FOOT HEALTH PRACTITIONER DIPLOMA COURSE Assignment Eight

Foot Health Practitioner Diploma Course – Assignment Eight – Page 1

FOOT HEALTH PRACTITIONER

DIPLOMA COURSE

Assignment Eight

TUTOR TALK: All images in this lesson, unless stated otherwise, were taken from the following source:

Wynn Kapit, Lawrence M. Elson (2004), The Anatomy Coloring Book 3rd Edition, Publisher: Benjamin Cummings

THE ENDOCRINE SYSTEM

TUTOR TALK: The learning outcomes for this module are:

• Identify the relationship between hormones and the endocrine system • Present a discussion on diabetes • Explore foot care for diabetics • Understand therapeutics and materia medica • Investigate the use of Corticosteroids • Understand some of the uses of padding

TUTOR TALK: Endocrine glands produce hormones that are liberated directly into the bloodstream. Hormones are chemical messengers. They act upon target tissues that may be some distance from the point at which they are produced. The target tissues then react to perform a function. This has real significance in our work due to the role of the pancreas in producing hormones that control blood sugar levels. Poor control of blood sugar levels leads to Diabetes mellitus – a multi-factorial disorder with far-reaching consequences upon many body systems. The feet are subject to damage in Diabetes mellitus. There are implications for wound healing and, in poorly controlled or long standing cases, tissue viability. Care of diabetic patients is an important aspect of our practice. It is vital that we should understand the effects of diabetes and the requirements of the condition.


THE ENDOCRINE SYSTEM All the organs of the endocrine system are glands. All the glands of the endocrine system are endocrine glands and release chemicals known as hormones into general circulation (other glands known as exocrine glands discharge their secretion via a duct to a particular place. Exocrine glands are not part of the endocrine system). The hormones they release are important to body functions. They regulate basic drives and emotions such as sexual urges, violence, anger, fear, joy and sorrow. They also promote growth and sexual identity, control body temperature, assist in the repair of broken tissue, and help to generate energy.

Location of endocrine glands and associated structures


Endocrine glands located throughout the body produce hormones and release them into the bloodstream. PITUITARY GLAND

• growth hormone – regulates the rate of growth • thyroid-stimulating hormone – stimulates the thyroid to secrete thyroxine • gonad-stimulating hormone – stimulates ovaries or testes to secrete sex hormones

THYROID

• thyroxine – controls the metabolic rate ADRENAL GLANDS

• adrenaline – prepares the body for action PANCREAS

• insulin – regulates the amount of sugar in the blood OVARIES

• female sex hormones – control sexual development TESTES

• male sex hormones – control sexual development HORMONES AND THE ENDOCRINE SYSTEM Each endocrine gland produces one or more hormones, each of which governs a particular body function. Growth, repair of tissues, sexual development, reproductive function, and the body’s response to stress are some of the aspects of body function controlled by hormones.


Most hormones are released constantly from birth, the actual amount varying with the needs of the body. Others are produced at certain times or for particular intervals of our lifespan. Growth hormone is released principally during childhood and adolescence. Sex hormones are produced by the male testes and the female ovaries from puberty onwards. The hypothalamus of the brain instructs the pituitary gland to produce release hormones, which in turn stimulate specific glands to produce particular hormones. A ‘feedback’ mechanism monitors and regulates blood hormone levels. If the level becomes too high the pituitary gland releases another hormone that inhibits endocrine gland activity. ENDOCRINE DISORDERS Endocrine disorders are usually caused by too much or too little of a particular hormone. They have a variety of causes and can be congenital or due to cancer, auto-immune disease, diabetes mellitus, injury and certain drugs. Natural hormone preparations or their synthetic equivalent are prescribed to treat deficiency. Drugs might be given to stimulate increased hormone production. In cases of over-production of hormone other drugs are administered to reduce the activity of the gland. Hormones or related drugs are used to treat other conditions. Corticosteroids are related to adrenal hormones and are used to relieve inflammation and to suppress immune system activity. Several types of cancer are treated with sex hormones. Female sex hormones are given as contraceptives and to treat menstrual disorders. Growth hormones are given to undersized children to improve their attained height. Oral corticosteroids are administered in Addison’s disease, a condition due to deficient secretion of the hormones cortisol and aldosterone by the adrenal cortex. Addison’s disease causes electrolytic upset, lowered blood pressure, diminution of blood volume, weight loss, hypoglycaemia, great muscular weakness, gastrointestinal upsets and pigmentation of skin. THE PANCREAS The pancreas is a flattened organ located to the rear of and slightly below the stomach. It is described as having head, body and tail.


The endocrine portion of the pancreas consists of about 1,000,000 clusters of cells called ‘pancreatic islets’ or ‘islets of Langerhans’. Three kinds of cells are found in these clusters:

1. alpha cells – which secrete the hormone glucagon that raises blood sugar level 2. beta cells – which secrete the hormone insulin that lowers blood sugar level 3. delta cells – which secrete growth hormone inhibiting hormone, somatostatin.

Glucagon and Insulin are the endocrine secretions of the pancreas and are concerned with regulation of blood sugar level. GLUCAGON The product of the alpha cells of the pancreas is glucagon, the action of which is to raise the blood glucose level. Glucagon accelerates the conversion of glycogen stored in the liver into glucose, a process called glycogenolysis. It also causes other nutrients stored in the liver such as amino acids, glycerol and lactic acid to come together to produce glucose in a process called gluconeogenesis. The liver then releases glucose into the blood, and the blood sugar level rises.


Secretion of glucose is controlled by a negative feedback system. When blood sugar level falls below the correct value, chemical sensors in the alpha cells stimulate the production of glucagon. When blood sugar levels rise, the cells are no longer stimulated and production slows. If this feedback system should fail for any reason, the alpha cells continue to secrete glucagon continuously and an excess of glucose is liberated. This excess of glucose is called hyperglycaemia – raised blood sugar level. Exercise and meals that are largely of protein raise the amino acid level in the blood and may cause an increase in glucagon secretion. INSULIN The product of the beta cells of the pancreas is insulin, the action of which is to lower the blood glucose level. All cells of the body need energy to function. This energy is provided in the main by glucose – a simple sugar carried as a solute in the blood. The glucose must enter into the cell through the cell membrane. The physiological action of insulin is the opposite to that of glucagon. Insulin decreases blood sugar level in several ways. Insulin accelerates the passage of glucose from the blood into the cells. Insulin accelerates the conversion of glucose into glycogen in the process of glycogenesis. Insulin also decreases glycogenolysis and gluconeogenesis. Insulin stimulates the conversion of glucose and other nutrients into fatty acids (lipogenesis), and helps stimulate protein synthesis. A negative feedback system regulates the production of insulin. Too much insulin lowers the blood sugar level excessively and leads to the condition hypoglycaemia. Insulin is necessary for entry of glucose into the cells.


