advance. I arrived in Nairobi the following day. This was the part of the journey I was least looking forward to: negotiating my way through Kenyan security, not losing any of my kit, and not accruing any charges!

Thankfully, my fretting was all for nothing: I passed through

ARTICLE my attending inpatients: these patients were the responsibility of the ward, and previously, when she had treated inpatients, the ward staff then neglect their duty to the patient. I understood her opinion, however, I was being directed to these patients by the Medical Officer who dealt with diabetic feet. Already I was treading the doctor: nurse fine line.

While treating patients in the dressings clinic I would explain why I used a particular method or dressing, and tried to demonstrate and emphasise the use of offloading the wound. I had with me a supply of felt, however, I was very keen to find a sustainable alternative.

customs and security without anyone looking into any of my boxes (and still without any charges). The staff at the airport were happy to help move the boxes of kit to the minivan and see me on my way. This next stage of the journey was long, hot, dusty and trying. I completed the marathon 9-hour drive with only one toilet stop, the toilets at the other two stops appearing a definite health risk.

Eventually I arrived at my apartment in Mombasa dusty, red and eager to get settled in. Contracts signed and kit unloaded into the apartment, I then set about cleaning bathrooms and changing beds before I could start to enjoy the wonderful new world in which I’d safely arrived.

I’d set myself clear objectives for my trip. I wanted to gain as much clinical exposure to diabetic foot wounds as possible, and to identify a sustainable source of appropriate materials that could be modified to off-load wounds on the diabetic foot. The technique of offloading/redistributing pressure from diabetic foot ulcers is a recognised method of promoting healing – and, as a direct result, can reduce the need to amputate limbs.

Furthermore, I was requested to design and implement a screening pro-forma to rate the risk of foot disease for patients with diabetes. This would then allow the patients to be stratified by risk, and treatment plans drawn up accordingly, starting with the population of patients with diabetes that attended CPGH diabetes clinic at that time.

Despite having to tread carefully around some nurses I really enjoyed my first few weeks at the hospital and time felt like it was racing by. I was flattered to be asked by the Diabetes Medical Officer and Consultant if I would attend the International Diabetes Day rally in downtown Mombasa, and give a talk to the guests. Due to the war and risk of terrorist attacks, however, the embassy advised against attending any rallies or public gatherings. I was disappointed not to go, but was compensated by attending a children’s diabetes camp run by the Diabetes Management and Information Centre, Kenya (DMI).

This camp was for four days in a local hotel. The children were aged 4-18 and the DMI offered the camp free of charge to around 55 children, three or four times a year. During the four days, the children learned how to manage their diabetes and had time to socialise with their peers. In my view, simply lecturing the children for several hours at a time was not the most effective, however, the children were very tolerant. They also have their blood sugar closely monitored at the camp: I was particularly moved by the patience and commitment of the older children at the camp in helping the younger children monitor their blood sugar. Several of the older children would often set their alarms to go off at night to check on the youngest children whose blood sugar was known to drop dangerously low during the night: they would then contact a member of staff if glucose was required.

I played my small part in the camp too. I talked to the children about how to look after their feet and check them for potential problems. I then demonstrated a foot assessment and explained what the instruments I used were and what they were used for. I tried to make this part as unacademic as possible, and got all of

My memories of the hospital were of a busy hub. CPGH served a large area and many people attended this hospital. The hospital building was ageing and looked tired and dank. Equipment was limited, running water was not always available in the clinic and basic resources such as gloves and swabs were sometimes unavailable, too. The hospital staff were very friendly though, and the clinicians in the diabetic clinic were delighted to have me.

As I hoped, clinical exposure to wounds was in abundance and I was immediately thankful for my planning and foresight into the items that would be the most valuable to me in the clinic. Patients attended the dressings clinic in the morning, and then I would attend inpatients in the wards afterwards. I regularly worked alongside one nurse who I had met on my pilot trip, and who had received some training in managing diabetic feet. She had been delighted to have me in the clinic on my pilot trip and seemed happy to have me back. She did, however, immediately protest page | 09

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the children to take off their shoes and socks and look at one another’s feet. I then worked my way through, checking and screening all the children’s feet for risk of ulceration and fungal infections, and dressed the surprising number of wounds. I also cut all toenails requiring it.

Back at the hospital, there was concern looming. There was a doctor’s strike planned and there appeared to be no way to avert it. I was concerned too, mainly because emergency care would be compromised. Only very limited services would be available and lives would be at risk. Moreover, some of the inpatients I had been treating had been waiting weeks for surgery and the strike would delay this even further, compromising treatment plans and putting the patients at new risks. Finally, I was concerned because the strikes would bring with them protests and demonstrations, which would present a potential safety risk – particularly as I planned to continue treating patients at the hospital during the strike.

I was especially worried for one of the inpatients I had been treating (ward patient A): he had been waiting for an amputation of the hallux for six weeks and his need for surgery was now great.

One week before I arrived in Kenya, he had presented to the hospital with extensive and badly infected wounds on both feet.

He was one of the first patients whose treatment the MO asked me to help manage. He had been assessed by one of the surgeons and recommended for belowthe-knee amputation, however, another surgeon advised the patient that this was not necessary and suggested that debridement surgery to clean the wounds and remove dead tissue would be sufficient, he added that if BKA was required it could be performed at a later date. So the patient had been scheduled for surgical debridement of both feet within a few days. The MO agreed with 10 | page

the ward staff that I would dress the patient’s wounds after the surgical debridement had been completed and until then, the wounds would be managed by the ward.

It took a further four days for the patient to have his debridement surgery. The next day, I visited the patient with the MO, a nurse from the ward and my clinical kit. Together we would reassess the wounds and formulate a management plan. I was prepared for the wound I was about to see but concerned that a BKA was the surgery that should have been performed. The patient was a lovely gentleman who was very happy that I was involved with his care. After reviewing the patient I was surprised that he had been on antibiotics up until surgery, but that the course had finished and no more had been prescribed. I discussed this with the MO, who prescribed a course of Metronidazole IV antibiotic plus painkillers, I took a swab from the wound and sent it for culture and sensitivity.

I treated the patient’s wounds daily at around noon for the first few weeks and left instructions on how to dress on the days I was not there. An active man, the patient found being restricted to a bed depressing. I mentioned this to the MO on more than one occasion and also requested physiotherapy, as the patient’s muscles appeared to be atrophying in front of my eyes due to inactivity. My request fell on deaf ears. At the same time I began experiencing difficulties on this ward. Each day I took my kit with me – the only additional equipment I required was sterile dressings packs and sterile gauze. These basics would have been necessary whoever was dressing the wounds, however, due to developing tension, this became a bone of contention with some of the ward staff.

On several occasions I met the patient’s wife, a lovely, quiet, almost shy and definitely humble woman. She was very concerned for her husband’s welfare: he was the only source of income for the family, who lived in Western Kenya. She too mentioned to me that her husband was very sad. As the staff still didn’t heed my concerns about this, I did what little else I could to comfort them: I gave them a book and the gifts of fruit my other patients brought for me. His wife would read to him in the afternoons – my patient’s bed was located on the outside part of the ward, therefore at night there was insufficient light. I was pleasantly surprised how this small gesture really lifted my patient’s spirits and he chatted more each time I visited.

ARTICLE On the other hand, the patient’s wounds were not doing so well: I could smell them when I stepped onto the ward, and when the dressings were removed the pus oozed and squirted, clearly still badly infected. The results of the culture and sensitivity test revealed that the patient had multiple organisms in the wounds.

The antibiotic he was receiving was insufficient and the infection was not sensitive to it.

This ward had not allowed me to record in the patient’s notes and advised me that it was unnecessary, as I was only dressing wounds. I contested this but was still not permitted to update the notes. One day, I insisted the patient be reviewed by an MO on ward, as his condition was deteriorating, and questioned why it had not been recorded that the patient was receiving his antibiotics as prescribed. I was met by the startling answer that they were not given because I was dressing the wound and had not been using it. I quickly realised that the IV solution prescribed was often used to irrigate wounds and so the nurses had not given it because they were not washing the wounds. I pointed out the antibiotic should have been given by IV but I was challenged on this! Medical staff often use IV antibiotics to wash wounds instead of administering them as IV. During the review, I assertively pointed out what had happened regarding the antibiotic, but I was offered no explanation. The decision to surgically amputate the patient’s left hallux had been made weeks ago but this still had not been performed. Now the patient’s feet were deteriorating, rife with infection that required antibiotics the patient could ill afford.

After making a fuss over the few days before the strike, the patient was scheduled for surgery - a blessing, it seemed. As a result of infection the spreading from the hallux, and now from other digits also, the surgeon performed a forefoot amputation, described in the notes as a Symes amputation. It was, in fact, a transmetatarsal, but the name of the surgery is irrelevant.

It was a disaster.

The patient’s foot was black with necrosis, oozed pus and was vascularly compromised. He was left with foot which no longer resembled a foot, was highly unlikely ever to heal and was even less likely ever to be functionally useful to the patient.

The first post-op dressing change was after the strike had begun. As I undressed the foot my heart plummeted to depths I have rarely experienced. I was not squeamish about the wound

in front of me: I was emotional. I felt a spectrum of emotions from anger and resentment to sorrow and regret. I described to the patient the result and only just held myself together. I also tried desperately hard to shield the patient’s wife from seeing it. I quickly realised that no one who was there would benefit from my emotion and so I reformulated it into action. I armed myself with pictures of the wound and headed for the picket line. I searched for the chief of surgery and insisted he listen to me. I describe the case and how it had been managed. I also named the surgeon who had butchered my patient. The surgeon was within earshot and heard me discussing the case with the chief, but shied away from speaking to me. The chief of surgery ordered a BKA - when the strike was over.

