Content

Prevalence of Diabetic Foot Pathophysiology Classification Diagnosis Treatment Diabetic Foot Education

Some Facts and Figures about Diabetic foot

According to WHO, in 2010, there are more than 8 million DM patients in Pakistan Many patients are undiagnosed yet Diabetes Mellitus is the largest cause of neuropathy Foot ulcerations is most common cause of hospital admissions for Diabetics Expensive to treat, may lead to amputation and need for chronic institutionalized care

Prevalence of Diabetic Foot

More than 80,000 amputations are performed on Diabetic patients each year in US 50% of people with amputations will develop ulcerations and infections in the contralateral limb within 18 months 58% will have a contralateral limb amputation 3-5 years after the first one 3 year mortality after first amputation is estimated as upto 50%

Some statistics of Diabetic Foot

Foot problems account for 40% of healthcare resources in developing countries

Some statistics of Diabetic Foot

85% of all amputations begin with an ulcer 49-85% of amputations can be prevented if proper care is taken

Pathophysiology of Diabetic Foot

PVD

Diabetic Foot
Neuropathy

Infections

PERIPHERAL VASCULAR DISEASES

Peripheral vascular disease in diabetes

15-40 times more likely to have lower limb amputation People over 70 years have a 70-fold increased risk of amputation An estimated 1 out of every 3 people with diabetes over the age of 50 have this condition * Patients with PAD have an increased risk of MI and stroke*

* http://www.diabetes.org/living-with-diabetes/complications/peripheral-arterialdisease.html

Causes of Peripheral vascular disease

Diabetes Smoking Hypercholesterolemia Hypertension

Pathophysiology of PVD

Peripheral Vascular Disease is commonly caused by atherosclerosis and usually affects the tibial, peroneal, aorto-iliac or infra-inguinal arteries

Stages of PVD
1. Occlusive disease without symptoms 2. Intermittent claudication 3. Ischaemic rest pain (night time) 4. Ulceration/gangrene

Symptoms of PVD

Intermittent claudication which can occur in both but is often worse in one leg Rest pain at night

Intermittent Claudication

Walking-induced pain in one or both legs that does not disappear with continued walking, and is relieved only by rest Claudication is present in 15% to 40% of Pts with peripheral arterial disease and associated with a ability to perform daily tasks

Varying presentations of patients with PVD

The majority of PAD patients do not have the classical symptoms of claudication

PAD patients 50 years Initial presentation*

Claudication
Rest Pain
10%35% of patients

Atypical leg pain

40%50% of patients

Asymptomatic
20%50% of patients

* Excluding patients with an initial presentation of critical limb ischemia. Adapted from Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

Signs of PVD

Dry flaky skin Diminished or absent pedal pulses Coolness of the feet and toes Poor skin and nails Absence of hair on feet and legs Ulceration may occur in association

Initial Screening of PVD

History of Claudication

Assessment of Pedal Pulses Obtain ABI Ankle Brachial Index

How to assess a patient with PVD

Palpation of foot pulses Dorsalis pedis (10% absent due to anatomical reasons) Tibialis posterior Capillary filling time should also be checked CFT of >5 seconds is prolonged

How to diagnose PVD

1. ABI

Duplex Imaging 3. Diagnostic Angiogram (less common now) 4. Ultrasound 5. MRI and CT
2.

Hirsch AT et al. Available at: http://www.acc.org/clinical/guidelines/pad/summary.pdf. Accessed March 22, 2006.

Ankle-Brachial Pressure
The most cost effective tool for PVD

Measuring the cuff pressure by Doppler in the posterior tibial or anterior tibial arteries compared to the brachial artery Intermittent claudication is associated with ABPI of 0.4-0.9 Values less than 0.4 is associated with critical limb ischemia

Duplex Imaging

Duplex arterial imaging allows narrowing or obstruction of blood vessels to be localized

Diagnostic Angiogram

Performed through a percutaneous arterial catheter Less commonly used now

PAD patients are at increased risk for CV ischemic events

Up to 1/3 of PAD patients will die in 5 years, 75% from CV causes PAD* (50 years old) 5-year outcomes

Limb morbidity 70%80% Stable claudication 10%20% worsening claudication 1%2% critical limb ischemia

CV morbidity
20%
Nonfatal CV event (MI or stroke)

Mortality
15% to 30%
75% from CV causes

* Patients with an initial clinical presentation of asymptomatic PAD, atypical leg pain, or claudication. Adapted from Hirsch AT et al. Available at: www.acc.org. Accessed March 22, 2006.

