Japanese Society for Foot Care and Podiatric Medicine

Greetings from the president

President, Japanese Society for Foot Care and Podiatric Medicine
Inaugural address, 3rd version

PODIATRY Project

I am Hiroto Terashi, Professor of Plastic Surgery at Kobe University Graduate School of Medicine and the current President of the Japanese Society for Foot Care and Podiatric Medicine.

The Japanese Society for Foot Care and Podiatric Medicine was established on July 1, 2019, following the merger of the former Japanese Society for Foot Care and the former Japanese Society for Limb Salvage and Podiatric Medicine. Dr. Shuzo Kobayashi served as the first President of this esteemed society. In September of the same year, I was honored to succeed Dr. Kobayashi as the second President, a position I have held for the past three and a half years.

Concurrent with assuming this role, I launched the PODIATRY Project as my inaugural address and guiding principle. However, due to the challenges posed by the COVID-19 pandemic, progress has been slower than anticipated, which may have caused frustration among many of our members. I am acutely aware that while this is an ambitious project, merely setting it in motion is insufficient.

I interpret my reappointment for a second term as both a reprimand and an encouragement to continue our efforts. In light of this, I intend to develop and advance the following projects. The framework, as before, will be known as the PODIATRY Project, with each letter of PODIATRY representing a key initiative. We are pleased to announce this as the 3rd version, effective February 2023.

We remain committed to advancing the field of podiatry and foot care in Japan, and I look forward to working alongside our dedicated members to achieve our goals.

１）Podiatric Medicine：Establishing a Japanese version of podiatric medicine, led by our academic society.

As is well known, in the West, podiatric medicine is on a par with medicine and dentistry, but in the East, there has historically been no podiatric medicine, only medicine and dentistry. The podiatric diseases we suffer from are a field of medicine alone, but since podiatric medicine does not exist within medicine in the East, the fields of its diagnostics, therapeutics and prevention have not advanced. In the future, just as in the West, there will be no establishment of a single department of podiatry in the Ministry of Education, Culture, Sports, Science and Technology in Japan, such as a medical department, dental department, engineering department, economics department, etc., so it is necessary to establish a Japanese version of podiatry medicine under the leadership of our academic society. The Japanese Society for Foot Care and Podiatric Medicine will play a leading role in this. In 2022, under the leadership of Chairman Nobuyoshi Azuma, a new guideline was published by this academic society. Unlike normal guidelines, this is a rare mixed guideline involving multiple medical departments and multiple occupations. Within it, we established the definition of “foot disease” for the first time in Japan. It states that “foot disease is defined as a morphological or functional disorder (circulatory disorder, nerve disorder) of the lower limbs or feet that affects standing and walking, as well as infections and accompanying foot lesions, in addition to unhealthy, unmanaged lower limbs or feet that threaten daily life”. Here, the concept of disease is embraced, and the need to look at the pre-stage of various disorders, namely, the pre-disease stage, is advocated. Based on this, I would like to emphasize the importance of getting involved even before the onset of conventional diseases.

２）Orthotist and Orthopedic shoes：Training orthotists and orthopedic shoe specialists who specialize in lower limb and foot deformities and foot ulcers.

The main job of a prosthetist and orthotist is to make prostheses (artificial hands, fingers and feet) and orthoses (assistive devices including shoe-type orthoses) that will fit the patients foot correctly, but we believe that there are still not many prosthetists and orthotists who are actively involved in lower limb and foot deformities and foot ulcers. The curriculum at the 10 schools where it is possible to take the national exam is not sufficient for this subject, and many people go on to work for private companies after obtaining their national qualification, making it difficult to secure people with the above-mentioned expertise. We would like to work proactively with these training schools (pre-graduate education) and the Prosthetists and Orthotists Association (post-graduate education) to help secure people who can adequately respond to lower limb and foot deformities and foot ulcers. In addition, there is only one institution in Japan that trains orthopedic footwear specialists, and it has been decided that this school will close. It has also been pointed out that there are few places where orthopedic footwear specialists can make orthotic footwear for the patients with lower limb and foot deformities or foot ulcers, and there is a danger that this school will close. We plan to further strengthen our ties with these schools and associations. To do this, we must work in conjunction with the strengthening of the incentives for health insurance (insurance-covered treatment) described below. Furthermore, in September 2021, the Ministry of Health, Labour and Welfare notified the governors of each prefecture of “the promotion of task-sharing/task-shifting within the scope of what can be implemented under the current system” to each medical organization other than doctors. The Japan Prosthetists and Orthotists Association was quick to respond to this, and in collaboration with our association, they have established a postgraduate education system for education and training to ensure medical safety.

