DIABETESDIABETESINSENSATE FOOTINSENSATE FOOT

October 27, 2005October 27, 2005Michael S. Brogan, PT, DPT, PhD, Michael S. Brogan, PT, DPT, PhD,

CWSCWS

Statement of the Statement of the ProblemProblem

Diabetes is the 6Diabetes is the 6thth leading cause of death in leading cause of death in the U.S. (1)the U.S. (1)

From 1990 to 1998 prevalence of diabetes From 1990 to 1998 prevalence of diabetes increased from 4.9 to 6.5% (2)increased from 4.9 to 6.5% (2)

Approximately 800,000 cases of diabetes are Approximately 800,000 cases of diabetes are diagnosed each year in the U.S. (3)diagnosed each year in the U.S. (3)

Approximately 17 million Americans (6.2% of Approximately 17 million Americans (6.2% of pop.) have diabetes – 5.9 million of them pop.) have diabetes – 5.9 million of them undiagnosed (3)undiagnosed (3)

Another 16 million have pre-diabetes Another 16 million have pre-diabetes (impaired glucose tolerance) (3)(impaired glucose tolerance) (3)

Complications of DiabetesComplications of Diabetes Particularly devastating to the foot, often leading to Particularly devastating to the foot, often leading to

amputation, if not treated early (4)amputation, if not treated early (4) 67% of hospital discharges for lower extremity 67% of hospital discharges for lower extremity

amputations in 1997 were related to diabetes (4)amputations in 1997 were related to diabetes (4) 85% of diabetes-related amputations are preceded by 85% of diabetes-related amputations are preceded by

the appearance of a foot ulcer (5)the appearance of a foot ulcer (5) Between 1989 and 1992, an average of 54,000 Between 1989 and 1992, an average of 54,000

diabetic amputations were performed (6)diabetic amputations were performed (6) In 1996, 86,000 people with diabetes underwent 1 or In 1996, 86,000 people with diabetes underwent 1 or

more lower extremity amputations (6)more lower extremity amputations (6) Total cost for those amputations - > $1.1 billion Total cost for those amputations - > $1.1 billion

dollars (7)dollars (7) In 1995, average individual cost of a minor In 1995, average individual cost of a minor

amputation was $43,000, and a major amputation amputation was $43,000, and a major amputation was $65,000 (8)was $65,000 (8)

Common Skin Disorders Common Skin Disorders Associated With DiabetesAssociated With Diabetes Diabetic Diabetic

DermopathyDermopathy – – round, reddish-round, reddish-

brown papules brown papules (lower leg)(lower leg)

Bullous DiabeticorumBullous Diabeticorum(upper & lower (upper & lower extremities)extremities)

Common Skin Disorders Common Skin Disorders Associated With DiabetesAssociated With Diabetes

Necrobiosis Necrobiosis LipoidicaLipoidica

Common Skin Disorders Common Skin Disorders Associated With DiabetesAssociated With Diabetes

Diabetic Diabetic Finger PebblesFinger Pebbles

Diabetic Foot UlcersDiabetic Foot Ulcers

Causes of Foot UlcerationsCauses of Foot Ulcerations

Peripheral neuropathy most common Peripheral neuropathy most common causecause

Sensory Loss Sensory Loss Without Sensory Loss Without Sensory Loss Ulceration Ulceration Rarely Rarely OccursOccurs

Mechanical Stress – repetitive tissue Mechanical Stress – repetitive tissue injuryinjury

Lack of painful feedbackLack of painful feedback

Further Causes of Further Causes of UlcerationUlceration

Mechanical StressMechanical Stress PressurePressure ShearShear

Intrinsic FactorsIntrinsic Factors Foot Deformities - bony prominencesFoot Deformities - bony prominences

Extrinsic FactorsExtrinsic Factors Environment around the footEnvironment around the foot

Tight shoesTight shoes

Chronic Foot UlcerationChronic Foot Ulceration

Loss of Protective Function & Loss of Protective Function & SensationSensation

Continue to Bear Weight on Continue to Bear Weight on Ulcerated AreaUlcerated Area

Uninterrupted Episodes of Uninterrupted Episodes of Repetitive StressRepetitive StressAutolysisAutolysisNecrosis of TissueNecrosis of Tissue