GLUCAGON Raises Blood Sugar Level Accelerates conversion of Glycogen to glucose in the liver (Glycogen-olysis) and conversion of nutrient to glucose in Liver (Gluco-neo-genesis) and releasing Glucose into the blood. Sugar can only be used by cells in the form of Glucose.

INSULIN Lowers Blood Sugar Level Reduces Glycogen-olyis caused by Glucagon and reduces Gluco-neo-genesis caused by Glucagon. Therefore Insulin is the antigen of Glucagon. Insulin accelerates transport of glucose to Glycogen into the Cells and conversion of glucose to Glycogen (Glyco-genesis). Glucose can only be stored in the liver as Glycogen.

Glycosuria is the escape of glucose into the urine.

Normal Blood Glucose Level If blood glucose levels fall below or climb above the range of normal, diabetic coma will be the result. Hypoglycaemia will be quick; Hyperglycaemia takes more time; but both are dangerous. Both conditions are avoidable by blood glucose control.


High Blood Glucose Level Leaks into Urine * Millimoles per litre. There are exceptions to these norms. Renal threshold can be higher or lower. DIABETES MELLITUS Diabetes = overflow, Meli = honey Diabetes mellitus is a group of disorders that are characterised by the deficiency or inneffectiveness of the endocrine secretion of the pancreas, insulin. Normally carbohydrates are absorbed in the form of simple sugar (glucose) through the walls of the small intestine. Glucose is stored primarily in the liver and, to a lesser extent, in the muscle tissues as glycogen, to which it is converted by the endocrine secretion insulin of the beta cells of the Islets of Langerhans of the pancreas. Glycogen can be readily converted back to glucose as cellular activity and the need of energy arise, by glucagon which is the product of the alpha cells of the Islets of Langerhans. Glucagon accelerates the conversion of glycogen into glucose and enhances the release of glucose into the bloodstream. It is inhibited by Insulin.


Insulin adjusts the level of glucose in the blood stream by:

1. Assisting the takeup of glucose by the cells. 2. Converting glucose into glycogen

Between them, glucagons and insulin maintain the normal blood glucose concentration. Failure of the pancreas to produce sufficient insulin has the effect of:

a. Increasing the blood sugar level (hyperglacaemia) and b. Preventing the cells utilising glucose for metabolism and energy production

When hyperglacaemia is present the excess blood sugar is removed from the bloodstream by the kidneys, causing glycosuria – a concentration of sugar in the urine. This causes the excretion of water to dilute the urine, leading to excess production of urine with increased frequency (the need to void, polyuria), and consequent thirst (polydipsia). In the case of inability to use insulin or if there is insufficient insulin produced, there will be only partial metabolism of fats, and this partial oxidation of fats produces toxic ketones. Because carbohydrates are only partially digested there is increased appetite to eat more (polyphagia) due to the need for nutrition. Although more is ingested there is accompanying weight loss. The lack of glucose within the cells for metabolism and energy production, the high glucose level in the bloodstream and the presence of ketones in the cells will precipitate a hyperglacaemic coma leading to death, unless insulin is administered. MAJOR DRUG GROUPS RELATED TO THE ENDOCRINE SYSTEM: Diabetes drugs / thyroid disorder drugs / pituitary disorder drugs / sex hormones DIABETES Diabetes is a general term for disorders characterised by excessive urination. It usually refers to diabetes mellitus – a condition which gives rise to an excess of sugar in the urine. With more than 200 million sufferers worldwide, diabetes is a common disorder.


TYPES OF DIABETES MELLITUS

1. Type 1 – juvenile onset – insulin dependant diabetes mellitus (IDDM)

Appears in young people, 50% of cases occurring around the time of puberty. An autoimmune condition or viral disease is thought to be responsible for the gradual destruction of the insulin-secreting cells of the pancreas. Symptoms include extreme thirst, increased urination, lethargy and weight loss. Insulin is administered by injection

2. Type 2 – maturity onset – non-insulin dependant diabetes mellitus (NIDDM)

Appears at an older age (usually over 40 years) and tends to onset gradually, which is why it is often not recognised immediately. Levels of insulin in the blood may actually be high, but the cells of the body have developed resistance to the effects of insulin, thus rejecting the glucose and leaving it in the blood at high levels. This is hyperglycaemia – high blood sugar. Obesity and the western life-style lacking exercise are implicated as the cause of maturity onset diabetes mellitus. Control may be possible by diet and exercise alone. If lifestyle change cannot be made to be effective, drugs can be administered.

3. Stress or latent diabetes mellitus

May occur during pregnancy or when under physical stress. The body fails to respond to insulin at its normal levels in the blood.

CONTROL OF DIABETES In diabetes an alteration in diet is vital. A healthy diet consisting of low-fat, high-fibre, low simple sugar (cakes and sweets) and high complex sugar (pasta, rice, potatoes) intake is advised. In Type 2 diabetes a reduction in weight alone may be sufficient to lower the body’s energy requirements and restore blood glucose to normal levels. If an alteration in diet fails, oral antidiabetic drugs are prescribed. Insulin can be administered if these treatments fail. Insulin may also have to be administered in pregnancy, illness or in the event of a general anaesthetic being required for surgery. The closer the control achieved, the lower is the risk of suffering the long term effects of diabetes – retinopathy, nephropathy, neuropathy, and poor tissue viability. Foot health practitioners need to be aware of the aetiology of non-healing wounds, neuropathy, low resistance to infection and the formation of diabetic ulcers.


