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From the address by ALEX ADAM, Podiatrist, to The IN Group Public Meeting, held Wednesday 9th February 2005 at the Balwyn Library Meeting Room, 336 Whitehorse Road, Balwyn.
The most important thing about podiatry is to do with postural balance. How many times have you heard the old saying "Stand up straight, get those shoulders back"? It is all to do with genetic balance. Basically it starts off in the foot. The way I describe the structure of the body is to do with two primary areas. They are to do with the skeletal system as well as the ligament system. Ligaments of the foot and body hold joints in certain positions. So when gravity bears down on us we don’t fall over.
The foot is designed a bit like an arch. The arch gives us stability in different shapes and forms We have high arch and flat foot and normal foot. In all scenarios the foot should give us stability. That stability comes about by a number of things. One is the shape of the joint. The shapes of joints are very important. The natural shape of the foot gives us a natural structure. The main area a podiatrist is interested in is the actual shape of the joint. The joint gives an inherent stability to the foundation. You can liken this to a house. You can build a beautiful house but if its foundations are not sound, eventually that house will fall over. A podiatrist asks ourself can we do something to improve the foundation?
What is holding the bones in the right place? It is the muscles. They are very important as prime movers. The main muscle group behind the foot ligament is the calf muscle. When we walk it is that muscle that is firing away.
Other muscles in the leg will be known to ladies because they can be associated with clawed toes, hammer toes. When these muscles are asked to do too much such as when wearing high heels this can be the result. Instability then increases.
Muscles aren’t the only item that is important to walking. Everything has a purpose and works in unison. As well as bones, ligaments and muscles, there are blood vessels – arteries and veins. If the muscle is not working properly, say overworking, these blood vessels become thrombosed. This is where Deep Vein Thrombosis comes from as well as varicose veins.
When a muscle is working too hard, it is not pumping properly, the blood pressure causes the side vessels to extend and become varicose. Anybody standing for a long period of time such as hairdressers, teachers, barbers, can end up with varicose or deep vein thrombosis problems. As far as the body goes, the main purpose of the way it works is to introduce normal forces. When we walk, our body wants, firstly, to use as little energy as possible, secondly, to walk in such a way that causes the least amount of stress on the skin.
We have a bag of skin that surrounds our skeleton. Both work together but also work independently. When there is a problem such as with too much movement in a shoe - the skeletal doing one thing and the skin another – we can end up with callouses and corns and the like. A podiatrist can often identify the problem that the skin presents.
If the foot is not working correctly, it may collapse inwards and we start walking on the inside part of the foot. More importantly, it also produces a rotation of the leg that goes up to the knee. This is where some osteo-arthritis of the knee comes from. This rotation can also cause osteo-arthritis of the hip and lower back. In our podiatry clinics we see this effect of walking on the inside of the foot.
We have 26 bones in our foot, living and continually being replaced. We go through three main periods of bone growth. When we are young, in our twenties, we are tall. As we get older we start to shrink, due to gravitational effect. If the new bone that is being laid down is not in the right place the forces are going to change. These forces can produce stress that can lead to osteo-arthritis, or an increase in rheumatoid-arthritis.
So what makes good structure? It is to do with our nervous system. When we have anything wrong with our nervous system there are going be inherent problems. The joints have cartilages in them. In those joints we have tiny nerve endings which are switches. Those switches will tell the brain where the joint is. This is known as proprioception, the knowledge of itself in space.
Anything that goes wrong with our nervous system, such as GBS or CIDP or stroke, will shut down the switch mechanism that is giving the brain the ability to know where it is in space.
It also allows the brain to activate muscles when we walk. Girls walking on the catwalk walk in an unnatural way because they are thinking about it. When we walk we don’t think about it because our subconscious is telling us how to walk, our nerve endings are telling us.
As a joint gets compressed it will contract a muscle that is opposite to it. When you have a demyelinating condition, why do we have muscle wastage? Why do we have footdrop? We have problems putting one foot in front of the other. It is because the signals are not getting back to the brain, the nerve endings are being short-circuited.
We put our foot down, we don’t know we are putting it, we know it is going down in a certain position. We should be able to put our foot down and lift the other foot off the ground without falling over. That is balance. Even if I stood there for five minutes my nerves will continue to tell the brain what is going on.
The big thing about nerves is they connect the
muscles to the spinal cord. The system contains a segment known as the spinal reflex that allows muscle movement during gait as well as a protective response to trauma. Every time a muscle works, it is also pumping blood. The central part of the nerve, the axon, conveys the electrical signal. When the myelin sheath surrounding the axon is demyelinated, say by some antibodies thinking the myelin is a foreign body, then the electricity leaks out and the nerve signal does not get through.