Sensory Loss Patient Sensory Loss Patient ProfileProfile

Non-CompliantNon-Compliant Ignore Treatment RecommendationsIgnore Treatment Recommendations

Education is necessary to combat Education is necessary to combat profileprofile

Assessment of Loss of Assessment of Loss of Protective SensationProtective Sensation

Nylon Filaments @ 10-g bending Nylon Filaments @ 10-g bending force recommended by the American force recommended by the American Diabetes AssociationDiabetes Association

Patients unable to perceive 10-g Patients unable to perceive 10-g have loss of protective sensationhave loss of protective sensation Increased risk of ulcerationIncreased risk of ulceration

ResearchResearch High pressure caused by excessive weight High pressure caused by excessive weight

bearing causes plantar ulcerationsbearing causes plantar ulcerations Pressure is higher in diabetic neuropathyPressure is higher in diabetic neuropathy Higher pressure associated with foot Higher pressure associated with foot

deformity, joint limitation, muscle weakness deformity, joint limitation, muscle weakness and atrophyand atrophy

Muscle Weakness (toe deformities)Muscle Weakness (toe deformities) Peroneal nerve-foot drop-equinovarus-Peroneal nerve-foot drop-equinovarus-

increased foot pressure-forefoot increased foot pressure-forefoot ulcerationulceration

Tibial Nerve-calcaneovalgus deformity-Tibial Nerve-calcaneovalgus deformity-increased heel pressure-heel ulcerationincreased heel pressure-heel ulceration

Most Common Most Common Sites of Ulceration Sites of Ulceration

in Diabeticsin Diabetics1st Metatarsal Head 1st Metatarsal Head Great ToeGreat Toe

Talking PointsTalking Points

Obesity, Poor Vision, Joint Limitation Obesity, Poor Vision, Joint Limitation (decreased flexibility) limit people (decreased flexibility) limit people from inspecting their feetfrom inspecting their feet

MirrorMirror Properly Fitted ShoesProperly Fitted Shoes Hx of Callus, Ingrown Toenails, Hx of Callus, Ingrown Toenails,

Blisters or Open Sores all increase Blisters or Open Sores all increase risk of injury.risk of injury.

Talking Points (cont.)Talking Points (cont.)

Painful foot problems are often a Painful foot problems are often a sign of early neuropathysign of early neuropathy

Pain with walking or elevation Pain with walking or elevation indicative of PVDindicative of PVD

Callus should be trimmed to reduce Callus should be trimmed to reduce pressure & to expose an underlying pressure & to expose an underlying problem problem

Pre-UlcerationPre-Ulceration

Local areas of non-blanchable Local areas of non-blanchable erythemaerythema

EcchymosisEcchymosis Subcutaneous hematomaSubcutaneous hematoma Neuropathic fractureNeuropathic fracture

Rapidly progress to unstable foot Rapidly progress to unstable foot deformity & lead to chronic ulcerationdeformity & lead to chronic ulceration

Wagner Ulcer Wagner Ulcer Classification Diabetic Classification Diabetic

Ulcers Ulcers GradeGrade 00 Intact SkinIntact Skin 11 Superficial UlcerSuperficial Ulcer 22 Deep UlcerDeep Ulcer 33 Deep Infected UlcerDeep Infected Ulcer 44 Partial Foot Gangrene Partial Foot Gangrene 55 Full Foot GangreneFull Foot Gangrene

Management Based on Management Based on Ulcer GradingUlcer Grading

Pre-ulcer:Pre-ulcer: Modified Footwear & activity, Modified Footwear & activity, PWBPWB

Superficial: Superficial: PWB, Relief Pads, Cast or SplintPWB, Relief Pads, Cast or Splint Deep: Deep: PWB, Cast or Splint, Probe, X-PWB, Cast or Splint, Probe, X-

Ray, Ray, CultureCulture Deep, Infected: Deep, Infected: PWB, Splint, Probe, X-ray, PWB, Splint, Probe, X-ray,

culture, culture, antibiotics, surgical antibiotics, surgical consultconsult

Dysvascular:Dysvascular: PWB, Splint, Vascular Studies, PWB, Splint, Vascular Studies, Vascular ConsultVascular Consult

* probing to bone, suspect osteomyelitis * probing to bone, suspect osteomyelitis

