Diabetes Foot Health and Prevention Program: A Podiatrist / RN Collaborative Practice Dr. Pamela Monk Visiting Podiatrist drpamelamonk@live.ca(204) 391-9719 Danna Ferry RN Ferry RN Services dlferry@live.ca (204) 509-9203 Diabetic Foot Health and Prevention Program Youville Diabetes Centre 33 Marion St. Winnipeg, MB R2H 0S8 Phone: 204-233-0262 ext 227 Fax: 204-233-1520
Diabetes Foot Health and Prevention Program: Objectives: Talk about who we are Why we developed the program The basis of the program Demonstrate what we do Discuss using this diabetic foot health model in other primary care and family physician practices
Who we are: Dr. Pamela Monk Podiatrist Danna Ferry RN
Podiatrists: Who are they?
Podiatrists: Who are they?
Podiatrist Scope of Practice Regulated Health Professionals Licensing body is the College of Podiatrists of Manitoba (COPOM) www.copom.org Podiatrists are medically trained healthcare professionals who specialise in diagnosing and treating disorders of the foot and lower limb.
Podiatrist Scope of Practice The Podiatry Act defines the practice of Podiatry as "the use of medical, physical, or surgical methodsto prevent, diagnose and treat ailments, diseases, deformities and injuries of the human foot, but does not include treatment of systemic disease except for the local manifestations in the foot."
Diabetes Foot Health and Prevention Program: A Podiatrist / RN Collaborative Practice For more information about Collaborative Care see the WRHA Website: http://www.wrha.mb.ca/professionals/collaborativecare/index.php
Diabetes Foot Health and Prevention Program: WHY?? One of the most devastating and costly complications of diabetes is lower limb amputation. In 2008/09, Canadian adults with diagnosed diabetes were almost 20 timesmore likely to be hospitalized with non-traumatic lower limb amputations than their counterparts without diabetes. In 2007, only 51%of individuals with diabetes surveyed in the CCHS met the clinical practice guidelines for foot examinations. Diabetes in Canada: Facts and figures from a public health perspective. Public Health Agency of Canada Ottawa 2011 p 31 Fig 2-2 http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/index-eng.php
HSC Diabetic Foot Clinic Multidisciplinary Team of Doctors from ID, Vascular, Ortho and Derm ; Nurses, Cast and Ortho techs Home Care Wound Care Nurses Long Term Care Wound Care Teams Publically Funded Family Physicians MHC Diabetic Foot Clinic Multidisciplinary Team of Doctors from ID, Vascular, Ortho and Derm ; Nurses, Cast and Ortho techs CHC s Nor West, HAC, Mt Carmel Nursing Foot and Wound care Diabetes Education Resource Teams Private Sector Physio Podiatrists Foot Care Nurses
What our clients told us : Foot Pain is a problem!
What our clients told us : Foot problems are FRUSTRATING!
