Interventions for Endocrine

1
Interventions for Endocrine
2
Diabetes Mellitus
3
Patient 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

4
Blood 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

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Estimated 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

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Self 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.

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Self 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.

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Performing 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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Symptoms 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

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Hypoglycemia 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.

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Hypoglycemia 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

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Hyperglycemia

• 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.

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What 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

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Signs and Symptoms of Hyperglycemia

• High blood glucose
• High levels of sugar in the urine
• Frequent urination
• Increased thirst

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Ketoacidosis

• 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

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Effects 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

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Evidence

• 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.

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Stress 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

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Stress 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

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Exercise 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

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Exercise Log for ___________
Date
Blood Glucose
Ketones present?
Blood pressure
Resting Heart rate
Exercise Heart rate
Perceived exertion
Exercise time
Exercise mode
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Vitals

• 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

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Self Monitoring

• Blood pressure cuffs
• Automated
• Heart rate monitors

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Ratings 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

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Skin Care and Foot Ware

• Wear shoes / footwear
• Inspect your skin
• Take care of your skin
• Check your shoes
• See health care provider

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Inspect 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

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Diabetic Mirror Inspection Light with
PolyCarbonate Mirror
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Take 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

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Check 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

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See 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

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American 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.

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Weight 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

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Weight 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!

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Nutrition

• 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

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Nutrition 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

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Nutrition 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.

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Therapeutic 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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Benefits 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

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EXERCISE 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.

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What 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

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Maximum 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)

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Maximum 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)

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Training Heart Rate Zone
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Exercise 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

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Exercise 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
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Evidence

• 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

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Evidence

• 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

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Evidence

• 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

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Acute 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

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Exercise 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

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Gait 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

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Evidence

• 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

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Diabetic Neuropathy
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Patient Education

• Comprehensive foot care instructions
• Reduce amputations by 45-85
• Decrease weight bearing stresses
• Diabetic education

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Diabetic Foot Prevention Program

• Podiatric Care
• Regular visits, examinations, and footcare
• Risk assessment
• Early detection and aggressive treatment of new
  lesions

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Diabetic Foot Prevention Program

• Protective Shoes
• Adequate room to protect from injury well
  cushioned walking sneakers, extra depth,
  custom-molded shoes
• special modifications as necessary.

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Diabetic Foot Prevention Program

• Pressure Reduction
• Cushioned insoles, custom orthoses, padded
  hosiery
• pressure measurements
• Computerized or Harris mat

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Diabetic Foot Prevention Program

• Prophylactic Surgery
• Correct structural deformities
• Hammertoes
• Bunions
• Charcot
• Prevent recurrent ulcers over deformities
• Intervene at opportune time

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Diabetic 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

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Modalities

• Precautions
• Heat/ice over areas of decreased sensation

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Anodyne 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

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Anodyne 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.

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Anodyne 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.

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Evidence

• 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

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Evidence

• 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

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Evidence

• 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

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Evidence

• 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

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Evidence

• 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.

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Evidence

• 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.

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Therapeutic Exercises

• Strengthening
• Aerobic
• Balance

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Exercise with Peripheral Neuropathy

• Recommended Exercises

• Precaution / Contraindicated

• Treadmill
• Prolonged walking
• Jogging
• Step exercises

• Swimming
• Bicycling
• Rowing
• Chair exercises
• Arm exercises
• Other NWB exercise

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Gait 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

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Removable 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

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Half 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

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Healing Shoes

• Post-op shoes
• Not recommended while wound is still healing
• Removable pressure relief insoles

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Diabetes 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

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Hammertoes

• 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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Hammertoes 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

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Surgical 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.

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http//www.footankleinstitute.com
84
Bunions 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)

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Bunion Xrays
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Bunion 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
87
Management 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

88
Charcot Foot
89
Management 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

90
Management 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

91
Bivalved 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

92
Total 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.

93
Evidence

• 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.

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Patellar 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.

95
Charcot 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.

96
Surgical 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

97
Surgical 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

98
Post 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.