Accepted Manuscript Title: The role of foot self-care behavior on developing foot ulcers in diabetic patients with peripheral neuropathy: a prospective study Author: Yen-Fan Chin Jersey Liang Woan-Shyuan Wang Brend Ray-Sea Hsu Tzu-ting Huang PII: DOI: Reference:
S0020-7489(14)00109-6 http://dx.doi.org/doi:10.1016/j.ijnurstu.2014.05.001 NS 2391
To appear in: Received date: Revised date: Accepted date:
20-7-2013 30-4-2014 2-5-2014
Please cite this article as: Chin, Y.-F., Liang, J., Wang, W.-S., Hsu, B.R.-S., Huang, T.t.,The role of foot self-care behavior on developing foot ulcers in diabetic patients with peripheral neuropathy: a prospective study, International Journal of Nursing Studies (2014), http://dx.doi.org/10.1016/j.ijnurstu.2014.05.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title: The role of foot self-care behavior on developing foot ulcers in diabetic patients with peripheral neuropathy: a prospective study
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Running head: Foot self-care behavior on diabetic foot ulcer
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Yen-Fan Chin a, Jersey Liang b, Woan-Shyuan Wang a, Brend Ray-Sea Hsu c, Tzu* ting Huang a,d, a
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School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan b School of Public Health, University of Michigan, USA c Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital,
Healthy Aging Research Center, Chang Gung University, Tao-Yuan, Taiwan.
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Tao-Yuan, Taiwan
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Corresponding author at: School of Nursing, Healthy Aging Research Center, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan. Tel: 886-32118800 ext 5321; fax: 886-3-2118700 E-mail:
[email protected] Acknowledgments We are grateful to the patients who generously participated in the study. We also thank all colleagues of the Division of Endocrinology and Metabolism in ChangGung Memorial Hospital for providing assistance in data collection. Conflict of Interest None declared Funding This study was funded by Chung-Gung Memorial Hospital Grant CMRPD1A0031.
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Background: Although foot self-care behavior is viewed as beneficial for the prevention of
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diabetic foot ulceration, the effect of foot self-care behavior on the development of diabetic foot
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ulcer has received little empirical investigation.
Objective: To explore the relationship between foot self-care practice and the development of
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diabetic foot ulcers among diabetic neuropathy patients in northern Taiwan.
Methods: A longitudinal study was conducted at one medical center and one teaching hospital in
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northern Taiwan.
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Participants: A total of 295 diabetic patients who lacked sensitivity to a monofilament were recruited. Five subjects did not provide follow-up data; thus, only the data of 290 subjects were
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analyzed. The mean age was 67.0 years, and 72.1% had six or fewer years of education.
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Methods: Data were collected by a modified version of the physical assessment portion of the Michigan Neuropathy Screening Instrument and the Diabetes Foot Self-Care Behavior Scale.
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Cox regression was used to analyze the predictive power of foot self-care behaviors. Results: A total of 29.3% (n = 85) of diabetic neuropathy patients developed a diabetic foot ulcer by the one-year follow-up. The total score on the Diabetes Foot Self-Care Behavior Scale was significantly associated with the risk of developing foot ulcers (HR = 1.04, 95% CI = 1.01– 1.07, p = 0.004). After controlling for the demographic variables and the number of diabetic foot ulcer hospitalizations, however, the effect was non-significant (HR = 1.03, 95% CI = 1.00–1.06, p = 0.061). Among the foot self-care behaviors, lotion-applying behavior was the only variable that significantly predicted the occurrence of diabetic foot ulcer, even after controlling for demographic variables and diabetic foot ulcer predictors (neuropathy severity, number of
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3 diabetic foot ulcer hospitalizations, insulin treatment, and peripheral vascular disease; HR = 1.19, 95% CI = 1.04–1.36, p = 0.012). Conclusions: Among patients with diabetic neuropathy, foot self-care practice may be
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insufficient to prevent the occurrence of diabetic foot ulcer. Instead, lotion-applying behavior predicted the occurrence of diabetic foot ulcers in diabetic patients with neuropathy. Further
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studies are needed to explore the mechanism of lotion-applying behavior as it relates to the
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occurrence of diabetic foot ulcer.
