1362404886 diab neuropa etiol mech con

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Diabetic Neuropathy - Etiology Diabetic Neuropathy - Etiology Mechanisms and ConsequencesMechanisms and Consequences

Sanjeev KelkarSanjeev KelkarConjoint LecturerConjoint LecturerFaculty of HealthFaculty of HealthUniversity of Newcastle University of Newcastle AustraliaAustralia

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Risk Factors For Risk Factors For Diabetic NeuropathyDiabetic Neuropathy

• MODIFIABLEMODIFIABLE• HYPERGLYCEMIAHYPERGLYCEMIA• HYPERTENSIONHYPERTENSION• INCREASED INCREASED

CHOLESTEROLCHOLESTEROL• SMOKINGSMOKING• ALCOHOL USEALCOHOL USE

• NON MODIFIABLENON MODIFIABLE• OLD AGEOLD AGE• LONG DURATION LONG DURATION

OF DIABETESOF DIABETES• HLA-DR 3/4 HLA-DR 3/4

GENOTYPEGENOTYPE• GREATER HEIGHTGREATER HEIGHT

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Etiology Of Diffuse Neuropathy - 1Etiology Of Diffuse Neuropathy - 1

• HyperglycemiaHyperglycemia

• Vasa nervorum closureVasa nervorum closure

• Abnormal fatty acid metabolismAbnormal fatty acid metabolism

• Myo inositol deficiencyMyo inositol deficiency

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Etiology Of Diffuse Neuropathy - 2Etiology Of Diffuse Neuropathy - 2

• Advanced glycated end productsAdvanced glycated end products

• Antibodies to neural tissuesAntibodies to neural tissues

• Neural growth factorsNeural growth factors

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Diabetic Neuropathy – Diabetic Neuropathy – PrevalencePrevalence

Neuropathy that is significant enough Neuropathy that is significant enough to cause foot ulceration may affect to cause foot ulceration may affect 40% of diabetic population especially 40% of diabetic population especially elderly with type 2 diabetes.elderly with type 2 diabetes.

Asymptomatic neuropathy 35%Asymptomatic neuropathy 35%

66

Feet ComplicationsFeet Complications

4%

1% 1%

37%Healed Ulcer

Acute Ulcer / GangreneNeuropathy

Leg Amputation

77

Current Co-Morbid Current Co-Morbid ConditionsConditions

88

Severe Late ComplicationsSevere Late Complications

1%

7%

3%

1% 1%

Legal Blindness MI/CABG/Angioplasty

Stroke ESRD Leg Amputation

99

Diabetes ComplicationsDiabetes Complications In Relation To Diabetes DurationIn Relation To Diabetes Duration

60%

35%29%

64%

32%19%12%

5% 4%4% 2% 2%2%

<5y5-10y>10y

Foot Eye MI Stroke ESRD

n=480n=626n=901

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Components of neuropathic foot Components of neuropathic foot transforming to diabetic foot - 1transforming to diabetic foot - 1

• A. Components of Ulcerative diabetic A. Components of Ulcerative diabetic neuropathic footneuropathic foot

• B. Non-ulcerative neuropathic B. Non-ulcerative neuropathic pathologies in diabetic footpathologies in diabetic foot

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A. Components of ulcerative A. Components of ulcerative diabetic neuropathic foot - 2diabetic neuropathic foot - 2

1. Neuropathic & Neuroischemic 1. Neuropathic & Neuroischemic footfoot

2. Neuropathic foot deformities2. Neuropathic foot deformitiesa. Clawed toesa. Clawed toesb. Pes cavusb. Pes cavusc. Hallux rigidus and valgusc. Hallux rigidus and valgusd. Hammer toed. Hammer toee. Nail deformitiese. Nail deformities

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A. Components of ulcerative A. Components of ulcerative diabetic neuropathic foot - 3diabetic neuropathic foot - 3