Peripheral vascular disease

Treatment
Quit smoking Walk through pain Surgical intervention

Aim for an A1C below 7%

Lower your blood pressure to less than 130/80

mmHg
Get your LDL cholesterol below 100 mg/dl

Distinguishing features of Ischemia

Symptoms Claudication Rest pain Palpation Cold, pulseless Inspection Dependent rubor Trophic changes Ulceration Painful Heels and toes

Neuropathy
Symptoms Usually painless Sometimes painful neuropathy Palpation Warm, bounding pulses Inspection High arch, Clawing of toes No trophic changes Ulceration Painless Plantar

Diabetic Neuropathy

Neuropathy

Changes in the vasonervorum with resulting ischemia Increased sorbitol in feeding vessels block flow and causes nerve ischemia Intraneural accumulation of advanced products of glycosylation Abnormalities of all three neurologic systems contribute to ulceration

Types of Diabetic Neuropathy

There are four types of diabetic neuropathy: Peripheral Sensory neuropathy (also called diabetic nerve pain and distal polyneuropathy) Proximal neuropathy (also called diabetic amyotrophy) Autonomic neuropathy Focal neuropathy (also called

Peripheral neuropathy sensory motor

Most common form of neuropathy Affects approximately 50% after 15 years Affects long nerves (feet and legs) first glove and stocking distribution Bilateral Equal symptoms in both limbs

Sensory Neuropathy
Loss of protective sensation Starts distally and migrates proximally in stocking distribution Large fibre loss light touch and proprioception Small fibre loss pain and temperature Usually a combination of the two

Sensory nerve damage

Nerve damage neuropathy

Symptoms:
Pain Numbness (loss of feeling) Tingling Muscle weakness Muscle cramping and/or twitching Insensitivity to pain and/or temperature Extreme sensitivity to even the lightest touch Symptoms get worse at night

Autonomic Neuropathy
Regulates sweating and perfusion to the limb Loss of autonomic control inhibits thermoregulatory function and sweating Result is dry, scaly and stiff skin that is prone to cracking and allows a portal of entry for bacteria

Autonomic nerve damage

Motor Neuropathy
Mostly affects forefoot ulceration Intrinsic muscle wasting claw toes Equinus contracture

Motor nerve damage

Acute painful Neuropathy

A common complication of

Diabetes The two types of neuropathies associated with pain are acute sensory nueropathy and chronic sensorimotor neuropathy

Causes of PDN

Hyperglycemia remains the major causative factor but PDN can also be seen in patients having HBA1C < 8% Smoking Hyperlipidemia Hypertension Obesity

Treatment of PDN
Glycemic Control Correction of metabolic derangements Medications e.g Tricyclic Antidepressants like Duloxetine Antiepileptics like Gabapentins and Pregablin and Carbamazepine Tramadol

Painless nature of diabetic foot disease

Localized callus

Diabetic peripheral neuropathy screening tests

Test sensation Biothesiometer Tuning fork 10 gm monofilament Ankle reflexes

Assessment of high risk characteristics

Motor Neuropathy and Foot Deformities

Hammer toes

Claw toes
Prominent metatarsal heads Hallux valgus Collapsed plantar arch

Hammer Toes

Claw Toes
2002 American Diabetes Association From The Uncomplicated Guide to Diabetes Complications Reprinted with permission from The American Diabetes Association

Hallux Valgus

2002 American Diabetes Association From The Uncomplicated Guide to Diabetes Complications Reprinted with permission from The American Diabetes Association

Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512

Sensory Neuropathy in Diabetes

Loss of protective sensation in feet Detect with 5.07/10-g Semmes-Weinstein monofilament 50% of insensate patients have no symptoms

Diabetes Care. 2006;29(Suppl 1):S24 Diabetes Care. 2004;27:1591

Monofilament Testing

Test characteristics:
Negative predictive value = 90%-98% Positive predictive value = 18%-36%

Prospective observational study:

80% of ulcers and 100% of amputations occur in insensate feet Superior predictive value vs. other test modalities
J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386

