Diabetes is a metabolic disease that also involves the peripheral nervous system. Living with high blood sugar over a period of years puts the body at risk for permanent organ damage.

One of the risks associated with diabetes is arteriosclerosis of the blood vessels, which also carries with it an increased risk for cardiovascular disease.

High blood sugar levels may affect the blood vessels in the eye, thus increasing the risk of haemorrhage and blood clots damaging the eye. In the past, diabetes used to be a common cause for blindness, but thanks to modern treatments this is rarely seen nowadays. The loss of sensibility in the hands in combination with retinopathy is especially debilitating since this may significantly decrease the patient’s ability to read Braille with their fingers.

The kidneys contain a vast number of tiny blood vessels which may be afflicted by arteriosclerosis, hence impairing the kidney’s ability to filter blood. Currently, approximately one-fifth of Swedish kidney transplant and dialysis patients have diabetes.

Impaired sensation in the foot increases the risk of skin ulceration since the patient loses protective sensation and can easily injure the skin. Diabetes may also cause damage to the feet due to restricted blood circulation in both large and small blood vessels, as well as blood circulation being impaired in both large and small blood vessels, as well as due to the impairing of the nerve function, which affects the sense of touch. With a reduced sense of touch one may easily step on sharp objects or walk with sand in the shoes without even noticing. This may lead to diabetic ulcers which, due to the impaired blood circulation, may take a long time to heal.

There is also a tisk that the muscles in the feet become weakened, which may cause the feet to be deformed. Over time, the foot load will also change, increasing the risk of abrasions. According to Stig Attvall, senior lecturer at the Diabetes Center, Sahlgrenska University hospital, damage to foot nerves, so-called peripheral sensory neuropathy, is seen in approximately 70-100% of diabetes patients with diabetic ulcers.

In cases of excessive diabetic ulcers, it is common for the foot to be completely or partially amputated. Diabetics today make up a vast portion of foot amputees worldwide. The risk of a diabetic developing diabetic ulcers during his/her lifetime amounts to approximately 25%. In the United States, an estimated 1.5 million diabetes-related ulcers are treated each year7, in addition to the 65,700 foot amputations carried out each year8.

In Europe, an estimated 1–1.4 million diabetics are afflicted by diabetic ulcers9. The vast number of diabetic ulcers and the related amputations (where applicable) could be substantially reduced if  treatment efforts were implemented earlier.

It should also be emphasized that the nerves in the arms and hands nerves may be affected by diabetes, which increases the risk of nerve entrapment (so-called carpal tunnel syndrome). Carpal Tunnel Syndrome (CTS) is more common on diabetes patients compared with the healthy population. Early detection is important since surgical treatment carries a good prognosis, and often leads to considerably improved sensibility in the hand.

For the foot, assessment of the protective sensation is essential for evaluation of the risk for skin ulceration. Being able to detect diminished protective sensation at an early stage reduces the risk for time-consuming medical foot ulcer care and amputations.

Today's methods for routine assessment of sensation in the hand and foot are primitive and not sufficiently standardised. For investigation of foot sensibility, tuning forks or a biothesiometer, working within one frequency band, are usually used. Both precision and accuracy are very low for that type of device. In fact, methods which only assess vibration sense within one frequency have proven quite insufficient for reliable results.

6, Volume 27, Number 2, 2009 • CliniCal Diabetes, A review of the Pathophysiology, classification, and treatment of foot ulcers in Diabetic Patients, Warren Clayton, Jr., MD, and Tom A. Elasy, MD, MPH

7, US Advanced Wound Market, Frost & Sullivan August 2010
9.J Wound Care 18 (4): 154, 2009