３）Diabetic Foot and Dialysis Foot：To strengthen public awareness of diabetic foot (diabetic foot lesions) and dialysis foot (lower limb lesions in dialysis patients).

The term “diabetic foot” has become more widely known through the activities of the Japanese Society of Foot Care and the Japanese Society for Limb Salvage and Podiatry, but the number of patients who actually develop ulcers and visit outpatient clinics continues to be high. Although we have been promoting this as part of our public relations activities in the new society that was formed after the merger, there is still a lack of publicity. At present, the number of patients strongly suspected of having diabetes in Japan is approximately 10 million (20 million if suspected cases are included), and if half of these patients have diabetic peripheral neuropathy, the number of patients with diabetic peripheral neuropathy is approximately 5 million. It can be said that there are approximately 5 million patients who have diabetes and are at risk of developing foot ulcers at any time. In addition, the number of patients with peripheral arterial disease (PAD) and the number of dialysis patients in Japan, who are susceptible to diabetes, are both on the rise. As part of the national policy to “prevent the deterioration of lower limb peripheral arterial disease in patients on dialysis”, the “lower limb arterial disease guidance and management additional payment” was introduced to encourage a change in awareness, but only around 70% of facilities have reported this to the local health and welfare bureau. The preventative effects of this are yet to be fully demonstrated. The calcification of blood vessels is well known as a complication of chronic renal failure, but it is also listed as a non-classical risk factor for arteriosclerosis, and can lead to lower limb blood flow disorders and skin disorders such as calciphylaxis. As mentioned in the previous section on podiatric medicine, pre-disease, or the stage before the onset of a disease, is also included in the category of podiatric medicine. It is not widely known that raising awareness of the need to prevent diabetic foot problems at the same time as diagnosing diabetes can also lead to the prevention of sarcopenia and frailty, and ultimately to the prevention of major lower limb amputation (the loss of a part of one's own body and the loss of the ability to walk). Under the guidance of Public Relations Committee Chair Yuko Mizokami, we believe that our society has a duty to further educate the public about diabetic foot problems.

４）Insurance Coverage: The aim is to obtain insurance points for medical treatment, including lower limb wound treatment, the fitting of orthotics, wound rehabilitation, and foot care.

Lower limb wound treatment includes appropriate diagnosis and wound treatment. In actual treatment, it is necessary to start by checking the correct way to wear shoes, removing shoes and socks, and checking the wound. After appropriate diagnosis and wound treatment, it takes almost 30 minutes for one patient, including putting on socks, teaching the correct way to wear shoes and walking.This is completely different in terms of quantity and quality from wound treatment for other parts of the body, but if appropriate reimbursement rate is assigned for medical insurance is not established, there is a risk that insufficient wound treatment may be carried out as a result, so there has been a desire for some time to obtain appropriate reimbursement rate. In relation to this, even in the first term, we established the “Ad Hoc Committee for Wound Treatment of Leg Ulcers” under the direct control of the Chairman of the Board of Directors, and under the guidance of the committee chairman, Norihiko Ohura, we actively lobbied the Ministry of Health, Labour and Welfare. We were thrilled when the new establishment of leg wound treatment and its management was reimbursed in the 2022 insurance revision.On the other hand, with regard to venous stasis ulcers, thanks to the strong guidance and cooperation of the Japanese Society for Vascular Medicine, we were able to open the way for our society-certified practitioners to obtain certification as elastic stocking conductors, a condition for inclusion in the previous insurance listing.From now on, we must continue to spread the preventive effects of foot care, which have been cultivated over many years within our organization, to the public society. We intend to strongly appeal to the Ministry of Health, Labour and Welfare that these measures for preventing foot problems will lead to the prevention of ulcer development and the reduction of medical costs. We believe that the spread of these measures should also be reflected in the field of home healthcare and nursing care, as we enter an era of super-aging. We must change the current situation where prevention and treatment of lower limb and foot disorders are only carried out in large hospitals and specialist hospitals. With this in mind, we set up a Home Healthcare Committee during my second term. In addition, with regard to the fitting of orthotics, we are also working to ensure that appropriate insurance coverage is provided for early rehabilitation for chronic lower limb wounds, including the fitting of orthotics for wounds such as rocker sole sandals and other necessary footwear, as this will help protect patients' ability to walk and protect their quality of life. As part of this, we would like to promote the use of the remote medical collaboration software JOIN. This software was developed by Dr. Kengo Matsumoto, a member of our academic society, and we are not only aiming to promote its use as a convenient tool, but also to use it as an incentive to help us obtain medical fees. We have therefore set up a second term of the “Working Group for Obtaining Medical Fees for the Remote Collaboration Software JOIN (Dr. Kengo Matsumoto, Head of the Working Group)” within the Academic Committee. We would like to consider this direction together with the newly established Digital Transformation (DX) Committee and the Smart Shoes/Foot Sensor Development/Practical Healthcare Data Promotion Working Group within it. We are considering connecting regional comprehensive care systems through remote collaboration software before and after the 2022 insurance revision, which allowed for the calculation of lower limb wound treatment and its management fee (new) as well as motor function rehabilitation for diabetic foot (additional).Currently, under the leadership of Certified Committee Chairperson Miki Matsuoka, we are in the process of revising the positioning and certification of the society's Foot Care Instructors and Certified Specialists. We recognize this as an important transformation related to obtaining various insurance listings.

