Podiatry Review May/June 2010

May/June 2010 Vol. 67 No. 3 ISSN 1756-3291

New Horizons in Skin Surgery Influence of High Heeled Footwear Bone History

The Institute of Chiropodists and Podiatrists Abductor digiti minimi

Cuboid

Metatarsals

Phalanges

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Contacts Editor: Mr. R. H. S. Henry Email: editor@iocp.org.uk Editorial Assistant: Mrs. B. K. Willey Email: bernie@iocp.org.uk Published by: The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Telephone: 01704 546141 or 08700 110305 Fax: 01704 500477 Email: secretary@iocp.org.uk Web: www.iocp.org.uk

Contents 1. Editorial 2. HPC News 3. Diabetes News 4. Article on Skin Surgery Martin Harvey 8. Article Elizabeth Brackwell 10. Complementary Therapy 12. Article - Arab Health Stephen Gardener 15. Personal Profile Helen Jephcote

Dear Reader

As I sit to write this editorial, I am looking out of the window at the sunshine. It seems to be the first time I have seen the sunshine this spring, come to that this winter as well! Let us hope we have a sunny summer - we deserve it!

What have we of interest and note in this issue of Podiatry Review? I have featured a treatise entitled “Influence of High Heeled Footwear and Pre-fabricated Foot Orthoses on Energy Efficiency in Ambulation” It is by Sarah A. Curran PhD,BSc(Hons), Joanna L. Holliday BSc(Hons) and Laura Watkeys BSc(Hons). It is longer than our usual articles but I felt if we ran it over two editions you, the reader, could lose the thread of the discussion points put forward. I found it an interesting article especially where it reveals “surveys have shown that 59% of American women and 78% of British women wear high heels on a daily basis”. Do you find that it bears out what you see everyday of your working life?

May/June 2010

We have news and views in from the Midland Area Council, Southern Area Council, North West Area Council as well as branch news from Leeds and Bradford, Cheshire North Wales, Stafford and Shropshire and Devon and Cornwall.

There is an article on professional regulation for complimentary healthcare sent in by Maggie Wallace, Executive Chair of the CNHC. Our old friend, Colin Lea, from the Health Professions Council, is involved in that organisation.

Finally, I am looking forward to seeing old friends and new at our A.G.M., CPD Lectures, Dinner Dance and Trade Show to be held at Eastwood Hall Nottingham on the 7th-9th May 2010. I have hired my medieval costume for the Friday evening barbeque and medieval evening - have you? As I have said before, the A.G.M. weekend promises to be educational, informative, and fun.

Roger Henry, Editor Podiatry Review

16. Article - Influence of High Heeled Footwear Sarah Curran Centre Page CPD Bone History 19. Article - Influence of High Heeled Footwear Sarah Curran (cont.)

23. Article - Back to Life Helen Lloyd 25. Branch News 34. Diary of Events IBC National Officers Annual Subscription: £25.00 Single Copy: £5.00 Including Postage & Packing ISSN 1756-3291

L-R Colette Johnston (Irish Area Executive Delegate), Malcolm Holmes (North West Area Executive Delegate), Ann Yorke (Scottish Area Executive Delegate), Robert Beattie (Chairman Executive Committee), Stephen Willey (Chairman Board of Ethics), Heather Bailey (President), Roger Henry (Honorary Treasurer), Bill Liggins (Chairman Board of Education), David Elliott (Midland Area Council Delegate), David Crew (Vice-Chairman Executive Committee), Mary Newnham (Southern Area Executive Delegate), Judith Kelly (acting Yorkshire Area Executive Delegate) © 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.

News News News

Remember! 2010 is the second Audit for our Profession

2.5% of our Chiropodists/Podiatrists will be selected at random to produce their CPD profile to the Health Professions Council. Are you ready?

The list below will give you some idea of the kinds of activity that might make up your CPD.

Work based Learning

Learning by Doing Case Studies Reflective Practice Clinical audit Coaching from others Discussions with colleagues Peer Review Being on a committee Work shadowing Secondments In-service training Supervising staff or students Expanding your role Analysing significant events Filling in self-assessment questionnaires Project work or project management

O

Professional activity

Involvement in a professional body Membership of specialist interest group lecturing or teaching Mentoring Being an examiner/tutor/expert witness Attending branch meetings Giving presentations Organising accredited courses

Formal/Educational Courses Further Education Research Attending Conferences Writing articles or papers Going to seminars

Self-Directed Learning

Reading journals/articles Reviewing books or articles Updating knowledge through the internet or TV Keeping a file of your progress

Other

Public service Voluntary work Courses

Listening Event

n 1st March 2010 I attended one of the listening event meetings arranged by the Health Professional Council at Albrighton Hall, Shrewsbury.

After signing in and a cup of coffee, Mr Marc Seale (Chief Executive) gave a welcoming address and pointed out that the numbers of allegations regarding ‘Fitness to Practise’ in Podiatry and compared them to those of different professions and how the HPC were managing the ongoing audits.

Jonathan Jones (Publications Manager) then spoke on CPD and all it entails, giving suggestions on how to mix our activities and ideas for our profiles.

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Distance learning Courses accredited by professional body Planning or running a course

At the end of the presention there was enough time for questions and answers from the floor to the executive.

Subjects included time allowed for CPD in the working week and deferment due to illness, bereavement and maternity leave. All questions were well answered and at the end of the meeting the committee made themselves available for members to approach them on a more personal level.

I felt it was certainly worth an afternoon away from my patients and it has helped me enormously to put CPD and my audit into perspective.

Helen Lloyd Western Branch

Diabetes UK is calling on the next Government to make diabetes a key priority for the forthcoming Parliament

Political leadership is critical to ensure that diabetes services are prioritised at both a national and local level.

Diabetes UK is, therefore, asking political parties and prospective parliamentary candidates to make diabetes a priority at the next election and throughout the forthcoming Parliament to ensure the NHS can cope with the increasing demands it will face from people with diabetes.

Top ten priorities We are asking the UK government that forms after the general election to work with us to:

1. Defuse the diabetes time bomb and identify diabetes early 2. Ensure children with diabetes have a future 3. Make diabetes services world class with true accountability 4. Prevent life-threatening complications and support self-management 5. Improve emergency and inpatient care 6. Ensure equal access to insulin pumps and other innovations 7. Protect the health of pregnant women and their unborn babies 8. End discrimination at work 9. Improve care for older people 10. Prioritise diabetes research

One of the biggest health challenges facing us today “Diabetes is one of the biggest health challenges facing the UK today," said Donna Castle, Public Affairs Manager at Diabetes UK. "If diagnosed late, left untreated, or poorly managed, it can lead to devastating complications such as heart disease, stroke and blindness.

“Diabetes costs the NHS 10 per cent of its annual resources – £9bn a year or £1m an hour. In the next 15 years these costs will escalate significantly as diabetes prevalence increases. That is why Diabetes UK is urging the next UK Government to make diabetes a key priority and to work with us to tackle this growing health epidemic.”

The number of patients diagnosed with diabetes in Scotland continues to grow New statistics from the Scottish Diabetes Survey show that 228,004 people in Scotland now have diabetes The growing numbers diagnosed with Type 2 diabetes accounts for the largest element of the increase. 199,264 now have Type 2 diabetes, up from 190,772 in 2008.

Being overweight or obese is attributed by the survey as one of the strongest factors behind the increase as well as an ageing population. The survey also suggests that more people are diagnosed with Type 2 at a younger age and some people are being diagnosed before symptoms develop.

The numbers of people recorded as having Type 1 diabetes dropped slightly from 27,464 in 2008 to 27,367. It is thought that this drop is due to Health Boards validating their records more thoroughly.

The survey reports that there is a continuation of the 40 year gradual increase in the incidence of Type 1 diabetes and the numbers of people surviving with Type 1 is also increasing as a result of better blood glucose control.

“These are truly alarming figures,” said Jane-Claire Judson, Diabetes UK Scotland’s National Director. “While some of the growth can be accounted for by an ageing population, the major cause for the increasing numbers diagnosed with Type 2 diabetes is our country’s obesity crisis.

“Many people do not realise how serious diabetes can be. It causes heart disease, stroke, kidney failure and blindness, and more deaths in the UK than breast and prostate cancer combined.”

The figures come as new SIGN guidelines on the treatment of diabetes in Scotland were published. The guidance updates the new drugs available and other services such as insulin pumps which should be available in Scotland. The full guide and a patient version are available from the SIGN website

3

New Horizons in General Podiatry Practice Skin Surgery Figure 1

A

Martin Harvey,

PGC BSc MInstChP

s we all learn in training, the skin is the largest organ in the body. As podiatrists we spend a lot of our time doing various things to the skin of the foot and lower limb yet podiatric dermatology is perhaps one of the least developed aspects of our profession.

It could be argued that this is a great pity, because study of the skin and performing minor surgery on the skin can be one of the most rewarding and interesting aspects of a suitably trained general podiatrist’s practice and a highly beneficial service to our patients. Minor surgery includes removal of Melanocytic Naevi (non-cancerous pigmented Moles), Basal Cell Papilloma (Seborrhoeic Keratosis – known in less politically correct days as Senile Warts), Epidermoid Cysts, Skin Tags (Fibroepithelial Polyps), Dermatofibroma (Histiocytoma), Pyogenic Granuloma, Verrucae Pedis (VP) and partial or full nail avulsions with or without phenolisation. For suitably trained and experienced clinicians with access to histopathology services to analyse specimens, the simpler premalignant skin lesions such as Bowens Disease (Intraepidermal Squamous Cell Carcinoma) and non-melanoma skin cancers such as Rodent Ulcer (Basal Cell Carcinoma) are additionally capable of being effectively performed at local levels (Schofield & Kneebone, 2006).

Figure 1. Bowens Disease (Intra-epidermal carcinoma in situ) Posterior calf 73 year old female. Before elliptical excision and subsequent skin closure with sutures and ‘steristrips’®. ©Martin Harvey 2009

Existing local skin surgery services in theory - and practice

Minor skin surgery is increasingly performed in community based locations such as NHS general medical practices, hospital outpatient departments and private high street locations such as ‘skin and mole clinics’. In NHS general medical practice, some primary care trusts set targets for a minimum number of procedures to be performed within the basic funding targets of that practice (the Quality Outcomes Framework – QOF), with further payments being made for each additional procedure performed over target in a set period.

The Darzi report’s ideal of “high-quality care as a consistent part of everyone’s experience of primary and community care” (Lord Darzi of Denham, 2008) includes the concept of effective local skin surgery services based on nationally agreed guidelines (Department of Health, 2007, pp. 16-17). However, the reality in certain instances is currently falling short of such aspirations, i.e. “Currently, there is no uniform care pathway for minor skin lesions in Battersea …” (Wandsworth Primary Care Trust, 2009)

Figure 2. Typical benign lesion. A Histiocytoma, which can be easily removed by elliptical excision if the patient requires it for cosmetic reasons or if diagnosis is in doubt and histopathological analysis is required. Good excision and closure technique, appropriate patient selection and support dressings during healing will minimise scarring. ©Martin Harvey 2009

4

Various guidelines on skin surgery have been published in recent years (Department of Health, 2006, The National Collaborating Centre for Cancer, 2006, Pulse, 2009). Minor surgery procedures are now performed routinely by a variety of health practitioners, including doctors and nurses who may, or indeed may not, have some form of recognised accreditation or formal training in them. The All Party Parliamentary Group on Skin has in fact expressed concerns in this area (APPGS, 2004) suggesting that training for non-GPwSI (General Practitioner with Special Interest) general medical practitioners and nurses in skin disease and treatment was often “inadequate”. In

response, the Royal College of General Practitioners state they are keen to encourage the provision of training opportunities amongst G.P’s, nurses and pharmacists (Field, 2006). As is so often case, the profession of podiatry is not mentioned, even though it can be argued that podiatrists are already highly skilled in certain minor procedures and in many instances need only the specific training, both theoretical and practical, to build on the already highly developed manual dexterity skills they do (or should!) have to make them highly competent minor skin surgeons of the lower leg and foot.

Podiatrists, Dermatology and Skin Surgery

As well as bone surgery, the training of podiatric surgeons cover theories of elliptical excision, punch and shave biopsies, partial and full nail avulsions and matrixectomies in an MSc syllabus, combined with practical pupillage over a period of 3 – 5 years (Queen Margaret University Edinburgh, 2010) . With only some 147 current practitioners, podiatric surgery is, and can be expected to remain, a proportionately small sector of the profession, limited by the level and length of training required, restricted numbers of available NHS appointments in the speciality and the need for invasive bone surgery to be performed in suitable operating theatres which precludes the full deployment of its skills in the average primary care facility (Ashford RL, Tollafield DR, Axe D., 1995). The frequently occurring clashes between some sectors of the medical profession, such as orthopaedic foot and ankle surgeons etc, and podiatric surgeons does also perhaps have some bearing on the continuing small numbers of this redoubtable band of practitioners.

Skin surgery, on the other hand is already widely practiced by, for example nurses, and in far greater volume than orthopaedic procedures so the potential for conflict with any other group (except perhaps some podiatric surgeons!) existing for a podiatrist extending their skills to include formal minor skin surgery is considerably less. In NHS or private general practice, podiatrists may already perform cryosurgery for items such as viral warts and periungual granuloma consequent to ingrown nails, using hand-portable pressurised canisters of cryogens (i.e.

