Postmenopausal Osteoporosis-- prevention
Alternatives to estrogen replacement therapy
Estrogen improves calcium absorption and reduces the amount of calcium lost in urine. Hormone replacement is not for everyone however, due to concerns of side effects as well as increased risk of breast and possibly uterine cancer
Recent research has shown that regular sessions of weight-bearing exercise, coupled with 1500 mg of calcium and 400-800 IU of vitamin D daily, can stop bone loss for some postmenopausal women. Results have been especially encouraging for those who participate in exercise programs designed to head off osteoporosis.
Direct measurement of bone density is the only way to be sure about the status of a woman's skeleton. Many physicians feel that all menopausal women who are wavering about estrogen replacement therapy (ERT) should have a density test. A woman's skeleton reaches its peak mass in her mid-thirties, and by the time she reaches menopause her bone mass will have changed as a result of aging and other factors, such as smoking and drinking (which reduce bone mass) and calcium intake and exercise (which build it). Density studies are performed at hospitals and freestanding imaging centers. One of the best scanning techniques, dual energy X-ray absorptiometry, offers both accuracy and minimal radiation exposure.
If the study indicates that a woman already has osteoporosis, then an exercise-calcium-vitamin program by itself will probably not offer sufficient protection. Her doctor may instead recommend treatment with Estrogen replacement therapy .
The bone density test can serve as a benchmark for preventive efforts. Many experts recommend having a second measurement 12 to 24 months later to make sure the protective program is working. After that, additional tests aren't needed unless her life-style or other health circumstances change dramatically.
Beneficial exercise needs to be frequent, progressive in intensity, and a habit. The best exercises "are those that ask the muscles to work harder than they would normally. The muscles, in turn, work on the bones. When a set of exercises becomes easy, it's time to work longer or harder.
The best exercises for strengthening bones include brisk walking, strength training, stair climbing, hiking, and dancing. Although swimming and cycling are good aerobic exercises, they put less weight on the bones -- and therefore do less to increase skeletal mass.
Any amount of physical activity is better than none at all. Some experts feel that ordinary activities such as gardening, raking, and house- work also help maintain physical fitness and healthy bones. However, anyone who has problems with balance or gait, or who hasn't moved a muscle in years, should consult a physician or a physical therapist before taking up vigorous exercise.
Since a woman's body uses calcium less efficiently after estrogen production falters, a woman needs to step up her calcium intake to 1500 mg daily when she suspects she is beginning menopause.
Many women do not get enough calcium from foods, particularly if they dislike milk, are lactose intolerant, or shun dairy products as being too high in fat. Researchers estimate that most people get only 400-600 mg of dietary calcium daily. Most physicians recommend taking supplements to compensate for calcium shortfalls.
Exercise causes the bones to use more calcium, and a healthy diet provides active bones with the raw materials they need. But there's an import- ant link in the metabolic chain: without vitamin D the small intestine can't absorb adequate calcium, no matter how much is available.
During most oft he year, vitamin D is synthesized by skin that is exposed to sunlight for at least 20 to 30 minutes daily. In winter, however, this doesn't happen for many people living in the continental United States. Not only are the ultraviolet rays that trigger the vitamin's production unavailable in winter, but also the duration of winter increases with distance from the equator. So in the northern tier of the United States -- above latitude 42 degrees north -- the skin can't make any vitamin D from November through February, or longer. During these months especially, nutritionists suggest taking 400 IU in a daily multi-vitamin tablet.
Researchers have also found that people over 65 have a difficult time manufacturing enough vitamin D at any time of year. According to scientists at the New England Medical Center, aging reduces the capacity of the skin to use sunlight to produce vitamin D. Some researchers now believe that vitamin D intake should be increased to 800 IU per day starting at age 65 to 70, and some scientists say that anyone over 50 should take 800 IU year-round. Larger amounts aren't recommended because they may be toxic.
Estrogen-replacement therapy coupled with an exercise and diet at present seems to be the best answer for older women who need to be concerned about minimizing bone loss. But it's not the only answer. A hormone- free program can be effective for women who understand their calcium requirements and who are resolute about regular exercise, a calcium-rich diet, and daily vitamin and mineral supplements.
Pre-menopause (mid-20s to early 50s)
1000 mg calcium/day 200 IU VITAMIN D/day
Menopause (early 50s to late 60s)
1000 mg calcium/day 400-800 IU VITAMIN D/day if taking ERT
1500 mg calcium/day 400-800 IU VITAMIN D/day if not taking ERT
Post menopause(late 60s, early 70s, and beyond)
1000 mg calcium/day 800 IU VITAMIN D/day if taking ERT
1500 mg calcium/day 800 IU VITAMIN D/day f not taking ERT
(Most ordinary multi vitamin tablets contain 400 IU VITAMIN D)
Exercise
Women who exercise regularly, regardless of age, should increase progressively up to 30- 60 minutes 3-5 days per week, include low-to-moderate weight-bearing exercises for variety, such as brisk walking, stair-climbing, dancing, hiking, or aerobics. Sedentary women should start walking (indoors or out) in proper footwear for 10 minutes per day 3 times a week; increase by one minute each week. Be patient and don't give up even if progress is slow. Walk with a friend or with a group for company, but don't compete with your companions.
Estrogen Replacement Therapy and Heart Disease
Many women who decide to take hormone-replacement therapy (HRT) base their decision on its reported protection against heart disease, the leading cause of death among women. Now a team of Dutch epidemiologists says that these benefits may have been exaggerated.
Results from large observational investigations have indicated that women who take HRT are 35-45% less likely to die from heart disease than those who don't, prompting many physicians to advocate HRT.
