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Outcomes in all of medicine, but especially wound care, go beyond the physical clinical presentation. Accordingly, the panelists discuss unique mental, social and emotional challenges wound care patients may face, and share their experiences and opinions on how best to provide support and care.

Q:

What mental, emotional or social challenges do you feel patients with chronic wounds may encounter in relationship to their condition? Why?

A:

Chronic wounds can certainly be a large burden on patients due to the necessary complexity of care, says Jacob Fassman, DPM, FACFAS, CWS. He adds that transportation issues and financial burdens of frequent visits are also very impactful. Both Dr. Fassman and Kazu Suzuki, DPM, CWS identify possible patient embarrassment from malodorous wounds, or needing to ask for help from family and friends as sources of distress and isolation. Both doctors also agree that pain management needs pose a significant challenge for wound care patients.

“Having chronic pain for months or years, let alone undergoing an amputation, can be devastating to one’s mental health,” says Dr. Suzuki. 

Citing the work of Beattie and colleagues, Valerie Marmolejo, DPM, MS says a perceived lack of control and loss of self are significant aspects of the psychosocial health ramifications of a diabetic foot ulcer (DFU).1 For example, Fejfarová and Jirkovská note that weightbearing restrictions impact the patient’s ability to perform daily activities, including work-related activities.2 Dr. Marmolejo says this may have a negative impact on a patient’s attitude and self-confidence.1-6

Q:

How might these patient challenges pose further treatment challenges for the clinician?

A:

“A key component in treating a patient with a chronic wound is to know that negative emotions will be involved,” says Dr. Marmolejo. 

The panelists agree that patients may express these negative emotions in a variety of different manifestations and behaviors. Patients may direct fear and anger at the provider, explains Dr. Marmolejo. She says it is important to understand the underlying reasons for these behaviors and still try to build a positive patient-provider relationship.

Patients with depression may not keep scheduled appointments, which challenges the provider to adequately and promptly address their condition, according to Dr. Suzuki. In addition to appropriate referrals to psychiatric professionals, Dr. Suzuki emphasizes awareness of pain management options. 

“I do my best to be proactive about pain counseling and management as there are many pharmacological interventions,” says Dr. Suzuki. 

For pain management, he notes that he would have patients start with acetaminophen around the clock (maximum 3,000 mg per day in divided doses) and use narcotic medication (such as tramadol, hydrocodone and oxycodone) for breakthrough pain. Dr. Suzuki says adjunctive pain medication options may include gabapentin, pregabalin (Lyrica®, Pfizer) and duloxetine (Cymbalta, Lilly). He adds that many of his patients also self-medicate with CBD supplements.

When it comes to pain control interventions, Dr. Fassman cautions providers to be aware of unwanted side effects such as somnolence, confusion or even addiction. 

Dr. Fassman adds that clinicians should carefully weigh and balance non-clinical issues such as transportation challenges and large or repetitive copays when formulating an appropriate treatment plan that still prioritizes positive outcomes.

Q:

What strategies have you employed to prevent or address psychosocial issues during wound treatment? 

A:

“I try to be direct and concise with patients who have chronic wounds,” says Dr. Fassman. “I will utilize phrases such as ‘It is essential, Ms. Jones, that you keep your appointment with me next week,’ or ‘It is critical you control your blood sugars in order to heal the wound and prevent you from losing your foot.’” 

Dr. Marmolejo relates that taking into account a patient’s psychosocial health is important and begins with a thorough assessment of a patient’s level of education, employment history, history of alcohol, tobacco and drug use, how the patient interacts with his or her social network, the patient’s knowledge and perception of how his or her comorbidities affect health, the patient’s goals of treatment and reasons for previous treatment successes and failures if applicable.1,2,5,7

Dr. Suzuki explains that he strives to be as empathetic and positive as possible during interactions with patients. He adds that close communications with primary care doctors and the patient’s family may also be helpful. Judicious use of antidepressant medications and help from psychiatry colleagues may also be worthwhile, maintains Dr. Suzuki.  

Q:

Do you have any interesting case examples from this population to share with readers? 