The patient suffered for a week until some of the doctors returned to work. The patient was distressed at having to return to theatre for a BKA. I was devastated. My focus turned to the other foot, which was beginning to rapidly deteriorate along with the patient’s general health. My real concern was that (in my opinion) the patient was septic. Anxiously, I swabbed the other wound again and sent it for culture and sensitivity, for which I paid. The wound was infected with multiple resistant organisms, both gram positive and gram negative bacteria. The patient could not afford the required antibiotics and so I paid for the first course to be given by IV. After this was finished, the patient would then buy an alternative combination of antibiotics.

At this time the atmosphere on the ward towards me changed from tentative and a little hostile to nasty. I was not permitted to use any sterile instruments on the wards, the drum of sterile gauze and betadine solution was often unavailable, and every day I was met by the same male nurse, who made a point of being particularly threatening towards me. He made it quite clear he did not appreciate my being on the ward, asking so many questions or reporting to the MO. On one occasion I thought he was either going to spit on me, or hit me.

Once again, after the patient had been for his BKA surgery there was discrepancy in antibiotics administered. I began to wonder if my being involved with this patient’s wound management was to his detriment, and whether the clinic nurse had been right – the ward staff were neglecting their duty to the patient.

Shortly after the BKA surgery, the patient died. The cause of death recorded on the post-mortem was sepsis.

I did not know how to react or how I was supposed to react. I was numb. I treated my patients and finished early that day. My faith, and that of my deceased patient, lead me to prayer. I found no other comfort. page | 11

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The strike was deemed unlawful and so some doctors returned to their positions after seven days while others persisted for 10 days. As a result, the clinic was very quiet. Patients did not attend for dressing changes as they thought the clinic was closed. Some patients changed dressings themselves at home and others kept the same dressings for a week or more. This caused a huge problem: due to the unrelenting heat, patients’ feet would excessively sweat under their dressings. Many wounds could not be left more than a day without being changed.

Meanwhile, in the clinic, I was having great success with several patients and staff, despite the strike. I was using the felt I had brought to offload and redistribute pressure and I was keen to implement an alternative material. The most suitable and available resource was rubber from discarded car tyres. This material is already used to create footwear in Kenya and so was an obvious place to start. I suggested this to the clinical staff at the hospital and they were not keen on the idea. I had not anticipated resistance to offloading wounds, and I was advised that this was not the job of the nurse dressing the wounds.

I tried to understand the rationale I was given, but it was alien to me. Patients were not aware of the difference this could make to their wounds and the staff at the hospital were not advising them that other clinics offered this, as CPGH would then lose the revenue for managing those wounds. I was becoming thoroughly

disheartened by CPGH. However, two nurses from another local hospital who had been sent to work with me had a completely different outlook. They were ready and willing to accept change to practices resisted

by CPGH. These nurses fully took on board the learning I had hoped CPGH nurses would, but didn’t. They grasped why offloading was important to wounds and were willing to discontinue practices that research had proven ineffective or detrimental to wounds, such as the use of acetic acid and washing wounds with IV antibiotics.

I had also arranged to visit other facilities that dealt with foot problems in the area. In particular I visited a small children’s hospital, which was not government funded. The hospital offers treatment free of charge for congenital conditions such as club foot, genu varum, genu valgum, arthrogryposis and spina bifida.

The hospital also offers boarding school for those children who would miss out on their education due to their treatment.

I felt inspired at this hospital. The staff, children and other volunteers there were genuine and caring. They were very interested in my profession and I too learned a great deal from them. I had the opportunity to assist with casting children with various conditions and I was delighted to see they were using resources such as rubber where appropriate. This gave me a renewed faith in myself. At CPGH I was reaching a stage where I was questioning what I was doing, whether I going to achieve anything, and generally feeling flat. However, spending time at the children’s hospital reminded me why I had come to Kenya: to help those who needed and wanted what I could provide.

Often during my trip, usually (in my opinion) as an excuse, I would hear someone saying: “this is Africa”. I dreaded hearing this. I understand the constraints of healthcare in Africa, international and NGO aid and how it can hinder a country’s development. But medicine is not ethnic specific. Everyone deserves healthcare regardless of gender, colour or condition.

I met many inspiring nurses and medical staff on my trip, and many who I was ashamed of and ashamed for. I helplessly witnessed discrimination and neglect of patients: on one occasion I was so embarrassed by a member of staff, and so sympathetic to a particular patient with HIV/AIDS, that I dressed him in preparation for an x-ray as he was unable to do it for himself. I even observed patients being left lying on the floor in a pool of their own urine, for no reason.

During my time in Kenya I met significant obstacles I had not anticipated. I assumed, based on my pilot trip, that the clinical time I could offer, however short, was wanted at CPGH. I also assumed that because senior staff at the hospital welcomed my

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profession and the offer of my services, that the staff I would be working with would also welcome my work. I was wrong. I was accepted to implement pro-formas and protocols the hospital desperately required, reduce the workload on other nurses, and promote wound healing techniques and strategies, but only as long as they did not differ greatly from current, out-of-date practice. This caused friction: I do not agree with washing wounds with IV antibiotics, or not treating a patient today because you are too tired.

In the September/October 2012 issue we will publish Joanne Sweeney’s Case Studies.

I learned a significant amount about myself on this trip. I am more confident and assertive than I realised. I can comfortably discuss patients’ needs with any other professional and am I not afraid discuss difficult issues. I gained great clinical experience managing complex wounds in less than ideal environments, confirming the clinical ability I knew I had.

In spite of all the difficulties I experienced during my trip, I achieved all of the objectives I had set out to, although not in all the places or ways I had anticipated. As a result of my time in Kenya, I believe that many patients are experiencing better, more regular wound care management. I have been requested to return to Mombasa to work in the diabetic clinic at CPGH, and also Mombasa Hospital, in addition to the other clinics I visited and worked at. This makes me feel appreciated for my expertise, by some (if not all) of those with whom I worked. Most importantly, I learned that I want to pursue a career dealing with health issues (particularly diabetic foot disease) at a population level. I intend to study a Masters Degree in Global Health in 2012.

The Cosyfeet Podiatry Award assists one person each year to develop their professional knowledge and skills while benefitting others. The £1000 award is open to any podiatrist or podiatry student who is planning voluntary work, a work placement or research, whether in the UK or abroad. It is designed to contribute to travel and living expenses. If you have been inspired by Jo’s story and would like to find out more about the Cosyfeet Podiatry Award please email prof@cosyfeet.co.uk. page | 13

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Podiatry as a Profession: My path to becoming a Podiatrist and my experience as a newly qualified practitioner: Part 5 Deirdre O’Flynn, BSc Podiatry M.Inst.Ch.P The end of April I got the opportunity to attend the 2012 Conference and Trade Exhibition in Southport. This was a new experience for me as it was my first conference since graduating.

I was really looking forward to meeting my friend from University who was also attending the conference for the weekend. She arrived from Edinburgh on the Friday evening. I flew into Manchester airport on Friday night. I discovered Southport is a beautiful town and was a great place to have the conference. It is a seaside town with a Victorian feel, a lot of the historical buildings were kept in a pristine condition. The conference was held in the Southport theatre and Conference centre. This was an ideal setting for the conference because it was very central with magnificent views overlooking the waterfront. The Saturday morning I woke up early, in anticipation for the day and the events which lay ahead. We arrived at the Conference Centre for 9 am where we were greeted by a very friendly member from the IOCP. She set us up with badges, lunch tickets and an information pack.

We wandered into a large room where several trade exhibitions were set up. At 9.30 I attended the padding and strapping workshop. This workshop was attended by about thirty other Health Professionals. I found this workshop valuable because it was a great opportunity to speak to other Podiatry Professionals.

I also got to learn some of their techniques they use in practice.

Most of the information the tutor had offered I had covered in University but it was worth refreshing my knowledge. Following this workshop I took some time to walk around some of the other trade stands. I spoke to some of the sales representatives. There were in excess of twenty trade exhibitions. The Lunula Laser caught my attention. It is a low level laser that is used in the treatment of Onychomycosis rather than oral medication that can be harmful, the laser is safer. It works by stimulating two wave lengths one to stimulate a natural immune response and the other for fungicidal activity. The patient would receive two 12 – minute treatments. After speaking to the sales representation I found this interesting and it would be much less time consuming for the patient. The alternative fungal nail drops would need to be applied daily for a period of six months. This is an innovative new treatment that could be used in our clinic in Midleton. The machine costs £25,000 which is a huge investment and I feel it warrants more research before we could purchase this. At 11 am my friend went to attend the Diabetes Workshop and I sat in on the Annual General Meeting. This gave me an insight into how the voting system works and it highlighted some issues that were concerning some members.

At 1pm we headed up to the restaurant for Lunch, the room was crowded with barely a seat to be found. We relaxed there for an hour and enjoyed a wonderful lunch. The rest of the afternoon was spent sitting in on Lecturers and attending workshops. I found the lecture on Lymphoedema very informative and interesting. The lecturer explained about manual lymph drainage in the treatment of Lymphoedema. The remaining workshops consisted of Toenail surgery and the use of hyfercation in the 14 | page

treatment of Verrucas. At 7 pm we attended the president’s reception. I got to meet the mayor of Southport and I was introduced to the President of the IOCP. This was a black tie event with everyone dressed to perfection. The dinner was wonderful and delicious. The tables were laid out exquisitely. There was a huge amount of detail and extravagance. Every person had an individually wrapped cup cake with a foot made of icing which I thought was a quirky idea. Also each place setting had the person’s name written on in a black and white foot attached to their wine glass which was creative and represented a Podiatry dinner dance perfectly. These little added touches made it extra special. The night went very fast with the awards ceremony, an auction and the president’s address and a 17 piece swing band to keep us entertained. I retired to bed in the early hours after a very enjoyable and eventful day. Overall I had an amazing weekend. It was very relaxing and entertaining. I got to speak to other Podiatrists and got to put names to faces of people I was previously in contact through emails. I will most definitely be signing up to go next year. I would strongly encourage other newly qualified Podiatrists to attend,it is a very note worthy and beneficial weekend. I want to also thank the IOCP for giving me the opportunity to attend.