But some epidemiologists suspected that part of this apparent benefit was due not to any medical intervention but to generally better health among women who are likely to use HRT. Therefore, they hypothesized that healthy women who can afford regular medical care are more likely to have lower rates of all illnesses, not just heart disease. These are also the women most likely to use estrogen supplements.
Tuesday, January 11, 2011
Prevention And Early Intervention For Diabetes Foot Problems
Prevention And Early Intervention For Diabetes Foot Problems
Prevention and Early Intervention for Diabetes Foot Problems: A Research Review
1. Methodology
Research articles, most published since 1990, were identified and retrieved through computerized searches of the National Library of Medicine database. This review is not meant to summarize the entire literature on the subject, but rather to present a condensation and consolidation of the major findings concerned with prevention of and early intervention for diabetes foot disease. Key points are highlighted in boldface.
2. The Scope of the Problem
National Goals for Diabetes Foot Care
The U.S. Department of Health and Human Services'' report specifying health objectives for the nation,Healthy People 2000, calls for a 40 percent overall reduction in lower extremity amputations (LEA) due to diabetes by the year 2000. A special population target goal for amputations is to reduce the 1984-87 rate of amputations in African Americans from 10.2 to 6.1 per 1,000 by the year 2000 (1). These goals are based on the estimate that at least 50 percent of the amputations that occur each year in people with diabetes can be prevented through proper foot care. To achieve the targeted 40 percent reduction, at least 80 percent of people with diabetes at high risk for lower extremity amputations must receive effective clinical management and foot care (1). Current data indicate that on average, 50 to 60 percent of patients with diabetes have a semi-annual foot examination (2,3).
Minorities at Higher Risk for Amputation
Analysis of a statewideCalifornia hospital discharge database indicated that in 1991, the age-adjusted incidence of diabetes-related lower extremity amputations per 10,000 people with diabetes was 95.3 in African Americans, 56.0 in non-Hispanic whites, and 44.4 in Hispanics. Amputations were 1.72 and 2.17 times more likely in African Americans compared with non-Hispanic whites and Hispanics, respectively. Hispanics had a higher proportion of amputations (82.7 percent) associated with diabetes as opposed to other causes of amputation, than did African Americans (61.6 percent) or non-Hispanic whites (56.8 percent) (4).
Amputation rates in San Antonio, TX, were 66.5 per 10,000 for whites, 120.1 per 10,000 for Mexican Americans, and 181.2 per 10,000 for African Americans (5). The incidence of amputations for Native Americans living on the Gila River Indian Reservation was 24.1 per 1,000 person-years compared to 6.5 per 1,000 person-years for the overall U.S. population with diabetes (6). Increased awareness and identification of diabetes-related foot disease is especially important in these high-risk minority groups.
Frequency of Foot Examinations
Examination of the feet by people with diabetes and health care providers is the most basic preventive action to be taken. In the 1989 National Health Interview Survey (NHIS), 52 percent of all people with diabetes stated that they checked their feet at least daily, but 22 percent stated that they never checked their feet. More self-exams were reported by insulin treated individuals that those who did not use insulin (3).
The NHIS also provided information on the frequency of foot examinations made by health professionals.Almost 53 percent of patients with diabetes reported no foot exam by a health professional within the past six months. The frequency of having no foot exam was highest in patients not using insulin (59 percent) (3). In a nationwide survey, primary care physicians reported performing semi-annual foot examinations for 66 percent of patients with type 1 diabetes and for 52 percent of patients with type 2 diabetes (2). A 1992 review of Indian Health Service medical records showed that close to 50 percent of patients with diabetes had documentation of an annual foot examination (7).
Personal and Financial Costs
Diabetes foot disease is a major burden for both the individual and the health care system and may increase as the population ages. Fifteen percent of all patients with diabetes in a population-based study experienced ulcers or sores on the foot or ankle. The prevalence increased with age, especially in patients who were age 30 or under at diagnosis of diabetes (8).
Foot disease is the most common complication of diabetes leading to hospitalization. In 1995, foot disease accounted for 6 percent of hospital discharges listing diabetes and lower extremity ulcers, with an average hospital stay of 14.7 days. Cost of care estimates for lower limb amputations in 1992 ranged from $24,000 to $27,000 and from $14,500 to $21,500 for rehabilitation. The average length of hospital stay for these two diagnoses ranged from 18.4 to 20.3 and 16.0 to 23.9 days, respectively (3). The total annual cost associated with diabetes foot disease is estimated to be more than $1 billion. This cost does not include surgeons'' fees, rehabilitation costs, prostheses, time lost from work, and disability payments (9).
After an amputation, the chance of another amputation of the same extremity or of the opposite extremity within 5 years is as high as 50 percent. The 5-year mortality rate after lower extremity amputation ranges from 39 to 68 percent (3).
3. Causative Factors
Risk Factors for Lower Extremity Amputation (LEA)
Peripheral neuropathy, peripheral vascular disease, and prior foot ulcer are independently associated with risk of LEA(10). A 1996 study of Pima Indians with diabetes confirmed this finding and included the presence of foot deformity as another independent risk factor (11).The presence of plantar callus also is highly predictive of subsequent ulceration in patients with diabetic neuropathy and is more predictive of ulceration than increased plantar foot pressures (12). Hyperglycemia is an additional risk factor. In a 1996 study, Finnish researchers determined risk factors for amputation in 1,044 middle-aged patients with type 2 diabetes who were followed for up to 7 years. Because the incidence of amputation was similar in both sexes (5.6 percent men and 5.3 percent women), all statistical analyses were carried out combining men and women.This study found that high fasting plasma glucose levels at baseline, high HbA1c, and the duration of diabetes were independently associated with a twofold risk of amputation. Signs of peripheral neuropathy, bilateral absence of vibration sense, and bilateral absence of Achilles tendon reflexes were two times more frequent in patients with amputation than in patients without amputation (13).
