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Over emphasis on sparse research?

Discussion in 'Diabetic Foot & Wound Management' started by louisemuir, Feb 9, 2017.

  1. louisemuir

    louisemuir Member


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    I have for years been using semi-compressed felt to successfully heal wounds. I pack out the arch with 'D' pad felt often 20 or 30mm' taping down each 10mm layer to stop it all moving and I extend the plantar padding to the heal -if deflecting a forefoot wound- again up to 30mm taping down well each 10mm layer. This technique has worked well for me and its easy to cut appetures in tape to allow the wound to be free for nurses to change between padding.

    Despite the success of this technique, however, hospital Podiatrists have rubbished the padding infront of clients and claimed that it is too bulky -which is then a patient compliance nightmare when the wound deteriorates as they have proceeded to use 3mm felt stuck to a tubigrip as deflection.

    The cause of this conduct though might well have been research based and on Australian Diabetes website their evidence for felt as a wound deflection material was very poor and it was advised not to use it. I asked Diabetes Australia researchers what was the research that they based this on and they said that it wasn't their research but that from the research available it was found that felt is an anomaly that no one understands as 5mm felt was found to decrease pressure more than 10mm.

    Despite having not looked at the research I am almost positive that this increase in stress found in the nearly completely but still only partially deflected area is the introduction of more friction -the more complete the partial deflection is this I have seen clinically in hypergranulation as a result of incomplete but nearly complete deflection.

    Otherwise it might have been, in my mind, due to 10mm padding creating more of an ankle equinus than 5mm felt and therefore increasing stress by pronation. Having not read the research I can't say but I have always worked with felt and have never found it to be an anomaly and in fact I have found it to behave very predictably when applied but it really won't fully deflect, I've found, until I fully deflect.

    Full rigid deflection is however the gold standard of wound care but total contact casting is a further compliance issue and is not always safe due to falls risk in the elderly therefore fully deflecting with felt despite being bulky and seriously unsexy with hospital podiatrist and researchers, will remain my treatment of choice in most cases.
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
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    It is always a tricky situation when your clinical practice does not gel with the alleged latest research. I deal with this on a daily basis in what I do, and when the evidence is lacking you have on fall back onto 'theoretical coherence' and 'biological plausibility'. When the evidence is conflicted, you have to critically evaluate that evidence without biases and blinkers on. When your clinical practice 'contradicts' the evidence, then we have professional, ethical and legal (check AHPRA guidelines) to work it out. Why are they different? What does your unbiased unblinkered critical appraisal of the research say? Clinical "success" can be a very deceptive thing (and is a very big topic I won't get into here).

    Lots of cognitive dissonance around this one

    I just about to record a video this PM dealing with one of those situations; where a lot of peoples good clinical experience and practice is contradicted my most of the good RCT's.

    (Just as an aside, there was some thought a while ago that full deflective padding was not quite a good thing as it encouraged wound oedema which would inhibit healing somewhat, so thought was that there dod need o be come pressure on the wound, but obviously a lot less so it healed.
     
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