12.10 Community Podiatry

Community Podiatry

Presented by: Iain Wilkinson, Jo Preston, Georgina Gill

 

 

Guest: Christina Eleftheriades

 

    Broadcast Date: 29th November 2022

    Recording Date: 26th October 2022

Download show notes here

Knowledge:

  • – To Know where community podiatrists are and how we can work with them 

Skills:

  • – To have an understanding of some of the key conditions and assessment questions we can ask patients about
  • be able to appropriately assess and advise a patient about footwear 

Attitudes:

  • – To consider how you might work with podiatrists in your work
Download Infographic here

Paper of the week

This weeks paper of the week is a systematic review of 79 articles looking at footwear and falls risk. Falls are known to most often occur during motor tasks with footwear having been identified as an environmental risk factor for both indoor and outdoor falls.

 

3 main areas were explored.

 

  1. What footwear do most older people wear? 

Older people wear inappropriate footwear inside and outside their hmes. A lack of knowledge about the importance of safe shoes and/or financial considerations may cpontirbute to why older people replace shoes less frequently.  Choice of footwear might be dictated by comfort and the need to accommodate painful feet leading to  older people wearing excessively flexible and/or overly long and wide shoes. Older people may select shoes without fasteners for the practical reasons that they do not have to bend down to tie laces or fasten straps. (Menant et a, 2008)

  1.  
  2. Is footwear a risk factor for falls in older people? 

Suboptimal footwear, regularly worn by older people, increases the risk of falls. There may be an increased risk of falls for those who walk barefoot, in socks, or in shoes without slip-resistant outer soles, or their risk of tripping by wearing ill-fitting slippers or shoes lacking fastenings. Wearing shoes that are the wrong size might also lead to foot problems which may then further contribute to falls risk. 

 

  1. What are the effects of specific footwear conditions on stability?

Researchers assessed a number of features of different foortwear such as assessing the impact of thicker running shoe type soles, raised heels, thicker and thinner soles. 

For older adults wearing running shoes they had an increased mean error in estimated joint position compared to younger adults, in addition to a baseline 162 percent lower joint awareness when compared to younger participants. 

 

More than ¼ of community dwelling older adults were reported to walk barefoot in their homes which again increased their risk of falling. 

Individuals who wore shoes with a high heel compared to those wearing lower or no heeled shoes had a slower walking speed, shortened stride length and increased cadence which could be explained as a more cautious walking pattern. 

 

Over all Menant et al report that older people should wear appropriately fitted shoes both inside and outside their homes with thin, hard soled shoes to optimise foot position.  A tread sole and bevelled heel may prevent further slips on wet and slippery surfaces. 

See the paper here

Social Media of the Week

Georgie: 

We spotted these lovely graphics by Sonia Sparkles on twitter which are a series of graphics designed to empower patients to be involved and ask questions about their care. 

Iain bought a  tweet from Neuroscientist Jessica Ross sharing a paper from their work looking for potential biomarkers for delirium.

A Day in the life of Community Podiatry

Podiatrists are specialists in assessment and management of the lower limb, and focus their treatments on the foot and ankle. They might work in hospital or community settings although the majority of NHS podiatry is provided through outpatient and community clinics. Patients are most often referred to podiatry services by their GP. 

Podiatrists cover a huge range of lower limb pathologies such as 

  • – wound care
  • – diabetes 
  • – nail surgery
  • – prescribing orthosis 
  • – musculoskeletal conditions

and work alongside MDT colleagues such as district and tissue viability nurses, OT’s, vascular and endocrine consultants and surgeons. Podiatrists themselves may select to specialise in certain areas of practice such as paediatrics, vascular specialty or many more. Some podiatrists may choose to undertake further training to become independent prescribers.

Back in episode 2.7 we discussed how foot health can be divided into two parts- form and function. In this episode we discussed key questions you can ask patients about their foot health and we considered how we consider foot health in our own assessments as clinicians. 

