The prevalence of diabetes continues to increase in the US (and worldwide) each year. Of all the complications that can arise, diabetic neuropathy is the most common – present in approximately 50% of people diagnosed. Diabetic Neuropathy can lead to other disabilities such as Diabetic foot ulcers, amputation, gait and balance impairment, and so on. It’s imperative that we, as clinicians, are equipped to properly identify the risks; and educate our patients and their caregivers to prevent such disability from occurring.
Risk Factors:
There are certain risk factors that may be present prior to a diabetic foot ulcer forming. These include poor control of blood sugar, cigarette smoking, previous foot ulcers and amputations, and most commonly, diabetic neuropathy and peripheral vascular disease.
Diabetic Neuropathy – As mentioned, this is very common among the diabetic population and can be very costly to their health. Diabetic Neuropathy happens when nerves become damaged from chronic uncontrolled high blood sugar. This damage can affect various parts of the nervous system that control motor, sensory, or autonomic functions – all of which can contribute to the patient developing a diabetic foot ulcer. If the nerves that control muscular control of the feet have been damaged, the patient may start posturing their feet in a way that is biomechanically destructive. This can cause increased pressure on bony prominences and other abnormalities and put their feet at higher risk for forming ulcers.
Diabetic neuropathy can also be characterized by pain and/or numbness in the legs and feet if the sensory nerves have been damaged. The pain is often directly associated with the nerve damage itself and is not in relation to an environmental or outward source of pain.
Numbness, on the contrary, presents other concerns. If a diabetic foot ulcer has started to develop, the person may not feel pain or other sensations usually associated with wounds. This may allow the wound to progress unnoticed, as the patient continues to bear weight over the ulcer. When autonomic dysfunction occurs, this can lead to changes in perspiration leaving the skin overly dry and prone to cracking.
Peripheral Vascular Disease – Smoking and Diabetes are among the most powerful risk factors in developing PVD. PVD is characterized by atherosclerotic changes of the blood vessels where the arterial walls gradually harden and narrow as plaque builds up inside. This restricts blood flow and limits the amount of oxygen and nutrients the blood can carry to that area. Some studies show an important distinction that PVD in a person with Diabetes mostly occurs in the femoral and tibial arteries. Other risk factors (such as smoking) will affect more proximal vessels. The nature of PVD makes it easy to imagine why this would put a person with Diabetes at risk for developing a foot ulcer – the feet are not getting the oxygen and nutrients they need to sustain healthy tissue!
The prevalence of PVD among people with Diabetes is difficult to pin down due to the variability of symptoms. Some people may present as asymptomatic. A great way for clinicians to help identify the presence of PVD is the Ankle-Brachial Index. Research has shown this to be highly sensitive and specific when compared to angiographically confirmed disease… and the great news for us is that it doesn’t require any fancy equipment!
For great resources to use in the clinic, check out our ‘Ultimate Guide to Managing the Diabetic Foot’!
Time for healing:
Wounds often take a longer time to heal for a person with diabetes, and here’s why:
Diabetic Neuropathy – As mentioned above, this could be a risk factor for developing diabetic foot ulcers to begin with, but it is also a major player in the wound healing process. If the nerve damage is contributing to a sensory loss… the person is going to be at a very high risk to reinjure/reopen the wound site again and again. They can’t feel it, so it won’t be “a problem” for them until it’s too late. A vicious cycle!
Peripheral Vascular Disease – Blood flow with good oxygenation and nutrition supply is essential to proper wound healing. When this is compromised, as it is in people with PVD, the body simply does not have the fundamentals that it needs to move through the wound healing process and repair tissues. If a more severe lack of oxygenated blood exists, this could lead to ischemia and necrosis of the tissues, which would then need to be debrided… making the wound larger. In other cases it could lead to gangrene and eventual amputation.
Infection – Diabetic foot ulcers are often at higher risk for infection, which would then prolong the healing process. When a person has diabetes, they produce certain enzymes and proteins that make the immune response less effective. So, when a diabetic foot ulcer is present and bacteria enters in, your body is already at a disadvantage in fighting off infection and moving on to healing the wound.
Prevention is Key!
If you or someone you know is at risk for developing diabetes, it is imperative to take steps toward prevention! This is sometimes easier said than done. But, making small changes at a time will give you the best results… by far! Don’t take everything on all at once. If you’re a clinician healing your patients and their families, don’t overwhelm them with information – start slow.
Check out this page to get great tips and resources from the American Diabetes Association on how to prevent Diabetes!
But if Diabetes is already present, there are plenty of ways we can still help our patients prevent complications, such as Diabetic neuropathy and foot ulcers.
- Get blood sugar under control – This seems obvious, right? But it’s often very difficult for people to do in real life. There are so many factors that play into this, from food preferences, habits, culture, family support, etc. It’s important to get as many team member as possible involved to help reinforce the small changes that the patient will need to make along the way.
- Follow up with appropriate practitioners – Depending on the risk factors identified, ensure your patient is seeing the experts they need. Some examples are: Endocrinologist for management of diabetes; Vascular Surgeon or Interventional Radiologist for management of PVD; Dietician for nutritional recommendations; Community based support groups for Psychosocial support; and of course Physical and Occupational therapy!
- Footwear recommendations – Especially if the person is presenting with Diabetic Neuropathy, you want to ensure that they have proper footwear to support their feet and prevent any unnecessary pressure of shearing of their skin. They may need to wear certain types of socks; and need education on how to properly don them in order to prevent bunching of the material within the shoe. They may do well with a wider size to allow more room, or they may need specially ordered Diabetic shoes. The Healthy Feet Store may be a great resource for some patients!
- Daily self-check/foot inspection – Once this becomes a habit, it will be an invaluable part of your Diabetic patient’s routine. This can be an effective way for prevention of diabetic foot ulcers through getting the patient to be more engaged in their care. They will need a long-handled mirror or a mirror they can place on the floor under their feet. Here are the steps involved:
- Skin inspection – Look at the skin on the top of your feet, the soles of your feet and in between your toes. (Use the long-handled mirror for places you are unable to see.) Observe for: cuts, scrapes, bruises, dirt/grime, blisters, discoloration, or developing calluses. Anything that is new or abnormal should be noted.
- Nail inspection – Look at your toenails for uneven edges, broken nails, ingrown toenails, or signs of infection.
- Sensation – Feel all over your feet for changes such as numbness, increased sensitivity, lumps/bumps, cold areas, tingling or painful areas.
- Smell – Try to smell the skin for fungal or bad odors. A change in smell or a bad odor can indicate a problem or a possible infection.
- Hygiene – Clean your feet of any dirt or grime and dry the skin very well. This will help to prevent any possible infections. Wash using warm, not hot water, and do not soak your feet. Apply lotion and rub it in until feet are dry.
As with many different aspects in healthcare, prevention certainly is key! But more often then not we are seeing patients after their conditions have become chronic and they are already experiencing a host of complications. It is no different with our patients with Diabetes. Identifying what is already present and what they are at continued risk for is where we can still play a role in prevention. We can prevent the progression of their disease or prevent the development of complications by providing education and strategies to make the changes they need to make more attainable.
If you want to learn more about wounds and wound management, have a look at our LIVE or SELF-PACED course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This course offers 7 Cont-ed units, practical downloadable tools and resources, and is taught by an expert wound care specialist who makes the education accessible to everyone. Check it out!
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