This month I am going to briefly talk about the Podofix nail brace. This is a technique we use in the clinic for the treatment of less severe cases of Onychocryptosis. It is relatively easy to apply and we use it on a regular basis in the clinic. The Podofix nail brace acts like a brace for teeth. As the nail grows out over time the brace will straighten the curvature of the nail slightly.

This method of treating Involuted nails and Onychocryptosis is safe and can used in Children and Diabetic patients. This makes it more appealing for those patients who have a nervous disposition to surgery. This brace is effective but it can fall off easily. This is due to the adhesive and the activity levels of the patient, for example playing soccer.

After a full detailed history is taken from the patient and a diagnosis is made. The various options available are discussed.

Figure.1 Treatment: The brace comes in four sizes and is composed of flexible plastic that can be conformed to each individual nail type. Within this plastic is a metal wire that is used to tighten the brace. The brace should fit exactly over the nail plate but should not cover the

ARTICLE lateral nail fold. When the appropriate brace is chosen, the nail plate and surrounding area is disinfected. The nail plate should be filed prior to treatment to remove any loose debris. A swap containing alcohol is used to wipe down the nail. This is left to dry.

This brace is slightly bent to conform to the curvature of the nail.

The brace is then wiped with alcohol and left to dry. A thin layer of adhesive is applied to the underside if the brace and this is placed on the nail plate. It is positioned slightly more to the area of the nail that is more involuted or piercing the sulcus. Pressure is applied on both edges of the brace for about 15 seconds. After 2 minutes the wire loop is tightened using the mental implement supplied in the box. This is tightened to a point that the patient is comfortable with. A wire cutter is used to cut the excess wire.

Pedigel is placed into the recess of the brace. This is left to set using the micro lamp for 15 seconds. The brace is left on for up to 6 weeks provided the brace doesn’t fall off. The brace is then removed the toe is reviewed and it may require a second brace.

Next month my dear friend Jennifer Cahill who recently graduated from the Queen Margaret University is going to talk about her experience post graduation. I would like to thank you all for reading my articles over the past twelve months and I hope to write more in the future.

References: Figure 1. Podofix components.2012. [Online image]. Available at: http://www.podofix.me/en/podofix_setup.html [Accessed May 15th 2012].

Figure 2. Glueing on the brace[Online image. Available at: http://www.podofix.me/en/podofix_setup_mode.html [Accessed May 15th 2012].

Figure 3. Microlamp.2012 [Online image]. Available at : http://www.podofix.me/en/podofix_setup_mode.html [Accessed May 15th 2012].

Podofix.2012.Podofix.[Online]Availableat:http://www.podofix.m e/en/podofix_setup_mode.html [Accessed May 15th 2012].

Figure 2

Figure 3

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CHAIRMAN’S ADDRESS

Chairman’s address 2012 You, the membership, have once again honoured me by electing me as your Chairman and I once again pledge myself to the betterment of the Institute and its members.

The next year will be one of consolidation. Planning was carried out last year, the Chairs of the various committees submitted business plans to the EC which were approved and are now being put into practice.

Changes which affect the profession have taken place over the past year both inside and outside the Institute.

Some of the latter are welcome, and I shall mention them later in this address, some, in the form of local and central government requirements are less welcome but are nonetheless with us whether we like it or not. You may be assured that the Executive Committee will take action on behalf of the membership each and every time any situation which might act to the detriment of the membership is drawn to the attention of Head Office.

Vigorous promotion of both the Institute as a professional body, and you, the member, has continued to take place.

Martin Harvey and Judith Barbaro-Brown have carried out a vast amount of work with the Department of Health concerning prescribing for podiatrists. When dealing with government bodies’ progress is notably slow, particularly in this case since podiatrists and physiotherapists are the first of the PAMs to be considered for extended prescribing rights and the officials involved are rightly concerned that the process should be faultless. This is crucial since our submissions will be the basis on which later submissions by other PAMs are predicated. We do not know the result as yet but hope for a good outcome and if we achieve what we desire, it is to be hoped that many Institute members will wish to be involved. A second notable change to the benefit of our members is that BUPA are changing their policy.

Formerly, a referral from a consultant was required to involve a podiatrist/chiropodist in the treatment of BUPA members.

As a result of the change, General Practitioners will have the authority to refer directly. It is fair to say that BUPA were not totally aware of the position of Institute members but this has now been corrected and the period of application has been extended for our members. There will be full details on the website in due course, and please do take advantage of this hard won benefit. It is not unknown for other medical insurers to follow BUPA policies and should this take place it will allow expansion of your practices.

Both the Department of Health and BUPA have expressed a requirement that practitioners who wish to take part in the above initiatives should go beyond the normal minimum standards required by both the Institute and the HPC. This year, therefore, the Institute will be producing a system to 16 | page

create a ‘chartered’ practitioner. This will be a fulfilling and enjoyable process for those who wish to be involved and will include CPD beyond that demanded by the HPC, peer review, and audit. There will be nothing to intimidate any practitioner and it is hoped that many members will wish to become involved, not just for the notable increase in revenue which may be expected, but for the kudos which they will enjoy and the opportunity to spread their commitment to colleagues. There will be other benefits which have to be agreed by the Executive Committee but our branch secretaries will be informed as soon as this takes place and thus members will be aware of decisions at the branch meeting following the Executive meeting.

Working to increase membership numbers will continue and it is heartening to report that a number of members at the Conference have volunteered to do just that and I thank those members for their commitment and willingness to share the burden of work. One submission to the web site made the point that the Institute is ‘the friendly organisation.’ This is absolutely true and furthermore it is by far the most democratic of all the organisations representing this profession and specialises in taking care of the private practitioner. Add to that it is the most progressive body and welcoming of new procedures – and arranges insurance for advanced practise – and we have a winning combination. We do not need to criticise others, we can simply offer more to committed practitioners, as well as providing help to those in private practice who need assistance with Health and Safety and other necessary but confusing requirements and guidelines. Please do your bit to bring in new members and make them welcome at our branches.

Under the watchful eye of our Hon.Treasurer financial savings have continued to be made and fiscally, the Institute is now stable. Savings will continue to be made although suitable investment will take place in necessary areas. Your representatives at the AGM will have informed you of the decision to dispose of the Sheffield Clinic. This action was not taken without a good deal of thought and debate.

However, the lease is required to be renewed this year and the financial figures showed that a large year on year loss had been made, and that this was projected to continue.

Whilst this is a disappointment to many who had put effort into bringing the clinic into profit, you may be assured that the staff will be looked after. As I made clear in my address last year, all sectors of the Institute will be required to run profitably where possible.

Our President, who deals with Human Resources has arranged for timely training to take place for the staff at Head Office, as well as updating the Health and Safety

CHAIRMAN’S ADDRESS aspects. This will enable the staff to serve you better and to work more efficiently and enjoyably under the direction of Jill, our hard working Company Secretary.

The web site will continue to expand and much will appear on the member’s only site regarding the changes which will shortly take place. On-line courses are already available and I urge you to take this financially advantageous route to CPD which will be expanded over the coming year.

The Institute, under the auspices of the Chairman of the Faculty of Education, has created a Local Anaesthetics course in association with a well-known university.

Successful completion is just the beginning of a huge range of extended practise. Many commentators see the acquisition of this qualification as simply a way of proceeding to nail surgery. Whilst it is true that nail phenolisation and similar techniques are an important and rewarding element of private practise, many other advanced procedures become available. As an example, serial L.A. injections for plantar fasciitis may be carried out but also the use of depo-medrone (with appropriate POM exemptions), tissue supplementation, intra-articular injections of hyaluronate for arthritic joints, prolotherapy and many more. This is a great opportunity and it is to be hoped that many members will ‘seize the day’.

The Executive Committee continue to investigate the currently confusing situation of ‘Any Qualified Provider’.

Basically, under the new Department of Health plans in England, Wales and Northern Ireland, the patient will be able to choose by which practitioner, and where they wish to be treated, provided that practitioner is on a list of those approved by the DoH. How this will work is far from clear but please be assured that the Institute will provide what details it possesses as soon as clarification is available. In the meantime the DXS preferential referral system remains a very good benefit for members; details can be found on the members’ only area of the web site.

Finally, our branches continue to provide not only CPD but that most important element of practise, mutual support. Please do take advantage of the opportunity to communicate and to enjoy the company of like-minded people. Please welcome students and other visitors and remember that you all have a valid contribution to make to the growth and prosperity of your organisation.

W. J. Liggins

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PRESIDENT’S ADDRESS

President’s Address April 2012 Dear Fellows, Delegates and Members

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PRESIDENT’S ADDRESS

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POSTBAG

Conference Letters Dear Jill and all the girls at Head Office, On behalf of myself and the Sussex Branch, I would like to thank you profoundly for all the hard work which must have gone on behind the scenes to produce such an outstandingly successful A.G.M. The hotel was very comfortable and so conveniently situated next to the Conference Centre. It was great to meet up with old friends and to make some new ones too.

The lectures and workshops were hugely appreciated - they were interesting, informative and, most importantly, very well delivered.

