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Motivational Interviewing by Podiatric Physicians
A Method for Improving Patient Self-care of the Diabetic Foot
Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes. Despite agreement that diabetic foot self-care is a key factor in prevention of ulcers and amputation, there has only been limited success in influencing these behaviors among patients with diabetes. While most efforts have focused on increasing patient knowledge, knowledge and behavior are poorly correlated. Knowledge is necessary but rarely sufficient for behavior change. A key determinant to adherence to self-care behavior is clinician counseling style. Podiatrists are the ideal providers to engage in a brief behavioral intervention with a patient. Motivational interviewing is a well-accepted, evidence-based teachable approach that enhances self-efficacy and increases intrinsic motivation for change and adherence to treatment. This article summarizes some key strategies that can be employed by podiatrists to improve foot self-care. (J Am Podiatr Med Assoc 101(1): 78–84, 2011)
Maggot Therapy in “Lower-Extremity Hospice” Wound Care
Fewer Amputations and More Antibiotic-Free Days
We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean ± SD age, 72.2 ± 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease. Twenty-seven of these patients (45%) healed during 6 months of review. There was no significant difference in the proportion of patients healing in the maggot debridement therapy versus control group (57% versus 33%). Of patients who healed, time to healing was significantly shorter in the maggot therapy than in the control group (18.5 ± 4.8 versus 22.4 ± 4.4 weeks). Approximately one in five patients (22%) underwent a high-level (above-the-foot) amputation. Patients in the control group were three times as likely to undergo amputation (33% versus 10%). Although there was no significant difference in infection prevalence in patients undergoing maggot therapy versus controls (80% versus 60%), there were significantly more antibiotic-free days during follow-up in patients who received maggot therapy (126.8 ± 30.3 versus 81.9 ± 42.1 days). Maggot debridement therapy reduces short-term morbidity in nonambulatory patients with diabetic foot wounds. (J Am Podiatr Med Assoc 95(3): 254–257, 2005)
Addressing pressure reduction in the treatment of diabetic foot wounds is a critical component of therapy. The total-contact cast has proven to be the gold standard of treatment because of its ability to reduce pressure and facilitate patient adherence to the off-loading regimen. Removable cast walkers have proven to be as effective as total-contact casts in pressure reduction, but this has not translated into equivalent time to healing. A simple technique to convert the removable cast walker into a device that is not as easily detached from the lower extremity, thereby encouraging the use of this device over a 24-hour period, is presented in this article. The procedure involves wrapping the cast walker with cohesive bandage or plaster of Paris. In the authors’ opinion, this technique addresses many of the disadvantages of the total-contact cast, resulting in an adequate compromise in this aspect of care. (J Am Podiatr Med Assoc 92(7): 405-408, 2002)
Wound debridement, when systematically performed, may be as important as off-loading in reducing the prevalence of chronic inflammatory by-products in a wound and thus in converting a chronic wound into an acute one. Although it has been suggested that aggressive surgical debridement of wounds may be beneficial, there have been few, if any, technical descriptions of this aspect of therapy. It is therefore the purpose of this article to describe the general principles, process, and technique of outpatient surgical debridement of noninfected, nonischemic neuropathic diabetic foot wounds performed at the authors’ institutions. The authors hope to foster further discussion leading to improvement in the process and the prevalence of such debridement. (J Am Podiatr Med Assoc 92(7): 402-404, 2002)
Maggot Debridement Therapy
A Primer
Treatment of chronic wounds of the lower extremity requires a systematic, multidisciplinary approach as well as flexibility in order to achieve acceptable, consistent short-term and long-term results. Maggots, once considered an obsolete therapeutic modality, can be a useful addition to the armamentarium of the foot and ankle specialist. This article describes the use of maggot debridement therapy for intractable wounds of the lower extremity. (J Am Podiatr Med Assoc 92(7): 398-401, 2002)
Verrucous Hyperplasia
A Common and Problematic Finding in the High-Risk Diabetic Foot
Although verrucous hyperplasia may be common in high-risk insensitive feet, the literature contains little discussion on this topic. Treatment of verrucous hyperplasia is aimed primarily at reducing the causative forces. In cases that result from edema, external compression has proved to be adequate. If verrucous hyperplasia on the foot results from frictional forces, then shoe modifications with proper fit, accommodative liners, or fillers in the case of amputation are necessary. In recalcitrant cases, excision of the affected tissue with local soft-tissue or graft coverage has been successful. We describe a 56-year-old man with verrucous hyperplasia. (J Am Podiatr Med Assoc 96(4): 348–350, 2006)
