THERAPEUTIC INTERVENTIONS IN MANAGEMENT OF DIABETIC FOOT

PRESENTER:
PARNEET KAUR BEDI MPT 2ND YEAR ROLL NO. 7978

Introduction
15% of people with diabetes develop foot ulceration (9) Risk factors: diabetic neuropathy structural foot deformity peripheral arterial disease Complications: Infection, osteomyelitis, gangrene Throughout the world, up to 70% of all leg amputees; are patients with diabetes. 85% of all Lower Extremity Amputations are preceded by a foot ulcer(9) Foot problems are the most common cause of admission to hospital for people with Diabetes.

Introduction (contd)
In developed countries up to 5% of people with diabetes have a foot problem.(9) In developing countries it is estimated that foot problems may account for as much as 40% of available health care resources (9) In most cases Diabetic foot ulcers and amputations can be prevented, it is estimated that up to 85% of amputation could be avoided.(9) Significant reductions in amputation can be achieved by well organised Diabetic foot care teams, good Diabetes control and well informed self care.

Multidisciplinary Team Management of Diabetes Foot Ulcers(10)

General Practitioner & Practice Nurse Diabetes Specialist Team (Medical & Nursing)

Orthopaedic Specialists Foot Ulcer Management

Public Health Nurses

Plaster technicians Vascular Specialists

Physiotherapists Physiotherapist

Orthotists

Diabetic foot
Diabetic foot can be defined as a group of syndromes in which neuropathy, ischaemia and infection lead to tissue breakdown or ulceration, resulting in morbidity and possible amputation. Neuropathy is caused by diabetic microvascular disease, leads to loss of foot sensation,may result in subsequent foot deformity, causing abnormal biomechanical loading of the feet, then breakdown of skin and ulceration

 Ischaemia is due to peripheral arterial disease. Infection often complicates neuropathy and ischaemia, causes considerable damage in diabetic feet.

Diabetic foot pathology grouped into the two broad categories Neuropathic Feet Neuro-ischaemic Feet

Neuropathic feet - warm, numb, dry, and usually painless and pulses remain palpable. Two main complications a) Charcot (or neuropathic) joints b) Neuropathic ulcers (found mainly on the soles of the feet). Minor trauma (eg, caused by ill-fitting shoes, walking barefoot or an acute injury) can precipitate a chronic ulcer.

Neuro-ischaemic feet - cool and pulses are absent. In addition to the neuropathic complications, intermittent claudication, rest pain and gangrene may occur. Neuro-ischaemic ulcers, resulting from localised pressure damage, are found mainly at the edges of the feet.

Risk Factors for Foot Ulceration

According to Boulton, Kirsner, & Vileikyte (2004), the triad of neuropathy, deformity and trauma is present in almost two thirds of patients with foot ulcers

Contributing Factors in the Pathogenesis of Ulceration

Neuropathy
Sensory Neuropathy Trauma, repetitive stress from walking or day to day activity Approximately 4560% of all diabetic ulcerations are purely neuropathic, while up to 45% have neuropathic and ischemic components

Motor Neuropathy anterior crural muscle atrophy or intrinsic muscle wasting can lead to foot deformities such as foot drop, equinus, hammertoes, and prominent plantar metatarsal heads.
Autonomic neruopathy results in dry skin with cracking and fissuring causes portal entry for bacteria

Foot deformities resulting from neuropathy, abnormal biomechanics, congenital disorders, or prior surgical intervention may result in high focal foot pressures, resulting in ulcerations.
Primarily located plantarly, although medial and dorsal ulcerations may occur from footwear irritation.

Trauma to the foot in the presence of peripheral sensory neuropathy is an important component cause of ulcerations, include Puncture wounds and blunt injury, Moderate repetitive stress resulting from walking or day to day activity Shoe-related trauma has been identified as a frequent precursor to foot ulceration Ulceration due to Peripheral Vascular Disease arterial insufficiency result in prolonged healing and elevates risk for amputation

Limited Joint mobility long standing diabetes result in Glycosylation of collagen leading to stiffening of capsular structures and ligaments (Cheiroarthropathy) subsequent reduction in ankle, subtalar, and first metatarsophalangeal joint mobility - result in high focal plantar pressure and increased risk of ulceration.

