Neuropathic Ulcers Flashcards
How many Americans have diabetes?
over 24 million
Incidence of neuropathic ulcerations:
15-25%
How many amputations is diabetes responsible for a year?
600,000
Symptoms of hyperglycemia
frequent urination
increased thirst
increased hunger.
Acutecomplications of DM:
Diabetic ketoacidosis
Nonketotic hyperosmolar coma
Long term complications of DM:
Heart disease Stroke Chronic kidney failure Foot ulcers Visual impairment
Type 1 DM:
Diagnosed in children or young adults
Results from an immune mediated destruction of pancreatic beta cells
Pancreas is becomes unable to produce insulin
Type 2 DM:
Diagnosed at middle age or later
Approximately 80% of diagnosed are overweight
Genetic predisposition to developing type 2
Start as “insulin resistance” where cells in the body do not respond properly to insulin
Excessive weight and inadequate physical activity are contributing factors
Hyperglycemia
Changes RBCs, platelets, and capillaries
Alters blood flow
Increases microvascular pressure
What do glycosylated proteins cause?
tissue trauma
What is accumulation of sorbitol due to?
to breakdown of glucose, results in tissue destruction
Where are diabetic wounds located?
Usually on tips of toes, lateral aspect of foot dorsum of foot, metatarsal heads especially 1st and 5th, heels, midfoot and at location of orthopedic deformity
What percentage of diabetic ulcers are neuropathic foot ulcers?
60-70%
15-20% of diabetic ulcers are from PVD
15-20% are mixed cause
Wound edges:
even, well defined, with and without undermining
What deformity is common in diabetic foot ulcers?
Hammer toe/claw toe
Skin changes with DM:
Cracking; callous formation
Reasons for delayed wound healing in DM:
Inhibited fibroblast activity Inhibited endothelial cell activity Decreased collagen deposition Delayed re-epithelialization Decreased re-endothelialization of microarterial anastomoses
Diabetic Risk Factors Contributing Delayed Healing and Neuropathic Ulcers
Vascular disease Neuropathy Mechanical stress Abnormal foot function and inadequate footwear Impaired healing and immune response Poor vision
Vascular Disease
Risk for PVD greater in patients with diabetes
Accelerated atherosclerosis
Thickening of basement membrane
Neuropathy
Most common complication of diabetes
Symmetrical, distal
Affects sensory, motor, and autonomic systems
Causes of neuropathy:
Neural ischemia
Segmental demyelination
Sensory neuropathy:
the most common type of diabetic neuropathy
causes pain or loss of feeling in the toes, feet, legs, hands, and arms
Autonomic neuropathy
causes changes in digestion, bowel and bladder function, sexual response, and perspiration
Can affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes
Motor neuropathy
Results in muscle atrophy and weakness Intrinsic muscle weakness/atrophy Decreases foot stability Leads to deformities Increased pressure and shear forces to foot
Sensory Neuropathy
50% of patients unaware they have lost protective sensation
Lack of protective sensation = lack of early detection to irritation or trauma
Paresthesias
At risk for pressure ulceration:
If unable to perceive 10g of pressure
Autonomic Neuropathy Ulcers:
Dry, cracked skin due to decreased ability to sweat
Increased rate of callus formation
Arteriovenous shunting leads to decreased perfusion
Uncontrolled vasodilation leads to osteopenia
Charcot foot
cycle of fracture and healing-
What happens in acute destructive phase of charcot foot?
inflammation, sublexation, bone fragments, fractures (deformity can be controlled in this phase)-
What does the acute destructive phase of charcot foot result in?
