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Finding sustainable solutions to the challenges encountered in providing appropriate, effective, low-cost footwear is the goal of a number of new initiatives. These initiatives provide opportunities for pedorthists seeking to get involved in international footwear and footcare development and educational projects.

What Problem Are We Trying to Solve?

Every 20 seconds, an amputation occurs somewhere in the world due to diabetes.¹ Diabetes and lymphatic filariasis (elephantiasis) are the two leading causes of global disability. Together they affect more than 500 million people, mostly from the "bottom billion."^2,3 Diabetes, elephantiasis, and other neglected tropical diseases, such as leprosy and Buruli ulcer, are common paths to limb impairment, amputation, mobility loss, and premature death. These dire outcomes are due to the absence of primary prevention of the disease or disabling condition coupled with failure to prevent secondary complications such as wounds, swelling, and loss of joint motion.⁴ Chronic conditions are currently responsible for 60 percent of the global disease burden; this number is expected to reach 80 percent by 2020 in less-resourced environments (LREs).⁵

Diabetes and other non-communicable diseases cause almost half of the disease burden in LREs,⁶ where the incidence of diabetic foot disease is unacceptably high.⁷ Though prevalence estimates are limited by the lack of screening, in some LREs foot problems may account for up to 40 percent of all health resources for diabetes.⁸ Fortunately, there is evidence that lower-limb problems can be managed effectively at low-cost through the implementation of comprehensive care programs that include effective footwear.^{9,10,11,12,13} The diabetes pandemic superimposed on the burden of neglected tropical diseases has exponentially increased the global demand for appropriate, low-cost, effective footwear.

How Does a Focus on Footwear Help?

As pedorthists, we know that footwear offers therapeutic benefits by redistributing pressure, accommodating deformities, relieving pain, and restoring joint mobility. In LREs, footwear is also a public health intervention. In environments with poor sanitation, footwear is recommended to protect children from contaminated soil despite the limited empirical evidence regarding its effect on the transmission of intestinal parasites and other mycobacteria, which are known to cause diseases like leprosy and Buruli ulcer disease in humans. Footwear is a first line of defense in protecting children who live in the highland areas of tropical Africa, Central America, and West India, where many individuals develop podoconiosis (podo), a form of elephantiasis. Podo results from a genetically determined abnormal inflammatory reaction to mineral particles in irritant red-clay soils derived from volcanic deposits (www.podo.org). Footwear also can protect individuals from common hazards such glass, snakebites, and rusting metal. Finally, footwear helps to keep the feet clean and to prevent infections from small entry lesions between the toes or from cracks on the soles of the feet. These infections can be life threatening and exacerbate existing conditions.

Foot affected by lymphatic filariasis. Photograph courtesy of Mary Jo Geyer.

The "Legs to Stand On" Approach

In June 2008, we facilitated an integrated footwear workshop organized by Handicap International (HI) in Bamako, Mali (www.handicap-international.org). According to Pierre Brantus, MD, medical consultant, neglected tropical diseases (NTDs), Federation Handicap International, "The initial aim was to use lymphatic filariasis as an entry point for addressing the issue of footwear as an integrated approach to the treatment of other diseases that manifest foot pathology [diabetes, leprosy]."¹⁴ HI suggested that the integrated approach would reinforce participation in diabetes and lymphatic filariasis programs, a concept that was later demonstrated to be true.¹⁵ Because approximately 60–70 percent of the healthcare services in LREs are provided by nongovernmental development organizations (NGDOs), and almost all foot care and footwear training is provided by NGDOs, providers recognize that a more uniform approach to this training is needed.

In countries where resources are scarce, scaling up healthcare interventions is best accomplished via community-based delivery and home management. The Legs to Stand On (LTSO) initiative is an evolution of the work begun by HI and the LF-NGDO Network. LTSO is an international initiative to improve outcomes associated with lower-limb care and preserve the mobility of people who live in LREs using an integrated approach to providing resources and services at the community level. The aim of LTSO is to develop a model for lower-limb care that can be duplicated in countries worldwide. The first goal of LTSO was to develop integrated training materials for affected persons and their families, community volunteer healthcare workers, and the facilitators responsible for training the healthcare workers. These training modules are complete and will be published in June 2012. Together with Linda Lehman, MPH, OTR, CPed, we will present the LTSO training modules at the NTD-NGDO Network workshop being held in conjunction with the International Lymphoedema Framework meeting, which is scheduled to take place June 28–30 in Montpellier, France. NGDO partners will use the materials to conduct demonstration projects in order to validate the model.

