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Diabetic Neuropathy - EtiologyDiabetic Neuropathy - Etiology
Mechanisms and ConsequencesMechanisms and Consequences
Sanj...
2
Risk Factors ForRisk Factors For
Diabetic NeuropathyDiabetic Neuropathy
• MODIFIABLEMODIFIABLE
• HYPERGLYCEMIAHYPERGLYCE...
3
Etiology Of Diffuse Neuropathy - 1Etiology Of Diffuse Neuropathy - 1
• HyperglycemiaHyperglycemia
• Vasa nervorum closur...
4
Etiology Of Diffuse Neuropathy - 2Etiology Of Diffuse Neuropathy - 2
• Advanced glycated end productsAdvanced glycated e...
5
Diabetic Neuropathy –Diabetic Neuropathy –
PrevalencePrevalence
Neuropathy that is significant enough toNeuropathy that ...
6
Feet ComplicationsFeet Complications
4%
1% 1%
37%
Healed Ulcer
Acute Ulcer / Gangrene
Neuropathy
Leg Amputation
7
Current Co-Morbid ConditionsCurrent Co-Morbid Conditions
8
Severe Late ComplicationsSevere Late Complications
1%
7%
3%
1% 1%
Legal Blindness MI/CABG/Angioplasty
Stroke ESRD Leg Am...
9
Diabetes ComplicationsDiabetes Complications
In Relation To Diabetes DurationIn Relation To Diabetes Duration
60%
35%
29...
10
Components of neuropathic footComponents of neuropathic foot
transforming to diabetic foot - 1transforming to diabetic ...
11
A. Components of ulcerativeA. Components of ulcerative
diabetic neuropathic foot - 2diabetic neuropathic foot - 2
1. Ne...
12
A. Components of ulcerativeA. Components of ulcerative
diabetic neuropathic foot - 3diabetic neuropathic foot - 3
3. Ne...
13
Components of Diabetic Foot - 4Components of Diabetic Foot - 4
Three components of neuropathy:Three components of neuro...
14
Components of Diabetic Foot -Components of Diabetic Foot -
55
Rather than acting in isolation neuropathyRather than act...
15
B. Non-ulcerative neuropathicB. Non-ulcerative neuropathic
pathologies in diabetic footpathologies in diabetic foot
1. ...
16
17
18
Diabetic foot – Mechanisms - 1Diabetic foot – Mechanisms - 1
Loss of pain sensation resultsLoss of pain sensation resul...
19
Diabetic foot – Mechanisms - 2Diabetic foot – Mechanisms - 2
Loss of sensation of joint position causesLoss of sensatio...
20
Diabetic foot – Mechanisms - 3Diabetic foot – Mechanisms - 3
Motor NeuropathyMotor Neuropathy
* Wasting of small intrin...
21
Diabetic foot – Mechanisms - 4Diabetic foot – Mechanisms - 4
Intrinsic deformityIntrinsic deformity
Clawing of the toes...
22
23
Diabetic foot – Mechanisms - 5Diabetic foot – Mechanisms - 5
Abnormal distribution of body weight,Abnormal distribution...
24
Diabetic foot – Mechanisms - 6Diabetic foot – Mechanisms - 6
Connective tissue changesConnective tissue changes
Hypergl...
25
Diabetic foot – Characteristics of aDiabetic foot – Characteristics of a
Neuropathic ulcerNeuropathic ulcer
* Painless ...
26
Neuropathic (n) / Ischemic ulcer (i)Neuropathic (n) / Ischemic ulcer (i)
Site Pressure points (n)Site Pressure points (...
27
Autonomic neuropathy - 1Autonomic neuropathy - 1
* Damages the sympathetic innervation of* Damages the sympathetic inne...
28
Autonomic neuropathy - 2Autonomic neuropathy - 2
Opening of arteriovenous channelsOpening of arteriovenous channels
War...
29
30
31
Autonomic neuropathyAutonomic neuropathy
classical signsclassical signs
Dry skinDry skin
FissuringFissuring
Distended v...