The trade Stands were well stocked and manned by pleasant, helpful staff. At this point I would like to add special thanks to Malcolm Holmes who worked so hard in this area and in arranging the workshops.

Lastly and by no means least my congratulations go to whoever organized the Swing Band. They were absolutely brilliant - a good time was had by both the dancers and those who sat and listened.

Congratulations all round on a thoroughly enjoyable and informative weekend.

With my very best wishes, Valerie Probert-Broster, Sussex Branch Secretary Dear Editor, Just to say…

Thank you all, for the hard work put in to make the A.G.M. the success that it was.

It was non stop all the way - Plenty of things to attend and do to suit everyone.

Jolly well done David Crew, Surrey and Berkshire Branch Dear Editor, The A.G.M. at Southport was excellent this year. Thanks go to the Head Office staff who have worked really hard to organise this event. The lectures and workshops were excellent with lecturers and tutors who made the subjects interesting and informative.

Special thanks go to Malcolm Holmes the trade show organiser.

The trade stands had plenty to sell and with new suppliers and products this year for members to view and discuss, it was excellent.

The swing band were entertaining and the food of high quality.

All the staff at the conference centre and the hotel were extremely helpful.

20 | page

I was shocked but delighted to receive the President's Prize for services to my branch. It was a lovely surprise.

If any members have not attended a Conference and Dinner Dance; where- have -you- been? You have missed out on valuable CPD and you missed the opportunity to meet other members of the Institute. The weekend is for learning but its also for a chance to let your hair down and have a great time. See you next year.

Denise Willis Cheshire North Wales, Staffs and Shropshire Branch Dear Editor, I must thank the girls at Head Office and Malcolm Holmes for organising such a wonderful Conference, A.G.M. and Trade Show in Southport last weekend. Venue and lay out of this Conference Centre was first class and I am delighted that it will be held there again next year. The Workshops proved to be a success and as usual were full to capacity and the Lectures were excellent.

It was good to catch up with friends and colleagues, browse round the Trade stands and add to my CPD. I would urge all Members who have never been to the Institute Conference before why not make an effort and give Southport a go in 2013.

Ann Yorke, West of Scotland Branch

Dear Jill, Bernie, Julie and Pauline How wonderful this A.G.M. 2012 has been. Everything was just fantastic; the venue, hotel, lectures, workshops and a bag with the Institute logo was a welcome gift. Everyone from the Office and Caroline made people so welcome. You did the Institute of Chiropodists and Podiatrists proud. What a credit you all are to Head Office.

I must mention those little cup cakes with the foot biscuit on our tables; how lovely they were and so delicious. They must have required so much time and patience to prepare.

In your quiet way, you are all the back bones of the Institute and we would be lost without you. Big THANK you to the “Four Musketeers of Head Office” Michèle Allison, Cheshire North Wales Branch

POSTBAG Dear Editor, The Nottingham Branch wish to say how very pleased and delighted it was to be awarded the Annual Branch Award For Endeavour at the Awards ceremony prior to the A.G.M. Dinner and thank those of the Executive Committee who gave the Branch their vote.

The hotel and Conference Centre at Southport very adequately suited our requirements and thanks are extended to all those who were involved in the organisations to ensure that the weekend was informative, comfortable and enjoyable.

Dear Colleagues, I finally arrived home from Southport at 12:03 this morning and fell into an exhausted sleep.

It was worth it though, I enjoyed every minute of the conference, the speakers were interesting, the workshop on nail surgery was rivetting and showed me that it's something I could get to grips with, if I can just pluck up the courage to give it a go!

The dinner dance was great too, I love swing music so, with the help of our resident dance expert, Mike, was able to dance the night away. Thanks to all of those who went to all the effort to arrange such a fantastic weekend.

The event did not appear to have been so well attended as previous years and was an opportunity missed as Southport, being a tourist destination, has many other hotels, restaurants, great shopping areas and entertainments close by the Conference Centre which makes for a welcome break for those who are not delegates but who would like to visit and be part of our Association's Conference weekend.

The 2013 Conference, A.G.M. and Trade Exhibition will be held at the Southport Conference Centre again next year and diary dates are expected soon!

Valerie Dunsworth, Nottingham Branch

It's a pity though that the conference was not better attended.

It was the best one that I have been to, but also the one with fewest people there. We are promised bigger and better next year, so please come along, you won't regret it.

Suzanne Edge, Hants and Dorset Branch Dear Editor, Just got back from Southport and would like to thank Malcolm, the girls at head office and all involved in putting on a very enjoyable conference. Great hotel and venue, excellent lectures and workshops and a real sense of fellowship which I feared had been lost.

I would hope all delegates go back to their branches and encourage as many members to attend next years A.G.M. which we were told will be even bigger and better.

More strength to OUR elbows.

Cheers Stephen Gourlay, West of Scotland Branch

Dear Editor, For those of you who didn’t attend this year’s conference I hate to say it but you missed out on a good time so book in early for next year’s conference as its coming back to Southport! Thanks to Malcolm Holmes for organising the Trade show along with the lectures and workshops as there were some last minute changes along the way.

Malcolm, your nail surgery workshop was brilliant and you did a lovely neat bi-lateral partial nail avulsion on one of my clients.

Not only did Malcolm have thirty-four members in attendance, he had to put up with ME as his assistant - poor man!

Congratulations to Nottingham Branch for beating us to the Branch Endeavour Award but just remember Western Branch have won it twice! Can you do it again next year?

I would like to thank everyone who donated raffle prizes for the Benevolent Fund, you all know who you are! Thank you to Joyce and Martin, Linda Pearson’s mum and son for running the stand.

Michelle Taylor, Western Branch page | 21

POSTBAG Conference Centre. We had a sea view and could walk to the pier and promenade before the start of conference. Excellent shopping was also nearby.

At the A.G.M. we gained a better understanding of the workings of the Institute and changes required for its future. The workshops and lectures were worthwhile, interesting and relevant. The conference and hotel staff were very welcoming and helpful. We were thrilled that Nottingham won the Branch Award and left on the Sunday, well fed and more motivated and energised for our practices.

Fiona Grove and Valerie Dannourah, Nottingham Branch Dear Editor, The conference of 2012 was a great success. Right from the beginning, the greeting on the doors was very inviting. All the lectures I've attended were very easy listening, very flowing and well organised especially the Friday afternoon lectures; I would come to the next conference even if I am retired by then as it was so very nice to meet people I've not seen for a year. Negative well there has to be one, the chairs in all lecture rooms were the most uncomfortable ever. Joking aside, it is a must for everyone who cares of the future of the Institute's future. Come on guys!

Bernie I am sure you can put it in the way it should sound. I most certainly had a great time.

Robert Sallay, Sheffield Branch Dear Editor, I would like to express my thanks for the 2012 A.G.M., trade show and conference. I thoroughly enjoyed it. and it gave me the opportunity to see all the new products at the trade show and to pick up a few bargains in the process! I really appreciated getting to understand what goes on behind the scenes at the Institute also and how they work for our benefit. As members you do miss out if you don't make the effort to attend.

The best moments for me are meeting up with friends I have made at other A.G.M.’s. We swap information and tips and generally ‘catch’ up. I even managed to get a note of a speaker for a free talk at a branch meeting! In addition I thought the dinner dance was fabulous and the swing band superb.

As our conference will be held at Southport again next year, I hope I will see more of the members from the nearby branches on at least one of the days and attending some of the work shops /lectures. YOU DO NOT KNOW WHAT YOU MISS OUT ON UNTIL YOU TRY IT! Christine Carrington, Western Branch Dear Colleague, Having both attended the A.G.M. in Southport on the 27th-29th April we wanted to write straight away to express how enjoyable and well run it was. We found the seaside town of Southport a welcoming, interesting and scenic location, ideal for everyone to enjoy and not be bored.

In particular the Ramada Hotel where we stayed was of a very high standard of accommodation and integrated with the 22 | page

Dear Editor, I start this letter with thanks to all the staff of the Institute, your delegates and visitors for making my wife and I so welcome at your A.G.M. trade show. If some of you wonder about my enthusiasm for your annual event, I can assure you that although a Chiropody and Podiatry organisations A.G.M. may not be everyone’s idea of a canny weekend away, this is one of our annual highlights and with good reason as we are able to exhibit our range of podiatry stationery products to a helpfully critical audience of professionals at a cost we are able to afford in the company of very friendly people.

Some other organisations run trade shows, charging extortionate prices for very small stands which we find completely unaffordable. Somehow they’ve lost sight of the fact that the reason for a trade show is so that members can see, evaluate and buy from the widest range of suppliers as well as meeting manufacturers and supplier face to face. That difference is what keeps the Institute head and shoulders above most of the rest. Your honest and open friendliness takes some beating. I trust that your informality and the friendliness which we enjoy annually may never be sacrificed in the name of organisational efficiency.

Finally, I wish to congratulate Roger Henry for his work as editor for such a long time and for his advice and guidance over so many years and for mercilessly forcing his long suffering staff to be so kind, tolerant, friendly and understanding towards us simple Geordies.

Des Currie, Printer, North East

POSTBAG

Dear Editor, I would like to express my thanks to all those people who have worked so hard to make the 57th Annual General Meeting and Conference such a success, especially all the girls at head office.

The range of topics covered were really interesting and informative with good speakers and interactive workshops where we could watch surgical procedures being carried out and explained step by step.

The location of this year’s A.G.M. made such good sense as it is the home of the Institute. The hotel and facilities were of a good standard with the conference centre next door and all under cover, which was a bonus considering the weather!!!!

Thanks for a marvellous weekend and here’s to another successful A.G.M. next year.

