2011 06 Podiatry Review November/December

The Ins tute of Chiropodists and Podiatrists

ISSN 1756-3291

Vol. 68 No. 6 - November/December 2011

Features within this issue l

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DoH IP Consultations Hyperhidroses Working with the Homeless

Independence

Initiative

Individualism

The Institute of Chiropodists and Podiatrists Podiatry Review Editor Roger Henry F.Inst.Ch.P., D.Ch.M. editor@iocp.org.uk

November/December 2011 Podiatry Review

Sub-Editor Robert Sullivan M.Inst.Ch.P.

Contents

BSc(Hons)Pod, PG Dip. TP Surg.

robert.sullivan@iocp.org.uk

1. Editorial and Contents

Editorial Assistant Bernadette Willey bernie@iocp.org.uk

2. Diabetes News

Editorial Committee Mrs. F. H. Bailey M.Inst.Ch.P. Mr. W. J. Liggins F.Inst.Ch.P., FPodA, BSc(Hons) Mrs. A. Yorke, M.Inst.Ch.P. Mrs. J. A. Drane, M.Inst.Ch.P.

7. Article - Podiatry as a Profession by Deirdre O’Flynn

Advertising Please contact the Editor for all matters pertaining to advertising editor@iocp.org.uk Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Tel: 01704 546141 Printed by Mitchell & Wright Printers Ltd., The Print Works, Banastre Road, Southport PR8 5AL Telephone: (01704) 535529

ISSN 1756-3291 Annual Subscription £25.00 Single Copy £5.00 incl P & P

4. Article- Hyperhidrosis by Julie Halford RGN

8. Article - Volunteering with London’s Rough Sleepers by Cosyfeet Podiatry award winner Andulkadir Abdul 13. Article - Older and Wiser by Beverley Wright 15. Peer Review Section 16. Article - Looking through the window of opportunity by James Woodburn, Kym Hennessy, Martijn P. M. Steultjens, Iain B. McInnes and Deborah E. Turner Centre CPD - Nail Conditions Part 2

by Carl Burrows and Roger Henry 19. Peer Review Section (cont.)

25. Independent Prescribing for Podiatrists by Martin Harvey 26. Rambling Roads 28. Annual Dinner Dance Information 29. 2012 A.G.M. Booking Form 32. Branch News 35. Classified Adverts 36. Diary of Events IBC National Officers

© 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.

Merry Christmas from the President, Chairman, Members of the Executive Committee, Secretariat and Staff at the Sheffield Training Centre.

Please Note that the Office and Training Centre will be closed between Saturday 24th December and Monday 2nd January 2011 (inclusive).

Dear Reader As the nights draw in, it’s time for study.

There are plenty of pending seminars from our branches: Leeds and Bradford seminar at the University of Huddersfield; West Middlesex seminar at Holiday Inn Express, Watford; Southern Area Council seminar at Anglia Ruskin University, Essex and also the Midland Area Council seminar in Birmingham; not forgetting our A.G.M. and lectures at Southport Convention Centre. So you can see there is plenty of academic activity, please participate. Details of all are inside.

On page 24 there is notification from the Department of Health on ‘consultations on proposals to introduce independent prescribing by physiotherapists and podiatrists’. On page 25 we give the favoured responses by the National Executive, Faculty of Education and the Board of Education of the Institute of Chiropodists and Podiatrists Please respond to the Department of Health website http;//www.dh.gov.uk/en/Consultations/Live consultations/DH-129981.

As the Christmas period is approaching and Christmas is supposed to be a time when one thinks of people less fortunate, I thought it was opportune to put in the article ‘Volunteering with London’s Rough Sleepers’

by Cosyfeet award winner Andulkadir Abdul.

It makes interesting reading.

Our main article is ‘Looking through the window of opportunity, is there a new paradigm of podiatry care on the horizon in early rheumatoid arthritis?’ by James Woodburn and colleagues.

On page 28 advance notice is given about our dinner dance to be held on Saturday 28th April 2012 at Southport Theatre and Convention Centre Lancashire. The evening starts with the President’s reception followed by a 3 course dinner. Afterwards you cab dance the night away to a swing band. Tickets are priced at £35. If previous years are anything to go by, you are in for a treat. Don’t forget the conference full details to follow later see page 29.

It only remains for me to wish you the reader compliments of the season and a healthy and prosperous New Year Best wishes Roger Henry, Editor Podiatry Review

Diabetes UK Researchers claim to reverse diabetes in mice

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team of researchers have identified a naturally occurring compound which can restore normal blood glucose control in mice with diabetes. The researchers, from the Washington University School of Medicine in St. Louis, have suggested that the discovery could lead to a potential treatment for Type 2 diabetes.

The compound, called nicotinamide mononucleotide, or NMN, is made by all cells in the body, and plays a key role in regulating how cells use energy. Professor Shin-ichiro Imai has described the results as "really remarkable," going on to say that "NMN improves diabetic symptoms, at least in mice." This has led to suggestions that it may one day be possible to take the compound much like a daily vitamin to treat Type 2 diabetes.

However, Imai acknowledged that they do not know if the same mechanism plays an equally important role in humans.

Dr Iain Frame, Director of Research at Diabetes UK, said, “The idea that Type 2 diabetes will be cured or prevented by taking a simple pill is not supported by this paper. The research is at a very early stage and has shown some benefit in female mice with diabetes and less benefit in male mice. Whilst promising, it would take an enormous leap of faith to assume a new pill will soon be on the market for people with, or at high risk of, Type 2 diabetes.”

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Diabetes UK and Tesco Diets team up to raise awareness of healthy eating

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iabetes UK is pleased to be working with Tesco Diets in a new partnership that will help raise awareness of the importance of healthy eating and weight management.

Tesco Diets will also aim to raise £100,000 through the ‘lbs for £s’ scheme, where £1 will be donated for every 1lb lost by a Tesco Diets member. The campaign is also supported by TV presenter Ruth Langsford, and ex-England cricketer and Strictly Come Dancing winner Darren Gough.

The proceeds of ‘lbs for £s’ will be donated to Diabetes UK and the Diabetes Federation of Ireland. Money raised for Diabetes UK will enable us to improve the lives of people with diabetes by funding vital projects including research, the Diabetes UK Careline and children and family support events.

Losing or managing weight is important to reduce the risk of Type 2 diabetes. For those already with the condition, weight management is an essential factor of good diabetes control.

Whilst people can diet successfully without following a diet plan, many people find the extra motivation and support helps. For anyone wishing to lose weight, Diabetes UK recommends that people choose a diet which caters to their individual needs and which they feel they can stick to.

The partnership with Tesco Diets does not mean we are endorsing their products or services or recommending their diet plans over anyone else’s. Diabetes UK recognises that this alliance will be a great opportunity to reach thousands of people with healthy eating advice and support.

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Hyperhidrosis - Sweaty Feet Cause, Treatment & maintenance Julie Halford RGN & medical advisor for the Hyperhidrosis Support Group www.hyperhidrosisuk.org sweating at most times during the day. This in turn may cause considerable social, psychological and occupational problems.

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rimary Hyperhidrosis affects at least 1% of the UK population and can have a devastating effect on the sufferer’s life. Often present in young children, but becoming more apparent in adolescents as these young adults become more aware of their bodies. Embarrassment with sodden hands, feet or axillae and the inability at times to even carry out simple tasks such as dealing with paper, metal and electrics, make a miserable existence for those who suffer with Hyperhidrosis.

Those who suffer from Plantar Hyperhidrosis often have sodden and smelly shoes and are either ostracised or bullied by their peers. (Halford et al 2009) Hyperhidrosis is linked to over activity in the sympathetic nervous system. Specifically, it is the Thoracic Sympathetic Ganglion Chain, which runs along the vertebra of the spine inside the chest cavity. This chain controls the apocrine and eccrine glands, responsible for perspiration throughout the entire body and, when it is over-active, it causes excessive Initial advice • Wear leather shoes only • Wear cotton socks or absorbent socks specifically designed for excessive sweating • Avoid tight clothing • Avoid all man made fabrics • Minimise obvious signs of sweating by wearing black or white clothing • Use emollient washes and moisturizers rather than soap- based cleansers • Identify any trigger factors for sweating such as crowded rooms, alcohol etc.

• Introduce to patient support group – www.hyperhidrosisuk.org

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After trying the aluminium Chloride antiperspirants, (Anhydrol Forte or Driclor) which most do not find helpful for the feet, as they often cause skin irritation, (1.

Charlson 2006) iontophoresis is the 2nd line of treatment for Hyperhidrosis & significantly reduces sweating in the treated limb in most cases. It is safe and practical and can be practised in a clinic setting or at home. The hands and the axillae can also be treated with iontophoresis & other areas have been treated with some success, but this is not standard practise. (2. Davis/Lawton 2009).

Iontophoresis is widely practised in the UK in most Dermatology departments, a few Podiatry clinics and a few Physiotherapy & Vascular departments . Patients often buy their own machines for home use and are able to carry on their treatment indefinitely at home. (3. Halford et al 2009).

The treatment is pain free, safe, cheap to run and can be done as often as is necessary About 85% of patients get a complete cessation of sweating in their feet by just using tap water. Each session last for 30 minutes.

Those who do not get a complete cessation of sweating can add Glycopyrromium Bromide (POM) solution to the baths. (4.

Dolianitis 2004) (Details from The Hyperhidrosis Support Group www.hyperhidrosisuk.org) The treatment can be carried out in two anatomical areas simultaneously. (5. Elkhyat 1993) Maintenance sessions need to be carried out just as soon as the sweating recurs. For some this is twice a week and for others, once a month or so. It is important that the maintenance session is done just as soon as the feet become clammy and are not fully sweating again; otherwise the patient may need to do the full treatment protocol of 7 sessions over a 4 week period again.

Advise patients that they may not notice any difference in their sweating until they have had about 4 treatment sessions

Treatment times (STD Pharm 2011) Extremities to be Treated

Treatment Times Polarity 1

Treatment Times Polarity 2

Total

Feet Only

15 mins

15 mins

30 mins

Hands only

10 mins

10 mins

20 mins

Hands and Feet

10 mins

10 mins

20 mins

Axillae

10 mins

10 mins

20 mins

Please email Julie Halford at the support group for the full protocol details if you would like them: info@hyperhidrosisuk.org

There has never been a case of cross infection following iontophoresis treatment.

References: 1. Charlson. Managing Palmer Hyperhidrosis. Mims Dermatology Vol. 2. 4: 2006.

2. Davies & Lawton. An alternative treatment option for compensatory hyperhidrosis after endoscopic thoracic sympathectomy. Clinical & Experimental Dermatology. 35: 105-106. 2009.

3. Halford et al. BMJ. 18th April 2009. Vol. 338. 942-944.

4. Dolianitis. Iontophoresis with Glycopyrrolate for the treatment of palmoplantar hyperhidrosis. Aus Journ Derm (2004) 45. 208-212.

5. Elkhyat et al. Treatment of hyperhidrosis by iontophoresis of weakly mineralised water. Cutaneous biopysics lab, dept of derm, 25030 besancon, france. Dec 1993.

Other useful resources: WEBSITE: www.hyperhidrosisuk.orgc– EMAIL: info@hyperhidrosisuk.org Free patient leaflets available on request http://www.iontophoresis.info – http://www.nhs.uk/conditions/hyperhidrosis – http://www.bad.org.uk//site/829/default.aspx

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On Sunday 9th October Devon and Cornwall branch held a meeting at the Kenford House Hotel, Exeter.

Osteopath Rebecca Popplewell D.O. gave a very interesting & informative lecture on posture & stance.

There were 16 members present.

Roger Henry, Devon and Cornwall Branch 6

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Podiatry as a Profession: My path to becoming a Podiatrist and my experience as a newly Qualified Practitioner Deirdre O’ Flynn B.Sc. Podiatry Background: My name is Deirdre O’ Flynn and I am from Cork in the South West of Ireland. In 2009 I decided I would like to go back to university and to undertake a degree. I would be returning as a mature student and I felt any Professional degree I would undertake would have to be considered very carefully as I would be giving up my career to pursue a new beginning. I spent time researching where I could study the degree, what the degree would involve and what had the best job prospects post graduation.

After considering other Professional degrees I decided Podiatry was the degree for me. I choose Podiatry because it is a Medical Profession that offers great prospects. The Profession offers flexibility where it would enable me to work in both the private and public sector. It is also a profession that is increasing in demand with the higher incidences of Diabetes, the huge increase in verrucae and fungal infections and, in general, people are becoming more conscious of their health and fitness which encourages people to seek professional help for foot problems.

I chose to study my degree in the Queen Margaret University in Edinburgh which is regarded very highly in the academic field.

Edinburgh was a city which fascinated me, steeped in culture and history and had an air of mystery to it. Edinburgh also had direct flights to Cork which was an additional bonus.

My time at University: I moved into student halls in the University which was a completely new experience for me. I initially felt nervous and started to question myself. Had I made the right decision moving to Edinburgh? What if I didn’t enjoy my course? What if I didn’t get on with my flatmates? The room was small and the flat was noisy. I had a single bed with an en suite bathroom that was tiny. One advantage of the flat was the views from my bedroom window. I had a view of a beautiful green area with a pond which was home to two swans. It took me a while to get used to living in a small flat.

My first day at University was daunting. I remember feeling it was like my first day back at school again. I sat there nervously not knowing anyone. I had a feeling of uncertainty in my mind of what lay ahead for me over the coming few years. I was in a new country away from my close family and friends. I had left my family, boyfriend, friends, job and the comfort of my own home behind.

As I got to know my classmates and lecturers I felt better about my decision to change career and my initial uncertainty was replaced with enthusiasm and excitement. I found the lecturers extremely helpful and understanding to people’s different situations. As I got to know my classmates I discovered some of them were in the same situation as me, away from home and had changed careers. My class was composed of a mixture of young students and mature students which I found to be a great balance. I remember my first week at University a lecturer told us this was going to be a difficult degree and was not to be taken likely. I knew then I would have to work very hard because for me failing was not an option.

After some time I settled in well, my flatmates became great friends who were full of life, fun and lots of drama. It was a multi cultural flat. My flatmates were from Jamaica, Poland, Scotland and Northern Ireland.

The first two years seemed to go very fast; my weeks were filled with lectures and clinical placements. I found my first essay very difficult to write. I had not written an essay for many years. When

the time came to submit my first essay I must have read over it twenty times checking for mistakes. Before the marks were given I was extremely anxious, I was unsure whether I had met the criteria the lecturer was looking for. To my relief and joy I had received a very good mark, this increased my confidence for future essays I had to write.

Going into my final year I worried I may not get a job after graduating. This played on the back of my mind. With the recession and cut backs I felt it may not be as easy as when I started out to study my degree. One day in class my tutor asked me what had I planned to do after graduating. I had hoped to return home to Cork and get a job. He suggested he had a colleague who had a practice in Cork and was looking to employ a Podiatrist for his expanding business. This would be a fantastic opportunity for me. I contacted the clinic in Cork and called in for an interview before I graduated.

To my joy he offered me a job. I was to start when I had succeeded in all my exams.

My time at university was exciting and fun but was also stressful and worrying at times. The three years were not easy. The exams were difficult also the assignments and work placement were challenging. Overall the hard work and determination was worth every minute of it. I have learnt so much and achieved academic and practical knowledge with my degree. I have performed Surgery on ingrown nails and I have treated patients for bio-mechanical problems. I have learnt anatomy and physiology. I have sat 1000 hours of clinical placement with the NHS. I found the lecturers very helpful. If a student was struggling either in exams or clinical placements, the lecturer offered help where possible. I found the lecturers to be great listeners and offered valuable support.

I finished in May this year and I graduated with my degree in July.

I started my new role as a Podiatrist in Cork in June. My week consists of domiciliary work, private clinics and I also provide a podiatry service to hospitals in the Cork area. My patients vary from children as young as two up to the elderly of 92.

In the clinic I feel I have learnt so much in my short time. A typical day in the clinic I see patients with bio-mechanical problems, patients with very painful Corns, Bunions, Ingrown toe nails, Verrucae and many other podiatry problems.

Since I started working at the clinic I have performed many surgeries on ingrown toe nails which I feel keeps my knowledge up to date. In clinic we typically perform partial nail avulsions on both sides of the nail when possible; this is more cosmetically pleasing for patients. I have also performed surgery on verrucae with a hyfrector which is used for very persistent or large verruca.

In clinic we do things slightly different to University due to the high volume of patients. You have to appear confident and professional at all times in your own ability to treat patients which isn’t always easy as patients look for the boss to treat them, as they have been attending the clinic for a long time, and looked on me as a student still. I found this to be disheartening at first but my colleagues told me not to take this personally and gradually I began to build up trust with the patients until a point was reached where they felt comfortable in my ability to treat them.

I am now working for four months at the clinic and I love every minute of it. Over the next few months I will be highlighting some of the case studies I have been involved with in the clinic and will publish them in this journal.

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Volunteering with London’s Rough Sleepers Cosyfeet Podiatry Award Winner, Abdulkadir Abdul, was awarded £1,000 to assist with his travel and living expenses during his voluntary work with rough sleepers in Central London. Here he reports on his experiences.

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chose to work with homeless and vulnerable people in London because I hoped the experience would help me develop into a more rounded and broader thinking practitioner. By learning from the service user’s complex medical needs I hoped to build on my competencies and knowledge of the psychosocial effects of drugs and alcohol misuse, and to develop my communication skills before I graduate and commence employment. At the same time, I wanted to help raise awareness of these vulnerable individuals and the effects of rough sleeping on their wellbeing.

Homelessness is a global problem affecting people in so many ways.

Capturing a single definition of homelessness is a challenge that has led to many different definitions being used from country to country or even within regions of the same country. For the purposes of this report we are going to define ‘homelessness’ as an umbrella term that refers to the condition of people who are without regular housing because they lack “fixed, regular, and adequate night-time residence” (U.S. Department of Housing and Urban Development 2011). Under this definition, individuals who rely on families or friends for ‘sofasurfing’ or who have temporary accommodation such as bed and breakfast or hostels are considered homeless. As this illustrates, not all homeless people are rough sleepers. Rough sleeping is defined by the government as, ‘people sleeping, about to bed down… or actually bedded down in the open air…’. ‘Rough sleeping’ can also include sleeping in places not designed for habitation such as sheds (Communities and Local Government 2008).

Ascertaining precise figures for the rough sleeping population is notoriously difficult due to its transient nature. Rough sleepers may stay ‘on the move’ in order to protect themselves as they are often subject to mugging and assaults. The available data for London comes from 13 outreach teams that operate in particular boroughs of London. When an individual is contacted by outreach teams or the other services working with rough sleepers, their details are entered onto a database - ‘Combined Homeless and Information Network’, (CHAIN) which is commissioned and funded by government and managed by the homeless charity Broadway.

During my placement with the Central London Community Healthcare Podiatry Service, I was fortunate enough to be involved in this contact work. One evening was spent on the streets with the outreach team from Connection at St Martins from 7pm to midnight.

After I went home, the team continued until 3am. They do this on average 6 days a week! Adrian Purchase (a member of the outreach team) explained; “When the outreach team meets a rough sleeper they quickly try to build rapport by introducing themselves and the type of work they do in order to avoid confrontation. They then ask about the person’s general health and wellbeing. Adrian added.

