Transcript The Use of Electrical Stimulation and an Off

DIABETES
INSENSATE FOOT
October 27, 2005
Michael S. Brogan, PT, DPT, PhD, CWS
Statement of the Problem
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Diabetes is the 6th leading cause of death in the U.S. (1)
From 1990 to 1998 prevalence of diabetes increased
from 4.9 to 6.5% (2)
Approximately 800,000 cases of diabetes are diagnosed
each year in the U.S. (3)
Approximately 17 million Americans (6.2% of pop.)
have diabetes – 5.9 million of them undiagnosed (3)
Another 16 million have pre-diabetes (impaired glucose
tolerance) (3)
Complications of Diabetes
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Particularly devastating to the foot, often leading to amputation,
if not treated early (4)
67% of hospital discharges for lower extremity amputations in
1997 were related to diabetes (4)
85% of diabetes-related amputations are preceded by the
appearance of a foot ulcer (5)
Between 1989 and 1992, an average of 54,000 diabetic
amputations were performed (6)
In 1996, 86,000 people with diabetes underwent 1 or more lower
extremity amputations (6)
Total cost for those amputations - > $1.1 billion dollars (7)
In 1995, average individual cost of a minor amputation was
$43,000, and a major amputation was $65,000 (8)
Common Skin Disorders
Associated With Diabetes
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Diabetic
Dermopathy –
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round, reddish-brown
papules (lower leg)
Bullous Diabeticorum
(upper & lower extremities)
Common Skin Disorders Associated
With Diabetes
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Necrobiosis Lipoidica
Common Skin Disorders Associated
With Diabetes
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Diabetic Finger
Pebbles
Diabetic Foot Ulcers
Causes of Foot Ulcerations
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Peripheral neuropathy most common cause
Sensory Loss
Without Sensory Loss Ulceration Rarely
Occurs
Mechanical Stress – repetitive tissue injury
Lack of painful feedback
Further Causes of Ulceration
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Mechanical Stress
Pressure
 Shear
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Intrinsic Factors
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Foot Deformities - bony prominences
Extrinsic Factors
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Environment around the foot
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Tight shoes
Chronic Foot Ulceration
Loss of Protective Function & Sensation
 Continue to Bear Weight on Ulcerated
Area
 Uninterrupted Episodes of Repetitive
Stress
 Autolysis
 Necrosis of Tissue
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Sensory Loss Patient Profile
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Non-Compliant
Ignore Treatment Recommendations
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Education is necessary to combat profile
Assessment of Loss of Protective
Sensation
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Nylon Filaments @ 10-g bending force
recommended by the American Diabetes
Association
Patients unable to perceive 10-g have loss of
protective sensation
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Increased risk of ulceration
Research
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High pressure caused by excessive weight bearing
causes plantar ulcerations
Pressure is higher in diabetic neuropathy
Higher pressure associated with foot deformity, joint
limitation, muscle weakness and atrophy
Muscle Weakness (toe deformities)
 Peroneal nerve-foot drop-equinovarus-increased
foot pressure-forefoot ulceration
 Tibial Nerve-calcaneovalgus deformity-increased
heel pressure-heel ulceration
Most Common Sites of
Ulceration in Diabetics
1st
Metatarsal Head
Great Toe
Talking Points
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Obesity, Poor Vision, Joint Limitation
(decreased flexibility) limit people from
inspecting their feet
Mirror
Properly Fitted Shoes
Hx of Callus, Ingrown Toenails, Blisters or
Open Sores all increase risk of injury.
Talking Points (cont.)
