Total Contact Casting as Part of an Adaptive Care Approach: A Case Study
Providing care for patients with challenging wounds and comorbidities requires an open mind. When Ms. T, an elderly woman with schizophrenia and a chronic diabetic foot ulcer that was not responding to treatment, presented at Victory Memorial Hospital Diabetic Foot Clinic (VMH DFC), Brooklyn, NY, care providers needed a plan that allowed consideration of all available care options to achieve the best outcomes.
The well-known nursing theorist/researcher Sister Callista Roy’s1 perspective on the human experience can be easily applied in wound care. On the sensitive relationship between man and the environment, Sister Roy writes about an ongoing adaptation, survival, and resilience as part of a journey through life. Similarly, wound care clinicians continually address the issue of maladaptation as a factor in the breakdown of the integumentary system. When the skin – the organ of temperature regulation and the major barrier to microbial invasion – has been compromised, the body is in danger of invasion by organisms that can lead to sepsis and death. In this case study of a patient with a diabetic foot ulcer, the patient’s altered coping mechanisms were rendered less effective by diabetes mellitus2 and other comorbidities that required persistence and ingenuity from caregivers.
Offloading is a recognized option for foot ulcers. One such option – total contact casting (TCC), which provides pressure relief and a moist wound-healing environment and facilitates patient mobility while the wound is healing – is not practiced in many centers, primarily because of the scarcity of Board-certified pedorthists (BCPs) competent, knowledgeable, and experienced regarding application and modification of the casts. Additionally, to be done correctly, clinicians using TCC need approximately 45 minutes for the procedure in addition to the time needed for the initial removal of the cast and dressing, and assessment of the wound. Thus, experience teaches this approach is not widely used.
The authors’ diabetic foot clinic is part of a larger outpatient department at the facility. Clinicians at this non-profit clinic do not bill patients privately for any service. The care team includes a Board-certified pedorthist (BCP) experienced in TCC; once peripheral circulation and perfusion to the lower extremities are determined to be intact, patients with plantar ulcers (weight-bearing surfaces) are immediately considered for TCC. Patients also are evaluated for any lower extremity weakness, motor imbalances, and unsteady ambulation that might make TCC unsafe, as well as for sufficient cognitive ability to follow instructions regarding the use of assistive devices such as a cane or walker.
Ms. T presented with an ulcer of >18 months duration with no evidence of cellulitis or gangrene. She was evaluated and met the criteria for TCC; casting was started along with treatment involving a succession of topical wound dressings and applications whenever wound healing showed signs of slowing. The casting stabilized the local wound environment, keeping the patient infection-free for 5 years until the wound closed. Moisture-control foam dressing impregnated with nanocrystalline addressed moisture balance and bacterial control necessary to achieve healing within the closed, protected environment created by TCC until the wound finally responded. Total contact casting (see “Total Contact Casting: The Details”) appeared to be the pivotal treatment that provided a healing environment for this serious wound.
The purpose of this case report is not only to increase clinician appreciation for the impact TCC can makes on the progress of the patient’s overall condition and to acquaint the reader with the purpose and wound care benefits of TCC for diabetic foot ulcers, but also to illustrate the overall benefits of mobility and ambulation for patients with diabetes and healing wounds. In this case, mobility affected the patient’s management of her diabetes.
This presentation is not intended to be a study in topical wound therapies. When considering all the classifications of dressings and the number of dressings that fall within each classification, it would be inaccurate to say one particular dressing outperforms the rest based on one wound. Different classifications of dressings can be combined and hundreds of pharmaceutical applications can be added to the mix, exponentially increasing the choices for topical wound therapies. The dressing that finally helped heal this wound serendipitously brought together the elements needed for that particular wound to the wound environment, underscoring Sister Callista’s philosophy of adaptation and persistence.
