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Effectiveness of scalpel debridement for painful plantar calluses in older people: a randomized tria

Discussion in 'Gerontology' started by NewsBot, Aug 9, 2013.

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  1. NewsBot

    NewsBot The Admin that posts the news.

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    Effectiveness of scalpel debridement for painful plantar calluses in older people: a randomized trial
    Karl B Landorf, Adam Morrow, Martin J Spink, Chelsey L Nash, Anna Novak, Julia Potter and Hylton B Menz
    Trials 2013, 14:243
     
  2. wdd

    wdd Well-Known Member

    The title of this study "Effectiveness of scalpel debridement for painful plantar calluses in older people: a randomised trial" doesn't seem to describe the study as accurately as a slight modification of the first line of the conclusion, "The benefits of real or sham scalpel debridement for reducing pain associated with forefoot plantar calluses in older people.

    For me the second description homes in more precisely on the focus of the study, ie changes in pain levels, while the actual title seems to suggests some more general form of 'effectiveness' or more accurately lack of effectiveness.

    If someone has more than one painful site how efficiently can they focus on and give an accurate account of the pain from one of the sites?

    Participants were required to nominate the most painful callus site on the plantar aspect of their forefeet and they were asked to concentrate on that site when completing all outcome mearures.

    Following baseline assessments,.... they initially received treatment of nails and hyperkeratotic lesions other than those on the plantar surface of the metatarsal heads (for example, dorsal digital lesions)

    If you have a bad sore head and some one asks you to focus on a pain in you foot, does the pain in your head affect your assesment of the pain in your foot? Similarly does the proximity of the two painful sites affect your assessment of the pain level, ie if you have a very painful external 5th digital corn and a moderately painful plantar callus how well can you assess the pain from the plantar callus?

    Put generally, is there an interaction between pains from different sites and to what extent does concentrating on one site allow the pain from the other site/s to be ignored?


    The outcome of this study and others seems to fly in the face of the experience of many, if not all, podiatrists who spend the greater part of their working day reducing callus and would seem to question the value of their work work that was and is the central work of the majority of podiatrists?

    My major concern is that the researchers are more likely to be podiatrists who, for a range of reasons, do not wish to be directly associated callus and corn and who, along with many other podiatric specialists, have taken big steps to separate themselves from the core work of actually reducing corn and callus. I wonder to what extent the mind set of the researchers, with respect to callus and corn reduction, interfers with their interpretation of the data?

    Bill
     
    Last edited: Aug 10, 2013
  3. See also:
    http://rheumatology.oxfordjournals.org/content/44/2/207.short

    So, that's now two placebo controlled trials which show that scalpal debridement of plantar callus is no more effective at reducing pain than a "sham" debridement.

    Our own study showed that scalpal debridement resulted in increased pain in some individuals 6 weeks post debridement. Timson S, Spooner SK. A comparison of the efficacy of scalpel debridement and insole therapy in relieving the pain of plantar callus. Br J Podiatr 2005;8:53-9

    Do I make part of my living debriding callus? Yes. Should I be debriding callus? Not sure, but the published scientific evidence isn't looking so good. Anecdotally, my patients choose to come back regularly and pay for me to debride their callus- what should this tell me?

    BTW, the linky to the journal article in the OP doesn't find the paper.
     
  4. wdd

    wdd Well-Known Member

    Go to the link and then go to articles. it's within the first half dozen articles.

    Bill
     
  5. wdd

    wdd Well-Known Member

    Conclusions: the benefits of real scalpel debridement for reducing pain associated with forefoot plantar calluses in older people are small and not statistically significant compared with sham scalpel debridement. When used alone scalpel debridement has limited effect in the short term, ....

    Is this another way of saying: Any apparent reduction in pain, associated with plantar callus reduction, is purely placebo effect? Could they have conluded that the patients would gain the same benefit from homeopathy?

    However these findings do not preclude the possibility of cumulitive benefits over a longer period or additive effects when combined with other interventions.

    Given that the subjects were taken from the patient list and that the normal return period to their clinic is six weeks (in the UK eight weeks) the study, in practical terms, does preclude the possibility of a cumulative effect. Either that or the results were a manifestation of the cumulative effect or a cumulative effect is only apparent if the return interval is less than six weeks?

    It might also be reasonable to assume that prior to this treatment or sham treatment they had benefitted from 'other interventions'. Might these previous interventions plus any cumulative effect have had some influence on the results?

    Bill
     
  6. Bill, what they are basically saying is that from the point of treatment to six weeks later, at each measurement point there were small differences in the pain scores betwen the treatment and placebo groups, but statistically these differences were not significant. You might want to ask each of the patients if these differences in pain levels were significant to them.

    Cummulative? In this study the patients callus was only debrided once, what we don't know is what would happen to the patients pain scores following multiple treatments and/ or over a longer time frame.

    Prior treatment is important. In our study we took patients who had received no previous treatment for their callus.
     