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Key words: diabetic neuropathies, foot ulcer, self-care, behavior
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4 1. Introduction A diabetic foot ulcer (DFU) is an important precursor of lower limb amputation. In Taiwan, although the prevalence of DFU hospitalizations is only 1.1% (Huang et al., 2012), the
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amputation rate of hospitalized DFU patients ranges from 29.0–61.3% (Huang et al., 2012;
Wang and Chen, 2007), as most hospitalized DFU patients have peripheral neuropathy (Wang
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and Chen, 2007). Because foot-care clinics are not popular in Asian countries (Boulton et al.,
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2005) such as Taiwan, it is important that we advocate for DFU prevention, especially among patients with diabetic peripheral neuropathy.
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Foot self-care behavior, one kind of diabetes mellitus self-management behavior, is viewed as beneficial for DFU prevention (Boulton, 2010) and, as such, is an essential part of patient
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education for DFU prevention (Bakker et al., 2012). Gonzalez and colleagues (2010) found,
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however that two foot self-care practices (foot inspection and inspection of the inside of shoes
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before wearing them) did not predict a subsequent DFU among diabetic neuropathy patients. Further, there is no other evidence-based literature on the relationship between foot self-care
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behaviors and the occurrence of a DFU.
Moreover, although several DFU risk-stratification systems have been developed (MonteiroSoares et al., 2011), there is no research on the appropriateness of these systems for predicting DFU in Asian countries and no research on predictors of a DFU among diabetic neuropathy patients. Therefore, this study had two purposes. First, we examined the predictors of the occurrence of a DFU. Second, we examined the relationship between comprehensive foot selfcare practice and a DFU, after controlling for demographic variables and DFU predictors (neuropathy severity, number of DFU hospitalizations, insulin treatment, and peripheral vascular disease) in diabetic neuropathy patients.
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5 2. Methods 2.1 Design and Participants This study, which used a longitudinal research design, is part of a larger study (Chin and
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Huang, 2013; Chin et al., 2013). We collected baseline data from March 2010 to May 2011 at two hospitals in northern Taiwan. Convenience sampling was used. Diabetic patients referred by
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their physicians were assessed and tested by a 10g Semmes Weinstein monofilament for
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eligibility to participate in the study. The inclusion criteria included patients who had type 2 diabetes, were at least 20 years old, and lacked sensitivity to the 10g Semmes Weinstein
feet, could not walk, and had an existing DFU.
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monofilament. The exclusion criteria included patients who had undergone amputation of both
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2.2 Institutional Review Board for Human Subjects
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The Institutional Review Board for the Protection of Human Subjects Committee approved
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the protocol, and informed consent was obtained for each participant. For those eligible for the study, a detailed informed consent form that included the purpose and procedure of the study was
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provided. The rights of participants were emphasized, including that their refusal to participate in or to withdraw from this study would not affect their receipt of subsequent medical services. For those who signed the informed consent, data collection was conducted. 2.3 Procedure
The first author and three well-trained research assistants assessed the feet of subjects to determine their score on the physical portion of the modified Michigan Neuropathy Screening Instrument (MNSI) as well as interviewed subjects about their foot self-care behaviors. The number of DFU hospitalizations and data from medical records of subjects also were collected. Then, subjects were followed up for their DFU occurrence. The following strategies were used to
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6 maintain the accuracy of the DFU information. First, subjects were asked to contact us if they developed a DFU during the one-year follow-up period. They also were asked to circle the date of a DFU occurrence on their calendars. Second, when subjects visited the clinic, in addition to
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physicians’ conducting a foot inspection, they were encouraged to ask subjects whether they had a DFU between visits. Third, we inspected the feet of subjects for scars or lesions and reviewed
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their medical records for DFU treatment at the time of the three-month and one-year follow-up
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interview. During the interview, we verified the DFU occurrence information with subjects. We developed a list of reasons for a DFU and asked participants to indicate which applied. For
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subjects who could not recall the exact date of the DFU occurrence, we confirmed the exact date
2.4 Measures
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2.4.1 Diabetes Foot Self-Care Behavior
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with their family members.