32
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 1Charcot’s arthropathy - 1
1868 French neurologist I.M...
33
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 2Charcot’s arthropathy - 2
Relatively rareRelatively r...
34
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 1Charcot’s arthropathy - 1
Sympathetic failure-- incre...
35
Fig
Charcot’s
Foot with
Acute Stage
of
Destruction
36
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 4Charcot’s arthropathy - 4
Painless disintegration of ...
37Fig Bilateral Charcot’s Foot in Acute Stage of Destruction
38
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 5Charcot’s arthropathy - 5
Acute Charcot’s arthropathy...
39
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 6Charcot’s arthropathy - 6
Differentiation from osteom...
40
Neuropathic joint orNeuropathic joint or
Charcot’s arthropathy - 7Charcot’s arthropathy - 7
Early diagnosis and interve...
41
Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers –
Economic ConsequencesEconomic Consequences - 1- 1
Neur...
42
Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers –
Economic ConsequencesEconomic Consequences - 2- 2
• DF...
43
Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers –
Economic ConsequencesEconomic Consequences - 3- 3
• Fo...
44
Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers –
Economic ConsequencesEconomic Consequences - 4- 4
• 5-...
45
Total Mean Duration ofTotal Mean Duration of
HospitalizationHospitalization
Cause SpecificCause Specific
14.7
8.2
14.5
...
46
Total Mean Hospitalization CostTotal Mean Hospitalization Cost
CauseCause SpecificSpecific
11.2
7.7
19.6
7.6
5.9
11.2
7...
47
TEN COMMANDMENTS OF DIABETICTEN COMMANDMENTS OF DIABETIC
FOOT CAREFOOT CARE
1.1. DO NOTDO NOT walk barefootwalk barefoo...
48
TEN COMMANDMENTS OF DIABETICTEN COMMANDMENTS OF DIABETIC
FOOT CAREFOOT CARE
5.5. DO NOTDO NOT walk bearing weight on af...
49
TEN COMMANDMENTS OFTEN COMMANDMENTS OF
DIABETIC FOOT CAREDIABETIC FOOT CARE
8.8. CUTCUT the nails regularly, trim them ...
50
Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers –
Need of the hourNeed of the hour
• Paucity of data reg...
51
Effect Of Patient Education OnEffect Of Patient Education On
Amputation RatesAmputation Rates
Knee & Above
12%
15%
5%
4...
52
Factors and markers of low-risk versus high-Factors and markers of low-risk versus high-
risk diabetic feetrisk diabeti...
53
Factors and markers of low-risk versus high-Factors and markers of low-risk versus high-
risk diabetic feetrisk diabeti...
54
Diabetic Foot Wounds Are LikeDiabetic Foot Wounds Are Like
ICEBERGICEBERG
55
Diabetic neuropathyDiabetic neuropathy
Scope of the syndrome - 2Scope of the syndrome - 2
• DiffuseDiffuse
• 1. Distal ...
