THE POWER OF BALANCE

by Dr. Kenneth B. Rehm, DPM

Dr. Kenneth Rehm, a podiatrist and diabetic foot care specialist, delivered the following as the keynote address, at the annual seminar of the Diabetes Action Network, held July 4, 2005, in Louisville, Kentucky, at the annual convention of the National Federation of the Blind.

I had a heck of a year this year. I had hip replacement surgery, and I was forced to hang around my house recuperating. Well, for those of us who are used to being workaholics and busy all the time, you start to feel like a caged animal while at the same time feeling that your body chemistry is off balance. The anesthesia and the surgical stress surely take a toll on a person for quite a while. You know your physiology is off when you feel tired, sluggish, and paradoxically, at the same time "antsy."

At any rate, when you get a chance to stay home like that, you do a lot of thinking. I am sure we've all had occasion to do just that.

Anyway, throughout my homebound status, I was thinking about health in general, and I came to the realization that health depends on the power of balance. Because I'm a podiatrist, biomechanics, physical and physiologic balance have always meant a lot to me; but, what about the power of balance in one's lifestyle? That is, social and psychological balance? I had an epiphany that balance in life allows for clarity of thought and control of emotions and the ability to reframe life's circumstances. This balance of mind and clarity in one's life allows one to deal with life's challenging situations in a non-impulsive organized way. When something positive is accomplished, this serves as a reward, of sorts, and lends to a feeling of positive reinforcement; much like the feeling of checking off tasks from your to-do list.

Life is not so confusing; you feel you are moving in a direction created by you. Once life is lived with clarity and balance, the feeling of control over your life, your health and your health challenges takes life in a new direction! A person could see the forest through the trees. They can see where they are going in life and figure out a strategy to get there. What's the old saying, if you don't know where you're going, you won't know when you get there?

Simply said, the power of balance in life gives you balance of thought, emotion, and clarity, with the net result of feeling control over your life, AND over your disease process. These feelings are very motivating and powerful, and serve as a feeding ground for creativity, living in the moment and on purpose!

Experts say this creates one of the healthiest states of mind we could have. That is: the power of control over yourself, over your disease, over your life. This allows for a lightness of being, a creative spirit, a caring about those things in life you thought were not as important as you and your disease, enjoying and appreciating the everyday simplicities of life and those things you used to enjoy, a passion for and about life, compassion for others, and the energy and motivation to deal with what life gives us.

This motivation leads us to the tools we need to thrive, not just survive. We take self control, we become assertive, we become aggressive, and these words are borne: "Okay life, what do I have to do now? What ever it is, I'm ready for it. I'm going to do it." SO WHAT..NOW WHAT?

That's what makes us healthy, that feeling -- feeling metabolically good; your body's in balance, you're not tired, you're not weak, you re not cold, you're not shaky, you're not anxious or depressed, and you have the ability to re-frame what happens to you. This puts you in the moment and on purpose. You're not thinking about something in the past, or dreading something in the future, and your actions are determined by what your logic and your motivation tell you. You're not acting out of impulse or compulsion, or any other destructive emotion. This re-born state of mind affects the whole body: the joints, the nerves, the arteries, the bones, the veins, and most importantly, what I'm going to be talking about -- the feet.

Remember, the feet have joints, nerves, ligaments, veins, arteries, and bones. For your general health, you need them all to be in good shape. You need to achieve balance. Here's a useful concept I call D.O. A. P.E.A.R. That's an acronym. A healthy symbolism as well, because eating a pear is one of the healthiest things we could eat. What does DO A PEAR stand for?

D stands for balanced diet,
O stands for balance in occupation,
A stands for balance in activities and recreation,
P stands for balance in posture,
E stands for balance in exercise and physical conditioning,
A stands for a balance in attitude and mental conditioning,
R stands for balanced nourishing relationships.

OK, now you have my message: D.O. A. P.E.A.R. -- every single day!

Let's go into a little more detail.

DIET

Of course you all know about diet. And they're discovering the importance of the right kind of fiber in foods we eat. We are finding out how the lack of fiber in our foods can be detrimental. Increased fiber can actually lower some of the detrimental effects that carbohydrates can have on our body. Increasing one's intake of fiber can have a positive effect on gastrointestinal tract, blood sugar, and the level of damaging inflammation in the body. Researchers are finding out that inflammation is really part of the cause of diabetes, arthritis, and heart disease. The link is being researched right now.

Pay attention to the right diet for you, including the right kinds and amounts of carbohydrates, proteins and fats. We all need all three of these.

OCCUPATION

We can become very stressed in our occupations, and these stresses we undergo can cause us to build up stress hormones. These stress hormones affect our blood sugar, our diabetes, our mental facility and the way we think, the way we feel, and the way we act and react. We have the power to control all this.

ACTIVITIES

I guess what I am saying here is that balancing your career activities with other activities, such as parenting, chores and recreation, is essential.

