Podiatry Review March/April 2011 by The Institute of Chiropodists & Podiatrists

The Ins tute of Chiropodists and Podiatrists

ISSN 1756-3291

Vol. 68 No. 2 - March/April 2011

Features within this Issue: • Peer Reviewed Articles

Presentation of Molluscum Contagiosum Part 2 - Treating Talipes Equinovarus

• A.G.M. Booking Form • National Oﬃce Candidates

Independence

Initiative

Individualism

March/April 2011 Podiatry Review

Contents 1. Editorial

The Institute of Chiropodists and Podiatrists Podiatry Review Editor Roger Henry F.Inst.Ch.P. DChM editor@iocp.org.uk Sub-Editor Robert Sullivan M.Inst.Ch.P. BSc(Hons)Pod, PG Dip. TP Surg.

Subeditor@iocp.org.uk Press and Public Relations Officer Fred Beaumont Tel: 0191 297 0464 Editorial Assistant Bernadette Willey bernie@iocp.org.uk Editorial Committee Mrs. F. H. Bailey M.Inst.Ch.P Mr. R. Beattie Hon.F.Inst.Ch.P., LCh., HChD Mr. S. Gardiner M.Inst.Ch.P BSc(Hons) PGDip Mr. W. J. Liggins F.Inst.Ch.P, FpodA, BSc(Hons) Mrs. A. Yorke, M.Inst.Ch.P Mr. J. W. Patterson, M.Inst.Ch.P., BSc(Hons)

DChM, MSc

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

2. Diabetes UK News 3. Maintaining Standards of Competence and Performance Iain B. McIntosh 6. Personal Profile Loreto Sime 6. Cosyfeet Podiatry Award 8. Critical Appraisal Judith Barbaro-Brown 10. A Classification Method for Determining Adult Foot Types Roberta Nole MS. PT. C.Ped 12. A.G.M. Timetable 13. A.G.M. Booking Form 14. Nominations for National Office 15. Peer Review Section Centre CPD Article - Forensic Podiatry: A Short Overview, Professor Wesley Vernon, OBE PhD 19. Peer Review Section (cont.) 24. Branch News 26. The Institute of Chiropodists and Podiatrists announces the award of our quality mark to H. J. Hall 26. Devon and Cornwall A.G.M. and Lecture 30. Letter to Editor 32. Classified Adverts 33. 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.

Dear Reader I hope you like your ‘new look’ Podiatry Review, we have had several compliments on this new look - it seems to have gone down well. What is in the March/April issue of Podiatry Review of interest and note? Our old friend Iain B McIntosh has written an article on ‘Maintaining Standards of Competence and Performance’ well worth reading! Judith BarbaroBrown has sent in an article on ‘Critical Appraisal’ for which we thank her very much. The Continuing Professional Development pull-out section entitled ‘Forensic Podiatry - a short overview’ is by Professor Wesley Vernon OBE PHD - a different slant on a rapidly growing facet of podiatry. We also have two excellent articles for our peer review section starting from page 15 - thank you to Janet McGroggan and Bill Liggins. Our Annual Conference and A.G.M., Chiropody Supplies Exhibition and Annual Dinner Dance is being held this year at Beaumont House, Windsor from Thursday 12th May 2011 through till Saturday 14th May 2011. There is a very good series of lectures and, as always, I am looking forward to seeing old friends and new. If you can spare the time to visit, it would be to your advantage both professionally and personally. The itinerary and booking form are on pages 12 and 13. You can also phone Head Office direct on 01704 546141 to book. Look forward to seeing you there Roger Henry, Editor

Artificial pancreas in pregnancy promises fewer diabetes deaths and abnormalities

esearch funded by Diabetes UK has for the first time successfully demonstrated the potential of an artificial pancreas in pregnant women with Type 1 diabetes. It is hoped the development could drastically reduce cases of stillbirth and mortality rates among pregnant women with the condition. Pregnancy poses additional risks for women with diabetes as hormonal changes make it very difficult to keep blood glucose levels within a safe range, especially at night. As a result of high blood glucose levels, babies of women with diabetes are five times as likely to be stillborn, three times as likely to die in their first months of life and twice as likely to have a major deformity. Hypoglycaemia (low blood glucose) in pregnancy is a major cause of maternal mortality. Two in three mothers with pre-existing diabetes have Type 1 diabetes. To be published in the February 2011 issue of 'Diabetes Care' and led by Dr Helen Murphy of Cambridge University, the study evaluated the performance of an artificial pancreas or ‘closedloop insulin delivery system’ in ten pregnant women with Type 1 diabetes. The researchers found the device was able to automatically provide the right amount of insulin at the right time, maintain near normal blood glucose levels and, in turn, prevent nocturnal hypoglycaemia in both early and late pregnancy. The artificial pancreas was created by combining a continuous glucose monitor (CGM) with an insulin pump, both of which are already used separately by many people with Type 1 diabetes.

Previous studies have shown improved blood glucose control and reduced hypoglycaemia with overnight use of an artificial pancreas in children with Type 1 diabetes but this is the first time it has been successfully used in pregnant women with the condition. “For women with Type 1 diabetes, self-management is particularly challenging during pregnancy due to physiological and hormonal changes. Previous studies indicate that pregnant women with the condition spend an average of ten hours a day with glucose levels outside the recommended target,” said Dr Murphy. “These high blood glucose levels increase the risk of congenital malformation, stillbirth, neonatal death, preterm delivery, macrosomia [oversized babies] and neonatal admission. So to discover an artificial pancreas can help maintain near-normal glucose levels in these women is very promising,” she added. Diabetes UK Director of Research, Dr Iain Frame, said: “Although early days, this exciting area of research, funded by our donors, has huge potential to make pregnancy much safer for women with Type 1 diabetes, and their babies. “It’s a fantastic example of how existing technologies, in this case, insulin pumps and CGMs, can be adapted and developed to benefit as many people with diabetes as possible. We now need to see an extension of this study, one which tests larger numbers of women, and then take it out of the hospital and in to the home setting.”

Diabetes UK welcomes Monday’s decision by the World Health Organisation (WHO) to accept the use of the HbA1c test in diagnosing diabetes

he HbA1c test measures the amount of glucose being carried by the red blood cells in the body and indicates a person’s blood glucose levels for the previous two-to-three months. People with diabetes have at least one HbA1c test a year after diagnosis but now, following a review by the WHO, the test has been recommended to also be used for diagnosing diabetes. To date, the most frequently used diagnosis tests typically require taking a blood sample from a patient and measuring the glucose content. In some tests, the patient has to fast and then consume a high glucose drink with blood being taken before and after and the glucose levels compared. Some clinicians already carry out HbA1c tests as a means of diagnosing but it has not yet been widely used. According to the world health body, the HbA1c test offers a more practical and patient-friendly approach to diagnosing the condition that already affects over 3.5 million people in the UK and over 220 million people worldwide. Dr Ala Alwan, Assistant Director General of WHO’s Non-communicable Diseases and Mental Health Cluster, said the addition of this test for diagnosing diabetes is a positive development, provided that stringent quality assurance tests are in place and measurements standardised.

"Unlike other means of diagnosis, it does not require a patient to fast before a blood sample is taken, nor to consume a glucose drink that many people find unpalatable. HbA1c also has the advantage of reflecting the person’s average blood glucose levels over the preceding two-three months," said Dr Alwan. Simon O’Neill, Diabetes UK Director of Care, Information and Advocacy, explained that: "This recommendation does not mean other tests for diagnosing diabetes will be shelved. Doctors will continue to use their clinical judgement about which test is most appropriate for their patients on an individual basis. This advice from the WHO simply provides an assurance that it is acceptable to add HbA1c to the range of options available for testing for diabetes." In response to questions about the financial implications of introducing the test more widely, O’Neill countered that: "The costs of the HbA1c test are likely to be higher than those for the traditional tests used but the staff time saved in GP surgeries and the convenience for patients is likely to outweigh these."

Maintaining Standards of Competence and Performance Iain B. McIntosh (Former Chiropody Schools Inspector) BA(Hons). MBChB., FFTMRCPS(Glas)

s registered health professionals we are required to establish high standards of clinical performance and personal conduct, which have to be maintained as part of the fitness to practise process. The latter demands competence and the demonstration of skills and knowledge, to practise effectively and safely. The Health Professionals Council investigates formal complaints of professional misconduct and incompetence.

conditions or be the trigger for an audit of practice procedures. If we are to learn from unfortunate occurrences they must be considered in depth. An appropriate immediate response to the complainant can often defuse the situation and permit a continued amicable patient/ professional relationship. As many as 40% of claims are due to failures in communication, record keeping and breaches of confidentiality and many are preventable.

There has been a doubling of the rate of litigation in the NHS in England within a decade. Risk of harm to patients is an unavoidable feature of clinical practice and reduction of risk should be a proactive, integral part of professional work, with measures in place to prevent errors and reduce potential patient damage. All involved in health care are vulnerable to error and have a duty to continually seek improvement in individual personal practice, which may encompass critical event analysis, audit and continuing professional development.

Significant harm may befall patients in the course of treatment triggering personal suffering, anxiety and stress. Adverse consequences to patient’s well-being often result from errors which do not constitute negligence, but which cause misery and discomfort with knock-on effects. There is a also a price for the professional to pay in terms of anxiety, stress, loss of personal confidence, and patient trust. They are best avoided and can be, by anticipation of potential problem areas. A significant proportion of adverse events are preventable if anticipated in practice procedures. An effective programme for reducing adverse events can be established from study of these situations and the adoption of risk reduction strategies – risk management - as an integral part of daily practice.

