Journal of Gerontological Nursing

THERAPEUTIC AND HEALING FOOT CARE: A Healthy Feet Clinic for Older Adults

Marilyn M Pattillo, PhD, RN, CS, NP

Abstract

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COrWAAON FOOT PROBLEMS IN HEALTHY FOOT CARE CLINIC CLIENTS (N= 43)…

Although foot health is important to the general well-being of all individuals, it is critical for older adults. With advancing age, individuals often lose flexibility and visual acuity necessary for maintaining self-care for good foot health, increasing risks for problems. Weak and painful feet can affect balance, safety, and general willingness to ambulate. Poor mobility and reconditioning are risks for falls.

Providing foot care should be a core competency for nurses who specialize in gerontology. Nurses have a responsibility to routinely examine the feet as part of their assessment, to educate their staff and themselves on how to provide hygienic foot care, and to recognize the need for early referral to a specialist. The manner in which foot care is assessed and delivered is also important. The Foot Care Clinic for Healthy Elders discussed in this article incorporates the clinical importance of early screening and disease prevention with holistic care and use of soaks, massage, and specific exercises for the feet. The clinic was founded as a service to older adults, and revenue generation is not a goal. In addition, the clinic also serves as a "teaching laboratory" for nursing students and community nurses on the importance of foot health and foot care.

The purposes of this article are to affirm the benefits of an organized foot care program for older adults and the importance of competent and caring gerontological nurses skilled in foot assessment and care. This article discusses the concepts of function and holistic care; selected literature on foot assessment, risk factors, and foot care procedures; and a report of the clinic itself highlighting the procedure, clients served, and foot problems encountered.

CONCEPTUAL FRAMEWORK

Function

Function can be defined as an individual's ability to perform basic tasks for self-care and tasks needed to support independent living (Gallo, Reichel, & Anderson, 1995). Assessment of function, crucial in older and disabled clients, is based on the assumption that potentially problematic clinical conditions can be identified early and treated properly. Having a "function" perspective means older adults' concerns are considered and realistic goal setting in light of chronic conditions is paramount. As an example, one of the key tasks according to the Katz Index of Activities of Daily Living that determines an individual's ability to live independently is the ability to transfer in and out of bed and chair, and to ambulate to the toilet (Gallo et al., 1995). Safe and frequent ambulating and the confidence to do so can be dependent on strong, supple, and pain-free feet.

Holistic Care

The Foot Care Clinic incorporates holistic health principles of mind, body, and spirit; foot massage; and exercise. The influence of mind and spirit over the body is well documented in the literature (Bright, 2002). Nursing is a process between the nurse and the client and requires an interpersonal and interactive nurse-client relationship. Three characteristics of the nurse practicing holistic care are facilitation, nurturance, and unconditional acceptance. Facilitation implies nurses help individuals identify, mobilize, and develop their own strengths (Erickson, Tomlin, St Swain, 1983).

Foot massage, as a nursing intervention, has been long recognized as preventive and therapeutic, and practiced throughout history by a variety of cultures. North American Indians have used foot massage as a healing therapy for generations. For centuries, the Cherokee of North Carolina have acknowledged the importance of feet in maintaining physical, mental, and spiritual balance. The roots of foot care and treatment are clearly embedded in ancient history (Dougans, 1996; Lidell, 1984).

Ability to exercise and physical activity are often barometers by which an individual's health, abilities, and wellness are judged. The inability to exercise or perform activities of daily living is among the first indicators of decline. Movement therapy directed at the feet and toes can increase strength and flexibility of the toes, prevent foot discomfort, increase morale, and improve balance and body awareness (Ebersole & Hess, 2001).