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1362571981 diab neuropa etiol mech con

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1362571981 diab neuropa etiol mech con

  1. 1. 1 Diabetic Neuropathy - EtiologyDiabetic Neuropathy - Etiology Mechanisms and ConsequencesMechanisms and Consequences Sanjeev KelkarSanjeev Kelkar Conjoint LecturerConjoint Lecturer Faculty of HealthFaculty of Health University of NewcastleUniversity of Newcastle AustraliaAustralia
  2. 2. 2 Risk Factors ForRisk Factors For Diabetic NeuropathyDiabetic Neuropathy • MODIFIABLEMODIFIABLE • HYPERGLYCEMIAHYPERGLYCEMIA • HYPERTENSIONHYPERTENSION • INCREASEDINCREASED CHOLESTEROLCHOLESTEROL • SMOKINGSMOKING • ALCOHOL USEALCOHOL USE • NON MODIFIABLENON MODIFIABLE • OLD AGEOLD AGE • LONG DURATIONLONG DURATION OF DIABETESOF DIABETES • HLA-DR 3/4HLA-DR 3/4 GENOTYPEGENOTYPE • GREATER HEIGHTGREATER HEIGHT
  3. 3. 3 Etiology Of Diffuse Neuropathy - 1Etiology Of Diffuse Neuropathy - 1 • HyperglycemiaHyperglycemia • Vasa nervorum closureVasa nervorum closure • Abnormal fatty acid metabolismAbnormal fatty acid metabolism • Myo inositol deficiencyMyo inositol deficiency
  4. 4. 4 Etiology Of Diffuse Neuropathy - 2Etiology Of Diffuse Neuropathy - 2 • Advanced glycated end productsAdvanced glycated end products • Antibodies to neural tissuesAntibodies to neural tissues • Neural growth factorsNeural growth factors
  5. 5. 5 Diabetic Neuropathy –Diabetic Neuropathy – PrevalencePrevalence Neuropathy that is significant enough toNeuropathy that is significant enough to cause foot ulceration may affect 40% ofcause foot ulceration may affect 40% of diabetic population especially elderlydiabetic population especially elderly with type 2 diabetes.with type 2 diabetes. Asymptomatic neuropathy 35%Asymptomatic neuropathy 35%
  6. 6. 6 Feet ComplicationsFeet Complications 4% 1% 1% 37% Healed Ulcer Acute Ulcer / Gangrene Neuropathy Leg Amputation
  7. 7. 7 Current Co-Morbid ConditionsCurrent Co-Morbid Conditions
  8. 8. 8 Severe Late ComplicationsSevere Late Complications 1% 7% 3% 1% 1% Legal Blindness MI/CABG/Angioplasty Stroke ESRD Leg Amputation
  9. 9. 9 Diabetes ComplicationsDiabetes Complications In Relation To Diabetes DurationIn Relation To Diabetes Duration 60% 35% 29% 64% 32% 19%12% 5% 4%4% 2% 2%2% <5y5-10y>10y Foot Eye MI Stroke ESRD n=480n=626n=901
  10. 10. 10 Components of neuropathic footComponents of neuropathic foot transforming to diabetic foot - 1transforming to diabetic foot - 1 • A. Components of Ulcerative diabeticA. Components of Ulcerative diabetic neuropathic footneuropathic foot • B. Non-ulcerative neuropathic pathologiesB. Non-ulcerative neuropathic pathologies in diabetic footin diabetic foot
  11. 11. 11 A. Components of ulcerativeA. Components of ulcerative diabetic neuropathic foot - 2diabetic neuropathic foot - 2 1. Neuropathic & Neuroischemic foot1. Neuropathic & Neuroischemic foot 2. Neuropathic foot deformities2. Neuropathic foot deformities a. Clawed toesa. Clawed toes b. Pes cavusb. Pes cavus c. Hallux rigidus and valgusc. Hallux rigidus and valgus d. Hammer toed. Hammer toe e. Nail deformitiese. Nail deformities
  12. 12. 12 A. Components of ulcerativeA. Components of ulcerative diabetic neuropathic foot - 3diabetic neuropathic foot - 3 3. Neuropathic callus3. Neuropathic callus 4. Neuropathic ulcers4. Neuropathic ulcers a. Ulcer over pressure points ona. Ulcer over pressure points on sole, later callus ulcerssole, later callus ulcers b. Decubitus ulcersb. Decubitus ulcers c. Puncture wound ulcersc. Puncture wound ulcers d. Traumatic ulcersd. Traumatic ulcers
  13. 13. 13 Components of Diabetic Foot - 4Components of Diabetic Foot - 4 Three components of neuropathy:Three components of neuropathy: *sensory – painful, painless*sensory – painful, painless *Motor*Motor *Autonomic*Autonomic All contribute to diabetic foot and orAll contribute to diabetic foot and or ulcerationulceration
  14. 14. 14 Components of Diabetic Foot -Components of Diabetic Foot - 55 Rather than acting in isolation neuropathyRather than acting in isolation neuropathy exerts its vicious effectsexerts its vicious effects in concert with angiopathy andin concert with angiopathy and immunopathy leading to ulcerationimmunopathy leading to ulceration and infectionsand infections