HistoFreezer®) Bulk-delivered liquid nitrogen systems are less commonly used by podiatrists, especially those in private practice, due perhaps to costs and storage factors, however this is still the technique of choice in minor surgery and could perhaps represent something that could form the basis of co-operative ventures between local groups of podiatrists. Nail surgery by way of partial or total avulsion and phenolisation under injected digital nerve blockade analgesia, is practiced to varying extent, dependent on the training and facilities of individual practitioners and their access or otherwise to local anaesthetics. (Ashford RL, Tollafield DR, Axe D., 1995) No other type of skin surgery is formally taught in current BSc podiatry courses and the dermatology component of a typical podiatry degree may be illustrated by the fact that it is a 20 point module in a 360 point degree (University of Huddersfield (1), 2010) In the general podiatry sector, by contrast to the relatively fully exploited current potential of podiatric surgery, there appears to be an increasing trend towards a broadening range of skills and knowledge being available via postgraduate

education that could enable the generalist to either substantially develop the depth of a specific area of knowledge as practitioners with a special interest (PwSI) or simply widen the scope and depth of their generalism. An example of this is fullformulary prescriber training at level 6 or 7, which although delivered via nurse independent prescriber courses, currently only permits podiatrists to act as supplementary prescribers, but which appears due to change to full prescribing independence following last years department of health report on the subject (Department of Health, 2009). Further examples of master’s level podiatry-specific training in various subjects include musculoskeletal conditions of the lower limb, multiprofessional management of the foot in diabetes, and tissue viability in lower extremity wounds (University of Huddersfield (2), 2010) Improving and developing training and skills in podiatric dermatology and the types of skin surgery that could be practiced in primary care, as either a PwSI specialism or just a component of more effective generalism, could be a particularly valuable addition to the currently growing range of postgraduate development courses. As podiatrists are recognised and insured as independent clinicians within their own area of practice, qualified practitioners could offer a directly approachable service for lower-limb skin problems and appropriate surgery. Such a concept would appear to accord well with the ethos expressed in the Darzi report.

Figure 3 Figure 3. A podiatrist learning the delicate art of the basic interrupted suture – on pigskin. ©Martin Harvey 2009

Qualifications allowing the use of local anaesthetics if not already held, entry to a suitable course validated by a recognised academic body, access to appropriate mentoring and suitable locations in which to operate would of course be required to permit lawful and responsible practice of skin surgery. Training to allow access to basic antibiotics or preferably supplementary or independent prescribing would also assist in post-surgical or non-surgical management of skin pathologies. The challenges and effort required to implement the above are perhaps large, but the potential for benefit to both the profession of podiatry in terms of future development and the contribution to the health of the community we serve could be substantial indeed and worthy of such investments. ©M.Harvey. February 2010. e.mail; martin@podmed.info

5

Bibliography and Sources of Further Information

Ashford RL, Tollafield DR, Axe D. (1995). Podiatry Education in the UK. The Foot, 5 (1), 1-7.

Chen SC, Bravata DM, Weil E. (2001). A comparison of dermatologists’ and primary care physicians' accuracy in diagnosing melanoma. Arch Dermatol 137 , 1627–1634.

Department of Health. (2009). Allied Health Professions prescribing and medicines supply mechanisms scoping project report. London: Department of Health.

Department of Health. (2007). Guidance and competencies for the provision of services using GP's with special interests. London: Department of Health UK. Department of Health. (2006). Our health, Our Care, Our Say: A New Direction for Community Services. London: HMSO.

Durham, New College. (2009). Undergraduate Prospectus (podiatry). New College Durham School of Early Years, Health and Social care.

Field, P. S. (2006). Curriculum statement on skin conditions. London: Royal College of General Practitioners.

Glasgow Caledonian University. (2009). BSc(Hons) Podiatry prospectus.

Glasgow Caledonian University.

Health Professions Council. (2009, Jan 21). Statistics - current. Retrieved Jan 21, 2009, from http://www.hpc-uk.org/aboutregistration/theregister/stats/ Lord Darzi of Denham. (2008). high-quality care for all. London: Department of Health.

Pulse. (2009, March 12th). NICE to review skin cancer guidance after GP minor surgery row. Retrieved Jan 21, 2010, from Pulse online: http://www.pulsetoday.co.uk

Queen Margaret University Edinburgh. (2010, Jan 6). MSc Theory Of Podiatric Surgery. Retrieved Jan 23, 2010, from Queen Margaret University Website: http://www.qmu.ac.uk/courses/PGCourse.cfm?c_id=213

Royal College of General Practitioners. (2004). The future of general practice: a statement by the Royal College of General Practitioners. London: Royal College of General Practitioners.

Schofield, J. & Kneebone, R. (2006). Skin Lesions - a practical guide to diagnosis, management and minor surgery p5. Metro Commercial Printing Limited, Hertfordshire WD24 7 UY

The all party parliamentary group on skin (APPGS). (1997). An Investigation into the Adequacy of Service Provision and Treatments for Patients with Skin Diseases in the UK. London: Houses of Parliament.

The All Party Parliamentary Group on Skin (APPGS). (2004). Report on Dermatological Training for Health Professionals. London: Houses of Parliament.

The London Skin Centre. (2007). The London Skin Centre-General Dermatology. Retrieved Jan 23, 2010, from The London Skin Centre web site: www.the-dermatology-centre.co.uk

The National Collaborating Centre for Cancer. (2006). Improving outcomes for people with skin tumours. London: National Institute for Clinical Excellence.

University of Huddersfield (1). (2010, jan). Human and Health Sciences, Prospectus. Retrieved Jan 23, 2010, from Huddersfield University: http://www2.hud.ac.uk/hhs/courses/

University of Huddersfield (2). (2010, Jan). Podiatry MSc/PgDip/PgCert.

Retrieved Jan 23, 2010, from University of Huddersfield web site: http://www2.hud.ac.uk/courses/part-time/pt_ipp.php?ipp=1255

Wandsworth Primary Care Trust. (2009). Practice based commissioning business case outline for minor skin surgery services. London: Wandsworth PCT.

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Dr. Elizabeth Blackwell: A Pioneer in Medicine and Education for Women Suzanne Edge M.Inst.Ch.P

E

31st May 2010 is the hundredth anniversary of the death of Dr. Elizabeth Blackwell, the first woman to receive a medical degree

lizabeth Blackwell was a one woman revolution. Denied a place at twenty nine different colleges throughout the United States she was finally accepted to Geneva college in New York, because the faculty asked the students to vote whether or not to admit her. They, thinking her application a joke, voted yes!. The joke however, was on those who tried to thwart her studies when in January 1849 she graduated first in her class, becoming the first English speaking woman to be given a medical degree.

In a life full of extreme highs and lows, Elizabeth’s first good fortune was to be born to Quaker parents, who believed that all people are equal in the eyes of God, so, unusually for the early 19th century, she, along with her sisters received an education, taught at home by the family’s servants. Bad luck struck in those early years too, six of her sisters and two of her brothers died. Then, in 1832, when Elizabeth was 11 years old, a fire destroyed her father’s business and the family moved to New York City to start anew. Business opportunities were numerous in the new world at the time, but being fiercely abolitionist, reduced the choices drastically for their father. A chance to open a sugar refinery in Ohio, which did not require the use of slaves to harvest the cane, seemed the ideal solution, so they moved again, this time to Cincinnati.

It was there, just three months later, that disaster struck.

Elizabeth’s father died of biliary fever, leaving the family bereft and without financial support. Forced to earn a living, Elizabeth became a teacher in Kentucky, but did not enjoy this life at all and a dying friend’s remark, that most of her suffering would have been avoided had her physician been a woman, stirred Elizabeth’s pioneering spirit.

In order to prepare for admission into medical school, Elizabeth lived in the homes of firstly Dr. John Dickson and then his brother Dr. Samuel Dickson, two men sympathetic to her cause, using their extensive medical libraries to study. The welcome that Elizabeth received in Geneva, was though, much less sympathetic. The townspeople thought she had some sort of malicious intent, or that she was mad to want to study medicine. She was barred from certain classes, or ridiculed and embarrassed by the teachers. Most of the students were polite to Elizabeth though, looking upon her as an older sister-like figure and by the time that she graduated, public opinion had turned around so much, that the graduation ceremony was packed with thousands of well wishers, who let out a cheer as she ascended the stage, to collect her certificate.

Receiving an MD was only the beginning of a difficult career path for the new Doctor Blackwell. Banned from practicing in most hospitals in America, she went to Paris and started her post graduate studies at La Maternitee hospital. These studies were cut short however, when she caught purulent ophthalmia

8

from a baby she was treating and had to have her eye removed, effectively putting an end to her hopes of becoming a surgeon.

Returning to America, Elizabeth still found it impossible to find work in the all male hospitals, so in 1857, joined together with her sister Emily and Marie Zakrzewska, both of whom had followed in her footsteps and were newly qualified doctors themselves, to open the New York Infirmary For Indigent Women And Children. Leaving the day to day running of the Infirmary to the others, Elizabeth returned to England to continue her post graduate studies at Bedford College For Women. Whilst there, she toured the United Kingdom, giving lectures encouraging women to aspire to study as she had and about hygiene and good practices within the home; causes which remained at the core of her writing and teachings throughout her life and career. It was during this time in England, that Elizabeth became the first female doctor to have her name entered onto the General Medical Councils medical register, on 1st January, 1859.

Eventually, just encouraging other women to try to gain places at the still male dominated universities was not enough and the three doctors opened the Women’s Medical College at the New York infirmary, to train the next generation of female doctors. A year later, Elizabeth returned to England for good and along with Florence Nightingale, opened the London School of Medicine for Women. Elizabeth took the chair in Gynaecology.

In 1907 after an eventful life of work and travel, the now elderly Elizabeth was injured in a fall at her home in Bristol, which left her very frail. In 1910 she suffered a stroke, which proved fatal and she died on the 31st of May. So it was that 100 years ago this month, the world lost one of the first pioneers in the cause of women’s equality.

The influence that Elizabeth Blackwell had upon women’s liberation and the face of the medical community cannot be overestimated. Battling against the suffocating sexist attitude of most of society in the nineteenth century, was a personal struggle to which she rose, admirably. Saying: “It is not easy to be a pioneer - but oh it is interesting! I would not trade it for one moment, even the worst moment, for all the riches in the world.”

It is no exaggeration to say that, had she not had the good fortune and sheer determination to gain that first university place, the cause of women’s equality in education could have been held back for decades. For the countless women who have followed in her stead and all those who have benefited indirectly from the change in attitudes which she helped to advance, it was all worth while. Dr. Blackwell herself commented: “If society will not admit of women’s free development, then society must be remodelled.” She made a pretty good start at doing just that.

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9

P ro fes s ion a l r eg ul a t ion fo r c om pl em e n t a r y h e a lt h c a r e A ‘quality’ organisation Look for the CNHC quality mark of registration In the public interest

Did you know that complementary healthcare has now come of age with the establishment of a UK regulatory body for the sector? The Complementary and Natural Healthcare Council (CNHC), established in the public interest, is already being cited as an example of an effective voluntary regulator.

Like the HPC, CNHC covers a wide number of professional disciplines, all of which have to meet its standards before practitioners are eligible to apply for registration. The register went live in January 2009 and CNHC currently registers: 2000. Alexander teachers 2001. aromatherapy 2002. massage 2003. nutrition 2004. reflexology 2005. shiatsu and 2006. yoga practitioners

2000 individuals had been registered, or were in the process of being registered, by December 2009. We will shortly be adding those practising sports and remedial therapy. cranio sacral, Bowen, reiki and naturopathy.

During 2010 it is also hoped that other professional groups, including hypnotherapists, professional healers and micro systems acupuncturists will be choosing to register. Other practitioners may well become eligible over time.

DH support

Kate Ling, from the Department of Health, has recently gone on record confirming that ’ the CNHC is the only voluntary regulatory body which has official government backing. No other organisation has the same exacting criteria or focus on safety and quality. The more people who register with CNHC the more it will be recognised as the only organisation which provides the guarantee that members of the public are looking for’.

She went on to say that whilst it was not possible to make CNHC registration a requirement or condition for GP or PCT referral, “we are recommending that referrals should only be made to CNHC registered professionals’.

10

Entry standards

In order to be eligible to be admitted to the CNHC Register, a practitioner must: G

G

G G G G G

G G

Have undertaken a programme of education and training which meets, as a minimum, the National Occupational Standards for that profession/discipline or

Have achieved competency to the level of the National Occupational Standards* for the therapy/discipline concerned by means of relevant experience of at least three years and /or relevant training and been assessed by their peers as having met those standards and Have met the agreed standards of proficiency for that profession/discipline

Have provided an independent reference of their good character Have declared that they do not hold a criminal record Have declared that there are no health issues that impact on their ability to practice

Have declared that they have not been the subject of any disciplinary or civil proceedings against them in relation to their practice Hold current professional indemnity insurance Have agreed to abide by the CNHC Code of Conduct, Performance and Ethics

*National Occupational Standards define what a competent person should be able to do when they carry out a particular activity or function. Skills for Health, an independent agency, is responsible for establishing National Occupational Standards across a wide range of health care disciplines, including many complementary therapies. More information at www.skillsforhealth.org.uk

CNHC structure

CNHC consists of a main Board, three Committees: Conduct and Competence, Professional Standards and Finance; and a Profession Specific Board (PSBs) for each of the professional groups eligible for regulation.

The Board and Committees consist entirely of lay members, who have undergone a public process of appointment. Between them the members provide a wide range of knowledge, skills and experience which contribute significantly to the work of the organisation - including professional regulation, general management, finance, consumer affairs, education, law, and business.

The PSBs provide the formal link between the Board, Committees and the professions regulated. This takes the form of essential, high quality professional input into the work of the organisation. PSB members also provide the ‘due regard’ element, where required, for professional conduct activity.

The CNHC Executive Chair, Maggy Wallace, has a substantial national and international background in professional regulation, education and the health service and was most recently Chair of a Foundation Trust. The organisation’s CEO/Registrar Maggie Dunn, was national negotiator in the NHS for UNISON, where she established the Fitness to Practise unit and was the lead advocate.

