Transcript Diabetic Peripheral Neuropathy

Diabetic neuropathy
Slides current until 2008
Diabetic neuropathy
Diabetic foot disease –
the high-risk foot
Peripheral neuropathy
Curriculum Module III-7C
Slide 2 of 37
Peripheral vascular
disease
Peripheral neuropathy and
peripheral vascular disease
Slides current until 2008
Diabetic neuropathy
Some statistics
Curriculum Module III-7C
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• Half of all limb amputations are caused
by diabetes
• Risk is 40 times increased in diabetes
• 70% of people die five years following
an amputation
• Foot problems account for 40% of
healthcare resources in developing
countries; 15% in developed countries
Slides current until 2008
Diabetic neuropathy
Some statistics
Curriculum Module III-7C
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• 85% of all amputations begin with an
ulcer
• Foot problems cost USD 6 billion/year
in the USA
• 49-85% of amputations can be
prevented
Slides current until 2008
Diabetic neuropathy
ACTIVITY
Curriculum Module III-7c
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Discuss
• How and when people have their
feet examined in your country?
• What conditions put people at high
risk of injury in your country?
Slides current until 2008
Diabetic neuropathy
Peripheral neuropathy –
sensory motor
Curriculum Module III-7C
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• Most common form of neuropathy
• Affects approximately 50% after
15 years
• Affects long nerves (feet and legs)
first
– glove and stocking distribution
• Bilateral
• Equal symptoms in both limbs
Slides current until 2008
Diabetic neuropathy
Diabetic peripheral neuropathy –
risk factors
Curriculum Module III-7C
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• Poor glycaemic control
• Long duration
• Age
• Height
• Excessive alcohol
Slides current until 2008
Diabetic neuropathy
Nerve damage – neuropathy
Curriculum Module III-7C
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• Symptoms:
– burning
– pins and needles
– pain
• No symptoms
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C
Slide 9 of 37
Slides current until 2008
Diabetic neuropathy
Painless nature of diabetic foot
disease
Curriculum Module III-7C
Slide 10 of 37
Slides current until 2008
Diabetic neuropathy
Sensory nerve damage
Curriculum Module III-7C
Slide 11 of 37
Slides current until 2008
Diabetic neuropathy
Motor nerve damage
Curriculum Module III-7C
Slide 12 of 37
Slides current until 2008
Diabetic neuropathy
Localized callus
Curriculum Module III-7C
Slide 13 of 37
Slides current until 2008
Diabetic neuropathy
Autonomic nerve damage
Curriculum Module III-7C
Slide 14 of 37
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C
Slide 15 of 37
Take off the shoes!
Slides current until 2008
Diabetic neuropathy
Diabetic peripheral neuropathy
screening tests
Curriculum Module III-7C
Slide 16 of 37
• Test sensation
– Biothesiometer
– Tuning fork
– 10 gm monofilament
• Ankle reflexes
Slides current until 2008
Diabetic neuropathy
Assessment of high risk
characteristics
Curriculum Module III-7C
Slide 17 of 37
Slides current until 2008
Diabetic neuropathy
Charcot’s arthropathy
Curriculum Module III-7C
Slide 18 of 37
• Artery-vein shunting
• Increased blood flow
• Bone resorption
• Commonly misdiagnosed
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C
Slide 19 of 37
Acute vs chronic Charcot’s arthropathy
• Unilateral
• Warm, swollen
• No temperature
difference
• Relatively pain free
• Rigid foot deformity
• Bounding pedal pulses
• Grossly misshapen
foot
• Deformity may be present
Slides current until 2008
Diabetic neuropathy
Charcot’s arthropathy
Curriculum Module III-7C
Slide 20 of 37
Slides current until 2008
Diabetic neuropathy
Charcot’s arthropathy – treatment
Curriculum Module III-7C
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• Acute phase
– Non weight-bearing
– Total contact cast
• Chronic phase
– Orthopaedic surgery
Slides current until 2008
Diabetic neuropathy
Circulation
Curriculum Module III-7C
Slide 22 of 37
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
Curriculum Module III-7C
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• Cause: decreased perfusion
due to macrovascular disease
• Sites: more distal
Tibial and peroneal arteries
(segment between the knee and
the ankle but aortic-illiac to knee
less frequently)
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease in
diabetes
Curriculum Module III-7C
Slide 24 of 37
• 15-40 times more likely to
have lower limb amputation
• People over 70 years have a
70-fold increased risk of
amputation
Slides current until 2008
Diabetic neuropathy
Risk factors characteristics of
atherosclerosis in diabetes
Curriculum Module III-7C
Slide 25 of 37
• More common
• Affects young age group
• No sex difference
• Smoking
• Faster in progress
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
Curriculum Module III-7C
Slide 26 of 37
• Symptoms
– Intermittent claudication
– Rest pain
• No symptoms
– Inactivity
– Neuropathy
Slides current until 2008
Diabetic neuropathy
Signs of vascular disease
Curriculum Module III-7C
Slide 27 of 37
• Diminished or absent
pedal pulses
• Coolness of the feet
and toes
• Poor skin and nails
• Absence of hair on feet
and legs
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
and diabetes
Curriculum Module III-7C
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• Symptoms and signs of peripheral
vascular disease
• There are four stages:
1. Occlusive disease without symptoms
2. Intermittent claudication
3. Ischaemic rest pain (nighttime)
4. Ulceration/gangrene
Slides current until 2008
Diabetic neuropathy
Vascular assessment
Curriculum Module III-7C
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Palpation of foot pulses
– Dorsalis pedis (10%
absent due to anatomical
reasons)
– Tibialis posterior
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
non-invasive evaluation
Curriculum Module III-7C
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• Methods
– Doppler pressure studies (ABI)
– Duplex arterial imaging
• Rationale
– Identify and confirm presence of
disease
– Predict healing of ulcers or
determine need for early surgical
intervention
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
non-invasive evaluation
Curriculum Module III-7C
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• Doppler ultrasound
– Measures pressure at brachial,
pedal and toe arteries
– Ankle Brachial Index (ABI)
<0.9 abnormal
0.9 to 1.0 normal
>1.3 non-compressible
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
non-invasive evaluation
Curriculum Module III-7C
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• Duplex arterial imaging –
allows narrowing or obstruction
of blood vessels to be localized
Slides current until 2008
Diabetic neuropathy
Peripheral vascular disease
Curriculum Module III-7C
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Treatment
• Quit smoking
• Walk through pain
• Surgical intervention
Slides current until 2008
Diabetic neuropathy
Risk categorization system
Curriculum Module III-7C
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Category Risk profile
Check-up frequency
0
No sensory neuropathy
Once a year
1
Sensory neuropathy
Every 6 months
2
Sensory neuropathy
/peripheral vascular
disease/foot deformities
Every 3 months
3
Previous ulcer
Every 1-3 months
Slides current until 2008
Diabetic neuropathy
Cause of diabetic amputation
Curriculum Module III-7C
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Neuropathy or vascular disease
Trauma
Ulcer
Failure to heal
Infection
Amputation
Pecararo
Slides current until 2008
Diabetic neuropathy
Curriculum Module III-7C
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An amputation
every 30 seconds
due to diabetes
Slides current until 2008
Diabetic neuropathy
ACTIVITY
Curriculum Module III-7c
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• How to do a foot assessment
• Participants to form pairs and do a
foot assessment on each other
Slides current until 2008