The condition is caused by poor blood-glucose control associated with diabetes
Dealing with neuropathy
• Keep blood glucose levels in your target range.
• If you have problems, get treatment immediately.
• Check your feet every day. If you can’t feel pain, you might not notice an injury.
• If your feet are dry, use a lotion on your skin but not between your toes.
• Wear well-fitting shoes and socks.
• Use warm water to wash your feet, and dry them carefully.
• Get special shoes, if needed. If you have foot problems, Medicare may pay for shoes.
• Be careful with exercising. Talk with a diabetes clinical exercise expert.
Source: American Diabetes Association, www.diabetes.org
It’s a very uncomfortable situation: the loss of sensation on your feet.
Not being able to feel whether the ground is hot or cold, or whether your shoes don’t fit right. Or worse, not noticing the damage you could be causing to your feet.
“When you realize you’ve lost pain, you are in trouble,” says Dr. Andrew Boulton, professor of medicine in the division of endocrinology, diabetes and metabolism of the University of Miami Miller School of Medicine.
Boulton has witnessed the consequences of not feeling pain.
The patient who walked around without noticing he had a nail through his shoe. Another one who took a stroll on the beach not realizing the hole slowly carved on his foot by the hot sand. Or the man who felt asleep near a chimney and woke up to the smell of something burning — his feet.
Boulton is an expert on neuropathy, a disease prompted by poor glucose control, among other factors. The condition causes nerve damage, impairing feeling in the foot.
Neuropathy acts similarly to an electrical circuit being disrupted. The nerves send messages to your brain about heat, cold, touch and pain. Nerves communicate how and when to move your muscles, and also have control over systems like sweat glands or digestive functions. So when these nerves are damaged, communication stops.
It’s important to take steps to prevent foot injuries, Boulton says.
“Use your eyes and look where you are walking,” he says. “All this is preventable. This doesn’t need to happen if you look after your feet.”
This is important advice since diabetes is the most common cause of foot ulcers, says Dr. Robert Kirsner, professor of dermatology at the University of Miami Miller School of Medicine.
“Because patients don’t have sensation, they may not have any symptoms,” Kirsner says. “That’s why it’s critical that patients with diabetes examine their feet regularly, and when they go to their physician, their feet get examined.’’
Ulcers or foot wounds can cause serious problems if they don’t heal because, in worst cases, this increases the chances of amputation.
“If we can heal the ulcer faster and better, those complications can be diminished,” he says. Eliot Prince, a patient of Kirsner, is well aware of the importance of looking after your feet.
The 47-year-old Miami native credits Kirsner for saving the toes on his left foot. About seven years ago Prince, who had been diagnosed with diabetes in 1992, had noticed that two toes on his left foot were darkening and had started to swell.
He went to Nassau, hoping that the salty waters of the island would heal his foot. He was putting his socks on when his hand slipped, removing some of the skin. He flew back to Miami the next day. At the hospital he was told it could be gangrene and that his two toes might have to be cut off.
“I didn’t have gangrene but if you would have seen them you’d thought I had gangrene because my toes were black.”
He wanted a second opinion, and a friend told him about Kirsner.
“He cut off the skin, examined it. He knew what he was looking for,” Prince says. Kirsner told him that the wound was treatable and prescribed him a cream that eventually healed his foot.
People with neuropathy can also develop ulcers. They have to wear special shoes to remove pressure from the wound, Kirsner explains.
“That’s the most important thing with neuropathic foot ulcers, to remove pressure off the wound,” he says.
Special shoes or boots improve the way people walk by making them take fewer steps and shortening the length of their stride.
Another foot-related complication is excessive dryness, a sign that the sweat glands aren’t working properly. In those cases, special moisturizers are prescribed to help deal with the discomfort. When you have dry, cracked feet, you are more likely to get a fungus infection, Kirsner explains.
Fungus cause microscopic changes on the skin; it’s an opening that allows bacteria to come in and cause an infection.
“A fungal infection on a diabetic patient is more important than in other patients because infections on diabetic patients have more complications,” Kirsner adds.
By Douglas Rojas-Sosa
Showing posts with label neuropathy. Show all posts
Showing posts with label neuropathy. Show all posts
Thursday, November 17, 2011
Tuesday, November 8, 2011
EXERCISE AND NEUROPATHY: Not mutually exclusive
A classic case of innovative research turning conventional wisdom on its head is changing the way clinicians approach exercise in patients with diabetic neuropathy.
For decades, patients with type 2 diabetes and peripheral neuropathy were cautioned against weight-bearing exercise out of fear that the accompanying stress on the foot would lead to plantar ulcers. Then, in 2003, scientists began to report surprising findings.
“Prior to those studies, the feeling was that weight-bearing exercise was too risky to recommend to patients who lacked sensation,” said Joseph LeMaster, MD, MPH. LeMaster, for many years an associate professor in the Department of Family and Community Medicine at the University of Missouri, will move to the University of Kansas this fall. “There was evidence that people with neuropathy had increased plantar pressures, and those were considered an independent risk factor for foot ulcers.”
In 2003, LeMaster and his colleagues published a study of 400 diabetes patients with a history of foot ulcers and found that increased weight-bearing activity didn’t increase the risk of reulceration. Moreover, the most active subjects saw the most significant risk reduction, and the effects were the same regardless of whether subjects retained foot sensation.1
That same year, researchers from Washington University in St. Louis reported in Clinical Biomechanics that diabetes patients with a history of plantar ulcers were 46% less active and accumulated 41% less daily stress on the forefoot than nondiabetic and diabetic control subjects without a history of such ulcers.2 At first, the finding seemed so counterintuitive that people weren’t sure what to make of it. The authors ultimately concluded, conservatively, that subjects with a history of plantar ulcers were susceptible to injury at relatively low levels of tissue stress.
These studies flung open the door to further investigations, however. In 2004, scientists confirmed in Diabetes Care that neuropathic patients who exercised more had lower rates of ulceration than those who were relatively sedentary.3 Two years after that, in 2006, researchers in Italy reported that, far from being deleterious, exercise could help prevent neuropathy’s onset or modify its natural history.4 Right on cue, then, in 2008, Washington University researchers reporting on the Feet First study noted that promoting weight-bearing activity did not lead to significant increases in foot ulcers.5 Finally, in 2010, the American Diabetes Association, together with the American College of Sports Medicine, acknowledged this accumulating body of evidence and published new guidelines that, for the first time, endorsed weight-bearing exercise for patients with diabetic neuropathy in the absence of foot ulcers.6
“The new guidelines represent a big change,” said Michael Mueller, PT, PhD, a professor of physical therapy at Washington University School of Medicine. “For the first time, people with diabetic neuropathy are explicitly encouraged to do weight-bearing exercise.”
Although this rhythmic chronology outlines what appears to be a straightforward investigation that changed medical practice, the story is more nuanced. A number of questions have bedeviled researchers, and continue to. For example, what’s the chicken and what’s the egg? That is, do people get more ulcers because they get less exercise, or do they exercise less because of their ulcer history? Or, for that matter, are other variables involved that no one yet understands? These and other issues, such as how to distinguish those at highest risk of ulceration from their peers and how to adjust exercise regimens accordingly for individual patients, are only now starting to become clear.
Foundations
Back in 2002, Mueller published a paper in Physical Therapy whose relevance to this issue was not immediately clear, but which turned out to have a big impact. In that article, he proposed a “Physical Stress Theory” (PST) of tissue adaptation, the premise of which was that changes in the relative level of physical stress cause a predictable adaptive response in biological tissues.7 In a nutshell, the theory suggests that tissues respond to stress in predictable ways: stress levels that are too low lead to reduced stress tolerance and atrophy; mid-level stress produces no change; moderately high levels increase tolerance; and too much stress leads to injury and tissue death. The goal for practitioners seeking to increase their patients’ strength and resilience was to identify the levels that increased tolerance and work carefully from there.
Mueller also made several points that affected later researchers:
1. Stress exposure is a composite value comprising magnitude, time, and direction of stress application.
2. Extreme deviations from the maintenance stress range have serious consequences.
3. Individual stresses combine in complex ways to contribute to the overall level of stress exposure, and tissues are affected by the history of recent stresses.
4. Excessive stress can arise due to a brief, high-magnitude stress; a long duration of low-magnitude stress; or a repetitive application of moderate stress.
5. Inflammation occurs immediately after injury, reduces the injured tissue’s stress tolerance, and requires that the tissue be protected from further stress until the inflammation subsides.
Many of these points turned out to be crucial to understanding how to manage diabetic neuropathy in the context of exercise.
Variability
The lead author of the 2004 study in Diabetes Care was David Armstrong, DPM, MD, PhD, professor of surgery and director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson. An important aspect of his team’s findings was not just that more active subjects were less prone to ulcers, but that variability in activity was an important predictor of ulcer risk. Eight of 100 patients with diabetic neuropathy ulcerated during the average evaluation period of 37 weeks, and although they were significantly less active than those who remained ulcer-free, there was also much more variability in their exercise levels, as measured by high-capacity computerized accelerometer/pedometers.
“People who had wide swings in activity were at greater risk,” Armstrong told LER. “An example would be someone who’s not very active, then suddenly remembers their grandkid’s birthday and leaps off the couch, runs to the car, then spends an hour and a half walking around the mall. They do more in a couple of hours than they usually do in two days.”
When Armstrong and his colleagues first evaluated their data, they were flummoxed.
“We sat there wondering what was going on,” he said.
Their conclusion, however, echoed Mueller’s observations about the importance of tissue stress levels and the consequences of extreme deviation in them.
“We believe what we’re seeing is that it’s just like a lot of other places in the body,” Armstrong explained. “If you don’t use it, you lose it. If skin is allowed to atrophy, then maybe it’s weaker than skin that’s getting tenderized, as it were, by frequent activity.”
Armstrong noted that patients must be monitored carefully, as they were in his study, and that exercise has to be optimized for the individual.
“People can’t run a marathon with profound neuropathy, but we’d like to try to train them so they could slowly become more active,” he said. “We want to dose activity the way you’d titrate a drug.”
As for the chicken-and-egg problem—which comes first, the ulcer or the lower activity levels?—researchers are continuing to probe the reasons first ulcers appear. Manish Bharara, PhD, a research assistant professor at SALSA and a colleague of Armstrong’s, speculated that overall control of blood glucose levels may affect the resilience of damaged tissues.
