Neuropathy (Nerve Disease)    

 

Nerve Disease (Neuropathy)
About 15 million Americans suffer from neuropathy, a nerve problem that can damage the nervous system and cause unrelenting aches and pains. In particular, 60% of diabetics develop peripheral neuropathy when their blood glucose reaches and remains at dangerous levels for several years.

When blood glucose levels rise too high and remain too high, the glucose molecule attaches itself to cells permanently and is eventually converted to a poison sugar called sorbitol that destroys nerve cells (nerve death). 

The signs of nerve damage include tingling, burning, and the loss of feeling (touch) in the feet, which lead to a high incidence of foot infections, foot ulcers, and amputations.

If motor or autonomic nerves are damaged, this can lead to the loss of muscle control, bladder control, and bowel control. Eventually, after many years of poor blood glucose control and deterioration of the nervous system, the cells in the brain may also become damaged.

Please Note: Foot care is very important. It is critical for diabetics to pay special attention to their feet, since the feet are very susceptible to sores and cuts that don't heal and can lead to gangrene and amputation.

Peripheral Neuropathy
The peripheral nerves that go to the arms, hands, legs, and feet are responsible for relaying information from the central nervous system (brain and spinal cord) to muscles and other organs. Peripheral nerves also relay information back to the spinal cord and brain from the skin, joints, and other organs. High blood glucose levels create trace chemicals that damage the blood vessels that bring oxygen to some nerves and cause oxidative stress to nerve cells, and the degeneration of nerve fibers and the myelin sheath covering on the nerves.

In addition, the high glucose and insulin levels can cause calcium and other minerals to leech from the synaptic junctions. Synaptic junctions can only retain a limited amount of glucose, insulin, and electrolytes; therefore, when glucose or excess insulin enters, something else must be released. Since there is usually a plentiful supply of calcium and potassium from food, as well as a plentiful supply of oxygen from the lungs, these elements are generally the first to be discharged. However, once the nerve cell becomes shorter, it remains in that condition until it is over stimulated.

The calcium ion pump is responsible for the propagation of the nerve impulse along the myelin sheath. As a result, each time the synaptic junctions and nerve cells lose calcium, they conduct fewer impulses. A similar process is facilitated by the electric fields of tiny electrical charges, which are keyed to potassium levels. Atrophy occurs when any body part is used with less and less frequency.

Similarly, when the electrical signals are not propagating correctly and the body assumes that the nerve is no longer necessary and, to conserve energy, further reduces support for that nerve cell. In turn the nerve cell shrinks in order to function due to a reduced input of fuel and oxygen while still keeping itself viable until the nerve ceases to function.

Consequently untreated diabetes, hypoglycemia or poor glucose control could cause wide variations in the blood calcium, potassium, sugar, insulin, and oxygen levels thereby resulting in oxygen deprivation and loss of nerve integrity. Damaged nerves stop sending messages or send messages too slowly or at the wrong times. This leads to neuropathic symptoms such as tingling or numbness in the feet.

As a result, damage to these peripheral nerves can make the arms, hands, legs, or feet feel numb. Also, you might not be able to feel pain, heat, or cold when you should. You may feel shooting pains, burning or tingling like “pins and needles”. These feelings are often worse at night and make it difficult to sleep. Most of the time these feelings are on both sides of your body, like in both of your feet, but they can be on just one side.

Some of the other symptoms of peripheral neuropathy include prickly or burning pains, tightness of the skin, hypersensitivity to touch, impaired coordination, balance problems, difficulty climbing stairs or difficulty getting up from a sitting position, urinary urgency, erectile dysfunction, acid reflux and lightheadedness. The numbness that typically accompanies neuropathy can be particularly problematic because minor injuries may go unnoticed, turning into health problems that are not minor at all.

Peripheral nerve damage can change the shape of your feet because foot muscles get weak and the tendons in the foot get shorter. In some cases, failure of nerves controlling blood vessels, intestinal function, and other organs results in abnormal blood pressure, digestion, and loss of other basic involuntary processes. Peripheral neuropathy may involve damage to a single nerve or nerve group (mononeuropathy) or may affect multiple nerves (polyneuropathy).

