Clinical Skills in Treating the Foot

Warren Turner, Linda M. Merriman

• Publisher: Churchill Livingstone
• Year: 2005
• ISBN:
  9780702036330
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The eagerly awaited new edition of Clinical Skills in Treating the Foot has been revised and updated with the needs of a broad range of health professionals in mind. For anyone treating patients with foot disorders, Clinical Skills in Treating the Foot will provide invaluable support through three key areas: Section 1 is concerned with the general principles of managing foot disorders and the context in which treatment of the foot takes place. Included are chapters on treatment planning, evidence based practice, governance and audit, clinical protocols, clinical emergencies and health promotion. Section 2 examines the application of clinical therapeutics to foot disease and includes chapters on operative techniques, surgery and the foot, pharmacology, physical therapy, mechanical therapeutics, chairside devices, prescription devices and footwear therapy. Section 3 considers the particular needs of special groups and includes chapters on the adult foot, the child's foot, sports injuries and management of tissue viability. With its clarity of text and liberal use of case studies and illustrations, the latest edition of Clinical Skills will be required reading for practising and student podiatrists. It will also be a valuable reference and guide for all others involved in the provision of treatment of the foot. This book has been written as a companion volume to the editors' Assessment of the Lower Limb, also published by Elsevier Churchill Livingstone.

• Written by an experienced team of clinicians who also understand the needs of students as well as practitioners
• Logical and clear structure makes it easy to use for both clinicians and students
• Each chapter is self-contained and can be used for independent reading topics
• Case histories and clinical comment sections illustrate important clinical points
• Key points and summaries provides assistance for learning and review
• Features approximately 400 illustrations

• Half of the contributors are new - more experienced clinicians than those used for the previous edition
• New chapter by new author on Clinical Governance (replacing old chapter of Audit and Outcome Measurement)
• Major revision by new authors of chapter on Treatment Planning to reflect new developments and changes in pracice
• Completely rewritten chapter by new authors on Clinical protocols
• Major revision by new author of the chapter on Foot health education and promotion
• Major rewrite with new author of the chapter on Pharmacology which will have expanded sections on topical and injected steroids and prescription medicines.
• Major revision by new authors of the chapter on Physical therapy
• New section on chairside devices in the chapter on Mechanical therapeutics in the clinic (new authors involved)
• Chapter on Prescription orthoses now replaced with new chapter by new authors on Prescription devices..
• Major rewrite by new author of the chapter on sports injuries
• New chapter on Managing tissue viability repaces the old chapter on the Management of foot ulcers and now incorporates the material previously covered in old appendices 1 and 2 on Management of exudation in ulcers and Footcare advice for people with diabetes.

Section 1

Essential principles of management

Outline

Chapter 1: Treatment planning

Chapter 2: Evidence-based practice and clinical governance

Chapter 3: Clinical protocols

Chapter 4: Clinical emergencies

Chapter 5: Health and health promotion

1

Treatment planning

Warren A. Turner and Linda M. Merriman

CHAPTER CONTENTS

Introduction

Who needs treatment for disorders of the foot?

What is ‘treatment’?

The treatment planning process

Principles underpinning treatment

Components of a treatment plan

The multidisciplinary team approach

Why do treatment plans fail?

Summary

INTRODUCTION

Ineffective clinical interventions often arise from incorrect diagnosis, ineffectual planning of treatment or a combination of both. The formulation of clear treatment plans is crucial for the delivery of effective and efficient foot care. Effective treatment planning for patients with foot health problems can make a significant contribution to the health of communities.

Mobility, independence, symptom relief and quality of life can be significantly enhanced by effective provision of foot health services. Patients can be maintained for longer in their own communities, retaining their independence, maintaining activity levels and thereby reducing the load on acute or long-term hospital and care facilities.

