MESSAGE from the CPMA PRESIDENT Applications That Help Our Pa- Ting More and More Calls and Tion

winter 2009

NEWSLETTER MESSAGE FROM THE CPMA PRESIDENT applications that help our pa- ting more and more calls and tion. Let us know what activi- tients. From ESWT to Hypro- emails from members about ties you’re involved in and also cure implants, we are making specific issues. That is good, advise how the CPMA can help advancements in new treat- and that is what your associa- support your efforts. Also, ments for our patients. tion is here for. continue giving us ideas of how you want your association to We are also growing as a pro- I encourage you to continue to grow. Together, we can make fessional association. Besides take advantage of and support the CPMA even better in the increasing our membership your national podiatry associa- future. ■ roster, we are also expanding opportunities for our mem-

Mario G. Turanovic, DPM bers. In addition to looking President, at new affinity benefits, the Canadian Podiatric Medical Association Happy Birthday CPMA is also expanding network opportunities with other Happy :: As we close out 2008 and podiatry associations, such as to Us!!! look forward to 2009, it’s the American Podiatric Medi- Birthday! worth taking a moment to re- cal Association and the Fed- flect on where we’re at, both eration Internationale des Pod- in terms of the podiatry pro- ologues. Through both of these fession and your national po- organizations, CPMA mem- diatry association. bers receive benefits, such as discounted rates for the 2009 To copy an old advertising slo- APMA Scientific Seminar in To- gan, “we’ve come a long way ronto this coming summer and baby.” Our profession has free online education courses grown extensively over the for members through the FIP past few years and our scope website (www.fipnet.org) of practice continues to expand. Through continuing ed- Our communication is also ex- ucation opportunities such as panding. Our website and our the provincial conferences and newsletter provide avenues for online education, our members our members to stay informed are able to expand their learn- about activities and events ing curve with new ideas and in podiatry. We are also get-

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Be a part of the action !

:: For the first time in the American Podiatric Medical Association’s history, their national scientific seminar is leaving U.S. soil and Toronto, Ontario is the lucky city to play host to the 2009 APMA conference.

The conference takes place July 30-August 2, 2009 at the Metro Toronto Convention Where Your Patient Centre. The meeting will fea- ture interesting and informa- is Our Patient tive breakfast symposia, strong educational tracks, attention- grabbing plenary sessions, and a variety of hands-on work- www.precisionorthotics.com shops in multiple academic in- terest areas. As well, there will be a broad array of products and services showcased at • Friendly, attentive staff • Fine finishing the Metro Toronto Convention Centre’s spacious exhibit hall. • Exacting standards • Prepaid overnight shipping

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No excuses – it’s a great opportunity to continue your educational learning curve, For information Forcall information toll-free call toll-free dialogue and meet your col- leagues and network with like 1-800-661-1-880202-661 1-8221 minded professionals. Take a moment now to visit the con- #4-744 Fairview#4-744 Road Fairview Road ference website and regis- Victoria BC V9A 5T Victoria BC V9A 5T9 ter as a delegate. Visit http:// [email protected] www.apma.org/s_apma/sec. [email protected] asp?CID=10&DID=2821

2 Happy Birthday to Us!!!

:: It’s time to celebrate -- panded their outreach to their 2009 is the Canadian Podi- community through involve- atric Medical Association’s ment in a wide range of events, 85th birthday! such as diabetes clinics and educational awareness opportu- The CPMA was first estab- nities to breast awareness ac- lished on November 24, 1924 tivities and Special Olympics. as the Canadian Association of Chiropodists. On March 31, To all CPMA members – take Happy 1958 it was renamed the Cana- a moment to celebrate the dian Podiatry Association and achievements made in our on March 4, 1996 it became profession over the years. Cel- the Canadian Podiatric Medi- ebrate too your continuing cal Association commitment to podiatric pro- Birthday! fessionalism and community Over the years our profession involvement. has grown and so has our orga- nization, bringing it to the point Happy Birthday! where we truly are the premier foot specialists across Canada. Our growing scope of practice includes an enhancement of services for our patients from better surgical procedures, expanded prescribing rights for drugs and having hospital admitting privileges. Similarly, many of our members have ex-

3 Diabetes and podiatry – an important connection

:: Despite November being In- • every 30 seconds, a lower- betes. This represents about 1 couraging that more and more ternational Diabetes Day, or limb is lost to diabetes some- in 17 Canadians - 5.5 % of all of our podiatrists are playing perhaps because of, diabetes where in the world. women and 6.2 % of all men. an important role in greater is becoming almost a house- • it is estimated that by 2025, Older Canadians are more awareness about the diabetes hold word. Perhaps that’s be- diabetes will reach 333 mil- likely to have diabetes. In 2005- and the importance of taking cause no matter where you lion people, according to the 2006, 22% of people (approxi- good care of your feet. are in the world, diabetes is International Diabetes Foun- mately 1 in 5) in the 75-79 year reaching epidemic numbers dation. old age group had been diag- In fact, podiatry associations around the world. Just con- • including a podiatrist in the nosed with diabetes. This was around the world are taking sider these statistics: treatment process can de- almost 10 times the proportion the disease very seriously and crease the chance of a lower seen in Canadian adults aged are hosting diabetes focused limb amputation by as much 35-39 where the prevalence conferences, producing educa- as 85 percent! was 2.3%, or 1 in 43. Overall, in tional materials and taking part adults aged 20 and older, death in various diabetes-related ac- According to the Public Health rates for those with diabetes tivities. One Canadian example Agency of Canada, in 2005- are two to three times greater is the Annual Diabetes Seminar 2006, approximately 1.9 mil- than those of the general popu- that the British Columbia Asso- lion Canadian men and women lation. Among 20-39 year olds, ciation of Podiatrists organizes had been diagnosed with dia- individuals with diabetes die at each year (see the article on a rate more than six times that pages 16 and 17). of the general population, while in the 60-79 year age group the In addition to the special dia- rates are about twice as high. betes section that the FIP has developed for the 2009 World Aboriginals and certain popu- Foot Health Awareness Month lations, such as Asians, His- guide, the American Podiat- panics, and Africans, have a ric Medical Association has significantly higher risk of de- also focused efforts to pro- veloping diabetes. Estimates duce informational materials of the prevalence of diabetes for its Elect to Save Your Feet in Aboriginal people have been campaign. found to be as much as 3 to 5 times that in non-Aboriginal There are numerous materials populations. available to assist podiatrists in their efforts to educate their A podiatric physician plays an patients about diabetes. And integral role in the diabetes the CPMA will soon be adding management team so it’s en- a special diabetes focus on our website. 