Essential therapeutic objectives(8)

Debridement - include: autolytic, enzymatic, mechanical, and surgical Pressure relief (off-loading) Total non-weight bearing: crutches, bed, wheel chair Total contact casting Foot casts or boots Removable walking braces with rocker bottom soles

Total contact orthoses custom walking braces Patellar tendon-bearing braces Half shoes or wedge shoes Healing sandal surgical shoe with molded plastizote insole Accommodative dressings: felt, foam, felted-foam, etc, Shoe cutouts (toe box, medial, lateral, or dorsal pressure points) Assistive devices: crutches, walker, cane, etc.

Surgical Management
Curative surgery, is performed to effect healing of a non-healing ulcer or a chronically recurring one when off-loading and standard wound care techniques are not effective Surgeries include exostectomy, digital arthroplasty, sesamoidectomy, single or multiple metatarsal head resections, joint resections, or partial calcanectomy Ablative surgery, is a common sequela to gangrene and ulcers associated with osteomyelitis. Prophylactic or elective surgical correction of structural deformities that cannot be accommodated by therapeutic footwear Common operations performed include the correction of hammer toes, bunions, and various exostoses of the foot. Tendo-Achilles lengthening procedures are often performed to reduce forefoot pressures

PT Management for Diabetic Foot

Prevention and Management of neuropathy Management of biomechanical problems of diabetic foot Management of diabetic foot ulcers Patient education and foot care Management of following amputation and surgeries Control of diabetes

Management of Neuropathy
Sensory Neuropathy sensory reeducation for cutaneous and proprioception Motor neuropathy manage muscle weakness of the leg and intrinsic muscles of the feet manage foot deformities secondary to muscle wasting, like foot drop Biomechanical abnormalities foot drop, Charcots joints, clawing of toes etc., Amputation and Surgeries pre and post operative PT

Low-level laser therapy for diabetic foot wound healing

Increases the speed, quality and tensile strength of tissue repair, and also resolves inflammation and provides pain relief. Improves wound epithelialisation and increases cellular content, granulation tissue, collagen deposition and microcirculation. Stimulates the immune system, and decreases free radical oxidation processes. Many studies observed a regeneration of microcirculation in the ulcer and a regeneration of lymphatic circulation. The laser irradiation method produces a sterilizing effect from bacteria that over-infect the diabetic ulcer.

 Lasers used in wound-healing applications include the gallium-aluminum (GaAl), galliumarsenide (GaAs), and helium-neon (HeNe) laser. The power of these lasers ranges from 0.001 watts (1 mW) to 0.05 watts (50 mW), producing minimal heating of tissue.

Diabetic foot at the beginning of lowlevel laser therapy

Diabetic foot at the end of treatment period

Electrical Stimulation and Wound Healing

Electrical stimulation has been demonstrated to enhance wound healing. The mechanism by which healing occurs include inhibition of bacterial growth, effects on fibroblasts motility, increased expression of transforming growth factor on fibroblasts.(6) Procedure involves applying a low level electrical current to the base of the wound or the peri-wound using conductive electrodes. Electrical stimulation given daily with short pulsed asymmetric waveform was effective for enhancement of healing rates for patients with diabetes (Lucinda L. Baker, 1997)

Proliferation Phase Polarity - negative Pulse rate - 100 - 128 pps Intensity - 100-150 volts Duration - 60 minutes Frequency 5-7 x per week, once daily

Epithelialization Phase
Polarity - alternate every three days ie 3 days negative followed by 3 days positive Pulse rate - 64 PPS Intensity - 100-150 volts Duration - 60 minutes Frequency 5-7 x per week, once daily

Ultrasound therapy
Ultrasound has been shown to be of benefit in all three phases of wound repair (inflammation, proliferation, remodeling). Ultrasound caused the degranulation of mast cells, which accelerated the inflammatory process. For most dermal wounds, it is preferable to utilize a frequency of 3 MHz. 1 MHz wound be more effective on deeper structures or peri-wound skin.