LITERATURE REVIEW

Normal and Abnormal Changes of the Aging Foot

The human foot consists of 26 bones (one-fourth of all the bones in the body), 19 muscles, 107 ligaments and tendons, and blood vessels (Seidel, Ball, Dains, & Benedict, 2003). The average person takes approximately 10,000 steps per day. Each step can place two to three times the force of body weight on the feet. With time, this extensive repetitive use can lead to normal changes associated with aging, which include wider and longer feet, mild settling of the arches, and loss of natural padding on the bottom of the heels. The skeletal system can undergo an alteration in equilibrium between bone deposition and bone resorption, where resorption dominates, resulting in bone loss. Weight-bearing bones of the feet may become predisposed to fractures. Bony prominences can become more apparent with the loss of subcutaneous fat. Cartilage around joints deteriorates, which produces loss of normal range of motion of the foot and ankle. A progressive decrease in reaction time, speed of movements, agility, and endurance (especially when compounded by disuse) also can exacerbate the aging process (Hefland, 1993).

Abnormal foot changes tend to be exacerbated with prolonged use of ill-fitting shoes. The incidence of foot problems, which can include bunions, hammer toes, clawing of the toes, calluses, and corns, tends to peak in the fourth, fifth, and sixth decades of life. A sedentary lifestyle and any health problem that contributes to reduce physical activity can further hasten the problematic musculoskeletal changes to the ankles and feet (Teasdall, Holman, Hodges, & Stauffer, 1999).

Risk Factors

Risk factors for foot problems in elderly individuals include:

* Gout.

* Neglect.

* Burning.

* Infection.

* Small injuries.

* Ill-fitting shoes.

* Venous disorders.

* Diabetes mellitus.

* Cardiac disorders.

* Improper foot care.

* Decreased sensation.

* Rheumatoid arthritis.

* Degenerative joint disease.

* Peripheral vascular disease.

* Nail problems (thickening).

* Stabbing pain that is worse at night.

Older adults often lose flexibility and visual acuity necessary for maintaining good foot health, increasing their risk for problems (Hefland, 1993).

Foot Care Protocols

Most of the foot care protocols reviewed were written for diabetic clients with foot complications. Plummer and Albert (1996) argue all older adults should receive the same foot care screening and follow up as those with diabetes mellitus. In a study comparing foot problems in non-diabetic individuals with those in diabetic individuals, they found older adults without diabetes mellitus can be at high risk for footrelated disease and should receive the same foot care screening, education, and follow up as those with diabetes. Older clients should routinely undergo a history of foot care practices (e.g., toenail and callus care, soaking, walking, barefoot, footwear). Plummer and Albert (1996) recommended older adults who have peripheral neuropathy, uncontrolled diabetes mellitus, peripheral vascular disease, or physical or psychosocial limitation in particular require more than routine care and must be referred to foot care specialists.

A number of older adult foot care articles written by nurses reveal a variety of helpful approaches to establishing a foot care protocol (Brown, Boosinger, Black, Gaspar, & Sather, 1982; Bryant & Beinlich, 1999; Chung, Î983; Hayes & Cox, 1999; Westley & Glick, 1997). Brown et al. (1982) described their research project that used a structured foot assessment guide, foot soaks without soap, and a topical mineral oil application with massage to address dry skin of the feet of nursing home residents.

Chung (1983) described a 1-day mini-health fair where foot assessments were conducted at a day care center. Common complaints of participants at the day care center were identified and simple interventions were provided that brought immediate relief (e.g., too tight shoes).

Hayes and Cox (1999) reported on their quasi-experimental repeated measures study using 5-minute foot massages on patients in critical care. Although no significant effect on peripheral oxygen saturation was noted, a significant decrease in heart rate, blood pressure, and respirations during the foot massage was observed. This provided some evidence of the potential effect of increasing relaxation to critically ill patients in intensive care.

Westley and Glick (1997) described their foot care for residents of public housing as an innovative nursing service. Working at an onsite nursing clinic as part of a network of primary care health community centers, they found that with relatively little extra education for the nursing staff and for minimal cost, foot care could become an integral part of nursing services provided in many different types of community health settings.