We need recreation, where we can play, and where we just do things for fun. Not to go out compulsively drinking or whatever, but just to have real fun, with family members and friends. This all affects your health, your diabetes, and of course your feet, which we will eventually cover here.

In addition, one of the most important activities we can pursue is one of self education, which includes reading about your condition and being assertive enough to ask questions of your doctor. This gives us the healthy feeling of control.

POSTURE

I've always been a big advocate of proper posture, but I never really internalized the importance of posture, until I had my hip surgery. My new hip, and the development of arthritis that led to my surgery, produced atrophy in some of my muscles, and I was limping. Some muscles were accommodating, and going into spasm, and some muscles were becoming weaker; my posture was changed, I was limping, and I was putting physical pressure and stress where it wasn't supposed to be. I was all out of balance!

I had always felt postural balance was important, but I was living a personal lesson on how important it is.

And then I had a new hip put in, and I started doing physical therapy, building up the muscles. This feeling of having good posture again, in my feet, my ankles, my knees, my hip, my neck, and my back, created energy in me. I didn't feel "dragged out" any more. Does anyone have that experience where you're in good posture, and you automatically feel good, and you feel like going out to work, and make money, and doing all kinds of projects and being creative? I call that creative energy. Good posture can give you that experience.

If your muscles have been affected by diabetes, then you may relate to this. Proper structure and alignment of the neck, shoulders, back, hip, legs, ankles and feet are essential to good posture; and in diabetes, it is particularly important in protecting your feet from the ravages of diabetic neuropathy.

EXERCISE

Exercise; don't be couch potatoes; get out there and move. I see, in my practice, lots of people who are ninety, a hundred, some times even over a hundred, and the one thing that keeps them young, my friends, is movement. They move their bodies and their joints in a regular and consistent manner. They don't have to run marathons! They don't have to be at the gym every day. They just make it a point to move every day. They move around, they move their joints, they sweep the floor they, vacuum the rug, they walk the dog, they take the stairs. Healthy people keep on moving. Moving those joints and muscles is so important. So folks, my advice to you is to turn everyday activities into opportunities for movement and exercise! Like I said, you don't have to go to the gym; you could do things, like take the stairs or walk the dog, and have a regular and consistent way of getting exercise.

Foot exercises are done with the special Diabeti-Cream massage program and with the special Foot-Log.

ATTITUDE

We have been speaking of attitude this whole presentation, because without the proper attitude and the emotions that support it, we will not have the strength to do everything else we need to do to stay healthy, the very things we have been talking about. A healthy attitude has to be number one. It is behind everything positive we do.

In a nutshell, to recap what is important about attitude, it's important to acknowledge you have a condition that may lead to unhealthy complications. We need to be creative enough to develop the ability to re-frame our negative circumstances. That is, having the ability to put whatever happens to us into a different context, a context that works for us. A lot of you have probably done this with your eyesight challenges. This is what the psychologists are always trying to teach us: to be able to re-frame, and sometimes, it's just as simple as teaching our brains, and getting into the habit of re-framing. It is not easy to do, but can be a simple concept. Once, the circumstances are looked at in a new light, with a fresh perspective, the healthy positive emotions flourish! We are no longer in denial about our diabetes or complications, we like ourselves again, we want to take care of ourselves and are ready to take on the world.

Re-framing circumstances allows humor to come into your life. Laughter produces those healing juices so important in the body. I have noticed that in diabetes, depression, anxiety and the uncontrolled blood sugar that sometimes is sometimes goes along with those unhealthy feelings actually compound the pain and the agony of the neuropathy and make it worse! People who get neuropathy, and then get upset and depressed about it, have more of it. What happens is, when they get upset over neuropathy, this increases the level of pain they have. Pain fibers in the brain are very near the depression fibers and so depression can cause increased pain and increased pain can cause depression.

When you have pain, try to focus away from the pain and re-frame your circumstances. Don't feel sorry for yourself and get deeper into the pain and depression. You will gain when you re-frame the pain.

RELATIONSHIPS

The important thing here is that we can't do it alone! Having a supportive family and friends is not only of practical importance, but nourishing relationships are proven to be physiologically helpful as well. Even having a pet can be a very healthy experience. And we all know a good hug every day helps. I have been to nursing homes where residents have literally not been touched, except by a nurse or a doctor, for years. The human touch is so important to good health.

Keeping all this in mind, it is now time to talk about how these things affect the feet in diabetes. The goals are to prevent amputation and keep the feet healthy so the person can stay active and maintain the ability to walk and enjoy their normal activities. I know, personally what it's like to have to sit on the couch and watch TV, and not be able to get up, not be able to walk or drive a car. It's so hard to have to be dependent. So, I like to keep people's feet healthy, because that's what keeps a person independent, mobile and in control of their life. They are able to feel like a person.