Our Goal: Diabetic Foot Health and Prevention Program Collaboration with Podiatrist and RN Diabetes Community Care (Accessible) Evidenced based best practice Effective prevention of complications Effective treatment for pain To start at diagnosis of diabetes Refer to specialist teams PRN
Initial Neurovascular and Biomechanical Lower Limb Assessment: Brief Medical History Diabetes particulars Duration of DM Level of BG control, Last A1C What specifically has brought client here Baseline mobility Pain assessment
Initial Neurovascular and Biomechanical Lower Limb Assessment: Skin and nails (any pathology) Vascular Skin and nails (signs of vascular compromise) ABI and waveform Doppler sounds Neurological testing 10 gram monofilament Vibration, light touch, blunt/sharp, ankle reflex, plantar response, temperature sense, proprioception
Initial Neurovascular and Biomechanical Lower Limb Assessment: Biomechanical assessment Deformity ROM Muscle strength or wasting Gait Abnormality Walking aids
After examination completed: Any immediate treatment or off-loading needed is done All findings discussed and teaching for self-care done Any prescriptions needed are given Report to Family Physician along with suggestions for further referral PRN Follow-up plan for all of the above
Case Study: Client A Sep 30/13 61 year old white male Type 2 DM for 2 years, last A1C 7% 1984 herniated disc WCB injury with spinal fusion L 4-5 2004 (had sx 4 times) Post-surgical deficit L foot drop Falls about twice a month Using L foot drop assist (not AFO) Staying active VERY important to him
Case Study: Client A cont d Findings: Vascular good. Possible arterial flow L foot Stiff pes cavus foot on the R Loose, floppy foot on the L with sensation, proprioception and muscle strength 0.5 cm tibial length R longer than L High-stepping uneven gait
Case Study: Client A cont d Treatment: Explanation and demonstration of his biomechanical issues Orthopedic shoes L AFO with slight heel lift Recommended lighter AFO for comfort Appropriate education and F/U to minimize falls and further joint damage
Case Study: Client B Dec 17/12 69 year old white male Type 2 DM for 10 years, insulin & oral meds Worked all day standing on concrete floors C/O foot pain to the dorsi of both feet For at least 6 months or longer R > L Sometimes sharp pain when standing Aching pain when sitting Started on Gabapentin but stopped with LFT s Off and on Lyrica with no relief
Case Study: Client B cont d Findings: Vascular acceptable for his age No signs of peripheral neuropathy Fixed 1 st MTPJ (halluxes) bilaterally Rest of foot hypermobile and +++pronation Inflamed soft fluctuant SC mass on mid-dorsi each foot ~ 5.0 cm in diameter at site of pain
Case Study: Client B cont d Report to Family Physician: Possibly acute bursitis from biomechanical imbalance. Treating with arch supports and protective padding and shoes with firm sole If pain does not resolve recommend MRI/cortisone injections for inflamed masses We will follow this client in 6 weeks
Case Study: Client B cont d Treatment and Education: Explained biomechanical origin of condition and how footwear could improve it. Provided arch support and protective felt padding immediately Advice for footwear with firm supportive soles (he had already purchased some) Supportive slippers at home Booked F/U with Foot Nurse to monitor
Case Study: Client B cont d Follow-up at 2 weeks: Wearing therapeutic footwear consistently Pain d from 9/10 daily to 4.5/10 Follow-up at 8 weeks Pain d from 4.5/10 to 1-2/10 at 8weeks and only present if too long on his feet Inflammation visibly reduced by half
Case Study: Client C June 12/12 26 year old white female Type 2 DM for 2 years BG improving on Metformin Occasional arch and knee pain History of plantar fasciitis Anxiety ++++ and working with Youville Counsellor for same
Case Study: Client C cont d Findings: When Questioned about DM control to date: Reported wt. lose of 118 lbs since diagnosis Walking ~ 5 kms/day Neurovascular exam normal Pes cavus Hallux valgus stage 1 bilaterally Rearfoot and forefoot varus ~ 10 Slight pronation Good runners for walking but poor footwear at work
Case Study: Client C cont d Treatment, Education and F/U Reinforced her progress to date with excellent self-management and lifestyle changes Provided arch supportive insoles and advised use of same at all times to prevent foot pain and plantar fasciitis F/U in 1 year with Foot Nurse showed her happy and active
Discussion Do you think that we have met our objectives? Any suggestions? What do you think of this type of lower limb assessment being available to all people with diabetes? Being used to develop a standard for Diabetes care in the community setting? Is anyone interested in working with us?
Thank you for listening!
Contact information: Dr. Pamela Monk Visiting Podiatrist drpamelamonk@live.ca(204) 391-9719 Danna Ferry RN Ferry RN Services dlferry@live.ca (204) 509-9203 Diabetic Foot Health and Prevention Program Youville Diabetes Centre 33 Marion St. Winnipeg, MB R2H 0S8 Phone: 204-233-0262 ext 227 Fax: 204-233-1520