The Seattle FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) trial found 107 community-dwelling men and women older than age 80, randomly assigned to strength, endurance, or a combined program targeting lower extremities, had less risk of falling compared with a control group, which received no exercise. The study also found emphasizing one aspect of treatment, such as the lower extremities, might impact another, such as fall risk, which offers the hope of additive effects of a specific type of treatment on other dimensions, including falls (Coogler & Wolf, 1999).

The FICSIT initiatives were launched in 1990 by the National Institute of Aging (NIA) to improve physical function in old age. Research from FICSIT trials has demonstrated the benefits of strength training for older adults and the value and cost effectiveness of targeted, fall prevention programs for elderly individuals. It is estimated that each year falls are responsible for costs of more than $12 billion in the United States, and the costs caused by physical frailty are much higher (NIA, 2003).

THE FOOT CARE CLINIC FOR HEALTHY ELDERS

The administrator of an assisted living facility who was concerned about falls and safe ambulation within the facility approached the author to ask if any program could be initiated to help increase awareness about safety and fall prevention. The administrator offered free space, a converted apartment on the second floor next to the elevator, as well as marketing, laundry, and housekeeping support. The opportunity to open a "gerontological nursing practice" that focused on foot care, a much needed but often neglected service, and to provide a clinical setting for nursing students was enticing.

The activity director coordinated a sign-up sheet posted next to the dining room. The clinic was open for 4 hours every other week and was staffed by the author, a professional nurse in advance practice. The nurse provided nursing license and other credentials as well as proof of liability insurance. The client, in turn, agreed to pay $10 for each 30- to 45minute visit. Although the scope of an advance practice nurse could have been much greater than the services offered, the clinic was to be a site for wellness and health promotion. Doing so kept the clinic simple and the liability minimal.

The foot clinic was marketed as a nurse-run wellness clinic offering "foot protection activities" for "healthy feet." Foot protection activities included a short history, gait and balance assessment, foot examination, foot soaking, simple nail trimming, massage, education about selfcare, and foot and toe exercises. These activities were promoted to older adults and their families as playing an integral role in healthy and successful aging by preventing foot problems and possibly falls.

Because of the emphasis on wellness and health promotion, only relatively healthy older adults were seen in the clinic. Before opening the clinic, a quick survey of 25 conveniently available facility residents in the dining hall in one afternoon revealed there would be an adequate supply of fairly healthy feet that needed tending to support twice a week clinic operations. Healthy feet were defined as feet having intact protective sensation, bilateral pedal pulses, no severe deformity, no prior foot ulcer, and no amputation. Eight clients were found upon screening with complaints of sudden loss of sensation, severe foot deformity, history of foot ulcer, prior amputation, leg pain or swelling that persisted for more than 72 hours, new-onset intermittent claudication, infection, and a non-healing blister. They were promptly screened and referred to a visiting podiatrist or their private physician.

During its first year of operation, the clinic averaged 7 to 9 visits per month (after 10 months of service, total client visits were 75). Typically, clients were women with an average age of 84. All visited the clinic because of increasing difficulty (e.g., visual acuity, hand tremors, unable to bend, unable to reach toes) in performing their own nail care. Additionally, many were attracted to the opportunity to talk with a nurse, ask questions about their medications, and generally learn more about how to stay independent.

Most (90%) of the clients used mobility aids (e.g., canes, walkers, wheelchairs). As soon as a client entered the office, demeanor, gait, balance, and footwear were assessed. The atmosphere was relaxed and home-like. Clients sat in a chair and the nurse was on the floor or a footstool. Nurses who worked in the clinic preferred to be on the floor and to converse with the client in this dependent position. Clients knew they had at least 30 to 45 minutes of the nurse's undivided attention. There was no music to distract or compete with listening.

Supplies and Equipment

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TABLECOrWAAON FOOT PROBLEMS IN HEALTHY FOOT CARE CLINIC CLIENTS (N= 43)

TABLE

COrWAAON FOOT PROBLEMS IN HEALTHY FOOT CARE CLINIC CLIENTS (N= 43)

Equipment and supplies for the program were obtained easily from any grocery or department store. Initial set-up cost was approximately $27 for two square white basins for soaking, moisturizing soap, soft brush, cotton towels, emery boards, toenail clippers, lotion, and bleach (for cleaning of equipment between clients).

