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New Meta-Analysis Cites Benefit Of Podiatry Interventions In Fall Prevention

Multifaceted and multifactorial interventions involving podiatry produced a significant decrease in the rate of falls in community-based senior citizens, according to a recently published systematic review and meta-analysis involving over 6,500 participants.

According to the study, published by Age and Ageing, multifaceted podiatry interventions included routine podiatry, patient education, footwear and/or orthoses if required and foot and ankle at-home exercises. Multifactorial interventions including podiatry were defined as those emphasizing a multidisciplinary team approach including risk assessment by a podiatrist and referral to podiatry. The study authors note that this data mostly applies to senior citizens in the community and that further research on these interventions in care homes, such as skilled nursing facilities, is necessary. 

Janet Simon, DPM, a member of the American Podiatric Medical Association’s (APMA) Public Health and Podiatric Preventive Medicine Committee, feels that podiatry clearly has a role to play in assessing and managing patients at high risk for falls. She relates that podiatrists can be involved in managing lower extremity weakness, balance issues, applicable medications, environmental factors and foot function. 

Denise Bonnin, DPM agrees, stating that in addition to foot health care, podiatrists participate in patient education, health advocacy and rehabilitation. 

“Within fall prevention teams or services, the role of the podiatrist can further involve undertaking training of other clinical staff in the recognition of medical factors that influence postural stability, gait and footwear,” explains Dr. Bonnin, who is in private practice in Piscataway and Hillsborough, N.J. “One can also promote the value of the podiatrist to others in the greater health care team.”

When thinking about fall prevention in “care homes,” Dr. Simon says it is important to consider the footwear the patient uses in his or her home environment. Care facilities vary in patient population and setting. Therefore, Dr. Simon says the types of shoes or socks patients are instructed to use may also vary. 

Dr. Bonnin shares the challenge of integrating oneself into the established team at the care facility if the team is already in place. She relates that cultivating a sense of mutual respect is key in encouraging the team to take your expertise into consideration. 

Dr. Bonnin says her practice regularly screens for fall risk and repeats this screening every six months or sooner if there is a medical event changing the patient history. Dr. Simon conducts a basic fall screening on all patients over the age of 65 and those with other risk factors for falls. Dr. Simon then combines basic screening questions with a comprehensive review of the medical history and medication list, leading to a discussion with the patient and family about the benefit of a full fall prevention assessment. 

“This assessment can be provided by the podiatrist or other providers such as home health staff, who may have the added benefit of being able to evaluate the patient in his or her living environment,” says Dr. Simon, who is in private practice in Albuquerque, New Mexico. “Often I receive feedback from family members that having an (objective observer) assess the home environment is extremely helpful since the family often feels powerless in affecting changes for their loved ones.”  

Dr. Simon also relates success with physical or occupational therapy pre-surgically to train patients on the use of assistive devices and post-injury or post-surgical supervised therapy when indicated to help avoid falls.

When Is It Safe For A Patient To Drive After Total Ankle Arthroplasty?

A recent study in Clinical Orthopedics and Related Research addresses the best timeframe for patients to resume driving after a total ankle replacement (TAR).

In the study, McDonald and colleagues tested brake reaction time in 60 patients at six weeks postoperatively and repeated the test weekly until patients achieved a passing brake reaction time. The study authors also took the results of a driver readiness survey, age, functional status, pain scale, range of motion and radiographic findings into consideration. 

At six weeks post-TAR, 92 percent of patients achieved a passing brake reaction time and were considered safe to drive. All patients passed the brake-reaction time testing at nine weeks postoperatively. Those who failed at six weeks had higher pain scale scores, diminished plantarflexion and a failed driver readiness survey in comparison to those with passing scores. 

Jason R. Miller, DPM, FACFAS, FAPWCA, feels the results of this study are similar to what he has experienced in his practice. He cites age and condition of the patient prior to surgery as key factors. 

“Physical therapy is crucial in cases of older or more deconditioned patients, and we will occasionally request the input of the physical therapist before clearing the patient to drive,” says Dr. Miller, Director of the Pennsylvania Intensive Lower Extremity Fellowship Program in Malvern, Pa. 

Dr. Miller relates that specific weightbearing and driving clearance algorithms are very patient- and surgeon-specific. He says he feels safer in the six- to nine-week range postoperatively with allowing a patient to drive after a TAR procedure if he or she is demonstrating good strength. 

Although he feels this study could have some applications to other areas of foot and ankle surgery, Dr. Miller advises caution in applying this data to fusion procedures due to motion being eliminated and necessitating longer times to driving. 

“TAR is a motion-increasing procedure in most patients,” explains Dr. Miller, who is board-certified in reconstructive rearfoot/ankle surgery and foot surgery. “Therefore, one could extrapolate that time to driving could be expected to be quicker with a TAR than an ankle or hindfoot fusion.” 

Study Evaluates Intralesional Vitamin D3 Versus Zinc Sulfate For Plantar Warts

Here one can see multiple recalcitrant plantar warts. In this study, authors noted that 80 percent of the vitamin D3-treated patients and 70 percent of the zinc sulfate-treated patients achieved a complete response three months after the last treatment session. Photo courtesy Christina A. Weber, DPM, FACFAS, and Kristine M. Hoffman, DPM.In a recent study, authors compared intralesional injections of vitamin D3 and zinc sulfate for the treatment of plantar warts.

Twenty patients received intralesional injections of vitamin D3 (2.5 mg/mL) and 20 patients had intralesional injections of 2 percent zinc sulfate. Both groups had up to four treatment sessions with sessions occurring at two-week intervals, according to the study, which was published in the Journal of Dermatological Treatment

Noting that both treatment options appear to be effective for plantar warts, the study authors noted that 80 percent of the vitamin D3-treated patients and 70 percent of the zinc sulfate-treated patients achieved a complete response three months after the last treatment session. 

Joseph Vella, DPM, says these study findings encourage him to use intralesional vitamin D3 or zinc sulfate for plantar warts, especially as an alternative to treatments that are difficult to tolerate.

“The study is promising in that it gives physicians another tool in the treatment of verruca,” explains Dr. Vella, who is in private practice in Gilbert and San Tan Valley, Arizona. 

“Many physicians, including myself, hesitate to use intralesional bleomycin, or similar treatments, due to concerns of systemic toxicity and pain. Not only do we have two more potential treatments for those warts that just are not responding to anything but we also can use them with more assurance that the patient won’t suffer systemic consequences.”

Dr. Vella adds that his usual algorithm for pedal verruca can include canthradin (Cantharone®, Dormer Laboratories), Verruca-Freeze® (CryoSurgery, Inc.), silver nitrate or electrodessication and curettage. 

News and Trends
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By Jennifer Spector, DPM, Associate Editor

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Despite this verification of accumulating evidence of the role of the podiatrist in fall prevention, there continues to be promotion of unfounded benefits of bilateral AFO bracing by colleagues and even by past officers of the APMA. Until podiatrists cease advocating unproven interventions, we will not gain credibility in the public health arena in the area of fall prevention.

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