Gayle E. Reiber

Pathways to diabetic limb amputation. Basis for prevention.

We defined the causal pathways responsible for 80 consecutive initial lower-extremity amputations to an extremity in diabetic patients at the Seattle Veterans Affairs Medical Center over a 30-mo interval from 1984 to 1987. Causal pathways, either unitary or composed of various combinations of seven potential causes (i.e., ischemia, infection, neuropathy, faulty wound healing, minor trauma, cutaneous ulceration, gangrene), were determined empirically after a synthesis by the investigators of various objective and subjective data. Estimates of the proportion of amputations that could be ascribed to each component cause were calculated. Twenty-three unique causal pathways to diabetic limb amputation were identified. Eight frequent constellations of component causes resulted in 73% of the amputations. Most pathways were composed of multiple causes, with only critical ischemia from acute arterial occlusions responsible for amputations as a singular cause. The causal sequence of minor trauma, cutaneous ulceration, and wound-healing failure applied to 72% of the amputations, often with the additional association of infection and gangrene. We specified precise criteria in the definition of causal pathway to permit estimation of the cumulative proportion of amputations due to various causes. Forty-six percent of the amputations were attributed to ischemia, 59% to infection, 61% to neuropathy, 81% to faulty wound healing, 84% to ulceration, 55% to gangrene, and 81% to initial minor trauma. An identifiable and potentially preventable pivotal event, in most cases an episode involving minor trauma that caused cutaneous injury, preceded 69 of 80 amputations. Defining causal pathways that predispose to diabetic limb amputation suggests practical interventions that may be effective in preventing diabetic limb loss.

Preventive Foot Care in People With Diabetes

A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation. These strategies must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb, and thus improve the quality of life for people with diabetes.

Risk Factors for Amputation in Patients with Diabetes Mellitus: A Case-Control Study

OBJECTIVE To identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus. DESIGN Case-control study. SETTING A Veterans Affairs medical center. PATIENTS Eighty patients having amputation associated with diabetes and 236 diabetic controls without limb lesions were enrolled before surgery from the 21,167 inpatient care and outpatient surgical patients seen at the Seattle Veterans Affairs Medical Center during a 30-month period. MEASUREMENTS Selected vascular, neuropathic, environmental, health care, self care, nutritional, metabolic, lifestyle, and psychosocial risk factors were measured in all patients before surgery. RESULTS Statistically significant risk factors identified from analysis included insufficient mean below-knee and foot cutaneous circulation (odds ratio, 161; 95% CI, 55.1 to 469); ankle-arm blood pressure index less than 0.45 (odds ratio, 55.8; CI, 14.9 to 209); absence of lower leg vibratory perception (odds ratio, 15.5; CI, 8.3 to 28.7); low levels of high-density lipoprotein (HDL) subfraction 3 less than or equal to 0.7 mumol/L (odds ratio, 4.9; CI, 2.9 to 8.3); and no previous outpatient diabetes education (odds ratio, 3.2; CI, 1.6 to 6.6). A logistic regression analysis done to control for the potentially confounding effects of age; race; socioeconomic status; diabetes duration, type, and severity confirmed these findings and added a statistically significant interaction between foot transcutaneous oxygen tension and peripheral vascular disease history. Clinical interventions to alter these risk factors were identified, including aggressive treatment of infection, diabetes education, protective footwear, and preventive footcare. CONCLUSIONS Multiple risk factors exist along the continuum of conditions and events leading to lower extremity amputation in diabetes. Modification of certain risk factors by patients and health professionals may reduce the risk for amputation and thus decrease the human and dollar costs that accompany limb loss in this prevalent chronic disease.

The Independent Contributions of Diabetic Neuropathy and Vasculopathy in Foot Ulceration: How Great Are the Risks?

