Does Compliance Hamper The Efficacy Of Removable Cast Walkers?

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By Brian McCurdy, Associate Editor

Compliance may be an issue for diabetic patients wearing removable cast walkers, according to the results of a recent study on activity patterns. A recent study in Diabetes Care assesses the activity patterns of those with diabetic foot ulcerations and finds those involved in the study did not have adequate plantar pressure relief for nearly 75 percent of the steps they were taking. The study tracked 20 patients with neuropathic diabetic foot wounds, which were all classified as University of Texas grade 1 stage A. The patients each received a standard removable cast walker (Royce Medical) to relieve plantar pressure during ambulation. Researchers recorded total activity on computerized accelerometers that patients wore on their waists and correlated the activity to accelerometers that were attached to the cast walkers and which patients could not access. Researchers had instructed patients to wear the casts continuously for seven days. Each patient took a mean 1,219.1 steps (+/-821.2) per day and researchers noted they walked “significantly more” while not wearing the removable cast walker than they did while wearing it. This resulted in the devices recording only 28 percent of the patients’ movement. “This figure was quite remarkable to us as these patients were all walking on open plantar wounds,” says the study’s principal investigator, David G. Armstrong, DPM, the Director of Research and Education within the Department of Surgery, Podiatry Section at the Southern Arizona Veterans Affairs Medical Center. He attributed the phenomenon to a lack of painful feedback, what the late Paul Brand, MD, called “the gift of pain,” due to neuropathy. What Factors Affect Compliance? Why were patients taking 72 percent of their steps without plantar protection? As co-author Brent Nixon, DPM, explains, the three major components of compliance are the patient’s environment, condition and motivation. Factors which could influence compliance are whether the patient lives alone, has to climb steps or lives in the city. Dr. Nixon says other considerations in a patient are blindness, depression and complicating medical conditions. “I have found that I need to give the patient a gentle talk about his or her condition and the possibilities of the complications that can result in failure to comply,” notes Dr. Nixon, Chief of Podiatry in the Department of Surgery at the Southern Arizona Veterans Affairs Medical Center. “If absolute compliance is not possible, we do our best to console the patient.” “I have worn TCCs and removable cast walkers, such as the Active Offloading Walker, for some 10 days at a time,” says Dr. Armstrong. “I can tell you that it’s a pain in the neck. If I didn’t have to wear it — if I wasn’t in pain — then I surely wouldn’t wear it. It is the same with our patients.” To aid in compliance, Dr. Nixon says he provides patients “every useful aid necessary to unload the affected limb,” such as wheelchairs with leg extensions, crutches, walkers and motorized scooters. The key to such cast walkers is a well-padded, non-removable splint or cast, he notes. A Proposal For An Instant TCC In a recent editorial in Diabetes Care, Dr. Armstrong and study co-author Andrew Bolton, MD, propose using non-removable offloading devices for neuropathic patients needing plantar protection. Although the doctors note such devices have not been used because of a concern that total contact casts (TCCs) require expertise to use and can injure a neuropathic foot, they suggest using an instant total contact cast. Instant TCCs would be cast walkers that are made non-removable when they are wrapped in coban or plaster. Instant TCCs would be advantageous because of their lower weight, ease of application and the fact that they are cheaper because the patient can use the same cast walker throughout treatment, according to Drs. Armstrong and Boulton. “Only then, when we put together what we ‘take off the wound’ (pressure) with what we ‘put on’ the wound (advanced dressings and devices), will we see any real improvement in outcomes on a worldwide basis,” says Dr. Armstrong, a member of the Board of Directors of the American Diabetes Association. Study: Rofecoxib Is Effective For Post-Bunionectomy Pain By Brian McCurdy, Associate Editor A new pilot study suggests rofecoxib is effective in relieving pain following a bunionectomy. The double-blind, randomized study tracked 27 patients with moderate or severe pain 24 hours after surgery who received 50 mg of rofecoxib (Vioxx, Merck) a day and 26 who received the placebo. Patients taking Vioxx had a 10.5 mean score on the total pain relief over eight hours (TOPAR8) score, compared to 4.0 for the placebo, according to Merck. On days two to five, patients taking rofecoxib experienced “significant analgesic effect versus the placebo,” according to the study. Nicholas Grumbine, DPM, says he uses Vioxx as an inflammatory but not for pain relief. “I don’t think (Vioxx) is that good of an analgesic,” notes Dr. Grumbine, a Diplomate of the American Board of Podiatric Surgery. He says he prefers to prescribe Vicodin and Darvocet for pain. Additional trials with Vioxx are underway, according to the study’s lead investigator Paul J. Desjardins, DMD, PhD. He notes the FDA has increasingly started to view lower-extremity pain as a “useful model” to predict the effects of pain medications following different types of non-podiatric surgery. Study Finds Foot Melanoma Is Most Lethal By Robi Garthwait, Contributing Editor The American Cancer Society estimates that about 54,200 new cases of melanoma will be diagnosed and more than 7,500 people will die from the disease in the United States this year. Now a study suggests that individuals diagnosed with melanoma of the foot or ankle face a poorer prognosis than do individuals diagnosed with melanoma elsewhere on the body. The study, published in the July/August issue of The Journal of Foot and Ankle Surgery, looked at 148 patients with a primary melanoma of the lower extremity between 1967 and 1999. Thirty-seven of the melanomas were located on the foot or ankle. The “five-year survival rate of patients with melanoma of the foot was only 52 percent compared with 84 percent in patients with a primary melanoma elsewhere in the lower extremity,” states Ronald A. Sage, DPM, co-author of the study. In addition, “the study period included 32 years, but 65 percent of the foot/ankle patients were diagnosed in the last 10 years,” notes Dr. Sage, a Professor and Chief of the Section of Podiatry within the Department of Orthopedic Surgery and Rehabilitation at the Stritch School of Medicine at Loyola University. He says this suggests “an increased incidence of this tumor and the need for an increased index of suspicion in evaluating abnormal skin lesions of the lower extremity.” Melanomas most often appear as pigmented lesions and can be found anywhere on the foot, including under a toenail. Risk factors include excessive sun exposure, a family history of skin cancer and having fair skin. Dr. Sage also expressed surprise that “foot lesions were more lethal than other lower extremity melanomas.” The study suggests foot melanomas may be more advanced when discovered and that they are also prone to misdiagnosis. “Podiatric physicians should use this information as a reminder that malignancies can occur in the foot and suspicious lesions should be biopsied,” says Dr. Sage. “The examiner should recall the ‘ABCD’ acronym of asymmetric shape, border irregularity, color variation and diameter greater than 6 mm as indication for biopsy or proper excision.” PICA To Cease Coverage In Two States By Brian McCurdy, Associate Editor A major podiatric insurer will soon end its coverage for DPMs in two states. The Podiatry Insurance Company of America (PICA) will stop writing for Mississippi and Montana in 2004, according to PICA President and CEO Jerry Brant, DPM. Combined, the states have about 60 podiatric policies, according to Dr. Brant. He attributes the ending of coverage to “unfavorable legal climate and losses” in the states, saying Mississippi and Montana have experienced malpractice problems that have plagued parts of the United States. “Tort reform doesn’t cut it. It has to be meaningful and cover a wide area of reform,” says Dr. Brant, who notes that although some states have approved a $250,000 cap, it can be pierced in certain circumstances. “The country itself has not had a whole lot of meaningful tort reform.” PICA will also raise its premiums next year, due to the increasing severity and frequency of claims, and rising costs of reinsurance, according to Dr. Brant.

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