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“Finally healed”: that was the easy bit!

Dear all, I hope you are all keeping well in these trying circumstances! Here are a few of the recent key diabetic foot publications. The main paper I want to bring your attention to is a review of a very important facet of diabetic foot management (Mueller, 2020). In my opinion, this topic is sub-optimally addressed clinically and certainly within the literature. It is a brief review of post-ulcer mobilisation and was published as part of the proceedings of the diabetic foot symposium held in the Hague last year. I recommend that you read all of the contributions in the Diabetes and Metabolic Syndrome journal (2020: 14(4)).

Dear all, I hope you are all keeping well in these trying circumstances! Here are a few of the recent key diabetic foot publications. The main paper I want to bring your attention to is a review of a very important facet of diabetic foot management (Mueller, 2020). In my opinion, this topic is sub-optimally addressed clinically and certainly within the literature. It is a brief review of post-ulcer mobilisation and was published as part of the proceedings of the diabetic foot symposium held in the Hague last year. I recommend that you read all of the contributions in the Diabetes and Metabolic Syndrome journal (2020: 14(4)).

There are lots of publications about treating diabetic foot ulcers from wound care dressing studies, surgery, etc, but very few on a structured approach to relapse prevention. This paper suggests a 5-point approach to safe and effective foot ulcer rehabilitation. It is based on available evidence, which sadly is sparse and not without bias. It is in keeping with the International Working Group on the Diabetic Foot guidelines, here, to develop post-ulcer service provision. I can hear you saying “wait a minute, we all do this …” but consider that 40% and 60% ulcers relapse in years 1 and 3, respectively. We are getting it universally wrong.

What does Mueller suggest? Firstly, that gradually reducing offloading should continue for 1–3 months after healing with special attention within month one. It recommends offloading for 1–2 hours a day with inspection, slowly increasing until the foot can tolerate full-time shoe wearing by 30 days. There is no guide on how to increase the time of shoe weight-bearing. The second recommendation is to wear properly fitting therapeutic shoes that reduce excessive stresses and protect the foot. Several papers show the effectiveness of therapeutic footwear but we must bear in mind that compliance, ‘correct fitting’ and availability are all crucial.

Although the author doesn’t specify, I would recommend this includes tailored insoles too. The next recommendation is to slowly increase activity level (steps/day); again, this appears logical, and perhaps an overlooked concept. However, there is no evidence on how to do this or, in fact, that this prevents re-ulceration. Reportedly, a fortnightly 10% increase in step count is an effective way to increase activity in those with neuropathy (Mueller et al, 2013). However, during this randomised study, 4 out of 13 subjects developed a foot ulcer. The fourth recommendation is to avoid large variations in steps per day. We know from a few studies that newly healed ulcer sites appear to have considerably reduced stress tolerance and so are easily damaged (Lott et al, 2005; Lazzarini et al, 2019). Hence, this concept would appear to be sensible, although not evidence-based. The last recommendation is for patient education on self-care, particularly regarding daily visual foot inspection either by patients or caregivers during and post remobilisation. This is common sense but also evidence suggests unperceived pre-ulcerative lesions can be halted when a patient becomes aware and protects them.

Ulcer relapse is a huge global problem. While these recommendations give a framework to structure relapse prevention services, more research is needed. Additionally, and this is only my perspective, unless we identify the component ulcer aetiologies, we will fail. Although neuropathy is a large player, it is only part of the problem. In relapse and new ulcer prevention, my question is “why do 66–81% NOT ulcerate?” I think this is a useful team discussion paper for foot ulcer service review and development.

Lazzarini PA, Crews RT, van Netten JJ et al (2019) Measuring plantar tissue stress in people with diabetic peripheral neuropathy: a critical concept in diabetic foot management. J Diabetes Sci Technol 13(5): 869–80
Lott DJ, Maluf KS, Sinacore DR, Mueller MJ (2005) Relationship between changes in activity and plantar ulcer recurrence in a patient with diabetes mellitus. Phys Ther 85(6): 579–88
Mueller MJ, Tuttle LJ, Lemaster JW et al (2013) Weight-bearing versus non-weight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial. Arch Phys Med Rehabil 94(5): 829–38
Mueller MJ (2020) Mobility advice to help prevent re-ulceration in diabetes. Diabetes Metab Res Rev 36(Suppl 1): e3259 

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