Presentation at the BAPO Conference in Telford 2013. Starts by describing the screening and assessment process for the diabetic foot and the important differences between them. It describes the importance of risk stratification of the individual as this will determine the essential characteristics of the protective footwear for the individual. The key to effective management is to make sure that individuals are treated according to their risk of ulceration. Keeping those at the lowest risk from progressing is vital for cost efffective management. The presentation also describes the nature of the orthotic prescription and how this should relate to the patients risk level.
3. The Starting Point
for Effectiveness
Screening Is..
Quick & Simple
Assess Patient’s Risk
Level
Not the Same as
Assessment
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4. What Do We
Screen For?
Previous Amputation
Significant deformity
Significant callus
Active ulceration
Previous ulceration
Vascular insufficiency
Neurological insufficiency
Able to self care?
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5. Low Risk
Moderate Risk
High Risk
Ulcerated
5 % Active Ulcers or Infection -
revascularisation or amputation
Multidisciplinary management
15 % High Risk
Intensive foot protection
20 % Moderate Risk
Regular foot protection60% Low Risk
Routine annual screening
Risk Stratification
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8. • Detects early
disease
• Involves tests that
have a predictive
value and an agreed
cut-off point for
referral
• Requires healthcare
worker trained for
competence in
screening
• Does not involve a
treatment plan
• Patient does not
influence outcome
Screening
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9. Assessment
• Establishes a diagnosis
• Involves clinical decision
making skills and clinical
autonomy for onward
referral
• Requires a healthcare
professional with the
appropriate training/
competence in assessment
• Decides on a future
management plan
• Patient may influence
outcome
• Reassessment is patient-led
depending on symptoms or
response to therapy
Adapted from Article in DFJ,Vol. 9, No. 4. Mousley, M
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15. Biomechanical Assessment
• Range of motion
• Deformity
• Flexibility
• Rigidity
• Sensory
Reduced joint mobility leads to elevated plantar pressure
Sauseng & Kastenbauer
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16. “Diabetic” Shoes
Soft and Roomy
Uppers
We Must Save Money
.. But Who Has the Skills?
How
Complicated
Can Shoes Be..?
Pressure Relief?
Rocker Sole?
Bespoke or Stock?
Relieve Pressure?
Actually ..
More Complicated
than
Most realise
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17. Basic Shoe Function
•Prescription Matrix – Defines function
•Function – Defines Style/Design
Possibilities and constraints
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18. Footwear Design Criteria
Spectrum of Activity
• Newly screened
neuropathic foot
• Moderate Risk
• Non-ulcerated
• Deformed neuro-
ischaemic foot
• High Risk
• Previous Ulceration
Individuals with these presentations
require a completely different
approach
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19. • Shoe and Contact Surface
(footbed) Must Work Together
• Materials & Structures Chosen
& Positioned for BOTH Control
and Tissue Matching
• Shoes Need to act like the
“Skeleton” as well as the “Soft
Tissues” - Support as well as
protect
• “Soft” Uppers not Necessarily
Best - Match to the Ambulatory
Status and Load Expectations
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21. Foot Orthoses
• Integral Part Of Shoe Design
• Total Contact Orthoses
• Functional Foot Orthoses
• Simple Insoles
• The Foot Orthoses Type Will Impact On The
Volume Of The Shoe
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23. You Have to Have Faith - and then
build rational processes for
management
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24. Conclusion
• Base on individual patient
needs
• Materials to suit the interfaces
• Don’t design the foot orthosis
without thinking of the shoe
• Multi-disciplinary education
and mutual understanding of
orthotic interventions
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