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The Diabetes Foot Self-Care Behavior Scale (DFSCBS) (Chin and Huang, 2013) measures seven foot self-care behaviors (inspecting the bottom of the foot and between toes, washing and
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drying between toes, applying moisturizing lotion, inspecting inside of the shoes, and breaking in the shoes). A 5-point Likert scale was used to rate the frequency of performance of the foot selfcare behaviors. A higher score indicates better performance of foot self-care behavior. The DFSCBS has a significant correlation with the foot-care subscale of the Chinese version of the Summary of Diabetes Self-care Activity questionnaire (Chin and Huang, 2013). It also has been shown to differentiate between participants with and without a history of foot ulcers. The DFSCBS has a two-week test-retest reliability of 0.95 (Chin and Huang, 2013). In this study, the internal consistency was acceptable (Cronbach’s alpha = 0.73).
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7 2.4.2 Michigan Neuropathy Screening Instrument (MNSI) The MNSI is a popular tool for screening foot neuropathy. The second part of the MNSI is a physical assessment that has five aspects: skin and structural abnormality inspection, foot ulcer,
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ankle reflex, vibration, and monofilament testing (Sorensen et al., 2006). A cutoff score of 2 was shown to have high specificity (95%) and sensitivity (80%), with a positive predictive value of
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97% and a negative predictive value of 74% of diabetic peripheral neuropathy (Feldman et al.,
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1994). In this study, the Rydel-Seiffer (128 Hz) semi-quantity fork was placed on the dorsal distal joint of the big toe of subjects to measure their sense of vibration. The score was
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determined as 1 when subjects could not feel the fork vibration. If subjects could feel the fork vibration only when the scale of the semi-quantity fork showed five or less, the score was
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determined as 0.5. If subjects still could not feel the fork vibration, even when the scale of the
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semi-quantity fork showed more than five, the score was determined as zero (Liniger et al.,
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1990). If subjects had one amputated foot, we could not assess the vibration and ankle reflex in both feet. Thus, for subjects with two feet, we separately calculated the MNSI score of each foot
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and then chose the higher one for the subsequent data analysis. 2.5 Data Analysis
SPSS for Windows 20.0 (SPSS, Inc., Chicago, IL, USA) was used to perform all statistical analyses; specifically, Cox regression was used. First, we examined each of the independent variables separately in bivariate Cox regression models to identify predictors of the occurrence of a DFU. Second, the predictive powers of the significant foot self-care practices of the DFSBS were tested, after controlling for demographic variables (i.e., age, gender, and education), and the identified DFU risk factors.
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8 3. Results 3.1 Sample characteristics A total of 295 subjects were recruited. Five subjects did not provide follow-up data;
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specifically, two declined any further interviews, and three could not be reached. Thus, only the data of 290 subjects were analyzed. As seen in Table 1, approximately half (n = 149, 51.4%)
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were male, 169 (58.3%) were over 65 years old (mean = 66.97, SD = 11.01), 209 (72.1%) had
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six or fewer years of education, 78 (26.9%) had a history of hospitalization due to a DFU, 30 (10.3%) had a history of foot amputation, and 56 (19.3%) had a foot deformity. By the one-year
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follow-up, 85 subjects (29.3%) had developed a DFU. Among them, 46 subjects (54.1%) were healed within two weeks, but 24 (28.2%) were not healed after one month.
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3.2 Predictors of DFU
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Cox regression univariate analysis revealed that the number of hospitalizations due to a DFU,
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the score of the physical assessment portion of the modified MNSI, insulin treatment, peripheral vascular disease, and DFSCBS scores predicted DFU occurrence by the one-year follow-up
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(Table 1). When the number of DFU hospitalizations increases by one point, the risk of a DFU occurrence is 1.76 times the original risk. When the score on the physical assessment portion of the MNSI increases by one point, the risk of a DFU occurrence is 1.43 times the original risk. The risk of a DFU occurrence of subjects with insulin treatment is 1.69 times the risk of those without insulin treatment. The risk of a DFU occurrence of subjects with peripheral vascular disease is 1.90 times the risk of those without peripheral vascular disease. Finally, when the DFSCBS score increases by one point, the risk of a DFU occurrence is 1.04 times the original risk. The mean time of DFU occurrence for categorical predictor variables is presented in Table 2.
