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  • There are several risk factors for developing diabetic neuropathy. Two of the main contributing factors are glucose control and duration of diabetes. Those who have had diabetes for at least 25 years and/or those who have had poor glucose control are at greatest risk of developing symptoms. Mechanical injury can lead to compression of the nerves and cause disorders such as carpal tunnel syndrome and other compression neuropathies. Autoimmune dysfunction can cause inflammation of the nerves which can aggravate neuropathy. Inherited traits can increase susceptibility to nerve disease. Finally, lifestyle factors such as smoking and alcohol abise can cause blood vessel damage leading to nerve damage.
  • Up to 70% of people with diabetes will experience nervous system damage in their lifetime. The pain and discomfort caused by diabetic neuropathy, at a minimum, contributes to a diminished quality of life. At it’s worst, diabetic neuropathy is a major contributing cause of lower-limb amputation. The next three slides will review the risk factors, pathogenesis, and diagnosis of diabetic neuropathy.
  • Diminished sensation in the foot can prevent the patient from recognizing painful stimuli resulting from ill-fitting shoes, poor foot hygiene or minor trauma to the foot. Left unnoticed and untreated, these can lead to foot ulcers. Loss of nerve axons in the foot can also lead to muscle atrophy which can, in turn, lead to imbalance and weight shifting that can cause dislocation, stress fractures, and even lead to joint deterioration (Charcot arthropathy). The combination of poor blood flow to the extremities and loss of sensation in the foot due to nerve damage contribute to the development of ulcers and infections that can lead to amputation. In 2000-2001, about 82,000 nontraumatic lower-limb amputations were performed annually among people with diabetes.
  • Testing for sensory neuropathy with the 5.07/10g monofilament has been demonstrated to predict ulcer and amputation risk in five prospective studies. For foot ulceration, the negative predictive value of normal sensing varied from 90-98%, that is, only a small percentage of patients who can sense the monofilament will develop a foot ulcer. On the other hand, the positive predictive value for foot ulcer of failure to sense the monofilament was 18-36%, that is, 18-36% of the patients who could not feel the monofilament developed an ulcer. In a prospective 32 month observational study, 80% of foot ulcers and 100% of amputations occurred in patients with insensate feet to the 5.07/10g monofilament. Monofilament testing has superior predictive value as compared to other test modalities such as the 128Hz tuning fork, pin-prick, cotton wisps, or the presence or absence of neuropathic symptoms.
  • Neuropathy+%26+Diabetic

    1. 1. An Overview
    2. 2. Cause of Neuropathic pain <ul><li>Diabetes (Periphera l Diabetic Neuropathy- PDN) </li></ul><ul><li>Alcoholism </li></ul><ul><li>Amputation </li></ul><ul><li>Back, leg, and hip problems (Sciatica, Fibromyalgia) </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Facial nerve problems </li></ul><ul><li>HIV infection or AIDS </li></ul><ul><li>Multiple sclerosis </li></ul><ul><li>Spine surgery </li></ul>
    3. 3. Risk Factors <ul><li>Glucose control </li></ul><ul><li>Duration of diabetes </li></ul><ul><li>Damage to blood vessels </li></ul><ul><li>Mechanical injury to nerves </li></ul><ul><li>Autoimmune factors </li></ul><ul><li>Genetic susceptibility </li></ul><ul><li>Lifestyle factors </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Diet </li></ul></ul>
    4. 4. <ul><li>What is it? </li></ul><ul><li>Diabetic neuropathies are a family of nerve disorders caused by diabetes. ( nerve supplying to various organs are affected) </li></ul><ul><li>Longer and uncontrolled diabetes is the root cause of Diabetic Peripheral neuropathy. (DPN) </li></ul><ul><li>Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs </li></ul>Diabetic Neuropathy
    5. 5. Diabetic Neuropathy <ul><ul><li>About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including: </li></ul></ul><ul><ul><ul><li>Impaired sensation or pain in the feet or hands </li></ul></ul></ul><ul><ul><ul><li>Slowed digestion of food in the stomach </li></ul></ul></ul><ul><ul><ul><li>Other nerve problems </li></ul></ul></ul><ul><ul><li>Diabetic Neuropathy is ONE of the most commonly encountered neuropathic pain syndromes in clinical practice. </li></ul></ul>Am J Health Syst Pharm. 2004;61:160-176;
    6. 6. General Epidemiology of Diabetic Peripheral Neuropathy <ul><li>252 million diabetics worldwide </li></ul><ul><li>Foot problems account for largest number of hospital bed days used for diabetic patients </li></ul><ul><li>1-4% of diabetics develop foot ulcer annually, 25% in lifetime </li></ul><ul><li>45-75% of all lower extremity amputations are in diabetics </li></ul><ul><li>85% of these preceded by foot ulcer </li></ul><ul><li>Two-thirds of elderly patients undergoing amputation do not return to independent life </li></ul>
