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Wound Care
for the
Neurovascular Impaired
Foot Meeting Report
August 26, 2002
In her second presentation for Sunny Hills in less than a year, Nancy Elftman, CO, CPed., pointed out that for people who have neuropathic (insensate) problems in their feet; almost half of their foot ulcerations are preventable. This is important, because studies have shown that for this population, there is only a 50% survival rate at three years after amputation. There is an increasing number of neuroarthropathy cases in diabetic adolescents, so diabetic screening is important, particularly for those with a family history. Off-loading of foot ulcers is vital to a wound care program and is intended to delay or prevent amputation.
Some of the tools to access neuropathy in the clinical setting include:
- Monofiliment - This standardized test of protective sensation evaluates the ability to feel a pressure of 10 grams on the bottom of the foot. Without this sensory feedback, a person will likely continue to walk on traumatized skin quickly escalating the injury which leads to inflammation, ulceration and infection.
- Temperature - Variations of greater than three degrees from adjacent areas can mean poor circulation (if it’s lower) or, if the temperature is higher, that the body is rushing blood to a traumatized area. In some conditions, this test will point to pathology much sooner than X-rays will.
- Harris mat/pressure distribution - This shows the weight bearing pressures on the bottom of the foot when standing/walking. Over time, pressures as low as 2-3 pounds can even cause problems and the static vs. dynamic version of this diagnostic test demonstrates the significant shear forces that exist during walking. Shear forces exacerbate the trauma experienced by the skin. Taking shorter steps can reduce shear forces by 50%. Wearing two thin, seamless socks can also help reduce shear to the foot.
- Visual inspection- Calluses, loss of hair growth, shin dryness, edema, shoe wear pattern and many other signs can help determine what’s wrong.
Another important test is the “ankle/brachial index” (ABI), which determines if there is a blockage of blood flow to the foot. Obviously, this is crucial to the ability of the foot to heal. Sometimes compression hose are used to control edema (swelling) in the lower leg and Nancy stressed that an ABI value of greater or less than 0.8-1.0 is a contraindication for compression hose. Many compression stockings have their maximum pressure starting just above the ankle. Ideally, the pressure should start at the foot and decrease as it goes higher on the leg and Nancy showed us a new two-piece design that is much easier to don.
Crucial to the treatment of wounds is to “off-load” the pressure from the ulcerated area, or better yet, to prevent an ulcer from developing in the first place. In many cases, we can fit special pre-made sandals which have special inserts we can modify according to the severity of the ulcer. Some pre-made shoes (designed with extra space inside) can accommodate a custom molded insert which can frequently prevent or delay the need for custom shoes.
For more severe cases, total contact orthoses, like the neuropathic walker or the orthotic dynamic system (ODS) splint, not only contain a custom molded accommodative insole to off-load high pressure areas, but restrict ankle motion and shear forces to the foot by incorporating special modifications.
Finally, Nancy showed us a brand new but clinically proven sock that contains silver threads connected to batteries and a computer circuit, applies a reversing ion flow to the limb to increase blood flow very significantly. We’ll keep an eye on this innovation!
Our goal in hosting this seminar was to “get on the same page” with our allied health care colleagues in Orange County and clarify the “off-loading” options we can offer our clients who have neuropathic foot conditions.
To contact Nancy Elftman, E mail her at: handsonfoot@earthlink.net
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