Diabetic Foot Problems

When diabetes is not well controlled, damage to the organs and impairment of the immune system is likely. Foot problems commonly develop in people with diabetes and can quickly become serious.

• With damage to the nervous system, a person with diabetes may not be able to feel his or her feet properly. Normal sweat secretion and oil production that lubricates the skin of the foot is impaired. These factors together can lead to abnormal pressure on the skin, bones, and joints of the foot during walking and can lead to breakdown of the skin of the foot. Sores may develop.
  
  
• Damage to blood vessels and impairment of the immune system from diabetes make it difficult to heal these wounds. Bacterial infection of the skin, connective tissues, muscles, and bones can then occur. These infections can develop into gangrene. Because of the poor blood flow,  antibiotics cannot get to the site of the infection easily. Often, the only treatment for this is amputation of the foot or leg. If the infection spreads to the bloodstream, this process can be life-threatening.
  
  
• People with diabetes must be fully aware of how to prevent foot problems before they occur, to recognize problems early, and to seek the right treatment when problems do occur. Although treatment for diabetic foot problems has improved, prevention - including good control of blood sugar  level - remains the best way to prevent diabetic complications.
  
  
  • People with diabetes should learn how to examine their own feet and how to recognize the early signs and symptoms of diabetic foot problems.
    
    
  • They should also learn what is reasonable to manage routine at home foot care, how to recognize when to call the doctor, and how to recognize when a problem has become serious enough to seek emergency treatment.

Diabetes Foot Care

The Importance of Good Foot Care

The following are good foot care tips:

• Check your feet every day for cuts, red spots, sores or infected toenails.
• Wash your feet every day in warm, NOT hot water. Dry your feet well and especially between the toes.
• Put on a thin coat of lotion or petroleum jelly on the tops and bottoms of your feet. Do not put the lotion between your toes because it can cause an infection.
• Treat corns and calluses gently. Check with your doctor or podiatrist about how to care for them.
• Trim your toenails weekly or have a foot doctor do it if you can’t see well or reach your feet.
• Wear shoes and socks constantly. Never go barefoot because you could step on something and hurt your feet.
• Always check the insides of your shoes to make sure there are no stones or other objects in them.
• Wear socks at night if your feet get cold. Check your feet often in cold weather in case of frostbite.
• Put your feet up when sitting. Wiggle your toes for 5 minutes, two or three times a day.
• Do not cross your legs for long periods of time.

Diabetic Neuropathy
When you have “peripheral” neuropathy in your feet, it’s very difficult to feel pain, cold, or heat. Because you have loss of feeling, you may not feel a foot injury. If you develop a blister, you may not know it. Often, you won’t notice a foot injury until the skin breaks down and becomes infected.

Because of this lack of sensation in your feet, wearing shoes that don’t fit well can potentially cause this kind of damage to your feet. That’s why it’s so important to wear properly fitted shoes.

Diabetic Shoes
Diabetic shoes are specially fitted for people who have even mild forms of neuropathy. There are companies that specialize in pedorthics, which is the design of footwear and special insoles that can prevent or lessen foot injury and pain.

Diabetic shoes are often made wider and deeper that regular shoes, with a larger “toe box.” This is partly to have room if insoles are needed. The pedorthic insoles are usually custom made for each individual diabetes patient. This ensures the fit and helps with uneven weight distribution or rubbing. The shoes should also allow good air circulation.

Trained Professionals
Diabetics need to have their shoes fitted by a trained professional, like a podiatrist. What you need in a diabetic shoe are:

• Breathable construction—sandals and fabric shoes are best
• Deep and wide design—to allow for insoles
• Designs with no interior seams that could rub
• Easily adjustable fit—elastic can help

Are Diabetic Shoes Covered by Medicare?
Medicare Part B will cover most of the cost of diabetic shoes, but the doctor treating you must certify that you meet all the following conditions:

1. You have diabetes
2. You have at least one of the following conditions:
   • Foot amputation—partial or complete
   • Past foot ulcers
   • Calluses that can become foot ulcers and/or lead to nerve damage
   • Poor circulation
   • Deformed foot
3. You are being treated under a comprehensive diabetes care plan and need therapeutic shoes and/or inserts because of diabetes.