  15. 15. 15 B. Non-ulcerative neuropathicB. Non-ulcerative neuropathic pathologies in diabetic footpathologies in diabetic foot 1. Charcot’s Foot1. Charcot’s Foot Acute / chronic bone destruction andAcute / chronic bone destruction and deformed diabetic foot and toes withdeformed diabetic foot and toes with pathological fracturespathological fractures 2. Diabetic painful neuropathy2. Diabetic painful neuropathy
  16. 16. 16
  17. 17. 17
  18. 18. 18 Diabetic foot – Mechanisms - 1Diabetic foot – Mechanisms - 1 Loss of pain sensation resultsLoss of pain sensation results in neuropathic injury due to,in neuropathic injury due to, repeated unrecognized trauma,repeated unrecognized trauma, inflicted in many different waysinflicted in many different ways
  19. 19. 19 Diabetic foot – Mechanisms - 2Diabetic foot – Mechanisms - 2 Loss of sensation of joint position causesLoss of sensation of joint position causes the foot to land in abnormal foot positionthe foot to land in abnormal foot position on ground leading to areas of excessiveon ground leading to areas of excessive and low pressure leading to injury duringand low pressure leading to injury during walking or if the shoes are not properlywalking or if the shoes are not properly selected will hurt at placesselected will hurt at places
  20. 20. 20 Diabetic foot – Mechanisms - 3Diabetic foot – Mechanisms - 3 Motor NeuropathyMotor Neuropathy * Wasting of small intrinsic muscles of foot* Wasting of small intrinsic muscles of foot leading to weaknessleading to weakness *Imbalance between the flexor and*Imbalance between the flexor and extensor musclesextensor muscles
  21. 21. 21 Diabetic foot – Mechanisms - 4Diabetic foot – Mechanisms - 4 Intrinsic deformityIntrinsic deformity Clawing of the toesClawing of the toes Prominence of metatarsal headsProminence of metatarsal heads Flattening of the archFlattening of the arch
  22. 22. 22
  23. 23. 23 Diabetic foot – Mechanisms - 5Diabetic foot – Mechanisms - 5 Abnormal distribution of body weight,Abnormal distribution of body weight, concentrated on smaller areas likeconcentrated on smaller areas like metatarsal head and the heel.metatarsal head and the heel. Excess pressure loading of these areasExcess pressure loading of these areas finally results in callus formation.finally results in callus formation. Rise of Pressure > 30 times at callusRise of Pressure > 30 times at callus
  24. 24. 24 Diabetic foot – Mechanisms - 6Diabetic foot – Mechanisms - 6 Connective tissue changesConnective tissue changes Hyperglycemia causes non enzymaticHyperglycemia causes non enzymatic glycation of collagen and keratinglycation of collagen and keratin Increase in cross linkingIncrease in cross linking Become rigid and inflexibleBecome rigid and inflexible Tissue break down in places where thereTissue break down in places where there is high horizontal shear forceis high horizontal shear force
  25. 25. 25 Diabetic foot – Characteristics of aDiabetic foot – Characteristics of a Neuropathic ulcerNeuropathic ulcer * Painless - Develops on pressure points* Painless - Develops on pressure points (metatarsal heads/heel)(metatarsal heads/heel) * Pulsations intact unless superadded* Pulsations intact unless superadded ischaemia is also presentischaemia is also present * Decrease in* Decrease in pain / temperature as alsopain / temperature as also in the vibration perceptionin the vibration perception * Punched out ulcer surrounded by callus* Punched out ulcer surrounded by callus * Most ulcers from within out* Most ulcers from within out
  26. 26. 26 Neuropathic (n) / Ischemic ulcer (i)Neuropathic (n) / Ischemic ulcer (i) Site Pressure points (n)Site Pressure points (n) Sides / tips of toes (i)Sides / tips of toes (i) Pain --- ( n ) +++ ( i )Pain --- ( n ) +++ ( i ) Callus ++ ( n ) --- ( i )Callus ++ ( n ) --- ( i ) Pulse ++ ( n ) --- ( i )Pulse ++ ( n ) --- ( i ) ABI > 1( n ) < .6 ( i )ABI > 1( n ) < .6 ( i ) Healing ++ ( n ) --- ( i )Healing ++ ( n ) --- ( i )
  27. 27. 27 Autonomic neuropathy - 1Autonomic neuropathy - 1 * Damages the sympathetic innervation of* Damages the sympathetic innervation of lower limblower limb * This results in* This results in Decreased sweatingDecreased sweating Results in dry skin fissures / cracksResults in dry skin fissures / cracks Super added infectionSuper added infection
