Podiatry Review September/October 2012

Podiatry Review

ISSN 1756-3291

Volume 69 No.5. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal September/October 2012

• Department of Health News • Head Office News

• The Effects of Foot Orthoses on Walking Stability in Patients with early Rheumatoid Arthritis

INSTITUTE OF CHIROPODISTS AND PODIATRISTS

SEPTEMBER/OCTOBER 2012 VOL 69 No.5

Editor Mr. W. J. Liggins FInstChP, FPodA, BSc(Hons)

Academic Editor Robert Sullivan Dip.Pod.Med., BSc (Hons), PGCert, LA., PGCert.

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

Editorial Assistant Bernadette Willey bernie@iocp.org.uk

Advertising Please contact Julie Aspinwall secretary@iocp.org.uk

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Contents

Department of Health Press Release Independent Prescribing ..................................................2 Editorial .............................................................................3

Editorial Committee Mrs. F. H. Bailey MInstChP Mr. M. Harvey M.Inst.Ch.P., B.Sc (Hons) Mrs. J. A. Drane MInstChP

ISSN 1756-3291

PODIATRY REVIEW

The Institute of Chiropodists and Podiatrists

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© The Institute of Chiropodists and Podiatrists.

The Editor and the Institute of Chiropodists and Podiatrists accept no responsibility for any opinions expressed in the articles published in the Journal; and they do not accept responsibility for any discrepancies in the information published. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior written permission of the publishers.

The Effects of Foot Orthoses on Walking Stability in Patients with early Rheumatoid Arthritis Dr. Vicki Cameron-Fiddes PhD, Dr. Derek Santos PhD, QMU ................................................4

Zoonotic Disease Pathogens in Fish used for Pedicure David W. Verner-Jeffreys, Caig Baker-Austin, Michelle J. Pond, Georgina Rimmer, Rose Kerr, David Stone, Rachel Griffin, Peter White, Nicholas Stinton, Kevin Denham, James Leigh, Nicola Jones, Matther Longshaw, Stephen Feist..................................10 Personal Profile David Collett M.Inst.Ch.P ...................................................12

Independent prescribing by Podiatrists W. J. Liggins FInstChP, FPodA, BSc(Hons) ...............................13

Tendon and Tissue Problems of Foot and Ankle Iain B. McIntosh BA(Hons) MBChB. FFTMRCGPS(Glas) ............14

Appointment Problems David Fairclough M.Inst.Ch.P .............................................16

Case Study Joanne Sweeney .............................................................18 Domiciliary Practice – My Experience Diana Grogan M.Inst.Ch.P ..................................................21

Driving and Diabetes Diabetes UK ....................................................................24 Posterior Tibial Tendon Dysfunction (PTTD) ..................28 Rambling Roads Achilles Hele ...................................................................30 Branch News ...................................................................31 Classified Adverts ............................................................33

Diary of Events ................................................................34 National Officers..............................................................36

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PRESS RELEASE

Institute of Chiropodists and Podiatrists UK-first in proposing change in law to help Podiatrists improve patient care

Health Minister gives agreement to take forward change in legislation to allow Podiatrists access to independent prescribing in a world-leading strategy to improve patient safety and care.

Southport, Merseyside, 24th July, 2012: Minister announces approval of proposal for the Medicines Act be amended allowing appropriately trained advanced practitioner Podiatrists to independently prescribe medicines to patients within their care and within their specialised scope of practice. The Institute has worked in close collaboration with the Society of Chiropodists & Podiatrists and the Department of Health on these developments.

Representatives from The Institute of Chiropodists & Podiatrists have been involved in a four year project by the Department of Health to look at proposing a change in legislation which would allow Podiatrists and Physiotherapists to provide enhanced care provision to a wide range of patients. The proposed extension to allow independent prescribing will increase patient choice without compromising patient safety. Independent prescribing would improve outcomes for patients, whilst also providing greater costeffectiveness and choice for patients and NHS commissioners.

Podiatrists would use independent prescribing where this would facilitate effective treatment for the patient, providing the right medicine at a point when it is directly needed, preventing deterioration in the patient’s health, and in preventing unnecessary hospital admissions.

Podiatrists are statutorily registered autonomous health professionals who focus on the diagnosis, management and treatment of foot and lower limb disorders. Specialist Podiatrists see many patients at high risk of amputation, e.g. those with diabetes, impaired blood supply to the lower limb, foot ulcers and wounds; or those requiring surgery, e.g. correction of deformity. The most well-known specialisms include musculoskeletal (biomechanical and gait problems, sports injuries), diabetes care (assessing risk of, and managing, foot ulcers and wounds) and rheumatology. Other specialisms are in dermatology, footwear, surgery and children’s lower limb problems. The public increasingly use NHS and independent-sector Podiatrists directly (e.g. via self-referral) for diagnosis and treatment, without contacting a doctor, but 02 | page

the Podiatrist keeps the GP informed of treatment given irrespective of the route of referral. Since the Medicines Act (1968) was introduced, Podiatrists have used medicines safely and effectively in their professional practice in a broad array of community and acute settings, with a range of medicines used, spanning musculoskeletal disorders, diabetes care, skin disorders, foot surgery, and in the care of the elderly.

Mr. Bill Liggins, Chair of the Executive Committee of the Institute of Chiropodists & Podiatrists said: “We are delighted that the Department of Health has further recognised the value of the podiatry profession in contributing to patient care, and welcome the proposed change in legislation that will allow Podiatrists to provide an even greater level of service to their patients, with safety and effectiveness at the core of care provision”.

The full Department of Health announcement can be found at: https://www.wp.dh.gov.uk/mediacentre/2012/07/24/physiot herapists-and-podiatrists-set-to-gain-prescribing-powers For more information or to request an interview, contact: Judith Barbaro-Brown email/phone: secretary@iocp.org.uk 077 010 63967 OR

Martin Harvey email/phone: secretary@iocp.org.uk 0740 163 2822

EDITORIAL As you know, an announcement was made at the 2012 A.G.M. and subsequently confirmed in the minutes, that with regret, the Institute was to dispose of the loss making clinic at Sheffield. What could not be announced (it was under embargo) was that following advice from management consultants and our own Accountant, we were negotiating the rental of a property in Southport.

The lease on the buildings in both Sheffield and the existing Head Office in Southport fall due in September of this year and the decision whether to take out another 10 year lease on both or to move on had to be made. I am very happy to inform you that the lease of 150 Lord Street, Southport, has now been agreed. This is a superb, dignified building with sufficient space for all the activities in which we wish to be involved. Lord Street is the premiere shopping and business area of Southport with large numbers of people being drawn to the sophisticated facilities. '150' as it has become known, is set back from the road with a garden frontage and is opposite the busy shopping area.

The top floor will become our new Head Office and will include a magnificent boardroom which will be rented out as a meeting room to other organisations when not required by the Institute. Another large room will be used as a teaching room for City and Guilds, CPD for the membership and other courses.

Planning permission has been obtained for a clinical area on the ground floor which will become a centre of excellence for podiatry with a small retail facility attached. In addition to podiatry, we will be encouraging part-time use by other professions to enhance the business; physiotherapy or osteopathy for example. There are eleven parking spaces available - more than enough for our use, so plans are in hand to rent out two of these to provide further income. The cost of the rental is less than that of Sheffield and the old Head Office combined, so savings will be made. We, in the Institute, quite rightly boast that we are 'the friendly one'. This extends to our staff and I can assure you that whilst one of the Sheffield staff has opted to remain with us and continue employment at the Southport clinic, the other staff are taken care of and have been found alternative employment.

This is a very exciting time for both the Institute in particular and podiatry in general and I can assure you that the Executive Committee first and foremost thinks of its members, and this move is to create a centre of excellence of which we can all be proud. Sefton Council have been enormously interested and encouraging and see our presence as a very positive innovation for Southport and the surrounding area.

There are many people who have been involved in '150' and it is invidious to pick out individuals and their contributions.

However, the sometimes difficult and frequently frustrating financial negotiations, planning permissions, condition surveys and the host of other issues pertaining to the acquisition have been dealt with by our Hon.Treasurer Jacquie Drane, frequently working late at night whilst others sleep, and I pay tribute to her on your behalf. Thank you Jacquie.

More and more podiatrists are beginning to develop a special interest in musculo-skeletal conditions, particularly Rheumatoid Arthritis, sometime known as rheumatoid disease. The condition is a diffuse connective tissue disease occurring particularly in the peripheral joints and causing active and progressive destruction of the joints. The aetiology is unknown although it is recognised as an autoimmune disorder. Females are most commonly affected and the age of onset is usually between 25-50 years of age, in contrast to the far more common osteo arthritis which is generally regarded as late onset and is associated with ‘wear and tear’ of joints. Most podiatrists will see such patients as a result of rheumatoid nodules which occur under sites subject to trauma and the resulting foot pain which can be frequently treated by relatively simple offloading measures. It is a pleasure, therefore, to read that colleagues at Queen Margaret University have been studying the relationships between rheumatoid arthritis and walking stability, with particular reference to the effects of foot orthoses. According to their paper, the use of appropriate orthoses significantly affected walking stability and they suggest that early intervention is indicated. The paper, which should be read in full, gives scientific validity to measures taken clinically and as suggested, may lead to further studies.

Members will have the opportunity to look around the facility at the 2013 conference if not before, so register your interest now!

W. J. Liggins

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ARTICLE

The Effects of Foot Orthoses on Walking Stability in Patients with Early Rheumatoid Arthritis Dr. Vicki Cameron-Fiddes PhD Dr. Derek Santos PhD, Queen Margaret University, Edinburgh Abstract Objectives. To investigate the effects of foot orthoses on walking stability in patients with RA, when walking with shoes only, and with shoes and foot orthoses.

Methods. Thirty five patients with early RA were recorded walking, with the use of the F-scan in-shoe plantar pressure measurement system. Pressure was measured at seven anatomical sites of the foot; condyle, midfoot, first metatarsal head, second metatarsal head, third to fourth metatarsal heads, fifth metatarsal head and hallux. The Timing Analysis Module (TAM) was used to display the difference between the maximum and minimum pressure values, referred to as the variance of pressure (VOP) at each anatomical site. The greater the VOP the worse the stability. Patients were measured at baseline, three months and six months.

Results. The foot orthoses significantly reduced the VOP at all anatomical sites in the foot (p<0.001). This reduction was significant between baseline and three months, baseline and six months, and three months and six months (p<0.01). A significant reduction in VOP was also seen in the no orthoses condition over the six months.

Conclusions. Foot orthoses may effect walking stability in patients with early RA, and could form part of a falls prevention programme.

Introduction RA is a chronic and progressive disease that may cause walking instability, leading to falls[1, 2]. The Prevention of Falls Network Europe (ProFaNE) describes a fall as an unexpected event in which the participant comes to rest on the ground, floor or lower level[3]. About one in three adults with RA fall each year[4, 5, 6] and those with arthritis report more injurious falls than those without arthritis[2].

Foot orthoses are worn inside the shoe to control any abnormal movement of the foot during walking, and have been reported to influence stability[7]. The effect of foot orthoses on postural stability has recently been investigated, in the general, and sporting populations[8, 9, 10]. However, up to 70% of falls occur in locomotion[11, 12] and standing postural stability tests are not closely associated with walking ability[13].

The effects of foot orthoses on walking stability in patients with RA are clinically important as patients often describe a fear of falling. A recent study showed that 60% of RA patients have a fear of falling[5]. This is higher than that previously detailed in older persons with RA[4], and higher than that 04 | page

described among community dwelling lower extremity amputees[14]. No study to date has investigated the effect of foot orthoses on walking stability in patients with RA.

Falls are often referred to as accidents, however, the incidence of falls have been shown to differ significantly from a probability distribution, which indicates that causal processes are involved in falls, and are not random events [15].

Falls occur from poor postural stability, that is, the interaction of multiple sensory, motor and integrative systems. These include reaction time, vestibular function, vision, peripheral sensation and muscle force[16]. Impairments in each of these areas are associated with increased risk of falling[3]. Risk factors for falls are three times more prevalent in RA patients as compared to controls[17]. Severe pain and disability, causing altered sensory information from the articular surfaces, capsules, and ligaments of arthritic joints, may result in poor postural stability in RA[1,2]. This includes muscle weakness and changes in gait[18,19]. Additionally, disuse and steroids can cause muscle weakness in patients with RA, as well as reduce visual acuity due to cataract formation and so implicated in postural stability[17].