Adverse events with patients will inevitably arise over every practitioner’s life time .How they are dealt with, will determine whether they proceed to formal complaint or litigation. The Medical Defence Union (MDU) has noted that responding positively and promptly when things go wrong and giving an explanation, with apology where appropriate, will often prevent the matter progressing further. 90% of complaints reported to the MDU are resolved at local level. Good practice principles dictate that patients who complain about care or treatment have the right to expect a prompt, open, constructive and honest response, with the assurance that the situation will not be repeated. Professional peril will threaten if complaints are ignored or there is resort to procrastination. They should serve as a warning of the need to monitor professional behaviour and be seen as a learning exercise to promote change in behaviour, routine and habit, to ensure similar circumstances do not recur. Mistakes and near misses, even of a predominantly personal nature should be considered an opportunity to learn and adapt and a time for reflection. They should always be considered for significant event analysis looking at human error, system failure and latent

Many adverse events are multi factorial, but do involve human error at some stage. They often result from a cascade of relatively minor failures. An example of this in terms of human tragedy was the recent explosion on the oil rig off Florida, when single equipment and management failings progressively summated to ultimately lead to a cumulative disaster. A significant proportion of adverse events are not due to lack of knowledge or experience, but due to human and/ or organisational failure. There are two approaches to the management of error,the “Person” approach and the “Systems” approach, with the former concentrating on unsafe acts by the provider at point of delivery. This untoward event may be due to carelessness, inattention, or skill failure in a set procedure. The system approach concentrates on set systems of working and how failure in the system leads to downstream adverse event. This may result from poor training or inadequacy of equipment or its misuse. 3

Failure of a podiatrist to recognise the need for scrupulous sterility procedures when dealing with the skin of a diabetic patient may result from poor training and lack of expertise and knowledge – human failing, whereas the inadequacy of the sterilising equipment to function effectively may be a systems failure. Adverse events frequently involve consideration of both factors and are often multi-factorial embracing human error at some stage.

instance the registrant was convicted of breaching the Data Protection act as he had accessed a patient record without good reason or consent and had disclosed information to a third party without consent.

Potential pitfalls in breaches of confidentiality At reception desk - can private conversations be overheard?

Managing the pitfalls of clinical practice The primary requirement is to identify problem areas with the potential for complaint. Common pitfalls are: Medical records. Confidentiality. Communications. Working systems.

E-mail communication: Are e-mails recorded and dealt with securely? Computer, and software storage: protected access and secure storage with back-up?

Consent.

Medical records: stored securely and colour coded for allergies?

Health and safety stipulations.

Consent to treatment: recorded with refusals annotated?

Risk Management Identify the potential pitfall.

Risk Assess How likely it is to happen? Assess the likelihood of the risk causing harm or complaint. Is it reasonably practical to reduce the risk?

Medical records Should be dated, legible, methodically recorded, complete and timely. They should not be altered later and negatives responses should be recorded- patient opts not to accept advice. Abbreviations should be avoided. Telephone conversations should be recorded. Sensitivies. allergies to medications should be recorded prominently in a different ink colour. In one study of negligence claims in health professionals 21% of records were found to be poor, inadequate or absent.

Confidentiality Professional standards insist that patient confidentiality is paramount. In case studies published by the HPC, an investigation showed that a registrant’s fitness to practice was impaired because he had used personal details from patient records to canvass for private work when he did not have patient consent for such use of data. In another 4

Telephone answering, fax reception - Are messages recorded in a private area, passed confidentially and correctly?

Podiatrist/patient Communications Complaints dealt with promptly and according to a practice protocol. Is an apology promptly forth coming? Are staff trained and work to a practice protocol? Are complaints investigated and subject to event analysis. Are laboratory test results promptly advised to patient? Is the appropriate information on procedures available to patients?

Working Systems Incoming and outgoing mail – recorded and acted on promptly. Telephones, fax, e-mails – messages recorded, passed on, actioned timeously. Computers – secure, backed-up. Appointments – waiting times reviewed? On-time accessibility. Records – secure, accurate and timely recorded. Staff delegation. Training adequate? Appropriate delegation. Confidentiality maintained. Management protocols in place. Guidelines agreed. Adequate supervision. Regular appraisal of performance.

Demonstration of Professional competence Regular continuous professional development fully recorded. Complaints procedures and protocol in place for self and staff. Initiation of critical and adverse event analysis and change of procedures if indicated. Audit of procedures, systems and management undertaken when appropriate. Recognition that adverse events will occur and their anticipation in clinical and organisational procedures and systems management. Practice to high professional standards using published guidelines and protocols. Regular staff appraisal and assurance that they work to agreed protocols. Confidentiality given high priority. Informed patient consent obtained, validity maintained and recorded- particularly if advice declined. Equipment and sterilising procedures meet with Health and Safety Regulations, with â&#x20AC;&#x153;sharpsâ&#x20AC;? in particular discarded with diligence.

Summary Adverse patient encounters, significant and critical adverse events will occur in clinical practice over time. Some will result in informal and formal patient complaint. Institutional investigation and litigation can often be avoided if prompt apology, where appropriate is made, with an explanation regarding the unfortunate turn of events. Professional peril will threaten if complaints are ignored or there is resort to procrastination. A significant proportion of adverse events are preventable if anticipated in practice procedures. 40% of claims are due to failures in communication, record keeping and breaches of confidentiality and many are preventable. 40% of claims are due to failures in communication, record keeping and breaches of confidentiality and many are preventable. An effective programme for reducing adverse events should be established with adoption of risk reduction strategies â&#x20AC;&#x201C; risk management - as an integral part of daily practice.

Personal Profile Loreto Sime B.Sc. (Pod. Med.), M.Inst.Ch.P., AIYS (Dip. Reﬂex.)

“I can do that!” I was born in Southern Ireland, and came over to Walton Hospital (now part of Aintree Hospital) to study for my SRN. I really enjoyed my time there, and made many life-long friends who have spread far and wide. However, I am still in contact with some of them. Whilst studying there I met my future husband Stuart, and so decided to stay in Liverpool. Nursing back then meant working on the wards covering the hours from 7:30 a.m. till 8:00 p.m., with blocks of weeks on night duty, and weeks of fulltime study. We covered all duties from cleaning, making beds to looking after the patients and all disciplines from Neuro to children to Medical to Orthopaedic. It was hard work. Without realising it at the time, it was providing a grounding for my present career. Our knowledge of the body and its systems has advanced somewhat since then, but really a lot of it remains the same i.e. the brain is still in the same place and we still contain the same number of bones! I then married Stuart, and we had three children. I did intend to return to some kind of work after they were old enough, though I was not interested in going back to nursing. But as they say “The best laid plans” and all that. Things did not go according to our original plans. Our first born Dominic had both learning and physical difficulties and that meant me staying at home to care for him much longer than planned. We have two younger children namely Denise (who went into Nursing and is now a police constable, and she has three wonderful children (I’m really not biased) and our youngest son Adrian. They have now all left home, and I have changed the locks. No matter what adversity one faces there is always a silver lining, and it is solely as a result of attending to Dominic’s needs (i.e. Orthopaedic Surgery at Alder Hey Children’s Hospital, and Chiropody Clinic) that gave me the idea to become a Chiropodist. I thought “I can do that”. In 1996 whilst reading the Best Women’s magazine I noticed an advertisement from Wright Street offering courses and the opportunity to do the practical at Southport. It could not have been better designed for me since we live in Formby which meant that I would not have to leave home when doing the practical.

I will always be grateful to Carl Burrows for his advice concerning the written examination, and to Jill and Cath for their practical supervision in Southport. I had promised myself on the final day of the course that this was it. No more examinations ever. I started my domiciliary practice in 1998, and by late 1999 was able to set up my clinic in Birkdale Village in Southport. I have not looked back since, and am really enjoying my career. In 2009 I was invited by BNII Sefton to open a Chiropody Clinic at the hospitals Diagnostic Centre in Blundellsands. Whilst reading the Podiatry Review (honestly Roger I really do read it) I saw a mention of the BSc degree course in New College Durham, I once again said “I can do that”. Indeed one evening whilst reading the Podiatry Review I noticed that a BSc course at New College Durham was being advertised. I then decided that “I am going to do that”. Before I had time to change my mind I applied and was accepted for the course. I then discovered that my friend and fellow branch member Michelle Taylor was on the course at the same time. Stuart drove us all to Durham, and provided moral support during the week. It was hard work, enjoyable, satisfying, and interesting in that order. We all supported one another. It was nice to know that a friend was going the course as well. What a sense of achievement it gave Michelle and I when we received our BSc degree certificates in July at New College Durham. That alone, was worth all the effort. Whilst still on a high with euphoria we egged one another on to sign up for the MSc Podiatry course at Queen Margaret’s University in Edinburgh. We have just started this four year course, and from someone who said “I will never do another examination again”. Just remember “If I can do it so can you”. It takes time and commitment, but if important (which it is) you will always find the time. Two of my friends from my time at Southport are due to start the BSc this month. I wish both of them well. Maybe they are saying “If she can do it so can we”. I do hope so.

Applications Invited for Cosyfeet Podiatry Award 2011

Cosyfeet’s annual Podiatry Award assists one person each year to further their professional knowledge and skills. The £1,000 award is open to any podiatrist or podiatry student who is planning voluntary work, a work placement or research, whether in the UK or abroad. It is designed to assist with travel and living expenses.

Those considering entering for the award should visit www.cosyfeet/award for further information and to enter online.

Former winners have undertaken a wide range of projects including those relating to Diabetes, Leprosy, Talipes equinovarus, poverty and homelessness. Some have travelled to Africa or China while others have conducted voluntary work or research here in the UK.

Cosyfeet is the UK’s leading supplier of footwear, socks and hosiery for extra wide, swollen or problem feet. 9000 health professionals recommend Cosyfeet products to their patients. For more information email prof@cosyfeet.co.uk or call 01458 447275.

The winner will be expected to submit a report and photographs of their experience, and to be included in Cosyfeet publicity relating to the award.

Membership Membership of the Institute of Chiropodists and Podiatrists is open to chiropodists/ podiatrists registered with the Health Professions Council and Foot Health Practitioners who qualify for acceptance.