A:

Dr. Suzuki shares a case of a woman in her mid-40s with chronic leg wounds over 10 years due to thalassemia (a genetic blood disorder that causes anemia), resulting in multiple hospital admissions. He notes the patient is clinically depressed and only presents for appointments every other week or so. He relates that he sees this in other patients that deal with chronic, lifelong diseases. While some of these patients manage reasonably well, Dr. Suzuki says others experience hopelessness and neglect their medical conditions.

Dr. Fassman relates seeing a recent patient with a chronic, plantar foot ulceration. As an attorney, the patient found it challenging to be able to offload appropriately as he had to be in court and meetings, etc. The patient unfortunately developed a limb-threatening infection, which required hospitalization a few days before a planned vacation out of the country. The patient adamantly expressed he was leaving for his trip “no matter what.” 

“I utilized phrases with him such as ‘You have a limb- and potential life-threatening situation if you take a long flight out of the country,’ and ‘It is essential you stay in the hospital where you will have the support and care necessary,’” emphasizes Dr. Fassman. While it took repeated efforts, Dr. Fassman notes the patient did eventually cancel his trip.

A frequent concern she hears from past students, residents and fellows, says Dr. Marmolejo, is how to discuss the situation with a patient when an amputation is required. Taking the potential negative aftermath out of this conversation is a talent honed with time, according to Dr. Marmolejo. 

“This conversation can be traumatic for the patient, causing a multitude of emotions, including aggressive and negative ones that may be provider-directed,” notes Dr. Marmolejo. “The provider must learn to give the patient grace, understanding and honesty, and not take the expressed emotions personally. Additionally, one must strive to understand the patient’s perspective and concerns in order to address him or her appropriately, building a relationship with the patient that facilitates the best functional outcome and quality of life.”  

Dr. Fassman is a Fellow of the American College of Foot and Ankle Surgeons, and a Certified Wound Care Specialist (CWS). A Diplomate of the American Board of Foot and Ankle Surgery, Dr. Fassman is in private practice in Colorado Springs, Colo.

Dr. Marmolejo is a clinical wound specialist with LifeNet Health and is a medical writer with Scriptum Medica. 

Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles, CA. He can be reached at [email protected]

References

1. Beattie AM, Campbell R, Vedhara K. ‘Whatever I do it’s a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429-439.

2. Fejfarová V, Jirkovská A, Dragomirecká E, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res. 2014:371938. DOI: 10.1155/2014/371938. Available at: https://www.hindawi.com/journals/jdr/2014/371938/. Published March 25, 2014. Accessed April 13, 2020.

3. Vileikyte L, Rubin RR, Leventhal H. Psychological aspects of diabetic neuropathic foot complications: an overview. Diabetes Metab Res Rev. 2004;20 Suppl 1:S13-8.

4. Vileikyte L. Psychosocial and behavioral aspects of diabetic foot lesions. Curr Diab Rep. 2008;8(2):119-125.

5. Roukis TS, Stapleton JJ, Zgonis T. Addressing psychosocial aspects of care for patients with diabetes undergoing limb salvage surgery. Clin Podiatr Med Surg. 2007 Jul;24(3):601-610.

6. Kinmond K, McGee P, Gough S, Ashford R. ‘Loss of self’: a psychosocial study of the quality of life of adults with diabetic foot ulceration. J Tissue Viability. 2003;13(1):6-8, 10, 12 passim. Erratum in: J Tissue Viability. 2003;13(2):80. 

7. Iversen MM, Midthjell K, Tell GS, et al. The association between history of diabetic foot ulcer, perceived health and psychological distress: the Nord-Trøndelag Health Study. BMC Endocr Disord. 2009 Aug 25;9:18.

 
By Colorado Foot and Ankle
April 29, 2020
Category: Foot Care
Tags: Shoes   Injuries  
The Right ShoesExercise is an important aspect of keeping our bodies healthy and happy. That’s why it’s so important to wear the correct shoes for certain activities. Whether you’re an athlete, workout buff, or enjoy walking and hiking, you need the proper footwear. It makes the difference between enjoying your favorite activities and sitting out with an avoidable injury. Talk to your podiatrist to have your feet evaluated for your future workout needs.
 
Essential Equipment
All exercise involves your feet, ankles, and knees. Placing pressure on them puts you at risk for strains, sprains, and wear-and-tear injuries. Find shoes made specifically for the activity you engage in while also providing a good fit. They should accommodate your body and activity level. 
 
