Intervention Considerations for Foot Neuropathies

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Footwear

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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

Proper and effective offloading is key to healing foot ulcers. There are many options for offloading, ranging from therapeutic footwear to limiting gait with wheelchair use. The basic components of proper offloading the foot involve (1) redistrubuting weight bearing forces across the enrire plantar surface of the foot and (2) assist in supporting the lower leg throughout the gait cycle, and (3) decreasing over all activity even when wearing an offloading device.

According to the 2019 update from the International Working Group on the Diabetic Foot (IWGDF) any individual who is at moderate risk for developing a diabetic foot ulcer or currently has an active foot ulcer should wear therapeutic footwear that accommodates their foot shape and fits appropriately. Patients who are at greatest risk for the development of a foot ulcer or who have a history of healed ulcers benefit from the use of the most advanced offloading devices available. Patients who have healed ulcers will require continued use of offloading foot wear to prevent ulcer reformation and limit callus buildup.

Table 1.

Method	Description	Removable by patient? If not, frequency of change	Benefits	Risks or Negatives
Most Effective Methods
Total Contact Cast (TCC)	considered the gold standard in offloading has minimal padding conforms to the shape of the foot and leg helps support that entire lower extremity below the knee	No Requires skilled application Frequency of change: once a week	most effective to offload the footand is the first choice treatment option by the IWGDF protects the foot from additional trauma and deformity promotes tissue repair forces the patient to be compliant with offloading	risk of skin breakdown if not applied correctly can hinder mobility and cause muscle stiffness and joint atrophy with prolonged use contraindicated for patients who have untreated or active osteomyelitis or an untreated soft tissue infection
Irremovable Knee-high Cast Boot or Offloading Boot(removable walker boot or removable cast walker)	off the shelf device designed with a special plantar footplate that will help offload the foot	Yes, BUT can be made irremovable by applying casting material over the velcro straps Does not require skilled application Frequency of change: once a week	many studies show has an equal outcome to the total contact cast easy removability allows for wound assessments and care allows for more comfortable movement in daily life tends to be better tolerated by the patient as compared to the total contact cast	risk of skin breakdown if not fitted correctly if patient is not compliant with wearing, has a significantly lower healing ability as compared to the TCC
Charcot Restraint Orthotic Walker (CROW)	custom-moulded to the patient's foot and leg built of very durable material secured with velcro straps	Yes, BUT can be made irremovable by applying casting material over the velcro straps if needed	very effective in offloading	expensive to produce
Less Effective Methods
Cast Shoe or Post-op Shoe	solid plantar surface to protect the plantar aspect of the foot apply felted foam or "football dressing" around the area needing off-loading	Yes	Inexpensive option	Felted foam can ONLY be used in combination with appropriate footwear
Wedge Shoe or Half-shoe	the forefoot does not have plantar support other than a small shelf for the forefoot and the toes to rest upon all weight bearing is forced through the heel	Yes	can be very effective in offloading the forefoot or the toes if utilised appropriately	Requires a lot of education and training to alter gait mechanics for proper offloading

Other Off-Loading Considerations

When a patient with an at-risk foot has no active foot ulcers and/or has achieved healing of past wounds, they should be placed in appropriate long-term offloading footwear. Other options to consider include:

Custom-moulded shoe insert. These inserts redistribute pressure from body weight throughout the plantar surface of the foot. Allows patient to wear their own shoes, and give them the option to wear different shoes while decreasing the risk of developing or redeveloping a wound.

Foot orthosis. Fills in the space in a patient's shoe due to a toe or partial foot amputation. This allows the shoe to fit more appropriately and improves gait dynamics.

Semi-rigid orthotic. These orthotics are useful for pressure reduction over calluses on the weight-bearing surface of the foot

Rigid rocker bottom sole. Improves gait dynamics by promoting roll over of the entire plantar surface with improved push-off. This style of shoe sole puts the propulsion point behind instead of over the metatarsal heads to aid in the offloading throughout the gait cycle.

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Special Topic: What makes appropriate footwear?

Evaluate the fit with the patient in the standing and preferably later in the day when feet are more likely to be swollen. Footwear should be sufficiently sized to accommodate the foot without excessive pressure on the skin:

• The inside length of the shoe should be 1-2 cm longer than the patient's foot
• The inside width should equal the width of the foot at the metatarsal phalangeal joints (or the widest part of the foot)
• The inside height should allow enough room for all the toes to rest naturally

Refer the patient for specialized or customized footwear if:

• off-the-shelf footwear are not available that can accommodate a foot deformity
• there are signs of abnormal loading of the foot in standing or during gait

Therapeutic Interventions

Rehabilitation professionals such as physiotherapy and occupational therapy can establish and monitor personlised exercise programmes, assist wound care professionals by inspecting the state of the patient's feet, and provide important patient and care provider education.

Therapeutic Exercise

• plays a role in preventing or counteracting peripheral artery disease (PAD) in patients with diabetes
• may improve the distance a patent can walk before limited by pain or muscle cramps due to intermittent claudication (claudication distance) with PAD
• can disrupt the progression of diabetic peripheral neuropathy
• can have a significant positive effect on HbA1c reduction in patients with diabetes
• stretching and maintaining available range of motion of the Achilles tendon and flexor hallucisto decrease fall risk and improve gait dynamics

Strengthening

Considerations and modifications to typical strengthening interventions may be needed:

• patient should always wear their therapeutic footwear
• precaution that additional pressure is not placed on an active wound or other high-risk areas
• perform fewer repetitions with increased frequency throughout the day to decrease repetitive stress to high-risk areas of their feet
• educate patient and/or their care providers to regularly monitor feet for signs on pressure. See education section below for more information.
• perform open-chain exercises versus closed-chain exercises to further decrease plantar pressure on the foot

Endurance training

Improving cardiovascular endurance and stamina will benefit a patient's overall health. However, cardiovascular training should be closely monitored and advanced slowly.

• patient should always wear their therapeutic footwear
• utilise upper extremity training for cardiovascular health: upper extremity bike, resistance training with elastic bands or hand/wrist weight
• utilise devices which allow for modification of lower extremity weight-bearing: rowing machine, total gym at lower angles, stationary bike
• educate patient and/or their care providers to regularly monitor feet for signs on pressure.

Balance and Proprioception

Balance and proprioception often exist hand-in-hand in the clinic, and with fall prevention and gait training.

• patient should always wear their therapeutic footwear
• frequent balance and fall assessment is recommended
• please review this article for more information on balance training

Gait Training

Therapeutic exercise is also extremely important for all patients that have gait abnormalities or problems with their feet, but particularly with diabetics. ou 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.

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