We offer professional and business support To discuss further about becoming a Member or Associate of the Institute please call us and we would be happy to talk to you. The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside, PR9 0TL Telephone 01704 546141 email bernie@iocp.org.uk

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DL DLT 7

Critical Appraisal Judith Barbaro-Brown Msc Bsc(Hons) PGCE, DpodM, MChS Critical appraisal forms part of a much larger entity – that of evidence-based practice, or evidence-based medicine (EBM). The strategy is that the clinician considers the best evidence available when making a decision regarding treatment, often in partnership with colleagues, the patient, or other service users. However, in order to identify the best evidence or practice, a large body of research and literature may need to be examined, sifted, and analysed, and this is what is determined as ‘critical appraisal’. Much of the research we read is flawed, and so it may be difficult to separate what is valuable from what is not applicable. It is the skill of critical appraisal that allows the reader to identify inconsistencies, assumptions, and flaws in the research process, and then balance these against the outcome of the research in order to decide whether the outcome has value and reliability, and can underpin a clinical decision.

The process suggested by Guyatt et al is divided into sections, as follows: Section 1. Are the results of the study valid? Screening questions: 1. Did the trial address a clearly focused research question? 2. Did the authors use the right type of study? Detailed questions: 1. Was the assignment of patients to treatments properly randomised? 2. Were all the patients who entered the trial properly accounted for at is conclusion? 3. Were patients, health workers, and study personnel ‘blind’ to treatment?

The process of critical appraisal provides a systematic way of assessing the validity, results and potential usefulness of published research, providing the link between the somewhat isolated world of research and the real-life experience of clinical practice. The skills required are not difficult to acquire, and rely heavily on a straight-forward, common-sense approach to reading and thinking.

4. Were the groups similar at the start of the study?

There are many different types of paper that could be appraised, and the approach changes slightly depending on whether the paper reflects a trial, a review, a case study, or a qualitative study. In some cases, there are well-accepted strategies for assessment, and it would be wise for the novice in critical appraisal to follow one of these.

Section 3. Will the results help locally?

As an example of how to follow the critical appraisal process, the example of the review process in a randomised controlled trial will be used.

Randomised controlled trials (RCTs) Guyatt, Sackett & Cook (1993) suggested a checklist which could be used when examining an RCT. This type of design is frequently used in testing the efficacy or effectiveness of healthcare services or health technologies. As suggested by the name, RCTs involve the random allocation of different interventions (treatments versus placebo) to subjects. As long as numbers of subjects are sufficient, this ensures that both known and unknown variables are evenly distributed between treatment groups. In the hierarchy of evidence that influences healthcare policy and practice, RCTs are considered by most to be the top individual unit of research. They are considered the most reliable form of scientific evidence because they are thought to eliminate chance and bias. The use of this methodology can minimise accidental or intentional bias, but does not infer that every RCT is of good quality. This is where the process of critical appraisal should be employed, as only by examining the research method and process can the reader determine whether the outcome of the research is reliable and valid. 8

5. Apart from the intervention, were the groups treated equally? Section 2. What are the results? 1. How large was the treatment effect? 2. How precise was the estimate of the treatment effect?

1. Can the results be applied to the local population? 2. Were all clinically important outcomes considered? 3. Are the benefits worth the harms and costs?

Adapted from: Guyatt GH, Sackett DL, Cook DJ (1993) Users guide to the medical literature. II how to use an article about therapy on prevention. Journal of the American Medical Association 270: 2598-2607, and 271: 59-63. The first two questions of section 1 should be looked at as screening questions, allowing the reader to decide whether the study merits further consideration. Hopefully, the answers to these can be found very early on in the paper, and should really be made clear in the abstract. If the answer to either of these question is not a clear ‘yes’ then it is probably not worth spending further time on the paper. All of the questions in section 1 are used to asses the trial method. If the methods are satisfactory, then it is more likely that the results will be useful – a poor or flawed research method is unlikely to yield meaningful results. Use of randomisation aims to avoid the any possibility of selection bias. The test that randomisation has been successful is that different treatment groups have same characteristics at baseline, e.g. the same number of men and women, or older or younger people, or degrees of disease severity. Checking to see

which method of randomisation has been adopted can give the reader an indication of the methodological rigour of the trial, and hence its likely validity. Correct randomisation also ensures that the groups are similar at the start of the trial.

the confidence interval gives an idea about how much certainty can be attributed to the results - a very wide interval may indicate that more data should be collected before anything meaningful can be said about the results.

Also of importance in relation to the questions in section one is checking to see if all the recruited participants are accounted for at the end of the trial. It’s not unusual for some patients to drop out of a trial, for whatever reason, and whilst this is an accepted problem, as long as the dropped-out participants are discussed, then the trial can still be assessed as having validity. However, this changes if more than 15% of the participants drop out. In reality, the intention to treat analysis is more useful than actual completion of treatment analysis, as this covers all participants in each randomised group.

In addition to the confidence interval, the significance of any differences between the groups should be discussed, and is usually expressed as a p-value, used to indicated statistical significance. The standard p-value adopted which implies that the results have statistical significance is p<0.05. The lower the pvalue, the less likely the result has occurred by chance, so the greater significance is attached to the result. A p-value of 0.05 corresponds to a 5% chance.

The process of ‘blinding’ means that as a participant you are unaware to which research group you belong – whether it is the active treatment group or the placebo group. If the participants were aware of their grouping, it may influence their reporting of results or outcomes. The same effect can occur with both health workers and study personnel. However, whilst it is not always essential to have health workers ‘blind’ it is essential to the rigour of the research process that the study personnel go through the blinding process, in order to prevent reporting bias. As it is essential that the groups are treated equally, the use of blinding takes on further importance to make sure that changes to outcomes are attributed to the intervention rather than differences in group management. Of high importance, but which is not mentioned in Guyatt et al guidelines, are the ethical considerations of the study. There should be mention how issues with informed consent, confidentiality, risk factors, withholding or denying treatment, and participant distress, are dealt with. If the paper fails to mention these issues, then immediately its validity is called into question – this does not necessarily mean that the authors did not deal with the issues, but failure to discuss them in a paper is extremely poor, and in such cases these papers would not be published in the majority of scientific journals. Moving to look more closely at section 2 questions, we then look to examine the results. This can sometimes be complex as different trials use different outcome measures, but commonly a measure of relative risk is adopted. The chance of a particular outcome being observed in an individual is the ‘risk’, which can be either positive or negative. Comparing the risk in the intervention and control groups gives a measure of relative risk. A relative risk of 1 occurs when the incidences are the same in the two groups. If it is hoped that the intervention leads to more of the outcome being measured, such as an increase in ulcer resolution rates, then a relative risk of more than one is desirable. If it is hoped that intervention creates less of the measured outcome, such as a reduction in lower limb ulceration, amputation, or death, then a relative risk of less then 1 is looked for. However, because the trial can only examine a small percentage of the overall population, there is always some doubt about how the results can be applied to the population as a whole. This is where something known as a confidence interval (CI) is used, and indicates the range of doubt around the best estimate. Simply put, the confidence interval is the mean of the sample group which is used to estimate the mean of a larger population. The width of

Finally, in section 3 the questions relate to the usefulness to the wider population, in particular to the groups of patients to which the reader relates. Large differences between the trial group, and the reader’s group would make it difficult to apply the trial results locally. A further question to ask is whether the trial has addressed the issues and outcomes that relate to the reader’s group – if not, then further evidence from other trials would be required in order to change local practice. Finally, but no less importantly, do the costs involved in applying any changes suggested by the trial outcomes outweigh the potential negative costs? These costs not only relate financially, but also involve, time, quality if life, and social impact. In addition to an RCT, there are numerous other types of experimental and research design, all of which provide varying degrees of evidence relating to outcomes. By learning the process of critical analysis relating to an RCT, one can apply these skills to the analysis of other methodologies, using similar strategies. Good strategies for the more commonly-encountered research processes can be found at: http://www.sign.ac.uk/methodology/checklists.html On this webpage, provided by SIGN, the Scottish Intercollegiate Guidelines Network, there is also a tutorial, found by clicking the green ‘online tutorials’ tab at the top left of the page. Choosing to follow the ‘asthma guideline’ development tutorial takes the reader through the process of how to develop a treatment guideline by using evidence available through different types of trial and research process. Task Select a situation you commonly encounter in your work, or a situation where you already have guidelines in place that require updating – it does not necessarily need to be a direct clinical question, but can also relate to management or personal development issues. Using the strategy suggested in the SIGN asthma tutorial, go through the process of developing new, or updating old, guidelines which can applied in your own area. This activity can be carried out on your own, or as a group task. In the latter case, it may be beneficial to have an initial discussion with all group members before assigning individual tasks, followed by an on-going group effort to produce a set of guidelines. Don’t forget that these new guidelines will need to be revisited on a regular basis, the interval for which can be decided by the group, and will contribute to on-going continual professional development activity. 9

A Classification Method for Determining Adult Foot Types Roberta Nole

MS. PT. C.Ped

Roberta Nole is owner of Stride Inc Custom Foot Orthotics, Stride Physical Therapy & Pedorthic Center and Nolaro24, LLC. She is a graduate of the University of Scranton (B.S. 1982); the University of Connecticut (M.A. Sports Medicine, 1984 and B.S. Physical Therapy, 1984); and received her training in Pedorthics at Northwestern University, board certified in 1993. She has developed a clinical specialty in biomechanics of the foot and ankle and orthotic treatment, lecturing and practicing in this area since 1986. Nole has authored on the biomechanical foot examination process in Orthotics & Prosthetics in Rehabilitation (Butterworth and Heinmann, Boston, 2000) and is the inventor of the novel 24 foot-typing algorithm presented in her courses.

oberta Nole, inventor of the QuadraStep System™, has recently introduced her foot typing system into the U.K. This method provides an algorithmic process of identifying 24 naturally occurring foot types present within the human population. According to Gregg Quinn FCPodS, research shows that development of the human foot can be traced back to our ancestral origins and further, that the development of an individual’s foot is genetically controlled. Typically, foot assessment requires manual measurements, and/or sophisticated scanning or pressure mapping technology. Nole’s research is based on her experiences as a physiotherapist and instructor on foot biomechanics, and owner of a custom foot laboratory. Her goal was to simplify the examination process to make it more reliable and user friendly for the clinician, without the need of expensive technology.

type is a uniquely functioning foot that is easy to detect by simple visual observation of that foot in standing and walking. Identification of a Quad type is relatively easy to perform through visual assessment of one or more foot characteristics, utilizing a simple 4-step process. The first step towards identifying a quad type is to determine whether the rearfoot is “compensated” or “uncompensated”. A compensated rearfoot is one that has the ability to pronate at the subtalar joint; while, an uncompensated rearfoot cannot. A compensated rearfoot that can pronate (Quad types B, D & F) will demonstrate significant drop in vertical arch height, and increased internal tibiofibular rotation. Conversely, an uncompensated rearfoot cannot pronate (Quad types A, C & E) and therefore allows minimal to no drop in vertical arch height, and tibiofibular external rotatation. Thus, in step one of this four step process, the clinician simply observes arch height and tibial-femoral rotation to deduce the rearfoot type. The second step in the process is to identify forefoot type: neutral, varus (inverted forefoot), or valgus (everted forefoot) by assessing “toe-sign”. A neutral toe-sign indicates a neutral forefoot, and is present when some toes are visible both medial and laterally when viewed posteriorly. Conversely, an excessively abducted forefoot indicates a forefoot varus; while an adducted forefoot reveals a forefoot valgus.

