Diabetic Patient Care: Education+Teamwork = Rx for Success

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By Sherry Metzger

Taking a comprehensive, education-focused, team approach to patient care goes a long way to improving quality of life for persons with diabetes.

The American Diabetes Association (ADA) estimates that more than 20 million adults and children in this country have diabetes, and nearly one-third of this population is undiagnosed. People with diabetes often have other health risks such as high blood pressure and cholesterol that can lead to early heart attacks or strokes. In addition, two serious complications of diabetes-neuropathy and poor blood circulation-make people with diabetes prone to many foot problems, the foremost cause of hospitalizations among persons with diabetes. When left untreated, these problems can necessitate surgery or amputation, making diabetes the leading non-traumatic cause for lower-extremity amputations (LEA) throughout the world. Proper diabetic patient care, particularly foot care, decreases foot problems and infections that can lead to amputation.

According to the Centers for Disease Control (CDC), 60 percent of all LEA occur among persons with diabetes and 85 percent of those amputations are preceded by a foot ulcer, a non-healing wound, or open sore. Nerve damage, as a result of abnormal sugar metabolism, neurovascular, autoimmune, and lifestyle factors causes persons with diabetes to experience a decrease and/or loss of sensation in their lower extremities over time, known as peripheral neuropathy. Therefore, a patient is at risk of acute injury, such as that being caused by stepping on a sharp object, going undetected due to improper pain perception. The patient cannot sense normal pressure either; thus, friction against bony prominences can cause ulcers.

Coleen Napolitano, DPM, assistant professor of podiatry in the Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Mayfield, Illinois.
Coleen Napolitano, DPM, assistant professor of podiatry in the Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Mayfield, Illinois.

Because chronic high blood glucose levels (hyperglycemia) can restrict blood circulation, particularly to the feet, wounds that were caused by pressure points and go undetected due to neuropathy persist as a result of poor vascular supply. Small foot problems such as dry skin, ingrown toenails, cuts, blisters, corns, and calluses can become non-healing ulcers in persons with diabetes. Also, foot deformities such as hammertoe and bunions can lead to ulcers. In serious cases, patients can develop Charcot foot, a non-infective, destructive lesion of a bone and joint with collapse of joint spaces, often accompanied by a fracture and/or dislocation of one or more ankle and foot joints in a patient who has peripheral neuropathy. Untreated foot ulcers can worsen into bone infections that require surgery or amputation. They can even become life threatening.

"It's not that diabetic patients are non-complying," explains Coleen Napolitano, DPM, assistant professor of podiatry in the Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Mayfield, Illinois. "They just don't realize they're hurting themselves. They don't have the protective sensation, so they don't know. Unless they deal with wounds in a timely manner, they can become limb-threatening or life-threatening."

Though amputations are sometimes necessary for persons with diabetes as a result of multiple factors and progression of the disease, preventive care reduces the risk for complications. "Prevention is of great importance," emphasizes Rodney Stuck, DPM, associate professor of podiatry in the Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System. "Once a person with diabetes ends up with a wound, there can be complications. There can be a failure to educate or communicate well with patients because our time is limited. But we need to make sure they use proper foot care and that they get the same information from all of their care professionals." Diabetic patient care management includes managing blood glucose levels, proper diet, exercise, and medication, as well as preventive strategies that include patient education, skin and nail care, and appropriate footwear.

Patient education is the most important element of comprehensive diabetic patient care. "Why do we have to see so many ulcers or amputations?" asks Roger Marzano, CPO, CPed, vice president of Clinical Services, Yanke Bionics Clinics Inc., Akron, Ohio, and past president of the Pedorthic Footwear Association (PFA). "We educate on lung cancer and breast cancer and have made great improvements in those areas. We need to be more proactive. When persons with diabetes are diagnosed, we need to be more informative as a medical profession-not to scare them-but just to warn them in the same way we warn smokers or women [about breast cancer]."