SYMPTOMS AND EFFECTS OF DIABETES MELLITUS The initial symptoms and effects are:

• Glycosuria – escape of glucose into the urine which can easily be detected from a urine sample

• Polyuria – increased frequency due to increased production of urine to dilute and excrete the

excess sugar

• Polydipsia – increased drinking in response to thirst to replace the voided fluids

• Polyphagia – excessive eating in an attempt to acquire adequate nutrition – there is an attendant weight loss despite this

• Slowness to heal – wounds stand open longer and there is a reluctance to heal

• Susceptibility to infection – wounds become infected easily and do not resolve as they should

The normal ability of the body to heal quickly is compromised and there is a reduction in the resistance to infection. A wound in a diabetic heals slowly, may ulcerate and might in severe cases lead to cellulitis, septicaemia or gangrene. We must take great care not to wound a diabetic patient. A small wound to a diabetic can be potentially more serious than a large wound to a non-diabetic. If a diabetic is cut, or a wound incurred during, for instance, nail cutting, the operator must take the utmost care to ensure that the wound is thoroughly cleansed, treated with an antiseptic and adequately protected by a suitable dressing (sterile when applied) to defend until healed. Follow-up appointments should be made if there is any doubt that resolution will be retarded or incomplete so that wound management and monitoring can be pursued. As soon as a problem is perceived it is wise to act promptly and refer the patient to the GP with a referral letter stating the problem, a short history and your management to the point of referral.


THE IMPORTANCE OF TREATING DIABETES If diabetes is left untreated, the continuous high blood glucose level damages various parts of the body. The major problems arise from the build-up of atheroma in the arteries, which narrows the blood vessels and reduces the flow of blood. This can result in heart attacks, blindness and kidney failure. Reduced circulation in the lower limbs causes intermittent claudication, increases the risk of thrombosis, and leads to neuropathy and poor healing of wounds with the risk of diabetic ulcer and gangrene. The earlier the diagnosis, the sooner control can be achieved and the closer that control can be, the greater is the reduction of long term effects. Good control of diabetes in pregnancy reduces the risk of abnormalities in the baby, or of miscarriage. If diabetes is diagnosed early and the patient complies with all the advice given, the diabetes will have little effect and a full and entire lifespan is to be expected. However, if balance is not maintained and the patient chooses to ignore advice on lifestyle, the diabetes will have so many effects upon so many systems of the body that life will be much reduced in quality and duration. In addition to the polyuria, polydipsia, polyphagia and their acute effects there will be longer term effects particularly to the heart, mechanisms responsible for infection resistance and wound healing, sight due to retinal deterioration, and the kidneys may be affected. There may be neuropathies of the legs and feet due to the effects upon the peripheral circulation. Peripheral neuropathy is of vital interest to the foot health worker. Due to the diabetes there is disruption of the blood supply to the extremities, which starves the peripheral nerve endings and receptors of proper nourishment. There is a consequent loss of sensation, which allows injury to be sustained but not appreciated.

A man who suffers from indifferent control of his diabetes mellitus treads on a plank of wood from which protrudes a rusty nail. Because of his peripheral neuropathy he does not feel pain as the nail enters the foot. Two weeks later, whilst taking a bath, he sees blood on the towel he has been standing upon to dry himself. Turning up the sole of the foot, there is a deep infected and ulcerating wound at the point of entry. There is a red tell-tale track of lymphangitis on the back of the leg and a lump behind the knee which he has never noticed before (an enlarged lymph node). This all comes as a complete surprise.

The above demonstrates why a diabetic must be instructed to visually examine the feet daily. If the task proves impossible, a relative or friend can often be recruited to assist with this, although tricks such as placing a mirror on the floor can help to make examination easier. Any injury should be cleansed carefully, treated with an antiseptic preparation and protected until healed.


Daily hygiene using simple, non-scented soap and careful trimming of the nails by a trained foot health practitioner are essential to foot care. Water temperature of baths and showers should be tested with the elbow or the hand (the fingers are less affected by the neuropathy) before introducing the feet. Hosiery should be changed daily and should be free of bulky seams and darns. Shoes should fit well and be in good state of repair. Neuropathy can be very unpleasant for the diabetic, causing great pain, the feeling of the foot being in a vice, or of being very hot. Alternatively, and quite as dangerous, the foot may not register pain, which is a protective mechanism. Those with no sensation left report the feeling of ‘floating above the ground’ because they have no appreciation of weight upon their feet when standing or walking. Their feet ‘feel as if they don’t belong to them’. Neuropathy may affect one or more toes, and part or whole of the foot. Often it has ‘sock’ distribution, meaning that it affects the area usually covered by a man’s short sock. Amputation may follow quite quickly upon this since diabetic ulcers form readily on weight-bearing parts of the neuropathic foot with little sensation remaining. TESTING FOR NEUROPATHY Every diabetic has the potential to develop neuropathic ulceration, but the risk varies with the level and progress of the condition. Neuropathy may occur in the long term diabetic or in those in whom control is or has been poor. Identification of those most at risk allows the correct level of support to be given. Standard fibres These are precision manufactured short lengths of plastic monofilament in several diameters. The filament is pressed against the part to be examined. The filament bends when a predetermined load is applied; for instance, the 10 gram monofilament will bend when the tip exerts a pressure of 10 grams upon the skin. If the patient cannot feel the monofilament at specified points upon the foot there is sufficient loss of sensation to be at risk of developing a neuropathic ulcer. Tuning forks The tuning fork vibrates at a particular pre-determined frequency, dependant upon its manufacture. In clinical use it is usual to employ a tuning fork that vibrates at 128 cycles per second – equivalent to the note ‘middle C’ on a piano.


The fork is struck in order to cause it to vibrate. The base of the tuning fork is then applied to the apex of each toe in turn. Record is made of the patient’s ability to sense the vibration. The vibration recognition sense is one of the first sensation losses to occur in neuropathy, and is followed by loss of sense of touch. Loss of proprioceptive feedback occurs following this, at which point there is a seriously increased risk of neuropathic ulceration. Neuropathy may be painful, even when there is no agent to cause pain. Burning sensations are commonly experienced. Often the pain disappears to be replaced with numbness or complete lack of sensation and proprioceptive feedback. Biothesiometer The biothesiometer is an electronic machine designed and employed to produce vibration. It is applied to specific parts of the foot and the patient is asked to report as soon as sensation is perceived. Readings are from 0 to 50 volts, the higher the reading the lower the sensitivity. ADVICE ON FOOTCARE FOR THE DIABETIC It is essential that the diabetic patient pays great attention to foot care, and the following instruction should be given – preferably in the form of a hand-out. The establishment of good habits of hygiene are important to all diabetics but become even more vital where there is peripheral neuropathy and/or vascular insufficiency. FOOTCARE FOR DIABETICS AND OTHERS AT RISK

1. Wash the feet daily in warm, but not hot water. Test the temperature of the water with the elbow or a thermometer – not the hand, which may also be affected. Use soap (not detergent) or an emulsion prescribed by your GP if the skin is excessively dry. Dry the feet thoroughly with a soft towel, dabbing rather than rubbing the skin.