3. Neuropathic callus3. Neuropathic callus4. Neuropathic ulcers4. Neuropathic ulcers

a. Ulcer over pressure points on a. Ulcer over pressure points on sole, later callus ulcerssole, later callus ulcers

b. Decubitus ulcers b. Decubitus ulcers c. Puncture wound ulcersc. Puncture wound ulcersd. Traumatic ulcersd. Traumatic ulcers

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Components of Diabetic Foot - Components of Diabetic Foot - 44Three components of neuropathy: Three components of neuropathy: *sensory – painful, painless*sensory – painful, painless

*Motor*Motor*Autonomic*AutonomicAll contribute to diabetic foot and or All contribute to diabetic foot and or

ulceration ulceration

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Components of Diabetic Components of Diabetic Foot - 5Foot - 5

Rather than acting in isolation Rather than acting in isolation neuropathyneuropathy

exerts its vicious effects exerts its vicious effects in concert with angiopathy and in concert with angiopathy and

immunopathy leading to ulceration immunopathy leading to ulceration and infections and infections

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B. Non-ulcerative B. Non-ulcerative neuropathic pathologies in neuropathic pathologies in diabetic footdiabetic foot

1. Charcot’s Foot1. Charcot’s FootAcute / chronic bone destruction Acute / chronic bone destruction andand

deformed diabetic foot and toes deformed diabetic foot and toes withwith

pathological fracturespathological fractures2. Diabetic painful neuropathy2. Diabetic painful neuropathy

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Diabetic foot – Mechanisms Diabetic foot – Mechanisms - 1- 1

Loss of pain sensation results Loss of pain sensation results in neuropathic injury due to, in neuropathic injury due to, repeated unrecognized trauma, repeated unrecognized trauma, inflicted in many different waysinflicted in many different ways

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Diabetic foot – Mechanisms Diabetic foot – Mechanisms - 2- 2Loss of sensation of joint position Loss of sensation of joint position

causes the foot to land in abnormal causes the foot to land in abnormal foot position on ground leading to foot position on ground leading to areas of excessive and low pressure areas of excessive and low pressure leading to injury during walking or if leading to injury during walking or if the shoes are not properly selected the shoes are not properly selected will hurt at placeswill hurt at places

2020

Diabetic foot – Mechanisms Diabetic foot – Mechanisms - 3- 3Motor NeuropathyMotor Neuropathy

* Wasting of small intrinsic muscles of * Wasting of small intrinsic muscles of foot leading to weaknessfoot leading to weakness

*Imbalance between the flexor and *Imbalance between the flexor and extensor muscles extensor muscles

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Diabetic foot – Mechanisms Diabetic foot – Mechanisms - 4- 4

Intrinsic deformityIntrinsic deformityClawing of the toes Clawing of the toes Prominence of metatarsal headsProminence of metatarsal headsFlattening of the archFlattening of the arch

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Diabetic foot – Mechanisms Diabetic foot – Mechanisms - 5- 5Abnormal distribution of body weight, Abnormal distribution of body weight,

concentrated on smaller areas like concentrated on smaller areas like metatarsal head and the heel.metatarsal head and the heel.

Excess pressure loading of these areasExcess pressure loading of these areasfinally results in callus formation.finally results in callus formation.Rise of Pressure > 30 times at callusRise of Pressure > 30 times at callus

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Diabetic foot – Mechanisms - Diabetic foot – Mechanisms - 6 Connective tissue changes6 Connective tissue changes

Hyperglycemia causes non enzymaticHyperglycemia causes non enzymaticglycation of collagen and keratin glycation of collagen and keratin Increase in cross linking Increase in cross linking Become rigid and inflexibleBecome rigid and inflexibleTissue break down in places where Tissue break down in places where

therethereis high horizontal shear forceis high horizontal shear force

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Diabetic foot – Characteristics Diabetic foot – Characteristics of a Neuropathic ulcerof a Neuropathic ulcer

* Painless - Develops on pressure points * Painless - Develops on pressure points (metatarsal heads/heel)(metatarsal heads/heel)

* Pulsations intact unless superadded * Pulsations intact unless superadded ischaemia is also presentischaemia is also present

* Decrease in* Decrease in pain / temperature as also pain / temperature as also in the vibration perception in the vibration perception