  28. 28. 28 Autonomic neuropathy - 2Autonomic neuropathy - 2 Opening of arteriovenous channelsOpening of arteriovenous channels Warm skin ( misleadingly healthy )Warm skin ( misleadingly healthy ) Shunting of nutrients and oxygen fromShunting of nutrients and oxygen from the tissuesthe tissues Impaired vascular response to infectionImpaired vascular response to infection
  29. 29. 29
  30. 30. 30
  31. 31. 31 Autonomic neuropathyAutonomic neuropathy classical signsclassical signs Dry skinDry skin FissuringFissuring Distended veins over the dorsum of footDistended veins over the dorsum of foot and the ankleand the ankle
  32. 32. 32 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 1Charcot’s arthropathy - 1 1868 French neurologist I.M. Charcot1868 French neurologist I.M. Charcot First described in tabesFirst described in tabes Can also be seen in leprosy, syringomyelia,Can also be seen in leprosy, syringomyelia, hereditary sensory neuropathy,hereditary sensory neuropathy, Charcot Marie Tooth disease etcCharcot Marie Tooth disease etc
  33. 33. 33 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 2Charcot’s arthropathy - 2 Relatively rareRelatively rare Potentially devastating disorderPotentially devastating disorder Long standing diabetesLong standing diabetes Dense peripheral neuropathyDense peripheral neuropathy Peripheral vascular disease is typicallyPeripheral vascular disease is typically absentabsent
  34. 34. 34 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 1Charcot’s arthropathy - 1 Sympathetic failure-- increased bloodSympathetic failure-- increased blood flow due to arteriovenous anastomosisflow due to arteriovenous anastomosis Bone demineralisation (diabeticBone demineralisation (diabetic osteopenia)osteopenia) Susceptibility to minor, recurrent fracturesSusceptibility to minor, recurrent fractures
  35. 35. 35 Fig Charcot’s Foot with Acute Stage of Destruction
  36. 36. 36 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 4Charcot’s arthropathy - 4 Painless disintegration of bone in responsePainless disintegration of bone in response to trivial traumato trivial trauma Common joints involved areCommon joints involved are – Tarso metatarsalTarso metatarsal – Metatarso phalangealMetatarso phalangeal – Ankle jointAnkle joint – Knee jointKnee joint
  37. 37. 37Fig Bilateral Charcot’s Foot in Acute Stage of Destruction
  38. 38. 38 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 5Charcot’s arthropathy - 5 Acute Charcot’s arthropathy may mimicAcute Charcot’s arthropathy may mimic infectioninfection Chronic Charcot’s foot is classicallyChronic Charcot’s foot is classically described as ‘bag of bones’described as ‘bag of bones’ (Gross destruction of joint surfaces and(Gross destruction of joint surfaces and bone with effusion which is typicallybone with effusion which is typically painless)painless)
  39. 39. 39 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 6Charcot’s arthropathy - 6 Differentiation from osteomyelitis is difficultDifferentiation from osteomyelitis is difficult * TC 99 Scan* TC 99 Scan * Indium labeled white cell scan* Indium labeled white cell scan * MRI* MRI
  40. 40. 40 Neuropathic joint orNeuropathic joint or Charcot’s arthropathy - 7Charcot’s arthropathy - 7 Early diagnosis and intervention are importantEarly diagnosis and intervention are important to prevent deformity and loss of functionto prevent deformity and loss of function Treatment includesTreatment includes *Long term immobilization in plaster of Paris*Long term immobilization in plaster of Paris cast, (up to even 1 year)cast, (up to even 1 year) *Charcot’s Restraint Orthotic Walker (CROW)*Charcot’s Restraint Orthotic Walker (CROW) which allows pressure to be off loadedwhich allows pressure to be off loaded *Pamidronate - tried as a new treatment of*Pamidronate - tried as a new treatment of Charcot’s arthropathyCharcot’s arthropathy
  41. 41. 41 Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers – Economic ConsequencesEconomic Consequences - 1- 1 Neuropathy that is significant enough toNeuropathy that is significant enough to cause foot ulceration may affect 40% ofcause foot ulceration may affect 40% of diabetic population especially elderlydiabetic population especially elderly with type 2 diabetes.with type 2 diabetes.
