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1362405083 diabetic neuropathy


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diabetic neuropathy

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1362405083 diabetic neuropathy

  1. 1. 1 Diabetic Neuropathy in the Context of Diabetic Foot Podiatry Workshop Kuala Lumpur 18 – 19 November 2K Dr.Ashok Kumar Das Dean, Director, Prof. and Head Dept. of Medicine, JIPMER Pondicherry
  2. 2. 2 Diabetic Neuropathy in the Context of Diabetic Foot - 2 DFU - cause for more amputation than any other pathology. Is it inevitable? St. Vincent’s and Health 21 WHO Declaration have called for reduction in amputation in diabetic foot. Most contemporary and challenging issue
  3. 3. 3 Diabetic Neuropathy in the Context of Diabetic Foot - 3 “5-10% of all diabetic patients have foot ulceration of various degrees and about 1% undergo amputation” “Diabetes accounts for upto 50% of non traumatic leg amputations” “Of all the diabetic amputees about 50% will lose their life or their other leg by 3 years”
  4. 4. 4 Diabetic Neuropathy in the Context of Diabetic Foot Foot ulcers result in *Morbidity * Mortality “Enormous health care expenditure” “Psychosocial problems” Paucity of data regarding prevalence of diabetic foot in India
  5. 5. 5 Diabetic Neuropathy in the Context of Diabetic Foot - 5 Neuropathy that is significant enough to cause foot ulceration may affect 40% of diabetic population especially elderly with type 2 diabetes.
  6. 6. 6 Indian Patients Our major problem is neuropathic ulcer 85 - 95 %, 10 – 15% vascular. -younger patients -mean age of amputation earlier - number of amputations for neuropathic ulcer
  7. 7. 7 Indian Context Eminently preventable Amputation in a diabetic neuropathic ulcer is deplorable Need of the hour * Awareness/ education * Early identification of a high risk foot and its appropriate management
  8. 8. 8 Components of neuropathic foot transforming to diabetic foot - 1 A. Ulcerative diabetic neuropathic foot components B. Non-ulcerative neuropathic pathologies in diabetic foot
  9. 9. 9 A. Components of ulcerative diabetic neuropathic foot - 2 1. Neuropathic foot and Neuroischaemic foot 2. Neuropathic foot deformities a. Clawed toes b. Pes cavus c. Hallux rigidus and valgus d. Hammer toe e. Nail deformities f. Charcot foot
  10. 10. 10 A. Components of ulcerative diabetic neuropathic foot - 3 3. Neuropathic callus 4. Neuropathic oedema 5. Neuropathic ulcers a. Callus ulcers b. Ulcer over the pressure points on the sole c. Decubitus ulcers d. Puncture wound ulcers e. Traumatic ulcers
  11. 11. 11 B. Non-ulcerative neuropathic pathologies in diabetic foot 1. Charcot Foot Acute, chronic bone destruction and deformed diabetic foot and toes 2. Pathological fractures 3. Diabetic painful neuropathy
  12. 12. 12 DN in context of diabetic foot - 1 Our job – look after “NDF at risk” A: Preventive measures Treatment rapid and intensive Rest Off load Antibiotics Foot wear Patient education
  13. 13. 13 DN in context of diabetic foot - 2 B. Metabolic control Hyperglycemia Hypertension Hyperlipidaemia Cessation of smoking C. Deformity management D. Callus management E. Debridement and dry skin and fissure management
  14. 14. 14 DN in context of diabetic foot - 3 F. Mechanical control Off load, Off load, Off load by rest, crutches, walkers, protective shoes, heel protective pad, decrease plantar pressure by removal callus G. The importance of callus removal in NFU decrease plantar pressure know full dimension of the ulcer deep swab drainage of exudate, removal of dead tissue H. Infection control I. Educational control
  15. 15. 15 Diabetic neuropathy Scope of the syndrome - 1 Three components of neuropathy: *sensory – painful, painless *Motor *Autonomic All contribute to diabetic foot ulceration Asymptomatic neuropathy 35%
  16. 16. 16 Diabetic neuropathy Scope of the syndrome - 2 Diffuse 1. Distal symmetric sensorimotor polyneuropathy 2. Autonomic neuropathy A.Sudomotor B.Cardiovascular C.Gastrointestinal D.Genitourinary
  17. 17. 17 Diabetic neuropathy Scope of the syndrome - 3 Focal 1.Cranial neuropathy 2.Radiculopathy/plexopathy 3.Entrapment neuropathy 4.Asymmetric lower limb motor neuropathy- Diabetic amyotrophy
  18. 18. 18 Diabetic neuropathy Scope of the syndrome - 4 Rather than acting in isolation neuropathy exerts Its vicious effects in concert with angiopathy + immunopathy leading to infections