Falls risk assessment and prevention in patients with RA has not been well described. The complex nature of the disease necessitates a multidisciplinary team (MDT) approach, and so falls prevention, targeting specific physiological factors, will vary throughout the MDT. In particular, podiatrists provide information about appropriate footwear, that has been shown to be an important factor associated with falls[20]. As well as footwear advice, podiatrists prescribe foot orthoses to manage foot and ankle problems associated with RA. The aim of the study is to investigate the effectiveness of foot orthoses on walking stability in patients with early RA. Method A total of 35 patients (6 males and 29 females) participated in the study from November 2006 to July 2008. The age of the participants was between 26 to 80 years (mean age 52.4 years; S.D 13.3 years). Disease duration ranged from one month, to one year and nine months (mean disease duration 0.7 years; S.D 0.6 years). No individual had been managed previously with foot orthoses. Patients with concomitant musculoskeletal disease, endocrine disorders, especially Diabetes Mellitus, and neurological disease, were also excluded from the study.

Ethical approval was granted (Fife and Forth Valley Local Research Ethics Committee) and written consent was obtained according to the declaration of Helsinki.

ARTICLE The F-scan in-shoe plantar pressure measurement system (Tekscan, Inc., Boston, MA) was used to investigate the effect of foot orthoses on walking stability, with the Timing Analysis Module (TAM). The TAM provides an array of foot striking timing parameters and information for seven anatomical sites of the foot; the condyle (the heel), the midfoot, the first metatarsal head, the second metatarsal head, the third to fourth metatarsal heads, the fifth metatarsal head, and the hallux. The variance graph shows how long each anatomical site of the foot was in contact with the sensor, as a percentage of the total stance. The entire range of recorded values for all phases of the walking trial can be viewed, referred to as the variance of pressure (VOP). Tekscan state that viewing the VOP can give the user some idea of the foot’s stability. So, the greater the VOP the poorer the stability is thought to be[21].

The data that was analysed is summarised in table one. The VOP at the condyle during the first ten percent of the gait cycle was investigated, as the loading response occurs during this time, and facilitates the heel rocker which aids postural stability[22]. During 10 to 30% of the gait cycle midstance occurs, which assists the ankle rocker. Postural stability is also achieved by the foot during midstance[22], and so VOP at the midfoot was explored during ten to 30% of the gait cycle. Terminal stance facilitates the forefoot rocker through 30%-50% of the gait cycle.

The metatarsals provide postural stability as the heel lifts off the ground and prepares for the swing phase. VOP at the metatarsals was investigated during 30%-50% of the gait cycle.

VOP at the hallux was examined during the last 10% of the stance phase of gait[22].

The study design was a within subject controlled study.

Patients presented for data collection at baseline, three months and six months. Patients randomly walked with shoes only, and with shoes and orthoses. The type of orthoses used was the Slimflex Plastic® (Algeos Ltd). Patients wore standardised footwear throughout the study. At each visit the patient was weighed in kilograms (kg) with electronic scales.

The patient conditioned the sensor insole, as recommended by the manufacturer. The sensor insole was then calibrated using the patient’s weight. Six walking trials were recorded.

The same procedure was repeated at visit two at three months, and visit three at six months. The same set of sensor insoles were used for each individual patient at each data collection session.

Results Graphs one, two and three show the mean difference in the VOP for all patients, at the seven anatomical sites at baseline, three months and six months, with the foot orthoses as compared to with no orthoses. The greater the VOP the poorer the stability is thought to be. The error bar graphs show the overall distribution of the data with a 95% confidence interval, and suggest that foot orthoses do affect walking stability in patients with RA. The mean, S.D and p value of VOP for each group is shown in table two.

The VOP at the first, second, third and fourth, and fifth metatarsal heads was parametric, and so a repeated measures

design was used. The VOP was significantly reduced with the use of the foot orthoses (p<0.01) at all the metatarsal heads.

This reduction in VOP was significant between baseline and three months, baseline and six months, and three months and six months (p<0.01). The VOP was also significantly reduced in the no orthoses condition (p<0.01) at all the metatarsal heads. Similarly, this reduction in VOP was significant between baseline and three months, baseline and six months and three months and six months (p<0.01).

The VOP at the condyle, midfoot and hallux was nonparametric, and so a Friedman’s test was used to analyse the data. The Friedman’s test was significant at the condyle, midfoot and hallux (p<0.01) with the foot orthoses. An exact Wilcoxan test with Bonferroni adjustment was then carried out to determine where the significance was occurring over the six months. The Wilcoxan test was significant (p<0.01) at the condyle, midfoot and the hallux between baseline and three months, baseline and six months, and three months and six months with the foot orthoses. The Friedman’s test was also significant in the no orthoses condition (p<0.01), and this was significant (p<0.01) between baseline and three months, baseline and six months, and three months and six months.

Discussion The aim of the study was to investigate the effectiveness of foot orthoses on walking stability in patients diagnosed with early RA. The study findings show that foot orthoses do improve walking stability in patients with RA. There are two major ways that foot orthoses can affect walking stability; biomechanically, and by altering sensory input. From a biomechanical perspective, foot orthoses can alter the kinematics and kinetics of the foot and lower limb during walking, and so reduce the stress in the tissues that cause injury and pain[23]. Foot orthoses reduce the magnitude of pathological forces and/or stresses acting on selected structural components of the foot and lower limb that are either injured or uninjured, to either heal injuries or avoid injuries, and so prevent pain[24]. Foot orthoses may affect walking stability by supporting the foot in a more structurally efficient way, and so making the patient feel more steady and secure when walking[10].

Different structural foot types for measures of standing postural control have been compared, and it was found that pronated and supinated feet have poorer postural control than individuals with neutral feet[25]. This is clinically relevant for patients with RA, who typically present with a pes planus, or a pes cavus foot type. The aim of the foot orthoses prescription is to support the foot in a more neutral position, so this enhanced alignment may also contribute to improved walking stability. A randomised clinical trial into the impact of rigid foot orthoses on balance parameters in excessively pronated feet has also been investigated[26]. They concluded that stabilisation of the rearfoot with the foot orthoses helped to maintain balance. Similarly, they explain that by limiting excessive subtalar joint pronation, internal rotation of the tibia is also limited, and so balance at the knee and lower leg is also maintained.

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ARTICLE Sensory input is essential for balance and gait, and it has been postulated that foot orthoses may affect walking stability by altering the sensory input. The effect of facilitation of sensation from plantar foot-surface boundaries on postural stabilisation in young and older adults has been reported[27]. It was concluded that mechanical facilitation of sensation from the boundaries of the plantar surface of the foot can improve the efficacy of certain types of stabilising reactions evoked by unpredictable postural perturbation. It has been suggested that this theory may be incorporated into the prescription and fabrication of foot orthoses[27]. The effect of textured foot orthotics on static and dynamic postural stability in middleaged females was investigated and it was found that there were no significant differences between the base of support[28]. They further concluded that there was no detrimental effect on postural stability. This is clinically valuable, as clinicians can prescribe foot orthoses knowing that they will not have an adverse effect on postural stability.

Foot orthoses have been shown to improve the functional and proprioceptive capabilities of both injured and not injured ankle joints[29]. Proprioception refers to joint position sense, so this suggestion is disputed, as if you change a joints position with foot orthotics, you will not improve or change the proprioceptive signal from that joint. The signal will be the same but the joint will be in a different position. What the orthoses may do is provide more signals that the central nervous system can combine with the proprioceptive signals and other inputs. One way that more signals may be provided is by the orthoses altering the pressure on the plantar mechanoreceptors, that are responsible for proprioception.

Mechanoreceptors are found in abundance in the skin on the sole of the foot[30].

The F-scan system produces a large output of data, and so selected data from certain parts of the gait cycle were analysed. The components of the gait cycle were chosen based on the principles and findings of Perry[22]. While these gait analysis theories are well recognised, it is acknowledged that the gait of a patient with RA may be altered[18]. However, the literature does not specify at what stage in the disease gait changes can occur, and so it is difficult to use such criteria to describe gait. A slow shuffling rheumatoid gait has been used to describe walking in patients with severe, and more established disease. Abnormal gait patterns in patients with early RA have not been detailed. Future research studies using gait characteristics should clearly identify and categorise the type of gait prior to data collection.

A systematic review and meta-analysis of randomised clinical trials of interventions for the prevention of falls in older adults was undertaken[31]. The paper concluded that the most effective intervention was a multifactorial falls risk assessment and management programme. They also found exercise programmes to be effective in reducing the risk of falling. The current evidence base for interventions to reduce falling in patients with RA, include rehabilitation to improve quadriceps

06 | page

sensorimotor function, and to reduce health assessment questionnaire (HAQ) scores[32]. However, dynamic exercise therapy has been found not to improve HAQ scores, and so may not reduce risk of falling[33]. No studies have shown that fall risk can be improved by reducing RA disease activity. HAQ score have been found to be associated with increased fall risk, and so could provide an easy screening tool for falls[17]. Foot pain is noted to be a significant independent predictor of poor balance and physical functioning[34]. This is in agreement with the findings of Kaz Kaz[17] who state that patients with ankle and foot symptoms were at greatest risk from falls, whereas hip involvement did not seem to have an effect. The first ever randomised clinical trial is currently being carried out to investigate the efficacy of a multi-faceted podiatry intervention to improve balance and prevent falls in older people[35]. Foot orthoses are included in this podiatry intervention programme, and findings will considerably add to the current evidence base on the effect of foot orthoses on walking stability.

The foot orthoses significantly affected walking stability between baseline and three months, and baseline and six months (p<0.01). This suggests that foot orthoses provide an almost immediate effect on walking stability, which was evident in this study by three months. The current evidence base advocates early intervention in patients with RA, to improve long-term outcome[36]. These walking stability findings are particularly relevant for patients with RA, as they further support early podiatry referral to identify orthoses need.

It should be noted that patients with RA may also indirectly benefit from foot orthoses, to improve walking stability and prevent falls. Patients with RA are often found to be less physically active than those without RA due to painful and stiff joints, and inactivity may increase fear of falling[37, 38].

Additionally, inactivity may increase the risk of some comorbid conditions, such as obesity and cardiovascular disease.

The odds of falling more than doubles with the addition of Table 1 Data analysed Anatomical Site

Gait Cycle (%)

Condyle

0 - 10

Midfoot

10 - 30

Mhead5

30 – 50

Mhead3-4

30 – 50

Mhead2

30 – 50

Mhead1

30 – 50

Hallux

50 - 60

ARTICLE each co-morbid condition[5]. Foot orthoses have been shown to limit pain[39] and so may increase physical activity levels in patients with RA, and thus indirectly prevent falls caused through inactivity.

Postural stability is typically investigated by measuring the variability in ground reaction forces beneath the feet, and the centre of pressure of these forces, referred to as postural sway.

Postural sway has been found to be a reliable and valid way to determine static balance[40]. However, up to 70% of falls happen during walking[11, 12] and standing balance tests have been found to only be moderately associated with walking ability[13]. The need for new techniques to measure walking stability was identified by Menz, Lord and Fitzpatrick[41] and they used accelerometers to measure movement patterns of the head and pelvis over irregular surfaces. The method described is based on the procedure detailed by Moe-Nilssen[42]. The F-scan in-shoe system using the VOP to report postural stability is not described elsewhere in the literature. Following on from these findings, a consequent study is currently being undertaken to compare the F-scan with the VOP, to an accelerometer, to evaluate walking stability.

Conclusion Walking instability causes falls, and patients with RA are at risk from falls. Falls prevention in RA has not been clearly described.

Foot orthoses may improve walking stability in patients diagnosed with early RA which suggests that they have a role to play in falls prevention in RA. The results suggest that clinicians can expect to see an improvement in walking stability with the use of the foot orthoses by three months. A randomised controlled trial comparing foot orthoses with a placebo intervention is required to further substantiate the effectiveness of foot orthoses on walking stability in RA. A clinical study to undertake this work is currently being implemented.

Acknowledgements The authors would like to thank Hotter for supplying the footwear and the Fife Rheumatic Diseases Unit (FRDU) for their help and support.

Graph 1 Foot Stability (Condyle and Midfoot)

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29. Jerosch J, Hoffstetter I, Bork H, Bischof M. The influence of orthoses on the proprioception of the ankle joint. Knee Surg, Sports Traumatol, Arthrosc 1995 March; 3(1): 39-46.