In addition to the training materials that were created during the 2008 meeting, a prototype low-cost, made-to-measure sandal (developed by Janisse) was introduced that could be modified for various foot pathologies. Since that time, the footwear has evolved and is currently being tested at the University of Pittsburgh (Pitt), Pennsylvania, by master of science in prosthetics and orthotics (MSPO) students. The testing protocol involves determining the physical and biomechanical properties of the sandal materials as well as the effectiveness of the sandals in redistributing plantar pressure and the performance of the sandals compared to barefoot walking via motion analysis. Developing culturally appropriate, effective, low-cost footwear prototypes for various pathologies is part of the LTSO model. To help ensure the program's sustainability, part of the LTSO plan is to explore strategies to develop small retail footwear businesses and materials manufacturing facilities.

Getting Involved

We are working with the Pedorthic Foundation to launch a new initiative to develop an international curriculum for footwear technicians, technologists, and pedorthists. This program, known as "FootFitters," was announced by Janisse at the IVO Congress international pedorthic meeting in Sydney, Australia, in March 2012. Janisse, who also serves as chair of the FootFitters Program Executive Group, solicited funds and the participation of international stakeholders while at the meeting.

Here's how you can get involved:

1. Participate in the curriculum development.
2. Collaborate as a technical expert.
3. Compete in Pedorthic Foundation or Footfitters grand design challenges.
4. Co-sponsor research, dissemination, education, or innovation activities.

Dennis Janisse, CPed, is president and CEO of National Pedorthic Services, headquartered in Milwaukee, Wisconsin. He also is a clinical assistant professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, Milwaukee, adjunct professor at University of Pittsburgh, Pennsylvania, and director of scientific affairs for Orthofeet, Northvale, New Jersey.

Mary Jo Geyer, PhD, PT, CPed, specializes in wound care, lymphedema management, and pedorthics. She is a faculty member, researcher, and the academic coordinator of clinical education for the MSPO program at the University of Pittsburgh.

For more information about LTSO, visit www.legstostandon.org or contact

References

1. International Diabetes Federation. 2011. Diabetes Atlas, 5th ed.
2. World Health Organization. Lymphatic filariasis fact sheet. www.who.int/mediacentre/factsheets/fs102/en/
3. World Health Organization. Facts and figures about diabetes fact sheet. www.who.int/diabetes/facts/en/index.html
4. Macdonald, J. and M. Geyer, eds. 2010. Wounds and Lymphoedema Management. WHO Press: Geneva, Switzerland.
5. World Health Organization. "Innovative Care for Chronic Conditions: Building Blocks for Action," global report. www.who.int/chp/knowledge/publications/icccglobalreport.pdf
6. Lopez, A., C. Mathers, M. Ezzati, D. Jamison, and C. Murray. 2006. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. The Lancet 367(9524): 1747–57.
7. Abbas, Z. and L. Archibald. 2005. Epidemiology of the diabetic foot in Africa. Medical Science Monitor 11(8):RA262–70.
8. Boulton, A. J. M., L. Vileikyte, G. Ragnarson-Tennvall, and J. Apelqvist. 2005. The global burden of diabetic foot disease. The Lancet 366(9498):1719–24.
9. Apelqvist, J. and J. Larsson, J. 2000. What is the most effective way to reduce incidence of amputation in the diabetic foot. Diabetes/Metabolism Research and Reviews 16(S1):S75–83.
10. Bakker, K., Z. Abbas, and S. Pendsey. 2006. Step-by-Step, improving diabetic foot care in the developing world. A pilot study for India, Bangladesh, Sri Lanka and Tanzania. Practical Diabetes International 23(8):365–9.
11. Pendsey, S. and Z. Abbas, 2007. The Step-by-Step Program for reducing diabetic foot problems: A model for the developing world. Current Diabetes Reports 7:425–8.
12. Calle-Pascual, A. 2002. A preventive foot care programme for people with diabetes with different stages of neuropathy. Diabetes Research and Clinical Practice 57(2):111.
13. Cross, H. and L. Newcombe. 2001. An intensive self-care training programme reduces admissions for the treatment of plantar ulcers. Leprosy Review 72(3):276–84.
14. Brantus, P. 2009. Ten years of managing the clinical manifestations and disabilities of lymphatic filariasis. Annals of Tropical Medicine and Parasitology 103(S-1): 5–11.
15. Cantey, P., J. Rout, G. Rao, J. Williamson, and L. Fox. 2010. Increasing Compliance with Mass Drug Administration Programs for Lymphatic Filariasis in India through Education and Lymphedema Management Programs. Public Library of Science - Neglected Tropical Diseases 4(6): e728.