VI Nordic P&O Congress in Iceland - Part Three
Nerrolyn Ford PhD CPO
Dr. Ford is an Australian practitioner who was on faculty in the P&O program at the British Columbia Institute for Technology in Canada until recently, when she accepted a similar position in Sweden. She presented an excellent overview of her pragmatic work on Observational Gait Analysis [OGA].
Nerrolyn's primary point was that visually analyzing gait could be very unreliable. For example, Keenan and Bach studied a cohort of podiatrists who were asked to identify hind foot motion using OGA. The ability of these clinicians varied widely, with at least one doctor scoring less than chance at correctly identifying whether or not the foot was pathological.
On the other hand, practical methods such as the use of slow motion video has been shown by Krebs et al [1985] and others to enable trained observers to achieve at least moderate inter-rater and intra-rater reliability at recognizing orthopedic gait deviations. Ford and colleagues used head-mounted cameras to study how experienced prosthetists, therapists, and physicians conducted OGA as compared to a group of P&O student novices and lay people.
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In summary, the students tended to fixate on the foot region, and to rapidly survey the entire body without keying in on any specific comparisons. In contrast, the experts compared motion at each joint to the contralateral side, and to adjacent joint motion, in a much more systematic manner. Experts in general, and physical therapists in particular, also spent more time observing the head, arms, and trunk rather than just the lower limbs. Virtually everyone studied used a "top down" strategy, initially watching motion of the head and trunk region, and then progressively moving their gaze to more and more distal joints.
These data were used to investigate the most effective manner to train novice CPO students to improve their gait analysis skills. Although Nerrolyn recognizes that Computerized Gait Analysis [CGA] is far more accurate and comprehensive than OGA, her work is intended to optimize the effectiveness of this low cost method for clinical evaluation that is likely to continue to be the worldwide norm for decades to come.
Per Holstein MD
Dr. Holstein is one of the most recognized world experts in the management of diabetic feet, so this talk on the Diabetic Neuropathic Foot was a superb overview of the latest thinking in the rapidly changing management of this difficult pathology. He summarized the situation by noting that the diabetic foot is threatened by four different problems at once:
- Neuropathy, resulting in loss of protective sensation
- Rigidity, resulting in increased plantar forces during ambulation
- Low resistance to infection, leading to potentially life-threatening complications
- Poor circulation, compromising tissue viability and healing potential
Dr. Holstein is a staunch advocate of the multi-disciplinary diabetic foot clinic team, and offered good evidence that this approach results in maximum effectiveness in preserving and protecting these at-risk patients. He reviewed the literature, which showed convincingly that Total Contact Casting [TCC] remains the most proven and - over the longer term - the most effective mechanical method to facilitate wound healing. Prefabricated walking devices such as the Aircast have been shown to be comparable in the short run, but take more time to achieve healing and do not heal as large a percentage of patients. Holstein advocates the use of custom-molded foot orthoses inside prefabricated walking boots as one possible method to increase their effectiveness.
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He reviewed the world literature on various "healing accelerants" and found little evidence that they were effective for this population. He has been investigating "biosurgery" using medical grade fly larvae to debride infected heel ulcers, which are among the most difficult wounds to manage. Because the maggots only eat dead tissue, they appear to meticulously clean the healing ulcer without harming the healthy tissue. This initial study on this historic technique shows that the results are significantly better than placebo effect, so this may indeed have merit in today's world.
Dr. Holstein also noted that while custom foot orthoses are well accepted in the management of the at-risk diabetic foot, they require ongoing monitoring and regular modification to be effective. He observed that there is presently no data supporting the superiority of one type of FO over another, so that decision remains a clinical judgment.
He reviewed surgical methods in some detail, suggesting that metatarsal head resections for recalcitrant forefoot lesions were generally effective while tendo-Achilles lengthenings had not proven as successful in the long term.
He concurred with the results of McCabe et al [1998] who demonstrated that comprehensive treatment of the diabetic foot by a multidisciplinary team can reduce the rate of limb loss as much as 1200 per cent, and has proved to be significantly more effective than screening alone. Using this method, the Danes have reduced the overall incidence of major amputation by 80 percent over the past 20 years; 90% decrease in amputation rate for Type II diabetics and a 60% decrease in the rate of amputations for Type I diabetics.
Perhaps most significantly, Dr. Holstein informed the audience that there is now an international consensus on the management of the diabetic foot, and this information is available on CD for $15Euros from www.idf.org/bookshop and for $25Euros in text format. This is an excellent resource that all clinicians who work with diabetic individuals will want to have in their professional library.
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