The culmination of Nole’s research has generated a matrix of 24 specific foot types, and explains that a resultant foot type is actually a sum of it’s parts. What this means is that the morphology of a particular foot type is created by a unique combination it’s rearfoot and forefoot components. This foot typing system subclassifies rearfoot types into 4 categories, and forefoot types into 6 categories; producing the matrix of 24 foot types. Generally, these 24 foot types can be subcategorized into 6 subgroups of 4, which Nole refers to as a “Quad”. Each Quad 10

The 6 quad matrix thus is the resultant combination of coupling a compensated or uncompensated rearfoot; with a neutral, varus or valgus forefoot. In step 3 of the assessment process the examiner observes gait. Each coupled quad type demonstrates its own specific sequence of compensatory weightbearing mechanisms during gait, and thereby reveals itself to the examiner via its uniquely characteristic gait pattern. In the 4th and final step, the plantar foot is inspected for calluses that correspond to the functional loading portions of that foot during gait, offering further confirmation of foot type. Nole rationalizes that the key to successful orthotic intervention necessitates understanding the underlying foot type, and that each orthosis must be constructed uniquely to that foots functional demands. Implementing a pragmatic method of foot assessment can offer many additional advantages such as insight to surgical and rehabilitative outcomes, the design of shoe soles, and the prediction and prevention of injury.

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Institute of Chiropodists and Podiatrists 2011 Annual Conference and A.G.M.

Beaumont House, Beaumont Estate, Burfield Road, Old Windsor Timetable Thursday 12th May 2011 1:00 p.m. National Officers Meeting 2:00 p.m. Arrival of Delegates 2:30 p.m. Executive Committee Meeting 5:00 p.m. Standing Orders Committee 6:30 p.m. TH1 Lecture - Silicones and their use in Podiatry (Max 30) 8:00 p.m. Evening Meal: Dining Room Friday 13th May 2011 9:00 a.m. - 5:00 p.m. Medical Trade Exhibition: Hanover Suite 1 and Hanover Lounge 8:30 a.m. Credential Officers and Scrutineers Briefing: Hanover Suite 3 9:30 a.m. - 5:00 p.m. Assembly – All Delegates to be present: Hanover Suite 3 9:30 a.m. Mayoral Tour of the Trade Exhibition 9:45 a.m. Opening of Conference: Hanover Suite 3 10:00 a.m. 26th Annual General Meeting of The Members Emergency Benevolent Fund: Hanover Suite 3 10:00 a.m. F2 Workshop 1 – Practical Use of Silicones: Hanover Suite 2 10:15 a.m. Annual General Meeting: Hanover Suite 3 11:00 a.m. Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 11:30 a.m. Annual General Meeting: Hanover Suite 3 11:30 a.m. F3 Workshop 2 – Use of Liquid Nitrogen and New Regulations: Hanover Suite 2 12:30 p.m. Lunch Restaurant and Medical Trade Exhibition: Hanover Suite 1 2:00 p.m. Annual General Meeting Continues: Hanover Suite 3 2:00 p.m. F4 Workshop 3 – Lasers, Their use in Podiatry: Hanover Suite 2 3:00 p.m. Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 3:30 p.m. Annual General Meeting: Hanover Suite 3 followed by Question Time 3:30 p.m. F5 Workshop 4 – Vascular Assessments using Dopplers: Hanover Suite 2 6:30 p.m. - 7:15 p.m. Presidents Drinks Reception: Hanover Suite 1 and Lounge SPONSORED BY CANONBURY 7:15 p.m. Presentation Ceremony (whilst seated at Dinner Tables): Hanover Suites 2 and 3 7:30 p.m. Annual Dinner and Dance: Hanover Suites 2 and 3 Saturday 14th May 2011 9:00-5:00 p.m. Medical Trade Exhibition: Hanover Suite 1 and Hanover Lounge 9:30 a.m. S6 Lecture 1 “Treatment of mild to moderate osteoarthritis of the knee with visco supplement injections by Podiatrists” Martin Harvey, MInstChP, PGCE, BSc – Hanover Suite 3 9:30 a.m. S7 Workshop 1 – Use of Liquid Nitrogen and New Regulations: Hanover Suite 2 10:30 a.m. Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 11:30 a.m. S8 Lecture 2 “Inter Profession Dissonance” Judith Barbaro-Brown, MSc, BSc (Hons), PGCE, DPodM, MChS – Hanover Suite 3 11:30 a.m. S9 Workshop 2 – Lasers, Their use in Podiatry: Hanover Suite 2 12:30 p.m. Lunch: Restaurant and Trade Exhibition: Hanover Suite 1 2:00 p.m. S10 Lecture 3 “Dementia, How to Interact with Patients” Patricia Pope, RGN Hanover Suite 3 2:00 p.m. S11 Workshop 3 – Cryosurgery using a Cryo Alfa unit: Hanover Suite 2 3:00 p.m. Refreshments and Medical Trade Exhibition: Hanover Suite 1 and Lounge 3:30 p.m. S12 Lecture 4 “Dementia, Effects on Practice” Patricia Pope, RGN – Hanover Suite 3 3:30 p.m. S13 Workshop 4 – Practical Paddings and Strappings: Hanover Suite 2 4:30 p.m. CLOSE OF CONFERENCE

THE INSTITUTE OF CHIROPODISTS AND PODIATRISTS HOTEL ACCOMMODATION APPLICATION FORM

2011 Conference - Beaumont House, Old Windsor ALL HOTEL ACCOMMODATION AND THE DINNER/DANCE MUST BE BOOKED ON THIS FORM PLEASE COMPLETE THE FORM IN BLOCK LETTERS

2011 Annual General Meeting Nominations for National Office President - Two Nominations

Mrs. Heather Bailey East Anglia Branch

Mr. Roger Henry Devon and Cornwall Branch

Chairman, Executive Committee - Two Nominations

Mr. William Liggins Birmingham Branch

Mr. Stephen Willey Sheffield Branch

Vice-Chairman, Executive Committee - Two Nominations

Board of Ethics - One Nomination Mrs. Colette Johnston Northern Ireland Branch

Mr. Malcolm Holmes Western Branch

Mr. Charles Goldman London Branch

Chairman, Board of Education - One Nomination Mr. Robert Sullivan Republic Ireland Branch

Vice-Chairman, Board of Education - One Nomination Mr. Martin Harvey Birmingham Branch

Standing Orders Committee - Two Nominations. Two persons to be elected Mrs. Linda Pearson Western Branch

Mr. Martin Hogarth Leeds Branch

Peer Review Section

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

ince the last edition of the Journal and its new Peer Review section, I have had a number of phone calls and emails as well as some much appreciated letter post. One of the most important points about peer review is your comments and thoughts. Remember you are the peers of these authors, and your remarks and views are most welcome. I would encourage you to submit articles. Writing is nothing to be afraid of. I was terrified of writing and I was a terrible writer. I enrolled at Anglia Ruskin University to study my primary podiatry degree. The experience I gained through that university, not to mention the encouragement from Beverly Wright (who was lucky to have any hair left at the end of my four years), has stood to me well. She and the other tutors helped me to develop my research and learning skill and without their help I would not be coming to the end of my MSc. program. If I can write so can you. It is not about degrees, it is about having something to say, supporting it through referencing, and making your contribution. If I can write so can you. It is I would love to see you all writing. We on the peer review team will help and encourage you in any way we can. Many of the professional articles in the Journal are worthy of inclusion in this section, and I hope that some of these writers will submit their work for review Weofon the peer by our panel experts. Havereview a go, after all this is your Journal, your voice. It is time to be heard

There are two dermatology specialists on the review panel at this time; I am only in receipt of the comments from Dr. St. Clare. Her details, and those of Dr. Gregor’s are in the review section of the last edition. Her comments are as follows: “It is always a pleasure to review a dermatology article. This case is presented in a classical review style, and gets the points needed for diagnosis across quite well. I would also point out that medical colleagues often misdiagnose this condition and subject the patient to futile treatments. As podiatrists, you are in a prime position to diagnose this condition, which is making quite a comeback. You would be well advise to study this article and ask yourself some questions, primarily ‘would you have made the correct diagnosis and, what other tests could you have used?” I have enjoyed reading the articles sent for review so far. We have a number of interesting podiatry related topics coming up over the coming months, and I do hope to see some more articles from Our Members coming in also.

