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Prevention and Early Intervention for Diabetes Foot Problems

6. Clinical Issues

Provider Foot Care Practices

In a study of provider practice, researchers found that clinicians were likely to prescribe preventive foot care behaviors when they were aware of a patient's high risk for LEA as evidenced by prior history of foot ulcer. Clinician awareness of two other risk factors (peripheral neuropathy or peripheral vascular disease), however, did not increase preventive care practices. The researchers concluded that physicians and patients need periodic reminders to identify patients in all high-risk categories for ulcer or amputation and to provide additional care such as podiatric visits and education in self-care10.

A study of nurse practitioner practice patterns was conducted to determine their consistency with the American Diabetes Association (ADA) standards of care. An audit of 78 medical records representing a proportionate number for each of six masters-prepared, certified nurse practitioners revealed discrepancies between established standards and the degree to which they were documented. Comprehensive foot care examinations (required annually by ADA standards) were documented in 23 percent of the charts reviewed26.

Self-care Limitations in the Elderly

In one study, barriers to carrying out daily foot care noted by elderly subjects included lack of motivation, forgetfulness, vision problems, joint and knee problems, and family responsibilities24. The ability of elderly people to identify foot lesions was investigated further in a matched comparison, controlled study. Findings showed that 43 percent of patients with a history of foot ulcers could not reach and remove simulated lesions on their toes; over 50 percent of the older subjects reported difficulty trimming their toe nails; and only 14 percent had sufficient joint flexibility to allow inspection of the plantar aspect of the foot. The investigators concluded that elderly people who are unable to perform daily self-care of the feet would benefit more from regular foot care given by others than from intensive education27.

Exercise

In people with diabetes, regular exercise can lower blood glucose, improve insulin sensitivity, raise HDL cholesterol, improve blood flow and heart muscle strength, enhance fibrinolysis, control weight, increase muscle mass, and provide an overall sense of well-being. Because of these effects, regular exercise may also delay the onset of neuropathy and atherosclerosis.

People who have had type 1 diabetes for more than 10 years, or type 2 diabetes for more than 5 years, should be screened for medical risk prior to beginning an exercise program. While the presence of neuropathy does not rule out exercise, care should be taken not to worsen soft tissue and joint injury or cause foot ulcers or bone injury. Stretching muscles before exercise is important to prevent ligament strain. Swimming or bicycling are recommended forms of exercise because they avoid abrasion to the feet28. Attention to the construction and fit of footwear is essential.

WebMD Public Information from the U.S. National Institutes of Health

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