Intervention Considerations for Foot Neuropathies

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (8/09/2023)

Original Editor - User Name

Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson and Jorge Rodríguez Palomino  

Footwear

ADD INFORMATION HERE

The next area I want to talk about is footwear. Based on your findings during your overall thorough foot assessment, you need to determine what is the best footwear for your patient to be in. So, if you have a patient who only has loss of protective sensation, then an off-the-shelf shoe with maybe a custom-moulded insert might be enough. But you want to make sure the shoe fits appropriately, because remember, if they don't have good sensation, the patient isn't the best judge of what shoe fits appropriately for them. So, you want to make sure it's a shoe that fits their foot well, probably a wider shoe with a deeper toe box, even if they don't have deformities yet, they need that space so their toes aren't being squeezed. And that usually is adequate for patients who don't have risk factors for developing an ulcer other than their loss of sensation.

Offloading Devices

Once they have these increased risk factors, then you need more advanced types of offloading devices. So, for those patients who are at highest risk of developing an ulcer or they already have a wound, they really need the most advanced offloading devices available. The one that is the most studied and probably the most well known is the total contact healing cast. It's a cast applied to the lower leg, different than a cast applied for someone with a broken leg. It has minimal padding and it really conforms to the shape of the foot and the leg so that it helps support that entire lower extremity below the knee. There is some significant risk factors if the cast isn't applied appropriately because of that lack of padding. So it needs to be applied with someone who has the skill and appropriate application of the cast. It needs a big rocker bottom with a heel so the foot is supported as they roll over it during gait. The total contact healing cast really forces the patient to be compliant because they don't easily take that cast off. I have had some patients who've taken their cast off, but it's very difficult. So it really is a rare instance where the patient removes it prior to coming back for it to be removed. It is a contraindicated device for patients who have untreated or active osteomyelitis or an untreated soft tissue infection. Those need to be controlled before using a cast. And it is sometimes something that the patient refuses because they don't want to wear a cast. But it is the most effective to offload the foot.

Another device that's been found to be pretty much equally effective through the studies that I've seen, is an irremovable knee-high cast boot or offloading boot. It needs to be one that's designed with a special plantar foot plate that will help offload the foot as well as the boot that is applied to the leg. But when you make it irremovable by applying cast material around the velcro straps, then it also forces compliance. And many studies show that has an equal outcome to the total contact healing cast, but it's a little more comfortable for patients to wear. It's off the shelf, so it doesn't require the skill of application. And it tends to be just better tolerated by the patient overall.

The third device, which is also very effective in offloading, is the CROW walker. And CROW stands for Charcot Restraint Orthotic Walker. It is a little bit more expensive because it is custom-moulded to the patient's foot and leg, and it's built of very durable material because they wear it for long periods of time, but it is also very effective in offloading. It does use velcro straps to hold it on, so if the patient tends to take it off and not wear it all the time. Then again, you can make that one irremovable by putting casting material around the velcro straps, if you find that necessary. All three of these are very effective in offloading anything on the plantar surface by completely redistributing the weight bearing to the entire plantar aspect of the foot, as well as helping support the lower leg, so you get a little bit of offloading through the lift of the device supporting that lower leg during gait. These are also effective for patients who have identified that they may be starting a Charcot exacerbation. By putting them in one of these devices, you can really stabilise that foot and keep the collapse from happening quite so extensively. Although, patients should be advised that with any of these devices, whether it be because you're suspecting a Charcot exacerbation or a significant wound, they really need to decrease their activity overall. Patients tend to think when they have this cast or this boot on that they're free to do whatever they want, and this can create problems. So education in minimising their activity, at least a little bit, will also help achieve that offloading that you're looking for.

The total contact healing cast or an irremovable walking boot need to be changed once a week so that you can examine the wound, clean the wound, change the dressing, make sure there's no adverse events that are happening inside the walking device, and then that device is reapplied. And those get changed weekly until the wound has completely healed and the callus has been completely resorbed. And at that point, the patient needs to go into a more definitive offloading footwear, like I talked about, to help keep that risk low so that they don't have a recurrence of that wound or that callus, at least for quite a while because they're wearing their footwear.

