Title: Interventions for Endocrine
1Interventions for Endocrine
2Diabetes Mellitus
3Patient Education
- Patient and family education assumes a primary
role in prevention - Blood Glucose Levels
- Effects of exercise on blood glucose levels
- Stress Management
- Exercise logs
- Proper foot ware and skin care
- Vitals
- Self monitoring Heart rate / BP
- Perceived exertion
- Weight management
4Blood Glucose Levels
- Fasting blood glucose levels
- Normal ? lt110 mg/dL
- Unsafe for exercise
- Do not exercise if blood glucose is over 240 and
Ketones (sign of fat metabolism) are present - Hemoglobin A1c
- Normal ? lt 6.5
- Ketones
- Urinary ketone testing is important in patients
with type 1 diabetes - Test strips are available at pharmacies
5Estimated Average Glucose (eAG)
- Estimated Average Glucose (eAG) is a new way for
patients to understand how well they are managing
diabetes. - Reduction of A1c by 1 10 reduction in
relative risk of microvascular complications from
DM
6Self Monitoring of Blood Glucose (SMBG)
- Self-monitoring of blood glucose (SMBG) is an
important component to the control diabetes - SMBG has been recommended for people with
diabetes in order to achieve a specific level of
glycemic control and to prevent hypoglycemia - SMBG has become a standard of care in the
management of diabetes.
7Self monitoring of Blood Glucose (SMBG)
- SMBG can aid in diabetes control by
- Development of an individualized blood glucose
profile - SMBG data can be helpful in creating or modifying
the diabetes management regimen - Giving people with diabetes and their families
the ability to make appropriate day-to-day
treatment choices in diet and physical activity
as well as in insulin or other agents - Improving patients recognition of hypoglycemia
or severe hyperglycemia - Enhancing patient education and patient
empowerment regarding the effects of lifestyle
and pharmaceutical intervention on glycemic
control.
8Performing Self-Monitoring of Blood Glucose
(SMBG) by Diabetes Type
- Type-1 diabetes
- Perform SMBG three or more times per day.
- Adjust intensity of monitoring to intensity of
insulin therapy. - Perform SMBG three or more times every day when
multiple doses of insulin are administered every
day. - Type-2 diabetes
- The exact frequency is undetermined.
- Perform SMBG at a sufficient rate to reach
glucose goals. - If taking insulin therapy, perform SMBG three or
more times each day. - Gestational diabetes mellitus
- Perform SMBG three or more times each day.
- Data from the American Diabetes Association3
DiPiro JT, et al., 20026and Mooradian AD, et
al., 1998.8
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10Symptoms of Hypoglycemia
- Shakiness
- Dizziness
- Sweating
- Hunger
- Headache
- Pale skin color
- Sudden moodiness or behavior changes, such as
crying for no apparent reason - Clumsy or jerky movements
- Seizure
- Difficulty paying attention, or confusion
- Tingling sensations around the mouth
11Hypoglycemia Treatment
- The quickest way to raise blood glucose and treat
hypoglycemia is with some form of sugar. - Once you've checked blood glucose and treated
hypoglycemia, wait 15 or 20 minutes and check
blood glucose again. - If blood glucose is still low and symptoms of
hypoglycemia don't go away, repeat the treatment.
- Encourage the patient to eat your regular meals
and snacks as planned to keep their blood glucose
level up. - If the patient passes out, get immediate medical
attention.
12Hypoglycemia Treatment
- Many people with diabetes like to carry glucose
tablets. - Other sources of sugar or simple carbohydrates
also work well to treat hypoglycemia, such as
fruit juice, hard candies, pretzels or crackers.
- The important thing is to get at least 15-20
grams of sugars or carbohydrates. - To treat hypoglycemia you should stick with
something that is mostly sugar or carbohydrates. - Foods that have a lot of fat as well as sugars
and carbohydrates, such as chocolate or cookies,
do not work as quickly to raise blood glucose
levels. - Foods with 15 grams carbohydrates
- 4 oz (1/2 cup) of juice or regular soda
- 2 tablespoons of raisins
- 4 or 5 saltine crackers
- 4 teaspoons of sugar
- 1 tablespoon of honey or corn syrup
13Hyperglycemia
- Hyperglycemia is the term for high blood glucose,
happens when the body has too little insulin or
when the body can't use insulin properly. - A major cause of complications with diabetes
- Hyperglycemia happens from time to time to all
people who have diabetes. - Learn to identify the symptoms of hyperglycemia
so you can treat it quickly. - When high, patients can lower blood glucose level
by exercising, unless ketones are present in your
urine.