“In diabetes patients, metabolic control affects other aspects of physiology, and could affect the quality of the tissue that is regenerated as someone heals,” he said.
A couple of Armstrong’s earlier papers may shed light on the issue, as well. In a 2001 article in the Journal of the American Podiatric Medical Association, Armstrong and his colleagues noted that diabetic patients with a history of neuropathy or ulceration took more steps per day inside the home than outside, and that only 15% of them wore their prescribed footwear inside.8 A paper in Diabetes Care in 2003 reported that subjects with foot ulcers wore their off-loading devices for only a minority of steps taken each day.9 Noncompliance with preventive footwear or curative devices could conceivably be similar in effect to low activity levels, then, in that both are associated with ulceration and poor healing. One possible explanation is that, compared to high-activity patients, low-activity patients are taking significantly fewer steps per day in footwear designed to help their feet avoid injury or heal (activity studies have not consistently reported compliance data).
“It even turns out that sometimes just standing for long periods can be potentially dangerous,” Armstrong noted.10 “This is all about better identifying risk and helping us better coach activity. We’re trying to get people moving, and in a lot of ways, that’s how we measure success.”
Individual cases
The Feet First study made it clear that clinicians must carefully consider the patient’s history when prescribing exercise, according to lead author LeMaster.
“In that study, we felt that the exercise program, combined with the careful monitoring we conducted, showed that the benefits of exercise outweighed the risks,” he said. “But it’s quite another thing to say that people who have lots of recent foot ulcers should go out and do this. A good percentage of the people in the study had had prior ulcers, and we didn’t find that to be a predictor [of ulceration during the trial]. But we restricted people from walking if they had any breakdown during the study.”
People with a history of frequent and recurrent ulcers, he added, should be viewed in a different category than those included in the research. Furthermore, the study’s subjects had their feet examined weekly by a physical therapist for the first three months, and had a hotline to call if they showed signs of ulceration later.
Mike Mueller, a coauthor of the 2008 Feet First paper, likened the evolving view of exercise in those with neuropathy to a similar evolution in thinking about exercise in cardiac patients a few decades ago.
“There was a time when the prevailing opinion was that if you’d had a heart attack, you should not exert yourself,” Mueller said. “We came to learn that if you monitor the heart carefully and keep it within a safe range, exercise is beneficial. It’s similar with the neuropathic foot, although we’re still learning what the guidelines should be.”
Adjusting exercise programs to the individual based on variables such as ulcer history is still an emerging field, he noted, and based both on the evidence provided by research and on clinical experience.
“I believe that once you’ve had a full-thickness ulcer, you’re in a whole different category,” he said. “Even a mild one sends up a red flag that you’d better watch this person. There’s so much heterogeneity in the group of people who have diabetes and neuropathy that the program really needs to be tailored to the individual.”
Joint biomechanics
Part of the problem with such tailoring is that only recently has research begun to describe the relationship between biomechanics and diabetic neuropathy.
For example, a 2007 paper in the Journal of Applied Biomechanics found that diabetic subjects with neuropathy had stiffer ankles than diabetic subjects without neuropathy.11 It’s known that normal mobility allows the foot to flexibly dissipate impact, then become rigid during push-off.12 Restricted mobility in the foot and ankle joints, then, could hinder this transition and contribute to abnormal plantar loads.13
Citing such evidence, Smita Rao, PhD, an assistant professor of physical therapy at New York University, published a paper in 2006 outlining how changes in muscle could account for decreased range of motion (ROM) and increased stiffness in patients with diabetes.14 In a subsequent article in Gait & Posture, she and her colleagues reported that decreased sagittal motion of the first metatarsal and lateral forefoot and frontal motion of the calcaneus were key elements that could contribute to increased, sustained plantar loading in patients with diabetes and neuropathy.15
“There’s a big push to emphasize exercise in patients with diabetes and peripheral neuropathy, but those patients are also at higher risk for tissue breakdown, so I wanted to explore the mechanisms that put them at risk,” Rao told LER. “We showed in the Gait & Posture paper that a lot of these patients try to reduce the effects of their stiffness by walking slower and taking shorter steps. When I examine them, I want to look at ankle range of motion, all the mechanical factors that may affect tissue breakdown; but I also want to assess how they walk, find focal regions of high pressure, then put those two together to see if walking is the best activity for this person. Some might need protective footwear, and some should ride a stationary bike instead.”
In her current research, Rao and her colleagues at NYU are examining ways to bring a number of fields together.
“My grandfather had diabetes, so I have a personal connection to the field,” she said. “All these negative effects begin with high blood sugar, so we’re trying to combine medical, surgical, and rehabilitative interventions in patients with diabetes and neuropathy.”
Exercise and balance
Other research has looked at the importance of augmenting exercise with balance training, which has been shown to improve clinical balance measures in neuropathic patients.16 A study published in Diabetes Care in 2010 demonstrated, moreover, that six weeks of such training reduced the risk of falls in 16 older patients with type 2 diabetes and mild to moderate neuropathy.17 In that research, exercise sessions included a balance/posture component (lower-limb stretches and leg, abdominal, and lower-back exercises) and a resistance and strength-training component using machines. The regimen led to better reaction times and affected sensory, motor, and cognitive processes, leading to a significant decline in risk of falls.
Lead author Steven Morrison, PhD, director of research in the School of Physical Therapy at Old Dominion University in Norfolk, VA, told LER that his group’s work was motivated partly by the fact that older diabetes patients’ risk of falling is 10 to 15 times that of healthy age-matched controls, which affects their confidence and ability to exercise.
“To be balanced, you need a certain amount of strength and a certain amount of coordination,” he said. “We found that after six weeks of training, type 2 diabetic individuals become more like the control group—there’s very little difference in terms of how much they sway and what their balance is like.”
Monitoring
David Sinacore, PT, PhD, a professor of physical therapy and medicine at Washington University, and one of the researchers involved in studies of exercise and neuropathy there, emphasized that monitoring—by clinicians or the patients themselves—is crucial to successful exercise programs in those with diabetic neuropathy, particularly if they also have foot deformities such as those resulting from Charcot arthropathy.
“I’m a firm believer that these folks need to exercise for their diabetes,” he said. “But if they start to develop lesions, they need to be addressed.”
Of course, as most clinicians know, there is often a gap between ideal and real-world monitoring levels.
“It’s hard for these patients to check the bottom of their feet regularly, so they sometimes don’t do it,” Sinacore said.
One way to help is with temperature monitoring. Sinacore recommends foot-temperature gauges that patients can use right after exercising, some of which are hook-shaped to ease plantar access.
“When we monitor them here, we check temperature before and after exercise,” he said. “We’re looking for hot spots and temperature differences that may indicate that they’re developing a lesion.”
In such cases, therapists recommend that patients decrease their exercise levels for a while and have their footwear modified to relieve pressure.
David Armstrong agreed that thermometry provides a way of keeping track of the damage caused by weight-bearing exercise.
“We want our patients to dose their activity by checking their skin temperature just as they dose their insulin by checking their glucose,” he said.
His colleague, Manish Bharara, conducts innovative research in this aspect of care.18
“In the last decade we’ve learned that a four-degree difference between two similar sites on both feet is an ulcer risk,” he said. “If the pattern persists over multiple days, the patient should reduce activity and immediately see a doctor.”
Bharara and his colleagues are developing a thermometry scale to address some of the inconveniences typically associated with measuring foot temperature at several sites. Patients stand on it—it’s similar to a bathroom scale—while it measures foot temperature at 20 sites on each foot and records the data. The scale speaks to the patient—telling him, for example, that his right big toe temperature is 5° warmer than the left. Moreover, if the scale detects an abnormal pattern for more than two days, it can be programmed to send a message to the physician’s office and make an appointment.
“Something like this could really help manage patients’ diabetes better, because the biggest barrier is compliance,” Bharara said.
New research
Other researchers are examining variables that affect neuropathic patients’ exercise capabilities, as well. For example, at the Center for Lower Extremity Ambulatory Research at Rosalind Franklin University in Chicago, Bijan Najafi, PhD, associate professor of applied biomechanics, has studied factors including gait initiation in this context.19 As opposed to the measures of steady-state walking—such as rate or number of steps—typically used in exercise studies, a prolonged gait initiation phase (the period between upright posture and steady-state gait) may be associated with increased fall risk.
“During the initiation of the step, there’s an important acceleration phase, and it creates a lot of resistive force,” Najafi said. “We’ve found that neuropathy patients have longer gait initiation. This makes sense, because to reach steady-state gait, people have to gather somatosensory feedback to find the speed at which they can walk safely and minimize energy costs. Neuropathy patients have impaired somatosensory feedback, though. But we believe that if we can provide a good exercise to compensate, we may be able to improve the gait initiation phase.”
One way to help, Najafi thinks, is to take a cue from the dance world.
“If you’re trying to explain a movement problem to a dancer he may not get it, but if you put a mirror in front of him and show him the correct position of the joints, he can improve his motor skills,” he said. “The brain is plastic, and if it realizes there’s an error, it will try to minimize it next time. So we hope that by letting neuropathy patients observe their errors this way, they may improve their motor skills.”
Cary Groner is a freelance writer based in the San Francisco Bay Area.
For decades, patients with type 2 diabetes and peripheral neuropathy were cautioned against weight-bearing exercise out of fear that the accompanying stress on the foot would lead to plantar ulcers. Then, in 2003, scientists began to report surprising findings.
“Prior to those studies, the feeling was that weight-bearing exercise was too risky to recommend to patients who lacked sensation,” said Joseph LeMaster, MD, MPH. LeMaster, for many years an associate professor in the Department of Family and Community Medicine at the University of Missouri, will move to the University of Kansas this fall. “There was evidence that people with neuropathy had increased plantar pressures, and those were considered an independent risk factor for foot ulcers.”
In 2003, LeMaster and his colleagues published a study of 400 diabetes patients with a history of foot ulcers and found that increased weight-bearing activity didn’t increase the risk of reulceration. Moreover, the most active subjects saw the most significant risk reduction, and the effects were the same regardless of whether subjects retained foot sensation.1
That same year, researchers from Washington University in St. Louis reported in Clinical Biomechanics that diabetes patients with a history of plantar ulcers were 46% less active and accumulated 41% less daily stress on the forefoot than nondiabetic and diabetic control subjects without a history of such ulcers.2 At first, the finding seemed so counterintuitive that people weren’t sure what to make of it. The authors ultimately concluded, conservatively, that subjects with a history of plantar ulcers were susceptible to injury at relatively low levels of tissue stress.