30. Kennedy PM, Inglis JT. Distribution and behaviour of glaborous cutaneous receptors in the human foot sole. J Physiol 2002; 538(3):995-1002.

31. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, et al. Br Med J 2004; 328:680.

32. Bearne LM, Scott DL, Hurley MV. Exercise can reverse quadriceps sensorimotor dysfunction that is associated with rheumatoid arthritis exacerbating disease activity. Rheumatology 2000; 41:157-166.

33. ven den Ende CH, Breedveld JM, Le Cassie S, Dijkmans BA, De Mug AW. Hazes JM. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomized clinical trial. Ann Rheum Dis 2000; 59 (8):615 – 621.

34. Menz HB, Lord SR. The contribution of foot problems to mobility impairment and falls in community dwelling older people. J Am Geriatr Soc 2001;49 (12):1651 – 1656.

35. Spink MJ, Menz HB, Lord SR. Efficacy of a multifaceted podiatry intervention to improve balance and prevent falls in older people: a study protocol for a randomised trial. BMC Geriatri 2008; 8:30.

36. Emery P, Breedveld FC, Dougados M, Kalden JR, Schiff MH, Smolen JS. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002; 61:290-297.

37. Ekblom B, Lorgen O, Alderin M, Fridstrom M, Satterstrom G. Physical performance in patients with rheumatoid arthritis. Scand J Rheumatol 1974; 3 (3):121-125.

38. Minor MA, Hewett JE, Webel RR, Dreisinger TE, Kay DR.Exercise tolerance and disease related measures in patients with rheumatoid arthritis and osteoarthritis. J Rheumatol 1988 June; 15 (6):905 -911.

39. Woodburn J, Helliwell PS, Barker S. Changes in 3D joint kinematics support the use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. J Rheumatol 2003; 30:2356 – 2364.

40. Suomi R, Koceja DM.Postural sway characteristics in women with lower extremity arthritis before and after and aquatic exercise intervention. Arch Phys Med Rehabil 2000; 81(6):780 – 785.

41. Menz HB, Lord SR, Fitzpatrick RC. Acceleration patterns of the head and pelvis when walking on level and irregular surfaces. Gait Posture 2003; 18(1):35-46.

42. Moe-Nilssen R. A new method for evaluating motor control in gait under real-life environmental conditions. Part 1: The instrument. Clin Biomech 1998; 13:320 – 327

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ARTICLE Graph 3 Foot Stability (Hallux)

Graph 2 Foot Stability (Metatarsals)

Group

Group

Table 2 Mean (SD) and P value for VOP Baseline Condyle Three Months Condyle Six Months Condyle Baseline Midfoot Three Months Midfoot Six Months Midfoot Baseline First Metatarsal Three Months First Metatarsal Six Months First Metatarsal Baseline Second Metatarsal Three Months Second Metatarsal Six Months Second Metatarsal Baseline Third/Fourth Metatarsals Three Months Third/Fourth Metatarsals Six Months Third/Fourth Metatarsals Baseline Fifth Metatarsal Three Months Fifth Metatarsal Six Months Fifth Metatarsal Baseline hallux Three Months Hallux Six Months Hallux

Mean (SD) of In-shoe NO Orthoses 121.43 (140.96) 67.07 (77.24) 45.52 (53.98) 29.92 (14.69) 22.40 (11.10) 15.33 (7.81) 48.19 (18.59) 34.07 (12.08) 23.94 (7.49) 31.08 (7.48) 24.62 (6.08) 18.41 (3.81) 26.49 (5.75) 23.24 (4.64) 19.61 (4.81) 22.91 (6.23) 21.13 (5.46) 17.72 (4.72) 68.93 (80.12) 64.12 (80.31) 46.03 (59.36)

Mean (SD) of In-shoe Orthoses 60.49 (53.39) 32.20 (44.25) 18.72 (29.16) 23.71 (7.41) 15.31 (6.45) 8.31 (4.41) 29.96 (10.06) 21.08 (8.14) 13.99 (6.85) 23.13 (7.29) 16.53 (5.33) 10.00 (4.09) 20.95 (5.77) 17.23 (5.24) 13.58 (6.08) 18.64 (5.69) 15.62 (4.69) 12.45 (4.63) 60.18 (69.27) 42.38 (56.16) 30.74 (43.59)

P Value 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001

Key Messages 1. Foot orthoses may aďŹ&#x20AC;ect walking stability in patients with early RA. 2. Foot orthoses could form part of a falls prevention programme in patients with early RA. 3. The F-scan in-shoe plantar pressure measurement system could provide a valid and reliable way to measure walking stability.

Acknowledgements The authors would like to thank the Fife Rheumatic Diseases Unit (FRDU) for their help and support with this study.

KEY WORDS: Walking Stability, Foot Orthoses, Rheumatoid Arthritis, F-scan, Plantar Pressure

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ARTICLE

Zoonotic Disease Pathogens in Fish used for Pedicure

David W. Verner-Jeffreys , Craig Baker-Austin, Michelle J. Pond, Georgina S. E. Rimmer, Rose Kerr, David Stone, Rachael Griffin, Peter White, Nicholas Stinton, Kevin Denham, James Leigh, Nicola Jones, Matthew Longshaw, and Stephen W. Feist

Doctor fish (Garra rufa) are freshwater cyprinid fish that naturally inhabit river basins in central Eurasia. They are widely used in the health and beauty industries in foot spas for ichthyotherapy (Kangal fish therapy or doctor fish therapy) (Figure; Technical Appendix Figure 1)(1). During these sessions, patients immerse their feet or their entire bodies in the spas, allowing the fish to feed on dead skin for cosmetic reasons or for control of psoriasis, eczema, and other skin conditions.

A survey during the spring of 2011 identified 279 fish spas in the United Kingdom, and the number has probably increased since then(1). The Fish Health Inspectorate of the Centre for Environment, Fisheries & Aquaculture Science estimates that each week 15,000–20,000 G. rufa fish are imported from Indonesia and other countries in Asia into the United Kingdom through London Heathrow Airport (the main border inspection post for the import of live fish). However, ichthyotherapy has now reportedly been banned in several US states and Canada provinces because of sanitary concerns(1). In the United Kingdom, a limited number of infections after fish pedicures have been reported(1). Unfortunately, little is known about the types of bacteria and other potential pathogens that might be carried by these fish and the potential risks that they might pose to customers or to ornamental and native fish.

On April 12, 2011, the Fish Heath Inspectorate investigated a report of a disease outbreak among 6,000 G. rufa fish from Indonesia that had been supplied to UK pedicure spas. Affected fish showed clinical signs of exophthalmia and of hemorrhage around the gills, mouth, and abdomen. More than 95% of the fish died before the remaining fish were euthanized. Histopathologic examinations identified systemic bacterial infections with small gram-positive cocci, mostly in the kidneys, spleen, and liver.

Bacterial isolates cultured from affected fish were identified as Streptococcus agalactiae (group B Streptococcus) according to a combination of biochemical test results (API Strep; bioMérieux, Marcy l’Étoile, France), Lancefield grouping with serotype B (Oxoid Limited, Basingstoke, UK), and molecular (partial 16S rRNA gene sequencing) testing methods.

Multilocus sequence typing of a representative isolate (11013; Technical Appendix Table)(2) indicated that it was a sequence type (ST) 261 S. agalactiae strain (http://pubmlst.org/sagalactiae). This same ST261 profile was first identified in an isolate (ATCC 51487) from a diseased tilapia in Israel(3). The clinical appearance of the disease and the diagnostic results suggested that S. agalactiae was the causative agent of the fish illness and deaths.

10 | page

To determine whether S. agalactiae and other bacterial pathogens might be carried more widely by these fish, from May 5, 2011, through June 30, 2011, the Fish Health Inspectorate of the Centre for Environment, Fisheries & Aquaculture Science visited Heathrow Airport 5 times to intercept and sample consignments of G. rufa from Indonesia. A taxonomically diverse range of bacteria were identified, including a Technical Appendix Figure 1. Doctor fish variety of human surrounding foot during ichthyotherapy. pathogens capable of causing invasive soft tissue infections. These pathogens included Aeromonas spp(4), potentially pathogenic clinical-type Vibrio vulnificus isolates(5), non–serotype O1 or O139 cholera toxin–negative V. cholerae isolates(6), Mycobacteria(7), and S. agalactiae(3,8). Isolates were resistant to a variety of antimicrobial drugs, including tetracyclines, fluoroquinolones, and aminoglycosides (Technical Appendix Table). Other studies have also reported high levels of multidrug resistance in bacteria associated with imported ornamental fish(9).

Water is a well-recognized source of bacterial skin infections in humans. V. vulnificus can cause wound infections and primary septicemia, resulting in high mortality rates, especially among persons with predisposing risk conditions (e.g., liver disease, diabetes, or impaired immune function)(5). S. agalactiae is a common cause of skin and soft tissue infections, especially in older adults and those with chronic diseases such as diabetes mellitus(8). Although S. agalactiae ST261 is not considered to be one of the genotypes typically associated with invasive disease in humans(3), a fish-adapted strain could eventually take advantage of the opportunity afforded by repeated exposure and thereby also affect humans. Additionally, Mycobacteria spp. can occasionally cause disease in humans through contact with fish (M. marinum), and pedicure treatments have previously been associated with M. fortuitum infections(10).

ARTICLE Recently, the risks associated with exposure to G. rufa fish were reported to be low(1). To date, there are only a limited number of reports of patients who might have been infected by this exposure route(1). However, our study raises some concerns over the extent that these fish, or their transport water, might harbor potential zoonotic disease pathogens of clinical relevance. In particular, patients with underlying conditions (such as diabetes mellitus or immunosuppression) should be discouraged from undertaking such treatments, especially if they have obvious breaks in the skin or abrasions. This risk can probably be reduced by use of disease-free fish reared in controlled facilities under high standards of husbandry and welfare.

Author affiliations: Centre for Environment, Fisheries & Aquaculture Science Weymouth Laboratory, Weymouth, UK (D.W. Verner-Jeffreys, C. Baker-Austin, M.J. Pond, G.S.E. Rimmer, R. Kerr, D. Stone, R. Griffin, P. White, N. Stinton, K. Denham, M. Longshaw, S.W. Feist); University of Nottingham, Sutton Bonington, UK (J. Leigh); Oxford Radcliffe University Hospitals, Headington, UK (N. Jones) Acknowledgment: The UK Department for Environment Food and Rural Affairs provided funding for this study through projects FA001 and FB002.

References 1. Health Protection Agency Fish Spa Working Group. Guidance on the management of the public health risks from fish pedicures: draft for consultation. 2011 Aug 31 [cited 2012 Mar 21]. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131045549 2. Jones N, Bohnsack JF, Takahashi S, Oliver KA, Chan MS, Kunst F, Multilocus sequence typing system for group B Streptococcus. J Clin Microbiol. 2003;41:2530–6. DOIPubMed 3. Evans JJ, Bohnsack JF, Klesius PH, Whiting AA, Garcia JC, Shoemaker CA, Phylogenetic relationships among Streptococcus agalactiae isolated from piscine, dolphin, bovine and human sources: a dolphin and piscine lineage associated with a fish epidemic in Kuwait is also associated with human neonatal infections in Japan. J Med Microbiol.2008;57:1369– 76. DOIPubMed 4. Janda JM, Abbott SL. The genus Aeromonas: taxonomy, pathogenicity, and infection. Clin Microbiol Rev. 2010;23:35–73. DOIPubMed 5. Jones MK. Oliver, JD. Vibrio vulnificus: disease and pathogenesis. Infect Immun.2009;77:1723–33. DOIPubMed 6. Morris JG. Non–O group-1 Vibrio cholera—a look at the epidemiology of an occasional pathogen. Epidemiol Rev. 1990;12:179–91.PubMed 7. Wagner D, Young LS. Nontuberculous mycobacterial infections: a clinical review.