Medicare also requires the following:

• A podiatrist of other qualified doctor prescribes the shoes.
• A doctor or other qualified individual provides the shoes.
• If you meet the conditions above, you are covered for one of the following per year:
• One pair of depth-inlay shoes and three sets of inserts
• One pair of customized shoes that have been molded to your foot (including inserts). These are made if you have a foot deformity and cannot wear deep-inlay shoes.

Medicare-Approved Suppliers
For Original Medicare Part B to cover your diabetic shoes, you must get them from a Medicare-approved supplier.

NOTE: If you have a Medicare Advantage Plan, check with your individual plan to see cover limits.

Take Care of Your Feet
Wearing diabetic shoes and taking good care of your feet will help prevent damage and injury to your feet. Discuss any questions you might have with your primary doctor or podiatrist.

Diabetic Foot Care Causes

Several risk factors increase a person with diabetes chances of developing foot problems and diabetic infections in the legs and feet.

• Footwear: Poorly fitting shoes are a common cause of diabetic foot problems.
  
  • If the patient has red spots, sore spots, blisters, corns, calluses, or consistent pain associated with wearing shoes, new properly fitting footwear must be obtained as soon as possible.
    
    
  • If the patient has common foot abnormalities such as flat feet, bunions, or hammertoes, prescription shoes or shoe inserts may be necessary.

• Nerve damage: People with long-standing or poorly controlled diabetes are at risk for having damage to the nerves in their feet. The medical term for this is peripheral neuropathy.
  
  
  • Because of the nerve damage, the patient may be unable to feel their feet normally. Also, they may be unable to sense the position of their feet and toes while walking and balancing. With normal nerves, a person can usually sense if their shoes are rubbing on the feet or if one part of the foot is becoming strained while walking.
    
    
  • A person with diabetes may not properly sense minor injuries (such as cuts, scrapes, blisters), signs of abnormal wear and tear (that turn into calluses and corns), and foot strain. Normally, people can feel if there is a stone in their shoe, then remove it immediately. A person who has diabetes may not be able to perceive a stone. Its constant rubbing can easily create a sore.

• Poor circulation: Especially when poorly controlled, diabetes can lead to accelerated hardening of the arteries or atherosclerosis. When blood flow to injured tissues is poor, healing does not occur properly.

• Trauma to the foot: Any trauma to the foot can increase the risk for a more serious problem to develop.

• Infections
  
  
  • Athlete's foot, a fungal infection of the skin or toenails, can lead to more serious bacterial infections and should be treated promptly.
    
    
  • Ingrown toenails should be handled right away by a foot specialist. Toenail fungus should also be treated.

• Smoking: Smoking any form of tobacco causes damage to the small blood vessels in the feet and legs. This damage can disrupt the healing process and is a major risk factor for infections and amputations. The importance of smoking cessation cannot be overemphasized.

Diabetic Foot Care Symptoms

• Persistent pain can be a symptom of sprain, strain, bruise, overuse, improperly fitting shoes, or underlying infection.

• Redness can be a sign of infection, especially when surrounding a wound, or of abnormal rubbing of shoes or socks.

• Swelling of the feet or legs can be a sign of underlying inflammation or infection, improperly fitting shoes, or poor venous circulation. Other signs of poor circulation include the following:
  
  
  • Pain in the legs or buttocks that increases with walking but improves with rest (claudication)
    
    
  • Hair no longer growing on the lower legs and feet
    
    
  • Hard shiny skin on the legs

• Localized warmth can be a sign of infection or inflammation, perhaps from wounds that won't heal or that heal slowly.