“Where the individual is new to the streets their details will be taken and entered onto CHAIN. Referral will be made to St Martin’s where they will be assigned a duty worker. This worker will risk assess their situation and provide assistance according to their needs. If the contact is considered vulnerable, (this may be due to age, disability etc), they will be offered a place in St Martin’s night shelter while a plan of action is considered. If the person is from another area, (i.e. another London borough or not from the city or from a different country completely), they will be encouraged to ‘reconnect’ to that area as they will probably be eligible for more statutory help there.”

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According to CHAIN 3,673 people were seen sleeping rough on any one night in London in the year 2009/10. This is believed to be over half of all rough sleepers in England and represents an increase of more than 200 people from the previous year. This increase is thought to be the result of the rise in non-UK rough sleepers, mainly from Central and Eastern European (CEE) countries. If this group is excluded, the number of people seen rough sleeping is in fact reduced by 3% from the year before (Broadway Street to Home 2010).

It is not known for certain why London (and specifically central London) has more rough sleepers than anywhere else in the country, but it could be because of its vibrancy, the opportunities it presents for employment and because it is a transport hub. The presence of supportive day centres and night shelters may also be a draw but it can be seen as a ‘chicken and egg’ situation. The phrase “the streets of London are paved with gold” was coined a long time ago, but the concept still brings people to London! In November 2008 the Mayor of London, Boris Johnson, made a commitment to reduce the numbers of rough sleepers close to zero by the end of 2012 by outlining 15 strategies in the document titled; No One Left Out – Communities Ending Rough Sleeping (Communities and Local Government 2008).

Central London Community Healthcare has also recognised the problem and the need for a specialist approach to providing healthcare for this group of people who have multiple, complex health needs, by funding its own Homeless Health Team (HHT). The team is comprised of specialist nurses and GPs. The team works alongside specialist counsellors, psychiatrists, drug and alcohol workers, a podiatrist and a dentist amongst others, all working together in a multidisciplinary team with the aim of improving the health and wellbeing of this group.

NHS medical services, (including podiatry), are provided at three of the largest charity run day centres for homeless people in Westminster. The Passage Day Centre in Victoria, Connection at St Martins on Trafalgar Square and West London Day Centre in Marylebone. There are also two GP practices for homeless people in Westminster, (Great Chapel Street Medical Centre in Soho and The Dr Hickey Practice in Victoria).

The general services provided by the day centres include food, legal, social and benefit advice, washing and laundry facilities. This onestop shop approach means homeless people are more likely to access the services and help that they need.

My ideas about rough sleepers were challenged the moment I stepped into a centre for homeless people on the first day of my placement with Alison Abdul standing outside the Gardiner, (Specialist Podiatrist West London Day Centre for Homeless and Vulnerable People with Central London Community Healthcare podiatry team).

We agreed to meet up at West London Day Centre, (see figure 1) and when I arrived on Monday morning, after being greeted by the friendly

volunteers at reception, I was asked to wait in the foyer while they contacted Alison to inform her of my arrival. I took the opportunity to look around at my surroundings and the service users. To be honest, I don’t know what I was expecting. The room was full of homeless people talking to one another and eating food they had bought from the canteen. The atmosphere was calm and friendly, which is not what I had expected of people whose lives, (I thought), centred around drugs and prison – my preconceived ideas.

After showing me around the day centre, Alison described the services provided and explained the house rules. I asked Alison, “What happens when a new service user walks in the door for the first time?” She replied; “The specialist workers and volunteers talk to them to find out what assistance they might require. This could include food, washing or medical care. They might also advise on accommodation, welfare, benefit and employment options.”

If they need to see the doctor, nurse or podiatrist, they are advised to put their name on a list held at reception. Some will do this without prompting as they come in, and others, often the more vulnerable, (due to mental health issues for instance), will not do so and do not ask for help. It is these individuals that Alison reminds the volunteers to approach, particularly as they need more encouragement to use the services.

There are so many reasons why people sleep rough, (see table 1).

On my first week of placement I came across Mr. RM who had been rough sleeping for about 9 months. Mr. RM is a ‘visa over stayer’, who has been in the country for about 40 years. He is 60 years old, originally from India and came to England for work. He had most recently been working as a professional chef in outer London, but was dismissed by his employer in November 2009 due to the government tightening the law on illegal workers.

Table 1: Some of the reasons why people become rough sleepers • • • • • •

Mental illness; Unemployment; Family breakdown; Drug and alcohol misuse; Mortgage arrears and repossession; Over staying on visas, failed asylum seekers etc.

Consequently he also lost the room he was renting and so became homeless and started sleeping rough. Alison said that at first he avoided talking about how he had become homeless and only recently revealed what had happened after having built up a rapport with her. He had previously claimed that he was forced by his employer to work when he was unwell and had left his job for that reason. This case clearly shows that service users may not always be honest about their personal history. Alison was keen to stress that individuals will often withhold their previous history in order to access the services they desperately need and which they fear may otherwise be denied them.

Mr. RM is well known by the day centre’s staff and his medical records showed that he had been accessing the service since 2003.

He suffers from; hypertension, hypercholesterolemia, angina (for which he had undergone a coronary artery stent procedure), and type 2 diabetes mellitus with amputation of the right hallux in 2010 due to recurrent ulcers and infections.

His general practitioner back in West London had prescribed irbesartan and bisoprolol, warfarin, aspirin, clopidogrel, rovustatin, gliclazide and metformin.

Mr. RM is a single man with no dependants. He had been coming to the clinic daily to get his ulcer dressings changed. On examination he presented with a deteriorating, non-healing apical ulcer of the right second toe, (see figures 2, 3 and 4). The surrounding skin was more macerated and strike through on the dressing was greater than usually noted. A vascular assessment revealed that he had reduced circulation to his feet, but with no signs or symptoms of intermittent claudication or rest pain. A neurological examination revealed significant bilateral peripheral neuropathy and he had previously been diagnosed as having a right Charcot foot.

Figure 2 and 3: Plantar and dorsal views of apical ulcer right 2nd toe

The ulcer deterioration was thought to be due to walking longer distances recently. He reported that this was due to his GP signing him ‘fit for work’. His benefits had therefore ceased and he had to walk to all appointments as he could not afford the bus fare. He was clearly disturbed by his GP’s action and Figure 4; Patient’s orthopaedic often he would seem withdrawn and sandal with exudate from dressing complained to Alison and me about strike through visible on insole his frustrations.

Due to his poor health and the risk of the ulcer becoming infected, he was allocated a place in the night shelter at Connection at St Martins. He was still under the diabetic MDT (multidisciplinary team) and specialist podiatrist in outer London as he was still registered with his local GP. Alison encouraged him to continue to attend appointments with this team on a regular basis and sought their advice on the more complex aspects of his care. He was given help with bus fares to these appointments by St Martins. His management plan included irrigation, debridement, redressing, pressure relief, diabetic foot care advice, (which had to be tailored to his difficult circumstances), and wound swab. An x-ray of his foot, which was ordered to rule out bone infection, was also carried out under the diabetic multidisciplinary team in outer London. He was put on antibiotics (flucloxacillin 500mgs QDS and ampicillin 500mgs QDS) for a week by his GP. When the swab results came back they revealed the presence of a moderate growth of methicillin-resistant Staphylococcus aureus (MRSA). His x-ray result did not show anything abnormal.

Figure 5; Educating staff at one of the hostels in Victoria about the most common podiatric conditions. (Tips were also given on how to recognise, prevent, treat and above all, how to seek medical assistance).

Apart from working in the clinics in day centres, Alison’s remit extends further and includes visiting hostels and events organised by hostels and charities in order to raise awareness of services provided by the NHS in Westminster for homeless people. Her role is also to educate the hostel staff and residents about the benefits of good foot health and common podiatric problems seen with homeless people, (figures 5 and 6).

Figure 6; Abdul sharing a joke with a service user and talking to him about his feet at an annual football tournament organised by the housing charity Look Ahead.

9

On my second week of placement I was fortunate enough to have the opportunity to spend time shadowing extended members of the multidisciplinary team and also professionals from outside agencies working with this patient group. I spent time with the specialist homeless nurse Cat Barr and drug and alcohol worker Karen Wiltshire, a psychiatric nurse by background. Cat and Karen are both based at Great Chapel Street Medical Centre. I also shadowed specialist physiotherapist Liz Hart, (from The Medical Foundation for the Care of Victims of Torture) based at Finsbury Park.

When I worked with Cat we came across patients complaining that they found it difficult to cope with their addictions and who therefore wanted help to quit. Cat assessed the patients’ commitment and the level of their addiction in order to work out the extent of help they might require. This was a revelation to see as people still tried to turn their lives around despite all odds!

The Medical Foundation is a UK registered charity dedicated to the treatment of torture survivors. The services provided include: medical consultation, examination and forensic documentation of injuries, psychological treatment, support and practical help. During 2008 the charity worked with more than 2,000 torture survivors, mainly clients from Sri Lanka, Democratic Republic of Congo, Sudan and Iran.

According to the CHAIN database the number of non UK rough sleepers has increased by 36% from the previous year (Broadway Street to Home 2010). The pie chart below illustrates the breakdown of their nationalities, (see figure 7).

Fig. 7: Pie chart, showing the breakdown the nationalities of non-UK rough sleepers

Base: 3247 (excludes 426 people whose nationality is not known) Source: Broadway Street to Home 2010

Liz Hart told me that many rough sleepers come from a background where they have experienced torture. This can lead to them isolating themselves from mainstream society because they find it difficult to trust people, especially those in authority like ourselves. Liz advised when one encounters a torture victim in a clinic one should be very sensitive and try one’s utmost to build a mutual partnership that promotes trust and respect. Liz further explained when one intends to carry out an intervention one should explain one’s intentions prior to carrying out the action rather than expecting the patient to have prior knowledge of what is going to take place. Imagine a patient who has issues of trust with people in authority coming into the clinic complaining of a painful corn, and, before obtaining informed consent, the clinician picks up the scalpel to enucleate the corn!

Liz, (see figure 8) explained that people resort to torture as a way of intimidating, repressing and dehumanising their victims. In the past, most torture methods used were of a physical nature. However, current torture methods have become more sophisticated and include psychological trauma. This conceals evidence of torture and induces long lasting grief and suffering.

Falanga is one example of physical torture relating to the feet. The victims are subjected to Fig. 8; Liz Hart (specialist physiotherapist) working with a torture survivor. Photo courtesy of Medical Foundation.

10

gruesome beating to the soles of the feet with objects such as canes or metal bars to the point where the victim’s feet swell up or they lose consciousness altogether due to the intense pain inflicted.

Liz also advised that when one has a torture survivor as a patient who frequently fails to turn up for appointments, one should hesitate before discharging them and instead contact them to ask why. By getting to the bottom of things Liz explained, one will demonstrate to the patient that we care and therefore strengthen the rapport. The patient for instance might find it hard to attend morning appointments due to being awake the whole night reliving their ordeals through flash backs and nightmares. As a result, Liz urges us to work in partnership with the patient to reschedule future appointments that will be convenient for both parties in the hope that the patient will access care more effectively.

With the majority of patients unable to convey their ordeal to clinicians working with them due to a language barrier, it is common practice for interpreters to be used. Medical interpreters facilitate communication between parties by breaking down both linguistic as well as cultural barriers. This helps greatly to establish trust and respect.

On average, Alison sees 6-8 patients in a session and out of these 23 patients will require an interpreter. I remember one occasion where a Lithuanian female patient came in and wanted to see Alison as she had painful debilitating corns. The patient was new to the day centre so nothing was known about her in terms of her previous history. When the patient came into the clinic she was accompanied by her male partner who was also new to the centre. The patient and her partner had limited English proficiency, but more so the patient. The patient asked her partner to interpret for her but Alison explained to her that we had professional interpreters available over the phone which she would prefer to use, (following Trust protocol). Initially the patient was not happy with this and insisted that her partner could do a good job as he often interpreted for her. Alison then explained to the patient that it was good practice to use a professional interpreter in order to ensure that a clear history of the foot problem is gained. This would enable Alison to offer the best advice and treatment. The patient was happy with this explanation and therefore allowed the consultation to go ahead without her partner and with the aid of a telephone interpreter.

At the end of the consultation I questioned Alison’s decision not to use the patient’s partner as an interpreter. She replied that it was good practice, both for the reasons given to the patient, and because many of the centre users are unpredictable with sometimes volatile behaviours due to alcohol, drugs and mental health issues. Having good security protocols in place is paramount in order to work safely.

Both Alison and Liz advise that when using interpreters one should consider the following in relation to the patient: • Gender. Certain cultures do not allow interaction between sexes; • Accent. Can create difficulties in interpreting between the patient and interpreter.

• Age. Certain cultures view their elders as leaders and therefore using a younger interpreter is seen as belittling; • Ethnicity. The smaller the ethnic group in the UK the higher the risk of the interpreter knowing the service users and therefore compromising confidentiality.

Figure 9: Support needs profile of those seen rough sleeping in 2009/10.

Source: Broadway Street to Home 2010

According to CHAIN, nearly every other person seen sleeping rough in 2009/10 was abusing alcohol (48%), three in ten had a mental health problem and 33% had a drug support need, (see fig. 9).

One afternoon Alison asked me to do a search on the medical database to see if the residents from a particular hostel bed list had accessed the HHT service before as she was planning to give a talk to the staff at the hostel. The striking thing about the findings was that only a handful of the residents had accessed the service but the majority were illegal drug abusers.

This was reflected in my session with Karen Wiltshire, (drug and alcohol worker). The take home message from the session was that when taking a medical history, one should consider asking the patient about their use of recreational drugs alongside the usual alcohol and smoking, as the findings could have a significant impact on the patient’s treatment in terms of patient compliance, the side effects of illegal drugs, and drug to drug interaction. For instance, a patient using drugs might find it difficult to act on advice to take regular exercise in order to improve health as they may be spending much of their time feeling drowsy or high. Knowing what the patient is taking recreationally could shed light on the symptoms they are experiencing. For example, being aware that a patient is injecting cocaine in the feet could well explain their symptoms of anaesthetised feet or it could reveal drug to drug interaction.

During my last week of the placement I came across Mr. JW. He is a 60 year old Englishman who became homeless and started sleeping rough soon after getting divorced in the early 2010. The patient expressed confusion and an inability to recall events as they happened. The exact reason as to why he was divorced was not sought. However, it was clear that he had found it difficult to move on as on several occasions he had attempted to end his life by cutting his wrists. He was a hospital inpatient for one week and reported that he had been discharged with no follow up. It was unclear if Mr. JW was seen and assessed by a psychiatrist following his recent attempt on his life but the wounds were cared for by the practice nurses at his GP surgery. In the past, efforts had been made to find him a hostel place but without success as he was deemed “intentionally homeless” as he had separated from his wife. Mr. JW appealed against the decision but was declined intermediate accommodation.

Mr. JW is a heavy drinker and smoker. He was using a walking stick to help him with balancing as he had reduced motor control due to alcohol related nerve damage: the result of his lengthy history of excessive alcohol consumption. The cognitive deficit was also alcohol related, (Wernicke Korsakoff’s syndrome). He is short sighted and wears spectacles. Due to his lack of co-ordination he would fall frequently and a recent fall had caused him to break his spectacles and hurt his hands and feet. Mr. JW also claimed that he was finding it increasingly difficult to remove his shoes because of the impaired motor control of his hands and so had been unable to remove his footwear for 8 months! He also added that he feared taking his shoes off, as he would attract commuters’ attention. On examination Mr. JW presented with mild trench foot, swollen hands and feet, reduced sensation to his feet and ankles but surprisingly no sign of a break in the skin or infection, (figures 10, 11 and 12). To reduce alcohol related nerve damage, his GP prescribed him with terazosin 2mg, thiamine 100mg and vitamin B12 tables daily.

Figure 10; Patient’s feet without shoes

Figure 11 & 12; Patient bare footed revealing the extent of the problem

Prior to treatment Mr. JW was encouraged to clean his feet using warm water and hydrex, (figures 13 and 14). It must be said the smell in the room was so overwhelming that we had to open all the windows, doors and repeatedly spray the clinic with air freshener for some time after the consultation. Examination of his footwear revealed that his shoes were worn out to the degree that the inner

lining of the shoe was no longer visible, and had left an imprint on the soles of his feet. The socks were rigid and sticking to the patient’s skin so he had to be helped to remove them.

Fig. 13; Mr. JW washing his feet using warm water and hydrex

Fig. 14; Mr. JW’s feet after wash

Treatment included trimming and filing the toenails and debridement of callus, (figures 15, 16 and 17). After treatment the patient was issued with a fresh pair of socks and shoes. Mr. JW was then advised to go to the park and remove his footwear from time to time in order to allow his feet to “breathe”. He was also encouraged to take advantage of the washing facilities at the day centre more often and seek help before things got too severe..

Figure 15, 16 and 17: Mr. JW’s feet after his treatment

Mr. JW’s management plan included arranging for him to see an optician to test his eyesight and issue him with a new pair of glasses, and to see a day centre support worker for benefit advice and emergency accommodation. When Mr. JW was risk assessed his status was considered very high risk due to several suicide attempts, the cognitive impairment that renders him confused and forgetful and his neurological deficit that leaves him susceptible to frequent falls.

Among the benefits of accommodating ex-rough sleepers in hostels is that they are assigned key workers that work in partnership with the service users in order to assist them back into mainstream society. This can include making sure they join their local GP surgery, are receiving their benefit entitlements, attend regular workshops and activities as organised by key workers in order to improve their life and social skills, and keep their appointments, (with the key worker acting as advocate). They will have regular meetings with their key worker to monitor progress and set achievable long and short-term goals.

People who abuse drugs whether it be legal or illegal, place themselves at greater risk of mugging and assaults and this further reduces their survival rates on the streets. A survey completed by the charity Crisis in 1991/1992, found the life expectancy of rough sleepers to be 42 years, compared to that of the national average at the time, (74 for men and 79 for women) (Grenier 1992). Despite the findings now being out-dated, the survey still demonstrates the fact that living on the streets has a marked effect on one’s health status and life expectancy in general.

The following and final case report describes an ex-rough sleeper, Mr. JM, a 64-year old Irishman. Even though Mr. JM is no longer homeless and is under the care of his local GP surgery in outer London, he would come back to The Passage Day Centre to use the services when the going got tough. He had been banned from using the day centre and encouraged to use mainstream local services in outer London as he was no longer homeless but was still very vulnerable.

One morning just before opening time, Alison found Mr. JM alone outside the day centre in a wheelchair. We did not know that he was banned from the day centre when we found him so took him into the day centre ground floor staff area as he could not go downstairs to the clinic due to mobility problems.

11

Mr. JM was sharing his second floor flat in South London with his 19-year old son. He reported that he had returned from Ireland 2 weeks previously where he had had a left below knee amputation.

He said that he had discharged himself from the hospital. That morning he had got himself onto the bus with his wheelchair and come to The Passage as he was unable to use his bath at home and had to crawl up and down the stairs.

Mr. JM is a poor historian so it was difficult to get an accurate history of his state of health. However, this is what Alison managed to gain from him.

