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Neuropathic Ulcers

Introduction neuropathic ulcers


Also know as diabetic ulcers
Prevalence of diabetes, US = 18.2 million
Incidence of ulcers: 15%25%
Responsible for over 600,000 amputations/year
80% following a foot ulcers

51% of ulcers attained closure (1999)

Physical therapy tests and


measures

Assessment of Circulation
Pulses and capillary refill
Doppler Ultrasound or ankle-brachial index

Assessment of sensory integrity


Semmes-Weinstein monofilaments
Light touch sensation varies with location

Classification of neuropathic ulcers


Wagner classification system

Classifying wounds
the 5PT method
1.
2.
3.
4.
5.
6.

Pain
Position
(Wound) Presentation
Periwound and structural changes
Pulses
Temperature

Characteristics of neuropathic ulcers


Pain

Absent or minimal

Position

Plantar aspect of the foot


Areas of increased plantar pressure

Wound presentation

Round, punched out lesion


Callus rim
Little or no drainage
Necrotic base uncommon

Periwound and structural changes Dry, cracked, callused


Structural deformities
Pulses

Normal

Temperature

Normal or increased

Neuropathic ulcer

Prognosis for neuropathic ulcer


Average healing time 1214 weeks
Great variability in healing rates

Better prognosis
Smaller, superficial (Wagner grade 1 or 2)
Decrease in size within 4 weeks of treatment

Physical therapy interventions

Coordination, Communication, and


Documentation
Team approach

Physician
Surgeon
Podiatrist
Nutritionist/Diabetic educator
Endocrinologist
Orthotist
Psychological counselor
Social worker

Patient instructions

Disease process/medical management of DM


Role of exercise and safety guidelines
Risk factor reduction
Proper shoe wear and foot care guidelines
Use of lotion, white cotton socks
Performing daily foot checks
Toe nail care

Precautions for neuropathic ulcers


1. Many patients do not show signs of
infection when infected
2. Monitor for signs of hypoglycemia
Refer for medical testing
Bone scan or X-ray: suspected
osteomyelitis
Wound culture and sensitivity: suspected
infection

Local wound care

Offload ulcer
Callus: pared flush with epithelial surface
Petroleum-based moisturizer daily
Toe spacers
Adjunct modalities
Negative pressure wound therapy
Ultrasound
Electrical stimulation

Total contact casting


For grade 1 and 2 ulcers
Modified short leg casts
Toes enclosed in the cast
Fiberglass casts walking heel or cast shoe

Assists wound healing

Disperses weight bearing forces


Controls edema
Protection from trauma and microorganisms
Assists with patient adherence

Contraindications: osteomyelitis, gangrene,


fluctuating edema, active infection, and ABI < 0.45
Precautions: patients with fragile skin

Prescription, application, and


fabrication of devices and equipment
Temporary Footwear
Felt or foam inserts
Padded AFO
Walking shoes

Permanent Footwear
Fit
~ longer than the longest toe,
with snug heel fit
Last should match shape of foot
Extra-depth toe box

Fit in the middle of the day


Break in shoes gradually
Soft, moldable materials with
heel height < 1
Soft inserts may decrease
pressure

Characteristics of footwear
Characteristics

Total contact cast Padded AFO Walking shoe

Ulcer grade

1,2

1,2,3,4

1,2,3,4

Removable

No

Yes

Yes

Pressure distribution Total contact

Insole to distribute pressure

Shear forces

----

--

Rocker-bottom

Yes

Yes

Yes

Enclosed toes

Yes

Yes

Yes

Weight

Moderate

Heavy

Light

Cosmesis

Fair

Fair

Good

Other physical therapy interventions


Therapeutic exercise
ROM exercises
Great toe extension
Talocrural dorsiflexion
Subtalar joint motion

Aerobic exercise
Glycemic control

Manual therapy

Gait and mobility training


PWB gait
Assistive device

Decrease plantar pressure


Step-to pattern
Slower speed
Shuffling gait

Footwear modifications

Medical interventions
Glycemic control
Pharmacologic management
Paresthesias
Concomitant arterial insufficiency

Antibiotic therapy
Cultures average four to five microbes
Broad-spectrum antibiotic: topically, orally, or
intravenously

Radiological Assessment
X-rays and bone scan (gold standard)

Surgical interventions
Debridement
Large amounts of necrotic tissue or osteomyelitis

Incision and Drainage (I and D)


Antimicrobial bead implantation
May be more effective than oral or intravenous antibiotic therapy

Surgery for abnormal foot function or tissue performance

Joint arthroplasty
Tendon lengthening
Stabilization of Charcot deformities
Reduction of abnormal biomechanics
Revascularization surgery

Amputation
Gangrenous, and grade 4 or 5 wounds