And so, I've developed the Keep Your Feet ... Healthy TM program. It's a lower extremity amputation prevention program.

Number 1: Keep your feet clean. As a matter of fact, I developed a special foot soap shampoo that is low PH, and does not destroy the protective layer of the skin. We find that if a diabetic is able to protect the acid mantle protective layer of the skin, they will be less likely to have foot problems. There's a protective layer of acid on the skin that, when destroyed, it is theorized, the skin could break down easier, and so these foot soaps have a lower PH than the commercial soaps. People like to soak in it, or use the "Soapy Soles," my little foot-shaped pads that you use in the bath, so you don't have to reach down and clean your feet. They fill the "Soapy Soles," and use it in the bath or shower to clean the feet and enjoy those little massage acupressure knobs.

Number 2: Keep your feet warm. I see people going around without shoes and socks. This leaves the feet unprotected, but it also allows the feet to become cold. When the feet are cold, the tiny blood vessels go into spasm, and this decreases the blood flow. Then, a lot of people who have cold feet put their feet near something hot, like a fire, and because a lot of people with diabetes lose feeling in their feet, they wind up burning their feet, causing blisters, ulcerations, infections, gangrene and amputations.

How many people in here are diabetic? Quite a few, I see. And how many suffer from neuropathy? Again, there are many of you. So, keep your feet warm, but don't keep them hot, don't put them by the fire. You have to be very careful.

Number 3: Keep your feet protected, with good shoes and good socks. Medicare allows special shoes made for the diabetic and arch support inserts to go into the shoes, because it is proven good shoes and arch support protect the feet, and reduce the likelihood of amputation. Medicare will pay for 80 percent and then the 20 percent co-pay could be picked up by Medicaid, Medi-Cal or your secondary coverage.

Number 4: Keep your feet safe. Don't put your feet in the face of danger or risk. For instance, don't mow your lawn barefoot, and don't warm your feet in front of a fire.

Number 5: Keep your feet conditioned, which means if they're too dry, use a foot cream specially formulated for use by people who have diabetes. I formulated, designed and manufacture a special diabetic foot-conditioning cream that is made to work in concert with the shampoo and toenail/skin debrider. These special products I formulated and produced are designed to work together as a program to enhance the effectiveness of the foot protecting process: 1) Clean the skin with the ph-sensitive shampoo; 2) Debride the fungus and bacterial from the skin and nails and cuticles with ToesEase Oil and; 3) Condition the skin to put essential moisture back into the skin, prevent it from leaving, and make the skin more resilient. The foot cream is a low-friction cream that allows for a good foot massage. This is an excellent way to provide needed exercise of the foot joints. Exercising the foot with the Foot-Log foot roller is an excellent way to exercise the small joints of the feet. STIFF SKIN AND STIFF JOINTS ARE BAD!

Number 6: Keep you feet free from excess moisture. Some people sweat too much, possibly because of autonomic neuropathy from diabetes. This can cause an environment that can predispose to fungal and bacterial infections.

Under certain circumstances, Medicare pays for this foot care. You have to be diabetic, and you have to have neuropathy and all that kind of stuff.

Number 7: Keep your toenails healthy and trimmed. Toenail fungus is very common. There are ways to keep the fungus under control, and the cuticle supple and healthy. Keep your toe nails trimmed and healthy. I'd like you to see you go to a professional, a podiatrist if you can, because there are certain ways you need to cut your nails, and certain areas surrounding your toenail you need to cut, like the callus nail groove, and you need to shave down that top layer of dry thick scaly nail.

Number 8: Keep your calluses trimmed. The thick callus that can build up can actually be a source of abnormal pressure on the skin, and can be responsible for ulceration and infection.

Number 9: Keep your feet working with exercise. To help you do that, we recommend a foot rolling device called a Foot-Log that is designed to exercise and stretch the small joints of the feet. Another good way of exercising the feet is with a low-friction massage, such as that which is accomplished with Diabeti-Cream.

Stiff skin and stiff bones are bad, because when the foot is stiff, it doesn't properly absorb the pressures and shock of the pounding, rubbing, or tearing when the foot moves during walking. Do you see how all this is tying in with good shoes, with orthotic inserts or arch supports, with foot cream to soften the skin, so it can be supple and amendable to the pressures inside the shoe? Are you understanding the concepts? A nice, soft, supple, workable foot that can get out of the way, if it has to, with protective, reactive movement; and can move with the terrain, one that's not stiff, or too dry.

Number 10: Keep your feet balanced. Some people's feet hit the ground tilted, and, to compensate, they have to move and wiggle their feet all over, and when they wiggle their feet to regain their balance, their toes grab, and their knees yank, and their hips ouch, and their backs tilt. You have to be in balance, and it starts with your feet. Imbalance occurs as the foot hits the ground. To create balance, we have to keep the foot aligned as it hits the ground. We have to intercept the foot as it hits the ground. The only way we know how to do that is with appropriate fitted shoes and orthotic inserts within the shoes.