At the time of initial presentation, Ms. T was a 75-year-old Caucasian woman with a medical history that included schizophrenia, obesity, diabetes mellitus type 2, and severe Charcot foot deformities of both feet. She presented at the authors’ clinic in September 2000 with a large Wagner Stage III non-tracking diabetic foot ulcer on the right plantar surface along with local cellulitis. The ulcer measured 8 cm x 9.5 cm. Ms. T reported she had been treated at two other wound care centers for 6 months and 12 months, respectively. She was de-conditioned from limited exercise (centers often will off-weight plantar ulcers by recommending severely restricted ambulation). Her blood cultures were negative and her immediate and past history was negative for fevers. Her white blood cell count was elevated (13,500) and the wound periphery appeared mildly cellulitic. Based on clinical judgment, she was treated with an antibiotic (ciprofoxacin 500 mg every 12 hours) until her blood count was normal (14 days). Her blood sugars remained slightly but persistently elevated (140-180) despite insulin adjustment by the physician on the diabetic foot clinic team. Ms. T’s meals were being delivered to her home through a community agency. This service responds to special dietary needs and the patient was on a “no concentrated sweets” diet. However, because she was an outpatient, assessing her dietary intake and its alignment with her therapeutic goals was difficult. She was seen monthly by a VMH DFC nutritionist for the first 3 months, after which she was seen as needed at the recommendation of the wound care nurse.
Charcot foot and perfusion. A series of lower extremity x-rays supported the diagnosis of Charcot collapse of the foot infrastructure. Peripheral pulses in both Ms. T’s legs and feet were strong, her feet felt warm, and capillary refill was positive at 1 second. Gross vascular examination did not indicate arterial insufficiency – in particular, arterial-venous Doppler study revealed no vascular insufficiency to the lower extremities. The wound was a healthy red color, moist, and insensitive. The ulcer on the plantar surface of the foot was positioned over a bony prominence, signifying the etiology was due to pressure as opposed to arterial insufficiency that usually presents in the toes. Patients with arterial insufficiency rarely develop Charcot deformities – Ms. T’s x-rays showed Charcot deformities in addition to the thinning of bone cortex associated with autonomic hyperperfusion. Autonomic hyperperfusion results in the “wash out” of bone minerals, especially calcium.3-5
Schizophrenia. Three months before coming to the clinic, Ms. T’s family consulted a private psychiatrist. This was Ms. T’s son’s effort to take charge of her medical care and have her admitted to a skilled nursing facility to care for her wound. Evaluation confirmed she was legally competent. Ms. T had not been “sent” to the Diabetic Foot Clinic by regular referral channels – she had heard about the clinic from one of her neighbors and she had made a conscious decision to seek help from the center.
The wound had a far-reaching impact on Ms. T’s overall well-being. Care team members understood that her psychiatric condition put her at high risk for relapse after the wound was healed, but they felt her immediate needs and the danger of eventual sepsis and amputation outweighed that risk. During prior treatment in other wound centers, she trialed two offloading braces without any improvement. She routinely refused any recommended surgery to speed healing by removal of abnormal bone protrusions. One such bony prominence seen on x-ray was situated immediately under the area of the ulcer and was identified as the pressure point (see Figure 1).
During the 3 weeks before starting TCC, a home care nurse changed Ms. T’s foot ulcer dressings on a daily basis. Ms. T’s dressings always showed tampering when she arrived in clinic. Ms. T occasionally missed clinic appointments but always called the clinic to inform staff she would not be coming and to reschedule. The patient’s psychiatric condition was not judged to be an impediment to immediate treatment. Before starting the TCC (which previously had not been considered), Ms. T was presented with all the information regarding the procedure and alternative options for care. She accepted this treatment without reservations, especially because she was told she would be able to resume most of her normal activities by wearing the cast.
Total contact casting. Having met all the casting criteria (see “Total Contact Casting: The Details”), Ms. T was started on TCC in the summer of 2000, 3 weeks after she presented to the clinic. Casting was a particularly good choice for her because the cast prohibited access to the wound. When first casted, the wound involved much of the plantar surface of the foot, measuring 8 cm x 9.5 cm.