4 Benefits of membership

:: Yes, it’s true! Membership Acting as the national voice • discounted rates to join • preferred rates for debit in the CPMA does have its for podiatrists in Canada, the APMA, which includes transactions privileges. In addition to the the CPMA is involved with copies of APMA news, the • negotiation of a member dis- CPMA representing its mem- legislative and policy changes educational journal JAPMA counted rate for the purchase bers and the podiatry profes- affecting podiatry both pro- as well as discounted rates of defibrillators sion with a variety of national vincially and federally. for conferences • preferred rates for liability organizations – the Canadian • automatic membership in the insurance and more. Diabetes Association, Cana- But there are also benefits for FIP, which includes access We continue to explore dian Orthopedic Association members as individuals too, to free online educational new opportunities for other and Canadian Health and Life including: credits discounts and benefits for Insurance Association, to name • 10% discount at all Fairmont our members. If you have a few – the CPMA also negoti- • reduced rates for many hotel properties around the a suggestion for additional ates fee schedules and cover- podiatry conferences held in world benefits for us to consider, age for professional services Canada • member discount with Hertz send an email to jjeneroux@ provided by podiatrists. Rentals xplornet.com or call toll-free to 1-888-220-3338. ■

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Paris Trade Ad(colour) Nov06.ind1 1 11/22/06 12:26:08 PM Get Ready for the 2010 World Congress

:: While it’s a bit early to pack Amsterdam is the capital of The Nether- your bags, its not too early to lands and is one of Europe’s most exciting start making plans to attend cities. It boasts nearly 800 years of history the 20th FIP World Congress as well as a rich cultural life full of theatres, Precision • Reliability • Versatility • Value of Podiatry that will be held in museums, restaurants and shopping. Amsterdam, The Netherlands on May 12-15, 2010 at the RAI The Schiphol Airport is also a major hub, Exhibition and Convention making it an easy flight destination for most Centre. major cities across Canada.

If you’re interested in being a speaker at the World Congress, visit the website in the new year for information about the Call for Papers – http://fipworldcongress.org/ ■

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:: People with diabetes are Because many people with di- the following P.A.D. warning tested for P.A.D. Testing is also at higher risk for having Pe- abetes do not have feeling in signs: recommended for people with riphereal Arterial Disease their feet or legs due to nerve diabetes under the age of 50 (P.A.D.). Some studies have disease, they may have P.A.D. • Fatigue, tiredness or pain in with other risk factors, such found that one out of three but cannot feel any symptoms. legs, thighs or buttocks that as smoking, high blood pres- people with diabetes over age As a result, they do not know always happens when walk- sure or cholesterol problems. 50 has P.A.D., and P.A.D. is that they have P.A.D., or they ing but that goes away when (Source: APMA website) ■ even more common in African may have it for a long time be- resting. Americans and Hispanics who fore it is diagnosed. Further, • Foot or toe pain at rest that Want more information have diabetes. when blood flow to feet and often disturbs sleep. about PAD – check out the legs is narrowed or blocked • Skin sores or wounds on the PAD Coalition website at Having P.A.D. and diabetes due to P.A.D., it takes longer for feet or toes that are slow www.padcoalition.org In can be a very serious problem. cuts or wounds to heal, which to heal. particular, check out the Re- People who have both diseases may increase the risk for ampu- sources section, which in- are much more likely to have tation (or losing a foot or leg). Because most people with cludes a guideline, a handy a heart attack or stroke than P.A.D. do not have any symp- pocket reference, clinical those who just have P.A.D., and Remind your patients with di- toms, guidelines released by tools, patient education they are more likely to die at a abetes that they need to talk leading vascular organizations materials and professional younger age. with their health care provider recommend that people with education opportunities. 12/5/08 9:40 AM Page 1 right away if they have any of diabetes over the age of 50 be

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:: Epidemiologists are pre- Considering that diabetic foot Survey being conducted by the questionnaire which is located dicting an epidemic of Type care is intrinsically multidisci- University of Brighton. at https://healthinfo.brighton. 2 diabetes on a worldwide plinary, disagreement between ac.uk/qa2/. In addition there basis (Virally M. et al 2007). professionals may lead to con- The purpose of the study is to are a few questions about your The International Diabetes Fe fusion, uncertainty and even determine the extent to which profession, gender and the deration has estimated that avoidance of recommended health care professionals agree country that you practice in. 246 million adults have diabe- foot care behaviour by people on what constitutes good foot tes and that by the year 2025, with diabetes (Kneepkens H health behaviour for persons There are 30 questions on the that figure will rise to 380 mil- questionnaire, which will take lion. Further projections of the approximately 5 minutes to global prevalence of diabetes complete. The questionnaire is have been estimated to reach on the secure website from the 366 million in 2030 (Wild S. University of Brighton, and the et al 2004) researcher will be the only person with the password to ac- Diabetic foot ulcer-related cess the data. It is anticipated morbidity could be substan- that the results of this research tially reduced by patients’ ac- will be published in an appro- tive engagement in self-care priate journal in 2009. of the feet (Boulton AJM. et al 2004). However educa- I do hope you will find the tional interventions have not time to take part in this sur- met with universal success. vey which will help inform any (Valk GD et al 2001). There is future foot health care educa- little evidence that educational tion programs for people with leaflets impact on behaviour 2006) with the potential to with diabetes and to explore diabetes. (Riemsma R et al 2002). How- result in serious preventable the differences of opinion that ever, the provision of leaflets is health consequences. healthcare professionals have Alistair McInnes regarded as an essential part about good foot behaviour. This Senior Lecturer, School of of routine care and patients With this in mind, you are en- will be measured utilizing a five Health Profession and patient groups frequently couraged to provide input to the point likert scale response to Division of Podiatry, stress the need for consistent Diabetic Foot Health Education a series of statements on the University of Brighton advice in education about self- Email - A.D.McInnes@brigh- management of diabetes (Day ton.ac.uk JL et al 1992). Telephone - 01273 644709 ■

