“How many people do you know who have had a lower limb amputation? Your response may likely be “none”. It may surprise you to learn that there are approximately 6,000 partial foot amputations occurring in Australia each year, with that number expected to triple by the year 2050 (Dillon, 2014). This number is far too high. So, what can we do about it? As Orthotists, one of our key roles is to work with people who have diabetes, as this is one of the primary causes of damage to feet which often results in partial foot or below knee amputations. We educate people with diabetes about the importance of taking care of their feet, along with assessing and prescribing lower limb orthoses and footwear to reduce the risk of injury, or to assist healing and protection of already injured feet.

What is Diabetes?
We have a vital organ in our bodies called the pancreas. The main function of the pancreas is to produce a hormone called insulin, which works to regulate the sugar levels in our blood. Diabetes refers to a chronic disease where our body is unable to produce and/or use insulin. No insulin = no control of our blood sugar levels, thereby causing a high blood sugar level. When poorly controlled,
these high blood sugar levels can cause serious health complications such as stroke, heart disease, high blood pressure, kidney disease, vascular disease, nerve damage and foot problems (National Diabetes Strategy Advisory Group, 2015).

There are two common types of diabetes – Insulin Dependent (Type 1) and Non-Insulin Dependent (Type 2). The underlying disease process is different between Type 1 and Type 2 diabetes, however the effects on the body and in particular, the feet, are exactly the same. We often refer to people with diabetes as also having “high-risk feet”.

What are high-risk feet?
As mentioned, diabetes-related health complications can include vascular disease, nerve damage and foot problems. Nerve damage often corresponds to reduced sensation or reduced ‘feeling’ in the legs and feet. A person with diabetes may accidentally stand on a something sharp and cut their foot, but they don’t feel the pain due to this nerve damage. Vascular disease means the body has poor circulation of blood through its blood vessels, mostly the vessels leading to the legs and feet. This poor circulation means that any injury or damage to the skin on the legs and feet takes longer than normal to heal.

The combination of nerve damage and vascular disease in a person with diabetes is a recipe for disaster. When someone accidentally injures their foot, doesn’t feel it and has bad circulation in their legs and feet, the wound can turn in to an ulcer. When an ulcer has developed it becomes very difficult to heal and usually requires a team of health professionals to combine different treatments from different areas of specialty. In some cases, ulcers can become severely infected and eventually lead to the need for a partial foot or below knee amputation.

What is an Orthotist?
An Orthotist (pronounced: Ortho-tist) is an allied health professional who is clinically responsible for the assessment, prescription, design, manufacture and fitting of all types of orthoses to patients. An Orthosis is an externally applied device that is used to modify the structural or functional characteristics of the neuro-muscularskeletal systems. You may have heard of the term “orthotics”, which is a common word that many people use to describe orthoses designed specifically for their feet. However, orthoses can be applied to the whole body, not just the feet. An orthosis is the true term for a brace or appliance that is designed and fitted external to the body in order to achieve one or more of the following goals: control or alter biomechanical alignment, protect and support a healing injury, assist rehabilitation, reduce pain, increase mobility and increase independence.

AOPAs complete occupation summary for Orthotist/Prosthetists can be found here.

How do Orthotists manage high-risk feet?
Ulceration is the most common problem in people with diabetes and high-risk feet. Ulcers can be caused by a traumatic injury (for example, a person accidentally standing on something sharp); or can be caused by high pressure areas on a foot caused by inappropriate footwear or altered foot biomechanics (for example, a person with very wide feet who wears shoes that are too narrow).

Orthotists are involved in the biomechanical assessment of each individual foot to determine the cause of a wound or ulcer. Orthotists will then prescribe an appropriate orthosis to unload or offload the points of pressure that are causing the ulcer. Offloading pressure from an ulcer will prevent the ulcer from getting worse and encourage the wound to heal. Orthotic treatment will usually involve a custom-made lower-limb orthosis and customised footwear. Some example of orthoses often provided by Orthotists include:

• Custom-made Foot Orthoses
• Custom-made Ankle Foot Orthoses
• Removable Walkers (you may have heard these commonly referred to as “moon boots”)
• Custom-made Charcot Restraint Orthotic Walkers (CROWs)
• Total Contact Casts

Multi-disciplinary team management of high risk feet is most effective for ulcer healing and amputation prevention (National Health and Medical Research Council, 2011). A multi-disciplinary health care team should consist of an Orthotist, Podiatrist, Wound Nurse, Dietician, Endocrinologist, Orthopaedic Specialist, Vascular Specialist and an Infectious Disease Specialist. There are many multi-disciplinary high-risk foot clinics in operation around the country. For example, a number of hospitals in Melbourne have well-established high-risk foot clinics where Orthotist’s provide regular services each week. These pre-existing clinics demonstrate a successful multi-disciplinary approach to high-risk foot management, with almost all decisions regarding the prescription of offloading orthoses conducted in a consultative manner.

Orthotists are an essential member of any multi-disciplinary health care team and high-risk foot clinics in particular. Orthotists can help to prevent lower limb amputations in people with diabetes by:

• providing education on how to care for high-risk feet;
• providing protective, pressure-relieving orthoses to prevent injury to feet; and,
• prescribing, manufacturing and fitting custom-made offloading orthoses, to offload wounds and ulcers to facilitate healing.

Visit our website to find out more information about the role of Orthotist/Prosthetists and where to study to become an Orthotist/Prosthetist (www.aopa.org.au).

References
Dillon, MP; Kohler, F & Peeva, V. (2014). Incidence of Lower Limb Amputation in Australian Hospitals from 2000 to 2010. Prosthet Orthot Int, 38(2): 122-132

National Diabetes Strategy Advisory Group. (2015). A Strategic Framework for Action: Consultation paper for the development of the Australian National Diabetes Strategy. Accessed from http://www.health.gov.au/internet/main/publishing.nsf/Content/A2950D249CBF14A5CA257D0A000D3E17/$File/NDS%20Consultation%20Paper.pdf

National Health and Medical Research Council (NHMRC). (2011). National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. NHMRC, Melbourne.”

Author
Ella Nicolson BPO(Hons), cOP-AOPA, MISPO
Membership & Communications Officer, Australian Orthotic Prosthetic Association (AOPA)

Ella graduated from La Trobe University in 2006 with a Bachelor of Prosthetics & Orthotics (Honours). Ella currently resides in the cool climate of Hobart, Tasmania, where she works part-time as an Orthotist/Prosthetist and part-time for AOPA. AOPA is the peak professional body representing Orthotist/Prosthetists in Australia. Ella’s clinical interests are orthotic management for children with neuromuscular conditions, preventing amputation through effective orthotic management of patient’s with high-risk feet and prosthetic rehabilitation for lower limb amputees.

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