Inside perspective: the role of the podiatrist in diabetes

Inside perspective: the role of
the podiatrist in diabetes
Christine Kiernan
Access to podiatry services is of paramount importance in managing potential
and established foot problems related to diabetes
Patients with poorly controlled diabetes are at a significant risk for foot ulceration, which has become a major predictor
of lower limb amputation.1 The role of the podiatrist in the management of foot problems has been identified in recent years. It
may be argued that access to podiatry services is of paramount
importance in managing potential or established foot problems
related to diabetes, and recent studies suggest that access to
podiatry care can reduce the economic burden of diabetic foot
ulcers in prevention and treatment.2
Gabbay et al3 suggest that podiatrists have a significant opportunity to explore motivational approaches to empower
patients in changing behaviour which may improve quality of
care and patient outcomes. This involves eliciting patients’ own
intrinsic motivation for making necessary changes. As podiatrists are on the frontline of foot care, a combination of appropriate education, support and guidance can help increase
patient motivation.
The classical barriers to healing arising from diabetic foot
wounds include a deterioration of the vascular and/or the neurological status of the patient owing to a deterioration of glycaemic control which may be further complicated by a history
of hyperlipidaemia and smoking. It is for these reasons that
strong links must be formed with all care providers as the cause
for ulceration is often multifactorial, which requires multidisciplinary care.
Nube et al4 cited that a history of foot ulceration, ischaemia
and foot deformity were significant predictors for re-ulceration.
A complication of autonomic and sensory neuropathy can lead
to an alteration in the structure of the foot which may lead to
areas of high pressure which often results in ulceration.
Diabetic foot wounds are frequently treated in a multidisciplinary diabetes clinic. It is thought that the podiatrist contributes
to the prevention and management of diabetic foot problems
as follows:
•Adds to the patient education programme
•Early detection of vascular and neurological deterioration
•Biomechanical assessment
•Risk stratification
•Wound management and provision of sharp debridement.
Foot ulceration in diabetes can lead to lengthy hospital stays.
As trauma is frequently considered to be a significant precipitator to ulceration, correctly identifying an area of increased pressure could reduce the event of ulceration. Footwear is often
a strong contributor to the development of ulceration in the
insensate foot. Foot ulcers caused by footwear often present on
both feet in the same anatomical region, ie. bilateral subungual
haematoma.
When identified, it is often beneficial to classify a foot ulcer
using a recognised wound classification system, such as Texas or
Wagner, as this will help assess the need for specialist intervention. A review of the response to treatment will also assist in
developing care programmes.
Diabetic foot ulcers are treated in both community and hospital settings. A strong link to support networks in a hospital setting can provide vital assistance in rapid access to the following
services:
• Radiology
• Laboratory tests
• Vascular team
• Endocrinology team
• Community podiatry
• Orthotist – semi/fully bespoke footwear
• Tissue viability and wound care – community health clinic
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Table 1
Summary of recommendations, National Diabetes Working Group, 2010 Risk Group
Risk group
Risk category
Foot examination frequency
Examiner
Green
Low risk
Annual
Primary care nurse or GP
Amber
At risk (moderate-risk category) Annual or more frequently (as per
individual requirements)
GP/primary care nurse/community podiatrist/hospital diabetes clinic
Pink
At risk (high-risk category)
Annual or more frequently in specialised clinic and community clinic
(as per individual requirements)
GP/primary care nurse/community podiatrist (plus
formal annual review by foot protection team
podiatrist)
Red
Active foot disease
At least once weekly or as required
by a member of the diabetes multidisciplinary team
Foot protection team/ diabetes multidisciplinary
team
• Acute care – additional needs.
Access to the above services will allow expert assessment and
emergency management where indicated. In the case of active
foot disease (see Table 1), patients can also access specific debridement services with appropriate off-loading devices, such as
specialised casting, where required.
The use of radiology services and laboratory blood tests can
determine the difference between the pathological changes involved in the Charcot foot and osteomyelitis.
Where infection is suspected, it is helpful to swab any presenting exudate to isolate organisms. The choice of antibiotic
will often depend on the clinical severity of the wound, if there
is discomfort, substantial discharge or odour or if there is an
epidemiologically significant coloniser. It is also important to assess the vascular status of the patient and if there is possibility of
bony involvement.5,6
Timmins and Chadwick7 have identified the following core elements as essential to wound-healing in foot ulceration:
• Off-loading
• Debridement
• Re-vascularisation
• Infection control.
Appropriate dressing selection can also advance the wound
healing process although, as the authors note, in the absence of
the elements listed a dressing is unlikely to compensate.
Table 1 provides a comprehensive tool to assist in assessing and
stratifying individual patient needs in order to provide a patient
with a management plan:
Whether new patients present with a diabetic foot ulcer to a
GP surgery, a community health centre or a hospital setting, it is
vital that a brief vascular and neurological assessment takes place.
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The importance of an educational programme is often underestimated and may help prevent the development of future ulceration if implemented appropriately.
Check the location of the wound to assist in determining the
cause and assess the wound using a recognised classification system. Early detection and treatment can lead to favourable outcomes and increased patient empowerment. f
Christine Kiernan is a podiatrist with the adult diabetes
services team in Tallaght Hospital, Dublin
References
1. Jeffcoate WJ, Harding KG. Diabetic foot ulcers, Lancet, 2003; 361(9368): 15451551
2. Carls G, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, DeFrancis RR, Wang S,
Bagalman JE, Christina JR.The Economic value of specialised lower-extremity medical care by Podiatric physicians in the treatment of diabetic foot ulcers, Journal of
the American Podiatric Medical Association, 2011; 101(2): 93-115
3. Edmonds M. Best treatment care pathways for diabetic foot patients in primary
and secondary care, The Diabetic Foot Journal, 2007;10(4)
4. Gabbay RA, Kaul S, Ulbrecht J, NM Scheffler, Armstrong DG. Motivational interviewing by Podiatric physicians, Journal of the American Podiatric Medical Association, 2011; 101(1): 78-84
5. Table 1 Recommendations, National Diabetes Working Group, June 2010
6. Leese G, Nathwani D,Young M (et al.). Use of antibiotics in people with diabetic
foot disease: a consensus statement, The Diabetic Foot Journal, 2009; 12: 62-74
7. Nube V, Molyneux L, Constantino M, Bolton T, Mc Gill M, Chua E, Twig S, Yue D.
Diabetic foot ulceration: why are some patients in a revolving door? The Diabetic
Foot Journal, 2008; 14(4)
8. Timmons J, Chadwick P. Right product, right wound, right time?, The Diabetic Foot
Journal, 2010; 13(2)
9. The Infectious Disease Society of America sourced from: www.idsociety.org
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