Diabetic feet#2
Molly Pitcher C.P.O.
Description
Collection
Title:
Diabetic feet#2
Creator:
Molly Pitcher C.P.O.
Text:
Wow, this is indeed one of those most frustrating cases. You enter this
field with all good intentions to help people and then you are faced with
these types of individuals. It drives ya nutzo. First things first, be
sure to document very clearly that she is not following medical advice and
note her EXACT WORDS. She is without a doubt going to lose more of her
limbs, so start your defense now.
I have success with two things when the midfoot is involved for the diabetic.
We experimented with a CAM walker and 1 1/2 thick custom plastazote insole
(surrounding the entire foot with appropriate reliefs).We did this for many
years with great success. Medicare, however, now will not cover a CAM walker
unless it is specifically for a fracture. So, there went that idea and good
success. Depending on your situation, this may be a
good idea. She will not be super stable in bilateral CAM walkers, though.
She also could wear the dressings with a CAM walker instead of your custom
plastazote insert and still get some benefit there.
Another thought- maybe more for the future- is an Arizona brace. Let me know
if you are not familiar with this brace & I'll forward an 800 # (at home
right now). It's a leather custom foot / ankle Ox designed specifically for
mid and hindfoot problems. They work quite well but will not accommodate
dressings. They are very cosmetic which should be appealing to your lady.
Don't know if she's draining, but if so, leather is probably
not indicated. Again, maybe a future thought.
Is circulation impaired? I've had a few clients like this myself and you
are fighting a losing battle unless you have adequate blood flow.If you do
have adequate blood then try the Arizona AFO's for better control.Make sure
you build in extra relief at the spot of the ulceration.
Your efforts have been valiant. I have seen a few of these come through my
office in the last few years. Unfortunately no one treatment will work for
all people no matter how similar their situation.I work with a handful of
good physicians, all of whom have their own philosophies. A general
consensus among them would include include pressure redistribution away from
pressure intolerant areas. (this you have been trying to do with you custom
molded footplates and so on.)
The next step would be to shift weight off of the foot all together with use
of a Crow walker (with PTB support) or another form of orthosis which
utilizes the calf musculature (calf lacer) or patellar tendon as an area of
weight bearing. This needs to be attached to a shoe with a rigid rocker
bottom and total contact soft interface.
There is an Aircast diabetic walker boot that may also work well. This boot
has a removeable plastizote insert that can be modified or replaced, a rigid
rocker bottom and a means of shifting weight proximally. With this boot
there can be some area for patient error (must maintain pressure in air
cells).
I believe your only option is CROW walkers. You can unload the ulcer areas.
I would remove as much of the dressing as possible and make your mold over
dressing, if the Dr. is unwilling to put her in total contact cast and change
it out each week. Thats is how the Dr.'s I work with do. Without pressure
relife little chance of healing ulcers.
You could try making Carvile Sandals for another option. Not used as much as
we used to but would give pressure relife, but not much control.
When you have a patient who is unwilling to follow instructions, it is fair
to assume that they are non-compliant in other aspects as well. I don't feel
there is anything that you can do orthotically for this woman. I would do the
following:
1) show her what a BK prosthesis looks like etc...Sounds like they are
definitely in her future
2) Have a very frank conversation with the ortho about what our limitations
are. Lest the doctor and the patient blame you for a problem the patient is
partly responsible for. Believe me your competition isn't going to be able to
help this woman either. I deal with this everyday and I decided I would only
except responsibility for situations within my control. This one is beyond
yours.
There are only two solutions for this patient as I see it: The Neuropathic
Walker or the Total Contact Cast. The situation you have described is not
unusual (except for the bilateral involvement) and your biggest challenge is
to manage the compliance problem. You will not make any progress until your
patient signs on to the program. I have had a
small number of patients in bilateral Neuropathic (or CROW) Walkers and they
are able to get around reasonably well. You may want to explore the
possibilities for resolution of the plantarflexor contractures.
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field with all good intentions to help people and then you are faced with
these types of individuals. It drives ya nutzo. First things first, be
sure to document very clearly that she is not following medical advice and
note her EXACT WORDS. She is without a doubt going to lose more of her
limbs, so start your defense now.
I have success with two things when the midfoot is involved for the diabetic.
We experimented with a CAM walker and 1 1/2 thick custom plastazote insole
(surrounding the entire foot with appropriate reliefs).We did this for many
years with great success. Medicare, however, now will not cover a CAM walker
unless it is specifically for a fracture. So, there went that idea and good
success. Depending on your situation, this may be a
good idea. She will not be super stable in bilateral CAM walkers, though.
She also could wear the dressings with a CAM walker instead of your custom
plastazote insert and still get some benefit there.
Another thought- maybe more for the future- is an Arizona brace. Let me know
if you are not familiar with this brace & I'll forward an 800 # (at home
right now). It's a leather custom foot / ankle Ox designed specifically for
mid and hindfoot problems. They work quite well but will not accommodate
dressings. They are very cosmetic which should be appealing to your lady.
Don't know if she's draining, but if so, leather is probably
not indicated. Again, maybe a future thought.
Is circulation impaired? I've had a few clients like this myself and you
are fighting a losing battle unless you have adequate blood flow.If you do
have adequate blood then try the Arizona AFO's for better control.Make sure
you build in extra relief at the spot of the ulceration.
Your efforts have been valiant. I have seen a few of these come through my
office in the last few years. Unfortunately no one treatment will work for
all people no matter how similar their situation.I work with a handful of
good physicians, all of whom have their own philosophies. A general
consensus among them would include include pressure redistribution away from
pressure intolerant areas. (this you have been trying to do with you custom
molded footplates and so on.)
The next step would be to shift weight off of the foot all together with use
of a Crow walker (with PTB support) or another form of orthosis which
utilizes the calf musculature (calf lacer) or patellar tendon as an area of
weight bearing. This needs to be attached to a shoe with a rigid rocker
bottom and total contact soft interface.
There is an Aircast diabetic walker boot that may also work well. This boot
has a removeable plastizote insert that can be modified or replaced, a rigid
rocker bottom and a means of shifting weight proximally. With this boot
there can be some area for patient error (must maintain pressure in air
cells).
I believe your only option is CROW walkers. You can unload the ulcer areas.
I would remove as much of the dressing as possible and make your mold over
dressing, if the Dr. is unwilling to put her in total contact cast and change
it out each week. Thats is how the Dr.'s I work with do. Without pressure
relife little chance of healing ulcers.
You could try making Carvile Sandals for another option. Not used as much as
we used to but would give pressure relife, but not much control.
When you have a patient who is unwilling to follow instructions, it is fair
to assume that they are non-compliant in other aspects as well. I don't feel
there is anything that you can do orthotically for this woman. I would do the
following:
1) show her what a BK prosthesis looks like etc...Sounds like they are
definitely in her future
2) Have a very frank conversation with the ortho about what our limitations
are. Lest the doctor and the patient blame you for a problem the patient is
partly responsible for. Believe me your competition isn't going to be able to
help this woman either. I deal with this everyday and I decided I would only
except responsibility for situations within my control. This one is beyond
yours.
There are only two solutions for this patient as I see it: The Neuropathic
Walker or the Total Contact Cast. The situation you have described is not
unusual (except for the bilateral involvement) and your biggest challenge is
to manage the compliance problem. You will not make any progress until your
patient signs on to the program. I have had a
small number of patients in bilateral Neuropathic (or CROW) Walkers and they
are able to get around reasonably well. You may want to explore the
possibilities for resolution of the plantarflexor contractures.
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list.
Citation
Molly Pitcher C.P.O., “Diabetic feet#2,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/215446.