Infection.2004;32:257–70. DOIPubMed 8. Skoff TH, Farley MM, Petit S, Craig AS, Schaffner W, Gershman K, Increasing burden of invasive group B streptococcal disease in non-pregnant adults, 1990–2007. Clin Infect Dis.2009;49:85–92. DOIPubMed 9. Verner-Jeffreys DW, Welch TJ, Schwarz T, Pond MJ, Woodward MJ, Haig SJ, High prevalence of multidrug-tolerant bacteria and associated antimicrobial resistance genes isolated from ornamental fish and their carriage water. PLoS ONE. 2009;4:e8388. DOIPubMed 10. De Groote MA, Huitt G. Infections due to rapidly growing mycobacteria. Clin Infect Dis.2006;42:1756–63. DOIPubMed First published in its entirety in EID journal Volume 18, Number 6 - June 2012 wwwnc.cdc.gov/eid/article/18/6/11-1782_article.htm

Article DOI: http://dx.doi.org/10.3201/eid1806.111782

Zoonotic Disease Pathogens in Fished used for Pedicure

page | 11

PERSONAL PROFILE

David Collett MInstChP Wolverhampton Branch

Like many people I didn’t know what I wanted to do when I left school and ended up working for an interior design company, where I trained as an upholsterer, upholstering everything from three piece suites to redesigning room’s at large country houses. As the company expanded, they relocated down south and unable to make the move I found myself looking for another job which came in the form of an architectural iron mongers selling just about anything you could think of and a few you couldn’t.

After a few years there I found myself becoming very disillusioned with the job and looking for a new challenge but didn’t know quite what. It was then that I saw an advert in one of the national newspapers advertising the Institute’s course and sent off for a prospectus. Upon being accepted on the course I found myself enjoying the modules and wanting to learn more.

After completing my exams I chose to do my practical training at the training school in Southport, on Lord Street and found my time there really enjoyable, and have made some lifelong friends. When all the training was over and I was back home, it was time to put what I had learnt into practice so I started a domiciliary round slowly building up my round in the local town.

After a few years and many an aching back and sore knee from all that bending down I thought it was time to make the move to a surgery. I found one for sale in a small market town near where I lived that was doing two days a week and decided to give it a go. I’m glad to say that it has gone from strength to strength and I now have a thriving business seeing to the needs of all the surrounding villages.

I suppose this is the part of my review where I talk about my interest and hobbies and say I enjoy scuba diving, bungee jumping and trekking across the frozen wastes of the Antarctic, but to be quite honest with you all, I have a busy enough time keeping up with the normal things in life. I like to meet

12 | page

up with friends over a nice meal and a good bottle of wine. My main interests are gardening and antiques, we spend a lot of our spare time at antique fairs and auctions where we can indulge our passion for antique furniture, China and silver, we are always looking for that elusive piece that will bring us our fortune so we can retire to somewhere exotic, in my dream’s!

I am currently Branch secretary for our local area (Wolverhampton Branch) where I try to make our meetings as informative and interesting and fun along the way. I also sit on the Midland Area Council which has just held a successful seminar this year, Midland Area have chosen me to represent them at the EC as their delegate which has opened up a whole new side to the institute I didn’t know existed. This has been interesting for me as I can see the progression of things carried out at branch level going right the way through to head office. At the last EC meeting I was again chosen as delegate and I have also been asked to sit on the Board of Education. At the moment a lot of exciting developments are taking place and we, as an Institute, are now taking a more academic role in education and widening our scope of practice to our members which can only be a good thing. I feel this is a very exciting time to be a member of the Institute of Chiropodists and Podiatrists with the profession taking ever greater steps to progress the profession.

I am proud to call myself a Member of the Institute of Chiropodists and Podiatrists and feel we can all hold our heads up high as one of the leading associations in the Country. If we all pull together and attend our local branch meetings and show our support for all the hard work and effort that is being done on our behalf, we can only go from strength to strength and prosper.

INFORMATION ARTICLE

page | 13

ARTICLE

Tendon and Tissue Problems of Foot and ankle Iain B. McIntosh BA(Hons)MBChB.FFTMRCGPS(Glas) Former Chiropody Schools Inspector

Tendon, musculo-skeletal foot and ankle problems are not uncommon and can cause significant impairment with walking and function. Surveys report that about 22% of the population complain of experienced foot pain in the previous month and 60% have had an episode of foot pain in the last six months. Hallux valgus, corns calluses and nail pathologies are often found on general medical examination. Age, obesity, female sex, peripheral arthritis and diabetes mellitus are all associated with foot pathology.(1.2) These problems are associated with decreased ability in activities of daily living, reduction in walking speed, disturbed balance and an increased likelihood of falls. Foot disturbance if untreated can have a considerable effect on well-being beyond the related pain and discomfort. The conditions can become chronic, for instance, Achilles tendinitis can become a tendinosis and last for periods up to two years with crippling effect, before healing ultimately occurs. Ankle, heel, toes and forefoot are most affected by musculo skeletal problems .Relatively few patients consult medical professionals about them and not all seek the attention of a podiatrist. There is a tendency for individuals to dismiss the symptoms and soldier on in the hope that time will solve the problem.

Heel pain is responsible for about a third of GP foot and ankle consultations. Pain from the postero-superior aspect of the calcaneous bone often relates to prominent exostoses on the superior border of the bone, sometimes known as a Hagland deformity,or a “pump bump”. Repeated dorsiflexion of the foot causes friction between the exostosis and the Achilles tendon near its insertion. This results in tendinopathy and inflammation of the retro calacaneal bursa and a syndrome of retrocalcaneal bursitis, exacerbated by footwear with a hard heel counter and exercise, particularly running up hill.(3)

Management aims to reduce the inflammation and mechanical irritation .The patient should avoid footwear with a rigid heel counter and use accommodative padding. Local inflammation may be reduced by ice applications, stretching exercises and antiinflammatory medications. If this fails, heel lifts or functional orthoses may be required.

Plantar heel pain is common and often caused by plantar fasciitis. The patient complains of pain in the region of the medial calcaneal tubercle. This is worse on weight bearing first thing in the morning and typically settling after walking a few steps, before returning with prolonged weight bearing. Clinically a localised area of inflammation can often be felt along the antero-medial border of the calcaneous at the attachment of the plantar fascia.

The main treatment involves stretching of the plantar fascia and the Achilles tendon, with the former thought to be more beneficial. Low-Dye adhesive taping helps to relive pain if applied for a short period of 4-5 days. There is evidence that foot orthoses offer symptom relief over longer times of several months but are no better than placebo if the condition lasts longer than a year.

Although plantar and posterior heel pain is mainly of mechanical origin, the health professional should be aware of the possibility

14 | page

of underlying systemic disease. Attachments of tendons and fascias in this area are often the site of arthropathies, such as spondylitis and arthritis. If there are doubts as to causation the patient should be referred to a primary care physician.(4)

Pain in the forefoot accounts for about 20% of non traumatic GP consultations. Pain in the ball of the foot is often referred to as metatarsalgia which is a description and not a diagnosis.

Atrophy of the intrinsic small muscles of the foot along with the plantar fat pad is common in elderly people, causing in loss of cushioning under the metatarsal heads with resulting areas of increased pressure in the forefoot and accompanying pain.

Cushioning shoe insoles can often relieve symptoms and advice to the patient as to the cause often relieves the worry that this is a more serious condition.(5.6)

Occasionally a benign Morton’s neuroma of the intermetatarsal nerves can occur where they branch into the plantar digital nerves. Often seen in women, they appear in the third and fourth metatarsal space and may be due to repeated trauma to the nerve and surrounding connective tissue. Patients complain of pain of sharp or burning nature, in the plantar aspect of the foot and inter-metarsal space at the level of the metatarsal head, or they feel they are walking “on a lump” or small stone. Clinically pain can be elicited by squeezing the metatarsals together in a medial-lateral direction and applying pressure to the intermetatarsal space by thumb. Sometimes this procedure brings an audible click which arises from the displacement of the neuroma from the inter-metatarsal space. Treatment involves patient education regarding the wear of flat footwear with adequate width in the forefoot and a well cushioned sole.

Orthoses can be helpful and metatarsal pads placed proximal to the neuroma may reduce compression between adjacent metatarsal heads and reduce symptoms. Conservative measures such as these are effective in bringing relief in 40% of cases. If there is no resolution, the neuroma may have to be excised by a surgeon with an 80% success rate.(7) Hallus valgus (the bunion) occurs in 36% of people aged over 55 years. They are not a benign condition as they can be painful. As this deformity progresses lateral deviation of the halluxand has an impact on quality of daily living. Clinically there is lateral displacement of the hallux accompanied by medial deviation of the first metatarsal resulting in progressive subluxation of the first mtp. joint. As the deformity progresses lateral deviation of the hallux begins to interfere with the normal alignment of lesser toes causing hammer toe or claw deformities. Pressure from footwear then causes painful hyperkeratotic lesions – corns and calluses - on both plantar and dorsal aspects of the foot, An adventitious bursa on the medial prominence of the bunion can also develop.

There is a multifactorial causation with 90% of people reporting a family tendency to bunions and there may be a genetic predisposition to bunions. Modifiable features such as the wear of roomy, less pointed more appropriate footwear are important.

It is interesting to note that the condition is rare in populations who walk unshod. Splints and orthoses are often recommended

ARTICLE but have limited effect on symptoms and do nothing to correct the deformity. Even after operative intervention a sizable number of patients are unsatisfied with the end result.(8)

Simple conservative measures practised by the podiatrist can alleviate if not cure. The paring away of keratotic skin and the removal of calluses reduces pressure between toes and brings pain relief and avoids the appearance of associated septic corns.

Judiciously applied padding can also relieve pressure and diminish discomfort. Many of the female afflicted continue to wear tight pointed-toe fashion shoes which continue to confine the forefoot and encourage an on-going problem.

Foot and ankle problems are common medical features presenting in primary health care(9)

The podiatrist is often first to be approached for a professional opinion and a diagnosis. Many of these problems can be alleviated by attention to keratotic lesions and appropriate cushioning and padding of foot and toes. These conditions can be crippling and good foot care especially in elderly people can ensure they remain mobile and retain a good quality of life and ability to indulge in conventional and rewarding activities of daily living into advanced old age. Sadly a considerable number become house-bound due to lesions of the foot which can be alleviated if not cured by prompt and adequate remedial measures from a podiatrist.

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References

1. Garrow AP, Silman AJ, Macfarlane GJ. The Cheshire Foot Pain and Disability Survey: a population survey assessing prevalence and associations. Pain 2004;110(1-2): 378-84 2. Dunn JE, Link CL, Felson DT, et al. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004; 159(5): 4918 3 Hung EHY, Kwok WK, Tong MMP. Haglund syndrome - A characteristic cause of posterior heel pain. Journal of the Hong Kong College of Radiologists 2009; 11(4): 183-853 4 Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and ankle, part 2: achilles tendon disorders. Am J Sports Med 2009;37(6):1223-34.

5 Landorf K, Radford J, Keenan A, Redmond A. Effectiveness of low-Dye taping for the short-term management of plantar fasciitis. Journal of the American Podiatric Medical Association 2005;95(6):525-30.

6 Landorf K, Keenan AM, Herbert RD. Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis. Journal of the American Podiatric Medical Association 2004;94:542-49.

7. Owens R, Gougoulias N, Guthrie H, Sakellariou A. Morton’s neuroma: clinical testing and imaging in 76 feet, compared to a control group. Journal of Foot & Ankle Surgery 2011;17(3):197-200.

8 Piqué-Vidal C, Solé M, Antich J. Hallux valgus inheritance: pedigree research in 350 patients with bunion deformity. The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons 2007;46(3):149.

9 M Backhouse Common musculo skeletal foot problems Geriatric Medicine 2012.May27-34

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ARTICLE

Appointment Problems David Fairclough, MInstChP Western Branch I believe I can say with some certainty that there is not a chiropodist alive that does not have some problems on an ongoing basis with appointment mix ups. How many times have you received a phone call or picked up a voice mail complaining that you have not turned up at the allotted time and date, or had a patient turn up at clinic for an appointment unexpectedly.

Yes, the practitioner may possibly be to blame, and if it is something we experience more than on the odd occasion, and it's down to our neglect, we need to address it effectively if we want to maintain a professional practice. However, if we are organising our practice correctly and effectively we often find that the mistake is down to the patient, though they often don't see it that way, and we need to be diplomatic while biting our lips and somehow fit them in as an act of good will; though the patient sees it as you trying to correct your mistake.

There are though, a number of strategies every practitioner can employ to dramatically reduce appointment problems and keep the practice organised, effective, and profitable.

First let us take a look at the problem in respect of domiciliary visits. If you happen to be both clinic based and domiciliary, make sure you do not make double booking. Is it possible a colleague at the clinic may be booking appointments for you while you are taking bookings whilst out? There are a number of simple solutions to this problem, including using a secure web-based appointment system or calendar that can be accessed via a smart phone so removing the possibility of double booking.