• Any break in the skin is serious and can result from abnormal wear and tear, injury, or infection. Calluses and corns may be a sign of chronic trauma to the foot. Toenail fungus, athlete's foot, and ingrown toenails may lead to more serious bacterial infections.

• Drainage of pus from a wound is usually a sign of infection. Persistent bloody drainage is also a sign of a potentially serious foot problem.

• A limp or difficulty walking can be sign of joint problems, serious infection, or improperly fitting shoes.

• Fever or chills in association with a wound on the foot can be a sign of a limb-threatening or life-threatening infection.

• Red streaking away from a wound or redness spreading out from a wound is a sign of a progressively worsening infection.

• New or lasting numbness in the feet or legs can be a sign of nerve damage from diabetes, which increases a persons risk for leg and foot problems.

Diabetic Foot Care Treatment

Self-Care at Home

A person with diabetes should do the following:

• Foot examination: Examine your feet daily and also after any trauma, no matter how minor, to your feet. Report any abnormalities to your physician. Use a water-based moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear cotton or wool socks. Avoid elastic socks and hosiery because they may impair circulation.

• Eliminate obstacles: Move or remove any items you are likely to trip over or bump your feet on. Keep clutter on the floor picked up. Light the pathways used at night - indoors and outdoors.

• Toenail trimming: Always cut your nails with a safety clipper, never a scissors. Cut them straight across and leave plenty of room out from the nailbed or quick. If you have difficulty with your vision or using your hands, let your doctor do it for you or train a family member how to do it safely.

• Footwear: Wear sturdy, comfortable shoes whenever feasible to protect your feet. To be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting recommendations or shop at shoe stores specializing in fitting people with diabetes. Your endocrinologist (diabetes specialist) can provide you with a referral  to a podiatrist or orthopedist who may also be an excellent resource for finding local shoe stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes or shoe inserts.

• Exercise: Regular exercise will improve bone and joint health in your feet and legs, improve circulation to your legs, and will also help to stabilize your blood sugar levels. Consult your physician prior to beginning any exercise program.

• Smoking: If you smoke any form of tobacco, quitting can be one of the best things you can do to prevent problems with your feet. Smoking accelerates damage to blood vessels, especially small blood vessels leading to poor circulation, which is a major risk factor for foot infections and ultimately amputations.

• Diabetes control: Following a reasonable diet, taking your medications, checking your blood sugar regularly, exercising regularly, and maintaining good communication with your physician are essential in keeping your diabetes under control. Consistent long-term blood sugar control to near normal levels can greatly lower the risk of damage to your nerves, kidneys, eyes, and blood vessels.

Prevention

Prevention of diabetic foot problems involves a combination of factors.

• Good diabetes control

• Regular leg and foot self-examinations

• Knowledge on how to recognize problems

• Choosing proper footwear

• Regular exercise, if able

• Avoiding injury by keeping footpaths clear
  
  
• Having a doctor examine the patient's feet at least once a year using a monofilament, a device made of nylon string that tests sensation

Outlook

• Age: The older the patient, the more likely they are to have serious problems with the feet and legs. In addition to diabetes, circulatory problems and nerve damage are more common in the elderly person with diabetes. The elderly may also be more prone to sustaining minor trauma to the feet from difficulties with walking and stumbling over obstacles they cannot see.

• Duration of diabetes: The longer the patient has had diabetes, the more likely they have developed one or more major risk factors for diabetic lower extremity problems.

• Seriousness of infection: Infections that involve gangrene almost universally go on to amputation and also carry a high risk of death. Ulcers larger than about 1 inch across have a much higher risk of progressing on to limb amputation, even with proper treatment. Infections involving deep tissues and bone carry a much higher risk of amputation.

• Quality of circulation: If blood flow is poor in the patient's legs as a result of damage to the blood vessels from smoking or diabetes or both, it is much more difficult to heal wounds. The likelihood of more serious infection and amputation is greater.

