Off-loading for the Prevention of Diabetic Foot Ulceration

THE ROLE OF OFF-LOADING IN THE PREVENTION OF DIABETIC FOOT ULCERATION

INTRODUCTION OF DIABETIC FOOT ULCER

In the modern techno-world diabetic foot ulcer is the most common reason of lower extremity amputation which makes it highly essential that ulceration in the foot of a patient with Diabetes mellitus must be taken care of immediately or else it will lead to a more serious condition and the end result will be amputation of the leg. As stated in ‘The Lancet’ an early diagnosis is imminent as this condition has high chances of recurring even after the ulcer is treated but medical intervention can prevent amputation. Health care research has been neglecting the importance of planning and taking adequate prophylactic measures to prevent the onset of diabetic foot ulceration and treatment were being given based on clinical diagnosis and results but more importance was to be given to scientific facts and extensive studies were to be done to assess the root cause of the incidence of diabetic foot and timely measures were to be taken (1).

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Patients with diabetes have higher chances of getting hospitalized with foot problems and this can only be taken care of by a careful analysis by the family physician during the patients’ routine visits. Simple office tests such as the nylon filament test (2) can be performed in the office so that those patients in the risk category can be identified and prophylactic measures can be taken to prevent the ulcer from forming. This is a simple test wherein the feet are examined and the pressure is applied on certain pressure points in the feet and if the patient is not able to sense the pressure applied then he is considered at risk for developing an ulcer in the region and the doctor advises him to take extra care to prevent the ulcer from forming.

In spite of seeking medical help diabetic foot ulcers often develop to more chronic conditions and lack of timely intervention to prevent this condition may lead to amputation of the lower extremities and at times may even be fatal. In a normal individual, when harmful pressure is applied on the feet making it difficult for the person to handle, then the brain sets off a pain alarm (1). But, in the case of diabetic patients, due to excessive nerve damage the sensation of pain is lost and an ulcer forms and this will be noticed only after it is too late to redeem. But, with the advent of technology and medical science off-loading helps in preventing further damages and one has to choose the right kind of off-loading modality that suit’s one’s purpose.

Risk Factors for patients suffering from diabetic foot (2)

PREVALENCE

Studies conducted in the west of Ireland to assess the prevalence of diabetic foot complications show that almost 4.7% (Institute of Public health in Ireland, 2006) of the population is suffering from the debilitating disease called diabetes and out of which an increasing majority of patients are suffering from developing foot ulcers of which some of them have already undergone lower extremity amputation. Pilot studies conducted among a sizeable number of diabetes population in the west of Ireland shows that they have vascular insufficiency and have neural dysfunction in the feet. These data are to be treated with concern as these prevalent conditions are associated with increased risk of ulceration which left unattended will lead to more irreversible complications (Nather et al, 2008) (3).

INCIDENCE

The need of podiatric inputs in the field of diabetic foot study is necessary and for this pilot studies, researches, data cumulative study must be done to prevent incidence of diabetic foot complications in the Irish population. Pilot studies conducted on diabetic foot complications in the west of Ireland reveal that pedal neural dysfunction was detected in up to 30% of the screened population and vascular impairment in 17% of those screened (3). With timely intervention and prophylactic measures the case of diabetic foot ulcers can be controlled and with just an initial investment of podiatric clinics across the republic of Ireland the economic impact of growing incidence of diabetic foot ulcers and associated disorders that can lead to downfall of the healthcare system can be reduced and stabilized.

COST

In developed countries, health care resources account that diabetes-related complications are the most costly and studies conducted at St. James Hospital, Dublin reveal that the annual hospital expenditure on the treatment of diabetic foot ulceration amounted to 74,000 pounds (Smith et al., 2004). In an Irish healthcare setting, the cost of managing diabetic foot ulceration was studied and on screening of thirty patients who were admitted for diabetic foot complications it was revealed that out of the thirty, amputations were performed in eight of the patients and one died with a non-healing ulcer. The net hospital expenditure was 704,000 and an average of 23,489.63 per admission (4).

IMPACT

According to Dr. Canavan, almost 50% of the people with diabetes who undergo a lower limb amputation are of working age and that HSE was not channeling the financial and human resources in the health system effectively to tackle diabetes. The direct in-patient costs amount to €239 million (4) and this is estimated only for the hospital care and not for the cost of dressings or antibiotics. Taking all of these factors into account it has become of national economic importance to devise a national strategy to manage diabetes so that the healthcare resources need not be spent on preventable complications. Instead the financial resources must be channeled for setting up more diabetic management clinics with podiatric clinical settings and recruitment of diabetic specialists.