Educating persons with diabetes about proper foot care begins with prophylactic skin and nail care. Properly washing the feet daily with lukewarm water, drying thoroughly in between the toes, and applying lotion to prevent cracking and a non-medicated powder to keep feet dry is important. Trimming toenails straight across prevents ingrown toenails. Persons with diabetes should routinely check their feet for calluses, blisters, or sores and should not attempt to treat those without first consulting their doctor. Pressing the toenails to see how quickly the color returns is a way to check for proper circulation. Because approximately half of amputations can be prevented if minor problems are caught and treated in time, calling a doctor at the first signs of redness, swelling, pain, or numbness can be crucial. "Some persons with diabetes think that because it doesn't hurt, they don't have to see a doctor," says Stuck. "Even if you're scheduled to see a doctor in a week, we'd rather have you come in and see us right away."

Diabetic footwear and orthoses for offloading the foot are key components in preventing foot ulcer formation, wound healing, and healing after surgery. Persons with diabetes should never walk barefoot, indoors, or outdoors. One study shows that not wearing shoes triples the risk of diabetes-related lower-extremity amputation ( Diabetes Care , 27 (November 2004): 2,636-2641). Persons with diabetes should wear socks that are well padded and half an inch longer than the big toe. Socks should be seamless and free of elastic bands. Comfortable socks protect the feet by reducing skin irritations that result in foot ulcers.

A variety of specially designed diabetic shoes and walking boots are commercially available to the public. "Most patients can get an off-the-shelf' shoe," says Stuck, "as long as there is adequate width for the foot, high enough for the toes and deep enough for multiple-density inserts. Some patients, such as those with neuropathy or vascular disease or severe deformities, need prescription footwear, and we'd refer them to an orthotist or pedorthist for a custom-molded shoe."

Because there are many types of footwear, orthoses, and prostheses for the diabetic patient, fitting them appropriately is highly individualized. Most wear extra-depth shoes with molded liners or custom molded shoes with AFOs. For severe deformities, the Charcot Restraint Orthotic Walker (CROW), a patellar weight bearing ambulatory device (PTB) or ischial weight bearing ambulatory walker (ICB) can be used.

Wound Care

Some types of footwear are used in particular to help with wound care and healing. Changing the pressure on the bottom of the foot is the most effective way to treat a foot ulcer. The total contact cast (TCC) is the gold standard in treating plantar foot ulceration. Popularized in the 1980s, TCC distributes pressure evenly on the bottom of the foot, and ulcers typically heal within several weeks. Another treatment method utilizes pressure-relief walkers, such as the Active Offloading Walker TM , Ossur, Mission Viejo, California, which contain patented insoles with removable, shock-absorbing units to accommodate pressure areas. Pneumatic walkers are also frequently used to relieve plantar pressure by manually adjusting the pressure in hand-inflatable aircells contained in the pressure-reducing rocker soles.

The Circulator Boot TM , Circulator Boot Corporation, Malvern, Pennsylvania, is the only FDA-approved boot and is an in-office method for treating foot wounds. The patient undergoes a series of treatments with this system that includes a boot, valve assembly, and heart monitor. The boot compresses certain portions of the leg during the end-diastolic phase of the heart cycle, effectively increasing blood circulation. In addition, antibiotics can be applied before treatment, which allows the medicine to circulate more effectively. According to a 15-year collection of office and hospital data involving 1,035 patients and 2,177 treatments, patients who used the Circulator Boot showed significant healing or improvements in their diabetic wounds and circulation (Dillon, R.S. MD, "Fifteen Years of Experience in Treating 2,177 Episodes of Foot and Leg Lesions with the Circulator Boot," Angiology , May 1997; Vol. 48).

In addition, debridement can optimize wound healing. Surgical or sharp debridement is most often used, though non-enzymatic methods are also common. Extensive surgical debridement would take place in an operating room under anesthesia, though minor debridement is often done in a podiatrist's office. "A healthy wound is one that is free of necrotic tissue and is moist," says Napolitano. "Proper debridement allows for exposure of moist, healthy tissues."