• Alcoholic; • Heavy smoker; • Heart problems; • History of mini stroke; • Type 1 diabetes mellitus; • Medication – ramipril, aspirin, water tablets, insulin.

The examination of his right foot revealed that he was wearing a trainer with lateral cut outs, (see figures 18, 19 and 20). The removal of his sock revealed a blister on the apex of the 2nd toe and a recently dressed shallow aseptic ulcer at the apex of hallux. Mr. JM was questioned and revealed that he had attended his local specialist diabetic clinic the previous day. The decision was made to remove the dressing and check his foot in view of his vulnerability. Both the ulcer and blister were irrigated and redressed. The patient was then issued with a post-operative sandal and a clean pair of socks.

Figures 18, 19 and 20 show Mr. JM’s condition on arrival at the clinic, and the modification he had made to his footwear

Mr. JM’s medical records showed that he last accessed the day centre one year previously and was seen by Alison in similar circumstances.

The patient then had several wounds on his feet that he was dressing himself with sticking plasters. After his foot had been dressed on that occasion, he was referred back to his GP and his local hospital diabetes service. His blood sugar was tested (20 mmoles) at the time by the homeless nurse and he reported that he just took his insulin every now and then when he felt like it. Records with the homeless medical service go back to at least 2004. The patient was repeatedly advised to use his GP services rather than the HHT. A call was made to his specialist diabetic podiatrist to inform her that he had attended The Passage that day and what treatment had been given. He was well known to that service and apparently he had

left the UK unannounced several weeks previously. At the time he had a necrotic left heel. His specialist diabetic podiatrist also said that he had turned up on his own in his wheelchair at the clinic the day before. It was then established that he had an appointment to see her again the following week. Mr. JM was subsequently reminded of this.

The day centre health worker contacted the patient’s GP who was unaware of Mr. JM’s recent amputation. The GP was advised by the health care worker of the patient’s difficulty managing at home. A GP appointment was made for later that day for referrals to be made for Mr. JM to obtain more suitable ground floor accommodation and other necessary help and support.

This case clearly shows the vital need for ex-rough sleepers to be supported to become part of mainstream society once housed. The survey by the charity Crisis found that it takes 3 weeks for rough sleepers to adapt to homelessness and therefore to become isolated from mainstream society (Grenier 1992). This case also illustrates the challenges presented by managing diabetes and diabetic footcare in vulnerable individuals, and the difficulties ex-homeless people often have moving on from the support services that they become so familiar with when homeless. This therefore has to be well managed and they will need support to use more appropriate services in the community.

On my placement with HHT I have come across many service users in a variety of different circumstances and in my opinion all their stories deserve to be individually acknowledged but I have only been able to describe a few here due to lack of space. Nevertheless, I feel the cases that I have mentioned have captured the message that I have tried to convey.

The experience has taught me a lot of things over and above what I had anticipated. During the placement I learnt a lot about myself, the profession and the career that I have chosen. Personally, the experience has taught me to respect life as it is and not to take it for granted as things could change in an instant. This was demonstrated repeatedly through meeting and talking with the rough sleepers I encountered during the placement. Professionally, I have also learnt that no patient is the same as another, even if they appear to present with similar complaints. So, ultimately this experience has taught me to treat each patient holistically and as an individual, taking into account their wider socioeconomics circumstances in order to diagnose and treat/manage their condition appropriately.

I would like to close this report by expressing my sincere gratitude to Alison Gardiner and The Homeless Health Team for allowing me to work alongside them and benefit from their wisdom and experience. Secondly, I would like to thank my personal tutor Mr. Ivan Bristow for his support and encouragement to enter for the Cosyfeet Podiatry Award. Last but not least, I would like to thank Cosyfeet for giving me the opportunity to develop my skills.

If you would like to help, whether financially or by volunteering your time, with any of the charities mentioned in this report, you can do so by contacting or visiting their website addresses outlined in table 2.

Table 2: Charities working with rough sleepers mentioned in this report and their contact details Name of charity The Passage day centre The Connection at St Martin-in-the-Field Medical Foundation Crisis West London day centre

Type of services Day centre service and night shelter Day centre service Care for the torture survivors Helping with advice and housing homeless people Day centre service

Website address http://www.passage.org.uk/how we help day centre 2167.aspx http://www.connection-atstmartins.org.uk/ http://www.torturecare.org.uk/ http://www.crisis.org.uk/index.php http://www.wlm.org.uk/

Contact number 0845 880 0689 0207 766 5555 207 697 7777 0300 636 1967 020 7569 5900

References: Broadway Street to Home 2010, Street to Home Annual Report 2009-10, Available from: http://www.broadwaylondon.org/CHAIN/NewsletterandReports [Accessed on 30th August 2010] Communities and Local Government 2008, No One Left Out – Communities ending rough sleeping, Available from http://www.communities.gov.uk/publications/housing/roughsleepingstrategy [Accessed on 06th September 2010] Grenier P (1992) Still dying for a home An update of Crisis’ 1992 investigation into the links between homelessness, health and mortality, Crisis, Available from: www.crisis.org.uk/data/files/.../still%20dying%20for%20a%20home.pdf [Accessed on 30th August 2010] U.S. Department of Housing and Urban Development (2011) Federal Definition of Homeless, Available from: http://portal.hud.gov/hudportal/HUD?src=/topics/homelessness/definition [Accessed on 30th August 2010] If you have been inspired by Abdul’s story and would like to find out more about the Cosyfeet Podiatry Award please email prof@cosyfeet.co.uk

12

Older and Wiser!

Beverley Wright MInstChP, BSc (Hons) PGCE, PGDip

Yes, it is true as we get older - we also get wiser!

W

ell, according to the researchers at the University Geriatrics Institute of Montreal they have discovered that as we age, our brains do not slow down when compared to the equivalent level of performance of younger brains. In fact the Martins et al (2011) study found that the older brain does indeed become wiser, because of years of learned abilities and wisdom.

So, is it safe to say or assume that the majority of us were already aware of the fact that the older we got, the wiser we will become?! Well, even some old proverbs, rhymes, poems and fables such as: Aesop’s fable the ‘Hare and the Tortoise’, the ‘Three Wise Monkeys (a pictorial maxim aka the ‘Three Mystic Apes’) from the Tōshō-gū shrine in Nikkō, Japan and ‘A Wise Old Owl’ by Edward H Richards, which most of us have either heard of or read about, seems to suggest we do. Particularly, as these depict the slow, non-challenging pace of the tortoise, the monkey’s wise message not to reflect or be exposed to evil and the patient behaviour of an old owl, which are all synonymous with age; but it is the latter we perceive as wisdom and one of the many favourable attributes we are likely to associate with getting older. As we learn more about ageism and the mental and physical changes that take place, we have come to understand that ageing does not always result in a significant lack of cognitive function (Monchi, 2011, Wang et al 2011); unless of course there is an age related disease and/or conditions that may then impair cognitive brain function and abilities to perform everyday tasks (Lizio et al, 2011). However, Martins et al (2011) study has now found the neurobiological evidence to show that as the brain gets older, it does in fact learn to better allocate its resources.

Martins et al (2011) study set out to investigate how ageing affects brain patterns during the performance of a lexical analog of the Wisconsin Card Sorting Task, which has been shown to strongly depend on fronto-striatal activity. In other words the researchers proposed to explore the brain regions and pathways involved in the planning and execution of language pairing tasks.

More importantly the researchers were interested in knowing what happens when they (the researchers) changed the rules of the tasks many times throughout the duration of the study to the unsuspecting participants.

The sample of recruits in Martins et al (2011) study were divided into a group of 24 participants aged from 18 to 35 years old and a group of 10 participants aged 55 to 75 years old who were still professionally active (which could be good news for our ageing population of practicing Chiropodists, Podiatrists and Foot Health Practitioners). Both groups performed the same lexical set-shifting task, where each participant’s speed of execution and the relevance of their responses were evaluated. The participants brain activity was also examined using functional neuroimaging to indicate any activation of the fronto-striatal loops during the planning and execution stages of a given task.

Outcomes of Martins et al (2011) study reveals that the younger brain is more reactive to negative reinforcement than the older one. The researchers discovered that when the younger participants made mistakes during their tasks, they had to plan and execute new strategies to get the right answer. Thereby, activating and recruiting various parts of their brains to resolve

the task, before undertaking the next one. However, in the older participants, when they made a mistake on a task their brains did not react or recruit from its various regions, until they had began the next task. This according to Dr Monchi indicates “that with age, we decide to make adjustments only when absolutely necessary. It is as though the older brain is more impervious to criticism and more confident than the young brain.”

Dr Monchi (2011) concludes that “Overall, our study shows that Aesop's fable about the tortoise and the hare was on the money: being able to run fast does not always win the race – you have to know how to best use your abilities. This adage is a defining characteristic of aging.”

References: Lizio R, Vecchio F, Frisoni GB, Ferri R, Rodriguez G, Babiloni C. 2011. Electroencephalographic rhythms in Alzheimer's disease. Int J Alzheimers Dis. 2011;2011:927573. Epub 2011 May 12.

Martins, R., Simard, F., Provost, J-S., and Monchi. O. 2011. Changes in Regional and Temporal Patterns of Activity Associated with Aging during the Performance of a Lexical Set-Shifting Task. Cereb. Cortex (2011) first published online August 24, 2011 doi:10.1093/cercor/bhr222.

Wang M, Gamo NJ, Yang Y, Jin LE, Wang XJ, Laubach M, Mazer JA, Lee D, Arnsten AF. 2011. Neuronal basis of age-related working memory decline. Nature. 2011 Jul 27;476(7359):210-3. doi: 10.1038/nature10243.

Related Reading: Schuster L, Essig M, Schröder J. 2011. Normal aging and imaging correlations Radiologe.

2011 Apr;51(4):266-72. German.

13

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Peer Review Section

The Board of Education and what we can achieve with your Direction An information article by

Robert Sullivan BSc (Hons), Dip.Pod.Med, PgC.L.A, PgD.Pod.Serg, FSSChP, FIChPA, MRSM, M.Inst.ChP.

The most important member in the Institute is you

W

e are a very lucky association, every member’s voice and opinion is vital, it is ‘The Life Blood of The Institute’. We are a family of Foot Health Professionals and “all of us” without discrimination. This year you elected an academic Board/Faculty which is made up of myself as Chair, Martin Harvey as my Deputy, assisted by Ann Yorke, Judith Barbaro-Brown, Joanne Casey, Beverley Wright and other members of the Executive Committee.

We all take our responsibility seriously; it is through this Academic Board that we are better able to represent the entire membership. You have at your disposal an excellent resource which you need to take full advantage of.

Members of this Institute have varying levels of practice and clinical ability; it is this variety that makes us, as an Institute, so unique.

Recently I wrote to the Area Councils asking for guidance in providing you with your CPD. I expected a lot of guidance. I have received only two responses to date.

It is the desire of The Board/Faculty of Education to offer educational courses and CPD at the level, time and venue you choose. The Board/Faculty would like you to direct the type of educational programmes and CPD we offer.

clinical service you offer. My contact details are available from the web site and Head Office and in the box at the bottom of this request.

Podiatry Review has undergone a great deal of change over the last year, the quality of the articles published has changed, the presentation has become more professional.

Are the articles in the Review helpful to you in your practice; do they fulfil your need for information? If not we need to know about it.

To continue development the Institute needs the input of you, the most important member. You are the future of the Institute, your voice counts. I will undertake to reply to every letter, call, email sent to me. Every thought is important, every suggestion is valid, every voice will be heard.

Thanks for taking the time to read and respond

The Board/Faculty of Education of The Institute of Chiropodists and Podiatrists

The Board/Faculty wants to make CPD more accessible to you and offer it at Area Council level to be delivered at seminars or in your own home, on-line via our website and/or by CD presentations. It is not necessary to travel to Sheffield for CPD. One of The Board’s function is to source, develop and provide whatever course you want and deliver it to you. The courses can be about anything from padding and strapping, local anaesthesia to nail and skin surgery. There is a wide range of subjects to choose from which reflect the diversity of our membership.

The Board/Faculty is passionate about education and personal development. My personal opinion is that CPD should have an immediate impact on clinical practice and, where possible, the potential to increase our income.

Please send me your thoughts; email only takes a few minutes. It really is time for all of us to grow and develop; education is the key no matter what level of practice and

We would like to have your guidance to develop our educational programmes to sort your needs.

To do this we need your input.

Talk to me robert.sullivan@iocp.org.uk CPD to go from the people who know

15

Peer Review Section

Looking through the ‘window of opportunity’: is there a new paradigm of podiatry care on the horizon in early rheumatoid arthritis?

James Woodburn1*, Kym Hennessy1, Martijn P. M. Steultjens1, Iain B. McInnes2 and Deborah E. Turner1 *

Corresponding author: James Woodburn jim.woodburn@gcu.ac.uk

Author Affiliations 1 Musculoskeletal Rehabilitation Research Group, Institute of Applied Health Research, School of Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, UK 2

Glasgow Biomedical Research Centre, University of Glasgow, 120 University Place Glasgow, G12 8TA, UK

Abstract Over the past decade there have been significant advances in the clinical understanding and care of rheumatoid arthritis (RA). Major paradigm changes include earlier disease detection and introduction of therapy, and ‘tight control’ of follow-up driven by regular measurement of disease activity parameters. The advent of tumour necrosis factor (TNF) inhibitors and other biologic therapies have further revolutionised care. Low disease state and remission with prevention of joint damage and irreversible disability are achievable therapeutic goals. Consequently new opportunities exist for all health professionals to contribute towards these advances. For podiatrists relevant issues range from greater awareness of current concepts including early referral guidelines through to the application of specialist skills to manage localised, residual disease activity and associated functional impairments. Here we describe a new paradigm of podiatry care in early RA. This is driven by current evidence that indicates that even in low disease activity states destruction of foot joints may be progressive and associated with accumulating disability. The paradigm parallels the medical model comprising early detection, targeted therapy, a new concept of tight control of foot arthritis, and disease monitoring.

‘Podiatrists are experts on foot disorders: both patients and rheumatologists can profit from the involvement of a podiatrist’ - Korda and Balint, 2004 [1].

Early RA There is no established definition for early rheumatoid arthritis.

Historic criteria for the classification of RA such as the American College of Rheumatology classification criteria are based on patients with long-standing disease. These criteria lack sensitivity in early disease and delaying treatment until patients fulfil such criteria is no longer acceptable. By symptom duration, the definition of early RA has progressively shortened from <5 years to <12-24 months, whilst very early disease indicates the period within the first 12-16 weeks of symptoms [2]. In practice early arthritis is often undifferentiated and may go on to remission, develop into established RA or other form of arthritis, or remain undifferentiated [3-5]. The imminent introduction of the new EULAR/ACR diagnostic criteria for RA will substantially improve matters in the medium term. Meantime, the clinical challenge in early disease is to recognise inflammatory arthritis, exclude diseases other than RA, estimate the risk of patients developing persistent, erosive, and irreversible disease, and to initiate therapy and thereafter monitor disease for optimal outcome [6].

Advances in early RA Understanding of rheumatoid arthritis has undergone a revolution in the past two decades in clinical and discovery domains [3].

Notably, concepts of the pathogenesis of RA have evolved considerably in this period, leading directly to introduction of biological therapeutics [6]. The development of an optimal strategic approach includes the early use of traditional disease-modifying anti-rheumatic drugs (DMARDs) and prompt advent of biologic based interventions in appropriate patients. In consequence, outcomes that can now be achieved are significantly advanced. A 16

key message from recent research is the requirement for rapid recognition and early ‘aggressive’ intervention. Consider the following evidence, that; – Ultrasound (US) and magnetic resonance imaging (MRI) studies demonstrate erosive changes from the early stages of RA [7-9].

– Functional loss occurs early and once present is often irreversible [5].

– Mortality rates for RA are increased [10].

– A biological ‘window of opportunity’probably exists whereby intervention can alter the ultimate pathogenetic fate for the disease, leading to improved outcomes [11-14]. This is supported by evidence which indicates that early introduction of most treatment modalities is associated with improved clinical response rates. Early intervention with potent biological agents appears to offer profound improvements in clinical response rates and in the magnitude of benefit. A modest proportion of patients may achieve subsequent drug free periods of remission. A new strategy in early RA called ‘tight control’ aims for remission and tailors the treatment strategy to individual patients’ disease activity [15-17]. Tight control is achieved by regular monitoring using composite, largely objective disease activity indices, the components of which capture both joint damage and functional impairment.

Finally, good clinical practice indicates that it is difficult to justify delay in treating inflammatory disease once it is recognised.

Peer Review Section

Foot involvement in early RA Small joint arthritis is a hallmark feature of early RA and the feet are frequently involved at onset. Evidence to support this is taken from prospective and retrospective cohort studies which estimate the prevalence to be between 35-70% [18-20]. Prevalence is also high in all presenting inflammatory arthritis sub-types. In a very early arthritis cohort of 634 patients with symptoms ≤ 16 weeks duration, the ankle joint (18.9%) was the second most frequently involved joint after the knee (47.3%) in those with monoarthritis.

In oligoarthritis (2-4 joints affected) the distribution of joint involvement was also high for the feet including ankle (43.5%), tarsus (7.9%), metatarsophalangeal (MTP) joints (18.1%) and toe joints (6.0%). In those patients with polyarthritis (≥ 5 joints affected), 50.3% had involvement of the MTP joints, 33.7% the ankle, 17.7% the tarsus and 9.7% the toe joints [2]. In a cohort of UK RA patients with <2 years duration, 90% of patients had experienced foot pain at some point of their illness [20].

Synovitis is detected clinically by joint swelling and effusion.

Pain and tenderness indicates soft-tissue and structural joint damage, the consequence of inflammation, which is best detected and graded using plain x-ray or US. In the forefoot, van der Leeden et al (2008) found that 70% of patients with RA had pain and swelling of at least one MTP joint at diagnosis, decreasing to between 40-50% after two years with commencement of DMARD therapy [19]. However, both the prevalence and severity of forefoot joint damage progressively increased in this cohort over 8 years of follow up (prevalence 19% at baseline increasing to 60% and mean forefoot erosion score 1.3 at baseline increasing to 7.9).

Even patients in disease remission (based on the 28 joint count disease activity score - DAS28) may still have residual active disease in the feet. Discordance between DAS and DAS28 remission has been attributed to activity (tenderness and swelling) in the ankle and foot joints [21]. van der Leeden et al (2010) has shown that in 848 patients with recent onset RA, those reaching the DAS28 <2.6 remission criteria, 29% of cases had at least one painful MTP joint and 31% had at least one swollen MTP during an eight year follow up [22]. However, Kapral et al (2007) found higher patient global assessment of disease activity in patients with swollen and tender foot joints who were DAS28 inactive, concluding that assessment of the feet and ankles are important only in the clinical evaluation of patients with RA [23]. The reasons for localised disease persistence in the foot joints are unknown but mechanical factors have been postulated [24,25].

Retrospective radiographic studies suggest that involvement of the ankle and tarsus in early disease is rare with evidence of destructive changes observed in <1% of cases [26,27].

However, diagnostic MRI and US studies have been useful in detecting early synovitis in these joints as well as tendinopathies and bursitides, although none of these are epidemiological investigations [28-31]. Early involvement of the peritalar joints and tendinopathy of tibialis posterior in particular have been implicated in development of acquired pes planovalgus [24,32].