David Collett, Wolverhampton Branch Dear Editor, Many thanks to everyone who made the 57th A.G.M. at Southport such a success. Considering we were compelled to change venue at a late stage of preparation I think the organisation of the weekend was excellent and thanks go to Head Office for all their hard work.

The Trade Show as ever was useful and is always an opportunity to familiarise ourselves with the latest products and techniques. I imagine most of us these days order our requirements online or by phone so it’s great to meet some of the people that we deal with regularly but never see. It really does make a difference and is beneficial for establishing good working relations with our suppliers.

CPD opportunities abounded once again this year and as usual standards were very high. The Lectures I attended were informative and relevant to my work as a Podiatrist. I heard positive reports from those who attended the workshops and that’s the thing… we take away much more than we put in when we attend our A.G.M. The sacrifice of a long journey/loss of work etc is easily offset by the huge gains in up to date information/high quality education and the support and advantage received from being a Member of a professional body such as The IOCP. In addition, good food and accommodation. See you next year.

Jon Ollivier, Teesside Branch

Dear Editor, Firstly please let me congratulate the conference team on a great job well done, particularly as they had to find a venue at short notice.

The hotel and conference centre were first rate. There will always be those that will find fault but until they have had to arrange a conference and realise how much goes on behind the scenes to make it run seamlessly, I say “shush”.

The trade show and conference being held cheek by jowl meant you had every opportunity to talk to all the trade show folk and quiz and question them as much as your heart desired. Just to be able to meet the many people who you have done business with over the years was a plus; and to put a face to the voice down the end of the phone, fax or email was a bonus: like the larger than life Mr. Curry (the printer who I met for the first time in person four years ago after doing business with him since 1986).

They have supported us all this time, so it is nice to return the compliment and support them: • on the Canonbury stand the MD in person, Mr. Has Bakker, was personally taking orders and enthusiastically sharing his knowledge of his products.

• on the Hillary Supplies stand three generations of the family were there with a range of new products as well as the old favourites, giving talks as well some free samples.

• one company Algeos graciously let their chiropody chair be used in the demo of the new laser treatment for Onychomycosis while verrucae and ingrown toe nails where being treated with a Hyfrecator by Mr. Martin Harvey and Mr. Robert Sullivan demonstrating the use of the equipment supplied by Schuco.

While all this was going on there were other lectures on palliative care, pharmacology, hip and knee replacement therapy, lower limb lymphodema, nail surgery and padding and strapping The conference this year was 30 years after the first that I ever attended. Once again I had the pleasure of catching up with old friends (often only seen only once a year at conference); to share

Dear Editor, Just to say the conference this year was in a lovely location. The hotel was beautiful and clean. It was a great opportunity to meet friendly faces again. Also, it was well organised. Thanks to all who took part in the conference for a very interesting and knowledgeable weekend.

Claire Mann, Sheffield page | 23

POSTBAG said, “I don’t think I’m good enough to do that”. His response was “If you didn’t think you were good enough you would not be here”. It was at that point that I realised, there are probably many Chiropodists/Podiatrists out there who are unaware of how much support they have from the Institute.

It is in the interest of the Institute that all practitioners excel as every Chiropodist/Podiatrist is a representative of our profession, and the continual strive for a high level of professionalism. So may I humbly suggest that you, my fellow Chiropodist/Podiatrist take advantage of this support through attending branch meetings, becoming a member of the Institute and maintaining membership, as well as going to conferences, etc. all of which I do not have available in Trinidad, where I live.

the laughter and tears - for those fellows we had lost; to share with others what my years of experience have taught me, and to learn more from others from all over the world, including one lady from the West Indies.

Every year I have attended I have learned something new at the conference. This year I was able to find out first-hand about new treatments for fungal nail infections as well as the new chemical treatment for verrucea, and a new sandal foot-bed from Langer shhh – all in all (plus the CPD) the trip was more than worthwhile.

Only problem I had to pick which of them I do because I could not do them all.

Over these 30 years, the Institute has seen many changes - now we are a far more confident animal, yet some questions are the same - and the answers will always be the same, for united we will STAND and divide we will fall…

•

Why are numbers at branch meetings so low?

•

Why, when there is strength in numbers, and the collective learning experience has been proven time and time again to improve retention of facts, don’t members take advantage of the conference and all the wealth of experience that would be at their disposal?

•

Where else are you going to find together in one place a printer, the MDs of 5 plus supply companies, and a chiropodist whose practice is in the West Indies?

•

Add to this three ex-presidents of your professional body, the current president and the EC, and you have the collective wealth with all those present of 1,000 years of experience in one room.

Now I challenge you to play a better trump card than that.

This brings me to my point of thanks to Julie, Jill, Bernie & Pauline who work in the office at the Institute and who were all very helpful during the conference, as well as those who took the time to speak with me about my work in Trinidad, such as Mr. Martin Harvey, Mr. Alisdair Reid and Mr. Robert Sullivan. There is a very high instance of diabetes per capita in Trinidad and an even higher rate of amputations which can be significantly reduced.

Another interesting aspect of the conference was the opportunity to casually discuss with other Chiropodist/ Podiatrist, the different products or processes used among us which gives the practitioner a different point of view and which happened with such ease either at the lunch break or around the trade stands.

But… Next time, I’ll remember to pack lots of sunshine for everyone.

Michael Franklin, South Wales Branch PS see you next year

Once again thank you.

Nicole Nanton, Overseas Member

Dear Editor, Footnotes from Trinidad Due to the itinerary for this years’ conference I was encouraged to attend and can certainly say that I am pleased that I did.

Dear Editor, This year, my grandson, Martin and myself were invited by Western Branch to help run the tombola. We enjoyed meeting you all again and also helping to relieve you of your spare monies, all in aid of the Benevolent Fund, raising more than last year.

Thank you all for supporting the cause. See you next year!

Mrs. Joyce Rollinson

One moment that stands out for me is when I attended the workshop on nail surgery with Mr. Malcom Holmes. After his expert demonstration, one of the people attending the workshop 24 | page

POSTBAG

Dear Editor, The Conference in Southport was really great. The venue was excellent and it was good to catch up with colleagues that I haven’t seen for a year or more. It was a nice to be re-elected to the Standing Orders Committee and I was really surprised to have been presented with a President’s Award. Thank you to the very kind colleagues who voted for me. To anyone who hasn’t attended a conference, its a great way of networking, meeting new colleagues whilst learning.

useful both within our practices and beyond. Mr. Nicholas Emms, Consultant Orthopaedic Surgeon, gave an excellent presentation on hip and knee replacement. Then there was the extraordinary after dinner speech on Customs & Excise sea vessels - a real treat for everyone.

It was good to meet up with fellow professionals and compare notes - I look forward to travelling up next year. The hotel and centre were comfortable and efficient - glad to learn that we are using the same venue in 2013. Best wishes to everyone who made it such a success.

Paul Simons, Birmingham Branch

Looking forward to seeing you all at next years conference.

Linda Pearson, Western Branch Dear Editor, My Nan and myself were invited by Mum’s branch to help run the tombola at the recent A.G.M. in Sheffield. I really enjoyed meeting up with all the friendly faces from last year.

I was asked to be a Guinea pig in one of the veruccae workshops on the Saturday which was a good experience as I got to ‘test’ some pioneering technology. Thanks Robert; verucca’s clearing up well!

I Also had the honour of presenting the Mayor’s wife with a bouquet of flowers at the Dinner Dance, looking forward to seeing you all again next year!

Martin Pearson Dear Editor, The A.G.M. and Conference in Southport was a great success.

Many thanks to Malcolm, Jill, Bernie, Julie and Pauline for a superb occasion.

The Institute business was conducted with vigour and goodwill, while the standard of the lectures was, again, very impressive.

Though sobering, the lecture on Palliative Care, was insightful and

Dear Editor, Congratulations to everyone involved in organising this years conference in Southport. The venue was spot on, a town centre location, with lots of space for the trade show exhibitors, and the dinner dance in the evening. Great band too. My kind of music.

Having been on the organising end of one of these events I appreciate just how much planning and work goes into making everything happen at the right time. All our head office staff did us a fantastic job on top of their normal workload.

I think we had the best range of lectures and workshops ever.

You have set the bar high for future years.

For those of you unable to be there this year, plans are already made to be back in Southport next year. What more could you ask for? A fun weekend, good company, CPD, and sunny Southport for a weekend!

May I take this opportunity to register my thanks to the members of the Leeds/Bradford branch who put my name forward to be considered for the President’s award. My sincere thanks must also go to Madam President for granting the prize.

The whole event came as a total surprise to me. A very nice one!

Thank you all once again.

Norman Hodge, Leeds/Bradford Branch page | 25

TRADE SHOW

The IOCP wish to thank the following, for their support at our recent Conference Algeos Barrier Healthcare Ltd Beehive Solutions Canonbury Products Ltd Chiropody Express Currie International Cutera Cuxson Gerrard Delcam D. L. Townend and Son Gallagher Heath Insurance Services Hilary Supplies MDS Medical Ltd Ocean Pharma GMBH Peak Performance Products Ltd Primcogent Solutions Reed Medical Sidas UK Swann-Morton TalarMade The Langer Group

26 | page

INFORMATION

Beware of saying ‘Yes’ to that late night Drink!!!

Julie Dillon - Yorkshire Area Council Delegate Late one night I was walking to my room before the Executive Committee meeting the next day when a voice called out “Julie, come and join us”. When I looked around, seated at a small table, were two of our most illustrious members, Bill Liggins, Chairman and Robert Sullivan, Chairman of the Board of Education. Before I could politely decline, Robert was at the bar saying “what do you want to drink Julie?” I thanked him and dutifully took my seat round the table. The usual pleasantries were exchanged, the weather, the journey up and then out the blue Robert asked me “well Julie, what is your opinion of the Podiatry Review?”

