screening, assessment and footwear prescription in diabetic foot disease
DESCRIPTION
This is our presentation for the British Association for Prosthetists and Orthotists meeting to be held in Telford, March 22/23rd 2013. We cover foot screening, assessment and footwear prescription in diabetic foot disease. Footwear in diabetes is much misunderstood. It is important that footwear is prescribed with an understanding of the individual patient's risk level. We describe a rational process for doing this. All footwear for persons with diabetic foot disease may have some consistent features - but there is no such thing as "diabetic footwear" in the sense of one design being good for everyone.TRANSCRIPT
Diabetic Foot Disease
Screening, Assessment and Prescription
William A Munro, Derek Jones
Screening
What is it?Why do it?
The Starting Point for Effectiveness
Screening Is..
Quick & Simple
Assess Patient’s Risk Level
Not the Same asAssessment
What Do We Screen For?
Previous AmputationSignificant deformity
Significant callusActive ulceration
Previous ulcerationVascular insufficiency
Neurological insufficiencyAble to self care?
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
Patient Information Leaflets
Foot Screening in Scotland
• 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
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
• Protection
• Prophylaxis
• Ambulant pressure relief
Purpose of
Shoes
Preventing Trauma MeansControlling the Mechanical
“Environment”
Pressure
Friction
Shear Force
Foot has ..
✓Altered Sensation
✓Altered Tissue Mechanics
✓and Structu
ral Anato
my
Mechanical Challenge
Series ofInterfaces
ExternalForce
SkeletalForce
Ground - Shoe Sole - Insole - Soft Tissue - Bone
Mechanical Challenge
Orthotic Prescription
• Deformity• Significant
• Non-significant
• Ambulation
• Biomechanical
• Neuropathy
• Vascular
• Pain
• Previous Ulceration
• Environment
Biomechanical Assessment• Range of motion
• Deformity
• Flexibility
• Rigidity
• Sensory
Reduced joint mobility leads to elevated plantar pressureSauseng & Kastenbauer
“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?
Basic Shoe Function
•Prescription Matrix – Defines function
•Function – Defines Style/Design Possibilities
Footwear Design CriteriaSpectrum of Activity
• Newly screened neuropathic foot
• Moderate Risk
• Non-ulcerated
• Deformed neuro-ischaemic foot
• High Risk• Previous Ulceration
• 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
Fashion Options
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
NO
Due to Complexity of the Situation
You Have to Have Faith - and then build rational processes for
management
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