These findings are supported by the Diabetes Control and Complications Trial (DCCT), a ten-year clinical study that concluded in 1993. The DCCT demonstrated that keeping blood glucose levels as close to normal as possible slows significantly the onset and progression of eye, kidney, and nerve diseases caused by diabetes. The study showed that any sustained lowering of blood glucose helps, even if the person has a history of poor control (14).
Causal Pathways for Lower Extremity Amputations (LEA)
A study conducted at the Seattle Veterans Affairs Medical Center examined the causal pathways for LEA in patients with diabetes and identified the most common sequences of events. Seventy-three percent of the amputations in study subjects were a result of the causal sequence of minor trauma, cutaneous ulceration, and wound-healing failure. Estimates of the cumulative proportions of various causes indicated that86 percent of amputations were attributed to initial minor trauma causing tissue injury (15).
Precipitating or Pivotal Events
In the causal pathway study noted above, foot trauma was caused by shoe-related repetitive pressure leading to cutaneous ulceration in 36 percent of all cases, accidental cuts or wounds in 8 percent, thermal trauma (frostbite or burns) in 8 percent, and decubitus ulceration in 8 percent (15). Similarly, another study found that in one-third of diabetic amputees with peripheral arterial disease, the initial lesion was self-induced.The most common cause of self-injury was ill-fitting new shoes; the second most common cause was cutting toenails improperly (16). Other investigators identified external precipitating factors in 84 percent of study patients with foot ulcers. The most common factors were ill-fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia (17).
4. Screening for Patients at Risk
Screening Tools to Identify High-Risk Feet
The importance of identifying individuals at risk for foot ulceration and LEA and the need for preventive foot care practices for both the provider and the patient have been noted (18). Several simple screening tools have been developed to identify people at high risk.These tools include a patient report and a clinical examination to quantify loss of peripheral sensation, foot deformities, peripheral vascular disease, and prior foot ulcers. Use of these measures has been shown to predict subsequent ulceration and amputation (19).
In one study, during annual patient examinations, researchers recorded the presence of a foot deformity, history of lower extremity ulceration or amputation, and the ability to perceive the Semmes-Weinstein 5.07 10-gram monofilament at eight sites on the plantar surface of each foot. Based on the findings, subjects were classified as sensate or insensate and placed in one of four risk categories. Insensitivity to the monofilament occurred in 68 (19 percent) of the patients screened. Over a 32-month follow-up period, 41 of these patients developed ulcerations and 14 amputations occurred (19).
Identifying patients'' risk category for foot ulceration helps to determine the frequency needed for provider foot examinations, the level of emphasis on self-care of the feet, and patient responsibilities (20).
5. Provider and Patient Education
Education Reduces Lower Extremity Abnormalities
In a randomized, controlled study, researchers provided intervention patients with foot care education, behavioral contracts, and telephone and postcard prompts. The researchers placed foot care prompts on the medical record, and provided practice guidelines and flow sheets to clinicians assigned to those patients. Results showed thatprimary care physicians in the intervention group conducted more examinations of lower extremities, identified those at risk for amputation, and referred more patients for podiatric care. Patients in the intervention group received more patient education, made more changes in appropriate self-care behaviors, and had fewer short-term foot problems than patients in the control group (21).
The Components of Good Patient Education
Findings from several studies help determineeffective components of patient education that contribute to successful patient outcomes. Theseinclude giving detailed foot care recommendations, requesting patient commitment to self-care, demonstrating and practicing foot care procedures, and communicating a persistent message that foot complications can be avoided by self-care. In comparing the effectiveness of intensive versus conventional education, researchers found that patients in the intensive group showed greater improvement in foot care knowledge, better compliance with the recommended foot care routine, and greater reduction in the number of foot problems requiring treatment (22).
Foot care recommendations and demonstrations should include: washing, drying, and inspecting the feet; cutting toenails; treating minor foot problems; selecting suitable footwear; dealing with temperature extremes; and contacting the physician if problems do not resolve quickly. Patients with high-risk feet should inspect them twice a day. Those with peripheral neuropathy, vascular disease, or eye disease should not attempt to cut their own toe nails as this can lead to serious self-inflicted injury. It is important for the provider or diabetes educator to review with the patient all written take-home instructions for self-care of the feet (20).
Researchers found that the frequency of desired self-care behaviors improved when patients were given specific instructions such as "dry between toes" and "file calluses" rather than more general instructions such as "avoid injury to your feet." To be more effective, the investigators recommended that instructions should be stated as precisely as possible such as "don''t go barefoot indoors (21)."
Patients should never be allowed to walk on open plantar ulcers since continuous application of mechanical load will prevent healing. Walking aids, footwear modifications, or other interventions must be used to relieve weight (23).
A pilot program for African Americans consisted of a 15-minute orientation meeting between a diabetes nurse educator and the person with diabetes, a take-home foot self-care packet, and a follow-up telephone interview. During the telephone interviews, subjects reported that the most useful parts of the take-home packet were the patient instruction booklet, the large hand mirror included in the packet, and the foot care knowledge self-test with explanations of the answers. Subjects also valued the reminder cue that was repeated in bold face on each page of the booklet telling them to call the doctor immediately if any cut, bruise, or blister does not begin to heal after one day (24).
Step-by-step guidelines have been published to assist providers to conduct patient education workshops on foot care including how to attract participants, promote the workshop, develop the agenda, identify appropriate speakers, and conduct a post-workshop evaluation (25).