• Compliance with the treatment plan: How well the patient follows and participates in the treatment plan developed with doctors and nurses is crucial to the best recovery possible. Ask questions if any aspects of the care or treatment plan are unclear. Let the doctor know if something in the plan doesn't seem to be working.

• Wound care centers: A wound care center is an excellent resource if available. It brings together many specialists and approaches to aid in the treatment of the diabetic foot problem. These centers will often be able to offer the most up-to-date therapies and even may have experimental protocols available for people who have not responded to traditional therapy.

• Individual physician and nurse skills: Ask about your doctor or nurse's expertise in dealing with diabetic lower extremity problems. Knowledge about and experience with these problems may lead to earlier diagnosis and more appropriate therapy.

Due to the fact that diabetes can cause circulation problems and nerve damage, as well as other conditions that can affect the feet, some people with diabetes will want special diabetic shoes or orthotics created especially for their condition.

The foot is especially affected by diabetes because:

• diabetes damages the nerves (damage can occur to the foot and not be detected) - this is called peripheral neuropathy.
• diabetes also affect the circulation. Poor circulation can affect the ability of the body to heal when damage occurs.
• those with diabetes are more prone to infection - the body's processes that normally fight infection respond slower and often have trouble getting to infections due to the poor circulation.
• diabetes can also affect the joints, making them stiffer
• other diabetes complications that can also affect the foot, for example, kidney disease (affects proteins that are involved in wound healing) and eye disease (can't see the foot to check for damage).

As a consequence of these factors a number of things can go wrong:

• the foot may get damaged and you do not know about (for example, your shoe rubs a sore onto a toe that gets infected - you can not feel it because of the peripheral neuropathy - you can not heal very well due to the infection and poor circulation).
• foot ulcer are common (see below)
• infections can spread
• the ultimate of this process is an amputation. Diabetes is the main cause of amputations.
• Charcot's joints is another complication of diabetes in the foot, especially if peripheral neuropathy is present - the neuropathy cause a numbness (imagine spraining your ankle and not knowing you have done this. You will continue to walk on it - imagine the damage that this would do. 

The Do's and Don'ts of Foot Care
If you have diabetes, there are a lot of things you need to do to prevent the problems from developing in your foot:

1) Wash your feet daily (use a mild soap and lukewarm water). Dry very carefully, especially between the toes. It often helps to use talcum powder to dust the foot to further reduce moisture, however be certain to remove all the powder after dusting, as it should not leave a residue between the toes. If the skin is dry, use a good emollient - BUT, not between the toes).

2) Inspect your foot daily (check sores, cuts, bruises, changes to the toenails; use a mirror to look under the foot if you can not see it).

3) Look after your health (loose weight; stop smoking; exercise; reduce your alcohol consumption)

4) Look after your feet:

• cut toenails straight across and never cut into the corners; use an emery board or file on sharp corners.
• do not try to remove corns and callus yourself - see a Podiatrist for this; NEVER use commercial corn cures - this is so important in those with diabetes as it is so easy to damage the skin.
• avoid going barefoot, even in your own home (this lessens the chance of some accidental damage)

5) Fitting of footwear is very important. Poorly fitted shoes are a common cause of problems in the foot of those with diabetes. Some advice:

• get your feet measured each time you buy new shoes (foot size and shape change over time).
• make sure the shoe fitter is experienced.
• new shoes should be comfortable when purchased and should not need a "break-in" period.
• they should fit both the length and width of the foot, with plenty of room for the toes.
• avoid shoes with high heels, pointed toes or tight around the toes (these put too much pressure on parts of the foot and can contribute to ulcers)

6) See a Podiatrist, at least annually.

Note: For more information about foot care, and neuropathy, get the  Nerve Health & Neuropathy  ebook. If you need diabetic shoes, contact our office for a referral.

Damage to Autonomic Nervous System & Brain

Diagnosis & Tests
The diagnosis of diabetic neuropathy is made on the basis of symptoms and a physical exam. During the exam, the doctor may check blood pressure and heart rate, muscle strength, reflexes, and sensitivity to position, vibration, temperature, or a light touch.

