DIABETIC FOOT ULCERATION AND QUALITY OF LIFE: STUDIES THAT EMPLOYED GENERIC APPROACH Studies into the effects of foot ulceration on patients’ physical functioning, psychosocial func- tioning and QoL have made clear that foot ulcers can be a source of severe disability, which in turn has a negative impact on QoL.
One of the first studies in this area was conducted in Manchester, United Kingdom, by Carrington and associates.36 Using a battery of self-report psychological instruments, the investigators have compared the psychological status among diabetic people with chronic foot ulcers, unilateral lower limb amputations and diabetic control subjects with no history of foot ulceration.
Psychological assessment included the Psychosocial Adjustment to Illness Scale, the Hospital Anxiety and Depression Scale, a foot questionnaire specifically designed to assess the attitudes and feelings diabetic persons have towards their feet and a QoL ladder.
The study reported that patients with both chronic foot ulcers and unilateral amputations had poorer psychosocial adjustment to diabetes than did the control subjects.
Specifically, these
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two groups had made significantly poorer psychosocial adjustments to their situations in the domains of domestic and social environment and reported poorer overall QoL.
In addition, foot ulcer patients reported significant problems with their employment and more psychological stress than did the control subjects.
Interestingly, no significant differences in psychosocial adjustment were observed between the ulcer and the amputee groups.
This could, in part, be due to patient selection bias as pointed out by the authors of this paper: while all subjects with foot ulceration had recurrent, non-healing foot ulcers of at least 3 months duration, all but one of the amputee patients had a below-knee amputation and were mobile with no ulcers on the remaining foot at the time of the interview.
It was therefore concluded that future studies should include patients with varying amputation levels, i.e. minor (e.g. toe) and major (below knee/above knee), and varying duration of foot ulceration.
A study from Sweden by Ragnarson Tennvall and Apelqvist did exactly that by comparing the health status in 457 diabetes patients with current foot ulcers, to those with primary healed ulcers, and those who had undergone minor or major amputations.30 The researchers used a 5-item generic measure of health status, the EQ-5D.
Each item in this instrument assesses separate health-related dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression with the response choice of no problems, some problems and severe prob- lems.
A single numeric index of health status was then generated from the five dimensions.
In addition, this instrument contains a visual analogue scale (VAS) where patients are asked to rate their present health on a scale from 0 to 100.
The results of this study demonstrated that subjects with current ulcers had lower health status than both patients who had healed primarily without any amputation and those who had undergone a minor amputation.
Patients who had undergone a major amputation had poorer health status than both patients who healed primar- ily and patients who had undergone a minor amputation.
Interestingly, this study also failed to demonstrate significant differences between the current foot ulcer and major amputation groups, as did the study by Carrington and colleagues.
This could indicate that (a) either the two groups do not differ in terms of their health status, or (b) the generic questionnaires are not sensitive enough to pick up more subtle differences that exist between these groups of patients.
The results of the following reports cast further doubt as to the appropriateness of generic questionnaires when examining the health status of patients with foot ulceration, especially in the domain of mental functioning.
A study by Meijer et al., using the SF-36, compared the health status and mobility between diabetic patients with either past or present foot ulceration and diabetic individuals without a history of foot ulcers.37 The results of the study demonstrated that the presence or history of foot ulceration had a negative impact on physical (physical role, physical functioning and mobility) but not mental functioning.
Similar results were obtained by Ahroni et al., who demonstrated prospectively that the development of neuropathic com- plications including foot ulceration and amputation was associated with a decline in four out of eight SF-36 scales representing physical functioning (general health, physical functioning, physical role and vitality).38 In contrast, a recent study, which compared the performance of the generic SF-12 and a neuropathy and foot-ulcer-specific questionnaire, the Neuropathy and Foot-Ulcer-Specific Quality of Life instrument (NeuroQoL; described below), demon- strated that while the mental functioning scale from the SF-12 was not associated with foot ulcer presence, a foot-problem-specific emotional burden scale from the NeuroQoL showed a strong association with the presence of foot ulceration and was the most important link between foot ulceration and reduced QoL.39 These findings point to the importance of using condition-specific questionnaires when studying the effects of foot ulceration on individual’s health status and QoL.
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140 PSYCHOLOGICAL AND BEHAVIOURAL ISSUES IN DIABETIC FOOT ULCERATION
DIABETIC FOOT ULCERATION AND QUALITY OF LIFE: ADDRESSING THE PATIENT’S PERSPECTIVE The studies described above used generic questionnaires, the content of which was imposed by the investigators and did not emerge from patients affected by foot ulcers.
Thus, the findings from these studies left a gap between foot ulceration as abstractly defined and the patient’s ex- perience of foot ulceration that is essential for framing effective interventions.
It is increasingly recognised that QoL, rather than being a mere rating of health status, is actually a uniquely personal experience, representing the way that individuals perceive and react to their health status.40 This recognition emphasises the importance of addressing the patient’s perspective rather than the researcher’s views when measuring QoL.
In an attempt to overcome these shortcomings, several questionnaires assessing QoL from the perspective of an individual af- fected by foot ulceration were recently developed.
Examples include the Diabetic Foot Ulcer Scale (DFS)41 and the NeuroQoL.39 A series of interviews with foot ulcer patients and their caregivers were conducted to elicit life domains affected by foot ulceration that are important to an individual’s QoL.
These interviews demonstrated that the loss of mobility caused by non- weight-bearing treatment is central to foot ulcer experience.
It results in severe restrictions in activities of daily living, including daily tasks, leisure activities and employment.
Brod, for example, reported that approximately half of the interviewed patients had either retired early or lost time from work, and career opportunities were sometimes missed.42 Moreover, limited mobility causes problems with social and interpersonal relationships and perceptions of diminished value of the self due to inability to perform social and family roles.
A recent study employed the NeuroQoL to investigate the impact of diabetic neuropa- thy (symptoms and foot ulceration) on QoL.39 Findings from this investigation were largely consistent with the main themes that have emerged from prior qualitative studies.
Patients experiencing neuropathic symptoms (pain, lost or reduced feeling in the feet and unsteadiness) and foot ulcers reported severe restrictions in daily activities (e.g. leisure, paid work and daily tasks), problems with interpersonal relationships and changes in self-perception (e.g. being treated differently from other people).
This study demonstrated that among the psychosocial variables, changes in self-perception as a result of foot complications have most devastating effects on an individual’s QoL.
In summary, diabetic foot ulceration is a source of severe physical dysfunction, emotional distress and poor QoL.
While foot ulceration is not predictive of depressive symptoms, it is a source of ulcer-specific emotional responses, which either facilitate (fear of potential consequences) or inhibit (anger at health care providers) preventive foot self-care actions.
Patients respond to diabetic foot complications by creating their own models or understanding about this medical disorder, which is largely inconsistent with the practitioner’s view (the biomedical view), resulting in a lack of foot self-care.
The health care provider’s ability to understand and share the patients’ common sense perspective is therefore central to effective health care provider, patient communication and should potentially lead to better foot self-care and fewer foot ulcers and amputations.