podiatrist Archives - Diabetes Counselling Online

Guest Blog: Foot care, diabetic #neuropathy

March 11, 2015 by helwild 6 Comments

One of our Closed groups on the Social Media platform of Facebook is called ‘Diabetes Education and Management’. This group is supported by Diabetes Educators and a Midwife, a Dietitian, and a Pharmacist, as well as Mental Health Counsellors.

Recently one of our Diabetes Educators posted a link to a blog about complications and Foot Care in diabetes management, a fairly regular topic of discussion. Footcare form edited July 09

A very heartfelt and powerful response came from a member of the group, Zac. Zac has very strong views on the importance of seeking truth, accurate information, and developing informed knowledge about foot care and diabetic neuropathy in particular. He warns about the high risks associated with poor diabetic control, and not being proactive in our own health care, risks that he believes were not made clear to him before it was too late. Here are Zac’s powerful words:

This topic is very interesting to me, being a Diabetic T2 for a few years now. I visit my Clinic only once a year. They make my appointments, not me. BUT I just wish I had’ve been told about the seriousness of COMPLICATIONS of Diabetes as so far as Peripheral Neuropathy is concerned, as I now have it.

Not once was I referred to a Podiatrist, so I asked to make an appointment, only to be told they are not taking any more patients as they are over loaded. Well, I didn’t bother too much about it at the time, as I didn’t have Peripheral Neuropathy, and thought nothing of it. Until, that is, for another 2 yrs. By then, my feet felt like they were in a bucket of bull ants.

Not realising this was nerve damage, I put up with it, until, on one of my visits to my Clinic the nurse did a small test on my feet. She looked at them and said, “Oh, your feet are fine.” So I asked, “What would be making my feet feel like they are being bitten by bull ants?” She looked at them again, said she didn’t know, and again, said she thought my feet were fine, so home I went, feeling disappointed.

On the next visit, I demanded. I said, “Something is SERIOUSLY WRONG with my feet, please help me.” So the nurse called in some guy, whom I wasn’t introduced to, and he put a name to it, called it ‘Peripheral Neuropathy’. Well, I was just over the moon that someone had finally worked out what was wrong with them!

But then he said, “Go to your chemist buy some Phanalgon Cream. This helps some people.” my reply was, “But I want something that will definitely help my feet!”

He said, “There is no cure for Peripheral Neuropathy.”

So I said, “You’re kidding me, in this day and age there is no cure for it?”

He said, “Yes, no cure.”

So home I went, with Phanalgon Cream in hand, only to have a bad reaction to it. My skin started to peel off from my feet, as it has chilli in it. So I tried again when my feet healed, but used less of the cream. Still I had a reaction to it, so I gave that the flick…..

I’m ANGRY at myself. First of all, for being so flippant about Diabetes; and not educating myself about complications which I never knew existed. And I’m ANGRY at my Clinic for not pointing these matters out to me in the first place. After all, isn’t this why we attend clinics? When the nurse used to test my feet, I was never given an explanation as to why. It’s the same with my eye tests. I was never told that Diabetes can affect your eyes. I just thought it was a normal eye test…Sorry this is long winded but if I can help just ONE person to realise the seriousness of Diabetes Complications then it will have been worth while typing all of this.

I just wish I had been warned. Peripheral Neuropathy is the pits, and I don’t have a normal life now. I am practically house bound because of it…..If you have read this far I Thank You and I Thank you David Mapletoft and Sally Marchini and for everything I have learned through your expertise and knowledge, even though it’s too late. Well, not too late as far as Diet is concerned, but it’s too late for my suffering feet. Thank you Zac

Zac has kindly shared his experience here. Do you have a similar experience? Can you give Zac any suggestions on how to manage his foot discomfort and pain?

Helen Wilde

Senior Counsellor

Helen has been a Counsellor with the service since 2003. She has been the parent of someone living with Type 1 diabetes since 1979, and has lived with type 2 diabetes herself since 2001.

Please Share!

Diabetic Nerve Damage: Neuropathy

January 11, 2015 by Imagine_David Leave a Comment

Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood glucose can injure nerve fibers throughout your body, but diabetic neuropathy most often damages nerves in your legs and feet.