9 PROVINCIAL UPDATES MANITOBA

BRITISH COLUMBIA We have been providing small presentations to the public re- :: The British Columbia Asso- Our next AGM is scheduled for :: 2008 has been a year of ex- garding the profession, scope ciation of Podiatrists (BCAP) February 28, 2009. citing change for the Mani- of practice and diabetic aware- has completed the renova- toba Podiatry Association. ness and care. tions at its new headquarters Scott Schumacher The executive committee is in downtown Vancouver. President, BCAP ■ currently still in the process of The Manitoba Podiatry Associ- updating the Manitoba Podia- ation has continued to provide This has included new flooring, try Association bylaws, and continual professional develop- paint, furniture and better stor- we hope to complete them ment seminars for its members age capability. in 2009. too. These have included a pre- sentation from the Manitoba The BCAP has now resolved Ombudsman, lectures on lo- the reimbursement issues for cal anesthesia, diabetic wound the Rural Travel program, and care and lower limb anatomy. we are now paid up to date. We are in the process of updating We have also had a new ex- our fee schedule for DVA and ecutive committee elected will next be approaching the ALBERTA that I know will take the Mani- BC government to update our toba Podiatry Association even fee schedule provincially. further in 2009 and the years :: Alberta is undergoing also released “Vision 2020” to come. We’re still winding our way some changes in healthcare which lays out plans for Alber- through the Health Professions delivery as a result of a re- ta’s health-care system for the As Past President of the Mani- Act (HPA). It appears we will cent amalgamation of nine next 10-15 years. toba Podiatry Association, I be the last professional group regional health authority would like to take this oppor- to be absorbed into this legis- boards into one provincial The Alberta Podiatry Asso- tunity to thank all the members lation. We’ve been repeatedly health board, the Alberta ciation is also busy working on for their support over the three told that this would happen Health Services Board. Also the legislative requirements years that I have been on the soon, but the time frame for included in the amalgamation needed for its inclusion into the Executive Committee. I know this to occur has proved to be are the Alberta Mental Health Health Professions Act. Much that the Manitoba Podiatry As- rather elastic. Board, the Alberta Cancer like its counterparts in British sociation will continue to grow, Board and the Alberta Alco- Columbia, the time frame for develop and meet the needs The new podiatric resident at hol and Drug Abuse Commis- inclusion has been ongoing for of its members. I look forward Vancouver General Hospital is sion (AADAC). The rationale several years, but it looks like to seeing the Manitoba Podia- Dr. Sydney Yau. He began his behind the amalgamation is we are getting very near to ac- try Association flourish in the residency July 1, 2008. to ensure the provincial health tual movement. coming years. system is patient-focused and provides equitable access to all Mario G. Turanovic D.P.M. Warm regards and Merry Albertans. President, Alberta Podiatry Christmas, Association ■ Hayley Edwards In early December the Alberta Past President of the Mani- Health and Wellness minister toba Podiatry Association ■ 10 PROVINCIAL UPDATES

ONTARIO QUEBEC Plans are already in the works for the upcoming graduating class. They will be holding their stress management purposes graduation event at L’Auberge and to respond to emergen- Estrimont near Sherbrooke on cies; “dispense” drugs, pri- May 2 and 3, 2009. :: The chiropody and the po- marily for purposes of patient :: Three half-time faculty diatry professions in Ontario self-care; have access to addi- professors were added to the When this class graduates, this were invited by the Health tional drugs; and reformat the UQTR staff in Fall 2008 – Dr. will increase the number of po- Professions Regulatory Advi- drug list to refer to categories Francois Allart, in charge of diatrists practicing in Quebec sory Council (HPRAC), along or classes of drugs, rather than the Orthopedics department; to over 100, which hasn’t been with 11 other professions, to specific drugs. Dr. William Lee, in charge of seen in a long time. participate in HPRAC’s re- the Surgical department; and view of prescribing rights Representatives of the OPMA, Dr. Ann Gagné, in charge of Francois Giroux and the administration of the College and the OSC met the Podiatric Medicine de- Quebec representative to the substances by non-physician with HPRAC on November 24 partment. CPMA ■ professions. The OPMA was to discuss the joint submis- surprised that chiropody and sion in detail and to respond to podiatry were included, be- HPRAC’s questions. Everyone cause the more comprehen- who participated in the meet- sive review of the chiropody ing, including Millicent Vork- and podiatry professions apich-Hill from the OPMA, that the Minister of Health came away thinking that things and Long-Term Care asked went very well and the group SASKATCHEWAN HPRAC to conduct is ex- responded effectively to all of :: There have been minor attend and be assessed by pected to get underway any HPRAC’s questions. changes in Saskatchewan the Fit Feet program as well day now. over the past year. Our as other health care profes- Nonetheless, the OPMA would membership numbers re- sions. We anticipate a great In any event, the Ontario Po- not be at all surprised if HPRAC mains the same. Our pro- turnout and already have sev- diatric Medical Association, defers its recommendations fessional association has eral volunteers to help out. the College of Chiropodists pertaining to chiropody and very few members as it is and the Ontario Society of Chi- podiatry until it completes the not obligatory to join thus Continuing Professional Med- ropodists joined together to more comprehensive chirop- our funds are very limited ical Education is still challeng- prepare a submission that was ody/podiatry review at the end to do much towards profes- ing for us as here as there are transmitted to HPRAC on No- of 2009. sional development. Sas- very few "podiatry" confer- vember 12. From beginning to katchewan members of the ences in this province. The end, the submission was pre- HPRAC’s staff and consultants college can now become in- universities of Saskatchewan pared in about two weeks. A are expected to make their pro- corporated. The legislature and Regina do host regular copy of the submission is avail- posals to the HPRAC Council has finally approved this CPME meetings but none able on the OPMA and HPRAC on December 18 and 19, after with royal assent. directly related to podiatry. web sites. which HPRAC will finalize its However, we are welcome report for submission to the The first Special Olympics to attend and gain education In essence, the submission Minister by the end of Janu- Healthy Athletes will take hours at our discretion. asked for the right for Chiropo- ary 2009. place in Regina, Saskatch- dists and Podiatrists to: admin- ewan on June 19-21, 2009. Edward Hauck ■ ister inhalants such as oxygen James Hill, DPM, FACFAS We expect 300 athletes to and nitrous oxide for pain and President, OPMA ■ 11 World Foot Health Awareness Month

