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Diabetic neuropathy. Diabetic foot disease – the high-risk foot. Peripheral neuropathy. Peripheral vascular disease. Peripheral neuropathy and peripheral vascular disease. Some statistics. Half of all limb amputations are caused by diabetes Risk is 40 times increased in diabetes
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Diabetic neuropathy Slides current until 2008
Diabetic foot disease –the high-risk foot Peripheral neuropathy Peripheral vascular disease Peripheral neuropathy and peripheral vascular disease Slides current until 2008
Some statistics • Half of all limb amputations are caused by diabetes • Risk is 40 times increased in diabetes • 70% of people die five years following an amputation • Foot problems account for 40% of healthcare resources in developing countries; 15% in developed countries Slides current until 2008
Some statistics • 85% of all amputations begin with an ulcer • Foot problems cost USD 6 billion/year in the USA • 49-85% of amputations can be prevented Slides current until 2008
Discuss • How and when people have their feet examined in your country? • What conditions put people at high risk of injury in your country? Slides current until 2008
Peripheral neuropathy – sensory motor • Most common form of neuropathy • Affects approximately 50% after 15 years • Affects long nerves (feet and legs) first • glove and stocking distribution • Bilateral • Equal symptoms in both limbs Slides current until 2008
Diabetic peripheral neuropathy – risk factors • Poor glycaemic control • Long duration • Age • Height • Excessive alcohol Slides current until 2008
Nerve damage – neuropathy • Symptoms: • burning • pins and needles • pain • No symptoms Slides current until 2008
Painless nature of diabetic foot disease Slides current until 2008
Sensory nerve damage Slides current until 2008
Motor nerve damage Slides current until 2008
Localized callus Slides current until 2008
Autonomic nerve damage Slides current until 2008
Take off the shoes! Slides current until 2008
Diabetic peripheral neuropathyscreening tests • Test sensation • Biothesiometer • Tuning fork • 10 gm monofilament • Ankle reflexes Slides current until 2008
Assessment of high risk characteristics Slides current until 2008
Charcot’s arthropathy • Artery-vein shunting • Increased blood flow • Bone resorption • Commonly misdiagnosed Slides current until 2008
Unilateral Warm, swollen Relatively pain free Bounding pedal pulses Deformity may be present No temperature difference Rigid foot deformity Grossly misshapen foot Acute vs chronic Charcot’s arthropathy Slides current until 2008
Charcot’s arthropathy Slides current until 2008
Charcot’s arthropathy – treatment • Acute phase • Non weight-bearing • Total contact cast • Chronic phase • Orthopaedic surgery Slides current until 2008
Circulation Slides current until 2008
Peripheral vascular disease • Cause: decreased perfusion due to macrovascular disease • Sites: more distal Tibial and peroneal arteries (segment between the knee and the ankle but aortic-illiac to knee less frequently) Slides current until 2008
Peripheral vascular disease in diabetes • 15-40 times more likely to have lower limb amputation • People over 70 years have a 70-fold increased risk of amputation Slides current until 2008
Risk factors characteristics of atherosclerosis in diabetes • More common • Affects young age group • No sex difference • Smoking • Faster in progress Slides current until 2008
Peripheral vascular disease • Symptoms • Intermittent claudication • Rest pain • No symptoms • Inactivity • Neuropathy Slides current until 2008
Signs of vascular disease • Diminished or absent pedal pulses • Coolness of the feet and toes • Poor skin and nails • Absence of hair on feet and legs Slides current until 2008
Peripheral vascular disease and diabetes • Symptoms and signs of peripheral vascular disease • There are four stages: • Occlusive disease without symptoms • Intermittent claudication • Ischaemic rest pain (nighttime) • Ulceration/gangrene Slides current until 2008
Vascular assessment Palpation of foot pulses • Dorsalis pedis (10% absent due to anatomical reasons) • Tibialis posterior Slides current until 2008
Peripheral vascular diseasenon-invasive evaluation • Methods • Doppler pressure studies (ABI) • Duplex arterial imaging • Rationale • Identify and confirm presence of disease • Predict healing of ulcers or determine need for early surgical intervention Slides current until 2008
Peripheral vascular diseasenon-invasive evaluation • Doppler ultrasound • Measures pressure at brachial, pedal and toe arteries • Ankle Brachial Index (ABI) • <0.9 abnormal • 0.9 to 1.0 normal • >1.3 non-compressible Slides current until 2008
Peripheral vascular diseasenon-invasive evaluation • Duplex arterial imaging – allows narrowing or obstruction of blood vessels to be localized Slides current until 2008
Peripheral vascular disease Treatment • Quit smoking • Walk through pain • Surgical intervention Slides current until 2008
Risk categorization system Slides current until 2008
Cause of diabetic amputation Neuropathy or vascular disease Trauma Ulcer Failure to heal Infection Amputation Pecararo Slides current until 2008
An amputation every 30 seconds due to diabetes Slides current until 2008
How to do a foot assessment • Participants to form pairs and do a foot assessment on each other Slides current until 2008