A Semmes-Weinstein monofilament was used to assess protective sensation in the feet of patients. A 10gram (5.07 log) monofilament wire is applied to each foot at 10 sites (i.e., the plantar aspect of the first, third, and fifth digits; the plantar aspect of the first, third, and fifth metatarsal heads; the plantar midfoot medially and laterally; the plantar heel; and the dorsal aspect of the midfoot). Loss of protective sensation generally is indicated by a patient's inability to feel the monofilament at 4 or more of the 10 sites (Kumar et al., 1991; Sloan & Abel, 1998).

Another test to assess sensory function of the feet was with a tuning fork. A vibrating tuning fork (the tuning fork with lower Hz) was placed against several bony prominences, beginning at the most distal joints (toes) of the feet. A buzzing or tingling sensation should be felt. Clients were asked to say when and where the vibration was felt. Occasionally, the tines were dampened before application to see if clients could distinguish a difference (Seidel et al., 2003).

History

Clients were asked for a brief history to screen for pre-existing systemic disorders (e.g., circulatory problems, diabetes mellitus, heart disease, kidney disease, arthritis, hypertension), surgical foot history, allergies, and current medications. Much attention (and teaching) was given to medications, especially common drugs such as warfarin, aspirin, ibuprofen, and herbal agents such as vitamin E and gingko biloba. These medications have the side effect of bleeding as a primary indication or as an interactive effect. Clients also were asked about their use of home foot care remedies and their understanding of self-care.

Physical Examination

Physical examination of the foot was thorough because of the prescriptive exercises given at the end of each foot care session. Typically, the examination of the foot included an evaluation of the skin's appearance; the color of the foot and nails; and whether there was any swelling, masses, or indurations. The nails were inspected to determine whether they were thickened, enlarged, or ingrown. The feet were examined for function during stance and gait. The muscles of the feet and ankles were inspected for gross hypertrophy or atrophy (Seidel et al., 2003).

The bones, joints, and surrounding muscles of the foot were palpated to detect any tenderness. Heat, tenderness, swelling, crepitus, and resistance to pressure were noted. No discomfort should occur where pressure is applied to bones or joints. Muscle tone should be firm, not hard or doughy. Inflamed joints or areas of tenderness identified from history were palpated last. Crepitus can be felt when two irregular bone surfaces rub together as a joint moves, when two rough edges of a broken bone rub together (Seidel et al., 2003). After the dorsalis pedis and posterior tibial arteries were palpated to assess blood flow, sensory testing of the foot was conducted using the monofilament method described previously.

During foot assessment, the elderly individuals were usually attentive and interested. They were curious about why a particular test (e.g., monofilament test) was being performed. Empirically, it appeared that when older adults understood the anatomy and pathology that affect their foot problems, they were more likely to perform more appropriate self-care activities.

Next, active and passive range of motion, as well as muscle strength of the foot were assessed. Clients were asked to first contract the ankle and foot muscles by extending or flexing the joint and then to resist when the examiner applied opposing force. Muscle strength of the feet was compared bilaterally and should have full resistance to opposition. Full muscle strength of the feet requires complete active range of motion. Often, weakness results from disuse atrophy. Excessive or limited motion was identified (Seidel et al., 2003).

In many foot care protocols found in the literature, the toes were often not given meaningful attention, but, assuring muscle strength and flexibility of the toes is important and can help with general balance and stability of the feet. Toes were evaluated in this foot care clinic for flexion and extension by asking clients to bend and straighten the toes. Abduction of the toes was assessed by asking clients to fan the toes apart; and for adduction, by having clients return the toes to the neutral position (Seidel et al., 2003). Encouraging older adults to bend, straighten, and fan toes occasionally promotes blood circulation and muscle and joint flexibility. Throughout this assessment, nurses were teaching and reinforcing good habits.

