EUROPEAN PRESSURE ULCER ADVISORY PANEL

ABSTRACTS FROM THE FOURTH EPUAP OPEN MEETING
University of Pisa, Italy, 28–30 September, 2000

TELEMEDICINE AS A METHOD OF ASSESSING AND ADVISING ON THE MANAGEMENT OF PRESSURE ULCERS

Dr David Gould, Consultant Dermatologist; Mrs Heather Newton, Clinical Nurse Specialist for Tissue Viability/Wound Care; Royal Cornwall Hospitals NHS Trust, Cornwall, England

Pressure ulcer management is seen as a role primarily for nursing staff. However, providing a truly effective service for the more complex cases requires a multi-professional approach. It is often difficult to obtain advice from individual disciplines at appropriate times during the patient’s management. This presentation describes a tele-medicine system, which enables a number of specialist opinions to be accessed in order to plan appropriate management of a single clinical problem, in this case, pressure ulcers. The store and forward tele-medicine system has been available in Cornwall for the management of complex Dermatological conditions and wound care problems for the last two years. We describe how the system can be used to provide management advice from the Tissue Viability Specialist, Dermatologist, Plastic Surgeon, Vascular and Orthopaedic Surgeons. The advantages such a system provide are rapid access to specialist opinions and the ability to access this opinion from a distance, which can be more convenient for the patient. Early prompt advice and appropriate management has the potential to reduce costs. The benefits of such a system for patients and staff, both in primary and secondary care, are demonstrated highlighting the truly multi-professional approach to the management of pressure ulcers.

Dr Luigi Uccioli, Cattedra. di Endocrinologia, Dipartimento di Medicina Intema, Universita di Roma, ‘Tor Vergata’, Italy

Peripheral neuropathy is a major risk factor for foot ulceration in diabetic patients. Foot deformities may be independent by diabetes or may be the consequence of peripheral neuropathy; in both cases they represent an additional risk factor. Peripheral vascular disease is responsible of the outcome of foot ulceration; in fact it impairs the healing rate in those patients making them at risk of lower-limb amputation. The relationship between peripheral neuropathy and risk of ulceration has several evidences that may be summarized by the development of high plantar pressures related to foot deformities, limited joint mobility and callus that in presence of foot insensitivity are responsible of unnoticed traumas and tissue breakdown. Foot deformities, either when independent from diabetes, or when related to a long lasting diabetes with peripheral neuropathy are responsible for increased pressure under the foot soles. This is due to the appearance of a pes cavus with claw or hammer toes and hallux valgus and a consequent concentration of the pressures on the metatarsal heads during the walking cycle.

Limited joint mobility is associated with an increased plantar pressure and a greater history of foot ulceration. The movements of the subtalar joint are of special interest in the diabetic foot, because any reduction in mobility of this joint may cause an increase in plantar pressures during walking. In the presence of limited joint mobility, the foot is unable to provide its shock-absorbing mechanism and may lose its ability to maintain normal plantar pressures. The presence of limited joint mobility can result in abnormally high intrinsic plantar pressures and lead to plantar ulceration, the final mechanism involves prolonged repetitive moderate stress. The callus is at the same time the cause and consequence of high plantar pressures, in fact callus has been related to the points of high plantar pressure, and callus removal may reduce peak plantar pressures by 30%. The relationship between insensitivity and foot ulceration may be simply represented by the fact that the patients cannot feel the repetitive stress caused by high pressure under the foot and therefore are not in the condition to protect the foot. Additional mechanisms may be related to the use of too narrow shoes, that may damage the feet directly. In presence of peripheral neuropathy the patients may have the feeling of perfectly fitting shoes, wearing shoes that are sometimes a half or one size less than required. In addition foreign bodies can penetrate the shoes unnoticed, and give ulceration remaining under the feet during walking. This is the reason why patients should check inside their shoes for the presence of foreign bodies.

Extensive literature deals with the risk of ulceration related to the presence of foot insensitivity, and insensitivity to 5.07 monofilaments is present in more than 90% of patients with foot ulceration. Footwear and appropriately fitted insoles may drastically relieve the areas of high intrinsic pressures and decrease the mechanical stress of walking to safe levels. In fact it has been demonstrated that appropriate shoes and insoles are able to reduce foot ulcer relapse rate in a group of very high risk diabetic patients. We must underline that the use of specific footwear is recommended for the prevention of foot ulceration.

Of course, diabetic patients without long term complications do not need special shoes; their use must be encouraged also in patients with diabetic complications (i.e., peripheral vascular disease and/or peripheral neuropathy) but without previous ulceration, but their use should be mandatory in patients who have experienced a previous ulceration. Different is the role of specific between footwear in presence of foot ulceration. Theoretically, patients with an open ulcer should not wear any type of shoe, because maintaining the pressure over a healing area determines a reduction in the healing rate. Different systems have been employed to reduce high pressures over the ulcerated area (i.e., total contact cast, scotchcast, walking cast) with different results. The use of shoes in the healing time should be reserved to the situations in which it is not possible to use the already mentioned systems, or when after their use the healing has not been fully observed (i.e., after the removal of a contact cast). In this situation the use of shoes should be limited to half shoes or healing sandals, or temporary shoes. In selected cases in which the ulcer is superficial (i.e., Wagner 1) and the patient asks for normal looking footwear, if the shoe and the insert allow a reduction of peak pressure to safe levels, a rocker bottom shoe can be used.

References:

• Duffy JC, Patour CA, (1990) Management of the insensitive foot in diabetes: lessons learned from Hansen’s disease, Military Medicine, 155: 575–579.
• McNeely MJ, et al. (1995) The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration, Diabetes Care 18: 216–219.
• Sosenko JM, et al. (1990) Comparison of sensory-threshold measures for their association with foot ulceration in diabetic patients, Diabetes Care 13: 1057–1061.
• Young MJ, et al. (1994) The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds, Diabetes Care, 17: 557–560.
• Schoenhaus HD, et al. (1991) Biomechanics of the foot. In: Frykberg RG (Ed), The High Risk Foot in Diabetes Mellitus. Churchilll Livingston. New York, pp. 125, 137.
• Uccioli L, et al. (1995) Manufactured shoes in the preven-tion of diabetic foot ulcers, Diabetes Care, 18: 1376–8.