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DIABETES INSENSATE FOOT

DIABETES INSENSATE FOOT. October 27, 2005 Michael S. Brogan, PT, DPT, PhD, CWS. Statement of the Problem. Diabetes is the 6 th leading cause of death in the U.S. (1) From 1990 to 1998 prevalence of diabetes increased from 4.9 to 6.5% (2)

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DIABETES INSENSATE FOOT

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  1. DIABETESINSENSATE FOOT October 27, 2005 Michael S. Brogan, PT, DPT, PhD, CWS

  2. Statement of the Problem • Diabetes is the 6th leading cause of death in the U.S. (1) • From 1990 to 1998 prevalence of diabetes increased from 4.9 to 6.5% (2) • Approximately 800,000 cases of diabetes are diagnosed each year in the U.S. (3) • Approximately 17 million Americans (6.2% of pop.) have diabetes – 5.9 million of them undiagnosed (3) • Another 16 million have pre-diabetes (impaired glucose tolerance) (3)

  3. Complications of Diabetes • Particularly devastating to the foot, often leading to amputation, if not treated early (4) • 67% of hospital discharges for lower extremity amputations in 1997 were related to diabetes (4) • 85% of diabetes-related amputations are preceded by the appearance of a foot ulcer (5) • Between 1989 and 1992, an average of 54,000 diabetic amputations were performed (6) • In 1996, 86,000 people with diabetes underwent 1 or more lower extremity amputations (6) • Total cost for those amputations - > $1.1 billion dollars (7) • In 1995, average individual cost of a minor amputation was $43,000, and a major amputation was $65,000 (8)

  4. Common Skin Disorders Associated With Diabetes • Diabetic Dermopathy – • round, reddish-brown papules (lower leg)

  5. Bullous Diabeticorum (upper & lower extremities)

  6. Common Skin Disorders Associated With Diabetes • Necrobiosis Lipoidica

  7. Common Skin Disorders Associated With Diabetes • Diabetic Finger Pebbles

  8. Diabetic Foot Ulcers

  9. Causes of Foot Ulcerations • Peripheral neuropathy most common cause • Sensory Loss Without Sensory Loss Ulceration Rarely Occurs • Mechanical Stress – repetitive tissue injury Lack of painful feedback

  10. Further Causes of Ulceration • Mechanical Stress • Pressure • Shear • Intrinsic Factors • Foot Deformities - bony prominences • Extrinsic Factors • Environment around the foot • Tight shoes

  11. Chronic Foot Ulceration • Loss of Protective Function & Sensation • Continue to Bear Weight on Ulcerated Area • Uninterrupted Episodes of Repetitive Stress • Autolysis • Necrosis of Tissue

  12. Sensory Loss Patient Profile • Non-Compliant • Ignore Treatment Recommendations • Education is necessary to combat profile

  13. Assessment of Loss of Protective Sensation • Nylon Filaments @ 10-g bending force recommended by the American Diabetes Association • Patients unable to perceive 10-g have loss of protective sensation • Increased risk of ulceration

  14. Research • High pressure caused by excessive weight bearing causes plantar ulcerations • Pressure is higher in diabetic neuropathy • Higher pressure associated with foot deformity, joint limitation, muscle weakness and atrophy • Muscle Weakness (toe deformities) • Peroneal nerve-foot drop-equinovarus-increased foot pressure-forefoot ulceration • Tibial Nerve-calcaneovalgus deformity-increased heel pressure-heel ulceration

  15. Most Common Sites of Ulceration in Diabetics • 1st Metatarsal Head • Great Toe

  16. Talking Points • Obesity, Poor Vision, Joint Limitation (decreased flexibility) limit people from inspecting their feet • Mirror • Properly Fitted Shoes • Hx of Callus, Ingrown Toenails, Blisters or Open Sores all increase risk of injury.

  17. Talking Points (cont.) • Painful foot problems are often a sign of early neuropathy • Pain with walking or elevation indicative of PVD • Callus should be trimmed to reduce pressure & to expose an underlying problem

  18. Pre-Ulceration • Local areas of non-blanchable erythema • Ecchymosis • Subcutaneous hematoma • Neuropathic fracture • Rapidly progress to unstable foot deformity & lead to chronic ulceration

  19. Wagner Ulcer Classification Diabetic Ulcers • Grade • 0 Intact Skin • 1 Superficial Ulcer • 2 Deep Ulcer • 3 Deep Infected Ulcer • 4 Partial Foot Gangrene • 5 Full Foot Gangrene

  20. Management Based on Ulcer Grading • Pre-ulcer: Modified Footwear & activity, PWB • Superficial: PWB, Relief Pads, Cast or Splint • Deep: PWB, Cast or Splint, Probe, X-Ray, Culture • Deep, Infected: PWB, Splint, Probe, X-ray, culture, antibiotics, surgical consult • Dysvascular: PWB, Splint, Vascular Studies, Vascular Consult • * probing to bone, suspect osteomyelitis