14What causes hyperglycemia?
- Type 1 Patient may not have given themself
enough insulin. - Type 2 Their body may have enough insulin, but
it is not as effective as it should be. - Patient ate more than planned or exercised less
than planned. - Stress from an illness, such as a cold or flu.
- Other stress, such as family conflicts or work or
financial stress
15Signs and Symptoms of Hyperglycemia
- High blood glucose
- High levels of sugar in the urine
- Frequent urination
- Increased thirst
16Ketoacidosis
- If you fail to treat hyperglycemia, ketoacidosis
(diabetic coma) could occur. - Ketoacidosis develops when the body doesn't have
enough insulin. Without insulin, the body can't
use glucose so the body breaks down fats to use
for energy. - When the body breaks down fats, waste products
called ketones are produced. - The body cannot tolerate large amounts of ketones
and will try to get rid of them through the
urine. Unfortunately, the body cannot release all
the ketones and they build up in the blood, which
can lead to ketoacidosis. - Ketoacidosis is life-threatening and needs
immediate treatment. Symptoms include - Shortness of breath
- Breath that smells fruity
- Nausea and vomiting
- Very dry mouth
17Effects of exercise on blood glucose levels
- Chronic hyperglycemia in both type 1 and 2 DM is
considered to be a significant factor in the
development of microvascular complications - Exercise improves glucose uptake and exercise
training was shown to decrease insulin
requirements. - Exercise increases sensitivity to insulin
although mechanism is not well understood
18Evidence
- Investigation of effect on glycosylated
hemoglobin, blood pressure, and body mass index
of diabetes intensive education program in
patients with type 2 diabetes mellitus - Beyazit E, Mallaoglu M Am J Mens Health 2011
5(4) 351-357 - A Diabetes Intensive Education Program in
Patients (DIEP) intervention program improved - systolic and diastolic blood pressure and
glycemic control through patient self-management
education, establishment of an individualized
care plan, behavioral goal setting, and close
surveillance of patients. - In this study, A1C levels decreased by 2 in the
intervention group as compared with 0.1 in the
control group.
19Stress Management
- Stress affects blood glucose levels
- A body under stress reacts by pumping stress
hormones into the blood. - such as cortisol norepinephrine
- The hormones make the body release stored glucose
and fat so the body has extra energy - The extra glucose can only be used if there is
enough insulin - Stress hormones also effect the bodys ability to
use insulin
20Stress Management Basics
- You cant control stress only your reaction to
stress - Concentrate on how you react!
- Deal with today, not yesterday or tomorrow
- Listen to music
- Exercise
- Get good rest
- Write in journal
- Learn to say no!
- Laugh
21Exercise Logs
- Patients should keep logs of the following when
starting a new exercise program. Include - Blood glucose
- Ketones present
- Blood pressure
- Resting HR
- Exercise HR
- Perceived exertion
- Exercise time / distance
22Exercise Log for ___________
Date
Blood Glucose
Ketones present?
Blood pressure
Resting Heart rate
Exercise Heart rate
Perceived exertion
Exercise time
Exercise mode
23Vitals
- Blood Pressure
- At every visit
- Goal lt 130/80
- Heart rate
- Teaching patients how to monitor HR
- Resting
- After warm up
- During exercise
- After exercise
- 5 minutes after completing
24Self Monitoring
- Blood pressure cuffs
- Automated
- Heart rate monitors
25Ratings of Perceived Exertion
- RPE
- 0
- 0.5
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- Intensity Level
- Nothing
- Very, Very weak
- Very weak
- Weak (light)
- Moderate
- Somewhat strong
- Strong
- Very strong
- Very, very strong
26Skin Care and Foot Ware
- Wear shoes / footwear
- Inspect your skin
- Take care of your skin
- Check your shoes
- See health care provider
27Inspect your skin
- Look at your feet everyday
- Including bottoms of feet and between toes
- Mirrors
- Magnifying glass
- Family members / CG
- Look out for these things on your feet
- Blisters
- Sores
- Corns
- Calluses
- Red spots
- Swelling
- Drainage from sore
- Broken toenails
- Cracked skin
- Odor
- Pain
28Diabetic Mirror Inspection Light with
PolyCarbonate Mirror
29Take Care of Your Skin
- Wash feet gently everyday
- Dry feet well
- Lotions to soften dry skin (non alcohol based)
- Never treat corns, calluses or toe nails with
sharp instruments - Cut toenails straight across
- Padding / air circulation
- Clean white socks
- Do not walk barefoot
- No heating pad to warm feet
30Check your Shoes
- Check every day before you put them on
- Check size and width
- Do not wear old worn out shoes or socks
- Shop in afternoon
- Break in new shoes gradually
31See Health Care Provider
- Get blood glucose under control
- Keep regular appointments with Doctor
- Call your health care provider immediately if you
find a wound on your foot
32American Diabetes Association, Clinical Practice
Recommendations, 2011
- The physician should evaluate blood glucose
control and disease complications. - The patient with diabetes (type 1 or 2) should
have the following - An annual retinal eye exam.