Common Foot Problems

Thirty-two (43%) of the 75 clients seen in the clinic had toes that were in normal alignment with each other, and all they needed were their toenails clipped, a soothing massage, and a friendly conversation. One client was a frail but alert 97-year-old retired accountant who changed his socks daily and wore proper fitting shoes all his life. The skin of his feet was soft and supple, toes were pink without fungus, and all joints had pain-free range of motion.

Forty-three (57%) clients had complaints of dry skin and presented with hyperkeratosis, some deviations of the toes (e.g., hammer toes, hallux valgus), bunions, ingrown toenails, dermatitis, and fungal infections (Table). Those who were deemed to have minor problems were kept as clients (n = 35); others (n = 8) with more serious problems were referred for specialized care.

Dry, scaling skin (xerosis) was the most common foot problem. Thinner epidermis allows more moisture to escape from the skin. Inadequate fluid intake, diminished amount of sebum secreted by the sebaceous glands, and nutritional deficiencies can contribute to dry skin. Except for the retired accountant, all of the clients presented with some keratosis in the form of corns (usually on the digits), and calluses (usually under or over metatarsal heads or over other bony prominences). Corns often appeared over misshapen hammertoes. A hammertoe is a hyperextension of the metatarsophalangeal joint and distal joint with flexion of the toe's proximal joint. This can occur when footwear is too short and crunches up the toes.

Hallux valgus, which is a lateral deviation of the great toe that may cause overlapping with the second toe, also can result from narrow fitting footwear (Hefland, 1993). A swollen and tender bunion can form to produce a valgus, making walking difficult. One client, an 82-year-old woman who said she wore high heels with pointed toes for many years when she worked as a salesperson at a downtown department store, presented with severe hallux valgus with toes cramped against each other. She said that she enjoyed always being dressed up and is currently "paying the price." She was referred to the podiatrist for care.

Ingrown toenail is often caused by extrinsic pressure on the toe, which can trap the sharp corner of an improperly cut nail into the medial or lateral soft tissues. Continuous irritation of the soft parts by the nail leads to inflammation and possible infection. Predisposing factors for the development of ingrown toenails include improper trimming, heredity, improper shoe fit, and obesity. Clients with ingrown toenails were referred to the podiatrist (Teasdall et al., 1999).

Fungal infection of the toenail begins with an area of localized discoloration beneath the nail that starts at the tip, moves proximally, and ultimately enters through the nail plate itself. As the nail bed becomes chronically irritated from persistent local inflammation, an accumulation of hyperkeratotic debris leads to thickening, cracking, and brownish-yellow discoloration. The enlarged nail may make it difficult for the client to find comfortable shoes (Teasdall et al., 1999). Foot soaking made trimming hard nails more manageable in the foot clinic.

Atrophic dermatitis is a cutaneous inflammatory condition caused by irritants, allergens, infections, extreme temperature, humidity, and poor circulation already aggravated by dry skin (Parkinson & Griffin, 1997). When foot eczema was suspected in the foot clinic, referral was made to the podiatrist. Three clients presented with ankle edema related to constricting garters, obesity, and prolonged sitting.

Foot Soak

After assessment of the feet and problem identification, the feet were soaked. If clients allowed, scented oil was used with a moistening soap in the foot soak. Although the literature cautions about the use of scented ingrethents because of possible allergic reactions, in many well and low-risk older adults, the benefits outweigh the risks.

Herbalists and healers have recommended herbal foot baths for centuries. The healing ingrethents can be absorbed through the skin and the use of aromatherapy can help stimulate the limbic system, trigger memory, and possibly elicit a range of responses from relaxation to stimulation (Dougans, 1996; Westley & Glick, 1997).

Soaking for 3 to 5 minutes in a warm footbath, with or without herbs, softens toenails, calluses, and corns. The temperature of the water was tested on the inner aspect of the arm. A soft washcloth was used around the toenails to remove dead skin. The feet were dried thoroughly, a nail clipper was used to trim toenails, and an emery board was used to file the nails, maintaining a straight edge. The toenails were trimmed so a few millimeters of skin remained visible just beyond the margin. The feet were covered with moisturizer or foot cream such as a dimethicone skin protectant to prevent dry skin. Gloves were never used in any of the care provided.