    7. 7. DPN: Symptoms <ul><li>Positive symptoms </li></ul><ul><ul><ul><li>– Burning, stabbing or tingling pain, numbness & prickling sensation </li></ul></ul></ul><ul><ul><ul><li>– Sharp pains or cramps </li></ul></ul></ul><ul><ul><ul><li>– Extreme sensitivity to touch (allodynia) </li></ul></ul></ul><ul><ul><ul><li>– Can result in sleep interference, depression, anxiety & severe disability </li></ul></ul></ul><ul><li>Negative symptoms </li></ul><ul><ul><ul><li>– Numbness or insensitivity to pain or temperature </li></ul></ul></ul><ul><ul><ul><li>– Loss of balance and coordination </li></ul></ul></ul><ul><li>Symptoms (Pain) often worse at night </li></ul><ul><ul><li>Patients are most dejected by this phenomenon of heightened pain at night </li></ul></ul><ul><ul><li>This occurs since stimulation is reduced at night as compared to activity during the daytime. </li></ul></ul><ul><ul><li>Therefore perception of pain heightens during nighttime </li></ul></ul>
    8. 8. Pathophysiology: Diabetic Foot Ulceration <ul><li>NEUROPATHY </li></ul>Sensory Loss of protective sensation Motor Abnormal foot biomechanics Autonomic Reduced skin compliance and lubrication Ulceration Infection Vascular insufficiency
    9. 9. Complications of Polyneuropathy <ul><li>Foot Ulcers </li></ul><ul><li>Dislocation and stress fractures </li></ul><ul><li>Amputation </li></ul>
    10. 10. Diabetic Foot Ulcers
    11. 11. Diabetic Foot Ulcer- Basics <ul><li>Foot problems are a major cause of morbidity and mortality in people with diabetes. </li></ul><ul><li>In people with neuropathy or peripheral vascular disease, minor trauma to the foot can lead to skin ulceration, infection and to gangrene, resulting in amputation. </li></ul><ul><li>Appropriate management can prevent or heal diabetic foot ulcers, thereby reducing the amputation rate. </li></ul><ul><li>Characteristics demonstrated to confer high risk of ulceration include previous ulceration, neuropathy, structural deformity, peripheral vascular disease, other microvascular complications and smoking. </li></ul>
    12. 13. Screening to identify at risk patients <ul><li>ASK about factors associated with foot ulceration: </li></ul><ul><ul><ul><li>Previous foot ulcers </li></ul></ul></ul><ul><ul><ul><li>Prior lower extremity amputation </li></ul></ul></ul><ul><ul><ul><li>Long duration of diabetes (> 10 yrs) </li></ul></ul></ul><ul><ul><ul><li>Poor glycemic control (HGA1C > 9%) </li></ul></ul></ul><ul><ul><ul><li>Impaired vision </li></ul></ul></ul><ul><li>EXAMINE </li></ul><ul><ul><ul><li>Footwear to ensure proper fit </li></ul></ul></ul><ul><ul><ul><li>Sensation, plantar pressures, vascular disease </li></ul></ul></ul>JAMA 2005;293:217-28
    13. 14. JAMA 2005;293:217-28 Screening Methods – Monofilament Foot Exam
    14. 15. Utility of Monofilament Testing <ul><li>Predicts ulcer/amputations: </li></ul><ul><li>NPV (normal sensing) = 90-98% </li></ul><ul><li>PPV (fail to sense) = 18-36% </li></ul><ul><li>Prospective 32 mo observational study: </li></ul><ul><ul><li>80% of ulcers/100% of amputations in insensate feet </li></ul></ul><ul><li>Diabetes Care 2006; 29(Suppl 1):S25 J Fam Pract 2000; 49:S30 Diabetes Care 1992; 15:1386 </li></ul>
    15. 16. Sensation is normal by monofilament Does this patient have neuropathy? YES!
    16. 17. FOOT CARE !!! Guidelines for the Prevention and Management of Diabetes Foot Ulcer
    17. 18. FOOT CARE PATIENTS “DOs” <ul><li>Check your feet every day for cuts, cracks, bruises, blisters, sores, infections or unusual markings. </li></ul><ul><li>Check the colour of your legs and feet. Look for swelling, warmth or redness. </li></ul><ul><li>Clean cuts and scratches with mild soap and water and cover with a dry dressing. </li></ul><ul><li>Trim your nails straight across. </li></ul><ul><li>Wash and dry your feet every day, especially between the toes. </li></ul><ul><li>Always wear a good supportive shoe. </li></ul><ul><li>Exercise regularly. </li></ul>
    18. 19. FOOT CARE PATIENT “DON’Ts” <ul><li>Never cut your own corns or calluses. </li></ul><ul><li>Never treat your own in-growing toenails or slivers with a razor or scissors. </li></ul><ul><li>Don’t use over-the-counter medications to treat corns or warts. </li></ul><ul><li>Don’t apply heat to your feet with a hot water bottle or electric blanket. You could burn your feet without realizing it. </li></ul><ul><li>Avoid extreme heat and cold. </li></ul><ul><li>Don’t wear tight socks, garters or elastics, or knee highs. </li></ul><ul><li>Don’t smoke. </li></ul><ul><li>Don’t sit for long periods of time. </li></ul>
    19. 20. FOOT CARE - RECOMMENDATIONS <ul><li>Foot examinations in adults by both patients and healthcare providers should be an integral component of diabetes management to decrease the risk of foot lesions and amputations . </li></ul><ul><li>Foot examination should include assessment of structural abnormalities, neuropathy, vascular disease, ulcerations and evidence of infection. </li></ul><ul><li>Foot examinations should be performed at least annually in all people with diabetes, commencing at puberty and at more frequent intervals in those at high risk . </li></ul>
    20. 21. <ul><li>People at high risk of foot ulceration and amputation require foot care education, proper footwear, counselling to avoid foot trauma, smoking cessation and early referrals if problems occur. </li></ul><ul><li>A person with diabetes who develops a foot ulcer requires therapy by healthcare professionals who have experience in diabetes foot care. Any infection must be treated aggressively. </li></ul>FOOT CARE - RECOMMENDATIONS