Other devices that are also an option, especially if the cast or an irremovable device is contraindicated, or the patient refuses it, or you don't have access to it, you can use a cast shoe or a post-op shoe because it has a solid plantar surface to protect the plantar aspect of the foot so they're not walking barefoot or with poor quality shoes, but you need to do something to provide the offloading support because these shoes by themselves do not provide any offloading. So you can use felted foam around the area of a callus or a wound to help offload that particular area when they're in this device, or you can do what has been called a football dressing or a very, very bulky gauze dressing with lots of plantar padding to help offload the plantar aspect of the foot while they're wearing these devices.

The other device is the half-shoe, or we call it a wedge shoe, where the forefoot of that shoe doesn't have any plantar support other than a little shelf that the forefoot and the toes rest upon, and all of the weight is forced to the heel. The half-shoe can be very effective in offloading anything on the forefoot or the toes if it is utilised appropriately. So this requires a lot of education for the patient. They need to be told that they must walk more slowly than they're used to walking, and that they need to use what we call a step-to gait, where the foot or the leg with the half-shoe is advanced forward, and the other leg, the uninvolved leg, is brought to the foot, the involved foot, but not past it. This eliminates the risk of them rolling over and putting pressure on their forefoot, which we're trying to avoid. So if you're hearing a patient walk down the hall and you know they're in a half-shoe and you're hearing a double click each time they take a step with that foot, then you know they're not walking appropriately because they're actually rolling over and putting pressure on the forefoot, which is what we're trying to avoid. So lots of education with a half-shoe. All of those types of devices are much less effective in offloading, but they can help with some areas if you don't have access to the more sophisticated types of devices.

So if you are able to find the patient or identify the risks before they develop a wound, or once the wound is healed, they've been in a cast and now the wound is gone and the callus is gone, or you were able to achieve wound healing through other means, then they definitely need something long-term for their footwear. And in this case, most of the time they really benefit from a custom-moulded insert that they might be able to wear in an off-the-shelf shoe. So they can get the insert that fits their foot that will redistribute the pressure throughout the plantar surface. They buy an off-the-shelf shoe with a larger toe box and a wider toe box if necessary. They take out the insert that comes with the shoe, and they put in the insert that was custom-moulded to their foot. Very often this will help reduce their risk factors, give them footwear they can wear for long periods of time without redeveloping a wound, or the length of time between occurrences will be extended, and if you're monitoring them closely then you can catch it before it becomes a wound, and get them back into a cast or a walking boot until that area resolves again.

According to the International Working Group in their 2019 update, any individual who's at moderate risk for developing a diabetic foot ulcer, or they have a foot ulcer that hasn't healed yet on the non-plantar aspect or the dorsal aspect of their foot should also wear therapeutic footwear that accommodates their foot shape, that fits appropriately, and it has these custom-moulded inserts, if at all possible. If they've had some sort of toe amputation, you should also consider a foot orthosis, which fills in the gap where that amputation was to help the shoe fit more appropriately. Unfortunately, the last time I was working at the hospital in this country, in the United States, insurance companies, and particularly Medicare, didn't cover foot orthoses. So that was more difficult for us to get for some of our patients. But if you can get them, they're very helpful in keeping that shoe fitting appropriately.

If the patient has a very large callus or multiple calluses on the weight-bearing surface of their foot, one, you want to debride it down to as smooth of a level as possible if you can. But the International Working Group also recommends that in this case, the patient should be in a semi-rigid orthotic so they can roll over those areas and they're not pushing off in the areas where the calluses are. Other studies also talk about patients who are at very high risk or have those very big calluses on their feet. And they recommend therapeutic footwear with a rigid rocker bottom sole so that they're again rolling over the entire forefoot where you get a lot of that push off, which typically tends to be where those calluses are. And it puts the weight bearing or the propulsion point behind the metatarsal heads instead of on the metatarsal heads, which helps with the offloading as they continue walking.

