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Diabetic neuropathy

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Diabetic foot disease –


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the high-risk foot

Peripheral neuropathy
Peripheral vascular
disease

Peripheral neuropathy and


peripheral vascular disease

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Some statistics
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• Half of all limb amputations are caused


by diabetes
• Risk is 40 times increased in diabetes
• 70% of people die five years following
an amputation
• Foot problems account for 40% of
healthcare resources in developing
countries; 15% in developed countries

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Some statistics
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• 85% of all amputations begin with an


ulcer
• Foot problems cost USD 6 billion/year
in the USA
• 49-85% of amputations can be
prevented

Slides current until 2008


Diabetic neuropathy
ACTIVITY Curriculum Module III-7c
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Discuss

• How and when people have their


feet examined in your country?

• What conditions put people at high


risk of injury in your country?

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral neuropathy –
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sensory motor

• Most common form of neuropathy


• Affects approximately 50% after
15 years
• Affects long nerves (feet and legs)
first
– glove and stocking distribution
• Bilateral
• Equal symptoms in both limbs

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Diabetic peripheral neuropathy –


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risk factors

• Poor glycaemic control


• Long duration
• Age
• Height
• Excessive alcohol

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Nerve damage – neuropathy


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• Symptoms:
– burning
– pins and needles
– pain

• No symptoms

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C
Slide 9 of 37

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Painless nature of diabetic foot


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disease

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Sensory nerve damage


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Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Motor nerve damage


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Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Localized callus
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Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Autonomic nerve damage Slide 14 of 37

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C
Slide 15 of 37

Take off the shoes!


Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C

Diabetic peripheral neuropathy


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screening tests

• Test sensation
– Biothesiometer
– Tuning fork
– 10 gm monofilament

• Ankle reflexes

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C
Slide 17 of 37

Assessment of high risk


characteristics

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Charcot’s arthropathy
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• Artery-vein shunting

• Increased blood flow

• Bone resorption

• Commonly misdiagnosed

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C
Slide 19 of 37

Acute vs chronic Charcot’s arthropathy

• Unilateral • No temperature
difference
• Warm, swollen
• Relatively pain free • Rigid foot deformity

• Bounding pedal pulses • Grossly misshapen


• Deformity may be present foot

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Charcot’s arthropathy
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Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Charcot’s arthropathy – treatment


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• Acute phase
– Non weight-bearing
– Total contact cast
• Chronic phase
– Orthopaedic surgery

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Circulation
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Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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• Cause: decreased perfusion


due to macrovascular disease

• Sites: more distal


Tibial and peroneal arteries
(segment between the knee and
the ankle but aortic-illiac to knee
less frequently)

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease in


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diabetes

• 15-40 times more likely to


have lower limb amputation

• People over 70 years have a


70-fold increased risk of
amputation

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Risk factors characteristics of


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atherosclerosis in diabetes

• More common
• Affects young age group
• No sex difference
• Smoking
• Faster in progress

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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• Symptoms
– Intermittent claudication
– Rest pain

• No symptoms
– Inactivity
– Neuropathy

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Signs of vascular disease


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• Diminished or absent
pedal pulses
• Coolness of the feet
and toes
• Poor skin and nails
• Absence of hair on feet
and legs

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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and diabetes

• Symptoms and signs of peripheral


vascular disease

• There are four stages:


1. Occlusive disease without symptoms
2. Intermittent claudication
3. Ischaemic rest pain (nighttime)
4. Ulceration/gangrene
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C
Slide 29 of 37

Vascular assessment

Palpation of foot pulses


– Dorsalis pedis (10%
absent due to anatomical
reasons)
– Tibialis posterior

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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non-invasive evaluation

• Methods
– Doppler pressure studies (ABI)
– Duplex arterial imaging

• Rationale
– Identify and confirm presence of
disease
– Predict healing of ulcers or
determine need for early surgical
intervention
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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non-invasive evaluation

• Doppler ultrasound
– Measures pressure at brachial,
pedal and toe arteries
– Ankle Brachial Index (ABI)
<0.9 abnormal
0.9 to 1.0 normal
>1.3 non-compressible

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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non-invasive evaluation

• Duplex arterial imaging –


allows narrowing or obstruction
of blood vessels to be localized

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Peripheral vascular disease


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Treatment

• Quit smoking

• Walk through pain

• Surgical intervention

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C
Slide 34 of 37

Risk categorization system

Category Risk profile Check-up frequency

0 No sensory neuropathy Once a year

1 Sensory neuropathy Every 6 months


Sensory neuropathy
2 /peripheral vascular Every 3 months
disease/foot deformities
3 Previous ulcer Every 1-3 months

Slides current until 2008


Diabetic neuropathy
Curriculum Module III-7C

Cause of diabetic amputation


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Neuropathy or vascular disease

Trauma

Ulcer

Failure to heal

Infection

Amputation Pecararo
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C
Slide 36 of 37

An amputation
every 30 seconds
due to diabetes

Slides current until 2008


Diabetic neuropathy
ACTIVITY Curriculum Module III-7c
Slide 37 of 37

• How to do a foot assessment

• Participants to form pairs and do a


foot assessment on each other

Slides current until 2008