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9 3.3 Predictive Power of Foot Self-Care Behavior Three of the seven foot self-care behaviors of the DFSCBS (bottom-of-the-foot inspection, between-the-toes inspection, and moisturizing lotion application) were significant predictors of a
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DFU. After controlling for demographic variables, the predictive power of the three self-care behaviors was still significant. After controlling for demographic variables and risk factors of a
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DFU (number of DFU hospitalizations, score on the physical assessment portion of the modified
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MNSI, insulin treatment, and peripheral vascular disease), only lotion-applying behaviors significantly predicted subsequent DFU (Table 3).
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4. Discussion
In this study, 29.3% of subjects developed a DFU by the one-year follow-up. The incidence
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of DFU in our study is much higher than that in a study by Gonzalez et al. (2010) in the UK and
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USA (19% by the 18-month follow-up). One possible reason is that their exclusion criteria were
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different. They excluded patients with a severe foot deformity, an amputated foot, and peripheral arterial occlusive disease, whereas we included such patients. These four criteria are used in
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almost all DFU risk-stratification systems (Monteiro-Soares et al., 2011). Patients with multiple DFU risk factors may have a higher DFU incidence than those with only one DFU risk factor. Thus, the DFU incidence in our study is much higher than the DFU incidence in the research of Gonzalez et al. (2010).
4.1 Predictors of DFU
In this study, we identified four biomedical DFU predictors, including insulin treatment, peripheral vascular disease, the number of DFU hospitalizations, and the score on the physical assessment portion of the MNSI. Among these, insulin treatment and peripheral vascular disease also were predictors in previous studies (Crawford et al., 2011; Monteiro-Soares et al., 2011).
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10 The use of insulin implies a patient’s need for advanced treatment for blood sugar control (Linton, 2012), which reflects the severity of diabetes and its relationship to the occurrence of a DFU. Peripheral vascular disease impedes the blood supply to the foot, which results in ischemic
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DFU (Boulton, 2010). In regard to the number of DFU hospitalizations and score on the physical assessment portion of the MNSI, no previous study has explored this relationship and the
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subsequent occurrence of a DFU.
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The number of DFU hospitalizations is a powerful predictor of a DFU in this study. When the number of DFU hospitalizations increases by one point, the risk of a DFU occurrence is 1.76
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times the original risk. One possible explanation is that certain unidentified risk factors, such as alcoholism and the number of microvascular complications, result in a DFU hospitalization as
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well as a subsequent DFU occurrence. Previous studies revealed that alcoholism (Altenburg et
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al., 2011) and the number of microvascular complications (Winkley et al., 2007) were associated
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with a DFU recurrence. These factors also may impede the healing of a DFU and increase the risk of infection, thus resulting in a hospitalization due to a DFU. We suggest that healthcare
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personnel use the number of DFU hospitalizations as a DFU predictor for patients with diabetic neuropathy.
The score on the physical assessment portion of the modified MNSI is a significant predictor of a DFU occurrence by the one-year follow-up. The risk of a DFU occurrence is 1.43 times the original risk, when the score on the physical assessment portion of the MNSI increases by one point. In the physical assessment portion, five items are assessed: skin and structural abnormality inspection, foot ulcer, ankle reflex, vibration, and monofilament testing (Sorensen et al., 2006). These items are included in the clinical guidelines for DFU management and prevention proposed by the International Working Group on the Diabetic Foot (Bakker et al., 2012).
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11 According to the guidelines, a foot assessment for diabetic neuropathy patients should be conducted by healthcare personnel every one to six months. In Taiwan, however, healthcare personnel do not routinely deliver foot assessments for
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diabetic patients. Although patients who enroll in the pay-for-performance program in Taiwan’s National Health Insurance Program can receive a yearly foot examination, fewer than 40% of
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diabetic patients are enrolled in the program (Department of Health, 2013), and most had mild
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severity of disease (Chang et al., 2012). In our study, the foot assessment took less than five minutes per patient. Thus, we suggest that foot assessment for diabetic patients, especially for
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diabetic neuropathy patients, by healthcare personnel should be delivered regularly as part of a clinical care routine to identifying the risk of a DFU.