Therapeutic Interventions

Therapeutic Exercise. Therapeutic exercise is also extremely important for all patients that have gait abnormalities or problems with their feet, but particularly with diabetics. They need physiotherapy, occupational therapy to really help monitor their exercise programmes, monitor their feet, and educate them along the way as to what they need to do during their exercise programmes. So, very importantly, range of motion, strengthening and stretching, which physiotherapy, that's really where we started. But you want to target those joint areas that you've identified in your assessment as being at high risk. The Achilles tendon shortening, the flexor hallucis shortening, really showing patients as long as they have flexibility in those joints, how to keep them stretched out and more mobile and flexible and supple during gait, so they really reduce those risk factors. If the patient can't do it, or if they need reinforcement, then educating their family member or caregiver is also very important.

Strengthening. is also important. You do need to be careful if the patient has a wound on the weight-bearing surface of their foot in doing strengthening exercises so that you're not putting additional pressure on the wound or the high-risk areas that you've identified during exercise. So you can perform strengthening exercises, but you might need to make some modifications. You want to make sure in all cases they're wearing their therapeutic footwear so they have the best protection of their foot during the exercise programme. You might want to do fewer repetitions and have them doing those exercises more often during the day so that you're not putting that repetitive stress in areas of their feet that are at risk. And you also want to make sure that if you're doing the exercise or instruct the patient or family member if they're doing it at home to check their feet quite often during their exercise regimen to make sure they're not seeing any red spots that would indicate pressure or changes in the wound status that would indicate that they're putting too much stress on the wound and if so they would need to back off until those exercises can be modified again. And you may need to modify even more and do maybe more open-chain exercises versus closed-chain exercises where you're using exercise bands or ankle weights to help do some of the strengthening exercises without the plantar pressure on the foot

Endurance training. Definitely they need to wear their footwear. They do need to increase their cardiovascular stamina to help with their overall health. But you want to start slow and build it gradually so that you can constantly monitor their feet and make sure they're not having any adverse effects while they're doing this endurance training. And really concentrate maybe on the upper extremities to help with cardiovascular exercises. The upper extremity bike, elastic bands, doing exercises over their head to help with their cardiovascular health instead of doing the weight-bearing exercises that you're used to thinking about with endurance training. And then you can also think about using devices where you can modify the weight-bearing, like a rowing machine or a total gym at the lower angles or a stationary bike, but getting them onto it in a way that their risk areas, especially if it's just on one foot, can be accommodated while they're using that equipment and they're not putting quite so much pressure during the exercise programme

Proprioception and Balance. Proprioception and balance kind of go hand in hand as far as assessment and training to make sure that they decrease their risk of falls and other injuries related to deficits in both of these areas. Proprioception involves multiple senses, but it also plays hugely into the patient's ability to have good balance during gait and during activities. So I really talk more about the balance aspect of it, knowing that it will also address their proprioception deficits. But again, always have them in their therapeutic footwear if they have it. You really work on balance through a variety of mechanisms. You want to decrease their base of support to challenge their balance while they're doing these activities with a less base of support. You want to do those with supervision. So if they start to lose their balance, someone is close by to help them regain their balance. They could also use a chair or a railing, if they've got a railing in their house that is on a flat surface that they can use so that they can stabilise themselves if they start to lose their balance. You want to work on one-legged standing, exercises in one-legged standing. You want to challenge their gait with different surfaces, different speeds, different stride lengths, anything that can really help challenge their balance during active gait and other activities so that they can figure out how to compensate or adjust and make sure that they don't have injury by falling or tripping or stubbing their toe on something because they've lost their balance and they have to adjust more quickly

Swimming/Aquatic Therapy. Another exercise that can be very beneficial for any individual, but particularly with patients with diabetes is swimming. Although you can't have them swimming in a public pool if they have a wound on their foot, but if they have just pre-ulcerative lesions or they don't have a wound and they're trying to build up their endurance and their strength, then doing water exercises will effectively offload during the exercise programme and swimming in general will increase endurance and increase their overall health remarkably well. So swimming is a great alternative. If they have a private swimming pool that has chlorination or other means to make sure the water stays clean, then they could use their own pool for some of these water exercises and for swimming, but never a public pool.

