Peripheral Neuropathy and Weight-Bearing Exercise Such as Walking

 

The traditional clinical view has discouraged weight-bearing activity such as walking for people with diabetic peripheral neuropathy. The presumption was that weight-bearing activities increase the risk of foot ulcers among patients with diabetes and insensate feet. This advice forced people with diabetic neuropathy into a big dilemma: you need to exercise to stay healthy, but you also need to reduce repetitive loading on your feet.

The recognition of the overall importance of exercise for people with diabetes continues to grow. The American Diabetes Association (ADA) now makes these general recommendations for people with Type 2 diabetes:

• Get at least 150 minutes per week of moderate intensity aerobic physical activity. The ADA defines moderate intensity as 50-70% of maximum heart rate.
• Perform resistance training (weight lifting for example) 3 times a week unless a patient’s other medical conditions counsel against it.

For people with diabetes and severe peripheral neuropathy, the ADA says “it may be best to encourage non-weigh-bearing activities such as swimming, bicycling, or arm exercises.” ADA Standards of Medical Care in Diabetes – 2009.

What about this advice from the ADA? In weighing this advice, practitioners should also consider several recent studies. Two descriptive studies indicate that patients with diabetes and insensate feet who engage in daily activity decrease their risk of foot ulceration compared to those who are less active. LeMaster et al. 2003; Armstrong et al. 2004. A more recent, randomized controlled trial found that promoting weight-bearing activity did not lead to increases in foot ulcers among people with diabetic neuropathy. LeMaster et al. 2008. (follow links to get free copy of full article.)

If you have diabetic peripheral neuropathy, you should discuss this topic with your podiatrist and other health care providers. Don’t hesitate to provide them with the LeMaster article.

Diabetic Socks – Ask Your Doctor before You Follow the Advice from the CDC

What kinds of socks should people with diabetes wear? There is lots of bad advice about diabetic socks on the worldwide web. However, you don’t expect that bad advice to come from the United States Center for Disease Control (CDC).

The CDC makes this recommendation to people with diabetes: “When you exercise, wear cotton socks and athletic shoes that fit well and are comfortable. After you exercise, check your feet for sores, blisters, irritation, cuts, or other injuries.” CDC, Exercise and Diabetes.

Is there any evidence to support this recommendation of the CDC?

Most of the research regarding sock materials has been done with socks on healthy feet. The United States military has done extensive research. The U.S. Army Center for Health Promotion and Preventive Medicine has assimilated that research and recently recommended soldiers use synthetic socks because they manage moisture better. USACHPPM Injury Prevention, Physical Training and Sports Injury Prevention Guidlines 2009.

Douglas H. Richie, Jr., DPM, recently wrote an article “Therapeutic Hosiery: an Essential Component of Footwear for the Pathologic Foot,” in Podiatry Management, Oct. 2008, pp. 125-134. After reviewing the available evidence, Dr. Richie makes this recommendation to podiatrists: “Synthetic fiber socks are preferred to natural cotton fiber socks for use by patients with pathologic feet.”

If you have diabetes, your doctor should be advising you on an exercise routine. Be sure to ask your doctor about the kind of socks you should be wearing. If your doctor is unaware of the research cited in this article, don’t be afraid to discuss it with her or him.

Patient Compliance in Diabetic Foot Care

An article I recently read in Lower Extremity Review, entitled Diabetes: Improving foot care compliance¹ discusses the challenge practitioners’ face in keeping foot care top-of-mind with their patients.

The Total Contact Cast (TCC) is the “gold standard” for healing diabetic foot ulcers.  However, very few practitioners prescribe them.  Moreover, patients are resistant to using the device consistently. The TCC is bulky and unattractive, making the resistance understandable.

Ryan Crews, the author of this article, made an interesting comment regarding the commonly misunderstood topic of calluses, stating “…many individuals consider calluses to be protective in nature. However, calluses on the feet actually result in increased pressure (similar to walking on any other hard object) and stress on the soft tissue below, thereby contributing to ulcer formation.”

While some people use lotions and files to reduce callus formation on the plantar surface of their feet, others have gone the opposite route, choosing to let calluses build up: citing protection against blisters and other skin abrasion, as the desired outcome. Based on Crew’s statement and our own experience, calluses should absolutely be reduced and prevented, whenever possible.

Ultimately, the most effective foot care solutions are those that maximize mobility (within the limits defined by one’s physician), support the healing & prevention of skin trauma, and are cosmetically acceptable.  While a TCC may be the most clinically effective at healing diabetic ulcers, it doesn’t do well on the other two requirements.

