Podiatrists and Orthotics in Diabetes

Wendy Smith

Size of the problem

More than 220 million people worldwide have diabetes (WHO 2011)

Prevalence increases with age; over 10% of those aged over 65 years have diabetes
Prevalence increases with obesity 1 in 10 of those with diabetes will have a foot ulcer at some point during the course of their diabetes

Diabetic Foot Disease

In the UK is the largest single reason for those with diabetes to be admitted to hospital (Boulton 2005)
Up to 100 people per week in the UK have a limb amputated as a result of diabetes Most important clinical manifestations are:
Neuropathy Ischaemia Structural deformity Ulceration

Foot ulceration is a sign of systemic disease and should never be regarded as trivial
(Edmunds & Foster 2006)

Development of Diabetic Foot Disease

Diabetes Mellitus Neuropathy MOTOR Weakness Atrophy Deformity SENSORY Loss of protective sensation AUTONOMIC Anhidrosis Dry skin Fissures Decreased Sympathetic tone (Altered blood flow regulation) Neuropathic oedema Trauma Vascular Disease MICROVASCULAR Structural: Capillary BM thickening Functional: A-V shunting Increased blood flow, MACROVASCULAR Atherosclerosis

Abnormal Stress
High Plantar Pressure Callus Formation

Ischaemia

Reduced nutrients & Capillary blood flow Osteoarthropathy /Deformity Impaired Response to infection

Amputation

DIABETIC FOOT ULCERATION

Amputation

Development of Diabetic Foot Disease

Diabetic foot ulceration usually occurs at sites of

abnormally high pressure

(Jeffcoate & Macfarlane 1995)

Pressure =force per unit area applied to a surface

Force types:

Vertical (ground reaction force/shock)

Shear (horizontal force/friction)

Mainstay of orthotic management is to minimise these forces

Biomechanics
Biomechanics is the science which studies structures and functions of biological systems using the knowledge and methods of mechanics.
(Hatze 1971)

.and podiatric biomechanics ?

Podiatric biomechanics is the study of forces acting on the human body its structure and function with particular reference to the lower limb, the foot and related pathology. and the utilisation of this information in various treatment regimes to change these forces for more efficient function.

Foot Function
The foot and ankle must be able to:

adapt to uneven terrain and act as a rigid lever for push off absorb rotation of the lower extremity offer balance offer protection The inability to perform any of these tasks creates problems both locally and further up the kinetic chain

Foot function in diabetes some of the issues

Neuropathy
motor Ischaemia Limited Joint movement

sensory autonomic

micro vascular

e.g. cheiroarthropathy

macro vascular

.add to this any non-diabetes related foot problems

Motor Neuropathy
Intrinsic muscle wasting of the foot Proximal phalanx instability Flexor/extensor imbalance Resultant clawing of toes, high arch, anterior fat pad displacement Prominent metatarsal heads & IPJs

Motor Neuropathy

Sensory Neuropathy
Reduced pain, pressure and touch sensation

Tendency to wear tight shoes to stimulate weakened pressure receptors

False sense of a good fit Proprioceptive loss results in the inability to receive/perceive information regarding movement and position of the body Unsteady gait and poor balance

Autonomic Neuropathy
Reduced sweating Dryness Tendency to fissure Reduced resilience to horizontal shearing forces

Neuropathic osteoarthropathy (Charcot)

Combination of: Motor Sensory Autonomic

Proprioceptive neuropathies

Neuropathic osteoarthropathy (Charcot)

Ischaemia
Impacts upon tissue viability Repetitive moderate pressures of 275-400kPa will result in callus and ulcer formation A constant pressure of as little as 20 kPa can result in necrosis

Limited Joint Mobility

Glycosylation of collagen containing tissues occurs Thickening of the skin with loss of joint mobility

Cheiroarthropathy identified in the hands by the prayer sign

Some indications that there is an increased risk of ulceration in patients demonstrating this as it affects the foot

Biomechanics and Diabetes

Paul Brand on the neuropathic foot said:

medicine. The biological responses to these denervated limbs are qualitatively similar to those of normal limbs. It is the permitted pattern of mechanical stress that is different

The whole problem is one of mechanics, not of

Foot deformity

Methods of reducing pressure on the foot

Diabetic foot ulceration usually occurs at sites of

abnormally high pressure

(Jeffcoate & Macfarlane 1995)

Callus removal (debridement) Footwear advice, adaptation

Orthoses
Prescription footwear

Surgery

Callus removal (debridement)

significantly reduces plantar foot pressures in the diabetic foot (Young 1992)

Footwear advice

Footwear Diary
Do our patients wear the shoes we think they do?