And then the other thing to keep in mind, if a patient has an open wound is they should never, ever go into fresh water. So if the patient lives near a lake or a river and they talk about swimming, they really need to have somebody assess their foot every single time before they go into the water because any little opening in their skin can cause an infection that can get pretty serious. So swimming needs to be done with caution, but it can be very effectively used as a good exercise

Follow-up Appointments/Reassessment

So as far as the patient following up, based on your risk assessment for the neuropathies in their feet, there are some guidelines that have been recommended by the International Working Group that talk about an annual visit. So any patient, truly, whether you have diabetes or not, everybody should have an annual physical or an annual checkup. If a patient is diabetic and they do not have loss of protective sensation and they do not have peripheral arterial disease, then an annual checkup is usually adequate. If they have either loss of protective sensation or peripheral arterial disease, then they need a designated follow-up twice a year to make sure those deficits haven't gotten worse or they haven't developed a problem related to those deficits that needs to be addressed. If they have both peripheral artery disease and loss of protective sensation or if they have loss of protective sensation and deformities or they have peripheral artery disease and deformities, then they need to follow up with their physician two to three times a year. And in my personal opinion, I would err on the side of caution and make sure they see their primary care physician or their podiatrist three times a year.

If they have loss of protective sensation and peripheral arterial disease, and they have one or more of these deficits: either a history of an ulceration; a lower extremity amputation, whether that's a minor amputation or a major one; or end-stage renal disease. So if they have both loss of protective sensation and peripheral artery disease, and at least one of these other ones that I just mentioned, then they should follow up with their primary care physician or their podiatrist three to four times a year. And again, I would recommend four times a year to make sure they're closely monitored.

Patient Education

Finally, I really want to talk about patient education. As I said earlier, patient education is critical because if you don't get the patient doing what you're asking them to do between visits, then whatever you do during their visits is not going to have much of an effect. Education needs to start early and be repeated often. Diabetes is an overwhelming disease, so the more you repeat things, the more different ways you educate the patient, the better your chances of getting some retention, some buy-in, and some cooperation and the follow-through. So there are several areas that you really need to focus on in education, and this isn't even talking about their blood sugar control monitoring and those kinds of things. This is just related to the peripheral neuropathy and the findings that you've identified in the foot assessment.

So the first thing is to make sure they understand that they should always be in their therapeutic footwear, whatever it is they're recommended to wear, they should be in that at all times. They should never walk barefoot. They should never walk only in socks. They should never walk with shoes without socks. That's the first piece of education. They should never wear thin-soled slippers to walk around the house. And all of these factors, meaning they should always have their therapeutic footwear on, involves indoor and outdoor activities. They always need to have their feet protected.

They need to be educated in how to do their foot inspection as well as their shoe inspection. So they need to inspect and assess the entire surface of their foot, all of those areas that we talked about earlier to make sure there's no areas of concern that they need to follow up on. They also need to examine the inside of their shoe. They're looking for abnormal wear patterns that indicate they need a new pair of shoes, or they need to have their gait assessed because maybe they're walking differently. They need to look for any rough areas that can cause friction or abrasion inside their shoe, even through a sock. And they're looking for anything, any foreign objects that might've gotten in their shoe, a small pebble or something that could cause problems when they put their shoe on for the next time. They also want to look at their nails, their web spaces, all of those areas that I talked about in assessing the entire part of the foot.

You want to talk about hygiene. They should wash their feet every single day, using soap and water, rinsing the soap off, and then making sure they dry their foot very thoroughly, including the web spaces. Show them how to use a face cloth or the edge of a towel and go down in those web spaces and manoeuvre the towel back and forth gently to dry the web spaces, so there's no retained moisture when they put their sock and shoe on that can cause maceration. After they've washed and dried their feet, it's important that they moisturise using an emollient, a cream, a lotion to hydrate and lubricate that skin to keep it as supple and healthy as possible. But you do want to educate them that they should never apply the lotion between their toes because again, it will retain more moisture and can cause maceration when they put their sock and shoe on. So they moisturise their foot, the tops of their toes, the bottoms of their toes, but not between their toes.

