Therapeutic Foot Care and Massage for People with Diabetes
- Tue, 8/31/10 - 2:39pm
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Diabetes Mellitus (DM) is a group of chronic diseases characterized by increased levels of glucose, resulting from defects in insulin production or insulin action or both. Sensory neuropathy occurs as a result of damage to specific nerve structures (axon, cell body and or myelin sheath) due to the hyperglycemia and insulin deficiency. These neurological defects alter the protective mechanism and reduce, or alter, the perceptions of temperature, touch, and pain which often lead to a neuropathic ulcer and an amputation.
Conducting a foot and lower extremity exam includes assessing the dermatologic status, presence of calluses, identifying localized areas of inflammation, edema, perfusion status, and musculoskeletal / biomechanical status. A foot exam must include determining the neurologic status, assessing daily foot care routine, and assessing foot wear to include sock wear, and use of over-the-counter or prescribed compression therapy.
Foot care and foot massage has shown, in the literature, to be an essential part of daily care to prevent injuries and detect small changes early for intervention. Foot care includes hygiene, assessment, and intervention. The goal of hygiene is the bathe the feet, paying particular attention to web spaces, painful joints, paronychia (pain or tenderness around the nail/cuticle), and providing the benefits of gentle touch. By palpating and observing during the hygiene phase clinicians can gather data for the foot exam.
Data to be collected prior to foot care intervention is assessment of perfusion, neuropathy, dermatologic, edema, pain, and musculoskeletal (biomechanical) deformities. The lack of perfusion is the single most important indicator necessitating an amputation. The posterior tibialis and dorsalis pedis pulses are to be evaluated. Check the capillary refill and make a general assessment of the skin of the lower extremity. If the skin is shiny, taut, and hairless, especially of the great toe (hallux) and if there is muscle atrophy; be suspicious.
Sensory neuropathy is the single most important indicator of an impending wound, which could lead to an amputation. Test the plantar surface of the foot with a 5.07 = 10 gram Semmes-Weinstein monofilament for touch sensation, and or a 128 cps tuning fork for vibratory sensation. Know the sensory status for risk of wounds and amputation, and for teaching the client and caregivers of the level of sensation for activities of daily living.
Assess the skin and nails of the feet. Check the skin appearance, color, texture, and turgor, presence of corns, calluses, discoloration/sub callus hemorrhage, lipodermatosclerosis, anhydrosis, and plantar warts. Also check for tinea pedis, interdigital maceration, fissuring, dry, scaly, circular lesions, and severe fungal infections. Check the nails for onychomycosis (fungal), onycryptosis (ingrown/ingrowing), onychogryphosis (rams horn), onycholysis (lifting), or subungal hematoma (blood collection under the nail). Ten percent of all dermatologic conditions are in the nails. Unusual lesions, discolorations on the plantar surface of the feet and under the nails may be suspicious of malignant melanoma.
Edema of the lower extremity is more common than not. Who can defy gravity? Assess for localized or generalized edema, and check for dependent or pitting and assess for bilateral or unilateral. Most people, to include people with diabetes, need to be in some compression, any compression is better than none. Consider a low dose, over-the-counter 10-15 mmHg compression knee-high sock. Be very careful not to confuse anti-embolitic stockings (TED) with compression. Anti-embolitic stockings are indicated for those lying in bed not up dangling or ambulating.
Musculoskeletal assessment is actually an evaluation of the biomechanical status. Assess for muscle group strength testing or weakness by conducting passive and active range of motion, and conducting weight bearing and nonweight bearing exercises. Check for the presence of foot deformities and investigate the underlying etiology if it is due to trauma, disease, or if spontaneous, or unknown. Evaluate the gait and use of walking aides. Use a pressure mapping device to identify sites of high pressure which has a level A evidence in the research both, for identifying areas to off-load but also to educate the client on the need for specific shoes, inserts, orthotics, and daily observation of feet.
Assess the patients’ routine foot care. Investigate and teach daily cleansing/bathing (NEVER Soaking), daily moisturizing, toenail care and barefoot and stocking foot walking behaviors. The research has shown that daily self-foot examinations are the number one patient/client intervention that prevents a wound leading to an amputation.
Assess the patients’ footwear. What is the shoe design, shape, width, depth of toe box? Does the shoe fit the foot? What are the patterns of wear? Check the external and internal lining of the shoe. Is it bottoming out? Are there use of insoles, orthotics? Are they commercially available, customized, or over-the-counter?
In the assessment of the lower extremity a determination of risk for wounding and an amputation should be conducted. Our role as clinicians with people with diabetes, is to identify those at risk due to loss of protective sensation (LOPS), history of previous ulceration, elevated plantar pressures, rigid foot deformity, poor diabetes control (HgA1c > 7%) and >10year duration of diabetes. The Lower-Extremity Amputation Prevention (LEAP) promotes foot screening, patient education, and appropriate footwear selection, daily inspection of the foot, by the patient or caregiver, and management of simple foot problems in a timely manner.
1. Bennett, P.C. (2006). Foot Care: Prevention of Problems for Optimal Health. Home Healthcare Nurse, 24, 5, 325-329.
2. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. WOCN Clinical Practice Guideline Series, 2004
3. Snyder, R.J., Kirsner, R.S. et.al. (2010). Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes. Ostomy Wound Management, 56 (suppl 4), S1-S24.