This study evaluated changes in pressure imparted to diabetic foot wounds using a novel negative pressure bridging technique coupled with a robust removable cast walker. Ten patients had plantar pressures assessed with and without a bridged negative pressure dressing on the foot. Off-loading was accomplished with a pressure-relief walker. Plantar pressures were recorded using two pressure-measurement systems. The location and value of peak focal pressure (taken from six midgait steps) were recorded at the site of ulceration. Paired analysis revealed a large difference (mean ± SD, 74.6% ± 6.0%) between baseline barefoot pressure and pressure within the pressure-relief walker (mean ± SD, 939.1 ± 195.1 versus 235.7 ± 66.1 kPa). There was a mean ± SD 9.9% ± 5.6% higher pressure in the combination device compared with the pressure-relief walker alone (mean ± SD, 258.0 ± 69.7 versus 235.7 ± 66.1 kPa). This difference was only 2% of the initial barefoot pressure imparted to the wound. A modified negative pressure dressing coupled with a robust removable cast walker may not impart undue additional stress to the plantar aspect of the foot and may allow patients to retain some degree of freedom (and a potentially reduced length of hospital stay) while still allowing for the beneficial effects of negative pressure wound therapy and sufficient off-loading. (J Am Podiatr Med Assoc 94(5): 456–460, 2004)
Background: Exercise has not been studied extensively in persons with active neuropathic diabetic foot wounds, primarily because a device does not exist that allows patients to exercise while sufficiently off-loading pressure at the ulcer site. The purpose of this project was to demonstrate a device that reduces cycling plantar forefoot pressure.
Methods: Ten healthy participants rode a recumbent bicycle under three cycling conditions. While the left foot interaction remained constant with a standard gym shoe and pedal, the right foot was exposed to a control condition with standard gym shoe and pedal, gym shoe and specialized cleat, and gym shoe with an off-loading insole and specialized cleat. Pressure and contact area of the plantar aspect of the feet were recorded for a 10-sec interval once during each minute of each condition’s 7-min trial.
Results: The off-loading insole and specialized cleat condition yielded significantly lower (P < .01) peak pressure, contact area, and pressure–time integral values in the forefoot than the specialized cleat condition with gym shoe, which yielded significantly lower values (P < .01) than the standard gym shoe and pedal.
Conclusion: Modifications to footwear may alter plantar forefoot pressures, contact area, and pressure–time integrals while cycling. The CLEAR Cleat could play a significant role in the facilitation of fitness in patients with (or at high risk for) neuropathic wounds. (J Am Podiatr Med Assoc 98(4): 261–267, 2008)
Foot Problems in Older Adults
Associations with Incident Falls, Frailty Syndrome, and Sensor-Derived Gait, Balance, and Physical Activity Measures
Background:
Research on foot problems and frailty is sparse and could advance using wearable sensor–based measures of gait, balance, and physical activity (PA). This study examined the effect of foot problems on the likelihood of falls, frailty syndrome, motor performance, and PA in community-dwelling older adults.
Methods:
Arizona Frailty Cohort Study participants (community-dwelling adults aged ≥65 years without baseline cognitive deficit, severe movement disorders, or recent stroke) underwent Fried frailty and foot assessment. Gait, balance (bipedal eyes open and eyes closed), and spontaneous PA over 48 hours were measured using validated wearable sensor technologies.
Results:
Of 117 participants, 41 (35%) were nonfrail, 56 (48%) prefrail, and 20 (17%) frail. Prevalence of foot problems (pain, peripheral neuropathy, or deformity) increased significantly as frailty category worsened (any problem: 63% in nonfrail, 80% in prefrail [odds ratio (OR) = 2.0], and 95% in frail [OR = 8.3]; P = .03 for trend) due to associations between foot problems and both weakness and exhaustion. Foot problems were associated with fear of falling but not with fall history or incident falls over 6 months. Foot pain and peripheral neuropathy were associated with lower gait speed and stride length; increased double support time; increased mediolateral sway of center of mass during walking, age adjusted; decreased eyes open sway of center of mass and ankle during quiet standing, age adjusted; and lower percentage walking, percentage standing, and total steps per day.
Conclusions:
Foot problems were associated with frailty level and decreased motor performance and PA. Wearable technology is a practical way to screen for deterioration in gait, balance, and PA that may be associated with foot problems. Routine assessment and management of foot problems could promote earlier intervention to retain motor performance and manage fear of falling in older adults, which may ultimately improve healthy aging and reduce risk of frailty.
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.
Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