The doctor may also perform other tests to help determine the type and extent of nerve damage including a foot exam, nerve conduction test, electromyography test, sensory testing, heart rate variability check, ultrasound, and a nerve or skin biopsy.

A comprehensive foot exam assesses skin, circulation, and sensation. The test can be done during a routine office visit. To assess protective sensation or feeling in the foot, a nylon monofilament (similar to a bristle on a hairbrush) attached to a wand is used to touch the foot. Those who cannot sense pressure from the monofilament have lost protective sensation and are at risk for developing foot sores that may not heal properly. Other tests include checking reflexes and assessing vibration perception, which is more sensitive than touch pressure.

A nerve conduction test checks the transmission of electrical current through a nerve. With this test, an image of the nerve conducting an electrical signal is projected onto a screen. Nerve impulses that seem slower or weaker than usual indicate possible damage. This test allows the doctor to assess the condition of all the nerves in the arms and legs.

An electromyography (EMG) test shows how well muscles respond to electrical signals transmitted by nearby nerves. The electrical activity of the muscle is displayed on a screen. A response that is slower or weaker than usual suggests damage to the nerve or muscle. This test is often done at the same time as nerve conduction tests.

An ultrasound test uses sound waves to produce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can show how these organs preserve a normal structure and whether the bladder empties completely after urination.

Brain Damage
Current research indicates a connection between diabetes and Alzheimer’s disease. Since diabetes damages the nerves of the peripheral and autonomic nervous systems, it would follow that, eventually, it would affect the nerve cells of the brain itself.

The average human brain, which weighs about 3 pounds, is comprised of billions of neurons (brain cells), water, and phospholipids, namely arachidonic acid and docosahexaenoic acid. The brain produces electrical signals, which, together with chemical reactions, lets the parts of the body communicate.

Although the brain is only 2% of the body’s weight, it uses 20% of the oxygen supply, more than 50% of the glucose, and gets 20% of the blood flow. Blood vessels (arteries, capillaries, veins) supply the brain with oxygen and nourishment, and take away waste. More subtly, the blood-brain barrier protects the brain from chemical intrusion from the rest of the body. Blood flowing into the brain is filtered so that many harmful chemicals cannot enter the brain.

When a part of the brain (e.g. brain cells, blood vessels, neuro-transmitters) becomes damaged due to a combination of consistently high blood glucose levels and other factors, after a period of years, a diabetic may develop Alzheimer’s or some other brain-related ailment. These other factors may include exposure to aluminum (e.g. sodas, aluminum utensils) and other chemicals and toxins that have gradually built up in the body, and some accumulating in the brain.

This can lead to a formation of a sticky plaque that inhibits the transmission of brain signals. This decrease in signal transmission causes atrophy and death of the brain cells, which leads to further decreased signal transmission, and decreased neural transmission, which leads to further deterioration of the brain’s function. This decrease in brain function may be exhibited in many ways, including a significant increase in memory loss, e.g. confusion, forgetfulness, or a major change in behavioral and personality such as unprovoked anger or loss of social skills.

Note: Neurotransmitters are small molecules whose function is to transmit nerve signals (impulses) from one nerve cell to another. Neurotransmitters are chemical messengers that neurons use to tell other neurons that they have received an impulse. There are many different neurotransmitters - some trigger the receiving neuron to send an impulse and some stop it from doing so.

Neurotransmitters include: acetylcholine, serotonin, histamine, glutamate, gamma aminobutyric acid glycine, aspartate, histamine, norepinephrine, epinephrine (adrenalin), endorphins, dopamine, adenosine triphosphate (ATP), and nitric oxide.

Because of the amount of time that it may take for the brain to begin deterioration, the diabetic will experience problems with one or more of the other organs long before a disease like Alzheimer’s settles in. Consequently, there is time to nourish, protect, and exercise the brain to prevent these types of complications.