I responded by saying that a lot of time and effort was obviously put into the articles and it is sometimes unfair to be critical to those who so often and willingly give up their free and precious time to help others. I have to admit with this response I felt a rather warm and satisfied feeling as I thought this was rather diplomatic! However, this did not satisfy Robert “yes, but what do you really think of the articles?”

Remembering some of the comments of branch members I was really on the back foot! I took a deep breath and said somewhat hesitantly “well maybe there are times when some of the articles are a little too indepth”. I also ventured to say

that several members felt that the articles were pitched too high and not relevant to them.

At the last meeting of Leeds/Bradford branch, I had suggested that perhaps we could run a Practical Hints column in Podiatry Review. Members could write or email methods that they had found helpful in dealing with problems when treating patients. These need not be those found in text books but simply methods that had worked for them. Members could also write in to ask for solutions to practical problems.

I explained this to Bill and Robert who immediately said “O.K. you start the ball rolling”.

I am pleased to say that Leeds/Bradford will be happy to kick-start this column but I am appealing to all branches to become proactive and to take up the challenge. Please send in hints or questions to the Review either by email to bernie@iocp.org.uk or by post to 27 Wright Street, Southport, PR9 0TL. Your name does not have to be printed if you wish to remain anonymous. Please remember we are all batting and fielding for the same side. We are one team working together for each other.

page | 27

ARTHRITIS NEWS

Arthritis Research UK www.arthrisresearchuk.org Faulty Gene Implicated in Debilitating Brittle Bone Disease Osteoporosis Arthritis Research UK scientists have discovered new ways to help detect and treat the debilitating brittle bone disease osteoporosis.

According to a scientific study published today (Thursday 19 April 2012) in the European Journal of Human Genetics, women with a faulty gene have lower bone mass and lose nearly 10 times more bone than women who have a correct copy of a receptor for the energy molecule ATP - (the P2X7 receptor).

Osteoporosis is a devastating condition that affects half of all women and a fifth of men over 50 in the UK. The disease can reduce quality of life and more than a 100,000 people die each month because they are not diagnosed and treated early enough.

Dr. Alison Gartland from the University of Sheffield, who is leading the research, said: “This research is really important as it may help identify women who are at more risk of developing bone diseases such as osteoporosis.”

This latest finding follows on from earlier work by the team, published in the Journal of Biomechanics in January 2012, which discovered how individual cells in our bones respond to the stresses and strains every day when we walk, climb stairs or even raise a glass of wine or beer.

“Bone cells release different amounts of the energy molecule ATP depending on the type of mechanical loading or stress that they experience,” added Dr. Gartland.

“We know that exercise is important to build strong healthy bones, but this latest research might explain how it works. If drugs can control the release of ATP during exercise it could help build bigger and stronger bones.”

The team also investigated the way cells detect and control the amounts of ATP released. They found that when a receptor called P2Y13 was changed it slowed down bone loss that would usually cause osteoporosis. This led them to suggest that a drug to switch off this receptor could reduce the onset of osteoporosis, in a third academic paper published in the journal Molecular Endocrinology in January of this year.

Dr. Gartland added: “It’s when things go wrong that diseases such as osteoporosis develop – and then our bones can break as easily as snapping a breadstick.

“We are really excited by these results as it gives us three new ways to try and tackle bone diseases. We have been working very hard over the past few years using a variety of approaches to better understand how our bone cells work, how they communicate with each other and how that can go wrong.”

Medical director of Arthritis Research UK, Professor Alan Silman, said Dr. Gartland’s research was “exciting.”

“Osteoporosis is a condition of age-related bone loss and one of the major factors that leads to fractures in older people. The reasons underlying osteoporosis are several, and include poor diet, lack of exercise and smoking, but there is also a substantial genetic basis,” he added.

“Over the past two decades ARUK has invested a considerable amount into attempting to identify the genes that might be responsible.

28 | page

“Identifying these genes can help both in targeting individuals afor prevention strategies plus identifying new ways of early diagnosis and the possibility of new drug therapy.

“This exciting research shows there is a very strong link between particular genes with the rate of bone loss with age.

These women who had ‘bad’ type of a particular gene had almost ten times greater bone loss than women with a normal type of gene, which is a substantial difference. Follow-up studies could lead to great benefits for patients.”

Dr. Gartland will be presenting her group’s work early in the summer at a series of international meetings in Oxford, Tokyo, and at the annual meeting of the Bone Research Society and National Osteoporosis Society.

The research was funded by Arthritis Research UK and the European Commission.

CONDITION CORNER

Achilles Tendonitis

By Mr. Michael Hooper In House Podiatrist, The Langer Group Achilles Tendonitis is the inflammation of the large tendon in the back of the ankle. It is a common overuse injury that tends to occur in middle-aged recreational athletes. The overuse causes inflammation that can lead to pain and swelling. Furthermore, Achilles Tendonitis can lead to small tears within the tendon and makes it susceptible to rupture.

Signs and symptoms: • Pain in back of heel, sometimes at the insertion point at the calcaneus or around 2-5cm above the insertion point • Experience pain most significantly after periods of inactivity (eg. First thing in the morning or after periods of rest) • Commonly brought on by running and jumping • Pain on weight bearing • Possible onset due to increased activity or biomechanical overuse • Patients usually have less than the required 90 degrees plus 10 of ankle joint dorsiflexion • Can be brought on in patients who regularly wear high heeled shoes Diagnoses • A thorough history taken from the patient • A thickening of the tendon • Location of problem on physical examination • Early treatment is important to reduce the degenerative changes in the tendon and avoid chance of rupture • Ultra sound scan can show changes in the tendon • Pain on dorsiflexion of the ankle Differential diagnoses • Achilles Tendon Rupture • Ankle Fracture • Ankle Impingement Syndrome • Ankle Sprain • Athletic Foot Injuries • Calcaneofibular Ligament Injury • Compartment Syndromes • Retrocalcaneal Bursitis • Talofibular Ligament Injury • Haglunds deformity

What are the treatment options?

• An adjustable heel raise (Clearly Adjustable or Adjust-A-Lift). Patient to remove layers over a period of time to stretch out the tendon.

• Simple heel raise to reduce excursion on the tendon • Stretching exercises for Calf muscles (gastrocnemius and soleus) • Immobilisation in severe acute injuries with a walker/cast boot • Ultrasound therapy • Shockwave therapy • An orthotic to improve gait and reduce tension on the posterior muscles

Orthotic adaptions that could help with Achilles Tendonitis A heel raise can be added to a prefabricated orthotic that either has the components included with it or by using EVA. Heel raises are added in mm and you would usually add between 5-10mm depending upon the patients’ foot. You can have a heel raise added to a custom device or if being used as a short term measure can be included separate to the shoe. Precautions must be taken when using with an orthotic made from rigid material as this will affect the pitch of the device (the level between the rearfoot and the forefoot).

The Langer Group Emerald Way Stone, Staffordshire ST15 0SR 0845 678 0182 www.langergrp.com page | 29

DIABETES NEWS

Type 2 diabetes risk linked to low testosterone levels Low levels of testosterone in men could increase their risk of developing Type 2 diabetes, a study funded by Diabetes UK suggests.

Researchers from the University of Edinburgh have found that low testosterone levels are linked to a resistance to insulin – a hormone that controls blood glucose levels.

increased risk of developing Type 2 diabetes, but this study provides evidence that there can be increased risk even when body mass is not affected.

Testosterone acts on fat cells This study is the first to directly show how low testosterone levels in fat tissue could be involved in the onset of Type 2 diabetes. Testosterone, which is present throughout the body, acts on fat cells through molecules known as androgen receptors. These receptors enable testosterone to activate genes known to be linked to obesity and diabetes.

“Yet while testosterone-impaired mice developed insulin resistance whatever diet they were given, the effect was considerably more pronounced on those fed on a high fat diet. This reinforces Diabetes UK advice that a healthy balanced diet is important for everyone, and particularly for those already at high risk of developing Type 2 diabetes.

Obesity is a known risk factor for Type 2 diabetes.

However, the researchers stated that the study showed that low testosterone is a risk factor irrespective of body weight.

The research showed that mice with impaired testosterone function were more likely to be insulin resistant than mice in which testosterone functioned normally. These findings could help explain why older men are more at risk of developing Type 2 diabetes, because testosterone levels fall in men as they age.

Impaired testosterone function linked to weight gain in mice The study also showed that mice with no androgen receptors in their fat tissue were more likely to show signs of insulin resistance compared to mice with androgen receptors. The mice that lacked androgen receptors also became fatter, compared to other mice and developed full insulin resistance, when both types of mice were fed a highfat diet.

Scientists believe that a protein called RBP4 plays a crucial role in regulating insulin resistance when testosterone is impaired. They found that levels of RBP4 were higher in mice in which the role of testosterone was impaired.

The Edinburgh team say that its findings could lead to the development of new treatments that regulate production of RBP4 and reduce the risk of Type 2 diabetes in men with lower levels of testosterone.

They are now planning to study people with Type 2 diabetes to see if their levels of testosterone correlate with levels of RBP4.

Healthy balanced diet important to reduce risk Dr. Iain Frame, Director of Research at Diabetes UK, said, “We already know that low testosterone levels are associated with increased obesity and therefore with 30| page

“Further work is needed to translate these initial findings into clinical practice, as it is important to emphasise that results in mice may not necessarily have direct relevance for humans. But good basic research such as this represents early steps towards potential new treatments, and we are pleased to see research we have funded producing useful results which may benefit people living with diabetes at some point in the future.”