Using the Monofilament Demonstrate on forearm or hand Place monofilament perpendicular to test site Bow into C-shape for 1 second Test 4 sites/foot Heel testing does not predict ulcer Avoid calluses, scars, and ulcers

Monofilament Testing Tips

Insensate at 1 site = insensate feet

Falsely insensate with edema, cold feet

Test annually when sensation normal

Use monofilament
< 100 times day Replace if bent Replace every 3 months

Vibration Testing

Biothesiometer
Best predictor of foot ulcer risk

128-Hz tuning fork at halluces

Equivalent to 10-g monofilament Newly recommended by ADA

Diabetes Care. 2006;29(Suppl 1):S25 Diabetes Res Clin Pract. 2005;70:8

Management of Neuropathies
Sensory Neuropathy A shoe neither too tight nor too roomy is appropriate Autonomic Neuropathy together with senosry An insole should provide optimal distribution of pressure, reduction of sheer stress and shock absorption

Charcots Arthropathy
Charcot foot is a sudden softening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). The bones are weakened enough to fracture, and with continued walking the foot eventually changes shape. As the disorder progresses, the arch collapses and the foot takes on a convex shape, giving it a rocker-bottom appearance, making it very difficult to walk.

Charcots Arthropathy

Charcot foot is a very serious condition that can lead to severe deformity, disability, and even amputation

Charcots arthropathy

Charcots Arthropathy
Charcot foot symptoms may include: Warmth to the touch (the foot feels warmer than the other) Redness in the foot Swelling in the area Pain or soreness

Management of Charcots Foot

Treatment for Charcot foot consists of: Immobilization. Because the foot and ankle are so fragile during the early stage of Charcot, they must be protected so the soft bones can repair themselves. Complete non-weightbearing is necessary to keep the foot from further collapsing. The patient will not be able to walk on the affected foot until the surgeon

Management of Charcots Foot

During this period, the patient may be fitted with a cast, removable boot, or brace, and may be required to use crutches or a wheelchair. It may take the bones several months to heal, although it can take considerably longer in some patients. Custom shoes and bracing. Shoes with special inserts may be needed after the bones have healed Surgery. In some cases, surgery may be required.

DIABETIC FOOT INFECTIONS

Some facts about Diabetic foot Ulcer

Diabetic foot problems such as ulceration, infections and gangrene are the most common cause of hospitalization among Diabetic patients

Evaluating the Patient with a DFI

Patient

Systemic response Fever, chills, sweats, cardiovascular status Metabolic status Hyperglycaemia, electrolyte imbalance, hyperosmolality, renal impairment Cognitive function Delirium, depression, dementia, psychosis Social situation Support, self-neglect Limb/Foot Wound

Evaluating the Patient with a DFI

Limb or Foot Vascular (Ischaemia , Venous insufficiency) Neuropathy Infection Wound Size, depth Necrosis, gangrene Infection

DIABETIC FOOT ULCERS

Diabetic Foot Ulcer

The enormity of the global burden of diabetic foot diseasethis much neglected, but potentially devastating, complication of a disease that is reaching epidemic proportionsSomeone, somewhere, loses a leg because of diabetes every 30 seconds of everyday

Lancet. 2005;366:1674

Prevalence of Diabetic foot ulcer

25 % of diabetics will develop a foot ulcer

40-80% of these ulcers will become infected 25 % of these will become deep

10-30 % of patients with a diabetic foot ulcer will go on to amputation

Etiology of Diabetic Foot Ulcer

The majority of foot ulcers appear to result

from minor trauma in the presence of sensory neuropathy The critical triad is most commonly seen in patients with diabetic foot ulcers are peripheral sensory neuropathy, deformity and trauma Hyperglycemia remains the mainstay in the onset and progression of neuropathy

Causal Pathways for Foot Ulcers

Neuropathy % Causal Pathways Neuropathy: Minor trauma: Deformity: 78% 79% 63%

Deformity

Minor Trauma
- Mechanical (shoes) - Thermal - Chemical

Behavioral

Poor self-foot care

ULCER

Diabetes Care. 1999; 22:157

Pre-ulcer Cutaneous Pathology

Persistent erythema after shoe removal Callus with subcutaneous hemorrhage Fissure Interdigital maceration, fungal infection Nail pathology

Pre-ulcer

AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002

Case Study

A patient comes with the complain of pre-ulcer (callus with subcutanoeus hemorrhage on the tip of the third digit This pre-ulcer (callus with subcutaneous hemorrhage) on the tip of the third digit with its claw-toe deformity could easily go undetected. Pre-ulcers must be promptly and carefully debrided to determine if there is already an underlying ulcer.