:: As you probably know, May Medical Association’s mem- tes. Given the alarming statis- a poster each year in conjunc- is Foot Health Awareness bers are entitled to use the tics on diabetes, CPMA mem- tion with the theme. The 2009 Month, an event that is cele- FIP resources. ber associations may want to poster illustrates the diabetic brated around the world. But use the materials already pro- team working on the foot. what you might not know is that The 2009 materials have al- vided by the FIP about this very each year the Federation Inter- ready been prepared and are important issue. Visit www.fipnet.org to view the nationale des Podologues cre- available on the FIP website at materials available to help you ates materials and resources www.fipnet.org. For the 2009 The FIP has prepared a re- promote Foot Health Aware- that member countries can use campaign, the FIP has focused source guide, designed in a way ness Month in May 2009. ■ to promote the month in their on the diabetic foot and the dis- to make it easy for members to own country. As a member of ciplinary team that is involved use the information in a variety the FIP, the Canadian Podiatric in caring for people with diabe- of ways. The FIP also creates

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12 by Dr. Christopher L. MacLean, Ph.D., Director of Biomechanics, Paris Orthotics Lab Division In-office 3D Foot Scanners Vancouver, British Columbia

:: Experienced and successful example, the most common nomenon. That is, the orthosis of area) data. Until someone foot care specialists and lead- casting error is the Supinated is only as good as the model teaches how the magic works, ing manufacturers of custom Cast and the resulting nega- from which it is made. it is physically and mathemati- foot orthoses would agree tive impression typically pres- cally impossible to develop a that the single most impor- ents with a false metatarsus Whether you are in clinical true three-dimensional (3-D) tant factor influencing the adductus and/or a false fore- practice, or in the manufac- model of the foot from 1-di- quality of finished orthoses foot inversion. Typically, pa- turing sector, this is an im- mensional (vertical; not A-P and clinical outcomes is the tients will return to your office portant time to re-emphasize or M-L), pressure data. Al- quality of the neutral suspen- with complaints of discomfort this point as new technolo- though, a fancy on screen pre- sion cast. Without question, inferior to the medial calca- gies appear on the market that sentation may give the illusion compromised cast quality will neal tubercle or cuboid area. present alternatives to what of a 3-D plantar profile of the result in an orthosis: 1) that In addition, insufficient tal- we know as best practice for foot, it is not capturing the 3-D is intolerable and uncomfort- ocrural dorsiflexion or a failure functional orthotic prescrip- spatial anatomy of the foot. able; and 2) that is ineffective to position the midtarsus in its tion and manufacturing. For in producing a positive clinical closed-packed position can instance, there are a plethora What pressure mapping can outcome. result in a false forefoot plan- of pressure-mapping systems do is inform about increased/ tar flexion. These subtle vari- available on the market. They decreased areas of pressure We have learned a great deal ances in casting position can do not measure spatial data, and the trajectory of the cen- over the past 20 years about lead to what we refer to as the they measure one-dimensional tre of pressure. What we do common casting errors. For garbage in – garbage out phe- pressure (force per given unit not know is the correlation

13 In-office 3D Foot Scanners

between pressure measures and how the foot functions dynamically in 3-D. Pressure technology, as well as scanning devices that only collect 3-D data from three to seven anatomical sites on the foot, can only be used for extrapola- tion to create an approximate model of the foot; a model that is then matched to a Library of foot shape files, prefabricated insert shapes or prefabricated foot positive molds.

Figure 1: Neutral suspension technique with plaster (left) and VPS (right). This being said, the custom foot orthotic industry is enter- ing into an exciting time where tions available today: some of standard (i.e. NSCT) and what mising the NSCT in the manu- we expect (very shortly) to these are hand-held devices we know is best practice in the facture of CFOs will result in have a new technology that (borrowed from the O&P in- clinic as well as the lab. Aban- an inferior product. Two ex- allows the foot care specialist dustry) and others are of the doning the NSCT is required to amples of compromised cast to accurately capture the 3-D box variety. What is concern- compensate for the physical positioning that are emerging anatomy of the plantar surface ing is that some lab suppliers limitations of some scanners, due to scanner limitations are: with plaster-like accuracy. of these more recent scanning or limited technology. 1) with the handheld devices, Three-dimensional scanning technologies have been sug- the clinician not being physi- has been used for the past 30 gesting abandoning the gold What we know is that compro- cally able to maintain the foot years in the orthotics & pros- in the subtalar neutral posi- thetics (O&P) industry for tion with the midtarsus locked the scanning of amputation but requiring the patient to stumps prior to the manufac- maintain this position while turing of custom check sock- the scan is taken; and 2) with ets. In our industry, we have box-type scanners, requir- employed cast scanning tech- ing that the foot be in contact nology for the past 10 years to with the glass interface so scan the interior aspect of the that inadequate camera sys- neutral suspension cast prior tems can capture sufficient to applying automated cast data. Neither of these scan- corrections. ning technologies allow for the clinician to maintain accurate Until recently, there have only positioning. been two, true three-dimensional foot scanners available In addition, we advocate that on the market: 1) the Sharp- scanner technology be open Shape; and 2) Bergmann foot architecture. That is, if you as scanners. There are more op- Figure 2: Anterior view (upper) & Posterior (lower) views a clinician want to order from