O Protective footwear needs to be worn for more

than 9.6 hrs/day to be effective

(Chanetlau & Hagge 1994)

Self Image and Footwear

Some thoughts on why people may not wear advised footwear Do you wear shoes purchased for outside wear in your home? Do you wear particular clothes/outfits for particular events? Do you match your footwear to your outfit?

Footwear adaptation

Can we adapt the footwear the patient is comfortable with wearing?

Foot orthoses
Prior to the 1970s primarily composed of rubber, cork and leather
Since that time the introduction of thermoplastics has allowed for advantages in design, versatility and application. They are hypoallergenic, moisture and bacteria resistant, and heat mouldable

Who should provide the foot orthoses?

The orthotist The podiatrist The pedorthist Does any one member of the team involved with that patient have all the required skills?

? ?? ? ? ? ? ?

Orthotists and orthoses

Orthotists specialise in the design fabrication fitting alignment and adjustment of orthoses. An orthosis is any device added to the body to stabilise or immobilise a body part, prevent deformity, protect against injury, or assist with function.

Range of orthoses provided by Orthotists

Upper Extremity Orthoses HO hand orthosis WHO wrist hand orthosis EO elbow orthosis EWHO elbow wrist hand orthosis SO shoulder orthosis Lower Extremity Orthoses: FO foot orthosis Footwear AFO ankle foot orthosis KO knee orthosis KAFO knee ankle foot orthosis HKAFO hip knee ankle foot orthosis HO hip orthosis

Spinal Orthoses CO cervical orthosis CTLSO cervical, thoracic, lumbosacral orthosis TLSO thoracic, lumbosacral orthosis LSO lumbosacral orthosis

Prescription of orthotic devices and shoes

Properly prescribed orthotics and footwear is critical in the management of diabetic foot disease both to prevent ulceration and amputation and in their management if this does occur Often those providing overall care poorly understand them Limited research evidence to allow effectiveness to be determined Podiatrists and Orthotists are aware of each other but do we really understand each other

Characteristics of orthotics and footwear

Treatment decisions should be based on risk status

A low risk patient with a functional abnormality may be managed with a rigid functional orthotic in their own shoes A foot with mild deformities may be managed with extra-depth or modular footwear
The high risk patient will often require custom made/bespoke footwear and insoles

Classification of foot orthoses

Manufacture: Custom Customizable Prefabricated Material: Rigid Semirigid Cushioning

Role: Corrective/Functional Accommodative/cushioning Pressure redistribution

Decision regarding which is used should be based on individual need

Total Contact Insole

Decrease:
areas of high pressure by redistribution shock (vertical ground reaction force) shear (horizontal movement)

Accommodates and stabilises deformities

Total Contact Insole

30 40% reduction in plantar pressure over the first metatarsal head with increased total contact area (Albert & Rinoie 1994) Lemmon et al (1997) achieved maximum reduction of 29% pressure over the 2nd metatarsal head with insole thickness of 12.7mm

Prescription footwear
Improving compliance by moving from this, to..

these

Traditional NHS Footwear Provision Associated Problems

? Footwear knowledge of referring Consultant Patient given minimum say (style/colour) No podiatry involvement No review Long wait for provision Expensive/monopoly

? Follow-up review by referrer

? Audit

Diabetic footwear requirements

Soft leather uppers Extra depth for TCIs, prominent toes etc Secure well fitting heel and padded collar Adjustable fastening

No protruding decorative seams

Stock footwear
Off the shelf
Offers extra depth

Range of sizes kept in clinic (male and female)

Lightweight Soft leather Attractive Inexpensive

Semi-bespoke (modular) footwear

Adaptations possible by last modification e.g. to allow room for an HAV

Cost approximately twice as much as Stock Footwear

Bespoke Footwear

Suitable for feet unable to fit into stock or semibespoke footwear e.g. Charcot

Individual last construction required

Expensive approximately x5 more than Stock Footwear

Healing Sandals

Sandal / Total Contact Inlays

Aircast boot

Total Contact Cast (TCC)

Foot in Diabetes UK

FDUK now has more than 1500 members from various countries around the globe including the UK, Australia, France, New Zealand, USA, Canada, Spain, Italy, India and more. Members include Podiatrists, Diabetes Specialist Nurses, Doctors, Orthotists, Microbiologists, Podiatry Students and Lecturers, Student Nurses and many more professions.

Their feet are in our hands

Thank you

wendy.smith@gcu.ac.uk