These studies flung open the door to further investigations, however. In 2004, scientists confirmed in Diabetes Care that neuropathic patients who exercised more had lower rates of ulceration than those who were relatively sedentary.3 Two years after that, in 2006, researchers in Italy reported that, far from being deleterious, exercise could help prevent neuropathy’s onset or modify its natural history.4 Right on cue, then, in 2008, Washington University researchers reporting on the Feet First study noted that promoting weight-bearing activity did not lead to significant increases in foot ulcers.5 Finally, in 2010, the American Diabetes Association, together with the American College of Sports Medicine, acknowledged this accumulating body of evidence and published new guidelines that, for the first time, endorsed weight-bearing exercise for patients with diabetic neuropathy in the absence of foot ulcers.6
“The new guidelines represent a big change,” said Michael Mueller, PT, PhD, a professor of physical therapy at Washington University School of Medicine. “For the first time, people with diabetic neuropathy are explicitly encouraged to do weight-bearing exercise.”
Although this rhythmic chronology outlines what appears to be a straightforward investigation that changed medical practice, the story is more nuanced. A number of questions have bedeviled researchers, and continue to. For example, what’s the chicken and what’s the egg? That is, do people get more ulcers because they get less exercise, or do they exercise less because of their ulcer history? Or, for that matter, are other variables involved that no one yet understands? These and other issues, such as how to distinguish those at highest risk of ulceration from their peers and how to adjust exercise regimens accordingly for individual patients, are only now starting to become clear.
Foundations
Back in 2002, Mueller published a paper in Physical Therapy whose relevance to this issue was not immediately clear, but which turned out to have a big impact. In that article, he proposed a “Physical Stress Theory” (PST) of tissue adaptation, the premise of which was that changes in the relative level of physical stress cause a predictable adaptive response in biological tissues.7 In a nutshell, the theory suggests that tissues respond to stress in predictable ways: stress levels that are too low lead to reduced stress tolerance and atrophy; mid-level stress produces no change; moderately high levels increase tolerance; and too much stress leads to injury and tissue death. The goal for practitioners seeking to increase their patients’ strength and resilience was to identify the levels that increased tolerance and work carefully from there.
Mueller also made several points that affected later researchers:
1. Stress exposure is a composite value comprising magnitude, time, and direction of stress application.
2. Extreme deviations from the maintenance stress range have serious consequences.
3. Individual stresses combine in complex ways to contribute to the overall level of stress exposure, and tissues are affected by the history of recent stresses.
4. Excessive stress can arise due to a brief, high-magnitude stress; a long duration of low-magnitude stress; or a repetitive application of moderate stress.
5. Inflammation occurs immediately after injury, reduces the injured tissue’s stress tolerance, and requires that the tissue be protected from further stress until the inflammation subsides.
Many of these points turned out to be crucial to understanding how to manage diabetic neuropathy in the context of exercise.
Variability
The lead author of the 2004 study in Diabetes Care was David Armstrong, DPM, MD, PhD, professor of surgery and director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson. An important aspect of his team’s findings was not just that more active subjects were less prone to ulcers, but that variability in activity was an important predictor of ulcer risk. Eight of 100 patients with diabetic neuropathy ulcerated during the average evaluation period of 37 weeks, and although they were significantly less active than those who remained ulcer-free, there was also much more variability in their exercise levels, as measured by high-capacity computerized accelerometer/pedometers.
“People who had wide swings in activity were at greater risk,” Armstrong told LER. “An example would be someone who’s not very active, then suddenly remembers their grandkid’s birthday and leaps off the couch, runs to the car, then spends an hour and a half walking around the mall. They do more in a couple of hours than they usually do in two days.”
When Armstrong and his colleagues first evaluated their data, they were flummoxed.
“We sat there wondering what was going on,” he said.
Their conclusion, however, echoed Mueller’s observations about the importance of tissue stress levels and the consequences of extreme deviation in them.
“We believe what we’re seeing is that it’s just like a lot of other places in the body,” Armstrong explained. “If you don’t use it, you lose it. If skin is allowed to atrophy, then maybe it’s weaker than skin that’s getting tenderized, as it were, by frequent activity.”
Armstrong noted that patients must be monitored carefully, as they were in his study, and that exercise has to be optimized for the individual.
“People can’t run a marathon with profound neuropathy, but we’d like to try to train them so they could slowly become more active,” he said. “We want to dose activity the way you’d titrate a drug.”
As for the chicken-and-egg problem—which comes first, the ulcer or the lower activity levels?—researchers are continuing to probe the reasons first ulcers appear. Manish Bharara, PhD, a research assistant professor at SALSA and a colleague of Armstrong’s, speculated that overall control of blood glucose levels may affect the resilience of damaged tissues.
“In diabetes patients, metabolic control affects other aspects of physiology, and could affect the quality of the tissue that is regenerated as someone heals,” he said.
A couple of Armstrong’s earlier papers may shed light on the issue, as well. In a 2001 article in the Journal of the American Podiatric Medical Association, Armstrong and his colleagues noted that diabetic patients with a history of neuropathy or ulceration took more steps per day inside the home than outside, and that only 15% of them wore their prescribed footwear inside.8 A paper in Diabetes Care in 2003 reported that subjects with foot ulcers wore their off-loading devices for only a minority of steps taken each day.9 Noncompliance with preventive footwear or curative devices could conceivably be similar in effect to low activity levels, then, in that both are associated with ulceration and poor healing. One possible explanation is that, compared to high-activity patients, low-activity patients are taking significantly fewer steps per day in footwear designed to help their feet avoid injury or heal (activity studies have not consistently reported compliance data).
“It even turns out that sometimes just standing for long periods can be potentially dangerous,” Armstrong noted.10 “This is all about better identifying risk and helping us better coach activity. We’re trying to get people moving, and in a lot of ways, that’s how we measure success.”
Individual cases
The Feet First study made it clear that clinicians must carefully consider the patient’s history when prescribing exercise, according to lead author LeMaster.
“In that study, we felt that the exercise program, combined with the careful monitoring we conducted, showed that the benefits of exercise outweighed the risks,” he said. “But it’s quite another thing to say that people who have lots of recent foot ulcers should go out and do this. A good percentage of the people in the study had had prior ulcers, and we didn’t find that to be a predictor [of ulceration during the trial]. But we restricted people from walking if they had any breakdown during the study.”
People with a history of frequent and recurrent ulcers, he added, should be viewed in a different category than those included in the research. Furthermore, the study’s subjects had their feet examined weekly by a physical therapist for the first three months, and had a hotline to call if they showed signs of ulceration later.
Mike Mueller, a coauthor of the 2008 Feet First paper, likened the evolving view of exercise in those with neuropathy to a similar evolution in thinking about exercise in cardiac patients a few decades ago.
“There was a time when the prevailing opinion was that if you’d had a heart attack, you should not exert yourself,” Mueller said. “We came to learn that if you monitor the heart carefully and keep it within a safe range, exercise is beneficial. It’s similar with the neuropathic foot, although we’re still learning what the guidelines should be.”
Adjusting exercise programs to the individual based on variables such as ulcer history is still an emerging field, he noted, and based both on the evidence provided by research and on clinical experience.
“I believe that once you’ve had a full-thickness ulcer, you’re in a whole different category,” he said. “Even a mild one sends up a red flag that you’d better watch this person. There’s so much heterogeneity in the group of people who have diabetes and neuropathy that the program really needs to be tailored to the individual.”
Joint biomechanics
Part of the problem with such tailoring is that only recently has research begun to describe the relationship between biomechanics and diabetic neuropathy.
For example, a 2007 paper in the Journal of Applied Biomechanics found that diabetic subjects with neuropathy had stiffer ankles than diabetic subjects without neuropathy.11 It’s known that normal mobility allows the foot to flexibly dissipate impact, then become rigid during push-off.12 Restricted mobility in the foot and ankle joints, then, could hinder this transition and contribute to abnormal plantar loads.13
Citing such evidence, Smita Rao, PhD, an assistant professor of physical therapy at New York University, published a paper in 2006 outlining how changes in muscle could account for decreased range of motion (ROM) and increased stiffness in patients with diabetes.14 In a subsequent article in Gait & Posture, she and her colleagues reported that decreased sagittal motion of the first metatarsal and lateral forefoot and frontal motion of the calcaneus were key elements that could contribute to increased, sustained plantar loading in patients with diabetes and neuropathy.15
“There’s a big push to emphasize exercise in patients with diabetes and peripheral neuropathy, but those patients are also at higher risk for tissue breakdown, so I wanted to explore the mechanisms that put them at risk,” Rao told LER. “We showed in the Gait & Posture paper that a lot of these patients try to reduce the effects of their stiffness by walking slower and taking shorter steps. When I examine them, I want to look at ankle range of motion, all the mechanical factors that may affect tissue breakdown; but I also want to assess how they walk, find focal regions of high pressure, then put those two together to see if walking is the best activity for this person. Some might need protective footwear, and some should ride a stationary bike instead.”
In her current research, Rao and her colleagues at NYU are examining ways to bring a number of fields together.
“My grandfather had diabetes, so I have a personal connection to the field,” she said. “All these negative effects begin with high blood sugar, so we’re trying to combine medical, surgical, and rehabilitative interventions in patients with diabetes and neuropathy.”
Exercise and balance
Other research has looked at the importance of augmenting exercise with balance training, which has been shown to improve clinical balance measures in neuropathic patients.16 A study published in Diabetes Care in 2010 demonstrated, moreover, that six weeks of such training reduced the risk of falls in 16 older patients with type 2 diabetes and mild to moderate neuropathy.17 In that research, exercise sessions included a balance/posture component (lower-limb stretches and leg, abdominal, and lower-back exercises) and a resistance and strength-training component using machines. The regimen led to better reaction times and affected sensory, motor, and cognitive processes, leading to a significant decline in risk of falls.
Lead author Steven Morrison, PhD, director of research in the School of Physical Therapy at Old Dominion University in Norfolk, VA, told LER that his group’s work was motivated partly by the fact that older diabetes patients’ risk of falling is 10 to 15 times that of healthy age-matched controls, which affects their confidence and ability to exercise.
“To be balanced, you need a certain amount of strength and a certain amount of coordination,” he said. “We found that after six weeks of training, type 2 diabetic individuals become more like the control group—there’s very little difference in terms of how much they sway and what their balance is like.”
