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Screening, Assessment and Prescription in Diabetic Foot Disease

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.

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Screening, Assessment and Prescription in Diabetic Foot Disease

  1. 1. Diabetic Foot Disease Screening,Assessment and Prescription William A Munro, Derek Jones 1Tuesday, August 13, 2013
  2. 2. Screening the Diabetic Foot What is it? Why do it? 2Tuesday, August 13, 2013
  3. 3. The Starting Point for Effectiveness Screening Is.. Quick & Simple Assess Patient’s Risk Level Not the Same as Assessment 3Tuesday, August 13, 2013
  4. 4. What Do We Screen For? Previous Amputation Significant deformity Significant callus Active ulceration Previous ulceration Vascular insufficiency Neurological insufficiency Able to self care? 4Tuesday, August 13, 2013
  5. 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 5Tuesday, August 13, 2013
  6. 6. Patient Information Leaflets are available Foot Screening in Scotland 6Tuesday, August 13, 2013
  7. 7. 7Tuesday, August 13, 2013
  8. 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 8Tuesday, August 13, 2013
  9. 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 9Tuesday, August 13, 2013
  10. 10. • Protection • Prophylaxis • Ambulant pressure relief Purpose of Shoes 10Tuesday, August 13, 2013
  11. 11. Preventing Trauma Means Controlling the Mechanical “Environment” Pressure Friction Shear Force Foot has .. ✓Altered Sensation ✓AlteredTissue Mechanics ✓and Structural Anatomy 11Tuesday, August 13, 2013
  12. 12. Mechanical Challenge Series of Interfaces External Force Skeletal Force Ground - Shoe Sole - Insole - Soft Tissue - Bone Consider the interaction between these elements 12Tuesday, August 13, 2013
  13. 13. Mechanical Challenge 13Tuesday, August 13, 2013
  14. 14. Orthotic Prescription “Matrix” • Deformity • Significant • Non-significant • Ambulation • Biomechanical • Neuropathy • Vascular • Pain • Previous Ulceration • Environment 14Tuesday, August 13, 2013
  15. 15. Biomechanical Assessment • Range of motion • Deformity • Flexibility • Rigidity • Sensory Reduced joint mobility leads to elevated plantar pressure Sauseng & Kastenbauer 15Tuesday, August 13, 2013
  16. 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 16Tuesday, August 13, 2013
  17. 17. Basic Shoe Function •Prescription Matrix – Defines function •Function – Defines Style/Design Possibilities and constraints 17Tuesday, August 13, 2013
  18. 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 18Tuesday, August 13, 2013
  19. 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 19Tuesday, August 13, 2013
  20. 20. Fashion Options 20Tuesday, August 13, 2013
  21. 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 21Tuesday, August 13, 2013
  22. 22. NO Due to Complexity of the Situation 22Tuesday, August 13, 2013
  23. 23. You Have to Have Faith - and then build rational processes for management 23Tuesday, August 13, 2013
  24. 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 24Tuesday, August 13, 2013

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