6. Clinical Issues
Provider Foot Care Practices
In a study of provider practice, researchers found that clinicians were likely to prescribe preventive foot care behaviors when they were aware of a patient''s high risk for LEA as evidenced by prior history of foot ulcer. Clinician awareness of two other risk factors (peripheral neuropathy or peripheral vascular disease), however, did not increase preventive care practices. The researchers concludedthat physicians and patients need periodic reminders to identify patients in all high-risk categories for ulcer or amputation and to provide additional care such as podiatric visits and education in self-care (10).
A study of nurse practitioner practice patterns was conducted to determine their consistency with the American Diabetes Association (ADA) standards of care. An audit of 78 medical records representing a proportionate number for each of six masters-prepared, certified nurse practitioners revealed discrepancies between established standards and the degree to which they were documented. Comprehensive foot care examinations (required annually by ADA standards) were documented in 23 percent of the charts reviewed (26).
Self-care Limitations in the Elderly
In one study, barriers to carrying out daily foot care noted by elderly subjects included lack of motivation, forgetfulness, vision problems, joint and knee problems, and family responsibilities (24). The ability of elderly people to identify foot lesions was investigated further in a matched comparison, controlled study. Findings showed that43 percent of patients with a history of foot ulcers could not reach and remove simulated lesions on their toes; over 50 percent of the older subjects reported difficulty trimming their toe nails; and only 14 percent had sufficient joint flexibility to allow inspection of the plantar aspect of the foot. The investigators concluded that elderly people who are unable to perform daily self-care of the feet would benefit more from regular foot care given by others than from intensive education (27).
Exercise
In people with diabetes, regular exercise can lower blood glucose, improve insulin sensitivity, raise HDL cholesterol, improve blood flow and heart muscle strength, enhance fibrinolysis, control weight, increase muscle mass, and provide an overall sense of well-being. Because of these effects,regular exercise may also delay the onset of neuropathy and atherosclerosis.
People who have had type 1 diabetes for more than 10 years, or type 2 diabetes for more than 5 years, should be screened for medical risk prior to beginning an exercise program. While the presence of neuropathy does not rule out exercise, care should be taken not to worsen soft tissue and joint injury or cause foot ulcers or bone injury. Stretching muscles before exercise is important to prevent ligament strain. Swimming or bicycling are recommended forms of exercise because they avoid abrasion to the feet (28). Attention to the construction and fit of footwear is essential.
7. Special Footwear for the Insensate Foot
Repetitive Stress and Special Footwear
People with intact sensation respond to repetitive stress that occurs during walking either by shifting the pressure to another part of the foot, by modifying the way the foot meets the ground, by resting, or by checking their shoes for problems.With the loss of peripheral sensation, however, many people with diabetes have no indication of lower extremity pain, pressure, or trauma and do not take measures to modify repetitive pressures. Lack of feeling makes shoe-fitting assistance essential.
Properly constructed and well-fitting shoes and shoe inserts can minimize localized stresses by redistributing forces during walking. Besides helping patients keep feet healthy, shoes and orthoses also can help prevent diabetes complications. Investigators in a recent study found that after healing of the initial ulcer, re-ulceration occurred after one year in 58 percent of patients who resumed wearing their own footwear, compared to 28 percent of those who wore therapeutic footwear (29).
Another study compared the prevalence and severity of foot deformities and the development of ulceration in people with diabetes after a great toe amputation. The investigators found thatbecause of altered pressure distribution, the foot with great toe amputation developed more frequent and more severe deformities of the lesser toes and metatarsophalangeal joints compared to the other intact foot. Because these patients were at high risk for subsequent ulceration, the use of special inserts and footwear to protect the feet was highly recommended (30).
Prescription Footwear and the Medicare Shoe Benefit
Professionally fitted shoes and prescription footwear are an important part of the overall treatment of the insensate foot because they aid in preventing limb loss.Footwear should relieve areas of excessive pressure, reduce shock and shear, and accommodate, stabilize, and support deformities.
Shoes should be long enough, and have room in the toe area and over the instep. Shoes with laces allow adjustment for edema and deformities. Most people with early neuropathic changes can wear cushioned commercial footwear such as walking or athletic shoes. Some people also may need the pressure areas redistributed with custom orthotics that often require depth footwear.
Custom-molded shoes, depth shoes, inserts, and shoe modifications can be fitted and furnished by a podiatrist, orthopedic foot surgeon, orthotist, or pedorthist. Depth-inlay shoes provide more room for toe deformities and for the insertion of customized insoles. Extra-wide shoes provide more room for bunions and other abnormalities. Rocker sole shoes reduce pressure under metatarsal heads and toes. They are particularly useful for reducing the risk of ulceration in patients with a stiff and rigid first metatarsal joint.
Since 1993, the Medicare shoe benefit has made special footwear available to more patients than ever before.To obtain coverage, patients must have physician certification that they are at high risk for ulceration or amputation, receive a written footwear prescription from a podiatrist or other qualified physician, and obtain the footwear from a qualified provider or supplier who will then file the appropriate claim forms (31).
8. Conclusion
The staggering human and economic costs of diabetes foot disease may be reduced significantly with increased practice of several simple preventive care measures designed to prevent foot ulcers and lower extremity amputations. Routine annual foot screening facilitates early interventions to reduce the incidence of the most common precipitating events including injury and footwear-related trauma to the insensitive foot.The key elements of preventive care include: annual examination of the feet by health care providers to determine risk factors for ulceration; subsequent exams of high risk feet at each patient visit; patient education about daily self-care of the feet; and careful glucose management. The national health objectives for the year 2000 to decrease the rate of amputation in the population overall, as well as in specific high risk minority groups, serve as a call to action for both health care providers and people with diabetes to make routine diabetes foot care a high priority. thank u. dr.guru.
