Teaching Independence

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June 2003

By Laura Durgin, PT

Laura Durgin, PT, reviews skin care and positioning with a patient following amputation.

Diabetes is one of the most prevalent and expensive health care problems Americans face. Sixteen million people are at risk for, or already suffer from, the many complications of this disease, including limb amputation, heart disease, vision difficulties, renal failure, and gastroparesis. Although patients are not admitted to rehabilitation settings for control of the primary disease, we often treat these patients when the secondary complications cause severe impairments, as is the case with lower limb amputations.

Sixty percent of all amputations of the lower extremities are performed on patients with diabetes. Although this is a traumatic, life-altering event, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years, even with successful healing of the primary amputation site.¹ Among individuals with foot lesions, 54% respond to conservative treatment of antibiotics and proper wound care; 14%, however, will require immediate amputation.² In some cases, primary surgical intervention may include incision and drainage of the infected area. In this situation, the physician may recommend a non-weight bearing (NWB) status for the patient, to decrease stress on the limb and promote healing. This recommendation is often for several months, and, despite the risk of amputation, family and employment obligations may supersede a patient’s adherence. A physical therapist may train the patient in using crutches or a walker for functional mobility while remaining NWB. Specialized footwear that shifts weight to different areas of the foot is frequently prescribed. Despite these interventions, patients often will continue to walk on insensate, ulcerated feet.

EDUCATION CHALLENGES

Since it is well documented that patients with diabetes benefit from education programs to assist in self-management to reduce the risk of complications, rehab professionals have included diabetes education programs in comprehensive treatment plans for years.3-5 Through these programs, we know we must ask, “Why are patients presenting to rehabilitation hospitals with diabetes-related complications and, often, very little knowledge of how to manage their disease?” Funnell and Anderson identified the challenge of providing education to patients with diabetes in our current health care system. We have a system designed to manage acute illness, with little time allotted to teach prevention and daily management of chronic conditions.6

Despite these shortcomings, we need to look more closely at how we educate patients. Self-management of diabetes can be complicated and overwhelming, and loss of a limb is devastating and life-altering. An advantage to inpatient rehabilitation is the team approach. Patients express goals for rehabilitation, and members of the team can focus on functional outcomes that incorporate those goals. Creating an environment that is conducive to learning and listening, such as eliminating visual and auditory distractions, will help patients absorb information.7 It is important to identify the patient’s learning style for optimal carryover of information. Multiple modes of teaching can be utilized including discussions, question and answer sessions, demonstrations, handouts, videos, and lectures.

A COMPREHENSIVE METHOD

Clinicians at Spaulding Rehabilitation Hospital in Boston incorporate an interdisciplinary education approach to treatment. Education for patients with diabetes-related amputations might include such topics as positioning, strengthening, skin inspection, adherence to dietary restrictions, and monitoring of blood glucose. To monitor education on an individual basis, each clinician enters data into an education flow sheet related to the daily session. This includes topic and content, whether the family also received instruction, the learner’s readiness to participate in training, method of teaching, and outcome of the session. With the flow sheet, we are able to identify patterns of participation and barriers to learning, and later modify the treatment plan if necessary. This comprehensive look at the way patients learn and retain information ensures better success after discharge.

Self-management of diabetes involves active participation, responsibility, and accountability. Patients must be able to make sound judgments regarding immediate responses to situations, as in the potential for hypoglycemia or hyperglycemia. Also, they must understand the long-term consequences of decisions, as in failure to adhere to a positioning program for residual limb care. Encourage patients to take the initiative and play an active role in the rehabilitation process. When educating patients, make sure to ask open-ended questions to confirm comprehension. Instead of asking, “Do you know your exercise program?” ask the patient, “Why is it important to lie in a prone position daily?” Encouraging patients to problem solve by providing scenarios for discussion is also helpful. “What would you do if you noticed that you had an opening on the end of your residual limb?” as opposed to “Did you check your skin today?” will produce better carryover and independence.

Table 1. Sample evaluation chart for assessment of patient education.

FAMILY HELP AND FOLLOW-UP

It is also important to consider the benefits of supportive family members and friends. Daily skin inspection is imperative to avoid skin breakdown and infections, yet the patient may not be independent in monitoring for several reasons. Sensation may not be a reliable indicator due to neuropathy, and diabetic retinopathy may interfere with the ability to adequately inspect the skin. In this case, patients may involve a family member or friend to assist with skin inspection. It is important to educate all those who will inspect the skin, ensuring that everyone can recognize complications and know when medical attention is necessary.

Follow-up is a key in determining if retention has actually occurred. At Spaulding, patients are scheduled for a 4-week follow-up with the prosthetic clinic after discharge. A multidisciplinary team—physiatrist, prosthetist, and physical therapist—monitors prosthesis use and residual limb care, and records the patient’s report on exercise program, prosthesis use, and functional mobility. We have found that many patients return for this appointment able to independently manage their prostheses and diabetes.

Diabetes is a widespread disease with complications that tax our health care resources and endanger the lives of those it affects. Although we may not see those patients until they are somewhat affected by the complications, we should take every measure to ensure that patients have the tools to manage their conditions independently and consistently.

Laura Durgin, PT, is senior physical therapist, Amputee/Vascular Program, at Spaulding Rehabilitation Hospital in Boston. References

Meltzer DD, Pels S, Payne WG, et al. Decreasing amputation rates in patients with diabetes mellitus: an outcome study. J Am Podiatr Med Assoc. 2002;92:425-8.
Pittet D, Wyssa B, Herter-Clavel C, Kursteiner K, Vaucher J, Lew PD. Outcome of diabetic foot infections treated conservatively: a retrospective cohort study with long term follow-up. Arch Intern Med. 1999;159:851-856.
Krook A, Holm I, Pettersson S, Wallberg-Henriksson H. Reduction of risk factors following lifestyle modification programme in subjects with type 2 (non-insulin dependent) diabetes mellitus. Clin Physiol Funct Imaging. 2003;23:21.
How do we teach four million diabetics? Am J Nurs. 1965;65(11):105-107.
New tools for diabetic instruction. J Maine Med Assoc. 1965;56(9):206-7.
Funnell MM, Anderson RM. Working toward the next generation of diabetes self-management education. Am J Prev Med. 2002;22(4 suppl):3-5.
Shafir RZ. The Zen of Listening: Mindful Communication in the Age of Distraction. Wheaton, Ill: Quest Books; 2000.

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June 2003