14 a variety of different labs, you or full weightbearing images, if can. The only constraint is that so desired. whatever lab you choose must be able to receive the digital One of the other key benefits image files with their exist- of this technology is that it will ing automation corrections allow the clinician to efficiently software. An example is the evaluate the impressions on SharpShape scanner. It is built screen prior to sending them as an open architecture plat- Figure 3: Medial (top) & Lateral (bottom) views to the lab. The VPS provides form meaning that you, the the practitioner with a simple, clinician, can order from any fully rotatable image utility so SharpShape Lab. This is an that the image can be evalu- open choice that we believe We believe that we have found of pg 14)). This technology ated from several perspectives you should have as a clinician a solution that addresses all of utilizes 2 lasers and 2 cam- not limited to but including: 1) in the same way you do with these previous shortcomings eras and therefore is capable the forefoot:rearfoot can be a roll of plaster. The reality is and, in particular, the concern of capturing critical data up evaluated from an anterior that most foot care specialists about being able to precisely the sides of the foot and, most (Figure 2 (upper)) or posterior use more than one lab. Unfor- duplicate NSCT positioning importantly, the entire poste- perspective (Figure 2 (lower)); tunately, what some labs have and the clinician user inter- rior heel. In addition, because 2) a medial view (Figure 3 (up- chosen to do is take a scanner face. For the reasons given of this the foot is not required per)); 3) a lateral view (Figure built on open architecture, and above, it is imper- to be in contact with the 3 (lower)); and/or 4) inferior converted it to closed archi- ative that a foot glass, the practitioner view (Figure 4). These data tecture by adding computer scanner allows can easily position depicted in figures 1-4 repre- code that limits it to only their the practitio- the foot in the sent three-dimensional, spa- lab service. ner to accu- subtalar joint tial data with a resolution of 1.5 rately position neutral po- mm. Lastly, it is easy to re-scan At Paris Orthotics, we have the subtalar sition with (in less than three seconds per been striving to find a new so- and midtarsal the mid- foot) when the images are un- lution that addresses a number joints: com- t a r s u s satisfactory and a poor repre- of disadvantages to these pre- promising on l o c k e d sentation of the NSC position. vious technologies including: this technique w h e n We hope that this will help to will only result scanning significantly cut down on cast- • an inability to entirely dupli- in garbage in – prone or ing errors and that there will cate the neutral suspension garbage out. s u p i n e . be many examples of the ex- cast technique (NSCT) posi- The VPS cellent image in – great ortho- tioning, The in-office c o m e s sis out phenomenon. • poor clinician-screen inter- scanner technol- e q u i p p e d face for efficient evaluation of ogy that we are with a wire- For more information about this foot position accuracy, currently work- less remote article, contact Chris Maclean at • difficulty in transporting to ing on in conjunc- that the clini- [email protected] multiple clinic sites, tion with Chad cian or patient or www.parisorthotics.com  • being built on Closed (or McDaniel, PhD can activate (on Open converted to Closed) is the VeriScan request). The architecture, and Podiatric Scanner VPS can also be • expense. or VPS (Figure 1 (top used to take partial

Figure 4: Inferior view 15 Highlighting the Annual Diabetes Seminar and BCAP Dinner

:: For the past seven years, event were shoe fit checks by the British Columbia Podiatry New Balance and foot screen- Association (BCAP) has been ings by BCAP members. As building and growing a very well, Dr. Art Hister (a local fam- successful diabetes-focused ily doctor who has become a event. Now in its 7th year, t.v. personality) gave two talks the Annual Diabetes Seminar at the public forum; talks were and BCAP Diabetes Dinner is also provided at the forum by comprised of three compo- a dietician and an accountant. nents (see sidebar) hosted Phil Moore from Lady Sport in over a Saturday and Sunday Vancouver served as the Mas- during Diabetes Month in No- ter of Ceremonies. vember. “We are very fortunate to re- The 2008 event held on No- ceive great local media cover- vember 1 and 2 at the Marriott age of the event˝, added co-or- Vancouver Pinnacle in Van- ganizer Dr. Joseph Stern. “This couver, B.C. saw 125 physicians year’s event, dubbed the “7th and podiatrists attend the two- annual evening of diabetes day health care professionals awareness of seasonal cheer”, seminar and learn from leading included the serving of 248 di- experts in diabetes. As well, abetes-calculated meals at the 1000 people attended the pub- free dinner. For many of those lic forum and were screened who attended the dinner, this by Vancouver Coastal Health may be their only holiday din- employees for blood pressure, ner of the season.” glucose, etc. In addition to the educational “We have a very strong work- forums, thousands of dollars ing relationship with the Ca- worth of prizes were awarded nadian Diabetes Association at the dinner, including a trip (CDA) and this is the premier for two to Las Vegas, three event for the CDA in Vancou- walkers, Vancouver Canucks ver during diabetes awareness signed jersey and hockey stick, month in November,” noted Dr. two nights at the Vancouver Tim Kalla, one of the event’s Marriott hotel, 250 pairs of key organizers. “The event is a New Balance socks (one to lot of fun and really puts podia- each person) plus countless try in the spotlight during Dia- other prizes. betes Month. Kalla also acknowledged the Other highlights of this year’s great support and commitment

16 Diabetes event at a glance

The three components of the Annual Diabetes Semi- nar and Dinner event are:

1. Diabetes Conference for Healthcare Professionals The conference is dedicated to educating healthcare professionals about managing and treating patients with diabetes. Speakers include leading experts in diabetes, and topics appeal to podiatrists, physicians and nurses.

2. Diabetes Forum The diabetes forum, which runs from 2:00 – 6:00 p.m. on Sunday, is a public forum focused on providing the general public with diabetes-related information. In addition to 15 exhibitors, the forum also includes foot and retinal screenings, blood glucose monitoring and cholesterol checks as well as talks focused on healthy eating demonstrations, foot health, etc. Partners involved in this event include BCAP, University of British Columbia (UBC), the Canadian Diabetes Association, New Balance and London Drugs. This year’s event drew 1,000 people.

3. Diabetes Dinner The Diabetes dinner, which takes place from 6:00 -8:30 p.m. on Sunday evening, is provided free of charge to people with diabetes, many of whom are underprivi- leged. The meal and ingredients are specified by a dietician and the calories, carbohydrates, fat, etc., are put on the table. This year we had chefs from the local culinary institute volunteer to help prepare the meal.

By establishing a partnership with the UBC, we have been able to create a larger seminar and reach out to a broader audience, both in terms of healthcare profes- from all the participants over sionals and people with diabetes. the years, especially New Bal- event. “We are willing to help ance. Doctors Kalla and Stern them get started. This is an Publicity for the event is provided by the Canadian Dia- would like to call on CPMA amazing event that people look betes Association, which includes media releases. The members in other cities to get forward to each year,” stated CDA also handles the registration for the dinner. UBC involved and host their own Kalla.  Conference Planning Services coordinates the hotel ar- rangements for all aspects of the event.