Monitoring
David Sinacore, PT, PhD, a professor of physical therapy and medicine at Washington University, and one of the researchers involved in studies of exercise and neuropathy there, emphasized that monitoring—by clinicians or the patients themselves—is crucial to successful exercise programs in those with diabetic neuropathy, particularly if they also have foot deformities such as those resulting from Charcot arthropathy.
“I’m a firm believer that these folks need to exercise for their diabetes,” he said. “But if they start to develop lesions, they need to be addressed.”
Of course, as most clinicians know, there is often a gap between ideal and real-world monitoring levels.
“It’s hard for these patients to check the bottom of their feet regularly, so they sometimes don’t do it,” Sinacore said.
One way to help is with temperature monitoring. Sinacore recommends foot-temperature gauges that patients can use right after exercising, some of which are hook-shaped to ease plantar access.
“When we monitor them here, we check temperature before and after exercise,” he said. “We’re looking for hot spots and temperature differences that may indicate that they’re developing a lesion.”
In such cases, therapists recommend that patients decrease their exercise levels for a while and have their footwear modified to relieve pressure.
David Armstrong agreed that thermometry provides a way of keeping track of the damage caused by weight-bearing exercise.
“We want our patients to dose their activity by checking their skin temperature just as they dose their insulin by checking their glucose,” he said.
His colleague, Manish Bharara, conducts innovative research in this aspect of care.18
“In the last decade we’ve learned that a four-degree difference between two similar sites on both feet is an ulcer risk,” he said. “If the pattern persists over multiple days, the patient should reduce activity and immediately see a doctor.”
Bharara and his colleagues are developing a thermometry scale to address some of the inconveniences typically associated with measuring foot temperature at several sites. Patients stand on it—it’s similar to a bathroom scale—while it measures foot temperature at 20 sites on each foot and records the data. The scale speaks to the patient—telling him, for example, that his right big toe temperature is 5° warmer than the left. Moreover, if the scale detects an abnormal pattern for more than two days, it can be programmed to send a message to the physician’s office and make an appointment.
“Something like this could really help manage patients’ diabetes better, because the biggest barrier is compliance,” Bharara said.
New research
Other researchers are examining variables that affect neuropathic patients’ exercise capabilities, as well. For example, at the Center for Lower Extremity Ambulatory Research at Rosalind Franklin University in Chicago, Bijan Najafi, PhD, associate professor of applied biomechanics, has studied factors including gait initiation in this context.19 As opposed to the measures of steady-state walking—such as rate or number of steps—typically used in exercise studies, a prolonged gait initiation phase (the period between upright posture and steady-state gait) may be associated with increased fall risk.
“During the initiation of the step, there’s an important acceleration phase, and it creates a lot of resistive force,” Najafi said. “We’ve found that neuropathy patients have longer gait initiation. This makes sense, because to reach steady-state gait, people have to gather somatosensory feedback to find the speed at which they can walk safely and minimize energy costs. Neuropathy patients have impaired somatosensory feedback, though. But we believe that if we can provide a good exercise to compensate, we may be able to improve the gait initiation phase.”
One way to help, Najafi thinks, is to take a cue from the dance world.
“If you’re trying to explain a movement problem to a dancer he may not get it, but if you put a mirror in front of him and show him the correct position of the joints, he can improve his motor skills,” he said. “The brain is plastic, and if it realizes there’s an error, it will try to minimize it next time. So we hope that by letting neuropathy patients observe their errors this way, they may improve their motor skills.”
Cary Groner is a freelance writer based in the San Francisco Bay Area.
Monday, June 20, 2011
New Guidelines on Best Treatments for Diabetic Nerve Pain
The American Academy of Neurology has issued a new guideline on the most effective treatments for diabetic nerve pain....
This guideline was developed in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation.
Diabetic nerve pain, or neuropathy, is caused by nerve damage. "When neuropathy strikes, it is painful and can disrupt sleep; because of this it can also lead to mood changes and lower quality of life," said lead guideline author Vera Bril, MD, FRCP, with the University of Toronto and a member of the American Academy of Neurology. "It is estimated that diabetic nerve pain affects 16 percent of the more than 25 million people living with diabetes in the United States and is often unreported and more often untreated, with an estimated two out of five cases not receiving care."
According to the guideline, strong evidence shows the seizure drug pregabalin is effective in treating diabetic nerve pain and can improve quality of life; however, doctors should determine if it is appropriate for their patients on a case-by-case basis.
In addition, the guideline found that several other treatments are probably effective and should be considered, including the seizure drugs gabapentin and valproate, antidepressants such as venlafaxine, duloxetine and amitriptyline and painkillers such as opioids and capsaicin. Transcutaneous electric nerve stimulation (TENS), a widely used pain therapy involving a portable device, was also found to be probably effective for treating diabetic nerve pain.
"We were pleased to see that so many of these pain treatments had high-quality studies that support their use," said Bril. "Still, it is important that more research be done to show how well these treatments can be tolerated over time since diabetic nerve pain is a chronic condition that affects a person's quality of life and ability to function."
The recommendations of this guideline will serve as the foundation for a new set of tools the AAN is creating for doctors to measure the quality of care they provide people with nerve pain. The measures will be released in 2012.
The following is a snapshot of the strong evidence (Level A) and moderate evidence (Level B) recommendations that were in the guidelines released by the AAN:
The guideline is published in the April 11, 2011, online issue of Neurology®, the medical journal of the American Academy of Neurology, and was presented April 11, 2011, at the American Academy of Neurology's Annual Meeting in Honolulu.
Bril, J. England, G. M. Franklin, M. Backonja, J. Cohen, D. Del Toro, E. Feldman, D. J. Iverson, B. Perkins, J. W. Russell, D. Zochodne. Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology, 2011; DOI: 10.1212/WNL.0b013e3182166ebe
This guideline was developed in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation.
Diabetic nerve pain, or neuropathy, is caused by nerve damage. "When neuropathy strikes, it is painful and can disrupt sleep; because of this it can also lead to mood changes and lower quality of life," said lead guideline author Vera Bril, MD, FRCP, with the University of Toronto and a member of the American Academy of Neurology. "It is estimated that diabetic nerve pain affects 16 percent of the more than 25 million people living with diabetes in the United States and is often unreported and more often untreated, with an estimated two out of five cases not receiving care."
According to the guideline, strong evidence shows the seizure drug pregabalin is effective in treating diabetic nerve pain and can improve quality of life; however, doctors should determine if it is appropriate for their patients on a case-by-case basis.
In addition, the guideline found that several other treatments are probably effective and should be considered, including the seizure drugs gabapentin and valproate, antidepressants such as venlafaxine, duloxetine and amitriptyline and painkillers such as opioids and capsaicin. Transcutaneous electric nerve stimulation (TENS), a widely used pain therapy involving a portable device, was also found to be probably effective for treating diabetic nerve pain.
"We were pleased to see that so many of these pain treatments had high-quality studies that support their use," said Bril. "Still, it is important that more research be done to show how well these treatments can be tolerated over time since diabetic nerve pain is a chronic condition that affects a person's quality of life and ability to function."
The recommendations of this guideline will serve as the foundation for a new set of tools the AAN is creating for doctors to measure the quality of care they provide people with nerve pain. The measures will be released in 2012.
The following is a snapshot of the strong evidence (Level A) and moderate evidence (Level B) recommendations that were in the guidelines released by the AAN:
The guideline is published in the April 11, 2011, online issue of Neurology®, the medical journal of the American Academy of Neurology, and was presented April 11, 2011, at the American Academy of Neurology's Annual Meeting in Honolulu.
Bril, J. England, G. M. Franklin, M. Backonja, J. Cohen, D. Del Toro, E. Feldman, D. J. Iverson, B. Perkins, J. W. Russell, D. Zochodne. Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology, 2011; DOI: 10.1212/WNL.0b013e3182166ebe
Thursday, April 14, 2011
American Diabetes Association's New Clinical Practice Recommendations Promote A1c as Diagnostic Test for Diabetes and Pre-Diabetes
Faster, easier test could help reduce number of undiagnosed with diabetes and pre-diabetes.
The American Diabetes Association's (ADA) new Clinical Practice Recommendations being published as a supplement to the January issue of Diabetes Care call for the addition of the A1c test as a means of diagnosing diabetes and identifying pre-diabetes. The test has been recommended for years as a measure of how well people are doing to keep their blood glucose levels under control.
"We believe that use of the A1c, because it doesn't require fasting, will encourage more people to get tested for Type 2 diabetes and help further reduce the number of people who are undiagnosed but living with this chronic and potentially life-threatening disease. Additionally, early detection can make an enormous difference in a person's quality of life," said Richard M. Bergenstal, MD, President-Elect, Medicine & Science, ADA.
"Unlike many chronic diseases, Type 2 diabetes actually can be prevented, as long as lifestyle changes are made while blood glucose levels are still in the pre-diabetes range."
A1c is measured in terms of percentages. The test measures a person's average blood glucose levels over a period of up to three months and previously had been used only to determine how well people were maintaining control of their diabetes over time. A person without diabetes would have an A1c of about 5 percent.
Under the new recommendations, which are revised every year to reflect the most current available scientific research, an A1c of 5.7 -- 6.4 percent would indicate that blood glucose levels were in the pre-diabetic range, meaning higher than normal but not yet high enough for a diagnosis of diabetes. That diagnosis would occur once levels rose to an A1c of 6.5 percent or higher.
The ADA recommends that most people with diabetes maintain a goal of keeping A1c levels at or below 7 percent in order to properly manage their disease. Research shows that controlling blood glucose levels helps to prevent serious diabetes-related complications, such as kidney disease, nerve damage and problems with the eyes and gums.
The A1c would join two previous diagnostic tests for diabetes, Fasting Plasma Glucose (FPG) and the Oral Glucose Tolerance Test (OGTT), both of which require overnight fasting. Because the A1c is a simple blood test and does not require fasting, allowing patients this option could increase willingness to get tested, thereby reducing the number of people who have Type 2 diabetes but don't yet know it.
According to the Centers for Disease Control and Prevention, one-fourth of all Americans with diabetes, or 5.7 million people, don't realize they have it. Another 57 million have pre-diabetes and 1.6 million new diagnoses are made every year.