５）Ambulation without Amputation (zero lower limb amputations): Protect walking and eliminate lower limb amputations.

We believe that protecting a patient's natural walking ability is close to human dignity. However, there is currently no data in Japan showing a decrease in the number of patients who have to undergo lower limb amputation. There is also no data showing that avoiding major amputation improves life prognosis. The data we have so far shows that it is possible to maintain a patient's walking ability by preserving the length of the lower limb as much as possible. Unfortunately, it is also true that, in patients with peripheral arterial disease (PAD), once a wound develops and they reach the stage of critical limb ischemia (CLI), nearly one in four patients will have already lost their ability to walk at the time of their first consultation. This means that in the group of patients with PAD, the condition (sarcopenia and frailty) that causes them to lose their ability to walk is already present even before they develop a wound, so it is clear that this is a medical issue that needs to be addressed by departments such as diabetes, cardiology, and dialysis. Protecting the walking ability of patients with wounds is becoming more widely known, but there is still a lack of focus on maintaining the walking ability of the patients who do not have wounds. To address this, we believe that it is the responsibility of our society to raise awareness not only among the general public (through public relations activities) but also among medical professionals more widely. It is important that our society, as a cross-sectional society, takes a leading role in advocating the importance of “preventive medicine” to prevent diseases before they become latent, while collaborating with other societies. I believe that it is the responsibility of each member of the society to continue to advocate this to the societies to which they belong. In this context, the Lower Extremity Artery Disease(LEAD), Frailty Research WG (headed by Dr. Nobuyoshi Azuma) must also play its part.

６）Translational Research: We will promote basic research that will lead to clinical applications.

Unfortunately, this was one of the projects that did not progress in the first term. The aim of translational research is to select promising findings from the results of basic research and to formulate a development strategy that comprehensively covers the process from basic research to clinical research required for the development of pharmaceuticals and medical devices, with the aim of efficiently and effectively leading to practical application as a medical treatment. At present, our society is a motley crew of people from many different professions and many different departments. Although there are many basic and clinical studies in each profession and department, there is no unique research in our society. However, we believe that the probability of being able to conduct cross-sectional research that is unique to our society is higher than other societies. To do this, we should unify our goals and conduct research in multiple professions and departments to achieve them. For example, if the goal is “maintenance of walking”, intervention research can be achieved by having many professions participate. For example, even if the aim is “to improve blood flow in the treatment of a certain new device via endovascular therapy”, the results may change depending on whether or not rehabilitation professionals are involved. This is one of the strengths of our society, which is a motley group of people not found in other academic societies. We would also like to add the promotion of research that leads to clinical results as one of the strategies of our society. At present, the only research we are promoting is the “Lower Extremity Artery Disease(LEAD) and Frailty Research” project, which has been approved as a working group within the Academic Committee. We would also like to promote cross-disciplinary research that is unique to our society in other fields as well.

７）Rehabilitation for Gait and Daily Living: Promoting rehabilitation to prevent wound occurrence, enhance wound healing, and maintain quality of life.