INFORMATION

Safety Notice – Urgent - Adrenaline (Epinephrine)

An IOCP member has brought attention to the fact that certain medical suppliers serving the Podiatry profession are supplying 1 in 10,000 Adrenaline (Epinephrine) pre-loaded injection syringes, without drawing attention to the fact that these are NOT suitable for the routine treatment of Anaphylaxis.

For the treatment of Anaphylaxis the preferred concentration of Adrenaline used should be 1:1000 administered Intramuscularly (IM) - usually in the anterolateral aspect of the thigh - in the following doses: (repeat these after 5 minutes if no improvement) Adult 500 micrograms Intramuscular (0.5ml) Child more than 12 years 500 micrograms Intramuscular (0.5ml) Child 6 -12 years 300 micrograms Intramuscular (0.3ml) Child less than 6 years 150 micrograms Intramuscular (0.15ml) A 1:10,000 concentration of Adrenaline is one of the drugs used in cardiac resuscitation. At this concentration it should only be administered Intravenously (IV) for this purpose, and only by appropriately trained Health Professionals in an environment that permits monitoring of continuous ECG and pulse oximetry and frequent non-invasive blood pressure measurements as a minimum.

Even in cases where individuals are trained in immediate life support techniques that include IV Adrenaline, the UK Resuscitation Council advise that such training is : “….insufficient experience to use IV adrenaline for the treatment of an anaphylactic reaction. In patients with a spontaneous circulation, intravenous adrenaline can cause life-threatening hypertension, tachycardia, arrhythmias, and myocardial ischaemia (Resuscitation Council Advanced Life Support Manual 6th Edition, January 2011) In cardiac arrest (PEA/Asystole) or life-threatening arrhythmia (VF/PVT), Intravenous Adrenaline would be titrated and not administered undiluted from a pre-loaded syringe, it would usually be administered via an on-going fluid challenge. A measure of its

potency via the intravenous route is illustrated by the fact that a child may respond to a dose as small as 1 microgram/kg of body weight.

This requires very careful dilution and checking to prevent dose errors.

1:1,000 Adrenaline for Anaphylaxis treatment is usually encountered in Epipens®, Anapens® and similar auto-injectors, as well as, less usually, single-use glass ampoules. It must be stressed that the use of 1:1,000 Adrenaline, administered at recommended doses via an intramuscular route, is a relatively safe treatment for Anaphylaxis that may save a life. As explained above the IM doses given in Anaphylaxis can be repeated after 5 minutes which demonstrates their safety.

1:1,000 Adrenaline must never be administered Intravenously, it could rapidly kill.

Martin Harvey Podiatrist Prescriber, Vice-Dean IOCP Board of Education. UK Resuscitation Council Life Support Provider. Instructor/Assessor for HSE approved FAW training centre 22/99

page | 31

BRANCH PROFILE

A message from our Secretary Janet Nute South Wales and Monmouth branch of IOCP is a small but active group of about 20 members who get together for meetings four times a year. I have been secretary for at least twenty-five years and Michael Franklin (known to most of you) also has been chairman for many years. We have about sixty members but some we rarely see and some we have never seen! The members that come to meetings are all committed to CPD and we always have some CPD on the agenda at every meeting.

Some members have been friends from as far back as the 1970’s and 80’s when we worked together at Scholl (the Scholly dollies). We have some good fun together reminiscing. I wonder what health and safety would think of it now!!!

“Sterilizing “with surgical spirit and having a quick puff of a cigarette in the back room seemed quite normal then and we quite often had to extinguish resulting fire in the waste bin!........ All good fun!!!!!!!

But I digress.......

We have had many eminent speakers at our regular seminars such as Dr Peter Evans of the Royal Gwent Hospital a specialist in Diabetes, also Martin Harvey and Judith Barbaro Brown. Esther Danahar (one of our group) gave an excellent talk recently on Vitamin B deficiency and pernicious anaemia We always have a first aid course every year and we usually have our autoclaves serviced on this day together with PAT testing. Twenty of us attended a day course in March on health and safety. There was an exam at the end of the day which we all passed . These certificates are issued from the Chartered Institute of health and safety executive and will cover our practices for the next three years. It was a really interesting day aan nd we all enjoyed it. We had a lovely buffet lunch and some free time to chat to colleagues. This I feel is as important as C CP PD a s w wee can learn as much from passing on ideas to each other and talking over problems as we can from structured learning.

We hold our meetings at the prestigious Villllage Hotel, Cor o yto t n,, Cardiff . The hotel has excellent facilities and is easy to find. The staff are very obliging and alw ways make k us feel welcome. Laura and Gemma are our coordinators and Jason or David are our usual helpers on the day. Som o e of yyo ou may remember we had the conference at the same hotel a few years ago o.. It is also possible to have a swim there if there is time. Unfo orrtunately, due to rising costs and our low branch budget, we may not be able to continue there, but we will cro osssss that br b idge when we come to it. I think it is so important to have a ggo ood venue so that good speakers are attracted to come and also members know what facilities they can expect to have.

We allsso haavve a branch library with a very good seleecctio on n of chiropodial books to lend out. We always have a ‘bit of a do’ for Christmas. This is usually at the ssaame venue and n at the same date as the branch AGM (post Christmas) Geographically br a n ncch memberrss are verryy spread out but we stiilll have enough keen members to keep going. Anyone interested in joining us for CPD can contact me by phone or email 02920 331927 planetjaneett_007@fsmail.net.

te u N t Jane

32 | page

RAMBLING ROADS Volume 20 Issue 2, the May number of ‘Casebook’, the Medicolegal journal of the Medical Protection Society features the case of a 58 year old poorly controlled diabetic who attended at her General Practitioner’s surgery with a swollen foot. On examination an extensive area of tissue breakdown was noted and the G.P. diagnosed an infected diabetic ulcer.

The patient was referred to the local hospital where the patient came under the care of the multidisciplinary team who debrided the ulcer and treated her with intravenous antibiotics. The infection was controlled and the patient referred back for treatment in the community. Unfortunately she developed chest and back pain and was seen again by her G.P. who took meticulous notes and treated her accordingly.

A month after her initial hospital admission she developed severe back pain and urinary retention and was admitted to hospital as an emergency admission. Investigations revealed osteomyelitis at T10 and an epidural abscess. This case demonstrates that apparently localised foot problems can involve other, more proximal structures and that care should always be taken to ensure that diabetic patients follow their treatment meticulously. For the practitioner it also demonstrates the importance of detailed and meticulous note taking and interprofessional communication. Details of the evaluation and treatment of diabetic foot ulcers can be found at: http://clinical.diabetesjounrals.org/content/24/2/91.full The use of such terms as ‘mind boggling’ has no place in serious professional journals, even in a review column such as this. However, ‘New Scientist’ of 21st April 2012 carries a report of technology that today seems close to science fiction, although it is confidently predicted that the future, at least in this instance, is very close. 3 dimensional printers are a reality and are cheap at approximately $2,000.00. These devices can produce (or ‘print’) plastic objects from computerised design.

A team of researchers at Glasgow University led by Lee Cronin has produced a digital blueprint to make a selection of chemicals. The printer creates the laboratory equipment from the computer design and places the correct chemicals in the correct reaction flasks to produce the required modified chemicals. By altering the sizes of the equipment and the speed of mixing, the resulting chemicals can be altered. One way that this might benefit medicine is the local production of basic drugs. The team point out that technology today is such that even in countries where basic drugs are unavailable, mobile telephones are quite common and if the 3D printers can be supplied then simple chemicals such as corn syrup; glycerol and paraffin could be manipulated to create the necessary drugs.

The instructions on how this can be achieved could be easily downloaded to a computer via the mobile telephone. The team plan to initially create T.ibuprofen using the new technique.

Achilles (whose spouse occasionally and very unsportingly refers to his dwindling thatch of hair) is delighted to read in Nature Communications, DOI:101038/ncomms1784 that hair

follicles pre-grown from stem cells have been successfully transplanted into the scalp of hairless mice. Since small numbers of the stem cells can grow large numbers of hair follicles those gentlemen currently follicularly challenged may one day look forward to a bushy new head of hair.

Multiple sclerosis (MS) affects around 100,000 people in the U.K. and the aetiology is unclear. There is certainly a genetic background and it does seem that there may be a viral component – the Epstein-Barr virus has been mentioned as a possible factor. Most people are diagnosed between the ages of 20-40, but it can affect all ages and almost twice as many women have MS than men. It is reported at Neurology DOI:10.1212/WNL.Ob013e3182535cf6 that people who took part in a trial 19 years ago and were prescribed interferon beta have a 46% reduced mortality rate compared with the group that took a placebo. The effect of the drug is believed to be a reduction of oxidative stress in the nervous system.

‘Talking Health’ 3rd Edn. The complimentary magazine of BMI Healthcare details the story of professional golfer Andrew Murray, the former European Open champion. In the late 1990s he suffered from osteo-arthritis of his hip to such an extent that he could no longer complete a round of golf without 6-8 anti-inflammatory tablets. He was reluctant to consider a total hip replacement because although suitable for older patients, the dislocation rate and poor long term outcomes had been noted in younger patients with a high demand for physical activity. An alternative treatment, the Birmingham Hip Resurfacing (BHR) technique, had been originated by Consultant Orthopaedic Surgeon Mr Derek McMinn and designed for young and active patients. The implant is designed to conserve the normal hip anatomy and offers a good range of movement, excellent stability and reduced risk of dislocation when compared to the traditional replacements. In the case of Andrew Murray, he continues to compete at the highest level and the implant has been in situ for more than a decade.