CNHC Work Programme 2010-2011 G

G G G G G G

G G G

Continuing to raise the profile of CNHC, with significant investment in building awareness of the register and the CNHC quality mark amongst practitioners and amongst the general public

agreeing the criteria for new professions wishing to register establishing a CPD policy and considering revalidation issues establishing an accreditation policy

identify areas of professional policy work for audit hearing complaints and appeals as required

monitoring changes in the wider regulatory arena particularly in relation to fitness to practise issues and identifying general and specific implications for CNHC analysing relevant fitness to practise cases heard by other bodies and identify the learning for CNHC

re-assessing CNHC’s policies and procedures in the light of lessons learned above

Continuing to build and sustain good relationships with a range of stakeholders, including professional associations, other regulatory bodies, consumer advice agencies, Ministers, MPs and key opinion formers

Complaints

Perhaps unsurprisingly, given the high visibility of complementary healthcare, CNHC has already had its first complaints. Again, perhaps also unsurprisingly, the complaints related to the nature of advertising and therapeutic efficacy. Whilst the Fitness to Practice Panel upheld the complaints, they were of the view that they did not impair the practitioner’s fitness to practice. CNHC is now working with the PSB s and Professional Associations to ensure that practitioners have access to advice on accurate and effective advertising.

Future emphasis

During 2010, CNHC will concentrate on increasing its registrant numbers, to maintain professional and financial viability. To support this expansion we will be continuing to focus our efforts on raising awareness of the CNHC Register and quality mark within the health service, complementary health field and among the general public that make use of complementary healthcare services.

Continued collaboration will also be necessary with a wide range of organisations within the complementary healthcare sector and beyond to encourage both initial and sustained interest in registration/re-registration to ensure maximum registration numbers are obtained within the targeted disciplines. Substantial activity will also continue with organisations such as higher education institutions offering complementary health courses; and employers, particularly those with a specific interest in CAM use eg Hospices, health and fitness centres.

Contacts with other bodies

A range of useful preliminary visits have taken place with other key healthcare regulators, including the Health Professions Council, Nursing and Midwifery Council, General Chiropractic Council, General Osteopathic Council and General Medical Council. Memoranda of Understanding are being drawn up with the NMC and GOsC and arrangements have been made with the other bodies for the exchange of key information, such as the removal of practitioner names from the professional registers. Visits have also been made, or are planned, to the key Royal Colleges and other significant professional associations.

CNHC has already established some useful links with a variety of providers within healthcare and education and would welcome increased contact with commissioners and providers in all sectors.

Further information Please visit the CNHC web site at www.cnhc.org.uk ; email us at info@cnhc.org.uk or phone 020 178 2199 Maggy Wallace, Executive Chair CNHC

11

Arab Health

by Stephen Gardener, PGDip BSc (Hons), M.Inst.Ch.P had the honour and pleasure of being invited to Arab Health; Dubai, UAE, congress in January. I was surprised to find out that I was the only Podiatrist present amongst thousands of people.

This created great interest from the 35 countries.

I

Arab Health congress takes place over four days at Dubai’s International Convention and Exhibition Centre. This congress is the largest multi-track medical conference in the world. Thousands of delegates get the chance to meet, discuss and debate cutting edge thinking over 18 key topic areas related to the healthcare sector.

The congress is a unique forum for scientific exchange, enabling medical professionals to interact with leading researchers, scholars and renowned speakers to keep abreast of the latest practices and technologies.

The congress was opened by His Highness Sheikh Mohammed Bin Rashid Al Manktoum, UAE VicePresident and Prime Minister and Ruler of Dubai along with his wife Her Royal Highness Princess Haya Bint Al Hussein who is a practicing Physician.

This was followed by Lord Ara Darzi of Denham who is the UK’s Ambassador for Healthcare and Life science. Lord Darzi lectured at the congress on the first portable home haemodialysis machine which is manufactured in the UK. He currently is a practising surgeon at Imperial College London where he specialises in keyhole, cancer and robotic surgery.

Whilst walking around the exhibition it was interesting to see that the UK was well represented and to see some familiar names such as, Escherman, Timesco, Physio-med and London Orthotics Company to name but a few.

Also at the congress was a familiar face to myself and possible many of our members, Peter and Julia Shaw from C&P Medical Ltd who was here keeping a close eye on the market, looking for new products for Podiatrists at great prices.

My Invitation was extend to attend a reception at the British Embassy, hosted by HM Consul General Mr Guy Warrington and Lord Darzi. This was time to focus on business developments in healthcare at home and aboard.

Although this was a very tiring four days, the benefits and educational development was most rewarding to me and those who attended.

The stimulating, business-focused atmosphere was clearly felt by me and all during the four day event.

My time could not be complete without visiting Dubai Healthcare City which is a “City that makes health its priority”; this it certainly does by its worldclass state-of-the-art centre for medical excellence.

Healthcare city is home to two hospitals with over 90 outpatient clinics and diagnostic laboratories with over 1,700 licensed professionals and allied healthcare professionals from across the globe.

12

Healthcare City boasts two communities, the medical and wellness community. The medical community focus on acute services and occupies an area of 4.1 million square feet.

The wellness community covers 19 million square feet. You can see why Healthcare city has received National and international recognition for its achievements in healthcare.

On my return to the UK, it gave me time to reflect on my own clinical decisions, practice and practice developments and how I can improve the high standard patient care I esteem to.

This has been a great exposure to different healthcare systems and practices and is valuable CPD for myself and developing both my practice and clinical needs of my patients.

I am looking forward to being invited to next year’s Arab Health.

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Institute of Chiropodists and Podiatrists Institute of Chiropodists and Podiatrists

2010 Annual Conference & AGM 2010 Annual Conference & A.G.M. Eastwood Hall, Mansfield Road, Nottingham, NG16 3SS

Eastwood Hall, Mansfield Road, Nottingham, NG16 3SS

Insert Photos from page 26 November/December 2009 issue

Friday, 7th May 2010 12.00p From 2.00pm 2.00pm 3.30pm 4.30pm 6.30pm 7.30pm

Trade Exhibition Opens - Chatterley Suite Arrival of Delegates Refreshments in Trade Exhibition - Chatterley Suite Lecture - !"#$%&&#"'(%&)%*'+%",#,'-./'0'12#"%,&34'!#5367"*8'0 Lawrence Suite Lecture - Greg Quinn “The Foot Shape we inherit and why symptoms occur - Lawrence Drinks Reception in Trade Exhibition - Chatterley Suite Barbeque & Medieval Evening with Games and Archery (Medieval Fancy Dress Optional)

Saturday, 8th May 2010 9.00am Trade Exhibition Opens - Chatterley Suite 9.30am Opening of Conference - Lawrence Suite 9.45am Concurrent Sessions Annual General Workshop 1 Workshop 2 Diabetic Assessment Masterclass in Silicone Meeting Orthoses Lawrence Suite 11.00am 11.30am

12.30pm 2.30pm 3.30pm 4.00pm 6.30pm 7.30pm

Workshop 3 Nail Surgery in Private Practice

Refreshments in Trade Exhibition - Chatterley Suite Concurrent Sessions Annual General Workshop 1 Workshop 2 Workshop 3 Nail Reconstruction Padding & Strapping Infection Control Meeting Lawrence Suite Lunch and Trade Exhibition - Restaurant Lecture - Maureen O’Donnell - “Expert Witness and Medical legal” Lawrence Suite Refreshments in Trade Exhibition - Chatterley Suite Lecture - Dr Menos Lagopoulos - “Lower Limb anatomy and pathology of the foot” Lawrence Suite President’s Reception - Lawrence Suite Annual Dinner and Dance - Lawrence Suite

Sunday, 9th May 2010 9.30am Lecture - Dr Andrew Franklyn-Miller Royal Navy - “Reducing Lower limb injury” 10.30am 11.00am 11.15am 12.30pm'

14

Lawrence Suite Annual General Meeting - Lawrence Suite Refreshments - Chatterley Suite Annual General Meeting - Lawrence Suite Lunch - Restaurant

Personal Profile Helen Jephcote

I

M.Inst.Ch.P

was born in Hamilton in March 1959, attended Low Waters Primary School, St John’s Grammar School and Hamilton Grammar school when it became a comprehensive secondary school to complete my education.

Since my early school years I wanted to be ‘something in medicine or the medical profession’ and as my strengths at school lay in English, Anatomy, Physiology & Health, and Biology everything seemed to be pointing me in that direction, however, jobs in the medical field would require me to remain in school, college and eventually university for a few more years of studying and I was not prepared to continue in school as I was hungry to earn my living in the big wide world.

My first job was in a factory which made motors for ventilation fans and was a great laugh if a bit rough and ready. I was then accepted for the Civil Service and embarked on a career in income tax, Ministry of Defence and Scottish Government. Running concurrently with my time in the Civil Service I was also a very active member of the Territorial Army and after the challenges of the working week I spent the weekends on exercise, learning military skills, attending courses and meeting new people.

All this combined with a busy family life at home left me little time to myself but I was happy with my busy life.

As the years drifted by I was becoming disillusioned with the Civil Service and wanted to do something different, so when an opportunity arose to go on a short tour of duty in Ireland with an infantry unit, I jumped at the chance and took an 8 month career break and set off on an adventure.

The tour was definitely different to my normal routine, it challenged all my interpersonal, administrative and military skills to their limits, I worked shifts instead of 9 – 5 and really enjoyed the way of life.

Coming back to work after that took a lot of adjusting and it was then I started thinking of the possibility of a new career and my initial plan to be something in the medical profession.

It was around that time that my husband, who is also a very active member of the Territorial Army, was leaving for a tour of duty in Bosnia in November 1998. The children were settled in their own lives and jobs which left me with some quiet evenings to fill so I looked around for a subject to study and found the Scholl chiropody course advert. I visited a local chiropodist to find out what it was all about, liked the treatment I received, applied and was accepted on the course and started studying chiropody for my future profession.

Of course nothing runs as smoothly as planned and what seemed like the day after my husband’s plane left the ground the children had job and family crises which had to have instant and costly solutions, the washing machine and car broke down and everything seemed to be against me completing my modules in time for submission. Thankfully things became easier and I managed to settle down to a workable solution of work, study, family time and TA balancing act to finally pass all my modules and sit the exams in August of 1999. I applied to attend my eight weeks clinical practice in the Scholl clinic in Worthing, West Sussex and joined the winter ‘class of 99’. We had such fun whilst learning all the practical skills and treating our patients and every year we try to have a reunion at the A.G.M., but to date not all of us have been able to attend so perhaps next year as we celebrate our 11 years in practice we will get our “class reunion”. I wonder whatever happened to that pink boa……………?

I joined the Institute of Chiropodists and Podiatrists in November 1999 and started domiciliary practice in 2000 firstly on a part time basis and embarked on a full time career in 2004 after leaving the civil service. I am a staunch member of the West of Scotland Branch and have served as secretary of the branch. I always enjoy the branch meetings and look forward to attending the A.G.M.

I am still an active member of the Territorial Army and have completed 3 tours of duty in Ireland, Bosnia and Iraq. I am currently the Traffic Officer for my unit having worked my way through the ranks to reach Captain, commissioning after my last tour of duty in Iraq.

My hobbies are gardening and reading which in themselves are fairly gentle pursuits, however, the gardening can be tough depending on the season and the reading, if not to do with work or TA, has to wait until holiday time. I do some running for charity (one or two per year) and have just completed the Sports Relief 3 miles in St Andrews on 21 March. I contribute to many other charities regularly and support the military charities Help for Heroes, Erskine Hospital and Poppy Scotland.

Family wise, I am married to Jeff and we have two children and five grand children who are an absolute delight and keep us very busy especially during the summer holidays when we all try to get together and spend some quality time.

I am certainly happy with my lot and enjoy being busy with my practice, family and TA. Life is a journey of learning and I learn something new every day.

15

I nf l u e n ce o f H i g h H e e l e d F o o tw e a r a n d P r e - f a b ri c a t e d Fo o t O r th o s e s o n E ne rg y E f f i c i e n cy i n A m b u l a ti o n

by Sarah A. Curran PhD, BSc(Hons)1, Joanna L. Holliday BSc(Hons)1, Laura Watkeys BSc(Hons)2

The Foot and Ankle Online Journal 3 (3): 1

Background: Although changes in kinematics and repetitive impact forces produced by high heeled footwear can be minimized by pre-fabricated foot orthoses, their effects on energy efficiency and comfort are less understood. The purpose of this study was to investigate if an increase in high heeled footwear and selected pre-fabricated foot orthoses altered energy consumption and improved comfort.

Materials and Method: Ten healthy females (age range 21 – 34 years) who were regular high heel wearers volunteered for the study. Five footwear conditions were randomly assigned: heel height of 15mm (flat), 45mm (low), 70mm (high), high with McConnell® orthosis and high with Insolia® orthosis. Heart rate (HR), volume of oxygen consumed in liters per kilogram (VO2/kg), respiration exchange ratio (RER), physiological cost index (PCI) and the number of steps (NoS) were monitored whilst walking on a treadmill at a speed of 4.2km/hour and 0% incline for 10 minutes. The Footwear Comfort Scale was also completed following each condition.

Results: HR, VO2/kg, RER, PCI and NoS were significantly increased for the high (p<0.001) condition compared to the flat and low conditions. Significant differences (p<0.001) were also noted between the high and high with McConnell® and Insolia® conditions with a reduced HR, VO2/kg, RER, NoS and PCI. A significantly improved overall Footwear Comfort Scale was also noted between the high, McConnell® and Insolia® conditions (p<0.001).

Conclusions: This study supports previous work that wearing high heels are less energy efficient than flat shoes. It also suggests that selected pre-fabricated foot orthoses in high heeled footwear may improve energy efficiency and perceived comfort to wearing high heels alone. These combined benefits and the specific design of biomechanical interventions of orthoses for high heeled footwear should be explored further.

M

Key words: High heeled footwear, Energy, Physiological cost index, Pre-fabricated orthosis, Comfort.

odern day fashion trends continue to promote the design and popularity of high heeled footwear. Surveys have shown that up to 59% of American women1 and 78% of British women2 wear high heels on a daily basis.