Whirlpool Therapy
Objectives of whirlpool treatment: Vasodilatation Increased blood flow Softening and loosening of necrotic tissue Mechanical debridement Wound cleansing: debris and topical agents Exudate removal --- > reduced infection Pain management

Pressure relief

Its generally not what you put on these wounds that heals them, but rather what you take off. Armstrong (2001)Diabetes care 24:6

Offloading Devices
Offloading the diabetic foot ulcer is a key element to successful wound healing.(12) Asymmetric gait pattern and/or difficulties with balance are essential factors to keep in mind when describing offloading devices to patients with peripheral neuropathy. (13)

Patient Education
Education is essential as an empowerment strategy for diabetes self-management and prevention or reduction of complications Education is based on identified individual needs, risk factors, ulcer status, available resources and ability to heal. Following elements should be included in basic foot care programs (14)

Awareness of personal risk factors; Value of annual inspection of feet by a healthcare professional; Daily self inspection of feet; Proper nail and skin care; Injury prevention; and When to seek help or specialized referral

Prevention
Prevention through control of risk factors is key(14) Optimal glycemic control Control of hyperlipidemia Control of hypertension Optimal treatment for renal disease, peripheral vascular disease Education : neuropathy (proper foot care and footwear) Smoking cessation

World Diabetes Day (November 14th), a date that marks the birthdate of Frederick Banting, who discovered insulin with Best, Collip, and McLeod in Toronto in 1922.

Campaign to secure a United Nations Resolution on diabetes was led by the International Diabetes Federation (IDF) A global symbol for diabetes

The icon stands for unity in diabetes and symbolizes support for the United Nations Resolution on diabetes.

1) Neuropathic pain and diabetes. [Review], Kapur, Dilip, Diabetes/Metabolism Research Reviews. 19 Suppl 1:S9-15, 2003 JanFeb. 2) Measuring the pain threshold and tolerance using electrical stimulation in patients with Type II diabetes mellitus, Telli & Cavlak, Journal of Diabetes and Its Complications 20 (2006) 308 316 3) Comfort and support improve painful diabetic neuropathy, whereas disappointment...Gloria Kaye; Alison Okada Wollitzer; Lois Jovanovic, Diabetes Care; Aug 2003; 26, 8; ProQuest Medical Library pg. 2478. 4)Annals of the Royal College of Surgeons of England (1979) ASPECTS OF TREATMENT*Management of the diabetic foot John A Dormandy FRCS St James's and St George's Hospitals, London. 5) The Relationship Among Pain, Sensory Loss, and Small Nerve Fibers in Diabetes, Lea Sorensen; Lynda Molyneaux; Dennis K Yue, Diabetes Care; Apr 2006; 29, 4; ProQuest Medical Library pg. 883 6) Painful Diabetic Neuropathy, Veves et al, American Academy of Pain Medicine 1526-2375/08/$15.00/660 660674

REFERENCES

6)Effect of Electrical Stimulation on Chronic Leg Ulcer Size and Appearance Physical Therapy . Volume Number 1 . January 2003. 7)Management of leg ulcers P K Sarkar, S Ballantyne, Postgrad Med J 2000;76:674682. 8) The role of primary care in the prevention of diabetic foot amputations http://www.internationaljournalofcaringsciences.org Jan - Apr 2008 Vol 1 Issue 1 9) Pendsey SP. Epidemiological aspects of diabetic foot. Int J Diab Dev Countries 1994;14:37-38. 10) Armstrong DG, Peters EJG, Athanasiou KA, Lavery LA. Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg 1998;37:303-307 11) Curran F, Nikookam K, Garrett M, et al. Physiotherapy: A novel intervention in diabetic preulceration. Proceedings of the 2nd International Symposium on the Diabetic Foot, 1995 12)Uccioli L, Fagila E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18:1376-1377. 13) Viswanathan V, Sivagami M, Saraswathy G, Gautham G, Das BN, Ramachandran A. Effectiveness of different types of footwear insoles for the diabetic neuropathic foot. Diabetes Care 2004; 27:474-477. 14) Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ. Intensive education improves knowledge, compliance and foot problems in type 2 diabetes.

Diabet Med 1991;8:111-117