1717 Great conference, great time and great location

:: Banff, Alberta was the location of the International Re- gion VII Podiatry Conference. Held on October 17-19, 2008 at the majestic Banff Springs Hotel, the conference provided a strong, well-rounded academic program. In addition to articles about surgery, diabetes and other topics, Mario Turanovic with Janet McInnes, SOCAP Chair, Joanna the conference also provides Brown SOCAP Chief Executive and Kathleen Stone, APMA Vice President groundbreaking technology – a 1st in Canada at a podiatry conference first – live-feed real- time video conference with Dr. David Armstrong. In fact, the event went so smoothly that both SOCAP and the APMA are considering using the technology for future conferences.

Ron Jensen, APMA President-Elect; Robert Chelin, FIP Presi- dent; Glenn Gastwirth, APMA Executive Director; Mario Tura- novic, CPMA/APA President; Ross Taubman, APMA President and Joe Caporusso, APMA Board Member

In addition to the strong lecture program, one of the highlights of the conference was the Ok- toberfest dinner on the Satur- Banff also served as the location for the 2008 CPMA AGM. Next year’s AGM will take place July 29, 2009 in Toronto, day evening.  O n t a r i o .

18 MARK your CALENDAR and plan to attend …

2009 Dates 2010 Dates 2010 Dates March 19-21 May 12-15 May 12-15 DFCON 2010 FIP World Congress 2010 FIP World Congress Los Angeles, California Amsterdam, The Netherlands Amsterdam, The Netherlands www.dfcon.com www.fipnet.org www.fipnet.org

March 20-23 July 15-18 APMA Annual Scientific Conference APMA House of Delegates Meeting Seattle, Washington Washington, D.C. www. apma.org 2013 Dates April 2-5 July 21-25 Midwest Podiatry Conference APMA Annual Scientific Conference Chicago, Illinois Las Vegas, Nevada www.midwestpodiatryconf.org 2011 Dates www. apma.org April 21-22 July 28-31 APMA Annual Scientific Conference SOCAP House of Delegates Assembly Boston, Massachusetts Birmingham, England www. apma.org 2014 Dates July 28 July 24-27 APMA Annual Scientific Conference CPMA Annual General Meeting Honolulu, Hawaii Toronto, Ontario 2012 Dates www. apma.org July 28-August 2 August 16-19 APMA Annual Scientific Conference APMA Annual Scientific Conference Toronto, Ontario Washington, D.C. www.apma.org www. apma.org 2015 Dates November 19-21 July 23-26 SOCAP Annual Scientific Meeting APMA Annual Scientific Conference Harrogate, England Orlando, Florida www. apma.org UQTR Podiatry Students get involved in the community :: The doctorate program in COMSEP is a non-profit or- nosis and treatment pro bono. sive attention they received podiatric medicine at the Uni- ganisation active in Trois-Riv- The interns, now pursuing the from the interns and clinicians. versité du Québec à Trois- ières since 1986. Its mission practical component of their The April 4 first-time patients Rivières (UQTR) favours an is to help the poor and needy doctorate program, found this received follow-up treatment approach which fosters com- improve their living conditions, experience very enriching. during their second visit on munity service. Recently, in- and its services include literacy April 11,” Morin added. terns at the podiatry clinic training, collective cooking and “The interns were highly mo- of the university had their job training. tivated,” Josée Morin, Admin- Given the high level of satis- first experience with mem- istrative Assistant at the clinic faction expressed by patients, bers of COMSEP, the Centre Since COMSEP members can situated in the Albert-Tessier students and clinicians alike, d’organisation mauricien de ill afford podiatric services, pavilion, commented. “The the experience will certainly be services et d’éducation popu- last April the team at the po- COMSEP patients – for most repeated. laire, a centre in the Mauricie diatry clinic of the university of whom this was a first-time region that provides social and agreed to devote two days dur- podiatric consultation – were “Community involvement is popular education services. ing which they provided diag- very appreciative of the exclu- very important in podiatry training. Teaching staff want to develop student awareness of this and encourage trainees to incorporate such involvement in their professional practice later,” Morin said.

The original text was published in French in the online newspaper Entête, vol 7 No 30, July 10, 2008 at www.entete.uqtr.ca. Entête is a UQTR publication..

By Serge Boudreau ■

Sylvie Lafond, COMSEP Coordinator, Dr. Philippe Legaré, Sylvie Tardif, Director-General, COMSEP, Mireille B. Desrosiers, student, and Jean-Pierre Adam, Administrative Director, Podiatry Clinic, UQTR. (Photo Flageol)

20 2008 CDA Guidelines Available Online

:: The Canadian Diabetes As- nadian Diabetes Association’s living with type 1, type 2 and sociation 2008 Clinical Prac- status as a leader in diabetes gestational diabetes. tice Guidelines for the Pre- prevention and management. vention and Management of The website is designed to en- Diabetes in Canada is now An Expert Committee of the able healthcare professionals available at http://www.dia- Association’s Clinical & Scien- who are working in diabetes-re- betes.ca/for-professionals/ tific Section developed the Ca- lated fields to review the guide- resources/2008-cpg/. nadian Diabetes Association lines in their entirety. To go di- 2008 Clinical Practice Guide- rectly to an individual chapter, Published only once every five lines by assessing international please use the web-enabled years, the Association’s Clini- peer-reviewed literature on this links found on the Table of through the website. Alterna- cal Practice Guidelines for the chronic condition to update the Contents page (http://www. tively, you can download the Prevention and Management previous guidelines. Repre- diabetes.ca/for-professionals/ 2008 Clinical Practice Guide- of Diabetes in Canada representing a broad range of health resources/2008-cpg/). lines in PDF format. sent the best and most current disciplines, the professionals evidence-based clinical prac- evaluated the best evidence Printed copies of the 201 page Note: A French language ver- tice data for healthcare pro- to guide screening, prevention, 2008 Clinical Practice Guide- sion of these guidelines is also fessionals. On a global stage, diagnosis, care, management lines are also available for pur- being made available on the the Guidelines support the Ca- and education for Canadians chase (CAD $25.00 per copy) wiebsite.