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Although foot deformity and amputation history are utilized in all DFU prediction systems
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(Monteiro-Soares et al., 2011), in this study, they did not predict a DFU occurrence. One
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possible explanation for the lack of a significant relationship between foot deformity and subsequent DFU is that some covariates, such as the severity of foot deformity, the
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appropriateness of footwear, and walking activity, were not controlled (Rhim and Harkless, 2012). In regard to the lack of a significant relationship between amputation history and a subsequent DFU, there are no studies on the relationship between amputation history and DFU occurrence among diabetic neuropathy patients. One possible explanation for the lack of a significant relationship is that foot self-care behavior intervened in the relationship between amputation history and a DFU occurrence. In this study, the DFSCBS score of patients with a history of amputation was much higher than those of patients without a history of amputation (mean ± SD = 27.10 ± 7.16 vs. 20.25 ± 7.56, p < 0.001). Some amputation patients may prevent
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12 a DFU by engaging in foot self-care practice, which would decrease the risk of a DFU among this population. 4.2 Predictive Power of Foot Self-care Behavior
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In this study, foot self-exam behaviors were associated with the occurrence of a DFU;
however, after controlling for demographic variables and other DFU predictors, the relationship
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was non-significant. This finding is consistent with that of Gonzalez et al. (2010). There are two
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possible explanations for this non-significant relationship. First, patients who detected an abnormality (e.g., redness, swelling) of their foot by self-exam practice may not deliver
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subsequent management, such as receiving an anti-fungal treatment or changing shoes. Second, foot self-exam practice cannot prevent some kinds of DFU, such as those caused by a cut or
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burns on the foot.
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A DFU may result from fissures and cracks, which occur frequently in diabetic patients with
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autonomic neuropathy (Oe et al., 2012). Thus, the practice of applying lotion is suggested for treating the dry skin of the feet (Bakker et al., 2012; McInnes et al., 2011). Previous studies
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revealed that lotion can relieve the fissures and dryness of skin on the feet of diabetic patients (Garrigue et al., 2011; Pham et al., 2002). Nevertheless, there is no data that support the effect of the application of lotions for the prevention of a DFU. In this study, lotion-applying behavior was positively associated with the occurrence of a DFU. There are two possible explanations for this finding. First, the frequency of lotion application may not be related to improvement of the skin after lotion application but, instead, may reflect the need for alleviating the dryness of the skin. For alleviating the dryness of skin, lotion should be applied in an adequate dose, with adequate frequency, and by the correct method (Hurlow and Bliss, 2011); thus, lotion
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13 application, even more than once a day, may be inadequate to alleviate the dryness of the skin (Hurlow and Bliss, 2011). Further, the frequency of lotion application may reflect the severity of disease of the subjects
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in the DFU group. Those who engaged in adequate foot lotion application may have suffered from fissures of their foot that are associated with autonomic neuropathy (Oe et al., 2012). Thus,
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although engaging in adequate lotion applying practice, these patients may have a higher risk of
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a DFU than do those without autonomic neuropathy. Additionally, inappropriate lotion application may deteriorate the skin of the foot. Some subjects in this study told us that they
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always applied anti-inflammatory lotion to treat the dryness of their foot. A steroid, which is the main ingredient of anti-inflammatory lotion, may result in thin skin (Linton, 2012), which could
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precipitate the occurrence of a DFU.
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5. Conclusion
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This is the first study that explored the relationship between foot self-care practice and subsequent occurrence of DFU. We found that foot self-care practice may be insufficient to
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prevent the occurrence of the DFU among patients with diabetic neuropathy and that lotionapplying behaviors may be associated with the occurrence of DFU in diabetic patients with neuropathy.
6. Study Limitations
Some limitations of this study need to be mentioned. First, more than two-thirds of the subjects had six or fewer years of education. Thus, the result may not be generalizable to a more educated population. Second, we did not evaluate some confounding variables, such as the subsequent self-care process, after changes in foot health were detected, including the type of foot lotion and the appropriateness of the foot lotion application. Third, due to a limited budget,
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14 we could provide foot inspection for subjects only at 3 and 12 months after their enrollment. Thus, recall bias may have resulted in the underestimation of DFU occurrence in this study. Further studies may improve the accuracy of a DFU record by increasing foot-inspection
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frequency to an interval such as every three months.