Foot associated functional impairment in early RA is poorly understood. van der Leeden et al (2008) estimated the prevalence of walking disability in an early arthritis cohort to be 57% [19].

Case-series data reveal the early stages of irreversible foot-related walking disability and, by detailed gait analysis, functional impairment at the ankle, tarsus and MTP joints [24].

What are the consequences of persistent or residual active foot disease which is not optimally managed? It is beyond the scope of this review to consider all the evidence but studies which span the paradigm shift in the clinical understanding of RA suggest high prevalence, high burden and an overall negative impact on quality of life. For example, a cross-sectional study of 1000 patients with established RA found that 80% of patients reported current foot problems and 71% reported difficulty in walking due to problems with their feet [18]. The prevalence of foot joint involvement did not differ between those in receipt of biological therapy (31%) and naïve patients. Highly prevalent features including pain history (90%), stiffness (77%), numbness (79%), and swelling (39%) have been reported in recent UK cohorts; and foot deformity (82-86%) and skin pressure lesions (79%) in Colombian and New Zealand cohorts [20,33,34]. Ultimately, foot-disease impacts negatively on health related quality of life [35].

Non-pharmacological interventions for foot disease in early RA: evidence and guidelines There is emerging evidence to suggest that multidisciplinary team care of patients with RA, including podiatry input, is effective in both inpatient and outpatient settings [36]. The specific contribution of podiatry may be unclear and difficult to separate as interventions such as insoles, splints and orthoses can be provided by other means, for example by an orthotist, physiotherapist or occupational therapist or bought over-thecounter by the patient. There is however a paucity of evidence for podiatry-led specialised foot care in early RA [36,37]. Only one randomised controlled trial of foot orthoses in relatively early disease has been published indicating that customised rigid foot orthoses, designed to control correctable rearfoot deformity and off-load painful joints, were more effective than standard orthoses prescribed under medical care for reducing foot pain and disability and restoring function [38,39]. This work has informed expert-led recommendations of several European groups [37,40]. For example, Gossec et al (2009) suggest that metatarsal pain and/or foot alignment abnormalities should be looked for regularly and that appropriate insoles should be prescribed if needed [37]. Forestier et al (2009) provide a disease-activity/staged non-pharmacological treatment strategy in which corrective orthoses are recommended after resolution of a flare, to restore functional range of motion and correct the level of physical activity [40]. In this protocol, preventative plantar insoles are recommended in stable early RA as part of a strategy to enable patients to accept their disease and prevent functional deterioration.

Despite this obvious lack of evidence, recommendations for foot care feature in many UK and European guidelines. These are summarised in Tables 1 and 2 for both early and established disease. Various recommendations are made for inclusion of podiatrists in the multidisciplinary care team, access to foot care, assessment and review, and various interventions including insoles, orthoses and footwear. However the level of supporting evidence is low, mainly at the ‘good clinical practice’ and ‘expert opinion’ agreement level. No reference to specialist podiatry assessment or extended scope practice could be found.

17

Peer Review Section

Table 1 Guidelines and recommendations for foot related non-pharmacological interventions in early rheumatoid arthritis.

Scottish Intercollegiate Guidelines Network Management of early rheumatoid arthritis [69] Clinical practice guidelines for the use of non-pharmacological treatments in early rheumatoid arthritis [37] British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of rheumatoid arthritis (the first 2 years) [70] European League Against Rheumatism recommendations for the management of early arthritis [71] Multidisciplinary guidelines for the management of early rheumatoid arthritis [72]

Multidisciplinary team care Podiatry is part of the multidisciplinary team care.

Full-time dedicated podiatrist specialising in rheumatology is essential.

Access to foot health care ‘Good practice’ to offer all patients with early RA a podiatry referral.

Access to podiatry should be available according to patient need. Podiatry services should provide specific and dedicated service for diagnosis, assessment and management of foot problems associated with RA. Timely intervention for acute problems is important.

Foot care can relieve pain, maintain function and improve quality of life.

Foot Health Assessment/Review Metatarsal pain and/or foot alignment abnormalities should be looked for regularly.

Annual foot review/assessment is recommended for patients at risk of developing serious complications in order to detect problems early.

Appropriate lower limb assessment for vascular and neurological status is needed. Assessment of lower limb mechanics and foot pressures should occur Annual foot review is recommended for patients at risk of developing complications.

Orthoses/Insoles/Splints Some evidence for the efficacy of foot orthoses for comfort, and stride speed and length.

Appropriate insoles should be prescribed if needed.

Orthoses are an important and effective intervention in RA. Use of orthoses has shown short term relief of pain only, rather than an effect on disease activity.

Joint protection included-orthoses not specifically mentioned.

Therapeutic footwear Appropriate footwear for comfort, mobility, and stability is well recognised in clinical practice but little available evidence.

There should be a provision of specialist footwear if needed.

Woodburn et al. Journal of Foot and Ankle Research 2010 3:8 doi: 10.1186/1757-1146-3-8

Table 2 Guidelines and recommendations for foot related non-pharmacological interventions in established rheumatoid arthritis.

American College of Rheumatology Subcommittee on rheumatoid arthritis guidelines for the management of rheumatoid arthritis [73] Arthritis and Musculoskeletal Alliance Standards of care for people with inflammatory arthritis [74] Podiatry Rheumatic Care Association Standards of care for people with musculoskeletal foot health problems [75] National Institute for Health and Clinical Excellence Rheumatoid arthritis National clinical guideline for management and treatment in adults [76] 18

British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the management of rheumatoid arthritis (after the first 2 years) [77] Clinical Practice Guidelines for non-drug treatment (excluding surgery) in rheumatoid arthritis [40]

Multidisciplinary team care People with inflammatory arthritis should have ongoing access to local multidisciplinary team. Podiatrists are part of the multidisciplinary team.

Early referral for surgical opinion if required.

Access to foot health care All people with a sudden ‘flare-up in their condition should have direct access to specialist advice and the option for early review with the appropriate multidisciplinary team member.

Timely access to foot health care - diagnosis, assessment and management.

Adequate information/education should be given for self-management and signs/symptoms of deterioration in foot health and need to access specialist help promptly.

All patients with RA and foot problems should have access to a podiatrist.

Every patient with RA should be informed of the rules of foot hygiene and of potential benefit of referral to a podiatrist.

A podiatrist should be consulted to treat nail anomalies and hyperkeratoses on the feet of patients with RA.

Foot health assessment/review Foot health care providers must understand the consequences of systemic disease on the feet and be able to identify warning signs that require timely referral to specialist medical care. Musculoskeletal foot health assessment should include: General health; Foot health; Systemic factors; Lifestyle/Social factors; Pain management; Need for other assessments as required. Foot health assessment should occur within 3 months of diagnosis - doesn’t have to be done by foot health specialist. Annual review of foot health needs are desirable - doesn’t have to be done by foot health specialist. Where there is substantial change (better/worse) in disease activity, foot health should be reviewed.

All patients with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs.

Feet, footwear and orthoses should be regularly examined.

Orthoses/Insoles/Splints Non-pharmacological treatment recommendations include joint protection but do not specifically mention orthoses Functional insoles and therapeutic footwear should be available to all people with RA if indicated.

Limited evidence for the use of foot orthoses - no consensus regarding choice of orthoses but reduction of pain and improved function of the foot are reported.

Customised orthotic insoles are recommended in the case of weightbearing pain or static foot problems Customised toe splints may be preventive, corrective or palliative to enable the wearing of shoes Orthoses should be regularly examined

Therapeutic footwear Semi-rigid orthotic supportive shoes can be effective for metatarsalgia reduction in pain, disability, and improvement in activity as measured by the Foot Function Index have been reported.

Patients should be advised about footwear. Footwear should be regularly examined. Extra-width off-the-shelf or therapeutic shoes thermoformed on the patient’s foot are recommended when the feet are deformed and painful, or if it is difficult to put on shoes - such shoes reduce pain on walking and improve functional capacity. Off-the-shelf therapeutic thermoformed shoes for prolonged use are indicated when other types of footwear have failed. Palliative customized therapeutic shoes may be prescribed when the feet are seriously affected.

Woodburn et al. Journal of Foot and Ankle Research 2010 3:8 doi:10.1186/1757-1146-3-8

Continued Professional Development

The Institute of Chiropodists and Podiatrists

Continuing Professional Development This article is one of a series of educational documents that can be inserted into your portfolio and be a contribution towards your personal CPD learning.

Summary of

Nail Conditions Part 2

By Carl Burrows, FInstChP, DChM and Roger H. S. Henry, FInstChP.

Psoriasis Definition:

Onychoatrophia; Onychogryphosis; Onycholysis; Onychomadesis; Splinter haemorrhages; Brachonychia (short nails with reduced width)

A chronic relapsing and remitting scaling skin disease occurring at any age, affecting any part of the skin surface and nails.

Aetiology: The exact cause of Psoriasis is unknown though there are both inherited and environmental factors which influence the disease.

If the Psoriasis is pustular, subungual pustules are present.

Pitting of the nails is common in Psoriasis and is extensive. If there are very few pits the cause is probably trauma

Treatments: Chiropodists can give Psoriasis of Nail reassurance to the patient and this is important as many think this condition is infectious.

Otherwise the condition falls under the dermatologist who may use Ultra Violet Light accompanied by certain medicaments.

Methotrexate and Topical Steroids are used more frequently as the ultra-violet does not penetrate the nail plate very effectively.

Extensive Nail Destruction due to Psoriasis

The following long list of nail conditions can all occur in Psoriasis: Beauâ&#x20AC;&#x2122;s Lines; Brittle Nails; Koilonychia; Lamellar Splitting; Leukonychia; Onychorrhexis;

Pitting & Subungual Haematoma in a Psoriatic nail

Pustular Psoriasis

A Severe Example of Pustular Psoriasis

November/December11CPD

Continued Professional Development Lichen Planus Description: Skin condition characterized by flat topped itchy papules affecting the skin of the arms, legs and back and the mucous membranes. In 10% of cases the nails are affected.

Aetiology:

unknown

Effects: as in Psoriasis there are many, viz. Pterygium; Koilonychia; Onychorrhexis; Shedding; Onychoatrophia; Onycholysis; Pitting; Onychoschizia.

Eczema of the Nails

Treatment: Usually confined to topical steroid creams prescribed by a dermatologist. Sometimes systemic steroids are used.

Pterygium Description: An irreversible wing-shaped scarring of the nail which occurs in two forms, dorsal and ventral. The proximal nail fold extends over the nail plate in the former case and in the latter the hyponychium is distally extended and fused with the nail.

Causes:

2 Examples of the effect of Lichen Planus on Nails

Treatment: Chiropodially this would be confined to cosmetic aspects.

Dermatologically - Topical or Systemic Antihistamines ; Topical or Systemic Steroids

Dermatitis / Eczema

Dorsal Congenital Bullous Dermatoses Burns Dyskeratosis congenita Lichen Planus (commonest) Onychotillomania Radiodermatitis Raynaudâ&#x20AC;&#x2122;s disease and Peripheral vascular disease Graft-versus-host disease

Ventral Congenital Familial Formaldehyde Nail hardeners.

Idiopathic Peripheral Neuropathy Raynaudâ&#x20AC;&#x2122;s disease and Systemic Sclerosis Trauma

Description: Nowadays these two terms are synonymous. Usually with dermatitis the cause is an external one, e.g. occupational irritants, and in eczema the cause is internal (and often associated with asthma). Dermatitis simply means inflammation of the skin and there is no actual definition of eczema, which is usually visible on the palms of the hands and soles of feet. Again, the nails are affected in only a proportion of those suffering from the disease.

Coarse Pitting seen in Eczema

November/December11CPD

Dorsal Pterygium

Ventral Pterygium

Continued Professional Development Onychomadesis:

Systemic Disease Manifestations Beau’s Lines

Description: Common condition also known as reeded nail, in which longitudinal striations appear the length of the nail which seem like scratches which might have been inflicted by an awl.

Causes: Atherosclerosis; Ageing Process; Peripheral Vascular Disease; Raynaud’s Disease; Frostbite; Darier’s Disease etc.

Description: Transverse band-like depressions extending from one lateral edge of a nail to the other.

Etiology: Mostly caused by systemic disease though trauma can be responsible. Illness is usually severe such as cancer / chemotherapy, pneumonia, zinc deficiency, severe attacks of measles etc.

Features: The width of the groove dictates the duration / severity of the disease which caused it.

Two Examples of Onychorrhexis

Side-effects of drugs on nails Onychomadesis Beau’s Lines

Description: Spontaneous separation of the nail from the matrix area.

The drugs responsible for this problem are the cytotoxics, the retinoids and some antibiotics.

In addition any of the following conditions can be responsible: local inflammation (such as in paronychia), fever and other systemic upsets, bullous dermatoses, Lyell’s syndrome, keratosis punctata, local trauma, X-irradiation, acrodermatitis, hypoparathyroidism, yellow nail syndrome

Nail Growth: The line will move distally as the nail grows. Bearing in mind the full growth of a finger nail takes about six months and that of a toe-nail approximately 2 years, it is possible to estimate the time scale of the trauma.

In this example several successive Beau’s Lines are evident indicating an on-going general health problem

Onychomadesis - note the separation is proximal

In Stroke (Hemiplegia) patients, the Beau’s Lines only appear on the non- paralysed side of the body.

November/December11CPD

Continued Professional Development

Nail Conditions Part 2 Questionnaire 1.

What skin disease manifests itself in the nail in this manner? See image 1 below.

4.

These two pictures show the dorsal and ventral view of which nail condition? See images 4a and 4b below.

2.

In which skin condition characterized by flat topped itchy papules affecting the skin of the arms and legs are, in 10% of cases, the nails affected?

5.

What is the commonest cause of this frequently encountered nail condition? See image 5 below.

6.

3.

Which skin disease nowadays has two titles which are synonymous? How would it show in the nails, what other common systemic disorder accompanies the problem and what treatment might be employed to control it?

Which two drug groups are responsible for the nail condition onychomadesis?

7.

What can you deduce from observing Beauâ&#x20AC;&#x2122;s lines in a patientâ&#x20AC;&#x2122;s nails?

1

4a

4b

5

Membership of The Institute of Chiropodists and Podiatrist is open to chiropodists/podiatrists registered with the Health Professions Council

Some form of severe illness - frequently; a heart attack; cancer; chemotherapy; pneumonia etc. The position of the lines on the nail are indicative of an approximation of the time scale of the disease.

Q7

Cytotoxins and retinoids - look them up!

Q6

Atherosclerosis - frequently as a complication of old age.

Q5

Contact the Secretary for details:

Pterygium

Q4

Eczema / dermatitis - asthma - coarse pitting (unlike fine pitting in psoriasis) - topical steroids and in severe cases sometimes systemic steroids.

The Institiute of Chiropodists and Podiatrists

Q3

Lichen Planus

Q2

Psoriasis

Q1

Answers: November/December11CPD

27 Wright Street, Southport, Merseyside. PR9 0TL Tel: 08700 110305 Email: secretary@inst-chiropodist.org.uk

Peer Review Section

A new paradigm for podiatry in early RA What new opportunities do recent paradigm shifts in the management of early RA offer podiatrists? Evidence presented earlier indicates that active foot disease persists in many patients despite recent treatment advances. Moreover, access to biological therapy is variable, there are practical challenges to undertaking DAS28 monitoring in routine practice, and the required changes to service provision to accommodate new care pathways are barriers in translating evidence to practice [17,41,42].

Consequently, in clinical practice remission rates are around 20% depending on which criteria are used [43,44]. This evidence, combined with current guidelines and good clinical practice, indicates the need for ongoing multidisciplinary team care, including podiatry, in early RA. Local development of this paradigm is based on experience from an academic-clinical partnership initiative in Glasgow, UK. Support for specialist podiatry training and professional development, clinical practice, and research and audit are jointly provided by academic rheumatology/podiatry units at The University of Glasgow and Glasgow Caledonian University in conjunction with National Health Service clinicians. This model is expanding in Scotland with knowledge transfer facilitated through the Podiatry Practice Development Group for Rheumatology, a National Health Services Quality Improvement Scotland Health Board network initiative for allied health professions. Key aspects of the paradigm include:

Early detection - widespread dissemination and uptake of referral guidelines The necessity to obtain specialist referral to guarantee early diagnosis and rapid treatment is evidenced by facts that structural damage occurs early in RA, that joint destruction increases the risk of irreversible disability, and that early introduction of most treatment modalities is associated with improved clinical response. The importance of clinical examination cannot be overlooked. Simple tests such as the MTP squeeze test are highly predictive of persistent erosive arthritis (outcome) and HAQ disability [33,45]. Recognising this, Emery and colleagues (2002) developed an early referral recommendation tool for primary care doctors (Appendix 1) [46]. Given the high prevalence of MTP joint involvement at onset, podiatrists should be aware of these guidelines when encountering patients with forefoot pain. Such patients can reach podiatrists through a number of referral routes with an initial diagnosis of mechanically-related metatarsalgia.

The algorithm is easy to understand and apply and should be widely disseminated among podiatrists.

Therefore, under this new paradigm we propose to increase the knowledge and understanding of early RA, including the mandate for early recognition and treatment. The early referral algorithm proposed by Emery et al (2002) should be brought to the attention of all podiatrists utilising national networks for dissemination and training [46].

Targeted therapy - aggressive management of residual foot disease Recommendations for podiatry/foot care in early RA places an emphasis on access, annual review for those at risk of developing foot complications and timely interventions (Table 1). Currently, definition of need, risk, and timeliness are poorly understood. A pragmatic approach may be to identify three groups of patients.

Firstly those with low disease activity (by DAS28) who have residual disease activity in the foot with associated impairment and disability. Case identification can be facilitated by raising awareness among the rheumatology multidisciplinary care team, including training sessions on foot problems, examination and management.

Red flag conditions should be prioritised e.g., tibialis posterior tendinopathy with early flat-footedness, persistent synovitis in any of the tarsus joints and persistent, non-responsive and symptomatic forefoot disease despite low disease state/remission. Further work is required before evidence based recommendations can be made for routine screening of all early RA patients. The second group are those with medium to high disease states where personalised nonpharmacological interventions are undertaken based on the presenting impairments to act in conjunction with the systemic management. The third group are those patients who fail to respond to biological therapy or are ineligible and require close monitoring and care of active foot joints.

In our opinion, targeted foot care should be delivered by specialist podiatrists working in a multidisciplinary clinic in both primary and secondary care. Extended scope practice should include specialist training in diagnostic ultrasonography (using recognised training pathways, for example the PGcert in Medical Ultrasound); corticosteroid injection therapies; nonpharmacological interventions; gait analysis and rehabilitation. In the UK, multidisciplinary foot clinics in rheumatology are not new and they generally comprise of the podiatrist, extended-scope physiotherapist and orthotist [47,48]. The rheumatologist, nurse specialist and orthopaedic surgeon may be in attendance or a rapid referral pathway developed. Evidence for such an approach is lacking, but the area has been identified as a research priority.