  7. It might be more realistic and useful in a study such as this to control or monitor the weightbearing activity level of the subjects since it seems likely if the foot pain of the subjects is greater, then they will walk less, just to reduce their pain. My guess is that if subjects with painful plantar callouses were separated into two groups, debridement and sham debridement, and they were then monitored for activity level and pain level, that the debridement group would have significantly more hours of weightbearing activity than the sham debridement group.

    People who have these lesions invariably will significantly curtail their weightbearing activities to avoid intolerable pain. People who have these lesions debrided invariably will report that they are able to do significantly more hours of weightbearing activities immediately after debridement. I would think that an optimally-designed study of this nature should control or measure activity level post-treatment. After all, increased weightbearing activity and reduced pain with weightbearing activities is the goal of these treatments.....isn't it??
     
  8. wdd

    wdd Well-Known Member

    I have often wondered how the 'normal' return periods of, say 4<8 weeks was arrived at. I never felt is was designed with any idea of 'cure' in mind.

    I have often thought that, combined with other interventions, a genuine and significant positive cumulative effect might be witnessed if the return interval was around 1 week, at least for the first three months and possibly six months.

    Could you design a good and successful business model based on weekly callus reductions?

    Bill
     
  9. Rob Kidd

    Rob Kidd Well-Known Member

    Callus rather amuses me. When I was on the teaching staff at Northampton, not very long after they "revolutionised" clinical teaching by having specialist clinics (Orthopaedic clinic, Phys med, dermatology, paediatric etc), I was on the ortho [aka biomechanics] clinic when a student from the dermatology clinic next door came through and asked if I knew any dermatology. My reply was: "MMMmmmm, well, a little, try me" He then said, "come and look at my patient: have I taken enough hard skin off that"!
     
    Last edited: Aug 11, 2013
  10. Often, when patients tell me their callus is painful, I remove the glove on my left hand and show them the apices of my lesser fingers. Without this hard skin, playing the guitar for more than 20 minutes would be impossibly painful. It's there for a reason - just like the callus on their feet. Once they understand that principle, taking them to the next step of addressing why the lesion is occurring, is relatively straightforward. That said, removal of often the slighted increase in epidermal thickness, often gives a reduction in the acute symptoms many of our patients experience.

    Not with my fingers though.
     

    Attached Files:

  11. Luckily...... no hair on the palms....:rolleyes:
     
  12. Never had no trouble turning on the charms... "No for the 13th time"- stuffies
     
  13. I'm right-handed, Kevin.
     
  14. blinda

    blinda MVP

    Regretting googling `hairy palms` :eek::eek:
     
  15. "Hairy palms" and "sick"????? Bel you simply need to get out more...;):drinks
     
  16. PostMortem

    PostMortem Active Member

    Hi all,

    PA never ceases to amuse and educate me :). When I worked in North Cumbria, over 10years ago now :eek: , we used an episode of care model within the NHS, this allowed the Podiatrist to provide an intensive 6 month period of treatment that could include weekly visits for debridement of painful lesions. The cumulative effect could be remarkable with resolution of HDs leading to discharge of the patient. A great deal of effort went into 'empowering' the patient to self-care for these lesions, change footwear, etc. and simple insoles were frequently used to aid pressure relief or simply cushion the affected area.

    As a business model in private practice, I offer this as an option, but not many take it up? Most patient seem happy to take the easy option and let someone else do it for them.
     
  17. wdd

    wdd Well-Known Member

    Traditionally, return periods for debridement (in otherwise healthy patients) seem to be based essentially upon the answers to two questions:

    How long does it go before it becomes painful?

    Are there any appointments available then?


    Is there a more scientific rationale based on say physiology, biomechanics, dermatology, ...ology?

    I would think that ideally any business model should be backed-up by science although it seems that it hasn't been up to now?

    Bill
     
  18. wdd

    wdd Well-Known Member

    Maybe pain is not the criterion on which the decision to debribe should be based?

    Excluding of course the ongoing criterion of needing to make a living.

    Bill
     
  19. Pain is certainly the principal criteria which patients use to make the judgement that debridement is required.
     
  20. The keratinocyte transit time is suggested to be between 40-56 days. Obviously there will be variation in this, but it would seem a reasonable point to start.
     
  21. For many patients, the predominant influence has been the NHS appointment system over the years. On my first post after graduation, my "induction" consisted of a 10 minute meeting with the Area Chiropodist who handed me a diary and a set of clinic keys and said "good luck!" When I asked about patient appointments he said that today's patients would be seen in seven weeks time - all of them. Each day was Groundhog Day - only at seven week intervals. Then it was eight, nine, ten, eleven - as holidays and increasing caseloads pushed up the Rx intervals. The concept of flexible capacity by using different scheduling strategies never occurred to him. For many patients the six, seven, eight-week return has been hard-wired into them by the NHS and bears little or relation to their symptomatic lesions.

