ORTHOTICS AND OFFLOADING Emma Davidson MSci Orthotist.
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Transcript of ORTHOTICS AND OFFLOADING Emma Davidson MSci Orthotist.
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ORTHOTICS AND OFFLOADINGEmma Davidson MSciOrthotist
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INTRODUCTION
Causative Factors
Biomechanics and Gait
Offloading Factors
Offloading Approaches
Challenges
Key Referral Information
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DIABETIC MDT
“The primary objective in managing diabetic foot problems is to promote mobilisation. This
involves managing both medical and surgical problems and involving a range of medical
experts in related fields.”
(Bridges et al, 1994).
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NICE GUIDELINES
Determine the need for interventions to prevent the
deterioration and development of Achilles tendon contractures
and other foot deformities
Perform an orthotic assessment and treat to prevent recurrent
disease of the foot.
People in hospital who are at moderate or high risk of
developing a diabetic foot problem should be given a
pressure redistribution device to offload heel pressure.
Nice inpatient guideline 2011
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THE FOOT AND ANKLE
28 bones 55 articulations
Often subdivided into:
Rear-foot
Mid-foot
Fore-foot
Interface with ground for entire kinetic chain.
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CAUSATIVE FACTORS
Peripheral Neuropathy
Deformity
Ischemia
Trauma
Shear Stress
Peak Plantar Pressure
Abnormal Biomechanics
“For us to effectively prevent ulcers, we need to have a better understanding of why they occur, and try to integrate the
implications of pressure, shear, temperature, physical activity, skin properties, and even moisture.”
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PERIPHERAL NEUROPATHY Sensory
Loss of protective sensation
Motor Intrinsic muscle imbalance, atrophy
Autonomic Dry, fragile skin, fissure – route in for infection
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DEFORMITY
Unopposed intrinsic muscle
pull.
Limited joint mobility.
Migration of plantar fat pads
due to excessive bony
pressures.
Callus formation.
Footwear challenges
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ISCHEMIA
Intermittent claudication.
Decreased rate of capillary return.
Cooler temperature.
Absent Pulses
Discolouration
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TRAUMA Increased risk
Delay in treatment
Potential infection
Foreign objects
Ill fitting footwear
Thermal
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PEAK PLANTAR PRESSURE
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SHEAR FORCE
Horizontal component of Ground Reaction Force
Under researched as difficult to measure
AP Force component
ML Force component
Environmental Friction
Surface next to skin.
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BIOMECHANICS
Sagittal Plane Facilitation theory (Dananberg 1986)
Three rockers of gait. Sagittal plane blockades:
Ankle Equinus Forefoot Equinus Loss of motion at MTPJs specifically 1st
Structural Hallux Limitus / Rigidus Functional Hallux Limitus
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GAIT ABNORMALITIES
Decreased walking speed
Increased single and double support time
Decreased proprioception
Compensatory gait deviations due to sagittal
blockades.
Drop foot and / or compensations
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CHARCOT ARTHROPATHY
Immediate offloading if suspected.
Maintain integrity of bony alignment whilst active.
Prevent secondary rocker bottom deformities.
Move into custom insoles and protective footwear
once stable.
If rocker bottom mid foot already developed offload
to prevent secondary ulceration.
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TYPE OF ULCER
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OFFLOADING FACTORS Location of ulcer
Presence of infection
Vascular function
Volume of exudate
Oedema
Deformity
Skin integrity
History of amputation
Balance and mobility
Activity levels
Compliance
Socioeconomic factors
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TYPES OF OFFLOADING
Debridement
Upper limb walking aids
Wheelchair/bed rest
Surgery
ORTHOSES
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GOLD STANDARD
Below knee total contact cast
Slipper cast
Inpatient Care
PRAFO
Inflatable gutter
Heel Pro
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CUSTOM BRACES
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OFFLOADING SHOES
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LONG TERM PRESCRIPTION
Footwear
Stock Modular Bespoke
Shape Capture
Draft / measures Cast Scan
Insoles
Stock Simple Total Contact Insoles Functional Foot Orthosis
Shape Capture
Draft Impression Box Cast Scan
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INSOLES Multi – layer construction
Material properties.