Notes on DebridementNotes on Debridement

Non-Ischemic Foot Ulcers: cleaned, Non-Ischemic Foot Ulcers: cleaned, Debrided & DressedDebrided & Dressed Wound debridement has been shown to Wound debridement has been shown to

improve healing time of non-ischemic improve healing time of non-ischemic foot ulcersfoot ulcers

Callus should be trimmed to reduce Callus should be trimmed to reduce pressure, expose underlying pressure, expose underlying problems & promote problems & promote epithelializationepithelialization

Reducing Weight Bearing Reducing Weight Bearing StressesStresses

Objective: To reduce weight bearing stresses on Objective: To reduce weight bearing stresses on the foot (plantar ulcers)the foot (plantar ulcers)

MethodsMethods Crutches or Walker (PWB)Crutches or Walker (PWB) Gait Training (decrease step length to reduce Gait Training (decrease step length to reduce

forefoot pressure)forefoot pressure) Walking CastsWalking Casts

Decrease pressure, decrease edema, Decrease pressure, decrease edema, protect from re-injuryprotect from re-injury

Contraindicated for infected ulcersContraindicated for infected ulcers Caution: moderate or severe edema, Caution: moderate or severe edema,

fragile atrophic skin, deep ulcerationfragile atrophic skin, deep ulceration

Walking CastsWalking Casts

Decrease pressure, decrease Decrease pressure, decrease edema, protect from re-injuryedema, protect from re-injury

Contraindicated for infected ulcersContraindicated for infected ulcers

Caution: moderate or severe Caution: moderate or severe edema, fragile atrophic skin, edema, fragile atrophic skin, deep ulcerationdeep ulceration

Total Contact CastsTotal Contact Casts Minimize risk of secondary infectionMinimize risk of secondary infection Bony prominences are paddedBony prominences are padded

(tibial crest, malleoli, navicular, (tibial crest, malleoli, navicular, posterior heel, toes)posterior heel, toes)

Inner layer of plaster, carefully Inner layer of plaster, carefully molded for optimal total-contact fitmolded for optimal total-contact fit

Combination of minimal padding & Combination of minimal padding & molding for better distribution of molding for better distribution of pressurepressure

The Use of Electrical The Use of Electrical Stimulation and an Off-Stimulation and an Off-Loading Technique For Loading Technique For

the Treatment of the Treatment of Diabetic Foot UlcersDiabetic Foot Ulcers

Michael S. Brogan, PT, MS, DPT, CWSMichael S. Brogan, PT, MS, DPT, CWS

Laura E. Edsberg, Ph.D.Laura E. Edsberg, Ph.D.

PurposePurposeTo Evaluate the efficacy of To Evaluate the efficacy of

electrical stimulation and electrical stimulation and off-loading for the off-loading for the treatment of diabetic foot treatment of diabetic foot ulcersulcers

Case HistoryCase History 52 year old male with Diabetes52 year old male with Diabetes Insulin dependentInsulin dependent ComorbiditiesComorbidities

Renal failure (daily dialysis)Renal failure (daily dialysis) Severe diabetic neuropathySevere diabetic neuropathy Left B/K amputationLeft B/K amputation Left hand 3Left hand 3rdrd & 4 & 4thth distal digit amputations distal digit amputations

Referred for 2 chronic open wounds, Right Foot Referred for 2 chronic open wounds, Right Foot (Chronicity > 3 years)(Chronicity > 3 years)

Previous CarePrevious Care Various topical applicationsVarious topical applications Various dressingsVarious dressings AntibioticsAntibiotics DebridementDebridement

1-6-03

1-6-03

InterventionsInterventions Electrical StimulationElectrical Stimulation

High Volt Pulsed CurrentHigh Volt Pulsed Current 150v, 120pps, 255ppi150v, 120pps, 255ppi Stainless Steel Electrodes (4x4)Stainless Steel Electrodes (4x4) 30 minutes, 5 X week30 minutes, 5 X week Immersion TechniquesImmersion Techniques

Object: Object: improve blood flowimprove blood flow Reduce edemaReduce edema Inhibit bacterial growth Inhibit bacterial growth Enhance closureEnhance closure

