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What biomechanics assessments in diabetes?

Discussion in 'Diabetic Foot & Wound Management' started by Foot fan, May 18, 2006.

  1. Foot fan

    Foot fan Active Member

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    Bridging the gap

    Hi everyone,

    I am currently trying to conduct a research task in Biomechanics for my work place - a high risk clinic in a hospital (primarily diabetic). Currently the clinic does not use any biomechanic assessment techniques and the most we do with an orthotic is add some plastazote. What they are hoping for from me is a clinical pathway and biomechanics assessment form that is clinically applicable (and simple to assess) but also theoretically sound and drawn from current practice.

    Initially I was to conduct this through literature review but current articles suggest that 'analysis' be completed with expensive equipment that the clinic will not be able to purchase on their limited budget. When I explained this to the supervisor, my research was redirected onto the global scene, I am now expected to bridge this gap between research and clinical practice by finding out how the rest of the world is assessing biomechanics clinically. At first this seemed a relatively straight forward task but after many solid hours sifting through biomechanics information I have realised this is indeed a huge task. Even focussing only on English speaking countries (no offence intended to those members who do not live in primarily English speaking countries, I would value your input too) I have literally hundreds of institutions and organisations that would have valuable input.

    Having only 8 months and no set time to complete this task on my own, it does not take a mathematician to work out the numbers don't add up. I have looked through the biomechanics resources linked to this page and they are fantastic but there is just so much. I am not afraid of reading and am looking forward to getting back into biomechanics but does anyone have any suggestions as to how to tackle this particular issue so as to develop a well rounded, unbiased assessment strategy without going crazy, blind or both??? :eek:
  2. Craig Payne

    Craig Payne Moderator

    Expensive pressure measuring equipment is helpful, but not necessary. Any good clinician can find high pressure areas without it.

    The first question to ask is, what are the biomechanical factors that lead to an increased risk of foot complication in the person with diabetes? .... they are the factors that should be assessed for. Vanessa Nube's paper earlier this week on Biomechanical Risk Factors Associated with Neuropathic Ulceration of the Hallux in People with Diabetes Mellitus is a good place to start.
    Last edited by a moderator: May 19, 2006
  3. javier

    javier Senior Member

    From, I have read you are looking for develop somekind of questionary for clinical purposes. Am I right?

    Perhaps, I can help you. You do not need an expensive equipment for diabetic assessment. First of all, you should define your goals based on your population. Which are your goals?

    Also, a quick refering manual is the International Consensus on the Diabetic Group from the International Working Group on the Diabetic Foot http://www.iwgdf.org/

    It is a good start. Many times the easiest way is the best way ;)
  4. Cameron

    Cameron Well-Known Member

    Foot fan et al

    I am working in a multidiscipline team directed to provide education and support to highter risk clients likely to become frequent users of hospitals. The initiative its to try to reduce hospital bed time and the progam is available to self motivated clients willing and capable of coming to terms with the seriousness of their illness(es). The program is directed at people over 16 so Type I diabetics are fewer than Type II in the population and people living with gestational diabetes are excluded. So my observations below relate to Type II diabeticsm considered at the higher risk catagory of ulceration.

    As a part of the preparation of the team, we have had to get to know each other and what we do. Sharing knowledge of skills and perceptions has been very useful and in some cases very revealing. Apart from inter-professional rivalry which is lighthearted it has been essential to move forward as the team integrates. Feedback to other disciplines about podiatry which is now happened often enough as to establish a pattern, is the number of clients who complain to other disciplines, their foot orthoses as being uncomfortable and unhelpful. When naturally directed to mention this to their podiatrists most clients avoid this either because the pod will not listen them or defends their action as that is all that can be done. Many client's impression of pod service freely share with other members of the team that they are aware the podiatirsts are trying their hardest but feel it too impolite to feedback the biomechanical devices were not helpful and instead accept foot problems are part of their diabetic condition.

    Now this anecdotal evidience does not pertain to those many occassions when foot health services have made valuable contributions to the care of the foot at risk but it does give a reminder that we may not be always be as receptive to clients needs as we content ourselves to be.

    Worth a thought

  5. Foot fan

    Foot fan Active Member

    To a teacher and respected podiatrist/podologist (considering you are actually treating now or should be when your team takes off)

    1) To ignore the biomechanical side of the diabetic foot is to leave off a vital arm in the treatment of the diabetic foot. Pressure redistribution is listed in any diabetic literature as an important part of both healing and preventing ulceration. How would you intend on achieving this redistribution without due regard to biomechanics?

    2) Biomechanics does not necessarily have to culminate in the production of an orthotic - indeed it could be a stretching regime, strapping, EPA, mobilisations, the list goes on. In truth there are very few diabetic patients that can tolerate a customised device. The part that annoys me presently is that we send ALL of our patients to have orthotics made by a bootmaker using a computer. To me, that is an inadequate response to a common problem.

    What we (well me actually) are intending to do is create a clinical pathway to consider the biomechanical aspects of our patients when assessing them (in conjuction with neuro-vascular assessment) and identifying if there are any clinical applications that can be used to prevent complications or alleviate symptoms.

    Just ignoring biomechanics or pretending orthotics are inappropriate for everyone is not going to solve the issue that has been identified.

    The problem that arose was an issue of applying current biomechanical opinion/research to a clinical situation. Basic chairside tests seem to be rather outdated but is the result still useful. I am expected to find out how other clinicians around the world are assessing biomechanics and determine whether the methods they are using will yield meaningful results. Sounds simple enough but where do you start?
  6. Cameron

    Cameron Well-Known Member

    Foot fan

    As I previously stated, " Now this anecdotal evidience does not pertain to those many occassions when foot health services have made valuable contributions to the care of the foot at risk but it does give a reminder that we may not be always be as receptive to clients needs as we content ourselves to be."

    So there is no argument from me re the importance of biomechanical assessment but conditons do clearly apply in the interpretation and implementation when dealing with specific patient groups. My clinical colleagues were concerned when those occassions arose that casted foot orthotics had proven inappropriate and the podiatrist had refused to do anything about it.

  7. Foot fan

    Foot fan Active Member

    But this still does not solve the problem of what should be a priority as far as assessments are concerned and what the goals should be i.e what do we need the data for. The aim of assessing biomechanics seems to be to determine what is normal from abnormal but in a group where you expect it to be abnormal - what should we look for and aim for?
  8. Foot fan

    Foot fan Active Member

    I fear with biomechanics there is no 'easy way' but thanks again
    Last edited: May 22, 2006
  9. javier

    javier Senior Member

    Not necessarily. Not all diabetics have foot mechanical conditions.

    If I were you, I would do the following:

    1. Classify patients according to risk level. You can check the article: DG Armstrong, LA Lavery and LB Harkless "Treatment-based classification system for assessment and care of diabetic feet" Journal of the American Podiatric Medical Association, Vol 86, Issue 7 311-316,1996. It is quite good guide.

    2. Define your assessment based on risk level and time available for each patient.

    3. Write a clinical pathway, questionaries and protocols based on above.

    3. Check results.

    Do not worry about academic discussions. Sometimes things are easier than you think. Just try to develop a simple and useful protocol based on your requeriments.

    I hope it helps.

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