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New York/New Jersey VA Health Care Network
Prevention Better than Cure: To Avert Amputation
Monday, January 30, 2017
VA New York Harbor Healthcare System (VANYHHS) is currently working on the second year of a four year $1.1 million grant from the VA Rehabilitation Research and Development Service (Washington, DC) to find a way to prevent the recurrence of foot ulcers in Veterans who have had a previous healed diabetic foot ulcer.
At VANYHHS, (and nationwide) approximately 25 percent of patients have diabetes and at least 80 percent of the non-traumatic amputations at the Harbor are caused by the complications of recurrent diabetic foot ulcers. “This is a huge problem,” says Sundar Natarajan, MD, MSc, who is leading this trial. To date, 96 patients have been recruited in this study and Dr. Natarajan is hoping to reach the goal of 238 participants within the next 2 years.
Many Veterans with diabetes have neuropathy related to their illness. Dr. Natarajan explains that neuropathy is a condition which causes patients to lose feeling in their toes or other parts of their feet and disordered circulation. Diabetes causes slower healing and a greater chance of infections. Therefore, minor injuries can lead to skin breakdown, ulcer formation and subsequent infection without the patient noticing or treating the injury for a long time. Once the infection has spread, the foot or part of the foot may have to be amputated.
This outcome is particularly difficult since the problem usually occurs in older patients who also may have other complications of diabetes such as kidney disease, heart disease or other serious, debilitating health problems. Understanding this, VA has created special foot clinics and provides supplies to encourage better self-care, such as mirrors for Veterans to examine their feet and cushioned shoe inserts or special shoes to minimize pressure on foot areas at risk. However, the biggest challenge is to get patients to follow self-care practices that are proven to reduce the risk of recurrent diabetic foot ulcers.
Harbor’s STEP UP team is encouraging patients to be more aggressive in taking charge of their own preventive healthcare. This new Harbor program is focused on motivating patients to adhere to recommended self-care practices and to monitor the temperature of foot soles using a special foot thermometer. In order to establish the effectiveness of this new approach, the STEP UP team are conducting a randomized clinical trial.
“We’ve developed a new approach in this randomized clinical trial,” says Dr. Natarajan referring to the trial which involves a team of ten staff members (see photo). “The first part is getting people to take better care of their feet. The second part involves monitoring pre-ulcer foot health with a foot thermometer. These are in the context of typical diabetes care such as eating healthy, staying physically active, and taking medications as prescribed.”
The thermometer is held by the patient at six different parts of the sole and temperatures are recorded by the patient. Dr. Natarajan says that if a patient has healthy feet, both feet will generate the same temperature level. However, when an ulcer is about to develop, the temperature of an area on the affected foot may be higher due to inflammation.
If there is a discrepancy between the two feet, the research counselors are consulted. In most situations, resting for 24 hours with the affected foot elevated brings the temperature to a normal level. If not, the patient is referred to a foot specialist for follow-up care which typically involves excluding non-ulcerative conditions and providing off-loading shoes. Foot thermometry offers patients a way to detect and stop ulcers before they develop.
Interested in participating or in getting more information? Please call the STEP UP team at 212-951-3395.