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15 References Altenburg, N., Joraschky, P., Barthel, A., Bittner, A., Pöhlmann, K., Rietzsch, H., Fisher, S., Mennicken, G., Koehler, C., Bomstein, S.R, 2011. Alcohol consumption and other psycho-
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social conditions as important factors in the development of diabetic foot ulcers. Diabetic Medicine 28(2), 168-174.
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Bakker, K., Apelqvist, J., Schaper, N.C., the International Working Group on the Diabetic Foot
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Editorial Board, 2012. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/Metabolism Research and Reviews 28(Suppl. 1), 225-231.
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Boulton, A.J.M., 2010. The diabetic foot. Medicine 38(12), 644-648.
Boulton, A.J.M., Vileikyte, L., Ragnarson-Tennvall, G., Apelqvist, J., 2005. The global burden
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of diabetic foot disease. Lancet 366(9498), 1719-1724.
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Chang, R.E., Lin, S.P., Aron, D.C., 2012. A pay-for-performance program in Taiwan improved
31(1), 93-102.
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care for some diabetes patients, but doctors may have excluded sicker ones. Health Affairs
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Chin, Y.F., Huang, T.T., 2013. Development and validation of a Diabetes Foot Self-Care Behavior scale. Journal of Nursing Research 21(1), 19-25. Chin, Y.F., Huang, T.T., Hsu, B.R.S., 2013. Impact of action cues, self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy. Journal of Clinical Nursing 22(1-2), 61-68. Crawford, F., Mccowan, C., Dimitrov, B.D., Woodburn, J., Wylie, G.H., Booth, E., Leese, G.P., Bekker, H.L., Kleijnen, J., Fahey, T., 2011. The risk of foot ulceration in people with diabetes screened in community settings: Findings from a cohort study. QJM 104(5), 403410.
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16 Department of Health, Executive Yuan National health insurance quality of medical care information disclosure network. http://www.nhi.gov.tw/mqinfo/Content.aspx?List=3&Type=DM, 10/6/2013
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Feldman, E.L., Stevens, M.J., Thomas, P.K., Brown, M.B., Canal, N., Greene, D.A., 1994. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis
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Garrigue, E., Martini, J., Cousty-Pech, F., Rouquier, A., Degouy, A., 2011. Evaluation of the moisturizer Pédimed® in the foot care of diabetic patients. Diabetes and Metabolism 37(4),
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Gonzalez, J.S., Vileikyte, L., Ulbrecht, J.S., Rubin, R.R., Garrow, A.P., Delgado, C., Cavanagh,
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P.R., Boulton, A.J., Peyrot, M., 2010. Depression predicts first but not recurrent diabetic foot
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ulcers. Diabetologia 53(10), 2241-2248.
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Huang, Y.Y., Lin, K.D., Jiang, Y.D., 2012. Diabetes-related kidney, eye, and foot disease in Taiwan: An analysis of the nationwide data for 2000-2009. Taiwan Yi Xue Hui Za Zhi
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111(11), 637-644.
Hurlow, J., Bliss, D.Z., 2011. Dry skin in older adults. Geriatric Nursing 32(4), 257-262. Liniger, C., Albeanu, D., Bloise, D., Assal, J.P., 1990. The tuning fork revisited. Diabetic Medicine 7(10), 859-864.
Linton, A.D., 2012. Introduction to medical surgical nursing (5th ed.). Saunders, St. Louis. McInnes, A., Jeffcoate, W., Vileikyte, L., Game, F., Lucas, K., Higson, N., Stuart, L., Church, A., Scanlan, J., Anders, J., 2011. Foot care education in patients with diabetes at low risk of complications: a consensus statement. Diabetic Medicine 28(2), 162-167.
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17 Monteiro-Soares, M., Boyko, E.J., Ribeiro, J., Ribeiro, I., Dinis-Ribeiro, M., 2011. Risk stratification systems for diabetic foot ulcers: A systematic review. Diabetologia 54(5), 11901199.
