Don’t Tiptoe Around It !

By Dr. Helen Rees, BSc (Hons)

Overver 100,000 Canadians have been diagnosed with Multiple Sclerosis (MS). Canada has one of the highest rates of MS in the world and MS is the most common neurological disease affecting young adults in Canada (Multiple Sclerosis Society of Canada, 2013).

Chiropodists/Podiatrists need to become more aware of this complex disease. We studied and learned about MS at university and frequently see patients with MS in our offices. Can we do more for our patients diagnosed or even not yet diagnosed with MS?

A 30 year old female, presented with numbness and poor coordination when walking and a slight foot drop in her left foot. She also had lower leg oedema. She was diagnosed with MS 2 years ago, but prior to this the doctors were looking into aetiologies which included diabetes and other neurological diseases. If this patient had come into your office prior to her diagnosis would her presenting symptoms have resulted in you advising her to see her family doctor to get a referral to a neurologist?

Should our profession be looking out for early signs of MS?

Are we competent to recognise the signs and symptoms?

If a patient presented in our offices with numbness, tingling or oedema in the leg would we even consider MS as a differential diagnosis?

Undoubtedly the importance of maintaining optimal foot health for patients with MS should not be overlooked.

 

You Can’t Manage What You Can’t Measure

By Dr. Axel Rohrmann

prosenex1 prosenex2

 

 

 

 

 

 

 

 

The current model of testing for peripheral neuropathy:

The diagnosis of neuropathy is based on subjective interpretation of symptoms and signs such as loss of vibratory or light touch sensation and reduced or absent ankle reflexes. Temperature discrimination ability is not routinely screened. Vibration sensation is evaluated by a 128Hz tuning fork with limited reproducibility and stimuli gradation ability. The monofilament test has often inconsistent reproducibility in general practice as it is infrequently replaced.

Currently there is no world-wide available hand held device that is relatively simple and standardized, with the ability to grade temperature discrimination and vibration stimuli perception for a diabetic foot neuropathy screening exam. Diabetic Foot Screening Device creates an objective and more worldwide standardized physical examination protocol for early diagnosis and prevention of peripheral neuropathy, leg amputations and chronic lower extremity pain. It will produce objective indications for aggressive glycemic control, as well as dramatically improve patient compliance based on early detection of potentially devastating complications. It may detect earliest indications for treatment with novel medications.

Proposed Solution:

The Prosenex Dynamic Neuroscreening Device(DND) is a non-invasive screening device to objectively grade possible earliest signs of small and large fiber dysfunction. The device will screen for small fibers vitality by patients ability to discriminate 2 ‘ C temperature changes from 15 ‘ C to 40 ‘ C , compared to the fixed 25 ‘ C baseline. Large fibers health screened by 5 amplitudes of 128 Hz vibration frequency. The DND screens for the presence of neuropathy through the use of objective temperature and vibration sensitivity testing.

Vibration Perception

The device actuates a tip which vibrates at 5 different amplitudes at a standard frequency of 128Hz. Large fiber health or neuropathy can be screened and tracked based upon the lowest amplitude that the patient can sense to establish a baseline and detect changes over time on various areas of the foot or other extremities.

Temperature Discrimination

The device provides for two temperature pads. One pad is fixed at 25 °C while the other pad can vary from 15-23°C in 2 degree increments in the cold mode and 27-40°C in 2 degree increments in the warm mode . After the variable temperature is set, each pad is touched to the same area in succession to determine if the patient can discern the difference. Small fiber vitality or neuropathy can be screened and tracked based upon the smallest temperature difference the patient can discern to establish a baseline and detect changes over time on various areas of the foot or other extremities.

Clinical Experience:

I have been using this DND device for all Neurovascular foot screening functions as part of the assessment for over 8 months now and have been delighted with the machine. I have found it to be simple, effective and most importantly reliable in being able to determine both small and large nerve fibre function. Benefit if for both the patient who is assessed and possibly diagnosed on a reproducible and reliable device, and for the clinician who can quantify their result and use it for baseline comparison data.

