|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||
Simply checking your diabetic patients' feet remains the most effective wayto save their lower limbs, experts agree.
The resounding theme among diabetic-foot specialists at the 65th ScientificSessions of the American Diabetes Association (ADA), held June 10–14 inSan Diego, was that despite the development of sophisticated neuropathic testsand wound dressings, foot-care education is the most crucial tool forpreventing lower-leg amputations. This includes teaching patients to ask theirdoctor for a foot examination at every visit.
"The first step is to take their shoes and socks off and look at yourpatients' feet," says Lawrence Lavery, DPM, MPH, professor of surgery atthe College of Medicine of Texas and staff podiatrist at the Edward Hines Jr.Veterans Affairs Hospital in Maywood, Ill. "It doesn't have to be donewith any fancy instrument."
Foot ulcers are among the most common complications of diabetes, with aprevalence of 4–10%. They become infected frequently, can be expensiveto treat, and usually are the first step toward amputation of a lowerextremity.
People with diabetes are 25 times more likely to lose a leg than those whodo not have diabetes, says Karel Bakker, MD, a specialist in internalmedicine, diabetology, and endocrinology at Spaarne Hospital in Heemstede, theNetherlands. And 85% of lower-limb amputations begin as an ulcer, he says. Ina patient with diabetes, that wound often is precipitated by nerve damage thatcreates an insensitive foot, and the patient may not be aware of an injuryuntil it becomes a serious problem.
There is a 56% likelihood that a patient with diabetes who presents with afoot wound will have to take antibiotics, and of those who do, 20% are likelyto have an amputation, says podiatrist David Armstrong, DPM, PhD, of the Dr.William M. Scholl College of Podiatric Medicine at Rosalind FranklinUniversity of Medicine and Science in North Chicago,Ill.
The dramatic risk of foot ulceration can be reduced by appropriatescreening and intervention, conclude Armstrong and colleagues in a recentsystematic review of the efficacy of methods to prevent diabetic foot ulcersin the primary caresetting.1
SIMPLE SCREENING
Low-cost, low-technology evaluations and preventive processes are enough tosubstantially reduce the rates of risk, Lavery concurs. "We're nottalking about thousands of dollars for tests."
Simple tests that can screen for loss of sensation should be performed onboth feet. Touching the end of the patient's toe with a piece of cotton or athin plastic fiber (monofilament test) can assess his or her sense of lighttouch or pressure. A cold instrument held to the leg or foot can evaluatesensation of temperature. And a vibrating tuning fork held to the foot canassess the patient's sensation of vibration.
Most physicians have a 128-Hz tuning fork, and vibrationtesting—"a very strong measurement"—takes just 30seconds, Lavery says.
"You don't even need a power source," says Andrew Boulton, MD,professor of medicine at the Diabetes Research Institute at the University ofMiami. "You don't have to buy any specialized equipment. The key thingis to remove their shoes and look."
Because many new therapies for the diabetic foot are expensive, peoplethink they must be good, Boulton continues. But sometimes when patientsreceive a brand-new dressing or skin substitute, they feel better and walk onan injured foot when they shouldn't. The danger with sophisticated wound-caredressings and coverings is that they deceive the patient and the doctor, hesays.
"What's pioneering is to say, `Let's go back to the basics,'"Boulton says. "Most of all, if you can't feel it, don't walk on it. Ouraim is to close that wound as quickly as possible."
Most simple neuropathic ulcers can be cured in 2–3 months withoff-loading and casting, Boulton says.
TAKE THE PRESSURE OFF
The gold standard for reducing pressure on a wound to help it heal is theambulatory total-contact cast, Armstrong reported at the ADA meeting. Andthough removable casts have been shown to be as effective in the lab, inclinical practice patients wore the removable devices for only 28% of thesteps they took in aday.2
"We wonder why with expensive skins and gels patients come backlooking just as bad," he says.
Armstrong notes research that finds wrapping a removable cast with abandage or plastic to make "an instant total-contactcast"—accompanied with counseling about the importance of keepingthe device on—heals almost as well as a traditional total-contact deviceand is cheaper.3
Physicians typically are able to see their diabetic patients only onceevery three months, Lavery points out. "As physicians, we need toheighten patient awareness for home care with simple tools." 
Footnotes
Ideal management for preventing and treating diabetic foot problemsincludes:
Also read ADA's foot care recommendations online athttp://care.diabetesjournals.org/cgi/content/full/28/suppl_1/s4.
Warning signs of the foot at risk:
Source: International Working Group on the Diabetic Foot, InternationalDiabetes Federation
References
2. Armstrong DG, Lavery LA, Kimbriel HR, et al.: Activity patterns ofpatients with diabetic foot ulceration: Patients with active ulceration maynot adhere to a standard pressure off-loading regimen. DiabetesCare 26:2595–2597, 2003.
3. Katz IA, Harlan A, Miranda-Palma B, et al.: A randomized trial oftwo irremovable off-loading devices in the management of plantar neuropathicdiabetic foot ulcers. Diabetes Care 28: 555–559, 2005.
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