  19. 19. 19 Neuropathic foot components Neuropathic ulcer Neuropathic joint Neuropathic oedema
  20. 20. 20 Diabetic foot – Mechanisms - 1 Loss of pain sensation results in neuropathic injury due to repeated unrecognised trauma inflicted in many different ways
  21. 21. 21 Diabetic foot – Mechanisms - 2 Loss of joint positon sense results in abnormal foot posture This may lead to injury when the shoes are not properly selected or during walking
  22. 22. 22 Diabetic foot – Mechanisms - 3 Motor Neuropathy * Weakness * Wasting of small intrinsic muscles of foot *Imbalance between the flexor and extensor muscles
  23. 23. 23 Diabetic foot – Mechanisms - 4 Intrinsic deformity Clawing of the toes Prominence of metatarsal heads Flattening of the arch
  24. 24. 24 Diabetic foot – Mechanisms - 5 Abnormal distribution of body weight Weight gets concentrated on smaller areas like metatarsal head and the heel. Excess pressure loading of these areas finally results in callus formation.
  25. 25. 25 Diabetic foot – Mechanisms - 6 Body weight in patients with plantar ulcers was significantly greater than in those with neuropathy but no ulcer.
  26. 26. 26 Autonomic neuropathy - 1 * Damages the sympathetic innervation of lower limb * This results in Decreased sweating Results in dry skin fissures / cracks Super added infection
  27. 27. 27 Autonomic neuropathy - 2 Opening of arteriovenous channels Warm skin ( misleadingly healthy ) Shunting of nutrients and oxygen from the tissues Impaired vascular response to infection
  28. 28. 28 Autonomic neuropathy classical signs Dry skin with fissuring Distended veins over the dorsum of foot and the ankle
  29. 29. 29 Connective tissue changes Hyperglycemia causes non enzymatic glycation of collagen and keratin Increase in cross linking Become rigid and inflexible Tissue break down in places where there is high horizontal shear force
  30. 30. 30 Neuropathic ulcer * Painless * Develops on pressure points (metatarsal heads/heel) * Pulsations intact unless superadded ischaemia is also present * Decrease in pain / temperature as also in the vibration perception * Punched out ulcer surrounded by callus
  31. 31. 31 Neuropathic (n) /Ischemic ulcer (i) Site Pressure points (n) Sides / tips of toes (i) Pain --- ( n ) +++ ( i ) Callus ++ ( n ) --- ( i ) Pulse ++ ( n ) --- ( i ) Abi > 1 ( n ) < .6 ( i ) Healing ++ ( n ) --- ( i )
  32. 32. 32 Quantitative tests for neuropathic assessement - 1 1. Measurement of light touch sensation - Nylon monofilament (Semmes Weinstein) 2. Measurement of thermal sensitivity - Marstock Thermode
  33. 33. 33 Quantitative tests for neuropathic assessement - 2 The advantage of the assessment with monofilaments or biosthesiometry is the detection of whether the patient has lost protective pain sensation that would render him susceptible to foot ulceration. Nylon monofilaments test the threshold to pressure sensation
  34. 34. 34 Quantitative tests for neuropathic assessement - 3 Monofilament: This is a simple technique. When applied perpendicular to the foot it buckles at a force of 10 gms Areas to be tested include plantar aspect of big toe metatarsal heads of first, third and fifth and the plantar surface of heel. Filament not to be applied over the callus
  35. 35. 35 Quantitative tests for neuropathic assessement - 4 1. Measurement of vibration *Biosthesiometer *Graduated tuning fork 2. Nerve conduction studies
  36. 36. 36 Management of Neuropathic Ulcer - 1 General measures Specific measures
  37. 37. 37 Management of Neuropathic Ulcer - 2 Good glycemic control Treatment of infections Management of neuropathic oedema
  38. 38. 38 Management of Neuropathic Ulcer - 3 All ulcers irrespective of their cause will be slow to heal in presence of oedema, due impairment of local flow Neuropathic oedema can be treated with Diuretics Ace inhibitors Ephedrine ( 30 mg tds ) D/d hypo albuminemia cardiac failure
  39. 39. 39 Management of Neuropathic Ulcer - 4 “Over 90% of predominantly neuropathic ulcers will heal satisfactorily with conservative measures”
  40. 40. 40 Management of Neuropathic Ulcer - 5 “Key to the management is the relief of pressure that caused the initial lesion” Pressure is off loaded most effectively by encasing the foot in a light plaster of paris cast. *Total contact cast *Removable scotch cast boot, custom made shoes etc.