- Glycemic control The A1C goal for patients in
general is an A1C goal of lt7. A Hemoglobin A1C
(HbA1c) test two times a year if stable glycemic
control quarterly in patients whose therapy has
changed or who are not meeting glycemic goals. - An annual LDL-C screening performed, with a
goal of lt100mg/dl as the primary goal of therapy
for adults. Very high-risk patients, LDL
lt70mg/dl. - Nephropathy screening should be performed
annually to test for the presence of
microalbuminuria in type 1 diabetic patients with
diabetes duration of 5 years and in all type 2
diabetic patients, starting at diagnosis and
during pregnancy. -
33Weight Management
- BMI Classification
- 18.5 or less Underweight
- 18.5 to 24.99 Normal Weight
- 25 to 29.99 Overweight
- 30 to 34.99 Obesity (Class 1)
- 35 to 39.99 Obesity (Class 2)
- 40 or greater Morbid Obesity
34Weight Management
- For overweight patients, losing as little as 7-10
percent of body weight may improve many of the
problems linked to being overweight, such as high
blood pressure and diabetes. - Slow and steady weight loss of no more than 1-2
pounds per week is the safest way to lose weight. - Too rapid weight loss can cause muscle loss
rather than fat. It also increases the chances of
developing other problems, such as gallstones and
nutrient deficiencies. - Making long-term changes in eating and physical
activity habits is the only way to lose weight
and keep it off!
35Nutrition
- Goals of nutrition education in diabetes
management - To achieve and sustain blood glucose
- Blood pressure levels as near normal
- Maintain a lipid profile that decreases the risk
for developing CVD - Prevent chronic complications
- Address individual nutrition needs
- Maintain the pleasure of eating
- Referral to Register Dietitian
36Nutrition Carbohydrates
- Promoting healthful, quality carbohydrate sources
such as whole grains, fruit, vegetables, and
low-fat or non-fat dairy, rather than highly
processed foods and sweets, makes good
nutritional sense. - Using sweets and sugars in moderation is
recommended, especially for individuals who need
to lose weight
37Nutrition Fats
- Choose leaner meats
- Eat foods containing water-soluble fiber, oatmeal
or other whole grain oat cereal, dried beans,
fruit, and vegetables - Use less added sauces and gravies
- Choose olive or canola oil, or trans fat free,
soft tub margarines in place of solid spreads or
butter. - Eat fish twice a week.
- Choose nonfat milk, 1 rather than 2 milk, or
whole milk.
38Therapeutic Exercises
- Strengthening
- Aerobic
- Graded Exercise Test
- Where to start
- Warm up and cool down period
- Proper foot ware
- Diabetes identity bracelet
- Hydration is important to prevent elevation in
blood glucose and abnormal heart function
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40Benefits of Exercise
- Decreases the risk factors for CAD
- Improves lipid profile
- Decrease Blood pressure
- May decrease body weight and body fat (esp.
intra-abdominal fat) - Help prevent or delay the onset of type 2 diabetes
41EXERCISE INTENSITY
- Intensity of exercise can be summarized as
follows - Light Intensity is 40-59 of max HR reserve.
- This range is reserved for those starting an
exercise program after years of inactivity. - Moderate Intensity is 60-74 of max HR reserve.
- This is the normal range for most people.
- High or Vigorous Intensity is 75 and higher of
the Max HR reserve. - This level of effort is for athletes desiring a
high level of fitness.
42What is maximum HR reserve?