A new paradigm for podiatrists focuses on combination therapy targeted at inflammatory lesions and associated mechanically-based impairments. This should include ultrasoundguided aspirations, intra-articular and soft-tissue corticosteroid injection therapy with cast immobilisation for residual lesions, and customised orthotics, exercise and gait training for associated impairments. Patients with evidence of joint instability and passively correctable deformities should be targeted with highly personalised orthotics, exploiting newer computer-aided design and manufacture capabilities where available. Orthotics treatment can be combined with exercises, gait training, and therapeutic footwear, as well as joint protection and disease management advice and support. Minor surgical procedures including nail surgery and cryosurgery are within the scope of practice for UK podiatrists. Bone, joint and soft-tissue surgery is restricted to those with advanced training and beyond the scope of this review.

Important training issues related to current guidelines for RA patients in receipt of biological and other immune system suppressing medication should be provided during training [49].

UK podiatrists also have limited prescribing rights and within the multidisciplinary clinic for early RA, access is generally limited to analgesic, corticosteroid and antibiotic medicines.

Podiatrists should also be trained to recognise and appropriately refer disease flare and other associated complications. This includes, for example, skin and nail infections of the feet in patients receiving biological therapy as previously reported [50,51]. Podiatrists also possess core skills to assess and monitor peripheral vascular and neurological diseases. Routine techniques such as ankle-brachial pressure indices can be applied to screen for potential risk factors for cardiovascular disease [52].

Under this paradigm we propose that specialist podiatry roles are created, supported by high-level training and mentorship, and that podiatrists actively engage in Early Arthritis Clinics as part of the multidisciplinary team. Accordingly patients should be targeted and treated aggressively using injection therapy and personalised rehabilitation interventions, with appropriate referral where indicated.

19

Peer Review Section

Tight control of foot arthritis and disease monitoring

The concept of tight control can be applied for peripheral joints as a central paradigm for podiatrists to aim for the lowest foot disease state or remission. Care can then be escalated or tapered based on monitoring foot disease and related impairment and disability using a number of clinical metrics. These are summarised in Table 3 as candidate outcomes for core and extended datasets. These span foot-specific disease activity, joint destruction, and impairment and disability, with a balance of objective and patient-orientated outcomes. Swollen and tender joint counts are based on the Ritchie Articular Index which originally incorporated the tibio-talar, subtalar, midtarsal, MTP and interphalangeal joints [53]. The Structural Index is a semiobjective scale to measure foot deformity and function. It works adequately in practice but requires validation [54]. The Foot Function Index (FFI) and Foot Impact Scale (FIS) for RA are well-validated RA specific outcome tool for foot related impairment and disability [55,56]. The psychometric properties of both instruments currently make them the most appropriate outcome instruments to determine treatment escalation or tapering [57]. Routine monitoring by DAS28 has led to larger numbers of patients reaching low disease state through increased changes in DMARD treatment [58]. On that basis use of the FFI and FIS must be promoted among podiatrists to drive treatment change and provide objective treatment targets.

Table 3 Candidate outcome for core and extended clinical foot datasets.

Outcome Domain

CORE 1. Swollen foot joint count 2. Tender foot joint count

Active disease Joint. destruction/softtissue damage.

3. Foot Impact Scale-RA

Foot impairment and disability.

4. Structural Index

Foot deformity.

5. Radiographic erosions

Joint destruction

EXTENDED 6. Ultrasound core set

7. Gait analysis

Active disease/joint destruction.

Soft-tissue disease.

Functional.

- spatiotemporal, plantar pressure, joint motion and forces Woodburn et al. Journal of Foot and Ankle Research 2010 3:8 doi:10.1186/1757-1146-3-8

Radiographic erosions, scored using Sharp-van der Heijde method should be reviewed during routine follow-up. Within extended scope practice, B-Mode and power Doppler ultrasound (US) is being increasingly used by specialist podiatrists. The advantages, especially for inflammatory foot disease are well established and the clinical utility for podiatrists is extremely high. US permits better identification of synovitis and erosions in foot joints over conventional radiographs in early disease [5961]. US is superior to clinical examination for locating and quantifying synovitis, erosions and tendinopathies especially in complicated anatomical areas such as the peri-talar region [31,6265]. Moreover, US has been shown to beneficially influence the planning of local corticosteroid injection therapy in the foot; to provide more accurate needle tip placement and subsequent 20

injection as well as aspiration and infiltration of tendon sheaths, joint spaces and bursae. It lessens procedural pain and it leads to improved short-term efficacy [64,66,67]. Evidence is emerging of good competency standards among UK podiatrists undertaking US scanning techniques [68]. In an extended data set, and where access is available, three-dimensional gait analysis provides the most objective way of capturing functional changes in the foot.

It has been successfully employed in early RA to detect subtle but clinically important functional changes [24].

Past experience from multidisciplinary foot clinics in rheumatology indicate that patients should be regularly followed up until problems are resolved [47]. In early RA patients this should constitute low foot disease state or remission, with concomitant improvements in impairment, related disability and quality of life. Early detection and aggressive treatment within a therapeutic window of opportunity when disability is potentially reversible is critical.

Under this paradigm, we propose that podiatrists tightly control foot arthritis using personalised treatment plans which are agreed within the multidisciplinary team. Disease management should be escalated or tapered according to defined criteria combining objective image-based techniques and patient orientated outcomes.

Conclusions Proposals contained within this commentary are predicated upon major developments in the clinical understanding of RA and paradigm shifts concerning early detection and treatment, tight control of disease and monitoring, and the introduction of biological therapies. However, despite these advances evidence indicates that active disease in the foot is an ongoing problem in clinical practice. A new paradigm of podiatry care can adopt these advancements in early disease, exploiting the extended scope practice capabilities and training opportunities available. To evidence the paradigm, UK podiatrists are forming multi-centre research networks to facilitate cohort and interventions studies.

Studies are in progress to understand disease mechanisms, to assess the burden and impact of foot disease in early RA, to develop a minimum foot core-set, to define foot disease remission, and to pilot interventions, outcomes and health economic impact. These studies are building towards a definitive trial of the clinical and cost-effectiveness of foot care in early RA. If proven, the paradigm may be generalisable to other forms of inflammatory, post-traumatic and degenerative disorders in the musculoskeletal field as well as a model for the management of neurologic induced dysfunction, e.g., neuropathic ulceration and Charcot’s disease.

Competing interests The authors declare that they have no competing interests.

Authors’ contributions The authors conceived of the study and undertook the written review equally. KH led the electronic literature searches. All authors read and approved the final manuscript.

Appendixes Appendix 1. Early referral guidelines for newly diagnosed rheumatoid arthritis (after Emery et al 2002) [46].

Rapid referral to a rheumatologist advised in the event of clinical suspicion of RA, which may be supported by the presence of any of the following: ≥ 3 swollen joints MTP/MCP involvement- Squeeze test positive Morning stiffness of ≥ 30 minutes

Peer Review Section

Acknowledgements Dr Deborah Turner (reference 17832), is funded by Arthritis Research UK. This funding body had no role in design or conduct of the study or in the preparation of the manuscript or in the decision to submit the manuscript for publication.

1.

Korda J, Bálint GP: When to consult the podiatrist. Best Pract Res Clin Rheumatol 2004, 18:587-611.

PubMed Abstract | Publisher Full Text

2.

Mjaavatten MD, Haugen AJ, Helgetveit K, Nygaard H, Sidenvall G, Uhlig T, Kvien TK: Pattern of joint involvement and other disease characteristics in 634 patients with arthritis of less than 16 weeks’ duration. J Rheumatol 2009, 36:1401-1406. PubMed Abstract | Publisher Full Text

3.

Smolen JS, Aletaha D: Developments in the clinical understanding of rheumatoid arthritis. Arthritis Res Ther 2009, 11:204. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text

4.

Aletaha D, Huizinga TW: The use of data from early arthritis clinics for clinical research. Best Pract Res Clin Rheumatol 2009, 23:117-123. PubMed Abstract | Publisher Full Text

5.

Combe B: Progression in early rheumatoid arthritis. Best Pract Res Clin Rheumatol 2009, 23:5969. PubMed Abstract | Publisher Full Text

6.

McInnes IB, Jacobs JWG, Woodburn J, van Laar JM: Treatment of rheumatoid arthritis. EULAR module 1 2008, 1-11.

7.

Narváez JA, Narváez J, De Lama E, De Albert M: MR imaging of early rheumatoid arthritis.

Radiographics 2010, 30:143-163. PubMed Abstract | Publisher Full Text

8.

Boesen M, Østergaard M, Cimmino MA, Kubassova O, Jensen KE, Bliddal H: MRI quantification of rheumatoid arthritis: current knowledge and future perspectives.

Eur J Radiol 2009, 71:189-196. PubMed Abstract | Publisher Full Text

9.

Keen HI, Brown AK, Wakefield RJ, Conaghan PG: MRI and musculoskeletal ultrasonography as diagnostic tools in early arthritis. Rheum Dis Clin North Am 2005, 31:699-714. PubMed Abstract | Publisher Full Text

10. Gabriel SE: Heart disease and rheumatoid arthritis: understanding the risks. Ann Rheum Dis 2010, 69(Suppl 1):i61-64. PubMed Abstract | Publisher Full Text 11. Cush JJ: Early rheumatoid arthritis: is there a window of opportunity? J Rheumatol suppl 2007, 80:1-7. PubMed Abstract | Publisher Full Text 12. Huizinga TW, Landewé RB: Early aggressive therapy in rheumatoid arthritis: a ‘window of opportunity’? Nat Clin Pract Rheumatol 2005, 1:2-3. PubMed Abstract | Publisher Full Text 13. Quinn MA, Emery P: Potential for altering rheumatoid arthritis outcome. Rheum Dis Clin North Am 2005, 31:763-772. PubMed Abstract | Publisher Full Text 14. Boers M: Understanding the window of opportunity concept in early rheumatoid arthritis. Arthritis Rheum 2003, 48:1771-1774. PubMed Abstract | Publisher Full Text 15. Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R, Kincaid W, Porter D: Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Lancet 2004, 364:263-269. PubMed Abstract | Publisher Full Text 16. Ostör AJ, Conaghan PG: Tight control in rheumatoid arthritis improves outcomes. Practitioner 2009, 253:29-32.

17. Kiely PD, Brown AK, Edwards CJ, O’Reilly DT, Ostör AJ, Quinn M, Taggart A, Taylor PC, Wakefield RJ, Conaghan PG: Contemporary treatment principles for early rheumatoid arthritis: a consensus statement. Rheumatology (Oxford) 2009, 48:765-772. PubMed Abstract | Publisher Full Text 18. Grondal L, Tengstrand B, Nordmark B, Wretenberg P, Stark A: The foot: still the most important reason for walking incapacity in rheumatoid arthritis: distribution of symptomatic joints in 1,000 RA patients. Acta Orthop 2008, 79:257-261. PubMed Abstract | Publisher Full Text 19. van der Leeden M, Steultjens MP, Ursum J, Dahmen R, Roorda LD, Schaardenburg DV, Dekker J: Prevalence and course of forefoot impairments and walking disability in the first eight years of rheumatoid arthritis. Arthritis Rheum 2008, 59:1596-1602. PubMed Abstract | Publisher Full Text 20. Otter SJ, Lucas K, Springett K, Moore A, Davies K, Cheek L, Young A, Walker-Bone K: Foot pain in rheumatoid arthritis prevalence, risk factors and management: an epidemiological study. Clin Rheumatol 2010, 29:255-271. PubMed Abstract | Publisher Full Text 21. Landewé R, Heijde D, Linden S, Boers M: Twenty-eight-joint counts invalidate the DAS28 remission definition owing to the omission of the lower extremity joints: a comparison with the original DAS remission. Ann Rheum Dis 2006, 65:637-641. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 22. van der Leeden M, Steultjens MP, van Schaardenburg D, Dekker J: Forefoot disease activity in rheumatoid arthritis patients in remission: results of a cohort study. Arthritis Res Ther 2010, 12:R3.

PubMed Abstract | BioMed Central Full Text 23. Kapral T, Dernoschnig F, Machold KP, Stamm T, Schoels M, Smolen JS, Aletaha D: Remission by composite scores in rheumatoid arthritis: are ankles and feet important? Arthritis Res Ther 2007, 9:R72. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text 24. Turner DE, Helliwell PS, Emery P, Woodburn J: The impact of rheumatoid arthritis on foot function in the early stages of disease: a clinical case series. BMC Musculoskelet Disord 2006, 21:102.

BioMed Central Full Text 25. Turner DE, Helliwell PS, Siegel KL, Woodburn J: Biomechanics of the foot in rheumatoid arthritis: identifying abnormal function and the factors associated with localised disease ‘impact’. Clin Biomech (Bristol, Avon) 2008, 23:93-100. PubMed Abstract | Publisher Full Text 26. Belt EA, Kaarela K, Kauppi MJ: A 20-year follow-up study of subtalar changes in rheumatoid arthritis. Scand J Rheumatol 1997, 26:266-268. PubMed Abstract | Publisher Full Text 27. Kuper HH, van Leeuwen MA, van Riel PL, Prevoo ML, Houtman PM, Lolkema WF, van Rijswijk MH: Radiographic damage in large joints in early rheumatoid arthritis: relationship with radiographic damage in hands and feet, disease activity, and physical disability. Br J Rheumatol 1997, 36:855860. PubMed Abstract | Publisher Full Text 28. Woodburn J, Udupa JK, Hirsch BE, Wakefield RJ, Helliwell PS, Reay N, O’Connor P, Budgen A, Emery P: The geometric architecture of the subtalar and midtarsal joints in rheumatoid arthritis based on magnetic resonance imaging. Arthritis Rheum 2002, 46:3168-3177. PubMed Abstract | Publisher Full Text

29. Boutry N, Lardé A, Lapègue F, Solau-Gervais E, Flipo RM, Cotten A: Magnetic resonance imaging appearance of the hands and feet in patients with early rheumatoid arthritis. J Rheumatol 2003, 30:671679. PubMed Abstract | Publisher Full Text 30. Boutry N, Flipo RM, Cotten A: MR imaging appearance of rheumatoid arthritis in the foot. Semin Musculoskelet Radiol 2005, 9:199-209. PubMed Abstract | Publisher Full Text 31. Wakefield RJ, Freeston JE, O’Connor P, Reay N, Budgen A, Hensor EM, Helliwell PS, Emery P, Woodburn J: The optimal assessment of the rheumatoid arthritis hindfoot: a comparative study of clinical examination, ultrasound and high field MRI. Ann Rheum Dis 2008, 67:1678-1682.

PubMed Abstract | Publisher Full Text 32. Woodburn J, Helliwell PS, Barker S: Three-dimensional kinematics at the ankle joint complex in rheumatoid arthritis patients with painful valgus deformity of the rearfoot. Rheumatology (Oxford) 2002, 41:1406-1412. PubMed Abstract | Publisher Full Text 33. Rojas-Villarraga A, Bayona J, Zuluaga N, Mejia S, Hincapie ME, Anaya JM: The impact of rheumatoid foot on disability in Colombian patients with rheumatoid arthritis. BMC Musculoskelet Disord 2009, 10:67. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text 34. Rome K, Gow PJ, Dalbeth N, Chapman JM: Clinical audit of foot problems in patients with rheumatoid arthritis treated at Counties Manukau District Health Board, Auckland, New Zealand. J Foot Ankle Res 2009, 2:16. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text 35. Wickman AM, Pinzur MS, Kadanoff R, Juknelis D: Health-related quality of life for patients with rheumatoid arthritis foot involvement. Foot Ankle Int 2004, 25:19-26. PubMed Abstract | Publisher Full Text 36. Vliet TP, Pattison D: Non-drug therapies in early rheumatoid arthritis. Best Pract Res Clin Rheumatol 2009, 23:103-116. PubMed Abstract | Publisher Full Text 37. Gossec L, Pavy S, Pham T, Constantin A, Poiraudeau S, Combe B, Flipo R, Goupille P, Le Loët X, Mariette X, Puéchal X, Wendling D, Schaeverbeke T, Sibilia J, Tebib J, Cantagrel A, Dougados M: Nonpharmacological treatments in early rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine 2006, 73:396-402. PubMed Abstract | Publisher Full Text 38. Woodburn J, Barker S, Helliwell PS: A randomized controlled trial of foot orthoses in rheumatoid arthritis. J Rheumatol 2002, 29:1377-1383. PubMed Abstract | Publisher Full Text 39. Woodburn J, Helliwell PS, Barker S: Changes in 3D joint kinematics support the continuous use of orthoses in the management of painful rearfoot deformity in rheumatoid arthritis. J Rheumatol 2003, 30:2356-2364. PubMed Abstract | Publisher Full Text 40. Forestier R, André-Vert J, Guillez P, Coudeyre E, Lefevre-Colau M, Combe B, Mayoux-Benhamou M: Non-drug treatment (excluding surgery) in rheumatoid arthritis: Clinical practice guidelines.

Joint Bone Spine 2009, 76:691-698. PubMed Abstract | Publisher Full Text 41. Kay LJ, Griffiths ID, BSR Biologics Register Management committee: UK consultant rheumatologists’ access to biological agents and views on the BSR Biologics Register. Rheumatology (Oxford) 2006, 45:1376-1379. PubMed Abstract | Publisher Full Text 42. Lindsay K, Ibrahim G, Sokoll K, Tripathi M, Melsom RD, Helliwell PS: The composite DAS Score is impractical to use in daily practice: evidence that physicians use the objective component of the DAS in decision making. J Clin Rheumatol 2009, 15:223-225. PubMed Abstract | Publisher Full Text 43. Mierau M, Schoels M, Gonda G, Fuchs J, Aletaha D, Smolen JS: Assessing remission in clinical practice. Rheumatology (Oxford) 2007, 46:975-979. PubMed Abstract | Publisher Full Text 44. Sokka T, Hetland ML, Mäkinen H, Kautiainen H, Hørslev-Petersen K, Luukkainen RK, Combe B, Badsha H, Drosos AA, Devlin J, Ferraccioli G, Morelli A, Hoekstra M, Majdan M, Sadkiewicz S, Belmonte M, Holmqvist AC, Choy E, Burmester GR, Tunc R, Dimic A, Nedovic J, Stankovic A, Bergman M, Toloza S, Pincus T, Questionnaires in Standard Monitoring of Patients With Rheumatoid Arthritis Group: Remission and rheumatoid arthritis: Data on patients receiving usual care in twenty-four countries. Arthritis Rheum 2008, 58:2642-2651. PubMed Abstract | Publisher Full Text 45. Visser H, le Cessie S, Vos K, Breedveld FC, Hazes JM: How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. Arthritis Rheum 2002, 46:357-365.

PubMed Abstract | Publisher Full Text 46. 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. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 47. Helliwell PS: Lessons to be learned: review of a multidisciplinary foot clinic in rheumatology.

Rheumatology (Oxford) 2003, 42:1426-1427. PubMed Abstract | Publisher Full Text 48. Williams AE, Bowden AP: Meeting the challenge for foot health in rheumatic diseases. Foot 2004, 14:154-158. Publisher Full Text 49. Pieringer H, Stuby U, Biesenbach G: Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment? Semin Arthritis Rheum 2007, 36:278-286.