The next issue of the Journal will see the final article by Janet McGroggan on here chosen subject. Her contribution to this new review section has been most Dr. Martin Gregor, who has undertaken to review all welcome, as has the contribution of all our authors to articles by this author on this subject, reviewed the first date. article by Janet McGroggan. This is what he said:Her contribution We have three articles undergoing the review process t “The two articles to date are well written and at the moment on biomechanics, rheumatology and presented; again I would comment that any method of reflective practice. Look out for some of these anatomical correction that involves no surgical reviewed articles in our next issues. intervention is to be recommended. I am looking All there is for me to say is “enjoy these articles, and forward to the next article, and would like to see a remember that they form part of your CPD learning systematic review the subject, if the author is so This is what heon said:Look out some ofinthese reviewed articles in disposed. and should for be included your portfolio”. o 15

“enjoy these articles, and

Peer Review Section

CASE REPORT

An unusual presentation of discrete Molluscum Contagiosum at the apex of the 2nd digit Bill Liggins FInstChP, FPodA, BSc(Hons) Introduction Molluscum Contagiosum is a benign skin condition which is the result of the most common DNA pox viral infection in the western world. Buxton (1998). The lesions manifest as single white/pink papules of 2-8mm. in diameter, which can occur on any area of the skin although the condition is most commonly found on the trunk, face and neck, usually in multiples or groups. Gawkrodger (2008). The papules are domed shaped and frequently exhibit a central core or punctum, which when squeezed releases a caseous material in which the pathognomonic intracytoplasmic inclusions containing virions can be found. Buxton (1998).

Case Report

He did recall that the edge of the Right 2nd toenail had A pleasant, 45 year old male normally in good health split and he had removed a small section by pulling. was referred by his General Practitioner who reported that There were no similar lesions anywhere else on his body the patient had suffered for several months from pain in There was no relevant family history known and the 2nd toe of the Right foot. Initially the pain occurred neither his wife nor his son was affected by similar only on weight bearing but had been gradually increasing problems. The patient is a farmer and is required to and latterly had affected him at night due to pressure from stand/walk at work. He did not take part in any group bed clothes. He had obtained some relief by padding the sports. toes to prevent interdigital pressure between the 1st and There was no medical history of relevance; he had 2nd toes. Full Blood Count and glucose testing had been carried out 6 months prior to referral and the results were been generally fit and healthy throughout his life, was not all within normal parameters. The General Practitioner prescribed systemic medication and his only allergy was noted that the lesion appeared to be a corn or a verruca penicillin. and that the area was exquisitely tender to pressure. He attended for consultation in April of 2010, 4 days following G.P. referral, when he complained that the toe next to the big toe had become sore several months previously. He had noted a small, very painful spot which had become inflamed. Infection was suspected and he had been prescribed antibiosis which was ineffective. Onset of the condition was slow, he did not recall any episode of trauma and the condition had become progressively more painful. 16

On examination, a single circa 2mm diameter lesion was noted on the medial/apical aspect of the right 2nd toe adjacent to the toenail. The lesion was capped with keratinised tissue which was debrided. This revealed a circumscribed area of inflammation without disruption of the papillary ridges. A minor degree of inversion of both forefeet was present and this was compensated for on weight bearing by sub-talar joint pronation; this, however, was clinically not significant. In all other respects both feet exhibited no abnormality.

Peer Review Section

The differential diagnosis included verruca pedis, inclusion cyst from the damaged toenail, heloma (the lesion was not on a weight bearing area), fibroma, basal cell carcinoma, squamous cell carcinoma, nonpigmented melanoma, mucoid cyst.

secondary infection but pressure on the apex of the toe caused exquisite pain. The condition is spread by direct skin to skin contact, in a skin folds for example, or by scratching which releases the virus which is then transmitted to another part of the body.

A firm diagnosis could not be established, and following discussion with the patient it was therefore determined to excise the lesion and to forward the tissue for histopathological analysis. Under local anaesthetic, a wide ellipse was taken, encapsulating the lesion and 2mm of surrounding unaffected tissue all of which was retained for analysis. The defect was undermined to allow closure in 2 layers and standard inadine â&#x201E;˘, gauze and conforming bandage dressings were applied. Healing took place uneventfully, dressings were changed after 4 days and sutures were removed after 12 days when the laboratory report was discussed. The wound was reviewed after 12 weeks when healing was satisfactory, no regrowth was noted, the patient expressed himself satisfied and consented to a case study.

Despite the name, the condition is not very contagious (Buxton 1998) but can be transferred from person to person by direct contact; close contact sporting activities for example. The virus can also be transmitted sexually, in which case the papules are found in the genital area. There have been reports of the condition being contracted from swimming pools, shared towels and mats etc. (American Academy of Dermatology). Children are the most commonly affected section of the population, possibly because of immaturity of the immune system and the increased chance of direct physical contact with others. Patients who suffer with immunodeficiency diseases eg. AIDS, are at increased risk, as are those prescribed immunosuppressive drugs. The lesions normally resolve spontaneously, and treatment is usually unnecessary, particularly in children who generally appear unconcerned by the papules, although parents may be anxious. If treatment is necessary, similar techniques to the eradication of warts are appropriate; potential or full cautery, cryosurgery, topical treatments and, as in the case noted above, excision. A literature search did not reveal any previous report of isolated Molluscum Contagiosum in this anatomical area and the method of transmission in this case remains uncertain.

The Laboratory reported:

Macroscopy: The specimen consists of an ellipse of skin measuring 12 x6 x 6mm deep.

Microscopy: This is a papillomatous epidermal lesion with significant hyperkeratosis, parakeratosis and striking hypergranulosis. The cells of the stratum granulosum show huge basophilic granules in keeping with the Molluscum Contagiosum cytopathic effect. There is no dysplasia.

Conclusion: Lesion of right 2nd toe: Molluscum Contagiosum

Discussion: The papules of Molluscum Contagiosum are normally painless but can become secondarily infected and thus inflamed. In the case under discussion there was no

Molluscum Contagiosum (childâ&#x20AC;&#x2122;s toe) 17

Peer Review Section

Key points

• • •

Molluscum contagiosum is a common viral infection most frequently seen in children It is caused by a DNA pox virus and despite the name is not very contagious. Usually manifest as clusters of papules with a central punctum which when squeezed exudes a caseous material.

•

The most common differential diagnosis when rarely, a lesion appears on the foot, is verruca pedis, although other potential conditions must be borne in mind including non-pigmented melanoma.

• •

If treatment is required, similar techniques used to eradicate warts are appropriate . If there is doubt concerning diagnosis, complete excision, or biopsy if appropriate should be undertaken followed by histopathological analysis.

Molluscum Contagiosum - Photomicrograph

References Buxton, P.K. (1998). ABC of Dermatology 3rd Edition. BMJ Publishing, London Gawkrodger, David J. (2008). Dermatology - An Illustrated Colour Text 4th Edition. Elservier, London Molluscum Contagiosum URL: http://www.aad.org/public/publications/pamphlet/viral/mollscum.html. [19-11-2010] Molluscum Contagiosum URL: http://www.dermatlas.medjhmi.edu/index [19-11-2010]

Continued ProfessionalDevelopment

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.

Forensic Podiatry: A Short Overview Professor Wesley Vernon, OBE PhD

Head of Podiatry Services and Research Lead, Sheffield PCT, Visiting Professor, Huddersfield University, Visiting Professor, Staffordshire University

Definition and History Forensic podiatry has been defined as “the application of sound and researched podiatry knowledge and experience in forensic investigations, to show the association of an individual with a scene of crime, or to answer any other legal question concerned with the foot or footwear that requires knowledge of the functioning foot” (Vernon & McCourt, 1999). This area of podiatry is not new, however over the past 20 years, the discipline has changed from one which has a theoretical role in human identification to that of a regularly practised forensic science discipline with a defined role and scope of practise, underpinning research and a regulatory framework. The knowledge used in forensic podiatry is that used in clinical work albeit in forensic podiatry, being utilised in a different context usually that of human identification. It is not however the simple non-propositional knowledge acquired through practise and experience (Polyani 1967) that forensic podiatry practise is founded on, but instead, the “scientific” knowledge base of the profession including that derived through research, surveys, databases and the like. Forensic podiatry has been influenced by a number of practitioners of the past, but development in more recent times began over 40 years ago. In the UK, developments commenced with a paper by Lucock which considered how to examine a shoe in the context of human identification (Lucock, 1967). This was followed a number of years later by a suggestion from Doney, a Police Surgeon that podiatrists may be able to assist in forensic identification, through used of the fine detail held in their clinical records (Doney, 1984). This suggestion was later taken up by Vernon (1995) and later Sanger (Sanger & Vernon, 1997) who tested podiatrists ability to

identify an unknown person from their clinical records, demonstrating that this was feasible. This was later followed up by research into the potential of using the wear patterns of the shoe outsole in identification (Vernon, 2000, Vernon et.al., 2004), involvement in a number of small unpublished studies in forensic podiatry, case work, which commenced in the UK on a regular basis in 1996 and work on creating standards in the field (Vernon et.al., 2009, Vernon & Kelly, 2006). Taking a completely different direction, Kelly introduced the sub-discipline of forensic gait analysis through a landmark case in 2000 (Buncombe, 2000) and he has continued to act as an expert witness in this area. More recently, Reel has been researching the reliability of bare footprint measurement in identification, with important findings beginning to emerge from her work (Reel et.al., 2010). In Canada and the US, forensic podiatry involvement commenced with the involvement of Canadian podiatrist, Dr Norman Gunn in a high profile forensic case in 1972. Dr Gunn was the first podiatrist to undertake reported forensic case work. He continued to present expert evidence in many more cases and this was followed in 1981 by US podiatrists Dr’s Valmassey and Smith who reported having examined and refuted evidence presented by a forensic anthropologist in relation to footwear (Valmassey, 1982). In the following decade, Dr John DiMaggio, a US podiatrist and part time police officer began to connect identification requirements seen through his police work to the possibility of podiatrists being able to assist in such investigations. Having begun to become involved in case work, he began to lead a drive to publicise the potential of forensic podiatrists in forensic investigations in the US. Elsewhere, Australian podiatrist, Sarah Jones was granted a Churchill Fellowship to learn March/April11CPD

Continued ProfessionalDevelopment about forensic podiatry work in other countries (Winston Churchill Memorial Trust, 1995) and is believed to be regularly working on cases in the field. International collaborations have begun to define and agree standards and working practises in forensic podiatry. The areas of practise have been stated in a document which not only covers the tasks which a forensic podiatrist would undertaken in their work, but which also carefully defines the boundaries of practise by stating what forensic podiatrists would not do by virtue of such areas being covered by other forensic specialties (Vernon et.al., 2009). In the UK, such work has lead to a new scheme piloted under the auspices of the Forensic Science Society, for the competency testing of forensic podiatrists. The pilot was seen as successful and it is likely that this scheme will now roll out to other forensic disciplines (Forensic Science Regulator, 2011). The work of forensic podiatrists is also starting to be covered in the forensic literature, with various journal papers/articles (Vernon, 2006), chapters of textbooks covering forensic podiatry (Vernon, 2006b, DiMaggio, 2005) and more recently with the first dedicated forensic podiatry reference textbook having been published (DiMaggio, Vernon 2011).

