Cath Lab Digest

Literature Review
People with diabetes are at high risk for foot and leg ulcers. As the disease progresses, peripheral vascular disease and peripheral neuropathy may develop, with loss of Achilles and patellar reflexes and decreased vibratory sensation. Peripheral neuropathy may be the most important precursor to ulcer development. Distal symmetric polyneuropathy, the most common type of neuropathy in individuals with diabetes, involves sensory, motor, and autonomic nerve fibers, leading to reduced thermal and pain sensation, numbness, and painful paresthesias.1 When an insensate foot is subjected to even minor trauma or increased pressure, as with ill-fitting shoes, an ulcer may develop.
Neuropathic foot deformities also occur with the unopposed action of the extensor tendons, which leads to clawing of the toes and prominence of the metatarsal heads. Because of maldistribution of pressure, ulcers are more likely to develop on the areas underlying the metatarsal heads. Infection of chronic ulcers is a major cause of gangrene and, in turn, amputation. Amputation of the feet and legs is one of the biggest threats to adults with diabetes - the leading cause of lower extremity amputation among people aged 18 to 65 years. Ulceration, infection, and gangrene are leading causes of hospitalization at an annual cost of $1 billion.2
Patients are more likely to comply with a treatment regimen when they have sufficient knowledge about their medical condition. According to the American Diabetic Association, daily foot care and inspection can prevent the development of foot ulcers in people with diabetes.3 Preventive behaviors focus on not going barefoot, performing/receiving proper foot care, and wearing properly fitting shoes.
Because place or residence, region, and socioeconomic status shape health values, behaviors, and status, people with diabetes in rural settings may have unique problems. People living in rural areas are more likely to suffer from chronic conditions and are less likely to receive preventive care than their urban counterparts.4 The average number of people with diabetes in rural areas exceeds that of urban dwellers.5 In addition, about half as many physicians are available in rural areas, with the southern part of the United States having the fewest. Rural-dwelling people often seek help when their role performance is impaired; they tend to rely on social support networks because they often distrust outsiders. Folk medicine is sometimes used, and relatives and friends are the preferred source of medical information. Confidence in home remedies is high; in small towns, lack of privacy may prevent a person from seeking medical attention for "embarrassing" conditions.5 Rural-living people also face transportation and communication problems. In a study by Strickland and Strickland,4 50% of the minority population studied did not have cars, and 25% did not have phones. Both of these factors interfere with entitlement eligibility and access to health services.
The project described in this article was the first in a multiphase program of research that will follow a cohort of rural-dwelling people with diabetes through the progression of their disease, their foot care and foot wear practices, and the effects of the development of foot ulcers. All of the people in this study had been given information and guidance on foot care and shoe management at some time in their medical treatment history. This article reports the findings on self-care practices related to foot care of 61 rural people with diabetes mellitus. This pilot project used an instrument that had been previously validated in Thailand by the Siriraj Foot-Care Score.

Methods
Setting and participants. This descriptive study was conducted at a treatment facility sponsored by an academic medical center that services clients from 26 rural counties of a southeastern state.