Daily foot inspection for blister, callus & ulcer development is essential to preventing complications ranging from minor skin abrasions, to infection and amputation. Keep your feet healthy by making foot care a priority.

¹ Crews, Ryan, MS, CCRP. Lower Extremity Review. Diabetes: Improving Foot Care Compliance. Volume 1, Number 4. October 2009. PP. 25-30.

November – American Diabetes Month®

 

 

November is American Diabetes Month®. Diabetes leads to life-threatening complications such as heart disease, stroke, kidney disease, blindness, and amputation.

According to the American Diabetes Association, more than one-quarter of the American population is affected by diabetes:

•24 million children and adults in the United States live with diabetes; and

•57 million Americans are at risk for type 2 diabetes.

Visit the announcement for American Diabetes Month® for more information.

Tamarack™ Fabrication Guide Series – Free Motion & Dorsiflexion Assist Flexure Joint™ Guide Now Available!

In September 2009, Tamarack^™ Habilitation Technologies finished the first phase of its “Fabrication Guide Series”, designed to assist orthotists, prosthetists & pedorthists with fabricating custom orthoses using Tamarack Flexure Joints^™. We’ve compiled frequently asked questions, fabrication pictures and application instructions from nearly 15 years of Flexure Joint^™ sales to develop this helpful “How To” guide.

The latest version of the Tamarack Flexure Joint Fabrication Guide, posted to the Tamarack website today, includes fabrication steps for both the standard “free motion” (model 740) and “dorsiflexion assist” (model 742) Tamarack Flexure Joints^™.

Although our customers have been fabricating custom & semi-custom lower & upper limb orthotic & prosthetic devices for up to 15 years with Tamarack Flexure Joints^™, the Fabrication Guide is a very useful resource for healthcare professionals and technicians who work with Tamarack^™ products.

Download the Tamarack Flexure Joint – Model 740 / 742 Fabrication Guide on the Tamarack Website, or email us to have a hardcopy mailed to your O&P facility. Visit www.tamarackhti.com for more Tamarack products & resources.

Century College Orthotics & Prosthetics Scholarship Program

Posted by Adam Erickson, PE, Manufacturing Manager

I recently attended the Century College Scholarship Banquet, where Tamarack^™ Habilitation Technologies was just one of many companies and individuals recognized for their contributions toward student scholarships.  It was a pleasure to sit side by side with the scholarship recipients, and talk to them about their class work and their excitement towards completing school, and moving on into the work place.  

There are three local organizations (Tamarack^™, Otto Bock, and the Northern Plains Chapter of AAOP) who provide a total of 6 scholarships to students in Century’s Orthotics and Prosthetics Program.  In talking to the students and faculty, the program is doing great.  The classrooms are full, and there is a modest waiting list just to get into the program.  Judging from the plethora of job posting in the back of O&P publications, their services are needed!

Tamarack has always contributed product and materials to O&P schools around the world.  It was nice to see many companies are involved in scholarship awards as well.  There are many students out there faced with the decision of affording one more semester of school.  One small scholarship can be the difference maker!

Tackle Peripheral Neuropathy Head On, Taking Preventative Steps to Avoid Diabetic Foot Ulcers, Blisters and other Skin Trauma.

A recent article in the November 2009 issue of The O&P Edge, entitled “Getting a Grip on Peripheral Neuropathy” offers detailed information on the cause, and management of the various forms of peripheral neuropathy (PN). While PN is surely not limited to diabetes, the progression the disease brings a tidal wave of concerns, many of which stem from the improper management of blood glucose levels.

While the cause and involvement levels of peripheral neuropathy are many, the takeaway from the above-mentioned article is simple. Physician-patient communication is essential to the effective management of diabetes, and related conditions. It’s the patient’s most pertinent responsibility to take precautions, including the diligent management of blood glucose levels, and daily inspection of their feet. Since PN patterns itself in ascending order, injury prevention & treatment starts at the feet.

Here are some interesting facts, presented in the “Getting a Grip on Peripheral Neuropathy” article:

• Diabetes is the leading cause of lower-limb amputations.
• According to the Amputee Coalition of America (ACA), over half of all amputations in the USA are caused by stage 2 diabetes, and related complications.
• Optimal glycemic control remains the only available measure with proven efficiency in preventing or halting the progression of diabetic neuropathy (Boucek, Petr. “Advanced Diabetic Neuropathy: A point of No Return?”. The Review of Diabetic Studies, fall 2006).