2. Examine your feet thoroughly on all surfaces, check between the toes for cracks, corns,

blisters etc. Use a mirror on the floor to see underneath the foot if this helps. If you cannot see well enough to do this for yourself, ask the assistance of someone who can.

3. If you discover a problem apply a mild antiseptic and a clean bandage as necessary. Do not

sit on a problem, but instead seek the help of a Doctor or a Foot Health Practitioner.


4. Change your socks or hose daily for fresh, clean items, which should be free of darns, holes or prominent seams, and which must not cramp the toes.

5. Wear soft leather shoes that have sufficient room within and beware of discontinuities such as

stitching and decorative features that might cause rubbing of the foot.

6. Do not go barefoot, protect your feet at all times.

7. Beware of burning your feet in front of the fire – you might not feel the heat. Beware also of sunburn on your feet, and protect your feet against the cold and chilblains.

8. Do not cut down the sides of the nails or poke anything down beside them. If you have

difficulty in cutting your nails you should seek the help of a Foot Health Practitioner. It is not advisable to let a helpful neighbour to do this for you. The risk is too great to trust any but a properly trained person to assist you in this matter.

Diabetes mellitus is a disorder of carbohydrate metabolism, characterised by hyperglacaemia and glycosuria, and resulting from inadequate production or utilisation of insulin. The basic cause is still unknown but direct cause is failure of beta cells of the pancreas to secrete an adequate supply of insulin. It may be the result of a genetic disorder, but it may also result from a deficiency of beta cells caused by inflammation, malignant invasion of the pancreas, or surgery. Principal symptoms are:

• Raised blood sugar (hyperglacaemia) • Sugar in the urine (glycosuria) • Excessive urine production (polyuria) • Excessive thirst (polydipsia) • Increase in food intake (polyphagia) • Itching, frequently about the genitals • Loss of weight • Increase in infection, e.g. boils

When severe diabetes is allowed to progress without proper treatment, coma ensues, and deep coma can result in death.


Complications

• Low resistance to infections, especially those involving the extremities. • Ulceration of the lower extremities • Increase in incidence of toxemia in pregnancy • Cardiovascular and renal disorders • Eye disorders such as blindness

Prognosis Diabetes is a chronic, incurable disease but symptoms can be controlled and life prolonged by modern treatment. Patients can live a normal life. Treatment Consists of diet, insulin, exercise and hygiene measures. Control of diabetes is more difficult in an obese person. Blood determinations should be made at frequent intervals. The use of insulin is not required in every case. Mild cases may respond to drugs or diet control. Particular attention must be given to the feet, and especially the toes. General Hygienic Care The skin must be kept scrupulously clean, and irritation or bruises should be promptly attended to because any break in the skin heals with difficulty, and diabetics are susceptible to infection and gangrene. Because of poor circulation, feet require special care. They need to be kept clean and dry, especially between the toes. Care must be taken in trimming the toenails, as the slightest abrasion of the skin may become infected. The skin should be kept soft and smooth. Tight shoes must be avoided. Also, because of poor circulation, it is dangerous to apply local heat to legs and feet; to do so could lead to gangrene. In order to prevent complications diabetics need regular attention to their feet. DIABETIC EMERGENCIES Diabetics are subject to two very different conditions, both of which need urgent attention.


INSULIN REACTION (Insulin Shock/hypoglycaemia) This condition occurs when there is TOO MUCH INSULIN in the body. The condition rapidly reduces the level of sugar in the blood and brain cells suffer. Insulin reaction can be caused by taking too much insulin, by failing to eat, by heavy exercise and by emotional factors. SIGNS AND SYMPTOMS Fast breathing, fast pulse, dizziness, change in the level of consciousness, disturbances of vision, sweating, headache, numbness of hands or feet and hunger. DIABETIC COMA (hyperglycaemia) This condition occurs when there is TOO MUCH SUGAR and TOO LITTLE INSULIN in the blood, and body cells cannot gain nourishment. Diabetic coma can be caused by eating too much sugar, by not taking prescribed medication, as a result of stress or due to infection. SIGNS AND SYMPTOMS Diabetic coma develops more slowly than insulin shock, sometimes over a period of days. Drowsiness, confusion, deep and fast breathing, thirst, dehydration, fever, change in the level of consciousness and breath smelling of acetone or ‘pear-drops’. EMERGENCY AID FOR INSULIN REACTION AND DIABETIC COMA Looking for the signs and symptoms listed on the previous page will help to distinguish between the two emergencies. In addition, if the patient is conscious, you can ask two very important questions that will help determine the nature of the condition. QUESTION ONE:

“Have you eaten today?” Someone who has eaten, but not taken prescribed medication may be in a diabetic coma.


QUESTION TWO:

“Have you taken your medication today?” Someone who has not eaten, but has taken medication, may be having an Insulin reaction. DISTINGUISHING BETWEEN THE TWO TYPES OF DIABETIC EMERGENCIES CAN BE DIFFICULT – ALWAYS LOOK FOR MEDICAL WARNING BRACELETS. Insulin shock is a true emergency and requires prompt action! A person in insulin shock needs sugar – quickly! If the person is conscious, give sweets, fruit juice or a soft drink. Sugar given to a person in insulin shock can be life-saving! If the person is suffering from Diabetic Coma the sugar is not required, but will do no harm. MONITOR PATIENTS CAREFULLY – SEEK MEDICAL HELP.

TUTOR TALK: Now take a break and then try the self test questions below.

Q1. What do the glands of the endocrine system produce? Q2. Name the products of the pancreatic islets. Q3. Excess of glucose in the blood is called what? Q4. Insulin is necessary for entry of what? Q5. Too much insulin lowers the blood sugar excessively and leads to the condition known as what? Q6. What is Glycosuria? Q7. What are Ketones? Q8. List the initial symptoms of Diabetes mellitus. Q9. Insulin reaction occurs when there is what in the body?