Number 11: Maximize your circulation. Maximizing blood flow means delivering as much oxygen to the tissues that need it as possible. That is done by: 1) keeping your heart and arteries healthy by exercise, timely check-ups and vascular testing, appropriate diet and medications if needed, the strict avoidance of tobacco and second-hand smoke and; 2) keeping your legs elevated, avoiding a lot of the swelling called edema; 3) wearing the proper support hose and; 4) avoiding elastic bands that are too tight around the ankle.

Number 12: Keep your feet in check. Inspect your feet daily or have someone at your home inspect your feet every single day, by feeling and looking at them. You may need a mirror if you are doing the inspection yourself. Also, get your feet checked at least once a year by your foot healthcare professional if there is no neurological or circulation problem. If there is a problem, having your feet checked more often is indicated. This may be done by a podiatrist, primary-care physician, endocrinologist, nurse or nurse practitioner, physical therapist or a physician's assistant. These must be a foot healthcare professionals, and must have expertise in the field of diabetic foot and wound care.

Medicare pays for diabetic foot care in certain circumstances. They always pay for the initial visit, but follow-up care is contingent upon the patient having a podiatric problem, having neuropathy and/or circulation problems. Please don't be confused; Medicare pays for diabetic foot care, if these criteria are met, every nine weeks. That's for the routine preventive care; but if there was something wrong, like a fracture, infection, or an in-grown nail, you can go as often as you need.

I heard a question, about use of the product Bag Balm on the feet? Is it appropriate to use on the feet? Bag Balm, originally for sore cows, is supposed to be very good, but the formulas are not designed specifically for the diabetic foot. I make a diabetic foot cream, and I call it a super conditioner. It adds moisture to the skin, prevents moisture from leaving, and makes the foot more resilient. It's non-friction rub; it is very penetrative, and you can exercise with the foot; it penetrates, and you can you can massage the foot with it. It's a good massage; it has very little friction to it. I add some pain- relieving and anti-inflammatory elements, as a lot of the foot creams do.

Some of the conditioners, like Bag Balm, do a good job of keeping the moisture in, as Vaseline does. We used to use nothing but Vaseline; but now the science of skin care has grown, and the technology has become so sophisticated, we are really able to do a lot more for the skin problems associated with the diabetic foot.

What about diabetic neuropathy, which so often (but not always) manifests as pain in your feet? What is neuropathy? Neuropathy, neuro-pathy, neuro = nerve, and pathy = problem; neuropathy = some thing wrong with the nerve; what's wrong with the nerve? Some people think it's an inflammation of the nerve, some people think the covering of the nerve is altered, and some people think the circulation of the nerve is affected, and probably all three are true. But any time you have pain, pain is delivered though what? The nerve. And, neuropathy can take so many different forms.

I see so many people with this type of problem, it's become pretty simple for me, and I see it in simple terms: The way you walk puts pressure on certain nerves. When you have diabetic neuropathy, the nerves are more sensitive, because of the neuropathy, and walking right on these nerves creates a slight damage on the nerve. This creates the pain you feel, and usually a flattening of the arch happens then, throughout the foot.

Now something could be pinching the nerve, like a muscle. You could be walking on a nerve, in which case you're walking tilted, so you need a good arch support. That's why we say to keep your feet in balance. Those shoes protect you from the pressure.

There are three types of pressure we must deal with when walking: Direct pounding pressure, rubbing pressure, and tearing pressure. Picture your foot on the floor, staying still, but the foot is sliding inside the shoe. That is shearing or tearing pressure. A good shoe, with an arch support, helps to prevent that. These are the damaging forces that take place in your feet. So, if you have a foot affected by diabetes, protect yourself from these damaging influences.

Here Begins The Informal Discussion And Question/Answer Part of Dr. Rehm's Presentation

What are the principles you have to follow, every day, to keep your feet healthy?

First of all, you have to acknowledge the fact you have diabetes, so your feet are at risk. Some people are in denial about this. Educate yourself about the foot and things that affect the feet.

Inspect your feet daily. Look for open areas, cuts, bruises, ulcerations, corns, calluses, red areas, warm areas, discolorations or anything out of the ordinary.

Some people with diabetes have other medical conditions that alter the presentation of certain problems. For instance:
Some people with diabetes have thyroid conditions. Should they be concerned? Do such conditions affect the feet? Yes. A lot of people with thyroid problems get severely dry skin, and thick callus build up, as diabetics do, and you have to pay very close attention to the skin.

What is a "good" diabetic shoe? What are the criteria for choosing good shoes?

The very first thing I would do is find somebody who knows how to fit the shoes. You really have to depend on professional advice, here. Somebody who does not know about feet and shoes could miss a lot of the things that are important in fitting shoes. So what is important? The toe box has to be round and high; put your hands on the ends of your feet, and that's the toe box. A lot of people wear pointed shoes, but I like the rounded shoe, and I like that toe box high, allowing a lot of room for your big toe.

Next, the heel height should not be too high, and not too low; about an inch and a half, two inches at the most is a perfect sized heel. That puts the foot in a good position for going forth, for going forth through what we call the walking cycle. It also adds shock absorption at the phase of walking called heel strike.

You need a good heel counter, and good heel height. The heel counter is right above the heel; if you put your hands right around the heel, you can feel the leather that surrounds the heel. This is called the counter, and it has to be more or less ridged and supportive. Those of you who have good sneakers on, will see there's a part of the heel counter that is ridged and supportive.

And the shoe has to have a nice high vamp, one that doesn't cut into your feet. That's the part the shoe laces fit into, the vamp. It should have a nice protective tongue underneath it.

The base of the shoe, the sole of the shoe, has to keep the metatarsals stable, and has to bend right before the metatarsals; not be too flimsy in other words, and then the shoe has to be made of a good solid leather material, as opposed to a vinyl. There are some canvas and other substitute materials that are good, but basic rule of thumb is stick to a basic leather shoe.
Where can you find them?

There's a lot of places, and you can find many of them on line. My site, www.thediabeticfoot.com is a place for resources, and could help you find some of these places.

Brand names? I was asked about Birkenstocks. They tend to have a negative heel, but when they're made to the arch, when they have an arch support inside of them, and some Birkenstocks do, we'll actually make the foot platform into an orthotic shoe for you. That's the best kind. Birkenstocks are good when the platform is custom made for you. Otherwise they tend to have a low heel. Let's see, did I finish the shoes?

You could picture this type of shoe I've been talking about: A good sneaker or an oxford type shoe that has good movement in the sole and is supportive. You don't need to spend $500 to have a healthy shoe.

Did I have some other questions?

I have a problem with my left foot. Every time I get shoes, I wear out on the outside of the heel instead of on the level. It's only on the left side. I don't know why. I don't know if it's the foot, or my shoes. Why does this happen?

This is an absolutely great question. Somebody comes into my office, and I explain to them why they need orthotics. Does everybody know what an orthotic is for the shoe? It's an arch support made to your foot -- that's an orthotic. An orthotic is meant to alleviate some of the problems in movement of the foot. Orthotics hold the foot stable, as opposed to an arch support that just supports your arch when you're standing. That's all arch support means; but an orthotic is made to help your foot move throughout what we call the gait cycle, or the walking cycle. And so I tell the patient who's in front of me: "You know, when mother nature designed the foot, she didn't know, she forgot to put a man on the phone that day, because man would have said, 'I'm making all the ground flat,' and mother said: 'Oh no, I'm making the foot to go with sand and grass and exercise.'"

So, we have all this flat cement man had created, and we're all walking with different angles, we're hitting the ground with different angles, because our foot is attached to our ankle, and our ankle is attached to our leg, and our leg is attached to our knee, and everything has it's own angle, and we hit the ground with all these angles. And so, when we hit the ground with the foot, we're shearing the foot to get to the ground, and the idea of an arch support is to bring the ground up to the foot instead of allowing the foot to meet the ground. And, so your feet have an even distribution of wear, and you don't get this with an arch support type of device, you don't get this pounding and shearing that creates this wearing out of the shoe. You have to be there to really understand. You really have to be in my doctors' chair, and be holding your foot to understand, but basically, was that enough answer for that question?

We're all born with crooked feet. Mine are crooked one way, yours are crooked the other way, and someone else's crooked another way. Everybody's crooked. Is there anybody in here who is not crooked?

The interest in these fancy sneakers that everyone buys forces the shoe industry into more competitive strategies -- and they've had to make the shoes better. Foot technology is balance technology, and the computers we use to measure the feet and make shoes are fantastic. The technology is so good that if anyone here is wearing a heel, a lot of people wearing big sneakers, the heel is just about right.

New Balance, I like New Balance products; I like a lot of other shoes too, particularly about the heel question. Today we're getting away from strict fashion in the mainstream shoe industry, and more toward foot health. There are fashion stores that still make pointed, ugly, high-heel shoes for women, and when you wear a high-heel shoe, imagine the knuckles in your feet, called the metatarsal joint, are the only thing hitting the floor, the only thing bearing the whole weight of the body. I mean the poor metatarsal, with these high heels. I see these women walking; I can't stand it!

Why would a diabetic have flat feet?

The diabetic foot, just like anybody else's foot, flattens out as we get older, as our ligaments get looser. But, there is a special condition, a complication of diabetes, where the toes grab and force the foot to start pounding. When your toes grab, the metatarsal goes down, and the foot hits harder, and the bones break like pencils, like little tiny pencil fractures. Why? Because of the diabetes, the consistency of the bone changes a little bit. It becomes a little more brittle, more breakable; a condition called Charcot Deformity. This condition goes along with neuropathy; we can't feel our feet as we're walking along, and then they're easier to break, and they break in the mid-part of the foot called the tarsal part of the foot. This is where you get the flattening of the feet. It's a special problem that diabetics have and neuropathy patients have and it's called Charcot Deformity.

I have been asked to talk about amputation, and about the need to go get a second opinion. I have a patient in the hospital right now. And this patient was at one hospital, and I'm only a little podiatrist on staff at the hospital, and basically we call in a team: the general practitioner, the endocrinologist, the plastic surgeon, and the surgeon. Do you ever hear the term, some people don't know what they don't know, and therefore they "know everything?" Between you and me, some of the doctors who I know don't know. They just don't know, and therefore they think they know it all!

So I go to all these diabetes meetings, I go to circulation meetings, I go to all these diabetic foot meetings, and I keep up to date, because that's all I do is the diabetic foot. I live, eat, breathe, and sleep the diabetic foot. That's the kind of doctor you want to go to for your problem. I went to a hip doctor. All he did was eat, breathe, sleep, and drink hips. There's a certain step in learning called internalization, and then you don't even have to think about it. So this guy is in the hospital, and everybody wanted to cut the infected leg off.

Well, last year I had given a lecture at a world-wide convention in Hawaii about some of the new procedures that can save the foot. And one of them is called angiogram-angioplasty. It is done by radiologists. I work with a radiologist at another hospital, and I told these guys, "Don't cut the foot off. We can save the foot."

They said, "You're crazy. You are trying to save this guy's foot? He's going to get infected, and he's going to die, and you're going to save the foot? What does he need the foot for? He's not that active."

And I'm just about ready to throw up. I picked up his angiograms, and took them over on the other side of town, to the other hospital, where I work with the radiologist. I said to Greg, that's the radiologist's name, I said, "Greg, here's the film; what do you think, do you think we ought to cut this guy's leg off?"

He says: "No way, look at this artery here; how beautiful. We could pump blood through that, and we construct this, and we got a winner."

I pulled the guy out of that hospital, and put him in the other hospital, and I think today he's being operated on by the radiologist. I have to check in. We are going to save his foot.

What's the point of this statement? Never give up? No, there is a time to give up -- don t get me wrong. I've been in cases where it's absolutely hopeless, but what I'm trying to say is: have an open mind, because there's more available to you than what you might think. And realize that when you go to a professional, and depend on them for your life, whether it be an attorney, or an accountant, a dentist, or a doctor, they may not know what they don't know. And so you have to have a basket of information with you, so you can kind of judge where they re at. There's no right or wrong; I don't have an answer for you. I don't have an answer, but we should be armed and ready with questions. It happens too much.

Back to my earlier statement, if we're feeling down, it's a vicious circle. I was that way with my hip; I didn't t feel like getting back to work, and bed was bad, too. I was getting stiff; but I had to get up and exercise, to get my stiff hip better -- but I didn't feel like it, because I was weak. And it was a vicious cycle, and we have to pop ourselves out of the vicious cycle. You see a lot of this. We have to have the mental ability to pop ourselves out of the vicious cycle.

I'm a diabetic, I have been for 46 years, I went legally blind six years ago, and is it okay to wear sandals?

There are a lot of different types of sandals. Some are like flip-flops, but other sandals are made by the orthopedic companies. Those sandals are good. There are now sandals with custom made foot plates, to control the motion of your foot, and what happens when it controls the motion of your foot? It controls the motion of your knee, and the motion of your hip, and the motion of your back, and the motion of your neck, and don't I know it!

I have another question. I know there's companies out there that have magnetic insoles, is it okay to wear those?

I have no information. I've been trying to get research on that magnetic sole, because I get asked that question all the time. I do know that when Nixon came back from China in what was it, 1975? He brought all this information back to us, including about acupuncture using magnets. And that does seem to work, acupuncture using magnets, but the magnet has to be a really thick, high-power magnet. These thin magnets they use in the shoe, I'm not sure they work, and I see no research to the effect that they do.

What's a bunion?

A bunion is a big bump on the big toe side of the foot. It's caused by constantly pushing the foot forward, becoming flat footed when you walk. You're pushing the joint out of whack and it gets all scarred up. The fact is, if the bunions don't hurt, then there's no problem. We label things as problems, because they apparently don't look like everyone else's feet. In fact there is no a problem, unless there is a problem. That is, unless you couldn't walk, or you couldn't do your thing, walk the dog or whatever you like to do, garden, or whatever.

If you can't move as you like to do, then that's a different story. Then I say, "We have to get you in proper shoes, with arch support. We have to talk about you moving too much on that side of the foot; we have to talk about oral anti-inflammatories. And if everything else fails, we have to talk about surgery." So we have to really decide in our lives, what is a problem, and what is not.

If you have nerve pain, you have nerve damage. When the nerve is damaged, and there is what doctors call pathology, we call it neuropathy. And how do you help the neuropathy? The covering of the nerves is very responsive to the blood sugar. If you keep your blood sugar under control, the covering of the nerves becomes healthier.

Changes in blood sugar can cause swelling. The tissues become swollen from broken veins and the pooling blood, and this could push on the nerves. When we see this, we can recommend support hose. Massage can actually increase circulation around the nerve, the micro-circulation. And, you can actually rub away some of the metabolic bi-products like lactic acid. And further, you can produce what we call a reactive base of that dilation, which is an improvement in the circulation.

The other day, a patient asked me, "What is neuropathy?"

I said: "Picture this: If you were in my chair and you had sunburn on your leg, that sunburn may not hurt, but if I touch your leg, you go, 'ouch, it hurts.' Neuropathy is like a sunburn on a nerve; it may not hurt until you walk on it, because it's now extra sensitive. So neuropathy is an important problem.

There are three types of neuropathy. There is sensory neuropathy, where the nerves are affected that give sensation to the foot, and strangely enough, you can have a numb foot and at the same time have a foot that feels too much, because different types of nerve fibers become affected. You could be walking, and not feel your feet, but then put a shoe over it, and you can't stand it. The term used is paradoxical neuropathy. You could have both, super pain and numbness at the same time. That is sensory neuropathy.

Then we have autonomic neuropathy which means the nerves to the automatic glands and organs are affected. We sweat too much, or we sweat too little, or the skin becomes dry, or the eyes become affected, or the kidney, or the stomach and intestine could become affected as well.

Then there's motor neuropathy, which affects the nerves that work the muscles. And the muscles become weak, and/or smaller. The most common muscle to become affected is on the leg -- right below the knee. What can you do about that? Stretching, exercise, movement and eliminating the pressure and stress you put on it, by walking right. I can't stress the importance of proper shoes and arch supports enough, because when the muscles, affected by neuropathy, become off-balance, they become tight, or loose, causing one to plant their foot in abnormal ways.

You have to support your foot with a good arch support and shoe. It's so important; the shoe and arch support are the only things we have for interfacing the foot with the ground. We don't have a magic carpet; we don't have a magic floor. The only way we can affect the interface of the foot with the ground is to issue an arch support.

Sensory neuropathy is responsive to medication. Shoes or arch support have an effect on all types of neuropathy, but so do medicines. There's also physical therapy, and there's also different kinds of electric treatments; all kinds of electrical physical therapy gizmos we have. And it's wonderful, the technology, but blood sugar is also part of this control. Very important is tight glucose control.

You must control your diabetes at all times; that's the secret. A lot of us aren't that disciplined. I'm not making judgments; I'm just saying it's hard to go to the hot dog stand, and smell the hot dog, and not grab a nice, big, fat, kosher hot dog. It's got 80 tons of fat in it, my favorite thing.

I grew up in Cleveland, Ohio. And at the Cleveland baseball stadium, they had what they called Stadium mustard. It's a spicy mustard, best on kosher hot dogs. You can't beat it, and every time someone goes to Cleveland, they send me jars of this brown, spicy Stadium mustard. I love it. It doesn't have any sugar in it, but it's loaded with salt.

Question: Last fall I had bypass surgery, and they found, the doctor explained to me, that a leg should have four major blood vessels, and three of mine are clogged. So, my feet are really dry. So they opened the right leg, but they haven't opened the left leg yet, but since I'm walking around here at the convention I don't feel a difference in the two legs.

Do they hurt?

Oh, do they ache. I don't walk very far either.

What you need to do is contact a physician who can refer you to an interventional radiologist. These specialists can do an angiogram and possibly an angioplasty at the same time. These radiologists are well trained to do this now.

Cardiologists are doing this as well. It's all part of the field called interventional medicine, and it is the future. I support this new branch of surgery, because when they do the more extensive traditional vascular type of surgery, it can ruin the anatomy. But the interventional procedures rarely harm the anatomy, and if a traditional vascular surgery is needed, the anatomy is still there to support the procedure. Interventional radiology rarely ruins the anatomy, and a lot of success can be achieved in this way.

I've got to tell you a little story about how important neuropathy is. I did a lot of my diabetes research and study at the US Public Health service hospital in Carville, Louisiana. We started the diabetic foot program after the leprosy program. These people had leprosy. It was the biggest leprosarium in the continental United States, and then there was the leprosy colony in Hawaii. Years ago, in the 1930's, they used to sneak up on people who were diagnosed with leprosy, grab them, put them on a train, in a locked-cell jail-type train, lock them up, and head them right for Carville, Louisiana, and lock them up, there. Carville is a big 400-plus-acre farm, so they weren't really "locked up," but they were locked inside the gates of the facility. And one day, they went to New Orleans, which is about 60 miles from Carville, Louisiana, where the U.S. public health service hospital was.