Ms. T was alert and oriented and remained highly functional throughout her initial treatment, which lasted from January 2000 to March 2005. She rehabilitated well in the first few weeks of casting using a walker. Her mobility gradually increased and she became completely ambulatory with the aid of a cane; she was comfortable and happy with her freedom. She could navigate stairs and make almost daily excursions to the shops in her neighborhood to buy small food items, something she couldn’t do before. After starting TCC, increasing her mobility, and improving compliance with her “no concentrated sweets” diet (self-report), Ms. T’s blood sugar record significantly improved with only infrequent elevations > 120. She became increasingly vigorous and her weight decreased, although she remained mildly overweight (5’8” tall, 190 lb ± 5 lb). Although manifestations of Ms. T’s schizophrenia were noted in long conversations during casting when she exhibited flight of ideas, disorganized thinking, and secretiveness, she was able to travel to and from clinic alone, live alone, and self-manage her finances.
Fitful progress. The wound rapidly decreased in size to 3.5 cm x 2.5 cm within 2 months after starting casting, which was attributed largely to pressure relief. Initially, the dressing applied under the cast during this healing period was silver sulfadiazine cream 1% (SSD) with a dry cover dressing. A moderate amount of serous drainage was noted on the dressings when the cast was changed. Drainage is expected with each cast change, although the amount differs from patient to patient, due to an accumulation from the whole week. The experience at the VMH DFC has been that the better the arterial perfusion to foot wounds, the moister the wound bed tends to be and the greater the accumulation of drainage inside the cast at the time of change.
Nevertheless, preventing maceration of the normal tissues was a challenge in this case. Maceration caused by drainage or perspiration occurred around the wound, between the toes, and on other parts of the foot and was treated with gentian violet solution 1%. This is not only an effective drying agent, but also highly antifungal and effective against methicillin-resistant Staphylococcus aureus and other bacteria when applied to maceration and fungal eruptions.6-9 Routine bacterial blood counts performed every 2 months were normal.
When healing failed to continue after 4 months, the SSD was changed. Various absorbent dressings, either impregnated with antimicrobials or in combination with antimicrobial topical dressings and applications, were tried with little success.
To address cast-related maceration, attempts to discontinue casting and try other forms of off-weighting, including braces and splints, were tried without success. The status of the wound declined – for example, cellulitis and sepsis developed after 2 weeks in a “half-cast” (a custom-molded plaster half-shell).10 With this device, the patient’s dressing can be changed more often because the cast can be removed and reapplied. This change in treatment was made after 1 year of TCC when wound healing seemed to plateau at 3.5 cm x 2.5 cm. The rationale was that more frequent dressing changes might promote further healing. A silver-impregnated alginate dressing was used during the 2 weeks out of the TCC, before Ms. T’s hospital admission for septicemia. During Ms. T’s hospital stay, a full vascular consultation and workup was performed to evaluate any possible changes in her perfusion status since the beginning of treatment. Results indicated no large vessel vascular disease was present except for a benign varicose vein on the medial aspect of the right leg.
One week after Ms. T’s discharge from the hospital, TCC was resumed. Dressings were chosen according to their ability to absorb and control the drainage for the 7 days between cast changes11,12 and reported manufacturer claims regarding effective management of bioburden within the wound. Each new dressing (now including variations of foam and silver dressings) was tried for at least 3 weeks – a period based on general recommendations of the New York State Department of Health for skilled nursing facilities regarding wound care practices; state oversight sets an expectation that wounds will be carefully monitored for progress and that treatments will be changed in a judicious manner once wound progress stops or declines. Ms. T’s wound remained stable, free of infection, and granular while casted; it also remained the same size (3.5 cm x 2.5 cm ± 1-2 mm). This trial-and-error period lasted approximately 5 years, including time the patient was in the cast and short periods while off-weighting alternatives to TCC were tried.
A new dressing that combined a high-density absorbent foam and ionic silver nanocrystalline therapy was tried with better results.13,14 The response to the new therapy was immediate and dramatic, reducing wound area from 8.8 cm2 to 6 cm2 (30%) the first week. The wound healed within 10 weeks of initiating the new therapy and with weekly re-casting (see Figure 2). It is not clear what specific properties of the dressing had such a positive impact on the wound – the properties of the foam itself, the unique delivery system of the ionic silver, or both combined. Subtle, subclinical, intrinsic changes in the patient’s overall condition or locally in the foot may have been factors.