Another big thing to remember is that with the demyelination, the blood pumping system is affected and this can cause fluid to build up around the ankles. A good podiatrist can help in reducing this fluid.
If we don’t have any muscle structure can we still have stability? The answer is yes. Our stability is made up of two parts, the skeletal balance and the soft tissue that holds the skeleton together. If balance from one is taken away the other balance can be adapted. Muscle fibre is still there say for footdrop. If we don’t have the muscle to keep us upright, the next line of attack is to make sure that the 26 bones of the foot don’t fall over. This is where various orthotic devices have been introduced over the past 50 years. The definition of an orthotic is any device that changes the structure of the human body.
Biomechanical devices such as well fitting footwear, orthotics both foot and AFOs, splints, can improve the balance and thereby reduce the unpleasant effects, the trauma, both internal and external. The devices however must be properly balanced for the individual – off the shelf devices have limited effect. Palliative care such as foot care, cutting toenails properly, and regular foot inspection can also be helpful.
Q. Should we try to do without orthotics?
A. No, just make sure you get your orthotics from a reputable person. Orthotics should be made from measurements of the lower back, the hips, and the feet.
Q. I am not sure whether corns and callouses are caused by forces inside or external to the foot?
A. Both, If a person is wearing a poor fitting shoe then the forces in the foot will be pressing against part of the shoe, causing initially a callous and if shoe fitting is not corrected then the callous can turn into a corn.
Tinea can be caused by having toes too close
together caused by footwear and needs to be treated.
Comment on tinea. I used to suffer from tinea but I found that drying in between my toes made it disappear.
Tinea is a fungus and requires heat and moisture.
Men are worse than women in looking after their body with the attitude "I’ll be all right." I have seen more cases of amputation and gangrene in men than I have ever seen in women. When our bodies are compromised it won’t go away.
The simplest way to looking after your body is doing very simple things. Having baths is better for the feet than showers because they get soaped. Use cream to restore the moisture in the feet. Ureceme is a good product. It has 10% of urea which inhibits callouses. Avoid using too much alcohol such as methylated spirits. Daily inspection is worthwhile, using a mirror on the floor. Avoid extremes of heat. It is important to know yourself. Simple exercises inside are helpful for those who are handicapped for walking outside. All help the circulation.
Q. When I go to a podiatrist, what questions should I put? I go regularly but all he does is cut my toenails. On one occasion I asked whether I needed a change in my orthotics. The answer was no.
A. The big thing as far as any practitioner to ensure is that you depart happy. A podiatrist is there to look after your foot health, not cut toenails. My patients I see for half an hour. I observe and often detect other disorders such as kidney and heart disease. There are a number of diagnostic tools that your podiatrist should use each year. The first time a patient comes I carry out such an examination which serves as the base line. In five years time if I see something strange I can pick it up straight away.
Q. What is the prospect of getting feeling back in my feet after 9 years of GBS?
A. The big problem about neurological systems is that not much is yet known. It is known that regeneration will occur after time.
Q. I was particularly interested when you were talking about footdrop because my condition like a lot of other people’s is due to CIDP. The medical view is that some nasty antibodies have mistaken the myelin sheathing on my feet for a
foreign body and destroyed it. I have found my calf muscles have got weaker. I have been to a couple of physiotherapists who have given me exercises to carry out. Perhaps I am a bit lazy but I found they didn’t seem to do much. Have you any ideas as to how to strengthen the calf muscles?
A. A simple exercise would be to pull on your feet with a towel while pushing down, sitting in your chair say watching TV.
Q. Is podiatry supported by bulk billing?
A. The federal Government has recently announced that a patient attending a podiatrist, referred to by a doctor, qualifies for Medicare for 5 visits in a year.
Q. My husband has had a chronic attack of sciatica. Now his foot is dropping. Has the sciatica caused a muscle withering?
A. Everything is together. The sciatic nerve is the diameter of your thumb and runs down the leg from the bottom of the spinal column. His nerve has been pinched too long causing the muscle withering and the consequent footdrop. He needs to be checked out.
Comment. I had mild sciatica in my left leg recently and a son told me he had it badly some time ago and found vitamin B tables very helpful. So I tried Berocca vitamin B tablets and it cleared up within a week.
Vitamin B is very good for nerve regeneration.
IVIG Working Group
JOHN BURKE, IN Group committee member and our representative on this Federal and Victorian body, gave the following short report.
The supply of Intragam is not good at present. CSL has had two batches rejected by quality control and these have had to go back for reprocessing. A shortage of the 12gram bottles can be expected between now and June. The total supply will still be sufficient, using 3 gram bottles and possibly Sandoglobulin.