Nutritional Program for Good Nerve Health

To support good nerve health, patients should adhere to the following:

• Following a healthy plant-based diet, eating plenty of vegetables and some fruits
  
• Drinking raw vegetable juices (refer to the Power of Juicing ebook)
• Drinking plenty of fluids, especially filtered water
  
• Taking wholefood nutritional supplements, with focus on B-complex vitamins, especially B1, B6, B12 to help nerve regeneration; plus supplements such as ALA, evening primrose oil, turmeric, gingko, Omega-3s.
  
• Avoidance of alcohol, tobacco, drugs
• Avoidance of processed foods, pork, excess animal meat
  
• Exercising regularly, as directed by a physician

Diabetic Leg Ulcers

The conditions surveyed include infected wounds, skin ulcers and gangrene. These wounds, in the context of diabetes, are notoriously difficult to resolve. Healing resistance is thus a well-recognized element of frustration in their clinical care.

In most of the above conditions, multiple factors play into healing resistance. Among them are circulatory impairments, neurological deficits, tissue injury, and immunological compromise. A central factor is the proliferation of infectious microorganisms that, by the variety of their families, their toxin-producing capacities, and their resistance to antibiotics, offer daunting obstacles to standard treatment regimens.

Approximately 15% of the estimated 24 million Americans afflicted with diabetes mellitus develop lower leg skin ulcers and foot ulcers. Of those patients, 20% will eventually require amputations. Diabetes mellitus is the leading cause of nont-raumatic lower extremity amputation in the United States (LeRoith 2003).

In addition, people with pre-diabetes who develop lower leg/foot ulcers are also in danger of facing amputation. Why? Because they assume that just because they have not been diagnosed as a diabetic, they underestimate the danger of the leg ulcers!

Factors contributing to skin lesions in diabetes:

Arteries and arterioles in chronic diabetes are prone to plaque buildup (Tesfaye 2005). The precise reason for this phenomenon is still elusive, yet it is well documented that Type II non-insulin dependent diabetes is linked to abnormal blood lipid profiles known as diabetic dyslipidemia (Goldberg 2004). Low-density lipoproteins particles are smaller in size and thus more apt to adhere to vessel walls, resulting in progressive vascular occlusion (Beckman 2002; Renard 2004). Lowered oxygen and nutrient supplies stress tissue resilience and impair recovery from injury (Chapnick 1996).

Poorly controlled diabetes is correlated with peripheral nerve dysfunction. The mechanisms of diabetic injury to neurons are poorly understood. Higher blood glucose level seem to promote oxidative stress in neurons, but much more complex mechanisms are implicated (Tomlinson 2002).Diabetic neuropathy can involve motor, sensory, and autonomic system neurons. Sensory neuron malfunction is translated as loss of feeling, reflex loss, problems with limb position sense, tingling (paresthesias) and pain.

Motor impairment shows as muscle weakness. Autonomic neuropathy alters local circulation (Boulton 2004, Bensal 2006).

Chronic and repeating pressure on the skin compresses dermal arterioles, inhibiting tissue perfusion. Tissue weakness leads to ulceration. Ulcers are fertile ground for pathogenic microorganisms, and surrounding tissues become prone to cellulitis. At times, the ulcer crater reaches the underlying bone, initiating osteomyelitis (Boulton 2000).

The good news is that diabetic ulcers can be prevented and treated by following a superior nutritional program such as the Death to Diabetes wellness program.

Ulcers are wounds or open sores that will not heal or keep returning.

What are the symptoms of ulcers?

Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin.

What are the types of leg and foot ulcers?

The three most common types of leg and foot ulcers include:

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look.

1. Venous stasis ulcers

Venous ulcers are located below the knee and are primarily found on the inner part of the leg, just above the ankle.

The base of a venous ulcer is usually red. It may also be covered with yellow fibrous tissue or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discolored and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of edema (swelling).

Venous stasis ulcers are common in patients who have a history of leg swelling, varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80 to 90% of all leg ulcers.