Increased blood glucose Peripheral neuropathy Mechanical stress Ankle equinus Autonomic neuropathy causing increased blood flow resulting in osteolysis, osteopenia Trauma
Mechanical Stress
Abnormal or excessive forces predispose to ulceration
High plantar pressures overload tissue’s ability to repair itself
Abnormal Foot Function and Inadequate Footwear
Impaired ROM
Foot deformities
Prior ulcer/amputation
Poor footwear
Impaired ROM
Great toe ext, DF, subtalar joint
Increase vertical pressure and horizontal shear
Foot deformities
PF contracture, varus/valgus, Charcot foot
Impaired Healing and Immune Response
Decreased ability to build new tissue and fight infection
Decreased ability to fight infection
Increased frequency of osteomyelitis, soft tissue infections, candida
Impairs all 3 phases of wound healing
Poor Vision
Diabetes is leading cause of retinopathy, glaucoma, cataracts
Increases risk of trauma
Decreases ability to perform adequate foot care
Ulcer Characteristics
Larger and deeper wounds take longer to heal
Wounds present for longer time take longer to heal
Disease Characteristics
Poor glycemic control associated with increased risk of long-term complications
Complications can be improved/reversed with improved glycemic control
Inadequate Care and Education
Lack of cutting-edge knowledge
Delayed referrals
Poor adherence to clinical guidelines
Minor short-term complications but major long-term complications
Patients do not understand link between hyperglycemia and long-term complications
Absence of pain or short-term effects decreases patient adherence
PT Tests and Measures
for Neuropathic Ulcers
Circulation
Sensory integrity
Circulation:
Pulses Capillary refill Doppler ultrasound Ankle-Brachial Index TCPO2
Sensory integrity
Sensation to light touch
Sensation to vibration
Indications of circulation:
All open wounds
Decreased or absent pulses
Signs and symptoms of arterial insufficiency
History of PVD
Semmes-Weinstein Monofilaments
Occlude patient’s vision Begin with 5.07 monofilament Avoid calloused areas Each location tested randomly 3x At least 1 sham application at each point
Sensory Integrity indications:
All neuropathic ulcers
All patients with diabetes
All patients with plantar foot ulcers
Monofilament 4.17
Pressure produced: 1 gram
inability to feel: decreased sensation
Monofilament 5.07
10 grams of pressure
loss of protective sensation
Monofilament 6.10
75 grams of pressure
absent sensation
How many incorrect response with tunning fork indicates peripheral neuropathy?
at least 5
Grade 0 Wagner:
No open lesions
May have deformity or cellulitis
Integumentary Practice Pattern A (at risk)
or B (superficial skin involvement)
Grade 1 Wagner:
Superficial ulcer
Integumentary Practice Pattern C (partial thickness) or D (full thickness)
Grade 2 Wagner:
Deep ulcer to tendon, capsule, bone
Grade 3 Wagner:
Deep ulcer with abcess, osteomyelitis, or joint sepsis
Grade 4 Wagner:
Localized gangrene
Grade 5 Wagner:
Gangrene of the entire foot
“5PT” Method
Pain Position Presentation Periwound Pulses Temperature
Pain
Lack of pain complaint due to neuropathy
Possible paresthesias
Position
Plantar foot
Plantar aspect of metatarsal heads
Plantar aspect of midfoot if Charcot deformity
May occur under calluses
May occur in areas of pressure/friction from inappropriate footwear
Presentation
Round, punched-out lesions
Callused rim
Minimal drainage unless infected
Eschar or necrotic material uncommon unless infected
Periwound and Structural Changes
Skin is dry, cracked Callus present Structural deformities Claw toes Rocker-bottom foot Prior amputation
Pulses
Normal
May be accentuated with vessel calcification
Temperature
Normal
May be increased in areas of reactive hyperemia or infection
Good healing
smaller, superficial wound (Wagner 1 or 2)
present for less than 2 months
ulcers decreasing in size within 4 weeks of treatment
Poor healing:
large size
Risk of amputation 154x greater with infected ulcers
If 20–50% decrease in size not noted in first month of treatment
Average healing time of DU:
Large variability in healing rates
Average healing time 12–14 weeks
Patient/Client-Related Instruction
Disease process/management of DM Role of exercise and safety guidelines Risk factor reduction Daily foot checks Foot care guidelines
PT precautions:
May not show signs of infection due to decreased inflammatory response/PVD
Request culture and sensitivity for wounds that fail to respond to appropriate interventions
Osteomyelitis must be treated surgically
Intervention Goals
Tight blood glucose control
Off-loading
Aggressive debridement if arterial supply intact to decrease microbial load and remove senescent cells/biofilm
Removal of callous and irregular wound edges to allow healing from borders
Monitor blood sugar
Hyperglycemia common with infections and uncontrolled diabetes
Hypoglycemia may occur
Optimal Glucose < 150
>180 inhibits neutrophil activity
Off-Loading
Avoidance of all mechanical stress on injured extremity, essential for healing
Trauma causes most plantar wounds and ongoing trauma prevents healing
Total Contact Casting:
Cast is molded to foot and leg, dispersing weight-bearing forces over large area
Cast rigidity controls edema
Immobilization of foot protects from trauma and microorganisms
Assists with patient adherence
How does total contact casting heal wounds?
