Module 4: Neuropathic (Diabetic) Ulcers

Which condition is the 7th leading cause of death and the leading cause of amputation?

diabetes (responsible for over 600,000 amputations annually)

what is the etiology of neuropathic diabetic ulcers?

• tissue damage from hemodynamic changes and increase in microvascular pressure (hyperglycemia alters RBCs, platelets, and capillaries)

• glucose binds to proteins, causing glycosylated proteins (can damage vessels)

• sorbitol accumulation due to glucose breakdown (can cause plaques that build up in vessels)

tissue damage may occur by any of these, a combo of them, or in combo with something else

what are risk factors for neuropathic ulcerations and delayed wound healing?

• vascular disease

• neuropathy

• mechanical stress

• abnormal foot function

• prior ulcer or amputation

• decreased immune response

• poor vision

• ulcers that are large or chronic

• inadequate glycemic control

• inadequate progressional care and pt education

how does vascular disease increase risk of neuropathic ulcers?

risk for peripheral vascular disease is greater in pts with diabetes, and diabetes thickens the basement membrane, whcih may decrease O2 and nutrient delivery to the tissues

how does neuropathy increase risk for neuropathic ulcers?

most common complication of diabetes, affects more type II, may be caused by neural ischemia or segmental demyelination, increases risk of plantar ulceration greater than 3.5 times. affects sensory, motor, and autonomic systems

what are components of sensory neuropathy?

• lack of protective sensation (can’t perceive 5.07 monofilament)

• paresthesias (burning pain, tingling, aching)

what are the components of motor neuropathy?

• paralysis of foot’s intrinsic muscles

• resulting atrophy increases pressure and shear forces to foot

• loss of muscle function leads to instability during stance phase

  • leads to deformities

what are common foot deformities with diabetes?

• plantarflexion contractures

• claw-toe deformity

• hallux valgus

• forefoot varus or valgus

all have net result of increased plantar pressure at the metatarsal heads

what type of deformity is shown in the image?

claw toe deformity

what is charcot foot?

aka rocker bottom foot, bone deterioration and pathologic fractures lead to deformity, abnormal pressure and WB areas increases risk of ulceration

what deformity is shown in the image?

Charcot foot

what is autonomic neuropathy?

• disturbances in sweating mechanics, callus formation, and blood flow

• decreased ability to sweat leads to dry, less elastic, cracked skiin

• increased rate of callus formation

• arteriovenous shunting leads to decrease perfusion

• uncontrolled vasodilation leads to osteopenia

how can autonomic neurpathy affect the body?

can affect every body system- leading to resting tachycardia, exercise intolerance, orthostatic hypotension, gastroparesis, sexual dysfunction, and hypoglycemia unawareness

what is shown in the image?

autonomic skin changes

what are the characteristics of diabetic ulcers?

• located at the plantar aspect of foot (midfoot, heel, metatarsal heads)

• if pt has hallux valgus, increase risk of ulceration and medial 1st MTP joint/bunion

• wound margins often show callus formation, callused rim

• rarely eschar/necrotic material

• generally round shape

• minimal drainage

• generally painless

• pt may be unaware

what are concomitant impairments?

impairments that occur at the same time

what are some concomitant impairments in DM?

• reduced vision

• obesity

• delayed healing

• delayed immune response

what are the clinical guidelines for PT tests and measures for pts with neuropathic ulcerations?

• pulse examination (use of doppler ultrasound if nonpalpable)

• ankle-brachial index

• capillary refill (abnormal ABI, digital ulcer)

• sensory integrity

what is the ABI?

ration of the pressure in the ankle/LE to the pressure in the UE- the close to 1 the ratio is means that the pressure is the same all over the body. the ratio can increase or decrease will tell you about circulation

what ABI score indicates delayed capillary refill and warrant a referral to a physician for further evaluation?

less than 0.8

what components are part of the circulatory assessment?

• peripheral pulses

• capillary refill

• skin color and temp

• ABI

how might we screen for loss of protective sensation?

• semmes-weinstein monofilaments (5.07), avoid callused areas

• supplement with 128 Hz tuning fork on the first metatarsal head or malleolus to assess vibration perception

what is the wagner scale?

A system used to classify the severity of diabetic foot ulcers, ranging from stage 0 (no ulcer) to stage 5 (gangrene, requiring amputation). It assesses wounds based on depth, infection, and the presence of ischemia.

describe the scoring of the wagner scale

see image

what are the characteristics of neuropathic ulcers with the 5 PT method?

• pain

• position

• presentation

• periwound

• pulses

• temperature

what might the skin look like in DM patients?

• Skin may appear thin, dry, or shiny, with potential for ulceration and poor healing.

• higher risk for fungal infections and deformities of toe nails (onychomycosis)

what does treatment for diabetes ulcers include?

• team approach

• pt/client management

• preventative measures

• wound care

• total contact casting

• gait training

• balance

• therex

• medical and surgical interventions

what should we educate patients on with neuropathic ulcers?

• knowledge to manage chronic disease

• role of exercise and safety guidelines

• risk factor reduction

• daily foot checks

• foot care guidelines

• emphasize link between smoking and vascular complications

• emphasize importance of pt adherence

what are preventative measures in neuropathic ulcers?

• screening for loss of protective sensation

• proper footwear and orthotics

• behavior modification (weight loss, ETOH, smoking)

• encouragement of exercise, activity, and control of blood glucose levels

• daily inspection of shoes and feet

• proper cutting of toenaisl

• awareness of sensory deficits (limit exposure to heat, cold)

• maintain moisture and lubrication to skin to avoid cracking and drying

what is involved in wound care of neuropathic ulcers?

• debridement when implicated, moisturizer daily

• pressure relief (total contact testing, royce active walker, orthotics, cast shoe)

• choice of dressing to promote moist wound healing

• medical management of infection

what is total contact casting?

serial casting that should be changes at least once every week, or at max 2 weeks.

what are the disadvantages of total contact casting?

• need for expertise in application

• use of time and monetary resources

  • inability to examine wound daily

what are the contraindications of total contact casting?

• significant PVD

• infected wounds

• osteomyelitis

what are some medical/surgical interventions for NUs?

• debridement

• incision and drainage

• antimicrobial bead implantation

• surgery

• perfusion

• amputation (indicated for gangrene and wagner 4 or 5)

what is the prognosis like for healing with neuropathic ulcers?

• greater variability

• smaller/superficial NUs have better prognosis

• wagner grade 3+ increases amputation risk

• forefoot ulcers heal faster than heel ulcers

• better glycemic control = faster healing