    Most of my professional life I ave used a direct access appointment system - where the patient with HDs and s/call make their appointment when they are symptomatic. The key is being able to offer appointments within a short timeframe - certainly within five days. That then gives the clinician a mechanism for evaluating their Rx approach - footwear mods/insoles/orthotics etc - as the Rx interval can be used as a determinant of efficacy. I know that will not always be accurate - sometimes a reduction in pain leads to increased mobility - which will then maintain the keratinocyte transit rate - but the key here is your prescription protocols. Off-load a pressure lesion completely and it will resolve within six months - but the outcome is dependent on multiple factors, of which, compliance is but one.

    On the rare occasions that I haven't played guitar for a few months, my apical callus disappears within eight weeks and the skin returns to 'normal'. I suspect if I was to play even once a week for an hour the callus would be maintained. The interesting study would be what level of recurring pressure is needed to maintain a pathological lesion that leads to the variations that Simon mentions.

    Karl's papers are always interesting, but from a clinical rather than a research perspective, effective scalpel debridement in combination with a progressive approach to the alleviation of localised pressure and a reduction in the pathological tissue stress, should be enshrined and promoted by the profession as its primary USP!

    Remember this thread? http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1723
     
  22. Which is often why some in private practice especially are charged with the "cut and come again" business model. Personally, I think this is crazy. There may be a few patients whose condition is refractory, but not many. If you clear a persistent troublesome lesion, you don't lose a patient - you will gain a dozen more. Pedicures are fine and dandy but have no place as a clinical model for podiatric intervention.....in public or private care.
     
  23. citychiropody

    citychiropody Member

    cant see any mention of actually WHO is doing the treatment ...a podiatrist , nurse ???
     
  24. EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology.

    (Sackett D, 2002)

    I'm the first to shout that the plural of anecdotes is not data. But considering the vast, vast numbers of patients who pay good money to come back every 6-12 weeks to have their callus debrided, together with the depressing predictability of some patients to ulcerate when they've gone over "their time", I think the evidence would have to be pretty overwhelming to make me question the value of debridement.
     
  25. wdd

    wdd Well-Known Member

    Don't question the value of debridement, question the value of debridement at 6-12 week intervals? Did patients learn the 4-12 week interval from podiatrists?

    Bill
     
  26. Craig Payne

    Craig Payne Moderator

    Articles:
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    podiatrists
     
  27. wdd

    wdd Well-Known Member

     
  28. wdd

    wdd Well-Known Member

    It would be very interesting to look at the keratinocyte transition rates at different sites on the apexes of your fingers, eg epidermis underlying the callus, epidermis on the periphery and epidermis at say 1cm from the callus and to do it both during a period when you were playing the guitar and a period when you weren't.

    It might also be more informativerate if the keratinocyte tranition rate could be divided into two parts, ie from the basal layer up to the str.corneum and through the str. corneum.

    While I am sure that the superficial appearance of the skin returns to 'normal' within eight weeks, I wonder if microscopic examination of the epidermis, dermis and hypodermis would confirm it and if not what changes would you find and where?

    Best wishes,

    Bill
     
  29. I'll say it again.

    Unless the plantar lesion debridement study controls for post-debridement activity level in their subjects, the clinical effectiveness of plantar lesion debridement will likely be under-estimated due to the expected increased weightbearing activities in the individuals that did have debridement performed. Weightbearing activity level can easily be quantified these days by subjects wearing accelerometers pre- and post-debridement.

    http://www.sciencedirect.com/science/article/pii/S0378512211003690

    Once this type of study is done, controlling for or monitoring for pre- and post-debridement activity levels, I think the experimental results will more closely reflect what most podiatrists have observed practically daily during their practice careers: debridement of painful plantar lesions significantly affects the pain of weightbearing activities relative to the activity level of the individual.
     
  30. wdd

    wdd Well-Known Member

     
  31. wdd

    wdd Well-Known Member




    I have just re-read the thread Mark and I think it makes interesting reading. What is absolutely clear is that there are more questions than answers.

    I know that I Keep coming back over it but it seems to me that until the study of callus and corn become more biomechanically orientated not much progress is going to be made in terms of our understanding of the subject.

    When I say biomechanics I think that possibly, at levels approaching the microscopic, that mechanobiology (a sub-set of biomechanics) might have more to offer.

    Looking at the separate and combined roles of the cytoskeleton, cell junctions and extracellular matrix in force transmission and transduction might start to open our eyes to diferent ways of envisaging 'corn and callus', eg seeing the str.corneum as part of a tensegrity structure.

    Describing any hyperkeratotic lesion as a 'foreign body' or as an 'excrescence', which happens in the literature and during undergraduate teaching, surely demonstrates a significant lack of understanding of the astounding complexity of the human body and represents a trivialisation of the historical central focus of a profession.

    I am often astounded that searches of podiatric texts on corn and callus, eg Neales, produce so little of value. Even though there has been quite a bit of research in this area over the last forty or fifty years it doesn' seem to have been distilled into a comprehensive working hypothesis of corn and callus, etiology, pathology, etc. or if it has it doesn't seem to have been written up?

    The preceding two paragraphs are just rant or a professional tantrum so, 'mother father kindly disregard this letter'.

    Bill
     
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