The Sandoglobulin purchased last year is approaching its use by date. So more Sandoglobulin will be used and less Intragam.
The National Blood Authority has bought a supply of a brand of IVIG called Octagan produ- ced by another Swiss company. John believes all three brands, INtragam P, Sandoglobulin and Octagan are suitable for treatment of GBS/CIDP but the Australian Red Cross knows little as yet about Octagan. We will be checking further.
The IN Group congratulates Professor JOHN POLLARD and Dr BERNARD GILLIGAN for their well-earned Australia Day honours.
Officer (AO) in the General Division
Professor JOHN POLLARD
For service to medicine in the field of neurology,
particularly
in the study of peripheral nerve
disease and multiple neurosis.
Medal (AM) in the General Division
Doctor BERNARD GILLIGAN
For service to medicine as a neurologist.
A small part of their service to medicine has been their great support to The IN Group as Patrons during the twelve years of our existence. For this we are very grateful. Congratulations again!
We are grateful to our member JUNE CATHCART of Stawell for informing us about the upset The Australian Red Cross Blood Service has caused many country blood donors by closing 21 of their country donating agencies. Stawell is one of them, even though it has been operating for the past 35 years. June sent us "The Stawell Times-News" that devoted its first two pages to the "Blood Bank closed".
The Red Cross is replacing these centres with limited visiting mobile service. However Stawell does not qualify for this mobile service which requires 200 donations to be received in a period of one week. At present Stawell has between 30-40 donors on a regular basis. Now donors will have to drive to Horsham or Ballarat to donate blood, spending an hour driving up and an hour back and needing a driver.
The Red Cross has defended its decision by saying it will be more efficient to offer the limited mobile service and rationalise the blood bank process. It may be saving some money by these closures but surely they must be losing many blood donations.
National Party member and Health Spokesman Hugh Delahunty has called on the Red Cross to reconsider its closures. He has asked the State Government to intervene and provide additional funding. He is also writing to the Red Cross and inviting senior staff to meet with all the National Party’s country MPs.
Question to Dr Kornberg.
One of the Group, a sufferer from CIDP, has recently had an operation for Carpal Tunnel Syndrome and has asked whether there is any connection between the two.
Answer
Carpal Tunnel Syndrome is very common in the population and it may be because of the common nature of the disorder. The other thing is that nerve disorders do predispose you to having entrapment of nerves and CTS is an entrapment. Andrew Kornberg.
Dear IN Group,
I am 53 years young and up until a few months ago was still very active playing tennis, yoga, walking and bike riding. I have just been diagnosed with CIDP and am probably in shock even though for the past few months I have known there was something drastically wrong as I have not been able to propel myself at all or carry out any of my usual activities, the weakness in my legs and arms and the tingling in my feet and legs have become worse. I would like to find out as much as I can about the disorder and if any treatments help.
Heather Day, Darwin, NT
Reply
Dear Heather,
If you send me your address I will post you a CIDP booklet published by the UK GBS Support Group plus The IN Group brochure and latest quarterly newsletter "Information".
There are treatments for CIDP. When I was diagnosed with Progressive CIDP (with some difficulty) some 12 years ago, my neurologist said he would try up to six treatments to see which would be effective. So I was treated with
Plasmapheresis, predisolone, imuran, cyclo-sporine and intravenous immunoglobulin (trade
Name "Intragam"). I have been on the latter (24 gram every fortnight) for most of the past 12
years. With this treatment, the CIDP has not progressed beyond giving me footdrop – I can’t
move my feet up and down.
James Gerrand, Director.
n. eb decision. . i s that rp . are trying to reintroduce her to school. I am looking for information on GBS and came upon your support group and thought I would email you. I would be interested in joining the Group and receiving the newsletter. We live in rural eastern Victoria. I would be interested in being in contact with other parents of young children who have had this syndrome to discuss the return to school etc.
Having obtained Nancy’s address I posted her the GBS booklet published by the GBS Foundation International (USA based) plus The IN Group brochure and latest newsletter. If any member wishes to contact Nancy, contact me first and I will supply contact details.
James Gerrand, Director.
Member PETER SIMPSON would like to talk to people who have made good recoveries from from CIDP and are now living reasonably normal lives.
Peter’s wife Valerie has been in hospital for most of the last two years, with about half that time in the Intensive Care Unit at the Royal Melbourne Hospital. Before that they were living and working in the Northern Territory for the past 20 years. They now plan to settle in Melbourne.
Despite many relapses and difficulties, Valerie is determined to get back to a happy existence away from hospitals, even though she will almost certainly have residual disabilities. Learning from the experience of others could be a big help.
