Low Intensity Laser in Diabetic Foot

Microangiopathy

Gamal MoustafaGamal MoustafaCairo UniversityCairo University

LIMS Vol.26, 2011

The American Diabetes The American Diabetes Association Association

estimates that 6% of the general population over age of 40 has been

found to have diabetes and… … an equal number has not an equal number has not

been diagnosed yet..!been diagnosed yet..!

> 1.3 million new cases a year Albers et al., 2006

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10% IN EGYPT10% IN EGYPTOther 10% are undiagnosedOther 10% are undiagnosed= 18 Millions…!= 18 Millions…!

The Foot and Leg in DiabeticsThe Foot and Leg in Diabetics

• foot and leg are organs at risk in diabetics, and always have special problems

• These special problems are due to abnormal pressure distribution secondary to neuropathy, and impaired microcirculation

(Gibbons, 2003)

 There are 18 million diabetics in Egypt. (some of them are undiagnosed). Approximately 25% will develop foot problems and 6 to 10% will undergo amputation.. Thomas Learch 2004

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LEGS ‘RE IMPORTANTLEGS ‘RE IMPORTANTthe Renaissance masterpiece

Michelangelo's marble statue of David sculpted between 1501 to 1504.

Telegraph.co.uk - Science News

has dodgy legs

http://www.telegraph.co.uk/science/science-news/3336501/Michelangelos-David-has-dodgy-legs.html

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Logo of Cannes’ Cinema Festival 2011Logo of Cannes’ Cinema Festival 2011

We need to realize that maintaining our beauty isn’t confined just to the upper part of our body.…even if they look like tree trunks

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The Vascular System The Vascular System in Diabeticsin Diabetics

The diabetic has an increased incidence and severity of atherosclerotic peripheral vascular disease. However, the majority of diabetics who develop foot ulcers have palpable pulses and apparently have adequate peripheral blood flow.

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Metabolic Consequences Of Metabolic Consequences Of Diabetes Mellitus Diabetes Mellitus

These include multitude of vascular problems that impose insult to important organs like the heart, kidneys, eyes and also the skin

-------------------------------------------------------SKIN affected up to 70% of patients* SKIN affected up to 70% of patients* linked to damage to the microcirculation ,

neuron degeneration and impaired host impaired host mechanismsmechanisms

* * Yosipovitch G, et al. :Diabetes Care. 1998; 21:506-9.

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Damage To Skin Microcirculation Damage To Skin Microcirculation 1.1. Thickening Of Capillary Basement Membrane Thickening Of Capillary Basement Membrane 2.2. VasoconstrictionVasoconstriction3.3. Increased PermeabilityIncreased Permeability

Diminished Oxygen Tension Diminished Oxygen Tension And Hypoxia In Skin Tissues And Hypoxia In Skin Tissues

± Concomitant Large Vessel DiseaseConcomitant Large Vessel Disease

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HyperglycemiaHyperglycemia• Calcification of the tunica media (smooth muscle

layer) decreases the compliance of the arteries increases the permeability of the microvasculature.

• Thickening of the capillary basement membrane.• There is no evidence that either of these factors

affects delivery of oxygen to the tissues in the absence of proximal arterial occlusion.

• The autonomic neuropathy decreases the regulatory effect of the sympathetic nervous system on the arteriovenous vistulas remain open.

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Autonomic NeuropathyAutonomic Neuropathy

The autonomic neuropathy decreases the regulatory effect of the sympathetic nervous system on the arteriovenous vistulas that remain open. This opens the vascular flood gates and the blood flow to the foot is increased !. Many diabetic patients with neuropathic pathology of the foot have a five-fold increase of blood flow to the foot.

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Autonomic Neuropathy Autonomic Neuropathy

To assume that a diabetic patient with an ulcer has a vascular insuffiency is incorrect in approximately 70%

of foot ulcerations.the ischemic ulcer is often located on non weight bearing surfaces such as between the toes, dorsum of the toes, posterior aspect of the heel, lateral border of the foot, and in association with an ingrown toenail

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Motor NeuropathyMotor Neuropathy ((Common)1. Clawing of the toesClawing of the toes. The stocking/glove

pattern of muscle weakness leads to dysfunction of the small intrinsic musculature of the foot.

2. Equinus deformity Equinus deformity : The strong plantar-flexors overcome the weak dorsiflexors of the ankle.

3. High arched foot. High arched foot: The strong invertors overcome the weak evertors of the hindfoot

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Measurement of Skin Blood Flow Measurement of Skin Blood Flow

• Due to small size of its component vessels, blood flow in the skin microcirculation is difficult to assess and the measuring techniques are usually optical and noninvasive like laser Doppler flowmetry

• Helium neon gas or gallium aluminum arsenide elements :real-time microcirculatory changes with non contact probes over a 1.5mm3 by a signal generated through moving blood cells

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MeasurementsMeasurements

• This signal is proportional to the blood flow into the area under investigation calculated by arbitrary units over a calibration standard

• The type of laser light delivered does not damage the checked skin or produces an increase in tissue temperature.