OBJECTIVE To describe the relative contributions of neurological and vascular abnormalities to the overall risk of diabetic foot ulceration. RESEARCH DESIGN AND METHODS A case-control study of diabetic veterans from the Seattle Veterans Affairs Medical Center was conducted using data collected from 46 patients with diabetic foot ulcers and 322 control subjects. Neuropathy was determined by vibratory, monofilament, and tendon reflex testing. Macro-vascular disease was measured by ankle-arm blood pressure index, and cutaneous perfusion was measured by transcutaneous oxygen tension (TcPO2) on the dorsal foot. A multi variate logistic regression model was used to adjust for confounding variables and to calculate the odds ratios (ORs) for each independent risk factor. RESULTS Three variables were significant independent predictors of foot ulceration: absence of Achilles tendon reflexes (adjusted OR 6.48, 95% confidence interval [CI] 2.37–18.06), insensate to the 5.07 monofilament (adjusted OR 18.42, 95% CI 3.83–88.47), and TcPO2 <30 mmHg (adjusted OR 57.87, 95% CI 5.08–658.96). Absent vibratory sensation and low ankle-arm blood pressure index were not significant independent risk factors. CONCLUSIONS Both neuropathy and vasculopathy are strong independent risk factors for the development of diabetic foot ulcers. In our model, the strongest risk factor is impaired cutaneous oxygenation. However, in the clinical setting, sensory examination with a 5.07 monofilament probably remains the single most practical measure of risk assessment.

Phantom limb, residual limb, and back pain after lower extremity amputations.

This study describes the sensations and pain reported by persons with unilateral lower extremity amputations. Participants (n = 92) were recruited from two hospitals to complete the Prosthesis Evaluation Questionnaire which included questions about amputation related sensations and pain. Using a visual analog scale, participants reported the frequency, intensity, and bothersomeness of phantom limb, residual limb, and back pain and nonpainful phantom limb sensations. A survey of medication use for each category of sensations also was included. Statistical analyses revealed that nonpainful phantom limb sensations were common and more frequent than phantom limb pain. Residual limb pain and back pain were also common after amputation. Back pain surprisingly was rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in persons with above knee amputations. These results support the importance of looking at pain as a multidimensional rather than a unidimensional construct. They also suggest that back pain after lower extremity amputation may be an overlooked but very important pain problem warranting additional clinical attention and study.

Health and Health Behavior Differences

BACKGROUND Little is known about health and health behavior differences among military service veterans, active duty service members, National Guard/Reserve members, and civilians. Several important differences were identified among U.S. women from these subpopulations; to identify areas for targeted intervention, studies comparing men from these subpopulations are needed. PURPOSE To compare veteran, military, and civilian men on leading U.S. health indicators. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. In 2011, self-reported health outcomes were compared using multivariable logistic regression across male veterans (n=53,406); active duty service members (n=2144); National Guard/Reserve service members (n=3724); and civilians (n=110,116). RESULTS Multivariate logistic regression results are presented. Despite better healthcare access, veterans had poorer health and functioning than civilians and National Guard/Reserve members on several indicators. Veterans also were more likely than those on active duty to report diabetes. Veterans were more likely to report current smoking and heavy alcohol consumption than National Guard/Reserve members and civilian men, and lack of exercise compared to active duty men and National Guard/Reserve members. National Guard/Reserve men had higher levels of obesity, diabetes, and cardiovascular disease (versus active duty and veterans, active duty, and civilians, respectively). Active duty men were more likely to report current smoking and heavy alcohol consumption than civilians and National Guard/Reserve members, and reported more smokeless tobacco use than civilians. CONCLUSIONS Veterans have poorer health and health behaviors; increased prevention efforts are needed from veteran-serving organizations. Despite good health, active duty men reported unhealthy lifestyles, indicating an important area for prevention efforts.

Research articleHealth and Health Behavior Differences: U.S. Military, Veteran, and Civilian Men