"For large wounds, a Wound V.A.C. [Vacuum Assisted Closure, KCI Inc., San Antonio, Texas] causes it to heal more quickly by applying negative pressure and drainage to the wound," adds Stuck. "We also use engineered tissue, made from human cells or tissue, to cover larger wounds and care for it like a skin graft."

Diabetic Team Management

The ADA recommends a team approach to managing diabetic patient care because persons with diabetes face a myriad of health issues. "We work in concert with each other, even when we're not all seeing the patient at the same time," Napolitano explains. "We work through a team approach because the patient needs it." The most important member of this team is the patient, as he/she performs daily foot care and glucose monitoring. A primary care physician is the main patient caregiver and often heads the team, along with an endocrinologist, a diabetes specialist, and a podiatrist. Regular exams include checking blood pressure and heart rate, muscle strength, and reflexes.

Other team members can include a nurse educator, dietician, ophthalmologist, dentist, and exercise trainer. A nurse educator helps teach a diabetic patient how to perform daily self-care functions such as testing blood sugar and foot care. A dietician establishes proper nutrition for the diabetic patient, focusing on blood sugar, blood pressure, and weight concerns. Because persons with diabetes can experience autonomic neuropathy which affects the pupils of the eyes, making them less responsive to changes in light, and focal neuropathy, which can lead to an inability to focus the eye, double vision, and/or aching behind one eye, an ophthalmologist can be consulted. Persons with diabetes are at a higher risk for gum disease; therefore, regular visits to the dentist are important. Also, an exercise trainer can provide a fitness program to help manage weight and improve blood sugar control by checking levels before, during, and after exercise that show how the body responds to exercise.

Finally, orthotists/pedorthists play a significant role in managing the diabetic patient because of the many foot problems persons with diabetes experience. "I have a personal interest in my patients because I watched my own father struggle with this disease," says Marzano. "I focus on helping them save a limb by using appropriate shoes and diabetic inserts. Most of my patients, when you heal a wound, save a limb, or make sure they can walk so they can go to work and support their family, to them that's better than providing them with a prosthesis that is less functional and cosmetic, even with today's advanced prosthetic technology."

Comprehensive foot exams to assess the presence of neuropathy include monofilament testing; quanitative sensory testing to a variety of stimuli, such as vibration, temperature, or light touch; nerve conduction studies; and electromyography (EMG). Prosthetists also assist patients after amputation by creating prosthetic devices that will aid them in their rehabilitation. "The care my patients receive prior to their amputation brings them back for a prosthesis afterward," says Marzano. "I say to them, 'even though you have lost your battle in saving your limb, let's move forward and get you moving again with your prosthesis.'"

The decision to amputate depends on several parameters, and each patient is individually evaluated. "We are not quick to cut," says Napolitano, "but we want to maximize the patient's quick return to mobility. We try to treat wounds medically with antibiotics or surgically. However, in some patients, even if they have good vascular supply and they're taking care of themselves, might have underlying medical factors, such as kidney problems, that prevent them from healing." Napolitano explains that the patient parameters to consider include the presence of underlying infection, if off-loading pressure is working to heal the wound, and if the patient has blood sugar control, as well as the patient's vascular supply and nutrition. "We look at needs overall, to determine what's in their best interest. A person who rides a Harley is going to have different lifestyle goals than one who just wants to be able to go to the grocery store."

Marzano agrees. "Some limbs aren't worth saving," he says. "Some people have been off-loading weight to heal a wound by sitting in a wheelchair for so long that they've become deconditioned. Their heart, respiratory system, stamina, and mental outlook plunge while they're waiting for the wound to heal." Indeed, according to Stuck, preliminary data has shown patient perception of the amount of impairment they experience from an amputation is in the same category as that which they experience with an ulcer.

"Mentally, it's like they've lost the battle," adds Marzano. "We have to ask these questions: Can the patient be successfully shoed or braced, or is the deformity so severe that we can't maintain a healthy foot? Does the patient have paralysis, such as from a stroke? Is the patient obese? We try to determine the functional outcome and weigh the financial ramifications as well."