Case Study (Cont..d)

Treatment In this patient debridement did not reveal an underlying ulcer. Debridement of callus reduces subcutaneous pressure and helps to prevent subcutaneous hemorrhage and progression to an ulcer. This patients socks and shoe gear will have to be modified to accommodate his claw-toe deformities.

Case Study
64-year-old obese man Type 2 DM (15 yrs) BP (18 yrs) Dyslipidemia (18 yrs) CABG (10 yrs ago) Claudication (today; 25 yds) Insulin/Metformin/Statin/ACEI/HCTZ/ASA Comes with the complain Sore on my left foot, Doc

Case Study (continued)

Clinical evaluation of heel ulcer:

Probe reached bone Extensive subcutaneous abscess

MRI: extensive osteomyelitis

ABI: 0.2
Angiography: Inoperable severe vascular disease

Uncontrolled infection
Amputation necessary

Tragic Rule of 50

50% of amputations

Transfemoral/ transtibial level

50% of patients

2nd amputation in 5 years

50% of patients

Die in 5 years
Clinical Care of the Diabetic Foot, 2005

Tragic Rule of 15

15% of diabetes lifetime patients 15% of foot ulcers

Foot ulcer in

Osteomyelitis

15% of foot ulcers

Amputation

Evaluation of Diabetic Foot Ulcer

Documentation of the wounds size, shape,

location, depth, base and border. A sterile stainless steel probe is used to assess the depth of wound up till the bone, tendon or joint X-rays should be done MRI is also useful for detecting osteomyelitis, and deep abscess

Team Care Identification of high-risk patients Detection of early problems Educate/motivate self-care behaviors Prophylactic nail/skin care Therapeutic footwear Prompt, multidisciplinary treatment of ulcers

Lancet. 2005;366:1676

Team Care Reduces Ulcers/Amputations

50%-80% reductions in ulcers/amputations possible with Team Care Economic modeling studies Cost-effective if 25%-40% reduction in ulcer rate Cost-saving if > 40% reduction in ulcer rate

Lancet. 2005;366:1719 Diabetes Care. 2004;27:901

Treatment of Diabetic Foot Ulcers

Debridement:

Removal of all necrotic tissue, peri wound callus, and foreign bodies down to viable tissue After debridement, wound is irrigated with saline or cleanser and a dressing is applied Dressings available are hydrogels, foams, calcium alginates and skin replacement

Treatment of Diabetic Foot Ulcers

Debridement: In case of abscess, incision and drainage are essential with debridement Treating a deep abscess with antibiotics alone leads to delayed therapy and further mortality and morbidity

Treatment of Diabetic Foot Ulcers Offloading

Proper offloading remains the biggest challenge for HCPs Having patients use a wheelchair or crutch is the most effective method of offloading Total contact Casts (TCC) are difficult but significantly reduce pressure on wounds Post operative shoes or wedge shoes are also used but proper fitting is necessary

Treatment of Diabetic Foot Ulcers Infection Control

Coverage of gram positive and gram negative organisms like methicillin resistant Staph. Aureus, B-hemolytic Strep. Pseudomonas and enterococci Patients should be hospitalised and and treated with IV antibiotics Mild to moderate infection can be treated as OPD with Cephalexin, Amoxicillin with Clavulanate Potassium, Moxifloxacin or Clindamycin

Detecting Feet-at-risk

History:
Prior amputation or foot ulcer Peripheral artery disease (PAD)

Exam:
Insensate
Foot deformities Absent pulses Prolonged venous filling time Reduced ABI Pre-ulcerative cutaneous pathology

Prevalence of Amputation

50 % of patients with cellulitis will have another episode within 2 years 25-50 % of diabetic foot infections lead to minor amputations 10-40 % require major amputations

Cause of diabetic amputation

Neuropathy or vascular disease Trauma Ulcer
Failure to heal
Infection
Amputation

Physical Examination of the Feet in Persons with Diabetes

Risk categorization system

Category Risk profile 0 1 2 3 No sensory neuropathy Sensory neuropathy Sensory neuropathy /peripheral vascular disease/foot deformities Previous ulcer Check-up frequency Once a year Every 6 months Every 3 months Every 1-3 months