Prevention and Early Intervention for Diabetes Foot Problems: A Research Review
1. Methodology
Research articles, most published since 1990, were identified and retrieved through computerized searches of the National Library of Medicine database. This review is not meant to summarize the entire literature on the subject, but rather to present a condensation and consolidation of the major findings concerned with prevention of and early intervention for diabetes foot disease. Key points are highlighted in boldface.
2. The Scope of the Problem
National Goals for Diabetes Foot Care
The U.S. Department of Health and Human Services'' report specifying health objectives for the nation,Healthy People 2000, calls for a 40 percent overall reduction in lower extremity amputations (LEA) due to diabetes by the year 2000. A special population target goal for amputations is to reduce the 1984-87 rate of amputations in African Americans from 10.2 to 6.1 per 1,000 by the year 2000 (1). These goals are based on the estimate that at least 50 percent of the amputations that occur each year in people with diabetes can be prevented through proper foot care. To achieve the targeted 40 percent reduction, at least 80 percent of people with diabetes at high risk for lower extremity amputations must receive effective clinical management and foot care (1). Current data indicate that on average, 50 to 60 percent of patients with diabetes have a semi-annual foot examination (2,3).
Minorities at Higher Risk for Amputation
Analysis of a statewideCalifornia hospital discharge database indicated that in 1991, the age-adjusted incidence of diabetes-related lower extremity amputations per 10,000 people with diabetes was 95.3 in African Americans, 56.0 in non-Hispanic whites, and 44.4 in Hispanics. Amputations were 1.72 and 2.17 times more likely in African Americans compared with non-Hispanic whites and Hispanics, respectively. Hispanics had a higher proportion of amputations (82.7 percent) associated with diabetes as opposed to other causes of amputation, than did African Americans (61.6 percent) or non-Hispanic whites (56.8 percent) (4).
Amputation rates in San Antonio, TX, were 66.5 per 10,000 for whites, 120.1 per 10,000 for Mexican Americans, and 181.2 per 10,000 for African Americans (5). The incidence of amputations for Native Americans living on the Gila River Indian Reservation was 24.1 per 1,000 person-years compared to 6.5 per 1,000 person-years for the overall U.S. population with diabetes (6). Increased awareness and identification of diabetes-related foot disease is especially important in these high-risk minority groups.
Frequency of Foot Examinations
Examination of the feet by people with diabetes and health care providers is the most basic preventive action to be taken. In the 1989 National Health Interview Survey (NHIS), 52 percent of all people with diabetes stated that they checked their feet at least daily, but 22 percent stated that they never checked their feet. More self-exams were reported by insulin treated individuals that those who did not use insulin (3).
The NHIS also provided information on the frequency of foot examinations made by health professionals.Almost 53 percent of patients with diabetes reported no foot exam by a health professional within the past six months. The frequency of having no foot exam was highest in patients not using insulin (59 percent) (3). In a nationwide survey, primary care physicians reported performing semi-annual foot examinations for 66 percent of patients with type 1 diabetes and for 52 percent of patients with type 2 diabetes (2). A 1992 review of Indian Health Service medical records showed that close to 50 percent of patients with diabetes had documentation of an annual foot examination (7).
Personal and Financial Costs
Diabetes foot disease is a major burden for both the individual and the health care system and may increase as the population ages. Fifteen percent of all patients with diabetes in a population-based study experienced ulcers or sores on the foot or ankle. The prevalence increased with age, especially in patients who were age 30 or under at diagnosis of diabetes (8).
Foot disease is the most common complication of diabetes leading to hospitalization. In 1995, foot disease accounted for 6 percent of hospital discharges listing diabetes and lower extremity ulcers, with an average hospital stay of 14.7 days. Cost of care estimates for lower limb amputations in 1992 ranged from $24,000 to $27,000 and from $14,500 to $21,500 for rehabilitation. The average length of hospital stay for these two diagnoses ranged from 18.4 to 20.3 and 16.0 to 23.9 days, respectively (3). The total annual cost associated with diabetes foot disease is estimated to be more than $1 billion. This cost does not include surgeons'' fees, rehabilitation costs, prostheses, time lost from work, and disability payments (9).
After an amputation, the chance of another amputation of the same extremity or of the opposite extremity within 5 years is as high as 50 percent. The 5-year mortality rate after lower extremity amputation ranges from 39 to 68 percent (3).
3. Causative Factors
Risk Factors for Lower Extremity Amputation (LEA)
Peripheral neuropathy, peripheral vascular disease, and prior foot ulcer are independently associated with risk of LEA(10). A 1996 study of Pima Indians with diabetes confirmed this finding and included the presence of foot deformity as another independent risk factor (11).The presence of plantar callus also is highly predictive of subsequent ulceration in patients with diabetic neuropathy and is more predictive of ulceration than increased plantar foot pressures (12). Hyperglycemia is an additional risk factor. In a 1996 study, Finnish researchers determined risk factors for amputation in 1,044 middle-aged patients with type 2 diabetes who were followed for up to 7 years. Because the incidence of amputation was similar in both sexes (5.6 percent men and 5.3 percent women), all statistical analyses were carried out combining men and women.This study found that high fasting plasma glucose levels at baseline, high HbA1c, and the duration of diabetes were independently associated with a twofold risk of amputation. Signs of peripheral neuropathy, bilateral absence of vibration sense, and bilateral absence of Achilles tendon reflexes were two times more frequent in patients with amputation than in patients without amputation (13).
These findings are supported by the Diabetes Control and Complications Trial (DCCT), a ten-year clinical study that concluded in 1993. The DCCT demonstrated that keeping blood glucose levels as close to normal as possible slows significantly the onset and progression of eye, kidney, and nerve diseases caused by diabetes. The study showed that any sustained lowering of blood glucose helps, even if the person has a history of poor control (14).