As more and more people are being diagnosed with diabetes, proper education and team-managed care play an important role in decreasing the incidence of LEA in this population, as well as increasing quality of life and mobility.

Sherry Metzger, MS, is a freelance writer with degrees in anatomy and neurobiology. She is based in Westminster, Colorado, and can be reached at sherry@opedge.com

The High Cost of Type 2 Diabetes Complications

The Amputee Coalition of America (ACA) has joined forces with other leading health organizations to educate Americans that good diabetes management reduces the risks of serious health complications.

Type 2 diabetes accounts for 90 to 95 percent of all diagnosed diabetes cases and affects more than 18 million people in the United States. New data underscoring the growing incidence of serious complications from type 2 diabetes prompted a warning from ACA CEO Paddy Rossbach, RN, about "an epidemic of health complications from diabetes. Urgent action is needed to solve this crisis by educating people with type 2 diabetes about the importance of managing their blood sugar level."

Rossbach says that men and women with diabetes have a much higher incidence of specific health problems than individuals with normal blood sugar levels, particularly a prevalence of macrovascular problems:

  • Congestive heart failure occurs in 7.9 percent of people with diagnosed diabetes vs. only 1.1 percent of individuals without diabetes.
  • Heart attack occurs in 9.8 percent of people with diabetes compared to 1.8 percent of those without diabetes.
  • Coronary heart disease occurs in 9.1 percent of people with diabetes vs. 2.1 percent without diabetes.
  • Stroke occurs in 6.6 percent of people with diabetes compared to 1.8 percent without that disease.

Citing data from a new report, State of Diabetes Complications in America , Rossbach points out that chronic kidney disease occurs in 27.8 percent of people with diabetes vs. only 6.1 percent of those without diabetes, and foot problems including foot/toe amputation, foot lesions, and numbness in the feet occur in 22.8 percent of people with diabetes vs. 10 percent without diabetes. She also warns that eye damage occurs in 18.9 percent of people with diabetes.

The State of Diabetes Complications in America is an analysis of national health and economic data specific to type 2 diabetes complications, which was released recently by the American Association of Clinical Endocrinologists (AACE) in partnership with the members of a diabetes complications consortium that include the ACA, Mended Hearts, the National Federation of the Blind, and the National Kidney Foundation, and supported by GlaxoSmithKline.

Overall, an estimated three out of five people (57.9 percent) with type 2 diabetes have at least one of the other serious health problems commonly associated with the disease, and these health problems are taking a heavy financial toll on the United States. In 2006 nearly $23 billion was spent on direct medical costs related to diabetes complications, Rossbach reports. According to the State of Diabetes Complications in America , estimated annual healthcare costs for a person with type 2 diabetes complications are about $10,000-three times higher than that of the average American without diagnosed diabetes.* Annual out-of-pocket costs per individual are estimated at $1,600,* a significant amount considering that according to the National Health Interview Survey, an estimated 40 percent of adults with diabetes reported a family income of less than $35,000 per year in 2005.

"The...risk of developing the serious health complications associated with type 2 diabetes can be reduced," Rossbach says. "People with type 2 diabetes should work with their healthcare provider to develop a personal diabetes management plan that includes healthy eating, regular physical activity, and a comprehensive foot-care program."

Lifestyle changes alone may not be enough to lower blood sugar adequately, she warns, and many people with type 2 diabetes also may need medicines to control blood sugar levels. They should track how their diabetes plan is working by monitoring their blood sugar regularly with a blood glucose meter and by getting an A1c test. The AACE recommends an A1c target level of 6.5 percent or lower. Reaching this target is important since every one percent increase above six percent significantly elevates the risk of serious complications from diabetes.

* Cost estimates in this report were adjusted for inflation to reflect 2006 costs.

Information courtesy of the Amputee Coalition of America (ACA).
To learn more about managing type 2 diabetes and how to reduce the risk of diabetes-related complications, visit www.stateofdiabetes.com or  www.amputee-coalition.org