Depending on the affected nerves, symptoms of diabetic neuropathy can range from pain and numbness in your extremities to problems with your digestive system, urinary tract, blood vessels and heart. For some people, these symptoms are mild; for others, diabetic neuropathy can be painful, disabling and even fatal.

Diabetic neuropathy is a common serious complication of diabetes. Yet you can often prevent diabetic neuropathy or slow its progress with tight blood glucose management, and a healthy lifestyle.

Clinical context

Pain and paraesthesia are common peripheral neuropathic symptoms, and if the autonomic nervous system is involved, gastrointestinal, bladder and sexual problems arise.

Diabetic neuropathic complications increase the burden of self-care and overall management.

The clinical focus is on prevention via good glycaemic control, and early recognition facilitated by good history and routine sensory testing.

New modalities are arriving to assist in the management of diabetic neuropathies.

Before any treatment is instigated, exclusion of non-diabetic causes of neuropathy is suggested. This includes assessment for vitamin B12 deficiency, hypothyroidism, renal disease and review of neurotoxic drugs including excessive alcohol consumption.

Autonomic neuropathy

Autonomic neuropathy may result in:

orthostatic hypotension (also called postural hypotension, is a form of low blood pressure that can cause dizziness. It happens when the blood vessels do not constrict (tighten) as you stand up, which makes you feel dizzy) with >20 mmHg drop
impaired and unpredictable gastric emptying (gastroparesis), which can cause a person’s blood glucose levels to be erratic and difficult to control. Pro-kinetic agents such as metoclopramide, domperidone or erythromycin may improve symptoms
diarrhoea
delayed/incomplete bladder emptying
erectile dysfunction and retrograde ejaculation in males
reduced vaginal lubrication with arousal in women
loss of cardiac pain, ‘silent’ ischaemia or infarction
sudden, unexpected cardiorespiratory arrest especially under anaesthetic or treatment with respiratory depressant medications
difficulty recognising hypoglycaemia
unexplained ankle oedema.

Cardiovascular autonomic neuropathy should be suspected by resting tachycardia (>100 bpm) or orthostatic reduction in BP (a fall in SBP >20 mmHg on standing without an appropriate heart rate response). This applies to people not currently on antihypertensive agents that may cause variations in BP responsiveness such as beta blockers. It is associated with increased cardiac event rates.

Diagnosis

The diagnosis of diabetic neuropathy may include:

taking a medical history for symptoms typical of neuropathy
checking your feet and legs for responses to stimuli such as temperature, light touch, pain, movement and vibration
checking the reflexes at your ankles and knees
tests to exclude other possible causes of neuropathy (such as low vitamin B₁or thiamine levels).

Treatment

Damaged nerves cannot be repaired. However, the risk of further complications in the feet can be reduced by:

vigilance – regular inspection of the feet for early signs of trouble or potential problem areas (such as breaks in skin, signs of infection or deformity
getting help at the first sign of trouble – early treatment of foot ulcers gives the best chance that they will heal
good foot and nail hygiene
choosing appropriate socks and shoes properly fitted to the shape of your foot
avoiding activities that may injure the feet. Check shoes for stones, sticks and other foreign objects that might hurt your feet every time before putting your shoes on.

A referral to a podiatrist may be appropriate for assessment and ongoing preventive management of foot complications.

Treatment for painful neuropathy

Appropriate pain management can significantly improve the lives of people with diabetes and painful neuropathy. A number of different medications are available, which produce comparable effects.

Most people would begin with one of either:

serotonin-norepinephrine reuptake inhibitors (such as venlafaxine, duloxetine)
tricyclics antidepressants (such as amityptiline)
anti-epileptics (such as gabapentin, pregabalin).

If one type fails to provide the response required, it is usual to switch to or add another. If all three agents alone or in combination fail, then opioid analgesics and tramadol may be used as second-line treatments.

Prevention of diabetic neuropathy

Be guided by your doctor, but general suggestions to reduce the risk of diabetic neuropathy include:

Maintain blood glucose levels within the target ranges.
Exercise regularly.
Maintain a healthy weight for your height.
Stop smoking.
Reduce your blood pressure and lipid (fat) levels through diet and lifestyle changes, and medication where appropriate
Consult your doctor promptly if you have symptoms including pain, numbness or tingling in your hands or feet.
Have your feet checked at least yearly by your doctor, podiatrist or diabetes educator, or more often if you have signs of problems with your feet or other complications of your diabetes.