Diabetes mellitus. Diabetes mellitus is an endocrine dysfunction that affects every fiber of the human internal physical environment, resulting in the denaturing of proteins and collagen (glycolysation), accelerated aging of the organ systems, and a shortened lifespan in the affected individual.15 Early in the disease process, the skeletal muscles in the body become insulin-resistant, resulting in poor glucose utilization. It is increasingly apparent that insulin resistance as a metabolic syndrome precedes beta cell failure in the pancreas16; the inhibition of the renin-angiotensin system in the pathogenesis of diabetes also may be a factor.17 These changes in the normal glucose regulatory mechanisms in the body cause elevations in blood glucose that impact the pancreatic beta cells over time, resulting in beta cell apoptosis.18-20 As blood glucose becomes chronically elevated and continues untreated, the diabetic metabolism starts to breakdown fats and proteins for energy production, sending the person into ketoacidosis and coma. In some cases, diabetes even blocks nutritional absorption from the gut – ie, peripheral neuropathy- induced gastroparesis.21,22 Thus, diabetes mellitus is a maladaptive syndrome in the most molecular, physiological sense – if not addressed properly, the condition shortens the life of the affected person.
According to Roy,1 the inability to adapt to the external physical environment – ie, the inability to assimilate energy producing and restorative nutrition – ultimately results in death. However, if caught early and treated aggressively, including planned, successful nutrition, weight loss, and a regular exercise schedule – that is, if the input and assimilation within the system changes positively – the output will be a normal, active life.
Total contact casting. In 1998, Armstrong and Lavery,23 having noted a preponderance of wound literature addressing topical wound care and research on dressings, published a comprehensive review of evidence-based options for offloading diabetic wounds. The salient theme behind this review was that without offloading, all other treatment modalities would be “less than effective.”23 Many patients with chronic diabetic foot ulcers come into the VMH DFC with histories of non-healing wounds they have had for years. Total contact casting has become the “gold standard” of off-weighting in lower extremity amputation prevention.24,25 Rarely do patients with diabetic foot ulcers with similar presentation have to be casted more than 3 months before they are healed.
In 1999, Inlow et al26 postulated that offloading is the most important component in prevention and treatment of diabetic foot ulcers, citing peripheral neuropathy as a major contributing factor to more than 90% of diabetic foot ulcers. He developed a modified Carvelle Classification System that offered practitioners offloading options for different types of deformities and pressure points. An additional category for patients with diabetes and foot ulcers or acute Charcot events helps clinicians identify which patients would benefit from TCC.26
Literature27-29 describing the value and safety of TCC commonly cites the work done by Brand, the originator of the technique. Sinacore et al’s30 retrospective study of 30 patients with a total of 33 foot ulcers showed a healing rate with TCC of 82%, average size = 2.3 cm2, and an average of 44 days healing time for wounds that healed. In a retrospective study by Birke et al31 of 80 neuropathic ulcers, average size 1.7 cm2, 90% healed with a complication rate of 6%.
For decades, TCC was considered unsafe for use on plantar ulcers related to ischemia. However a prospective longitudinal study by Nabuurs-Franssen et al32 of 98 consecutive patients to assess the outcome and complications of TCC for neuropathic ulcers with present and absent peripheral arterial disease (PAD) and also with and without superficial infection found that ulcers with moderate ischemia or infection can be treated effectively with casting. This study showed that 69% of the patients with PAD healed with TCC, while only 36% healed when superficial infection was present in the ulcer. However, when heel ulcers were added to the mix (regardless of PAD and infection status), outcome was found to be poor. Overall, the non-infected group with no PAD and no heel ulcers had the highest healing rate (90%). Of note: in the treatment algorithms used at the authors’ clinic, ischemic ulcers are not casted and are followed by a vascular consultant because of a high incidence of complications when treated with TCC.25
In Ms. T’s case, TCC was so effective clinicians were able to salvage her limb, keep her infection-free, and prevent amputation for 5 years in the presence of a chronic open wound and diabetes. Keeping her actively ambulatory the entire time she was casted is credited with effectively controlling her blood sugar, as supported by the literature.33-40
Topical therapy. When clinicians choose a topical therapy and apply a dressing to a wound, they are essentially providing an alter-environment for that wound that introduces new conditions to promote healing and protect the wound from external factors. However, despite appropriate dressing, additional events and conditions can impact on the wound – eg, an increase in pressure, edema in the extremity, uncontrolled blood glucose, and disruption of the dressing, including tampering. In Ms. T’s case, TCC was crucial in controlling these variables until healing occurred.
