Treating the Diabetic Foot: All Hands on Deck
November 2010 Issue
Pedorthists must face the challenges presented by this population with all hands on deck.
Minor foot injuries such as blisters, cuts, and sprains can become serious and sometimes even deadly complications for people with diabetes. Common diabetic conditions, including poor circulation and neuropathy, can turn small wounds into ulcerations, and sprains or stress fractures into broken bones and collapsed foot joints. Left unnoticed and unchecked, such wounds can lead to lower-limb amputation or even death.
Trauma from ill-fitting shoes is the most common cause of ulceration, so it's important for pedorthists to be involved in the treatment plan for individuals with diabetes as early as possible. Unfortunately, this is often easier said than done. The American Diabetes Association (ADA) estimates that more than 20 million Americans have diabetes and, according to the Pedorthic Footwear Association (PFA), there are approximately 2,400 pedorthists in the United States today. Given the disparity between the need for pedorthists and the number of practicing pedorthists in the United States, it stands to reason that the majority of people with diabetes are not receiving care from a certified pedorthist. Perhaps not surprisingly then, when asked to name the biggest challenge the pedorthic profession faces today, many pedorthists interviewed for this article cited the difficulty in getting physicians and patients to understand the role that pedorthists play in the diabetic care continuum.
Education Starts with the Physician, Continues with the Patient
Some physicians don't understand the role of the pedorthist, says Harriet Cavanah Dart, CPed, with Sheck & Siress Prosthetics/Orthotics/Pedorthics, Chicago, Illinois. "As more O&P companies include 'pedorthics' in their names and logos, pedorthics will get on the physician's radar," she says. However, at present, "Shoes seem like a low-tech solution in a high-tech world." Dane K.Wukich, MD, chief of the Division of Foot and Ankle Surgery and an associate professor of orthopedic surgery at the University of Pittsburgh School of Medicine, Pennsylvania, agrees that this is generally true, though he works closely with a pedorthist in his office.
"There needs be more education out there, more training for physicians," he says. "It's important to have a really good dialogue between the foot doctor and pedorthist." Dart agrees. "When practicing pedorthists develop relationships with local doctors and offer high-quality in-service presentations...more physicans will become aware of the contribution a pedorthist can make to improve a patient's mobility." Wukich adds that there needs to be a team approach between the pedorthist and the surgeon although pedorthists say that this is difficult to balance because, like O&P practitioners, they are not reimbursed for follow-up visits or consultations with physicians.
It is also challenging to educate physicians about the difference between off-the-shelf rocker shoes and prescription rocker shoes, says David Castellanos, CPed, National Pedorthic Services, Madison, Wisconsin. Both can have radically different effects, and the off-the-shelf versions are sometimes seen as a cure-all.
"Physicians may not give a prescription," Castellanos continues. "They may send a patient to get an off-the-shelf rocker shoe, and it may be the totally wrong shoe." Wukich says that sometimes physicians write prescriptions for a general "orthotic," and likens this general prescription to a physician who tells the pharmacist the patient has high blood pressure and to prescribe "something" for it.
Patient education is just as important as physician education—and some might argue that this is even more critical. People with diabetes often don't understand why they need prescription footwear, says Dennis Janisse, CPed, president and CEO of Milwaukee-based National Pedorthic Services. Janisse, who is also a clinical assistant professor for the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, Milwaukee, adds that often people with diabetes expect government programs or medical insurance to pay for these items, and if they don't, those people typically don't get the prescription footwear they need, which leaves them vulnerable to limb loss and potentially life-threatening wounds.
"With these expectations, some of the patients who are most at risk are refusing or going without care," Janisse says. "Without education, they can't really make an informed decision."
Similarly, people with diabetes often don't recognize the importance of taking care of their feet, says Ryan Robinson, CPed (C), director of operations and co-founder of Walking Mobility Clinics, Ajax, Ontario, Canada. "Small things can turn into big things," he says. "It's amazing how quickly it can get away from you—from callus to bad callus to ulceration to deep ulceration to osteomyelitis, to potential amputation.
"Proper footwear, orthotic choices, and sock fittings are just as important as the medicines [people with diabetes] may require," he continues. "The diabetic foot is at risk, and we can avoid the potential pitfalls if we lead those with diabetes down the road to proper foot choices."