G.P. magazine of 14th March reports on the LMC conference in Wales. Many concerns were expressed about the impact of funding cuts and the rising workload in G.P. practices. Efficiency savings are required throughout the U.K. but each of the U.K. countries has adopted a slightly different approach. England has embraced the competitive model whist Scotland (the BMA favoured model) rejects competition and Scottish politicians believe that ultimately, their model will outperform the competitive model. Politicians from all major parties south of the border support the concept of a market in medicine and a role for providers including the private sector. It will take a number of years for the changes to take effect and to judge the results of both concepts.

Achilles Hele page | 33

DIARY

!!

July 2012

!

1

Wolverhampton Branch meeting 9:00 a.m. start Oakwell Motel,for Low Lane, Birstall Please telephone details Tel: 01924 475338 Tel: 0121 378 2888

7

Surrey and Berkshire Branch meetingWO3 7:303RX Harvester, Watford Road, Rickmansworth Pirbright Tel:903 0208 Tel: – 0208 6544660 2822

9

West Middlesex Branch meeting 8:00 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

8 p.m.

September 2012 2

Leicester and Northants Branch meeting 10:00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details – Tel: 01234 851182

8

Southern Area Council meeting at 1:00 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF – Tel: 01992 589063

9

South Wales and Monmouth Branch meeting 2:00 p.m.

Village Hotel,Motel, Coryton, Cardiff – Tel: 0292 033 1927 Oakwell Low Lane, Birstall

30 Essex Branch meeting 2:00 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890 – Please note there will be a first aid course preceding this meeting

October 2012 49

Birmingham andBranch the Shires Branch West Middlesex Meeting 8 p.m.meeting 8:00 p.m.

Red Harvester, Cross Centre, Evesham, Worcs – Tel: 01905 Watford Road, Rickmansworth WO3 3RX 454116

7

Chester North Wales Staffs and Shropshire Branch meeting. The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113

7

Wolverhampton Branch meeting 9:00 a.m. start Please telephone for details – Tel: 0121 378 2888

Tel: 0208 903 6544

15 Surrey and Berkshire Branch meeting 7:30 p.m.

Pirbright – Tel: 0208 660 2822 21 Midland Area Council meeting Tel: 07790 350109 for more Information

November 2012 0292 033 1927 4

South Wales and Monmouth Branch meeting 2:00 p.m. a.m.

Village Hall, Cardiff – Tel: 0292 03311.00 1927

4

West of Scotland Branch meeting 11:00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH – Tel: 0141 632 3283

Tel: 01924 475338

9

West of Scotland Branch meeting 11:00 a.m.

11.00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH – Tel: 0141 632 3283

10

W

8 p.m.

10 West Middlesex Branch meeting 8:00 p.m.

Algeos Harvester, Watford Road, Rickmansworth WO3 3RX T Algeos, Tel: 0208 903 6544 B

Harvester, Watford Road, Rickmansworth 12 West Middlesex Branch meeting 8:00WO3 p.m.3RX Tel: 0208 903 6544 Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

12 Hants and Dorset Branch meeting 7:45 Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: 01202 425568

22 Birmingham and the Shires Branch meeting 8:00 p.m.

01202 425568 Red Cross Centre, Evesham, Worcs – Tel: 01905 454116

01202 425568 A potpourri of dermatology – Paula Oliver

16 Western Branch meeting 12:15 p.m.

Liverpool Womens Hospital, Blair Bell Education Centre, Red Cross Centre, Worcs331827 Crown Street, L8 7SSEvesham, – Tel: 01745

Liverpool WomensBranch Hospital,meeting Blair Bell Education 23 Hants and Dorset and Social Event C 7.45 The Sir Walter Tyrrell, Lower Canterton, Nr. Lyndhurst SO43 7HD – Tel: 01202 425568

30 Nottingham Branch meeting 10:00 a.m.

Feet and Co, 85 Melton WestHoole Bridgford, TheRoad, Dene Hotel, Road NG2 6EN Tel: 0115 931 3492

25 Essex Branch meeting 2:00 p.m.

01473 830217 Hospital Education Centre Southend University Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890

30 East Anglia Branch meeting Barrow Village Hall, Nr. Bury St. Edmunds IP29 5AP Tel: 014730292 830217 033 1927

Tel: 01702 25 Leicester and460890 Northants Branch meeting 10:00 a.m.

Please noteCricket there willClub be a or firstKilsby aid course preceding Lutterworth Village Hall Please phone for details – Tel: 01234 851182

34 | page

DIARY

January 2013 6

Chester North Wales Staffs and Shropshire Branch A.G.M. and meeting.

The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113

12 Surrey and Berkshire Branch A.G.M. and meeting 7:30 Reading – Tel: 0208 660 2822 13 Western Branch A.G.M. 12:15 p.m.

Liverpool Womens Hospital, Blair Bell Education Centre, Crown Street, L8 7SS – Tel: 01745 331827 13 Wolverhampton Branch A.G.M. 10:00 a.m. start Please telephone for details – Tel: 0121 378 2888 16 Hants and Dorset Branch A.G.M. 7:45 Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: 01202 425568 17 Birmingham and the Shires Branch A.G.M. and meeting 7:30 p.m.

Red Cross Centre, Evesham, Worcs – Tel: 01905 454116

20 East Anglia Branch A.G.M. Barrow Village Hall, Nr. Bury St. Edmunds IP29 5AP Tel: 01473 830217 20 Nottingham Branch A.G.M. 10:00 a.m.

Feet & Co, 85 Melton Road, West Bridgford, Nottingham, NG2 6EN – Tel: 0115 9313492 20 West of Scotland Branch A.G.M. 11:00 a.m.

Express By Holiday Inn, Springkerse Business Park Stirling FK7 7XH – Tel: 0141 632 3283 20 Leicester and Northants Branch A.G.M. 10:00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details – Tel: 01234 851182 26 Southern Area Council A.G.M. at 1:00 p.m.

Victory Services Club, 63-79 Seymour Street, London W2 2HF – Tel: 01992 589063 27 Essex Branch A.G.M. 2:00 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890 27 Midland Area Council A.G.M. Tel: 07790 350109 for more information

Olympic Torch The Olympic torch arrived in South hpo p rt on Frid day 1st Jun une as part of the UK wid de relay. Torchbearers from near and far had been given the once-in- a-liffetime honour r of carryin ng the flam me th hrough the resort cheered on by hu un ndreds of well wishers. 81 year old Hiillda Bromlley was amongst those chosen. Hiillda has tirelessly sup pported many peop plle in South hp port for many years

page | 35

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Chiropody Supplies

Equipment For Sale Ultrasonic Cleaner Classic 2100 Autoclave Fm500 Portable Handrill Canonbury Domiciliary Bag Instruments, Trays, Sundries

£90 £100 £80 £90 £50 O.N.O.

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Chiromart UK ‘WHY PAY MORE?’ Suppliers of Autoclaves and Chiropody Surgery Equipment. Single items to full surgery set ups. Quality used and new. Also your equipment wanted, surgery clearances, trade- ins and part exchange CASH WAITING.... www.chiromart.co.uk Tel: 01424 731432 (please quote ref: iocp) LOST SPECTACLES – A pair of reading glasses (black with diamante trim) were found at the Floral Hall conference centre in Southport following the Institute’s A.G.M. and conference there at the end of April. If anybody wishes to claim them please telephone Head Office on 01704 546141.

FUNGAL INFECTIONS ARE INCREASING! There are now fewer products on the market that are available and can claim they really do work.

If your patients suffer from fungal infections then you may have a solution. .. USE MYKORED The results speak for themselves when treating fungal infections of the SKIN and/or NAILS. MYKORED The one product solution for fungal infection of skin and nails.

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DLT Hilary Supplies, 34A Halstead Road, Mountsorrel. Leics. LE12 7HF Tel: 0116 230 1900 Fax: 0116 230 3363 eMail: soniak@hilarysupplies.co.uk

36 | page

NATIONAL OFFICERS

National OďŹƒcers

National Officers

President Mrs. F. H. Bailey MInstChP

Area Council Executive Delegates

Chairman Executive Committee Mr. W. J. Liggins FInstChP, FPodA, BSc(Hons) Chairman Board of Ethics Mrs. C. Johnston MInstChP BSc(Hons)

Branch Secretaries

Chairman Board of Education Mr. R. Sullivan MInstCh.P BSc(Hons), Dip Pod Med, PGDip, Cert LA, FSSCh, FIChPA, MRSM,

Vice-Chairman Board of Education Mr. M. Harvey MInstChP, PGCE, BSc

Branch Secretaries

Honorary Treasurer Mrs. J. Drane MInstChP

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. Z. Sharman

01473 830217

Essex

Mrs. B. Wright

01702 460890

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

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. Massey

0161 486 9234

Northern Ireland Central

Mrs. P. McDonnell

028 9062 7414

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Republic of Ireland

Mr. C. Kerans

00353 1280 8816

Sheffield

Mrs. D. Straw

01623 452711

South Wales & Monmouth

Mrs. J. Nute

02920 331927

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

Southern Area Council Mr. D. Crew OStJ, FInstChP, DChM, CertEd

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mr. S. Gourlay

0141 632 3283

Yorkshire Area Council Mrs. J. Dillon MInstChP

Wolverhampton

Mr. D. Collett

0121 378 2888

Standing Orders Committee Mr. M. Hogarth MInstChP Mrs. L. Pearson MInstChP BSc Pod Med Secretary Miss A. J. Burnett-Hurst

Area Council Executive Delegates Midland Area Council Mrs. V. Dunsworth MInstChP DChM North West Area Council Mrs. M. Allison MInstChP Republic of Ireland Area Council Mrs. J. Casey MInstChP BSc Scottish Area Council Mr. A. Reid MInstChP

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