  42. 42. 42 Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers – Economic ConsequencesEconomic Consequences - 2- 2 • DFU - cause for more amputation than anyDFU - cause for more amputation than any other pathology.other pathology. • Most contemporary and challenging issueMost contemporary and challenging issue
  43. 43. 43 Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers – Economic ConsequencesEconomic Consequences - 3- 3 • Foot ulcers result inFoot ulcers result in MorbidityMorbidity MortalityMortality Enormous health care expenditureEnormous health care expenditure Psychosocial problemsPsychosocial problems
  44. 44. 44 Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers – Economic ConsequencesEconomic Consequences - 4- 4 • 5-10% of all diabetic patients have foot5-10% of all diabetic patients have foot ulceration of various degrees and aboutulceration of various degrees and about 1% undergo amputation1% undergo amputation • Diabetes accounts for up to 50% of nonDiabetes accounts for up to 50% of non traumatic leg amputationstraumatic leg amputations • Of all the diabetic amputees about 50%Of all the diabetic amputees about 50% will lose their life or their other leg by 3will lose their life or their other leg by 3 yearsyears
  45. 45. 45 Total Mean Duration ofTotal Mean Duration of HospitalizationHospitalization Cause SpecificCause Specific 14.7 8.2 14.5 13.9 32.5 9.4 11.1 21.5 25.7 6.7 16.0 13.2 0 10 20 30 40 50 60 Heart Neuro Eye NHW Kidney HBP Skin TB Paralysis Hyper Hypo Other Days
  46. 46. 46 Total Mean Hospitalization CostTotal Mean Hospitalization Cost CauseCause SpecificSpecific 11.2 7.7 19.6 7.6 5.9 11.2 7.1 13.9 27.5 0 20 40 60 80 100 Heart Neuro Eye NHW HBP Skin Hyper Hypo Other MeanCostinINR('000)
  47. 47. 47 TEN COMMANDMENTS OF DIABETICTEN COMMANDMENTS OF DIABETIC FOOT CAREFOOT CARE 1.1. DO NOTDO NOT walk barefootwalk barefoot.. 2.2. INSPECTINSPECT the feet daily for blisters, wounds,the feet daily for blisters, wounds, bleeding, smell, increased temperature at pressurebleeding, smell, increased temperature at pressure points of feet.points of feet. 3.3. DDO NOTO NOT apply hot fomentation / coldapply hot fomentation / cold compresses / electric heating pads / strong countercompresses / electric heating pads / strong counter irritant ointments to legs & feet.irritant ointments to legs & feet. 4.4. USEUSE correct footwear. Choose your footwear aftercorrect footwear. Choose your footwear after consulting your doctor. Always wear footwear withconsulting your doctor. Always wear footwear with socks with loose elastic.socks with loose elastic.