Areas of Practise There are four areas of forensic podiatry practise, record card identification, bare footprints, footwear and forensic gait analysis and these will be briefly considered in turn: Record card identification The detail kept by podiatrists that is relevant to their clinical practise includes information on a patients’ foot type, the presence of structural deformities of the foot (e.g. hallux valgus, hammer toes), related pathologies (corns, callus), scars and other skin blemishes and the treatments that were carried out. It is this information that is used in identification from podiatry records. In carrying out such work, the podiatrist involved would record the features present on the unknown foot or feet being examined and then compare these feature by feature to the detail recorded in an ante-mortem record which may, or may not pertain to the foot under examination. Having worked through this process, the podiatrist would use clinical judgment to state the likelihood of there being a match or a mismatch or mismatch between the foot and the records. in practise, this is the least used forensic podiatry technique, with the need for the use of the techniques involved typically relating to ad hoc cases of lost identity where the person has not been identified by other means (e.g. finger prints, DNA, odontology). Occasional reports March/April11CPD

are however received of requests being made of podiatrists when it is believed that one of their patients has gone missing and a body has been recovered, or when a body has been recovered which shows clear signs of recent podiatry treatment and the police are hoping that a local podiatrist can identify the missing person through their work and records.

Diagram 1 Gunn Lines

Bare footprint identification This area is more frequently considered by podiatrists in identification. Although the shod foot predominates in the Western world, scenes of crime do occur in which the perpetrator has left barefoot Diagram 2 prints at the scene through Optical Centre the circumstances of the Approach crime (e.g. rape, where the perpetrator has removed his clothing, where those involved have been relaxing at home, or at scenes of violence, where the offender has been separated from his shoes). The task is to describe the bare footprint at the crime scene and then to compare that footprint with another collected from a suspect. There are two basic approaches. The first of Diagram 3 Overlay these uses of linear lines Method Gunn lines (Vernon, 2006c) drawn between various features of interest (Diagram 1). Here, in the comparison between questioned and known footprints, the examiner is looking for lines connecting the same morphological features of the print which fall within +/- 5mm of each other. In a variation of this approach, the lines are drawn between “optical centres” - the “central

Continued ProfessionalDevelopment point of a morphological feature as defined by the centre of a circle when placed in a position of best fitâ&#x20AC;? (Vernon, 2006c) (Diagram 2). The second class of approach is known as the overlay method. Here, in simple terms, a tracing is made of a known exemplar footprint which has been left by a suspect under supervised conditions and this outline is superimposed onto a lifesize image of a questioned footprint taken from a crime scene (Diagram 3). The examiner then considers these from the perspective of overall fit, and compatible or incompatible gross and minor features present. In both comparison techniques the forensic podiatrist is looking for features of podiatric relevance, particularly in relation to overall foot size, toe formulae and foot pathology that may be apparent and would relate these as appropriate to known prevalence data. While features not of podiatric relevance may be recognisable (e.g. ridge detail), the examining podiatrist would not deal with this aspect of comparison, but instead would forward these to an expert specialised in the specalised area concerned. Footwear Identification Podiatrists involvement in footwear identification is in associating or disassociating a suspect with a particular shoe as opposed to associating/disassociating a shoe with the scene of a crime, which is the concern of the forensic marks examiner (Vernon et.al., 2009). In this task, the podiatrist will consider and compare the wear features of the shoes examined. These will include the foot impression on the sock liner or insole, outsole wear patterns, upper marks and distortions and crease lines of the shoe upper. The plantar foot impressions will be compared using the same techniques involved in bare footprint analysis and throughout, the examiner will be looking for any features which are compatible or incompatible, at the same time considering whether any apparent differences relate to the shoes being worn by different people, or whether these could have resulted from independent variable factors involved in the wearing of shoes of different styles or sizes. The examiner would also be interested in the fitting relationship between the shoe and the foot, particularly in relation to defence claims that a shoe has not been worn by a particular person by virtue of being too small, or too large. This task would require the internal size of the shoes to be confirmed with an internal size gauge as well as considerations of how the shoe has fitted the wearer from the various wear features of the shoe. In relation to footwear identification, podiatrists are often asked to provide an opinion as to whether a shoe has been worn by more than one person. Here, features of interest would involve multiple sets of toe impressions on

the insole of sock liner and on the lining of the shoe upper and the position of the upper crease marks as compared to medial and lateral distortions of the upper, where a mismatch between these features would indicate that the shoe could not have been worn by one person alone. Forensic Gait Analysis Kelly has described forensic gait analysis as â&#x20AC;&#x153;The identification of a person or persons by their gait or features of their gait, usually from CCTV footage and comparison to footage of a known individualâ&#x20AC;? (Kelly, 2000). In this work, the forensic podiatrist will use visual gait evaluation techniques as would be performed in the clinical situation. However, the nature of CCTV footage is often of poor quality, low resolution and with many additional variables involved (e.g. camera position, crime events). One such factor is the sampling rate of CCTV cameras, which is typically 2hz as opposed to the much higher sampling rate of 50 hz which is more usual with digital video recordings (DiMaggio & Vernon, 2011). As the examiner has to consider and deal with these variables, the type of analysis that is usually involved in forensic gait analysis is more complex to perform. After determining the suitability of the image and taking into consideration any variable factors present, the experts task is to identify gait, or any features of gait that remain apparent. The focus for this work is on factors of podiatric importance, particularly foot and lower limb function anomalies and caution is needed not to become distracted by other factors which appear to be similar, yet are not relevant to the expert gait analyst. Again, if such features were present, the podiatrist would refer these on to an appropriate expert for further analysis Evidential Considerations These then are the four areas of forensic podiatry practise. In performing this work it is however important to understand the value of the evidence under consideration and how this is handled. Evidence exists at two distinct levels - Identifying and Class Characteristic levels. An identifying characteristic is one that represents uniqueness (Bodziak,2000) and the presence of such characteristics allows an identification to me made with absolute certainty. Examples of such characteristics include the damage features affecting the shoe outsole in which the randomly created cut and nick marks of the outsole are believed to be unique (Bodziak,2000). Conversely, class characteristics are those characteristics which all similar items have in common (Bodziak,2000). Such characteristics show consistency and compatibility, but not uniqueness Examples of such characteristics include shoe make, type, size, colour. March/April11CPD

Continued ProfessionalDevelopment It is important to recognise that at this at this moment in time, there is no forensic podiatry knowledge currently available that has been proved to be unique, therefore forensic podiatrists deal with class characteristics alone (DiMaggio & Vernon, 2011). In combination however, class characteristics can create much stronger individuality than when viewed in isolation. Here, the prevalence of a particular characteristic in the population would be multiplied by the prevalence of another independent characteristic. It is essential however to ensure that when using class characteristics in this way, each characteristic is truly independent from all others in order to prevent the value of the evidence from being inadvertently exaggerated. An example of combining two such characteristics correctly would relate to the consideration of the presence of a Greek ideal at the same time as considering overall foot length as the Greek Ideal has no relationship to foot length. An example of an incorrect use of two variables would be to consider Greek Ideal and toe formulae as the Greek Ideal is an aspect of and not independent from the toe formulae. Future Developments The framework for practise having been defined, it is likely that awareness of forensic podiatry will now be raised. This can be expected to result in increasing demands for case assistance from police and lawyers. Within the podiatry profession, the raised awareness is likely to lead to a need for further literature in the area and formal courses of study in forensic podiatry. Indeed, Huddersfield University are commencing a post graduate certificate in forensic podiatry in September 2011 and Glasgow Caledonian University are also planning a MSc degree in forensic podiatry in the near future although a date for this course has not been stated. With the introduction of the first textbook dedicated to forensic podiatry (DiMaggio & Vernon, 2011), it is also probable that more literature will be required to further guide and inform practitioners interested in developing a career in this direction. Summary Forensic podiatry is therefore developing rapidly worldwide with advancing practise, a strengthening evidence base and with standards and protocols having been defined and introduced into practise (DiMaggio & Vernon, 2011). It is however essential that podiatrists interested in this field study approach this properly, taking the time to read, study, practise and be mentored before accepting work in the forensic podiatry arena independently. Authors contact details: wesley.vernon@nhs.net March/April11CPD