The reasons for wearing this style of footwear vary greatly with many women stating that they feel more confident and glamorous from the extra height gained.1,3 A further attraction relates to the appearance of a shorter foot, which is achieved by increasing arch height.4,5 This is also supported by Frey et, al.,6 who found that 86% of American women wore high heeled footwear that was too small for their feet.

Whilst elegance is perceived as a key characteristic, by its very nature the design of high heeled footwear can be considered as having a profound impact on gait and posture, and in particular lower limb function.

Efficient walking is achieved by forward transmission of one limb to the next using the least amount of energy.7 Footwear with a low heel is thought to conserve energy by providing a normal heel strike and smooth forward transmission of the limb. In contrast, high heeled footwear can result in an early heel strike and increased rearfoot inversion.8-11 Other alterations are a plantarflexed ankle throughout stance, which produces

16

postural changes causing the hip and knee to flex.9, 12-14 The plantarflexed foot position increases loading to the forefoot and in particular the first and second metatarsal heads.8,15-21 During swing phase, hip flexion is thought to be reduced, and whilst cadence may not be affected by high heels, stride length and velocity are decreased.12 Muscle function is also altered during high heeled walking8,22-26 with constant contraction of the lateral head of the gastrocnemius25 and an increase in activity of tibialis anterior23, 26 and rectus femoris.26

As a consequence to these changes, high heeled footwear is frequently linked as a cause or aggravating factor of pain and symptoms in the lower back, hip, knee, ankle and foot.15,27,28 In particular, evidence suggests that individuals who wear a high heel take a longer period of time to reach maximum knee flexion which disrupting the screw home mechanism of the knee and thus predisposes the joint to injury. Moreover, Stefenyshyn, et al.,29 showed that compared to barefoot, high heeled footwear increased concentric knee extensor activity. These findings are also supported by Kerrigan, et al.,30-32 who found that high heels increase peak varus torque by up to 26% when compared to barefoot. As a result, these factors are thought to produce abnormal forces at the tibiofemoral and patellofemoral joint which in turn predisposes the knee to injury and degeneration.

Foot orthoses are considered to be beneficial in reducing the repetitive impacts and changes in kinematics produced by high heeled footwear. In particular, they aim to improve weight distribution, comfort and stability. A previous study by YungHui and Wei-Hsien15 showed that custom made foot orthoses can reduce impact forces; heel and medial forefoot pressures, and improve perceived comfort compared to no insert. In particular, the total contact insole (TCI) showed the largest reduction in impact force (33.2%) and medial forefoot pressure (24%), and the highest perceived comfort compared to no insert. This study addressed kinetics and comfort of custom made orthoses. The contributions of alterations to energy consumption and perceived comfort to an increased heel height have not been investigated using pre-fabricated foot orthoses.

Whilst it is clear that a number of studies have explored the effects of high heeled footwear on lower limb function and loading, only a few have reported their effects on energy consumption. Mathews and Wooten33 noted an increase in energy expenditure in 10 females who walked on a treadmill wearing high heeled footwear. Ebbeling, et al.,28 also showed an increase in expenditure in heel heights of 50.8mm and above.

Energy consumption or expenditure is commonly recorded by directly measuring the volume of oxygen an individual has consumed. This approach however, is frequently restricted to a laboratory setting and has led to the introduction of proxy measures such as the ‘physiological cost index’. (PCI)34 This simple measure determines walking efficiency35 which has proven to be valid and reliable in a variety of health disciplines.36 It is also able to discriminate between various treatment interventions and walking devices.37-39 Nonetheless, to date the ability of the PCI to respond to changes in heel height is currently unknown and therefore requires investigation.

Investigating the impact of high heeled footwear and the effects of foot orthoses on energy consumption and comfort can provide the basis for improving the design of an orthosis and how to minimize pain and discomfort. The aim of this study was to examine if an increase in high heeled footwear and selected pre-fabricated foot orthoses changed energy consumption and improved perceived comfort. A secondary aim was to determine if the PCI, a proxy measure of energy consumption could be used as an indicator for monitoring the amount of energy used when wearing high heeled footwear.

The footwear used in this study was commercially available (Clarks© Ltd, UK) and were selected based on the similarity of construction such as forefoot width (D fitting) with a strap style and foot contact points. The key difference among this footwear was the height of the heel: a flat (15mm), a low (45mm) and a high heel (70mm) (Fig. 1 A – C). The foot orthoses used were commercially available pre-fabricated products: Insolia® (Insolia®, Salem, New Hampshire, USA) (Fig. 2 A and C) and Vasyli McConnell® Extended slim fit (Vasyli® International, Australia) (Fig. 2 B, D – E). To prevent slippage within the shoe, a new piece of double sided adhesive tape was applied to each prefabricated insert before each trial. Each participant was randomly assigned five conditions: (1) flat only (15mm); (2) medium only (45mm); (3) high only (70mm); (4) McConnell® (with high, 70mm); (5) Insolia® (with high, 70mm).

Equipment

A Woodway (Desmo, Germany) treadmill was used for each of the 5 experimental conditions. Volume of oxygen consumed in litres per kilogram (VO2/kg) and respiration exchange ratio (RER) were collected and calculated at one minute intervals using a Metalyzer 3B-R2 (Cortex, Germany).

The RER is the carbon dioxide (CO2) divided with O2 consumption. Heart rate (HR) was monitored using a VFIT monitor (Polarexpress Ltd, London), which was attached to the participant’s chest by a strap. This telemetry system records the electrical signals generated from the heart by the transmitter worn on the chest and displayed on a wristwatch receiver. A pedometer was used to record the number of steps (NoS) taken (WSG™ Digital Pedometer). The sensitivity of the pedometer was determined using the ‘shake test’ as described by Vincent and Sidman40 before data collection began. The pedometer was found to be within 3% of the actual number of shakes. The pedometer was positioned according to manufacturer’s instructions, and before data began the step number was cleared.

Methods

Participants and materials

Ten female university students volunteered to take part in the study. The participants had a mean age of 26.3 years (standard deviation [SD] 5.4, range 21 – 34 years), mean weight of 61.4kg (SD 7.9, range 51 – 73.9kg), and mean height of 160.5cm (SD 4.4, 153 – 167cm). All participants met the following inclusion criteria: no cardiovascular or neuromusculoskeletal conditions that might influence their walking pattern; currently wear footwear (size 5 [38] – 6 [39]) with a heel 2 – 5 times a week for at least 1 year. Ethical approval was sought from the School of Health Sciences Ethics Committee, University of Wales Institute, Cardiff before the study began. The study’s purpose and procedures was fully explained to each participant. Informed consent was obtained from all participants before taking part.

Figure 1

Footwear used for study (Clarkes© Ltd, UK).

(A = high, B = medium, C = flat)

17

Procedures

Data was collected in a quiet physiology laboratory over 2 sessions, at the same time of day for approximately 1 hour.

Prior to testing, the order for each experimental condition was randomly assigned to the participant to eliminate order effects.

Before data collection began, each participant was given a 5 minute acclimatization period on the treadmill for each experimental condition. The speed of walking was standardized to 4.2km/hour at a 0% incline. This speed was chosen because it falls within the mean comfortable speed.8,11,15,43 Figure 2 Pre-fabricated orthotic inserts. A) and C) Insolia® – the medial and lateral aspect of the insert are symmetrical. B), D) and E) McConnell® – an increased in height of medial aspect of the insert is noted (D) compared to the lateral (E).

Footwear Comfort Scale

Following each walking trial the Footwear Comfort Scale41 was used to determine the perceived comfort for the 5 conditions. The scale has been used by a number of authors15, 42 and consists of 8 questions (i.e. overall comfort, forefoot cushioning). Perceived comfort is rated using a 15mm visual analogue scale (VAS), with 0 (= 0 comfort point) labeled as ‘not comfortable at all’ and 15 as ‘the most comfortable condition imaginable’ (= 15 comfort points). For consistency, each participant was advised not to take into account the style and cosmetics of the footwear during comfort rating.

1.

Overall comfort

2.

Heel cushioning

3.

Forefoot cushioning

4.

Medio-lateral control

5.

Arch height

6.

Heel cup

7.

Heel width

8.

Shoe length

Following acclimatization, data were collected over a further 5 minutes at the same standardized speed. To minimize fatigue, each participant was allowed a 20 minute rest between each experimental condition and/or until their HR returned to its resting value. Each participant was instructed to look straight ahead whilst walking on the treadmill. The procedure was terminated if the participant felt uncomfortable, showed an unsteady gait, signaled to stop or when the walking period was completed.

Data and statistical analysis

The mean, SD and range were calculated for all of the measures investigated. The PCI was calculated using the following equation: Walking heart rate – resting heart rate divided by speed (m/min).34 A series of Kolmogorov-Smirnov tests were performed and showed all data to have a normal distribution p<0.001. A one-way analysis of variance (ANOVA) was performed to investigate the differences between each of the five conditions, whilst Tukey’s post hoc analysis was used to identify where the differences occurred. All data were analyzed using the software package SPSS® (version 15.0, London, UK) and a significance level set a p<0.05.

15mm VAS lines (not to scale) No comfortable at all

Most comfortable condition imaginable

Figure 3 Eight questions of the Footwear Comfort Scale and the 15mm VAS line.

Flat

Medium

High

McConnell®

Insolia®

HR* (beats/min)

85 ± 2.4 (60 – 111)

95.4 ± 3.2 (65 – 124)

111.1 ± 4.0 (98 - 130)

96.3 ± 5.9 (76 – 131)

97.8 ± 5.1 (71 – 122)

VO2/kg*

13.2 ± 1.7 (10 – 16)

15.6 ± 2.2 (13 – 19)

19 ± 2.4 (14 – 25)

14.8 ± 2.6 (12 – 18)

14 ± 1.8 (10 – 17)

RER*

0.64 ± 0.07 (0.49 – 0.71)

0.79 ± 0.10 (0.66 – 2.98)

0.85 ± 0.06 (0.76 – 0.98)

0.70 ± 0.04 (0.65 – 0.76)

0.64 ± 0.09 (0.41 – 0.75)

NoS*

1034 ± 35.1 (994 – 1086)

1196.8 ± 46.2 (1140 – 1463)

1257.1 ± 42.5 (1217 – 1334)

1134.7 ± 42.5 (1005 – 1198)

1095.4 ± 44.7 (1021 – 1198)

PCI* (beats/min)

0.175 ± 0.09 (0.01 – 0.33)

0.412 ± 0.20 (0.21 – 0.76)

0.623 ± 0.15 (0.39 – 0.93)

0.37 ± 0.34 (0.2 – 0.49)

0.322 ± 0.11 (0.20 – 0.63)

Measure

Table 1 Mean, SD and range of each condition and variable measured (*significant differences p<0.001, one-way ANOVA).

18

Continued ProfessionalDevelopment

Continuing Professional Development The Institute of Chiropodists and Podiatrists

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.

Bone Histology – Structure and Ossification

By Judith Brown

The majority the human skeleton is made up of a bony framework which facilitates locomotion, and also acts as a protective cage for internal organs. It is strong and light-weight, but is also a constantly changing tissue, undergoing a remodelling process throughout life. Structurally, the skeleton consists of bone tissue, cartilage, bone marrow, and periosteum, but there are many other terms used in the description of bone structure and function. To aid understanding, a brief description follows: Diaphysis – the shaft, or main portion of a bone Epiphysis – the distal or proximal end of a bone

Metaphysis – the area where diaphysis and epiphysis merge. In growing bone this is usually represented by the epiphyseal plate

Medulla – the central cavity which may contain bone marrow

Epiphyseal disks Articular cartilage Spongy bone

Proximal epiphysis

Space occupied by red marrow Endosteum Diaphysis Compact bone Medullary cavity

which then harden in a process of calcification (mineralisation).

The presence of collagen fibres is of great importance in this process, as they add strength – without collagen bone would be fairly brittle and easily damaged. The collagen provides tensile strength, allowing the bone to resist stretching and torsion. In addition, if no collagen is produced in the bony matrix, then no mineral salts will accumulate, and there is no calcification.

The overall architecture of bone is divided into cancellous bone (also referred to as trabecular bone or spongy bone) and cortical bone (also referred to as compact bone). Cortical bone forms a compact shell around the more delicate cancellous bone, which is formed by an inter-connecting latticework of trabeculae. In general, the peripheral skeleton is composed primarily of cortical bone, while the axial skeleton is composed of both cancellous and cortical bone. Because the surface area of cancellous bone far exceeds that of cortical bone, and is more metabolically active, cancellous bone is more severely affected if bone remodelling becomes uncoupled.

Compact (cortical) Bone

Yellow marrow Periosteum Distal epiphysis

Periosteum – the membrane surrounding the non-articular surface of the bone. The outer part of the periosteum is fibrous and contains blood vessels and nerves, whilst the inner, osteogenic layer also contains blood vessels as well as osteoclasts and osteoblasts.

Endosteum – the membranous lining of the medullary cavity, containing osteoprogenitor cells, from which osteoblasts and osteoclasts are derived.

Bone consists of a matrix, which contains different types of cells.

The matrix contains around 25% each of water and collagen fibres, and 50% mineral salts. The four types of cells in the matrix are osteoprogenitor cells, osteoblasts, osteocytes, and osteoclasts.

Osteoprogenitor cells are unspecialised cells with the ability to develop into osteoblasts, the cells which are able to form bone.

Osteocytes are mature bone cells that are derived from osteoblasts which have become surrounded by deposited bone, and can nolonger secrete bone material. Their role is maintain regular cellular activity rather than to produce new bone. Osteoclasts are involved in bone resorption and breakdown, and are therefore important in maintaining healthy bone tissue.

Bone matrix contains high levels of minerals, mainly in the form of hydroxyapatite crystals, with some calcium carbonate.