BACKGROUND Little is known about health and health behavior differences among military service veterans, active duty service members, National Guard/Reserve members, and civilians. Several important differences were identified among U.S. women from these subpopulations; to identify areas for targeted intervention, studies comparing men from these subpopulations are needed. PURPOSE To compare veteran, military, and civilian men on leading U.S. health indicators. METHODS Data were from the 2010 Behavioral Risk Factor Surveillance Survey, a U.S. population-based study. In 2011, self-reported health outcomes were compared using multivariable logistic regression across male veterans (n=53,406); active duty service members (n=2144); National Guard/Reserve service members (n=3724); and civilians (n=110,116). RESULTS Multivariate logistic regression results are presented. Despite better healthcare access, veterans had poorer health and functioning than civilians and National Guard/Reserve members on several indicators. Veterans also were more likely than those on active duty to report diabetes. Veterans were more likely to report current smoking and heavy alcohol consumption than National Guard/Reserve members and civilian men, and lack of exercise compared to active duty men and National Guard/Reserve members. National Guard/Reserve men had higher levels of obesity, diabetes, and cardiovascular disease (versus active duty and veterans, active duty, and civilians, respectively). Active duty men were more likely to report current smoking and heavy alcohol consumption than civilians and National Guard/Reserve members, and reported more smokeless tobacco use than civilians. CONCLUSIONS Veterans have poorer health and health behaviors; increased prevention efforts are needed from veteran-serving organizations. Despite good health, active duty men reported unhealthy lifestyles, indicating an important area for prevention efforts.

Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: Survey methods, participants, and summary findings

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention.

Effect of Weight-Bearing Activity on Foot Ulcer Incidence in People With Diabetic Peripheral Neuropathy: Feet First Randomized Controlled Trial

Background: Weight-bearing exercise has been contraindicated among people with diabetic peripheral neuropathy (DM+PN). However, recent cohort studies have suggested that daily weight-bearing activity is associated with lower risk for foot ulceration. Objective: The objective of this study was to determine the effect of a lower-extremity exercise and walking intervention program on weight-bearing activity and foot ulcer incidence in people with DM+PN. Design: This was an observer-blinded, 12-month randomized controlled trial. Setting: The settings were physical therapy offices in part 1 of the intervention and the community in part 2 of the intervention. Participants: The participants were 79 individuals with DM+PN who were randomly assigned either to a control group (n=38) or an intervention group (n=41) group. Intervention: Intervention components included leg strengthening and balance exercises; a graduated, self-monitored walking program (part 1); and motivational telephone calls every 2 weeks (part 2). Both groups received diabetic foot care education, regular foot care, and 8 sessions with a physical therapist. Measurements: Total and exercise bout–related daily steps at baseline and at 3, 6, and 12 months were measured by accelerometers. Foot lesions/ulcers were photographed and classified by an independent panel of dermatologists. Use of adequate footwear was monitored. Results: At 6 months, bout-related daily steps increased 14% from baseline in the intervention group and decreased 6% from baseline in the control group. Although the groups did not differ statistically in the change in total daily steps, at 12 months steps had decreased by 13% in the control group. Foot ulcer rates did not differ significantly between groups. Conclusion: Promoting weight-bearing activity did not lead to significant increases in foot ulcers. Weight-bearing activity can be considered following adequate assessment and counseling of patients with DM+PN.

Factors Influencing Disease Self-Management Among Veterans with Diabetes and Poor Glycemic Control

Specific AimAlthough the Department of Veterans Affairs (VA) has made significant organizational changes to improve diabetes care, diabetes self-management has received limited attention. The purpose of this study is to assess factors influencing diabetes self-management among veterans with poorly controlled diabetes.MethodsSurveys were mailed to patients with type 2 diabetes and a HbA1c of 8% or greater who attended 1 of 2 VA Medical Centers in Washington State (n = 1,286). Validated survey instruments assessed readiness to change, self-efficacy, provider advice, and diabetes self-care practices.ResultsOur response rate was 56% (n = 717). Most respondents reported appropriate advice from physicians regarding physical activity, nutrition, and glucose monitoring (73%, 92%, and 98%, respectively), but many were not ready to change self-management behaviors. Forty-five percent reported non-adherence to medications, 42% ate a high-fat diet, and only 28% obtained either moderate or vigorous physical activity. The mean self-efficacy score for diabetes self-care was low and half of the sample reported readiness to change nutrition (52%) or physical activity (51%). Individuals with higher self-efficacy scores were more likely to adhere to medications, follow a diabetic meal plan, eat a lower fat diet, have higher levels of physical activity, and monitor their blood sugars (P < .001 for all).ConclusionsAlthough veterans with poor diabetes control receive appropriate medical advice, many were not sufficiently confident or motivated to make and maintain self-management changes. Targeted patient-centered interventions may need to emphasize increasing self-efficacy and readiness to change to further improve VA diabetes outcomes.