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Preventing Preventable Diabetes Foot Disease
Part 2: Are Education and Shoes the Solution?
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Last week, I lamented the difficulties of treating the almost entirely preventable lower extremity complications of diabetes. I introduced one of my patients, who was admitted with a lower extremity infection that required surgery. We discussed some of the poor statistics associated with diabetic extremity complications, and I pointed out various steps in the process where we have opportunities to intervene. I then promised to have THE SOLUTION this week.
Well, friends, I can tell you with absolute certainty that I don’t have the solution to this very large and expensive problem. What? Were you actually expecting me to singlehandedly solve one of the largest problems facing our diabetic patients today? Ha!
All kidding aside, this is a large multifactorial problem that will require a multifaceted approach incorporating both health care professionals and our patients. Let’s take a look at some of the current prevention methods, and maybe we can together come up with strategies to help our patients.
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Is Education Effective?
Let’s talk first about education. Most of us spend significant amounts of time educating our patients about their various illnesses, and this remains an important part of medical care. However, with all that time we spend does the research bear out the effectiveness of education?
In December of 2014, the Cochrane Review published an analysis to assess the effectiveness of education in preventing diabetic foot ulcers.1 Their meta-analysis included 12 randomized controlled trials (5 of which had education effects as a primary endpoint). Two of these studies were found to be sufficiently powered, and only one of the 12 studies was found to be at low risk for bias. Overall, the reviewers found that education alone does not reduce ulcer or amputation rates. In fairness, it should be mentioned that some of the studies did show some decrease in ulcer and amputation with education, though they had significant methodological problems. Clearly more research needs to be done.
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“Unfortunately, current research shows education alone does not reduce ulcer or amputation rates. We should certainly, however, continue to educate our patients, even if the outcomes are not yet measureable.”
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There are several reasons why education might not prevent ulceration. For example, preventing or treating diabetic foot ulcers is, in many cases, a complex process in which patients might not truly understand the import significance of a foot ulcer after education. Additionally, various other barriers such as lack of clinical time to fully explain the problem, foreign language and social issues may also play a role. A patient with a right foot ulcer that lives alone and must drive himself to get food will be unable to comply with offweighting measures such as a total contact cast. Despite this, it would be ridiculous to suggest we not educate our patients.
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Shoes for Prevention
Do shoes prevent ulceration? Is the federal government correct in continuing to fund the diabetic shoe program? A recent systematic review by researchers on behalf of the International Working Group on the Diabetic Foot looked at the current literature in reference to four interventions: casting, footwear, surgical offloading and others (such as bedrest or wheelchairs).2 Their primary outcomes were ulcer prevention, ulcer healing and pressure reduction. We’ll focus our discussion here on ulcer prevention with shoes. They found 20 research studies (7 RCTs, 4 cohort studies, and 9 non-controlled studies) that looked at therapeutic shoes.
The researchers found the following two general conclusions (I recommend reading this well-done study for the details):
1. Prescription therapeutic shoes do indeed prevent foot ulcers compared with nonprescription shoes.
2. Prescription shoes work better when they are worn by patients for most of their steps during a day.
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“Prescription therapeutic shoes do indeed prevent foot ulcers compared with nonprescription shoes. That’s one solution we can depend on. ”
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These results seem obvious, but it is important for all of us to have well-designed studies actually demonstrate the efficacy of therapeutic shoes for ulcer prevention (especially considering how much money is spent on them). The crux, though, really is in detail #2: patients actually have to wear the shoes.
Armstrong and associates performed a prospective longitudinal study of 20 diabetic patients with either neuropathy and deformity or a prior ulcer history. Patients wore a pedometer for seven days, logged times entered and exited their homes and filled out a questionnaire. They found that 85% of patients wore prescribed shoes when outside the home. Sounds ok, right? Wrong. It turns out only 15% of patients wore their prescribed shoes when inside the home.3 To put this in perspective, they took more steps per day when in the home. The shoes clearly don’t do any good if the patients don’t wear them during the times they are most ambulatory.
Education and shoes. Two prevention methods for our diabetic patients with clear difficulties. These methods rely almost completely on a partnership between the doctor and patient to have any chance of success. Next week, we’ll consider a couple of other prevention options that lean more heavily on the physician, and we’ll finish up this little series with an overview of the whole process and some suggestions to help improve our prevention outcomes.
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