Causal Pathways for Lower Extremity Amputations (LEA)
A study conducted at the Seattle Veterans Affairs Medical Center examined the causal pathways for LEA in patients with diabetes and identified the most common sequences of events. Seventy-three percent of the amputations in study subjects were a result of the causal sequence of minor trauma, cutaneous ulceration, and wound-healing failure. Estimates of the cumulative proportions of various causes indicated that86 percent of amputations were attributed to initial minor trauma causing tissue injury (15).
Precipitating or Pivotal Events
In the causal pathway study noted above, foot trauma was caused by shoe-related repetitive pressure leading to cutaneous ulceration in 36 percent of all cases, accidental cuts or wounds in 8 percent, thermal trauma (frostbite or burns) in 8 percent, and decubitus ulceration in 8 percent (15). Similarly, another study found that in one-third of diabetic amputees with peripheral arterial disease, the initial lesion was self-induced.The most common cause of self-injury was ill-fitting new shoes; the second most common cause was cutting toenails improperly (16). Other investigators identified external precipitating factors in 84 percent of study patients with foot ulcers. The most common factors were ill-fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia (17).
4. Screening for Patients at Risk
Screening Tools to Identify High-Risk Feet
The importance of identifying individuals at risk for foot ulceration and LEA and the need for preventive foot care practices for both the provider and the patient have been noted (18). Several simple screening tools have been developed to identify people at high risk.These tools include a patient report and a clinical examination to quantify loss of peripheral sensation, foot deformities, peripheral vascular disease, and prior foot ulcers. Use of these measures has been shown to predict subsequent ulceration and amputation (19).
In one study, during annual patient examinations, researchers recorded the presence of a foot deformity, history of lower extremity ulceration or amputation, and the ability to perceive the Semmes-Weinstein 5.07 10-gram monofilament at eight sites on the plantar surface of each foot. Based on the findings, subjects were classified as sensate or insensate and placed in one of four risk categories. Insensitivity to the monofilament occurred in 68 (19 percent) of the patients screened. Over a 32-month follow-up period, 41 of these patients developed ulcerations and 14 amputations occurred (19).
Identifying patients'' risk category for foot ulceration helps to determine the frequency needed for provider foot examinations, the level of emphasis on self-care of the feet, and patient responsibilities (20).
5. Provider and Patient Education
Education Reduces Lower Extremity Abnormalities
In a randomized, controlled study, researchers provided intervention patients with foot care education, behavioral contracts, and telephone and postcard prompts. The researchers placed foot care prompts on the medical record, and provided practice guidelines and flow sheets to clinicians assigned to those patients. Results showed thatprimary care physicians in the intervention group conducted more examinations of lower extremities, identified those at risk for amputation, and referred more patients for podiatric care. Patients in the intervention group received more patient education, made more changes in appropriate self-care behaviors, and had fewer short-term foot problems than patients in the control group (21).
The Components of Good Patient Education
Findings from several studies help determineeffective components of patient education that contribute to successful patient outcomes. Theseinclude giving detailed foot care recommendations, requesting patient commitment to self-care, demonstrating and practicing foot care procedures, and communicating a persistent message that foot complications can be avoided by self-care. In comparing the effectiveness of intensive versus conventional education, researchers found that patients in the intensive group showed greater improvement in foot care knowledge, better compliance with the recommended foot care routine, and greater reduction in the number of foot problems requiring treatment (22).
Foot care recommendations and demonstrations should include: washing, drying, and inspecting the feet; cutting toenails; treating minor foot problems; selecting suitable footwear; dealing with temperature extremes; and contacting the physician if problems do not resolve quickly. Patients with high-risk feet should inspect them twice a day. Those with peripheral neuropathy, vascular disease, or eye disease should not attempt to cut their own toe nails as this can lead to serious self-inflicted injury. It is important for the provider or diabetes educator to review with the patient all written take-home instructions for self-care of the feet (20).
Researchers found that the frequency of desired self-care behaviors improved when patients were given specific instructions such as "dry between toes" and "file calluses" rather than more general instructions such as "avoid injury to your feet." To be more effective, the investigators recommended that instructions should be stated as precisely as possible such as "don''t go barefoot indoors (21)."
Patients should never be allowed to walk on open plantar ulcers since continuous application of mechanical load will prevent healing. Walking aids, footwear modifications, or other interventions must be used to relieve weight (23).
A pilot program for African Americans consisted of a 15-minute orientation meeting between a diabetes nurse educator and the person with diabetes, a take-home foot self-care packet, and a follow-up telephone interview. During the telephone interviews, subjects reported that the most useful parts of the take-home packet were the patient instruction booklet, the large hand mirror included in the packet, and the foot care knowledge self-test with explanations of the answers. Subjects also valued the reminder cue that was repeated in bold face on each page of the booklet telling them to call the doctor immediately if any cut, bruise, or blister does not begin to heal after one day (24).
Step-by-step guidelines have been published to assist providers to conduct patient education workshops on foot care including how to attract participants, promote the workshop, develop the agenda, identify appropriate speakers, and conduct a post-workshop evaluation (25).
6. Clinical Issues
Provider Foot Care Practices
In a study of provider practice, researchers found that clinicians were likely to prescribe preventive foot care behaviors when they were aware of a patient''s high risk for LEA as evidenced by prior history of foot ulcer. Clinician awareness of two other risk factors (peripheral neuropathy or peripheral vascular disease), however, did not increase preventive care practices. The researchers concludedthat physicians and patients need periodic reminders to identify patients in all high-risk categories for ulcer or amputation and to provide additional care such as podiatric visits and education in self-care (10).