The Japanese Society for Foot Care and Podiatric Medicine has established a satellite study group called the "Study Group on Prevention and Rehabilitation of Chronic Lower Limb Wounds," chaired by Nobuhide Kawabe. The group aims to develop knowledge and skills, conduct educational and awareness-raising activities, and establish intervention methods for social participation. It also focuses on wound healing, prevention of chronic lower limb wounds, and improving physical, mental, and daily living functions affected by the disease and treatment. This is achieved through close collaboration between physical therapists, prosthetists, orthotists, and occupational therapists under physician supervision. Since 2015, this study group has convened annually during both the former Japanese Society of Limb Salvage and Podiatry academic conference and our society's conference. To date, the group has conducted a multi-center study titled "Collaboration to Support the Purpose of Podiatry Treatment: 'Standing and Walking' - Early Intervention in Rehabilitation" as part of the Health and Welfare Administration Promotion Survey Project Subsidy (also known as Health Labour Sciences Research Grant; Oura Research Group "Core Research"). Specifically, we have been conducting two studies: “A study of the reacquisition of walking, wound healing and return to home for lower limb chronic wound patients who underwent rehabilitation during hospitalization” and “A prospective study aimed at reducing medical costs by shortening the length of stay and improving the walking rate for lower limb wound patients through early rehabilitation involvement”. These studies aim to demonstrate that appropriate early rehabilitation for patients with chronic lower limb wounds does not negatively impact wound healing, but rather promotes recovery of walking ability and facilitates return to home, potentially reducing future medical costs. As a result of these activities, the number of physical therapists in our society has increased dramatically. We aim to continue actively engaging with associations of physical therapists, prosthetists, orthotists, and occupational therapists - all rehabilitation intervention professionals - to contribute to maintaining and improving patients' mobility and quality of life through our society.
In addition, in podiatry, internal disorders such as heart disease, PAD, and kidney disease are also significantly involved, not just external disorders such as wounds. We also believe that it is necessary to be aware that rehabilitation is not just about walking, but also about maintaining one's lifestyle, so we added “and Life (for daily life)” to the original 7) Rehabilitation for Gait in the second version. As a result of these recognized efforts, the 2022 insurance revision included a "review of the calculation requirements for musculoskeletal rehabilitation fees," finally incorporating "diabetic foot lesions" as a target condition. We hope to see an increase in physical therapists entering this field in the future.

８）Yield Foot Care and Footwear Awareness among Asian Population : Promote a wide range of foot care and footwear awareness among the Asian population.

In many East Asian countries, there is not only a lack of shoe culture, but also a tendency to go barefoot or wear slippers indoors. It's time to share the foot care culture our country has developed with other countries, particularly in Asia, and provide guidance. However, this project has been delayed due to the coronavirus pandemic. According to the International Diabetes Federation (IDF), diabetes is increasing more rapidly in the Asian region than anywhere else in the world, and one third of the world's diabetic population is concentrated in this region. Comparative data on insulin secretion shows that Asians produce only half as much insulin as Caucasians in the United States, indicating a characteristic lower insulin secretion capacity in Asian populations. The adoption of Western diets high in fat and calories, sedentary lifestyles, and genetic factors contribute significantly to the rising number of diabetic patients among Asians. However, promoting exercise without proper foot care and appropriate footwear may lead to an increased risk of foot ulcers. I am sure that the meticulous Japanese foot care techniques will contribute to saving the feet of the diabetic patients in Asia, where the number of cases is increasing exponentially. I am convinced that the role of our society is to promote foot care and footwear to prevent this, and I would like to support the dissemination of these activities.
Additionally, recognizing the need to address children's foot health and footwear, we established the "Children's Foot and Footwear Reform Working Group (WG)" within the Academic Committee during our first term. This group has remained active even throughout the coronavirus pandemic. We would like to express our deep gratitude to Dr. Kaori Shionoya, the head of the WG. We are investigating whether hallux valgus and flatfoot, conditions common among Japanese people, begin to develop before school age. We're also assessing the appropriateness of wearing slip-on canvas shoes during critical periods of foot development. In Western societies, there is an education system in place to ensure that children wear the correct shoes from an early age, but in Japan there is no such culture. To verify these issues, we need to implement a long-term research plan studying changes in foot structure during childhood, including chronological changes in foot width, height, and arch height. This effort requires the understanding and cooperation of both educational institutions and shoe manufacturers. And in 2023, the WG finally completed the “Guide to Children's Shoes”. The intention is to provide it not only to academic society members, school health, and shoe manufacturing companies, but also to the general public society, and to use it as a basis for approaching the Ministry of Education, Culture, Sports, Science and Technology. We will continue supporting the WG's activities, aiming to protect the foot health of future generations of Japanese people from the moment their children take their first steps.

The PODIATRY Project, 3rd version,which consists of the eight items listed above, will be the statement of the president's future policy, and we will promote it as much as possible during his term of office.
In order to achieve this, we have set up the following 20 committees and 5 WGs.

If the committee does not work, the society will stagnate.
Under the new board of directors, we ask for the continued cooperation of all members.

Hiroto Terashi, MD, PhD
President of Japanese Society for Foot Care and Podiatric Medicine