Introduction

Trench foot is also known as NFCI, which is short for non-freezing cold injury. It is caused by long exposure to extreme cold, wetness, and an unhealthy living environment. Trench foot can lead to the breakdown of tissue and skin cells. This in turn raises the chance of getting infection and also increases the risk of death.¹

Quite a number of soldiers were found to have developed trench foot during the World War I. As of 1914, one of the commonest war strategy was known as trench warfare, where soldiers stood in damp and water filled trenches for extended periods. This means the soldiers were exposed to mud, cold, and wetness. This resulted in a large number of them being diagnosed with the condition known as trench foot, with many deaths recorded associated with trench foot. Dr Dominique Jean Larrey, who was a surgeon in the French army was the first to contract trench foot in the year 1812.

Although anyone can have trench foot, the military continues to be the group most affected by trench foot. People who lack homes and shelter are also greatly affected, due to unhealthy living environment and exposure to cold. 

Trench foot can occur within a short period of ten to fourteen hours. The tissue surrounding the affected area can also be damaged or destroyed.

Trench foot progresses from having a tingling sensation, to itching, and then numbness. Prevention remains the best approach to trench foot. This can be achieved by ensuring the feet are kept dry and clean, and of course, moisture-free. Poor or inadequate treatment can lead to complications such as permanent tissue damage, tissue death, or even loss of the affected foot.¹

Conditions not to be confused with trench foot

• Frostbite: This is a localised injury caused by cold. It occurs when the tissue is frozen due to extremely low temperatures, far below the expected freezing point. Trench foot requires moisture to occur, whereas frostbite does not. Also, a tissue already affected by trench foot can still develop frostbite. Other times, trench foot and frostbite occur at the same time²
• Pernio (Chilblains): this is an inflammatory lesion that is usually confined to an area. Disease conditions that occur due to inflammation, such as covid-19 or lupus can have complications that manifest as pernio even when one is not exposed to cold. Pernio can also occur due to cold. Continuous or long exposure to damp or dry cold is the primary cause of pernio. Pernio is often painful and itchy, with swollen areas of red or purple discolouration 
• Urticaria of cold: this occurs when contact with cold produces an allergy. This allergy then produces hives. This condition is also referred to as cold contact urticaria
• Raynaud's disease: this is a severe, yet temporary disease condition. Narrowing of blood vessels supplying the toe tips due to cold or distress (emotional), causes raynaud's disease. Toe tips may then temporarily turn blue 

Risk factors of trench foot

There are several factors that pose as risk to developing trench foot. They include:

• Lack of movement
• Wearing wet shoes and/or socks
• Wearing too tight clothes and/shoes
• Wearing wet clothing
• Tiredness
• Stress
• Poor nutrition
• Inadequate intake of fluids
• Presence of disease conditions such as diabetes or raynaud's disease
• Alcohol intoxication
• Mental instability
• Smoking²

Common forms of rehabilitation for trench foot

Rehabilitation for trench foot includes the use of various kinds of treatment, devices, and aids to help improve the function of affected areas. 

Rehabilitation for trench foot depends on how severe the condition is and the extent that it has affected function. The aim is to maintain maximum function of the affected area, encourage participation of the person involved, reduce dependence, improve quality of life, and prevent any more function. The common forms of rehabilitation for trench foot include:³

• Occupational therapy: this form of therapy helps you maintain a balanced life at the workplace, home, and community 
• Pharmacological rehabilitation: this form of therapy helps to improve physical and mental function, using medications to achieve it 
• Physical therapy: this form of therapy involves the use of various physical activities and exercises to enhance body movements, strength, sensation, and balance
• Use of assistive devices: this involves the use of various equipments, products, and tools to help with movements and function. Assistive devices that can be used for trench foot include splints, braces for ankle and leg, soft padding for shoes, and custom made shoes to fit properly 
• Recreational therapy: this form of therapy involves the use of sports/games, arts and crafts, relaxation, and pet therapy to help improve psychological, emotional, and social wellness 
• Surgical intervention: surgery may be a necessary intervention for trench foot. Surgery for trench foot is performed when all other treatment options has failed. It is done to remove dead tissue or even amputate the feet¹

