COMPREHENSIVE CARE CLINIC: DIABETES: Increased Activity May Decrease Risk of Foot Ulcers

Increased activity levels in patientswith diabetes may help protectthem from developing diabetic footulcers. Clinicians have long believedthat increased pressure on the foot,combined with stress from activity, ledto the development of ulcers; however,a recently published study found thatthe opposite might be true. Foot complicationsare the leading cause oflower-extremity amputations in peoplewith diabetes, and are a frequent causeof hospitalizations. Patients with diabeteshave a 15- to 40-fold higher riskof lower-extremity amputation thannondiabetics.

The study included 100 patients andexamined the relationship betweenactivity level and development of footulcers. Study subjects, who averaged68.5 years of age, wore computerizedactivity monitors to measure the numberof steps taken over a period of time.Patients were followed for a minimumof 25 weeks or until ulcerationoccurred. Eight percent of patientsdeveloped ulcers. The subjects whodeveloped ulcers had a much lowerlevel of activity than those who didnot develop ulcers. Further analysis ofthe data showed great variability inactivity patterns in the group withulcers. The pattern was characterizedby short bursts of activity in an overallsedentary lifestyle. This pattern wasmost prominent 2 weeks before ulcerdevelopment. The researchers concludedthat vulnerable skin might be athigh risk for damage if stress patternsare not consistent and that awarenessof this finding might help patientsmodify their activity to make it moreconsistent.

The majority of foot complicationsin patients with diabetes begin withformation of ulcers. Risk factors fordevelopment of ulcers include peripheralarterial disease, diabetic neuropathy,foot deformities, improper footwear,uncontrolled blood glucose, poorvision, and obesity. Early detection andearly treatment are key factors in preventingamputations. Routine footinspection is one of the easiest, leastexpensive ways to prevent foot ulcers,but it may be overlooked in routinephysician office visits. Noninvasivevascular and sensory tests may be usedin conjunction with physical examinationto identify patients at highest riskfor complications.

Minor foot injuries such as cuts,scrapes, blisters, and athlete's foot maybe cautiously self-treated. Patientsshould be counseled to avoid hot footsoaks, heating pads, and topical agentssuch as peroxide, iodine, and witchhazel, as these remedies may impedewound healing. Wounds should becleaned with a gentle cleanser andmoisturized with a topical antibiotic.Patients should be referred to theirphysician for any wound that does notheal rapidly.

Despite careful foot care, manypatients with diabetes may eventuallydevelop foot ulcers. These ulcers aretypically painless, as they are most likelyto develop in patients with neuropathy.Treatment generally begins withremoval of dead tissue and surroundingcalluses. X-rays may be taken torule out infection of the underlyingbone. Cultures may not be useful sincemost diabetic foot ulcers have multiplebacteria present. Broad-spectrum antibioticsare usually given, usually for anextended period of time if the bone isinfected.

Pharmacists can play a significantrole in helping their diabetic patientsprevent foot complications. Patients(or caregivers) should be counseled toinspect the feet on a daily basis. Feetshould be cleaned with soap and waterand dried carefully, especially betweenthe toes. Moisturizer should be used toprevent skin breakdown. Patients withchronically wet feet should use cornstarchand absorbent socks to absorbmoisture. Shoes should be examinedfor any areas that might cause frictionon the patient's foot. Pharmacists canalso perform monofilament tests toidentify peripheral neuropathy.

Medicare covers the cost of diabeticshoes, and patients should be referredto the appropriate source for specialfootwear if indicated.

Diabetic foot ulcers can be preventedwith careful maintenance andcounseling. New information aboutrisk factors continues to be published.Advice about levels of activity, in additionto more traditional counselingpoints, may help patients avoid complicationsthat may result in limbamputation. Pharmacists are uniquelypositioned as the most accessiblehealth care providers to guide peoplewith diabetes in the care and maintenanceof their feet.

Dr. Garrett is a clinical pharmacist practitionerat Cornerstone Health Care in HighPoint, NC.

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