Also present are smaller amounts of magnesium, fluoride, and sulphate. These minerals are deposited on the collagen fibres,

This type of bone is very dense, with few spaces within its structure, and forms the bulk of the diaphysis of the long bones, as well as the external layer of all bones in the body. Its role is to provide support and protection, and forms approximately 80% of skeletal mass. Adult compact bone typically has an arrangement of concentric rings. Blood vessels and nerves from the periosteum penetrate the compact bone through perforating canals (Volkmann’s canals), and connect with the medullary cavity, the periosteum, and the central canals (Haversian canals). These central canals run longitudinally through the bone, surrounded by concentric lamellae, which are rings of calcified bone matrix. Between the lamellae are very small spaces (lacuna), where there are osteocytes. There are many canals radiating from the lacunae, called canaliculi, which contain extracellular fluid, as well as the fine processes which extend from the osteocytes. This provides a communication system throughout the compact bone, providing a route for nutrients and minerals, as well as waste disposal. Osteocytes can also communicate with each other via the canaliculi. Each central canal with its associated lamellae, lacunae, osteocytes, and canaliculi is referred to as an osteon. Between the osteons are fragments of older osteons which have been reabsorbed during growth and redevelopment.

Spongy (trabecular, cancellous) Bone

Spongy bone represents around 20% of the skeletal mass. It is less dense, more elastic and has a higher turnover rate than cortical bone. It is found in the epiphyseal and metaphyseal regions of long bones and throughout the interior of short

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Continued ProfessionalDevelopment bones. Spongy bone constitutes most of the bone tissue of the axial skeleton - bones of the skull, ribs and spine. It consists of lamellae arranged in an irregular lattice of thin plates of bone known as trabeculae. There are relatively large spaces between the trabeculae which are filled with blood vessels and red bone marrow, producing erythrocytes. Within the trabeculae are osteocytes that lie within lacunae, with radiating canaliculi.

These osteocytes receive their nutrients directly from the surrounding blood vessels, therefore the arrangement of osteons seen in compact bone is not required in spongy bone.

Compact bone Osteon

Spongy bone Osteoblasts Osteoclast

Periosteum Osteocyte

Blood vessels and nerve in central canal Osteoblasts

Lamellae Canaliculus

Lacuna Osteocyte Canalicula

Lacunae containing osteocytes Lamellae

Osteon of compact bone

Canaliculi

Trabeculae of spongy bone

Osteon

Haversian canal

Periosteum

Volkmannâ&#x20AC;&#x2122;s canal

Bone requires a good blood supply as it is highly metabolically active. The highest number of blood vessels are found in the spongy bone. Blood vessels pass into bones from the periosteum. Taking a typical long bone as an example, the artery to the diaphysis is referred to as the nutrient artery via an opening called the nutrient foramen. Before reaching the medullary cavity it sends off branches to supply the Haversian canals as well as branches to supply the epiphysis. Once it passes to the medullary cavity it splits into a proximal and distal branch, supplying bone marrow, the inner portion of compact bone, metaphysis, and diaphysis. Periosteal arteries, accompanied by nerves, enter the Trabeculae diaphysis in many areas through perforating canals, and supply the outer area of compact bone, and the diaphysis. Veins accompany the arteries, as do a number of nerves, although the nerve supply is not extensive, Spaces containing and primarily the bone marrow and blood vessels supply is sensory.

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Bone formation

This process is known as ossification, which initially begins around the sixth to seventh week of fetal life. There are two patterns to this process : intramembranous, and endochondral.

Intramembranous ossification â&#x20AC;&#x201C; this is the formation of bone directly on or within loose connective tissues. These bones form directly from the embryonic mesenchyme without first being cartilaginous.

Endochondral ossification â&#x20AC;&#x201C; the formation of bone within hyaline cartilage. Here, mesenchyme is transformed into chondroblasts which then produce cartilage, and then is eventually replaced by bone.

The end product of both of these processes is bone, whose structure is the same no matter by which method it was produced. The first stage in both of these processes is the migration of embryonic mesenchymal cells to areas where bone formation will occur. The mesenchyme cells increase in size and number, and become osteoprogenitor cells. Where capillaries are small in number, these may develop into chondroblasts, but in areas where capillary numbers are high, they develop directly into osteoblasts.

Intramembranous ossification

With intramembranous ossification, mesenchymal cells in fibrous connective tissue begin to cluster together and differentiate into osteoprogenitor cells, and then osteoblasts, forming a centre of ossification. Osteoblasts begin to secrete bone matrix (osteoid) until they around completely surrounded by it. At this point matrix secretion stops, and the cells become mature osteocytes, sitting in their lacunae with communicating canaliculi. Calcium hydroxyapatite crystals are then deposited on collagen fibrils within the matrix, which then hardens. As the matrix develops it forms trabeculae which fuse with each other, creating the classical appearance of spongy bone. The spaces fill with vascularised mesenchyme which then differentiates into red bone marrow. On the outer surface of the bone, the vascularised mesenchyme condenses, and develops into the periosteum. Eventually, most of the spongy bone is replaced by compact bone, which is then remodelled during the growth and development process.

Endochondral ossification

In endochondral ossification, mesenchymal cells in fibrous connective tissue begin to cluster together and differentiate into chondrocytes which produce cartilage matrix. Additionally, the perichondrium (membrane) develops around these cells. The cartilage grows in length as the chondrocytes continue to divide, producing further matrix, resulting in interstitial growth (growth from within). Increase in thickness is due to the increased production of matrix by the chondrocytes. As the area if cartilage continues to grow, cells in its mid region begin to get larger, and eventually lyse (burst), releasing their contents into that matrix. This creates a change in pH, and triggers the calcification process. Once this occurs, other chondrocytes begin to die because nutrients cannot pass through the ossified areas. The spaces where these cells were are left empty, and the partitions between the lacunae break down, forming cavities.

Whilst this process is occurring, elsewhere a nutrient artery has penetrated the perichondrium, stimulating osteoprogenitor cells in that area to differentiate into osteoblasts. These cells begin to lay down a layer of compact bone under the perichondrium, known as the periosteal bone collar. Eventually, this area becomes known as the periosteum.

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Osteoblast

Blood capillary Centre of ossification

Mesenchymal cell Collagen fiber

Osteoblast Osteocyte in lacuna Canaliculus Newly calcified bone matrix

Mesenchyme condenses Osteoblast Trabeculae

Blood vessel

Compact bone

Periosteum Fibrous layer Osteogenic layer

Spongy bone

Periosteal capillaries begin to grow into the area of calcified cartilage, forming a periosteal bud, and taking within them osteoblasts, osteoclasts, and red bone marrow cells. The presence of this bud stimulates the growth of a primary ossification centre, where bone tissues replaces most of the cartilage. Osteoblasts then begin to produce more bone matrix over the remains of calcified cartilage, and begin the formation of the spongy bone. As the ossification centre enlarges towards the ends of the bone, osteoclasts break down the newly formed spongy trabeculae, leaving a cavity (medullary cavity), which then fills with red bone marrow. The diaphysis, which was

originally cartilage, is replaced by compact bone filled with red bone marrow. Blood vessels enter the epiphyses, where secondary ossification centres develop, usually occurring around the time of birth. In these secondary centres bone formation is similar to that in the primary centres, apart from one difference. Spongy bone remains in the interior of the epiphyses, with no medullary cavity. Also, cartilage remains between the diaphysis and epiphysis in the form of the epiphyseal plate, which will remain until growth and ossification is complete.

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Continued ProfessionalDevelopment Remnant of epiphyseal disk

Developing periosteum

Compact bone developing

Cartilaginous model Calcified cartilage

Compact bone

Secondary ossification centre

Blood vessel

Epiphyseal disk Medullary cavity

(a)

(b)

(c)

(d) Secondary ossification centre Primary ossification centre

Articular cartilage

Spongy bone

Medullary cavity

Medullary cavity

Spongy bone (e) (f) Epiphyseal disk Remnant of epiphyseal disk

Articular cartilage

In summary, bone is a dynamic tissue, constantly being remodelled in response to external stress, trauma, and metabolic status. It begins to develop in fetal life, and continues this process throughout childhood, until ossification is complete at around 20 years of age.

Skeletal bone mass then remains relatively constant until later in

life, when bone mass begins to decrease in both males and females (although frequently more rapidly in females), usually in response to hormonal changes, the ageing process, and co-morbidities.

Future articles will explore the regeneration and healing process in bone, as well as the role of bone in calcium homeostasis.

1. What are the names of the major parts of a long bone, and what are the functions of each?

4. What is the difference between spongy and compact bone in relation to their appearance, function, and location?

3. What is the composition of bone matrix?

6. What are the main events of intramembranous and endochondral ossification, and what is the difference between the two?

SAQs.

2. Which four cells are responsible for the production and maintenance of bone tissue?

5. What is ossification?

The Institute of Chiropodists and Podiatrists Training Centre, Sheffield

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Results

Differences: Metabolic variables and efficiency

The mean, SD and range for HR, VO2/kg, RER, NoS and PCI for each of the experimental condition are summarized in table 1. The one-way ANOVA showed significant differences between the five conditions for HR (F = 3.522, df 4, p=0.014).

RER (F = 14.418, df 4, p<0.001); VO2/kg (F = 7.391, df 4, p<0.001); NoS (F = 14.190, df 4, p<0.001), and PCI (F = 12.532, df 4, p<0.001).

Tukey’s post hoc analysis for HR only revealed significant differences (p<0.001) between flat and high condition, with a 23.5% increase in HR noted for the high condition. Post hoc analysis for VO2/kg demonstrated a series of significance differences (p<0.001) between the flat and medium, flat and high conditions. An increase in VO2/kg of 22.4% was noted for the high condition and slightly lower value of 15.5% observed for the medium condition.

Further differences were demonstrated between the high and McConnell® and Insolia® conditions. The VO2/kg was reduced by 22.2% for the McConnell® and 26.5% for the Insolia® condition.

Tukey’s post hoc comparisons revealed differences between the flat and high condition for the RER with a 25% (0.21) increase noted for the high condition. Significance differences were also noted between the high, the McConnell® and Insolia® conditions. The RER was noted to be reduced by 18% (0.15) and 25% respectively (0.21) compared to the high condition.

Post hoc analysis for the PCI revealed significant differences between the flat and medium, and flat and high conditions. A lower PCI of 58% (0.237) and 72% for the flat condition was noted when compared to the medium and high conditions respectively. Tukey’s analysis also demonstrated significant differences between the high and McConnell® and Insolia® conditions (p<0.001). The PCI was reduced by 49% and 41% for the McConnell® and Insolia® condition when compared to the high heel conditions.

Post hoc analysis demonstrated significant differences for NoS between all three height conditions (i.e. flat, medium and high) with more steps taken for the medium (13.6%) and high (17.8%) conditions.

Post hoc analysis also showed significant differences between the high and McConnell®, and high and Insolia® conditions.

Fewer steps were taken with McConnell® (10.8%) and Insolia® (13.7%) conditions.

Differences: Footwear Comfort Scale

The one-way ANOVA indicated significant differences between the five conditions for overall comfort (F = 4.213, df 4, p=0.06), heel cushioning (F = 5.108, df 4, p=0.002), forefoot cushioning (F = 5.571, df 4, p<0.001) and heel cup fit (F= 8.308, df 4, p<0.001). No significant differences were noted between the five conditions for the medio-lateral control (F = 8.470, df 4, p=0.269), arch height (F = 1.387, df 4, p= 0.254); shoe heel width 7.802, df 4, p=0.063), and shoe length (F = .783, df 4, p=0.542). Fig. 3 illustrates the comparison of perceived ratings for the five conditions.

Compared to the high condition (mean 7.8, SD 2.8) tukey’s post hoc analysis showed a significantly higher overall comfort rating for the McConnell® (mean 11.8, SD 1.6) and Insolia® conditions (mean 11.1, SD 1.4), with a 34% and 30% increase respectively. Post hoc analysis using Tukey’s revealed significant differences between the high and McConnell® (p=0.018) and the medium and McConnell® (p=0.002) conditions for heel cushioning. The mean rating of 12.9 (SD 1.5) was noted for the McConnell® condition, and was increased by 29% (mean 9.2, SD 2.7) and 35% (mean 8.4, SD 3.9) compared to the high and medium conditions.

Post hoc analysis demonstrated significant difference between the flat and high condition (p=0.017) for forefoot cushioning. It was noted that the flat condition had a mean rating of 9.2 (SD 2.8), whilst the high condition had a reduced rating of 6 (SD 1.2) producing a mean difference of 35%.

Further significant differences were noted between the high and McConnell® (p=0.034) and Insolia® (p<0.001) conditions for forefoot cushioning. The McConnell® condition had a higher mean rating of 9.4 (SD 1.5), whilst a rating of 11 (SD 1.2) was noted for the Insolia® condition. Compared to the high condition, this produced a mean difference of 36.5% and 46% for the McConnell® and Insolia® condition respectively.

Post hoc analysis also showed significant differences for heel cup fit between the flat and medium (p<0.001); flat and high (p<0.001); medium and McConnell® (p=0.035); and high and McConnell® (p=0.022) conditions. The flat condition had a higher mean rating of 11.4 (SD 2.5) compared to the medium and high conditions which had ratings of 6.2 (SD 2.9) and 6 (1.2) respectively. This produced a mean difference of 46% for the medium and 47% for the high condition. The McConnell condition had a mean heel cup fit rating of 9.6 (SD 2.2), which was 35.5% and 38% higher compared to the medium and high conditions. Figure 4 illustrates the mean values for each subsection of the Footwear Comfort Scale and the significant differences between conditions.

Discussion

This study sought to establish the influence of high heeled footwear and pre-fabricated foot orthoses on gait efficiency and perceived comfort. A further aim investigated if a proxy measure, the PCI could be used as an dictator for assessing energy expenditure whilst wearing high heeled footwear. The results of this study demonstrated clear links between an increase in energy and a reduction in perceived comfort as heel height increased. This link was reduced (reversed) upon the implementation of 2 types of pre-fabricated foot orthoses (McConnell® and Insolia®) which showed an improved efficiency and perceived comfort.