Pay attention to the wear on your older shoes. The soles show where you need more support in the future. The right shoe also feels good from the start. Don’t believe the sentiment that a shoe needs to be broken in. This is not true and creates ongoing problems. 
 
Matching Your Shoe to Your Sport
Different types of exercise affect your feet in different ways. Your shoes need to support the high-risk areas. 
  • Running requires shoes with shock absorption. Your feet take on a lot of pressure and friction. Cushioning your shoes in the correct areas keeps you from feeling the pain. 
  • Traction is important in sports that need quick changes in direction and sprinting, like basketball. Traction should never be too high or low. The right shoes keep you from slipping on the floor while letting you move and pivot.
  • Ankle support is a must. It limits the side-to-side movement that knocks your ankle out of alignment. This kind of support keeps ankle sprains at bay. For sports like basketball, hockey, skiing, and skating, make sure that your shoes aren’t too high. Otherwise, they will dig into your Achilles tendon. You can also wear soft ankle braces.
  • Arch support varies for everyone. Your podiatrist can test your foot to determine your gait. Depending on the results, your podiatrist can recommend orthotics or special shoe inserts.
Remember to Replace Your Old Shoes
Pay attention to the state of your shoes to understand when to replace them. When the condition starts to decline, especially the arch support and sole, it’s time to go shopping. Start looking for a replacement when they become uncomfortable and wear differently. You don’t have to wear shoes for a long time for them to wear out either. If you are participating in sports or activity on an almost daily basis, your shoes are bound to wear out quickly. 
By Colorado Foot and Ankle
April 23, 2020
Category: Foot Care
Tags: plantar warts  

Plantar warts are tiny growths that typically form on the heels and other portions of the feet that usually bear weight. This pressure might likewise cause warts to form inward under the callus, which is a thick, rough skin layer. HPV causes plantar warts, and it can enter the body via small breaks or cuts on the bottom part of the feet.

That being said, most cases of plantar warts are not serious health issues and often go away with home treatments. However, those who have diabetes, are immuno-compromised or have recurring plantar warts despite diligent home treatments, should visit their podiatrist here at the Colorado Foot and Ankle Clinic.

During a consultation at one of our offices in Briargate Parkway or Pikes Peak Ave, Colorado Springs, Dr. Eric Gessner, Dr. Bryan Groth, or Dr. Jacob Fassman, will examine your plantar warts and take into account your specific circumstances to recommend the most suitable treatment options for you.

How Do I Know If I Have Plantar Warts?

Symptoms of plantar warts include the following:

  • Tiny, grainy, and rough lesions or growths at the foot’s bottom part, typically on your heel’s forefoot and base of your toes
  • Thickened, hard skin covering a defined spot where the plantar warts have formed inward
  • Lesions that intrude on the normal ridges and lines on the foot’s bottom part
  • Black pinpoints that look like tiny seeds, which are clotted blood vessels
  • Tenderness or pain when standing or walking

How Do I Prevent Plantar Wart?

To minimize your risk of developing plantar warts, do the following precautions:

  • Keep your feet dry and clean.
  • Change your socks daily.
  • Avoid contact with warts, even your own, and always wash your hands thoroughly after you’re touched a wart.
  • Never scratch or pick at warts.
  • Don’t walk barefoot in locker rooms and around swimming pools.
  • Never use the same nail clipper, pumice stone, or emery board on your wart-free skin that you use on your warts.

When Should I See My Podiatrist?

Visit your podiatrist in our Briargate Parkway or Pikes Peak Ave, Colorado Springs, locations to get your plantar warts examined if:

  • Your warts become painful, bleed, or has changed color or appearance
  • You have tried wart medications, but your warts recur, multiply, or persist
  • Your warts are affecting your daily activities
  • You’re not 100% certain whether or not your lesions are plantar warts
  • Your feet have reduced sensation
  • You’re a diabetic
  • You have a compromised immune system due to an immune system disorder like AIDS or are taking immunosuppressants

Need Help With Your Plantar Warts? Call Us

Dial (719) 475-8080 to reach Colorado Foot and Ankle and schedule your appointment with Dr. Eric Gessner, Dr. Bryan Groth, or Dr. Jacob Fassman, in our Pikes Peak Ave or Briargate Parkway, Colorado Springs, locations.

