Preventative foot care for people living with diabetes

Riaan Knight, a medical orthotist and prosthetist, explains why preventative foot care is so important for people living with diabetes.

Father’s loss of limb directs choice of career

As a medical orthotist and prosthetist, I frequently deal with the debilitating effects of foot ulcers and amputation caused by vascular disease. Sadly, in my practise, vascular disease is almost always directly linked to diabetes.

Speaking from personal experience, I can’t emphasise enough the importance of diabetic foot care. As a young man, I had to watch my dad, who was diabetic, deal with the devastating effects of a recurring foot ulcer.

At first, he lost his mobility, he had to walk with crutches. Later, he lost his ability to drive a vehicle and then eventually, as to stop infection from spreading, he had to undergo an amputation of his left lower limb.

Although the medical aspect was dealt with successfully, he now faced a new dilemma, he used up all available sick leave and had to deal with the loss of his income.

On the upside, his successful rehabilitation with a prosthetic limb left a huge impression on me. I immediately knew I wanted to study medical orthotics and prosthetics.

It was during my studies that I realised to my dismay that if only the medical team followed proper orthotic management protocols, he may have never had re-ulceration or limb amputation. Research proved the effectiveness of foot orthotic treatment to assist in recurring foot ulcers. (Alprazolam)

I have often asked myself could we have cured his foot ulcer? Could we have prevented the amputation of his limb? What I do know is that foot orthotic studies confirm positive results.

Study with astounding results

A well-known study, done on the effectiveness of orthotic treatment in patients with recurrent diabetic foot ulcers, by Fernandez ML, Et al, published in the American Journal of Podiatric Medicine showed astounding results:

• “Before foot orthotic treatment, the re-ulceration rate in diabetic patients was 79% and the amputation rate was 54%. Two years after the start of orthotic therapy, the re-ulceration rate was 15% and the amputation rate was 6%.
• Orthotic therapy reduced peak plantar pressures in patients with re-ulcerations and in those without.
• Sick leave was reduced from 100% to 26%.”

The results are staggering. Yet, sadly the incidence of pressure ulcers in the diabetic community remains high and may very well increase.

Diabetes on the rise

The World Health Organisation (WHO) has predicted that there will be 380 million diagnosed diabetic patients worldwide by 2025. They further determined that Africa will face the second highest increase in prevalence of the disease.

A research study by the Non-Communicable Diseases Research Unit, based at Tygerberg Hospital, confirmed this “increase” prediction for South Africa. Their research found an above normal increase in persons diagnosed with diabetes in SA.

In fact, they state that the prevalence of diabetes increased amongst the female population from 8 to 14% and amongst male population from 5 to 10% for the period between 1980 and 2014.

Risk for foot ulcers

WHO further state that the lifetime risk for foot ulcers in people with diabetes is estimated to be as high as between 15 and 25%. Research further showed that 85% of all amputations done in diabetics are preceded by ulceration.

The at-risk diabetic would need to take cognisance of the fact that due to insufficient vascularity and neural dysfunction associated with diabetic neuropathy, he/she will always be at risk of developing a plantar foot ulcer. Preventative action should be high priority.

Preventative plantar pressure screening is essential

Unfortunately, an aspect that can greatly assist with the early detection of possible ulcer prone areas of the diabetic neuropathic foot has been ignored to a fair extend. Preventative plantar pressure screening is essential. Stop the ulcer before such can develop.

I am obviously aware of all other avenues of diabetic screening and complication prevention protocols. But, I do feel that it’s of paramount importance that diabetic foot care screening via specialised medical plantar pressure devices are developed and implemented in addition to those throughout South Africa.

Although such medical devices are available in the private sector, only a small handful is available to state patients. The conundrum is to convince government to invest in such fairly-expensive systems.

However, the money saved in long-term (unnecessarily used to fund wound treatment and limb prosthetics) would be astronomical and will far outweigh the initial set up cost.

Studies prove effectiveness of these systems

The effectiveness of these systems has been proved in many a medical research study. A study, by Joslin Beth Israel, Et al, at the Deaconess Foot Centre, Harvard Medical School, concluded that both the rearfoot and forefoot pressures are increased in the diabetic neuropathic foot, indicating an imbalance in pressure distribution with increasing degrees of neuropathy. The later stages of peripheral neuropathy play an important role in the aetiology of diabetic foot ulceration.

Another study, by the Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, showed that claw/hammer toe deformity is associated with elevated plantar pressures at the metatarsal heads in neuropathic diabetic patients. This condition increases the risk for plantar ulceration.

The fact remains that even healthy tissue placed under abnormal pressure over a prolonged period will break down and ulcerate. Unfortunately, in the case of diabetic patients even more so.

How does a plantar pressure device work?

Planter pressure devices can predict areas of abnormal pressures by measuring pressure over time and relating such to normative values from healthy individuals.

Another plus point is the ability of specialised integrated software as to recommend areas and percentage of correction to be applied via a suitable foot orthotic.

I strongly advise all high-risk diabetics to seek referral from their diabetologist (or medical doctor) to undergo such preventative foot care (preventative plantar measurement) screening on an ongoing basis. Prevention is better than the cure.