Diabetes Update

More than 16 million individuals in the United States are diagnosed with diabetes, and officials estimate that another 8 million are undiagnosed. Of the many complications of diabetes, none are more devastating than those of the foot.

The diabetic foot goes through many pathological changes, often leading to loss of digits or limbs.

The treatment costs for diabetic foot ulcers are enormous to both the patient and society. So costly that in some areas of the country health maintenance organizations (HMOs) are increasing health care insurance premiums as a direct result.

Despite much effort directed at prevention, the incidence of lower-extremity amputation in diabetics continues to rise. As a result, the American Diabetes Association's Consensus Report

Among people with diabetes, 2.4 million of them will experience a foot ulcer in their lifetime and 60,000 of these will undergo lower extremity amputation.
concludes that appropriate techniques for wound care that can reduce amputation rates are an essential prevention strategy. Home medical equipment providers can play an important educational role in both prevention and proper treatment of diabetic foot problems.

What Causes The Problem?

A combination of factors can lead to ulceration and possible amputation, but the loss of sensation from peripheral neuropathy is perhaps the most common one. Peripheral neuropathy may ultimately affects 50 percent of patients with long-standing diabetes.

Three types of neuropathy - motor, sensory, and autonomic - occur with diabetes mellitus. Motor neuropathy can lead to muscle atrophy and foot deformity, such as cocked-up toes, hammer toes or claw toes. These can become ulcerated at the tips or tops from increased pressure from the top of the shoe, the insole or both.

Sensory loss can allow painless trauma to the foot. For example, a diabetic patient confined to bed tends to keep the heels in the same position leading to pressure necrosis and skin breakdown. Unfortunately these are often incorrectly identified as pressure ulcers, and the underlying cause is not addressed. Autonomic neuropathy leads to decreased perspiration, and the end result is dry feet, erosion of the epidermis and fissures. This creates portals of entry for bacteria leading to cellulitis and infectious gangrene of the digits.

Peripheral vascular disease (PVD) is another complication that occurs in people with diabetes. It inhibits healing by limiting the flow of oxygen and nutrients to the affected area. The high level of glucose causes damage to both the small and large blood vessels of the body. Diabetes causes narrowing and blockage of the large blood vessels that supply blood to the legs and the result - an increased likelihood of amputation of the foot or leg for non-healing ulcers.

Another effect of diabetes involves the immune system, which normally protects us from bacteria, viruses and other types of infections. With high glucose levels the white blood cells of the immune system function poorly. In addition, all of the body fluids in a diabetic have higher levels of sugar and nutrients, which make them more inviting places for bacteria to grow and multiply.

This means that a patient with poorly controlled diabetes has a higher risk of infection, and the infections are harder to treat. It also results in slow healing of ulcers and frequent reappearance of wounds particularly on the feet.

So lack of feeling from nerve damage, poor healing due to compromised blood flow in the small and large vessels, and a poorly functioning immune system leave the diabetic susceptible to injury, skin breakdown and infection. Foot problems usually begin with an ulcer that forms on a toe or on the side of the foot. Because of decreased sensation, the diabetic may not realize that the ulcer is deep or that it has become infected, and the longer an ulcer remains open the more likely it will become infected.

Prevention Approaches

The American Diabetic Association (ADA) recommends a comprehensive vascular and neurologic exam at least annually for all individuals with diabetes.To prevent foot lesions and amputation, the most important steps are regular inspection of the foot and patient education in proper foot care. The patient should inspect the foot including the toes each day. During office visits the nurse or physician should also perform an inspection and review proper foot care with the patient. Educational programs must include instructions, reinforcement of their importance, open discussion of questions and frequent reassessment of patient compliance.

Any assessment of the diabetic patient should focus on the type of diabetes, the duration of the disease, current treatment and the level of control. Foot assessment should include documentation of sensation, deformities, calluses and ulcers as well as an examination of all the footwear used by the patient both in the home and the community. Visual examination may reveal signs of vascular compromise, such as dusky erythema of the foot with decreased hair and thickened nails.

The American Diabetic Association (ADA) recommends a comprehensive vascular and neurologic exam at least annually for all individuals with diabetes.

The foot may be cold to touch with decreased or absent dorsalis pedis and/or posterior tibial pulses. With a press and release on the dorsum of the foot, color should return to normal in 4-5 seconds. Delay in return of pink-blue color indicates vascular compromise. If the patient has an ulcer the presence of erythema and warmth greater than two centimeters around the wound may indicate presence of cellulitis which should be treated.

Pressure, repetitive trauma, friction and shear are forces that contribute to ulcer development. When not adequately addressed, these forces may also prevent diabetic wounds from closing and reduce the effectiveness of topical therapies. At present there is no effective treatment that can influence established diabetic neuropathy so reducing high plantar pressures is critical.

