Neuropathic Foot Flashcards
Why is important to learn about neuropathic foot?
50% with diabetes will develop neuropathy
leading cause of diabetic hospitalization
implicated in 50-75% of non -traumatic amputations
costs as much as $13.7 billion (amputations up to $1 billion)
mortality rates after amputation increase by 40% at one year, 80% at 5
What are causes of neuropathy?
Diabetes tumor, trauma, and other conditions autoimmune disease (RA, GBS, SLE) vitamin B, E, or niacin deficiency exposure to toxins (chemo, heavy metals, etc) infections (HIV, lyme disease, shingles)
What are the 4 types of neuropathy?
peripheral: affects UE or LEs
autonomic: affects cardiopulmonary system, temperature regulation, bowel, bladder, and sexual function
proximal: affects thigh, hip, and core muscles
focal: sudden loss of function in one nerve or a group of nerves
When should a foot exam be performed?
comprehensive exam should be completed at least annually; more often if complications exist
those with neuropathy should have feet visualized at EACH medical visit
those with diabetes should check their feet EACH day at home
look for cuts, blisters, s/s of infection, etc
use mirror if needed
enlist help of family/friends
What are the goals of foot exam?
establish history/diagnostic factors identification of risk intervention education EARLY INVOLVEMENT IS CRUCIAL
What should you include in the subjective exam?
Contributing diagnosis (DM, HIV, etc)
PMH and social factors
Medications
Complications: neuropathy, nephropathy, retinopathy, vascular disease (central or peripheral)
History of LE surgery, ulcer, or amputation
Current smoker/smoking history
HbA1c (if diabetes): averages blood sugar control over several months, it’s a %
What should be included in objective exam?
condition of skin, hair, and toenails deformities pulses sensation shoe wear
How do you evaluate skin?
Look if it’s intact.
is it thin, shiny, brawny, and/or frail
dry
calluses/wounds
How do you evaluate hair?
a sign of circulation. look at if it’s present or absent
How do you evaluate toenails?
are they thickened, deformed, ingrown
What deformities should you look out for?
prominent metatarsal heads
hammer/claw toes
hallux valgus (bunions)
charcot foot
What are claw toes?
hyperextension of MTP with PIP and DIP flexion
What are hammer toes?
hyperextension of MTP and DIP joints
How do you treat hallux valgus?
splint and keller bunionectomy
What is charcot arthropathy? treatment?
progressive bone destruction and ligament damage leading to arch collapse and impaired skin integrity.
treated with complete immobilization in a total contact cast, protected weight bearing
Who gets charcot arthorpathy? Cause?
affects about 9% of those with diabetes
unclear if etiology is neurotraumatic, neuro-vascular, or both
What pulses should you palpate for in your exam?
posterior tibialis, dorsal pedis
What is the ankle brachial index (ABI)?
you take BP of UE and BP of LE and divide them
What does a ABI measurement of >1.2, 1.2-1.0, 0.99-0.90 mean?
> 1.2= vessels are incompressible, consider toe brachial indexes
- 2-1.0= Normal
- 99-0.90= Acceptable
What does a ABI measurement of <0.50 mean?
<0.50= severe arterial disease
How do you assess sensation?
Semmes Weinstein Monofilament: 10g (5.07) monofilament, normal sensation is 1g so if you can’t feel 10 g you have lost protective sensation, 10 locations on foot (some sources say 12-13)
vibratory sensation: 128 Hz tuning fork, latency of 10 seconds or more indicates sensory loss, normal is 5 seconds
How is someone a low risk assessment?
preserved sensation, no deformity, intact circulation: annual foot exam, education, good footwear
How is someone a high risk assessment?
sensory loss, deformity, vascular disease, callus formation, history of ulcer, or amputation: comprehensive assessment, education, certification for diabetic shoes (if possible)
What is a critical part of taking care of neuropathy?
Documentation! especially if trying to get diabetic shoes
As a PT what is the most important part of your intervention?
EDUCATION!!!!
general diabetes self care, foot/skin care, daily skin checks, proper footwear (breathable, adjustable, wide toe box, good support)
What are two other parts of you intervention besides education?
Ulcers: dubulk callus (therapist or podiatrist), control moisture (wound and skin), decrease infection risk (silver products and antibiotic), edema management
pressure: offload pressure areas
How can you offload the foot?
total contact casts: change every 1-2 weeks orthotics/walking boot surgical shoes dressings: foam or felt cutouts: reduce pressure points in shoe assistive devices elevate heels with pillow under calves
What is covered by medicare?
covers 80% of cost of one pair of depth shoes and 3 pair of inserts
covered if following are met: patient has DM and patient has one or more of the following (poor circulation, foot deformity, history of partial or complete amputation, history of previous foot ulceration, history of pre-ulcerative callus, peripheral neuropathy with evidence of callus formation
How do you educate patients on foot care?
check feet daily
always wear shoes
do not apply lotion/oil between toes
have nails clipped by health care professional
manage calluses with emergy board/ped-egg
vicks vapor rub or tea tree oil for onychomycosis
immediately report changes
What are 4 other possible areas of patient education?
Exercise: >30 min/day, ideally both aerobic and resistance; consider foot integrity
Nutrition: monitor BMI, encourage (stable) weight loss; fresh fruits and vegetable (frozen better than canned); glucose levels before meal 90-130 mg/dl; glucose levels after meals less than 180 mg/dl
glycemic control: HbA1c goal of <6.5-7
specialist referrals: podiatry, wound care, nurse, educator, dietician
