Therapeutic Foot Care and Massage for People with Diabetes
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.
Use of therapeutic foot wear is the most important aspect of management for the ambulatory person with diabetes. People with diabetes must seek professional assistance in fitting of shoes properly, because peripheral neuropathy may preclude patients from recognizing proper fit. Therapeutic, customized shoes that are effectively off load problematic feet and deformities are essential. The shoe design recommendations are to allow for 0.5 inch space beyond the longest toe knowing that the longest toe may be the second toe not the great hallux. Allow for adequate width and depth for the toes to spread. Ensure that there is adequate ball width and check for heel-to-ball fit. Shoes should match the shape of the foot. Feet should be measured with a brannock foot measurer, or other device to ensure proper size and fit. Shoes should be fitted in the afternoon to allow for foot edema. Patients should stand and walk when being fitted for new shoes. Socks and stockings that would normally be worn with the shoes should be worn fitting new shoes. Both feet should be measured, and shoes fitted to the larger foot. Wearing of new shoes should be increased gradually 1-2 hours at a time with a routine foot inspection to check for areas of pressure following each wear session. Commercially available shoes should be made of natural materials such as leather or suede. Match the size and shape of the foot (rounded toe boxed toes). Have cushioned outer soles and removable inner soles with a deep toe box (should be able to pinch up shoe material at toe box). Shoes should be able to be secured with laces, Velcro, or hook/loop fasteners. People with diabetes are eligible for a therapeutic shoe bill – with the diagnosis of DM and one or more of the following –
•HX of partial or complete foot amputation
•HX of previous foot ulceration
•Current foot ulceration
•HX of pre-ulcerative callus formation
•Documented neuropathy with evidence of callus formation
•Poor or impaired circulation
The therapeutic benefits of foot care and massage are numerous. Interventions include skin care to manage hyperkeratotic lesions to include corns, calluses, and fissured heels, nail care to reduce hypertrophic nails due to onychomycosis or trauma. Managing an ingrown/ingrowing toenail before it becomes infected and needs to be amputated is of major concern to an individual who has poor perfusion and loss of protective sensation. Isolating macerated web spaces and treating tinea pedis before cellulitis ensues saves a foot from amputation. Identifying “hot spots” on the plantar or medial or lateral aspects of the foot due to a deformity that needs to be padded or off-loaded is critical for prevention of a wound.
Foot care involves a team effort to include a pedorthist, podiatrist, vascular surgeon, orthopedic surgeon, certified diabetic educator, physical therapist, or services of a wound care center. With therapeutic foot care – massage is can be incorporated. Gentle massage and gentle touch has been shown in the literature to help reduce anxiety, facilitate sleep, reduce pain, promote comfort, and improve circulation.
The latest evidence-based practice guidelines quoted that at least 30-40% of the People with Diabetes are not being treated according to the evidence, and that 20-30% are receiving inappropriate and unnecessary potentially dangerous care. Foot care and gentle massage are an important intervention for people with diabetes and people of age. Many of our PWD are also our Older Population. Our demographics have changed considerably and knowledge and implementation of simple concepts that are based on evidence to improve quality of care, prevent injuries, and amputations should be incorporated in all settings. Nurses can now become board certified in Foot and Nail Care through the Wound Ostomy Nurses’ Society for more information go to www.wocncb.org or www.tayLORDhealth.com.