100% 90% 80% 70% 60%

100% 1666 patients enrolled in prospective diabetic foot study

89% 90%

Outcomes By IDSA DFI Severity Classification

= 118.6, <0.0001
80% 70% 60%
54%

Hospitalization
X2 trend

LE Amputation
X2 trend = 108, p < 0.0001

78%

50% 40% 30% 20% 10% 10% 0% 6%

50% 40% 30% 20% 10% 3% 3% Mild Mild 0% Severe

46%

None No infection

Mild Moderate Severe Mild Moderate

No infection

None

Moderate Severe Moderate Severe

Armstrong, Lavery, Peters, Lipsky. Clin Infect Dis 2007

Diabetic Foot Education

Most foot problems are preventable Upto 85% of foot problems are preventable through early identification and prompt treatment by skilled health professionals.

Diabetic Voice, March 2005, Volume 50, Issue 1

Targeting education according to level of risk

Wide spectrum of foot risk; people require different levels of education Should be considered when providing footcare education

Lifestyle changes only required for those at high risk

Evidence-based stratification of services

Ulcer

High-risk foot clinic Intensive foot education and podiatry

High

Low

Neuropathy, previous amputation or ulcer Peripheral vascular disease Unable to feel monofilament Neuropathy, no previous amputation or ulcer General information

No neuropathy

Which people should we target for footcare education?

Footcare education Low risk simple advice no lifestyle change annual foot assessment High risk intensive education practical demonstrations significant behavioural changes focus on prevention

Footcare education Which behaviour- and lifestyle-changing strategies do we teach people with diabetes when they are at high risk?

Wash, touch and look at feet every day

Do not soak feet Test water temperature Wash and dry between toes Avoid herbs and ointments

Examine feet in good light

Learn to look for:

Bruises

Cuts
Blisters

Learn to look for:

Cracked heels Callus

Learn to look for:

Hammer toe

Clawed toes

Learn to look for:

Bunion Charcots arthropathy

Learn to look for:

Foot infection

Learning to care for skin Moisturiser preferably in a pump bottle Massage with cream not in open sores or between toes Without perfume

How to care for toenails

Do not to let nail grow too long

Cut straight across File sharp edges Ask a friend or relative

How to treat tinea

Anti-fungal lotion between toes Anti-fungal cream on feet Treat affected area and surrounding skin

What to do about fungal nails

Difficult to treat Thick nails should be filed

What to look for in socks

Wool or cotton

Padded socks
No tight tops No rough seams Knee-high stockings not advisable

What to look for in a shoe

Wide and deep at the toe

Thick rubber sole

No high heels

Firm heel counter

Lace-up or velcro Smooth lining

Footwear

When buying shoes

Buy in the afternoon Measure both feet Stand up to fit Wear in slowly Never wear new shoes all day

Being extra careful Before putting on shoes, check for

rough spots or loose objects

Preventing burns

Use sunblock on exposed skin

At least 3 m from heater

Turn off electric blankets

No hot water bottles

Never walk barefoot

Exercise

Walk only as far as is absolutely necessary

Non-walking exercises

Basic Footwear Education

Donts

Dos

Pointed toes Slip-ons Open toes High heels Plastic Black color Too small

Broad-round toes
Adjustable (laces, buckles, Velcro)

Athletic shoes, walking shoes

Leather, canvas

White/light colors
between longest toe and Diabetes Self-Management. 2005;22:33 end of shoe

Identify problem and act quickly

If no sign of improvement, contact

doctor or emergency services
Remember,
people with neuropathy do not feel pain!

Footcare educational material

Written material complements education Written at average reading age

Large font for visually impaired Pictures should be relevant to text

Evaluating the foot education program

Evaluate behavioural change not knowledge How many times have you checked your feet this week? How many times have you put cream on your feet this week?

Key messages

Stratify people according to level of risk Educate those at high risk Shoes are the most common cause of ulceration Identify problems early and treat promptly Health professionals need to be trained in diabetic foot care

Key messages
Get regular check-ups from a foot and ankle surgeon Check both feet every dayand see a surgeon immediately if there are signs of Charcot foot Be careful to avoid injury, such as bumping the foot or overdoing an exercise program

An amputation occurs every 30 seconds due to diabetes