Q10. What emergency treatment does a conscious patient in insulin shock require? Mark this test yourself – from the text. Remember that we are always here to help your understanding. AN INTRODUCTION TO THERAPEUTICS AND MATERIA MEDICA Materia medica is the science of the materials used in medicine. Therapeutics are agents that are curative or beneficial. This section of the course is an introduction to the terminology of materia medica, the classification of the medicaments and their main applications in foot health practice. The various medicaments can be described in several ways according to the mode of dispensation and the intended usage of the preparation. For example, salicylic acid can be incorporated within a dusting-powder, liquid or an ointment base. In dusting-powder form it would be useless for the treatment of a verruca. In liquid collodion form it would be unsuitable for use upon an athlete’s foot condition. The strength of the medicament must be appropriate to the action that is required of it and appropriate to the site to which it is to be applied. The base in which a preparation is made up can modify the action of the medicament contained. For instance, an agent that might prove aggressive in aqueous solution might be put up in a greasy base which would only allow slow release and would buffer the action. Preparations are classified by type or action:

• the base in which they are prepared • the way in which they are applied • the use to which they are put • the effect which they produce…etc.


Medicaments may be required to be:

astringent antibiotic keratolytic emollient analgesic anti-inflammatory styptic antiseptic absorbent fungicidal fungistatic rubefacient…etc.

Many of the preparations used in foot health practice fall into more than one of these categories. Some preparations take their title from the base in which they are dispensed. Collodions are substances that have as one of their constituents a preparation called pyroxylin, a compound formed by the action of Nitric and Sulphuric acid on cotton wool, the end result being a cellulose structure resembling raw cotton. Flexible collodions are composed of a compound of pyroxylin, castor oil and calophony (a yellow, sticky powder) soluble in ether and alcohol. Collodion, when painted on skin, leaves a protective film that may contain an antiseptic or caustic if so desired. Simple collodions contain glycerine, which makes the film more elastic and hence less likely to peel from the skin. Ointments are semi-solid preparations containing fats, waxes and oils. An ointment may be used to protect the skin, or as a vehicle to carry an active ingredient for therapeutic or pharmaceutical effect. An ointment may be designed to help the active ingredients to penetrate the skin for deeper therapeutic effect. Alternatively, a greasy, non-penetrative base will stay upon the skin surface when this is to be preferred. Ointments may be:

• epidermic – acting on the surface of skin • endermic – penetrating fairly deep into the skin • diadermic – absorbed through the skin into the blood stream.

Pastes are preparations containing a high proportion of powder mixed with a soft paraffin or stiffer lanolin base. The higher the proportion of powder to base, the stiffer will be the resultant paste. This is useful in the application of occlusive dressings in the treatment of verrucae. The caustic paste will spread less readily if it is of stiffer consistency.


Plasters are resin or plastic adhesives painted on to a supportive base such as cloth, paper or plastic, e.g. adhesive dressings or waterproof plasters. Plasters with zinc oxide adhesive adhere reasonably well in some conditions, but have the drawback that they can cause a dermatitis or ‘plaster-rash’ on sensitive skins. Products named Zo… or Zopla….. are zinc oxide based. Ha… or Hapla… indicates hypoallergenic which means that the adhesive – usually acrylic based – will not irritate the skin, allowing them to be worn for longer or by patients with sensitive skin. Hypoallergenic products are generally to be preferred in foot health practice, and they adhere well to the foot in most circumstances. Solutions may contain a medicament. The solvent is the liquid medium and the solute is that which is dissolved. The solute may vary in strength to produce the action required. The solvent may be chosen for effect; for example, if quick drying is desirable, alcohol dries faster than water. A solution in alcohol is commonly referred to as a tincture. Absorbents take up the secretions of the body. An absorbent is often a powder that may carry a medication, for example the use of talcum powder to take up sweat. The talc might carry an antipruritic chemical to control sweating, or perhaps a fungicide to prevent or treat Tinea pedis (athlete’s foot). Analgesics are agents that reduce pain. They may do so by creating a counter-irritation as in the case of rubefacients. They may reduce the conductivity of a nerve, the sensitivity of affected nerve endings, or the production of pain initiating kinins and prostaglandins. Anti-inflammatory agents act to reduce the calor, dolor, rubor and tumour of inflammation. Cold, as in the application of ice, is anti-inflammatory. So too are the NSAIDS (non-steroidal anti-inflammatory drugs). NSAIDS must be used with care since they have a host of known side-effects, some of which preclude their use in certain instances. Hydrocortisone creams 1% – 2% are useful for calming down an inflamed lesion and reducing the inflammatory swelling, but they do not play any part in correcting the reason for the inflammation, i.e. they do not kill the bacteria in septic inflammation. Sometimes it is useful to reduce inflammation, as in the case of the onychocryptotic nail, where the reduction in swelling and pain might allow better vision of the problem and access to the offending splinter. Applications may be liquid or semi-liquid for spreading on the skin. These may be solutions, suspensions or emulsions. Gels are semi-solid preparations usually based upon water and a gelling agent. They tend to be cosmetically acceptable as they are non-greasy and are useful for the application of water-soluble medicaments.


Lotions are liquid preparations for application without friction, either by dabbing on to the skin or applying upon a dressing. They may be used for drying or cooling the skin, deposition of medicaments, or moisturising the skin. Paints and varnishes. These alcoholic tinctures contain waxes and resins in solution. When applied to a wound the alcohol evaporates leaving a layer of antiseptic resin on the wound surface. This seals the wound with a defensive antiseptic film, which protects the body against bacterial invasion. Liniments are liquid or semi-liquids, usually containing alcoholic or oily constituents intended for application with friction. There are also a number of formulations that are applied with a brush or on dressings for soothing or anaesthetic purposes. Creams are viscous, semi-solid preparations consisting of one phase dispersed in a second immiscible phase. These preparations are naturally unstable unless an emulsifying agent is included and formulations must therefore be treated with care. Creams are generally cosmetically acceptable since they are not very greasy and vanish when rubbed in to the skin. They may be used for application of medicament or for purely emollient purposes. Aerosols are preparations that use an inert propellant to disperse a spray of fine powder on the skin. Like dusting powders they can be used to apply medicament evenly over a large area without touching. The aerosol preparation is generally convenient, allows good shelf-life of the preparation, and maintains the sterility of the contents where necessary. Aerosols are used to dispense disinfectants, antibiotics, burn and wound dressings, and anti or counter-irritants. Poultices are thick, pasty preparations used in the relief of pain and inflammation. They have modern application in some specialist dressings used in ulcer treatment. ANYTHING THAT IS APPLIED TO THE FOOT IS APPLIED FOR ITS ESSENTIAL PROPERTIES. Nothing is put on to the foot without due consideration of what is required to be done and full understanding of the properties and characteristics of that which is to be applied. Dressings, tapes, bandages and every chemical agent must be chosen for their individual intrinsic properties, which must be recognised and understood.