Foot Massage

The feet were massaged for 5 to 10 minutes using the following two relaxation techniques.

* Back and Forth Technique. The palms of the hands are on either side of the foot, fingers relaxed. One hand gently pushes forward and the other pulls back on the foot. This movement is continued, alternately pushing and pulling the foot back and forth fairly rapidly, keeping the hands constantly in contact with the foot (Udell, 1984).

* Ankle Rotation. The heel is supported by the opposite hand (right heel in left hand and vice versa) with the thumb around the outside of the ankle just below the ankle bone. The top of the foot, held by the other hand, is gently rotated a few times in one direction and then a few times in the other (Udell, 1984).

Foot Exercises

The exercises suggested were determined by the client's inherent physical and behavioral capacities. The American Orthopedic Foot and Ankle Society (n.d.) recommends simple exercises be performed to strengthen toes and prevent foot discomfort. Exercises used in the foot clinic include toe raise, toe point, and toe curl; golf ball roll; towel curls; and marble pick-up.

For toe point, toe raise, and toe curl exercises, each position was held for 5 seconds and repeated 10 times. This exercise was recommended for individuals with hammertoes or toe cramps. For golf ball rolls, a golf ball was rolled under the ball of the foot for 2 minutes. This massaged the bottom of the foot and was recommended for individuals with plantar fasciitis (heel pain), arch strain, or foot cramps. For towel curls, a small towel was placed on the floor. Using only the toes, the towel was curled toward the individual. The client then was instructed to relax and repeat this exercise five times. The marble pick-up required 20 marbles on the floor. Clients were asked to pick up one marble at a time with their toes and put it in a small howl until all 20 marbles were picked up. The towel curl and marble pick-up were recommended for individuals with hammertoes, toe cramps, and pain in the ball of the foot. These simple exercises can be performed while sitting or standing, depending on what is most comfortable for the client.

Many of the elderly individuals found the towel curl exercise much easier than the marbles. Older adults learned that correct, simple, and regular foot exercises would not only keep their feet in good shape, but also could combat further deformities and give them better balance.

Education

Foot education consisted of verbal instructions, demonstration, return demonstration, and printed advice as listed in the Sidebar.

CONCLUSION

A comprehensive and innovative nurse-run foot clinic located in an assisted living facility provided needed and much-appreciated service to older adults. Clients who used the clinic regularly reported increased awareness of the importance of foot exercises and the role of the foot in maintaining balance and leg strength. They shared what they learned with others in the facility, and through word-ofmouth, the clinic has grown, requiring an additional 8 hours per week to meet the needs of additional clients. Five graduate students have helped in providing the care under the supervision of the gerontological nurse. They refined their foot assessment and patient teaching skills.

Because foot care can directly influence the comfort, independence, and daily functional status of elderly individuals, gerontological nurses should have basic competence in routine foot assessment and foot care (Bryant & Beinlich, 1999; King, 1978). It is within the scope of practice for professional nurses to assess for early abnormalities, manage minor conditions, educate clients and families, and promptly refer for specialty care (Bryant & Beinlich, 1999). Professional nurses also have a responsibility to teach staff and caregivers about foot care and to include the feet routinely in their assessments.

Although this foot clinic was not started as a revenue- generating business, it is possible that entrepreneurial nurses could partner with others (physician groups and assisted living facilities) and develop a business plan incorporating the principles of this clinic and the market forces in their communities. In the meantime, the Foot Care Clinic for Healthy Elders will maintain its service orientation, be content with the opportunity to see interesting feet and interesting individuals, and continue to provide healing and therapeutic foot care.

REFERENCES

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COrWAAON FOOT PROBLEMS IN HEALTHY FOOT CARE CLINIC CLIENTS (N= 43)

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