Redistribute plantar pressures
Interface between soft tissue and shoe
Prevent plastic deformation of soft tissue
Restore joint moment equilibrium
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FOOTWEAR
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DIABETIC SPECIFICATION
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ROCKER SOLES
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THE FUTURE
Emerging technologies -
SurroGait Rx
Improvement in measuring
shear forces.
Early inclusion of orthotics in
treatment
More accurate pre-cursers for
ulceration
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CHALLENGES
Compliance
Patient education
Re-ulceration
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ORTHOTICS REFERRAL
Reason for referral
Previous ulcer history
Cause of ulcer
Location / Duration of
ulcer.
Risk factors
MDT clinic treatment
Socioeconomic issues
Previous offloading tactics
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THANK YOU
FOR LISTENING
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REFERENCES Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound
classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21(5): 855-9.
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35: 528-31.
Armstrong DG, Lavery LA, Kimbriel HR,et al. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure offloading regimen. Diabetes Care 2003; 26: 12595-97.
Armstrong DG, Lavery LA, Nixon BP, et al. It’s not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis 2004; 39(Suppl 2): S92-S99.
Brown, D., Wertsch, J.J., Harris, G.F., Klein, J., Janisse, D., 2004. Effect of rocker soles on plantar pressures. Archives of Physical Medicine and Rehabilitation 85, 81–86.
Armstrong DG, Peters EJ, Athanasiou KA, Lavery LA: Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg 37:303–307, 1998 3.
Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ: Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care 26: 1069–1073, 2003
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REFERENCES Van Deursen, Mechanical Loading and Off-Loading of the Plantar Surface of the
Diabetic Foot. Clinical Infectious Diseases 2004; 39:S87–91 International Best Practice Guidelines: Wound Management in Diabetic Foot
Ulcers. Wounds International, 2013. NICE clinical guideline 119 Inpatient management of diabetic foot problems NICE Clinical Guidelines for Type 2 Diabetes Prevention and management of
foot problems Meijer et al, The vertical component of the ground reaction force does not reflect
horizontal braking or acceleration per se. Clinical Biomechanics, Vol 24, Issue 6, July 2009, Pages 527–528.
Schaff PS, Shoes for the insensitive foot: the effect of a "rocker bottom" shoe modification on plantar pressure distribution. Foot Ankle, 1990 Dec;11(3):129-40.
F. B. Van De Weg et alwith diabetic foot ulceration Wound healing: Total contact cast vs. custom-made temporary footwear for patients, Prosthet Orthot Int 2008 32: 3
Jan S. Ulbrecht,Prevention of Recurrent Foot Ulcers With Plantar Pressure–Based In-Shoe Orthoses: The CareFUL Prevention Multicenter Randomized Controlled Trial Diabetes Care 2014;37:1982–1989 | DOI: 10.2337/dc13-2956
Terrier et al. Do orthopaedic shoes improve local dynamic stability of gait? An observational study in patients with chronic foot and ankle injuries. BMC Musculoskeletal Disorders 2013, 14:94
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REFERENCES A. Caselli, H. Pham, J.M. Giurini, D.G. Armstrong, A. Veves The forefoot-to-
rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration Diabetes Care, 25 (6) (2002), pp. 1066–1071
S.O. Oyibo, E.B. Jude, I. Tarawneh, H.C. Nguyen, D.G. Armstrong, L.B. Harkless, A.J. Boulton The effects of ulcer size and site, patient's age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers Diabetic Medicine, 18 (2) (2001), pp. 133–138
SICCO A. BUS, Effect of Custom-Made Footwear on Foot Ulcer Recurrence in Diabetes A multicenter randomized controlled trial. Diabetes Care 36:4109–4116, 2013
Welsh et al. A case-series study to explore the efficacy of foot orthoses in treating first metatarsophalangeal joint pain. Journal of Foot and Ankle Research 2010, 3:17
Zifchock et al, A comparison of semi-custom and custom foot orthotic devices in high- and low-arched individuals during walking. Clinical Biomechanics 23 (2008)
1287–1293 Yavuz M, Botek G, Davis BL: Plantar shear stress distributions: comparing actual
and predicted frictional forces at the footground interface. J Biomechanics. 40 (2007) 3045–3049