PRE-OPS must be capable of rapid kill of a wide spectrum of flora and fauna found upon the foot. But, at the same time, they must also be non-toxic, non-inflammatory and non-irritant to the tissues. Low-odour is also desirable. Chlorhexidine Gluconate 0.5% in 70% IMS (industrial methylated spirit) is safe and effective and probably the most popular pre-op in foot health situations. Dettol (Chloroxylenol) and Cetrimide (CTAB – cetyltrimethyl ammonium bromide) are also good pre-op solutions. POST-OPS leave the skin clean and it is desirable that they should continue to have a germicidal action for a period following their application. Chlorhexidine Gluconate 0.5% in 70% IMS is useful, as is Surgical Spirit. For painting local lesions compound Benzoin Tincture or Friar’s Balsam is well-proven. This applies an antiseptic seal, stops the area drying and stiffening, and helps to retain a dressing if required. STYPTICS AND HAEMOSTATICS are used to stop the small haemorrhages that occur normally in the course of our work. Ideally they must work rapidly, be non-toxic to a wound and must not detract from the healing process. Ferric Chloride 15% solution is instantaneous and reliable, being applied on cotton wool to the point of issue. This stings – warn your patient of your intention before you do this! Calcium Alginate provides a network of fibres that promote coagulation of blood. This meshwork is absorbed in the process of wound resolution. Calcium Alginate is available in sheet or ribbon form as ‘Kaltostat’. However pressure and, if necessary, elevation are all that will be needed even when treating a client who is taking Warfarin. ANTISEPTICS kill bacteria and are applied to a wound to cleanse and defend. Many substances are antiseptic but are also toxic to the tissues. It is advisable to avoid these and use only antiseptics which cause little toxicity and continue to work in the presence of organic matter such as blood, serum or pus. Povidine Iodene is perhaps the most universally used antiseptic, being available to us as ‘Betadine’ in dry powder aerosol, cream and paint presentations. Polynoxylin is a wide-spectrum antibiotic produced from formaldehyde and urea. It is non-toxic to tissues and its action is actually enhanced by the presence of pus or serum. It is available as ‘Anaflex’, which contains 10% polynoxylin.


CAUSTICS are medicaments that destroy organic tissue. Caustics are chemically diverse and have multiple modes of action. Silver Nitrate is widely used in different strengths and several forms. The 95% stick may be applied to small, newly arrived or shallow verrucae with the purpose of forming an eshar (scab) which, on falling away by keratolytic action, brings a layer of the infected tissue with it. The 95% stick may also be applied to the hypergranulation tissue that is sometimes produced in onychocryptosis in order to shrink the obscuring tissue. Silver Nitrate 25% solution is useful in the treatment of heloma molle, which form more slowly after application. Salicylic Acid is applied in several bases and concentrations in occlusive dressings to verrucae. The action is to macerate a mass of tissue containing the verrucae, which can be enucleated after (usually) 7 days application. The Salicylic Acid dissolves the nerve endings and cauterises the blood vessels present, thus allowing nearly pain-free and bloodless removal of the block of tissue containing the lesion. Care should, however, be taken if you intend to attempt this type of treatment. BEWARE OF THESE MEDICAMENTS There are just a few drugs which we must take note of because they have significance to our work. ASPIRIN Aspirin thins the blood and makes it less sticky. This helps the heart to push the blood that is made less viscous through the arteries, thus reducing the work the heart has to do. Patients who take aspirin are likely to bleed more freely, and it is more difficult to stop the bleeding. Take care to minimise wounding and have a styptic ready. NSAIDS Non-steroidal anti-inflammatory drugs are sometimes prescribed for osteoarthritis. They may reduce the clotting ability of the blood. Their action is effectively similar to that of steroids. WARFARIN Warfarin is used as an anti-coagulant to stop the blood from clotting within the vessels. Patients on Warfarin will be attending the Anti-coagulant Clinic and will carry a card to inform of this. Bleeding is likely to be more prolonged than normal and clotting time might be extended. Use a styptic and cover with a dressing to protect the clot when formed.


BETA BLOCKERS These drugs are administered in cases of angina, hypertension, migraine, irregular heart rhythms, to prevent further damage to heart muscle following a heart attack, and sometimes to reduce the physical symptoms of anxiety. They have the known side-effect of reducing the peripheral circulation and may cause the limbs, hands and feet to be cold. DIURETICS Some diuretics can cause a fall in potassium levels resulting in confusion and weakness. Others can raise the level of uric acid in the blood and increase the risk of gout. They may also raise blood sugar levels, causing problems for diabetics. STEROIDS Steroids suppress the autoimmune system and impair the ability of the body to resist the invasion of micro-organisms, thereby increasing the risk of serious infections. CORTICOSTEROIDS Often referred to simply as steroids, corticosteroids are derived from the natural hormones produced by the adrenal glands or their synthetic equivalents. Corticosteroids have two types of effect: glucocorticoid and mineralocorticoid. The glucocorticoid effects include the maintenance of normal levels of sugar (glucose) in the blood and the promotion of recovery from injury and stress. The main mineralocorticoid effects are the regulation of the balance of mineral salts and the water content of the body. When present in large amounts, corticosteroids reduce inflammation and suppress allergic reactions and immune system activity. We will often encounter the patient ‘on steroids’.