Addressing Charcot foot. One common challenge in a diabetic foot center is management of the Charcot foot.28 This phenomenon involves the crumbling of the infrastructure of the foot, classically seen in persons with diabetes and peripheral neuropathy. The denatured proteins caused by glycolysation in persons with diabetes find their way into collagen, producing an inferior quality of collagen fibers. This causes poor cross-linking of collagen fibers in the bone matrix, which leads to inferior patterns of mineralization in the bone.41 Decreased vitamin D3 hydroxylation also relates to the deranged mineral homeostasis and skeletal morphology seen in persons with diabetes (see Figure 3),42-50 making persons with diabetes more prone to fractures, especially when compounded with autonomic abnormalities in the peripheral circulation.
Abnormal proteins also affect the quality of the collagen in the connective tissue in the walls of the blood vessels, in some cases causing peripheral arterial insufficiency and in others venous insufficiency and yet in others a combination of both. The abnormal collagen also affects the arterioles and capillaries of almost all persons with diabetes, regardless of what is happening to their macro-vasculature. This is called small vessel disease.51 When the skin is broken, this capillary dysfunction renders persons with diabetes vulnerable to infection by preventing a fast, adequate immune response.52,53 This same small vessel disease affects the blood supply to small peripheral nerve endings, causing a decrease/increase in sensation and also affecting the autonomic nerves regulating the general blood flow through the larger arteries. Even clinicians not specialized in wound care are familiar with the devastating effects of arterial insufficiency, vascular constriction, and chronic occlusive disease. These conditions are more common in persons with diabetes due to autonomic abnormalities. However, an opposite autonomic vascular condition exists in some persons with diabetes that causes a hyperperfusion of the lower extremities. This condition effects a washout of bone minerals, resulting in Charcot fractures, collapse of the weight-bearing bones of the feet, and deformities.54,55 These patients frequently have unusual pressure points along the plantar surface of their feet as part of these deformities.56,57 Pressure ulcerations in these patients can be very persistent and because of the good blood supply, these ulcerations resist infection. It is not uncommon for a patient to report an ulcer persisting for a year or longer.
People with arterial insufficiency and claudication may progress to ischemia, requiring surgical intervention where possible. People who have arterial insufficiency usually do not have Charcot fractures and deformities. Commonly, they present with other types of foot deformities such as bunions, hammertoes, and the like but their ulcerations are less likely to develop on the plantar surface. The pain these patients experience in their feet and legs from chronic ischemia leads to decreased ambulation unless accompanied by decreased sensation from neuropathy. These patients are not good candidates for TCC and complete assessment by a vascular surgeon is required as part of the full therapeutic work-up.32,58-60
Applying Roy’s perspective. Roy’s nursing theory of adaptation breaks environmental “fields” down into focal, contextual, and residual stimuli.1 The diagram in Figure 4 illustrates how the particular focal issue is the wound; the contextual issues include the elements in the vicinity of the wound that have an immediate impact, including the patient’s physical reaction to the wound. The residual stimuli are the uninvolved environmental factors. The TCC contained the focal and contextual stimuli and created a rigid “wall” separating the residual stimuli, keeping the contextual stimuli constant. Roy’s principles of adaptation to the external environment, or even more importantly, how isolating the focal maladaptive element (the wound) and adjusting the environment to effect healing of the organism underscore the approach to Ms. T’s care. Because the TCC is changed only once a week, the high levels of moisture and microbes needed to be addressed. Many different dressings and combinations of dressings were tried. A combination of nanocrystalline technology and moisture-control foam seemed to provide the sensitive balance needed to heal this wound. Careful weekly assessments of each successive treatment revealed the wound healing dynamic. By adhering to Roy’s nursing theory principles, the wound finally was healed.
