Podiatry Review September/October 2011

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The Ins tute of Chiropodists and Podiatrists

ISSN 1756-3291

Vol. 69 No. 4 - September/October 2011

Features within this issue l l l

Diabetes News Dementia Awareness Week 2012 AGM information

Independence

Initiative

Individualism

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09:40

Page 1

Still recommending... tins of beans, water Introducing the bottles?

Podiatrist designed PediRoller “It's great! I now recommend it to all my patients” Martine, Podiatrist, Harley Street, London

“Using the PediRoller, I noticed a significant improvement in the foot pain I had been suffering from” Maxine, Hairdresser, Soho

TIRED FEET PLANTAR FASCIITIS ARCH PAIN HEEL SPURS LATEX FREE

PediRoller

Available from selected

and independent pharmacies

www.pediroller.co.uk

Cuxson Gerrard & Co. Ltd, 125 Broadwell Road, Oldbury, West Midlands B69 4BF, England.

Tel: 0121 544 7117 | www.cuxsongerrard.com | sales@cuxsongerrard.com Carnation PediRoller is a registered trademark. Carnation PediRoller International Design Classification LOC (07) CL. 28-03 Registration No. 4013861

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September/October 2011 Podiatry Review

Contents The Institute of Chiropodists and Podiatrists Podiatry Review Editor Roger Henry F.Inst.Ch.P. DChM editor@iocp.org.uk Sub-Editor Robert Sullivan M.Inst.Ch.P.

1. Editorial 2. Article: Viscosupplements for the knee and other joints by Martin Harvey 6. Article: Guillian Barre Syndrome

BSc(Hons)Pod, PG Dip. TP Surg.

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

9. Article: CPD and Lifelong Learning by Greg Quinn 10. Article: Faces of Dementia 12. 2012 AGM Programme 13. 2012 AGM Information

Editorial Committee Mrs. F. H. Bailey M.Inst.Ch.P Mr. R. Beattie Hon.F.Inst.Ch.P., LCh., HChD Mr. W. J. Liggins F.Inst.Ch.P, FpodA, BSc(Hons) Mrs. A. Yorke, M.Inst.Ch.P Mr. J. W. Patterson, M.Inst.Ch.P., BSc(Hons)

DChM, MSc

15. Peer Review Section 25. Rambling Roads 29. CPD Information

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

30. Branch News 33. Classified Adverts 34. Diary of Events 36. Branch Secretaries

Dear Reader Every time I look at a newspaper these days, it seems to be all doom and gloom. The financial news is not very encouraging, and what with the riots and looting, what a summer it has turned out to be. Never mind we will cheer ourselves up by reading Podiatry Review.

What have we of interest and note in this September/October issue of Podiatry Review? We have an article by Martin Harvey M Inst ChP, PGCert BSc Hons, Podiatrist Prescriber on Visco supplements for the knee and other joints.

We also have an article on GuillanBarre Syndrome. Guillan- Barre Syndrome is a disorder in which the body’s immune system attacks part of the peripheral nervous system.

There is an article by Greg Quinn FCPod S on CPD and life long learning.

This ties in neatly with an observation on a Health Professions Council event

by Christine Hughes of Kent branch. I liked her comment that “it’s all about learning and development that benefits you, your practice, and your patients”.

To round off we have an article on Runners in Safe Hands by Daniel Blackman B Sc Hons Pod M MCh S. Daniel is Director of Clinical Services, Biomechanical Consultant R.S. Scan LTD. We have endeavoured to put together an interesting journal for you the reader.

© 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

Don’t forget we are always pleased to hear your news, views and comments and will publish articles we think are of interest.

for any discrepancies in the information published. No part of this

ISSN 1756-3291

publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,

Annual Subscription £25.00 Single Copy £5.00 incl P & P

photocopying or otherwise, without the prior written permission of the Publishers.

Best wishes Roger Henry Editor Podiatry Review

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Viscosupplements for the knee and other joints - extended role pathways in Podiatric Medicine Martin Harvey PGCert BSc(Hons) Podiatrist Prescriber develop endoscopic ulcers, 1 in 70 a symptomatic ulcer, 1 in 150 a bleeding ulcer and 1 in 1200 will die from a bleeding ulcer 3 Topical NSAID’s, are considered safe, however a review of 953 studies on subjects receiving topical NSAID reported up to 39.3% of users reported an Adverse Effect (AE) at the application site AE, and up to 17.5% systemic AE’s. Additionally, 5 cases of warfarin potentiation with concurrent use of topical agents were reported (one resulting in gastrointestinal bleeding) In formal trials, the withdrawal rate from AE ranged from 0 to 21% in the topical agents, 0 to 25% in the oral NSAID and 0 to 16% in the placebo group. 4 The Knee - a vulnerable joint

The Problem During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period.

The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled. 1

Treating the problem Knees are traditionally in Orthopod territory but Podiatrists are the lower limb experts (how often do we see and deal with lower limb problems a couple of years after the Orthopod has treated an initial pathology?) Knee pain is often the Sequelae of a biomechanical pathology. We can treat the cause by orthoses etc. but it could still leave the patient in pain. The patient frequently then goes on a ‘treatment quest’ going from practitioner to practitioner often with greater and greater desperation as they move from traditional to less traditional to sometimes eventually frankly wacky ‘snake oil’ treatments

Treatments include: Steroids - which cause tissue atrophy and immune system depression, thus delaying healing 2.

Non-Steroidal Anti Inflammatory Drugs (NSAID’s) – a major study identified that of individuals over 60 years of age using oral steroids for more than 2 months; 1 in 5 will 2

Safe Alternative Hyaluronic acid was first isolated in 1934 by Karl Meyer, from the vitreous fluid of a bovine eye. When in the body, it is referred to as Hyaluronan (also known as Hyaluronic Acid or HA), and takes its name in part from its main location in the body, the hyaline cartilage.

Hyaluronan exists naturally in all living organisms (except plants) and is a universal component of the extra cellular space. HA can be found in a number of body tissues including skin, the ocular vitreous body, articular cartilage (as a structural component) and synovial fluid (where it acts as a lubricant, shock absorber, metabolic medium and filter).

In the case of a dysfunctional synovial joint, such as the knee, which may have mild to moderate osteoarthritis or cartilage damage, then the normal level or concentration of HA in the synovium may be deficient. In such a case it may be beneficial to augment this deficit by introducing HA by way of a sterile injection into the joint.

Where such injections give an improvement of symptoms, then such improvement will usually be temporary but can last for several months and is almost invariably welcomed by the patient, who can then have further injections if appropriate.

A Cochrane review concluded that such viscosupplements were comparable in efficacy to systemic treatments but with more local reactions and fewer systemic adverse events.

They were longer lasting in their beneficial effects (up to 26 weeks) compared to intra-articular steroids (although slower in onset of effect). Most became effective between 5 and 13 weeks after injection. 5

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Administrative Techniques Care is needed with Intra Articular (IA) injections so as not to introduce pathogens into the joint capsule; therefore sterile techniques and sterile single-use consumables must be used.

5. Attempt to aspirate the joint if possible to a) remove excess joint fluid (effusion) that may be present – sometimes termed ‘water on the knee’ b) allow visual, or if indicated, laboratory, examination of the aspirated fluid.

1. Position the patient comfortably with knee bent

It should be noted that aspiration is not always possible. In such a case if effusion is not excessive then intra articular injection of viscosupplement may still be of value.

Aspirated fluid may visually show traces of blood (haemarthrosis) or cloudy discoloration termed purulence (gout/infection), if so investigate further/refer.

2. Palpate and mark the entry portal 3. Cleanse entry area to a standard analogous to an invasive surgical procedure

6. If aspirate is clear then slow injection can be performed.

Leave needle in place, carefully and rapidly change syringe.

Once injection is completed, withdraw needle and keep digital pressure on the needle cannulation until bleeding has ceased, then cover the site with a sterile pad.

4. For pain control administer fast acting Local Anaesthetic (LA) to joint entry portal area to numb the skin and longer duration but slower acting LA into the joint to give extended pain relief over several hours.

Modest use and mobilisation of the joint without excessive loading can begin immediately.

•

If inflammation or infection develops then treat as appropriate.

•

Fast: Lidocaine 1 - 2% plain or Mepivacaine 2% plain for skin Slow: Marcaine 0.5% plain

Review the patient as required.

References

1 Peat.G., Ann Rheum Dis 2001; 60:91-97 doi: a0.1136/ard.60.2.91 2 Lehmann, P et al., Corticosteroid Atrophy in Human Skin. A study by light, scanning and transmission electron microscopy. Journal of Investigative Dermatology (1983) 81, 169-176; doi:10.1111/1523-1747.ep12543603 3 Tramer et al. Pain 2000;85;169-182 4 Una E., et al, Adverse Effects of Topical Nonsteroidal Antiinflammatory Drugs in Older Adults with Osteoarthritis: A Systematic Literature Review. The Journal of ~Rheumatology vol 37 no 6 April 2010.

5 Bellamy N, Campbell J, Robinson V, et al; Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006 Apr 19; (2): CD005321

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Runners in safe hands?

Daniel Blackman, BSc(Hons), PodM, SRCh, Mchs Runners, as a breed, are an odd bunch of folk, spending hours a day pounding through all weathers in pursuit of a personal best time, being driven by the only champion no one has ever beaten - the clock. No time is ever fast enough and no running style is ever good enough. However if you look at the research and commentary by physicians who deal with sports injuries unfortunately that day will come.

Dr James Garrick, Director of the Centre for Sports Medicine at St. Francis Hospital in San Francisco says that by far the most common sport that leads to injury is running. "Running jars the body from the foot all the way up into the back."

In the article I drew this comment from, he goes on to say that he has seen more runners than any other recreational athletes in his clinic. So who do the running community go to for help? Well the obvious are physiotherapists and sports massage therapists but do they come to us and do we as podiatrists, have a role in the rehabilitation / injury prevention arena or are we as a profession destined to be forever the Cinderella of the sports medicine world ?

As podiatrists it is at our very professional core to understand the mechanical function of the foot and therefore by association the movement seen in the leg and knee. As foot specialists we must have a sound understanding of footwear, its construction and the effects that has on running style and the shoe foot interaction and while in this article there is not the time or space to give a biomechanic refresher ( something we can all benefit from ) I want to give some time to the thorny issue of trainers and their impact on the biomechanics of running. I am asked when discussing injury prevention with patients what type of trainer should I buy?

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And how do I know what I should look for in a good trainer? We are now confronted with trainers having gel heels, mid foot control, stability or motion control zones and made on straight, racing or standard lasts.

As a clinician I am forced to understand relative shore values and material properties of rubbers and plastics that were never covered in any text book I was asked to read.

However some important fact to remember when giving out advice; if you plan to issue orthotics in your patient’s running shoes then you need to advise them to buy neutral trainers, that is, trainers without any medial control. The easiest way to spot control in trainers is to look on the inside of the trainer for a dark grey patch or markings indicating a higher density EVA, this will have the effect of giving increased medial control.

If a patient is very mobile then a stiff midsole trainer is useful in promoting good foot position. An easy way to check is to bend the trainer in half and check its flex point.

Finally get your runners to check the heel counter. On some makes the counter (the piece of material from the sole up to the TA) can be curved and pinched, this can be a major problem for those who suffer from Achilles tendonitis.

Director of Clinical Services Biomechanics Consultant RSscan Lab Ltd 14 Pegasus, Orion Avenue Addison Way, Great Blakenham Ipswich IP6 0LW Tel: 0845 118 0020 Web: www.rsscan.co.uk

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Personal Profile Beverley Wright FHEA, PGDip, PGCE, PGCert, BSc(Hons), M.Inst.Ch.P, MGICM, BSc, Pod.Med Life is a journey and a voyage of self discovery but I, like so many people, grew up with no idea of what I wanted to do with my life. I toyed with the idea of being a nurse, teacher or doctor, as you do in child’s play, but I do remember as a teenager wanting to become a jockey! However, the thought of being on a diet for the rest of my life (especially as I love food) was not appealing; despite my love and passion for horses, and both my father and grandfather having been amateur jockeys.

Born and raised in Essex, I grew up in a very close, happy family environment. Although, in the 1970’s my parents, disillusioned with the British economy, sold up and prepared to emigrate to Australia. At the eleventh hour, caught up in the emotional turmoil of leaving friends and family behind – we never left England.

I have indulged a good part of my working life and leisurely pursuits training and riding, even owning a few horses; in spite of having had a terrible riding accident just before my 13th birthday that resulted in missing half a year off school.

Although, I never thought of myself as very scholarly, just your typical, average student who had regular comments of ‘could try harder’ put on their school reports. I did by some miracle manage to get some CSE’s, GCE ‘O’ levels, (GCSE’s), go to college and get ‘A’ levels.

With each passing decade I have gone through a dramatic evolution. In the early 1980’s I won a scholarship and went to live and study in Shropshire, before going to America with the British Universities North America Club (BUNAC). This was a chance of a lifetime to spend a few months in a place I had always dreamed of going, meet new friends and be paid to do so. I did this for two years and met my future husband in the process. In my mid twenties I got married in Orlando, Florida - in a hot air balloon would you believe?