by reducing weightbearing pressure and shear force to the plantar aspect of the foot
Minimal padding
Maintains “total contact” with the foot and lower leg.
Closely molded
Contraindications to total contact casting?
Osteomyelitis Gangrene Fluctuating edema Active infection ABI less than 0.45
Gait and Mobility Training
PWB gait with assistive device Alter gait pattern to decrease plantar pressure Step-to pattern Slower steps Shuffling gait Footwear modifications
Off-loading devices
Crutches, wheelchair
Wedge shoes
Total contact casts
Prefabricated cast walker
Pressure relief
Orthotics
Cushions
Positioning
Options for temporary footwear:
Felt or foam inserts
Padded ankle-foot orthoses
Walking shoes
Benefits of temporary footwear:
Provides safe ambulation, pressure reduction, room for bandages
Can use when total contact cast is not an option
Wedge Shoe
reduces weight bearing pressure on the forefoot which promotes faster healing after surgery, trauma or when forefoot wounds or ulcerations are present.
DARCO HeelWedge
Off-loads pressure from the heel by shifting weight to the mid and forefoot to promote faster healing after surgery, trauma or when wounds or ulcerations are present on the heel
Wound Care Shoe System
Deep rocker sole
Four layers of differing density insoles that may be altered for off-loading
Leather upper lined with Plastazote® material
Sections may be removed from the leather upper without disturbing the liner to remove pressure
Prefabricated cast walker
Custom inflated aircells for individual fit and support
Rocker bottom and rigid sole
Allow forward progression in gait without transferring forces to the forefoot
Permanent Footwear dimensions:
Shoes should be ~½ inch longer than the longest toe with snug heel fit
Shoe last should match foot shape
Extra-depth toe box
Heel height < 1 inch
Permanent Footwear
Soft, moldable materials Soft inserts may decrease pressure Fit shoes at the middle of the day Break in shoes gradually Patients with severe foot deformities or amputations should be referred to an orthotist
Orthotics
Used to correct foot deformities and equalize pressure to prevent ulceration
Therapeutic exercise:
ROM
Aerobic
ROM Exercises
Assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion
Joint mobilizations may be helpful
Aerobic Exercise:
Assists with glycemic control
Assists with weight loss
Medical Interventions
Glycemic control
Even 1% decrease in hemoglobin A1c associated with improvements in many complications
Manage neuropathic pain/paresthesias
Anticonvulsants, antidepressants, capsaicin
Management of concomitant arterial insufficiency
Antibiotic therapy
Cultures of neuropathic ulcers average 4–5 different microbes
Most commonly group A Strep and Staph aureus
Radiological assessment
Fracture identification – Charcot foot
Presence of foreign bodies
Bone scan for osteomyelitis
Surgical Interventions
Debridement Necrotic tissue Osteomyelitis Incision and drainage Antimicrobial bead implantation
Who would be indicated for surgical interventions:
Surgery to address abnormal foot function or limited tissue perfusion Joint arthroplasty Tendon lengthening Stabilization of Charcot deformities and reduction of abnormal biomechanics Revascularization surgery Amputation Gangrene Wagner grade 4 or 5 ulcers
