Evolving Diagnostics and Contemporary Therapies are Redefining Diabetic Foot CareFriday, August 17, 2012
Armed with multiple comprehensive diagnostic tests and radical therapies and treatments, podiatrist Jeffrey Bowman DPM, MS, can treat patients with serious diabetic ulcers, achieving wound closure and preventing amputations. Here is what both patients and other medical providers should know about this important diabetes-related specialty.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
The development of a diabetic foot ulceration can be disturbing to patients and difficult for providers to treat. With underlying neuropathies or peripheral arterial disease causing poor blood circulation, people with diabetes (PWD) can have difficulties with wound healing.
Ulcerations can also go undetected for long periods of time especially for those people with diabetes who are immobile or have neuropathy. The continuation of open wounds can lead to infections and in the absence of treatment can exacerbate ulcerations leading to patients’ worst fears and medical providers’ biggest concerns: amputation of the limb.
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), “more than 60 percent of non-traumatic lower-limb amputations occur in people with diabetes. And in just 2006, about 65,700 non-traumatic lower-limb amputations were performed in people with diabetes.”
The silver lining for patients who have ulcerations or for PWD with fears about getting them is that there are revolutionary technologies making wound care seem like science-fiction by helping to decrease recovery times, treating wounds once considered untreatable, and staving off amputations that just a decade ago would have been the probable result.
With everything from the use of hyperbaric chambers (HBO) to stem cell therapies to skin substitutes, podiatrists have many more treatments at their disposal. Houston, Texas-based podiatrist Dr. Jeffrey Bowman (pictured above) is one such foot specialist who is utilizing the latest technologies to treat wounds and ulcerations.
Along with treating patients with existing ulcerations or other diabetes-related foot ailments, Dr. Bowman is a firm believer in patient education to help PWD prevent foot ailments.
As with other aspects of diabetes care and management, people can take proactive steps to care for their feet to avoid ulcerations.
DiabetesCare.net spoke to Dr. Bowman about the exciting new predictive diagnostic tests, the contemporary clinical wound therapies in use as well as those in development, and the overall clinical role podiatrists should play in diabetes care.
DiabetesCare.net: As there might be some who are not familiar with podiatry as it relates to diabetes, can you provide an overview of how podiatrists care for people with diabetes and when is it best for PWD to begin to see a podiatrist?
Bowman: We are the physicians of the foot and ankle. At my practice, we are all about diabetes education. We like to see people with diabetes as soon as their diagnosed, because we find it can help them in the long term care of their feet. If they learn some new information right away about the seriousness of their diabetes, the potential neuropathies, the ulcers that can form, these newly diagnosed patients will take the disease more seriously.
It’s like the old movie, “Scared Straight”. We want to give them the straight scoop and give them a healthy fear of what could go wrong, if they don’t take care of themselves.
DiabetesCare.net: What are you seeing mostly in your practice when it comes to the typical patient with diabetes?
Bowman: Most of my patients are type 2s, and they have been referred to me from other physicians. Diabetes does not discriminate. We have a large Hispanic population, and they are one of the fastest growing diabetic populations in the country. We are also treating this patient population as well.
DiabetesCare.net: Can you talk about some of the diagnostic tests your practice uses for diabetes patients?
Bowman: We can do digital x-ray to check for a bone infection. We can do a blood flow study that we can hook up to a patient’s lower limbs from just below the thigh down and we do segmental blood pressures known as ankle-brachial Index (ABI). We can detect if their feet are getting enough blood flow and if they are not, then we can refer them to a vascular surgeon. We also have diagnostic ultrasound where we can measure the depth, length, and width of the ulceration.
In addition, we have patients do thermal imaging, where they stand up, and it can show the weight under individual bones. I can then tell patients they are likely to have an ulceration in a specific area, and that we can do something now to prevent that such as custom made diabetic shoes.
We can also predict diabetic neuropathy; we perform a small 3mm biopsy, send it to the lab and count the number of nerve fibers present. This is clinically significant because even with a current neuropathy patient we can monitor the progression as well. This is called the Epidermal Nerve Fiber Density Test, which is performed by Bako Pathology.