  41. 41. 41 Preventing Neuropathic Foot Ulcers - 1 Regular inspection of foot - annually Identification of high risk feet – 3 mo / 6mo Careful choice of foot wear Regular chiropody Intense education
  42. 42. 42 Preventing neuropathic foot ulcers - 2 “As little as one hour’s education provided by the podiatrist resulted in 70% reduction in amputations over the following 2 years . as compared with a control group who did not receive the advice” Malone IM et al 1989
  43. 43. 43 Glycemic control and diabetic neuropathy Diabetes control and complication trial showed that intensive insulin therapy reduced the incidence of appearance of neuropathy by about 70%
  44. 44. 44 Intensive insulin treatment Reduced the clinical appearance of overt neuropathy in patients with subclinical neuropathy from 16% to 7% (57% reduction) Reduced the risk of developing clinically overt diabetic neuropathy by 60% over five years
  45. 45. 45 Neuropathic joint or Charcot arthropathy - 1 1868 French neurologist I.M. Charcot First described in tabes Can also be seen in leprosy, syringomyelia, hereditary sensory neuropathy, Charcot Marie Tooth disease etc
  46. 46. 46 Neuropathic joint or Charcot arthropathy - 2 Relatively rare Potentially devastating disorder Long standing diabetes Dense peripheral neuropathy Peripheral vascular disease is typically absent
  47. 47. 47 Neuropathic joint or Charcot arthropathy - 1 Sympathetic failure-- increased blood flow due to arteriovenous anastomosis Bone demineralisation (diabetic osteopenia) Susceptibility to minor, recurrent fractures
  48. 48. 48 Neuropathic joint or Charcot arthropathy - 4 Painless disintegration of bone in response to trivial trauma Common joints involved are Tarso metatarsal Metatarso phalangeal Ankle joint Knee joint
  49. 49. 49 Neuropathic joint or Charcot arthropathy - 5 Acute Charcot arthropathy may mimic infection Chronic Charcot foot is classically described as ‘bag of bones’ (Gross destruction of joint surfaces and bone with effusion which is typically painless)
  50. 50. 50 Neuropathic joint or Charcot arthropathy - 6 Differentiation from osteomyelitis is difficult * TC 99 Scan * Indium labelled white cell scan * MRI
  51. 51. 51 Neuropathic joint or Charcot arthropathy - 7 Early diagnosis and intervention are important to prevent deformity and loss of function Treatment includes *long term immobilisation in a plaster of Paris cast (for upto 1 year) *Charcot Restraint Orthotic Walker (crow) which allows pressure to be off loaded *Pamidronate - tried as a new treatment of Charcot arthropathy
  52. 52. 52 Newer (experimental) measures for treating neuropathy are Aldose reductase inhibitors Gamma linolenic acid Vasodialators (ace inhibitors /ca 2+ channel blockers) Aminoguanidine Nerve growth factors
  53. 53. 53 Management involves Bed rest Pressure offloading Reduction of oedema Glycemic control Most important step is the early detection of a high risk foot by simple tests / few quantitative tests