INTERDISCIPLINARY APPROACH TO CARE

Diabetic foot care at all stages, both preventive and in treating a diabetic foot ulcer, is based on a multidisciplinary team approach. At different stages of care the members of this team may vary. Various healthcare professionals have many overlapping roles. According to their training, practitioners from each discipline can make important contributions to the care of the patient.

In some cases, patients may be reluctant to agree to a team approach due to the time involved in attending multiple appointments. As far as reasonably possible, patient appointments with multiple providers should be scheduled for the same day at the same location.

Primary Care

Primary care providers, including nurse practitioners, are familiar with the complications that can arise from diabetic foot ulcers and the evidenced-based treatments that will prevent their development. Many patients with diabetes will be treated by a primary care provider, while others may be referred to an endocrinologist.

The primary care provider plays a key role in ensuring that all members of the patient’s healthcare team are aware of medical decision-making and the patient’s current status. For example, if the primary care provider believes that the time is drawing close to switch the patient from oral medication to insulin to maintain adequate control of their diabetes, then this information will be shared with the other team members so that each clinician can help prepare the patient for the transition.

Nursing

Nurses play a pivotal role in caring for patients with diabetes. In virtually every practice setting, nurses encounter patients who have diabetes and must be equipped with the knowledge and skills to care for these patients. As well as providing hands-on care, nurses function as educators, patient advocates, and coordinators of patient care. They also provide the patient with emotional support and recognize that the complexity of diabetic treatment, self-management, and the multiple goals and lifestyle changes patients have to work toward demand a tremendous amount of both physical and psychological adjustment and require consistent, empathetic support.

The nursing role in diabetic foot care includes:

• Patient assessment and screening
• Education
• Advocacy
• Coordination of patient care
• Community outreach

Physical Therapy

Physical therapy professionals assist patients with diabetes through all stages of care, starting with preventive foot care. Close to 80% of those who are referred for outpatient physical therapy have a diagnosis of diabetes or are at risk for developing diabetes. This places the physical therapist in a critical role in the care of patients with diabetes (Harris-Hayes et al., 2020).

In diabetic foot care, physical therapists play a major role in the following areas:

• Joint mobility
• Strengthening
• Assessment and management of skin integrity
• Management of swelling (edema)

A physical therapist can create an individualized exercise program with the patient, including aerobic and resistance exercises to help the patient meet weight loss and activity goals. Other interventions used by physical therapists to treat diabetic neuropathy and/or ulcers may include the following:

• Thermotherapy (infrared, global heat, ultrasound)
• Electrotherapy (e-stim, shockwave therapy, laser treatment, magnetic field treatment, galvanic current treatment)
• Therapeutic exercise (joint range of motion, stretching, Buerger-Allen exercise, proprioception/balance exercises)
• Shoe/footwear modification
• Prophylactic patient education (skin inspection, foot/toenail care, etc.)
• Wound care and/or debridement (within state-specific scope of practice)
• Patient/caregiver education
• Home/environmental modification recommendations
  (Harris-Hayes et al., 2020; APTA, 2021)

Musculoskeletal complications, which affect the foot in many patients with longstanding diabetes, put patients at elevated risk for developing skin ulcers. Alterations in the structure of the foot, including loss of flexibility and limited joint mobility, impede the foot’s ability to absorb and redistribute forces related to impact while walking. Foot deformities play a major role in increasing plantar pedal pressure, particularly at the metatarsophalangeal and subtalar joints (McDonald, 2019).

Physical therapists can identify early structural changes in the foot, evaluate a patient’s gait, and assess for signs of ulcerations. Physical therapy works closely with patients who have diabetes to minimize balance dysfunction that can occur with peripheral neuropathy. They can also advise patients on footwear, inserts to existing shoes, and techniques for weight distribution along the surface of the foot (Bryant & Nix, 2016).

Occupational Therapy

Occupational therapists are actively involved in diabetic foot care in a variety of clinical settings: acute care, long-term care, clinics, and community care. Apart from the functions that occupational therapists share with other members of the diabetic healthcare team, they address important areas of everyday life for patients with diabetes, including physical, cognitive, psychosocial, and sensory aspects.

Occupational therapists are instrumental in assisting patients with diabetes to integrate self-care activities into their existing routines. Occupational therapists also help patients overcome barriers to community participation, which is especially important to patients with limited financial resources. Studies show that occupational therapy interventions enhance the quality of life for patients with diabetes and play a positive role in patient adherence to treatment.