2. Arterial (ischemic)

Arterial ulcers are usually located on the feet and often occur on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes. Arterial ulcers also occur commonly in the nail bed if the toenail cuts into the skin or if the patient has had recent aggressive toe nail trimming or an ingrown toenail removed.

The base of an arterial or ischemic ulcer usually does not bleed. It has a yellow, brown, grey, or black color. The borders and surrounding skin usually appear as though they have been punched out. If irritation or infection are present, there may or may not be swelling and redness around the ulcer base. There may also be redness on the entire foot when the leg is dangled; this redness often turns to a pale white/yellow color when the leg is elevated.

Arterial ulcers are typically very painful, especially at night. The patient may instinctively dangle his/her foot over the side of the bed to get pain relief. The patient usually has prior knowledge of poor circulation in the legs and may have an accompanying disorder, such as those listed in the section, "What causes leg ulcers?"

3. Neurotrophic (diabetic)

Neurotrophic ulcers are usually located at increased pressure points on the bottom of the feet. However, neurotrophic ulcers related to trauma can occur anywhere on the foot. They occur primarily in people with diabetes, although they can affect anyone who has an impaired sensation of the feet.

The base of the ulcer is variable, depending on the patient's circulation. It may appear pink/red or brown/black. The borders of the ulcer are punched out, while the surrounding skin is often calloused.

Neuropathy and peripheral artery disease often occur together in people who have diabetes. Nerve damage (neuropathy) in the feet can result in a loss of foot sensation and changes in the sweat-producing glands, increasing the risk of being unaware of foot calluses or cracks, injury or risk of infection. Symptoms of neuropathy include tingling, numbness, burning or pain.

It is easy to understand why people with diabetes are more prone to foot ulcers than other patients. This is why people with diabetes need to inspect their feet and their shoes daily and wear appropriate footwear. People with diabetes should never walk barefoot.

What causes leg ulcers?

Leg ulcers may be caused by medical conditions such as:

How are leg ulcers diagnosed?

First, the patient's medical history is evaluated. A wound specialist will examine the wound thoroughly and may perform tests such as X-rays, MRIs, CT scans and noninvasive vascular studies to help develop a treatment plan.

How are leg ulcers treated?

At the Cleveland Clinic, patients are treated by a team of world-class experts in the Lower Extremity Wound Clinic in the Tomsich Family Department of Cardiovascular Medicine. This Clinic includes doctors, nurses and other medical specialists. These experts work together to determine the cause of the problem and develop an individualized treatment program.

The goals of treatment are to relieve pain, speed recovery and heal the wound. Each patient's treatment plan is individualized, based on the patient's health, medical condition and ability to care for the wound.

Treatment options for all ulcers may include:

Venous ulcers are treated with compression of the leg to minimize edema or swelling. Compression treatments include wearing compression stockings, multilayered compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician, based on the characteristics of the ulcer base and amount of drainage from the ulcer.

The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer. Types of dressings include:

Arterial ulcer treatments vary, depending on the severity of the arterial disease. Non-invasive vascular tests provide the physician with the diagnostic tools to assess the potential for wound healing. Depending on the patient's condition, the physician may recommend invasive testing, endovascular therapy or bypass surgery to restore circulation to the affected leg.

The goals for arterial ulcer treatment include:

Treatment for neurotrophic ulcers includes avoiding pressure and weight-bearing on the affected leg. Regular debridement (the removal of infected tissue) is usually necessary before a neurotrophic ulcer can heal. Frequently, special shoes or orthotic devices must be worn.

Wound care at home

Patients are given instructions to care for their wounds at home. These instructions include:

The treatment of all ulcers begins with careful skin and foot care.

Foot and skin care guidelines

Inspecting your skin and feet is very important, especially for people with diabetes. Detecting and treating foot and skin sores early can help you prevent infection and prevent the sore from getting worse.

Here are some guidelines:

How can ulcers be prevented?

Controlling risk factors can help you prevent ulcers from developing or getting worse. Here are some ways to reduce your risk factors: