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Interventions for Endocrine


Title: Interventions for Endocrine / Metabolic Bone Conditions Author: llacy Last modified by: SWEET, CHRISTINA Created Date: 5/4/2009 2:20:29 PM Document ... – PowerPoint PPT presentation

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Title: Interventions for Endocrine

Interventions for Endocrine
Diabetes Mellitus
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

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

Estimated Average Glucose (eAG)
  • Estimated Average Glucose (eAG) is a new way for
    patients to understand how well they are managing
  • Reduction of A1c by 1 10 reduction in
    relative risk of microvascular complications from

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.

Self monitoring of Blood Glucose (SMBG)
  • SMBG can aid in diabetes control by
  • Development of an individualized blood glucose
  • 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

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
  • 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

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

Hypoglycemia Treatment
  • Many people with diabetes like to carry glucose
  • 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
  • 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

  • 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

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

Signs and Symptoms of Hyperglycemia
  • High blood glucose
  • High levels of sugar in the urine
  • Frequent urination
  • Increased thirst

  • 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

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
  • Exercise increases sensitivity to insulin
    although mechanism is not well understood

  • 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.

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

Stress Management Basics
  • You cant control stress only your reaction to
  • 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

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

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

Self Monitoring
  • Blood pressure cuffs
  • Automated
  • Heart rate monitors

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

Skin Care and Foot Ware
  • Wear shoes / footwear
  • Inspect your skin
  • Take care of your skin
  • Check your shoes
  • See health care provider

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

Diabetic Mirror Inspection Light with
PolyCarbonate Mirror
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

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

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

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
  • 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.

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

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!

  • Goals of nutrition education in diabetes
  • 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

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

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
  • Eat fish twice a week.
  • Choose nonfat milk, 1 rather than 2 milk, or
    whole milk.

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

  • Intensity of exercise can be summarized as
  • 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.

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

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)

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)

Training Heart Rate Zone
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

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
  • 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

  • High-intensity resistance training improves
    glycemic control in older patients with type 2
  • 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
  • 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

  • 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
  • Control/Referent Group R Non-exercise control
  • Results
  • Systolic and diastolic blood pressure decreased
    significantly in the exercise group, but not the
  • 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

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

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

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

  • 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

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

Diabetic Foot Prevention Program
  • Podiatric Care
  • Regular visits, examinations, and footcare
  • Risk assessment
  • Early detection and aggressive treatment of new

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.

Diabetic Foot Prevention Program
  • Pressure Reduction
  • Cushioned insoles, custom orthoses, padded
  • pressure measurements
  • Computerized or Harris mat

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

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

  • Precautions
  • Heat/ice over areas of decreased sensation

Anodyne Therapy
  • Utilizes near infrared light to precipitate the
    release nitric oxide (NO) from hemoglobin and
    endothelial cells
  • Nitric oxide activates enzymes which cause
  • Used for diabetic neuropathic pain and may
    benefit hypoxic wounds.
  • http//

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

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.

  • 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

  • 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

  • The effect of monochromatic infrared energy on
    sensation in patients with diabetic peripheral
    neuropathy a double-blind, placebo-controlled
  • 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

  • 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
  • Anodyne therapy treatments significantly improve
    sensory impairment associated with peripheral

  • 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.

  • 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.

Therapeutic Exercises
  • Strengthening
  • Aerobic
  • Balance

Exercise with Peripheral Neuropathy
  • Recommended Exercises
  • Precaution / Contraindicated
  • Treadmill
  • Prolonged walking
  • Jogging
  • Step exercises
  • Swimming
  • Bicycling
  • Rowing
  • Chair exercises
  • Arm exercises
  • Other NWB exercise

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

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

Half Shoes
  • Wedges sole that ends proximal to the metatarsal
  • 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

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

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
  • Increased pressure under the metatarsal heads
  • Most common site for ulcerations
  • Impaired protective sensation
  • Ulcers can develop due to repetitive microtrauma

  • 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
  • People with hammertoe may have corns or calluses
    on the top PIP of that toe or on the tip of the
  • 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

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.

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)

Bunion Xrays
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
Management of Acute Charcot Neuropathic
  • Immobilization and reduction of stress are the
    mainstays of treatment for acute Charcot
  • Complete Non-Weight bearing with the use of
  • 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

Charcot Foot
Management of Acute Charcot Neuropathic
  • 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

Management of Post-Acute Charcot Neuropathic
  • 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

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

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.

  • 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.

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.

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

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

Surgical Intervention Cont
  • If the arthropathy is identified in its early
    stages and NWB is instituted, surgery is usually
  • 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

Post Surgical
  • Following surgery, patients are immobilized until
    skin temperatures and postoperative edema
  • 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.
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