Peter can be contacted on 0419 826 798 or by email at pandvsimmo@yahoo.com.au
Member BRONWYN CLARKE kindly sent this article that appeared in an internal Departmental newsletter ……how surprising to see CIDP mentioned! Hopefully this will remind readers of the need for blood and plasma donations.
Did you know it can take up to 225 plasma donations per year to keep a CIDP sufferer alive?
CIDP is a rare disease which attacks the peripheral nervous system, weakening muscles mainly in the arms and legs. Plasma donor and DSE Senior Analyst Chris Egan knows only too well the quantities of plasma needed to help patients on their road to recovery. After four years of fortnightly visits to the Southbank Blood Centre, Chris has made 110 donations or 70 litres of plasma that is used to make a range of products including Intragam to treat CIDP. "The Blood Bank wanted to collect 74 tonnes of plasma in the last financial year" he said. "A plasma donor can give a maximum of 25 donations a year so it needs at least eight donors to support each person with this disease."
About 600 Australians suffer from the disease in any one year and there are several hundred sufferers in Victoria alone. The uses for blood donations are many and varied and, with demand increasing, there are even more reasons to become a donor in this Blood Donor Awareness Month. A whole blood donor of 28 years, Chris says plasma can be donated every fortnight because it is replaced by the body more easily than whole blood. "Whole blood can be donated four times a year. There are some people who are not allowed to give blood through illness or having lived in England (because of ‘mad cow’ disease) – bit I would encourage everyone to give it a go."
DSE Manager of Integration Projects John McDougall has made 132 donations over the past 33 years. "The biggest challenge for new donors is to make donating a regular habit" he said. But with donors being tested for iron content, haemoglobulin, weight and blood pressure, the benefits to donors can outweigh the costs, he added. "It’s like getting a free mini health check every quarter," he said. "And snacks, coffee, newspapers and magazines are all part of the perks donors receive."
For more information or to make an appointment via the Australian Red Cross Blood Service call 13 14 95.
Dear Dr Bruce Day (The In Group Consultant Neurologist),
Someone asked whether there is a connection between diabetes and CIDP. A couple of our members have both. Is somebody with diabetes more likely to get CIDP? Or if one has CIDP is he/she more likely to get diabetes? Probably these queries are a bit way out.
James Gerrand.
Dear James Gerrand,
On the contrary, this is a very good question and very timely as we (peripheral neurologists worldwide) are currently struggling with this very issue. In short, if we see patients with diabetes whose electrophysiological studies satisfy the criteria of CIDP we will treat them as if they have CIDP and most will respond satisfactorily.
Based on these criteria quite a few (one figure I've come across is 6%) patients with so called diabetic neuropathy probably have an immune mediated neuropathy
There is some suggestion that diabetes is a risk factor for CIDP; I think this is still very unclear. In addition there are some diabetic neuropathies such as so called "diabetic amyotrophy" which are now well documented to be due to a microvasculitis and are currently being studied in large randomised placebo controlled trials using IVIG and high dose IV methylpredisolone. Case reports suggest these are likely to be very effective interventions.
This type of diabetic neuropathy is usually quite easy to distinguish from focal CIDP but this is not always the case. Furthermore some patients have typical diabetic amyotrophy but don't have diabetes by accepted criteria and it is a moot point as to whether they should be called focal CIDP or one of the many acronyms now attached to "atypical CIDP".
In any event it is clear there is a complex interaction between diabetes and immune mediated neuropathies. At this stage I would say that if one has diabetes there is perhaps an increased risk of CIDP but if you have long standing CIDP you probably don't have an increased risk of deve-loping diabetes apart from the added risk due to steroid usage.
Dr Bruce Day.
An article by Dr Joel Steinberg in the Fall 2003 "The Communicator", newsletter of the GBS Foundation International, concludes that the neuro-logicic complications from smallpox vaccination, such as a GBS-like picture, tend to be extremely rare. And the rare patients who develop such complications apparently recover relatively rapidly. It appears that, with respect to effects on the nervous system, smallpox vaccinations for children are rather safe.
Flower Show
Two old ladies were sitting on a park bench outside the local town hall where a flower show was in progress. One leaned over and said, "Life is so damned boring. We never have any fun any more. For $5, I’d take my clothes off and streak through that stupid flower show."
"You’re on" said the other old lady, holding up a $5 note.
As fast as she could, the first little old lady fumbled her way out of her clothes and, completely naked, streaked through the front door of the flower show. Waiting outside, her friend heard a huge commotion inside the hall, followed by loud applause. The naked lady burst through the door surrounded by a cheering crowd.
"What happened?" asked her waiting friend.
"I won first prize for "Best Dried Arrangement."
(Thanks, Jeff Richard.)