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Diabetic Foot Care - DerekJones presenting at Otto Bock Scandinavia

Presentation at Otto Bock Scandinavia - focusing on the diabetic foot and covering screening, biomechanics and orthotic management for ulcer prevention and treatment

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Diabetic Foot Care - DerekJones presenting at Otto Bock Scandinavia

  1. 1. Screening, Biomechanical Considerations and Orthotic Management of the Diabetic FootDerek Jones PhD, MBA
  2. 2. Presentation•Impact of Diabetes•Foot Screening•Biomechanics•Orthotic Management
  3. 3. We are living longerBut are we healthier
  4. 4. Chronic ImpConditions act o n So ciet y
  5. 5. A drop in the ocean? Diabetes Expenditure • 10% million affected inaffected world 2.9 of the UK NHS BudgetBudget 285 million UK NHS UK 10% of the people the £9 Billion per Year wide - 6.4% of population • £9£286 per per Year Billion Second Lifetime risk of foot ulceration - 25% • £286 per Second
  6. 6. Cost Burden for PatientsVaries with Country Cost of treating diabetic foot ulcers in five different countries. Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Diabetes Metab Res Rev. 2012 Feb;28 Suppl 1:107-11. doi: 10.1002/dmrr.2245.
  7. 7. Total ExpenditureApproximately £1.8 Billion per year in the UK Attributable to the Diabetic Foot
  8. 8. Life expectancy of someone with a foot ulceris less than someone withbreast or testicular cancer
  9. 9. Resources are always going to be limited
  10. 10. Screening What is it? Why do it?
  11. 11. Screening Is..The Starting Point for Effectiveness Quick & Simple Assess Patient’s Risk Level Not the Same as Assessment
  12. 12. What Do We Screen For? Previous Amputation Significant deformity Significant callus Active ulceration Previous ulceration Vascular insufficiencyNeurological insufficiency Able to self care?
  13. 13. Find Level ofIndividual Risk LOW MEDIUM HIGH ACTIVE
  14. 14. Risk Stratification 5 % Active Ulcers or 5 % Active Ulcers or Infection -- Infection revascularisation or revascularisation or amputation amputation Multidisciplinary Multidisciplinary management management 15 % High Risk 15 % High Risk Intensive foot Intensive foot protection protection Ulcerated 20 % Moderate 20 % Moderate High Risk Risk Risk 60% Low Risk 60% Low Risk Regular foot Regular foot Routine annual Routine annual protection protection screening screening Moderate Risk Low Risk
  15. 15. Match the Strategy & Activity to the Individual’s Level of Risk LOW RESULT is... • Most Effective Use ofMEDIUM Resources • Ulcer Prevention HIGH • Keep the Individual at Lowest Risk of UlcerationACTIVE
  16. 16. Patient Information Leaflets Foot Screening in Scotland
  17. 17. Diabetic Foot Ulceration Three Great PathologiesNeuropathy Ischemia Infection
  18. 18. Improved Survival of the Diabetic Fot The role of a specialised foot clinic ME Edmonds et al QJ Med 1986; August; 60(232):763-71
  19. 19. Getti ng towith B Grips iomec hani c s
  20. 20. Sho es abe tic” and R oomy “Di Soft U ppers Pressure Relief? Sto ck? or o ke esp Rock B er Sol W e M us t S e? ave Money .. But Who Has the Skills? Relieve Pressure? How ComplicatedCan Shoes Be..?
  21. 21. Your shoes caused my ulcer!
  22. 22. Enough!
  23. 23. Prevention“becomes cost effective if we reduce incidence of foot ulcers and amputation by 25%” Boulton et al; Lancet Nov 2006
  24. 24. Prevent Ulceration Strategy according to individual risk Ulcerated Improve ExtrinsicInfluences High Risk Moderate Risk Low Risk
  25. 25. Problem is one of Mechanics Paul Brand "The whole problem is one of mechanics, not of medicine. The biological responses of these denervated limbs are qualitatively similar to those of normal limbs.It is the permitted pattern of mechanical stress that is different"
  26. 26. Extrinsic Factors Repeated “Trauma”At ChronicRisk Wound Acute WoundIschaemia Infection
  27. 27. Preventing Trauma Means Controlling the Mechanical “Environment” sure Pr es on chan ics . nsati e s . Se y a h d e M natom ot re su AFo lte d Tis al Friction A e re ✓ Alt truct ur ✓ and S She ar ✓ For ce
  28. 28. Elevated Plantar Pressure Causative Factor in Ulceration and Ulceration is often a Precursor to Amputation
  29. 29. High Pressure is Bad Friction & Shear are Very Bad But do we understand these terms? Are we using them correctly?
  30. 30. But..Everything I tell you Is a “Lie”
  31. 31. Pres s ure Not Just a Tissue Surface Effect
  32. 32. Interface Effects
  33. 33. Pressure Tissue Damage is Likely “Safe”Reswick & Rogers Time
  34. 34. r eaSh Fr ict io n
  35. 35. Friction.. Good or Bad?
  36. 36. FrictionForce that resists the relative motion of two objects in contact OR The action of one object rubbing against another
  37. 37. Shear StressResults from a force parallel to the tissue which causes Tissue DeformationThe AMOUNT of deformation is known as Shear Strain
  38. 38. It’s a Challenge to Understand“Cause” & “Effect”We have to have a “model” “dynamic, quasi-linear, viscoelastic,structural model”
  39. 39. NO Due to Complexity of the Situation
  40. 40. Mechano-transductionMechanisms by which cells convert mechanical stimulus into physiological activity - anabolic and catabolic A field holding the keys to progress?
  41. 41. Improve footbed materials?
  42. 42. The Stiffness of the Upper needs to match the stiffness of the sole
  43. 43. KMS RangeKMS Range
  44. 44. • 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
  45. 45. Remember ..Biomechanics can provide insight.It should support every choice. But Much Confusion of Terminology
  46. 46. t ic tho ntOr me anageM
  47. 47. Orthotic Prescription be a Gamble Orthotic Prescription Should NotNot a Gamble
  48. 48. Orthotic Prescription• Deformity - Is it significant - Require a custom last?• Ambulatory status?• Biomechanical anomalies? Rigid or Hypermobile foot?• Neuropathic status?• Ischemia?• Environmental/Occupational factors?
  49. 49. Devices and Techniques• PRAFO Ankle Foot Orthosis• “Heel Relief” & “Forefoot Relief” Shoes• Axial-Offloading• AirCast• Wound Healing Casts
  50. 50. Progressive ProblemL & R Heels
  51. 51. Refused AmputationTwo Months Later
  52. 52. 156 weeks later Clinical Effectiveness PrizeDerek Jones, William Munro, Duncan Stang
  53. 53. PRAFO®Ankle Foot Orthosis
  54. 54. 38 year old Female DiabeticNeuropathy
  55. 55. “Parrot Beak” Fracture
  56. 56. AirCast Inflatable sections Rocker soleCustomisable footbed
  57. 57. Forefoot Relief•Upper stiffness•Rocker Position•Angle•Carbon stiffener Neuropathic Forefoot Lesion
  58. 58. Wound Healing Casts• Useful for multiple ulcer sites• Eliminate pressure on ulcer sites• Immobilise tissue layers to reduce deep tissue shear effects• Control oedema• Maintain mobility
  59. 59. You Have to Have Faith - andthen build rational processes for management
  60. 60. Thank youDerek Jones 2013