- Heart rate reserve (HRR) is a term used to
describe the difference between a person's
measured or predicted maximum heart rate and
resting heart rate. - A more accurate target heart rate zone using
Karvonen Formula - THR ((HRmax - HRrest) intensity) HRrest
43Maximum HR Example
- 43 year old
- 220-43177 (max HR)
- 177 x .50 88 (light intensity)
- 177 x .70 124 (moderate intensity)
- 177 x .90 159 (high intensity)
44Maximum HR Reserve Example
- 43 year old with a resting heart rate of 68
- 220-43177 (max HR)
- 177-68 109 (HR reserve)
- 109 x .50 68 122 (light intensity)
- 109 x .70 68 144 (moderate intensity)
- 109 x .90 68 166 (high intensity)
45Training Heart Rate Zone
46Exercise programs Type 2 DM
- 3-5 days per week
- For the majority of type 2 DM, low to moderate
intensity (40-70 VO2 max) - Minimum of 10-15 minutes each session with goal
of 60 minutes - Risk and complication
- Acute Glycemic responses
47Exercise and DM
Intensity HRmax RPE
Very light lt35 0-1
Light 35-54 2
Moderate 55-69 3
Hard 70-89 4-6
Very Hard gt90 7-8
Maximal 100 9-10
48Evidence
- The effect of combined resistance and home-based
walking exercise in type 2 diabetes patients - Aylin K, Arzu D, Sabri S, Hadan TE, Ridvan A
Int J Diabetes Dev Ctries 2009 29(4) 159-165 - 27 men and 11 women
- The mean age of the participants was 54.3 years
- Exercise training that includes resistance
training and home-based walking could be safe,
effective, and beneficial for patients with
diabetes
49Evidence
- High-intensity resistance training improves
glycemic control in older patients with type 2
diabetes - Dunstan DW, Daly RM, Owen N, Jolley D, De Courten
M, Shaw J, Zimmet P Diabetes Care 2002
25(10) 1729-1736 - 36 participants
- Treatment Group 1 High-intensity progressive
resistance training - Treatment Group 2 Control program (flexibility
exercise) - This study demonstrated that a high-intensity
resistance training program was safe and well
tolerated by older patients with type 2 diabetes
and was effective in improving glycemic control
and muscle strength
50Evidence
- The acute effects of in-patient physiotherapy
program on functional capacity in type II
diabetes mellitus - Ozdirenc M, Kocak G, Guntekin R Diabetes Res
Clin Pract 2004 64(3) 167-172 - Inclusion Criteria
- Type II diabetes due to poor glycemic control,
cardiac events, and/or foot problems. - 44 participants
- Treatment Group 1 Exercise rehabilitation
group. - Control/Referent Group R Non-exercise control
group. - Results
- Systolic and diastolic blood pressure decreased
significantly in the exercise group, but not the
control. - Distance walked during the 6-minute walk test
increased significantly more in the exercise
group then in the control group. - Estimated VO2max increased more in the exercise
group
51Acute Glycemic Response
- Moderate intensity exercise increases glucose
uptake by 2-3 mg/kg/min above usual requirements - Replenish glycogen stores after exercise
- To prevent hypoglycemia
- Time exercise to medication
- Good nutrition
- Glucose monitoring before and after exercise
52Exercise Programs Type 1 DM
- Metabolic control before exercise
- AVOID exercise if fasting glucose gt 240 mg/dl
and/or ketones are present - Ingest CHO if glucose is lt 100 mg/dl
- Glucose monitoring before and after exercise
- May need to adjust insulin and/or food intake
- Food intake
- Add CHO to avoid hypoglycemia
- Have CHO rich foods available during and after
exercise
53Gait Training
- Foot ware
- Diabetic shoes
- Often wider and deeper to allow orthotics which
are custom made - Diabetic socks
- Extend to the knee and provide firm support
- Well padded
- Absorb moisture
- Devices
- Walkers, canes, crutches
- Balance
- Diabetic patients walk slower, with greater step
variability, and present higher plantar pressure
than healthy controls - Stairs
54Evidence
- The gait and balance of patients with diabetes
can be improved a randomised controlled trial
- Allet L, Armand S, de Bie RA, Golay A, Monnin D,
Aminian K, Staal JB, de Bruin ED Diabetologia
2010 53(3) 458-466 - Type 2 diabetes and a clinical neuropathy.