A study of nurse practitioner practice patterns was conducted to determine their consistency with the American Diabetes Association (ADA) standards of care. An audit of 78 medical records representing a proportionate number for each of six masters-prepared, certified nurse practitioners revealed discrepancies between established standards and the degree to which they were documented. Comprehensive foot care examinations (required annually by ADA standards) were documented in 23 percent of the charts reviewed (26).
Self-care Limitations in the Elderly
In one study, barriers to carrying out daily foot care noted by elderly subjects included lack of motivation, forgetfulness, vision problems, joint and knee problems, and family responsibilities (24). The ability of elderly people to identify foot lesions was investigated further in a matched comparison, controlled study. Findings showed that43 percent of patients with a history of foot ulcers could not reach and remove simulated lesions on their toes; over 50 percent of the older subjects reported difficulty trimming their toe nails; and only 14 percent had sufficient joint flexibility to allow inspection of the plantar aspect of the foot. The investigators concluded that elderly people who are unable to perform daily self-care of the feet would benefit more from regular foot care given by others than from intensive education (27).
Exercise
In people with diabetes, regular exercise can lower blood glucose, improve insulin sensitivity, raise HDL cholesterol, improve blood flow and heart muscle strength, enhance fibrinolysis, control weight, increase muscle mass, and provide an overall sense of well-being. Because of these effects,regular exercise may also delay the onset of neuropathy and atherosclerosis.
People who have had type 1 diabetes for more than 10 years, or type 2 diabetes for more than 5 years, should be screened for medical risk prior to beginning an exercise program. While the presence of neuropathy does not rule out exercise, care should be taken not to worsen soft tissue and joint injury or cause foot ulcers or bone injury. Stretching muscles before exercise is important to prevent ligament strain. Swimming or bicycling are recommended forms of exercise because they avoid abrasion to the feet (28). Attention to the construction and fit of footwear is essential.
7. Special Footwear for the Insensate Foot
Repetitive Stress and Special Footwear
People with intact sensation respond to repetitive stress that occurs during walking either by shifting the pressure to another part of the foot, by modifying the way the foot meets the ground, by resting, or by checking their shoes for problems.With the loss of peripheral sensation, however, many people with diabetes have no indication of lower extremity pain, pressure, or trauma and do not take measures to modify repetitive pressures. Lack of feeling makes shoe-fitting assistance essential.
Properly constructed and well-fitting shoes and shoe inserts can minimize localized stresses by redistributing forces during walking. Besides helping patients keep feet healthy, shoes and orthoses also can help prevent diabetes complications. Investigators in a recent study found that after healing of the initial ulcer, re-ulceration occurred after one year in 58 percent of patients who resumed wearing their own footwear, compared to 28 percent of those who wore therapeutic footwear (29).
Another study compared the prevalence and severity of foot deformities and the development of ulceration in people with diabetes after a great toe amputation. The investigators found thatbecause of altered pressure distribution, the foot with great toe amputation developed more frequent and more severe deformities of the lesser toes and metatarsophalangeal joints compared to the other intact foot. Because these patients were at high risk for subsequent ulceration, the use of special inserts and footwear to protect the feet was highly recommended (30).
Prescription Footwear and the Medicare Shoe Benefit
Professionally fitted shoes and prescription footwear are an important part of the overall treatment of the insensate foot because they aid in preventing limb loss.Footwear should relieve areas of excessive pressure, reduce shock and shear, and accommodate, stabilize, and support deformities.
Shoes should be long enough, and have room in the toe area and over the instep. Shoes with laces allow adjustment for edema and deformities. Most people with early neuropathic changes can wear cushioned commercial footwear such as walking or athletic shoes. Some people also may need the pressure areas redistributed with custom orthotics that often require depth footwear.
Custom-molded shoes, depth shoes, inserts, and shoe modifications can be fitted and furnished by a podiatrist, orthopedic foot surgeon, orthotist, or pedorthist. Depth-inlay shoes provide more room for toe deformities and for the insertion of customized insoles. Extra-wide shoes provide more room for bunions and other abnormalities. Rocker sole shoes reduce pressure under metatarsal heads and toes. They are particularly useful for reducing the risk of ulceration in patients with a stiff and rigid first metatarsal joint.
Since 1993, the Medicare shoe benefit has made special footwear available to more patients than ever before.To obtain coverage, patients must have physician certification that they are at high risk for ulceration or amputation, receive a written footwear prescription from a podiatrist or other qualified physician, and obtain the footwear from a qualified provider or supplier who will then file the appropriate claim forms (31).
8. Conclusion
The staggering human and economic costs of diabetes foot disease may be reduced significantly with increased practice of several simple preventive care measures designed to prevent foot ulcers and lower extremity amputations. Routine annual foot screening facilitates early interventions to reduce the incidence of the most common precipitating events including injury and footwear-related trauma to the insensitive foot.The key elements of preventive care include: annual examination of the feet by health care providers to determine risk factors for ulceration; subsequent exams of high risk feet at each patient visit; patient education about daily self-care of the feet; and careful glucose management. The national health objectives for the year 2000 to decrease the rate of amputation in the population overall, as well as in specific high risk minority groups, serve as a call to action for both health care providers and people with diabetes to make routine diabetes foot care a high priority. thank u. dr.guru.
First Aid for Fractures and Sprains
First Aid for Fractures and Sprains
A fracture is a break or crack in a bone that can be caused by an accident, fall, or blow. Symptoms include a snapping sound as bone breaks, bone protruding from skin, detectable deformity of bone, abnormal movement of bone, grating sensation during movement, pain and tenderness, difficulty in moving or using the affected part, swelling, and discoloration.
A sprain refers to stretched or torn tendons, ligaments, and blood vessels around a joint and can be caused by an accident, fall, or blow. Symptoms of a sprain include pain, tenderness, swelling, and discoloration in the joint area.