  48. 48. 48 TEN COMMANDMENTS OF DIABETICTEN COMMANDMENTS OF DIABETIC FOOT CAREFOOT CARE 5.5. DO NOTDO NOT walk bearing weight on affectedwalk bearing weight on affected foot in case of presence of wounds or afterfoot in case of presence of wounds or after surgery.surgery. 6.6. DO NOTDO NOT sit cross legged for long timesit cross legged for long time.. 7.7. DO NOTDO NOT remove foot wear during travelremove foot wear during travel and place your feet on the floor of theand place your feet on the floor of the vehicle. This can cause burns.vehicle. This can cause burns.
  49. 49. 49 TEN COMMANDMENTS OFTEN COMMANDMENTS OF DIABETIC FOOT CAREDIABETIC FOOT CARE 8.8. CUTCUT the nails regularly, trim them square.the nails regularly, trim them square. 9.9. DO NOTDO NOT cut corns / calluses with blade orcut corns / calluses with blade or knife. Home surgery is dangerous.knife. Home surgery is dangerous. 10.10. CLEANCLEAN the feet twice a day with soap andthe feet twice a day with soap and water. Wipe the web spaces dry and applywater. Wipe the web spaces dry and apply softening agent to feet.softening agent to feet. OrdainedOrdained ByBy Dr. Arun BalDr. Arun Bal
  50. 50. 50 Diabetic Neuropathy and Ulcers –Diabetic Neuropathy and Ulcers – Need of the hourNeed of the hour • Paucity of data regarding prevalence ofPaucity of data regarding prevalence of diabetic foot in India, data from only a fewdiabetic foot in India, data from only a few places – need moreplaces – need more • St. Vincent’s and Health 21 WHOSt. Vincent’s and Health 21 WHO Declaration have called for reduction inDeclaration have called for reduction in amputation in diabetic foot.amputation in diabetic foot. • Efforts required to create awareness andEfforts required to create awareness and commitmentcommitment
  51. 51. 51 Effect Of Patient Education OnEffect Of Patient Education On Amputation RatesAmputation Rates Knee & Above 12% 15% 5% 46% 35% 60% Toe & Metatarsal Below Knee No Education Education University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et al. Diabete Metab 1993.
  52. 52. 52 Factors and markers of low-risk versus high-Factors and markers of low-risk versus high- risk diabetic feetrisk diabetic feet Low-risk foot High-risk footLow-risk foot High-risk foot All of the following:All of the following: One or more of theOne or more of the following:following: following:following: Intact protective sensation Loss of protectiveIntact protective sensation Loss of protective sensationsensation Pedal pulses present Absent pedal pulsesPedal pulses present Absent pedal pulses No severe deformity Significant footNo severe deformity Significant foot deformitydeformity
  53. 53. 53 Factors and markers of low-risk versus high-Factors and markers of low-risk versus high- risk diabetic feetrisk diabetic feet Low-risk foot High-risk footLow-risk foot High-risk foot All of the following:All of the following: One or more of theOne or more of the following:following: following:following: No prior foot ulcer History of foot ulcer orNo prior foot ulcer History of foot ulcer or callus pre-ulcerative calluscallus pre-ulcerative callus No amputation Prior amputationNo amputation Prior amputation Normal joint mobility. Limited joint mobilityNormal joint mobility. Limited joint mobility
  54. 54. 54 Diabetic Foot Wounds Are LikeDiabetic Foot Wounds Are Like ICEBERGICEBERG
  55. 55. 55 Diabetic neuropathyDiabetic neuropathy Scope of the syndrome - 2Scope of the syndrome - 2 • DiffuseDiffuse • 1. Distal symmetric sensorimotor1. Distal symmetric sensorimotor • polyneuropathypolyneuropathy • 2. Autonomic neuropathy2. Autonomic neuropathy • A.SudomotorA.Sudomotor • B.CardiovascularB.Cardiovascular • C.GastrointestinalC.Gastrointestinal • D.GenitourinaryD.Genitourinary

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