Clinical neuropathy was evaluated with a tuning
fork on a 9 point scale. - The average score for the intervention group was
3.23 and the average score for the control group
was 3.32 - 71 participants
- The gait speed and balance of diabetic patients
with a vibration perception of less than or equal
to 4 can be improved with exercise intervention
55Diabetic Neuropathy
56Patient Education
- Comprehensive foot care instructions
- Reduce amputations by 45-85
- Decrease weight bearing stresses
- Diabetic education
57Diabetic Foot Prevention Program
- Podiatric Care
- Regular visits, examinations, and footcare
- Risk assessment
- Early detection and aggressive treatment of new
lesions
58Diabetic Foot Prevention Program
- Protective Shoes
- Adequate room to protect from injury well
cushioned walking sneakers, extra depth,
custom-molded shoes - special modifications as necessary.
59Diabetic Foot Prevention Program
- Pressure Reduction
- Cushioned insoles, custom orthoses, padded
hosiery - pressure measurements
- Computerized or Harris mat
60Diabetic Foot Prevention Program
- Prophylactic Surgery
- Correct structural deformities
- Hammertoes
- Bunions
- Charcot
- Prevent recurrent ulcers over deformities
- Intervene at opportune time
61Diabetic Foot Prevention Program
- Preventive Education
- Patient education need for daily inspection and
necessity for early intervention - Physician education significance of foot
lesions, importance of regular foot examination,
and current concepts of diabetic foot management
62Modalities
- Precautions
- Heat/ice over areas of decreased sensation
63Anodyne Therapy
- Utilizes near infrared light to precipitate the
release nitric oxide (NO) from hemoglobin and
endothelial cells - Nitric oxide activates enzymes which cause
vasodilatation. - Used for diabetic neuropathic pain and may
benefit hypoxic wounds. - http//mhhs.woundcenter.net/2005_SAWC_anodyne_case
_report.pdf
64Anodyne Therapy
- Anodyne Infrared Therapy Systems are medical
devices that are indicated to increase
circulation and reduce pain, stiffness, and
muscle spasm - Anodyne therapy comes from the word anodyne,
meaning a medical treatment that soothes or
relieves pain. Anodyne therapy was first used in
1994.
65Anodyne Therapy
- Anodyne therapy is now being investigated for a
number of uses, including diabetic neuropathy - All forms of Anodyne therapy use infrared light.
Pads that emit the light are applied to the
surface of the skin. - At times, Anodyne therapy will resolve symptoms
in one or only a few sessions. For other
individuals, however, ongoing Anodyne therapy may
be necessary to experience relief from symptoms.
66Evidence
- Does anodyne light therapy improve peripheral
neuropathy in diabetes? A double-blind,
sham-controlled, randomized trial to evaluate
monochromatic infrared photoenergy - Lavery LA, Murdoch DP, Williams J, Lavery DC
Diabetes Care 2008 31(2) 316-321 - The authors concluded that there was no
statistical evidence that anodyne therapy was
effective in improving sensory perception
compared with the sham treatment
67Evidence
- Reversal of diabetic peripheral neuropathy with
phototherapy (MIRE) decreases falls and the fear
of falling and improves activities of daily
living in seniors - Powell MW, Carnegie DH, Burke TJ Age Ageing
2006 35(1) 11-16 - Reversal of peripheral neuropathy and use of
monochromatic near-infrared phototherapy (MIRE)
at home contributed to a 78 decrease in falls, a
79 decrease in balance-related fear of falling,
and a 72 increase in ADL
68Evidence
- The effect of monochromatic infrared energy on
sensation in patients with diabetic peripheral
neuropathy a double-blind, placebo-controlled
study - Clifft JK, Kasser RJ, Newton TS, Bush AJ
Diabetes Care 2005 28(12) 2896-2900 - No significant difference was found between
active and placebo monochromatic infrared energy
in improving plantar sensation in patients with
diabetic peripheral neuropathy
69Evidence
- Improvement of sensory impairment in patients
with peripheral neuropathy - Prendergast JJ, Miranda G, Sanchez M Endocr
Pract 2004 10(1) 24-30 - 21 patients with a diagnosis of diabetic
peripheral neuropathy, 6 patients with neuropathy
attributable to non-diabetic causes - All subjects received 10 forty-minute treatments
of Anodyne Therapy over a two week time period.