In this study, energy efficiency was derived from a series of measures which included HR, RER, VO2/kg and PCI. Although HR only showed a significantly higher increase of 23.5% for the high condition compared to the low, this finding is consistent with previous studies.28,43 Significant differences were noted between all five conditions for RER, VO2/kg and PCI. It was noted that the largest increase occurred between the flat and high conditions for the RER and VO2/kg, which again supports previous literature.28

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Figure 4 Footwear Comfort Scale results for all five conditions. (u (McCon = McConnell速; Insol = Insolia速)

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u = p<0.05 significant differences between conditions)

The data for the RER was at its highest (0.85) for the high condition which suggests that both fat and carbohydrates were the fuel source. Whilst the RER for the medium condition was at 0.79 (approaching a mixed source fuel), it was noted that the use of the McConnell® and Insolia® orthoses significantly reduced the RER to 0.70 and 0.64. This may indicate that the amount of energy (i.e. fat) used was reduced thus increasing overall efficiency. However, it could be argued that the RER results presented here seem a little high, which could be attributed to a small sample size. Therefore, further research involving a longer period of walking would be useful to gain a clearer picture of this parameter in high heel walking.

The PCI showed similar trends, but most notable were the significant differences observed between the high and McConnell® and Insolia® conditions. Here the values for the PCI were reduced to 49% (McConnell®) and 41% (Insolia®) and whilst these values were not as low as flat condition, the results do suggest that the use of pre-fabricated foot orthoses can reduce the amount of energy consumed. Since no previous data exists for the PCI in relation to high heeled footwear and pre-fabricated foot orthoses, direct comparisons are limited.

It is known that at a set speed, the most economical stride length and NoS are chosen. For this study, a pedometer was used to measure the naturalistic activity of the NoS for each condition whilst walking at a standardized speed of 4.2km/hour.

There was an increase in the NoS taken during the medium (13.6%) and high (17.8%) conditions compared to the flat condition. The increased use of energy whilst walking in high heels can be explained by the changes in lower limb biomechanics and stride pattern. An increase in heel height is considered to plantarflex the foot, and flexes the hip and knee.

These angular changes therefore result in a shorter stride length.8,9,12,15,19,28,44 Since the speed was kept constant throughout all of the conditions, the NoS during the high condition had to increase, which in turn, used more energy. Comparisons between the high and orthoses condition also showed significant differences with fewer NoS taken for the McConnell® (10.8%) and Insolia® (13.7%) conditions. Taking larger and fewer steps however may be a negative factor since less steps may result in higher sagittal and varus knee torques30-32 which in turn leads to joint damage (i.e. degenerative changes of the tibiofemoral and patellofemoral joints). Moreover, longer activation times of the rectus femoris16 and co-contraction of other lower limb muscles may also be linked to longer stride patterns which warrants further exploration.

While the findings presented in this study cannot suggest a dramatic angular change within the lower limb, it could be assumed that the pre-fabricated orthoses discreetly altered lower limb function. This assumption relates to a new paradigm advocated by Nigg which suggests that orthoses can filter the impact forces placed upon the foot and adjust muscular response to allow the individual to sustain their ‘preferred movement pathway.’45 Although it can be stated that wearing high heels will always influence lower limb function, adaptability to the condition and cushioning via foot orthoses are likely to have contributed to these changes. Moreover, all participants who took part in this study were experienced heel wearers and are likely to have already undergone soft tissue adaptation in the form of Davis’s law.46

Whilst kinetic analysis was beyond the scope of this present study, it could be assumed that the elastic (pressure) and viscosity (impact force) properties of the orthosis material could provide a number of benefits. For example, as well as providing cushioning they may have enhanced the capability of energy absorption and potential kinetic energy the lower limb body already processed. This may be particularly relevant for the McConnell® orthosis during heel impact, since it appeared to provide more cushioning. The Insolia® product however, is devised on the principle that weight is shifted posterior to the rearfoot, minimizing pressure and force within the forefoot. By controlling this pathway of progression during walking it could be suggested that less energy is used and stored, thus creating improved efficiency whilst walking in high heels.

Perceived comfort was influenced by heel height and the use of the orthoses (McConnell® and Insolia®). Four out of the eight sections of the Footwear Comfort Scale (overall comfort, heel cushioning, forefoot cushioning and heel cup fit) were significantly different between the five conditions. The mean overall comfort rating was 11 for the flat condition but reduced to 7.8 for the high heel condition. This value however, improved with the use of the McConnell® (mean 11.8) and Insolia® (mean 11.0) orthoses. These findings support previous work 3,15 and suggest that higher heels are uncomfortable, but the use of pre-fabricated foot orthoses can provide an improved comfort which is similar to that of flat footwear. Whilst the McConnell® and Insolia® conditions showed significantly improved ratings compared to the high condition (mean 9.2) for heel cushioning, it was noted that the McConnell® orthosis had a higher comfort score. This however, was not significant, but may indicate better shock absorbing properties of the McConnell® orthosis.

As with previous subsections of the footwear scale, the mean forefoot comfort score for the flat foot was higher at 9.2 and reduced to 6 for the high condition.

This was the lowest comfort score out of the 8 conditions; however the use of pre-fabricated foot orthoses significantly improved comfort with a mean of 11.7 noted for the McConnell® and 12.9 for the Insolia® orthosis. The lower value noted for the McConnell® orthosis can be attributed to impingement under the first metatarsal head that was stated by 7 out of the 10 participants. Furthermore, the improved comfort experienced during the Insolia® condition could be due to the reduced pressures at the forefoot as the orthosis shifts the weight from the forefoot to the midfoot and rearfoot.

A number of limitations are acknowledged in this study.

Firstly, the study may have been limited to the immediate effects of orthoses and the various heel heights on gait efficiency and perceived comfort. Secondly, the sample size was small and did not include a wide age range. Thirdly, data collection was limited to a laboratory setting and required participants to walk at a standardized speed in a straight line over a short period of time.

This approach can be considered as unrealistic since it fails to capture the everyday setting such as the required multidirectional changes in walking pattern and fatigue often experienced by women at the end of a day. In spite of these limitations, the inclusion of the PCI in this study has shown that it responds to an increase in heel height. The measure is appealing, since it is a simple and cost effective tool that can be used outside of the laboratory. Future research should focus on

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a larger and more diverse sample population that should include data collection at the beginning and end of the day to establish the role of fatigue. Multi-directional walking patterns such as the ‘figure of 8’ method36 could also be used. Information gained from additional studies can help to document the effects of high heeled footwear and to optimize the design and selection of pre-fabricated orthoses.

Clinical significance

The findings of this study should be viewed in terms of clinical context and significance. The wearing of high heeled footwear is discouraged by health care professionals with an interest in lower limb function and care. However, products such as the McConnell® and Insolia® (as well as others) have been produced in an attempt aid comfort and reduce the damaging impacts associated with wearing high heels. Whilst this study suggests some benefits of pre-fabricated foot orthoses when wearing high heels, further research is required.

This should involve kinetic, kinematic and electromyography to determine the effects of these pre-fabricated orthoses over a set period of time (i.e. to establish fatigue patterns).

Conclusion

The present results provide further information of the influence of high heeled footwear on energy efficiency and perceived comfort. The use of 2 pre- fabricated orthoses; the References 1.

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McConnell® and Insolia® have been shown to reduce the amount of energy used, as well as improve comfort whilst wearing footwear with a 75mm heel. The PCI represents a useful measure for documenting walking efficiency in high heeled footwear. Future research should be undertaken to determine how well the results generalize to more realistic walking patterns (multi-directional) and longer periods of wear to establish fatigue.

Acknowledgements

The authors would like to thank Mr. Bob Hardy (Clarks, UK) for providing the footwear used in the study. We would also like to thank Mr. Steve Sheldon (Canonbury Healthcare, UK) for supplying the pre-fabricated orthoses.

Conflicts of Interest

There are no conflicts of interest Address correspondence to:

1 2

Sarah A. Curran PhD, BSc(Hons) Senior Lecturer, Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Western Avenue, Cardiff, CF5 2YB, UK. Email: scurran@uwic.ac.uk; Phone +44 (0) 29 2041 7221.

Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Western Avenue, Cardiff, CF5 2YB, UK. Centre for Biomedical Sciences, University of Wales Institute, Cardiff, Western Avenue, Cardiff, CF5 2YB, UK.

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26. Hwang SJ, Choi HS, Choi HH, Kim HS, Kim YH. The evaluation of the lower extremity joint moments and muscle force during various high-heel walking. Key Engineering Mat 2006 26 - 328: 755-758.

27. Zipfel B, Berger LR. Shod versus unshod: The emergence of forefoot pathology in modern humans? The Foot 2007 17: 205- 213.

28. Ebbeling CJ, Hamill J, Crussemeyer JA. Lower extremity mechanics and energy cost of walking in high-heeled shoes. JOSPT 1994 19 (4): 190-196.

29. Stefanyshyn D, Nigg BM, Fisher V, O'Flynn B, Liu W. The influence of high heeled shoes on kinematics, kinetics, and muscle EMG of normal female gait. J Appl Biomech 2000 16: 309-319.

30. Kerrigan DC, Johansson J, Bryant M, Boxer J, Della Croce U, Riley P: Moderate-heeled shoes and knee joint torques relevant to the development of the progression of knee osteoarthritis. Arch Phys Med Rehabil 2005 86 (5): 871-875.

31. Kerrigan DC, Lelas JL, Karvosky ME: Women's shoes and knee osteoarthritis. Lancet 2001 357 (9262): 1097-1098.

32. Kerrigan DC, Todd MK, Riley PO: Knee osteoarthritis and high heeled shoes. The Lancet 351 (9): 1399 – 1401, 1998.

33. Mathews DK, Wooten EP: Analysis of oxygen consumption of women while walking in different style shoes. Arch of Phys Med Rehabil 1963 44: 569-571.

34. Macgregor J. Rehabilitation ambulatory monitoring. In Kendi R, Paul J, Hughes J (eds). Disability.

London: Macmillan, 159 – 172, 1979.

35. Sienko Thomas S, Buckon CE, Schwartz MH, Sussman MD, Aiona MD. Walking energy expenditure in able-bodied individuals: a comparison of common measures in energy efficiency.

Gait Posture 2009 29 (4): 592-596.

36. Graham RC, Smith NM, White CM. The reliability and validity of the physiological cost index in healthy subjects while walking on 2 different tracks. Arch Phys Med Rehabil 2005 86: 2041-2046.

37. Hood VL, Granat MH, Maxwell DJ, Hasler JP. A new method of using heart rate to represent energy expenditure: the total Heart Beat Index. Arch Phys Med Rehabil 2002 83: 1266-1273.

38. Burridge JH, McLellan DL. Relation between abnormal patterns of muscle activation and response to common peroneal nerve stimulation in hemiplegia. J Neuro Neurosurg Psychiatry 2000 69: 353-361.

39. Steven MM, Capell HA, Sturock RD, Macgregor J. The physiological cost of gait (PCG): a new technique for evaluating non-steroidal anti-inflammatory drugs in rheumatoid arthritis. Brit J Rheum 1983 22: 141-145.

40. Vincent S, Sidman C: Determining measurement error in digital pedometers. Measurement Phys Education Exercise 2003 7: 19-24.

41. Mundermann B, Nigg BM, Stefanbyshyn D, Humble R. Development of a reliable method to assess footwear comfort during running. Gait Posture 2002 16: 38-45.

42. Eslami M, Tanaka C, Hinse S, Anbarian M, Allard P. Acute effect of orthoses on foot orientation and perceived comfort in individuals with pes cavus during standing. The Foot 2009 19: 1-6.

43. Snow RE, Williams KR. Effects of gait, posture, and center of mass position in women walking in high heeled shoes. Med Sci Sports Exer 1990 22: S23.

44. KA Gillespie, Dickey JP. Determination of the effectiveness of materials in attenuating high frequency shock during gait using filterbank analysis. Clin Biomechanics 2003 18 (1): 50-59.

45. Nigg BM. The role of impact forces and foot pronation: a new paradigm. Clin J Sports Med 2001 11 (1): 2-9.

46. Tippett SR, Voight MJ: Functional Progression for Sport Rehabilitation. Champaigne, IL: Human Kinetics, 1995.

Back to Life H

Helen Lloyd, M.Inst.Ch.P aving been diagnosed with Polyarthropathy and Fibromyalgia a few years ago and received treatments in most of the departments at the Countess of Chester Hospital, the hydrotherapy pool has had to be the most successful, however in the last year my consultant sent me to the ‘Back to Life’ programme.

The ‘Back to Life’ programme consists of 3 hourly sessions over six weeks in a nearby gym consisting of relaxation sessions, excellent presentations of the anatomy of the back, pain management with drugs and other therapies, circuit training and a consultation with a physiotherapist to discuss the working environment. We were in a group of ten for which there were two physiotherapists and a ‘helper’. With the exception of myself, the rest of the patients had been in car or work related accidents and most had experienced serious back operations.

The detailed, illustrated lectures on the anatomy of the back were superb. Pain management was explained well by using the normal drugs that we all seemed to be taking plus other methods such as a ‘tens’ machine, heat or ice pads and various complementary therapies. I noted that it is common for arthritic patients to adjust their drugs instead of taking the full dose as prescribed - most patients tend to cut down when the pain is not severe and then increase the dosage when required. Evidence supports the theory that by taking less drugs on a regular basis the pain becomes more controlled.

I also learnt that although I had purchased a ‘tens’ machine several years ago, I had never actually used it properly and therefore it was not very effective. Previously, when giving my health history, I affirmed that I had used a ‘tens’ machine but claimed it didn’t help.

I was instructed to use the machine for an hour + (not 20 minutes as I thought) and to increase the frequency throughout the hour. Using it in this method proved very rewarding.

