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The Trouble With Cam Walkers

by Jarrod Shapiro, DPM
Joined practice July 2006 of
John K Throckmorton, DPM
Lansing, Michigan

I have a problem with cam walkers. Yeah, they're convenient. Yeah, they save you tons of time compared with applying a below knee cast. Yeah, they're a great revenue generator, especially with the pneumatic walkers. Yeah, they're handy for diabetic ulcers, as an alternative to the classic total contact cast. So with all the benefits to these devices, what's the issue? What's my problem you ask? What's Shapiro complaining about now? I have one word for you: NON-COMPLIANCE.

If you don't know what I'm talking about, then you must be a first year student. If you´ve ever treated a patient, you know what I'm talking about. As a new doc in my second year of practice, I'm becoming well versed with the non-compliance issue. Now, I have a tendency towards a hint of naiveté; I generally believe what people tell me and trust their word. On an individual level I have a lot of trust in people.
However, my faith in my patients' ability to comply with my instructions is waning quickly. I've had multiple episodes where my patients, for a variety of reasons, can not or will not do what I tell them. As a wound clinic attending, I see this with just about every patient. How many times do we heal out a venous ulcer patient and prescribe compression stockings, only to have them return with a recurrence because they never wore their stockings? I know what you're thinking: "Stockings hard to don and doff which increases non-compliance." How about those patients that never even tried to put them on?

Not convinced? How about diabetic neuropathic plantar ulcers? Dr Armstrong reported his study in Diabetes Care regarding the amount of time patients wore their off-weighting devices. Patients wore their devices a mere 25% of the time at home. My neuropathic ulcer patients are shocked when they actually listen to me and stay off their feet with resultant rapid healing. It's no wonder the Instant Total Contact Cast uses a circumferential strip of casting tape just to keep patients from removing them.

Is it just wound care that we see this ramped non-compliance? Sure. And I have some swamp land in Florida to sell you. Back to the cam walkers. I did a Lapidus on a 17 year-old recently and put her in a cam walker with strict non-weightbearing instructions. She made it 4 weeks before walking on it, and had been sleeping without the boot after 2 weeks with her parents' knowledge!!

If we go with my somewhat jaded hypothesis that almost all patients are non-compliant, how can we improve this? Here are my suggestions. You can write in with any thoughts of your own on this topic.

   1. Knowledge – Know your patients. Get to know them before any complex
      treatment, if possible. If you're ready to do surgery on a new patient, schedule them
      for a follow-up visit before you board the case. Learn about them a bit more
      before you pull out the scalpel. Remember, patients who know and like you are less
      apt to sue you.

   2. Education – Be sure your patients understand every aspect of their care.
      For surgeries, educate them on the risks of adverse events from their non-
      compliance, as well as very specific instructions. This includes weightbearing
      status, bathing, elevation, medications, etc.

   3. Understanding – Be sure you understand the personal factors about your
      patients. For example, if you prescribe a wheelchair, are there stairs into or in the
      house? If so, expect your patient to stand on his feet at some point. Is she a primary
      caregiver for someone else? My mother of three under-4-year-olds was unable to
      comply with crutches for her tibial stress fracture.

   4. Repetition – Have your patients repeat back to you what they're supposed
      to do.Quiz them. They'll retain much more if you do.

   5. DocumentationCharting protects you in case of complications (and litigation).
      Take the time to document your education efforts and any noncompliance events
      during care. Also, consider providing written instructions for your patients.
      It's helpful to have written material to refer back to.

As for now, I think I'll continue with the cam walkers, but I foresee many more BK casts to come…

Talk to me!

Jarrod Shapiro, DPM
PRESENT New Docs Editor


This program is supported by an
educational grant from
Ameripath/Dermpath Diagnostics