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21 Special Populations The effectiveness and safety in the following populations have not been studied, as the clinical trials with PENLAC excluded patients who: were pregnant or nursing, planned to become pregnant, had a history of immunosuppression (e.g., extensive, persistent, or unusual distribution of dermatomycoses, extensive seborrheic dermatitis, recent or recurring herpes zoster, or persistent herpes simplex), were HIV seropositive, received organ transplant, required medication to control epilepsy, were insulin dependent diabetics or had diabetic neuropathy. Patients with severe plantar (moccasin) tinea pedis were also excluded. So far there Prescribing Summary is no relevant clinical experience with patients with insulin dependent diabetes or who have diabetic neuropathy. The risk of removal of the unattached, infected nail, by the health care professional and trimming by the patient should be carefully considered before prescribing to Patient Selection Criteria patients with a history of insulin dependent diabetes mellitus or diabetic neuropathy. If a reaction suggesting sensitivity or chemical irritation should occur with the use of PENLAC, treatment should be discontinued THERAPEUTIC CLASSIFICATION and appropriate therapy instituted. Topical Antifungal Agent Use in Pregnancy: Teratology studies in mice, rats, rabbits, and monkeys INDICATIONS AND CLINICAL USE at oral doses of up to 77, 23, 23, or 38.5 mg, respectively, of ciclopirox Please read this entire section carefully to fully understand the as ciclopirox olamine/kg/day, or in rats and rabbits receiving topical indication for this product. doses of up to 92.4 and 77 mg/kg/day, respectively, did not indicate Topical treatment with PENLAC (Ciclopirox Topical Solution, 8% w/w) NAIL any significant fetal malformations. Teratology studies with ciclopirox free LACQUER is indicated as part of a comprehensive nail management program acid were performed in rats with oral doses of 20, 50, or 125 mg/kg/ in immunocompetent patients with mild to moderate onychomycosis day and in rabbits with oral doses of 12.5, 32, or 80 mg/kg/day; no (due to Trichophyton rubrum) of fingernails and toenails without lunula significant fetal malformations were noted. There are no adequate or involvement. The comprehensive management program includes frequent well-controlled studies of topically applied ciclopirox in pregnant women. removal of unattached, infected nails (e.g., monthly) by a health care PENLAC should be used during pregnancy only if the potential benefit professional with special competence in the diagnosis and treatment of justifies the potential risk to the fetus. nail disorders, including minor nail procedures. PENLAC should therefore Nursing Mothers: It is not known whether this drug is excreted in be used only under medical supervision. The safety and efficacy of daily human milk. Since many drugs are excreted in human milk, caution use for longer than 48 weeks have not been established. (See WARNINGS should be exercised when PENLAC is administered to a nursing AND PRECAUTIONS.) woman. Pediatric Use: Safety and effectiveness in pediatric patients have not been established. Pivotal Clinical Trial Data: Geriatric Use: Vehicle-controlled clinical trials of PENLAC conducted in PENLAC was used to treat onychomycosis of the great toenail (without the US did not include sufficient numbers of patients aged 65 and over to lunula involvement) in two double-blind, placebo-controlled pivotal studies. determine whether they respond differently from younger patients. Other Patients were treated once daily for up to 48 weeks in conjunction with reported clinical experience has not identified differences in responses monthly removal of the unattached, infected toenail by the investigator. At between elderly and younger patients. baseline, patients had 20-65% involvement of the target nail plate. Endpoint ITT Population Safety Information Study 312‡ Study 313‡ Efficacy WARNINGS AND PRECAUTIONS Variable Ciclopirox Placebo Ciclopirox Placebo Warnings Treatment 8/107 (8%) 1/107 (1%) 13/115 (11%) 1/115 (1%) PENLAC (Ciclopirox Topical Solution, 8% w/w) NAIL LACQUER is not for Success1 ophthalmic, oral, or intravaginal use. For use on nails and immediately Treatment 6/110 (6%)† 1/109 (1%) 10/118 (9%) 0/117 (0%) adjacent skin only. Cure2 Precautions No studies have been conducted to determine whether ciclopirox might Mycological 30/105 (29%) 14/105 (13%) 39/113 (35%) 10/114 (9%) Cure3 reduce the effectiveness of systemic antifungal agents for onychomycosis. 1 Treatment Success : negative culture, negative KOH, ≤ 10% involvement target nail Therefore, the concomitant use of PENLAC (Ciclopirox Topical Solution, 8% 2 Treatment Cure: negative culture & KOH, Global Evaluation Score = Cleared w/w) NAIL LACQUER and systemic antifungal agents for onychomycosis, 3 Mycological Cure: negative culture, negative KOH ‡ Denominators differ across variables because of missing data is not recommended. (See INDICATIONS AND CLINICAL USE.) †p = 0.055. All other values statistically significant (CMH≤0.02, stratified by centre) ADVERSE REACTIONS Post-treatment efficacy assessments were scheduled only for patients In the vehicle-controlled clinical trials conducted in the US, 9% (30/327) who achieved treatment cure. Some data on the post-treatment efficacy of patients treated with PENLAC (Ciclopirox Topical Solution, 8% w/w) of the product are available for 12 patients. Twelve weeks after stopping NAIL LACQUER and 7% (23/328) of patients treated with vehicle ciclopirox treatment, 3/6 patients maintained treatment success, and reported treatment-emergent adverse events (TEAE) considered by the 6/9 patients maintained negative mycology reports. investigator to be causally related to the test material. With the exception CONTRAINDICATIONS of Skin and Appendages, the incidence of these adverse events, within PENLAC (Ciclopirox Topical Solution, 8% w/w) NAIL LACQUER is each body system, was similar between the treatment groups and was contraindicated in individuals who have shown hypersensitivity to any of less than 1%. For Skin and Appendages, 8% (27/327) and 4% (14/328) of patients in the ciclopirox and vehicle groups, respectively, reported 22 its components. at least one adverse event. Periungual erythema and erythema of the proximal nail fold were the most common TEAEs causally related to study Administration drug. These events (coded as “rash”) were reported in 5% (16/327) of patients treated with PENLAC and 1% (3/328) of patients treated with DOSAGE vehicle. Other TEAEs thought to be causally related to study material in PENLAC (Ciclopirox Topical Solution, 8% w/w) NAIL LACQUER should the US vehicle-controlled studies included nail