Off-LoadingOff-Loading Reducing weight bearing forces on the foot is Reducing weight bearing forces on the foot is

critical for healing plantar ulcers (9)critical for healing plantar ulcers (9) Total contact casts used commonly for grade 1 & 2 Total contact casts used commonly for grade 1 & 2

neuropathic foot ulcersneuropathic foot ulcers Allows weight bearing forces to be dispersed over a Allows weight bearing forces to be dispersed over a

larger area, reducing plantar pressureslarger area, reducing plantar pressures Rigidity of cast assists with edema control, Rigidity of cast assists with edema control,

improving circulationimproving circulation Cast immobilizes the foot and ankle, reducing Cast immobilizes the foot and ankle, reducing

shearing forcesshearing forces Completely encloses the patient’s insensate foot, Completely encloses the patient’s insensate foot,

protecting it from further trauma & microorganismsprotecting it from further trauma & microorganisms Allows patient to be relatively activeAllows patient to be relatively active

TOTAL CONTACT CASTSTOTAL CONTACT CASTS Contraindicated Contraindicated

In grades 3, 4, and 5 In grades 3, 4, and 5 ulcersulcers

Fluctuating edemaFluctuating edema Active infectionActive infection ABI of less than 0.45ABI of less than 0.45

Requires skill to applyRequires skill to apply Plaster vs. Plaster vs.

FiberglassFiberglass Heel vs. Cast ShoeHeel vs. Cast Shoe

Off Loading Off Loading DonJoy Walking Boot (Cam Walker)DonJoy Walking Boot (Cam Walker) provides foot and ankle immobilization at provides foot and ankle immobilization at

0º, 10º, and 20º plantarflexion0º, 10º, and 20º plantarflexion protected range of motion in 10º increments protected range of motion in 10º increments

from 40º plantarflexion to 40º dorsiflexionfrom 40º plantarflexion to 40º dorsiflexion easily to don and doffeasily to don and doff easy to distribute weight bearing pressures easy to distribute weight bearing pressures

via ankle motion via ankle motion provides protection from traumaprovides protection from trauma allows for daily dressings and external allows for daily dressings and external

treatmentstreatments can be removed when not ambulatingcan be removed when not ambulating

Overview of Overview of InterventionIntervention

Wounds were treated 5 X week with Wounds were treated 5 X week with electrical stimulation in an aqueous electrical stimulation in an aqueous solution for 30 min per sessionsolution for 30 min per session

Wounds were first dressed with Wounds were first dressed with hydrogels and eventually hydrogels and eventually hydrocolloidshydrocolloids

Walking Boot worn whenever weight Walking Boot worn whenever weight bearing was anticipated (transfer & bearing was anticipated (transfer & gait)gait)

Outcomes HeelOutcomes Heel

1-6-03

7-29-03

Outcomes Plantar Outcomes Plantar SurfaceSurface

1-6-03

7-29-03

Clinical RelevanceClinical Relevance Case study does suggest that electrical Case study does suggest that electrical

stimulation and off-Loading for diabetic stimulation and off-Loading for diabetic neuropathic wounds is a viable treatment neuropathic wounds is a viable treatment optionoption

Walking Boots that allow for ankle motion Walking Boots that allow for ankle motion control offer an additional option for off-control offer an additional option for off-loadingloading

Chronic diabetic foot ulcers can be treated Chronic diabetic foot ulcers can be treated effectively by physical therapists in effectively by physical therapists in conjunction with referring physiciansconjunction with referring physicians

Chronic wounds in patients with severe Chronic wounds in patients with severe comorbidities can be healed using comorbidities can be healed using electrical stimulation and off-Loadingelectrical stimulation and off-Loading

Tid BitsTid Bits

Half CastsHalf Casts Ambulatory Aids, Ambulatory Aids, Molded Plastazote SandalsMolded Plastazote Sandals Post-Operative ShoesPost-Operative Shoes Pressure Relief, sculpting with Pressure Relief, sculpting with

Adhesive Felt Padding, Foot Adhesive Felt Padding, Foot Orthoses, Rocker SolesOrthoses, Rocker Soles

ModalitiesModalities

Shapero, C. Stanoch, J. Barrese, D. (2002). Acute Care Perspectives: 3 (11). APTA, pp1-6.

Following ClosureFollowing Closure

Proper FootwearProper Footwear Progress into Normal Weight Progress into Normal Weight

Bearing GaitBearing Gait