The American Diabetes Association's (ADA) new Clinical Practice Recommendations being published as a supplement to the January issue of Diabetes Care call for the addition of the A1c test as a means of diagnosing diabetes and identifying pre-diabetes. The test has been recommended for years as a measure of how well people are doing to keep their blood glucose levels under control.
"We believe that use of the A1c, because it doesn't require fasting, will encourage more people to get tested for Type 2 diabetes and help further reduce the number of people who are undiagnosed but living with this chronic and potentially life-threatening disease. Additionally, early detection can make an enormous difference in a person's quality of life," said Richard M. Bergenstal, MD, President-Elect, Medicine & Science, ADA.
"Unlike many chronic diseases, Type 2 diabetes actually can be prevented, as long as lifestyle changes are made while blood glucose levels are still in the pre-diabetes range."
A1c is measured in terms of percentages. The test measures a person's average blood glucose levels over a period of up to three months and previously had been used only to determine how well people were maintaining control of their diabetes over time. A person without diabetes would have an A1c of about 5 percent.
Under the new recommendations, which are revised every year to reflect the most current available scientific research, an A1c of 5.7 -- 6.4 percent would indicate that blood glucose levels were in the pre-diabetic range, meaning higher than normal but not yet high enough for a diagnosis of diabetes. That diagnosis would occur once levels rose to an A1c of 6.5 percent or higher.
The ADA recommends that most people with diabetes maintain a goal of keeping A1c levels at or below 7 percent in order to properly manage their disease. Research shows that controlling blood glucose levels helps to prevent serious diabetes-related complications, such as kidney disease, nerve damage and problems with the eyes and gums.
The A1c would join two previous diagnostic tests for diabetes, Fasting Plasma Glucose (FPG) and the Oral Glucose Tolerance Test (OGTT), both of which require overnight fasting. Because the A1c is a simple blood test and does not require fasting, allowing patients this option could increase willingness to get tested, thereby reducing the number of people who have Type 2 diabetes but don't yet know it.
According to the Centers for Disease Control and Prevention, one-fourth of all Americans with diabetes, or 5.7 million people, don't realize they have it. Another 57 million have pre-diabetes and 1.6 million new diagnoses are made every year.
Tuesday, March 8, 2011
Diabetic socks: More than meets the toe
With so much emphasis placed on proper diabetic footwear, especially for those who suffer from peripheral neuropathy, patients with diabetes may not realize how crucial the size, fit, fiber, and construction of socks also are. Since socks are an integral part of treatment, the following do’s and don’ts may help practitioners educate patients about proper sock selection and wear.
Do’s
Do prescribe specially constructed, seamless socks that have a soft, flexible, and stretchy toe area where the material is joined.
Do advise patients of the dangers of wearing socks with any irregularities, including darned socks or socks with holes. A seam, wrinkling, or a tiny fold can generate friction, creating microtrauma that can lead to ulceration and worse.
Do prescribe socks made of high quality fibers. They will last longer and wear evenly, instead of leaving thin spots where friction can occur.
Do look for socks made of stretchy synthetics with moisture-wicking properties to minimize the risk of infection and blisters. Any natural fibers should be blended with synthetics and make up a small portion of the total fiber content.
Do choose socks with antibacterial properties. Socks made with silver and copper fibers have been shown to decrease bacteria and combat foot odor.
Do pay attention to fit. Good diabetic socks conform to the foot and resist wrinkling inside the shoe. The best therapeutic socks fit no more than two shoe sizes and offer a range of four or five sizes to choose from.
Do prescribe therapeutic socks with silicone padding to reduce plantar pressure in patients with neuropathy. The padded socks are also a good choice for diabetic patients with rheumatoid arthritis. Double padding can be achieved by wearing two pairs of the socks, one inside the other. To accommodate the extra thickness, the shoe size needs to increase by at least 1/2 size, or suggest the patient wear the socks with extra-depth shoes.
Do make sure patients buy an adequate number of pairs to avoid the temptation to wear the same socks twice or revert to nondiabetic socks.
Do ensure that socks are not causing callus buildup or corns. The presence of a callus or corn on the surface of the foot should be a warning sign that abnormal skin shear is occurring.
Do tell patients how socks fit into their preventive care plan. Patients who find themselves in the high-risk category for ulcers and amputations should know that wearing properly sized prescription shoes and socks as well as visually inspecting and washing feet every day are all necessary to avoid infection.
Do tell patients who develop an infection not to wear socks until they’ve laundered them with bleach or another disinfectant.
Do stress the importance of regulating blood glucose, exercising, and quitting smoking to minimize the risk of foot ulceration and improve healing.
Don’ts
Don’t prescribe socks that are too tight for patients with poor circulation. If the patient has vascular disease as well as neuropathy, the socks need to have the capability of expanding as the foot and ankle swell.
Don’t prescribe socks that are too loose. They may bunch up, causing friction.
Don’t use socks with metallic fibers to treat infections or ulcers. Just because the sock itself resists bacterial growth does not mean it has been demonstrated to reduce infections on the surface of the foot.
Do’s
Do prescribe specially constructed, seamless socks that have a soft, flexible, and stretchy toe area where the material is joined.
Do advise patients of the dangers of wearing socks with any irregularities, including darned socks or socks with holes. A seam, wrinkling, or a tiny fold can generate friction, creating microtrauma that can lead to ulceration and worse.
Do prescribe socks made of high quality fibers. They will last longer and wear evenly, instead of leaving thin spots where friction can occur.
Do look for socks made of stretchy synthetics with moisture-wicking properties to minimize the risk of infection and blisters. Any natural fibers should be blended with synthetics and make up a small portion of the total fiber content.
Do choose socks with antibacterial properties. Socks made with silver and copper fibers have been shown to decrease bacteria and combat foot odor.
Do pay attention to fit. Good diabetic socks conform to the foot and resist wrinkling inside the shoe. The best therapeutic socks fit no more than two shoe sizes and offer a range of four or five sizes to choose from.
Do prescribe therapeutic socks with silicone padding to reduce plantar pressure in patients with neuropathy. The padded socks are also a good choice for diabetic patients with rheumatoid arthritis. Double padding can be achieved by wearing two pairs of the socks, one inside the other. To accommodate the extra thickness, the shoe size needs to increase by at least 1/2 size, or suggest the patient wear the socks with extra-depth shoes.
Do make sure patients buy an adequate number of pairs to avoid the temptation to wear the same socks twice or revert to nondiabetic socks.
Do ensure that socks are not causing callus buildup or corns. The presence of a callus or corn on the surface of the foot should be a warning sign that abnormal skin shear is occurring.
Do tell patients how socks fit into their preventive care plan. Patients who find themselves in the high-risk category for ulcers and amputations should know that wearing properly sized prescription shoes and socks as well as visually inspecting and washing feet every day are all necessary to avoid infection.
Do tell patients who develop an infection not to wear socks until they’ve laundered them with bleach or another disinfectant.
Do stress the importance of regulating blood glucose, exercising, and quitting smoking to minimize the risk of foot ulceration and improve healing.
Don’ts
Don’t prescribe socks that are too tight for patients with poor circulation. If the patient has vascular disease as well as neuropathy, the socks need to have the capability of expanding as the foot and ankle swell.
Don’t prescribe socks that are too loose. They may bunch up, causing friction.
Don’t use socks with metallic fibers to treat infections or ulcers. Just because the sock itself resists bacterial growth does not mean it has been demonstrated to reduce infections on the surface of the foot.
Thursday, January 27, 2011
Foot Care Is Essential With Diabetes
From inspecting your feet for sores to keeping your skin dry, proper foot care is essential when you have diabetes. Practice these tips to reduce the risk of infection and protect your feet.
You may think of diabetes as a blood sugar problem, and it is. But the nerve and blood vessel damage caused by diabetes can also become a problem for your feet if you develop neuropathy and lose feeling in your feet or hands or get an infection. To ensure the best possible foot health, follow these 11 easy tips to avoid injury, and your feet will be healthy longer.
Nerve damage is a complication of diabetes that makes it hard to feel when you have sores or cracks in your feet. “Patients with diabetes are looking for any changes in color, sores, or dry, cracked skin,” says podiatrist Steven Tiller, MD, of Portland, Ore. Place a mirror on the floor to see under your feet or ask a friend or relative for help if you can’t see all parts of your feet clearly.
When people with diabetes develop nerve damage or neuropathy, it’s hard to tell if the bath water is too hot. “They won’t realize they are actually scalding their skin,” explains Dr. Tillet. Stepping into a bath before checking the temperature can cause serious damage to your feet, and burns and blisters are open doors to infection. Use your elbow to check the water temperature before getting into the tub or shower.
Shoe shopping for people with diabetes requires a little more attention to detail than you may be used to. Tillet advises looking for shoes with more depth in the toe box, good coverage of both top and bottom, and without seams inside the shoe that can rub on your foot. Likewise, seek socks without seams, preferably socks that are padded and made from cotton or another material that controls moisture.
Wearing shoes with good coverage outside to protect your feet makes sense to most people, but even inside your house, puttering around without shoes puts your feet at risk for small cuts, scrapes, and penetration by splinters, glass shards, and the misplaced sewing needle or thumbtack. If you have neuropathy, you might not notice these dangerous damages until they become infected. It’s best to wear shoes at all times, even in the house.
Make sure that drying your feet is part of your hygiene routine. “The space between the toes is very airtight,” says Tillet. “Skin gets moist and breaks down, leading to infection.” Prevent this by toweling off thoroughly after washing your feet and by removing wet or sweaty socks or shoes immediately. You can still use moisturizer to prevent dry, cracked skin — just avoid putting it between your toes.
Attend to bunions, calluses, corns, hammertoes, and other aggravations promptly, so they don’t lead to infection due to pressure sores and uneven rubbing. Even seemingly harmless calluses may become problems if you ignore them, notes Tillet. See a podiatrist, a doctor who specializes in foot care, instead of heading to the pharmacy for an over-the-counter product for feet — some products are irritating to your skin and can actually increase the risk of infection even while they treat the bunion, callus, or corn on your foot.
Because wearing the correct shoes is so important, orthotic footwear is a great investment in protection and comfort. Shoes made especially for people with diabetes are available at specialty stores and through catalogs, or you can visit your podiatrist for advice. Medicare will cover one pair of diabetic shoes a year, with the addition of three inserts to reduce pressure on your feet. Your doctor may recommend this type of diabetic shoe if you have an ulcer or sore that is not healing.