The relaxation sessions, I found enjoyable, although quite difficult to perceive images of sun filled meadows and winding streams as the gym was in a cold basement and after a few minutes I could feel the cold creeping through my body and feet!

Next, the circuit training! This sounded very strange as we all think of this as running round halls, doing press-ups and jumps!

This involved training ourselves in the way we approach our every day life such as shopping - always use a trolley, never a basket and posture when pushing trolleys is important also; standing close to the handle and keeping upright. Vacuuming the carpets is yet another talent!

Always place hoover to the side of the body in order to lever with the legs and feet instead of standing behind and using the lower back to push. Watching ourselves in the gym mirrors for over five minutes whilst we walked was very beneficial.

And finally, when we come to replacing anything always think before

purchasing. Make sure the car seat is more comfortable and maybe a little higher than the last model, the door being larger so making a greater area for access? In the bathroom, fitting the washbasin just 5cm higher or hanging the toilet 10cm higher can make an enormous difference.

The consultation about my working day was interesting. I had already taken on board the reduction in working hours, the amount I carry in my domiciliary case and what the sitting arrangement are to be, but had not considered exercise in the middle of giving my consultation. I can now recommend giving your neck a stretch and rotating the head and shoulders in the middle of treatment. You should also have a short break between patients with a walk around the room.

I have tried to implement all the help and information that has been given to me and amazingly have found that although not fighting fit, I have certainly improved! My ‘sick’ days are less, so are the visits to the doctors and indeed the home visits from him when I have to have injections to get my body out of spasm.

Thank you to the wonderful staff for the support and help I have received and hopefully reading this article you can take on board such easy changes to help either yourself, a member of your family, a friend or indeed the patient sitting in front of you.

Students on Cohort 3 of the City and Guilds Level 4 Higher Diploma in Foot Healthcare

L-R Suzanne Ostler, Wendy Hopkinson, John Patterson, Joanne Proctor, Sheridan Fay Lee, Rosalind McCulloch

23

Leeds and Bradford Branch Seminar

aturday the 6th March saw me heading north to Huddersfield University, not the easiest of places to find but when I did eventually find it was well worth the effort. Martin Hogarth, ably assisted by others from the branch had everything running like a Swiss watch.

The venue and the speakers were excellent. The first lecture of the day was entitled â&#x20AC;&#x153;Bi lateral lower leg Oedema, DVT and Phlebitisâ&#x20AC;? and was presented in a very professional way by Miss. Liza Dunkley senior lecturer at the university.

Lecture three was by Judith Barbaro-Brown on the subject of â&#x20AC;&#x153;Rheumatology and the Footâ&#x20AC;?, and as usual with her interactive style of lecturing it was most informative and interesting. The last lecture of the day or as he called it the graveyard shift, was by Mr Jim Pickard who is a consultant podiatrist. He spoke about nail and other aspects of podiatric surgery with some excellent video footage. The modern way that bunions are dealt with has changed my views on this type of surgery.

S

I must say that I had a really good day and praise must go to the organisers for staging such an excellent event. I run these events every year in the north west so appreciate the work involved. The Institute is very lucky that it has people who are willing to give their time for nothing and to stage such professional events. I think other similar organisations are envious of us because of that fact.

After the tea break (or should I call it the breakfast break as in addition to the usual tea and coffee there were several varieties of Danish pastries) there was the second lecture.

This was on â&#x20AC;&#x153;Pharmacologyâ&#x20AC;? and was presented by our very own Martin Harvey, this was the first opportunity that I had had to listen to Martin, and what an excellent talk it was, so good in fact that it has prompted me to consider studying for my POMâ&#x20AC;&#x2122;s certificate.

Thanks to all at Leeds and Bradford for a really good days CPD at a very reasonable price.

The lunch break followed with time to chat and visit the trade stand, there were two of the traders who did not show which was a disappointment for the organisers, but I felt that no one else was particularly bothered.

Malcolm Holmes, (Western Branch)

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4 5 6 6 7 ! 6 6 6 For a Prospectus telephone Martin Harvey on: 01827 67962 or 0777 971 9962 Or book online at: www.aesthetist.co.uk Delegates must have a minimum 12 months experience in LA use and be annotated for LA on the HPC register

25

Southern Area Council 3rd Annual Seminar

T

he 3rd Southern Area Council Seminar took place on 6th March at the Best Western Calcot Hotel, Reading and was attended by 54 delegates and two trade stands. The lecturer for the day was Miss Emma Supple, Podiatrist and Podiatric Surgeon who gave her presentation titled “A Conversation About Feet”.

Emma talked at length about treatments in private practice including the management of the paediatric patient, an update in Pharmacology and the pharmaceuticals that we should and shouldn’t be using in practice and treatments of Hallux Abducto Valgus. She also talked about a procedure for treating flat feet called hyprocure- an innovative procedure that involves inserting a titanium stent that sits within sinus tarsai canal, which prevents the foot from hyperpronating and collapsing. Emma also mentioned her role working with the media and television and encouraged us all to do the same to promote foot care and our profession.

Throughout the day Emma looked at case studies brought in by delegates and gave us ideas of how best to approach treatment of these problems.

Overall the day was very successful, marred only by a computer glitch that was happily remedied by the joint efforts of the trade stands attendees and a member of the audience, to a round of applause.

We would like to thank Matt and Steve from C&P Medical and Rose from Bailey Instruments for bringing along their trade stands and supporting us.

You are always very welcome.

To round up the day we had a free prize draw and presented book vouchers to three delegates for £40, £25 and £15 who were all very pleased to receive them. Over the last three years of organising the seminar it has gone from strength to strength and we are seeing ever increasing numbers of people attending, a testament to our success. Every year we listen to feedback and try to give more of what our members want with our lectures.

We look forward to seeing you all again next year. Many of you travel quite a distance to be with us and we are very grateful of your support.

Gillian Webster, Education Officer Southern Area Council

Leicester and Northants Branch Autumn Seminar Saturday 28th November 2010 10:00 a.m. - 4:00 p.m.

Lutterworth Cricket Club, Coventry Road, Lutterworth

& Lecture & Trade Exhibitors & Autoclave Service & Full Details and Booking Form in July/August issue.

26

All enquiries contact sue.IOCP@ntlworld.com

North West Area Council 13th Annual Seminar

University of Central Lancashire, Preston

Last year saw us at our new venue at the University of Central Lancashire in Preston. Although slightly further for some people to travel from the North West, judging by the comments that we received that was a small price to pay.

%Although a little further from my home in Chester it was well worth the extra distance that I had to travel, a really good day& %The thing I like most about the NWAC. Seminars is the fact that all the lectures are by very eminent, professional people&

%As usual you managed to stage a wonderful days CPD at half the price many other organisations charge, well done everyone&

For 2010 we have again arranged key note speakers, we have a full morning on the relevant and important subject of dementia.

We will be instructed on the best ways of dealing with patients who prove difficult, and ways to interact with people who suffer with this dreadful affliction. There will be the usual two course cooked lunch followed by the afternoon session. This will consist of two talks relevant to our work, one will concern circulatory problems associated with the lower limb and the final one of the day will be on haematology. As usual there will be the trade exhibition running throughout the day.

People from all organisations will be more than welcome to attend and will be made very welcome.

So make a note in your diaries for Sunday, 21st November, 2010

27

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Cheshire North Wales Seminar C

hester and North Wales Staffordshire and Shropshire Branch invited David Dykes B.Sc. (Hons) MCC, MMCA, Chiropractor to their last branch meeting.

David explained what chiropractors do and the difference between chiropractic and osteopathy.

Chiropractic specialises in the diagnoses, treatment and management of problems in joints, ligaments and nerves in the body. Treatments consist of a wide range of manipulative techniques designed to improve function of the joints, relieving pain and muscle spasm. All chiropractors have undergone a minimum of 4 year full-time course and are registered with the General Chiropractic Council.

One of the methods of chiropractic is the McTimoney method, developed by the late John McTimoney over 50 years ago. It is well known for being a precise whole body approach to chiropractic care and is suitable for people of all ages.

There are 2 main types of chiropractor. Straight and mixed.

Straight chiropractor deals with adjustments only whereas mixed used adjustments and the use of other techniques such as Acupuncture and mobilisation.

The difference between osteopathy and chiropractic is that osteopathy looks at the restriction of blood flow causing the pain therefore they will loosen joints to improve this. They use bones as levers to improve condition of the other structures such as muscles, ligaments, tendons etc aiding the body's natural healing ability. Chiropractors focus on the spine and the alignment of vertebrae as the primary means to relieveing pain and tension. Misalignment in the vertebrae interfere with nerve messages and the interferences causes problems and pain throughout the body. Patients with neck and back pain tend to be referred to a chiropractor but they can deal with all other injuries.

David then asked for a volunteer to demonstrate foot mobilisation. After this, members were paired off to practice this on each other. David also had time to do a treatment on one of the members who was suffering with neck pain !

Members all agreed it was a worthwhile presentation and were able to take away with them additional knowledge of manipulation that they can use in their own practices.

Denise Willis, Secretary, Chester North Wales, Staffordshire and Shropshire Branch

29

Cherry juice could benefit arthritis sufferers

"If funding can be secured to embark on a further study, we can determine whether the use of tart cherry juice has implications for the management of some clinical pathologies that display high levels of inflammation and oxidative stress, such as rheumatoid arthritis and fibromyalgia," said researcher Dr Glyn Howatson.

He added that natural resources hold "untapped treatments" that could help alleviate the symptoms and improve the quality of life of people suffering from such conditions.

Rheumatoid arthritis, where joints become inflamed and painful, affects 350,000 people in the UK, while it is thought up to one person in 50 could suffer from muscle condition fibromyalgia.

The study assessed the experience of a total of 20 athletes who took part in the London marathon and was conducted in collaboration with Jess Hill of St Mary's University College.

A spokeswoman from Arthritis Research UK said that while the study was of interest, further research was needed to establish the effectiveness of cherries in the alleviation of arthritis symptoms. There was some evidence to show that large consumption of cherries could help some gout sufferers, she added.

30

Press Release Press Release Press Release

The tart juice, from Montmorency cherries, was found to boost the total oxidative capacity of the runners, helping to enhance their muscles' recovery from strenuous exercise.

Press Release

According to the results, the participants who consumed cherry juice suffered benefited over the two days following the marathon from faster recovery times, reduced inflammation and lower oxidative stress than the placebo group.

Press Release

In research carried out by the School of Psychology and Sports Sciences at Northumbria University, a group of marathon runners were given either cherry juice or a placebo twice daily for five days before a race and two days afterwards.

Osteoporosis risk factors underestimated by women

Press Release

Press Release

Arthritis sufferers could find that consuming cherry juice alleviates their symptoms, after a new study found the fruit had a beneficial effect on athletic recovery times.

Press Release

Press Release

Many women who are at a greater risk of bone fractures related to osteoporosis underestimate the implications of increased risk factors.

Results from the Global Longitudinal Study of Osteoporosis in Women revealed that just 43 per cent of postmenopausal women diagnosed with osteoporosis thought their risk of fracture was higher than their peers'.

Just one in three females who participated in the study and had two or more fracture risk factors thought they were more likely to actually fracture a bone than other women of the same age.

"We've found that many women aren't making the connection between their risk factors and the serious consequences of fractures," said the report's lead author, Dr Ethel Siris from the Columbia University Medical Centre at New York Presbyterian Hospital.

"Without a clear understanding of their risks, women cannot begin to protect themselves from fracture."

The study, published in Osteoporosis International, assessed 60,000 postmenopausal women from ten countries in Europe, North America and Australia using a five-point scale to measure self-perceived risk.

Osteoporosis is characterised by a loss of bone density, making sufferers more vulnerable to fractures and breaks. In the UK, the condition causes an estimated 70,000 hip, 120,000 spine and 50,000 wrist fractures each year.

A spokeswoman for Arthritis Research UK said that because osteoporosis was not painful and there were no obvious physical symptoms of disease many women were unaware that they had the condition until they suffered a fracture in a relatively minor fall or accident. www.arthritisreasearchuk.org

“Momentous Days for No r t h e r n I re l a n d ”

New Area Council

New Area Council

New Area Council

New Area Council

On Saturday the 27th of March the Northern Ireland branch of the Institute of Chiropodists and Podiatrists declared independence from the Irish Area Council. The existing Northern. Ireland branch was closed and two new branches, N.I. Regional and N.I. Central were duly formed. The new Northern Ireland Area Council was convened and officers appointed to the two new branches and to the Area Council.

We would to like to thank all at Head Office and the Executive Council for all their help in facilitating these changes.

We look forward to exciting new challenges as we set out to shape our own destiny for the first time.

Members of the new Northern Ireland Area Council Front row (L-R): Jim Patterson, Secretary - Thelma Patterson, Assitant Secretary - Stephen Preston, Chairman - May Maxwell,Vice Chair Back row (L-R): Shirley Stewart - Gillian Sturgess - Colette Johnston - NI Area delegate to Executive Committee - David McDonald - Patricia Malone - Colin Craig

Devon and Cornwall Branch I

n January the Devon and Cornwall branch held their meeting in the morning of the 24th and in the afternoon we had a lecture on diabetes. The lecture was give by Dr. Mollie Donohoe who is on the diabetic team at the Royal Devon and Exeter hospital. She is a leading consultant specialising in the diabetic foot and has a long tradition of providing education to podiatrists on medical issues.

She spoke about “Diabetic foot problems and diabetic management - an update” which included:- the prevalence of diabetes countrywide and the cost to the NHS; The Exeter guidelines and the ‘stepped’ approach to the treatment of Type 2 diabetes; integrated foot care concerning amputation audit; risk factors and the incidence of amputation in diabetic patients; foot care dilemmas; history and diagnosis;

management and treatment of ulcers and charcot’s joint/neuropathy and painful diabetic neuropathy. Examples of patients ulcers were shown on screen.