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Painful foot problems are often a sign of early
neuropathy
Pain with walking or elevation indicative of
PVD
Callus should be trimmed to reduce pressure &
to expose an underlying problem
Pre-Ulceration
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Local areas of non-blanchable erythema
Ecchymosis
Subcutaneous hematoma
Neuropathic fracture
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Rapidly progress to unstable foot deformity & lead
to chronic ulceration
Wagner Ulcer Classification
Diabetic Ulcers
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Grade
0
1
2
3
4
5
Intact Skin
Superficial Ulcer
Deep Ulcer
Deep Infected Ulcer
Partial Foot Gangrene
Full Foot Gangrene
Management Based on Ulcer
Grading
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Pre-ulcer:
Superficial:
Deep:
Modified Footwear & activity, PWB
PWB, Relief Pads, Cast or Splint
PWB, Cast or Splint, Probe, X-Ray,
Culture
Deep, Infected:
PWB, Splint, Probe, X-ray, culture,
antibiotics, surgical consult
Dysvascular:
PWB, Splint, Vascular Studies,
Vascular Consult
* probing to bone, suspect osteomyelitis
Notes on Debridement
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Non-Ischemic Foot Ulcers: cleaned, Debrided &
Dressed
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Wound debridement has been shown to improve
healing time of non-ischemic foot ulcers
Callus should be trimmed to reduce pressure,
expose underlying problems & promote
epithelialization
Reducing Weight Bearing Stresses
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Objective: To reduce weight bearing stresses on the foot (plantar
ulcers)
Methods
 Crutches or Walker (PWB)
 Gait Training (decrease step length to reduce forefoot
pressure)
 Walking Casts
 Decrease pressure, decrease edema, protect from reinjury
 Contraindicated for infected ulcers
 Caution: moderate or severe edema, fragile atrophic
skin, deep ulceration
Walking Casts
Decrease
pressure, decrease edema,
protect from re-injury
Contraindicated
Caution:
for infected ulcers
moderate or severe edema,
fragile atrophic skin, deep ulceration
Total Contact Casts
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Minimize risk of secondary infection
Bony prominences are padded
 (tibial crest, malleoli, navicular, posterior
heel, toes)
Inner layer of plaster, carefully molded for
optimal total-contact fit
Combination of minimal padding &
molding for better distribution of pressure
The Use of Electrical
Stimulation and an Off-Loading
Technique For the Treatment
of Diabetic Foot Ulcers
Michael S. Brogan, PT, MS, DPT, CWS
Laura E. Edsberg, Ph.D.
Purpose
 To
Evaluate the efficacy of
electrical stimulation and offloading for the treatment of
diabetic foot ulcers
Case History
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52 year old male with Diabetes
Insulin dependent
Comorbidities
 Renal failure (daily dialysis)
 Severe diabetic neuropathy
 Left B/K amputation
 Left hand 3rd & 4th distal digit amputations
Referred for 2 chronic open wounds, Right Foot (Chronicity > 3
years)
Previous Care
 Various topical applications
 Various dressings
 Antibiotics
 Debridement
1-6-03
1-6-03
Interventions
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Electrical Stimulation
 High Volt Pulsed Current
 150v, 120pps, 255ppi
 Stainless Steel Electrodes (4x4)
 30 minutes, 5 X week
 Immersion Techniques
 Object:
 improve blood flow
 Reduce edema
 Inhibit bacterial growth
 Enhance closure
Off-Loading
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Reducing weight bearing forces on the foot is critical
for healing plantar ulcers (9)
Total contact casts used commonly for grade 1 & 2
neuropathic foot ulcers
Allows weight bearing forces to be dispersed over a
larger area, reducing plantar pressures
Rigidity of cast assists with edema control, improving
circulation
Cast immobilizes the foot and ankle, reducing shearing
forces
Completely encloses the patient’s insensate foot,
protecting it from further trauma & microorganisms
Allows patient to be relatively active
TOTAL CONTACT CASTS
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Contraindicated
 In grades 3, 4, and 5
ulcers
 Fluctuating edema
 Active infection
 ABI of less than 0.45
Requires skill to apply
 Plaster vs. Fiberglass
 Heel vs. Cast Shoe
Off Loading
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DonJoy Walking Boot (Cam Walker)
provides foot and ankle immobilization at 0º, 10º,
and 20º plantarflexion
protected range of motion in 10º increments from
40º plantarflexion to 40º dorsiflexion
easily to don and doff
easy to distribute weight bearing pressures via
ankle motion
provides protection from trauma
allows for daily dressings and external treatments
can be removed when not ambulating
Overview of Intervention
Wounds were treated 5 X week with
electrical stimulation in an aqueous
solution for 30 min per session
 Wounds were first dressed with hydrogels
and eventually hydrocolloids
 Walking Boot worn whenever weight
bearing was anticipated (transfer & gait)
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Outcomes Heel
1-6-03
7-29-03
Outcomes Plantar Surface
1-6-03
7-29-03
Clinical Relevance
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Case study does suggest that electrical
stimulation and off-Loading for diabetic
neuropathic wounds is a viable treatment option
Walking Boots that allow for ankle motion
control offer an additional option for offloading
Chronic diabetic foot ulcers can be treated
effectively by physical therapists in conjunction
with referring physicians
Chronic wounds in patients with severe
comorbidities can be healed using electrical
stimulation and off-Loading
Tid Bits
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Half Casts
Ambulatory Aids,
Molded Plastazote Sandals
Post-Operative Shoes
Pressure Relief, sculpting with Adhesive Felt
Padding, Foot Orthoses, Rocker Soles
Modalities
Following Closure
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Proper Footwear
Progress into Normal Weight Bearing Gait