The theoretical role of off-loading in the case of diabetes mellitus

Since a diabetic patient has lost the sensation of pain it becomes difficult for the patient to identify a minor bruise that may develop into an ulcer. Pressure reduction or off-loading is essential for a patient who has just been treated for diabetic foot. Wound care is essential in case of diabetes effective management and off-loading or reducing the pressure plays a significant role in managing the healing process. There are various off-loading modalities such as the total-contact casts (TCC), removable cast walkers (RCW) and half shoes and studies have been conducted to compare the effectiveness to heal neuropathic foot ulcerations in diabetic individuals (5). Although less commonly used than RCW and half shoes the results reveal that TCC is better than the other two off-loading modalities and TCC heals comparatively higher number of wounds in a shorter duration of time (6). Customized therapeutic footwear is manufactured to suit the individual needs taking into account the deformity and the pressure points. Published studies reveal that TCC are a better option compared to other modalities but clinical skill is essential for its application (7). But another factor that is to be taken into consideration is that removable cast walkers enable daily wound inspection and timely care for the wound which is difficult in the former modality. However, one can conclude that wounds on the posterior heal cannot be treated with TCC although it has significant healing percentage. The best feature of RCW is paradoxically its disadvantage (8). Since this is removable it has the disadvantage of forced adherence which is taken care of by TCC which makes it a better alternative to treat neuropathic foot.

Evidence of Impact of off-loading

High risk diabetic feet is often prone to deformities and offloading of these feet is essential to prevent its recurrence. Diabetic foot ulcer has high chances of recurring even after healing if proper care is not taken to prevent its occurrence. The diabetic feet has certain high risk locations and research on clinical trials by Arts et al. show that highest success rates were seen at previous ulceration areas and Charcot feet whereas forefoot deformities showed the lowest success rates. Studies comparing the effectiveness of RCW and instant TCC showed comparable results in the healing of foot ulcers. In this study it was concluded that a significantly higher proportion of people using the TCC healed faster when compared to those using the RCC. Pressure reduction using the advancement in medical technology will be the corner stones of treatment so that lower extremity amputations can be avoided (9).

Discussion

Studies reveal that Ireland has the minimum number of podiatrists and hence effective management of diabetes foot is not possible. Effective measures must be taken to ensure that more qualified medical professionals specializing in this field must be recruited and diabetic foot clinics are set up where clinical tests like nylon filament tests are conducted for patients during their routine check-up in order to ensure that they are not at risk and counseling must be provided to create their awareness about foot ulcers and the risk factors associated with lower extremity amputation. According to the present scenario the current national and international guidelines (NICE, 2004; IDF, 2009; SIGN, 2010) advise that diabetic patients must receive a comprehensive annual foot examination and this must be done on a regular basis.

Conclusion

A team approach by the family physician and relatives is essential to creating a general awareness for the patient to improve foot hygiene and nail care. In addition to this the patient must understand that routine checkups are necessary and the doctor must also perform frequent foot examinations during the routine visits. Early detection is the key to controlling the incidence of this condition and ensuring the medical practitioners take adequate measures to do a routine examination during every hospital visit. Effective management of diabetic foot ulceration has a positive economic impact on the Irish health care budget and the health care system must take preventive measures to provide prophylactic care to diabetic patients and effective measures to educate the patients about pedal hygiene and its importance. Taking into account the importance of podiatry input in effective management of diabetic foot the manpower deficit in the country of Ireland must be accounted for and full–time podiatrists (90-100) must be assigned to the country to manage diabetes related complications.

REFERENCES

1. William JJ and Prof Keith JH. Diabetic foot Ulcers. The Lancet 2003; 361: 1545–51.
2. David GA and Lawrence A.L. Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. Am Fam Physician 1998; 57(6): 1325-32.
3. Sarah et al. Prevalence of Diabetic foot complication in the West of Ireland: A pilot study. The Diabetic Foot Journal 2010; 13(2):82-91.
4. Smith D, Cullen MJ and Nolan JJ. The cost of managing diabetic foot ulceration in an Irish hospital. Irish Journal of Medical Science 2004; 173(2): 89-92.
5. Adler AI, Boyko EJ, Ahroni JH and Smith DJ. Lower-extremity amputation in diabetes. E independent effects of peripheral vascular disease, sensory neuropathy and foot ulcers. http://care.diabetesjournals.org/content/24/6/1019.full
6. Gerit M, David A, Susie S. Standard, Appropriate, and Advanced Care and Medical Legal Considerations: Part one – Diabetic Foot Ulcerations. Wounds 2003:15(4)
7. Armstrong DG, Lavery LA. Evidence-based options for offloading diabetic wounds. Clin Podiatr Med Surg 1998; 15:95-104
8. Stephanie W and David A. Managing the diabetic foot: treatment, wound care and off-loading techniques. Diabetes Voice 2005; 50 (Special Issue):29-32.
9. Armstrong DG, Lavery LA, Wu S, Boulton AJ. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care 2005; 28: 551-4.