In 1998, Tamarack Habilitation Technologies introduced its low-friction interface material, ShearBan®, to the O&P community. Widely used in conjunction with traditional pressure management techniques, ShearBan reduces friction forces in areas of footwear, or an orthotic/prosthetic device, where redness, blisters, and ulcers form. While its optimal use is the prevention of skin trauma, ShearBan® also aides the healing of diabetic foot ulcers, by way of providing continual, long-lasting friction relief. ShearBan is only available to allied healthcare professionals, but a consumer-friendly form of ShearBan is available through retailers worldwide. Visit GoENGO.com to learn more about friction management with ENGO® Patches for rubbing & blister relief.

Moleskin – Review of an Outdated Foot Care Remedy.

Athletes seem to have a love / hate relationship with moleskin.  Some swear by it, while others recognize its faults, choosing to patch blisters with thinner materials that adhere and conform better to the skin.  Regardless of which side you take, I’d argue that people should stick to what works for them.  

I regularly read the Fixing Your Feet blog, a review of products that help prevent & treat common foot problems, hosted by John Vonhof, EMT-P and author of Fixing Your Feet: Prevention and Treatments for Athletes.  John has drained, patched and prevented foot blisters and other ailments at races across the world, including the ultimate – Badwater Ultramarathon.  Having read his Fixing Your Feet book and blog posts for years, I’ve developed great respect for John’s foot care remedies.  He’s patched thousands of blisters, trying every product and technique known. 

Check out John’ s recent post, detailing the disadvantages of Moleskin: Moleskin Galore

Whether you’re a professional athlete, healthcare professional or ordinary Joe or Jane, I highly recommend subscribing to the Fixing Your Feet blog – http://fixingyourfeet.com/blog/

Callus Prevention on Diabetic Feet through Friction Reduction

Recently published research out of Japan highlights the potential risk that calluses pose to people with diabetic neuropathy.

A group at the University of Tokyo looked at signs of inflammation under calluses on diabetic and non-diabetic feet (Nishide et al. 2009). The Tokyo group used ultrasonographic and thermographic imaging techniques to find evidence of traumatized tissue and elevated temperature. Even though the non-diabetic feet had more calluses, there were no signs of inflammation under the calluses on the non-diabetic feet. On the other hand, 10% of the calluses in the diabetic group had inflammation (Nashide et al. 2009).

Perhaps most concerning – inflammation under calluses may be very hard to detect. In the Nishide study, experienced wound care nurses and specialists could not identify the latent inflammation in the calluses, even though three of the five inflamed calluses had tissue damage reaching down to the muscle layer (Nashide et al. 2009).

The association between calluses and diabetic foot ulcers has long been known. Callus formation precedes ulcer formation in over 82% of patients with diabetic foot ulcers (Sage et al. 2001). Murray and co-workers reported that a callus is “highly predictive” of ulcer development (Murray et al. 1996). Therefore the link between calluses and ulcer formation seems clear.

Can calluses be prevented? Calluses form because of friction. This is well established in the scientific literature (Sanders et al. 1995; Carlson 2006). A reduction in friction therefore should slow callus formation. One way to reduce friction is to lower the coefficient of friction (COF) between surfaces – i.e., to make surfaces slide more easily in relation to each other.

Several interventions have been tried to reduce friction in footwear. They have shortcomings. Lubricating agents (such as oils, silicone, and powders) can initially decrease friction but, over time, can increase COF up to 35% above baseline (Knapik et al 1995). Materials such as moleskin have very high COFs when paired with commonly used materials such as a cotton sock is very high. (Carlson JM 2006). Socks can potentially reduce friction but the friction-relief is not targeted to the callus.

ShearBan® is a patch material that provides long-lasting, targeted relief from the harmful effects of friction. Unlike the typical bandage, ShearBan applies to footwear or other pieces of equipment. ShearBan has a surface made of a specially formulated material resembling Teflon® – the most slippery, friction fighting material known. This slippery surface should be placed opposite a callus, blister, or other hotspot to reduce friction and prevent harm to the skin. ShearBan can typically last for months inside footwear.

Another nice thing about ShearBan – a practitioner can easily try it out on her or his own feet. If you would like a free sample, please contact Tamarack.

Tamarack and Richie Announce Distribution Agreement for Richie Ulcer Guard

Tamarack Habilitation Technologies and Richie Technologies announced last Friday that we signed a distribution agreement. The agreement is for distribution of the Richie Ulcer Guard with ShearBan Technology™. The Richie Ulcer Guard is a patch designed for prevention and treatment of diabetic ulcers. Distribution efforts for the Richie Ulcer Guard will mainly focus on the podiatry market. View the full press release.