Routine clinical examination of the foot shape, callosities, shoe wear pattern and previous ulcer sites supplemented with pressure assessment readings can help to identify at-risk patients. Then appropriate devices such as stockings, insoles and shoes can be prescribed. HME providers should establish good relationships with diabetes referral sources for these products.

Treatment Advances

Debridement of devitalized tissue is the single most important factor in managing contaminated wounds such as diabetic ulcers. Aggressive debridement is necessary to facilitate healing, and wound cleansing is also an important component of the wound management protocol. Optimal wound healing cannot occur until all inflammatory foreign bodies, including necrosis and bone debris, have been removed from the wound.

Topical dressings that protect the diabetic ulcer while creating an environment conducive to healing, are indicated. Major categories of dressings indicated for diabetic wounds may include: absorptives, alginates, biologicals and synthetic membranes, collagens, composites, contact layers, foams, gauzes, hydrocolloids, hydrogels, impregnated dressings, silicone gel sheets, silver technology, transparent films, wound fillers and combination products.

For more information on the features and benefits of each dressing category, refer to the Wound Product Sourcebook, the desk reference and buyers' guide available from Green Mountain Wellness Publishers, Hinesburg, Vt., or go to the Web site www.woundsource.com.

A clean, granulating wound may be dry, moist or wet. Dry granulating wounds need moisture so dressings that add or retain moisture are appropriate. Use dressings designed to absorb excess fluid and protect the periwound skin in wounds with moderate to heavy exudate.

Topical antibiotics may be useful in reducing bacterial count in a diabetic ulcer but are not the primary line of treatment for infection. They should be applied sparingly, used with caution and only for limited periods of time.

Newer agents show promising results for the management of diabetic foot ulcers. These include bilayered skin equivalents and dermal replacements. Some are bioengineered, others are natural extracellular matrices such as porcine small intestinal submucosa. They usually remain in place after a single application for undisturbed healing.

Growth factors, either autologous or recombinant, are also indicated for the treatment of lower extremity diabetic neuropathic ulcers. They are agents that occur naturally in the body and are integral in the wound healing process. Autologous growth factors are harvested from a peripheral blood sample; recombinant are manufactured throung recombinant DNA technology. A new active treatment, cell proliferation induction (CPI), is non-invasive and does not require dressing removal. CPI uses a novel, localized energy field that actively stimulates secretion of growth factors and induces proliferation of fibroblast and epithelial cells critical for wound healing progress.

Role of the Supplier

Providers should develop ongoing relationships with their diabetic patients or health care professionals who treat them. They are in an excellent position to advocate active prevention programs with a focus on foot care and inspection and recommending products specifically formulated for the diabetic foot. From a skin care perspective, this includes cleansers, moisturizers and skin protectants designed to treat injured skin and help reduce friction. Several manufacturers market foot creams formulated with dimethicone or other ingredients that moisturize and protect the at-risk patient's skin.

Any provider who provides topical products such as wound cleansers and dressings should be alerted to non-healing ulcers. For example, misdiagnosed heel pressure ulcers may actually be diabetic neuropathic wounds. Determine if the patient is a diagnosed diabetic. If not, additional testing may be indicated. Vascular insufficiency may be present when an ulcer fails to heal despite good metabolic control, adequate debridement, parenteral antibiotic therapy and avoidance of weight bearing. In these cases, consultation with a vascular surgeon is indicated because surgical revascularization may result in limb salvage.

The extrinsic factors - pressure, friction and shear must be controlled. Patients with toe deformities such as cooked-up toes require a shoe with a bigger toe box. An in-depth shoe with a specially molded insole is frequently needed to prevent recurrence of ulcers by redistributing weight away from the previously ulcerated site.

Providers should develop ongoing relationships with their diabetic patients or health care professionals who treat them.

For a markedly deformed foot, such as Charcot foot, a molded shoe is indicated. A provider of customized shoes, molded insoles, pressure relief walkers, nonweightbearing walkers, crutches or transfer devices to unweight a plantar wound site is in a unique position - to educate on prevention and wound management and to work with insurers.

Health care plans vary in the foot care services they provide; however managed care plans look at diabetes as a key area for disease management. Ongoing assessment, early detection and intervention is critical to reduce incidence of ulceration and amputation. Many insurers are expanding coverage to include preventive modalities.

Providers should identify disease management telemedicine programs developing in their area. Telemedicine providers include nurse practitioners, physician assistants and clinical nurse specialists who all now receive direct reimbursement from Medicare. In addition home health agencies are forming partnerships with third-party payers as telemedicine providers.

Preventing serious foot complications from diabetes requires teamwork and ongoing patient education. The medical supply community has an important role as a member of that team.

This article appeared in the June 2000 issue of Home Health Products magazine, Vol. 8, No.6, p.14,16.

This article originally appeared in the June 2000 issue of HME Business.

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