Unfortunately, we have a lot of patients who have vision problems related to their diabetes or just vision problems in general, or they have limited mobility and they can't reach their foot to do a full thorough assessment. So in those cases, if they have good vision and they just can't reach their foot well, they can use a long-handled mirror to inspect the plantar aspect of their foot to make sure they don't have any wounds or calluses or any areas that need to be further inspected. If they have poor vision, then you really need a family member or a caregiver who's available every day to help them do a thorough inspection of their foot. We do know that a lot of our patients don't have access to a caregiver. They don't have family support. They're really trying to do the best they can on their own. So being creative and helping them find ways that they can at least do as much of an inspection as possible and the hygiene that goes with foot care is important. So if they need to prop their foot up on another chair and try to reach and feel with their hand to inspect the surfaces of their feet, that's better than nothing.

And then the hygiene, the same thing. If they have absolutely no ability to touch their feet with their hands, getting them long-handled scrubbers to clean their feet and then show them how to loop the towel over their foot to kind of dry their foot. Whatever you can think of that's creative to help them inspect and care for their feet will at least minimise their risk some, and then having them follow up with a primary caregiver, maybe more often than they normally would, can also help make sure their feet are maintaining their integrity.

Nail and callus care is another important feature that must be addressed, primarily addressing the fact that the patient and their family members should never cut their toenails or work on trimming their callus or their dry skin. Now, there may be a family member who can be trained to do some nail care and callus care. And if they've demonstrated competence and an understanding of what they need to be careful of and how to do it, that may be appropriate in some cases, at least in between visits to the podiatrist. But you really have to use caution when determining whether a family member is competent in that. And then if you are unable to help them with their nail care and they're unable to do it on their own then getting them to a podiatrist at some frequency to keep their nails under control and keep the calluses shaved is important.

The education needs to be structured through multiple different avenues and using multiple avenues with the same patient is also important to try to ensure that they're getting the most education and the most retention that they can during your education. So one-on-one or group discussions where you give them the information verbally is the place to start. You can repeat it a lot using verbal cues and stuff, but it's not the only mechanism. Using videos that you've done yourself or that you can find online that have good patient education can be used, as well as different software applications and booklets that you can get. In the United States, the American Diabetic Association has a lot of booklets available for patients and family members about foot care and hygiene and other aspects of diabetes care. You can do games and set up quizzes and challenge them to give you back the information, so that you can be assured that they're retaining at least some of the education you've given them and then repeating what they don't. So that they can get a better idea of their education and then using pictures or animated pictures to help with children or those persons who maybe can't read or have limited reading abilities to help them get a better understanding of what needs to be done.

This education needs to include what a foot ulcer is and what the consequences of getting a foot ulcer are, even using pictures. I mean, lay people don't like to see pictures of wounds, but if that will help reinforce the fact that you don't want one of these wounds on your foot, it might help them be more adherent with the education and the instructions that you're giving them. Education on self-care, the skin inspection and the hygiene that I talked about earlier. The appropriate footwear and how you need to wear the footwear all the time is important. And then seeking professional help when you've identified, when the patient has identified areas of risk or concern that need to be followed up on, or if they're just unable to do it at all and they have a concern that something's going on their feet. They need to have permission to seek professional help and go to their PCP (primary care provider) or other care provider to have that assessment done and that care provided.

Skin temperature monitoring, like I talked about earlier, if they have the availability of the infrared thermometer, so they can monitor their temperature. And like I said, if they notice a temperature change of more than 2,2 degrees Celsius in two consecutive days, then they really need to follow up and see what's going on with their foot. If they have that temperature change, they also need to be instructed to limit their activity until they can get into their PCP or podiatrist to figure out what's going on.

And then, finally, the psychosocial support for the patient and their family is also very important. Whether that be through a trained psychologist or counsellor, sometimes chaplains have resources available to assist a patient with some of this. Occupational therapy and speech therapy can certainly help with education, with making sure the education is geared to the appropriate level of understanding for each patient. But diabetes in general, as we all know, is overwhelming. And all of the aspects that they have to learn about and manage and understand can be completely overwhelming and make it very difficult for the person to cope with their disease, and they can develop a feeling of hopelessness. So through the education, hopefully we can convince them that they can cope with this and that they can have reasons to hope that they can prevent wounds or help heal wounds. But it is a team approach and it really takes a lot of people plus the patient and their family to get them the education they need, the resources they need so that they can manage their disease on the day-to-day basis to minimise their risks and have the best outcome possible.

Resources

• bulleted list
• x

or

1. numbered list
2. x