Search Results
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)
Through a discussion of the etiology and pathology of diabetic foot lesions with particular emphasis on ulceration and osteoarthropathy, the author will develop a plan for treatment and prevention using a multidisciplinary approach to such problems. Underlying risk factors including neuropathy, ischemia, infection, and, especially high pressures must be evaluated and appropriately ameliorated in order to promote resolution and avoidance of recidivism. Accordingly, conservative management with pressure-relieving devices, topical therapies, and prophylactic surgery on structural deformities plays an integral part in the overall podiatric management of the high-risk foot in diabetes mellitus.
Background:
We sought to determine the prevalence of lower-extremity arterial calcification in a cohort of patients with diabetes and associated foot pathology receiving inpatient treatment at an urban US tertiary health-care system.
Methods:
The primary outcome measure was defined as either radiographic evidence of vessel calcification or noninvasive vascular testing that resulted in any reporting of vessel noncompressibility or an ankle-brachial index greater than 1.1. Radiographic evidence of vessel calcification was defined as radiodense calcification in the proximal first intermetatarsal space (deep plantar perforating artery), anterior ankle (anterior tibial artery), or posterior ankle (posterior tibial artery) on dorsoplantar and lateral foot projections.
Results:
Of the 367 individuals included in the study, 359 underwent radiography, with radiographic evidence of calcification in 192 (53.5%). Noninvasive vascular testing was performed on 265 participants, with any reporting of noncompressibility or an ankle-brachial index greater than 1.1 observed in 153 (57.7%). Ninety-four participants (25.6%) demonstrated evidence of arterial calcification on the radiographs and noninvasive testing, meaning that 251 participants (68.4%) demonstrated evidence of arterial calcification on at least one test, including 63.6% of participants classified as black/African American race, 65.4% as white race, and 78.3% as Hispanic/Latino ethnicity.
Conclusions:
The results of this investigation increase the body of knowledge with respect to the evaluation and treatment of diabetic foot disease and may lead to future investigations on the topic of lower-extremity arterial calcification.
Background:
In this explorative study, we assessed the effect and feasibility of using motivational interviewing to improve footwear adherence in persons with diabetes who are at high risk for foot ulceration and show low adherence to wearing prescribed custom-made footwear.
Methods:
Thirteen individuals with diabetes, ulcer history, and low footwear adherence (ie, <80% of steps taken in prescription footwear) were randomly assigned to standard education (ie, verbal and written instructions) or to standard education plus two 45-min sessions of motivational interviewing. Adherence was objectively measured over 7 days using ankle- and shoe-worn sensors and was calculated as the percentage of total steps that prescribed footwear was worn. Adherence was assessed at home and away from home at baseline and 1 week and 3 months after the intervention. Feasibility was assessed for interviewer proficiency to apply motivational interviewing and for protocol executability.
Results:
Median (range) baseline, 1-week, and 3-month adherence at home was 49% (6%–63%), 84% (5%–98%), and 40% (4%–80%), respectively, in the motivational interviewing group and 35% (13%–64%), 33% (15%–55%), and 31% (3%–66%), respectively, in the standard education group. Baseline, 1-week, and 3-month adherence away from home was 91% (79%–100%), 97% (62%–99%) and 92% (86%–98%), respectively, in the motivational interviewing group and 78% (32%–97%), 91% (28%–98%), and 93% (57%–100%), respectively, in the standard education group. None of the differences were statistically significant. Interviewer proficiency was good, and the protocol could be successfully executed in the given time frame.
Conclusions:
Footwear adherence at home increases 1 week after motivational interviewing to clinically relevant but not statistically significant levels (ie, 80%) but then returns over time to baseline levels. Away from home, adherence is already sufficient at baseline and remains so over time. The use of motivational interviewing seems feasible for the given purpose and patient group. These findings provide input to larger trials and provisionally suggest that additional or adjunctive therapy may be needed to better preserve adherence.
The coronavirus disease of 2019 pandemic is driving significant change in the health-care system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, emergency room visits, hospitalizations, length-of-stay, and costs. However, podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the coronavirus disease of 2019 risk. The goal of podiatrists during the pandemic is to reduce the burden on the health-care system by keeping diabetic foot and wound patients safe, functional, and at home.
Foot Complications and Mortality
Results from Translating Research Into Action for Diabetes (TRIAD)
Background: We sought to study the impact of foot complications on 10-year mortality independent of other demographic and biological risk factors in a racially and socioeconomically diverse managed-care population with access to high-quality medical care.
Methods: We studied 6,992 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Foot complications were assessed using administrative claims data. The National Death Index was searched for deaths across 10 years of follow-up (2000-2009).
Results: Charcot's neuro-osteoarthropathy and diabetic foot ulcer with debridement were associated with an increased risk of mortality; however, the associations were not significant in fully adjusted models. Lower-extremity amputation (LEA) was associated with an increased risk of mortality in unadjusted (hazard ratio [HR], 3.21; 95% confidence interval [CI], 2.50–4.12) and fully adjusted (HR, 1.84; 95% CI, 1.28–2.63) models. When we examined the associations between LEA and mortality stratified by sex and race, risk was increased in men (HR, 1.96; 95% CI, 1.25–3.07), Hispanic individuals (HR, 5.17; 95% CI, 1.48–18.01), and white individuals (HR, 2.18; 95% CI, 1.37–3.47). In sensitivity analyses, minor LEA tended to increase the risk of mortality (HR, 1.48; 95% CI, 0.92–2.40), and major LEA was associated with a significantly higher risk of death at 10 years (HR, 1.89; 95% CI, 1.18–3.01).
Conclusions: In this managed-care population with access to high-quality medical care, LEA remained a robust independent predictor of mortality. The association was strongest in men and differed by race.
The author describes an effort that demonstrates a successful partnership between a professional education program in podiatric medicine, the Pennsylvania State Health Department, and the Professional Diabetes Academy, which served as the catalyst for health promotion, prevention, and education. Similar programs through adaptations geared to local resources could be developed as a demonstration of direct secondary prevention of the complications of diabetes in the older population and have the potential to help meet national goals to significantly reduce amputations.
Forty-nine consecutive subjects with established diabetic peripheral neuropathy were treated with monochromatic near-infrared photo energy (MIRE) to determine if there was an improvement of sensation. Loss of protective sensation characterized by Semmes-Weinstein monofilament values of 4.56 and above was present in 100% of subjects (range, 4.56 to 6.45), and 42 subjects (86%) had Semmes-Weinstein values of 5.07 or higher. The ability to discriminate between hot and cold sensation was absent (54%) or impaired (46%) in both groups prior to the initiation of MIRE treatment. On the basis of Semmes-Weinstein monofilament values, 48 subjects (98%) exhibited improved sensation after 6 treatments, and all subjects had improved sensation after 12 treatments. Therefore, MIRE may be a safe, drug-free, noninvasive treatment for the consistent and predictable improvement of sensation in diabetic patients with peripheral neuropathy of the feet. (J Am Podiatr Med Assoc 92(3): 125-130, 2002)