When making your next appointment with your patient you need to have a clear booking procedure to follow in order to avoid problems. This soon becomes second nature and does not present any extra effort.

Rule number one is; always write down the appointment time for the patient and give it to them. Verbal appointments are open to misunderstanding. This is the most common way for appointments to get mixed up. If you have to give them a time and date for them to record, e.g. on the telephone, speak slowly and clearly and then ask them to repeat it to make sure you both have the same information.

It may be useful to compose a purpose made appointment sheet that is large, say A4, making it harder to misplace than a business card. This should have your contact details at the top in case they need to cancel or alter the appointment. A sheet of this size should be able to list over 20 appointments in chronological order. Keeping a list of chronological appointments in one location prevents your patient looking at old appointment / business cards and mixing up times and dates which is another common cause of mix ups.

16 | page

One way to include an appointment sheet is to include it as part of a practice information pack. This may take the form of a booklet, or a collection of A4 sheets of paper giving a comprehensive breakdown on the practice. You will also have the opportunity to include booking and cancellation procedures in detail. When all the appointments in this have been filled, it will be time to issue your patient with a new updated practice information publication

If your patient has an appointment on a card, retain this old card and issue a new card in its place. Many older people like to use a traditional calendar and often ask you to enter the appointment on this, if so make it clear and simple and write in clear print, not double writing.

You may wish to consider using simple terminology such as ‘feet’ instead of chiropody, or podiatry which can easily cause confusion, particularly in the elderly. An example on a dated calendar would be FEET 10am. It is advisable to insert your phone number after this to save them looking for your number in case they need to phone you.

One major problem with calendars is the New Year. Many patients making their next appointment in November and December for the following year, do not have their next year's calendar, they seem to get these as part of their Christmas box, or if they have it they feel it unlucky to add any content until the new year has arrived. They will often put the appointment at the end of their current calendar with the intention of moving it forward onto the new calendar. However, this is often not done and we get a surge of appointment problems during January and February. Make sure you always give an additional written appointment time if this is the case.

Another problem for the domiciliary practitioner, which occasionally happens, is you arrive at a patient’s house and there is no reply. We have a few other considerations in this situation, if the patient is elderly and frail, or possibly disabled /vulnerable we must consider that they may have had a fall or accident. We may try and phone their home number from a mobile or contact a neighbour if we have any worries. It is at times a justifiable reason to check though windows if we have any serious worries.

When we find our patient has gone out and we have possibly been forgotten about, a simple polite note on the back of a business card often brings profuse apologies and a genuine reason for the mix up. Fortunately broken appointments on home visits are far fewer in the clinic environment.

We will though, on occasions, inherit a patient that does make a habit of breaking appointments, even without letting us know. We may turn up to on a regular basis to find they are out; ill; doing something else more important; had their feet done elsewhere etc.

ARTICLE This is of course something we cannot run with for too long, and it does need to be firmly dealt with in a tactful manner. We may politely inform the patient that we will need to make a charge for broken appointments in the future. Should they take any offence by this and decide to go elsewhere in future, your practice will only gain by it.

However, before things come to this, we may try to employ other tactics to resolve the problem. One is to phone the day before and ask if the patient is still able to keep the appointment.

This will hopefully make the patient realise that your time is valuable and ensure you are not let down again.

The patient that always breaks an appointment or continually cancels at the last minute may also expect you to fit them in very soon after the broken appointment. We must take care that in trying to do so does not inconvenience our other patients who always keep good time with appointments. If a patient who has broken an appointment has to wait a little while longer for their next appointment, they will understand you are only able to do so many patients in a week. I am not saying make them wait to prove a point, but do not let down other patients by trying to fit them in when time is very tight.

In the clinic we tend to have a greater number of patients who break their appointments. Often if it is a first time patient we will possibly never see them again and there is little we can do about it. With regular patients that may be frail, we may wish to

telephone them at a quiet moment, mainly to see that they are alright and if they need anybody contacting if they happen to have any problems.

You may, if you happen to have a high number of failures to attend, display a number on the clinic wall of those that failed to turn up. This will have the effect of making the patient who broke an appointment feel a pang of guilt without having to point fingers, it could read like: In July, 21 patients failed to attend appointments, if you cannot keep your appointment,, please let us know, thank you.

Appointments that patients have on a regular basis are much easier to manage. Mrs A may have an appointment on a Thursday afternoon at 4.30pm every six weeks. This is great as you are able to book ahead for the year to avoid any overbooking, however, there is at some point going to be an alteration to this pattern due to Christmas, holidays and countless other events that will crop up. It is advisable to make a note of the reason so you can remind your patient for the reason if there is any confusion.

I hope that the above may be of some help to other practitioners, they are though simply the way I try to handle my appointments. It is of course not perfect and I would welcome any ideas and strategies you may have in dealing with appointment problems. If you have any advice or comments on the subject please let me know: dafclinic@hotmail.co.uk

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CASE STUDY

CASE STUDY

18 | page

Joanne Sweeney

Cosyfeet Award Winner 2011

CASE STUDY

Fig 1. Wound after 4 weeks regular wound debirdement and oďŹ&#x201E;oading with felt only

References 1. Scottish Intercollegiate Guidelines Network. 116-Management of Diabetes. A National Clinical Guideline. Edinburgh.

2. Bianchi J, Gray D, Timmons J, Meaume S., Do all foam dressings have the same efficacy in the treatment of chronic wounds? Wounds UK 2011: 7 (1) 3. Cutting K, Kearsley EB, Amlani A. Hyiodine in action. Supplement to the Diabetic Foot Journal 2011; 14(4)

Fig 2. Wound after 8 weeks wound care and felt oďŹ&#x20AC; loading with additional strapping

Conclusion

In conclusion, this case was not managed with typical western appliances, however the theory and rationale for each intervention follows western methods. A workable solution for each component was found and healing was achieved. Further to this, last contact with the patient revealed the medium term management was appropriate and the wound currently remains closed (24th January 2012).

page | 19

PRESS RELEASE

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20 | page

INFORMATION ARTICLE

Domiciliary Practice – My Experience

By Diana Grogan, M.Inst.Ch.P North West Branch

Aim This is an article to all chiropodists/podiatrists to remind them of the pitfalls of practice outside the surgery environment. This is based on my last twelve years’ experience of nursing and care homes.

History I have had some homes that I left because after months of trying to organise them there is no continuity of care. This happened with one 92 year old gentleman who had an infected corn that went to the bone. I was not aware of this the first time that I saw this man. I referred him to his GP because there was necrosis to the tissue of the toe and it needed cleaning and draining under sterile conditions in hospital. His GP flatly refused to send him. The home then asked for the district nurses to visit. They state, certainly in Lancashire, that they do not attend foot problems, even to dress a wound. Other residents would have no money provided for chiropody so would not be seen for months, then problems are exacerbated and I was getting the fault laid at my door, yet the home has a duty of care to the residents and I was going every 6 weeks. I wrote and left after giving them twelve weeks (two rotations) to replace me, I cited that it was my concern of not being able to provide continuity of care.

The other case involves four homes around Lytham and St. Annes. These I have done for four and a half years with no problems.

The first home was the biggest and I started at 8.15 am. I took pre autoclaved instruments and a portable autoclave for resterilizing of instruments. I was based in the ‘sun lounge’. At my last rotation I was told I would have to move to the bathroom, which had a bath in the middle and no wheelchair access around it. The residents were sat next to the toilet, which had no lid on. Worse still, the electrical access point was twelve metres down the next corridor! The home’s attitude was “well that is what the hairdresser does; she runs several extension cables down the corridor to the bathroom”. This is a breach of Health and Safety regulations (Health and Safety Act 2004 1) not only for the cable and 240vs in a bathroom but the hazard of a resident falling over the cable, as there were bedrooms down that corridor. My only other option was to put the autoclave out of my sight down the corridor, which was worse than the electrical cable. In the end for that visit, I put the autoclave in the corner behind the bathroom door to be as safe as I could.

The next home; I used to use a bathroom and sterilise with precept but this is over four years ago. Since then I have used various small lounges until recently when I was moved to the ‘hairdressing’ room. I had power and agreed it would be fine providing they cleaned it before use as it was dirty and didn’t look like it had been cleaned in months.

The third home; I always used a bathroom but all instruments were sterilised before leaving the second one.

The fourth home; I had no problems, I always used a small lounge, and this was set to continue. Therefore, if the CQC really did have a policy on waste in a lounge environment then it would apply across the board.

The manager of Care home 1 (owner’s son) cited CQC regulations (Care Quality Commission) claiming this was the cause of the change. He stated that the potential waste matter was the problem for CQC and that they are ‘hot’ on this. This is a ruse to put you off pursuing a better environment. The CQC have no guidelines and no regulations on this matter. They are not interested.

The next point is Health and Safety. He had no issue with the extension cable of which a resident could fall over and the potential of electrocution by having 240vs in a bathroom. If either happened then both you and the home would be liable.

The home for breach of HSE rules 2 and negligence and you for allowing the situation to happen. The HSE WILL go after you, and these are imprisonable offences. (Health and Safety at Work Act 2004 1)

I pointed all this out The home then banned me from their premises. This then caused another headache as they then breach the Care Home Regulations Act 20013 which state that residents can see any medical practitioner they want. This is controlled by the local authority, and the homes then breach the residents’ rights and this will cause an investigation of restricted practice, which is a legislative breach and is serious in the eyes of the local authority.

Conclusion Please be aware of the conditions of which you are working.

If you are in a bathroom then the potential for cross infection is huge and this could come back on you, especially if it hasn’t been cleaned properly and there is a great risk of Clostridium Difficile infections if it is present in the home, and you may not be told about it. In my experience the homes NEVER tell you of infections, like this. With one exception, Leonard Cheshire have a process to deal with all patients on discharge from hospital and that is to assume all are infected with MRSA so full gowning procedures are put in place until swabs come back clear.

NEVER breach Health and Safety Regulations, these are the most onerous and jailbait! There is a reason that there are no 240v sockets in a bathroom. Water and electricity = electrocution and possible death. Again you would be responsible and could again be jailed if something goes amiss, that is you rather than the home. The home will deny that they had any involvement in what you did.

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INFORMATION ARTICLE Cleaning and Sterilisation Sterilization of instruments is changing. Even for nursing homes I carry a portable ultrasonic bath and tub of cleaner.

Some of you maybe have homes that will pay for single use instruments but those that I attend will not, so it is ultrasonics and autoclaves and ‘dressit’ packs to ensure and maintain a high degree of cleanliness and less chance of cross infection, but this is dependent upon the standard of overall cleanliness of the homes.

The Health Act 2006 4 (applicable to NHS bodies and best practice for non NHS practices) and guidance from NHS Estates and Medical and Healthcare products (MHRA) strongly recommend that surgical instruments are single use or if reuseable the process of decontamination takes place in a Sterile Services Dept. As most chiropodists do not have this facility then a caveat is in place. This states that re-usable equipment should be appropriately decontaminated between each patient using a risk assessment model.

The following terms have been adapted from the Department of Health, HSG (93)26, 1993a.

Cleaning: ‘is a process which physically removes contamination but does not necessarily destroy microorganisms. The reduction of microbial contamination cannot be defined and will depend on many factors including the efficiency of the cleaning process and the initial bio -burden. This now incorporates the use of ultrasonic cleaning baths and fluid.

Cleaning is the first step in the decontamination process. It must be carried out before disinfection and sterilisation to make the process effective. Thorough cleaning is extremely important in reducing the possible transmission of all micro-organisms, including the abnormal prion protein vCJD. Mechanical cleaning using a disinfection or ultrasonic bath is recommended (2006) now mandatory (2011). Blood covered instruments should be washed in cold water prior to thorough cleaning with detergent (fluid or enzyme in the ultrasonic bath will usually suffice). I usually soak in bleach first prior to ultrasonic cleaning. See ‘A Protocol for the local decontamination of surgical instruments’ (March 2001).

Ultrasonic baths If heavily used then the solution may need changing more regularly during any one operating session. There is full protocol list but I do not propose to list the obvious. See www.virox.com.

Remember instruments may need one or more treatments in the ultrasonic cleaner.