People with diabetes benefit from exercise, but you still must go easy on your feet. Many fitness classes and aerobics programs include bouncing, jumping, and leaping, which may not be the best activities for your feet, especially if you have neuropathy. Instead, look into programs, such as walking, that don’t put too much pressure on your feet. Just make sure you have the right shoe for whatever activity you choose.
The dangers of smoking run from your head to your feet. “The nicotine in a cigarette can decrease the circulation in the skin by 70 percent,” says Tillet. So if you smoke, you are depriving your feet of the nutrient- and oxygen-rich blood that helps keep them healthy and fights infection. “Diabetic patients already have risk factors that compromise their blood vessels. It’s never too late to stop smoking,” says Tillet.
“There’s a direct relationship between blood sugar level and damage to the nerve cells,” says Tillet. Out-of-control blood sugar leads to neuropathy, which will make it hard to know when your feet are at risk or being damaged. The better you are at controlling your blood sugar, the healthier your feet will be over the long term. Finally, if you already have an infection, high blood sugar levels can make it hard for your body to fight it.
Your doctor and your diabetes team are great sources of information if you need ideas and inspiration for taking care of your feet, quitting smoking, or staying on top of your “numbers” — your weight, blood sugar, and other measures of health, such as blood pressure. Of course, if you notice any changes in your feet that concern you, it’s a good idea to see your doctor before your next regularly scheduled check-up.
You may think of diabetes as a blood sugar problem, and it is. But the nerve and blood vessel damage caused by diabetes can also become a problem for your feet if you develop neuropathy and lose feeling in your feet or hands or get an infection. To ensure the best possible foot health, follow these 11 easy tips to avoid injury, and your feet will be healthy longer.
Nerve damage is a complication of diabetes that makes it hard to feel when you have sores or cracks in your feet. “Patients with diabetes are looking for any changes in color, sores, or dry, cracked skin,” says podiatrist Steven Tiller, MD, of Portland, Ore. Place a mirror on the floor to see under your feet or ask a friend or relative for help if you can’t see all parts of your feet clearly.
When people with diabetes develop nerve damage or neuropathy, it’s hard to tell if the bath water is too hot. “They won’t realize they are actually scalding their skin,” explains Dr. Tillet. Stepping into a bath before checking the temperature can cause serious damage to your feet, and burns and blisters are open doors to infection. Use your elbow to check the water temperature before getting into the tub or shower.
Shoe shopping for people with diabetes requires a little more attention to detail than you may be used to. Tillet advises looking for shoes with more depth in the toe box, good coverage of both top and bottom, and without seams inside the shoe that can rub on your foot. Likewise, seek socks without seams, preferably socks that are padded and made from cotton or another material that controls moisture.
Wearing shoes with good coverage outside to protect your feet makes sense to most people, but even inside your house, puttering around without shoes puts your feet at risk for small cuts, scrapes, and penetration by splinters, glass shards, and the misplaced sewing needle or thumbtack. If you have neuropathy, you might not notice these dangerous damages until they become infected. It’s best to wear shoes at all times, even in the house.
Make sure that drying your feet is part of your hygiene routine. “The space between the toes is very airtight,” says Tillet. “Skin gets moist and breaks down, leading to infection.” Prevent this by toweling off thoroughly after washing your feet and by removing wet or sweaty socks or shoes immediately. You can still use moisturizer to prevent dry, cracked skin — just avoid putting it between your toes.
Attend to bunions, calluses, corns, hammertoes, and other aggravations promptly, so they don’t lead to infection due to pressure sores and uneven rubbing. Even seemingly harmless calluses may become problems if you ignore them, notes Tillet. See a podiatrist, a doctor who specializes in foot care, instead of heading to the pharmacy for an over-the-counter product for feet — some products are irritating to your skin and can actually increase the risk of infection even while they treat the bunion, callus, or corn on your foot.
Because wearing the correct shoes is so important, orthotic footwear is a great investment in protection and comfort. Shoes made especially for people with diabetes are available at specialty stores and through catalogs, or you can visit your podiatrist for advice. Medicare will cover one pair of diabetic shoes a year, with the addition of three inserts to reduce pressure on your feet. Your doctor may recommend this type of diabetic shoe if you have an ulcer or sore that is not healing.
People with diabetes benefit from exercise, but you still must go easy on your feet. Many fitness classes and aerobics programs include bouncing, jumping, and leaping, which may not be the best activities for your feet, especially if you have neuropathy. Instead, look into programs, such as walking, that don’t put too much pressure on your feet. Just make sure you have the right shoe for whatever activity you choose.
The dangers of smoking run from your head to your feet. “The nicotine in a cigarette can decrease the circulation in the skin by 70 percent,” says Tillet. So if you smoke, you are depriving your feet of the nutrient- and oxygen-rich blood that helps keep them healthy and fights infection. “Diabetic patients already have risk factors that compromise their blood vessels. It’s never too late to stop smoking,” says Tillet.
“There’s a direct relationship between blood sugar level and damage to the nerve cells,” says Tillet. Out-of-control blood sugar leads to neuropathy, which will make it hard to know when your feet are at risk or being damaged. The better you are at controlling your blood sugar, the healthier your feet will be over the long term. Finally, if you already have an infection, high blood sugar levels can make it hard for your body to fight it.
Your doctor and your diabetes team are great sources of information if you need ideas and inspiration for taking care of your feet, quitting smoking, or staying on top of your “numbers” — your weight, blood sugar, and other measures of health, such as blood pressure. Of course, if you notice any changes in your feet that concern you, it’s a good idea to see your doctor before your next regularly scheduled check-up.
Thursday, January 20, 2011
New Wound Treatment for Non-healing Foot Ulcers
Results are expected by the end of the month in an efficacy study on a new drug that promises to improve diabetic wound care. Derma Sciences is wrapping up work on a phase 2 trial of DSC127, a drug already shown to speed up healing in animal tests.
According to Barry Wolfenson, executive vice president of global business development and marketing for the company, the study's last patient came aboard September 27, and the trial was set to wrap by the end of December 2010. After crunching the numbers, the company will be able to say how many patients' wounds were completely healed by the end of the 12-week study period.
"Should the DSC127 trial generate positive outcomes, we believe we will be able to attract several potential partners to handle further clinical testing of this drug and ultimately bring another treatment option to market for the millions of diabetics with chronic, non-healing foot ulcers," said company chairman and CEO Edward Quilty.
How does DSC127 work? Skin contains receptors for a natural peptide called angiotensin, and DSC127 is an analog of that peptide. In other words, it's a near-duplicate of what our own bodies produce--with one important difference. In its natural form, angiotensin raises blood pressure. According to Derma Sciencies, DSC127 does not. When applied to a wound, the drug appears to speed the growth of new skin without side effects.
Derma Sciences' phase 2 study includes a 12-week measure of durability. While early results should come out this month, that means that the study technically ends on March 27, Wolfenson said. More number crunching and and submission of a report to the FDA will take place afterward.
In November, the Princeton, NJ-based medical company received a $244,479 research and development grant for its work on DSC127 as part of the US healthcare reform bill. One billion dollars in the legislation was set aside for projects that address unmet needs or chronic conditions or could cut healthcare costs.
"Not only does this grant represent a non-dilutive source of financing, but we also are pleased that the US government has recognized the potential for DSC127 to make a significant difference in patient care," Quilty said
Clay Wirestone
Jan 11, 2011
According to Barry Wolfenson, executive vice president of global business development and marketing for the company, the study's last patient came aboard September 27, and the trial was set to wrap by the end of December 2010. After crunching the numbers, the company will be able to say how many patients' wounds were completely healed by the end of the 12-week study period.
"Should the DSC127 trial generate positive outcomes, we believe we will be able to attract several potential partners to handle further clinical testing of this drug and ultimately bring another treatment option to market for the millions of diabetics with chronic, non-healing foot ulcers," said company chairman and CEO Edward Quilty.
How does DSC127 work? Skin contains receptors for a natural peptide called angiotensin, and DSC127 is an analog of that peptide. In other words, it's a near-duplicate of what our own bodies produce--with one important difference. In its natural form, angiotensin raises blood pressure. According to Derma Sciencies, DSC127 does not. When applied to a wound, the drug appears to speed the growth of new skin without side effects.
Derma Sciences' phase 2 study includes a 12-week measure of durability. While early results should come out this month, that means that the study technically ends on March 27, Wolfenson said. More number crunching and and submission of a report to the FDA will take place afterward.
In November, the Princeton, NJ-based medical company received a $244,479 research and development grant for its work on DSC127 as part of the US healthcare reform bill. One billion dollars in the legislation was set aside for projects that address unmet needs or chronic conditions or could cut healthcare costs.
"Not only does this grant represent a non-dilutive source of financing, but we also are pleased that the US government has recognized the potential for DSC127 to make a significant difference in patient care," Quilty said
Clay Wirestone
Jan 11, 2011
Wednesday, January 19, 2011
Type II diabetes and Hypertension
In an observational cohort study of 11,526 patients with Type 2 diabetes and hypertension, the investigators, showed that 68% of patients with normal albumin excretion at baseline had developed micro- or macroalbuminuria after a mean follow-up period of 5.5 years, according to Dr. Suma Vupputuri, PhD, MPH, an epidemiologist at Kaiser Permanente Center for Health Research/Southeast in Atlanta, who presented the study.
In previous studies, researchers had estimated that nephropathy develops in one-third of diabetic patients, Dr. Vupputuri noted. These studies, however, were based on data that were collected when glycemic levels were higher and before aggressive treatment had been shown to reduce diabetic complications.
In the new study, micro- and macroalbuminuria rarely progressed to end-stage renal disease (ESRD). In addition, if macroalbuminuria is present at baseline, the use of ACE inhibitors or angiotensin receptor blockers (ARBs) has a protective effect, the study showed.
The study included subjects who were at least 18 years old and who had measurements of urine albumin-to-creatinine ratios (UACR) in 2001, 2002, or 2003, and at least one additional measurement three to eight years later. Investigators defined micro- and macroalbuminuria as a UACR of 30-299 and 300 mcg/mg or higher, respectively. A UACR below 30 was considered normal. The first UACR value recorded in a stage higher than at baseline defined progression.
Almost half of the patients with normal albumin excretion at baseline progressed to microalbuminuria, but few went beyond that stage. Similarly, ESRD seldom developed in patients who first presented with microalbuminuria or macroalbuminuria. Over 89 months of follow-up, patients with normal baseline UACR's showed the highest rate of progression, followed by those with microalbuminuria at baseline, and then macroalbuminuria at baseline (94.6, 44.1, and 6.7 per 1,000 patient-years, respectively).
