screening, assessment and prescription in diabetic foot disease
DESCRIPTION
Presentation at the BAPO Conference in Telford 2013. Starts by describing the screening and assessment process for the diabetic foot and the important differences between them. It describes the importance of risk stratification of the individual as this will determine the essential characteristics of the protective footwear for the individual. The key to effective management is to make sure that individuals are treated according to their risk of ulceration. Keeping those at the lowest risk from progressing is vital for cost efffective management. The presentation also describes the nature of the orthotic prescription and how this should relate to the patients risk level.TRANSCRIPT
Diabetic Foot Disease
Screening, Assessment and Prescription
William A Munro, Derek Jones1Tuesday, August 13, 2013
Screening the Diabetic Foot
What is it?Why do it?
2Tuesday, August 13, 2013
The Starting Point for Effectiveness
Screening Is..
Quick & Simple
Assess Patient’s Risk Level
Not the Same asAssessment
3Tuesday, August 13, 2013
What Do We Screen For?
Previous AmputationSignificant deformity
Significant callusActive ulceration
Previous ulcerationVascular insufficiency
Neurological insufficiencyAble to self care?
4Tuesday, August 13, 2013
Low Risk
Moderate Risk
High Risk
Ulcerated
5 % Active Ulcers or Infection - revascularisation or amputationMultidisciplinary management
15 % High RiskIntensive foot protection
20 % Moderate RiskRegular foot protection60% Low Risk
Routine annual screening
Risk Stratification
5Tuesday, August 13, 2013
Patient Information Leaflets are available
Foot Screening in Scotland6Tuesday, August 13, 2013
7Tuesday, August 13, 2013
• Detects early disease
• Involves tests that have a predictive value and an agreed cut-off point for referral
• Requires healthcare worker trained for competence in screening
• Does not involve a treatment plan
• Patient does not influence outcome
Screening
8Tuesday, August 13, 2013
Assessment• Establishes a diagnosis
• Involves clinical decision making skills and clinical autonomy for onward referral
• Requires a healthcare professional with the appropriate training/competence in assessment
• Decides on a future management plan
• Patient may influence outcome
• Reassessment is patient-led depending on symptoms or response to therapy
Adapted from Article in DFJ, Vol. 9, No. 4. Mousley, M
9Tuesday, August 13, 2013
• Protection
• Prophylaxis
• Ambulant pressure relief
Purpose of
Shoes
10Tuesday, August 13, 2013
Preventing Trauma MeansControlling the Mechanical
“Environment”
Pressure
Friction
Shear Force
Foot has ..
✓Altered Sensation
✓Altered Tissue Mechanics
✓and Structu
ral Anato
my
11Tuesday, August 13, 2013
Mechanical Challenge
Series ofInterfaces
ExternalForce
SkeletalForce
Ground - Shoe Sole - Insole - Soft Tissue - Bone
Consider the interaction between these elements
12Tuesday, August 13, 2013
Mechanical Challenge
13Tuesday, August 13, 2013
Orthotic Prescription “Matrix”
• Deformity• Significant
• Non-significant
• Ambulation
• Biomechanical
• Neuropathy
• Vascular
• Pain
• Previous Ulceration
• Environment
14Tuesday, August 13, 2013
Biomechanical Assessment• Range of motion
• Deformity
• Flexibility
• Rigidity
• Sensory
Reduced joint mobility leads to elevated plantar pressureSauseng & Kastenbauer
15Tuesday, August 13, 2013
“Diabetic” Shoes
Soft and Roomy
Uppers
We Must Save Money
.. But Who Has the Skills?
How Complicated
Can Shoes Be..?Pressure Relief?
Rocker Sole?Bespoke or Stock?
Relieve Pressure?
Actually ..More Complicated
thanMost realise
16Tuesday, August 13, 2013
Basic Shoe Function
•Prescription Matrix – Defines function
•Function – Defines Style/Design Possibilities and constraints
17Tuesday, August 13, 2013
Footwear Design CriteriaSpectrum of Activity
• Newly screened neuropathic foot
• Moderate Risk
• Non-ulcerated
• Deformed neuro-ischaemic foot
• High Risk• Previous Ulceration
Individuals with these presentations require a completely different
approach
18Tuesday, August 13, 2013
• Shoe and Contact Surface (footbed) Must Work Together
• Materials & Structures Chosen & Positioned for BOTH Control and Tissue Matching
• Shoes Need to act like the “Skeleton” as well as the “Soft Tissues” - Support as well as protect
• “Soft” Uppers not Necessarily Best - Match to the Ambulatory Status and Load Expectations
19Tuesday, August 13, 2013
Fashion Options
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Foot Orthoses
• Integral Part Of Shoe Design
• Total Contact Orthoses
• Functional Foot Orthoses
• Simple Insoles
• The Foot Orthoses Type Will Impact On The Volume Of The Shoe
21Tuesday, August 13, 2013
NO
Due to Complexity of the Situation
22Tuesday, August 13, 2013
You Have to Have Faith - and then build rational processes for
management
23Tuesday, August 13, 2013
Conclusion
• Base on individual patient needs
• Materials to suit the interfaces
• Don’t design the foot orthosis without thinking of the shoe
• Multi-disciplinary education and mutual understanding of orthotic interventions
24Tuesday, August 13, 2013