Disinfection ‘is a process used to reduce the number of viable micro-organisms, which may not necessarily inactivate some viruses and bacterial spores’. Disinfection will not achieve the same reduction in microbial contamination as sterilisation.

Sterilisation ‘is a process used to render the object free from viable micro-organisms, including spores and viruses.’ Use of bench top autoclaves.

22 | page

Risk assessment Medical equipment is categorised according to the risk that particular procedures pose to patients- by assessing the microbial status of the body area being treated. For example, items that come into contact with intact mucus membranes are classed as intermediate risk and require disinfection between each use as a minimum standard. Items that are associated with high microbial areas and come into contact with broken membranes are classified as high risk and must be sterilised before and decontaminated after use. Feet would come into this category especially O/C and infected corns.

Even some of the cleanest homes are a breeding ground for cross infections, and especially a bathroom. (Hospital Infection Society Working Party on Infection Control and Operating Theatres 20025).

I worked in a sterile area making medical injections for eight years. We grew botulism in the triple sterile filtered antiseptic sprays. My advice is do not work in a bathroom. One home did tell me the Care Quality Commission had told them not to put a chiropodist in the bathroom. Again CQC state they have no guidelines on this issue as it is outside their jurisdiction. It is also not in the Care Home Regulations 2001 available on the internet.

INFORMATION ARTICLE Summary Be aware of the dangers put in front of you and if you feel the situation put in front of you is not satisfactory DON’T do it. You may well want the money but the loss of your job, reputation and a chance of going to jail if something goes amiss albeit small is not worth it.

I got told not to return to my four homes as I would not breach Health and Safety Regulations to run extension cables to the bathroom, not only for the power point problem but the risk of a resident falling over it, down a corridor where there are bedrooms and wandering residents. This is more preferable as I can pick up other work, if there is an accident or an electrocution then everything I have worked for goes up in smoke and I could potentially be jailed. Not worth the RISK. I have researched this to its entirety and have got nowhere. I would not want to go back as the risk is too great. My sympathies go out to my poor patients that now lose their continuity of care. All the carers, I know are horrified at what has happened. One told me they are no longer allowed to paint ladies finger nails with the same nail varnish as each has to have her own pot, I don’t see this happening in the nail salons, yet I was expected to do a profession allied to medicine service in a bathroom/dirty hairdressing room!

Also be aware of the pitfalls of the homes trying to bully you into doing something that under normal circumstances you would never ever consider. They will always push the blame onto you to protect themselves and their breach of duty of care (Care Home Regulations 2001) and you would be appear to be compliant and therefore, equally culpable in the alleged breach.

They will also quote non-existent regulations to intimidate you into complying with their ‘procedures’. Note procedures are guidelines in house and have no basis in Law. This applies also to the court, they quote Civil Procedure Rules available on the HMRC service website or from any Court (CPR), but these are guidelines not Law. On talking to the Institute everything I have stated is correct but they again have no jurisdiction over the homes and nor should they. But, they will try to protect you and their message is also to follow your own instincts and if you think it is wrong then walk away.

I am writing this article to protect others of this profession and to give you the pointers to avoid the situation. Anyone wanting these homes around Lytham I would say walk away.

The grapevine tells me there are more problems to come, not least of all what is happening to upset their staff that will be bailing quicker than rats’ from a sinking ship!

References: 1.

2.

3.

4.

Health and Safety at Work Act (2004) Health and Safety Executive (1994) Care Home Regulations 2001 Part III, 12-1(a)(b)© 13-1 (a)(b)© Health Act 2006. Code of Practice for the Prevention and control of Healthcare Associated Infections. Dept of Health.

5. Hospital Infection Society Working Party on Infection Control and Operating Theatres 2002

For full account of the process of sterilisation go to www.virox.com

Editor’s Note: The opinions expressed in the article are those of the author and do not necessarily reflect the views of the Institute of Chiropodists and Podiatrists.

Congratulations to (left to right) Lisa Whitehouse-Foskett, Julie Booth, Lourdes Towson- Rodriguez, and Andrew Brunger who Graduated from Durham School of Podiatry with their BSc in Podiatry on Friday, 6th July 2012

page | 23

DIABETES NEWS

Diabetes UK Position Statement

DRIVING AND DIABETES Key points Changes resulting from an EC directive have led to the introduction of stricter rules for drivers of cars and motorcycles (Group 1 vehicles) when people treated with insulin apply or reapply for licences.

In contrast, the ban on people treated with insulin driving lorries and passenger carrying vehicles (Group 2 vehicles) has been lifted. These drivers can now apply for a licence, but must have an annual independent medical assessment to prove their fitness to drive, which includes providing evidence of safe glycaemic control based on frequent and regular meter readings.

Diabetes UK generally welcomes the changes for Group 2 licences as we do not believe in blanket bans and have always campaigned for people to be individually assessed for their fitness to drive.

However, Diabetes UK has concerns about aspects of the changes to the rules for Group 1 licences and we are working with the DVLA to address these and ensure that people with diabetes are not unfairly discriminated against in the licence application process.

Introduction Diabetes UK has always campaigned to ensure that people with diabetes are assessed fairly for their fitness to drive. We believe that all people with diabetes should be able to drive if they can prove their medical fitness. We maintain that people with diabetes pose no greater risk than other drivers and indeed there is no compelling evidence to suggest that they are more likely to have an accident than other drivers provided they take all necessary precautions. A review of the evidence for the European Working Group on Diabetes and Driving (1) found that any differences in risk were small compared with the differences in risk seen in the general population. A study in the UK (2) concluded that people using insulin did not pose a greater risk than the general driving population. There is some evidence, however, that recent severe hypoglycaemia or hypoglycaemic unawareness may be a predictor for future accidents (3).

24 | page

The charity for people with diabetes

Diabetes UK agrees that a person with diabetes should not be issued a licence if they cannot prove their medical fitness to drive. However, they should always be given the right to undergo assessment and the right to challenge a decision if their licence is revoked.

Diabetes UK advises people with diabetes on driving safely, in line with DVLA advice.

Current DVLA driving guidelines and restrictions for people with diabetes.

There are no restrictions for people who are on medications that do not cause hypoglycaemia.

People must inform the DVLA: If they use insulin or start to use insulin when they already have a licence If their condition changes; for example, if they develop complications which can affect their ability to drive such as retinopathy resulting in visual problems, or peripheral neuropathy (loss of sensation in the feet due to nerve damage), or a stroke interfering with sight, muscle strength or balance or other serious medical condition – even if their diabetes is not treated with insulin.

If they require laser treatment for retinopathy in both eyes (or in the remaining eye if they have sight in only one eye).

If they are experiencing recurrent severe hypoglycaemia (whether treated by medication or insulin) – see below.

People who have group 1 licences and are using sulphonylureas which may cause hypoglycaemia are not expected to inform the DVLA that they are treated by these medications and are not issued with a restricted licence.

Group 1 vehicles – cars and motorcycles For insulin users licences for cars and motorcycles (Group 1) are issued for one, two or three years, depending on the individual person’s medical condition.

Driving licences can be revoked or not issued if a person has recurrent severe hypoglycaemia, which is defined by the DVLA as ‘more than one episode of hypoglycaemia during a period of 12 months that required assistance from another person’. (This means 2 or more episodes in a 12 month

DIABETES NEWS period). Licences may also be revoked if someone has impaired awareness of hypoglycaemia and the DVLA require this if there is complete unawareness. Whilst the DVLA guidance does not define hypoglycaemia or hypoglycaemia unawareness, the Association of British Clinical Diabetologists (ABCD) has published guidance on this.

This states that as there is evidence for cognitive dysfunction around 3mmol/L, people who are asymptomatic when under this glucose concentration are at risk for impaired performance without awareness.

Given the inter-person variability for this and the margin for error in home glucose monitoring, a clinical assessment is advised (4).

Whilst people are not required to notify the DVLA if they are taking tablet medications that can cause hypoglycaemia (most commonly sulphonylureas see htt p : / / w w w. d i a b e te s . o rg . u k / G u i d e - to d i a b e te s / Living_with_diabetes/Driving/Hypoglycaemia/), they must inform the DVLA if they have experienced more than one severe hypoglycaemic episode in 12 months due to these medications.

Group 2 vehicles (LGVs and PCVs) From November 15th 2011 the blanket ban for insulin users for Group 2 vehicles – which includes lorries (large goods vehicles - LGVs) and passenger carrying vehicles (PCVs) was lifted. People being treated by insulin are now allowed to apply for a Group 2 licence providing they meet strict medical criteria and can demonstrate that they have adequate control of the condition with regular blood glucose monitoring. People with Group 2 vehicle licences who are treated with insulin will have to undergo annual independent medical assessments and show three month’s worth of blood glucose test results recorded on a memory blood glucose meter to demonstrate that their diabetes is adequately controlled.

People who start taking insulin to treat their diabetes (or who are newly diagnosed with Type 1) will need to take at least a three month break from driving Group 2 vehicles in order that they can show three months of blood glucose readings recorded on a memory meter to demonstrate that their diabetes is well controlled.

Concerns and implications Group 1 licences New standards for assessing fitness to drive for people with diabetes mean that people may have their licences revoked if they have recurrent severe hypoglycaemia.

Recurrent means more than one episode in a 12 month period and severe is defined as “requiring assistance from another person”.

People can also have licences revoked if they have reduced awareness of the warning signs of hypoglycaemia.

Diabetes UK has concerns about the way that these new standards are being implemented. It is important that people recognise that most hypoglycaemia is not severe and can be easily treated by the person themselves. It is only if the assistance is actually needed, because the person is unable to manage themselves, that would count as a reportable episode. If assistance is offered and received, but not needed, this would not be reportable. People can also experience severe hypoglycaemia on a temporary basis due to illness or an underlying condition that is resolved.

We also have concerns about the inclusion of severe night-time hypoglycaemia in the reportable incidents as the evidence for the impact that night-time hypoglycaemia has on driving is not clear.

Diabetes UK is aware that some people are putting their health at risk in order that they do not risk losing their driving licence; for instance by keeping their blood glucose high to avoid hypoglycaemia.

Diabetes UK is also concerned about the impact that the changes in the regulations for Group 1 drivers are having on the relationship between people with diabetes and their health care professionals. There are concerns that people will not report severe hypoglycaemic events or reduced awareness of hypoglycaemia (both of which can often be addressed with medical advice) as this could put their licence at risk.

We are working with the DVLA to ensure that the standards are communicated clearly and interpreted correctly by people with diabetes and health professionals in order that people are not needlessly having licences revoked or experiencing delays in getting their licences reissued.

We are also working with the DVLA to monitor the impact of the changes on people with diabetes and road safety.

We are also working in the UK and Europe to monitor the impact of the changes on drivers with diabetes.

Group 2 licences Diabetes UK believes that insulin users should be subject to rigorous individual medical assessment to prove their medical fitness to drive lorries and buses and has welcomed the changes that remove a blanket ban for people on insulin driving these vehicles.

Diabetes UK is concerned that, under the new rules, people who are newly diagnosed with Type 1 or those with Type 2 who are moving to insulin will have to take a break of up to six months from driving Group 2 vehicles in order

page | 25

DIABETES NEWS to go through the licensing procedure. This will be difficult for some vocational drivers.

Diabetes UK calls to action DVLA / Department of Transport should monitor the implementation of the changes and regularly publish how many people with diabetes are having their licences revoked and the reasons why.

DVLA / Department of Transport should monitor the impact of the changes on road safety.

DVLA should improve the guidance given to people with diabetes and to healthcare professions about the driving licence application and renewal process in order that it is fair and transparent.

DVLA should publish data showing how they currently meet targets for issuing and renewing medically restricted driving licences and take steps to reduce the delays experienced by people with diabetes when applying and reapplying for driving licences.

Conclusion Diabetes UK is working with the DVLA to improve the process for people with diabetes applying for driving licences and to monitor the impact of the changes. We will continue to work to ensure that the process is fair and transparent.

People with diabetes should be advised not to drive

• if they have just started to take insulin and their diabetes is not yet properly controlled • if they have difficulty in recognising the early symptoms of hypoglycaemia

• if their blood glucose level is less than 4.0 mmol/l or they feel hypoglycaemic

• if they have any problems with their eyesight that cannot be corrected by glasses / contact lenses.

Advice to people with diabetes who drive should include:• avoid long or stressful journeys if tired.

• if treated with insulin, test your blood glucose level before driving and regularly during a long drive – preferably every two hours.