* Punched out ulcer surrounded by callus* Punched out ulcer surrounded by callus* Most ulcers from within out* Most ulcers from within out

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Neuropathic (n) / Ischemic Neuropathic (n) / Ischemic ulcer (i)ulcer (i) Site Pressure points (n) Site Pressure points (n) Sides / tips of toes (i)Sides / tips of toes (i) Pain --- ( n ) +++ ( i )Pain --- ( n ) +++ ( i ) Callus ++ ( n ) --- ( i )Callus ++ ( n ) --- ( i ) Pulse ++ ( n ) --- ( i )Pulse ++ ( n ) --- ( i ) ABI > 1( n ) < .6 ( i )ABI > 1( n ) < .6 ( i ) Healing ++ ( n ) --- ( i )Healing ++ ( n ) --- ( i )

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Autonomic neuropathy - 1Autonomic neuropathy - 1* Damages the sympathetic * Damages the sympathetic

innervation of lower limbinnervation of lower limb* This results in* This results in

Decreased sweatingDecreased sweatingResults in dry skin fissures / Results in dry skin fissures / cracks cracks

Super added infectionSuper added infection

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Autonomic neuropathy - 2Autonomic neuropathy - 2

Opening of arteriovenous channels Opening of arteriovenous channels Warm skin ( misleadingly healthy )Warm skin ( misleadingly healthy )Shunting of nutrients and oxygen fromShunting of nutrients and oxygen fromthe tissuesthe tissuesImpaired vascular response to Impaired vascular response to

infectioninfection

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Autonomic neuropathyAutonomic neuropathyclassical signsclassical signs

Dry skin Dry skin FissuringFissuringDistended veins over the dorsum of Distended veins over the dorsum of

footfootand the ankleand the ankle

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Neuropathic joint or Neuropathic joint or Charcot’s arthropathy - 1Charcot’s arthropathy - 1

1868 French neurologist I.M. Charcot 1868 French neurologist I.M. Charcot First described in tabesFirst described in tabesCan also be seen in leprosy, Can also be seen in leprosy,

syringomyelia, syringomyelia, hereditary sensory neuropathy, hereditary sensory neuropathy, Charcot Marie Tooth disease etcCharcot Marie Tooth disease etc

3333


Relatively rare Relatively rare Potentially devastating disorderPotentially devastating disorderLong standing diabetesLong standing diabetesDense peripheral neuropathyDense peripheral neuropathyPeripheral vascular disease is typicallyPeripheral vascular disease is typicallyabsent absent

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Neuropathic joint or Neuropathic joint or Charcot’s arthropathy - 1Charcot’s arthropathy - 1Sympathetic failure-- increased bloodSympathetic failure-- increased bloodflow due to arteriovenous anastomosis flow due to arteriovenous anastomosis

Bone demineralisation (diabeticBone demineralisation (diabeticosteopenia)osteopenia)

Susceptibility to minor, recurrent fractures Susceptibility to minor, recurrent fractures

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Fig

Charcot’s Foot with Acute Stage of Destruction

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Neuropathic joint or Neuropathic joint or Charcot’s arthropathy - 4Charcot’s arthropathy - 4Painless disintegration of bone in Painless disintegration of bone in

response to trivial traumaresponse to trivial traumaCommon joints involved are Common joints involved are

– Tarso metatarsalTarso metatarsal– Metatarso phalangealMetatarso phalangeal– Ankle jointAnkle joint– Knee jointKnee joint

3737Fig Bilateral Charcot’s Foot in Acute Stage of Destruction

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Neuropathic joint or Neuropathic joint or Charcot’s arthropathy - 5Charcot’s arthropathy - 5Acute Charcot’s arthropathy may Acute Charcot’s arthropathy may

mimic infectionmimic infectionChronic Charcot’s foot is classically Chronic Charcot’s foot is classically

described as ‘bag of bones’described as ‘bag of bones’(Gross destruction of joint surfaces and (Gross destruction of joint surfaces and

bone with effusion which is typically bone with effusion which is typically painless)painless)

