Therapeutic Interventions in Management of Diabetic Foot

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THERAPEUTIC INTERVENTIONS INMANAGEMENT OF DIABETIC FOOT

PRESENTER:

PARNEET KAUR BEDI

MPT 2ND YEAR

ROLL NO. 7978


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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; arepatients with diabetes. 85% of all Lower ExtremityAmputations are preceded by a foot ulcer(9)

Foot problems are the most common cause of admission tohospital for people with Diabetes.


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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 careresources (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.


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Multidisciplinary Team Management of

Diabetes Foot Ulcers(10)

Foot Ulcer Management

Diabetes Specialist Team(Medical & Nursing)

General Practitioner &Practice Nurse

Public Health Nurses

Vascular Specialists

OrthotistsPhysiotherapists

Plaster technicians

Orthopaedic Specialists

Physiotherapist


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Diabetic foot Diabetic foot can be defined as a group of

syndromes in which neuropathy, ischaemiaandinfection lead to tissue breakdown orulceration,

resulting in morbidity and possibleamputation.

Neuropathy is caused by diabetic

microvasculardisease, leads to loss of foot sensation,mayresult in subsequent foot deformity, causingabnormal biomechanical loading of the feet,

then breakdown of skin and ulceration


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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 broadcategories

Neuropathic Feet

Neuro-ischaemic Feet


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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 onthe soles of the feet).

Minor trauma (eg, caused by ill-fitting

shoes,

walking barefoot or an acute injury) can

precipitate a chronic ulcer.


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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 fromlocalised pressure damage, are found mainly at

the edges of the feet.


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Risk Factors for Foot Ulceration

According to Boulton,

Kirsner, & Vileikyte(2004), the triad of

neuropathy, deformityand trauma is present in

almost two thirds ofpatients with foot ulcers


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Contributing Factors in the Pathogenesis

of Ulceration


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Neuropathy

Sensory Neuropathy Trauma, repetitive stress

from walking or day to day activity

Approximately 4560% of all diabetic ulcerationsare purely neuropathic, while up to 45% have

neuropathic and ischemic components


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Motor Neuropathy anterior crural muscle

atrophyor intrinsic muscle wasting can lead to foot

deformities such as foot drop, equinus,

hammertoes, and prominent plantar metatarsal

heads.

Autonomic neruopathyresults in dry skin with

cracking and fissuring causes portal entry forbacteria


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Foot deformitiesresulting from neuropathy,

abnormal biomechanics, congenital disorders, orprior 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.


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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 activityShoe-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


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Limited Joint mobility

long standing diabetesresult 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.


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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 orthosescusto

walking braces

Patellar tendon-bearing braces

Half shoes or wedge shoes

Healing sandalsurgical

shoe with molded plastizoteinsole

Accommodative dressings:

felt, foam, felted-foam, etc,

Shoe cutouts (toe box, medial,lateral, or dorsal pressure

points)

Assistive devices: crutches,

walker, cane, etc.


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Surgical Management

Curative surgery, is performed to effect healing ofa non-healing ulcer

or a chronically recurring one when off-loading and standard wound caretechniques are not effective

Surgeries include exostectomy, digital arthroplasty, sesamoidectomy,

single or multiple metatarsal head resections, joint resections, or

partial calcanectomyAblative 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


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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


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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 musclewasting, like foot drop

Biomechanical abnormalitiesfoot drop,

Charcots joints, clawing of toes etc., Amputation and Surgeries pre and post

operative PT


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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 andmicrocirculation.

Stimulates the immune system, and decreases free radical

oxidation processes.

Many studies observed a regeneration of microcirculationin the ulcer and a regeneration of lymphatic circulation.

The laser irradiation method produces a sterilizing effect

from bacteria that over-infect the diabetic ulcer.

L d i d h li li ti i l d th


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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 low-

level laser therapy

Diabetic foot at the end of

treatment period

i S i i i


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Electrical Stimulation and Wound Healing

Electrical stimulation has been demonstrated to enhance

wound healing. The mechanism by which healing occursinclude inhibition of bacterial growth, effects on fibroblastsmotility, increased expression of transforming growth factor

on fibroblasts.(6)

Procedure involves applying a low level electrical current tothe base of the wound or the peri-wound using conductiveelectrodes.

Electrical stimulation given daily with short pulsed

asymmetric waveform was effective for enhancement of

healing rates for patients with diabetes (Lucinda L. Baker,

1997)


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Proliferation Phase

Polarity - negative

Pulse rate - 100 - 128 ppsIntensity - 100-150 voltsDuration - 60 minutesFrequency 5-7 x per week, once daily

Epithelialization Phase

Polarity - alternate every three days ie 3 daysnegative followed by 3 days positivePulse rate - 64 PPSIntensity - 100-150 voltsDuration - 60 minutes

Frequency 5-7 x per week, once daily


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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 orperi-wound skin.


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Whirlpool Therapy

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

P li f


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Its generally not what you put on these wounds

that heals them, but rather what you take off.

Armstron 2001 Diabetes care 24:6

Pressure relief


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Offloading Devices

Offloading the diabetic foot ulcer is a keyelement to successful wound healing.(12)

Asymmetric gait pattern and/or difficulties withbalance are essential factors to keep in mind

when describing offloading devices to patients

with peripheral neuropathy. (13)


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P ti t Ed ti


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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


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Prevention

Prevention through control of risk factors is key(14)

Optimal glycemic control

Control ofhyperlipidemia

Control of hypertension Optimal treatment for renal disease, peripheral vascular

disease

Education :neuropathy (proper foot care and

footwear)

Smoking cessation


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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.


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REFERENCES 1) Neuropathic pain and diabetes. [Review], Kapur, Dilip,

Diabetes/Metabolism Research Reviews. 19 Suppl 1:S9-15, 2003 Jan-Feb.

2) Measuring the pain threshold and tolerance using electricalstimulation in patients with Type II diabetes mellitus, Telli & Cavlak,Journal of Diabetes and Its Complications 20 (2006) 308316

3) Comfort and support improve painful diabetic neuropathy,whereas disappointment...Gloria Kaye; Alison Okada Wollitzer; LoisJovanovic, 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 NerveFibers in Diabetes, Lea Sorensen; Lynda Molyneaux; Dennis K Yue,Diabetes Care; Apr 2006; 29, 4; ProQuest Medical Librarypg. 883

6) Painful Diabetic Neuropathy, Veves et al,American Academy ofPain Medicine 1526-2375/08/$15.00/660 660674


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6)Effect of Electrical Stimulation on Chronic Leg Ulcer Size and AppearancePhysical Therapy . Volume Number 1 . January 2003.

7)Management of leg ulcers P K Sarkar, S Ballantyne, Postgrad Med J2000;76:674682.

8) The role of primary care in the prevention of diabetic foot amputationshttp://www.internationaljournalofcaringsciences.org Jan - Apr 2008 Vol 1Issue 1

9)Pendsey SP. Epidemiological aspects of diabetic foot. Int J Diab DevCountries 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 novelintervention in diabetic preulceration. Proceedings of the 2nd InternationalSymposium on the Diabetic Foot, 199512)Uccioli L, Fagila E, Monticone G, et al. Manufactured shoes in theprevention 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 forthe diabetic neuropathic foot. Diabetes Care 2004; 27:474-477.14) Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ. Intensive educationimproves knowledge, compliance and foot problems in type 2 diabetes.

Therapeutic Interventions in Management of Diabetic Foot

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