Less Pain, More Gain

Nerve problems aren't inevitable. Controlling your diabetes can keep you on your feet

Joseph Stock, 67, of Waterford, Wis., learned he had diabetes in the mid-1990s. Since then, he's been careful to keep his blood sugar under control and watch for signs of any complications. "Being diabetic, I checked my feet regularly," he says. "I had not noticed anything when all of a sudden the nail on the big toe of my right foot fell off. I might have noticed the problem had it not been underneath the nail."

An emergency room doctor determined that the toe was seriously infected and couldn't be saved. It was amputated the next day, but doctors worried that if they didn't get Stock's infection under control quickly he would lose his leg below the knee.

Stock consulted a wound care specialist, who recognized that because Stock had good blood flow to the area, there was a chance to save the leg. He remained in the hospital, visiting the hyperbaric oxygen chamber almost daily and following up those sessions with additional wound care treatments.

After eight weeks, Stock was ready to go home. He had a new graft material placed over the wound site so it could continue to heal. Next came a medicinal-grade honey treatment, and finally a skin graft to the wound using healthy skin taken from his thigh.

"Within weeks I was completely healed and I was being fitted for a new pair of shoes," he says. "Now I can go walking, do activities around the house and even dance with my wife."

Control glucose, control complications

Diabetic neuropathy, which describes a variety of nerve problems and diseases, isn't inevitable. While neuropathy is more common in people who have had diabetes for a long time, keeping diabetes in good control can lower your risk of developing nerve problems or delay the onset of symptoms. Even if you've started to notice pain or discomfort in your extremities, especially in your feet, getting tight control of your blood sugars can help. Following a healthy lifestyle and taking medications, if needed, can keep nerve damage from progressing, and can even help reverse it.

"High glucose levels are toxic to the nerve. The nerve needs normal levels to use for energy, but it can't handle high levels and converts the glucose into other, irritating substances," explains Dr. Richard M. Bergenstal, president-elect, medicine and science, of the American Diabetes Association, and executive director of the International Diabetes Center at Park Nicollet in Minnesota. He suggests that you shouldn't worry about one high blood sugar reading here or there — the important point is to keep overall levels low.

Take care to bring your blood sugar down gradually, though. "When it rockets down very fast it can irritate the nerves temporarily," Bergenstal says. Talk to your doctor about the right blend of diet, exercise and medication to help stabilize your blood sugar.

Keeping diabetes in good control can lower the risk of developing nerve problems, but diligent foot care can prevent some severe complications.

Because the blood flow nourishes your nerves, keeping your vascular system healthy can also relieve some nerve pain. Bringing your blood pressure and cholesterol levels into normal ranges can help by improving your circulation and preventing plaque from building up in your arteries.

Some people with diabetic nerve problems have trouble with swelling in their legs, which can impair blood flow, notes Dr. Robert Gerwin, an attending physician at the Johns Hopkins Pain Treatment Center in Baltimore. In these cases, elevating the legs at night and using massage or pumps to alleviate the swelling can help improve circulation.

"Controlling swelling and edema in the legs may be as important as anything in treating leg ulcers and some foot ulcers," says Dr. Greg Catalano, a podiatric surgeon at Emerson Hospital 
in Concord, Mass.

Watch your step

Sally Matson, a certified wound, ostomy and continence nurse at Orlando Regional Healthcare in Florida, says three factors often combine to make healing challenging for people with diabetic neuropathy.

First, there's the lack of sensation. When the nerves aren't firing properly, it's hard to notice problems that would cry for attention with normal pain signals. Second, people with diabetes are prone to muscle wasting and bone deformities that can cause the foot to fall out of balance. Finally, impaired sweat and oil gland functions can lead to dry, scaly skin that can develop cracks and fissures where infectious germs can creep in.

It's easy to ignore preventive foot care, especially when you don't notice any discomfort. But slow-healing wounds and infections can lead to gangrene and may even require amputation. To avoid these problems, follow these tips:

• Wear good shoes, and wear them all the time (even in your home) to prevent injury. Shoes that don't fit properly can cause pressure ulcers. Closed-toe shoes with a wide toe box are ideal.
• Inspect your shoes before you put them on for anything that might be lodged inside that could harm your foot.
• After you've worn a new pair of shoes for an hour or two, inspect your feet for signs of a poor fit.
• Watch where you're walking, and keep an eye out for anything that might injure your foot.
• Look at your feet every day, checking for thick calluses, ulcers, athlete's foot, sores, ingrown toenails, corns, swelling, skin color changes or cracked skin. Make sure to check between your toes. Use a mirror to check the bottoms of your feet, or ask a friend to take a look if vision problems or obesity make it tough to check your feet on your own. "Nails have to be managed well and calluses have to be buffed down. A good podiatrist is crucial," Matson says. "A callus that's discolored or bleeding underneath is often a sign of a pre-ulcer."
• Don't trim your nails or treat calluses, warts or bunions at home, because it may result in injury. With diabetes, even small injuries can be very serious if an infection sets in.
• Wash your feet with lukewarm water daily, but don't soak your feet — soaking removes oil.
• Moisturize your feet with a cream or oil designed for diabetic foot care, but don't spread it between the toes.

Stay on top of it

If you do develop a foot ulcer, see your doctor, a podiatrist or a diabetic foot care specialist right away. "People need to get those wounds looked at quickly so they don't become chronic situations," says Catalano. Your doctor will develop a treatment plan, starting with a look at your diabetes control and other health conditions that can affect healing, such as high blood pressure and peripheral vascular disease. "You don't want to just focus on the wound. You need to look at the whole person," 
he adds.

It's important to keep pressure off the wound so it can heal. Matson says options range from special boots and half-shoes to crutches, wheelchairs and bed rest, depending on the severity and location of the wound.

Most diabetic wounds extend beneath the top skin layer, into fat, muscle and even bone. "You're going to have dead tissue there, and one of the key elements in dealing with these wounds is they need to be debrided," Matson says. "We want to get that cleaned up quickly because dead tissue has a greater chance for bacterial buildup." Debridement means removing the outer dead tissue from a wound in order to prevent infection and provide oxygen to the site to help in healing. Products with antimicrobial properties can help clean dead tissue from wound sites, though sometimes surgery is needed. Intravenous, oral or topical antibiotics and antifungal medications can help fight infection as well.

Once the wound is clean, your doctor will recommend dressings that promote healing. Wounds need to be kept moist, but not wet; various products can help depending on whether your wound is too wet 
or too dry.

Wounds tend to change over time. A wound may start out wet and draining, but as it heals it may become drier, so treatment may need to change to reflect the wound's progress.

"It's all about establishing a good balance in the wound so the body can heal itself using its own natural growth factors," Catalano says. For some people, like Joseph Stock, hyperbaric oxygen treatment can help the body heal.

Be sure to talk to your doctor at the first sign of any diabetic nerve trouble, injury or ulcer, so you can get prompt attention and increase your chances for a speedy recovery. An ounce of prevention is worth a pound of cure.