"Among patients with normal albumin at baseline, those who progressed to a higher stage of nephropathy were in general older, had a longer duration of diabetes, had higher mean blood pressures, and higher HbA1c's," Dr. Vupputuri said.
Patients who progressed from microalbuminuria were more likely to be male, with a longer duration of diabetes, higher mean blood pressure, and higher HbA1c levels. The progressors among the group with macroalbuminuria at baseline had similar risk factors as the microalbuminuria group plus lower estimated glomerular filtration rates and a diagnosis of cardiovascular disease or heart failure. In all the baseline cohorts, most patients were receiving antihypertensive agents (78%-91%), about half were on statins, and 67%-79% were receiving antihyperglycemic drugs. Insulin use went up and oral agents down with increasing nephropathy stage. ACE inhibitor or ARB use ranged from 61%-67% for all baseline groups whether they progressed or not, except for patients with macroglobulinuria who progressed. In this group, ACE inhibitor or ARB use was only 38%.
Because nephropathy is a major cause of cardiovascular disease and ESRD, it is important to understand the progression from normal levels of albumin excretion to micro- and macroalbuminuria and to define the risk factors for nephropathy progression.
Analyses showed that while ACE inhibitor or ARB use was not significantly associated with the progression of nephropathy for patients with baseline normal albumin excretion or microalbuminuria, use of these drugs was associated with a 47% decreased risk of progression in patients with baseline macroalbuminuria. In these patients, each five-year increment in age was associated with a 21% decreased risk. Each 10 mL/min/1.73 m2 increase in estimated glomerular filtration rate was associated with a 65% reduced risk.
Estimates of risk of progression could have been limited by survivor bias of patients who died before their nephropathy might have progressed, Dr. Vupputuri said. In addition, she said, "The use of ACE [inhibitors] and ARB's was lower than expected in this population." Therefore, greater use of these drugs may further reduce the burden of disease, she observed.
Although nearly half the people with normal albumin excretion developed microalbuminuria, only 6% progressed to macroalbuminuria, and a tiny fraction (0.09%) developed ESRD.
Renal and Urology News Dec. 2010
In previous studies, researchers had estimated that nephropathy develops in one-third of diabetic patients, Dr. Vupputuri noted. These studies, however, were based on data that were collected when glycemic levels were higher and before aggressive treatment had been shown to reduce diabetic complications.
In the new study, micro- and macroalbuminuria rarely progressed to end-stage renal disease (ESRD). In addition, if macroalbuminuria is present at baseline, the use of ACE inhibitors or angiotensin receptor blockers (ARBs) has a protective effect, the study showed.
The study included subjects who were at least 18 years old and who had measurements of urine albumin-to-creatinine ratios (UACR) in 2001, 2002, or 2003, and at least one additional measurement three to eight years later. Investigators defined micro- and macroalbuminuria as a UACR of 30-299 and 300 mcg/mg or higher, respectively. A UACR below 30 was considered normal. The first UACR value recorded in a stage higher than at baseline defined progression.
Almost half of the patients with normal albumin excretion at baseline progressed to microalbuminuria, but few went beyond that stage. Similarly, ESRD seldom developed in patients who first presented with microalbuminuria or macroalbuminuria. Over 89 months of follow-up, patients with normal baseline UACR's showed the highest rate of progression, followed by those with microalbuminuria at baseline, and then macroalbuminuria at baseline (94.6, 44.1, and 6.7 per 1,000 patient-years, respectively).
"Among patients with normal albumin at baseline, those who progressed to a higher stage of nephropathy were in general older, had a longer duration of diabetes, had higher mean blood pressures, and higher HbA1c's," Dr. Vupputuri said.
Patients who progressed from microalbuminuria were more likely to be male, with a longer duration of diabetes, higher mean blood pressure, and higher HbA1c levels. The progressors among the group with macroalbuminuria at baseline had similar risk factors as the microalbuminuria group plus lower estimated glomerular filtration rates and a diagnosis of cardiovascular disease or heart failure. In all the baseline cohorts, most patients were receiving antihypertensive agents (78%-91%), about half were on statins, and 67%-79% were receiving antihyperglycemic drugs. Insulin use went up and oral agents down with increasing nephropathy stage. ACE inhibitor or ARB use ranged from 61%-67% for all baseline groups whether they progressed or not, except for patients with macroglobulinuria who progressed. In this group, ACE inhibitor or ARB use was only 38%.
Because nephropathy is a major cause of cardiovascular disease and ESRD, it is important to understand the progression from normal levels of albumin excretion to micro- and macroalbuminuria and to define the risk factors for nephropathy progression.
Analyses showed that while ACE inhibitor or ARB use was not significantly associated with the progression of nephropathy for patients with baseline normal albumin excretion or microalbuminuria, use of these drugs was associated with a 47% decreased risk of progression in patients with baseline macroalbuminuria. In these patients, each five-year increment in age was associated with a 21% decreased risk. Each 10 mL/min/1.73 m2 increase in estimated glomerular filtration rate was associated with a 65% reduced risk.
Estimates of risk of progression could have been limited by survivor bias of patients who died before their nephropathy might have progressed, Dr. Vupputuri said. In addition, she said, "The use of ACE [inhibitors] and ARB's was lower than expected in this population." Therefore, greater use of these drugs may further reduce the burden of disease, she observed.
Although nearly half the people with normal albumin excretion developed microalbuminuria, only 6% progressed to macroalbuminuria, and a tiny fraction (0.09%) developed ESRD.
Renal and Urology News Dec. 2010
Wednesday, December 8, 2010
Foot Care Is Essential With Diabetes
From inspecting your feet for sores to keeping your skin dry, proper foot care is essential when you have diabetes. Practice these tips to reduce the risk of infection and protect your feet.
You may think of diabetes as a blood sugar problem, and it is. But the nerve and blood vessel damage caused by diabetes can also become a problem for your feet if you develop neuropathy and lose feeling in your feet or hands or get an infection. To ensure the best possible foot health, follow these 11 easy tips to avoid injury, and your feet will be healthy longer.
1. Nerve damage is a complication of diabetes that makes it hard to feel when you have sores or cracks in your feet. “Patients with diabetes are looking for any changes in color, sores, or dry, cracked skin,” says Dr. Weaver. Place a mirror on the floor to see under your feet or ask a friend or relative for help if you can’t see all parts of your feet clearly.
2. When people with diabetes develop nerve damage or neuropathy, it’s hard to tell if the bath water is too hot. “They won’t realize they are actually scalding their skin,” explains Dr. Weaver. Stepping into a bath before checking the temperature can cause serious damage to your feet, and burns and blisters are open doors to infection. Use your elbow to check the water temperature before getting into the tub or shower.
3. Shoe shopping for people with diabetes requires a little more attention to detail than you may be used to. At CKPA we advise looking for shoes with more depth in the toe box, good coverage of both top and bottom, and without seams inside the shoe that can rub on your foot. Likewise, seek socks without seams, preferably socks that are padded and made from cotton or another material that controls moisture.
4. Wearing shoes with good coverage outside to protect your feet makes sense to most people, but even inside your house, puttering around without shoes puts your feet at risk for small cuts, scrapes, and penetration by splinters, glass shards, and the misplaced sewing needle or thumbtack. If you have neuropathy, you might not notice these dangerous damages until they become infected. It’s best to wear shoes at all times, even in the house.
5. Make sure that drying your feet is part of your hygiene routine. “The space between the toes is very airtight,” When the skin has excess moisture it will break down, leading to infection.” Prevent this by toweling off thoroughly after washing your feet and by removing wet or sweaty socks or shoes immediately. You can use Ameriglel lotion to moisturizer and help prevent dry, cracked skin — just avoid putting it between your toes.
6. Attend to bunions, calluses, corns, hammertoes, and other aggravations promptly, so they don’t lead to infection due to pressure sores and uneven rubbing. Even seemingly harmless calluses may become problems if you ignore them. See a podiatrist, a doctor who specializes in foot care, instead of heading to the pharmacy for an over-the-counter product for feet — some products are irritating to your skin and can actually increase the risk of infection even while they treat the bunion, callus, or corn on your foot.
7. Wearing the correct shoes is so important, orthotic footwear is a great investment in protection and comfort. Shoes made especially for people with diabetes are available at Central Kansas Podiatry Associates, or you can visit with Dr. Weaver for advice. Medicare will cover one pair of diabetic shoes a year, with the addition of three inserts to reduce pressure on your feet. Your doctor may recommend this type of diabetic shoe if you have an ulcer or sore that is slow healing and to help prevent..
8. People with diabetes benefit from exercise, but you still must go easy on your feet. Many fitness classes and aerobics programs include bouncing, jumping, and leaping, which may not be the best activities for your feet, especially if you have neuropathy. Instead, look into programs, such as walking, that don’t put too much pressure on your feet. Just make sure you have the right shoe for whatever activity you choose.
9. The dangers of smoking run from your head to your feet. “The nicotine in a cigarette can decrease the circulation in the skin by 70 percent,” says Dr. Weaver. So if you smoke, you are depriving your feet of the nutrient- and oxygen-rich blood that helps keep them healthy and fights infection. “Diabetic patients already have risk factors that compromise their blood vessels. It’s never too late to stop smoking,”
10. “There’s a direct relationship between blood sugar level and damage to the nerve cells,” says Dr. Weaver. Out-of-control blood sugar leads to neuropathy, which will make it hard to know when your feet are at risk or being damaged. The better you are at controlling your blood sugar, the healthier your feet will be over the long term. Finally, if you already have an infection, high blood sugar levels can make it hard for your body to fight it.
11. Your doctor and your diabetes team are great sources of information if you need ideas and inspiration for taking care of your feet, quitting smoking, or staying on top of your “numbers” — your weight, blood sugar, and other measures of health, such as blood pressure. Of course, if you notice any changes in your feet that concern you, it’s a good idea to call us and come see Dr. Weaver before your next regularly scheduled check-up.
You may think of diabetes as a blood sugar problem, and it is. But the nerve and blood vessel damage caused by diabetes can also become a problem for your feet if you develop neuropathy and lose feeling in your feet or hands or get an infection. To ensure the best possible foot health, follow these 11 easy tips to avoid injury, and your feet will be healthy longer.