  21. Notes on Debridement • Non-Ischemic Foot Ulcers: cleaned, Debrided & Dressed • Wound debridement has been shown to improve healing time of non-ischemic foot ulcers • Callus should be trimmed to reduce pressure, expose underlying problems & promote epithelialization

  22. Reducing Weight Bearing Stresses • Objective: To reduce weight bearing stresses on the foot (plantar ulcers) • Methods • Crutches or Walker (PWB) • Gait Training (decrease step length to reduce forefoot pressure) • Walking Casts • Decrease pressure, decrease edema, protect from re-injury • Contraindicated for infected ulcers • Caution: moderate or severe edema, fragile atrophic skin, deep ulceration

  23. Walking Casts • Decrease pressure, decrease edema, protect from re-injury • Contraindicated for infected ulcers • Caution: moderate or severe edema, fragile atrophic skin, deep ulceration

  24. Total Contact Casts • Minimize risk of secondary infection • Bony prominences are padded • (tibial crest, malleoli, navicular, posterior heel, toes) • Inner layer of plaster, carefully molded for optimal total-contact fit • Combination of minimal padding & molding for better distribution of pressure

  25. The Use of Electrical Stimulation and an Off-Loading Technique For the Treatment of Diabetic Foot Ulcers Michael S. Brogan, PT, MS, DPT, CWS Laura E. Edsberg, Ph.D.

  26. Purpose • To Evaluate the efficacy of electrical stimulation and off-loading for the treatment of diabetic foot ulcers

  27. Case History • 52 year old male with Diabetes • Insulin dependent • Comorbidities • Renal failure (daily dialysis) • Severe diabetic neuropathy • Left B/K amputation • Left hand 3rd & 4th distal digit amputations • Referred for 2 chronic open wounds, Right Foot (Chronicity > 3 years) • Previous Care • Various topical applications • Various dressings • Antibiotics • Debridement

  28. 1-6-03

  29. 1-6-03

  30. Interventions • Electrical Stimulation • High Volt Pulsed Current • 150v, 120pps, 255ppi • Stainless Steel Electrodes (4x4) • 30 minutes, 5 X week • Immersion Techniques • Object: • improve blood flow • Reduce edema • Inhibit bacterial growth • Enhance closure

  31. Off-Loading • Reducing weight bearing forces on the foot is critical for healing plantar ulcers (9) • Total contact casts used commonly for grade 1 & 2 neuropathic foot ulcers • Allows weight bearing forces to be dispersed over a larger area, reducing plantar pressures • Rigidity of cast assists with edema control, improving circulation • Cast immobilizes the foot and ankle, reducing shearing forces • Completely encloses the patient’s insensate foot, protecting it from further trauma & microorganisms • Allows patient to be relatively active

  32. TOTAL CONTACT CASTS • Contraindicated • In grades 3, 4, and 5 ulcers • Fluctuating edema • Active infection • ABI of less than 0.45 • Requires skill to apply • Plaster vs. Fiberglass • Heel vs. Cast Shoe

  33. Off Loading • DonJoy Walking Boot (Cam Walker) • provides foot and ankle immobilization at 0º, 10º, and 20º plantarflexion • protected range of motion in 10º increments from 40º plantarflexion to 40º dorsiflexion • easily to don and doff • easy to distribute weight bearing pressures via ankle motion • provides protection from trauma • allows for daily dressings and external treatments • can be removed when not ambulating

  34. Overview of Intervention • Wounds were treated 5 X week with electrical stimulation in an aqueous solution for 30 min per session • Wounds were first dressed with hydrogels and eventually hydrocolloids • Walking Boot worn whenever weight bearing was anticipated (transfer & gait)

  35. Outcomes Heel 1-6-03 7-29-03

  36. Outcomes Plantar Surface 1-6-03 7-29-03

  37. Clinical Relevance • Case study does suggest that electrical stimulation and off-Loading for diabetic neuropathic wounds is a viable treatment option • Walking Boots that allow for ankle motion control offer an additional option for off-loading • Chronic diabetic foot ulcers can be treated effectively by physical therapists in conjunction with referring physicians • Chronic wounds in patients with severe comorbidities can be healed using electrical stimulation and off-Loading

  38. Tid Bits • Half Casts • Ambulatory Aids, • Molded Plastazote Sandals • Post-Operative Shoes • Pressure Relief, sculpting with Adhesive Felt Padding, Foot Orthoses, Rocker Soles • Modalities

  39. Shapero, C. Stanoch, J. Barrese, D. (2002). Acute Care Perspectives: 3 (11). APTA, pp1-6.

  40. Following Closure • Proper Footwear • Progress into Normal Weight Bearing Gait

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