disorders such as shape be used as a component of a comprehensive management program for change, irritation, ingrown toenail, and discoloration. The incidence of onychomycosis. Removal of the unattached, infected nail - as frequently nail disorders was similar between the treatment groups (2% [6/327] in as monthly - by a health care professional, weekly trimming by the the PENLAC group and 2% [7/328] in the vehicle group). Application site patient, and daily application of the medication are all integral parts of reactions and/or burning sensation of the skin were considered causally this therapy. Careful consideration of the appropriate nail management related to study drug in 1% of both PENLAC and vehicle-treated patients program should be given to patients with diabetes. (See WARNINGS AND (3/327 and 4/328, respectively). PRECAUTIONS.) The following table summarizes the most common TEAEs considered Nail Care By Health Care Professionals: Removal of the unattached, causally related to study drug, as reported in the US Phase II/III vehicle- infected nail - as frequently as monthly- trimming of onycholytic nail, and controlled trials. filing of excess horny material should be performed by professionals Body System PENLAC Vehicle trained in the treatment of nail disorders. TEAE n (%) n (%) Nail Care By Patient: Patients should file away (with emery board) loose nail material and trim nails, as required, or as directed by the health care 327 (100.00) 328 (100.00) No. of Patients Treated professional, every seven days after PENLAC is removed with isopropyl Patients with Related TEAEs 30 (9.2) 23 (7.0) alcohol. PENLAC should be applied once daily (preferably at bedtime or Skin and Appendages 27 (8.3) 14 (4.3) eight hours before washing) to all affected nails with the applicator brush provided. PENLAC should be applied evenly over the entire nail plate. Periungual erythema/ 16 (4.9) 3 (0.9) erythema of proximal nail fold If possible, PENLAC should be applied to the nail bed, hyponychium, and the under surface of the nail plate when it is free of the nail bed Nail disorders† 6 (1.8) 7 (2.1) (e.g., onycholysis). PENLAC should not be removed on a daily basis. Application Site Reaction/Burning Sensation 3 (0.9) 4 (1.2) Daily applications should be made over the previous coat and removed Other‡ 2 (0.6) 0 (0.0) with isopropyl alcohol every seven days. This cycle should be repeated All other Body Systems 0-1 (0.0-0.3) 0-3 (0-0.9) throughout the duration of therapy. †Nail disorders such as shape change, irritation, ingrown toenail and discoloration. ‡Other: Dry skin, pruritus. SUPPLEMENTAL PRODUCT INFORMATION SYMPTOMS AND TREATMENT OF OVERDOSAGE Use of PENLAC for 48 additional weeks was evaluated in an open-label The likelihood of overdosage from topical administration of ciclopirox nail extension study conducted in patients previously treated in the vehicle- lacquer, 8% is extremely low. In a test of acute oral toxicity in the rat, the controlled studies. Three percent (9/281) of patients treated with LD50 was greater than 10 mL/kg of ciclopirox nail lacquer, 8%. This PENLAC experienced at least one TEAE that the investigator thought was would be equivalent to 600 mL for an adult person weighing 60 kg or causally related to the test material. Mild rash in the form of periungual more than 1000 vials of 3 mL. Furthermore, overdosage by oral ingestion erythema (1% [2/281]) and nail disorders (1% [4/281]) were the most of nail lacquer would be unlikely because of its unpalatable taste. frequently reported. The remainder of TEAEs considered causally related to study drug occurred at an incidence of <1%. In controlled and open- label clinical trials conducted with ciclopirox nail lacquer, 8% outside of STORAGE AND STABILITY the US, adverse events reported were consistent with those seen in the PENLAC should be stored at room temperature between 15° and 30° C. US studies. To protect from light, replace the bottle into the carton after each use. CAUTION: Flammable. Keep away from heat and flame. Post-Marketing Experience Contact dermatitis has been reported as an adverse reaction in post- marketing surveillance of ciclopirox-containing products, including DOSAGE FORMS, COMPOSITION AND PACKAGING PENLAC ciclopirox nail lacquer, 8%. (Ciclopirox Topical Solution, 8% w/w) NAIL LACQUER is a clear, colourless to slightly yellowish solution for topical application to fingernails, toenails To monitor drug safety, Health Canada through the Canada and immediately adjacent skin only. It is available in 3 gram, 6 gram and Vigilance Program collects information on serious and 12 gram glass bottles with screw caps which are fitted with brushes. unexpected side effects of drugs. If you suspect you have had The full Product Monograph can be found at a serious or unexpected reaction to this drug you may notify www.sanofi-aventis.ca or by contacting sanofi-aventis Canada Vigilance: Canada Inc., 2150 St Elzear Blvd West, Laval, Quebec H7L 4A8, at 1-800-265-7927. By toll-free telephone: 866-234-2345 Copyright © 2009 sanofi-aventis. All rights reserved. By toll-free fax: 866-678-6789 sanofi-aventis Canada Inc., Laval, Quebec H7L 4A8 Online: www.healthcanada.gc.ca/medeffect By email: [email protected] By regular mail: Canada Vigilance National Office Marketed Health Products Safety and Effectiveness Information Bureau Marketed Health Products Directorate Health Products and Food Branch, Health Canada, Tunney’s Pasture, AL 0701C Ottawa ON K1A 0K9 23 PENLAC is indicated as part of a comprehensive nail management program in immunocompetent patients with mild to moderate onychomycosis (due to T. rubrum) of fingernails and toenails without lunula involvement. The comprehensive management program includes frequent removal of unattached, infected nails (e.g. monthly) by a health care professional with special competence in the diagnosis and treatment of nail disorders, including minor nail procedures. PENLAC should therefore be used only under medical supervision. The safety and efficacy of daily use for longer than 48 weeks have not been established. No studies have been conducted to determine whether ciclopirox might reduce the effectiveness of systemic antifungal agents for onychomycosis. Therefore, the concomitant use of PENLAC (Ciclopirox Topical Solution, 8% w/w) NAIL LACQUER and systemic antifungal agents for onychomycosis, is not recommended.

PENLAC is generally well tolerated: treatment related side effects were periungal erythema (5%) application site reactions and/or burning sensation of the skin (1%) and nail disorders (2%), including shape change, irritation, ingrown toenail and discolouration.

Please read the Indications and Clinical Use section, in the product monograph carefully before prescribing.

24 See prescribing summary on page 22