By: Neil Scheffler
Foot disorders are the number one reason that people with diabetes spend time in the hospital.
Maintaining tight blood glucose control is critical for prevention and management of diabetes complications such as open sores (ulcers), diabetic neuropathy and poor circulation in the feet.
Work with your diabetes care team to keep A1C levels on target; this is the first step toward maintaining foot health and preventing amputations.
What Causes Foot Ulcers?
These major factors increase the risk of foot ulcers and, ultimately, of amputation:
- Diabetic neuropathy
- Peripheral vascular disease (poor circulation)
- Foot deformities
- Tobacco use greatly increases the risk of amputations.
Diabetic neuropathy may be painful, or the feet may be numb. If the neuropathy is painful, your doctor can offer you many treatment options (see sidebar).
Your diabetes specialist or podiatrist should test for sensation in the feet with a hair-like fiber called a monofilament. If you do not feel the fiber, you are at great risk for ulceration, and daily foot care becomes vital. Loss of feeling is a loss of protective sensation.
You should inspect your feet at least once a day and report any changes such as redness, cuts, bleeding or open areas to your doctor or podiatrist immediately.
If you are unable to inspect your own feet, have someone look for you.
Tools for Wound Care
Methods of wound care and saving limbs from amputation has evolved over the years. There are dozens of products available to use on wounds. Some of my favorites include
- Gels with wound healing factors
- Artificial skin “grafts”
- Specialized wound dressings
- Vacuum machines that apply constant suction to the wound
These products should be used only under the direction of your doctor and wound care specialists.
Three considerations are vital when treating a wound:
1. Weight must be removed from the wound.
If you have a wound on your foot, you must remove pressure from the area involved. Some doctors use pads or casts to do this. Others will use crutches or a wheelchair. Whatever the method, you must use it all the time. Even a short trip to the bathroom at night, walking on the affected foot, may prevent the wound from healing,
2. There must be adequate blood supply.
A consultation with a vascular surgeon may be needed if circulation is poor. Today’s vascular surgeons play a vital role in getting enough blood to the feet to allow wounds to heal.
3. Any infection must be controlled.
Lack of outpatient diabetes education about appropriate foot care has been shown to significantly increase the risk of amputation. Stay informed by
- Joining your local diabetes peer group and attending their meetings.
- Asking your doctors and diabetes educators for any literature they may have available for you to take home.
- Making it a habit to read magazines like Diabetes Health.
- Using the Internet to learn as much as you can about diabetes.
And remember to visit your podiatrist regularly, at least yearly.
Knowledge is power, and the feet you save may be your own.
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Neil M. Scheffler, DPM, FACFAS, is a podiatrist in private practice in Baltimore, Maryland. He is a past president, Health Care and Education, Mid-Atlantic Region, American Diabetes Association
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Relief Is On the Way
Cymbalta Approved for Neuropathy Pain
By Cindy Onufer, RN, MA, BC-ADM, CDE
Relief may be on the way for the estimated five million Americans suffering from diabetes-related neuropathy pain, a stabbing, shooting, burning pain that is associated with nerve damage most often in the feet and legs.
In September 2004, the first FDA-approved drug for the treatment of diabetic peripheral neuropathy pain was announced by Eli Lilly & Company. Cymbalta (duloxetine) is an antidepressant drug, approved just the previous month by the FDA for the treatment of major depression. Cymbalta is a serotonin and norepinephrine reuptake inhibitor.
The priority FDA review and approval of Cymbalta for neuropathy pain was based on the results of two 12-week clinical trials testing doses of 60 and 120 mg per day in non-depressed adults with diabetes who had the neuropathy disorder for at least six months. The average age of patients in the study was 60 years old, and they had diabetes for an average of 11 years with neuropathy for an average of four years.
Cymbalta was shown to significantly reduce 24-hour average pain levels compared to placebo. However, Cymbalta doses of 120 mg per day, although safe and effective, were not tolerated as well by the patients as were the 60 mg per day doses.
Both doses were effective in relieving pain at night.
There are no treatments yet to heal or reverse neuropathy, the nerve damage that can be a complication of diabetes. Prevention is the best medicine. Maintaining tight control of blood glucose levels has been shown to reduce the risk of neuropathy by as much as 60 percent in large clinical studies such as the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS).
Keeping A1Cs lower than 7% (normal is 4% to 6%) is the key to successful prevention.
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Shoes-More Than a Fashion Statement: Protect Your Feet With the Proper Footwear
Proper footwear can save your limbs. Therefore, it is important to always wear shoes. That means indoors and outdoors. Minor traumas at home, such as stubbing a toe, can lead to needless amputations.
When shopping for footwear, buy shoes later in the day when your feet may be somewhat swollen. Have a knowledgeable salesperson-preferably a pedorthist (certified shoe fitter)-measure your feet every time you buy shoes and fit them properly to your feet. A good sports shoe is ideal for many people with diabetes.
Always wear socks with your shoes. A sock made of a wicking fabric such as CoolMax or acrylic will wick perspiration away, rather than holding the moisture against your skin. Dry feet are healthier and more comfortable.
If you have Medicare coverage and meet the criteria, you can get one pair of shoes and up to three pairs of custom inserts each year through the Therapeutic Shoe Program. To qualify, you must have diabetes and one of several other risk factors, such as poor circulation or a deformity. It requires some paperwork of your doctors, but it is worth it. Ask your podiatrist about this underutilized benefit.
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Did you know…?
- Fifteen percent of people with diabetes will develop an open sore (ulcer) on their feet at some time during their lives.
- Up to 50 percent of people who have had diabetes longer than 15 years will develop problems with the nerves in their feet, called diabetic neuropathy.
- Poor circulation is two to three times more likely to occur in people with diabetes than in the general population.
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A New Breakthrough Treatment: Anodyne Therapy
Does It Reverse Neuropathy?
By Linda Hicks, RN, MS, CDE
Anodyne therapy-also known as monochromatic infrared energy (MIRE)-has been clinically proven to increase local microcirculation, reduce pain, restore protective sensation, help restore balance and speed up healing of chronic wounds.
Anodyne therapy is noninvasive. The treatment consists of an invisible light, monochromatic infrared energy, which is emitted from small pads placed lightly on the skin. The light helps release nitric oxide into circulation, and the healing cascades from that.
Clinical improvements are often achieved with 30- to 45-minute treatments, three times per week, over a period of one month.
The only two contraindications are pregnancy and being treated for active cancer.
According to a study published in the July-August 2004 issue of Advances in Skin and Wound Care, the incidence of diabetic ulcers in an elderly diabetes population was reduced 79 percent after 12 months of anodyne therapy.
In the January 2004 issue of Diabetes Care, the first double-blind placebo-controlled crossover study using anodyne therapy showed significant and impressive results in decreased pain, restoration of sensation and improved balance.
Other published studies are available at Anodyne LLC’s Web site, anodynetherapy.com.
Linda Hicks, RN, MS, CDE, has been a nurse for 34 years. For nearly 20 years she also has worked as a patient education coordinator.