DIABETES INSENSATE FOOT

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DIABETESINSENSATE FOOT

• October 27, 2005
• Michael S. Brogan, PT, DPT, PhD, CWS

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Statement of the Problem

• Diabetes is the 6th leading cause of death in the
  U.S. (1)
• From 1990 to 1998 prevalence of diabetes
  increased from 4.9 to 6.5 (2)
• Approximately 800,000 cases of diabetes are
  diagnosed each year in the U.S. (3)
• Approximately 17 million Americans (6.2 of pop.)
  have diabetes 5.9 million of them undiagnosed
  (3)
• Another 16 million have pre-diabetes (impaired
  glucose tolerance) (3)

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Complications of Diabetes

• Particularly devastating to the foot, often
  leading to amputation, if not treated early (4)
• 67 of hospital discharges for lower extremity
  amputations in 1997 were related to diabetes (4)
• 85 of diabetes-related amputations are preceded
  by the appearance of a foot ulcer (5)
• Between 1989 and 1992, an average of 54,000
  diabetic amputations were performed (6)
• In 1996, 86,000 people with diabetes underwent 1
  or more lower extremity amputations (6)
• Total cost for those amputations - gt 1.1 billion
  dollars (7)
• In 1995, average individual cost of a minor
  amputation was 43,000, and a major amputation
  was 65,000 (8)

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Common Skin Disorders Associated With Diabetes

• Diabetic Dermopathy
• round, reddish-brown papules (lower leg)

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Bullous Diabeticorum (upper lower extremities)
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Common Skin Disorders Associated With Diabetes

• Necrobiosis Lipoidica

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Common Skin Disorders Associated With Diabetes

• Diabetic Finger Pebbles

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Diabetic Foot Ulcers
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Causes of Foot Ulcerations

• Peripheral neuropathy most common cause
• Sensory Loss
  Without Sensory Loss Ulceration
  Rarely Occurs
• Mechanical Stress repetitive tissue injury
• Lack of painful feedback

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Further Causes of Ulceration

• Mechanical Stress
• Pressure
• Shear
• Intrinsic Factors
• Foot Deformities - bony prominences
• Extrinsic Factors
• Environment around the foot
• Tight shoes

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Chronic Foot Ulceration

• Loss of Protective Function Sensation
• Continue to Bear Weight on Ulcerated Area
• Uninterrupted Episodes of Repetitive Stress
• Autolysis
• Necrosis of Tissue

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Sensory Loss Patient Profile

• Non-Compliant
• Ignore Treatment Recommendations
• Education is necessary to combat profile

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Assessment of Loss of Protective Sensation

• Nylon Filaments _at_ 10-g bending force recommended
  by the American Diabetes Association
• Patients unable to perceive 10-g have loss of
  protective sensation
• Increased risk of ulceration

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Research

• High pressure caused by excessive weight bearing
  causes plantar ulcerations
• Pressure is higher in diabetic neuropathy
• Higher pressure associated with foot deformity,
  joint limitation, muscle weakness and atrophy
• Muscle Weakness (toe deformities)
• Peroneal nerve-foot drop-equinovarus-increased
  foot pressure-forefoot ulceration
• Tibial Nerve-calcaneovalgus deformity-increased
  heel pressure-heel ulceration

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Most Common Sites of Ulceration in Diabetics

• 1st Metatarsal Head
• Great Toe

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Talking Points

• Obesity, Poor Vision, Joint Limitation (decreased
  flexibility) limit people from inspecting their
  feet
• Mirror
• Properly Fitted Shoes
• Hx of Callus, Ingrown Toenails, Blisters or Open
  Sores all increase risk of injury.

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Talking Points (cont.)

• Painful foot problems are often a sign of early
  neuropathy
• Pain with walking or elevation indicative of PVD
• Callus should be trimmed to reduce pressure to
  expose an underlying problem

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Pre-Ulceration

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

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Wagner Ulcer Classification Diabetic Ulcers

• Grade
• 0 Intact Skin
• 1 Superficial Ulcer
• 2 Deep Ulcer
• 3 Deep Infected Ulcer
• 4 Partial Foot Gangrene
• 5 Full Foot Gangrene

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Management Based on Ulcer Grading

• Pre-ulcer Modified Footwear activity,
  PWB
• Superficial PWB, Relief Pads, Cast or
  Splint
• Deep PWB, Cast or Splint, Probe, X-Ray,
  Culture
• Deep, Infected PWB, Splint, Probe, X-ray,
  culture, antibiotics, surgical consult
• Dysvascular PWB, Splint, Vascular Studies,
  Vascular Consult
• probing to bone, suspect osteomyelitis