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Differentiation from osteomyelitis is Differentiation from osteomyelitis is difficultdifficult

* TC 99 Scan* TC 99 Scan* Indium labeled white cell scan* Indium labeled white cell scan* MRI* MRI

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Early diagnosis and intervention are Early diagnosis and intervention are important to prevent deformity and loss of important to prevent deformity and loss of function function

Treatment includes Treatment includes *Long term immobilization in plaster of Paris *Long term immobilization in plaster of Paris

cast, (up to even 1 year)cast, (up to even 1 year)*Charcot’s Restraint Orthotic Walker (CROW) *Charcot’s Restraint Orthotic Walker (CROW)

which allows pressure to be off loaded which allows pressure to be off loaded *Pamidronate - tried as a new treatment of *Pamidronate - tried as a new treatment of

Charcot’s arthropathyCharcot’s arthropathy

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Diabetic Neuropathy and Diabetic Neuropathy and Ulcers – Ulcers – Economic ConsequencesEconomic Consequences - 1 - 1

Neuropathy that is significant Neuropathy that is significant enough to cause foot ulceration enough to cause foot ulceration may affect 40% of diabetic may affect 40% of diabetic population especially elderly with population especially elderly with type 2 diabetes.type 2 diabetes.

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Diabetic Neuropathy and Diabetic Neuropathy and Ulcers – Ulcers – Economic ConsequencesEconomic Consequences - 2 - 2• DFU - cause for more amputation than DFU - cause for more amputation than

anyany other pathology.other pathology.

• Most contemporary and challenging Most contemporary and challenging issueissue

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Diabetic Neuropathy and Diabetic Neuropathy and Ulcers – Ulcers – Economic ConsequencesEconomic Consequences - 3 - 3• Foot ulcers result inFoot ulcers result in MorbidityMorbidity MortalityMortality Enormous health care expenditureEnormous health care expenditure Psychosocial problemsPsychosocial problems

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Diabetic Neuropathy and Diabetic Neuropathy and Ulcers – Ulcers – Economic ConsequencesEconomic Consequences - 4 - 4• 5-10% of all diabetic patients have 5-10% of all diabetic patients have

foot ulceration of various degrees foot ulceration of various degrees and about 1% undergo amputationand about 1% undergo amputation

• Diabetes accounts for up to 50% of Diabetes accounts for up to 50% of non traumatic leg amputationsnon traumatic leg amputations

• Of all the diabetic amputees about Of all the diabetic amputees about 50% will lose their life or their other 50% will lose their life or their other leg by 3 yearsleg by 3 years

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Total Mean Duration of Total Mean Duration of HospitalizationHospitalizationCause SpecificCause Specific

14.78.2

14.5

13.9

32.5

9.411.1

21.525.7

6.7

16.013.2

0102030405060

Hear

t

Neur

o

Eye

NHW

Kidn

ey

HBP

Skin TB

Para

lysi

s

Hype

r

Hypo

Oth

er

Days

4646

Total Mean Hospitalization CostTotal Mean Hospitalization Cost CauseCause SpecificSpecific

11.2

7.7

19.6

7.65.9

11.27.1

13.9

27.5

0

20

40

60

80

100

Hear

t

Neur

o

Eye

NHW

HBP

Skin

Hype

r

Hypo

Oth

er

Mea

n Co

st in

INR

('000

)

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TEN COMMANDMENTS OF TEN COMMANDMENTS OF DIABETIC FOOT CAREDIABETIC FOOT CARE

1. 1. DO NOTDO NOT walk barefoot walk barefoot..2.2. INSPECTINSPECT the feet daily for blisters, the feet daily for blisters,

wounds, bleeding, smell, increased wounds, bleeding, smell, increased temperature at pressure points of feet.temperature at pressure points of feet.

3.3. D DO NOTO NOT apply hot fomentation / cold apply hot fomentation / cold compresses / electric heating pads / strong compresses / electric heating pads / strong counter irritant ointments to legs & feet.counter irritant ointments to legs & feet.