So they picked up Mr. Stein, who eventually wrote a book called Pain No More. He was a pharmacist in New Orleans, a very educated man. They picked him up, grabbed him in his business suit coming home from work. They put him on the train that went directly to Carville. It was almost like the Nazi trains. This is the truth. It was documented on TV, just a couple of years ago. If you have a chance to look up the stories associated with the history of Carville, it is an fascinating part of history.

So this guy was captured, and put in Carville. And he, with his creative, educated mind, started a newspaper, and started organizations, and a lot of other things that centered around improving the status of Hansen's disease and its victims. Then he started developing neuropathy, in his hands, and in his feet. And then, because of his leprosy, he started going blind.

So eventually he was blind, and he had no feeling. And then the doctors gave him Streptomycin, which is an antibiotic. And Streptomycin has a side-effect of doing damage to the cranial nerve responsible for hearing. You can lose your hearing as a side effect of taking it. So here was this educated guy who wound up bed-bound. He didn't have any sight, hearing, and absolutely no feeling in his hands and feet.

The doctor who put the word neuropathy on the map, the one who first discovered the condition exists, was working with him, and he worked an implant into the ear so the man could get a different type of hearing, a cochlear implant, and so now he was able to communicate. And the patient, Mr. Stein, was now able to hear, and now able to communicate.
We learned a couple of things from this. First of all, without your senses, you can't think. You only need one sense, he said. While he could not communicate, he said he absolutely could not form ideas. The second thing we found was the realization that the sense of touch is our validating sense. It could be our most important sense. If I see something, like a jacket, that I want to make sure is real, I touch it. The touching makes it either real or not real to me. Touch is our validating sense. So people who have neuropathy in their feet come in, and the other doctors say, "Oh, this guy is not compliant; he doesn't listen; he doesn't care, and he doesn't wear his shoes."

He's not being a bad patient; that's his neuropathy showing up. He doesn't feel his foot! Since he can't feel it, it is not real to him. This is a psychological truth. Our patient denies the pain, and the problem. He doesn't want it. And, it's ugly; when people have ulcers that ugly, they don't even want to look at the foot; they want to disown it. Then there's the typical diabetic denial. And so what's important to realize is, if you have neuropathy, you can overcome the denial by paying attention to your feet, by going to the doctor, by giving it attention, and forcing yourself out of this vicious cycle.

I want to summarize. The six most important things in preventing amputation, we call it the Keep your feet ... healthyTM program, the things you have to do every day, are:

1. Acknowledge the disease and educate yourself about it. Read about it, acknowledge you could have foot problems. That's tough to do; because a lot of people with chronic diseases don't like themselves any more. They don't want to take care of themselves, they want to take care of the people they were before they got the diseases, but not the people they are now, so it's tough.

2. Inspect your feet daily.

3. Get proper shoes with arch supports.

4. Employ good skin and nail care. I want to point out at least 30 percent of all diabetic problems come from skin and nail problems. Good care involves using a PH controlled environment where you have the appropriate shampoo or soap. Then you have the oil that debrides the fungus and bacteria from the skin. And then there is my Diabeti-Cream. This is a conditioning cream specifically designed for diabetics.

This makes up the triad program I recommend for the skin and nails. Make sure to have the skin, calluses and toenails trimmed by a professional. The triad skin program is very important, PH based.

5. Exercise your feet by massage, and buy and use foot rollers. Make sure the foot roller is the right size. The Foot-Log, the one we recommend and use, has little nubs on it that actually stimulate the acupuncture points of the feet.

6. Improve your circulation and control your swelling, called edema . You have to control the edema, the swelling of the feet, and I like to have my patients wear a very mild graduated support hose. But you don't need them very tight.

Are support hose better, or are diabetic socks?

If you have edema, swelling in your feet, I'd like you to wear some kind of support hose, and some people actually wear socks over them for extra protection. The diabetic socks are more for general protection.

Remember that your health program has to begin with mental conditioning. We really have to pay attention to that. It all starts with our brain, because if our mental and emotional state is not what it should be, then we become couch potatoes. That is not a good thing. If we deny what is important, we don't act on the important things.

The next thing is physical conditioning. You've got to feel good in the head, and then you've got to get to the point where you're saying, "What do I need to do?" Then, you need to get into good physical shape. Thank God I was in decent physical shape when I had my hip surgery. I didn't know I was going to need hip surgery, but I pulled through all the critical moments, because my body was in shape. Diabetes is the same way.

In ending, I just want to tell you: Keep your feet healthy, keep your kidneys healthy, keep your eyes healthy, keep your body healthy, live the right way and do the right thing, and, pay attention to prevention.

I'm available, like I say, by phone, you have the number: Phone: 1-866-499-3338; Website: www.thediabeticfoot.com
my name is Dr. Kenneth Rehm, you can call or write me any time, and I am really committed to helping you. And I'm so honored to be able to speak here.