April 2020

Preventing Re-ulceration in Diabetes

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In a recent short review, Michael J. Mueller, PT, PhD, FAPTA, provided 5 evidence-based suggestions for helping patients with diabetes and peripheral neuropathy (PN) safely and effectively increase their mobility after a healed foot ulcer. Mueller is a professor of physical therapy and radiology at Washington University School of Medicine in St. Louis.

In general, patients with healed foot ulcers also have multiple medical co-morbidities, including complications from diabetes that affect the cardiovascular system, the kidneys, the eyes, and most significantly, the peripheral nerves. In addition, the rate of re-ulceration is quite high for this population, from 40% at 1 year, to 60% at 3 years, and 65% at 5 years.

Adding to the health challenges, this group averages only 2000 steps per day (compared to those with diabetes, PN, and no ulcer at twice as many steps, and healthy controls at 4-5 times as many). While there is an association between high plantar pressures and neuropathic plantar skin breakdown, many experts believe that the skin tissues become less tolerant to everyday physical stresses due to disease progression combined with the reduction in weight-bearing activities after initial ulceration.

Newer evidence is showing that structured interventions can lead to high step counts and improved foot outcomes in patients with diabetes and PN. This newer evidence has led to changes in guidelines from both the American Diabetes Association and the International Working Group on the Diabetic Foot. The challenge that Mueller sought to answer in his review: how to safely resume and even enhance activity in this set of patients, considering existing foot deterioration (which allowed the ulcer to develop in the first place), prolonged immobilization and inactivity and the subsequent further deterioration and stress intolerance of the foot?

His overriding principle: progress slowly and consistently over the first 3 months after off-loading. Here’s the 5 steps he identified.

Because most ulcers recur in the first 3 months after healing, and particularly in the first month, carefully limit the initiation of activity while continuing moderate-to-maximum off-loading. The sharp increase in activity, he writes, is a likely contributor to early re-ulceration. Citing Brand’s emphasis on continued protection during healing, Mueller notes that the connective tissues around the wound continue to mature for weeks and months after the wound’s initial closure. He suggests weaning patients from off-loading devices for 1-2 hours per day, with that time spent in therapeutic footwear; this allows the foot to tolerate small amounts of plantar pressure for a limited time each day. Then, over the course of 20-30 days, slowly increase the amount of time each day spent in the therapeutic shoes until the patient can tolerate a full day’s wear. Both feet should be examined daily for any signs of redness or unusual skin issues.

Patients should transfer from the off-loading device into therapeutic footwear. These shoes should fit properly, accommodate the unique shape of the patient’s foot, and provide relief from plantar pressures. In accordance with Brand’s recommendation for a “healing shoe” – a shoe that can be worn specifically during this time, and mainly at home for recovery, Mueller notes that a second pair of shoes is also listed in newer guidances.

Citing prior work, Mueller recommends increasing average daily step count by approximately 10% every 2 weeks. This works in line with the idea of gradually weaning from the off-loading device while still maintaining daily visual inspections of the feet. He notes this may not be possible in patients with a severe deformity and recommends they be encouraged to meet activity goals by riding a stationary bicycle or swimming with protective pool shoes.

Research shows that the tissue in newly healed wounds has a limited capacity for stress tolerance, meaning sudden changes in cumulative stress can lead to skin failure. As such, Mueller advises that patients should avoid large daily variations in weight-bearing activities. He suggests that wheelchairs or scooters might be considered for one-day excursions that can’t be postponed until the transition phase is over. Additionally, referrals for physical therapy to improving strength, joint mobility, and overall activity might be considered.

Previous research has shown that pre-ulcerative lesions can be stopped from developing into ulcers once patients and their caregivers know what to look for. Advising patients on how to visually inspect their feet every day is key to this type of prevention. Daily inspection allows patients to identify skin changes, redness, or inflammation before they become significant problems.

Source: Mueller MJ. Mobility advice to help prevent re-ulceration in diabetes. Diabetes Metab Res Rev. 2020;36(S1):e3259.

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