DiabetesCare.net: What are some of the best tips and strategies for preventative foot care?
Bowman: The first thing is to see a podiatrist four times a year, even if you are well-controlled and don’t have any foot ailments. We can do a full check-up including screening with our diagnostic tools and technologies. We find that four times a year can help keep up with foot care, and there have been published studies to support this.
Due the loss of sensation, and unbeknownst to them, some patients are developing wounds that they do not feel or even detect because they are not looking at the bottom of their feet. To address this issue, we ask patients to take a mirror place it on the floor and put their feet over the mirror to see if there are any wounds or ulcers. We ask patients to do this daily.
We also have a comprehensive list of tips on our website about foot care for people with diabetes. However, some general tips include the following: Choose socks and stockings very carefully and be sure to change socks every day. It is important to avoid socks with holes in them or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toes socks will not squeeze your toes. We carry diabetic socks that have no seams. Also avoid stockings with elastic tops. When buying shoes make sure they are comfortable right away and you don’t have to break them in. People with diabetes should avoid pointed-toe styles and high heels. And after bathing, when drying feet, pat each foot with a towel and carefully between your toes.
DiabetesCare.net: What are the main diabetes-related issues you are seeing in your practice?
Bowman: The main aliments I’m seeing are neuropathy and diabetic foot ulcers. Occasionally, I’ll get referred a patient who is in end stage osteomylitis. And unfortunately, when it goes down to the bone, usually an amputation is often necessary. And we are all about saving limbs, not getting rid of them.
DiabetesCare.net: Can you take us through your typical treatment protocol for patients that are presenting with classic symptoms for diabetic ulcers?
Bowman: With ulcerations we do a special type of photography where we give the exact measurements of the wound it’s width, length, and depth. This is critical because it can tell us if it is healing in subsequent exams.
Next we will check the blood flow or ABI of the lower extremity and to the foot, because patients will not heal if they are not getting adequate blood flow.
Again, education is critical. If the patient, for example, is a smoker, we want to counsel them on the significance of quitting, and how it pertains to getting into better health and how it can help with the healing process. If people are habitual smokers, it will work against them when it comes to ulcers.
After the photography and blood flow test, I will debride the wound down, and if there are any signs of infection, I’ll do a culture, and put them on an antibiotic.
If the infection is in a later stage, then we will hospitalize them to provide them with an IV of antibiotics. Fortunately, I’m finding that I have to do the hospitalizations less and less, because more emphasis is being put on patient education.
We will also do a comprehensive physical exam and history on the patient. I want to know who else in the patient’s family is diabetic. Did these diabetic family members have foot ulcers, heart disease, or renal failure?
Depending on the size and depth of the wound, I will apply some type of enzyme agent on it, or I may have to put on a skin substitute or a graft. We will also show patients how to change their bandages.
Top image: Using a skin substitute like a collagen wound dressing can be unrolled and fit to match the patient`s ulcer. Once the ulceration starts to form granulation tissue, the wound can then begin to close and heal. Bottom images from left to right: A patient with an unhealed ulceration even after two grafts; same ulceration with application of collagen dressing; and lastly, four weeks after the dressing has been applied, closure of wound being realized and progression of healing shown.
DiabetesCare.net: One of the bigger, more talked about clinical trends in recent years has been this idea of coordinated care being exhibited in primary care practices, but interestingly enough it is being used in limb and wound centers. What are your thoughts on coordinated care?
Bowman: I always tell a patient with diabetes they need four doctors, a podiatrist, family practitioner, endocrinologist, and an ophthalmologist. Diabetes is going to affect the feet and the eyes the quickest of the complications, so PWD need to be well-cared for with providers of these specialties. Often times, a podiatrist is the first medical provider to diagnose diabetes.
I used to be a director at a foot and ankle wound care center, and I know it is extremely important to coordinate care. These centers are pretty prevalent now, and they are very well-equipped to help patients with diabetes heal.
