A Fresh Start At The Practice?

Fresh from the long weekend we welcome Ms Lauretta Zikalala to our podiatry practice. Lauretta is our new receptionist and will be the voice of the practice from today. Back at the practice today, (not exactly fresh!) after a tiring but stimulating weekend at the Diabetic Foot Working Group (DFWG) Congress. Armed with some new knowledge and revision of existing, Tshidi and I feel that we have more to offer our patients with diabetes.

We know that Podiatry and diabetes is not just about managing the serious complications such as foot ulcers. The key issue is the prevention of this complication and research shows that multidisciplinary interventions can reduce both ulcers and amputations. There is a major challenge in South African health care to educate everybody involved in diabetes about the need for proper foot health care.

Just to get patients and professionals to look at feet could prevent many complications. So many patients do not feel pain and are therefore misled into thinking that there is nothing wrong with their feet. Meanwhile they develop blisters from footwear, ulcers from objects like drawing pins, stones and other foreign bodies and burns and scalds from heaters or hot water. It is clear that we will have to develop innovative and cost effective interventions to reduce the numbers of amputations and to improve foot health awareness in South Africa.

For any health professionals reading this; do you know what an angiosome is? I’ll publish some references tomorrow. (I think you will be amazed). For the lay person, angiosomes allow vascular specialists and podiatrists, in the context of patient examination, to accurately assess the quality of blood flow to every part of the lower limbs and feet. This enables really accurate identification of those areas at risk due to inadequate blood supply. Most of us are familiar with the dermatomes which map out the nerve supply, but angisomes are something new. (Well they are to me!).

The Diabetic and the barley bag – part 2

Loss of sensation and reduced blood flow to the lower limbs and feet are a well known complication of diabetes. As winter progresses, people with diabetes are at increased risk from problems associated with damage caused by trying to keep the feet warm. The lady I wrote about on May 7 is still at high risk.

Fortunately she is sticking to her care routine and the toe has stabilised. The blistered skin dried and formed a hard crust – actually this is a dry gangrenous crust – has formed over the centre of the wound, but the edges are clean and pink. The primary key to a successful outcome is control of blood sugar and that is good. Secondary is the quality of wound care and hopefully we are up to standard.

The biggest problem we have when treating diabetic foot ulcers is to keep weight off, called off-loading. Naturally, this is very difficult for a patient who knows they have a foot ulcer, but doesn’t feel any pain. Remember, pain stops us from doing further damage to an injured body part.

Here are a few WINTER FOOT TIPS FOR PEOPLE WITH DIABETES.(It’s winter in the southern hemisphere).

Keep up the daily washing and drying -especially drying

Keep up/start a daily routine of gently massaging moisturiser into your legs and feet

Remember that your shoes may become tighter because you are wearing socks and closed shoes

When you take off your shoes, check your feet for tell-tale red marks – this means dangerous pressure

Check that your shoes do fit, you possibly haven’t worn then for some months

Thicker-soled shoes will keep your feet warmer

Don’t let your boots squeeze your calf muscles and reduce circulation

Keep your feet warm at night – wear socks. NOT nylon, but cotton or wool or mixtures

Heat your bed BEFORE you get in and turn off electric blankets and heating pads. Remove hot water bottles

Try to avoid sitting in draughts – difficult, because we have houses that are designed for coolness

Wrap a blanket around your legs and feet if you are in a cold room

Never sit too close to any fire or heater – (people have fallen asleep and burnt their legs & feet)

Try to keep your excercise routine going, even though it’s darker morning and evening

p.s. Cape Mohair make excellent socks

Diabetic Foot Dangers – ‘the barley bag’

As winter approaches the southern hemisphere, the risks of damage to the feet of people with diabetes increase. The weather turned nasty in Johannesburg last weekend – wet and cold – as a result I saw my first Autumn diabetic foot disaster yesterday. A burn on the big toe of a lady who went to bed with her ‘barley bag’. It doesn’t have to be barley, rice, lentils, in fact anything that can be heated in the microwave.

After heating the bag in the microwave this lady put it into the bed to warm it up. Her big mistake was, that when she went to bed she didn’t remove the bag from the bed. During the night her foot came to rest on the bag and burned her big toe, leaving a blister along the whole length it.

When she saw me, the blister had broken and the base was infected. So now she is under treatment for a foot ulcer. The sad thing is that I spent months in 2007 succesfully healing an ulcer on this lady’s other big toe.

So what’s the message? You could say the ulcer is a result of a failure of diabetic foot health education – we didn’t get the right message across – but it does highlight the fact that everybody involved in diabetic foot care has to be constantly alert to potential dangers. In this case we have a high risk patient with peripheral vascular disease and diminished sensation who made a mistake with serious consequences. So what are the key messages for winter protection for the diabetic foot?