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Oe, M., Sanada, H., Nagase, T., Minematsu, T., Ohashi, Y., Kadono, T., Ueki, K., Kadowaki, T., 2012. Factors associated with deep foot fissures in diabetic patients: a cross-sectional
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observational study. International Journal of Nursing Studies 49(6), 739-746.
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Pham, H.T., Exelbert, L., Segal-Owens, A.C., Veves, A., 2002. A prospective, randomized,
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Rhim, B., Harkless, L., 2012. Prevention: can we stop problems before they arise? Seminars in
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Sorensen, L., Molyneaux, L., Yue, D.K., 2006. The relationship among pain, sensory loss, and
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18 Highlights Diabetic foot ulcer (DFU) is the main reason for the hospitalization of diabetic patients and the main precursor of lower limb amputation.
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The foot self-care behavior is viewed as beneficial for the prevention of diabetic foot ulceration, though the effect of foot self-care behavior on the development of DFU has received little
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empirical investigation.
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The number of diabetic foot ulcer (DFU) hospitalizations and the score on the physical assessment portion of the modified Michigan Neuropathy Screening Instrument (MNSI) are
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predictors of DFU occurrence in diabetic neuropathy patients.
the occurrence of diabetic foot ulcers.
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Among patients with diabetic neuropathy, foot self-care practice may be insufficient to prevent
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diabetic patients with neuropathy.
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The lotion-applying behavior was associated with the occurrence of diabetic foot ulcers in
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19 Table 1. Cox Regression Univariate Analysis
Mean (SD) Age
66.97 (11.01)
No DFU Occurrence Mean (SD)
DFU Occurrence
n (%)
Mean (SD)
n (%)
65.31 (10.91)
67.66 (11.01)
149 (51.50)
Education (years)
5.69 (4.41)
Married
214 (73.80)
147 (71.7)
67 (78.8)
Unemployed
237 (81.70)
167 (81.5)
70 (82.4)
Living alone
12 (4.10)
8 (3.9)
4 (4.7)
No. of DFU hospitalizations
0.39 (0.75)
0.27 (0.54)
MNSI
2.43 (0.82)
2.34 (0.82)
Insulin treatment
123 (42.40)
Peripheral vascular disease
40 (13.80)
HbA1C
8.53 (1.77)
11 (12.9)
0.66 (1.06)
2.64 (0.79)
77 (37.6) 22 (10.7)
8.46 (1.74)
8.70 (1.84)
p 0.109
1.22 (0.79-1.87)
0.376
1.01 (0.96-1.06)
0.656
1.23 (0.73-2.08)
0.428
1.05 (0.60-1.84)
0.861
1.22 (0.45-3.34)
0.696
1.01 (0.98-1.03)
0.610
0.82 (0.60-1.13)
0.223
1.76 (1.40-2.21)
0.000
1.43 (1.09-1.86)
0.009
46 (54.1)
1.69 (1.10-2.59)
0.016
18 (21.2)
1.90 (1.13-3.20)
0.016
1.06 (0.94-1.19)
0.365
1.54 (1.74)
1.82 (1.94)
1.05(0.95-1.16)
0.327
20.96 (7.79)
20.16 (7.59)
22.88 (7.99)
1.04 (1.01-1.07)
0.004
Examining the bottom of the feet
2.31 (1.77)
2.12 (1.68)
2.76 (1.91)
1.20 (1.07-1.34)
0.002
Examining between toes
2.44 (1.84)
2.29 (1.79)
2.81 (1.91)
1.14 (1.02-1.28)
0.021
Washing between toes
4.05 (1.63)
3.98 (1.67)
4.24 (1.52)
1.09 (0.95-1.26)
0.216
Drying between toes after washing
2.86 (1.96)
2.89 (1.95)
2.79 (1.98)
0.99 (0.86-1.10)
0.816
Applying moisturizing lotion to the feet
2.82 (1.76)
2.62 (1.72)
3.32(1.76)
1.20 (1.06-1.36)
0.004
Checking the inside of shoes before wearing them
3.70 (1.77)
3.62 (1.80)
3.89 (1.71)
1.09 (0.96-1.24)
0.168
Breaking in new shoes
2.77 (1.86)
2.64 (1.85)
3.07 (1.84)
1.12 (1.00-1.25)
0.058
te
d
1.62 (1.80)
Baseline DFSCBS
Ac ce p
Serum creatine
19 (9.3)
an
30 (10.30)
15.82 (9.09)
us
14.80 (9.12)
Lower limb amputation history
48 (56.5) 6.04 (4.24)
cr
5.55 (4.47)
M
15.10 (9.11)
101 (49.3)
0.98 (0.97-1.00)
Male
Duration of DM (years)
HR (95% CI)
ip t
Total Sample
Note. DFU = Diabetic foot ulcer; MNSI = Physical assessment portion of the modified Michigan Neuropathy Screening Instrument; DFSCBS = Diabetes Foot Self-Care Behavior Scale.
