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Christine Berke MSN APRN-NP CWOCN-AP AGPCNP-BC cberke@nebraskamed.com

 No Conflicts of Interest No off label recommendations  Unless I tell you 

Objectives:  Recognize the correct assessment for diabetic

neuropathy & it’s implications for risk of a foot ulcer.  Educate the patient with diabetes regarding life style

changes necessary to prevent foot ulcers and decrease risk for amputation(s).

 Identify current Evidence for treatment of foot and/or leg ulcers with a primary etiology of neuropathy and/or peripheral vascular disease.

HouseKeeping

 Centers for Disease Control (CDC)  2015:  30.3 million U.S. have Diabetes Mellitus

 9.4% of population  7.2 million undiagnosed

 1 in 4 don’t know they have it  84 million over age 20 have pre diabetes  90-95% of Diabetes disease is Type 2  Incident increases with age; 25%over age 65

Statistics

https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

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  15-25% of people with diabetes will develop tissue

loss on their feet⁵  60% of diabetic foot ulcer (DFU) progress to

infection⁵  20% of those DFU lead to some form of amputation

 80% of DFU that present to emergency department are admitted to the hospital for treatment/surgery⁵

 30-80% of people with previous DFU (healed/amputated) will experience recurrence ~1yr⁵

Mortality rates for patients with amputations related to DFU: 20-60% 5 year survival rate⁵

Statistics

 One of several complications of Diabetes Mellitus¹²  Contributing causes for DFU:  Diabetic Peripheral Neuropathy (DPN)  Peripheral Arterial Disease (PAD)  Immunosuppression

 Strongest predictor of DFU ⁶  Chronic callus  Foot structure changes  DPN  PAD  Previous DFU

Diabetic Foot Ulcers

 Hyperglycemia⁷  Oxidative stress on nerve cells Neuropathy  Deposits of glucose in the nerve cells Nerve conduction  Tightens ligaments in the foot  Injures the nerves  Constricts arteries Ischemia, decreases blood flow

 Neuropathy⁷  Motor – imbalance of flexors/extensors – foot structure changes  Autonomic – impairs sweat gland function – dry skin, fissures  Sensory – peripheral sensation impaired

 Repetitive Trauma  Immune response changes⁷  Increased T lymphocyte apoptosis, inhibits healing

Pathology

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  Type 1 DM – after 5 years of diagnosis, annually  Type 2 DM – at initial diagnosis, annually  Symptoms vary based on sensory fibers involved  Small fibers – pain & dysesthesias (burning, tingling)  Large fibers – loss of protective sensation (LOPS)  Positive test indicates polyneuropathy with motor loss

 Small fiber tests: pinprick, temperature  Large fiber tests: vibration, monofilament, ankle

reflexes Consider other causes of peripheral neuropathy

Testing for DPN⁷`⁸

  10-g (5.07) monofilament  Eyes closed, resting quietly with feet exposed  4-10 sites – 1st, 3rd, 5th metatarsal heads, plantar hallux  Include reference sites to verify sensation detection  Test both feet  Results can vary between feet  Good time to examine for callus & deformities  Document Results!

Monofilament Testing⁷

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Monofilament 5.07

https://www.hrsa.gov/sites/default/files/hansensdisease/pdfs/leapfilament.pdf

https://youtu.be/ZzP_gijk6TA

  128-Hz tuning fork  Close eyes, touch base of vibrating fork to bony

surface of each toe in succession, ask when vibration begins and ends with each toe

 Pinprick test  Just proximal to toenail of the dorsal aspect  Blunt tip, don’t draw blood, test arm first  1st toe – L4; 2nd/3rd toes – L5; 5th toe – S1

Ankle reflex test  Achilles tendon tested, patient sitting with foot

neutral, strike tendon and watch/feel for plantar flex

Other Tests⁷

  Patient history  Cardiac  Kidney  Tobacco use

 Evaluate Limbs  Peripheral pulses  Palpate (bounding ≠ adequate flow)  Doppler (hand held versus laboratory)  ABI/TBI and/or duplex  Transcutaneous oxygen

DM and PVD¹⁻³

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  Evaluate limb volume  Edema  Varicosities  Compression & or elevation use/tolerance

 Skin exam  Moisture  Hair growth  Texture  Nails and Calluses  Temperature

DM & PVD (continued)