USES OF CORTICOSTEROIDS Corticosteroids are used to ‘damp-down’ inflammation – whatever its cause. Topical preparations are often used in the treatment of inflammatory skin disorders. These drugs may also be injected into a joint or around a tendon to relieve inflammation caused by injury or disease. However, when local application of the drug is not possible, it may be administered systemically by mouth or by intravenous injection. Corticosteroids are used in disorders of the immune system when it is excessively or inappropriately active, as in rheumatoid arthritis, irritable bowel disease and systemic lupus erythematosus. In these conditions they relieve symptoms and may temporarily halt the progress of the disease. Corticosteroids are administered regularly to treat asthma. They have no value in the treatment of an attack in progress, but act to prevent an attack by reducing inflammation of the bronchi and lung tissues. Some cancers of the blood (leukaemia) and the lymphatic system (lymphomas) respond to corticosteroid treatment. They also find use in suppression of organ transplant rejection. Corticosteroids block the action of prostaglandins – chemicals involved in triggering the immune response. They also depress the immune system by reducing the activity of certain types of white blood cell. CORTICOSTEROIDS – RISKS AND SPECIAL PRECAUTIONS Corticosteroid drugs can produce dramatic improvement in symptoms. When given systemically they can produce a sense of well-being, and even euphoria. Day to day side effects are rare. However, long term corticosteroid treatment carries a number of serious risks. Drugs with strong mineralocorticoid effects such as cortisone can cause water retention, swelling (particularly of the ankles), and an increase in blood pressure. Because these drugs reduce the effect of insulin they create problems in diabetics. They may even give rise to diabetes in susceptible individuals. Peptic ulcers may also result from steroid therapy. Because corticosteroids suppress the immune system, they increase susceptibility to infection. They also suppress symptoms of infectious disease.


Long term use may precipitate mood changes, acne, moon face, increased blood pressure, peptic ulcer, reduced effect of insulin, formation of dorsal fat deposits and osteoporosis. The use of corticosteroid drugs in the long term suppresses the production of the body’s own corticosteroid hormones. For this reason treatments that have lasted for more than a few weeks should be withdrawn slowly. Rapid withdrawal of the steroids might otherwise cause sudden collapse. Those treated for more than one month are advised to carry a warning card for two years. In the case of accident it may be necessary to boost defence against shock by administering extra hydrocortisone. COMMON CORTICOSTEROID DRUGS Beclomethasone / Betamethasone / Cortisone / Dexamethasone / Fluocinolone Hydrocortisone / Methylprednisolone / Prednisolone / Triamcinolone Materia medica is also concerned with the science of padding materials, tapes and bandages. Modern practice makes use of a host of wound covers and dressing materials. Adhesive padding materials are commonly applied directly to the skin of the foot. The presentation of the materials influences the application to which they may be put. If cotton is woven into a tube (tubegauze) it can be applied in the manner of a sock over a digit to retain an inner dressing. But cotton wets easily. A rayon fibre woven into a tube gives similar usage and appearance, but this time is water-resistant. If the cotton be knitted into a sheet it will produce a flexible and adaptive padding material known as ‘Fleecyweb’, a brushed cotton material which can be used to cover a three-dimensional surface without folding or creasing because the knitted construction allows three-dimensional adaptation. Fleecyweb is one of the most universally used dressing materials and gives great comfort and protection despite its minimal thickness. Applied to a skin surface that has been prepared by painting with Compound Benzoin Tincture or Friar’s Balsam it will retain upon the plantar surface of a foot for 4-6 weeks, allowing short immersions such as showering throughout this period. Adhesive tapes are used to retain dressings and pads. They too have a variety of properties that indicate suitability for particular purposes. Paper tapes (Micropore) are inexpensive. Non-woven, fibre-based tapes are very strong. Both types will form a ‘rope’ when subjected to linear tension, which means that they could form a ligature around a toe or foot. They must be used with care and it is not a good idea to encircle a part with such tapes. These tapes are best used to retain sheet dressings and pads. When a part has to be encircled it is best to employ a tape such as ‘Haplaband’ (Cuxson and Gerrard), which has a 30% linear stretch capability. Applied un-stretched, it has the potential to extend if a digit swells.


Adhesive cushioning is available in the form of foam sheets. Polyurethane foams collapse quickly but give short-term comfort. Latex foams are more dense and last longer. Foams may be of ‘closed cell’ or ‘open cell’ construction and have a wide range of characteristics. When considering the use of foam substances for padding purposes, one of the most important properties is the recovery rate of the foam following deformation. A foam that recovers quickly after being compressed beneath a foot will recover its full-thickness before the next foot-fall. A foam that recovers only slowly will retain the memory of the last foot-fall. Felts may be of natural fibre (wool) or man-made fibres. Most felts consist of a mixture of both. The felts used in foot health practice are usually semi-compressed, meaning that they will allow some further shaping in-situ before becoming fully compressed. They are used in situations where it is necessary to elevate a skeletal prominence or hold the footwear away from some anatomical process. Felts can be used to raise and support the skeleton of the foot as in the metatarsal pad or the tarsal cradle. Animal Wool is used to wrap digits and to form wool ‘nests’ for the protection of vulnerable extremities. It is usually obtained by combing creatures such as vicunas and llamas. The wool occupies very little space yet it pads the surfaces it covers and defends from friction. The use of animal wool is old-fashioned, but is proven by time and liked by patients. PADDING There is now a wide range of materials available for padding and protection purposes. This includes traditional felts and fleece, latex and polyurethane foams, synthetic rubbers, expanded polyethylene and expanded vinyl acetates. Modern practice is adding silicones, hydrogels and cross-linked polymers to this armamentarium. Each material has its own range of usefulness and the practitioner will come to favour certain products for particular purposes. There is room for considerable ingenuity and individuality here, for no two patients are alike in their needs, and the time-honoured conventional designs may need to be modified to suit the immediate requirement. If padding be placed directly over a lesion it will put pressure upon that lesion from the instant the shoe is fitted. But if the padding is placed beside or around the lesion in such a way as to hold the shoe off the sore or prominent part, then it will redirect such potential pressures away from the lesion and on to surfaces that can better take those pressures. This is an important principle that can be applied to any surface.


Padding may be directly applied to the skin surface and retained in position by adhesive, in which case it is likely that it will be lost upon first immersion in water. Alternatively, it may be made in such a manner as to be removable, to be fitted at will and retained by loop or elastic retention bands. Padding may also be expediently fitted into footwear where this is practical and may take the form of a specially designed insole or simply be a stuck-in pad to protect a heel or pad a shoe tongue. Silicone orthodigita may be formed around or between the digits and play a defensive and sometimes corrective role. These flexible forms stay in position simply because they anatomically fit the space they occupy, the surrounding tissues and footwear lying upon several aspects of the devices to keep them there. Most important to understand is this – that pressure causes lesions. Pressure is caused by confining the active foot within a shoe. Adding padding to that foot increases the gross amount that must go into the shoe. Adding too much padding or placing such padding in the wrong position will aggravate an already difficult situation. Padding must be carefully designed and skilfully applied if it is to prove beneficial. PRINCIPLES OF PADDING Padding is not the same as cushioning. Cushioning simply attenuates the rate of loading. Padding is aimed at diverting damaging forces, directing these forces to an area that can better take the stress. Hence a pad might be placed around or beside a pressure spot to carry the pressure instead of it having to be taken upon the lesion itself. The following traditional paddings, which can be made up by the practitioner at the chairside demonstrate the application of the principle. It should be noted that these devices can be made up in alternative materials and that there is scope for much individual adaptation to suit the needs of the particular case and the preference of the operator. The metatarsal pad This can be made to adhere directly to the skin of the plantar surface or may be made detachable by the addition of a retaining loop. The former is appropriate to the patient who cannot reach the feet – the later to the more mobile.