4.4. USE USE correct footwear. Choose your correct footwear. Choose your footwear after consulting your doctor. footwear after consulting your doctor. Always wear footwear with socks with Always wear footwear with socks with loose elastic.loose elastic.

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TEN COMMANDMENTS OF TEN COMMANDMENTS OF DIABETIC FOOT CAREDIABETIC FOOT CARE

5.5. DO NOTDO NOT walk bearing weight on walk bearing weight on affected foot in case of presence of affected foot in case of presence of wounds or after surgery.wounds or after surgery.

6. 6. DO NOTDO NOT sit cross legged for long sit cross legged for long timetime..

7. 7. DO NOTDO NOT remove foot wear during remove foot wear during travel and place your feet on the travel and place your feet on the floor of the vehicle. This can cause floor of the vehicle. This can cause burns.burns.

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TEN COMMANDMENTS TEN COMMANDMENTS OF DIABETIC FOOT CAREOF DIABETIC FOOT CARE

8. 8. CUTCUT the nails regularly, trim them the nails regularly, trim them square. square.

9.9. DO NOTDO NOT cut corns / calluses with blade cut corns / calluses with blade or knife. Home surgery is dangerous.or knife. Home surgery is dangerous.

10.10. CLEANCLEAN the feet twice a day with soap the feet twice a day with soap and water. Wipe the web spaces dry and and water. Wipe the web spaces dry and apply softening agent to feet.apply softening agent to feet.

Ordained Ordained By By Dr. Arun BalDr. Arun Bal

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Diabetic Neuropathy and Diabetic Neuropathy and Ulcers – Ulcers – Need of the hourNeed of the hour• Paucity of data regarding prevalence of Paucity of data regarding prevalence of diabetic foot in India, data from only a diabetic foot in India, data from only a

few places – need more few places – need more • St. Vincent’s and Health 21 WHO St. Vincent’s and Health 21 WHO

Declaration have called for reduction Declaration have called for reduction in amputation in diabetic foot.in amputation in diabetic foot.

• Efforts required to create awareness Efforts required to create awareness and commitmentand commitment

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Effect Of Patient Education On Effect Of Patient Education On Amputation RatesAmputation Rates

Knee & Above

12%

15%

5%

46%

35%

60%

Toe & Metatarsal

Below KneeNo Education

Education

University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et al. Diabete Metab 1993.

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Factors and markers of low-risk versus Factors and markers of low-risk versus high-risk diabetic feethigh-risk diabetic feet

Low-risk foot High-risk footLow-risk foot High-risk footAll of the following:All of the following: One or more of the One or more of the following:following: following:following:Intact protective sensation Loss of protective Intact protective sensation Loss of protective sensationsensationPedal pulses present Absent pedal pulsesPedal pulses present Absent pedal pulsesNo severe deformity Significant foot No severe deformity Significant foot deformitydeformity

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Factors and markers of low-risk versus Factors and markers of low-risk versus high-risk diabetic feethigh-risk diabetic feet

Low-risk foot High-risk footLow-risk foot High-risk footAll of the following:All of the following: One or more of theOne or more of thefollowing:following: following:following:

No prior foot ulcer History of foot ulcer No prior foot ulcer History of foot ulcer or callus pre-ulcerative callus or callus pre-ulcerative callus

No amputation Prior amputationNo amputation Prior amputation Normal joint mobility. Limited joint Normal joint mobility. Limited joint

mobilitymobility

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Diabetic Foot Wounds Are Diabetic Foot Wounds Are LikeLike

ICEBERGICEBERG

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Diabetic neuropathy Diabetic neuropathy Scope of the syndrome - 2Scope of the syndrome - 2

• DiffuseDiffuse• 1. Distal symmetric sensorimotor1. Distal symmetric sensorimotor• polyneuropathypolyneuropathy• 2. Autonomic neuropathy2. Autonomic neuropathy• A.SudomotorA.Sudomotor• B.CardiovascularB.Cardiovascular• C.GastrointestinalC.Gastrointestinal• D.GenitourinaryD.Genitourinary

1362404886 diab neuropa etiol mech con

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