As you may already know two medications are repeatedly being mentioned when treating Covid-19. These medications called hydroxychlorquine (Plaquenil) and azythromycin (Z-pack) are being used in symptomatic patients. They are used for very sick patients who are in respiratory distress and require intubation, but are now being used more early in the infection treatment. Doctors are using cocktails of drugs, 2-3 medications simultaneously, to interrupt several infection processes. These vary widely and are not standardized. Colorado Foot and Ankle would like to educate our patients that these medication both are known to cause very small percentages of spontaneous tendon ruptures, usually in the lower extremity. The rates would be about one percent in previous studies. What we don’t know is if the two medications together increase the rates of injury but intuitively we are concerned. We do know that the risk of tendon injury does increase when using steroid (Prednisone, Medrol Dosepack) with an antibiotic like azythromycin so be aware. Some tips for our community, if you have had treatments with the above medications and have developed a sore region of you Foot or Ankle consider, Tendinopathy. Usually, we would see this as a spontaneous swelling in the foot or ankle, surprisingly, these do not always hurt. Rest, Ice, Compression, Elevation (RICE Regimen) generally helps. Don’t stop the medications for Covid-19 but consider an evaluation. We haven’t seen a rise in Tendinopathy that would reach statistical significance as of late April but if widespread use of hydroxychloroquine and azythromycin continue it will likely occur. Our thoughts for you and yours. Bryan Groth DPM

Side Notes:
Azythromycin is commonly confused with Erythromycin.
Medication induced Tendinopathy usually has noticeable swelling and inflammation before rupturing so early detection is very helpful.

By Colorado Foot and Ankle
April 20, 2020
Category: Foot Issues
Tags: Arch Problems  

The arches of the feet play a role in supporting your body’s weight when standing or in motion. The tarsal and metatarsal bones make up the arches of the feet, also receiving additional support and stability from tendons and ligaments; however, our feet, like the rest of our body, can be affected by infections, disorders, and structural changes that can impact not only the health of our feet but also our mobility. It’s important to recognize the warning signs of arch problems so you know when you to see a podiatrist.

Arch Pain Causes

If you are dealing with arch pain it is most likely caused by an injury or by structural abnormalities in the foot. For example, those with very high arches as well as those with flat feet may experience arch problems due to these common structural issues.

As a result, there are other factors that could also lead to further arch problems including:

  • Being overweight or obese
  • Aging
  • Plantar fasciitis
  • Cavus foot
  • Posterior tibial tendon dysfunction

It’s important to understand a little bit more about these common foot disorders and how they could affect the arches of your feet.

Plantar fasciitis

This condition that causes inflammation and microtears in the plantar fascia is also the most common cause of heel pain. Of course, because the plantar fascia (a ligament that connects the toes to the heel bone) also supports the arches of the feet this can also lead to arch pain. This condition is usually the result of overuse and is seen most often in runners. If you have plantar fasciitis it’s important to avoid physical activities until the fascia has fully healed.

Cavus foot

This condition, which affects the structure of the foot, leads to excessively high arches. People who’ve had a stroke, as well as people with certain conditions such as cerebral palsy may be more likely to develop cavus foot. This problem causes arch pain when standing or walking and can increase the risk for ankle injuries. Your podiatrist may choose to treat cavus foot through custom-made orthotics (shoe inserts), bracing, or by recommending specialized and supportive footwear.

Posterior tibial tendon dysfunction

The posterior tibial tendon runs from the calf muscles to the inner portion of the foot. This condition leads to changes in the tendon, which in turn affects its ability to support the arches of the foot. Flat feet can be caused by posterior tibial tendon dysfunction, and this is often the cause of flat feet that develop in adulthood. Like the other conditions above, treatment for PTTD usually involves bracing, orthotics, or providing custom devices that provide additional support to the arches of the feet.

If you are experiencing foot pain, swelling or other problems that affect mobility then it’s time that you turned to a podiatrist for care. Conditions and injuries that don’t respond to rest and at-home care may require more advanced treatments and therapies.





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