DIABETES INSENSATE FOOT - PowerPoint PPT Presentation

1 / 45
About This Presentation
Title:

DIABETES INSENSATE FOOT

Description:

DIABETES INSENSATE FOOT ... Compliant Ignore Treatment Recommendations Education is necessary to combat profile Assessment of ... presentation format: – PowerPoint PPT presentation

Number of Views:106
Avg rating:3.0/5.0
Slides: 46
Provided by: MichaelB183
Category:

less

Transcript and Presenter's Notes

Title: DIABETES INSENSATE FOOT


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 - gt 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 _at_ 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
(No Transcript)
15
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

16
Most Common Sites of Ulceration in Diabetics
  • 1st Metatarsal Head
  • Great Toe

17
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.

18
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

19
Pre-Ulceration
  • Local areas of non-blanchable erythema
  • Ecchymosis
  • Subcutaneous hematoma
  • Neuropathic fracture
  • Rapidly progress to unstable foot deformity
    lead to chronic ulceration

20
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

21
(No Transcript)
22
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

23
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

24
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

25
Walking Casts
  • Decrease pressure, decrease edema, protect from
    re-injury
  • Contraindicated for infected ulcers
  • Caution moderate or severe edema, fragile
    atrophic skin, deep ulceration

26
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

27
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.

28
Purpose
  • To Evaluate the efficacy of electrical
    stimulation and off-loading for the treatment of
    diabetic foot ulcers

29
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 gt 3 years)
  • Previous Care
  • Various topical applications
  • Various dressings
  • Antibiotics
  • Debridement

30
1-6-03
31
1-6-03
32
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

33
(No Transcript)
34
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 patients insensate foot,
    protecting it from further trauma
    microorganisms
  • Allows patient to be relatively active

35
(No Transcript)
36
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

37
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

38
(No Transcript)
39
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)

40
Outcomes Heel
1-6-03
7-29-03
41
Outcomes Plantar Surface
1-6-03
7-29-03
42
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

43
Tid Bits
  • Half Casts
  • Ambulatory Aids,
  • Molded Plastazote Sandals
  • Post-Operative Shoes
  • Pressure Relief, sculpting with Adhesive Felt
    Padding, Foot Orthoses, Rocker Soles
  • Modalities

44
Shapero, C. Stanoch, J. Barrese, D. (2002). Acute
Care Perspectives 3 (11). APTA, pp1-6.
45
Following Closure
  • Proper Footwear
  • Progress into Normal Weight Bearing Gait
Write a Comment
User Comments (0)
About PowerShow.com