The reoccurrence of foot ulcers in the diabetic population is a common problem. It has been estimated that around 40 percent of patients with diabetes will suffer from ulcer reoccurrence within one year of healing, with this rising to 65 percent after five years.
What causes re-ulceration?
Re-ulceration can be caused by many of the factors that lead to primary ulceration, such as peripheral neuropathy, deformities of the foot and repetitive foot trauma resulting from loss of sensation.
Dr. Abd A. Tahrani, a National Institute for Health Research Clinician Scientist within the Institute of Metabolism and Systems Research at the University of Birmingham, UK, says, “Having a previous foot ulcer is the strongest predictor of developing a foot ulcer in patients with diabetes. Having peripheral vascular disease, recurrent minor trauma, minor foot lesions, smoking and poor glycemic control are amongst the predictors of foot re-ulceration in patients who have already had a diabetic foot ulceration.”
Both biological and behavioral factors may play a role in the high reoccurrence rates of diabetic foot ulcers.1 Indeed, it is important to research the role of psychobehavioral interventions in the prevention of foot problems in diabetes.
Prevention of ulcer reoccurrence
Foot problems have a significant financial burden on health services. Re-ulceration can lead to lengthy hospital admissions and even amputation. Implementing ways to effectively prevent the reoccurrence of ulcers is therefore of paramount importance.
Dr. Tahrani advises, “Preventative measures to reduce the risk of re-ulceration include the regular use of offloading measures/footwear, regular foot exam/screening, patient education, multidisciplinary care and some surgical interventions in selected patient groups. In addition, general measures such as stopping smoking and improving glycemic control and cardiovascular disease risk factors will be useful for the patient.”
Educating patients to be informed and proactive with regards to the monitoring and prevention of secondary foot problems is paramount. However, current limited research into this area suggests that targeted patient education alone is not sufficient to effectively prevent ulcer reoccurrence. Clearly, the dissemination of targeted patient information from clinicians and other health-care professionals needs to be improved. Patient education alongside treatment compliance may help to ensure the success of other interventions.
Educating patients to take better care of their feet following a foot ulceration can help prevent reoccurrence of the ulcer. Patients should be encouraged to follow a strict foot care plan, including actions such as inspecting feet daily, thoroughly washing and drying feet daily, cutting nails straight across and wearing socks at all times.
Monitoring the condition of the feet ensures the early detection of any lesions, which, if left unchecked, could result in ulceration. The International Working Group on the Diabetic Foot (IWGDF) guidelines recommend that high-risk diabetes patients monitor the skin temperature of their feet to prevent recurrent ulceration. This enables early indicators of inflammation within the foot to be detected. Research has shown that increased skin temperature of the foot is predictive of foot ulceration in people with diabetes.
While it is important for patients to be actively involved in the prevention of re-ulceration, the role that caregivers can also play should not be underestimated. The implementation of a comprehensive foot care program, carried out by professionals, has been reported to reduce the rate of re-ulceration by 40 percent.
In addition to educating patients on the importance of closely monitoring their health, caregivers should regularly monitor diabetes control, as well as check the patient’s feet for any early signs of ulceration.
The IWGDF guidelines state that caregivers should prescribe therapeutic footwear to high-risk patients to prevent foot re-ulceration by relieving plantar pressure.6 Studies have confirmed that therapeutic footwear that offloads pressure from the plantar region significantly reduces the risk of re-ulceration provided that the patient complies with its use.
Surgical techniques may be offered, which can offload plantar pressure through the correction of foot deformities. Limited research suggests that surgical offloading procedures, which help to reduce pressure across the foot, may be effective in preventing foot ulcer reoccurrence. However, more research is needed in this area to enable a better understanding of its efficacy.
There are various products on the market aimed at preventing the reoccurrence of foot ulcers in people with diabetes. There are also many new products currently being developed and tested. Smart insoles, for example, detect pressure within the foot and provide feedback to the patient in real time. These have been shown to be a cost-effective method of preventing re-ulceration in high-risk patients.
Products have also been developed to assist with the in-home monitoring of a patient’s foot temperature. As an example, Smart Mat technology shows real potential in helping to detect the development of ulceration as early as five weeks before the presentation of symptoms.
Furthermore, researchers have recently developed an iPad app that allows medical professionals to obtain consistent images of a patient’s feet. This enables them to track changes over time, alerting them to early indicators of ulceration.
What does the future hold?
Research in this area is becoming increasingly focused on interventions that target psychosocial and psychobehavioral factors. Interventions targeting these factors show potential as a means of preventing diabetic foot ulceration. Dr. Kate Greenwell, from the University of Southampton in the UK, presented her research in this area at the British Psychological Society conference in September 2018. Dr. Greenwell’s research group has developed the REDUCE maintenance approach, which is a novel cognitive-behavioral intervention. This focuses on reducing re-ulceration risk in people with diabetes by effectively managing associated emotions and behaviors. The team plans to conduct an effectiveness trial in the near future to measure the effectiveness of the REDUCE intervention.
Further research also needs to be carried out to reinforce the validity of the interventions currently recommended in the IWGDF guidelines. Additionally, research could benefit from a focus on technological advances in this area, as this shows real promise as an effective means for patient-led prevention of re-ulceration. In the meantime, there are many education-based strategies clinicians can use to help prevent re-ulceration in their patients.
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