PubMed Abstract | Publisher Full Text 50. Otter S, Robinson C, Berry H: Rheumatoid arthritis, foot infection and tumour necrosis factor alpha inhibition – a case history. Foot 2005, 15:117-119. Publisher Full Text 51. Davys HJ, Woodburn J, Bingham SJ, Emery P: Onychocryptosis (ingrowing toe nail) in patients with rheumatoid arthritis on biologic therapies. Rheumatology (Oxford) 2006, 45(Suppl 1):I171-I171.

52. del Rincón I, Haas RW, Pogosian S, Escalante A: Lower limb arterial incompressibility and obstruction in rheumatoid arthritis. Ann Rheum Dis 2005, 64:425-432. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 53. Ritchie DM, Boyle JA, McInnes JM, Jasani MK, Dalakos TG, Grieveson P, Buchanan WW: Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Q J Med 1968, 37:393-406. PubMed Abstract | Publisher Full Text 54. Platto MJ, O’Connell PG, Hicks JE, Gerber LH: The relationship of pain and deformity of the rheumatoid foot to gait and an index of functional ambulation. J Rheumatol 1991, 18:38-43.

PubMed Abstract 55. Budiman-Mak E, Conrad KJ, Roach KE: The Foot Function Index: a measure of foot pain and disability. J Clin Epidemiol 1991, 44:561-570. PubMed Abstract | Publisher Full Text 56. Helliwell P, Reay N, Gilworth G, Redmond A, Slade A, Tennant A, Woodburn J: Development of a foot impact scale for rheumatoid arthritis. Arthritis Rheum 2005, 53:418-422. PubMed Abstract | Publisher Full Text 57. van der Leeden M, Steultjens MP, Terwee CB, Rosenbaum D, Turner D, Woodburn J, Dekker J: A systematic review of instruments measuring foot function, foot pain, and foot-related disability in patients with rheumatoid arthritis. Arthritis Rheum 2008, 59:1257-1269. PubMed Abstract | Publisher Full Text

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Peer Review Section 58. Fransen J, Moens HB, Speyer I, van Riel PL: Effectiveness of systematic monitoring of rheumatoid arthritis disease activity in daily practice: a multicentre, cluster randomised controlled trial. Ann Rheum Dis 2005, 64:1294-1298. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 59. Wakefield RJ, Gibbon WW, Emery P: The current status of ultrasonography in rheumatology.

Rheumatology (Oxford) 1999, 38:195-198. PubMed Abstract | Publisher Full Text 60. Szkudlarek M, Narvestad E, Klarlund M, Court-Payen M, Thomsen HS, Ă&#x2DC;stergaard M: Ultrasonography of the metatarsophalangeal joints in rheumatoid arthritis: comparison with magnetic resonance imaging, conventional radiography, and clinical examination. Arthritis Rheum 2004, 50:2103-2112. PubMed Abstract | Publisher Full Text 61. Grassi W, Filippucci E, Farina A, Salaffi F, Cervini C: Ultrasonography in the evaluation of bone erosions. Ann Rheum Dis 2001, 60:98-103. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 62. Lehtinen A, Paimela L, Kreula J, Leirisalo-Repo M, Taavitsainen M: Painful ankle region in rheumatoid arthritis. Analysis of soft-tissue changes with ultrasonography and MR imaging. Acta Radiol 1996, 37:572-577. PubMed Abstract | Publisher Full Text 63. Premkumar A, Perry MB, Dwyer AJ, Gerber LH, Johnson D, Venzon D, Shawker TH: Sonography and MR imaging of posterior tibial tendinopathy. AJR Am J Roentgenol 2002, 178:223-232.

PubMed Abstract | Publisher Full Text 64. dâ&#x20AC;&#x2122;Agostino MA, Ayral X, Baron G, Ravaud P, Breban M, Dougados M: Impact of ultrasound imaging on local corticosteroid injections of symptomatic ankle, hind-, and mid-foot in chronic inflammatory diseases. Arthritis Rheum 2005, 53:284-292. PubMed Abstract | Publisher Full Text 65. Suzuki T, Tohda E, Ishihara K: Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor. Mod Rheumatol 2009, 19:235-244. PubMed Abstract | Publisher Full Text 66. Sofka CM, Adler RS: Ultrasound-guided interventions in the foot and ankle. Semin Musculoskelet Radiol 2002, 6:163-168. PubMed Abstract | Publisher Full Text 67. Sibbitt WL Jr, Peisajovich A, Michael AA, Park KS, Sibbitt RR, Band PA, Bankhurst AD: Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol 2009, 36:1892-1902. PubMed Abstract | Publisher Full Text 68. Bowen CJ, Dewbury K, Sampson M, Sawyer S, Burridge J, Edwards CJ, Arden NK: Musculoskeletal ultrasound imaging of the plantar forefoot in patients with rheumatoid arthritis: inter-observer agreement between a podiatrist and a radiologist. J Foot Ankle Res 2008, 1:5. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text

69. Scottish Intercollegiate Guidelines Network: Management of Early Rheumatoid Arthritis. A National Clinical Guideline. Edinburgh: Royal College of Physicians; 2000.

70. Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, Fokke C, Goodson N, Jeffreson P, Lamb E, Mohammed R, Oliver S, Stableford Z, Walsh D, Washbrook C, Webb F, On Behalf Of The British Society For Rheumatology And British Health Professionals In Rheumatology Standards, Guidelines And Audit Working Group: British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis (the first two years). Rheumatology (Oxford) 2006, 45:1167-1169. PubMed Abstract | Publisher Full Text 71. Combe B, Landewe R, Lukas C, Bolosiu HD, Breedveld F, Dougados M, Emery P, Ferraccioli G, Hazes JMW, Klareskog L, Machold K, Martin-Mola E, Nielsen H, Silman A, Smolen J, Yazici H: EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007, 66:34-45. PubMed Abstract | Publisher Full Text | PubMed Central Full Text 72. Hennell S, Luqmani R: Developing multidisciplinary guidelines for the management of early rheumatoid arthritis. Musculoskeletal Care 2008, 6:97-107. PubMed Abstract | Publisher Full Text 73. American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines: Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002, 46:328-346.

PubMed Abstract | Publisher Full Text 74. Arthritis and Musculoskeletal Alliance: Standards of Care for People with Inflammatory Arthritis.

London. Arthritis and Musculoskeletal Alliance; 2004.

75. Podiatry Rheumatic Care Association: Standards of Care for people with Musculoskeletal Foot Health Problems. London: Podiatry Rheumatic Care Association; 2008.

76. National Collaborating Centre for Chronic Conditions: Rheumatoid Arthritis: national clinical guidelines for management and treatment in adults. London: Royal College of Physicians; 2009.

77. Luqmani R, Hennell S, Estrach C, Basher D, Birrell F, Bosworth A, Burke F, Callaghan C, CandalCouto J, Fokke C, Goodson N, Homer D, Jackman J, Jeffreson P, Oliver S, Reed M, Sanz L, Stableford Z, Taylor P, Todd N, Warburton L, Washbrook C, Wilkinson M, On Behalf of the British Society for Rheumatology and British Health Professionals in Rheumatology Standards, Guidelines and Audit Working Group: British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years).

Rheumatology (Oxford) 2009, 48:436-439. PubMed Abstract | Publisher Full Text

IOCP_Chiropody

Do you want to write for our new Podiatry Review?

Articles - Branch News Human Interest Stories Product Information Anecdotes All will be considered

Donâ&#x20AC;&#x2122;t forget!

Writing articles counts towards your CPD portfolio Please email where possible to bernie@iocp.org.uk or send to Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Please note Podiatry Review copy date is the 1st of the preceding month prior to publication e.g. for the January/February issue copy date is 1st December 22

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Peer Review Section

Dear Editor, I found Mr. Isaacs rebuttal of my paper, Primus Metatarsus Supinatus (Rothbarts Foot): A Common Cause of Musculoskeletal Pain – Biomechanical vs Neurophysiological Model passionate and interesting, yet misleading.

I would like to revisit several points that Mr. Isaacs raised in his rebuttal letter:

Then Mr. Isaacs questions: “Has a study been carried out to test for correlation between Rothbarts Foot and a Kyphotic posture?” Apparently, Mr. Isaccs has not read two papers I published in the Journal American Podiatric Medical Association (2006, 2008) which statistically correlated foot twist (initiated by Rothbarts Foot) to postural distortions which are consistent with a kyphotic posture. Agreeably, more definitive studies need to be done in this area of postural mechanics.

Mr. Isaacs states: “Rothbarts Foot is a condition in And finally Mr. Isaacs questions my research that which the entire forefoot is inverted relative to the suggests (and which I firmly believe) that people with rearfoot”. This statement is incorrect. non twisting (hyperpronating) feet naturally have Rothbarts Foot is an inherited structural abnormality better posture, less joint and muscle pain and fewer in which the embryological medial column of the foot (e.g., part of the navicular, internal cuneiform, first visceral problems that people with twisting feet. He metatarsal and hallux) are in supinatus (structurally states that making this correlation is like saying “blond inverted) relative to the embryological lateral column people are less likely to contract influenza”. I can only of the foot. This is distinctly different from forefoot answer Mr. Isaacs by saying that I have found Wolfs varum, where the entire forefoot (metatarsals 1 -5) are Law (function follows form) to be very germane when positionally inverted relative to the bisection of the applied to postural mechanics. That is, by improving calcaneus. the function (attenuating foot twist); the posture (form) Apparently Mr. Isaccs did not read my paper improves. When the posture (form) improves, many published in the Journal of Bodywork and Movement chronic musculoskeletal and visceral pain issues Therapies (a peer reviewed publication) which diminish. My research site is replete with many describes the pathoembyological events that can result examples (www.RothbartsFoot.es). in an infant being born with Rothbarts Foot.

Prof/Dr. Brian A. Rothbart Cummings et al conducted a study at the University of Georgia to determine if the elevation of the first metatarsal could be accurately and reliably measured (both intrarater and interrater). Four examiners performed repeated measurements during two tests sessions separated by a week. Intrarater and interrater reliability (ICC (3,1)) ranged from 0.90 to 0.95 and 0.87 to 0.94, respectively. Day-to-day reliability (ICC (1,1)) ranged from 0.84 to 0.88 for all measures. They concluded that the elevation of the first metatarsal, pathogonomonic of Rothbarts Foot could be reliably and accurately measured.

Mr. Isaacs questions the link between postural distortions and the development of osteodegenerative arthritis. He states: “So, provided the posture is not distorted all the weight bearing joints will last forever?” The answer, quite simply, is that when the weight bearing joints function around their anatomical neutral position (as occurs with a non distorted posture), they will function better and last longer (but not forever). Over my past 40 years of clinical practice, this has been my experience. Over my past 40 years of clinical research, this has been my observation.

References: Cummings GS, Higbie, EJ 1997 A weight bearing method for determining forefoot posting for orthotic fabrication. Physiotherapy Research International, Vol 2(1):42-50. [This study was funded by a grant from the College of Health Sciences at Georgia State University].

Rothbart BA 2006. Relationship of Functional Leg-Length Discrepancy to Abnormal Pronation.

Journal American Podiatric Medical Association;96(6):499-507 Rothbart BA 2008.

Vertical Facial Dimensions Linked to Abnormal Foot Motion. Journal American Podiatric Medical Association, 98(3):01-08, May. Rothbart BA, 2002. Medial Column Foot Systems: An Innovative Tool for Improving Posture. Journal of Bodywork and Movement Therapies (6)1:37-46.

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CONSULTATIONS ON PROPOSALS TO INTRODUCE INDEPENDENT PRESCRIBING BY PHYSIOTHERAPISTS AND PODIATRISTS The Department of Health in association with MHRA is running two public consultations concerning proposals for physiotherapists and podiatrists to become independent prescribers of medicines. It also proposes that physiotherapist and podiatrist independent prescribers are allowed to mix licensed medicines prior to administration and direct others to mix, and to be able to prescribe independently from a limited list of controlled drugs.

We are interested in engaging responses from anyone, particularly; patients, carers, the public, charities and equality groups and also health and social care professionals, professional bodies and other relevant organisations.

The consultations: Open: Thursday, 15th September 2011 Close: Thursday, 8th December 2011 How to Respond The Consultation document, supporting documents (appendices) and reply form can be accessed in the following ways: Online at http://consultations.dh.gov.uk/ or at www.dh.gov.uk/health/2011/09/independent-prescribing/ Or you can request a copy to be posted to you: E-mail: ahpprescribing@dh.gsi.gov.uk, or Tel.: 0113 254 5846, or Write to: AHP Prescribing Project, Room 5E47, Department of Health, Quarry House Leeds LS2 7UE.

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Independent prescribing for Podiatrists Martin Harvey PGC BSc(Hons) MInstChP MASPC Vice-Dean Faculty of Education and Professional Development, Deputy Director Board of Education Institute of Chiropodists and Podiatrists

I

n 1999 a Department of Health report authored by Doctor June Crown CBE, reviewed the whole subject of medicines use and supply

by Health Professionals who were not Doctors, and unequivocally recommended that prescribing rights should be extended to suitably trained other Health Professionals where patient needs could clearly benefit from it. Nurses and Pharmacists were the first to go through this process, initially as ‘Supplementary Prescribers’ – i.e. they had to arrange a named-patient clinical management plan with a Doctor before they could prescribe for that individual. After further reports and evaluations on the safety of Nurse supplementary prescribing, it was decided to introduce Independent prescribing for this group, upon suitable conversion training, and in 2006 they became the UK’s first non-medical independent prescribers.

Since that time Nurse and Pharmacist independent prescribing has played an increasingly important role in front-line healthcare services and is seen by both medical practitioners and patients alike as a genuinely valuable asset.

Long before the concept of the Crown Report was even considered, since 1980 in fact, those UK Podiatrists (Chiropodists) who have suitable training, have, by way of a statutory exemption to the 1968 medicines act (as amended) been able to independently administer and supply a list of medicines that normally require a prescription from a Doctor. The list of medicines has steadily grown over the years as it has become evident to the regulatory bodies that Podiatrists have an enviable safety record in the responsible and effective use of restricted medicines. The ‘exemptions’ now include some local anaesthetics, steroids, pain-killers and antibiotics. It should be particularly noted that ‘administer and supply’ is NOT the same as prescribing, because it refers to items that the Podiatrist can purchase from pharmacies and then hold in stock until they require to use or directly supply them to a Patient.

No list can however meet all needs, especially in acute conditions encountered in primary care which may need varieties of medications that do not happen to be on such a list. In these cases the need to refer the patient to a Doctor or other prescriber, who may not themselves be a specialist in the foot and leg, can introduce substantial delays in effective treatment with possible adverse effect to the patient and substantial extra cost and workload to other elements of healthcare.

In an attempt to meet such needs, the medicines act was amended in 2005 to allow Podiatrists and Physiotherapists to undertake postgraduate training to qualify them as supplementary prescribers. The courses were available to Senior members of these professions who had a minimum of three years of post-graduate experience and who could demonstrate that supplementary prescribing would benefit the patient groups in which they practiced. The content of the course was essentially the same as that for Nurse and Pharmacist independent prescribers and involved either three months fulltime or six months part-time study at a suitable university at either level 6 or Masters level. Additionally, it involved some weeks of supported prescribing practice by a mentoring Doctor in a community setting. Pass marks for the examinations on the course were set substantially higher than Bachelor’s degree level and included elements such as clinical numeracy examinations which required 100% of correct answers to pass.

The underpinning principle of supplementary prescribing is that a medical practitioner diagnoses the ‘need’ for a prescription and the supplementary prescriber then prescribes to ‘manage’ that condition.

Whilst that worked in many cases for Nurses who often worked under the direction of a Doctor, both Podiatrists and Physiotherapists usually diagnose and treat conditions independently and in many cases are the ‘expert practitioner’ and have their own practices. After a few years it became apparent to most people involved that Podiatrist and Physiotherapist supplementary prescribing only worked where the prescriber worked in close contact with a Doctor, and even in such cases it was often the Supplementary Prescriber diagnosing the condition and suggesting the appropriate medicine. This resulted in a poor take-up of training courses by suitably qualified Podiatrists who instead chose to

rely on the independent ‘supply and administer’ route. By 2008 only 47 Podiatrists out of an estimated 13,000 plus in the UK had qualified as supplementary prescribers.

Accordingly, in 2009, the ‘Allied Health Professions (AHPs) Prescribing and Medicines Supply Mechanisms Scoping Project’ was commissioned by the Department of Health to establish whether there was evidence of service and patient needs to support extending independent prescribing to Podiatrists and Physiotherapists. The project found a strong case for extending independent prescribing and a suitable Department of Health task-force was established to take the work forward.

The task-force included Government medicines legislators and regulators, Pharmacists, Patient Representatives, Civil Servants and representatives of the professional bodies of Physiotherapy and Podiatry. The professional bodies are the Institute of Chiropodists and Podiatrists, the Society of Chiropodists and Podiatrists and the Chartered Society of Physiotherapists. The task-force is chaired by the UK Chief Allied Health Professions Officer under delegated authority of the Minister of Health.

The current status of work by the task-force is that an initial consultation exercise with other Health Professionals, Royal Colleges and the like has been concluded which overwhelmingly supported the concept. Suitable training courses have been designed together with appropriate safety and clinical governance controls. This has required substantial work by individuals from the groups outlined above.

The next stage is a public consultation exercise which was launched on 15th September 2011 and concludes on 8th December 2011. This invites comments upon a set of questions and proposals outlined on the department of Health’s website at http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_129981 for Podiatrists and http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_129983 for Physiotherapist.

The consultation closes on 8th December 2011 and it is hoped that individuals and groups, both private, public and professional will respond online. The favoured responses by the National Executive, Faculty of Education and the Board of Education of the Institute of Chiropodists and Podiatrists to the consultation questions are as follows: Q1.

Option 1. Independent prescribing for any condition from a full formulary 3 Q2. Yes 3 Q3. Yes 3 Q4. No 3 Q5. As appropriate to the respondent – see substantial evidence in the impact assessment document: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_130068.pdf Q6. Yes 3 Q7 As appropriate to the respondent – see substantial evidence in the equality document: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_130033.pdf Q8. As appropriate to the respondent – see substantial evidence in the equality document: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_130033.pdf Appendix B. As appropriate to the respondent - general comments if any regarding the documents on curriculum and practice guidance and any other comments.

NB. You do not have to provide any information in appendix B if you do not wish to, this includes personal information.

—— oOo —— 25

Rambling Roads September 2011 The Times of Wednesday 21st September notes that the world’s largest sperm bank is offering a 15% discount for redheads. Apparently, the company located in Denmark has reached capacity for redheaded sperm donors with 70 litres in stock. Seemingly, a sales drive is taking place amongst the Celtic races since the Scots and Irish in particular have a larger proportion of the population with red hair. This is due to a mutation on the MCIR gene which is reportedly carried by 40% of the population of Scotland. Historically, there has always been prejudice against the red haired; the ancient Egyptians burned alive the unfortunate possessors of the colour, whilst in 15th century Germany such individuals were regarded as witches. Should the ‘sales pitch’ succeed, there are 600 potential donors eagerly waiting to do their bit!