Anodyne treatments consisted of near infrared
photoenergy (890 nm) that was pulsed at 292 times
per second with a 50 duty cycle. Power density
was 8 mW/cm2 with average power per pad at 480
mW. - Anodyne therapy treatments significantly improve
sensory impairment associated with peripheral
neuropathy
70Evidence
- Improved sensitivity in patients with peripheral
neuropathy effects of monochromatic infrared
photo energy - DeLellis SL, Carnegie DH, Burke TJ J Am
Podiatr Med Assoc. 2005 95(2) 143-147 - The authors state that treatment with the
monochromatic infrared photo energy (MIRE) was
associated with improved foot sensation to the
5.07 Semmes-Weinstein monofilament in 1047
patients that were initially diagnosed with
peripheral neuropathy.
71Evidence
- Restoration of sensation, reduced pain, and
improved balance in subjects with diabetic
peripheral neuropathy a double-blind,
randomized, placebo-controlled study with
monochromatic near-infrared treatment - Leonard DR, Farooqi MH, Myers S Diabetes Care
2004 27(1) 168-172 - Anodyne Therapy System treatments in subjects who
have not progressed to profound sensory loss may
result in at least temporary restoration of
protective function.
72Therapeutic Exercises
- Strengthening
- Aerobic
- Balance
73Exercise with Peripheral Neuropathy
- Precaution / Contraindicated
- Treadmill
- Prolonged walking
- Jogging
- Step exercises
- Swimming
- Bicycling
- Rowing
- Chair exercises
- Arm exercises
- Other NWB exercise
74Gait Training
- Off loading
- Assistive devices
- Crutches
- Cane
- Orthotics
- Removable walker
- Charcot Restraint Orthotic Walker
- Half shoes
- Healing shoes
- Foot orthoses / shoe inserts
- Effective for reducing peak plantar pressure
under the MT heads - Good for prevention
75Removable Walker
- Padded removable AFO that immobilizes the ankle
- Has a rocker sole
- Includes pressure relieving insole
- Patient wears while walking
- Able to remove to inspect wound
76Half Shoes
- Wedges sole that ends proximal to the metatarsal
heads - Places the ankle in a small amount of
dorsiflexion to relieve MT head pressure - Eliminating toe off
- Not as effective as Removable Walker
- Not effective with heel cord contractures
77Healing Shoes
- Post-op shoes
- Not recommended while wound is still healing
- Removable pressure relief insoles
78Diabetes and Peripheral Neuropathy
- 30 of people with diabetes have some decreased
sensation in their feet - Diabetic neuropathy impairs the motor and sensory
function of the involved peripheral nerves - Impaired motor function
- Impaired muscle imbalances and can lead to foot
deformities - Increased pressure under the metatarsal heads
- Most common site for ulcerations
- Impaired protective sensation
- Ulcers can develop due to repetitive microtrauma
79Hammertoes
- Deformity of the second, third or fourth toes.
- The toe is bent at the PIP, so that it resembles
a hammer. - Hammertoes have flexion deformities of the PIP
joint, and flexible MP and DIP joints - Initially, hammertoes are flexible and can be
corrected with simple measures but, if left
untreated, they can become fixed and require
surgery. - People with hammertoe may have corns or calluses
on the top PIP of that toe or on the tip of the
toe. - They may also feel pain in their toes or feet and
have difficulty finding comfortable shoes.
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81Hammertoes Treatment
- Conservative treatment starts with new shoes that
have soft, roomy toe boxes. - Shoes should be one-half inch longer than the
longest toe - Avoid tight, narrow, high-heeled shoes
- Sandals as long as they do not pinch or rub other
areas of the foot - Toe exercises for HEP
- Gently stretch the toes manually
- Using toes to pick things up off the floor.
- Towel flat under your feet and use your toes to
crumple it - Surgery if conservative measures fail
82Surgical Correction of Hammertoe
- Simple outpatient surgery with limited downtime.
- The best option is to fuse the deformed and
contracted digit in a straight position. - This limits the need for future surgery and
deformity return. - In certain cases, a removal of a small area of
bone in the deformity area will decrease pain and
limit the need for a surgical waiting period that
is found with fusions. - Although the toe is not as stable as with a
fusion, in certain cases, an arthroplasty is the
best option for some patients.
83http//www.footankleinstitute.com
84Bunions Hallux Valgus
- The bunion is the enlarged medial prominence of
the first MTP joint. - Often there are secondary lesser toe deformities
(corns, calluses, hammertoes) - Treatment
- Shoe change widen the toe box,
- Arch heel support (bunion pads crowd shoe)
85Bunion Xrays
86Bunion Surgeries
Tightrope bunion procedure with re-alignment of
the 1st metatarsal and the great toe position.