REFERENCES Bodziak W.J., Footwear Impression Evidence, Detection, Recovery and Examination, (Boca Raton, CRC Press), 2000. Buncombe A., Gang leader is unmasked by his bandy-legged gait. The Independent, London, 2000, Jul. 13. DiMaggio J.A., The role of feet and footwear in medicolegal investigations, in Rich J., Dean D.E., Powers R.H., (New Jersey: Humana), 2005. DiMaggio J., Vernon W., Forensic Podiatry: Principles and Methods, Humana Press 2011. Doney I.E., “Mass disaster identification. Can chiropodists help?”, The Police Surgeon, 1984, Vol. 25, p. 14-20. Forensic Science Regulator, Newsletter, No. 17, www.homeoffice.gov.uk/publications/police/forensic-scienceregulator1/fsr-newsletter, Accessed 31-1-11. Kelly H., Old Bailey Central Criminal Court London. R-V Saunders, 2000. Lucock J.J., “Identifying the wearer of worn footwear”, Journal of the Forensic Science Society, 1967, Vol.7, No. 2, p. 62-70. Polyani M., The Tacit Dimension, , London: Routledge), 1967. Reel S., Rouse S., Vernon W., Doherty P., ‘Reliability of a TwoDimensional Footprint Measurement Approach’, Science and Justice Vol. 50, 2010, p. 133-118. Sanger D., Vernon W., The Value of a Strength Scale in Identification from Podiatry Records,” Journal of Forensic Identification, Vol. 47, No. 2, March 1997, p. 162 – 170. Valmassey R.L., “A podiatrist in court”, Pacesetter, Vol. 2, No. 4, 1982. Vernon W., “The use of podiatry records in forensic and s disaster identification (reprint),” Journal of Podiatric Medicine, Vol. 50, No. 12, Dec 1995, p.196 - 200. Vernon W., The functional analysis of shoe wear patterns: Theory and application, Unpublished PhD thesis, Sheffield Hallam University, Oct. 2000. Vernon W., “The Development and Practice of Forensic Podiatry” , Journal of Clinical Forensic Medicine, October 2006, p. 284-7. Vernon W., “The Foot in Identification” In: Thompson T., Black S., (Eds), Forensic Human Identification: An Introduction, Press, Nov. 2006b. Vernon W., “The Foot in Identification” In: Thompson T., Black S., (Eds), Forensic Human Identification: An Introduction, Press, Nov. 2006c. Vernon W., Brodie B., DiMaggio J., Gunn N., Kelly H., Nirenberg M., Reel S., Walker J., Forensic podiatry: role and scope of practice (In the context of forensic human identification). International Association for Identification http://www.theiai.org, 2009 Vernon W, Kelly H., New specialties: Forensic podiatry registration – the first eight weeks, CRFP Newsletter, 2006, Vol. 18, No. 10. Vernon ., McCourt F.J., “Forensic podiatry – a review and definition”, British Journal of Podiatry, Vol. 2, No. 2, May 1999, p. 45 – 48. Vernon W., Parry A., Potter M.,” A theory of shoe wear pattern influence incorporating a new paradigm for the podiatric medical profession”, Journal of the American Podiatric Medical Association, Vol. 94, No. 3, May/June 2004, p. 261-268. Winston Churchill Memorial Trust, http://www.churchilltrust.com.au/fellows/reports/science/, 1995, Accessed 31/1/11.

Peer Review Section

The Ponseti Method of Clubfoot Management The second in a series of three articles by Janet McGroggan, joint winner of the Cosyfeet Podiatry Award 2009 Abstract In article one I discussed Dr Ponseti, who dedicated his life’s work to developing a technique for treating talipes which aimed to produce a flexible, functioning, pain free foot. He researched previous techniques, dissected stillborn foetus’ affected by talipes and embraced the tri-planar nature of the deformation. The method he devised has been tested and documented and is now the standard treatment offered in the UK, with surgical treatment of the deformity a last resort. I attended a workshop in Manchester’s Chancellors Hotel and Conference Centre to learn the basics of the Ponseti method. In a room of 50 I was the only podiatrist. The following day I returned to master the advanced aspects of the method, and in a room of around 80 I was once more the only podiatrist. This raises a lot of questions that I will go into in article 3. In this article I will take you through my experience of the Ponseti methodology.

There are four stages to the treatment (see box 1) and each of these stages requires the same attention to detail as the others. The procedure must be adhered to in order to be as successful as possible.

A bone model workshop followed in which we got to work with skeletal models mimicking a foot affected by talipes (see picture 1). The faculty group moved around, working with us to show how the talus can be held and the first ray elevated as in the first stage of correction. Ms Naomi Davis2 who is a consultant orthopaedic surgeon in Manchester’s Children’s Hospital and the Ponseti organisation’s ambassador in the UK, then began a talk describing the manipulation involved in the Ponseti method.

In the first stage, manipulation, the treatment uses the mnemonic CAVE and corrects the deformity in the order of Cavus, Adductus, Varus and Equinus. The first three components are corrected simultaneously. All gripping techniques must be very soft using the pad of the digits. The manipulator can spend from 10 seconds to a minute gently manipulating the foot prior to casting but must be able to read the foot and never force it further than it is happy to go at each stage. There is no specific set number of manipulations which must be carried out as each foot is treated individually.

ay one began with Gavin DeKiewiet1 recapping on the subtalar joint and how it works. His talk emphasised the interaction between the ankle mortise and the subtalar joint. This was a nice revision of the triplanar motion available at these joints and how this is involved in the talipes deformity.

In order to correct the cavus, the manipulator must find the exact location of the talar head. This is laterally displaced and will be about 1cm anterior to the lateral malleolus. This is due to the medial displacement of the navicular, which will almost contact the medial malleolus. Whilst correcting the left foot, place the right thumb on the talar head and reaching round the back of the ankle, place the right index and middle fingers on the medial malleolus, taking great care not to touch the rear foot as this will obstruct the calcaneus, which will abduct automatically with the forefoot. Now place the index and middle fingers of the left hand below and medial to the first ray and elevate the first ray to bring the forefoot in planar alignment to the rearfoot. 19

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Correcting the cavus allows the forefoot to be abducted and as this happens the rearfoot will move into valgus. This can be felt as the navicular begins to move in front of the talar head, and as the calcaneus moves laterally underneath the talar head. When the anterior process of the calcaneus is palpable, abducting out from under the talus, adequate abduction has been reached. This is about 60° to the frontal plane of the tibia.

shape. If the parent or practitioner can see less than five toes in the cast then the cast has slipped. When this happens it is essential to have the cast removed as quickly as possible to prevent sores or further deformity. If the child is unable to be seen in clinic immediately then the parents must soak and remove the cast. This is one reason why plaster of paris is used rather than fibreglass.

Prior to adequate abduction being reached the foot is never dorsiflexed. When it is reached, this is the time to assess how much dorsiflexion is present and consider if a tenotomy is required. It takes an average of six manipulations and casting before a tenotomy is considered. The casting process requires an experienced practitioner who can work in close proximity to the manipulator. Denise Watson3 then began to detail the casting technique (see box 2) which begins once the manipulator is happy with the position of the foot and changes their grip to a one handed grip, thumb on the top of the metatarsal heads and index finger below, without altering the attained foot position. The manipulator’s free hand flexes the knee to 90º. Now a thin layer of padding is applied from toes to groin. This is to allow moulding of the plaster while protecting the limb. The manipulator’s fingers stay inside the padding until the casting practitioner is clear of the foot, then they quickly move their fingers to rest in the same position but on top of the padding, without the foot changing position. The plaster bandage is then applied three times around the foot (whilst the manipulator once again waits to place their hands on top of the plaster layer) then tightly round the ankle and snugly around the leg. This layer of plaster ends below the knee and the manipulator uses their free hand to mould an arc over the calcaneus in order to maintain its position in the cast. Then using the two handed grip they gently mould over the talar head and mould a slight medial arch shape. Once the below knee cast is dry the casting practitioner begins to cast above the knee, while the manipulator continues to flex the knee. The knee area of the cast is strengthened either by applying a short length of plaster over the leg proximally to distally or layering medially to laterally twice before continuing around the leg. The cast is brought right up to the groin area to maintain the knee in flexion and prevent slippage of the cast. In larger babies a small length of stockinet is used to provide comfort in the groin area. Once dry, the cast is trimmed dorsally to expose the full length of all the toes, providing a plantar toe plate to extend the toes and an opportunity for parent and practitioner to assess for cast slippage. This can occur for a variety of reasons including poor casting technique or a difficult limb 20

Incorporated into this presentation was a Skype feed into another room in the conference centre, where Naomi Davis demonstrated applying plaster to a baby brought in by its parents. After this talk and a cup of coffee we were separated into rooms with experienced practitioners, who demonstrated the casting technique on prosthetic talipes limbs (see picture 2) and then let us practice as both manipulator and casting practitioner. I found the manipulation more straightforward than I expected, but maintaining the correction as the caster applied padding and then plaster was another matter entirely, and this leg didn’t even have a kicking, crying baby attached to it! With a bit of practice I managed to change from a one handed grip to a two handed grip and back again, even managing an effective moulding technique around the key areas. As casting practitioner I found getting the right tension on the padding and plaster difficult, and as the plaster we were using was fast drying there was no time for hanging around. After a few tries it all made sense as I rolled the plaster round the tiny limb, ensuring that it still looked

Peer Review Section

like a leg afterwards. Exposing the toes in full with a neat arc was tricky, but the plaster knives we used rather than scissors were very user friendly.

Following this workshop, Chris Peach4 from Royal Manchester’s Children’s Hospital gave a talk on Pirani scoring which is an assessment tool used in clinic to grade the foot prior to and during treatment (See picture 3). It uses six measurements (see box 3) and scores each element as 0 – normal, 0.5 – mildly abnormal or 1 – severely abnormal. The use of Pirani scoring is controversial as it bears little relevance to the functioning foot but it is a good clinical tool as it is reliable, valid and responsive to change. Clinicians can use the system to measure the degree of deformity of each element, to assess if the deformity is correcting as expected or if there is a problem, and to assist in deciding if and when a tenotomy is required. Peach cited Dyer and Davis5 who researched the ability of Pirani scoring as a tool for predicting the number of casts needed for correction. They found that a score of four or more required at least four casts and a score of four or less required three or fewer casts. Referring to the rear foot scoring alone they reported that a score of 2.5 or three has a 72% chance of requiring a tenotomy, although this does not mean that a lower score rules out the chance of a tenotomy. After a very nice lunch, Guy Atherton6 from Bristol Royal Hospital for Children presented on the tenotomy. A tenotomy, which is necessary in 80% of cases, is carried out when the lateral head of the talus is reduced. Previously the procedure was carried out under general anaesthetic. As surgeons became more confident in carrying out the procedure they felt that a general anaesthetic was not necessary and began to use local anaesthetic as was recommended by Dr Ponseti. This not only avoided putting a baby under general anaesthetic, but lowered the time and cost of the procedure and allowed it to be carried out in clinic as a day procedure, relaxing parents and baby. So confident is Atherton that he has begun carrying out the procedure with no anaesthetic, as he claims that the needle is as sore as the knife, and palpating the tendo achilles becomes more difficult after anaesthetic is introduced. The tenotomy is a single cut of the tendo achilles. The blade enters vertically, quite high up the ankle as the calcaneus is not usually in the heel pad yet. The blade, either a beaver blade or any surgical blade, is turned horizontally and cuts through the tendon medial to laterally. The wound needs no stitches and the food is dorsiflexed to between 10° and 20°, abducted to its full potential (60°80°) and cast. This cast remains on for up to three weeks as the wound heals and the tendo achilles regrows. The general rule seems to be, if you are even thinking a tenotomy may be required then do one. Stuart Evans7 from Chelsea and Westminster Hospital then presented a talk on the boots and bar bracing stage of the treatment regime. This stage of the treatment requires the perseverance of the parents to ensure success as Evans reported a 95% recurrence rate of the deformity with 21