Cut a shield-shaped piece of 5mm semi-compressed white mixture felt with a hypoallergenic adhesive backing. Bevel the edges and skive the instep end. Shape the felt to lie around the lesions or cut out holes or pressure relief areas to coincide with them. This can be directly applied to the skin after removal of the backing paper. If applied to skin painted with Compound Benzoin Tincture it will adhere well for some time but is liable to come off when soaked as in bathing. Alternatively, cut the blank as above and customise it as before. But this time measure a suitable length (20cms) of 00 Tubegauze bandage. Stretch the Tubegauze so that it will not stretch further when worn. Lay this bandage around the middle three toes so that the tails fall upon the plantar surface through the 1/2 and 5/4 web spaces. Peel the backing paper on the felt pad half way down and use the exposed adhesive area to pick up the bandage tails so that the toe-loop formed is of an appropriate length. Remove the whole from the foot and peel the remaining backing paper. Tidy the bandage tails so that they run at an appropriate angle across the felt pad and traverse most of the adhesive area. Cut a piece of Fleecyweb and, having removed the backing paper, apply the sticky surface to the felt adhesive surface, thus trapping the bandage tails between the two sheets. Trim the edges and try upon the foot. This looped metatarsal pad can be removed for bathing and sleep, is related to the lesion and the foot by the loop, and is retained by the hosiery. These themes of direct adhesion or removability are applicable to any site and any padding. When the practitioner can completely design and make at the chairside either an adhesive or a removable device for any position upon the foot, then she/he might claim to have mastered padding technique. The dorsal roll / plantar prop This is a very useful device for protection of toe lesions. Apical problems can be protected by wearing the padding beneath the toes so that the tips are raised from the inner sole surface of the footwear. Worn over the dorsal surfaces of the proximal phalanges the same padding will protect lesions of the dorsal interphalangeal joints and help control mobile retracted lesser toes. When making this device it is recommended that it always be made on the dorsal aspect of the foot – whichever position it is intended to be worn in – for ease of fabrication.


Cut a length (20cms) of 00 Tubegauze. Stretch it as before and lay it around the middle three toes, the tails falling upon the dorsum of the foot having passed through 1/2 and 5/4 web spaces. Cut a length of 5mm white felt the width of the bases of the three middle toes, expose the adhesive and lay upon the dorsal toe bases, sticky-side up. Lay the bandage tails across the adhesive surface, so forming and fixing the length of the toe loop. Remove carefully from the foot and roll the felt around the bandage tails, securing them within. The size of the roll is determined by the number of turns which should be sufficient to protect the targeted lesions, but not bulkier than necessary. The roll should then be covered with a thin fibrous adhesive tape to make it more durable and prevent it unrolling. Positioned above or beneath the toes, this padding will be formed further to its required shape by the activity of the wearer and by in-shoe pressures. The bunion cup This may be cut from 7 or 10mm semi-compressed white felt. It may take the form of a complete cup with relief within, or it may be reduced to a crescent of felt placed proximally to the problem. Again, it may be directly adhered to the part, or may be related to the foot by a bandage toe-loop. Its purpose is to prevent the footwear applying pressure to the prominence. The shoe will be kept off by the padding which will transfer the shoe pressure to the first metatarsal area or the tissues around the joint.


ON SIMPLE INSOLES The principles of padding are directly applicable to simple insole manufacture. Suppose a metatarsal head were to be prominent, causing persistent pain. The fact that the area of tissue beneath the metatarsal head is trapped and subjected to trauma every time load is applied to the plantar surface means that not only will a painful lesion form, but that it will be aggravated at every step. If we cut and place a complete inner sole shape within the shoe the situation is not much altered. But if we cut a relief (a hole or depression) in the insole to coincide with the lesion, the sore spot will be afforded pressure relief since the foot structure will be supported everywhere other than the site of the lesion by the insole. This effect can be further enhanced by the fitting of appropriate arch fillers to increase the weight bearing area of the foot, thus spreading the load forces over a greater area. Unfortunately, this can only be done if there is enough depth within the shoe to accommodate the insole. It is counter-productive to ease a plantar problem but create a dorsal problem whilst doing so. Simple insole fabrication is made easier if a set of templates is purchased by which the inside shape and size of a shoe can be determined and duplicated. Pre-cut sized blank shapes are available from suppliers in a range of materials, but these will require to be held in a range of popular sizes. They will prove more expensive in the long term than equipping with the ability to cut from sheet materials as required. Wedges may be incorporated within simple insoles to improve the biomechanical function of the foot. Shaped elements may be incorporated to support and elevate depressed bones.


Typically, a base-board (often of leatherboard – regenerated leather) is fitted to the shoe and temporarily removed. Wedges, arch fillers, supporting buttons, etc are placed out upon it to suit the particular need. These components are then glued in position and the whole covered with an aesthetic top-cover of durable pigskin or synthetic material. The device is then ready for the shoe. There is a wide range of pre-cut and pre-formed insoles, and the practitioner needs to be aware of just what is available. Many modern synthetic materials are used to produce superbly accommodative footbeds which are professional in appearance and comfortable in wear. If care is taken in the prescription of simple insoles the life-quality of the patient can be much improved. The next assignment carries information on dermatological conditions.

TUTOR TALK: With this assignment you will find the question paper relating to the work you have completed in the last assignment. All that remains to do is to complete the question paper and return it to the College for marking. Complete the self-test in this lesson and check your answers against the text. Your tutor is always available to explain anything that you do not understand.

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STUDENT NOTES: Please use the space below for recording what you consider to be any pertinent information or notes. You may find it helpful to refer back to it later on!





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FOOT HEALTH PRACTITIONER DIPLOMA COURSE Assignment Eight