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OFFLOADING
….ARE YOU UNDER PRESSURE?
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Offloading – Definition.
Why – Discovering the need.
How – Exploring the methods.
Examples – Case histories.
What will be discussed today.
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Transference of forces away from a point of pressure or over-loading
This is the overall aim of any intervention
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To prevent or treat a
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MO
DERN
GLO
BAL E
PID
EM
IC
TYPE I
I D
IABETES
A.G.E.s"The pathobiology of diabetic complications: a unifying mechanism.".
Organisation for Economic Co-operation and Development 2014
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“Complex and Vulnerable”
Diabetic
Foot
Neuropathy
IschaemiaInfection
Mike Edmunds, 1984
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Reduction in
Major Amputations
1989-2014
Rubio et al 2014
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Foot Attack
Aetiology
Weight BMI
Footwear
Co-morbidities & Pharmacology
Activity Levels
Foot structure
Pathomechanicsand functional
anatomy.
Terrain
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PI prophylaxis
Improve local tissue viability
Promote wound healing
Close portal of entry to infection
Maintain integrity of
skin.
QOL
Objectives
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MDT Strategy of DFU care.
• Metabolic control
• Educational control
• Mechanical control
• Vascular control
• Wound control
• Microbiological control
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Orthopaedic felt, Wadding and layered bandaging.
This strategy is a holding treatment, filling in the contours to offload while the patient is referred to the Foot Protection Service.
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Total Contact Cast.
Specialist knowledge needed: limb swelling >constriction> ischaemic episode. Therefore best practice, don’t use if patient lives 1x hour+ from hospital
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Scotch-cast bootee/clam casting.
Apertures are out of fashion as wound can herniate through gap.Clam (bivalve) casts have a top and bottom and are bandaged together to form a TCC around the foot and ankle
X
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Off loading shoes
Reduces pressure sub fore-foot by over half. By shifting body weight to the mid-foot and heel.NB: consider effect of neuropathy on gait. Inappropriate dispensing could result in trips and falls. Knowledge and training is needed to dispense these items.
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Cast walkers Moon and Cam boots.
Mean pressure reduction based on height of device.HOWEVER these are flat inside and you will also need to construct a TC inlay.
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Special walkers: T-Brace.
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………And later,
We may move on to other devices such as……..
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Shoe Modifications.
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Casted inlays: direct / last form
Custom shoes and Orthotics.
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Patient A
Ischaemic HeartDisease
Heart Failure
LOPS
Chronic Renal Failure
OA & Gout
Pathomechanics
TYPE II DIABETIC
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Spot early signs of PI as well a scar from previous ulceration
Pressure mapping
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Pressure mapping
For A. Increased Pressure !!!Intervention
To design an interventionyou need to understand biomechanics/functional anatomy or you might make things worse.
“One strategy will not apply to all”.
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Pressure mapping
Modification=pressure reductionIntervention
Concept demo only….FYI Felt failed in 2 hours. Pressure was back!
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Pressure Increased pressure Reduced Pressure
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Before AfterAddition of a 6o
rear-foot post
Thorough knowledge of biomechanics is needed for these interventions
Its knowing what, and where to stick it..Old but true
gone
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Patient B TYPE II DIABETIC
Triple bypassIschaemic heart disease
Poor glycaemic control/poor adherence
Previous amputation and surgical debridement
Previous ulceration episodes
CVA
LOPS to the knee
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5cm
Starting point Pressure mapping
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Before TCC With TCC
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4 years in a rocker bottom
cast Boot
One week of TCC
Three weeks of TCC
(Healed!)
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Variation in practice and different levels of organisation of care between different DHBs
Variable organisation of and access to specialist diabetic podiatry services
Availability of healthcare professionals with expertise in the management of diabetic foot problems
Foot protection service should be led by a podiatrist with specialist experience in diabetic foot problems
NICE, 2015
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“Patients with no contact with a MDT-High risk foot service represent the majority of hospital admissions for DFUs.”
“This group on population estimates appears to be at high risk of amputation of the lower extremity and therefore early referral of this high-risk group might lower this risk.”
Plusch et al 2015
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Consider appropriate methods of referral.
• ALL ACTIVE FOOT ULCERATION SHOULD BE REVIEWED BY THE HIGH RISK FOOT CLINIC FOLLOWING THE MDT MODEL OF CARE.
• IF AN ADMISSION IS INVOLVED THE MDT FOOT SERVICE SHOULD BE INFORMED.
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Podiatry is integral to successful treatment of DFU
(known and evidenced since Edmunds 1984)
Allied health Alliance for best practice
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Dr Lea Whittington Consulting Diabetic specialist Podiatrist.
MCDHB
Gita Pragji Diabetic Specialist Podiatrist.
CPHO.