These are usually outpatient medical centers and so patients come in for treatment and can leave, which obviously helps patients with their quality of life. A lot of these treatments can also be done in an individual doctor’s office as well.
DiabetesCare.net: Are you working with any local primary care practitioners in coordinating care or even in a referral capacity?
Bowman: We have an event called “Lunch and Learn” at local primary care offices. We will visit over the lunch hour, and bring lunch for a doctor and his staff. I will then talk about diabetic foot care, treatments, and when they need to see a podiatrist.
For example, some primary care practitioners are not aware there are corrective shoes available for people with diabetes. These shoes are custom-made and meant to prevent ulcerations.
I try to do these “Lunch and Learns” once or twice a month. We have found that to be helpful in terms of educating staffs at PCPs’ offices and a good reminder for the PCP to screen the patient’s feet.
DiabetesCare.net: One of the scariest things for people with diabetes is the possibility of losing a limb. Yet there has been a great deal of work being done in podiatry to help people with diabetes avoid amputation. What are some of the ways patients are being treated today to avoid it?
Bowman: The biggest thing is patient education. Again counseling patients, whether you are a primary care provider or a podiatrist, on the importance of foot care can make a vital difference.
Sometimes it may be as simple as getting enough blood flow to the ulceration that can make the difference. Most people with diabetes will get some form of peripheral artery disease, especially if they are not controlled.
There are a number of therapies and treatments available to people. Skin substitutes are one wound and ulceration treatment that has really helped alleviate the number of amputations. Skin substitutes come in a variety of sources and they are made into sheets to cover the wound. We will tact it in the wound so it gets absorbed, and then forms granulation tissue. And with this type of tissue, patients will get closure of the wound.
I have had patients with diabetes who have ulcerations taking up most of the planter surface of their foot, and with skin substitutes and a regimen of non-weight-bearing, I can get them healed. And in these situations, you never see a patient more grateful, because we have been able to heal the wound and avoid amputation—and that is what we are about. Amputation is absolutely the last thing as physician wants.
Another is the use of hyperbaric oxygen (HBO) chambers. These chambers contain 100 percent oxygen and they help create more blood flow. We usually treat patients by bringing them in to get treatment for 30 straight days. Patients sit in the chamber and can relax by watching TV or reading a book. I have seen wounds that have been on a patient for a couple of years actually disappear in 6 weeks after HBO.
Hyperbaric chambers are another treatment option Dr. Bowman uses in his practice for diabetic foot ulcerations. Patients can relax, watch tv, or read as oxygen is delivered to the wound. Patients` ulcerations can begin to heal in just a few weeks.
If an infection is present, there is a therapy called the Wound V.A.C., where as the name suggests, it actually evacuates the infected area.
As I had mentioned earlier, diabetic shoes or custom orthotics can also help prevent further ulcerations.
I have also been performing treatments such as plasma rich protein (PRP) injections. For PRP, you draw the patient’s own blood, separate out the plasma, and inject it into the wound. We have seen some good healing with this treatment too.
DiabetesCare.net: What are some of the other exciting treatments on the horizon when it comes to wound healing?
Bowman: Stem cell technology is super exciting as I have gotten wounds to heal quicker than I ever have prior to that.
I was just named as an investigator for a clinical trial using a new product that contains stem cell technology. I’m going to be recruiting people with diabetes for free treatment, unless they are covered by insurance, on ulcers to test this new therapy.
The product comes in a graft or powder forms. In the couple of months since I have been using it, I’m pleasantly surprised at the rate patients are healing. And this is compared to other products I use.
In patients who have two wounds, I may use the stem cell therapy in one wound, and a skin graft product on the other that has been out for years. I can compare the efficacy and see which one is healing the wound better.
It is exciting for me as a practitioner because patients can come in with wounds that have been there for years and we can still treat these patients and get wound healing results for ulcerations and prevent amputations.
For anyone who lives in the Houston, Texas area, has diabetic foot ulcer(s), and is interested in learning more about or becoming a participant in Dr. Bowman’s stem cell clinical trial, you can contact his practice by phone at: 713-467-8886 or go to his website here.