Common things to consider for older persons feet: 

  • – Ageing feet have thinner skin, and we loose the fatty padding around our feet especially on the soles. This reduces some of the shock absorption.  Considering the moisture and any damage to the skin on feet in important, particularly between the toes as this can be a potential infection site. 
  •  
  • – Looking for hotspots can be a useful way to identify potential foot issues early. Look for areas of redness that might be the start of blisters and ulceration. the key in foot care is early identification and prevention. Look at the backs of heels, sides of feet and boney prominences, and try to encourage people to regularly check their own feet for changes. 
  •  
  • – If treating wounds or ulcerations consider the tape or dressings used on the thinning skin of older peoples feet.
  •  
  • – As people age there is a reduction in sensory feedback from the feet and this can be compounded by the impact of disease pathology such as diabetic neuropathy or stroke meaning wounds or injury may be worse before a person is aware of them.
  •  
  • – Are the feet a good colour and temperature? is there any vascular concerns? is there any acute vascular issues on top of chronic underlying conditions that need managing?

Footwear

Ensure footwear is well fitted and appropriate to a persons foot shape. Velcro is useful for people who’s feet change shape frequently for instance as a result of oedema. 

For a person with oedema a podiatrist may consider:

What is  the cause of that oedema? So, like you said, is it heart failure? Are there any kidney issues? Is it gravitational oedema because they can’t lie down at night time, so they’re sleeping in a chair and their feet are down all the time?

So do we need to get further input from the wider MDT? 

Do we need to think about compression bandaging? 

Have they got issues with the Lymph system? Do we need Lymph Bandaging? 

Do we need compression bandaging to manage that so that we can get into more of an over the counter shoe?

Jean

For Jean, along with the considerations we spoke about earlier, there are some specific considerations related to both her Parkinsons and Dementia. 

Parkinsons:

Jeans balance is more challenged with the Parkinson’s and her feet will be trying really hard to cope with these changes in gate and posture. So it may cause the toes to sort of splay and to claw. And this happens in an attempt to kind of grab the ground or the footwear to try and keep Jean  more stable. 

 

In time, because this is so repetitive, this can cause like a buildup of excessive pressure, particularly on the end of the toes, and this can then result in painful callus or it could even result in ulceration. So certainly that’s something to be really mindful of. And the changes in balance and confidence can often cause patients to take shorter strides and they strike the ground differently, so they tend to strike with a flatter foot instead of the heel. But that heel strike is really important for a good gait cycle and to gain adequate propulsion to move you into the next step.. To help with this, Jean should wear  really good fitting footwear with supporting sole, good fastenings, you want it really secured to the foot.

 

Allowing for Six to ten millimetres at the end of the shoe would be really useful because that gives the toes a bit more space to stretch out. And as the gait is quite shuffling as well, there would be that risk of the toes rubbing inside the actual shoe.

 

Podiatrists  would encourage Jean or anyone to be using a walking aid if they feel it’s needed. There can still be quite a lot of stigma around walking AIDS, but they can be really useful for people who need them. 

 

Patients who have Parkinson’s tend to stiffen up at the ankle because they’re not walking as effectively as they should. So practising heel to toe exercises whilst they’re sitting down can help keep those ankles a bit more flexible and a bit more mobile. 

Some people living with dementia may walk around for large periods of time in a day, considering the impact of that high load upon the feet is important. 

 

Having  nice cushioned, supportive footwear, that’s going to give them that good shock absorption and as much protection as possible, not just piling on pressure on every stride. And certainly not the barefoot as well. 

 

If they can if you can encourage them to wear shoes, even trainer style, with a velcro fastening, that’s going to be supportive and cushioned to try and minimise any problems that may occur.

 

 If there’s significant cognitive impairment, we might enlist help from family and carers. Does she need to apply emollients or certain creams to the feet, but not in between the toes? If we’re providing an Orthotic, we have to make sure that that orthotic is used in the most appropriate footwear.

Additional points 

Nationally there is a shortage of podiatrists in the UK, which contributes to longer wait times for patients. 

 

Podiatrists can complete a 3 year university degree, or some enter the profession via an accelerated pre registration MSc. Some NHS trusts also offer an apprenticeship route which also involves completing a degree.