• consult your doctor or diabetes specialist nurse if you have any worries on any of these points.

• inform the DVLA of your diabetes if you are treated with insulin.

26 | page

• inform the DVLA if you have any problems associated with your diabetes.

• keep copies of all correspondence with DVLA.

• ensure that you tell the doctor who looks after your diabetes about any episodes of severe hypoglycaemia so that they can be recorded appropriately in your notes with the date and circumstances of the event.

• keep in touch with your doctor, especially when they are communicating with the DVLA.

Further information http://www.diabetes.org.uk/Guide-todiabetes/ Living_with_diabetes/Driving/ http://www.diabetes.org.uk/Get_involved/Campaigning/ http://www.dft.gov.uk/dvla/medical.aspx http://www.diabetes.org.uk/upload/Guide%20to%20diabetes/ Living%20with% 20diabetes/driving/DVLA%20Group%202%20info%20booklet. pdf http://www.diabetes.org.uk/Professionals/News-updatesandalerts/ Updates/Driving-and-the-new-medical-standards-forpeoplewith-diabetes/ Diabetes UK Careline is staffed by trained counsellors, who can provide support and information about living with diabetes (including driving issues) Telephone 0845 120 2960 (operates a translation service) or call 020 7424 1000 and ask to be transferred to Careline.

Monday to Friday, 9:00am–5:00pm.

Textphone 020 7424 1031 (for people hard of hearing or deaf) Email careline@diabetes.org.uk

References 1. Professor Christian Berne et al, Diabetes and Driving in Europe, A report of the Second European Working Group on Diabetes and Driving, an advisory board to the Driving Licence Committee of the European Union, 2006

2. MacLeod KM “Diabetes and driving: towards equitable, evidence- based decision-making” Diabetes Medicine, 16, 282290, 1999; Lonnen KF et al “Road traffic accidents and diabetes: insulin use does not determine risk”, Diabetes Medicine 2008; 25(5):

PRESS RELEASE

Cosyfeet Announces Two Winners Due to the exceptional standard of entries this year, two students have been awarded the Cosyfeet Podiatry Award 2012.

Henry Lee, a ďŹ nal year Podiatry student at the University of Southampton, has been awarded ,1000 towards his planned learning programme in South east Asia. Here he will research alternative models and local approaches to the management of lower limb conditions which might be unknown to the wider world. He hopes to bring back new knowledge from the communities he visits, and through the exchange of ideas, explore how he can make long term, sustainable contributions to them.

Alia Sohail, a third year Podiatry student studying at Glasgow Caledonian University, has been awarded ,500 towards her work at the Prince of Wales hospital, Hong Kong. Here she plans to learn about local podiatry practice and help to educate Diabetes patients about proper foot care so as to prevent ulceration. She will also assist in the treatment of patients with leprosy, and those who have problems associated with Chinese foot binding, which was outlawed in 1948.

The Cosyfeet Podiatry Award assists podiatrists and podiatry students to develop their professional knowledge and skills while beneďŹ tting others. The award is open to those who are planning voluntary work, a work placement or research, whether in the UK or abroad. It is designed to contribute to travel and living expenses.

Henry Lee and Alia Sohail

â&#x20AC;&#x153;The standard of entries in this yearâ&#x20AC;&#x2122;s Podiatry Award has been outstanding,â&#x20AC;? says Cosyfeet Managing Director, Andrew Peirce. â&#x20AC;&#x153;We just couldnâ&#x20AC;&#x2122;t select a single entrant, and weâ&#x20AC;&#x2122;re delighted to be helping two people this year with such vital and interesting work.â&#x20AC;?

Cosyfeet is the UKâ&#x20AC;&#x2122;s leading supplier of footwear, socks and hosiery for extra wide, swollen or problem feet. 9,000 health professionals recommend Cosyfeet products to their patients. For more information email prof@cosyfeet.co.uk or call 01458 447275 For more information about the Cosyfeet Podiatry Award see www.cosyfeet.com/professionals.

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page | 27

CONDITIONS CORNER

Condition Corner: Posterior Tibial Tendon Dysfunction (PTTD)

The Posterior Tibial Tendon stabilises the hind foot against eversion and is subject to overuse.

Its overuse can occur due to tight posterior muscles and excessive pronation; this combination can cause the Posterior Tibial Tendon to be put under excess stress.

Later stages in adults can be called Adult Acquired Flat Foot, where the foot morphology changes. This condition is characterised by pain and a ‘bruising’ feeling along the medial side of the leg during activity.

What causes PTTD? • Non-steroidal anti-inflammatory drugs Overuse of the Posterior Tibial Tendon is often the (NSAIDs). cause of PTTD. The symptoms usually occur after • Shoe with a medial flare. activities that involve the tendon, such as running, walking, hiking, or climbing stairs. The patient often When Is Surgery Needed? has an unstable mid-foot characterised by an early heel • Fracture or dislocation. lift and a secondary pronation.

• Tendon laceration.

Symptoms: • Tarsal Coalition.

• Pain.

• Arthritis.

• Swelling.

• Neuropathy.

• Flattening of the arch.

• Neurological weakness.

Initially develops with pain along the course of

• •

the tendon.

Insertional pain described as a tearing pain around the Navicular.

Diagnoses: • Tenderness on palpation of the tendon.

• Inability to re-supinate the foot.

• Unstable mid-foot.

• Early heel lift during the gait cycle.

• Secondary pronation during heel lift.

Non-surgical Treatment: • Orthotic devices or bracing to support, immobilise or minimise exertion upon the tendon.

• Use of a Kirby Skive/Medial Heel combined with a Medial Flange.

• Short-leg cast or boot is worn to immobilise the foot and allow the tendon to heal.

• Physical therapy and strengthening exercises.

• Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilisation.

28 | page

Adaption: Medial Flange A Medial Flange is an adaption made to the medial side of an orthotic. This involves increasing the height of the medial border up to the Navicular, enhancing the level of support and control against medial drifting.

It is important to ensure that a deep cast is used when you require a flange higher than normal. This adaption is often used in conjunction with a Kirby Skive; which is designed to add more control to a heavily pronated foot type that would have a medially deviated Subtalar Joint Axis.

Indications for use: • Large amounts of Medial drift of the Navicular on weight bearing (drop and drift test).

• Tibialis Posterior Tendon Dysfunction.

• Prevent irritation on the medial edge of the device if patient is bulging over the side.

• Provide greater control and stability to the medial arch.

Socks for Crisis Guests

Cosyfeet will donate 500 pairs of socks to homeless people attending Crisis at Christmas centres across London from 23rd to 30th December this year. The socks will be offered to users of the volunteer podiatry service provided over the Christmas period.

EDUCATION Crisis at Christmas welcomed 3,200 guests in 2011. More than 350 of them saw a podiatrist. The charity is actively seeking volunteer podiatrists for the 2012 Christmas period.

For further information, contact the Crisis at Christmas volunteering team on 0844 892 8980 or visit the Crisis website www.crisis.org.uk/volunteering

Crisis is a national charity for single homeless people. At Christmas the charity provides companionship and support to alleviate loneliness and isolation, and to help people to take their first steps out of homelessness.

“Crisis are always seeking donations of suitable socks as well as all sorts of other items for use during the Christmas week,” says Cosyfeet’s Vicki Palmer. “We’re delighted to help.”

Cosyfeet make a wide range of socks including extra roomy and seam free socks for those with swollen or sensitive feet, complementing the company’s range of extra roomy footwear.

Podiatrist Jonathan Richards giving Cosyfeet socks to a Crisis at Christmas guest.

page | 29

RAMBLING ROADS The Higgs boson has finally been discovered. Although the discovery will initially in the main affect the world of particle physics, the overall effect will be profound. The ‘Higgs’ is the particle that gives all others mass, and is perhaps best comprehended by those, who like Achilles, do not have a higher degree in mathematics, as the ‘glue’ that holds all matter together. Peter Higgs of the University of Edinburgh had mathematically predicted the particle in 1964 but the then technology was insufficiently sophisticated to demonstrate the reality of the prediction. Scientists had long been puzzled by the apparent absence of the Higgs in the collisions at the Large Hadron Collider, until the energy level was increased to from seven Teraelectron volts to eight. New Scientist of 7th July reported that this had resulted in twice as much data being collected between April and June as had been collected in the whole of 2011. Within that data the Higgs boson was discovered at 125 Gigaelectronvolts, at just the energy level predicted. Although the discovery has vindicated the ‘standard model’ of how particles and forces interrelate, as in all good science, the answer has given rise to more questions. Quite how this may affect medicine is a long way in the future.

The crossover between the classical sciences does, however, become satisfyingly blurred in some areas. The same journal reports that a newly proposed detector made up of DNA might be used by physicists to solve the mystery of ‘dark matter’. The material is believed to make up 85% of matter in the universe but is notoriously difficult to detect and conflicting and ambivalent results have been experienced. The material is immune to electromagnetic and strong nuclear forces and believed to be formed of weakly interacting massive particles (WIMPS) which react only to gravity and the weak nuclear force. These conflicts could be resolved if the direction of the particles relative to the sun’s motion through the galaxy could be identified. A detector has been proposed by Andrzej Drukier of Biotraces, a biotech firm based in Herndon Virginia. It consists of a one metre square sheet of gold foil and a ‘forest’ of single strand DNA molecules suspended beneath in an ordered array. When a WIMP strikes the gold foil, a gold nucleus would be dislodged and this, in turn would sever DNA strands along its path. It is calculated that the cut strands could be tracked to within a nanometre in three dimensions. There are significant advantages to the proposed detector over the existing devices; it can operate at room temperature, whilst the others require cooling to close to absolute zero and by changing the material of the foil, it can be ‘tuned’ to look for particles of different energies. Who would have thought that biology might be the key to one of the great mysteries of physics?

30| page

Finally from that journal, and perhaps a little closer to home, Amy Paller and Chad Mirkin at the North Western University’s School of Medicine in Chicago have discovered a way to penetrate the skin barrier and deliver drugs to skin cancers such as melanoma. They coated microscopic gold spheres with RNA which penetrates the skin barrier by a yet to be discovered pathway. The interfering RNA (siRNA) targets one of the genes responsible for proliferation of the carcinoma cells without toxicity to the surrounding, normal, cells and thus destroys the malignancy.

The Australasian Podiatry Council are very active in the area of foot complications in diabetes and arranged for an APodC petition to be tabled in the Australian Federal Parliament on 1st March 2012. The petition called for an increase in podiatry appointments for known diabetics with foot complications to be subsidised by Medicare (the state run health payments system). The APC notes that the diabetic amputation rate in Australia is amongst the highest in the developed world and is taking action to highlight the contribution that podiatrists can make and the resulting savings, not only in amputation rates but hospital costs in addition. This is, of course, an internationally demonstrable truth and applies just as much to the UK.

The recent BMJ letter/comment section: http://www. bmj.com/content/345/bmj.e4275 questions whether medical clinicians should edit Wikipedia. It is known that there are a number of false or biased points of information that can be confusing to patients and if not dangerous are at least inappropriate. The replies confirm that the general feeling is that Wikipedia should be edited by a competent clinician, as it is being used by an increasing number of doctors, whilst also being accessed by an increasing number of the general population, especially by patients themselves. However, the contributor also points out that such a clinician would need to have the time to continually check the submissions for accuracy. Another contributor suggests that Wikipedia should retain a clinician to do the job. However, this seems unlikely. It is certainly the case in podiatry that a number of submissions to the site are directed more to the commercial than the clinical aspects of the profession and no doubt this will also be the case with medicine.

Achilles Hele

BRANCH NEWS

Cheshire, North Wales, Staffs and Shrops Branch

Our branch enjoyed a packed meeting in June. One of our members Alison Ash gave a talk on people with learning difficulties and how we, as health professionals, can have a better understanding to help our patients. Alison began with a brief background on her work with people who have speech and cognitive disabilities. This also covered those who need constant care. Some patients who have profound disabilities will have limited sight and hearing. She explained how best to approach these patients so they do not feel intimidated.

Patients with epilepsy were also covered. Members found this presentation extremely helpful and learned how important it was to be friendly, calm and make better contact. Hillary Supplies gave a short presentation on Onychogryphosis.

Details of products, such as Salu to soften the sulci were discussed along with nippers used. The trade stand was then shown to members.