• wash and dry your feet thoroughly
• remove any heating bags or hot water bottles before getting into bed
• turn off any heating pads or electric blankets when you get into bed
• make sure your winter socks are not too tight on your feet and around your legs
• take care that you can wriggle your toes in your shoes when you have thicker socks on
• remember that a thicker-soled shoe will keep your feet warmer
• if you live in a winter rainfall area, dry your feet as soon as possible after they get wet
• try wearing loose-fitting cotton or woollen socks in bed
• if your feet swell during the day, remember to allow for it when you wear your winter shoes or boots
• STOP SMOKING!

Take care of your pair and see a podiatrist

SA podiatrists ‘bitten’ by Crocs

At the recent meeting of the Northern Branch of the South African Podiatry Association (SAPA), local podiatrists learned more about this interesting and controversial footwear. Because Crocs have been around a while, the consensus amongst SAPA members was "try them before you dismiss them". (Remember the negative UK podiatry opinion in my Post of 16th September).

Gareth Kemp of Crocs SA showed us some of the many styles available in SA, including ‘All Terrain’, ‘Georgie’ – bright gumboots – and even ‘The Hydro’ which they say can function as a flipper! (Just right for Survivor). The medical styles have an enclosed forefoot – removing previous complaints – and the concerns about static electricity build-up are being addressed. There is also one style for people with at risk feet due to diabetes.

So do yourself a favour, visit www.mycrocs.co.za or if you can’t wait go and buy GENUINE Crocs. (I’m waiting for a free Trial pair, but not in pink!

Do podiatrists like Crocs?

Some do, some don’t.

“They should not be worn by people with diabetes” says a colleague in Cape Town.

On the other hand, a British podiatrist, writing in Podiatry Now, thinks they have great therapeutic potential and presents a case history as evidence. He suggests that they be researched by the podiatry profession.

Some UK websites are full of therapeutic ‘evidence’ and testimonials.

WATCH THIS SPACE!

Good News on the Diabetic Foot

The Diabetic Foot Symposium at the VASSA Congress yesterday was a great success. It marked the launch of DFWG, the Diabetic Foot Working Group.

This is a voluntary association which will serve as the overall representative body to promote awareness and optimal management of people with diabetic foot problems in South Africa. Its objectives include the prevention of amputation, promoting academic standards and the establishment of relationships amongst role players.

I have applied to join this group and I hope that it will be instrumental in developing a fully multidisciplinary  approach to the diabetic foot. The big challenge is to prevent some of the awful foot complications associated with diabetes in South Africa.

Also at the congress, Dr. Slabbert & Dr. Allard presented some data on a Lower Limb Amputation Survey in a South African Regional Hospital, which showed that, in their hospital, 74% of patients losing a leg for vasculopathy (disease of the blood vessels) are diabetic. (This by the way is in the first 6 months of 2007!!)

Through our practice we have set up a ‘virtual’ multidisciplinary diabetic foot clinic, where  as the podiatrist I can refer patients to a vascular surgeon, physician, opthalmologist, dietician and diabetes nurse educator. I say ‘virtual’ because although we are not all in the same place at the same time, we have quick access to each as required.

They said that "an intensive diabetic foot programme is necessary to decrease the amount of amputations performed in South Africa.

Foot Screening for Diabetes

A diabetes foot screening takes approximately a ½ hour and when it is finished the podiatrist will be able to identify the level of risk for diabetic foot complications. In addition, if referral to another member of the diabetes care team is required it will be done. Because foot problems are one of the main complications of diabetes, the podiatrist is able to manage non-ulcerative problems and foot ulcers.

The podiatrist treats all skin and nail related foot problems. Treatment includes appropriate foot health advice, cutting of nails, reducing calluses, enucleating corns, measuring for a simple insole, moulding for a foot orthotic, or even an operation to remove an ingrown toenail – this is carried out under local anaesthetic, usually in the podiatrist’s rooms and you go home straight afterwards. The podiatrist may decide on referral to another health care professional, such as an orthopaedic surgeon or physiotherapist. 

Although most podiatrists will manage any patient who consults them, modern podiatry has seen the development of practitioners with special interests in particular foot problems, these include chronic diseases like arthritis and diabetes, sports injuries and children’s’ foot problems. Therefore it is a good idea to find out if the podiatrist has a special interest in your problem.

No referral is necessary to see a podiatrist, although many patients are referred by their health practitioner.

Foot Care For People With Diabetes

My last two posts have been a clinical assesment of foot care for diabetics.  For those suffering from this complaint the following advice should help to protect your pair of feet and minimise the risks of deterioration.   And always get professional advice whenever you suspect anything may be wrong.

