In its 2002 National Diabetes Fact Sheet,1 the Centers for Disease Control (CDC) cited the following statistics:
- Seventeen million people - 6.2 percent of the population - have diabetes (11.1 million diagnosed, 5.9 million undiagnosed).
- The total medical cost of diabetes in the United States is $132 billion (as of 2002).
- Diabetes was the sixth leading cause of death listed on U.S. death certificates in 1999. It is believed that only approximately 35 percent to 40 percent have diabetes listed anywhere on the death certificate, and only about 10 percent to 15 percent have it listed as the underlying cause of death.
- Complications of diabetes include heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, dental disease, complications of pregnancy, and amputations.
- More than 60 percent of nontraumatic lower-limb amputations in the U.S occur among people with diabetes.
- From 1997 to 1999, about 82,000 nontraumatic lower-limb amputations were performed each year among people with diabetes.
Chiropractic care has much to offer patients who have diabetes. Because of circulatory concerns, these patients often develop extremity problems and symptoms, most commonly of the feet.2,3 As the diabetic process continues, neuropathy can lead to sensory difficulties, which often allows poor shoe fit, excessive pressure and friction, and even injuries, to go undetected.4-6 The eventual result is skin ulcerations, infections (which do not heal readily), and ultimately amputation in some cases.7,8
When treating a diabetic patient, it is the chiropractor's duty to evaluate the circulatory status in the extremities and to provide advice to help prevent the development of foot ulcers. In most people, the foot is seldom symptomatic. This is particularly true in the case of patients with a history or tendency to be diabetic.
Crucial Care Factors
Nutrition. Dietary modifications and vigilance with respect to food intake are required when dealing with a diabetic condition. Supplementation with vitamins, minerals and other products can be very useful, depending on each patient's condition and food habits.
Circulation. Circulatory status must be maintained at all costs through proper nutrition, regular exercise and protection from injury. Lower-extremity exercise is critical; just regular walking can stimulate the pumping of blood and fluids through the system, and prevent pooling and stasis. Gentle massage, along with elevation of the legs and compression stockings (when necessary) are useful adjuncts.
Shoe fit. Proper shoe selection can be critical in avoiding excessive frictional stresses to sensitive foot tissues.9 The last on which the shoe is built must match the shape and length of the foot. The vamp and the heel counter need to provide support without being overly restrictive or irritating. The size and shape of the toe box are critical: Prominent seams or stitching can rub and chafe, with disastrous results. Adjustable closures, such as full laces, can adapt to the changes in foot size and shape that occur during the day, and Velcro-type tabs are very helpful for patients who have difficulty lacing and tying knots. Slip-on styles usually are not recommended for patients with diabetes, due to the lack of adjustability and the need for a tight fit.
Shock absorption. An important consideration is preventing damage to the heel pads and absorbing the stresses of walking. The diabetic foot is particularly sensitive to the three to five Gs of force it must endure with every footstep. Normal shocks and stresses can result in damage and injury to sensitive diabetic feet. The sole of the shoe (insole, midsole and outsole) must be made of materials that are comfortable, durable and shock-absorbing.
Breakdown prevention. Custom-made, flexible foot orthotics are valuable and should be considered early in the treatment of a patient with diabetes. In the initial stages of the condition, an orthotic that is supportive of normal foot biomechanics is useful, as long as a special, shock-absorbing material is provided. Effective orthotics encourage efficient foot and lower-extremity biomechanics, while at the same time diffusing pressure stresses and preventing tissue breakdown. The ideal orthotic should be designed to be very comfortable and shock-absorbing, while still providing full corrective support for foot alignment and dynamics. This type of orthotic will allow your patient to continue to be active and to exercise regularly.
In the final stages of diabetic foot problems, a purely accommodative orthotic is all that can be tolerated. This type of "compromise" orthotic will absorb shock and prevent pressure sores, but it will not support the arches and biomechanics of the foot. In this case, cutouts and "divots" must be incorporated to allow the broken-down foot to function without excessive pressure on individual areas. It is much better to intervene early in this process and to prevent (or at least slow down) the development of this late stage.
Orthotics: A Valuable Support
The importance of proper shock absorption and shoe fit for the diabetic patient cannot be overstressed. Chiropractors who treat patients with diabetes must consider their need for comfortable, flexible foot orthotics that will provide support and forestall future biomechanical and tissue breakdown.
- Centers for Disease Control. National Diabetes Fact Sheet, 2002.
- Kosak GP, Hoar CS, et al. Management of Diabetic Foot Problems. Philadelphia: W.B. Saunders, 1984.
- Bild DE, Selby JV, et al. Lower extremity amputations in people with diabetes. Epidemiology and prevention. Diabetes Care 1989;12(1):24-31.
- Harkless LB, Dennis KJ. You see what you look for and recognize what you know. Clin Podiatr Med Surg 1987;4(2):331-339.
- Gibbons GW, Freeman D. Vascular evaluation and treatment of the diabetic. Clin Podiatr Med Surg 1987;4(2):337-381.
- Huntley A. The skin and diabetes mellitus (photo-essay). Dermatology Online Journal 1995;1(2). http://matrix.ucdavis.edu/DOJvol1num2/diabetes/neuropathy.html , accessed May 10, 2006.
- Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990;13(5):513-521.
- Levin ME, O'Neal MW (eds.) The Diabetic Foot, 3rd ed. St. Louis: C.V. Mosby, 1983.
- Dyck PJ, Thomas PK, et al. (eds.) Diabetic Neuropathy. Philadelphia: W.B. Saunders, 1987.
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