First Steps for Pedorthic Treatment of the Diabetic Foot
The first step for pedorthists is to interview the client to determine whether diabetic side effects could prevent the client from correctly wearing the shoe or insert, Castellanos advises. "I think of the patient as a whole. Their feet [are affected by] diabetes, but they often have other issues." For instance, one of Castellanos' clients has poor eyesight, and it wasn't until a follow-up visit that Castellanos realized the patient had placed two inserts into one shoe. Others may have neuropathy in their hands, preventing them from being able to tie their shoes. And still others may have cognitive problems and not understand or remember how to use the items properly.
"If people can't fasten their shoes or can't put on a compression stocking, you have given them items that they can't use," Castellanos says. "Unless you get an accurate history of the patient—that they have the ability to check their feet, ability to actually put on and take off their items, and you educate them, you are not always helping the patient. It's not just about giving them what they need but making sure they know how to use it."
One solution is to ask the patient to bring family members to the interview who can assist with their loved one's daily routines.
In a "perfect world," Robinson says, he would see persons with diabetes the day of diagnosis or the day after to immediately instruct them in self care of their feet. He would begin by explaining why their feet are at risk and the potential for injury if neuropathy occurs.
"For many people, this is a silent killer," says Robert S. Schwartz, CPed, president and CEO of Eneslow Pedorthic Enterprises, New York, New York. "Many people are not feeling pain [because of neuropathy]. When you don't feel pain, you don't have the same level of empathy for your problem as when you have pain."
Robinson says it's important for pedorthists to teach people with diabetes about why they are at risk, which includes telling them that their circulatory system is compromised and that there is a potential for serious foot injuries should neuropathy occur. He also recommends instructing patients about practicing daily preventative care, such as wearing no-seam socks, overturning their shoes each day to check for pebbles and other foreign material, and inspecting their feet daily for injuries, using a mirror if necessary.
Dart adds that if people feel respected, they are more likely to comply with their treatment plan.
"I don't take care of 'diabetics' because 'diabetic' is a condition," she says. "I talk to people who have diabetes. Diabetes is only a portion of who they are. Some feel they have been sentenced, and they are so discouraged that they don't do anything."
Pedorthists must check shoes, wear patterns, insoles, outsoles, linings, and uppers during every follow-up visit as well as measure their clients' feet, Schwartz says. Though most pedorthists make this a part of their regular practice, they say that it's a challenge to get their clients to recognize the importance of regular appointments.
Even recognizing that a certified pedorthist is a healthcare provider can be an issue, Dart says. "Sometimes it doesn't occur to them that they should schedule regular visits," she says.
Castellanos sends reminder cards for checkups, and that seems to help. "If you see patients on a regular basis, even if it's only every six months, you can do a lot of preventative care," he says.
Managing a Small Business
In addition to the challenges of managing individuals with various foot concerns, pedorthists must also be equipped to handle the daily concerns of running a retail business. Dart says that managing adequate inventory to accommodate all of the diabetic population's needs is expensive. A store's inventory needs to be large enough for clients to be able to try on different sizes, widths, and styles, and the shoes also need to have appropriately designed or modified outsoles. Dart says it helps to develop relationships with other stores that can be trusted to fit your customers' feet properly. It also can be difficult to find skilled shoe technicians to fabricate external shoe modifications, she says.
Choosing the Right Materials
To provide properly fitted shoes, the pedorthist must measure the foot, but since the measuring device is not three dimensional, anticipating the width is not as easy as it looks, Dart says. Charcot foot, neuropathy, ulcerations, and amputations of the toes and other parts of the foot are all challenges when fitting shoes.
In some cases, surgical consultation is required, Robinson says. At his clinic, physicians with extensive diabetic training are on staff. This includes the medical director, who runs a hospital-based wound clinic as well. There, pedorthists routinely seek the advice of the clinical staff in more complex cases.
It's not just about offloading the foot from the plantar aspect, Robinson says, but in some cases it's also about controlling the excessive shearing forces acting on the foot. This is achieved by better aligning the foot and improving the foot and leg biomechanics with use of a custom foot orthotic, orthopedic shoes, and shoe modifications. He often tops foot orthotics and lines the inside of braces and shoes with ShearBan®, a Teflon-based material, and pink Plastazote®, which is heat-moldable, antibacterial, and antimicrobial.
"[The fit] has to be very exact," Robinson says. "You cannot take any chances."