Peer Review Section

noncompliance to bracing within the first year. This is reduced to 70% - 80% in the second year, 30% - 40% in the third year and 10% - 15% in the fourth year. The child must wear the braces for 23 hours a day for three months, then at nap and night time for four years. In order to assist in compliance, the braces must be properly fitted i.e. the bar must be shoulder width and enough dorsiflexion must have been achieved to allow the heel to drop down in the shoe. (This can be seen through holes in the shoe.) If the shoe is too loose there will be friction and the skin will blister. Cotton socks must be worn under the shoes to prevent excessive sweating and sticking. The Mitchell brace (See picture 4) provides a soft moulded inner shoe with soft leather straps placed in strategic arrangement to provide adequate support. Other braces are also available, including the Denis-Browne splint, used in developing countries, as it can be made from available materials and manufactured easily. Abduction can be set at 60° - 80° in the talipes foot and if the condition is unilateral 30° - 40° in the unaffected foot.

Denise Watson’s features of effective plaster Features of a bad cast – Insufficient moulding, stockinet, knee not flexed enough, too loose, not high enough on thigh, toes not visible Features of a good cast – Snug, well moulded/sculpted, not too much padding around foot and ankle, toes clearly visible with good foot plate, high on thigh, still on at next appointment.

The elements measured in Pirani scoring Rearfoot measurements: Rearfoot Varus Dorsiflexion Empty Heel Midfoot measurements: Curved Lateral Border knowledgments The author wishes to thank Cosyfeet for their support in writing this article and global-HELP.org for their permission to use images and words.

References 1. DeKiewiet, G. 2010. The Ponseti Method Workshop. How the subtalar joint works. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre. 2. Davis, N. 2010. The Ponseti Method Workshop. The progression of manipulation. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre.

We then had a chance to examine some Mitchell braces. The shoes come off the bar and are strapped snuggly over the foot, then clipped onto the bar, which has been set at the correct level of abduction. Stuart told us about a gel insert he sometimes uses over the dorsum of the foot if there is some friction, but said that fresh cotton socks will suffice usually. The day concluded with talks on treating recurrences, common problems and clinical structures. These and the talks from day two will be discussed alongside the podiatrist’s role in my third article. Four Stages of the Ponseti Method of treating talipes Manipulation – Cavus, Adduction, Varus, Equinus Serial Casting – Padding, BK cast and molding, AK cast Tenotomy – Cast stays on for up to three weeks Braces – 23hrs a day for 3mths then night & nap until 4yrs

3. Watson, D. 2010. The Ponseti Method Workshop. The effective plaster. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre. 4. Peach, C. 2010. The Ponseti Method Workshop. Pirani scoring. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre. 5. Dyer, PJ & Davis, N. The role of the Pirani scoring system in the management of club foot by the Ponseti method. Journal of Bone and Joint Surgery - British Volume. 2006. 88(8):10821084. 6. Atherton, G. 2010. The Ponseti Method Workshop. Tenotomy. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre. 7. Evans, S. 2010. The Ponseti Method Workshop. Boots and bars. [lecture] October 10. Manchester: The Chancellor’s Hotel and Conference Centre.

Please address any correspondence to janetmcgroggan@hotmail.co.uk

PRESS RELEASE

Ag+ ions

New from Laufwunder – SENSITIVE BALM with micro granules of SILVER and CERAMIDES Itching, scaly, inflamed and irritated skin? Sounds familiar? Laufwunder Sensitive Balm with microsilver is a new product launched by Franz Lütticke (manufacturers of Mykored and Laufwunder footcare preparations) to help relieve these symptoms An effective product to be used by patients suffering from neurodermatitis during eczema free intervals. It has been designed for the daily, intensive care of very sensitive, dry and eczema prone skin. Its innovative ingredients improve moisture content and stabilise the skin’s flora by using micro silver granules (as opposed to the traditional Ethanol, Farnesol, Triclosan….) plus a superior ceramide complex (traditionally would be urea – which over the long term will weaken the epidermis, especially when over 20%) Why so effective? By incorporating micro silver granules into the product this provides a strong, natural anti microbial action – a resurgence from times past! 4 week trial at The German Dermatological Institute showed: Cream with 0.1% microsilver Increase in skin moisture Decrease in epidermal bacteria

It is free from perfume and colour and has excellent skin compatibility for those suffering from sensitive skin. Available in 75ml tubes and 450ml dispenser tubs. Only available through foot specialists in the UK, not available over the counter. For more information please contact: Sonia Kropp, Hilary Supplies, 34A Halstead Rd, Mountsorrel, Leics LE12 7HF Tel: 0116 230 1900 email:soniak@hilarysupplies.co.uk www.hilarysupplies.co.uk

The Institute of Chiropodists and Podiatrists

SOUTHERN AREA COUNCIL Spring 2011 Seminar Saturday 26th March 2011 10:00 am – 4:00 pm Registration/coffee 9.30 am at

Anglia Ruskin University, Bishop Hall Lane, Chelmsford, Essex Podiatry & Health Topics to include Clinical Governance, Cross Infections, Testing your Beliefs - What do you think your patients really want from a treatment? …and much more! Guest Speaker

Neil Simmonite MBA., BSc(Hons)., DPodM., PGCert Ed., MSCh Senior Lecturer, Professional Health Sciences, School of Health and Bioscience University of East London 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 • Raffle prize draw • CPD Certificate • Cost: £80.00 Closing date for bookings: 20th March, 2011 Please complete the booking form and return, enclosing a cheque for £80.00 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 2011 Name:………………………………………… Branch:……………………………………………… Address:…………………………………………………………………………………………………. ………………………………………………... …………………… Postal Code:……………………. Tel No:………………………………………... Email:…………………………................................... Dietary Requirements:………………………………………………………..………………………….. Signature:…………………………………….................................... Date:……………..………………

The Institute of Chiropodists and Podiatrists announces the award of our quality mark to H. J. Hall As an Institute we pride ourselves in our reputation as the leading organisation representing the private practitioner in the U.K. and further afield.

or some time The Institute has been talking about using our reputation and weight to assist manufacturers of foot care products in marketing their merchandise to the public by assigning our logo as a quality mark. This means that products such as creams, shoes, socks, etc undergoe rigorous testing and evaluation by us. If the product passes this process, we then offer the accreditation. It is with great pleasure that The Institute of Chiropodists and Podiatrists announces the award of our quality mark to H. J. Hall for their innovative Softop™ socks. These socks have been subjected to wear tests using the latest state of the art equipment, as well as trials by patients suffering with diabetes and other conditions that can cause oedemas. Patients taking part in the study used these Softop™ socks for a period of twelve weeks (they did wash them) and were monitored by clinicians who were briefed to look for comfort, suitability of purpose, patient view and whether they are helpful for patients with oedemas. The feed back was all extremely positive. The history of H. J. Hall goes back well over a hundred years when at the age of 28, John Hall, a foreman for a hosiery manufacturer in Hinckley, asked his bank for a £1,200 overdraft to build the first H. J. Hall factory in the small Leicestershire village of Stoke Golding. From a wage of £2 a week, he managed to save £500, a substantial sum in 1882. His wife, Sarah Hall, doubled this by raising a mortgage on their house, which she owned.

From a small firm employing 16 people and with a monthly turnover of £32 4s 4d, H. J. Hall has grown to become the largest independent UK sock manufacturer today. H. J. Hall has survived 129 years by focusing on what they do best – socks. This passion has enabled them to survive wars, recessions and depressions and allowed them to grow into the H. J. Sock Group. This group now encompasses Pantherella and Scott Nichol within its Company portfolio. H. J. Hall is proud of its constant innovation and creativity “We have partnerships with two leading British celebrities – both known for their skills and expertise in their specific fields. The tie up with Peter Jones from Dragons’ Den has proved so successful that the logical step to join up with another celebrity for our technical ranges was inevitable – and Ben Fogle was the ideal candidate - with the new range carrying his name it is proving to be highly commercial. Our professional accreditation from The Institute, will, we hope, give us a lead into the specific foot service market. With our passion for socks and the Institutes passion for feet we hope to be walking for a long time together”. The Institute would like to acknowledge the assistance of Anton Jenkins and his team for the supply of Softop™ socks and other technical data needed to complete this study. You can put your foot in no better sock.

Devon and Cornwall A.G.M. and Lecture On Sunday 23rd January, Devon and Cornwall branch held their A.G.M. and Lecture at the Exeter Court Hotel, Kennford, Exeter. Members elected were Chairman: Roger Henry; Secretary: Maria Reay; Treasurer: Helen Sangchi; Minutes and Social Secretary: Janet Rolfe; Auditors: Julia Caulfied and Philip Gardner.

Roger Henry, Chairman, Devon and Cornwall Branch

We welcomed Helen Sanchi as treasurer and gave thanks to Yasmin Druce who has been our treasurer for the past 3 years. We also welcomed Jon Beckwith, who has joined us from the Leicester and Northants Branch. There followed a lecture on plantar fasciitis (exercise and prevention). This was given by Chris Leech and Mike Jones from Cuxson Gerrard. 26

Treasurer, Helen Sangchi and Auditor, Julia Caulfield

WEST MIDDLESEX BRANCH SEMINAR Sunday, 26th June 2011 at Holiday Inn Express, Watford WD17 1UE 19, Bridle Path, St. Albans Road (01923) 28 86 00 PROGRAMME: 10:45

Registration, coffee and biscuits