A muscle strain refers to stretched or torn muscle. It can be caused by excessive physical effort or improper posture during activity. Symptoms include pain, stiffness, and possibly swelling in the affected area.
It is sometimes difficult to tell the difference between a fracture and a sprain or strain until an X-ray has been performed. If you cannot tell, treat it as a fracture.
Fracture:
1. SEEK MEDICAL ATTENTION IMMEDIATELY. Call for EMS, or transport victim to emergency room after immobilizing affected area. Wait for EMS and DO NOT attempt to transport victim if you suspect head, back, or neck injury; if there's a visible deformity of bone; or if the victim cannot be splinted or transported without causing more pain.
2. Suspect back or neck injury if victim is unconscious or has head injury, neck pain, or tingling in arms or legs. If neck or back injury suspected, DO NOT move victim unless necessary to save victim's life. See back or neck injury.
3. Immobilize and support affected bone in position found. DO NOT try to push protruding bone back into body or let victim move or use affected area.
4. Control any bleeding through direct pressure, but DO NOT elevate affected area. See bleeding,external.
5. If bone is protruding, cover with clean cloth once bleeding is controlled.
6. Observe for shock (see shock). DO NOT give victim anything to eat or drink.
7. Immobilize injured area, and, if no open wound present, apply ice pack wrapped in clean cloth.
fracture first aid
Apply ice pack to affected
area and cover with cloth.
Immobilizing Fractured Bone:
1. Check for sensation, warmth, and color of toes or fingers below suspected break.
2. Place padded splint under area of suspected break:
fracture first aid
Use belts or neckties
to bind splint
to arm but do not bind
on top of the break.
-Use board, rolled newspaper or magazines, broomstick, or rolled blanket for splint.
-Wrap splint in cloth or towels for padding.
-Bind splint to limb using neckties, cloth, belts, or rope. DO NOT bind directly over break.
3. Recheck often for sensation, warmth, and coloring. If fingers or toes turn blue or swell, loosen binding.
4. For arm or shoulder injury, place splinted arm in sling, with hand above elbow level. Bind arm to victim's body by wrapping towel or cloth over sling and around upper arm and chest; tie towel or cloth under victim's opposite arm.
fracture first aid
Create a sling for arm
injuries using whatever
cloth you can find.
Sprain or Strain:
1. Have victim rest, with affected area elevated.
sprain first aid
Keep the affected area elevated
and the victim at rest.
2. Apply cold compress or ice pack wrapped in cloth to affected area.
sprain first aid
Use an ice pack or cold compress
to combat pain and swelling.
3. If pain or swelling continue for more than 2 days, consult doctor
A fracture is a break or crack in a bone that can be caused by an accident, fall, or blow. Symptoms include a snapping sound as bone breaks, bone protruding from skin, detectable deformity of bone, abnormal movement of bone, grating sensation during movement, pain and tenderness, difficulty in moving or using the affected part, swelling, and discoloration.
A sprain refers to stretched or torn tendons, ligaments, and blood vessels around a joint and can be caused by an accident, fall, or blow. Symptoms of a sprain include pain, tenderness, swelling, and discoloration in the joint area.
A muscle strain refers to stretched or torn muscle. It can be caused by excessive physical effort or improper posture during activity. Symptoms include pain, stiffness, and possibly swelling in the affected area.
It is sometimes difficult to tell the difference between a fracture and a sprain or strain until an X-ray has been performed. If you cannot tell, treat it as a fracture.
Fracture:
1. SEEK MEDICAL ATTENTION IMMEDIATELY. Call for EMS, or transport victim to emergency room after immobilizing affected area. Wait for EMS and DO NOT attempt to transport victim if you suspect head, back, or neck injury; if there's a visible deformity of bone; or if the victim cannot be splinted or transported without causing more pain.
2. Suspect back or neck injury if victim is unconscious or has head injury, neck pain, or tingling in arms or legs. If neck or back injury suspected, DO NOT move victim unless necessary to save victim's life. See back or neck injury.
3. Immobilize and support affected bone in position found. DO NOT try to push protruding bone back into body or let victim move or use affected area.
4. Control any bleeding through direct pressure, but DO NOT elevate affected area. See bleeding,external.
5. If bone is protruding, cover with clean cloth once bleeding is controlled.
6. Observe for shock (see shock). DO NOT give victim anything to eat or drink.
7. Immobilize injured area, and, if no open wound present, apply ice pack wrapped in clean cloth.
fracture first aid
Apply ice pack to affected
area and cover with cloth.
Immobilizing Fractured Bone:
1. Check for sensation, warmth, and color of toes or fingers below suspected break.
2. Place padded splint under area of suspected break:
fracture first aid
Use belts or neckties
to bind splint
to arm but do not bind
on top of the break.
-Use board, rolled newspaper or magazines, broomstick, or rolled blanket for splint.
-Wrap splint in cloth or towels for padding.
-Bind splint to limb using neckties, cloth, belts, or rope. DO NOT bind directly over break.
3. Recheck often for sensation, warmth, and coloring. If fingers or toes turn blue or swell, loosen binding.
4. For arm or shoulder injury, place splinted arm in sling, with hand above elbow level. Bind arm to victim's body by wrapping towel or cloth over sling and around upper arm and chest; tie towel or cloth under victim's opposite arm.
fracture first aid
Create a sling for arm
injuries using whatever
cloth you can find.
Sprain or Strain:
1. Have victim rest, with affected area elevated.
sprain first aid
Keep the affected area elevated
and the victim at rest.
2. Apply cold compress or ice pack wrapped in cloth to affected area.
sprain first aid
Use an ice pack or cold compress
to combat pain and swelling.
3. If pain or swelling continue for more than 2 days, consult doctor
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