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ManagementManagementRegular Regular Glucose Testing is mandatorylets knowing how controlled is diabetic state

• Prevention* is the best.• 3 fold increases in basal skin blood flow

with some drugs like pentoxifylline and isradipine * *

• Vascular surgery Vascular surgery consultation only to symptomatic patients having a correctable large vessel occlusion

*1.Armstrong DG, et al: JAMA. 2005; 293(2):217-28.2.* * Rendell MS, et al: Angiology. 1997; 48(3): 203-213.

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Modern TechnologyModern Technology

LASER PHOTOTHERAPYLASER PHOTOTHERAPY

• Maximum power output : 500 , energy 10 Joules/cm² , frequency 2600 Hz

• Deliver nonnon-thermal light energy deep into the skin (8-15mm.)

• This promotes: photobiostimulation metabolic activation+ immunostimulation+ depression of prostaglandin synthesis + increase in lymph flow.

Activates And Dilates Skin Microcirculation With Increased Activates And Dilates Skin Microcirculation With Increased Antioxidant Activity And Stimulates ErythropoiesisAntioxidant Activity And Stimulates Erythropoiesis

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Laser PhototherapyLaser Phototherapy

• Improvement of blood flow, decrease in the adhesive ability of blood cells, and formation of new micro vessels and reducing pain .

• Endogenous prophyrins, act as photo sensitizers, and absorb photons thus initiating free radical reaction .

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StudyStudy

45 Patients in 2 groups

• Group I : 30 : received LILT • Group II : 15 : receives conventional therapy• Group III: Control group

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LIMS Vol.26, 2011

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StudyStudy

Eligibility criteria Diabetes for 3-6 years

under treatment suffering from obvious skin lesions.

Exclusion criteria : 1. Obese 2. Any degree of autonomic neuropathy, nephropathy, retinopathy, 3. Having active foot problems 4. Cardiovascular instability, 5. Medication known to affect peripheral blood flow

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StudyStudy

Laser Doppler Flowmetry Periflux system (LDF) , 407 probe connected

to LDPM perfusion measurement unit (with a computer )

Patients and all participants are instructed to wear protective goggles

Measurement of skin blood flowMeasurement of skin blood flow

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Laser Treatment TechniqueLaser Treatment Technique

• ASA Laser Bravo Terza scanner ASA Laser Bravo Terza scanner : delivers combined uniform He-Ne and infrared lasers over large area.

• In the resting motionless supine position the laser doppler probe was positioned touching skin with minimal pressure on the pulp of the right great toe fixed by a plastic holder.

• To test for viability and the degree of microcirculatory impairment, a combined laser Doppler and thermostatic probe was used for local heat provocation (for 3-5 minutes) during the quantifying process. An increase in blood perfusion in response to local heating indicates the amount of reserve capacity .

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TREATMENT : Laser ScannerTREATMENT : Laser Scanner

Applied perpendicular to the area of treatment on the lower leg and foot

(from above the malleoli till tip of the big toe)

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G M SAIED: Clinical Research July 5 , 2011 San Francisco

Laser Dosimetry Laser Dosimetry Energy 10 Joules/cm² Energy 10 Joules/cm² Frequency : 2600 Hz Frequency : 2600 Hz

20 minutes / session (12 sessions)20 minutes / session (12 sessions) Thrice weeklyThrice weekly

Study: Results Study: Results

• The average mean age in patients of group I was ± 45.4 years, height 168.93 cms. weight 80.46 kg. and BMI 28.18 kg/m2. For the control group the values were ± 45.26, 166.93, 77.60 and 27.83 respectively (Table 1).The youngest patient was 40 years and the oldest was 51 years in group I, and 40, 53 in group II and male to female ratio 3.2 to 2.in both.

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Skin LesionSkin Lesion No. of No. of PatientsPatients

Dryness Dryness In Uncontrolled Diabetes Body Loses Fluid. Causing Dry Skin . Dry Skin Can Be Itchy, Causing Pt. To Scratch And Make It Sore. Also, Dry Skin Can Crack. Cracks Cause Infection. And Paves The Way To Other Complications

1515

Diabetic bullae, nail changesDiabetic bullae, nail changes and alopecia and alopecia

1515

InfectionsInfections 1010PruritisPruritis 44Frank eczemaFrank eczema 11

Study: Results Study: Results Types of skin lesionsTypes of skin lesions

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Flow Changes following LILTFlow Changes following LILTItem Before

treatmentAfter

treatmentSignificanceat P <0.05

Maximum skin blood perfusion (*)

32.91 ± 9.97 48.47 ± 15.34 s

Minimum skin blood perfusion

16.45 ± 4.73 25.94 ± 7.50 s

Basal mean perfusion

24.68 ± 6.87 34.84 ± 12.39 s

% change of perfusion values

142.27± 50.30 175.24 ± 54.12 s

(*) Unites: = BPU (35)Fixed Combination 2011 Paris December 1-4

Study

142.27134.79

0

20

40

60

80

100

120

140

Group-I Group-II

Group-I

Group-II176.58

136.36

0

50

100

150

200

Group-I Group-II

Group-I

Group-II

(a)

Mean values of percentage change of perfusion betweenGroups I & II before (a) and after (b) the study.

Flow Changes following LILTFlow Changes following LILT

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LILT LILT Increases Increases SkinSkin Blood Flow by Blood Flow by

24%24%Average Basal , Maximal and Minimal Average Basal , Maximal and Minimal

Compared to Compared to 1.2 %1.2 % by conventional drugs by conventional drugs

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