Effective foot health provision is a highly cost-effective process but is reliant on the development of rational and appropriate treatment planning. This chapter explores who needs foot health treatment and how effective treatment planning can be enabled. The key components and processes involved in a treatment plan are identified.

WHO NEEDS TREATMENT FOR DISORDERS OF THE FOOT?

Decisions often have to be made regarding the provision of foot health services, particularly when such services are funded from limited public funds. How should resources for the management of foot problems be distributed? Who has the greatest need? Who should receive publicly funded foot health care, and who can afford to pay for self-funded care?

The answers to questions such as these are often difficult to find. Commissioners of public health services rely on information from a variety of sources to make key decisions concerning service provision. These include:

• patient demand

• evidence base for clinical and cost effectiveness of the service

• competing demands for funding

• health outcome targets

• risk of not providing services

• which individuals/groups are most at risk/in need?

• historical levels of service provision

• levels of service provision in comparable communities

• epidemiological trends

• impact on other services.

As well as public health organizations being in a position to identify population or community needs for foot health provision, individuals are often involved in identification of need for care. Many authors have attempted to define the term need. Bradshaw (1972) identified four types of need (Table 1.1). Kemp & Winkler (1983) adapted the above classification of need and utilized the following classification in their survey of podiatric need:

Table 1.1

Types of need as identified by Bradshaw (1972)

Type of need	Description
Normative	Need defined by an expert
Felt	A want expressed by the patient or a third party
Expressed	A felt need which is turned into action (demand)
Comparative	Arrived at by studying the characteristics of people in receipt of a service and identifying those with similar characteristics, but not in receipt, as being in need

• activated need: a requirement for foot care that is consciously recognized by the sufferer or a third party (demand); action is taken to meet the requirement

• felt need: a requirement for foot care that is consciously recognized by the sufferer or a third party but no action is taken to meet the requirement (potential demand)

• potential need: requirement for foot care that is not acknowledged by an individual yet a practitioner who undertook a clinical assessment of the individual would consider there was a need.

Two Department of Health (DoH) surveys concerning foot health needs have been undertaken (Clarke 1969, Cartwright & Henderson 1986). Both adopted similar methodologies and reported a high level of need that was not being met. Other needs-based surveys, although they adopted different methodologies, concurred with these findings (Kemp & Winkler 1983, Elton & Sanderson 1987, Wessex Feet 1988). More recently, a major study in Cambridge, UK has identified that a significant number of elderly people identified as being ‘low risk’ for serious foot disease have developed significant pathologies, including infection and ulceration within a short period of time (Campbell et al 2000). This study identified the greatest risk of serious pathology to be amongst those over 85 years of age and those who are unable to care for their feet themselves.

Research has shown that there are often differences between practitioners and the general public when assessing the level of need. Clarke (1969) commented that practitioners’ estimates of unmet needs (or normative needs) exceeded not only people’s demands for foot health services but also their perceived needs (felt needs that were not being met). A high percentage of the general public did not consider they were in ‘need’ of treatment despite practitioners arriving at a clinical decision that treatment was needed.

One interesting explanation for this phenomenon lies in research undertaken by Dunnell & Cartwright (1972). The authors asked 1400 adults about their general health: 28% said they were in excellent health, 39% good health, 24% fair health and 9% poor health. When those in ‘good’ or ‘excellent’ health were asked if they had experienced any health-related problems in the last few weeks, only 9% said they had not. The common symptoms reported were: ‘headaches, skin disorders, accidents and trouble with feet and teeth’. It would appear that the participants accepted that ‘trouble with feet’ was ‘part and parcel of life’.

Epidemiological studies have shown the level of foot health among the general public to be low. Minor foot and foot-related problems of the earlier years are often neglected but can, in some cases, lead to more serious health problems in middle and later years.

Need surveys are not always helpful in informing decisions about the allocation of resources. Manning & Ungerson (1990) believed that the incommensurability of different needs made distribution of resources according to need a poor guide to public policy. ...