1. Slides current until 2008 Diabetic neuropathy

2. Curriculum Module III-7C Slide 2 of 37 Slides current until 2008 Diabetic foot disease – the high-risk foot Peripheral vascular disease Peripheral neuropathy Peripheral neuropathy and peripheral vascular disease

3. Diabetic neuropathy Curriculum Module III-7C Slide 3 of 37 Slides current until 2008 Some statistics 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

4. Diabetic neuropathy Curriculum Module III-7C Slide 4 of 37 Slides current until 2008 Some statistics 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

5. Diabetic neuropathy Curriculum Module III-7c Slide 5 of 37 ACTIVITY Slides current until 2008 Discuss How and when people have their feet examined in your country? What conditions put people at high risk of injury in your country?

6. Diabetic neuropathy Curriculum Module III-7C Slide 6 of 37 Slides current until 2008 Peripheral neuropathy – sensory motor 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

7. Diabetic neuropathy Curriculum Module III-7C Slide 7 of 37 Slides current until 2008 Diabetic peripheral neuropathy – risk factors Poor glycaemic control Long duration Age Height Excessive alcohol

8. Diabetic neuropathy Curriculum Module III-7C Slide 8 of 37 Slides current until 2008 Nerve damage – neuropathy Symptoms: –burning –pins and needles –pain No symptoms

9. Diabetic neuropathy Curriculum Module III-7C Slide 9 of 37 Slides current until 2008

10. Diabetic neuropathy Curriculum Module III-7C Slide 10 of 37 Slides current until 2008 Painless nature of diabetic foot disease

11. Diabetic neuropathy Curriculum Module III-7C Slide 11 of 37 Slides current until 2008 Sensory nerve damage

12. Diabetic neuropathy Curriculum Module III-7C Slide 12 of 37 Slides current until 2008 Motor nerve damage

13. Diabetic neuropathy Curriculum Module III-7C Slide 13 of 37 Slides current until 2008 Localized callus

14. Diabetic neuropathy Curriculum Module III-7C Slide 14 of 37 Slides current until 2008 Autonomic nerve damage

15. Diabetic neuropathy Curriculum Module III-7C Slide 15 of 37 Slides current until 2008 Take off the shoes!

16. Diabetic neuropathy Curriculum Module III-7C Slide 16 of 37 Slides current until 2008 Diabetic peripheral neuropathy screening tests Test sensation –Biothesiometer –Tuning fork –10 gm monofilament Ankle reflexes

17. Diabetic neuropathy Curriculum Module III-7C Slide 17 of 37 Slides current until 2008 Assessment of high risk characteristics

18. Diabetic neuropathy Curriculum Module III-7C Slide 18 of 37 Slides current until 2008 Charcot’s arthropathy Artery-vein shunting Increased blood flow Bone resorption Commonly misdiagnosed

19. Diabetic neuropathy Curriculum Module III-7C Slide 19 of 37 Slides current until 2008 Acute vs chronic Charcot’s arthropathy Unilateral Warm, swollen Relatively pain free Bounding pedal pulses Deformity may be present No temperature difference Rigid foot deformity Grossly misshapen foot

20. Diabetic neuropathy Curriculum Module III-7C Slide 20 of 37 Slides current until 2008 Charcot’s arthropathy

21. Diabetic neuropathy Curriculum Module III-7C Slide 21 of 37 Slides current until 2008 Charcot’s arthropathy – treatment Acute phase –Non weight-bearing –Total contact cast Chronic phase –Orthopaedic surgery

22. Diabetic neuropathy Curriculum Module III-7C Slide 22 of 37 Slides current until 2008 Circulation

23. Diabetic neuropathy Curriculum Module III-7C Slide 23 of 37 Slides current until 2008 Peripheral vascular disease 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)

24. Diabetic neuropathy Curriculum Module III-7C Slide 24 of 37 Slides current until 2008 Peripheral vascular disease in diabetes 15-40 times more likely to have lower limb amputation People over 70 years have a 70-fold increased risk of amputation

25. Diabetic neuropathy Curriculum Module III-7C Slide 25 of 37 Slides current until 2008 Risk factors characteristics of atherosclerosis in diabetes More common Affects young age group No sex difference Smoking Faster in progress

26. Diabetic neuropathy Curriculum Module III-7C Slide 26 of 37 Slides current until 2008 Peripheral vascular disease Symptoms –Intermittent claudication –Rest pain No symptoms –Inactivity –Neuropathy

27. Diabetic neuropathy Curriculum Module III-7C Slide 27 of 37 Slides current until 2008 Signs of vascular disease Diminished or absent pedal pulses Coolness of the feet and toes Poor skin and nails Absence of hair on feet and legs

28. Diabetic neuropathy Curriculum Module III-7C Slide 28 of 37 Slides current until 2008 Peripheral vascular disease and diabetes 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

29. Diabetic neuropathy Curriculum Module III-7C Slide 29 of 37 Slides current until 2008 Vascular assessment Palpation of foot pulses –Dorsalis pedis (10% absent due to anatomical reasons) –Tibialis posterior

30. Diabetic neuropathy Curriculum Module III-7C Slide 30 of 37 Slides current until 2008 Peripheral vascular disease non-invasive evaluation 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

31. Diabetic neuropathy Curriculum Module III-7C Slide 31 of 37 Slides current until 2008 Peripheral vascular disease non-invasive evaluation 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

32. Diabetic neuropathy Curriculum Module III-7C Slide 32 of 37 Slides current until 2008 Peripheral vascular disease non-invasive evaluation Duplex arterial imaging – allows narrowing or obstruction of blood vessels to be localized

33. Diabetic neuropathy Curriculum Module III-7C Slide 33 of 37 Slides current until 2008 Peripheral vascular disease Treatment Quit smoking Walk through pain Surgical intervention

34. Diabetic neuropathy Curriculum Module III-7C Slide 34 of 37 Slides current until 2008 Risk categorization system

35. Diabetic neuropathy Curriculum Module III-7C Slide 35 of 37 Slides current until 2008 Cause of diabetic amputation Pecararo Trauma Ulcer Failure to heal Infection Amputation Neuropathy or vascular disease

36. Diabetic neuropathy Curriculum Module III-7C Slide 36 of 37 Slides current until 2008 An amputation every 30 seconds due to diabetes

37. Diabetic neuropathy Curriculum Module III-7c Slide 37 of 37 ACTIVITY Slides current until 2008 How to do a foot assessment Participants to form pairs and do a foot assessment on each other