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20 Table 2. Mean Time of DFU Occurrence Variable
Mean Time
95% Confidence Interval
Male
11.155
10.528-11.782
Female
11.466
10.931-12.002
Yes
11.357
10.864-11.850
No
11.532
ip t
Gender
11.392
No
11.196
an
Yes
10.700-12.365
us
Unemployed
cr
Married
Living alone Yes
10.918-11.867 10.311-12.081
10.156
7.848-12.464
11.440
11.008-11.872
10.209
8.790-11.628
11.521
11.079-11.962
10.879
10.170-11.588
11.735
11.226-12.243
Yes
10.185
8.921-11.449
No
11.599
11.152-12.046
M
No Lower limb amputation history
Insulin treatment No
Ac ce p
Yes
te
No
d
Yes
Peripheral vascular disease
Page 20 of 21
21
SE
HR (95% CI)
p
0.10
0.06
1.10 (0.97-1.25)
0.132
Age
-0.02
0.01
0.98 (0.96-1.00)
0.100
Male
-0.00
0.25
1.00 (0.61-1.63)
0.988
Education
-0.03
0.03
0.97 (0.91-1.03)
0.302
MNSI
0.31
0.15
1.36 (1.02-1.81)
0.038
DFU admission (number)
0.39
0.14
1.47 (1.13-1.93)
0.005
Insulin treatment
0.31
0.22
1.36 (0.87-2.11)
0.173
Peripheral vascular disease
0.55
0.28
1.73 (1.00-2.97)
0.049
0.05
0.06
1.05 (0.93-1.19)
0.446
Age
-0.02
0.01
0.98 (0.96-1.00)
0.092
Male
-0.01
0.25
0.99 (0.60-1.61)
0.956
Education
-0.03
0.03
0.97 (0.91-1.03)
0.302
MNSI
d
Table 3. Cox Regression Models for Predictors of Diabetic Foot Ulcers by Foot-Care Behaviors B
M
Model 2 Examine between toes
cr
us
an
Examine bottom of feet
ip t
Model 1
0.15
1.36 (1.02-1.82)
0.035
0.44
0.13
1.55 (1.20-2.01)
0.001
0.31
0.23
1.36 (0.88-2.12)
0.168
0.51
0.28
1.67 (0.96-2.88)
0.068
0.17
0.07
1.19 (1.04-1.36)
0.012
-0.02
0.01
0.98 (0.96-1.00)
0.050
0.11
0.26
1.12 (0.67-1.85)
0.670
-0.05
0.03
0.95 (0.90-1.02)
0.140
0.36
0.15
1.44 (1.07-1.92)
0.016
DFU admission (number)
0.39
0.13
1.48 (1.15-1.90)
0.002
Insulin treatment
0.21
0.23
1.23 (0.78-1.94)
0.366
Peripheral vascular disease
0.55
0.28
1.73 (1.01-2.98)
0.046
DFU admission (number) Insulin treatment
Ac ce p
Peripheral vascular disease
te
0.31
Model 3
Lotion Application Age Male
Education MNSI
Note. DFU = Diabetic foot ulcer; MNSI = Physical assessment portion of the modified Michigan Neuropathy Screening Instrument.
Page 21 of 21