Diabetic Neuropathy

1
This educational program is presented by
Integrated Practice Resources, LLC 8081
Congress Ave 2nd Floor Suite B Boca Raton, FL
33487 Phone [phone] Fax [phone]
2
Welcome to this program for physicians on the
detection and evaluation of Diabetic Neuropathy
with Loss of Protective Sensation.
3

• First, you will be presented with a clinical
  overview of diabetic neuropathy.
• Next, you will be introduced to a screening
  program for the detection of neuropathic loss of
  protective sensation and its confirmation using
  electrodiagnostic (EDX) testing.

4
THIS PRESENTATION INTRODUCES
AN ORGANIZED PROGRAM OF DIABETIC NEUROPATHY
DETECTION
5
Diabetic Neuropathy

• Its Detection and Evaluation

6
An expression often heard from patients who have
foot pain. . .
When your feet hurt, you hurt all over.
7
But when feet should hurt when injured, yet they
do not. . .

• Think Diabetic Neuropathy with Loss of Peripheral
  Sensation (LOPS)

8
Diabetic Neuropathy with Loss of Peripheral
Sensation (LOPS)

• Persons with LOPS are not aware of minor foot
  injuries that can become major problems.
• Even continuing to walk on a little pebble in the
  shoe that is not felt can result in skin injury,
  an open sore, ulcer formation, infection, and
  amputation.
• The cause of LOPS is believed to be related to
  blockage of small arteries that supply blood to
  the affected nerves.

9
Diabetic ulcer in a patient with LOPS. This was
a complication of a small blister caused by
walking with a pebble in a shoe.
10
Diabetic Neuropathy Facts

• Diabetes mellitus is believed to affect 15 to 16
  million Americans.
• Diabetic neuropathy is one of the most common
  manifestations of diabetes and potentially its
  most debilitating.
• Most studies agree that the overall prevalence of
  symptomatic diabetic neuropathy is approximately
  30 of all patients with diabetes.
• Because many patients are asymptomatic, it
  quietly and insidiously places its victim at high
  risk for devastating complications.

11
Classification of Diabetic Neuropathy

• A. Diffuse Neuropathy
• 1. Distal symmetric sensorimotor neuropathy
• 2. Autonomic neuropathy
• a. Sudomotor
• b. Cardiovascular
• c. Gastrointestinal
• d. Genitourinary
• 3. Symmetrical proximal lower limb motor
  neuropathy (amyotrophy)
• B. Focal Neuropathy
• 1. Cranial neuropathy
• 2. Radiculopathy and plexopathy
• 3. Entrapment neuropathy

12
Complications of Diabetic Neuropathy

• Foot ulceration
• Gangrene
• Amputations
• Sexual dysfunction
• Sudden death from cardiac arrhythmias

13
Complications of Diabetic Neuropathy

• Those patients who are symptomatic complain of
  frequent or continuous pain, numbness, or other
  severe discomfort in the affected extremity or
  dermatome.
• Despite the prevalence of diabetic neuropathy,
  many physicians fail to recognize it, and if they
  do recognize it, many fail to evaluate or treat
  these patients appropriately.
• Medical science stands poised to take a very
  aggressive approach to diabetic neuropathy
  preventing it, diagnosing it, controlling its
  secondary complications and symptoms, and
  possibly even reversing it.

14
Preventing Complications of Diabetic Neuropathy

• Physicians who screen for loss of protective
  sensation can play an important role in detecting
  and assessing diabetic neuropathy and preventing
  life threatening complications.
• A four-step neuropathy detection and evaluation
  program can be easily implemented in physicians
  offices.

15
Four-Step Diabetic Neuropathy Detection/Evaluation
Program

• STEP 1 Identify all patients who have diabetes
  when taking medical histories.
• STEP 2 Screen all diabetic patients over age 40
  for neuropathy irrespective of their presenting
  symptoms.
• STEP 3 Schedule patients who have positive
  screening results and are not under medical care
  for neuropathy for electrodiagnostic (EDX)
  confirmation and evaluation.
• STEP 4 Appoint patients who have had neuropathy
  detected, confirmed, and evaluated for a
  follow-up visit to outline a program of
  prevention and treatment.

16
EDX Testing for Diabetic Neuropathy

• Nerve conduction studies can demonstrate both
  demyelination and axonal degeneration.
• Demyelination primarily affects the nerve
  conduction velocity, which is slowed.
• Among the earliest detectable findings in
  diabetic neuropathy are distal slowing of nerve
  conduction velocity with axonal degeneration.
• Reduced amplitudes are a later finding consistent
  with advanced neuropathy.

17
Screening for LOPS

• Screen patients for loss of peripheral sensation
  (LOPS) with a 10, 5.07 Semmes-Weinstein
  monofilament.

18

• TESTING FILAMENTS AND PRINTED SCREENING
  DIRECTIONS ARE AVAILABLE AT NO CHARGE FROM THE
  FEDERAL HEALTH AND HUMAN SERVICES (HHS)
  DEPARTMENT
• Lower Extremity Amputation Prevention
• (LEAP) Program
• General Information Website
• And To Order Monofilaments
• www.hrsa.gov/leap

19
LOPS Monofilament Screening

• The 10 monofilament correlates with protective
  sensation.
• Protective sensation may be lost when the
  filament cannot be felt.
• The sensory exam should be done in a quiet and
  relaxed setting. The patient must not watch while
  you apply the filament.
• Test the monofilament on the patient's hand so
  he/she knows what to anticipate.
• Test at least 5 sites on each foot. Apply the
  monofilament perpendicular to the skin's surface.
• Apply just enough pressure to bend the
  monofilament.

20
Press until the filament bends.
21
Locations To Test
22
LOPS Monofilament Screening

• The total duration of the approach, skin contact,
  and departure of the filament should be
  approximately 1-1/2 seconds.
• Apply the filament along the perimeter and NOT ON
  an ulcer site, callus, scar or necrotic tissue.
  Do not allow the filament to slide across the
  skin or make repetitive contact at the test site.
  
• Press the filament to the skin so that it buckles
  at one of two times as you say "time one" or
  "time two." Have patients identify at which time
  they were touched. Randomize the sequence of
  applying the filament throughout the examination.
  
• Diabetic neuropathy is suggested when the patient
  cannot feel four or more sites.

23

• FOR INFORMATION ABOUT
• ELECTRODIAGNOSTIC TESTING FOR
• DIABETIC NEUROPATHY AND COMPLIMENTARY SCREENING
  MATERIALS
• contact a
• Integrated Practice Resources, LLC
• Physician Representative
• 1- [phone]