Robinson also asks his clients to return three weeks after the initial fitting to ensure he was successful with his goals. In severe cases, he asks them to return six months later, but in general, subsequent annual visits are standard.
Sometimes, the patient's diabetes progresses so far that the pedorthist can no longer help with his or her care, and surgery becomes necessary, according to Michael Pinzur, MD, professor of orthopedic surgery at Loyola University Medical Center, Chicago, Illinois. Pinzur has published extensively about Charcot foot treatments and has written many articles about the pedorthic management of the diabetic foot. "There is a limit to the amount of deformity that can be accommodated with therapeutic footwear," Pinzur says.
Sometimes, he adds, diabetic foot conditions are misdiagnosed, leading to delays in treatment and subsequently increased foot deformities. For instance Charcot foot, if caught early, can be managed with a cast to offload, but when bones fracture and crumble, surgery is necessary.
Receiving Adequate Reimbursement
Another challenge pedorthists face is getting adequate reimbursement from Medicare and insurance companies for shoes and modifications for deformed feet.
Even though pedorthists cannot bill for time spent to fit and provide clients with follow-up care, Dart says, "For people with diabetes, the follow-up care can be as crucial as the initial care." She adds that insurance companies need to understand that if they replace a person's pair of shoes for $200, the insured person may avoid a week-long hospital stay. She has seen situations where a person's shoes were badly worn or no longer fitting properly, and the insurance company would only pay for the insert and not for the new shoes.
Increasingly, insurance companies are following Medicare guidelines. Some pedorthists are not on insurance provider lists, and as a result, some clients must pay out-of-pocket, Schwartz says. Persons with diabetes who bypass insurance have more shoe choices than what Medicare allows.
When dealing with Medicare and insurance companies, proper documentation is crucial, but again, because many referring physicians are unfamiliar with the pedorthist's role, they must be continually educated about new Medicare requirements for the amount of documentation pedorthists need on file, Castellanos says. The forms need to be in the pedorthist's office before the diabetic footwear is delivered to the patients, and sometimes patients are left waiting because the physician either didn't fill out the form or didn't fill it out completely. "It's a matter of meeting the requirements and making sure you don't upset your doctors by asking them," he says.
There is no doubt that pedorthists face numerous challenges when dealing with patients with foot problems, especially those related to diabetes. And the need for pedorthic care is growing. Brian Lagana, PFA's executive director, underscores this need with a sobering statistic. "Last year, I saw a study that indicated that by 2025, with the increasing aging, diabetic, and obese populations in the United States, that there would be a need for approximately 100,000 pedorthists," he says.
With statistics like these, all hands will only cover a portion of the deck.
Susan Glairon is a freelance writer who lives in Longmont, Colorado.
Pedorthists say not much has changed in recent years for shoes and inserts for the diabetic foot, but certain products are being used more frequently, some shoes are more comfortable and stylish, and there is a larger selection of shoe inserts.
"A lot of time the low tech is the new high tech," says Ryan Robinson, CPed (C), director of operations and co-founder of Walking Mobility Clinics, Ajax, Ontario, Canada.
The process of unloading high pressure areas of the foot through total contact orthotics or AFOs is not new; however, physicians and pedorthists alike are prescribing and using them more extensively, he says.
Rocker-sole shoe modifications are also being prescribed more often than in past years. This simple shoe modification can be extremely effective in unloading pressure off of a high-risk area of the foot like the mid-foot or forefoot, our experts say.
Heat-moldable shoes, which have been available for some time, are also being used more frequently.
Compliance has long been an issue for custom-shoe manufacturers for the simple reason that some people are reluctant to wear what they consider to be ugly shoes. To address this issue, custom-shoe manufacturers are spending more time dealing not only with the proper fit of the shoe but also with aesthetics, increasingly offering more attractive styles to help improve patient compliance.
According to Dennis Janisse, CPed, new products are now available to address the negative affects of shear and friction on the feet; until recently there was no good way to decrease it in shoes. ShearBan® has been increasingly used in the last few years. This material can decrease shear force under an area and can help decrease ulceration, says David Castellanos, CPed.
Another relatively new concept is the use of silver, copper, and bamboo in socks, hosiery, and orthotic top covers to eliminate bacteria and fungus in the shoe.
There is a lot more education especially around the area of wound care, Robinson says. This encompasses the use of new products used by physicians in the treatment of ulcers, to the use of hyperbaric chambers to help facilitate wound healing.