Dr. Donohoe provided handouts for all attending. It was a very interesting presentation enjoyed by all.

Richard Wadley from D.L.T. attended our meeting and displayed various chiropody instruments, Ureka cream, Tea Tree oil and examples of Crocs shoes during our coffee break.

He also discussed autoclaves. He was thanked for taking the time and trouble to come to see us.

Roger Henry (Chairman) closed the meeting with thanks to Maria Reay for organising it all and Janet Rolfe for helping.

Roger Henry, Chairman - Devon and Cornwall Branch

Dear Roger,

I notice that your A.G.M. this year includes optional Archery on the Friday evening. How Dorothy and I wish we could join you.

Sadly, we are unable to do so. For many years we were both members of The Quarry Archers and Grand National Archery Society. Dorothy was much better than myself and won lots of medals at various shoots. Her bow had a draw weight of 38lbs which takes some drawing and holding on two fingers, keeping that up for a “round” which could last all day. I thought members might like to see this old photograph of Dorothy “in action”.

Fred Beaumont, Past President - North East Branch

31

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The Institute Strongly advises any applicants seeking employment to obtain a formal “Contract of Employment”

Chiropodist/Podiatrist Required

WIRRAL – Podiatrist required for busy clinic in HESWALL We are a team of five in a busy clinic and are looking for an experienced Podiatrist who will fit into this exceptional team.

Very high earning potential on a self employed fee sharing basis. The successful applicant will start with one day a week rising to two/three or four. A quick efficient manner and good sense of humour is essential.

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Instant Relief for Sufferers of Cracked Heels A

s warmer months approach and thoughts turn to preparing our feet for summer shoes, many people dread the recurring problem of this distressing condition.

Visually small breaks in the skin commonly referred to as Heel Cracks, or the clinical term Heel Fissures, commonly occur in a wide range of groups including females that wear open backed shoes, over-weight patients and patients with diabetes” as patients don`t like to be labeled as diabetic or obese. Treatment of this painful, unsightly and often chronic condition has proved to be challenging for health professionals such as; GP`s, chiropodists, podiatrists and pharmacists.

A recent case series produced by four private podiatry practices, under the auspices of the University of Southampton, evaluated the clinical use of medical grade tissue adhesive (Liquiheel™) for the treatment and management of dry heel fissures. It concluded that Liquiheel™ offered “instant and lasting pain relief following application…and functioned as an occlusive dressing with a reported microbial barrier, and were aesthetically pleasing to patients”.

The beneficial effects of using tissue adhesives for closure of simple lacerations have been demonstrated in Accident and Emergency departments. The production of Liquiheel™ involves a basic cyanoacrylate being distilled to achieve purity and to remove any toxic by-products, resulting in a low viscosity liquid. On contact with skin Liquiheel™ forms a solid film that bridges wounds and holds the apposed edges together. Since the adhesive film generally sloughs off within 5 to 10 days, as the epidermis regenerates, there is no need to remove the adhesive.

The Leading Podiatrist in the study, Belinda Longhurst, commented: “Overall the response was positive from patients and practitioners alike with regard to ease of application of the product, aesthetics and patient comfort. The majority of patients were delighted with the immediate and lasting pain relief and I was impressed with the apparent barrier to infection that Liquiheel™ provided”.

LiquiHeel™ is only available in the UK through 1Bailey Instruments Ltd www.baileyinstruments.co.uk

33

Diary of Events May 2010

Western Branch Meeting

Essex Branch Meeting 23rd May 2010 Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

13th June 12 noon Presentation by Darren Sandy “New Sterilisation Protocols” plus trade stand, Women’s Hospital, Crown Street, Liverpool Tel: 01745 331827

Southern Area Council Meeting

Nottingham Branch Meeting Sunday 23rd May at 7:00 p.m.

The Red Cross Centre, Nottingham Tel: 0115 932 8832

19th June at 1:00 p.m. Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 01992 589063

West of Scotland Branch Meeting

Sheffield Branch Meeting Thursday 20th May at 7:30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield Subject: A.G.M. Feedback Tel: 01623 452711

Sunday 6th June at 11:00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

Wolverhampton Branch Meeting

Southport Study Group CPD Sunday 6th June Royal Clifton Hotel, Southport

Tel: 07980 946129

Sunday 27th June - 10:00 a.m.

4 Selman’s Parade, Selman’s Hill Bloxwich WS3 3RN

Tel: 0121 378 2888

Surrey & Berkshire CPD Meeting

Yorkshire Area Council Meeting

17th May Tilehurst, Reading Contact Sue Marchant

14th June 7.30 p.m.

Crispin, 13 Queen Street, Morley, Leeds LS27 0NU

Tel: 0208 660 2822

West Middlesex Branch meeting 10th May at 8:00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

July 2010 Surrey & Berkshire Branch Meeting 3rd July at 1:30 p.m.

Greyfriars Centre, Reading

June 2010

Tel: 0208 660 2822

West Middlesex Branch meeting

Birmingham Branch 24th June at 8:00 p.m. Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

12 July at 8:00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

Leeds/Bradford Branch Meeting 6th June - 10:00 a.m.

The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

September 2010 Birmingham Branch

Leicester & Northants Branch 27th June Branch Meeting plus HPC audit guide Kilsby Village Hall, Registration & Refreshment 9:15 a.m.

Tel: Sue 01530 469816

Midland Area Council Meeting Sunday 13th June 10:00 a.m. Kilsby Village Hall, Kilsby, CV23 8XX Tel: 01865 434756

23rd September at 8:00 p.m. Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

East Anglia Branch Meeting plus CPD 19th September at 10:00 a.m.

Newmarket Day Centre, Fred Archer Way, Newmarket CB8 8NT Tel: 01223 881170

Essex Branch Meeting Oxford Branch Meeting 5th June at 10:00 a.m.

89 Rose Hill, Oxford OX4 4HT

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Tel: 01993 883397

19th September Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

London Branch Meeting

North of Scotland Branch Meeting

8th September at 7.30 p.m.

Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01895 252361

Please phone secretary for date and time The Heugh Hotel, Stonehaven, Aberdeenshire Tel: 01382 532247

Midland Area Council Meeting

Oxford Branch Meeting

Sunday 12th September 10:00 a.m. Kilsby Village Hall, Kilsby, CV23 8XX Tel: 01865 434756

North West Branch Meeting 26th September

Tel: 0161 486 9234

Nottingham Branch Meeting Thursday 2nd September at 7:00 p.m.

The Red Cross Centre, Nottingham Tel: 0115 932 8832

Southern Area Council meeting 11th September at 1:00 p.m.

Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 01992 589063

South Wales and Monmouth Branch Meeting 5th September Taffs Well Ex Service Mans Club, Taffs Well Tel: 02920 331927

Surrey & Berkshire Branch CPD meeting 20th September at 7:30 p.m.

Pirbright Village Hall

Tel: 0208 660 2822

9th October at 10:00 a.m.

89 Rose Hill, Oxford OX4 4HT

Tel: 01993 883397

Sheffield Branch Meeting October at 7:30 p.m. (date to be confirmed please phone secretary) SWD Sports Club, Heeley Bank Road, Sheffield Tel: 01623 452711

Surrey & Berkshire Branch meeting 11th October at 7:30 p.m.

Pirbright Village Hall

Tel: 0208 660 2822

Sussex Branch Meeting 24th October at 9:30 a.m.

The Bent Arms, High Street, Lindfield, RH16 2HP Tel: 01273 890570

Wolverhampton Branch Meeting Sunday 10th October 10:00 a.m.

4 Selmanâ&#x20AC;&#x2122;s Parade, Selmanâ&#x20AC;&#x2122;s Hill Bloxwich WS3 3RN

Tel: 0121 378 2888

Western Branch Meeting 5th September 12 noon Blair Bell Education Centre

Tel: 01745 331827

November 2010 Birmingham Branch

West Middlesex Branch meeting 13 September at 8:00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

West of Scotland Branch Meeting Sunday 19th September at 11:00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

October 2010 Devon and Cornwall Branch Meeting 10th October The Exeter Court Hotel, Kennford, Exeter Please phone secretary for details Tel: 01805 603297

Leeds/Bradford Branch Meeting 3rd October - 10:00 a.m. The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Midland Area Council Seminar Sunday 2nd October Kilsby Village Hall, Kilsby, CV23 8XX Please see inside Podiatry Review for details Tel: 01865 434756

25th November at 8:00 p.m. Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

Essex Branch Meeting 28th November at 2:00 p.m. Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

London Branch Meeting 17th November at 7.:30 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF Tel: 01895 252361

Leeds/Bradford Branch Meeting 7th November - 10:00 am The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Leicester & Northants Branch 28th November - Branch Seminar Lecture on Dermatology - Ivan Bristow, Southampton University, Trade support from Canonbury Autoclave servicing (by appointment), Lutterworth Cricket Club Registration and Refreshment 9:45 a.m.

Further details Tel: Sue 01530 469816

35

South Wales and Monmouth Branch Meeting

Nottingham Branch A.G.M.

7th November Taffs Well Ex Service Mans Club, Taffs Well Tel: 02920 331927

16th January at 10:00 a.m.

The Red Cross Centre, Nottingham MG8 6AT Tel: 0115 932 8832

West Middlesex Branch meeting

Oxford Branch A.G.M.

8th November at 8:00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

15th January at 10:00 a.m.

89 Rose Hill, Oxford OX4 4HT

West of Scotland Branch Meeting

15th January at 1:00 p.m.

Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 01992 589063

Sunday 14th November at 11:00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

Southern Area Council A.G.M.

Surrey & Berkshire Branch A.G.M. 8th January 10:00 a.m.

Greyfriars Centre, Reading

December 2010 Leeds/Bradford Branch Meeting 5th December - 10:00 a.m.

The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Tel: 01993 883397

Tel: 0208 660 2822

Sussex Branch A.G.M. 15th January at 9:30 a.m.

The Bent Arms, High Street, Lindfield, RH16 2HP Tel: 01273 890570

Western Branch A.G.M. and Branch Meeting 9th January 12 noon Blair Bell Education Centre, Seminar room 1 Tel: 01745 331827

January 2011 Birmingham Branch A.G.M. 13th January at 7:30 p.m.

Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

East Anglia Branch A.G.M. followed by meeting plus CPD 30th January at 10:00 a.m.

Newmarket Day Centre, Fred Archer Way, Newmarket CB8 8NT Tel: 01223 881170

Essex Branch Meeting and A.G.M. 30th January 2.:00 p.m.

Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

London Branch Meeting

Scottish Area A.G.M. followed by West of Scotland Branch A.G.M. Sunday 16th January at 11.00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

Wolverhampton Branch A.G.M. Sunday 21st March - 10:00 a.m.

4 Selman’s Parade, Selman’s Hill Bloxwich WS3 3RN

Tel: 0121 378 2888

Institute of Chiropodists and Podiatrists Website www.iocp.org.uk

19th January at 7.30 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF Tel: 01895 252361

Leicester & Northants Branch A.G.M. 23rd January A.G.M. plus meeting Kilsby Village Hall - 9:45 a.m. Registration and Refreshment 9:15 a.m. Further details Tel: Sue 01530 469816

Midland Area Council A.G.M. Sunday 30th January 10:00 a.m.

Kilsby Village Hall, Kilsby, CV23 8XX Tel: 01865 434756

North West Branch A.G.M. 16th January

36

Tel: 0161 486 9234

Visit the Members’ Forum Need a password?

Contact Head Office: 01704 546141

National Officers

Branch Secretaries

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

Birmingham

Mrs. J. Cowley

01905 454116

Bradford

Mrs. S. Keighley

01274 546424

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. S. Bennett

01223 881170

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Kent

Mrs. C. Hughes

01303 269186

Leeds

Mr. M. Hogarth

01653 697389

Leicester & Northants

Mrs. R. Rose

01582 668586

London

Mrs. L. Towson-Rodriguez 01895 252361

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. W. Massey

0161 486 9234

Northern Ireland Central

Miss G. Sturgess

0289 336 2538

Northern Ireland Regional

Mrs. T. Patterson

0289 145 6900

Nottingham

Mr. S. Gardiner

0115 932 8832

Oxford

Mrs. S. Harper

01993 883397

Republic of Ireland

Mr. R. Sullivan

00353 5856 059

Sheffield

Mrs. D. Straw

01623 452711

Sth Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mrs. J. Drane

01796 473705

Wolverhampton

Mr. D. Collett

0121 378 2888

Yorkshire Library

Mrs. J. Flatt

01909 774989

Chairman Executive Committee Mr. R. Beattie Hon. F.Inst.Ch.P Vice-Chairman Executive Committee Mr. D. A. Crew OstJ, F.Inst.Ch.P., DCh.M Chairman Board of Ethics Mr. S. Willey M.Inst.Ch.P., L.Ch. Chairman Board of Education Mr. W. J. Liggins F.Inst.Ch.P., F.Pod.A., B.Sc(Hons) Vice-Chairman Board of Education Mr. J. W. Patterson B.Sc(Hons)., M.Sc., M.Inst.Ch.P Honorary Treasurer Mr. R. H. Henry F.Inst.Ch.P., D.Ch.M

Standing Orders Committee Mr. C. B. Goldman M.Inst.Ch.P., D.Ch.M Mrs. L. Pearson M.Inst.Ch.P

Secretary Miss A. J. Burnett-Hurst

Area Council Executive Delegates Midland Area Council Mr. D. Elliott Hon.F.Inst.Ch.P Northern Ireland Area Council Mrs. C. Johnston M.Inst.Ch.P North West Area Council Mr. M. J. Holmes M.Inst.ChP., D.Ch.M, B.Sc.Pod Republic of Ireland Area Council Mr. R. Sullivan M.Inst.Ch.P Scottish Area Council Mrs. A. Yorke M.Inst.Ch.P Southern Area Council Mrs. M. Newnham M.Inst.Ch.P Yorkshire Area Council Mrs. J. Dillon M.Inst.Ch.P.

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