I purchased my device directly from the manufacturer and suggest you check out this product at

www.prosenex.com

Spring Fever

By Stuart Berry, BSc (Hons), Podiatry
As we start to focus on feet over the next few weeks, on the run up for May’s “Foot Health Month”, some of us have also been hard at it focussing on our feet with respect to running too – especially since Spring may (finally?) be here and we are all getting a spring in our step!pic#1

In many towns and cities across Canada ‘race season’ has already started and people are out in the streets training for their 5km, 10km, half- and full- marathons, notwithstanding all the other numerous events designed to test our endurance and athleticism. Oakville, Ontario is no exception and has just held two well organised races over the weekend of April 26/27th.

April 26th saw the ‘Race to End Diabetes’, benefiting the charity Juvenile Diabetes Research Foundation. This 5km race through Oakville reminded me of the importance of diabetes research, but also the importance of our role of specialists in foot health in educating patients and developing our services to enable ‘fit’ feet.
Click here to find out more about Type 1 Diabetes and the work of the JDRF  http://www.jdrf.ca/news-and-media/fact-sheets/type-1-diabetes/

pic2April 26th saw the Oakville Mercedes 10K race. The 10km course included stunning views of Lake Ontario and downtown Oakville and an unobstructed view of Toronto in the distance across the water. It was the perfect morning for a race. I ran the 10km race with friends and my running group, having commenced my training back when the winter ice was still on the sidewalks and pavement! Training ramped up gradually and included speed training and hill training to get me ready for the 10km race.
Runs always included a warm up and always included stretches afterwards. I also like to do some dynamic stretches once I am warm – taking joints and muscles through ranges of motion similar to what will be asked of them on a run. I have found this, along with slowly building up training and including days for rest and recovery has been the best way to avoid injury.

Oakville really was lucky with its race weekend – the sun was shining, but the temperature was not too high and I was happy to have completed the race in good time.
Why not share the stories of the races or events you have participated in, or plan to, this spring/summer, and in particular the ‘golden-gems’ you would like to share regarding training or avoiding injury.

Exposure to Nail Dust – An Occupational Hazard?

By Dr. Helen Rees, B. Sc.. (Hons)

The use of nail drills by Podiatrists/Chiropodists to improve patient toe nail conditions and therefore their ‘quality of life’ is a plauditory aim but what effect is it having on our health?

Exposure to nail dust and the inhalation risk was first described in the early 70′s  as an “Occupational Hazard”. Using a drill to reduce onychauxis nails generates finely divided nail particles. This airborne material could consist of keratin, fungal elements (eg Trichophyton rubrum) , bacteria, moulds and other microbial debris.

As far back as 1975, two female UK Podiatrists were diagnosed with allergy hypersensitivity to nail dust. Research by Millar (2000) suggested that, within podiatry, there was four times the UK prevalence of asthma, giving cause for concern. Breathing in respiratory sensitizers at work can cause occupational asthma. In the same study, podiatrists frequently reported problems with rhinitis and conjunctivitis, suggesting occupational health risks. As recently as February 2014 a study by Tinley et al showed podiatrists had an increased prevalence of nose microbes, most commonly Aspergilus, compared to a control group.

Obviously, exposure to nail dust and the associated risk will vary in offices due to the polices and practices in place, type of drill/burr, personal protection used and extraction/ventilation systems. However, with many more podiatrists complaining of or presenting with symptoms should we still be using drills?

Should we be developing our skills to move away from nail drills? What should we be teaching the next generation? If we know the risk to our health should we be changing our practices and policies?

Medical Marvel in Saskatchewan

By Dr. Axel Rohrmann

Every so often we’ll meet a patient whose story will take our breath away.  This patient was just such a patient and his story is nothing short of a miracle.

It was a cold winter’s day when he was huddled around a fire to keep warm while fighting the elements and threats of being a “homeless or street person”.medicalmarvel1

He couldn’t tell what exactly happened but recalls falling into the fire that was supposed to keep him warm. The nylon jacket he was wearing instantly melted to his skin. Fortunately a witness pulled him from the flames and smothered him in snow. He was rushed to the La Ronge hospital and then airlifted to Saskatoon where he was induced into a coma. During the weeks and months that followed he underwent numerous plastic and orthopedic surgeries. He had lost  all his fingers on his right hand and three from his left hand ( The thumb, third and 5th finger couldn’t be saved).

We all know the importance of a thumb so what the surgeons did is amputate the left hallux and transplant it to his left hand.medicalmarvel2

The transplant was a huge success and the thumb is functional, vascularised and sensate. It has enabled him to care for himself without the use of a prosthetic on the left hand. He has been newly diagnosed with  Type 2 diabetes and was seeing me for his baseline neurovascular assessment.  I will be seeing him in 6 months for a follow up and would relay any questions you may have. Wishing you all an inspired 2014.

 

Working in Canada

Written by Stuart Berry, BSc (Hons), Podiatry

They say moving house is one of the most stressful things that you can do in your life, therefore for those of you that are moving province or territory, or indeed moving country, I thought it would be helpful to ease the burden by giving you a page of resources which will help with your transition to your new home and new place of work by helping you get work-ready.

One of the things which will differ between continents, countries or event regions within countries is the regulatory frameworks which govern our practice – so do your research now is my tip.

Cultural, geographical, historical and demographic differences are some of the reasons regulatory frameworks may sometimes differ.  Within Canada it is worth remembering that podiatric medicine is therefore regulated at a provincial level and those working in one region will need to register with the appropriate regulator when working in another region.

It is of no surprise we see the differences in regulators reflected across the globe also reflected somewhat across Canada – for example the regulators of podiatry in Alberta and podiatry in British Columbia vary from the regulators of la podiatrie au Québec.   Similarly the other Canadian provinces or Territories will be different.

Each U.S state will also have a different regulatory framework and for those looking to work in a different continent, such as the Europe or Australasia again, there will be different regulators for either the country or region depending on the model of regulation.

TOP TIPS:

It is important to prepare ahead of time.  Like a good scout “be prepared”.  Know who regulates you in your new destination and how to access the relevant information you require.

Check that that you meet, or know how to meet, the requirements the new regulator will place upon you since all regulators are different.

Do as much as you can before your move.  Ensure you have registered with your regulator and are ready to practice as soon as you arrive, since going through the regulatory process can take weeks or months and you want to ensure you are work-ready.

Look out for words like ‘council’ or ‘college’: these are often words that indicate a regulator.

For those within Canada or moving to Canada to work within podiatric medicine, here are some useful resources to help with your research and relocation:

For information on credentials for foreign trained individuals.

Information on Alberta podiatry licencing.

Information British Columbia podiatry licencing

Information Manitoba podiatry registration

Information Nunavut podiatry licencing

Information Ontario podiatry or chiropody registration

Information Prince Edward Island podiatry licencing

Information Quebec podiatry licencing

Information Saskatchewan podiatry licencing

For Podiatry associations in the maritime provinces check out New Brunswick, Nova Scotia, PEI,

Overseas:

Finally, if you are looking at Australia or the United Kingdom, check out these regulators.

Like a good holiday, they say half the fun is in the planning, so with that in mind have fun doing all your research!

Well, I think that sums up my whistle stop tour of first step research for before you relocate, I hope it helps.

To debride or not to debride? That is the question

“To debride or not to debride? That is the question”.

By Dr. Helen Rees, B. Sc (Hons)

A critical question in the treatment of chronic wounds, diabetic foot ulcers, venous ulcers and pressure ulcers, is whether and how frequently debridement is needed.

Debridement is defined by Hinchcliffe et al (2008) as the removal of slough, surface debris and infected matter from the wound bed in an attempt to leave clean, viable tissue. Methods of debridement include sharp, mechanical, chemical, maggot therapy, surgical, autolysis and ultrasonic.

As skilled practitioners Podiatrists/ Chiropodists are ideally placed to undertake sharp debridement, a fundamental technique in daily clinical work, as long as it is remembered not to go beyond clinical scope of practice. It is essential to undertake a thorough vascular and neurological assessment prior to picking up a scalpel and be aware of the debridement risks if ischemia, poor venous return or poor tissue viability is recorded.

Debridement promotes healing by converting a chronic nonhealing wound environment into the ideal wound bed preparation, promoting wound healing. In addition to altering the environment of the chronic wound, debridement is a technique aimed at removing non-viable and necrotic tissue, thought to be detrimental to healing (Lebrum et al 2010 and Gordon et al 2012).

Debridement is achieved by removing wound edge tissue, such as hyperkeratotic epidermis (callus) and necrotic dermal tissue, foreign debris, and bacterial elements known to have an inhibitory effect on wound healing (Edmonds and Foster, 2006). Research by JAMA dermatology proved that patients with chronic wounds coming in every week for debridement were associated with faster wound healing.

The Royal College of General Practitioners’ Guidelines (RCGP, 2000) recommends debridement as a treatment of diabetic foot ulcers alongside local wound management and appropriate dressings.  Debridement is also recommended by the SIGN guidelines (1997), in conjunction with antibiotic therapy for infection and offloading modalities.

While the rationale for debridement seems logical, the evidence to support its use in enhancing healing is scarce. One of the most fundamental practices, debridement, has never been studied closely in randomized clinical trials.

So, as a Chiropodist/ Podiatrist, should we bring our patients in for wound/ ulcer debridement?  If so how often should we be debriding?

Let’s discuss this topic further, please add your comments:

Podiatry and the wound care patient.

Written by Dr. Axel Rohrmann

We all start out with visions of where we see ourselves within the profession, and as time passes our patient’s make changes to our vision that often come quite unexpectedly. I’ve just said good bye and have a wonderful Christmas with your family, to a patient who had been seen in the clinic for wound care once every 2-3 weeks over the past 3.5 months. Though there may be nothing unusual about the good bye gesture, what is unusual is  the fact that Christmas is still 9 weeks away. During the time that I had started treating this particular patient he had become a grandfather, completed some renovations in the home, and set a date for his retirement. Also while I was treating this patient new developments in the wound dressing industry presented themselves and we had the opportunity to trial a new dressing. As good fortune would have it, the dressing was a new antimicrobial dressing and although another silver dressing, the delivery system of silver was more efficient and effective than dressings of a similar nature. Wound care for this patient was multifaceted to accommodate his activities of daily living and footwear. He required offloading, arrangements for community dressing changes and regular debridements. Initial ulcer presentation was a sloughy and necrotic plantar proximal first lesion measuring 2.5 cm x 1.8 cm and Grade 2 on the University of Texas wound classification. Today was the first follow up after wound closure and scar tissue appeared to have good tensile strength.

Wound care is a changing and fascinating industry so long as the products are being understood and used appropriately during the appropriate stage of wound healing or wound state. The other challenging and exciting element of wound care if that every case is unique. Wounds may present in a similar fashion and have the same treatment outcome or goal of wound closure, but they reside on very different people. Different people have different environments, requirements and activities of daily living, nutritional status, transportation, socioeconomic means, understanding and self motivation. It is up to you, the clinician to understand not only the wound, but the person.

I absolutely love what I do, I’m blessed to be considered a wound healer and though I only treat the hole in the lower extremity it’s the whole patient that makes the process rewarding. We need to remember the moments that make our profession the special profession it is. We’re privileged to be able to provide the services we do and I look forward to many more years and helping many more patients.

Case Review – Toe Walking

By Dr. Axel Rohrmann

A healthy  9 year old girl was referred to me for “walking on the top of her feet”. Interesting as this sounds, I thought there had to be an error.

The patient, parents and a sibling sister were met at the reception and shown to my clinic room. Observation of gait showed that all gait determinants were within normal limits. During introductions and history it was revealed that the 11 year old sister also used to walk on the “top of her feet” until around age 6 when she spontaneously stopped. Assessing the feet it could be seen that there are mild skin changes on the dorsum of the inter-phalangeal joints and the metatarsal-phalangial joints. Read more »

Vandenbos Nail Procedure for Ingrown Toenails

By Dr. Axel Rohrmann

I received a call from a patient who inquired if I do a nail procedure called the Vandenbos nail procedure for ingrown toenails. I advised that there are many different ways to perform partial or total nail avulsions and that It would be best to see the site in question before deciding on the appropriate procedure. Read more »

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