Initial recovery phase (acute stage) of trench foot

This phase of care is vital and what to do includes:

• The affected area should be kept clean and dry
• Application of oil such as whale oil after cleaning
• The foot should be inspected on regular basis for early detection and prevention
• Signs of infection and gangrene should also be assessed on a regular basis
• Regular change of socks if it's use is necessary
• Use of prescribed NSAIDS or aspirin or acetaminophen for relief of pain and swelling
• Use of prescribed antibiotics for prevention or treatment of infection
• Use of radiant heat to maintain warmth on the affected area
• Rapid rewarming should be avoided as it can cause pain and swelling
• Ensure adequate rest
• Bare feet should be elevated during sleep
• Weigh bearing should be avoided unless advised by a healthcare professional¹

Physical therapy for trench foot recovery

This includes a range of movement, stretches, and exercises that increases your ability to be more mobile, flexible, and also increase strength. All this put together increases safety and confidence while moving.

The period of physical therapy is dependent on the type and nature of injury you are managing. It may last weeks, months, or even years. If you have trench foot, you will require the supervision of a therapist for this phase of care. Some examples of physical therapy are:

• Gentle massaging of the affected feet should be performed by a professional. It increases blood flow to the affected area
• Electrical stimulation of nerves 
• Stretching movements
• Training for strength in the affected feet, which may include weight bearing¹

Physical therapy usually commences after immediate care has been given. You may not require hospital admission for this range of exercises. 

Lifestyle adjustments and long-term foot care

The center for disease control and prevention (CDC), recommends the following as measures of prevention and treatment of trench foot:

• Socks should be taken off
• Do not go to bed with filthy socks
• The area affected should be washed right away
• Thorough drying of the feet
• Five minutes heat pack application to the affected area⁴

 In addition to the CDC guidelines, lifestyle modifications include:

• Quit smoking
• Quit alcohol
• Quit caffeine as it can cause narrowing of blood vessels (vasoconstriction) 
• Drink enough water daily to stay hydrated
• Learn all the risk factors of trench foot and avoid them
• Learn how to identify signs and occurrence of the condition
• Quickly check in with your healthcare provider if you think you might have trench foot
• Maintain regular follow-ups

Psychological and emotional rehabilitation for trench foot

Trench foot is a condition that can greatly affect the function of the affected area. This in turn can limit or even end one's career or means of livelihood. 

Trench foot can cause a range of psychological and emotional symptoms. The challenge of learning long-term lifestyle changes and the effort to adapt to the workplace and community, can be a contributing factor to psychological and emotional issues.⁵

This aspect of trench foot rehabilitation should not be ignored because it can have a negative effect on the general well-being of the individual undergoing rehabilitation. 

Psychological and emotional reactions can be manifested including:

• Feeling depressed
• Thought of suicide
• Feeling anxious
• Neglecting self-care and refusing to follow advice from healthcare professionals
• Relationship problems
• Feeling of shame and low self-worth
• Increase stress levels
• Easily angered
• Refusal to interact with others

Solutions include

• Integrating friends and family into the care and encouraging them to offer maximum support
• Rehabilitation goals should be achievable, whether it's short-term or long-term. Motivate the individual to participate and reach the set goal
• Healthcare professionals should aim at building trust. Show empathy and be a good listener
• The healthcare professional should carefully explain the condition and how long it may take to reach full recovery. It promotes participation in care by the individual being treated

Summary

Cold and wetness are important factors in trench foot. It was first discovered among military personnel and although it mostly affects them, anyone can develop trench foot. Unwashed socks, ill-fitting shoes, immobility, unhealthy environment, inadequate diet, and mental instability are risks to developing trench foot. Early detection and treatment can reduce complications. The goal of rehabilitation in trench foot is to maintain maximum function of the affected area, encourage participation of the person involved, reduce dependence, improve quality of life, and prevent any more function.