  Foot Exam  Clinician should be knowledgeable in DM foot

exam/care  Education (alone is not enough)  Patient and significant other(s)  Repeat each visit  Callus - often heralding lesion/risk for DFU⁹

 Self Exam of Feet  Daily or more (evaluate patient’s activity level)  After episodes of intense/unusual activity  Long handled mirror

Prevention of DFU¹⁻³

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 Foot Care  Cleaning – no soaking  Socks - compression  Lotions versus creams  Nail care  Fungal dermatitis

 Foot wear (protect, protect, protect)  Bare or stocking footed walking  Open toe shoes/sandals/Crocs™/flip flops/slippers  Shoe style, inserts, supports, replacement frequency  Must be worn in the house (only 15%compliance⁹)

 At night?  Escalating shoe wear

 Inserts – standard versus molded  Standard shoe versus custom made

Prevention (continued)

Maguire, J. 2012 http://www.podiatrytoday.com/transitioning-open-wound-final-footwear- offloading-diabetic-foot Accessed 10/2/17

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  Toe contracture  Hammer or claw toes

 Toe diversion  Hallux valgus

Arch  Lifting/Flattening

Ankle immobility  Foot drop  Gait changes

Charcot deformity  Acute versus Chronic

Structural Foot Changes

 Toe Contractures

 Toe Diversion

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Charcot

https://www.ncbi.nlm.nih.gov/books/NBK409609/ Accessed 10/2/17

  Treat/Control Systemic Conditions that Affect Wound

Healing  Manage co-morbid conditions/diseases

Offloading (can’t be stressed enough)  Protect the Wound from Trauma

Control Edema  Know Vascular Status

Use Evidence Based Topical Therapy  Promote a Clean Wound Base  Maintain a Moist Wound Environment  Control Bacteria/Treat Infection

Wound Care Focus

Bryant, R.A., Nix, D.P. Acute & Chronic Wounds: Current management concepts, 4th Ed. Mosby; St. Louis, 2012.

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  Identify and manage co-morbid conditions  Diabetes – Capillary BG, foot checks, footwear, nocturia  HTN, CAD, PAD – perfusion, edema, medications  Kidney disease  Obesity &/or malnutrition – weight loss & wound healing,

nutrition, fluids  Anemia  Sleep apnea

 Lifestyle choices – smoking, alcohol, drugs (OTC, prescribed, recreational)  Immunosuppression –  Cancer, organ transplant, Autoimmune disorders

 Interdisciplinary Team - Critical

Systemic conditions

  Wound Culture  Quantitative versus Qualitative

 Vascular studies  Arterial duplex, ABI/TBI, TcPO2  Venous duplex – standing to look for reflux

 Labs  CBC, Sed rate, CRP, Hgb A1C, BMP/CMP

 Xray versus MRI  Osteomyelitis

 Nutritional parameters  Weight, height, meal &/or fluid diaries/recall

 Vital signs

Diagnostic considerations

  Causes of Edema

 Venous insufficiency  Heart failure  Renal disease  Lymphedema

 http://www.lymphedemablog.com/  Lipedema

 Compression  Wraps  Stockings

 Electric pumps  Arterial  Venous  Lymphatic

 Elevation

Edema Management

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Offloading

 Gold Standard for treatment of DFU  Redistributes plantar pressure over a larger surface

area Assess patient risks  Mobility/Falls

 Inability to examine wound as frequently Neuropathy can interfere with recognition of

complications from the TCC

Total Contact Casting ¹⁻³·¹⁰·¹¹

https://www.youtube.com/watch?v=jtapSDECeG4

 Wound Exam

 Comprehensive & regular wound assessments  Measurements, wound tissue, color, edges, exudate, odor,

peri-wound skin  Photos for documentation  Address pain  Quickly identify wounds that are not healing or are

actively deteriorating  No progress for 2 consecutive weeks  Review entire care plan  Consider referral to specialist

 Consider palliative care if healing not realistic  patient focused care

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 Debride - if appropriate  Methods:  Autolytic, chemical*, enzymatic, biologic, surgical  Mechanical  Wet to dry dressings  F-tag 314 – limited situations, removes healthy tissue, increases

pain  Whirlpool  Pulse lavage

 Wound cleansers vs. Skin cleansers  Chlorhexidine  Dakin