From the Editor: The U.S. Centers for Disease Control tells us diabetes is the biggest producer of non-traumatic amputations in the United States. Most of these will be amputations of severely infected, non-healing, gangrenous feet and lower legs (86,000 in 1996, says CDC). Once things are that bad, there are few other options-so the best course, for diabetics and their health care providers, is prevention.
Dr. Rehm is a specialist in problems of the diabetic foot. Lately, he has taken his knowledge of foot care, and used it to create several foot-care products. But the core of any prevention program is patient education—so let's see what Dr. Rehm has to tell us.
I've been in practice for over 20 years. I graduated from medical school in
1976. I devote my practice to diabetic foot medicine. In 1992, I took a diabetic
foot care fellowship at the Hansen's Disease ("leprosy") center in
Carville, Louisiana, and we established a diabetic clinic there under the direction
of Dr. Patout. People who have leprosy have neuropathy, much like diabetics
do. We also developed diabetic foot care programs throughout the Mississippi
Delta, to help people who didn't have access to regular medical care.
There's a very high diabetic population down in the deep South. We also did
a lot of work helping to develop the LEAP, the Lower Extremity Amputation Prevention
program, that helps people save their feet.
Since I've come back to the San Diego area, we've developed our own version of the LEAP program here. When people come to see us, we have a several-point program of education, foot inspection and examination. We focus on the structure of the foot, the walking, the balance, the skin and the education and inspection.
Many of our patients show diabetic peripheral neuropathy. The patient's foot can be extremely painful, or numb, or both at the same time. Neuropathy shows up in many different ways, as dry skin, toenail problems, loss of sensation; it can show up as what we call hyperaesthesia, too much pain. Sometimes you lose proprioception, the ability to tell where your foot is in space. What's important about diabetic neuropathy is that if a non-diabetic has a numb foot, he or she knows it has gone numb, but in a diabetic who has severe peripheral neuropathy, the nerve pathway that tells you the foot is numb can itself be numb, so a lot of people don't realize the foot surface is numb.
How does diabetes involve the feet? It involves the feet by basically causing nerve problems, circulation problems, muscle and joint problems and infection problems—and these cause other things: Numbness, burning, dry skin, muscle weakness, calluses, cold feet... These in turn can cause orthopedic problems, such as: Deformities, walking problems, hammer toes, high pressure areas in the bottom of the foot where you get the big calluses under the metatarsal areas, thus ulcerations and other skin problems. And dry skin is a common manifestation of diabetes.
When a person has diabetes, the textbook says over 70% of foot complications can be prevented, but I say virtually 100% of them can, if they're caught early enough. This is the key thing! Almost all diabetic foot problems can be prevented, if caught in time. And when you say "caught early enough," that means treating the problem when it happens, managing conditions like neuropathy, rehabilitating people once they've had an injury or fracture.
PREVENTION IS THE BEST TREATMENT. The three things about prevention are very
important: Mental conditioning, overall physical conditioning, and to keep your
feet healthy. This last item includes several items, such as: Keep your feet
clean. Keep your feet warm. Keep your feet protected with the right shoes and
socks. Keep your feet SAFE — in other words, don't mow your lawn barefoot.
Keep your feet free of excess moisture. Keep your feet conditioned and free
from excess dryness. Keep your feet and toenails trimmed and healthy.
There are three more that I'd like to mention. Keep your feet working with exercise. In other words, excess glucose, from your diabetes, can build up in the joints and stiffen them. Keep your feet balanced when walking. A lot of people need arch supports, orthotics, in their shoes, so their feet don't wiggle all around, so they're not pronating, not putting sheering pressure in the bottom of their feet, which could cause hot spots, abrasions, and the possibility of ulcers. The last thing in the program is "keep your feet in check." That means you check them and you ask your doctor to check them. Diabetics should always have good shoes, and socks that fit properly, as well as foot cream, toenail oil, and foot shampoo.
My final word of wisdom is to be proactive. If you take care of your feet, you don't have to lose your feet or legs. Trouble doesn't have to happen.
EDITOR'S NOTE: Dr. Rehm's clinic, The Diabetic Foot and Wound Treatment Center, offers the following products he helped design. I've sampled them; and found them of good quality. Contact: Dr. Kenneth B. Rehm, The Diabetic Foot and Wound Treatment Center, 1529 Grand Avenue, Suite C, San Marcos, CA 92069; (760) 744-6226 (office phone) or (760) 744-6277 (fax)
* DiabetiCream, $30.00 (plus S&H), for a 4-oz. tube. Apply to clean, dry feet to help alleviate dryness and cracking. Use with massage to help increase circulation.
* Dr. Rehm's Special Foot Soap, $12.00/bar (plus S&H). Hand-made in small batches by the Maeda Family in Calexico, CA 92231
* ToesEase, ( foot and toenail cleaner) $20.00 (plus S&H) for an 8-oz. supply
* The Diabetic Sock, $10/pair (plus S&H), distributed by:
Stillwater Knitting Co., P.O. Box 287 Mount Airy, N.C. 27030. Non-binding top,
extra width in calf, non-constricting, hand- knit seamless toe, antimicrobial
treatment. 94% cotton, 5% nylon, 1% spandex, Made in USA.