1. Nerve damage is a complication of diabetes that makes it hard to feel when you have sores or cracks in your feet. “Patients with diabetes are looking for any changes in color, sores, or dry, cracked skin,” says Dr. Weaver. Place a mirror on the floor to see under your feet or ask a friend or relative for help if you can’t see all parts of your feet clearly.
2. When people with diabetes develop nerve damage or neuropathy, it’s hard to tell if the bath water is too hot. “They won’t realize they are actually scalding their skin,” explains Dr. Weaver. Stepping into a bath before checking the temperature can cause serious damage to your feet, and burns and blisters are open doors to infection. Use your elbow to check the water temperature before getting into the tub or shower.
3. Shoe shopping for people with diabetes requires a little more attention to detail than you may be used to. At CKPA we advise looking for shoes with more depth in the toe box, good coverage of both top and bottom, and without seams inside the shoe that can rub on your foot. Likewise, seek socks without seams, preferably socks that are padded and made from cotton or another material that controls moisture.
4. Wearing shoes with good coverage outside to protect your feet makes sense to most people, but even inside your house, puttering around without shoes puts your feet at risk for small cuts, scrapes, and penetration by splinters, glass shards, and the misplaced sewing needle or thumbtack. If you have neuropathy, you might not notice these dangerous damages until they become infected. It’s best to wear shoes at all times, even in the house.
5. Make sure that drying your feet is part of your hygiene routine. “The space between the toes is very airtight,” When the skin has excess moisture it will break down, leading to infection.” Prevent this by toweling off thoroughly after washing your feet and by removing wet or sweaty socks or shoes immediately. You can use Ameriglel lotion to moisturizer and help prevent dry, cracked skin — just avoid putting it between your toes.
6. Attend to bunions, calluses, corns, hammertoes, and other aggravations promptly, so they don’t lead to infection due to pressure sores and uneven rubbing. Even seemingly harmless calluses may become problems if you ignore them. See a podiatrist, a doctor who specializes in foot care, instead of heading to the pharmacy for an over-the-counter product for feet — some products are irritating to your skin and can actually increase the risk of infection even while they treat the bunion, callus, or corn on your foot.
7. Wearing the correct shoes is so important, orthotic footwear is a great investment in protection and comfort. Shoes made especially for people with diabetes are available at Central Kansas Podiatry Associates, or you can visit with Dr. Weaver for advice. Medicare will cover one pair of diabetic shoes a year, with the addition of three inserts to reduce pressure on your feet. Your doctor may recommend this type of diabetic shoe if you have an ulcer or sore that is slow healing and to help prevent..
8. People with diabetes benefit from exercise, but you still must go easy on your feet. Many fitness classes and aerobics programs include bouncing, jumping, and leaping, which may not be the best activities for your feet, especially if you have neuropathy. Instead, look into programs, such as walking, that don’t put too much pressure on your feet. Just make sure you have the right shoe for whatever activity you choose.
9. The dangers of smoking run from your head to your feet. “The nicotine in a cigarette can decrease the circulation in the skin by 70 percent,” says Dr. Weaver. So if you smoke, you are depriving your feet of the nutrient- and oxygen-rich blood that helps keep them healthy and fights infection. “Diabetic patients already have risk factors that compromise their blood vessels. It’s never too late to stop smoking,”
10. “There’s a direct relationship between blood sugar level and damage to the nerve cells,” says Dr. Weaver. Out-of-control blood sugar leads to neuropathy, which will make it hard to know when your feet are at risk or being damaged. The better you are at controlling your blood sugar, the healthier your feet will be over the long term. Finally, if you already have an infection, high blood sugar levels can make it hard for your body to fight it.
11. Your doctor and your diabetes team are great sources of information if you need ideas and inspiration for taking care of your feet, quitting smoking, or staying on top of your “numbers” — your weight, blood sugar, and other measures of health, such as blood pressure. Of course, if you notice any changes in your feet that concern you, it’s a good idea to call us and come see Dr. Weaver before your next regularly scheduled check-up.
Thursday, December 2, 2010
Comprehensive Care for Diabetic Neuropathy
Diabetic neuropathy is a common complication of diabetes that can be difficult to treat using oral medications alone. By addressing both the neuropathy and the underlying diabetes, patients experience better overall outcomes.
“The standard treatment for diabetic neuropathy involves medication management using either Neurontin [gabapentin], Lyrica [pregabalin] or Cymbalta [duloxetine],” says Kelly Miller, D.C., FASA, N.M.D., Clinical Director of Waldo Rehabilitation, Health and Wellness in Kansas City, MO. “However, statistically, those medications are only helpful for about 30% of patients suffering from diabetic neuropathy — and they are expensive drugs with many side effects.”
At Waldo Rehabilitation, Health and Wellness, treatment for diabetic neuropathy in patients with type 2 diabetes involves management of the patient’s disease through specialized nutritional services meant to help patients lose weight. This diet helps correct the metabolic syndrome.
“If patients’ blood sugar levels are unstable, their risk for developing other complications, such as retinopathy, kidney failure and nerve damage, is much higher,” says Dr. Miller. “We provide patients with type 2 diabetes education about their diabetes and the options available to help better manage their insulin resistance through lifestyle modifications. We have medical doctors, podiatrists, chiropractors and physical therapists on staff — all under one roof. This cooperative integration of the different disciplines allows us to treat chronic conditions, such as diabetes, in a comprehensive manner that can be challenging for a single provider.”
Diabetic Neuropathy Management
When patients present at Waldo Rehabilitation, Health and Wellness with diabetic neuropathy, a specific regimen of injections is utilized. Immediately following these injections, which are administered by a podiatrist, patients receive electrotherapy and infrared light therapy surrounding the injection site, which helps to not only anesthetize the fibers causing pain, but also increases circulation in the patient’s foot by 3,000%, according to Dr. Miller.
“By administering electrotherapy immediately after the injections have been completed, the medication is able to provide pain relief while also alleviating the numbness patients experience,” says Dr. Miller. “Improved sensory perception of the feet puts patients at decreased risk for wounds, infections and falls, which not only improves their overall well-being, but also reduces the amount of health care dollars spent on wound care. By taking a proactive approach to diabetes and diabetic neuropathy, we are able to reduce the number of patients who suffer from diabetic foot wounds, falls and other related health problems.”
For diabetic patients experiencing other health concerns, such as pain in their hips, knees and shoulders, physical therapy and chiropractic services are provided. Transdermal nutritional formulas are also used for diabetic neuropathy patients to help reverse any nerve damage that has been sustained and help them sleep.
“By utilizing a comprehensive approach that entails stabilizing blood sugar levels, correcting type 2 diabetes and applying specific nutrients — including B vitamins, melatonin, vitamin D and magnesium — patients have better outcomes for diabetic neuropathy,” says Dr. Miller. “In many cases, we can reverse nerve damage that has been sustained, which provides a much higher quality of life for patients.”
“The standard treatment for diabetic neuropathy involves medication management using either Neurontin [gabapentin], Lyrica [pregabalin] or Cymbalta [duloxetine],” says Kelly Miller, D.C., FASA, N.M.D., Clinical Director of Waldo Rehabilitation, Health and Wellness in Kansas City, MO. “However, statistically, those medications are only helpful for about 30% of patients suffering from diabetic neuropathy — and they are expensive drugs with many side effects.”
At Waldo Rehabilitation, Health and Wellness, treatment for diabetic neuropathy in patients with type 2 diabetes involves management of the patient’s disease through specialized nutritional services meant to help patients lose weight. This diet helps correct the metabolic syndrome.
“If patients’ blood sugar levels are unstable, their risk for developing other complications, such as retinopathy, kidney failure and nerve damage, is much higher,” says Dr. Miller. “We provide patients with type 2 diabetes education about their diabetes and the options available to help better manage their insulin resistance through lifestyle modifications. We have medical doctors, podiatrists, chiropractors and physical therapists on staff — all under one roof. This cooperative integration of the different disciplines allows us to treat chronic conditions, such as diabetes, in a comprehensive manner that can be challenging for a single provider.”
Diabetic Neuropathy Management
When patients present at Waldo Rehabilitation, Health and Wellness with diabetic neuropathy, a specific regimen of injections is utilized. Immediately following these injections, which are administered by a podiatrist, patients receive electrotherapy and infrared light therapy surrounding the injection site, which helps to not only anesthetize the fibers causing pain, but also increases circulation in the patient’s foot by 3,000%, according to Dr. Miller.
“By administering electrotherapy immediately after the injections have been completed, the medication is able to provide pain relief while also alleviating the numbness patients experience,” says Dr. Miller. “Improved sensory perception of the feet puts patients at decreased risk for wounds, infections and falls, which not only improves their overall well-being, but also reduces the amount of health care dollars spent on wound care. By taking a proactive approach to diabetes and diabetic neuropathy, we are able to reduce the number of patients who suffer from diabetic foot wounds, falls and other related health problems.”
For diabetic patients experiencing other health concerns, such as pain in their hips, knees and shoulders, physical therapy and chiropractic services are provided. Transdermal nutritional formulas are also used for diabetic neuropathy patients to help reverse any nerve damage that has been sustained and help them sleep.
“By utilizing a comprehensive approach that entails stabilizing blood sugar levels, correcting type 2 diabetes and applying specific nutrients — including B vitamins, melatonin, vitamin D and magnesium — patients have better outcomes for diabetic neuropathy,” says Dr. Miller. “In many cases, we can reverse nerve damage that has been sustained, which provides a much higher quality of life for patients.”
Monday, March 1, 2010
Foot Pain.…Make it STOP!!
Patients often ask, “How much pain will I have after surgery?” This is a very difficult question to answer because everyone experiences pain differently. This also makes testing someone for pain difficult. Everyone experiences pain at different levels and have different thresholds for tolerating pain. Pain is often difficult to locate. When our bodies experience a pain, it sends the signal through our brain through nerve fibers. Small nerve fibers called delta fibers send 90% of the pain signals to the brain to specific locations in the cortex of the brain. Testing these fibers shows us where the pain is coming from. Small nerve fiber testing is a painless test that can show where the pain is coming from in about 20 minutes. An EMG tests for nerve damage. Pain occurs before the nerve is damaged. By testing the small nerve fibers, it locates accurately with 95% sensitivity where the pain is before there is permanent damage. This leads to earlier and more effective treatment. If you are experiencing pain that is not responding to traditional treatment, consult with your physician to see if you are a candidate for small nerve fiber testing.
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