• Inspect feet daily for cuts, bruises, or any changes in shape
• Always wear shoes & socks even indoors
• Chemical agents or plasters to remove corns or calluses should not be used
• Wash feet daily & dry thoroughly, especially between the toes
• Wear correctly fitting shoes; always feel & look inside them; look for red areas on the feet
• Cut toenails to the curve of the nail; file with an emery board
• Don’t soak feet
• Protect your feet from very hot or very cold conditions
• Try to avoid putting pressure on the legs with tight sock tops, knee highs or garters
• Moisturize dry skin to make it more flexible
• Don’t be afraid to ask – get professional advice early
• Take good care of your pair

One Pair Must Last A Lifetime – The Diabetic Foot (2/2)

People with diabetes suffer from the same problems as those without diabetes, such as pes cavus (a high-arched foot), flat feet, bunions, deformed toes, corns, calluses, blisters, fungal infections etc. The risk is that often the foot is unable to respond to the stresses placed upon it. The body weight transmitted through a local area causes high pressure and leads to callus formation. If neuropathy is present, you won’t know that the callus is pressing on the softer skin underneath and eventually the skin can break down and an ulcer forms. Sometimes a foot with neuropathy becomes swollen and deformed and changes shape permanently, this is a serious condition called Charcot foot

The first signs of neuropathy could be strange sensations such as pins and needles, stabbing or shooting pains, or tingling, As the condition worsens, some people describe "ants or water running down the legs," or "a feeling of walking on cotton wool."

The circulatory changes which affect the feet are caused by hardening (arteriosclerosis) or narrowing (atherosclerosis) of the arteries. These conditions starve the tissues of blood. Occasionally a vessel becomes completely blocked and there is intense pain and the tissues begin to die due to lack of oxygen. Immediate referral to a vascular specialist is required. Other typical symptoms of PVD include pain in the calf of the leg when walking short distances or climbing stairs. Cold feet or legs. Red or blue toes. Loss of hair on the toes. Dry shiny skin on the feet and lower leg.

Unfortunately, far too many people with diabetes and their families are not well informed about the value and importance of footcare. Being informed and aware of the presence of any of the changes mentioned, will enable you to take appropriate action to prevent the serious complications of the diabetic foot.

The current approach to footcare for people with diabetes involves 5 key points:

• Regular inspection & examination of your feet
• Find out your risk level
• Be informed 
• Use appropriate footwear
• Have any foot problem treated

To lower your overall risk:

• See a podiatrist 
• Don’t use over the counter corn removers
• Don’t do bathroom surgery
• Keep your feet clean and dry
• Check you feet every day
• Keep your blood sugar level under 8

Footcare for people with diabetes is a team effort. In the case of PVD, early referral to a vascular specialist frequently saves a limb and restores the circulation to a limb or foot. An annual assessment by a podiatrist monitors how diabetes has affected your feet and enables the provision of appropriate treatment of foot problems.

One Pair Must Last A Lifetime – The Diabetic Foot (1/2)

The foot has been referred to as "the mirror of the diabetic state," but amongst health professionals mention of the diabetic foot usually produces visions of ulceration, infection, gangrene, and amputation. For someone with diabetes, foot problems are very significant because they can be life threatening. There are two main reasons for this.

• Nerve damage may cause numbness of the feet, so that the warning signals of pressure and pain no longer function properly – this is neuropathy.
• Circulation to the feet can be poor, causing slow healing – this is peripheral vascular disease (PVD)

The so-called diabetic foot develops because high blood glucose levels – hyperglycemia – damage nerves and blood vessels. Looking after your feet could save a limb and possibly your life, particularly if you are over 40 years old or if you have had diabetes for more than ten years.

Many serious and costly complications can affect the health of people who have diabetes. These can affect the heart, kidneys, and eyes, but it is the foot complications, which take the greatest toll. It has been reported that 40-70% of all lower extremity amputations are related to diabetes mellitus.

The diabetic foot is also a significant economic problem, especially if amputation results in prolonged hospitalization, rehabilitation, plus an increased need for social services and home care. In addition there is loss of income and emotional stress. Fortunately there is increasing evidence from countries such as Brazil, Sweden and the United Kingdom that amputations can be reduced considerably (in some cases by 50%), by implementing certain strategies. These include:

• Regular inspection of feet & footwear by trained people
• Preventive foot & shoe care for high risk feet
• Teamwork between patient, family and carers – getting informed
• Early detection of & intervention for PVD
• Continuous follow-up of patients with previous ulcers
• Registering amputations and ulcers

These strategies are important in today’s health care environment, because avoiding amputation can save large amounts of money. A British report estimated that for each amputation avoided, 4000 British pounds were saved, excluding indirect costs (e.g. loss of productivity, increased need for social services, etc.). There are good reasons to "take care of your pair" since research has shown that during their lifetime 1 in 10 people with diabetes will develop a foot problem.

More to follow….