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Notes on Debridement

• Non-Ischemic Foot Ulcers cleaned, Debrided
  Dressed
• Wound debridement has been shown to improve
  healing time of non-ischemic foot ulcers
• Callus should be trimmed to reduce pressure,
  expose underlying problems promote
  epithelialization

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Reducing Weight Bearing Stresses

• Objective To reduce weight bearing stresses on
  the foot (plantar ulcers)
• Methods
• Crutches or Walker (PWB)
• Gait Training (decrease step length to reduce
  forefoot pressure)
• Walking Casts
• Decrease pressure, decrease edema, protect from
  re-injury
• Contraindicated for infected ulcers
• Caution moderate or severe edema, fragile
  atrophic skin, deep ulceration

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Walking Casts

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

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Total Contact Casts

• Minimize risk of secondary infection
• Bony prominences are padded
• (tibial crest, malleoli, navicular, posterior
  heel, toes)
• Inner layer of plaster, carefully molded for
  optimal total-contact fit
• Combination of minimal padding molding for
  better distribution of pressure

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The Use of Electrical Stimulation and an
Off-Loading Technique For the Treatment of
Diabetic Foot Ulcers

• Michael S. Brogan, PT, MS, DPT, CWS
• Laura E. Edsberg, Ph.D.

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Purpose

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

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Case History

• 52 year old male with Diabetes
• Insulin dependent
• Comorbidities
• Renal failure (daily dialysis)
• Severe diabetic neuropathy
• Left B/K amputation
• Left hand 3rd 4th distal digit amputations
• Referred for 2 chronic open wounds, Right Foot
  (Chronicity gt 3 years)
• Previous Care
• Various topical applications
• Various dressings
• Antibiotics
• Debridement

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1-6-03
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1-6-03
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Interventions

• Electrical Stimulation
• High Volt Pulsed Current
• 150v, 120pps, 255ppi
• Stainless Steel Electrodes (4x4)
• 30 minutes, 5 X week
• Immersion Techniques
• Object
• improve blood flow
• Reduce edema
• Inhibit bacterial growth
• Enhance closure

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Off-Loading

• Reducing weight bearing forces on the foot is
  critical for healing plantar ulcers (9)
• Total contact casts used commonly for grade 1 2
  neuropathic foot ulcers
• Allows weight bearing forces to be dispersed over
  a larger area, reducing plantar pressures
• Rigidity of cast assists with edema control,
  improving circulation
• Cast immobilizes the foot and ankle, reducing
  shearing forces
• Completely encloses the patients insensate foot,
  protecting it from further trauma
  microorganisms
• Allows patient to be relatively active

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TOTAL CONTACT CASTS

• Contraindicated
• In grades 3, 4, and 5 ulcers
• Fluctuating edema
• Active infection
• ABI of less than 0.45
• Requires skill to apply
• Plaster vs. Fiberglass
• Heel vs. Cast Shoe

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Off Loading

• DonJoy Walking Boot (Cam Walker)
• provides foot and ankle immobilization at 0º,
  10º, and 20º plantarflexion
• protected range of motion in 10º increments from
  40º plantarflexion to 40º dorsiflexion
• easily to don and doff
• easy to distribute weight bearing pressures via
  ankle motion
• provides protection from trauma
• allows for daily dressings and external
  treatments
• can be removed when not ambulating

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Overview of Intervention

• Wounds were treated 5 X week with electrical
  stimulation in an aqueous solution for 30 min per
  session
• Wounds were first dressed with hydrogels and
  eventually hydrocolloids
• Walking Boot worn whenever weight bearing was
  anticipated (transfer gait)

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Outcomes Heel
1-6-03
7-29-03
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Outcomes Plantar Surface
1-6-03
7-29-03
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Clinical Relevance

• Case study does suggest that electrical
  stimulation and off-Loading for diabetic
  neuropathic wounds is a viable treatment option
• Walking Boots that allow for ankle motion control
  offer an additional option for off-loading
• Chronic diabetic foot ulcers can be treated
  effectively by physical therapists in conjunction
  with referring physicians
• Chronic wounds in patients with severe
  comorbidities can be healed using electrical
  stimulation and off-Loading

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Tid Bits

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

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Shapero, C. Stanoch, J. Barrese, D. (2002). Acute
Care Perspectives 3 (11). APTA, pp1-6.
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Following Closure

• Proper Footwear
• Progress into Normal Weight Bearing Gait