Patient and Family Carer Experience
What is Diabetic Neuropathy?
Neuropathy Affecting The Feet
Advice on Cutting Your Toenails
Symptoms of Neuropathy Affecting Your Feet and Hands
Wrong Sized Shoes
Neuropathy and Antidepressants
Diabetic Holiday Foot Syndrome
Patient and Family Carer Experience
Diabetes and Hearing Loss May be Due to Neuropathy
Patient and Family Carer Experience
Dealing with diabetic foot problems – A dual perspective
By Arabella Melville Research Fellow, NHS Centre for Reviews and Dissemination, York
My partner has been insulin dependent for 48 years. I’m fortunate, as a carer, to have access through my job to detailed and wide-ranging information about medicine and health. Naturally whenever Colin has a difficult problem, I use all the resources available to me to research the problem and seek out the evidence on the effectiveness of treatment options.
We are having to cope with the long-term effects of diabetes, including foot problems and painful neuropathy. I’d like to share what we have learnt.
First how to avoid it
Medical research shows that neuropathy develops later in people who maintain a consistently low blood glucose level through intensified insulin treatment. We have no personal experience of this: Colin wouldn’t be willing to consider all the obsessive monitoring and careful control. While it seems to be true that better control improves a diabetic’s long-term prospects, we worry about what it does to the quality of the greater part of his/her life. It is an individual decision, I guess.
Even with the best control, people who have been diabetic a long time [and even some people who have only just become diabetic] are likely to end up with foot problems.
Neuropathic pain. Nobody seems to know what causes it, beyond in the most general terms, nerve damage being associated with fluctuating blood sugar. But the effects are all too familiar to Colin: pain in a variety of forms – scalding or burning, a sensation akin to having a nail driven into the foot or having a toe pinched hard with pliers. It sounds to me like torture. It keeps him a awake at night sometimes and even when he falls asleep, his legs go into spasm and he’s restless.
So what answers have we found?
First the medical approaches. These have been systematically reviewed by the Pain Relief Unit in Oxford. Basically, there are two types of prescription only drugs that work to some extent, for most people. They are tricyclic antidepressants [imipramine and amitryptiline] and anticonvulsants [carbamazapine]. They appear to be equally effective, so if one doesn’t work, you try the other. They also have roughly equal levels of side effects, but overall are pretty safe in the doses used for neuropathic pain. Pain-killing drugs generally are not effective, nor is the application of heat, cold or transcutaneous electrical stimulation. Capsaicin cream may also be effective in some people, but can cause skin irritation.
Colin and I have experimented with others methods, some of which seem effective. We’d be interested to hear from other people who’ve tried these. He takes the herb hypericum [St John’s Wort]; we also use it in foot baths and in the form of hypercal cream [available from chemists and health food shops]. Careful research has shown that hypericum tablets are equivalent in antidepressant action to tricyclic antidepressants, but a lot safer; no formal research has been done of the effects on neuropathy. I suspect that the same parts of the nervous system are affected in similar ways by the two types of product, and that someone will one day demonstrate that hypericum can be helpful for neuropathic pain. We have also tried ibuprofen cream on the foot, and found it worked; but this was a recent experiment that we haven’t repeated because Colin has been free of pain since! We don’t attribute this to ibuprofen – he was only getting the odd twinge when we tried it and the benefit could be due to chance or the placebo effects. But we shall try it again when the pain recurs.
How did we achieve this wonderful pain-free period?
With shiatsu, a Japanese technique in which the therapist uses pressure on specific trigger points to adjust energy flow in the body, like acupuncture without needles. This is another method that has not been tested as a treatment for neuropathic pain by scientific research, but which I believed [from my knowledge of pain relief generally] was worth trying. I would expect acupuncture to be equally effective, but have no experience of it in this context. Shiatsu, carried out by a competent professional therapist, has a dramatic effect on Colin. In our experience, the benefit lasts for about a month, when the treatment has to be repeated.
Inevitably, after many years of neuropathy, Colin’s feet are affected in other ways. When he developed his first ulcer, I was fortunate to have access to the best information through the Research Centre where I work assessing the effectiveness of health care interventions. Some of my colleagues had completed a systematic review of interventions for diabetic foot ulcers and they advised me to find a specialist clinic where Colin could get expert treatment. He had to argue with the GP to go there, but succeeded in the end. He now sees the specialist chiropodist at regular intervals.
The most important aspect of treatment is to take the pressure off the ulcerated area. There are several facets to this:
- The first is the padding over the ulcer itself. I bathe and check his feet at least twice a week and dress any area that starts looking at all red, cracked or blistered, using felt padding held in place by highly porous sticking plaster. I then massage moisturising cream into his feet and this helps to stop sores developing.
- We were given some invaluable advice on socks. He now wears thick, cushioned walking socks inside out and if there’s likely to be a lot of stress on his feet, such as walking around town for an extended period, then he will ear a pair of fine cotton inner socks as well.
- Another way of reducing the pressure is wearing made to measure shoes. These are available on the NHS and they are simply wonderful. Colin has both boots and shoes supplied by the clinic – they fit like gloves, are soft and feel marvellous on his feet, and he wears them all day. Since he got these shoes he has not had any significant ulceration, just little lesions that I can normally treat at home.
Colin was told very firmly to rest and put his feet up. While we agree that it is important to elevate the feet for part of the day, we dispute the suggestion that he should rest completely. Exercise is very good for him, it’s good for his diabetic control and good for the circulation, particularly in his legs and feet where it is so important. We are convinced that one reason for his continued health is that he takes regular exercise. So he carries on walking every day. The doctors and nurses are amazed at how fast his ulcers heal and the orthopaedic appliance staff are amazed at how often his shoes come back to be repaired.
I checked the research on this question and found there was none. The advice on rest is based on assumptions and beliefs, not scientific evidence. However, I must emphasise that walking is only likely to be beneficial if further damage to the foot is prevented by multiple layers of soft padding and NHS made to measure shoes.