Although, potential health complications due to diabetes may happen; don not live in fear, by watching the amount and types of food you eat, exercising, and taking any necessary medications, you may be able to prevent short and long-term diabetes complications.

Keeping blood glucose close to normal can help prevent the long-term complications of diabetes.
Manage high blood pressure.
Monitor your blood sugar level and A1c.
Have regular reviews with your diabetes care team.

Talk to your health care professional team: ask questions and get answers that you understand….. prevention is better than a decreased quality of life.

Please Share!

Navigating the Australian Health System

December 18, 2014 by Imagine_David Leave a Comment

Health care in Australia is divided between Federal and State responsibility.

To make the most of the system it is wise to understand how to navigate these systems, so you can get the best ‘value’ to enable your diabetes self care plan to be most efficiently and affordably implemented.

The International Diabetes Foundation recognises that “People with diabetes have the right to understand their disease, make informed choices and receive care based on best practice. They must be part of the team that manages their condition.This can only be achieved if interdisciplinary teams and people with diabetes have the information and tools to make changes based on best practice and recognized improvement strategies are used to support meaningful system change.”

All too often people living with diabetes do not get the opportunity to have the specialist input from a diabetes educator or dietitian.

To make your diabetes self care plan most effective it is in your best interest to have an appropriate level of diabetes self management education.

A diabetes educator provides diabetes self-management education for people with diabetes. They play a major role in self-empowering the person with diabetes by focusing on an individual’s needs, providing knowledge, motivation and support to aid the prevention of diabetes related health complications.

Diabetes Educators have many years experience (some living with diabetes themselves) and can provide you with tailored education, upon the following:

Self blood glucose monitoring.
Oral hypoglycaemic agents.
Insulin initiation and titration.
Sick day guidelines.
Hypoglycaemia recognition and management.
Complication risk management.

Accredited Practising Dietitians can, in addition, provide you with a nutritional assessment and advice tailored to your individual needs, in addition to education upon the following:

Influence of nutrition on blood glucose control.
Carbohydrate counting and information.
Weight management.
Blood lipid management.
Related health issues.
Complication management.
Hypoglycaemia recognition and management.

State Health Systems:

State health systems often provide services such a diabetes self management education courses at community health centres or in public hospitals.

These courses may be a combination of individual and group self management education sessions, usually run by a diabetes educator and a dietitian. These diabetes self management programs are usually free.

Whatever type of diabetes you have been diagnosed with, this is a good place to start.

To find out more about what is available in your area make contact with your local hospital or community health service.

005 — **Navigating the System to Better Health**

Another way to find your local diabetes self management programs is via Diabetes Australia or ADEA.

What’s Next

By initially connecting with these state funded health care professionals, you can then navigate the Medicare system with your GP to connect in an affordable manner with other members of your health care team. e.g. podiatrist, exercise physiologist, psychologist/counsellor etc (ALL of whom are covered by the Medicare system).

Medicare – Federal Government Funding

Talk with your GP about the Medicare system, whats available to people with chronic health issues like diabetes.

The Chronic Disease Management (formerly Enhanced Primary Care or EPC) — GP services on the Medicare Benefits Schedule (MBS) enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions and stroke. There is no list of eligible conditions; however, the CDM items are designed for patients who require a structured approach, including those requiring ongoing care from a multidisciplinary team.

Whether a patient is eligible for CDM services is a clinical judgement for the GP, taking into account the patient’s medical condition and care needs, as well as the general guidance set out in the MBS.

Patients who have a chronic medical condition and complex care needs and are being managed by their GP under a GP Management Plan (item 721) and Team Care Arrangements (item 723) are eligible for Medicare rebates for certain allied health services on referral from their GP.

In summary:

Maximum of five (5) services per patient each calendar year
Medicare rebate of $48.95 per service, with out-of-pocket costs counting towards the extended Medicare safety net
Patient must have an Enhanced Primary Care (EPC) plan prepared by their GP (your GP is paid to produce this for you)
GP refers to allied health professional (referral NOT required if that health care professionals happens to be available for free in the State health care system)
Allied health professional must report back to the referring GP

CAUTION: In creating the Chronic Disease Management Plan ensure YOU and your GP knows who is available in the State health system for you to enable the best use of this plan.

Team Care Arrangements (item 723)

Provides a rebate for a GP to coordinate the preparation of TCAs for a patient who has a chronic or terminal medical condition and also requires ongoing care from a multidisciplinary team of at least three health or care providers.
In most cases the patient will already have a GPMP in place (but this is not mandatory).
The minimum claiming period is once every twelve months, supported by regular review services.
Involves the GP collaborating with the other participating providers on required treatment/services, agreeing to arrangements with the patient, documenting the arrangements and a review date in the patient’s TCAs, and providing copies of the relevant document to the collaborating providers.

**With good self care knowledge everything is possible.**

A Diabetes Self-Management Plan Review form can be downloaded here Diabetes. This document shows a guide to the goals made in collaboration between the doctor and the person living with diabetes.

CAUTION: If you have more than one of these in place, e.g 2 different doctors making 2 different plans for you, your health care provider may end up out of pocket and may charge you the full fee for service – with no rebate owing to you.

Any questions? Please ask, even the smallest of questions.

Kind Regards,

David, Diabetes Educator @ Diabetes Counselling Online

Please Share!

Your Feet

December 3, 2013 by Imagine_David 9 Comments

Not all people with diabetes will develop foot problems.

However, it is estimated that 10% of people with type 2 diabetes will have some nerve changes on diagnosis.

Reducing your risk of potential foot problems is the bottom line for all people with diabetes.

People with diabetes are more prone to infection, so even a tiny break in the skin – such as a blister or graze – can potentially lead to infection, gangrene and amputation.

Regardless of the type of diabetes you have, putting prevention into practice is an integral part of all diabetes self-care plans.

In my 15 years of practice in diabetes educator I have found that most people have no footcare plan – even after years of being diagnosed. Not knowing the things you can do each day to protect your feet puts you at risk.

Some examples of the things I have seen and heard:

JW: 54yr old, t2 diabetes, driver of heavy machinery – road building equipment / plant. Developed an ulcer where his foot was constantly in touch with the metal footrest in the vehicle. Did not take any action. Ulceration and lower leg amputation.

MC: 26yr old t1 diabetes, salesman. Cut foot at beach on rocks when surfing. Went stratight to local hospital. Antibiotics and stitches. Wound heal uneventfully.

TC: 62 yr old. History of heart disease. Smoker. Had a friend who had a foot ulcer for 4 years. Went walking on the beach in bare feet. Cut foot – infected. No treatment for 3 weeks. Foot ulcer. Healed 10 months later.

RF: active foot ulcer for 4 years. About to have surgery to foot for the 7^th time. Not amputated – yet.

AK: 23yr old t1 diabetes. At the end of a foot-care seminar said “so, I need to look after my feet like my wife looks after her face”

SE: 70 yr old man, t2 diabetes for 30 years. Checked his feet every day – sat on edge of bed and counted his toes. One day in the bathroom he heard a ‘tap tap tap’ on the bathroom floor. He had never looked at the bottom of his foot. Never. He had a drawing pin / thumb tack stuck in an infected wound. 6 months of hospitalisation before he finally had his leg amputated. Checking the bottom of his foot each day (as well as the top) would have saved his leg.

This foot care guide will help you identify some simple self-care strategies.

These strategies may help you prevent severe complications such as foot ulcer or leg amputation.

Diabetes has the potential to cause two problems that affect the health of your feet:

Loss of feeling (Peripheral Neuropathy) – this can happen if diabetes has damaged the nerves to your feet. Damaged nerves prevent pain and temperature sensations reaching your brain, therefore you may not be able to feel an injury to your foot when it occurs.

Poor blood flow (Peripheral Vascular Disease) – A reduction in blood flow to the feet will increase the risk of ulceration and amputation. Diabetes affects the elasticity of the blood vessels and can cause narrowing and blockage. This reduces the amount of blood that is supplied to the feet, meaning that there will be a delay in healing.

Smoking will damage your feet by reducing the blood supply.

I once saw a cardiologist present the following at a conference:

Diabetes + Smoking = Amputation

CHECK – EVERYDAY

Your feet for any redness, swelling, blisters or cuts. If you have difficulty reaching your feet, use a mirror or have someone look at them for you.
Before and after you wear your shoes, check them for objects that may have fallen into them. Objects such as small stones, gumnuts, twigs etc. Also, feel inside them for any material damage such as nails poking through the sole, rough or loose areas of material, which may injure your feet.
In between your toes to make sure they are not wet.

WEAR

Comfortable, well fitting enclosed shoes. They should fit well in the shop before you buy. Don’t depend on shoes stretching – they may not.
Good supportive footwear, which has a firm heel counter, flexible in the forefoot, and firm throughout the mid-foot. The shoe should also have a fastening device such as a buckle, velcro or laces.
With any new pair of shoes, wear the first time for no longer than 15 minutes. When you take them off after this time, check your feet for areas of redness or abrasion. If present return the shoe for a refund. If no redness or abrasion noticed, wear the shoes next time for up to 30 minutes, and check again. i.e. wear your new shoes in slowly.
Clean socks or stockings every day. Socks without tight elastic or seams are best. Try socks made specifically for people with Diabetes.
Bed socks or ugg boots if cold feet trouble you.

SELF FOOT CARE

DO’s:

Wash and dry your feet thoroughly, especially between your toes, every day.
Use a water-based cream such as sorbolene on your feet every day, but be sure not to apply cream between your toes.
Cut toe nails straight across and gently file rough edges. Never cut nails shorter than the end of your toe and don’t cut down the sides of the nail as this may leave jagged edges.
If you use a bath or foot spa check the water temperature with a bath thermometer. This will reduce your risk of causing a burn to your feet.

DON’T’S:

Don’t Soak your feet for long periods
Don’t use talcum powder on your feet
Don’t use any product that hasn’t been recommended by your podiatrist on corns, calluses or warts.
Don’t go bare-footed. The feet are at a greater risk of injury without shoes. Injury can lead to ulcers, infection, gangrene and possible amputation.
Don’t wear shoes without socks.
Don’t wear thongs or flip-flops or sandals.

WARNINGS

If you use hot water bottles, electric blankets or heaters, you may burn yourself and NOT FEEL it happening.
In winter do not put your feet near a fire or radiator. It is possible to burn your feet and NOT FEEL it happening.
If you find a break in the skin (cut, scratch, broken blister etc), you must clean it and keep it covered with a sterile dressing and see your doctor or a podiatrist as soon as possible.

FIRST AID

If you have a burn, cut, scratch, graze, broken blister, or any other area of broken skin, clean it and put a dry dressing on it to reduce the risk of getting it infected.
If it doesn’t seem to be getting better, or is deteriorating, see your Podiatrist or Doctor as soon as possible.

Hospital Plan:

Ask to see a podiatrist if you have a wound of any kind on your foot. My personal experience is having seen (on a number of occasions) a vascular surgeon with a plan to amputate a foot turn to the rescue of the same foot by the podiatrist.
Ask your family to check your feet for any signs of redness or broken skin (just as would have done yourself at home) if you are incapable of doing this yourself.
Ask your caring team (doctors and nurses) to refer you to the endocrine team if they have not done this. There is good evidence stating that your hospital recovery wil be less problematic if your BGL’s are well managed. Even for a few short days stay.
If you are capable, measure your own BGL pre and 2 hours post meals. The nurses looking after you are well meaning caring beings; but they are usually overworked and not in a position to measure your BGL as efficiently as you could yourself. This information can be invaluable in helping your recovery.

In your experience of hospitals, what would you be suggesting to include in a hospital admission plan?

Here is a self assessment tool that you can complete to see how your fare at present. I shall publish the scoring sheet next week.

This tool – the Nottingham Assessment of Functional Footcare – was developed by the team in Nottingham. Myself and a colleague podiatrist used it for the first time worldwide in clinical practice. We found that education based on this tool enhances the foot care of all participants. I hope that it can be a helpful guide for you as well.

NAFF unscored

If you would like some individual assistance to further your diabetes self care plan, simply complete one of our eConsul forms.

Safe travels,

David – Diabetes Educator @ Diabetes Counselling Online

Please Share!