Occupational therapy interventions in diabetic foot care include:

• Assessing the patient’s skills and competencies
• Assessing the patient’s environment and need for adaptation
• Educating the patient on energy conservation techniques
• Teaching patients how to use adaptive equipment
• Assisting patients with work and community participation
• Teaching stress management techniques
• Advising patients on meal planning and preparation
  (Stromsdorfer, 2020)

One successful occupational therapy program used with patients who have diabetes is called Resilient, Empowered, Active Living with Diabetes (REAL). The aim of the REAL program is to aid patients who are facing challenges in performing diabetes self-management activities (Shen & Shen, 2019).

Case Management

A case manager or social worker—although not directly involved in hands-on care of the patient—is an essential member of the diabetic foot care team. Case management in diabetic foot care provides:

• Patient assessment
• Input into the development of the patient plan of care
• Facilitation of services
• Patient advocacy

The case manager has clinical knowledge regarding the management of the diabetic foot and the treatment and management of diabetic foot ulcers should they develop.

The case manager is involved in patient assessment, developing the plan of care along with other team members, facilitation, and patient advocacy. The case manager or social worker helps the patient in navigating the healthcare system and identifying what resources are available, for example, insurance or Medicare benefits to purchase diabetic shoes or adaptive equipment.

For patients concerned about how their diagnosis and treatment will affect their employment, the case manager or social worker educates the patient on their rights under the Family Medical Leave Act (FMLA) and how to apply for FMLA leave through the human resources department at their place of employment. The case manager can also be instrumental in advocating for workplace modifications with an employer.

Diabetes Educator

Clinicians who specialize in diabetes care and education can become Certified Diabetic Educators (CDE) through the Certification Board for Diabetes Care and Education (formerly the National Certification Board for Diabetes Educators), founded in 1986. This qualification is available to nurses, occupational therapists, physical therapists, and other professionals who meet the examination requirements. Clinicians are expected to be already working in the area of diabetic education and providing diabetic self-management education to patients. The exam to become a CDE is not an entry-level exam, and clinicians taking this exam must be knowledgeable and experienced in diabetic care.

The CDE functions as an educator and advocate for patients of all ages with diabetes and across the continuum of care. The CDE has expertise in teaching diabetes self-management skills to patients with diabetes and is a valuable resource for other clinicians who work with patients who have diabetes (CBDCE, 2021).

(See also “Resources” at the end of this course.)

Podiatry Care

All patients with diabetes should have a podiatry consult as part of preventive care. A podiatrist will diagnose and treat conditions of the foot, ankle, and related structures of the leg, including diabetic foot care. The podiatrist works in close association with other members of the patient’s healthcare team to ensure that recommendations for care are integrated into the treatment plan for the patient.

A podiatrist provides the patient with diabetes with:

• Specialized foot assessment
• Identification of bone and joint deformities that can lead to areas of high pressure on the feet
• Recommendations for care, including prescriptions for inserts or diabetic shoes
• Education regarding foot care
• Early detection of complications
  (APMA, 2021b)

Orthotic Care

An orthotist can play a part in the care of the patient with diabetes by evaluating the patient for an orthosis, which can serve the following purposes:

• Assist with movement of the extremity
• Restrict movement in a particular direction as needed, to help reduce inflammation and improve stability and function
• Reduce weight-bearing and relieve areas of excessive pressure to the feet
• Reduce pain in the affected extremity

Orthotic devices used in diabetic foot care include ankle braces, shoe inserts, and footpads. Removable insoles in shoes provide pressure and shock absorption. When a patient is prescribed a shoe insert such as removable insoles, they are advised to wear their regular shoes to the fitting so that the foot care specialist can fit the appropriate insert for that shoe.

For patients with diabetes who have lost even partial sensation in their feet, it is recommended that they are fitted for individually modified shoes by a pedorthist or other trained foot care specialist (McDonald, 2019). A pedorthist has special training in the properties of footwear and the interactions between the patient’s feet and the shoes that they wear. Customized shoes for patients with diabetes are provided by the pedorthist. The goal of care is to provide nonsurgical intervention either to relieve a foot problem or to prevent it from becoming worse (PFA, 2018).

(See also “Resources” at the end of this course.)

Additional Team Members

Dietitians commonly see the patient once a diagnosis of diabetes is established or when weight management is identified as part of the patient plan of care. Since many patients with diabetes also have concurrent problems with arterial circulation to their feet, a consult to a vascular surgeon will frequently be ordered. A neurologist maybe consulted to perform nerve testing and assess the severity of peripheral neuropathy present.