NHS Key Skills Framework

Core

 

 

 

 

 

 

 

 

 

 

 

Health and Wellbeing

Communication 2: 

 

 

 

 

 

Personal and People development: 

 

Quality

 

 

 

HWB4 Level 2

 

 

HWB4 Level 3

Communicate with a range of people on a range of matters

 

 

Contribute to own personal development

 

Maintain the quality of own work

 

 

Enable people to meet ongoing health and wellbeing needs. 

 

Plan , deliver and evaluate care to meet peoples health and wellbeing needs

 

 

Foundation training Curriculum

Foundation Year 1

 

 

Section 2.6 Interface with HCPs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2.7 Interaction with Collegues

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4:20 Healthcare resource management

Describes the structure and importance of the wider healthcare team

 

 

 

 

Works effectively within the healthcare team for the benefit of patient care

 

Makes clear, concise and timely written and oral referrals to other healthcare professionals within the hospital

 

 

Acts as a member of the multidisciplinary professional team by supporting, respecting and being receptive to the views of other healthcare professionals

 

Works effectively with others towards a common goal e.g. accepts instructions and allocation of tasks from seniors at handovers and multidisciplinary team meetings

 

 

Demonstrates understanding of the organisational structure of the NHS and independent sector and their role in the wider health and social care landscape

 

 

Describes hospital and departmental management structure

 

 

Foundation Year 2

 

 

 

 

Section 2.6 Interface with other healthcare professionals 

 

 

 

 

Section 2.7 Interaction with Colleagues

 

Demonstrates ability to make referrals across boundaries / through networks of care (primary, secondary, tertiary)

 

Demonstrates initiative e.g. by recognising work pressures on others, providing support and organising / allocating work to optimise effectiveness within the clinical team

  

 

Section 2.7: continuity of care/ Interaction with colleagues

 

 

 

 

GP training Curriculum

 

 

 

 

Clinical management 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Managing complex and long term care

 

 

 

 

 

 

 

 

 

 

 

 

Working with colleagues and in teams 

 

 

 

 

 

 

 

 

 

 

 

Working well in organisations and systems of care

 



 

 

 

Organisation, management and leadership

 

 

 

 

 

 

 

 

Community orientation 

 

 

 

Contribute to an organisational and professional approach that facilitates continuity of care (e.g. through adequate record keeping and building long term patient relationships)

 

 

Organise follow up of your patients after referral through multiprofessional, team bases and structured approaches including monitoring, reviewing and regular care planning. 

 

 

 

 

Demonstrate the ability to effectively ‘navigate’ patients with multiple problems along and between care pathways, enabling them to access appropriate team members and services in a timely and cost-effective manner. 

 

 

 

 

Enhance working relationships by demonstrating understanding, giving effective feedback and maintaining trust. 

 

 

Appropriately seek advice from other professionals and team members according to their roles and expertise. 

 

 

Show commitment to a process of continuing professional development through critical reflection and addressing of learning needs. 

 

 

Recognise the importance of distributed leadership within health organisations, which

places responsibility on every team member and values the contribution of the whole team

 

 

Describe the current structure of your local healthcare system, including various role, responsibilities and organisations within it, applying this understanding to improve the quality and safety of care you provide. 

 

Core medical training curriculum 

 

Managing long term conditions and promoting patient self care: 

Define the role of rehabilitation services and the multi-disciplinary team to facilitate long-term care

 

Internal medicine training curriculum (Stage 1)

 

Cat 2.3 . Communicates effectively and is able to share decision making, while maintaining appropriate situational awareness, professional behaviour and professional judgement

Communicates effectively with clinical and other professional colleagues

 

 

Geriatrics and higher specialty training curriculum

 

 

 

 

 

 

 

 

 

 

27: 

 

 

 

 

 

 

 

 

 

 

 

 

 

30: 

 

 

Define the role of rehabilitation services and the multi-disciplinary team to facilitate long-term care

 

 

CGA Have knowledge of the major sources of financial support, especially attendance allowance

 

Have knowledge of the range of agencies that can provide care and support both in and out of hospital and how they can be accessed

 

 

Rehab and MDT working.  Roles and expertise of different members of interdisciplinary team