I lived in Florida for the next two years in supposed marital bliss, but sadly, it did not last and we were soon divorced. I did not return to England straightaway, but stayed and travelled around America doing a variety of jobs. In fact being a qualified scuba diver (BSAC and PADI) and an accomplished horsewoman/ instructor kept me employed. I have never been afraid of any type of hard work, so it was no surprise that I ended up riding in the dinner show, Arabian Nights in Kissimmee, Florida.

I became one of only a handful of women (and even fewer British women) to attain and hold a United States Trotting Association (USTA) Standard-bred racehorse trainers and drivers licence. I am also a licensed USTA Charterer and Clerk of the Course for parimutual racetracks and fairs.

I passed my chauffeurs licence, which enabled me to drive big (HGV equivalent) trucks. Furthermore, I got paid to act doing Shakespeare in the Park, TV commercials and entertainment programmes in the US and some amateur theatre too. I was even a background artist in films, and one in which I did appear with my daughter Serena was Cromwell Productions King Lear, directed by and starring Brian Blessed.

I attended the University of Kentucky and entered the world of nursing for a few years, before dramatic events finally brought me back home to England in1995, with my new baby Serena. My homecoming culminated in a return to work to support my daughter; but not back to nursing. I wanted to remain working in healthcare, so I decided to become a Podiatrist. But it did not end there! I carried on studying at various colleges/ universities and achieved further degrees in health and education.

Now in the new Millennium, I continue to lovingly raise my now teenage daughter Serena as a single parent, run a small Podiatry practice, and work very long hours as a University Lecturer at Anglia Ruskin University. In addition, I am the elected Chairperson of the Southern Area Council (SAC), Essex Branch Secretary, a tutor for the Institute of Chiropodists and Podiatrists of which I am a member; and I have recently been co-opted onto the Faculty of Education as an academic adviser. And if that was not enough! I am currently doing research on medical and healthcare education, and still studying!!

I am always trying to improve myself, as they say knowledge is power; well it has certainly opened a few doors for me along the way, and I think it has set a good example for my own daughter to follow. Of course this does mean I do not get much time to relax or enjoy any of my hobbies, such as horse riding, foil and epee fencing at my local fencing club; or even more importantly going to visit my beloved Nish.

On a final note from someone, who as a little girl, had no clue of what to do in the future, I have certainly packed in a lifetimes worth of career opportunities, study, work and above all a lot of fun. I have been a nurse and a teacher to name a few; and on becoming a doctor!? Well, I suppose that will happen one day, once I complete my PhD!!!

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Guillain-Barré Syndrome K B Whitaker Abstract: Patient A is a recovering alcoholic in his early forties, married with a family. Has had surgery and chemotherapy for cancer of the throat. Podiatric conditions: severe plantar callosites on both feet on the first and fifth metatarsal heads due to congenital pes cavus and helomas associated with concurrent digital retractions. He has very thin ankles, walks with an ataxic gait and wears specially made orthopaedic shoes (prescribed by his podiatrist).

Patient A presented to podiatrist complaining about progressive weakness and numbness in both legs and arms and was finding walking more and more difficult. Podiatrist recognised that this was not simply peripheral nerve damage from previous alcoholism and immediately referred Patient A to his GP who arranged for investigative tests to be done at hospital where Patient A was diagnosed with Gullain-Barré syndrome. Thankfully, due to early intervention he made a complete recovery.

Guillain-Barré (pronounced Ghee-lan Bar-ray) is named after two French doctors who first described the condition in 1916, Georges Charles Guillain and Jean-Alexander Barré. It is a rare but serious condition of the peripheral nervous system affecting about 1,500 people in the UK every year. It is slightly more common in men than women but can affect people of any age, including children.

The peripheral nervous system is the network of nerves that control the body's senses and movements. GuillainBarré syndrome is a disorder in which the body's immune system attacks part of the peripheral nervous system. The first symptoms of this disorder include varying degrees of weakness or tingling sensations in the legs. In many instances the weakness and abnormal sensations spread to the arms and upper body. These symptoms can increase in intensity until certain muscles cannot be used at all and, when severe, the person is almost totally paralyzed. In these cases the disorder is life threatening - potentially interfering with breathing and, at times, with blood pressure or heart rate - and is considered a medical emergency. Such an individual is often put on a ventilator to assist with breathing and is watched closely for problems such as an abnormal heart beat, infections, blood clots, and high or low blood pressure. Most individuals, however, recover from even the most severe cases of Guillain-Barré syndrome, although some continue to have a certain degree of weakness.

The exact cause of Guillain-Barré syndrome is unclear.

There is no way of identifying who is most at risk.

However, in most cases of Guillain-Barré syndrome, the person affected had a viral or bacterial infection a few weeks before getting the condition. What scientists do know is that the body's immune system begins to attack the body itself, causing what is known as an autoimmune disease. Usually the cells of the immune system attack only foreign material and invading organisms. In Guillain-Barré syndrome, however, the immune system starts to destroy the myelin sheath that surrounds the axons (the long, thin extensions of the nerve cells which carry nerve signals) of 6

many peripheral nerves, or even the axons themselves. The myelin sheath surrounding the axon speeds up the transmission of nerve signals and allows the transmission of signals over long distances.

In diseases in which the peripheral nerves' myelin sheaths are injured or degraded, the nerves cannot transmit signals efficiently. That is why the muscles begin to lose their ability to respond to the brain's commands, commands that must be carried through the nerve network. The brain also receives fewer sensory signals from the rest of the body, resulting in an inability to feel textures, heat, pain, and other sensations. Alternately, the brain may receive inappropriate signals that result in tingling, "crawling-skin," or painful sensations. Because the signals to and from the arms and legs must travel the longest distances they are most vulnerable to interruption. Therefore, muscle weakness and tingling sensations usually first appear in the hands and feet and progress upwards.

When Guillain-Barré is preceded by a viral or bacterial infection, it is possible that the virus has changed the nature of cells in the nervous system so that the immune system treats them as foreign cells. It is also possible that the virus makes the immune system itself less discriminating about what cells it recognizes as its own, allowing some of the immune cells, such as certain kinds of lymphocytes and macrophages, to attack the myelin. Sensitized T lymphocytes cooperate with B lymphocytes to produce antibodies against components of the myelin sheath and may contribute to destruction of the myelin. In two forms of GBS, axons are attacked by antibodies against the bacteria Campylobacter jejuni, which react with proteins of the peripheral nerves.

Guillain-Barré is called a syndrome rather than a disease because it is not clear that a specific disease-causing agent is involved. A syndrome is a medical condition characterized by a collection of symptoms (what the patient feels) and signs (what a doctor can observe or measure).

The signs and symptoms of the syndrome can be quite varied, so doctors may, on rare occasions, find it difficult

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to diagnose Guillain-Barré in its earliest stages.

Several disorders have symptoms similar to those found in Guillain-Barré, so doctors examine and question patients carefully before making a diagnosis. Collectively, the signs and symptoms form a certain pattern that helps doctors differentiate Guillain-Barré from other disorders. For example, physicians will note whether the symptoms appear on both sides of the body (most common in GuillainBarré) and the quickness with which the symptoms appear (in other disorders, muscle weakness may progress over months rather than days or weeks). In Guillain-Barré, reflexes such as knee jerks are usually lost. Because the signals travelling along the nerve are slower, a nerve conduction velocity (NCV) test can give a doctor clues to aid the diagnosis. In Guillain-Barré patients, the cerebrospinal fluid that bathes the spinal cord and brain contains more protein than usual. Therefore a physician may decide to perform a spinal tap, a procedure in which a needle is inserted into the patient's lower back and a small amount of cerebrospinal fluid from the spinal column is withdrawn for study.

There is no known cure for Guillain-Barré syndrome.

However, there are therapies that lessen the severity of the illness and accelerate the recovery in most patients. There are also a number of ways to treat the complications of the disease.

Currently, plasma exchange (also called plasmapheresis) and high-dose immunoglobulin therapy are used. Both of them are equally effective, but immunoglobulin is easier to administer. Plasma exchange is a method by which whole blood is removed from the body and processed so that the red and white blood cells are separated from the plasma, or liquid portion of the blood. The blood cells are then returned to the patient without the plasma, which the body quickly replaces. Scientists still don't know exactly why plasma exchange works, but the technique seems to reduce the severity and duration of the Guillain-Barré episode. This may be because plasmapheresis can remove antibodies and other immune cell-derived factors that could contribute to nerve damage.

In high-dose immunoglobulin therapy, doctors give intravenous injections of the proteins that, in small quantities, the immune system uses naturally to attack invading organisms. Investigators have found that giving high doses of these immunoglobulins, derived from a pool of thousands of normal donors, to Guillain-Barré patients can lessen the immune attack on the nervous system.

Investigators don't know why or how this works, although several hypotheses have been proposed.

The use of steroid hormones has also been tried as a way to reduce the severity of Guillain-Barré, but controlled clinical trials have demonstrated that this treatment not only is not effective but may even have a deleterious effect on the disease.

The most critical part of the treatment for this syndrome consists of keeping the patient's body functioning during recovery of the nervous system. This can sometimes require placing the patient on mechanical ventilatory assistance, a

heart monitor, or other machines that assist body function.

The need for this sophisticated machinery is one reason why Guillain-Barré syndrome patients are usually treated in hospitals, often in an intensive care ward. In the hospital, doctors can also look for and treat the many problems that can afflict any paralyzed patient - complications such as pneumonia or bed sores.

Often, even before recovery begins, caregivers may be instructed to manually move the patient's limbs to help keep the muscles flexible and strong and to prevent venous sludging (the buildup of red blood cells in veins, which could lead to reduced blood flow) in the limbs which could result in deep vein thrombosis. Later, as the patient begins to recover limb control, physical therapy begins. Carefully planned clinical trials of new and experimental therapies are the key to improving the treatment of patients with Guillain-Barré syndrome. Such clinical trials begin with the research of basic and clinical scientists who, working with clinicians, identify new approaches to treating patients with the disease.

Guillain-Barré syndrome can be a devastating disorder because of its sudden and unexpected onset. In addition, recovery is not necessarily quick. As noted above, patients usually reach the point of greatest weakness or paralysis days or weeks after the first symptoms occur. Symptoms then stabilize at this level for a period of days, weeks, or, sometimes, months. The recovery period may be as little as a few weeks or as long as a few years. About 30 percent of those with Guillain-Barré still have a residual weakness after 3 years. About 3 percent may suffer a relapse of muscle weakness and tingling sensations many years after the initial attack.

Guillain-Barré syndrome patients face not only physical difficulties, but emotionally painful periods as well. It is often extremely difficult for patients to adjust to sudden paralysis and dependence on others for help with routine daily activities. Patients sometimes need psychological counselling to help them adapt.

Scientists are concentrating on finding new treatments and refining existing ones. Scientists are also looking at the workings of the immune system to find which cells are responsible for beginning and carrying out the attack on the nervous system. The fact that so many cases of GuillainBarré begin after a viral or bacterial infection suggests that certain characteristics of some viruses and bacteria may activate the immune system inappropriately. Investigators are searching for those characteristics. Certain proteins or peptides in viruses and bacteria may be the same as those found in myelin, and the generation of antibodies to neutralize the invading viruses or bacteria could trigger the attack on the myelin sheath. As noted previously, neurological scientists, immunologists, virologists, and pharmacologists are all working collaboratively to learn how to prevent this disorder and to make better therapies available when it strikes.

Grateful thanks in composing this article go to the National Institute of Neurological Disorders and Stroke (NINDS). Further information www.ninds.nih.gov 7

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Do you want to write for our new Podiatry Review?

Articles - Branch News Human Interest Stories Product Information - Anecdotes All will be considered

Don’t forget!

Writing articles counts towards your CPD portfolio Please email where possible to bernie@iocp.org.uk or send to Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Please note Podiatry Review copy date is the 1st of the preceding month prior to publication e.g. for the September/October issue copy date is 1st August

Congratulations to the following members who have gained BSc (Hons) at New College Durham. The ceremony was followed by a fabulous champagne reception.

L-R Marguerite Hayes, Tony Eaton and Debra Straw

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L-R Debra Straw, Marguerite Hayes, Catherine Saul, Antony Eaton, Valerie Dannourah, Philip Downs

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CPD and Life Long Learning Greg Quinn FCPodS A few years ago, prior to the latest round of NHS reforms, a ‘Skills for Health’ consultation took place in Northampton. Delegates from healthcare organisations across the East Midlands voted to identify which issues were of most importance to them in relation to health workforce skills. An overwhelming majority (97%) felt that obtaining high-level commitment and investment in skills transformation was ‘important’ or ‘very important’. This probably resonates with what you believe.

Unfortunately many of us just don't have the time to look after our own training needs – perhaps too busy looking after the needs of the staff and patients, liaising with GPs and dealing with the 101 other things that cross our desks every day.

But you do have to think of your own needs. Just read the Dearing Report, Higher Education in the Learning Society Report of the National Committee of Inquiry into Higher Education. This recommends embracing lifelong learning to keep up-to-date with the current and future pace of change. This process of updating throughout life should be seen as a reinvestment by our nation in its people and is generally regarded as the basis of Continuing Professional Development (CPD).

The NHS positively encourages its entire workforce to follow a CPD programme. Under Agenda for Change staff set development targets each year and pass through pay "gateways" – in each banding.

This is, of course, less easy to achieve in private practice. However, it is essential that employers recognise and support the value of properly managed CPD schemes to attract, motivate and retain a workforce of the highest possible calibre... and that includes you - in a commitment to life long learning.

Clearly, attendance at conferences or training days usually implies costs directly or indirectly. But what is that cost if an employee or colleague is not as competent and up-to-date in their skills as possible? Employers should ensure employees are trained to carry out activities competently and these days, perhaps professional competence and accountability are more relevant than ever.

Very few professionals will find the pace of change has not affected them in the past decade or so. As professionals we must rely increasingly on our ability to respond rapidly to many factors, not least of which is a change in government policy. This is especially true of the NHS but perhaps now more so to the independent practitioner following the ‘Any Qualified Provider’ status being available for NHS podiatry services.

Across all disciplines, everyone is being asked to embrace and respond to change and become innovative in their working practices.

This means learning new skills and is not an option to be undertaken only by those already keen to update their skills; it must be embraced wholeheartedly by all. Personal development is the key to success for individuals and organisations.

It is no longer acceptable to be complacent about one's job. In the

past there was a culture of "a job for life" – but no more. We now have a portfolio of careers and multiple employers. Careers were once planned by employers, now employees are encouraged to plan their own. Training was seen as a one-off event to learn the job. Now we see lifelong learning and the development of transferable skills.

This concept does not only apply to updating your clinical skills of course. Could your knowledge of contracts be improved to increase your practice size? Do you run case management discussions or could you organise these with colleagues? What service developments are you planning for your practice? Do you spend too much time focusing on palliative care instead of timetabling a ‘special’ clinic? Do you liaise appropriately with other health care professionals? How many clinical audits do you carry out? Do you fully understand your practices finances and how you can maximise your profitability?

All these elements are part of your CPD. Embrace the challenge and you have an opportunity to see change in healthcare as a professional opportunity. Ignore it and you are likely to see it as a threat that spoils your enjoyment of a worthwhile and enjoyable career.

Greg Quinn is a Podiatric Surgeon, Educator and Business Management Consultant.

For enquiries or further information visit www.gregquinn.co.uk or e-mail gregquinn.podsurgeon@gmail .com

Greg Quinn Consulting www.gregquinn.co.uk New Independent Practical & Relevant Educational Workshops Venues: Kenwood Park Clinic, 28 Kenwood Park Rd, Sheffield, S7 1NF and Circle Clinic, Alcester Road, Stratford-upon-Avon, CV37 6PP Workshop & Dates: Module 1 – Treatment of the Rheumatoid Foot 10-12pm Saturday 8th October 2011 – Kenwood Park, Sheffield 10-12pm Saturday 29th October 2011 – Circle Clinic, Stratford-upon-Avon Module 2 – An Introduction to Biomechanical Foot Assessment 10-12pm Saturday 5th November 2011 – Kenwood Park, Sheffield 10 -12pm Saturday 26th November 2011 – Circle Clinic, Stratford-upon-Avon Module 3 – When to consider surgical referral for foot problems 10-12pm Saturday 3rd December 2011 – Kenwood Park, Sheffield 10-12pm Saturday 14th January 2012 – Circle Clinic, Stratford-upon-Avon Module 4 – Diabetic Foot Assessment 10-12pm Saturday 7th January 2012 – Kenwood Park, Sheffield 10-12pm Saturday 11th February 2012 – Circle Clinic, Stratford-upon-Avon Cost: £25 (inc VAT) per module or £90 if all four modules are booked.

Limited number of places.

To reserve a place: Email gregquinn.podsurgeon@gmail.com or call 07879 991971

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21st September World Alzheimer's Day

Faces of dementia

The theme for World Alzheimer's Day™ 2011 is 'Faces of dementia' In our materials and activities ADI and Alzheimer associations across the world will focus on the many issues surrounding the 'Faces of dementia'. They will be asking if you recognise the face of dementia while paying tribute to those who represent the 'Faces of dementia' in all parts of the world and working tirelessly to promote increased support and care for people with dementia and their carers.

Every year on 21 September Alzheimer associations across the globe unite to recognise World Alzheimer's Day and 2011 will be no exception with events taking place internationally. We are confident that the large numbers of people involved and the media coverage these events will gain can make a real difference for people with dementia, their families and carers worldwide.http://www.alz.co.uk/world-alzheimers-day

What is Alzheimer's disease?

Alzheimer's disease is the most common cause of dementia, affecting around 465,000 people in the UK. The term 'dementia' describes a set of symptoms which can include loss of memory, mood changes, and problems with communication and reasoning. These symptoms occur when the brain is damaged by certain diseases and conditions, including Alzheimer's disease. This factsheet outlines the symptoms and risk factors for Alzheimer's disease, and describes what treatments are currently available.

Alzheimer's disease, first described by the German neurologist Alois Alzheimer, is a physical disease affecting the brain. During the course of the disease, protein 'plaques' and 'tangles' develop in the structure of the brain, leading to the death of brain cells. People with Alzheimer's also have a shortage of some important chemicals in their brain. These chemicals are involved with the transmission of messages within the brain.

the right words. As the disease progresses, they may: • become confused and frequently forget the names of people, places, appointments and recent events • experience mood swings, feel sad or angry, or scared and frustrated by their increasing memory loss • become more withdrawn, due either to a loss of confidence or to communication problems • have difficulty carrying out everyday activities they may get muddled checking their change at the shops or become unsure how to work the TV remote.

In the later stages of dementia, loss of memory will be severe. People with dementia may not recognise close family members, familiar objects or environments. They may become very anxious and frustrated because of their lack of orientation and inability to communicate verbally.

Alzheimer's is a progressive disease, which means that gradually, over time, more parts of the brain are damaged.

As this happens, the symptoms become more severe.

While there are some common symptoms of Alzheimer's disease, it is important to remember that everyone is unique. No two people are likely to experience Alzheimer's disease in the same way.

People in the early stages of Alzheimer's disease may experience lapses of memory and have problems finding

Recently, some doctors have begun to use the term

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mild cognitive impairment (MCI) when an individual has difficulty remembering things or thinking clearly but the symptoms are not severe enough to warrant a diagnosis of Alzheimer's disease. Recent research has shown that individuals with MCI have an increased risk of developing Alzheimer's disease. However, the conversion rate from MCI to Alzheimer's is low (about 10-20 per cent each year), and consequently a diagnosis of MCI does not always mean that the person will go on to develop Alzheimer's.

So far, no one single factor has been identified as a cause for Alzheimer's disease. It is likely that a combination of factors, including age, genetic inheritance, environmental factors, lifestyle and overall general health, are responsible. In some people, the disease may develop silently for many years before symptoms appear.

Age is the greatest risk factor for dementia. Dementia affects one in 14 people over the age of 65 and one in six over the age of 80. However, dementia is not restricted to older people: in the UK, there are over 16,000 people under the age of 65 with dementia, although this figure is likely to be an underestimate.

Many people fear that they may inherit Alzheimer's disease and scientists are currently investigating the genetic background to Alzheimer's. It is known that there are a few families where there is a very clear inheritance of the disease from one generation to the next. This is often in families where the disease appears relatively early in life.

In the vast majority of cases, however, the influence of inherited genes for Alzheimer's disease in older people seems to be small. If a parent or other relative has Alzheimer's, your own chances of developing the disease are only a little higher than if there were no cases of Alzheimer's in the immediate family.

The environmental factors that may contribute to the onset of Alzheimer's disease have yet to be identified. A few years ago, there were concerns that exposure to aluminium might cause Alzheimer's disease. However, these fears have largely been discounted.

Because of the difference in their chromosomal makeup, people with Down's syndrome who live into their 50s and 60s are at particular risk of developing Alzheimer's disease.

People who have had severe head or whiplash injuries also appear to be at increased risk of developing dementia. Boxers who receive continual blows to the head are at risk too.

Research has also shown that people who smoke, and

those who have high blood pressure, high cholesterol levels or diabetes, are at increased risk of developing Alzheimer's.

There is no straightforward test for Alzheimer's disease or for any other cause of dementia. A diagnosis is usually made by excluding other causes which present similar symptoms. The GP will need to rule out conditions such as infections, vitamin deficiency, thyroid problems, depression and the side-effects of medication. An early diagnosis will have a number of benefits including the opportunity to plan for the future and access treatment, advice and support.

There is currently no cure for Alzheimer's disease.

However, drug treatments are available that can temporarily alleviate some symptoms or slow down their progression in some people.

People with Alzheimer's have been shown to have a shortage of the chemical acetylcholine in their brains. The drugs Aricept, Exelon and Reminyl (trade names for the drugs donepezil hydrochloride, rivastigmine and galantamine) work by maintaining existing supplies of acetylcholine. As of March 2011, these drugs are recommended as an option for people in the mild-tomoderate stages of Alzheimer's disease. Please refer to the National Institute for Health and Clinical Excellence (NICE) website for guidance (see Useful organisations at the end of this factsheet). Side-effects are usually minor but may include diarrhoea, nausea, insomnia, fatigue and loss of appetite.

A drug called Ebixa (trade name for the drug memantine) was launched in the UK in 2002. Ebixa works in a different way from the other three and is the only drug that is recommended for people in both the moderate and severe stages of Alzheimer's disease. Sideeffects may include dizziness, headaches and tiredness, and - rarely - hallucinations or confusion.

These drugs are not a cure, but they may stabilise some of the symptoms of Alzheimer's disease for a limited period, typically 6-12 months or longer.

Much can be done at a practical level to ensure that people with Alzheimer's live as independently as possible for as long as possible.

Further information Alzheimers Society Devon House 58 St Katharine's Way London E1W 1LB Tel: +44 (0) 20 7423 3500 mailto:enquiries@alzheimers.org.uk www.alzheimers.org.uk/ 11

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Next year the Institute will be breaking with yearrs of tradition by holding the 2012 Conference and Trade Exhibition in a very prestigious Conference annd Exhibition Centre in Southport.

The centre is in an excellent position right on the water front and the fabulous Ramada hotel is next door. The town centre is only a few minutes walk from the venue and there is a good communication network to Southport from all parts of the country. Liverpool and Manchester Airports are within easy access. There is also ample parking at the venue.

This year we will be pushing the boundaries on education, there will be three lectures, and all by eminent speakers who will not only educate but also amuse you with their talks. We will also be running four workshops throughout the conference with a wide variation that I am sure will be of great interest to all those who attend. These will include, use and demonstration of Hyfractors for the treatment of troublesome skin lesions, advanced padding and strapping workshop, which you will be able to apply straight away on return to your practice and a demonstration on the practical application of nail surgery and use of local anaesthesias. As numbers will be limited to these events it will be advisable to book them as soon as possible.

This year we have contacted many new trade houses so that there will be new products for you to look at and try, there will be many familiar faces in addition to many new ones, and will include such things as ffiinancial services advisers and Work wear suppliers, to name but a few.

If you should not be lucky enough to be your branch delegate then there will still be the opportunity for you to attend as a day delegate, and for a small charge you will be able to attend any CPD event that you wish and lunch will also be provided as will all certificates of attendance.

At the dinner dance next year we will be entertained by a 17 piece swing band, so make sure you bring comfy shoes as dancing will be a must. We have also negotiated exceptional rates at the Ramada Hotel for any day delegate who wants to stay overnight, or alternatively there is a Premier Inn hotel two minutes walk from the centre.

The conference will be open to any Foot Health practitioner, Chiropodist, or Podiatrist from any organisation and all will be made very welcome.

So makke a note on your calendar for next yearr and make sure you keep the 27th 28th annd the 29th of April clearr and come annd join us for w whhat will prove to be a wonderful weekend in Southport.

Further Information telephone 01704 546141 Email: secretary@iocp.org.uk

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Peer Review Section

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

I

t is the purpose of peer review to put the findings, thoughts and research of different authors and researchers before members of the profession, in order to discuss and assess and support or challenge their effectiveness. You, the readers of this section, are also the peers of the work you are reading.

It is the purpose of a peer-review section to inspire review and debate, to challenge and accept information or rebut it. Debates sometimes can become quite heated which is good as it helps to feed new research which in turn can develop new practice. On occasion a published article may present information that is challenged. This challenge, when well supported by evidence, is the very fuel of practice and development. All ideas are valuable when they can be backed up and supported by acceptable evidence. In the last issue of the Podiatry Review I published an article by Prof. Brian Rothbart entitled Primus Metatarsus Supinatus (Rothbart’s Foot) A common Cause of Musculoskeletal pain - Biomechanical vs Neurophysiological Model. This article received a number of comments. One of our readers feels so strongly about the article that he wished to write a rebutal of it. I, as editor of this section mut be unbiased in relation to the articles we publish. If an article is well supported by evidence and passes our review panel I publish it. This is not to say that the article published is correct or incorrect, it merely presents the point of view of the author or authors concerned. It is not for me to say that one article is good whilst another is not good. I supply the information and you, the reader decides. That is peer review in action.

Below is Mr. Robert Isaacs response to the above mentioned article. I welcome your comments.

“Dear Editor Biomechanics has made many advances over the last 40 years. Several visionaries have produced excellent models, published well researched and scientifically valid concepts and done good research in the area.

Unfortunately there have also been some models

published which fare less well when exposed to close scrutiny. Brian Rothbart recently published an article on such a model in this very journal. (1) Whilst one hesitates to be critical of anyone seeking to add to the sum of human knowledge, his article contained some things which appear to be misleading, and represents a lot of pure conjecture as scientific discovery.

“Rothbart’s foot” The foundation of this model is the concept of the Primus Metatarsus Supinatus (PMS) foot type, or as it is described in the article, Rothbart’s foot.

I will describe it as PMS. So what is PMS? The definitive test for the PMS is that the forefoot is off the ground (inverted) when the rearfoot is in neutral. If this sounds familiar, it is because it is. Back when Root published, (2-3) a forefoot which was inverted relative to the rearfoot was called a forefoot varus. The test of observing the position of the forefoot when the rearfoot is held in neutral can be found in several textbooks from decades back (2-3-4-5) So is it then the cause of this forefoot inversion which is unique to the “PMS” type? Sadly not. Rothbart, in the article, describes the deformity as being caused by torsion in the talus. One of the best known biomechanics textbooks in print (4) describes Forefoot varus as “an inverted position of the forefoot relative to the rearfoot.... due to inadequate frontal plane torsion of the head and neck of the Talus” So, to recap, Forefoot Varus is a condition described four decades ago in which the torsion of the talus causes the forefoot to be inverted when the rearfoot is in neutral (2-3-4-5). Whereas “Rothbart’s foot” is a condition in which the torsion of the talus causes the forefoot to be inverted when the rearfoot is in neutral.

Professor Rothbart goes on to describe the consequences of this foot type “PMS Forces the weight bearing foot to roll inward, 15

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forward and downward until the first metatarsal rests on the ground” (1) So when the forefoot is inverted relative to the rearfoot, the foot must pronate for the forefoot to rest flat on the ground. Once again a reader is gripped by a strong sense of déjà vu. This sounds a great deal like what Root described as a compensated forefoot varus.(2). Valmassy again summarises well, stating that:“Calcaneal eversion is required to.... allow the forefoot to purchase the supporting surface” (4) Rothbart describes the exact same sequellae to his foot type as Root and Valmassy do to forefoot varus. (3-4).

From there the article moves on to a discussion of the treatment for this foot type. Specifically, it discusses the effects of “Postural Control Insoles” (PCI’s). For anyone unfamiliar with these devices, it is essentially a flat insole with a medial wedge running under the 1st ray from mid arch to the end of the shoe. These, we are asked to believe, instantly caused the change in posture of the child in the article (1). The story is reported On Prof Rothbart’s website.

The following statements have been made by Rothbart:“A non distorted posture maintains correct alignment and healthy cartilage within weight bearing joints, so they remain healthy, mobile and pain free” Really? So provided the posture is not distorted all the weight bearing joints will last forever? Posture is the ONLY cause of joint pathology?!

“This (PMS) results in a Kyphotic posture”. Has a study been carried out to test for correlation between these two situations? And if a correlation existed could we prove that the PMS caused the Kyphosis rather than a common factor causing both? No. A statement like this, unsupported, has no more validity than if I were to say that Bunions cause hair loss!

And my personal favorite “People with non twisting feet usually have naturally good posture, less joint and muscle pain and fewer visceral problems than people with the PMS foot structure” One simply cannot make claims like this without any kind of investigative science to back them. I could as well say that blond people are less likely to contract influenza.

Without any proof it is pure supposition, as are the proposed benefits of Postural Control Insoles TM, Professor Rothbart advocates to treat “twisting feet”.

The process of scientific discovery can be a difficult one. Readers must examine the evidence before them and 16

make their own decisions. But I feel this particular article should be read with considerable care. Two pertinent sayings apply “Extraordinary claims demand extraordinary proof” and “that which is asserted without evidence can be dismissed without evidence”. Isaacs states that the similarity between the rather well recognized condition of forefoot varus (inversion of the forefoot when the rearfoot is in neutral, caused by talar torsion) and “Rothbarts Foot” (inversion of the forefoot when the rearfoot is in neutral, caused by talar torsion) seems to him rather too strong to call the latter an “unreported foot type”.

References 1. Rothbart B.A. Primus metatarsus Supinatus (Rothbarts Foot): A common cause of musculoskeletal pain – Biomechanical vs Neurophysiological Podiatry Review. Vol 68 No.4 - July/August 2011 2. Root, M.L., Orien, W.P., Weed, J.H., & Hughes, R.J. (1971).

Biomechanical examination of the foot. (Vol.1). Los Angeles: Clinical Biomechanics.

3. Root ML, Orien WP, & Weed JH. Normal & abnormal function of the foot. (19770 Clinical Biomechanics Corporation, Los Angeles: Clinical Biomechanics 4. Valmassy R: Pathomechanics of lower extremity function.

Clinical Biomechanics of the Lower Extremity. Mosby Yearbook; 59-84, 1995 5. S. Langer and J. Wernick. A practical manual for a basic approach to foot biomechanics. 3rd ed., Langer Biomechanics Group (U.K.) Ltd. (1989) 6. http://www.rothbartsite.com/Patient_Testimonials.html Accessed on 27/7/11 7. http://www.rothbartsite.com/Additional_Benefits.html Accessed on 27/7/11 8. http://rothbartsfoot.info/ Accessed on 27/7/11

Yours sincerely Robert Issacs Bsc(Hons)MChS Cert. KCHyp” In this month’s peer-review section is an article by Mr. Bill Liggins. This article has not been peer reviewed. I would like you, the readership, to actually review the article as you are his peers. All you have to do is, read what Mr. Liggins is saying and either agree or disagree with it. When you review this article you should support your comments with evidence to support the argument you wish to make. I look forward to your comments which we will publish in the next issue.

Robert Sullivan

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Peer Review Section

Firewalking - An Essay W J Liggins FInst.ChP. BSc(Hons) All animals possess a natural instinct to avoid fire. This is no less the case with homo sapiens than any other animal, despite the latter’s ability to control the energy and therefore make use of it to some extent. ‘Firewalking’ is defined as “the practice of walking barefoot over something such as hot stones or wood ashes, often as part of a traditional ceremony” (1) and is therefore generally perceived as ‘unnatural’ or at very best, a demonstration of ‘magical’ or religious fervour. The practice has existed since before recorded time and has been widespread across the globe. The IKung Bushmen of the Kalahari Desert use the technique as a part of their healing ceremonies whilst amongst others, clans in the Fijian Islands, girls in Bali and fakirs demonstrate their apparent resistance to pain by the assumption of a trance like state followed by a walk across hot stones or fiery embers.(2) The practice is often seen as a rite of passage, or a test of courage although there is frequently a religious connotation. Followers of Hinduism celebrate the Thimithi Festival by walking on hot coals to venerate the Goddess Draupadi who walked across fire to prove her fidelity. Japanese Taoists use fire-walking as a method of demonstrating their self-mastery and spiritual advancement.(3) The followers of the Shia sect of Islam walk over fire on the 9th and 10th days of Muharram (the first month of the Islamic calendar) to mourn the death of Hussain – the son of Hazrat Ali and Sayyeda Fatima (the Daughter of Mohammed), although many followers of Islam do not feel it appropriate to mourn too deeply as Hussain is blessed.(4) In Europe, Virgil writes of Arrun’s prayer to Apollo in which walking on glowing coals is mentioned.(5) Estinarstvo and Anastenária are respectively the Bulgarian and Greek Orthodox Christian fire-walking rituals which are performed in villages in the Strandzha Mountains in the southeast of Bulgaria and Greece. They are performed on the day of Saints Constantine and Helen or the day of the individual village's patron saint. The ritual is a unique mixture of Eastern Orthodox beliefs and older pagan traditions from the Strandzha Mountains. The head ‘nestinar’ may traditionally be succeeded only by his or her son or daughter, and only when he or she is too old or ill to continue performing the ritual. After sunset, the villagers build up a large fire and dance a horo (a traditional round dance) until the fire dies and only embers remain. The Nestinari's barefoot dance on embers then follows. It is popularly thought that some of the dancers reach a

religious state of trance while dancing, explaining why their feet do not burn and they allegedly do not feel pain.(6) Over the past 30-40 years a number of organisations have offered fire-walking as one of a range of techniques to build self-confidence in the individual and as teambuilding within businesses. Some companies exist which still claim to offer such techniques as glass-walking and fire-walking as alternative health therapies and claim that ‘mind over matter’ or ‘spiritual energy’ is a required element to successfully undertake the walk, for example: “The first method can be a test whether the belief in the numinous is powerful and strong enough. The second way is a test on the willpower, the third tests the abilities of imagination and magical discipline, the fourth the "Neither-Neither" state of mind. You can get burnings during a fire-walk, in spite of contrary statements by physicists. Do not forget this (I am sure, this won't happen). The cleansing power of the fire spirits can do minimal burnings at certain reflex zones at the feet, activating these points on this way.”(7) Clearly, the number of perfectly respectable companies involved in team building without the benefit of being imbued with feelings of divinity, who have no ‘magical discipline’ and who do not claim to be possessed by ‘the cleansing power of the fire spirits’ tends to debunk such questionable statements!

There are a number of well proven physical facts which demonstrate how the apparently ‘magical’ feat is achieved; however anatomy and physiology are rarely mentioned. The first recorded scientific investigation in the West was carried out by Harry Price of the University of London Council for Psychical Research in 1935. The examination of the phenomenon was carried out at Carlshalton in Surrey when Mr Kuda Bux, a Kashmiri ‘magician’ who was under examination for an unrelated ability mentioned that he had the ability to fire-walk and was willing to demonstrate how it was done. In this case charcoal was added to a previously prepared oak wood fire. Unfortunately, no chiropodist was present but the feet of Kuda Bux were examined by a medical practitioner who was convinced that no form of chemical had been applied to the plantar surface of the feet which were ‘soft and dry.(8) Bux walked across the glowing continued on page 18 17

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continued from page 17 charcoal four times without any sign of pain, and when his feet were afterward examined, there was no evidence of damage. A Mr Digby Moynahan who also attempted the walk jumped off the charcoal after two steps with some blistering. An extant photograph shows that Moynahan was lifting the opposite leg very high. This would result in the weight bearing foot being driven more deeply into the coals, and more importantly, for a longer period of contact. A later investigation carried out by the same body with different volunteers, a Moslem named Mr Ahmed Hussain and an Englishman, Mr Reginald Adcock resulted in no adverse effects to the surface tissues. The Council concluded that the low thermal conductivity of the burning wood and the brief time of contact between the feet and the coals offered the most likely explanation.(8) Heat can be transmitted in three ways, by radiation, by convection and by conduction.

Radiation is an electromagnetic wave of infrared energy and does not require contact between the irradiated body and the source of energy. A good example is the heat of the sun’s rays reaching the planet Earth. During a fire-walk, little radiation reaches the feet because of the relatively short length of time of the walk itself. Spectators in the region of the fire may experience far more heat on their faces because of the longer period they are subject to the radiation coupled with the higher sensitivity of the face to heat. This, in turn makes the performance appear even more impressive. Convection occurs when the excited, and hence less dense molecules of a gas, are displaced by the cooler and denser molecules (hot air rises). In the case of fire-walking, the gases held in the wood are all driven off by the initial burning, and charcoal is made by burning off the gases whilst excluding oxygen. There is therefore, little or no gas to be concerned about in the glowing coals during a fire-walk. Conduction is the transmission of heat by direct contact and is the most relevant form of energy transmission in this context.

Energy is transferred from molecules having higher levels of energy – the coals, to those with lower energy – the plantar surface of the feet, in an attempt to bring about equilibrium.(9) As noted by Price, the thermal conductivity of wood is low. The thermal conductivity of charcoal as used in the Carlshalton experiment is even lower and the brief contact of the foot with the coals allows little time for heat conduction. In addition, the larger the surface area of conduction, the less the conduction at a specific point on that surface area. It should be noted that the thermal conductivity of most metals is thousands of times higher than that of wood or charcoal, and despite claims to the contrary there is no 18

evidence of any individual walking on red hot metal without injury.

It has been suggested that the Leidenfrost effect may be an explanation for the phenomenon of burn free firewalking.(10) Johann Gottlob Liedenfrost investigated the effect extensively and published “A Tract About Some Qualities of Common Water” in 1765. The term describes the vaporisation of the surface molecules of water without the energy being immediately transferred to the water as a whole. This is commonly seen when a water droplet ‘sizzles’ on a pan heated to beyond the boiling point of water (1000C). The surface of the water in contact with the pan vaporises causing the droplet to move about rapidly. The thermal conductivity of water vapour is much lower than that of water and since the hotter the temperature of the pan, the smaller the contact surface of the water, the anti-intuitive situation occurs that the hotter the pan, the longer the droplet takes to disappear through radiation and slow conduction. Even more commonly, an individual ironing clothing will lick a finger and briefly apply it to test the hot surface of the iron. If the iron is sufficiently hot, the water on the finger will vaporise resulting in a ‘sizzle’ but the finger will remain uninjured. The effect was harnessed by ‘magicians’ who dipped their hand into vats of boiling lead without suffering ill effects. This feat was nobly repeated by Jearl Walker at Cleveland State University who also carried out several fire-walks.(10) In a healthy person the normal body temperature is maintained at 370C by the thermoregulatory centre in the hypothalamus. Heat is lost through the skin by means of vasodilation of the blood vessels and sweating. The plantar surface of the foot is well supplied with arteries, arterioles, veins and venules. The posterior tibial artery splits at the medial aspect of the heel to form the medial and lateral plantar arteries. The medial plantar artery splits just proximally to the 1st metatarsal head to form the anastomic branch to the medial plantar digital artery of the hallux and superficial digital branches to anastomose with the first, second and third plantar metatarsal arteries. The lateral plantar artery crosses medially just below the level of the metatarsal heads to form the plantar arch giving off the plantar digital arteries, and perforating branches.(11) The plantar digital veins arise from plexuses on the plantar surface of the digits and unite to form the four plantar metatarsal veins which run proximally to form the deep plantar venous arch which lies alongside the arterial plantar arch. The medial and lateral plantar veins accompany the corresponding arteries and after communicating with the great and small saphenous veins unite behind the medial malleolus to form the posterior tibial veins.(12) The continued on page 19

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Continued Professional Development

The Institute of Chiropodists and Podiatrists

Continuing Professional Development This article is one of a series of educational documents that can be inserted into your portfolio and be a contribution towards your personal CPD learning.

Summary of

Nail Conditions

By Carl Burrows, FInstChP, DChM and R. H. S. Henry, FInstChP, FRSH, APMA (USA)

NAIL FACTS 1. Finger Nails grow Faster than Toe-Nails.

4. Rate of Growth Decreases with Age.

2. Finger Nails grow 10 mm. in three months Toe-Nails grow at about a third of that rate.

5. Minor Trauma stimulates growth unless the nail bed is damaged, then this inhibits it.

3. Nails grow Quicker in Summer.

WHAT IS NAIL? A Hard Plate of Keratinised Cells; and is the end product of the matrix which contains the onychocytes which control growth.

FUNCTIONS OF NAIL: q Protection of dorsal surfaces of toes and fingers q Fine touch (counter pressure in toes) q Picking up of fine objects q Scratching!

They are also an indicator of the state of health, as many systemic conditions manifest themselves in the nails.

NAIL ANATOMY

BLOOD & NERVE SUPPLY TO NAILS Dorsal Digital Nerve

Blood Supply Dorsal View Blood Supply Lateral View

Volar Digital Nerve

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Continued Professional Development Nerve Supply of Nails

Normal Nail Surface Anatomy DESCRIPTION OF ANATOMICAL COMPONENTS Nail Plate: Consists of three layers: Dorsal //////////////////////////////////////// Intermediate xxxxxxxxxxxxxxxxxxxxxx Ventral |||||||||||||||||||||||||||||||||||||||||||| The layers are ridged to adhere to the nail bed.

Appearance is pink because of the underlying vascularity showing through its’ translucence.

Matrix: The area which produces the majority of the nail plate.

Onychocytes are formed here. They replicate and move distally.

New cells emerge at the proximal nail fold, forming the nail plate.

The most proximal matrix cells form the superficial nail layer.

Proximal (or posterior) Nail Fold: Extension of the skin which becomes a fold and consists of modified stratum corneum devoid of sebaceous glands. It terminates in the CUTICLE. Function: To protect the nail from irritants, allergens and bacterial and fungal pathogens.

Lunula: Lies at the proximal part of the nail and forms the white “half moon” in normal health. It is the most distal region of the matrix. (As yet, its anatomy and physiology is not fully understood).

Hyponychium Is the termination of the distal nail groove and the point at which the free edge of the nail emerges.

Blood Supply: Is by paired digital arteries which anastomose in several places to supply the bed and matrix and they terminate at the apex of the digits. Glomus bodies are present which unlike the arterioles, dilate in adverse cold conditions thus maintaining the temperature of the nail and preventing damage.

Nerve Supply: Is prolific, from branches of volar and dorsal digital nerves, hence the very acute sensitivity of the nails.

INFECTIONS FUNGAL ONYCHOMYCOSIS Aetiology: Infection caused by a variety of pathological dermatophytes: 1. Trichophyton Rubrum 2. Trichophyton Interdigitale 3. Trichophyton Mentagrophytes 4. Candida, Aspergillus & Scopulariopsis are also possible causes.

These fungi metabolise protein and use our keratin for food!

Symptoms: often ONYCHOMYCOSIS asymptomatic.

Features: Porous distorted nail which can appear yellow, brown, black etc. and is very “crumbly” in texture.

Diagnosis: requires culture/micro-scopy to be accurate.

Treatment: Thinning of nail plate and application of topical anti-fungal agents e.g. Gluconazole; Lamisil Cream, Loceryl, Monphytol tincture OR systemic medication with the terbinafine group of drugs e.g. Lamisil (expensive but very effective) [requires prescription from medical practitioner].

Differential Diagnosis: Psoriasis; Atherosclerosis.

INFECTIONS BACTERIAL PARONYCHIA (WHITLOW) Definition: bacterial or yeast infection with inflammation of the tissues surrounding the nail plate.

Aetiology: May be Acute - with many systemic causes - poor circulation, diabetes, reduced immunity, OR Chronic occupational wetting, chemical damage etc.

Acute Paronychia with pus in medial sulcus

Chronic Paronychia from occupational wetting

Causes: Usually an injury to the sulci or hyponychium from e.g. a thorn, torn “hang nail”, splinters, shoe friction etc. in conjunction with the above weakness. Pus colour will depend on the invading bacteria or yeast, commonly, Streptococci, Staphylococci, Pseudomonas, Candida.

Features: The nail is ridged and in the acute cases, pus is often visible in the sulci. Redness and swelling are evident in both acute & chronic cases.

Symptoms: Constant throbbing pain, accompanied by inflammatory signs of redness, heat, swelling and loss of function, as nature attempts to isolate the infection.

Treatment: If the infection appears superficial then foot baths as hot as the patient can bear are indicated and the application of aluminium acetate solution at least twice daily. It may be necessary to ‘lance’ and evacuate the pustule. If the appearance is that of a deep seated infection it is essential that the patient is referred for antibiotic therapy as soon as possible or for surgical intervention if permanent damage to the nail is to be avoided.

Complications: In the worst instance could lead to osteomyelitis involving the underlying phalanx.

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 23

Continued Professional Development ONYCHIA Definition: Bacterial or yeast infection with inflammation of the nail bed and/or the matrix. The condition often co-exists with paronychia Aetiology: Usually infection with streptococci or staphylococci Associated with - eczema, fungal infections, foreign bodies, constant wetting or chemical damage. As in paronychia, the condition may be acute or chronic.

Features: Inflammation is present with the cardinal signs of redness, heat, swelling and acute throbbing pain. Pus may or may not be visible beneath the nail plate. The nail plate may separate from the nail bed (onycholysis).

Symptoms: Very painful, throbbing digit.

ONYCHIA Treatment: Gently remove some of the nail plate to expose the lesion and evacuate the pus. Application of moist heat in the form of poultices. Non-adherent dressings. Rest.

Other Treatments: Antibiotic therapy may be required and the patient should be referred to their medical practitioner if this is the case. In resistant cases total nail avulsion under general anaesthetic may be the only solution. It is unlikely that local analgesic injections will be effective in this condition because of the infection present preventing the anaesthetic penetrating.

SYSTEMIC DISEASE MANIFESTATIONS

TRAUMA ONYCHOCRYPTOSIS Definition: A condition in which the lateral edge of the nail has pierced the sulcus. Most frequently this occurs in the hallux and can be either unilateral or bilateral. It is commonest in teenage males.

Etiology: Whilst the condition can occur spontaneously, it is often caused by faulty nail cutting. The other factors which are present include, involution of the nail, hyperhidrosis, over zealous use of foot baths and pressure from footwear (trainers are culprits).

Features: Zaias described 3 stages of development: 1. Minimal injury - spike removed, problem settles.

2. Pain; erythema; granulation tissue starts to form.

3. Hypergranulation (proud flesh) prevents access to the area and is extremely painful.

Symptoms: Vary from a mild pricking sensation to marked throbbing pain which is constant. Inflammation and infection are often present and obvious.

Complications: Occur especially in diabetics and patients on steroid therapy and include lymphangitis (lymph vessel), lymphadenitis (gland/node), cellulitis connective tissue of foot/limb).

Treatment: Remove spike of nail. Packing of sulcus - cotton wool - silicone etc. Interdigital wedge to remove pressure. If hypergranulation present, silver nitrate 90% stick. Nail Brace. Ultimately, surgery in form of partial or total nail avulsion.

If non-responsive - probably some nail spike still in situ.

DIABETES MELLITUS Features: Poor resistance to infection is common in diabetes, due to the debilitated condition of the tissues and circulation. Opportunist infections with moniliasis and candidiasis being particularly troublesome. Paronychia, lysis, mycosis and onchomadesis occur. Motor neuropathy causes digital deformities with subsequent nail problems and the sensory neuropathy can lead to undetected injuries to the nails.

Onychocryptosis showing Inflammation and Infection

Onychocryptosis with Hypergranulation Tissue

Onychogryphosis: (also known as Ramshorn Nail or Ostler’s Toe).

Description: Hypertrophied deformed nail.

Etiology: Violent Injury; Persistent Minor Trauma e.g. Sports Footwear; Neglect (frequently a cause in the elderly); Poor Circulation (in this last case the cause may be systemic and affect all toes).

Two Examples of How Nails May Appear in Diabetes Mellitus

Any persistently slow to heal nail lesion should be treated with suspicion that diabetes might be present and the patient referred accordingly.

Pathology: Back pressure on the nail fold prevents proper formation of developing nail. The cells increase as a protection initially, and this becomes a vicious circle with more and more debris formation.

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 24

Continued Professional Development NAIL CONDITIONS C.P.D. QUESTIONNAIRE Please study the illustrations below and when you have done so, fill in your diagnosis and the aetiology, signs and symptoms, and detail briefly, your treatment for each: (1)

Diagnosis:

The Proximal Nail Fold and Thickness Matrix Angles Determine Nail

Aetiology:

Features: Twisted claw-like or pebble shaped nail of grey/brown/black colour with subungual hyperkeratosis and transverse ridging.

Treatment: Remove cause. Reduce nail with diamond bur taking great care over the trapped nail bed. Evacuate subungual debris after applying H2O2. Nail may also be reduced by applying 40% Urea in Petroleum Jelly for 7-10 days, masking the area and subsequently removing softened nail plate.

Complications: Sore nail bed; adjacent toe ulceration; subungual helomata.

Signs & Symptoms: Your Treatment Suggestions

(2)

Diagnosis: Aetiology: Signs & Symptoms: Your Treatment Suggestions

Gryphotic Nails as Result of Neglect

SUBUNGUAL ExOSTOSIS: Description: An outgrowth of normal (as opposed to tumorous) bone beneath the nail plate.

Etiology: Trauma; Irritation from ill-fitting footwear.

Features: Elevated nail which sometimes sheds. Lesion visible below nail plate.

Treatment: X-Ray confirmation; protective padding; surgical excision.

Exostosis in a Lesser Toe

Exostosis in the Hallux

(A)

How fast do average toe-nails grow in 3 months? - 3+mm; 10+mm; 5+mm

(B)

Name the three layers of nail plate

(C)

What is the point at which the free edge of nail emerges called?

(D)

What is essential to accurate diagnosis of onchomycosis?

(E)

Apart from bacteria, what other pathogen is sometimes responsible for onychia?

(F)

What complication commonly arises in toes adjacent to Onychogryphosis?

(G)

What is the difference between Paronychia and Onychia?

(H)

What is the commonest cause of Onychocryptosis?

(I)

What is the differential diagnosis for sub-ungual exostosis?

(J)

Why does diabetes mellitus affect the toe-nails?

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 25

Peer Review Section

continued from page 18 plantar and palmar skin differs in many respects from the skin on the remainder of the body including the number of nerve endings and the number of sweat pores, the latter in the epidermis. These in turn are served by a complex plexus of capillaries which unite to form the arteries and veins noted above and are capable of rapid and profound dilation when subject to high temperature gradients. The additional sweat glands in the dermal tissues produce sweat which forms a thin layer over the surface of the epidermis to enhance grip. The normal stratum corneum on the plantar surface is up to fourteen times thicker than that on the remainder of the body and this can increase in pathological cases of callosity.

The author attended a fire-walk on 30th April 2011.

This was carried out for the charity The Mary Ann Evans Hospice and the walkers had all gained sponsorship for the event. The only commonality of the walkers was a desire to benefit the charity and a willingness to carry out the challenge, otherwise they were drawn from various employments and many were previously unknown to each other. The organising company(13) ensured that a fully equipped firefighter was on hand and that the area of the fire-walk was suitably roped off from the numerous spectators. The site of the walk was an area of grassland with ample room for movement. A thirteen feet by three feet trench was dug and filled with hard wood cuttings and chippings which were then set ablaze in the afternoon preceding the walk. Buckets of cold water were placed about two feet away from the end of the trench where the walkers would complete their challenge. At nineteen-thirty hours, the walkers met with the organiser who took them through a careful briefing with demonstrations which showed that, with selfconfidence, seemingly impossible tasks can be carried out with aplomb. Forms of disclaimer were signed and the walkers checked to ensure that no moisturising or other cream had been applied to the feet. The participants were instructed to walk steadily over the coals and to plunge their feet into the cold water after completing the challenge in order to douse any cinders attaching to the feet. Towards dusk the fire, which had burned to embers, was checked; large pieces of wood were removed and the embers flattened. Although the walkers were clearly motivated, it seemed that the spectators were more excited by the prospect of observing ‘the impossible’. Despite the fact that dusk had fallen – which made the glowing coals all the more impressive – there was no dew apparent on the grass.

An infra-red digital thermometer was used to measure the temperature of the fire pit at 5230C (973.40F). For comparison, a domestic barbecue (used to cook beef

steak and pork sausage) measured 5070C (944.60F) at the hottest portion of the burning charcoal (temperature taken on 3rd August 2011; a still, warm evening). A recording of a piece of burned, ash covered charcoal provided a temperature of 276.70C (531.10 F). The organiser checked the fire and carried out the initial walk himself. He was followed by the rest of the twenty walkers, none of whom refused to carry out the challenge.

Three of the walkers volunteered to have the temperature of their feet measured before and after the experience, prior to using the cold water. The results are shown in the table below.

Volunteer number

Temperature of plantar surface of right foot immediately prior to fire-walk (degrees centigrade)

Temperature of plantar surface of right foot immediately following fire-walk (degrees centigrade)

One

28.9

33.5

Two

24.9

27.9

Three

28.6

30.5

It seems therefore that the temperature rise of the feet of the three volunteers, although obviously meaningless for statistical purposes, does suggest an increase of only two to three degrees centigrade after being subject to a measured heat of 5230C for four steps. Clearly, dilation of the plantar vessels must have been profound and nearly instantaneous.

Anecdotally, in conversation with the walkers following the event, the majority stated that their feet tingled but that they did not experience heat from the fire pit until the end of the walk. Three of the twenty felt ‘burned’ and developed small blisters. It was notable that these people were rather anxious and walked very rapidly. Although initially reluctant, since the author had not attended the motivational discussion, the organiser was courteous enough to allow him to carry out the walk, having been convinced that he understood some of the physics underlying the experience: “The grass was cool, but not damp. The fire was still radiating considerable heat and was glowing brightly, although a thin layer of ash overlay the coals. I took the first step from the grass with my knees slightly in flexion, thus limiting heel strike. The coals felt a little warm to the foot but definitely not hot. The sensation was akin to walking on a fairly deep layer of broken biscuits or potato crisps. I took a further three steps in a similar fashion, trying to present the largest possible surface area of the foot to the fire and moving calmly but reasonably briskly in such a way as to avoid pronounced heel strike and toe off. I am convinced that I could easily have carried out a walk of double the length without overt tissue damage. After stepping off the fire, the plantar surfaces of both feet were continued on page 20 19

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 26

Peer Review Section

continued from page 19 covered in a fine layer of ash which required washing off later. In common with others of the walkers, I experienced some warmth and tingling of both feet but no pain at all.

On the following day, four areas of hyperaemia of circa 1mm diameter were noted on the plantar surface of the left foot, just proximal to the 2nd metatarsal head area, and three similar discolorations in precisely the same position on the right foot, both being proximal to the weight bearing areas. These were painless and could not, therefore be classified even as first degree burns. The epidermis thickened slightly in these areas and was shed with the normal skin squames over a period of three weeks. There have been no long term effects.”

In analysing the outcomes of the fire-walk, it should be noted that the walkers, having experienced the motivational talk, and being slightly anxious, were variously affected with an ‘adrenaline rush’. Their hearts were pumping faster with a resulting increase in blood flow to the feet. Although this produced increased sweating, the fine layer of ash thus adhering to the feet would have added insulation and prevented epidermal contact with the fire. It seems highly unlikely therefore that the Leidenfrost effect had any bearing on the lack of damage to the tissues. In addition, Bux experienced no damage, although his feet were quite dry (since he had wide knowledge of fire-walking, it is a reasonable assumption that he experienced no particular increase in adrenaline and hence no sweating). The poor thermal conductivity of wood and charcoal has been cited as the major factor in the lack of tissue damage to the foot.

However, it seems that there are other reasons which were not noted by Price in his original experiments: i)

the pressure of the cooler body (the foot) on the hotter body (the coal) will result in the hotter body losing heat rapidly

ii) water (blood, tissue fluid) has a high thermal conductivity whilst the coal has much less iii) the layer of ash adhering to the foot acts as an effective insulator iv) placement of the feet in such a way that the maximum area of the foot is in contact with the coals reduces the possibility of the heel and the metatarsals ‘digging in’ to the deeper, and hence hotter, areas of the coal. Running, or walking too fast will result in blistering v) walking firmly but briskly across the coals reduces the contact time between the feet and the charcoal vi) the complex venous plexus on the plantar surface of the foot, and the rapid dilation of the vessels when 20

subject to heat results in very effective local cooling and prevents the tissues from reaching the temperature that burning will take place vii) the thick stratum corneum on the plantar surface of the foot offers insulation. Callous might increase resistance to burning to some extent and the ‘tougher’ plantar surfaces of peoples who are generally unshod may offer increased protection Historically, the individuals carrying out fire-walks have been regarded as ‘special’, either with regard to courage or religious fervour. However, it seems that any normally fit and motivated person can successfully complete a short fire-walk without ill effects. Motivation is the key. The author was told by a firewalker that she suffered from two ‘phobias’. One was fire and the other heights. Having completed the fire-walk she intended signing the next day for a sponsored parachute jump. Needless to say, the process is not a good subject for do-it-yourself; the proper wood must be used and health and safety demands that certain rules are adhered to.

The final word must go to Jearl Walker, who as a physicist can be forgiven for overlooking the obviously important biological element:“I have long argued that degree-granting programmes should employ ‘fire-walking’ as a last exam. The chairperson of the programme should wait on the far side of a bed of re-hot coals while a degree candidate is forced to walk over the coals. If the candidate’s belief in physics (anatomy and physiology [author]) is strong enough that the feet are left undamaged, the chairperson hands the candidate a graduation certificate. The test would be more revealing than traditional final exams.”(10) Thanks are due to Mary Anne Evans Hospice and Mr Steve Stuttard of Survivorbility Ltd. References (1) Oxforddictionaries.com/definition/firewalking?region=us. accessed 26-07-11 (2) http://en.wilipedia.org/wiki/Firewalking. accessed 26-07-11 (3) www.naturalchoice.net/articles/firewalkhtm.htm. accessed 26-07-11 (4) www.inter-islam.org accessed 27-07-11 (5) Virgil. Aeneid XI, pp 787-788 Trans. Robert Fitzgerald.

Pub Vintage Books 1990.

(6) www.youtube.com.watch?v=rittIjheQo. accessed 27-07-11 (7) http://www.howstuffworks.com/framed.htm?parent=firewalking.htm&url =http://serendip.brynmawr.edu/bb/neuro/neuro00/web2/Shaw.html accessed 28-07-11 (8) http://www.harrypricewebsite.co.uk/Famous%20Cases/firewalkbyharryprice.htm accessed 29-07-11 (9) http://www.articleworld.org/index.php/Heat_transmission accessed 29-07-11 (10) http://darkwing.uoregon.edu/~linke/papers/Walker_leidenfrost_essay.pdf (11) Logan B., Singh D., Hutchings R., McMinn’s Colour Atlas of Foot and Ankle Anatomy. Pub. Mosby, London 2004 (12) Howden R. (Ed). Grays Anatomy.

Pub. Longmans, Green & Co. London 1926 (13) Stuttard S. Survivorbility Ltd. 61 St LawrenceQuay, Manchester M50 3XT. www.survivorbility.com

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 27

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Cosyfeet Podiatry Award for Glasgow Student

Joanne Sweeney, who will graduate in Podiatry from Glasgow Caledonian University this summer, has been awarded the Cosyfeet Podiatry Award 2011. The £1000 grant will help fund her travel and living expenses during her 3-month voluntary project at the Coast Provincial General Hospital in Kenya.

Much of the work that Joanne will do in Kenya will assist with her Masters degree in Global Health, focusing on writing future policy on the treatment of noncommunicable diseases.

One of the main aims of the project is to identify sustainable sources of alternative materials for offloading pressure from wounds on vulnerable feet. The application of offloading techniques on foot wounds is a recognised method of promoting healing, and as a direct result, reduces the incidence of limb amputation.

In addition, Joanne plans to lead the development of a resource area for staff and patients for the purposes of health promotion and education. She will also assess the screening protocol for patients with vulnerable lower

limb and foot conditions, which are often secondary to systemic diseases such as Diabetes, Post Polio and Cerebral Palsy.

Joanne will travel to Kenya early in the new year. During the project much of her time will be spent in clinic, and in running tutorials for nursing staff with little or no prior foot care training. These nurses have daily contact with patients who have vulnerable feet.

“This project is going to force me to be resourceful and to work under duress without typical equipment and supplies,” says Joanne. “I’m really looking forward to implementing my four years of undergraduate training, and to creating more positive outcomes for lower limb patients in the Coastal Province of Kenya.”

Joanne plans to write a blog of her experiences in Kenya, which can be accessed from December onwards at http://kenyafootproject-josweeney.blogspot.com For more information about the Cosyfeet Podiatry Award see www.cosyfeet.com/professionals

21

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 28

North West Area Council Seminar The 14th North West Area Council will be holding their Seminar at the University of Central Lancashire on 16th October, 2011.

The lectures this year are on Parkinsons Disease – Another view, Its impact on feet by Dr. Emma Allison, Lower Limb Vasculature by Michelle Weddell M.Sc. Dip.Pod M. and Heart Failure by Wendy Barradale.

The lecture theatre at the University is superb with comfortable seating and space. The trade stands are putting on a great show this year providing members a good variety of products and consumables. There is a hot two course lunch provided and tea and coffee is available throughout the day. At the end of the Seminar there will be a prize draw and you will gain a valuable CPD Certificate for your portfolio’s. All for the price of £65.00. Free parking is available. Book now for your place, on a very worthwhile and enjoyable day.

The Booking form is on page 30. Please book by 7th October.

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33893 Chiropody 44ppA4 17/08/2011 13:56 Page 29

Diabetes UK

D

VLA consultation on amending medical driving licence standards (Apr 2011)

The DVLA have consulted on proposals to amend driving licence standards for vision, diabetes and epilepsy with reference to Annex III to Directive 91/439/EEC and 2006/126/EC. The consultation on the proposed changes will affect the minimum medical standards for driving in relation to diabetes and covers both Group 1 and Group 2 licences.

The consultation proposes to amend UK driving for the following standards: Drivers experiencing recurrent severe hypoglycaemia shall not be issued a licence – ‘severe recurrent hypoglycaemia’ is now defined as ‘a second severe hypoglycaemia during a period of 12 months’ Any Severe Hypoglycaemic event, even when not driving, must be reported and will now lead to driver reassessment.

Drivers with impaired awareness of hypoglycaemia will not be issued licences, nor be able to renew. Impaired awareness is now defined as a total absence of warning symptoms.

Group 1 Drivers with tablet treated diabetes will not be required to inform the DVLA unless they develop visual complications or hypoglycaemia. This is on the basis that they are under regular medical review – based on NHS prescribing reviews taking place every 12 months.

Drivers treated by insulin will now be able to apply for Group 2 licences based on the 5 point criteria and an annual review undertaken by an expert diabetologist.

Diabetes UK has responded on behalf of our members and all people affected by the proposed changes. Current UK Driving Regulations and application procedure should be adhered to until the DVLA enact these changes.

The National Insitute for Clinical Excellence (NICE) has ruled against the use of Lucentis (Ranibizumab) for the treatment of diabetic macular oedema (DMO) within the NHS. DMO is an

eye condition which affects around 50,000 people in the UK and causes loss of vision.

If left untreated it can lead to blindness.

For the past 25 years, laser treatment has been the current standard treatment on the NHS and although it does stop deterioration, it has not been shown to improve vision. Over time, laser surgery can cause irreversible damage to the surrounding eye tissue due to the destructive nature of the treatment.

Lucentis is the first licensed treatment to improve vision and vision-related quality of life in people with sight loss due to DMO. Research has shown that Lucentis not only offers stabilisation of vision loss but that it can also lead to significant improvements in vision.

NICE has rejected the use of Lucentis on the grounds of expense: injections cost £742 per eye, and some patients can require multiple monthly injections. However, people currently treated with Lucentis have the option to continue treatment until they and their clinicians consider it appropriate to stop. The full Final Appraisal Determination can be downloaded from the box on the right.

Barbara Young, Chief Executive of Diabetes UK, said, "This decision means more people will needlessly lose their sight.

We pressed hard to make this treatment available on the NHS and we will campaign for NICE to reconsider its decision. The cost of looking after people with sight loss far outweighs the cost of Lucentis treatment, let alone the human cost.

"We are very concerned local health services will use this decision as an excuse to stop treatment. We will monitor the situation across the country closely to ensure patients currently receiving Lucentis continue to do so as per the NICE guidance.

We would also like to see urgent testing into alternative treatments for diabetic macular oedema."

Social Networking Medical Professionals have been advised to be wary about who has access to their personal material through social networking sites such as Facebook and Twitter. The British Medical Association has issued advice and warned Doctors and other medical professionals to be wary of who they make friends with and certainly not to accept friendship requests from patients as this could risk damaging their professionalism, by inappropriate boundary transgressions. It could also conflict with ethical issues.

The British Medical Association issued advice urging medics and students not to blur the boundaries with people they are treating or have treated in the past, for example by accepting a Facebook friendship request.

Chairman of the BMA's Medical Ethics Committee Dr Tony Calland said: "Social media presents doctors and medical students with opportunities, as well as challenges. The BMA guidance is important as it provides doctors with the tools to prevent potential social media pitfalls.

"Medical professionals should be wary of who could access their personal material online, how widely it could be shared and how it could be perceived by their patients and colleagues."

23

33893 Chiropody 44ppA4 17/08/2011 13:56 Page 30

HPC Event

Christine Hughes M.Inst.Ch.P Many times in the last few years, branch members have anguished over how one should present a continuing professional development profile. It seemed that it could develop into a mountainous task.

What we should look for is a mixture of learning activities that are relevant to our clients. Nobody would expect to get credit for attending a jewellery course and claiming it improved their podiatry standards!

I recently took time out to attend a “Meet the HPC” event. It was time well spent. I came away feeling the HPC might be human after all! I reached the conclusion that the requirements of HPC are not so confusing and are, infact, in everybody’s best interest!

The question often asked is how much do I need to include if I am called to Audit? The HPC do not, in fact, want to be snowed under with countless mountains of individuals paperwork and they set a word count limit. It is a brief report - not an academic thesis! The evidence needs to show improvement to the quality of our work and be of benefit to our service users. Professionals selected for audit would be required to submit four or five activities which have most benefited the individual’s practice. There are no set amount of ‘hours’ required. The important issue is ‘what we have learnt’ and how we have effected it in practice.

Continuing professional development is basically about learning and individual development. For example, no person would spend a fortune on an advanced, computer based, publicity course, if they did not own a computer, however there may be someone else who would benefit from the course, to discover the best way to further promote the services provided within their business.

It is about learning and Development that Benefits your practice.

Lastly, one thing we should all strive to be are Professionals of the highest standard and continuing to learn and improve is obligatory.

Of course we need to keep a record of any activities for the improvement of services but it is not something that is limited by the prescription of the HPC. Obviously we do need to keep evidence of what activity took place, a record that dates the events and our feelings after the experience but whether we keep this information on-line, in a notebook, bag or a box under the bed is immaterial.

Congratulations Photos of the recently graduated cohort 3 on the C&G diploma course at Sheffield.

The students have worked really hard, been a joy to teach and we all at Sheffield wish them all the very best always in their new careers Suzie Ostler

L-R Back Row: Joanne Proctor, Beverley Wright (Institute Inspector) Chris Maggs L-R Front Row: Wendy Hopkinson, Rosalind McCulloch, Sheridan Lee 24

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Rambling Roads August 2011 ‘New Scientist’ 25th June has news that is distinctly bad for lovers of red wine. The molecule reseveratrol, which is understood to be responsible for the protective action of red wine, has had some of its chemicals synthesised. Plants have the ability to produce a variety of chemicals named polyphenols which have the potential ability to fight many diseases including cancer. Unfortunately, the chemicals are only made in a small quantity which makes it difficult to isolate them, and reseveratrol is highly unstable. Scott Snyder at Columbia University in New York and his team have managed to build polyphenols from compounds that they resemble including vaticanol C which is known to kill cancer cells. The only crumb of comfort for red wine drinkers is that research is at an early stage, so it will be necessary to imbibe moderate amounts for some time to come.

The Editorial of the Journal of The Royal Society of Medicine vol. 104 No 7, makes the point that like it or not, changes are going to take place within health care delivery. The point is made that amongst the planners, little thought is given to the local implementation of the changes, and suggests that Centres for Healthcare Improvement should be created to work with the local health economy to deliver sustained improvements at the point of care. The authors envisage that the centres would form an integrated network involving all healthcare organisations, higher educational institutions, the local community and patients.

The centres would provide opportunities for local, national and international networking as well as developing staff for experiential practice – learning by doing - as well encouraging formal education and research.

Goodbye to Charcot’s neuropathy as the cause of Charcot’s foot?

PodiatryArena (on line) http://www.podiatryarena.com/podiatry-forum/showthread.php?t=2396 features a series of investigations into the problem. Jean-Martin Charcot in 1883 first described the condition which now bears his name.

The patients whom he studied suffered from syphilis with associated tabes dorsalis insensitivity. He therefore believed that intrinsic bone weakness was the underlying condition, and was caused by neurogenic deficiencies in bone nutrition caused by the disease. Currently diabetes is the most common precursor to both lower limb neuropathy and Charcot’s foot. A number of recent studies, notably Sympathetic neuropathy in diabetes mellitus patients does not elicit Charcot osteoarthropathy. Christensen TM, Simonsen L, Holstein PE, Svendsen OL, Bülow J.J Diabetes Complications. 2011 Aug 1.

[Epub ahead of print] suggests that the condition is caused by a disorder of the microvasculature not directly related to neuropathy but rather to inflammatory events localised to the affected joints.

Also on the Arena, the thread ‘There is no Barefoot Running Debate’ has received no less than 50 replies, many from the most respected practitioners of sports podiatry. It seems that there is a ‘cult’ amongst some runners who feel that all potential lower limb disorders associated with running will cease if only they (and the rest of the running community) carry out their sport in bare feet. Because of damage caused by nails, glass etc. to be found on most roads and pavements in the developed world, ‘minimal’ running shoes have been produced.

It seems that the good advice of sports podiatry specialists is being ignored by some sections of the running community and the accusation made that ‘they would say that because they derive their income from treating feet, and the use of shoes causes problems in feet.’ It is all in vain to point out barefoot runners tend to mid-foot or forefoot ‘strike’ to avoid the shock

of heel strike or that a greater proportion of barefoot runners are seen with injuries than their shod contemporaries. The answer seems to be ‘African runners are good and African runners don’t wear shoes.’ Unfortunately for the barefoot cult, African (and all other) runners do wear shoes when running on flat, hard surfaces (there have been exceptions to prove rules, but these were track runners). All the studies carried out thus far indicate that whilst some training in bare feet can strengthen the intrinsic muscles, it is better to run long distances shod than unshod. This is so much so that New Balance (sports footwear company) is putting a warning on their latest minimal running shoe - " NB Minimus shoes. The product "increases the strain on the foot, calf, and Achilles tendon".

The Independent newspaper of 4th August p17 ‘Health’ reports that vulnerable patients who are visited by carers have had their door security codes and key safe combination codes printed on the outside of envelopes above their addresses. The codes were entered into address fields on the database used by NHS ‘Connecting for Health.’ The Department of Health has launched an investigation but has said that there have been no reports of intruders entering people’s homes because of the lapse – yet.

New Scientist of 30th July reports that a hereditary form of blindness has been delayed or reversed for the first time.

Leber’s Hereditary Optic Neuropathy is a mitochondrial disease which strikes men in their twenties leading to total blindness within three to six months of symptoms first appearing. In a recent trail eleven people out of fifty-five who received the drug idebenone could read an extra two lines on a standard vision chart after six months and nine people who could previously read no letter could do so by the end of the trial. It is thought that idebenone substitutes for failed mitochondrial enzymes which deliver energy to transport electrons to the cells of the optic nerve. The research, which is being carried out at Newcastle University, is acknowledged not to be a cure but research is to continue.

The same journal dated 6th August carries a report by Ferris Jabr on ‘helminth therapy’. This method of self-treatment is based on the fact that parasites which live in the human body are able to counter the effects of the immune system by chemically blinding the immune response to the fact that the parasite is an invading organism. Hence, the theory goes, if parasites could be induced to breed in the human body, people who suffer from immune disorders such as Crohn’s Disease, ulcerative colitis and acute allergies would be protected from the overreaction of the immune system. Although scientists are taking an interest in the subject, there are a number of difficulties, not least the source of the worms. A case is noted of a female who asked a friend who already suffered from infestation for a stool sample. From this she bred a dish brimming with the parasites, a sample of which she then drank.

In another case a male who had suffered the effects of Crohn’s disease for fifteen years swallowed 2,500 pig whipworm eggs every two weeks for three months. In the year 2010 he allowed 35 hookworm larvae to burrow into his skin and was later examined in New York’s Queens Hospital where his “small bowel looked almost completely normal”. Ethical Committees are reluctant to pass this type of research since helminths can cause severe illnesses and in some cases have been shown to intensify rather than supress allergies. However, some research is currently being carried out.

Achilles Hele 25

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Insurance News • Insurance News • Insurance News • Insurance News • Insurance News • Insurance News •

Heath Lambert have changed their name to GALLAGHER HEATH Following the acquisition of Heath Lambert

by Arthur J. Gallagher (UK) Ltd, Heath Lambert have changed their trading name to Gallagher Heath.

What else is changing? Nothing; we will still have the same contacts we had before even e-mail addresses are remaining unchanged at present.

It will mean, however, having the benefit from being part of the wider group, and Gallagher Heath will have considerably more

negotiating power with insurers as they are now one of the top 5 brokers in the world!

Please rest assured, they will remain fully committed to ensuring you receive continuity of service and do not envisage this being anything other than a change of name.

Your initial contact is Margaret Hackett 01384 822202 email MHackett@heathlambert.com

Insurance News • Insurance News • Insurance News • Insurance News • Insurance News • Insurance News •

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NORTH WEST AREA COUNCIL 14th ANNUAL SEMINAR at

The University of Central Lancashire, Preston on Sunday, 16th October, 2011 PROGRAMME 9:30 a.m.

Registration Tea, Coffee and Biscuits

10:00 a.m.

Lecture:

11:00 a.m.

11:30 a.m.

Tea, Coffee and Biscuits Lecture:

12:30 p.m.

2:00 p.m.

3:00 p.m.

Heart Failure, Wendy Borradale

Parkinson’s disease, another view, its impact on feet Dr. Emma Allison, MBBs. Hons Lunch, Tea and Coffee and Trade Stands

Lecture:

Lower Limb - Vasculature, Michelle Weddell, Msc, Dip, Pod M Prize Draw and CPD. Certificate issue and close of seminar

If you plan to attend please send your details and a cheque made payable to: ‘IOCP North West Area Council’ for £65.00 (This includes all refreshments and cooked lunch) Send to: Mr. Bryan Massey, 104, Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG For more information please contact David Topping (Secretary) 01772 615769 !

!

Booking Form

NWAC 14th ANNUAL SEMINAR 2011 I enclose a cheque for £65 made payable to the IOCP North West Area Council Name:..........................................................................................................................................................

Address: ...................................................................................................................................................... ..............................................................................................

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

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

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

Email: ................................................................

Please Return to Mr. B. Massey, 104 Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG

30

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SHEFFIELD BRANCH SEMINAR Sunday 23rd October, 2011 10.00 – 15.00 at

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

ÂŁ35.00 to include Buffet Lunch

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

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

New Innovations in Diabetic Care Jenny Roby Nurse Practitioner

FOR A PLACE PLEASE CONTACT:

DEBBIE STRAW 01623 452 711

(Closing Date September 30th, 2011) 31

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Leicester & Northants Branch Seminar At

Lutterworth Cricket Club On Sunday 27th November 2011 9.30 – 4.30 · · · ·

Lectures include:Dementia, how to interact with patients - Pat pope Dememtia- effects on practice - Pat Pope Plantar Fasciitis- exercise & prevention - Chris Leech Drug update - Local Pharmacist Free parking and lunch included Autoclave servicing by prior arrangement Trade stands Registration starts at 9.30 for 10.00am start

Cost of Day only £45.00 ......................................................................................................................................................

Name............................................................................................................................................

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

To attend this seminar please return this slip with your cheque for £45 To Mr D Ayres, Little Acre, Stemborough Lane. Leire. Leicestershire. LE175EX

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Classified Advertisements

Practices for Sale

80p per word - minimum £8.00 Box Number & sending replies: £4.00 extra Classified Advertisements placed by Members: 45p per word minimum £4.50

Trade Classified Advertisements Eighth page (minimum) £85.00 + VAT. The closing date for receipt of Classified Advertisements is the 1st day of the month preceding publication i.e. Jan-Feb issue - 1st Dec.

All Classified Advertisements must be prepaid and sent to:-

Bernie, Podiatry Review,

PRACTICE FOR SALE KENT Surgery/Domiciliary Established 15 years Turnover £30,000 on 3.5 - 4 day week.

Accounts Available £35,000 Tel 01424 882666

THE ADVERTISING DEPARTMENT, CHIROPODY REVIEW 27 Wright Street, Southport,

IOCP_Chiropody

Merseyside. PR9 0TL. Tel: 08700 110 305 or 01704 546141 Fax 01704 500477 Email: adman@iocp.org.uk

Chiropody Supplies

Practices for Sale BARNSLEY AREA - DOMICILIARY BUSINESS FOR SALE/RENT DUE TO RE-LOCATION – Routine Chiropody Treatment, Friendly Patients, Turnover Approx £28,000 For 3.5 Days - Potential for further expansion.

For more information Telephone: 0786 6332 756

www.PODWASTE.co.uk

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) Recruitment VACANCY FOR PODIATRIST/CHIROPODIST in Brand New clinic in busy pharmacy Teddington Middlesex. Contact Mrs. Gandhi 07947 806095 PODIATRIST TO JOIN BUSY CLINIC IN HESWALL WIRRAL Due to the opening of a second clinic on the Wirral.

Heswall Chiropody is now in a position to offer a posting to a Podiatrist/Chiropodist.

The Successful applicant will have at least five years experience of which at least two must be in the private sector.

Earning potential is extremely high with a choice of days worked starting with one day per week going on to three or more days.

For Further Information please telephone 0151-342-9665

Discounted rates Any size clinic/practice No long term contracts Full UK coverage Easy payments

(0800 988 7897

Info@podwaste.co.uk

AMBER CHIROPODY SUPPLIES

Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including: * Instruments & Equipment * Padding & Appliances * Dressings & Adhesives * Biomechanics

* Domiciliary * Sterilization * Diagnostics * Retail Products

To view our website/online store please visit:

www.ambersupplies.co.uk 33

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Diary of Events September 2011

West of Scotland Branch Meeting and full CPD Day 11th September 9.30 am

East Anglia Branch Meeting 11th September 10 a.m.

Barrow Village Hall, Nr Bury St Edmunds Tel: 01473 830217

Essex Branch Meeting 18th September

Presentation on the Paediatric Foot and Chemical Treatment of Verrucae Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH Tel: 01796 473705

Education Centre, Southend University Hospital, Carlingford Drive Southend on Sea Tel 01702 460890

West Middlesex Branch Meeting 12th September

Hants and Dorset Branch Meeting 14th September 7.45 p.m.

The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX Tel: 0208 903 6544

Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Talk: Tax and the small business - Elise King HMRC Tel: 01202 425568

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

Leicester and Northants Branch Meeting 4th September 10 a.m.

Kilsby Village Hall CPD Lecture on Padding and Strapping by Chris Leech TBC Registration and refreshments at 9.45 a.m.

Tel: Sue 01530 469816

October 2011 Cheshire, North Wales Staffs and Shrops Branch Meeting 2nd October at 10.00am The Dene Hotel, Hoole Road Chester CH2 3ND Tel 01244 321165

Devon and Cornwall Branch Meeting 9th October 10 a.m.

Exeter Court Hotel, Kenford, Exeter EX6 7UX Tel: 01805 603297

Leeds/Bradford Branch Meeting 6th October 10 a.m.

London Branch Meeting 7th September 7.30 p.m.

The Oakwell Motel, Low Lane, Birstall, Nr Leeds WF17 9HD Tel 01924 475338

Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 0208 586 9542

Midland Area Council 23rd October 10.00 a.m.

North West Branch Meeting 27th September 7.30 p.m.

North West Area Council 14th Annual Seminar

St Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR Tel: 0161 486 9234

Nottingham Branch Meeting 18th September 10.00 am British Red Cross Centre, Phoenix Park, Nottingham Tel: 0115 931 3492

Southern Area Council Meeting 10th September 1 p.m.

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

Western Branch Meeting 4th September at 10.30 a.m.

Seminar Room 1, The Women’s Hospital Liverpool Lecture: Biomechanics for the Terrified workshop Gareth Hicks Autoclave calibration available - contact secretary for details.

Tel: 01745 331827

Kilsby Village Hall, CV23 8XX Tel: 01386 47695 16th October start 9.30 See page 30 for details

Sheffield Branch Seminar 23rd October - 10.00a.m - 3.00 p.m.

SWD Sports Club, Heley Bank Road, Sheffield S2 3GL Tel: 01623 452711

Surrey and Berkshire Branch Meeting 10th October 7.30 p.m.

Pirbright Village Hall.

Tel: 0208 660 2822

Wolverhampton Branch Meeting 9th October 10 a.m.

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

November 2011 Birmingham Branch Meeting 17th November 8 p.m.

British Red Cross Centre, Evesham Tel: 01905 454116

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Diary of Events Essex Branch Meeting 20th November

East Anglia Branch AGM 29th January

Education Centre, Southend Univerrsity Hospital, Carlingford Drive Southend on Sea Tel 01702 460890

Haymarket Day Centre

Hants and Dorset Branch Meeting 18th November 7.45 p.m.

Our usual ‘Social Occasion of the Year’ dinner out with friends/partners/colleagues. Venue to be arranged.

Tel: 01202 425568

Tel: 01603 440828

Essex Branch Meeting and AGM 29th January Education Centre, Southend University Hospital, Carlingford Drive, Southend on Sea Tel 01702 460890

Hants and Dorset Branch AGM 9th January 2011 7.45 p.m. coffee (meeting 8 - 10 p.m.)

Leeds/Bradford Branch Meeting 6th November 10 a.m.

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

The Oakwell Motel, Low Lane, Birstall, Nr Leeds WF17 9HD Tel 01924 475338

Leicester and Northants Branch Meeting plus AGM 22nd January 10 a.m.

Leicester and Northants Branch Seminar -

Lutterworth Cricket Club LE17 4RB Registration and refreshments at 9.45 a.m.

Tel: Sue 01530 469816

Lutterworth Cricket Club LE17 4RB Lectures: Dementia: “How to interact with patients” and “effects on practice”, Plantar Fasciitis Pharmacist invited to give drug update £45 including lunch and free parking 10 a.m. start. Registration and refreshments at 9.45 a.m.

Autoclave calibration by prior arrangement (Max 12) Tel: David 01455 550111

London Branch Meeting 16th November 7.30 p.m.

Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 0208 586 9542

Sussex Branch Meeting 20th November The Bent Arms, Lindfield, West Sussex Tel: 01273 890570

West of Scotland Branch Meeting 6th November at 11.00 a.m.

London Branch AGM 18th January 7.30 p.m.

Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 0208 586 9542

Midland Area Council AGM 29th January 10.00 a.m.

Kilsby Village Hall, CV23 8XX Tel: 01386 47695

North West Branch AGM and Meeting 15th January 11 a.m.

St Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR Tel: 0161 486 9234

Nottingham Branch AGM 15th January 10.00 am

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

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

December 2011

British Red Cross Centre, Phoenix Park, Nottingham Tel: 0115 931 3492

Southern Area Council AGM 21st January 1 p.m.

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

Surrey and Berkshire Branch AGM 14th January 1.30 p.m.

Greyfriars Centre, Reading.

Leeds/Bradford Branch Meeting 4th December 10 a.m.

Tel: 0208 660 2822

The Oakwell Motel, Low Lane, Birstall, Nr Leeds WF17 9HD Tel 01924 475338

Western Branch AGM 8th January at 12.15 p.m.

Meeting at 1.45 p.m.

Seminar Room 1, The Women’s Hospital Liverpool Tel: 01745 331827

Nottingham Branch Meeting 4th December 10.00 am British Red Cross Centre, Phoenix Park, Nottingham Tel: 0115 931 3492

Scottish Area AGM 22nd January 10.30 a.m. followed by West of Scotland Branch AGM

January 2012

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

Birmingham Branch AGM 12th January 7.30 p.m.

Wolverhampton Branch AGM 15th January 10 a.m.

British Red Cross Centre, Evesham Tel: 01905 454116

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

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National Officers

Branch Secretaries

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

Birmingham

Mrs. J. Cowley

01905 454116

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. Z. Sharman

01473 830217

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Chairman Board of Education Mr. R. Sullivan, M.Inst.Ch.P., B.Sc.(Hons), Dip. Pod. Med,

Leeds/Bradford

Mr. N. Hodge

01924 475338

PGDip, Cert.L.A, FSSCh, FIChPA, MRSM

Leicester & Northants

Mrs. S. J. Foster

01234 851182

Vice-Chairman Board of Education Mr. M. Harvey, M.Inst.Ch.P., PGCE, B.Sc.

London

Mrs. F. Tenywa

0208 586 9542

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

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

North West

Mr. B. Massey

0161 486 9234

Northern Ireland Central

Miss G. Sturgess

0289 336 2538

Secretary Miss A. J. Burnett-Hurst

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Oxford

Mrs. S. Harper

01993 883397

Republic of Ireland

Mr. C. Kerans

00353 1285 3150

Sheffield

Mrs. D. Straw

01623 452711

South Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mr. S. Gourlay

0141 632 3283

Wolverhampton

Mr. D. Collett

0121 378 2888

Yorkshire Library

Mrs. J. Flatt

01909 774989

Chairman Executive Committee Mr. W. J. Liggins, F.Inst.Ch.P., F.Pod.A., B.Sc.(Hons) Vice-Chairman Executive Committee Mr. M. Holmes, M.Inst.Ch.P., D.Ch.M., B.Sc. Pod Chairman Board of Ethics Mrs. C. Johnston, M.Inst.Ch.P., B.Sc.(Hons)

Honorary Treasurer Mrs. J. Drane, M.Inst.Ch.P.

Area Council Executive Delegates Midland Area Council Mrs. V. Dunsworth, M.Inst.Ch.P., D.Ch.M. North West Area Council Mrs. M. Allison, M.Inst.Ch.P. Republic of Ireland Area Council Mrs. J. Casey, M.Inst.Ch.P., B.Sc. Scottish Area Council Mrs. A. Yorke, M.Inst.Ch.P. Southern Area Council Mr. D. Crew, OStJ, F.Inst.Ch.P., D.Ch.M., Cert.Ed. Yorkshire Area Council Mrs. J. Dillon, M.Inst.Ch.P. 36

33893 Chiropody 44ppA4 17/08/2011 13:57 Page 43

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1ST RAY TE CH

NOLOGY CH

NOLOGY

1ST RAY TE

Get your free DANANBERG Lower Limb Manipulations DVD When you order a pair of Vasyli Dananberg Orthotics*

1ST

AY

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£26.50** (pair)

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In this instructive DVD Dr. Dananberg presents a collection of lower limb manipulations including: 1st Metatarsal, Ankle, Cuboid, Knee – Popliteus, Testing Peroneous Longus and Testing Posterior Tibialis.

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LADIES

F 3-4½

F 3½-5

XSml

71HDF06

Sml

F 5-6½

F 5½-7

71HDF08

Med

F 7-8½

F 7½-9

71HDF10

Lrg

F 9-10½

F 9½-11

71HDF12

XLrg

F 11-12½

F 11½-13

+

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MEN’S 71HDF04

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Dananberg

MAL INDICATO R

VASYLI

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To get your free DVD buy a pair of Dananberg Orthotics before 31.10.11 at www.canonbury.com or by calling 01280 706661 quoting reference DNRE8.

Professional Orthotic Device with removable 1st Ray Sections

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Award winning podiatrist Dr. Howard Dananberg is renowned for his work on the development of the concepts of Functional Hallux Limitus, Sagittal Plane Biomechanics and Gait-related Lower Back Pain. Dananberg, named one of the most influential podiatrists in America by Podiatry Management Magazine, is a founder member of the Vasyli ‘ThinkTank’.

Medical

Performance through innovation

H E A L T H C A R E

W I T H

Y O U

E V E R Y

S T E P

01280 706661 www.canonbury.com *Offer is limited to one DVD per practitioner and is valid until 31.10.2011. ** Excluding VAT and delivery.