Prevention and Early Intervention for Diabetes Foot Problems
6. Clinical Issues continued...
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.
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
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.
7. Special Footwear for the Insensate Foot
Repetitive Stress and Special Footwear
People with intact sensation respond to repetitive stress
that occurs during walking either by shifting the pressure to another part of
the foot, by modifying the way the foot meets the ground, by resting, or by
checking their shoes for problems. With the loss of peripheral sensation,
however, many people with diabetes have no indication of lower extremity pain,
pressure, or trauma and do not take measures to modify repetitive
pressures. Lack of feeling makes shoe-fitting assistance