Researchers at the VA New York Harbor Healthcare System have a four–year, $1.1 million award from the VA Rehabilitation Research and Development Service to find a way to prevent the recurrence of foot ulcers in Veterans who have had a previous healed diabetic foot ulcer. The project, known as "STEP UP to Avert Amputation in Diabetes," is now in its second year.

The STEP UP team is encouraging patients to take charge of their own preventive care. The program aims to motivate them to adhere to recommended self–care practices and to monitor the temperature of the soles of their feet using a special foot thermometer. The team is testing the approach in a clinical trial. To date, nearly 100 patients have been recruited. The team hopes to reach its goal of 238 participants within the next two years.

The fact that neuropathic areas at risk for ulceration are associated with increased skin temperature was first noted in leprosy patients. The application of this idea in people with diabetes was pioneered by podiatry researcher Dr. David Armstrong, formerly with VA in Chicago.

"We are building on their work to develop and test a stronger intervention and more of a home–based program," says Natarajan. He notes that Armstrong is a collaborator on the current project.

The thermometer used in Armstrong's earlier work is no longer available, says Natarajan. His team is now using a special infrared thermometer – the DermaTemp, made by Exergen – that he says is "cheaper and more durable." He says his group's approach also incorporates more behavioral science methods to motivate patients.

Patients hold the thermometer at six different parts of the sole and record the temperatures. Natarajan says that if a patient has healthy feet, both feet will generate approximately the same temperature levels. However, when an ulcer is about to form, the temperature of that area on the affected foot may be higher, due to inflammation.

If there is a discrepancy between the two feet, the research counselors are consulted. In most situations, having patients rest for 24 hours and elevate the affected foot brings the temperature down to normal. If not, the patient is referred to a foot specialist for follow–up care. That typically involves ruling out non–ulcerative conditions, and providing special shoes that alleviate pressure.

Natarajan says foot thermometry is a promising way to help patients detect and stop ulcers before they develop, but the challenge is getting patients to self–monitor their foot temperatures daily. To that end, STEP UP is testing a new phone–counseling approach designed to motivate patients to self–monitor their foot temperatures and take better care of their feet overall. Natarajan says he hopes this will "lead to a new strategy to prevent the devastating complications of foot ulcers."