Note metal anchors securing the Tightrope cord in
place between the two bones
Drawing of bunion after surgery. Note the shift
of the 1st metatarsal towards the second
metatarsal for realignment of the column and
fixation of the bones together with the two
screws from top to bottom
http//www.footankleinstitute.com
87Management of Acute Charcot Neuropathic
Osteoarthropathy
- Immobilization and reduction of stress are the
mainstays of treatment for acute Charcot
arthropathy - Complete Non-Weight bearing with the use of
crutches - There is an increase in pressure to the
contralateral limb predisposing it repetitive
stress and ulceration or neuropathic fracture - Following a period of off-loading, a reduction in
skin temperature and edema indicates the stage of
quiescence at which point the patient progresses
into the post-acute phase of treatment
88Charcot Foot
89Management of Acute Charcot Neuropathic
Osteoarthropathy
- Adjunctive treatment
- Bisphosphonate therapy
- Bisphosphonates are specifically targeted to the
skeleton but may even localize preferentially at
sites of active bone resorption - to help expedite the conversion of the acute
process to the quiescent, reparative stage - When it comes to using bisphosphonates during the
acute phase of Charcot, the research is limited,
but promising - Ancillary bone growth stimulation
- promote rapid consolidation of fractures
90Management of Post-Acute Charcot Neuropathic
Osteoarthropathy
- Progression to protected weight bearing is
permitted, usually with the aid of some type of
assistive device - Application of total contact casts or other
off-loading modalities - Bi-valved cast
- total contact casting (TCC)
- patellar tendon-bearing braces
- Usually 4-6 months before returning to permanent
foot ware
91Bivalved Cast
- is cut in half to detect or relieve pressure
underneath, especially when a patient has
decreased or no sensation in the portion of the
body
92Total Contact Casting (TCC)
- The TCC employs a well-molded, minimally padded
cast that maintains contact with the entire
plantar aspect of the foot and lower leg. - Functions to mechanically unload the ulcer site
and reduce the vertical shear stresses,
redistributing the pressure of walking over the
entire foot and lower leg. - The application
- Requires a skilled technician
- considerable application time
- numerous applications over the duration of
plantar ulcer healing - It has been well documented that improper cast
application can cause ulceration.
93Evidence
- Bone mineral density during total contact cast
immobilization for a patient with neuropahtic
(Charcot) arthropathy - Hastings MK, Sinacore DR, Fielder FA, Johnson JE
Phys Ther 2005 85(3) 249-256 - Total contact casting as a treatment to resolve
inflammation and protect the foot from additional
trauma was supported by the decrease in skin
temperature and edema during intervention period.
- Loss of bone during cast immobilization and NWB
indicates that the intervention may increase risk
of future fractures. - Important to protect the foot as weight bearing
activities progress and provide protective
footwear. Individual started osteoporotic.
94Patellar Tendon-Bearing Braces
- Winged tibia plate is pre-formed to fit the tibia
and support patellar tendon bearing - Unique rocker design allows patients to closely
simulate a near normal gait without abnormal
loads on any joints - Long-term PTB brace use, especially in the
limited weight-bearing patient, should be
regularly adjusted to ensure adequate brace fit.
95Charcot Restraint Orthotic Walker
- Custom molded
- Fully padded
- The weight-relieving AFO minimizes the forces
going through the foot. - The rocker bottom and the custom molded insert
enhance healing and off-loading of the affected
area.
96Surgical Intervention
- Reconstructive surgery may be considered if a
deformity or instability exists that cannot
effectively be controlled or accommodated by
prescription footwear or bracing - The goal of any surgery undertaken on the Charcot
foot is to create a stable, plantigrade foot that
may be appropriately accommodated
97Surgical Intervention Cont
- If the arthropathy is identified in its early
stages and NWB is instituted, surgery is usually
unnecessary - surgery in the acute stage is generally not
advisable due to the extreme hyperemia,
osteopenia, and edema present - Surgical intervention during the acute phase,
however, may be considered in the presence of
acute subluxation without osteochondral
fragmentation
98Post Surgical
- Following surgery, patients are immobilized until
skin temperatures and postoperative edema
normalize - prolonged cast immobilization
- progress to a removable cast walker
- followed by permanent prescription footwear
- Mean times from surgery to the wearing of
therapeutic shoes have been reported in the range
of 7 months.