Much from ‘New Scientist’ this month. The 13th August issue prints a report from Proceedings of the National Academy of Sciences. The repair or reconstruction of damaged cartilage has always been a matter which has interested chiropodists and podiatrists. Stem cells were collected from the perichordrium of the ear by Takanori Takebe at Yokohama City University. The stem cells were removed and injected into mice where they successfully grew into cartilage which was still healthy after 10 months. The first clinical application is to take place shortly

Paula Radcliffe is to undergo further foot surgery. According to the Daily Mail of 27th September the 37-year-old, who recently qualified for the London Olympics with a time of 2hr 23min 46sec, is due to have scans on an ‘unattached bone’ tomorrow before the operation on Friday. The surgery is to correct hallux valgus.

‘When I point my foot there's a big lump on top of it,' said Radcliffe. 'When I run it gets into my ligaments and causes inflammation.’ Hopefully, the corrected feet will assist her in gaining a medal at the 2012 Olympics.

‘Casebook’ the medical journal of the Medical Protection Society prints a cautionary tale in Volume 4, Issue 3. The writer points out that there is no such thing as ‘minor’ surgery.

A patient was referred by her GP to a general surgeon with the complaint of warts on the middle finger of her dominant hand.

She underwent diathermy of the warts but returned after some days with a black, sloughy wound over a 1.5cm area on the dorsum of the Proximal Interphalangeal Joint. This became infected and when she was seen subsequently the extensor tendons were exposed. A skin graft failed to take and the wound healed by secondary intention with scar formation.

This unfortunately, affected her employment which required her to carry out a good deal of typing. A similar scenario can be imagined in relation to the foot when diathermy or cryosurgery is carried out. These techniques are by and large safe and well tolerated; however, experience is necessary when applying the procedures to weak or denervated tissues.

26

The diagnosis of Diabetes Mellitus is increasing; indeed the incidence of the condition is predicted to continue to increase exponentially. Very often, the chiropodist/podiatrist may be the first practitioner to whom the patient presents with neuropathy of the foot. The same journal reports on a case of a 20 year old female who became dizzy and nauseous. Her pulse and blood pressure were normal. When her GP asked the mother whether the patient was passing urine normally, the mother replied that she was passing copious amounts of urine and drinking a large amount of water. The patient became comatose and was taken into hospital where the receiving staff noted the classical signs of ketone on the breath. Unfortunately, she was left with some neurological impairment. The moral of the story is that a full history of every patient should be taken and questions concerning polydipsia and polyuria asked in appropriate cases.

It would not be the first time that a podiatrist has successfully diagnosed type I diabetes.

The web site ‘Podiatry Arena’ is carrying the latest views on disposable instruments and sterilisation. The Institute, in its ‘minimum standards’ (see web site) states that steam sterilisation is the only acceptable method. However, it seems that across the world there are various methods still in use including baking instruments in ovens, the old (ineffective) glass bead sterilisers and amazingly, simply wiping an instrument with an alcohol soaked tissue. The consensus appears to be that for surgery based practice the ideal is steam sterilisation, whilst for domiciliary practices pre-sterilised disposable instruments are the best. There are numerous companies that supply disposable instruments, some of whom advertise in Podiatry Review or on the web site. As in all these things the price drops markedly according to the volume purchased.

More from ‘New Scientist’, this time dated 24th September.

The multi-drug resistant microbe is becoming increasing threatening in hospital medicine, so where can scientists look for new antibiotics? One promising line of enquiry is the dim and distant past. Ben Cocks of LaTrobe University in Australia is investigating the possibility of harvesting basic innate immune cells from the pouch of the Tamar wallaby. Cell mediated antibodies in the adaptive immune system target specific flaws in the chemistry of an invading organism and conventional antibiotics work in a similar way. Unfortunately pathogens evolve to become resistant to antibiotics and the immune system, resulting in the immune system – and drug companies - having to identify new flaws in the pathogen. The process repeats itself until the multi-resistant organisms are produced. The cruder innate immune system produces proteins that target the lipids in the cell membranes of the pathogen and are thus less likely to produce resistance. Cock’s team found genes that code for 14 cathelicidin peptides in the marsupial pouch and in laboratory testing discovered that this could

destroy a number of multi-resistant pathogens without damaging human cells. A similar, synthetic peptide was developed that worked against a wide range of bacteria and was 10 to 30 times more potent than tetracycline (PLosOne,DOI:10.1371/journal.pone.0024030).

It comes as no surprise to chiropodists/podiatrists that every individual’s gait is unique. The same journal notes that a computer can identify persons by their gait pattern with 99.8 per cent accuracy. Todd Pataky of Shinsu University in Japan and his colleagues examined the result of 1040 steps taken on a pressure mat device. The resulting information was used to create an algorithm to pick out patterns in peoples steps and then tested the outcome; the system was shown to be incorrect in only 3 cases. It has been suggested that the sensors – at $20,000 each – could be used to identify passengers who would be asked to walk barefoot through security. Christopher Nestor of the University of Salford in Lancashire thought that the system could be used for diagnosis of foot conditions and the production of orthoses. Nothing new there then!

Back to Diathermy. The Journal of The Royal Society of Medicine Vol.104 No.9 carries an article by Ramachandran and Aronson pointing out that whilst Nagelschmitt, a Berlin physician coined the term diathermy in 1907, the first reported case of the use of the technique was by John Marshall of

University Hospital, London, in 1851. Although crude direct cautery using hot metal had been used for many centuries to cauterise wounds, the use of electricity for this purpose had not been utilised in surgery previously. The patient presented with a fistula in the right cheek which had resulted in multiple abscesses; following a variety of other treatments Marshall threaded a platinum wire through the wound and heated it by passing a current from a battery for nine seconds. This resulted in healing of the chronic wound. He wrote a case study of the procedure and this was read to the Royal Medical and Chirurgical Society of London; a body of which he eventually became President. Marshall was an interesting man and the paper deserves reading in its entirety.

A foot care award project is highlighted in the August/September issue of ‘Assistive Technologies’. The scheme run by Cardiff and Vale University Health Board won the award for training staff, as well as ‘Age Concern’ and residential and nursing home health workers to provide patients with basic foot care. Chiropodist Theresa King (not a member of the Institute) said “As people are living longer, we need to be pro-active in identifying health risks, and providing efficient and empathic care.

This project without a doubt demonstrated that we listened and understood a basic need to help make a difference.” Around 168 people have attended the training programme so far.

Achilles Hele

The Institute of Chiropodists and Podiatrists

Leeds and Bradford Branch Seminar Saturday 3rd March 2012

University of Huddersfield 9:00 a.m.

9:15 a.m.

9:30 a.m.

10.30 a.m.

11:00 a.m.

12:00 noon 1:30 p.m.

2:30 p.m.

3:00 p.m.

4:00 p.m.

Registration Introduction Lecture (to be confirmed) Ms. Dianne Churchill-Hogg. Infection Control (part 1) Coffee / Trade Stalls Lecture (to be confirmed) Ms. Dianne Churchill-Hogg. Infection Control (part 2) Buffet Lunch / Trade Stalls Lecture. Miss Liza Dunkley, Senior podiatry Lecturer / Huddersfield University Coffee / Tea break Lecture Miss Liza Dunkley, Senior Podiatry Lecturer / Huddersfield University Finish and Collection of CPD certificates

If you wish to attend, please complete the booking form a.s.a.p. and send to Mrs. I. Shaw, 32, West Oval, Harrogate, HG1 3JW enclosing cheque for £80.00 payable to I.O.C.P. Leeds Branch. If you require more details contact Martin Hogarth on 01653 697389 The Seminar is open to all Chiropodists / Podiatrists and FHP from all organisations, all will be made welcome.

Booking Form Name: (BLOCK CAPITALS)....................................................................................................................................................................................

Address: ............................................................................................................................................................................................................. ...........................................................................................................................................................................................................................

Telephone No: ......................................................E-Mail: ......................................................................Date: .................................................

27

Institute of Chiropodists and Podiatrists

Southport Theatre and Convention Centre, The Promenade Join us for a fantastic evening with all funds raised donated to the Members Emergency Benevolent Fund

The evening starts with the President’s Reception followed by a 3 course dinner.

Afterwards you can dance the night away to our swing band.

Tickets are priced at £35 per person Or a table of ten for £300

THE INSTITUTE OF CHIROPODISTS AND PODIATRISTS 2012 NATIONAL CONFERENCE AND ANNUAL GENERAL MEETING Southport Theatre & Convention Centre, SOUTHPORT BOOKING FORM ʹ TO BE USED BY NON OFFICIAL BRANCH/EC DELEGATES DAY DELEGATE/LECTURES AND THE DINNER/DANCE MUST BE BOOKED ON THIS FORM PLEASE COMPLETE THE FORM CAREFULLY IN BLOCK LETTERS AND CHECK PRIOR TO POSTING AS NO AMENDMENTS CAN BE MADE ONCE FORM RECEIVED Name: ..................................................................................................................................................................................................

Address:................................................................................................................................................................................................ ..........................................................................Postcode͙​͙​͙​͙​͙​͙​͙​͙​͙​͙͙͘​͙​͙͘Telephone Number................................................ ........................................

NAME(S) OF ATTENDEE(S) ͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙͙͘​͙͘​͙͘​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙͙͘​͙​͙​͙​͙​͙​͙​͙ MEMBER OF WHICH PROFESSIONAL BODY͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙͙͘​͙͘​͘ th

Friday, 27 April 2012 2.00pm Lecture Silicon Injections into feet (Main conference area) £20 6.00pm Lecture Pharmacology (Main conference area) £20 Includes admission to the Trade Exhibition

G G G ά͙​͙​͙​͙​͙.

th

Saturday, 28 April 2012 Day Delegate Rate- possible choice of 4 lectures/workshops including lunch in Ramada Plaza Hotel and refreshments in the Trade Show - £70 (saving over £20.00) G ά͙​͙​͙​͙​͙.

9.30am Workshop Advanced Padding & Strapping (Syndicate room) G 11.30am Workshop TM2 (Syndicate room) G 2.30pm Lecture Dermatology (Main conference area) G 2.30pm Workshop Demonstration on the practical application of nail surgery (Syndicate room) G G 4.00pm Lecture Knee Replacements (Main conference area) 4.00pm Workshop Cautery of troublesome skin lesions and verrucae using Hyfrecators (Syndicate room) G Includes admission to the Trade Exhibition 7.00pm PƌĞƐŝĚĞŶƚ͛Ɛ ZĞĐĞƉƚŝŽŶ for guests attending the Dinner Dance and includes a complimentary glass of Wine/Orange juice 7.30pm until midnight Dinner Dance and Awards Ceremony ŝŶŶĞƌ ĂŶĐĞ dŝĐŬĞƚƐ Λ άϯϱ ƉĞƌ ƉĞƌƐŽŶ dž͙​͙​͙​͙​͙​͙ people G ά͙​͙​͙​͙​͙.

NAMES ATTTTENDING DINNER E ͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙͘​͘​͙͘​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙͘

Names of persons with whom you would like to be seated at the Dinner Dance ( Saturday) ʹ Whilst we will endeavour to meet your requestt,, we cannot guarantee this.......................................................................................

Special Requirements Vegetarian G Vegan G Other Requests/Dietary needs͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙​͙ TOTAL , ================== To book accommodation please see https://www.conferencebookings.co.uk/delegate/STH2012IOCP Payment 1. Credit Card - Credit card charge of 2% applies and Debit Card charge of 50p applies ප DĂƐƚĞƌ ĂƌĚ ප ^ǁŝƚĐŚ Card Type: ප Visa ප DĂĞƐƚƌŽ Card Number: .................................................................... ................... House Number͗ ͙​͙​͙​͙​͙ Postcode........................ sĂůŝĚ &ƌŽŵ͗ ͙͘​͘​͘​͘​͘​͘​͘​͘​͘​ͬ͘͘​͘​͘​͘​͘​͘​͘​͘​͘​͘ džƉŝƌLJ ĂƚĞ͗ ͙͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​ͬ͘͘​͘​͘​͘​͘​͘ϯ ĚŝŐŝƚ ƐĞĐƵƌŝƚLJ ĐŽĚĞ͗ ͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘ Maestro /Switch issue no: .................

Named Cardholder: ................................................... ........... ĂƌĚŚŽůĚĞƌ͛Ɛ ^ŝŐŶĂƚƵƌĞ͗ ͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘ 2. Cheque / ĞŶĐůŽƐĞ Ă ĐŚĞƋƵĞ ĨŽƌ ά͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘​͘ ŵĂĚĞ ƉĂLJĂďůĞ ƚŽ ͞dŚĞ /ŶƐƚŝƚƵƚĞ ŽĨ ŚŝƌŽƉŽĚŝƐƚƐ ĂŶĚ WŽĚŝĂƚƌŝƐƚƐ͟ Please note that full payment must be received before confirmation can be sent ʹ Please feel free to contact us should you not receive confirmation with one week Please return your completed form with payment to: The Institute of Chiropodists & Podiatrists, 27 Wright Street, Southport, Merseyside, PR9 0TL Telephone number 01704 5 546141 TERMS AND CONDITIONS If a booking is cancelled and no replacement participant can be found, the following cancellation charges will be incurred: x Cancellation 31 days or more before the event takes place: no charge x Cancellation between 14 days and 31 days before the event takes place: 50% of total price x Cancellation less than 14 days before the event takes place: 100% of total price The Institute of Chiropodists and Podiatrists reserves the right to cancel or reschedule seminar location or times, or to arrange a substitute lecture if this is absolutely necessary and out of our control. In these cases The Institute of Chiropodists and Podiatrists are not required to compensate travel or accommodation costs, loss of working time or other damages.

Rates include VAT @ current rate

VAT No 712 5290 59

REF: AGMDD2012

)#" /RTHOTICS "I -ONTHLY .EWSLETTER

)SSUE

$,4

4REATING 3ESAMOIDITIS WITH /RTHOTIC 4HERAPY "Y !BBIE .AJJARINE "3C 0OD 1-5 5+ $IP 0OD .37 0ODIATRIST !USTRALIA 3ESAMOIDITIS IS NOT A PARTICULARLY COMMON CONDITION AND CAN BE DIFlCULT TO DIAGNOSE AND TREAT 3ESAMOIDITIS IS PAINFUL INmAMMATION OF THE SESAMOID APPARATUS WHICH IS LOCATED IN THE FOREFOOT UNDER THE ST -40* 3ESAMOIDITIS IS CHARACTERISED BY PAIN AT THE lRST METATARSAL SESAMOID COMMONLY OCCURRING IN COMBINATION WITH A PLANTAR mEXED ST METATARSAL 4HIS CONDITION MAY PRESENT AS OFTEN AS IN OF OVERUSE TYPE FOOT INJURIES $ENNIS AND -C+INNEY

3ESAMOIDITIS TYPICALLY AFFECTS PHYSICALLY ACTIVE YOUNG PEOPLE AND IN MY EXPERIENCE IS MORE COMMON IN SPORTING PEOPLE WHO REQUIRE BALANCE ON THE BALL OF THE FOOT SUCH AS BALLET DANCERS BASKETBALLER NETBALLER

CRICKET PLAYERS AND SOCCER PLAYERS AS THEY ATTEMPT TO STOP AND CHANGE DIRECTION BY PIVOTING OR PUTTING PRESSURE ON THE FOREFOOT AREA AND SPECIlCALLY THE BALL OF THE ST -40* 3ESAMOIDITIS CAUSES PAIN IN THE BALL OF THE FOOT UNDER THE ST -40* AND COMMONLY AFFECTS THE MEDIAL INNER SIDE 4HE PAIN MAY BE CONSTANT OR IT MAY OCCUR WITH OR BE AGGRAVATED BY

MOVEMENT OF THE BIG TOE JOINT )T MAY ALSO BE ACCOMPANIED BY SWELLING EDEMA THROUGHOUT THE PLANTAR ASPECT BOTTOM OF THE FOREFOOT

30

APPROXIMATELY ONE HALF THE BODY S WEIGHT AND BALANCES PRESSURE ON THE BALL OF THE FOOT 4HE HALLUX BIG TOE HAS TWO PHALANGES AND TWO JOINTS INTERPHALANGEAL JOINTS

TOGETHER WITH TWO SMALL SESAMOID BONES THE MEDIAL AND LATERAL SESAMOID BONES 4HE SESAMOIDS ARE IMPLANTED OR EMBEDDED IN THE mEXOR HALLUCIS BREVIS TENDON WHICH EXERTS PRESSURE FROM THE BIG TOE AGAINST THE GROUND AND AIDS IN THE ACT OF WALKING DURING THE TOE OFF PHASE OF GAIT 4HE SESAMOIDS NOT ONLY HAVE TO ENDURE THE PRESSURE OF BODY WEIGHT AND GRAVITY BUT ALSO THE CONSTRICTIVE PRESSURE OF THE mEXOR HALLUCIS BREVIS TENDON

3ESAMOIDS

&IGURE 0LANTAR ASPECT

DOWN AGAINST THE GROUND DURING GAIT 0ATIENTS WHO SUFFER FROM 3ESAMOIDITIS OFTEN EXHIBIT A lXED OR MOBILE PLANTAR mEXED ST METATARSAL WHICH MAINTAINS THE ST -40* IN A PLANTARmEXED POSITION ON IMPACT 4HE LESSER METATARSALS ARE ABLE TO ABSORB THE IMPACT IN THE GAIT CYCLE HOWEVER

THE ST -40* IS RIGID AND THE SESAMOID TAKE THE FULL IMPACT DURING TOE OFF 2EPETITIVE CHRONIC PRESSURE AND TENSION ON THE FOREFOOT WILL CAUSE THE SURROUNDING TISSUES TO BECOME IRRITATED AND INmAMED )N SOME CASES THE SESAMOIDS MAY BIFURCATE AND IN SEVERE CASES NECROSIS MAY OCCUR 4HE PRACTITIONER SHOULD ALWAYS CHECK THE PATIENT FOR A 0LANTARmEXED ST USING THE COMMON TEST IN WHICH THE MOVEMENT OF THE JOINT SHOULD BE MM DORSImEXION AND MM PLANTAR mEXION OR A TOTAL RANGE OF APPROX MM 4HIS TEST WILL IDENTIFY IF THERE IS A LIMITATION IN THE JOINT S RANGE OF MOTION DUE TO A lXED OSSEOUS CONDITION 4O PERFORM THIS TEST 7ITH THE PATIENT IN THE SUPINE POSITION MAINTAIN THE FOOT IN THE NEUTRAL POSITION

'RIP THE LESSER METATARSALS LINE THE THUMBS UP AND THE RANGE OF MOVEMENT SHOULD BE MM UP AND MM DOWN $UE TO PRONATION THE SESAMOIDS DISPLACE LATERALLY CAUSING TRAUMA TO THE SESAMOID APPARATUS 4HIS CAN CHANGE THE PATIENT S GAIT AS THEY TRY TO COMPENSATE AND MAY CAUSE OTHER UPPER BODY COMPENSATORY EFFECTS

INCLUDING HIP PAIN

)T IS GENERALLY ACCEPTED THAT THE SESAMOIDS PERFORM TWO PRINCIPAL FUNCTIONS !BSORBING IMPACT FORCES IN THE FOREFOOT DURING WALKING THROUGH A SERIES OF ATTACHMENTS TO OTHER STRUCTURES IN THE FOREFOOT !CTING AS A FULCRUM TO PROVIDE THE mEXOR TENDONS WITH A MECHANICAL 4REATMENT

USUALLY NON INVASIVE AND INCLUDES ORTHOTIC THERAPY TO TREAT THE PLANTARmEXED ST 'ENERALLY A DEmECTION WILL NEED TO BE INCORPORATED INTO THE ORTHOTIC TO REMOVE OR REDUCE THE PRESSURE FROM THIS AREA 4HE 0LANTARmEXED ST 2AY DEmECTION IS CUT AROUND THE ST -40* AND THEN THE EDGES ARE HEATED AND SMOOTHED TO TAPER THE EDGE OF THE ORTHOTIC AND AVOID IRRITATION SEE &IGURE 4HE ORTHOTIC ITSELF HAS IN BUILT FOREFOOT SUPPORT UNDER THE ND TO TH AND SUPPORTS THIS AREA SIMILAR TO A BAR

-ODIFYING THE PATIENTS SHOES IS NOT OVERLY EFFECTIVE AS EACH PAIR WOULD NEED TO BE MODIlED 4HE EASIER APPROACH IS A HEAT MOULDABLE ORTHOTIC INCORPORATING A 0LANTARmEXED ST RAY DEmECTION MODIlCATION WHICH CAN BE MOVED AND TRANSFERRED FROM SHOE TO SHOE WITH RELATIVE EASE )N ADDITION THE BIG TOE MAY BE BOUND WITH STRAPPING TAPE OR ATHLETIC STRAPPING TO IMMOBILIZE THE JOINT AS MUCH AS POSSIBLE AND ALLOW HEALING TO TAKE PLACE !CUPUNCTURE CAN BE USED TO REDUCE INmAMMATION AND ANTI INmAMMATORY DRUGS CAN BE TAKEN TO REDUCE SWELLING 2%&%2%.#%3 -ICHAUD 4 # &OOT /RTHOSES AND /THER &ORMS OF #ONSERVATIVE &OOT #ARE 7ILLIAMS AND 7ILKINS "ALTIMORE

PP

2OOT - , /RIEN 7 0 AND 7EED * ( #LINICAL "IOMECHANICS .ORMAL AND !BNORMAL &UNCTION OF THE &OOT #LINICAL "IOMECHANICS #ORP ,OS !NGELES #HAPTER

&IGURE 0LANTARmEXED ST 2AY $EmECTION CREATED IN ORTHOTIC

IOCP_Chiropody

IPP 2012 - One-stop Conference for Health Professionals The 12th Independent Podiatry Professionals conference will be held at the Telford Park Inn on March 4th and 5th 2012.

Places are selling fast for this one-stop conference where health professionals can update their knowledge across a selection of key topics including diabetes, vascular assessment, footwear and infection control. Organised by the Professional Events company, the two day event will include a series of lectures and workshops to challenge and stimulate debate across the podiatry profession. â&#x20AC;&#x153;This is the 12th year we have organised the IPP event, and it continues to grow from strength to strength,â&#x20AC;? said Jackie of Professional Events. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a popular learning option because we combine important updates with refresher information and, as we are supported by a large trade exhibition, delegates can often negotiate excellent discounts and offers and see relevant new products all in one place at one time. â&#x20AC;&#x153;With the HPC audit due in June 2012, an important innovation this year is the opportunity for delegates to bring their portfolio to be audited in a guided work group â&#x20AC;&#x201C; weâ&#x20AC;&#x2122;re anticipating that this will be a very popular and busy session.â&#x20AC;? The IPP will be held at the Telford Park Inn on Sunday afternoon 4th and Monday 5th March 2012, delegates can choose to attend on one or both days of the event. Many delegates return to this popular event each year to socialise with fellow professionals so the Professional Events team has negotiated discounted rates for accommodation at the Telford Park Inn of ÂŁ47 bed and breakfast or just ÂŁ65 to include a dinner with fellow delegates at 7.00pm in the hotel dining room with a quiz (sponsored by Hotter Shoes) in the bar at 9.00pm.

Call: 01274 885523 Email: chiropody@trycare.co.uk Web: www.trycare.co.uk

For more information please visit: www.professionalevents.co.uk or contact Professional Events on 01625 521239.

Trycare, Station Road, Clayton, Bradford BD14 6JA

We would like to wish you all a very Merry Christmas and a Happy New Year.

Thank you for your business in 2011 and we look forward to working with you in 2012.

TRYCARE FOR ALL YOUR FOOT CARE PRODUCTS Email chiropody@trycare.co.uk for your FREE sample of Chirocream Foot Care Cream

31

Midland Area Council 4th Annual Seminar Sunday March 11th 2012 Village Hotel, The Green Business Park, Dog Kennel Lane, Shirley, Birmingham B90 4GW off Junction 4 of the M42

“Cannot Possibly Diabetes” have

PROGRAMME 9:00

Registration, Tea, Coffee and Danish Pastries

9:20

Welcome Address by IOCP President Heather Bailey

9:30

‘LIZARD SPIT

AND ALL THAT’

Jane Sennett, Diabetic Practitioner Overview on Diabetes, New Treatments, Injection Devices, Blood Glucose Monitoring 10:45

Refreshments and Biscuits

11:15

HANDS ON DIABETIC TESTING Gareth Hicks, Podiatrist BSc, Bailey Instruments Practical Workshop on Neurological and Vascular assessment of the Diabetic Foot

12:45

Lunch and Trade

2:00

SILICONE ORTHOSIS FOR DIABETICS Michelle Weddell Podiatrist BSc (Hons) Workshop on how to use silicone putty to make orthosis for your diabetic patients

3:00

Tea and Coffee

3:20

AN

Y

ON THE FEET

Jim Osborne Optometrist MSc FCOptom FAAO Can the eyes tell us what is happening to the diabetic foot?

4:30

CPD Certificates and Close of Seminar COST £55 (£5 reduction if booked before 1st January 2012)

!

The seminar is open to Chiropodists and Practitioners from all organisations and all will be made very welcome.

Further information contact Pam 0138647695 or Valerie 01902332847

!

Booking Form NAME (for badge) .........................................................................

Branch ..............................................................

Address......................................................................................................................................................................... ......................................................................................................................................................................................

Tel: .................................................................................

Diet Requirements...........................................................

Signature........................................................................

Date .................................................................................

Please complete the form and send with remittance (cheques payable to Midland Area Council) To MAC Treasurer Mrs. Pam Osborne, 8 Andrews Drive, Evesham, Worcestershire, WR11 2JN

32

WEST MIDDLESEX BRANCH SEMINAR Sunday, 6th November 2011 at the Holiday Inn Express, 19, Bridle Path, St. Albans Road, Watford WD17 1UE Telephone: (01923) 28 86 00 PROGRAMME: 10.45

Registration, coffee and biscuits

12:45

11:15

A Diabetic Talk –

by Gareth Hicks, Podiatrist B.Sc.

Practical session on foot assessment using instruments described in the talk

14:00

Coffee and biscuits

12:00

Sandwich buffet

Questions

Close of Seminar and CPD Certificates Cost is £20 - Please contact Hyacinth Tyrrell - Tel: 07873493946 The Institute of Chiropodists and Podiatrists

SOUTHERN AREA COUNCIL Spring 2012 Seminar Saturday 24th March 2012 10:00 a.m. – 4:00 p.m.

Registration / Coffee 9:30 a.m. at

Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex More details to follow about the guest speakers and workshops Delegate Information The SAC Seminar includes: • Speaker Presentations • Workshops in the afternoon – Seminar delegates will have an opportunity to attend all the workshops • Opportunity to network with like minded professionals – the Seminar is open to all Health Professionals and Chiropodists & Podiatrists from all organisations • Market Place – Trade and information exhibitors • Lunch, refreshments and free parking • Easy to get to by bus, car or train (directions available) • CPD Certificate • Cost: £60.00

Closing date for bookings: 19th March, 2012

Please complete the booking form and return, enclosing a cheque for £60.00 made payable to the IOCP Southern Area Council to: Mrs. Flavia Tenywa (SAC Hon. Treasurer), 96b High Street South, East Ham, E6 3RL. For further information: Tel: 0208 586 9542, Mobile: 07956 980815 or E-mail: fixmytoe@aol.com !

!

SAC Spring Seminar 2012 Name: ......................................................................................

Branch:.......................................................................................

Address: ........................................................................................................................................................................................... ...................................................................................................................................

Tel No: .....................................................................................

Postal Code: .............................................

Email:.........................................................................................

Dietary Requirements: .....................................................................................................................................................................

Signature:...................................................................................................................

Date:.........................................................

33

Hants and Dorset Branch Meeting Meeting commenced @ 8:00 p.m. 14/9/11 We were given an extremely interesting and informative talk by Elise King, a representative from H.M.R.C. about all aspects of running one's own business. It was very clearly explained, and covered the explanation of National insurance contributions, class 2 & class 4.The importance of record keeping,and how to calculate business expenses (what is an allowed expense and what is not), and the advantages and disadvantages of the mileage rate method as opposed to the actual cost method of claiming for your vehicle.

Chester North Wales, Staffs and Shrops Branch Nail Reconstruction Workshop Trade Stand Supplied by Canonbury

Suzanne gave us her report from the S.A.C. meeting that she attended, and said that the Institute was under quite tight financial pressure at the moment,and that they would like more uptake on the various courses they were running, but most of them are up in the North.

Next meeting date is 18th November, which will be our social meeting, and it was suggested that the venue would be The Walter Tyrell in the New Forest, postcode SO43 7HD, for those of you with a sat nav.

Please contact Julia, if interested, so that she can book the restaurant accordingly.

Susan Douglas, Hants and Dorset Branch

discount on orders over £85.00 made at the meeting which included free postage. Canonbury also offer courses and workshops and Ben discussed these.

After his presentation, he handed out to the members, new 2012 diaries and wallets containing news of other offers from Canonbury.

After the business meeting and raffle, Heather and Sarah set up their ‘clinic’ to demonstrate the use of UV Cured Gel Nails. These are used on nails that have been damaged through fungal infections or trauma in which the nails grow deformed or unsightly. It is also used to replace nails that have been lost through trauma. After the

CNW branch members enjoyed a meeting with a difference on the

demonstration, they asked for a willing volunteer to have the

2nd October. Always trying to encourage members to embrace new

treatment. One of the members tried this and was impressed how

ideas and techniques, two of its members Heather Ratcliffe and Sarah

good the results were.

Crook presented a Nail Reconstruction Workshop. Heather and Sarah

All the members worked in groups to try the procedure for

have been using this technique for some time in their practice and

themselves. This workshop was useful and informative and would

were asked by members to demonstrate this procedure.

Ben Stead from Canonbury Products kicked off the meeting discussing new products that the company have, including their Dermatronic cream range. Members were able to try this and all agreed that it was a good product. He also offered members 7.5%

New Socks for the Homeless 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.

Crisis is a national charity for single homeless people. At Christmas the charity provides companionship and support to

34

It was also explained how easy it is to do a self assessment on-line, so perhaps those of us who have been paying our accountants for years to do just that, could perhaps take the plunge and have a go.

bring additional income to members practices. At the end of the meeting Ben Stead from Canonbury was on hand to finish members orders. Members all agreed that it was a very worthwhile workshop and enjoyed trying a new innovative product.

Denise Willis, Branch Secretary

alleviate loneliness and isolation, and to help people to take their first steps out of homelessness.

“Crisis are always looking for donations of suitable socks as well as all sorts of other food and clothing for use during the Christmas week,” says Cosyfeet’s Vicki Palmer. “We’re delighted to be able 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.

Crisis at Christmas are always looking for podiatrists to volunteer over the 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

Recruitment PODIATRIST TO JOIN BUSY CLINIC IN HESWALL WIRRAL Due to the opening of a second clinic on the Wirral.

Heswall Chiropody is now in a position to offer a posting to a Podiatrist/Chiropodists. The successful applicant will be able to achieve very high earnings with a choice of days worked - starting with one day per week going on to three or more days. For further Information please telephone 0151-342-9665.

Room for Rent TREATMENT / CONSULTATION ROOM TO RENT in Private Dental / Osteopath Practice in Alton.

Negotiable F / PT rental, inc phone / Reception.

Enquiries: 01420 544408 / jacquie@watercressdentalpractice .co.uk

www.PODWASTE.co.uk

IOCP_Chiropody

Discounted rates Any size clinic/practice No long term contracts Full UK coverage Easy payments

(0800 988 7897 Chiropody Supplies

Info@podwaste.co.uk

AMBER CHIROPODY SUPPLIES Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including:

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)

* Instruments & Equipment * Padding & Appliances * Dressings & Adhesives * Biomechanics

* Domiciliary * Sterilization * Diagnostics * Retail Products

To view our website/online store please visit:

www.ambersupplies.co.uk 35

Diary of Events Essex Branch Meeting and A.G.M.

November 2011 Birmingham Branch Meeting 17th November 8:00 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

Essex Branch Meeting 20th November Education Centre, Southend University Hospital, Carlingford Drive Southend-on-Sea. Tel: 01702 460890

29th January – Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea. Tel: 01702 460890

Hants and Dorset Branch A.G.M. 9th January 2011 7:45 p.m. coffee (meeting 8:00 - 10:00 p.m.) – Crosfield Hall, Broadwater Road, Romsey, SO51 8GL. Tel: 01202 425568

Hants and Dorset Branch Meeting 18th November 7:45 p.m. – Our usual ‘Social Occasion of the Year’ dinner out with friends/partners/colleagues.

Venue to be arranged.

Tel: 01202 425568

Leeds/Bradford Branch Meeting 6th November 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel: 01924 475338

Leicester and Northants Branch Meeting plus A.G.M. 22nd January 10:00 a.m.

Lutterworth Cricket Club LE17 4RB. Registration and refreshments at 9:45 a.m.

Tel: Sue 01530 469816

Leicester and Northants Branch Seminar

London Branch A.G.M.

Lutterworth Cricket Club LE17 4RB. Lectures: Dementia: “How to interact with patients” and “Effects on Practice”, Plantar Fasciitis; Pharmacist invited to give drug update – £45 including lunch and free parking 10:00 a.m. start. Registration and refreshments at 9:45 a.m.

Autoclave calibration by prior arrangement (Max 12) Tel: David 01455 550111

18th January 7{30 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

Nottingham Branch A.G.M. 15th January 10:00 a.m. – British Red Cross Centre, Phoenix Park, Nottingham.

Tel: 0115 931 3492

Midland Area Council A.G.M.

London Branch Meeting 16th November 7:30 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 0208 586 9542

29th January 10:00 a.m.

Kilsby Village Hall, CV23 8XX.

Tel: 01386 47695

Sussex Branch Meeting

North West Branch A.G.M. and Meeting

20th November – The Bent Arms, Lindfield, West Sussex.

Tel: 01273 890570

15th January 11:00 a.m. – St. Joseph’s Community Centre, Harpers Lane, Chorley PR6 0HR. Tel: 0161 486 9234

West of Scotland Branch Meeting

Nottingham Branch A.G.M.

6th November at 11:00 a.m. – Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

15th January 10:00 a.m. – British Red Cross Centre, Phoenix Park, Nottingham.

Tel: 0115 931 3492

West Middlesex Branch Meeting

Southern Area Council A.G.M.

14th November – The Harvester, Croxley Green, Rickmansworth, Herts WD3 3RX. Tel: 0208 903 6544

21st January 1:00 p.m. – Victory Services Club 63-79 Seymour Street, London W2 2HF. Tel: 01992 589063

December 2011

Surrey and Berkshire Branch A.G.M.

Leeds/Bradford Branch Meeting

14th January 1:30 p.m. – Greyfriars Centre, Reading.

Tel: 0208 660 2822

4th December 10:00 a.m. – The Oakwell Motel, Low Lane, Birstall, Nr. Leeds WF17 9HD. Tel: 01924 475338

Western Branch A.G.M.

Nottingham Branch Meeting 4th December 10:00 a.m. – British Red Cross Centre, Phoenix Park, Nottingham.

Tel: 0115 931 3492

Scottish Area A.G.M.

January 2012 Birmingham Branch A.G.M. 12th January 7;30 p.m. – British Red Cross Centre, Evesham.

Tel: 01905 454116

East Anglia Branch A.G.M. 29th January – Haymarket Day Centre.

36

15th January at 12:15 p.m. Meeting at 1:45 p.m.

Seminar Room 1, The Women’s Hospital Liverpool.

Tel: 01745 331827

Tel: 01603 440828

22nd January 10:30 a.m. followed by West of Scotland Branch A.G.M. – Express by Holiday Inn, Springkerse Business Park, Stirling FK7 7XH. Tel: 01796 473705

Wolverhampton Branch A.G.M. 15th January 10:00 a.m. – 4 Selman’s Parade, Selmans Hill, Bloxwich WS3 3RN. Tel: 0121 378 2888

National Officers

Branch Secretaries

President Mrs. F. H. Bailey, M.Inst.Ch.P.

Birmingham

Mrs. J. Cowley

01905 454116

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. Z. Sharman

01473 830217

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Leeds/Bradford

Mr. N. Hodge

01924 475338

Leicester & Northants

Mrs. S. J. Foster

01234 851182

London

Mrs. F. Tenywa

0208 586 9542

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. Massey

0161 486 9234

Northern Ireland Central

Miss G. Sturgess

0289 336 2538

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Oxford

Mrs. S. Harper

01993 883397

Republic of Ireland

Mr. C. Kerans

00353 1285 3150

Sheffield

Mrs. D. Straw

01623 452711

South Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mr. S. Gourlay

0141 632 3283

Wolverhampton

Mr. D. Collett

0121 378 2888

Chairman Executive Committee Mr. W. J. Liggins, F.Inst.Ch.P., F.Pod.A., B.Sc.(Hons) Vice-Chairman Executive Committee Mr. M. Holmes, M.Inst.Ch.P., D.Ch.M., B.Sc. Pod Chairman Board of Ethics Mrs. C. Johnston, M.Inst.Ch.P., B.Sc.(Hons) Chairman Board of Education Mr. R. Sullivan, M.Inst.Ch.P., B.Sc.(Hons), Dip. Pod. Med., PGDip, Cert.L.A, FSSCh, FIChPA, MRSM

Vice-Chairman Board of Education Mr. M. Harvey, M.Inst.Ch.P., PGCE, B.Sc. Honorary Treasurer Mrs. J. Drane, M.Inst.Ch.P. Standing Orders Committee Mr. M. Hogarth, M.Inst.Ch.P. Mrs. L. Pearson, M.Inst.Ch.P., B.Sc., Pod. Med. Secretary Miss A. J. Burnett-Hurst

Area Council Executive Delegates Midland Area Council Mrs. V. Dunsworth, M.Inst.Ch.P., D.Ch.M. North West Area Council Mrs. M. Allison, M.Inst.Ch.P. Republic of Ireland Area Council Mrs. J. Casey, M.Inst.Ch.P., B.Sc. Scottish Area Council Mrs. A. Yorke, M.Inst.Ch.P. Southern Area Council Mr. D. Crew, OStJ, F.Inst.Ch.P., D.Ch.M., Cert.Ed. Yorkshire Area Council Mrs. J. Dillon, M.Inst.Ch.P.

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