Initially, the goal for treating Ms. T’s foot ulcer was complete healing. However, as time passed, this goal changed to preventing the ulcer from worsening. This change in prognosis was carefully and clearly discussed with Ms. T and her family on several occasions at the behest of the clinic staff. They were content with continuing casting with this new goal in mind, but also maintained a realistic but reserved hope that some new dressing would eventually heal the wound. In the meantime, Ms. T and her family were happy with her lifestyle while she was wearing the cast, expressing feelings of confidence that the cast was protecting her wound and preventing infection and possible amputation. Once the ulcer healed, Ms. T was carefully assessed on a regular basis so new ulcerations would be treated promptly while they were still small, effecting rapid healing and allowing her to return to wearing her custom-molded shoes.
Case Report Postscript
Ms. T was casted for and received diabetic custom-molded shoes 5 years after she first presented at the VMH DFC and the subsequent initiation of the TCC. Her psychiatric idiosyncrasies are a challenge and a barrier to her learning and following instructions.61,62 She continues to refuse home care visits or assistance. She chooses to stay in her own apartment rather than become a resident in an adult care or skilled nursing facility. She remained ulcer-free for 7 months, then over a period of 15 months, re-opened her wound three times. However, because she is reliable about checking for drainage on her socks when retiring and immediately arrives in the clinic when drainage appears, the wounds are addressed while they are still small and superficial. Nanocrystalline moisture control barrier foam dressing has been used with TCC to re-heal the ulcer two more times and she is currently receiving the same therapy for the third recurrence.10 She has been re-casted for a new pair of custom-molded shoes to prevent another recurrence.
Ms T’s blood sugars for the most part have remained within normal range. She attributes occasional elevations to dietary indiscretions, especially during holidays and visits to her family who, thanks to the care provided, she now can frequently visit.
Avoiding amputation is the underlying premise and goal of diabetic foot centers modeled after the HRSA LEAP program. Ms. T will require close maintenance care and foot assessments every 6 weeks, but this is a slight inconvenience to the patient and small cost to her health insurance compared to that of an amputation and the comorbidities that frequently accompany that drastic alternative
Healing foot ulcerations can be frustrating and tedious, especially when clinicians are tempted to view success in narrow time frames. Yet clinicians dealing with diabetic foot ulcers find that even with fast-healing ulcers, the underlying chronic condition frequently causes repeated breakdown of the same wounds or the appearance of new wounds in other areas of the feet and legs. A harsh reality at many for-profit wound centers is the termination of treatment before achieving closure of an ulcer to keep wound closure statistics competitive. One of these for-profit centers had discharged Ms. T as soon as it became apparent that her wound-healing time would extend beyond their longest statistic.
True to the message of Sister Roy, the authors’ clinic is committed to its patients regardless of how long it takes to heal their wounds. Sometimes goals have to be adjusted and patients and clinicians must be resigned to the inevitability of a non-healing wound. The goal might be to keep the wound as stable as possible, mobilized, and free of infection, using treatments that maximize the quality of the patient’s life. This does not mean that new strategies, different clinician consultants, or additional referrals will not be sought. The mission of the authors’ clinic is to provide the highest quality of care possible while keeping patients informed of all options and respecting their care choices.
Total contact casting afforded Ms. T’s clinicians some measure of control of her wound, keeping all the variables constant and the pressure off to facilitate accurate assessment of each local wound treatment. Consideration of the whole patient and understanding the interactions, the ebb and flow that is ongoing among the focal, contextual, and residual stimuli as in Roy’s model, is key to treating any patient, especially those with complex conditions such as diabetes mellitus