Shortly after we looked through different materials and their uses. Chris presented Michelle Weddell with a lovely bouquet and all members received goody bags including swatch samples. We all enjoyed our day at the factory and will be retuning on Sunday 18th November for a four hour workshop “Chair side Orthoses”.

Linda Pearson, Branch Secretary

Joseph Foot Mobilisation System developed by Brian S. Joseph DO FHEA 7 Hurstwood Road, Temple Fortune, London NW11 0AS Tel: 0208 458 2586 Email: footmobilisation@gmail.com

After the business meeting our branch were treated to another presentation by Bethan Riley from Springback. Bethan trained as a podiatrist after previous occupations and was interested in biomechanics. Bethan explained that back pain is a functional problem not a medical problem and in the NHS £7.00 in every £10.00 is spent on back pain. She outlined what back pain is and why it occurs. She asked members to do some exercises to demonstrate how back pain occurs. She demonstrated with the use of the equipment how she is able to make the joints in the back to move and to ease stiffness and to restore muscle tone to regain movement. Bethan also treated one of the branch members who suffers with back pain. She gave DVD’s to every member to demonstrate her treatments.

Members enjoyed this presentation immensely. They all agreed that it was important to look after their backs during their work.

Denise Willis, Branch Secretary

Western Branch visit to Algeos

On Sunday 10th June 14 members of Western Branch attended the Algeos Factory in Liverpool.

Firstly we were told about the history of the factory.

Followed by a factory tour was thoroughly interesting, we were lead around the different areas, looking at many different types of materials used in the production of orthoses, machines from cutting materials to embossing a finished custom made pair of orthoses with your own customised crest.

Afterwards Algeos kindly provided refreshments and cakes were brought in by Chris Carrington.

page | 31

BRANCH PROFILE

32 | page

CLASSIFIED

Chiropody Supplies

Practices For Sale

Worcestershire Podiatry Practice in multidisciplinary Natural Health Centre Reception 9:00 a.m. to 6:00 p.m. Monday to Friday Established 1984 – £35K Turnover Ultra-modern equipment Price negotiable – Selling due to illness Please contact: 0740 3927481

Retirement Sale Practice North East Essex

Fully Equipped Clinic Turnover £30,000 based on 3 days Scope for expansion – Transitional help if required Initial enquiries to Richard Sexton and Co., Accountants Tel: 01206 578421 (Ref: JM)

hanics FREE biomecse !

Sale of Chiropody Practice in Dartmouth, Devon an area of outstanding natural beauty

u e-learning cour

Visit www www.biomechanics-education.com .biomechanics-education.com tto o tak take ey your our fr free ee e-lear e-learning ning cour course se no now! w!

RECEIVE CPD POINTS ON THIS COURSE

Classified Advertisements 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,

THE ADVERTISING DEPARTMENT, PODIATRY REVIEW 27 Wright Street, Southport, Merseyside. PR9 0TL.

Tel: 08700 110 305 or 01704 546141

Fax 01704 500477

Email: bernie@iocp.org.uk

T/O £38,000-£40,000, and state of the art equipment sale negotiable. Total change of life style, with good schools in the local area.

Dartmouth lies in the South Hams, in close proximity to the sea, Moors, Exeter, Plymouth, Torquay, Cornwall all within 2 hours journey. please call me on: 01803 839562, or e-mail me to: roger@rogerchilcott.plus.com

Midlands Area

Opportunity to purchase/lease established practice @ 10 years – Midlands area Off-Road parking for 2 cars Commercial shop front, ground floor access with 2 bedroom accomodation flat above.

Live & work on the premises or £525 rental yield if desired Entire freehold Building, Business, and Assets offers around £235,000 or lease of business Please contact David on Tel: 07990 973257 for further details

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)

page | 33

DIARY

September 2012 !

2

Oakwell Motel, Low Lane,Branch Birstall meeting 10:00 a.m.

Leicester and Northants Tel: 01924 475338 Lutterworth Cricket Club or Kilsby Village Hall Please phone for details 8 p.m.

Tel: 01234 851182 Harvester, Watford Road, Rickmansworth WO3 3RX

9

9

30 Nottingham Branch meeting 10:00 a.m.

Feet and Co., 85 Melton Road, West Bridgford, NG2 6EN Tel: 0115 931 3492

October 2012

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

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

4

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

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

7

Tel: 0208 903 6544

8

!!

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

Village Hotel, Coryton, Cardiff Tel: 0292 033 1927

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

Harvester, Watford Road, Rickmansworth, WO3 3RX Tel: 0208 903 6544 11 NorthTel: West Branch meeting 7:00 p.m.

01924 475338 St. Joseph’s Parish Club, Harpers Lane, Chorley, PR6 0HR 11.00 a.m.

Tel: 0161 486 9234 Oakwell Motel, Low Lane, Birstall

12 Hants and Dorset Branch meeting 7:45 p.m.

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

16 Western Branch meeting 12:15 p.m.

Liverpool Women’s Hospital, Blair Bell Education Centre, Crown Street, L8 7SS 01202 425568 Tel: 01745 331827 A potpourri of dermatology – Paula Oliver

30 East Anglia Branch meeting RedVillage Cross Centre, Evesham, Barrow Hall, Nr. Bury Worcs St. Edmunds, IP29 5AP Tel: 01473 830217

30 Essex Branch meeting 2:00Hotel, p.m. Hoole Road The Dene Southend University Hospital Education Centre, Carlingford Drive, Southend-on-Sea, SS0 0RY Tel: 01702 460890 Please note there will be a first aid course preceding this meeting 0292 033 1927

34 | page

9

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

RedWest Cross Centre, Branch Evesham, Worcs.

Middlesex Meeting 8 p.m.

Tel: Harvester, 01905 454116 Watford Road, Rickmansworth WO3 3RX Chester North Wales Staffs and Shropshire Branch meeting The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113 Tel: 0208 903 6544

7

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

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

Pirbright Tel: 0208 660 2822

18 Sheffield Branch meeting 7:30 p.m.

0292Club, 033 1927 SWD Sports Heeley Bank Road, Sheffield, S2 3GL Tel: 01623 452711 11.00 a.m.

21 Devon and Cornwall Branch meeting 11:00 a.m.

Lecture on Nutritional Therapy The Exeter Court Hotel, Exeter Tel: W 01805 603297 10 8 p.m.

21 Midland Area meeting Tel: 0208 903Council 6544 Tel: 07790 350109 for more Information

Harvester, Watford Road, Rickmansworth WO3 3RX

01202 425568

November 2012

Liverpool Womens Hospital, Blair Bell Education C

4

4

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

01473Cardiff 830217 Village Hall, Tel: 0292 033 1927 West of Scotland Branch meeting 11:00 a.m.

Express

By Holiday Tel: 01702 460890 Inn, Springkerse Business Park, PleaseFK7 note7XH there will be a first aid course preceding Stirling, Tel: 0141 632 3283

DIARY 12 West Middlesex Branch meeting 8:00 p.m.

Harvester, Watford Road, Rickmansworth, WO3 3RX Tel: 0208 903 6544 22 Birmingham and the Shires Branch meeting 8:00 p.m.

Red Cross Centre, Evesham, Worcs.

Tel: 01905 454116 23 Hants and Dorset Branch meeting and Social Event 7:45 p.m.

The Sir Walter Tyrrell, Lower Canterton, Nr. Lyndhurst, SO43 7HD Tel: 01202 425568 25 Essex Branch meeting 2:00 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend-on-Sea, SS0 0RY Tel: 01702 460890 25 Leicester and Northants Branch meeting 10:00 a.m.

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

January 2013 6

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

12 Surrey and Berkshire Branch A.G.M. and meeting 7:30 p.m.

Reading Tel: 0208 660 2822 13 Western Branch A.G.M. 12:15 p.m.

Liverpool Womenâ&#x20AC;&#x2122;s Hospital, Blair Bell Education Centre, Crown Street, L8 7SS Tel: 01745 331827 13 Wolverhampton Branch A.G.M. 10:00 a.m. start Please telephone for details Tel: 0121 378 2888 15 North West Branch A.G.M. 7:00 p.m.

St. Josephâ&#x20AC;&#x2122;s Parish Club, Harpers Lane, Chorley, PR6 0HR Tel: 0161 486 9234 16 Hants and Dorset Branch A.G.M. 7:45 p.m.

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

17 Birmingham and the Shires Branch A.G.M. and meeting 7.30 p.m.

Red Cross Centre, Evesham, Worcs.

Tel: 01905 454116 17 Sheffield Branch A.G.M. and meeting 7:30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield, S2 3GL Tel: 01623 452711 20 East Anglia Branch A.G.M. Barrow Village Hall, Nr. Bury St. Edmunds, IP29 5AP Tel: 01473 830217 20 Nottingham Branch A.G.M. 10:00 a.m.

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

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

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

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

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

March 2013

21 Sheffield Branch meeting 7:30 p.m.

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

page | 35

NATIONAL OFFICERS

National OďŹ&#x192;cers

National Officers

President Mrs. F. H. Bailey MInstChP

Area Council Executive Delegates

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

Branch Secretaries

Chairman Board of Education Mr. R. Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg,. Pg,Dip., M.Acu,.

FSSChP. FIChPA. M.Inst.Ch.P

Vice-Chairman Board of Education Mr. M. Harvey MInstChP, PGCE, BSc Honorary Treasurer Mrs. J. Drane MInstChP

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

Area Council Executive Delegates Midland Area Council Mr. D. Collett M.Inst.Ch.P

North West Area Council Mrs. M. Allison MInstChP

Republic of Ireland Area Council Mrs. J. Casey MInstChP BSc Scottish Area Council Mr. A. Reid MInstChP

Southern Area Council Mr. D. Crew OStJ, FInstChP, DChM, CertEd Yorkshire Area Council Mrs. J. Dillon MInstChP 36 | page

Branch Secretaries Birmingham

Mrs. J. Cowley

01905 454116

Devon & Cornwall

Mrs. M. Reay

01805 603297

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

East Anglia

Mrs. Z. Sharman

01473 830217

Hants and Dorset

Mrs. J. Doble

01202 425568

Essex

Mrs. B. Wright

01702460890

Leeds/Bradford

Mr. N. Hodge

01924 475338

London

Mrs. F. Tenywa

0208 586 9542

North of Scotland

Mrs. S. Gray

01382 532247

Leicester & Northants North East

Mrs. S. J. Foster

Mrs. E. Barwick

01234 851182

0191 490 1234

North West

Mr. B. Massey

0161 486 9234

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Sheffield

Mrs. D. Straw

01623 452711

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Northern Ireland Central Republic of Ireland South Wales & Monmouth

Mrs. P. McDonnell

Mrs. J. Nute

028 9062 7414

02920 331 927

Sussex

Mrs. V. Probert-Broster

01273 890570

Western

Mrs. L. Pearson

01745 331827

Mr. S. Gourlay

0141 632 3283

Teesside

West Middlesex

West of Scotland Wolverhampton

Mr. J. Olivier

Mrs. H. Tyrrell Mr. D. Collett

01287 639042 0208 903 6544

0121 378 2888

National Podiatry Conference 7th - 9th Ju

Further Details in Nov-Dec Podiatry Review and on website www.iocp.org.uk

A step forward in managing INGROWING TOENAILS GENTLY CUSHIONS AND PROTECTS

INGROWING TOENAILS CAN BE MANAGED IN THE EARLY STAGES BY OFFSETTING PRESSURE AWAY FROM THE AFFECTED AREA. The design of the Carnation Ingrowing Toenail Protector is based on the measurements and 3D images of the big toes of a representative sample of the UK population. These have been used to mould a specially formulated high performance gel which creates a secondary layer of protection around the toe while leaving the painful area clear from any additional pressure which would exacerbate the condition.

BENEFITS INCLUDE: CUSHIONS AND PROTECTS INSTANT RELIEF WASHABLE AND REUSABLE EXTRA SOFT GEL ONE SIZE FITS ALL

IN A USER TRIAL: 84% said the product gently cushioned and protected the nail 66% of users stated they had instant relief from the product “An innovative and useful product - I wish this had been invented years ago. I’ve noticed a substantial improvement during use as shoes are no longer rubbing”.

PODIATRIST DESIGNED

“The product was fantastic, it prevented my shoes from pressing on the delicate area of my ingrowing toenail and reduced discomfort”.

Reference Cliniresearch on behalf of Cuxson Gerrard & Co Ltd amongst 68 patients with ingrowing toenails.

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

www.cuxsongerrard.com