Neuropathic Ulcers PT 632

Briefly describe what Type I DM is.

insulin dependence, the pancreas is not making enough insulin and can lead to hyperglycemia if left untreated.

Why is insulin needed in the body?

to transport glucose to cells for oxidative metabolism of ATP, no glucose = body uses other means to produce ATP like fat or protein which is not sustainable

What is DM Type 1A?

juvenile diabetes or IDDM

- autoimmune mediated

- some genetic predisposition

What is DM Type 1B?

idiopathic (strongly hereditary)

What causes DM Type 2?

obesity and hereditary risk factors that lead to eventual insulin resistance and eventual failure of pancreatic insulin secretion

The visceral fat that accumulates d/t an unhealthy lifestyle begins to act as what kind of organ? What are the 3 things it begins to secrete?

acts as an endocrine organ and secretes

1. inflammatory mediators

2. adipokines

3. free fatty acids

How does genetic susceptibility provoke possible DM type 2?

polygenetic or monogenetic factors like MODY can predispose someone to insulin resistance

How does aging make someone more susceptible to DM type 2?

beta-cell mass found in the pancreas decreases with aging and predisposes someone to insuline resistance

What 4 different types of medications predispose someone to possible DM type 2?

- corticosteroids

- anti-psychotics

- highly active anti-retrovirals

- progestin-only oral contraceptives

Describe relative insulin deficiency**

over the course of years beta-cells "tire out" as insulin resistance worsens and leads to a decrease in insulin secretion

Describe absolute insulin deficiency**

over the course of many many years, beta-cells deteriorate until they stop producing insulin all together (since the body perceives a state of "glucose starvation" FFAs are released to be used as fuel)

What does absolute insulin deficiency cause?

hyperglycemia, leading to glucotoxicity (hyperglycemia is toxic to beta-cells)

Is there a genetic factor for type II diabetes?

yes, there is a huge one

What A1C percentage is associated with poor wound healing?

8.5% (an A1C >8% can increase amputation risk by 5-fold!!)

What level of glucose is associated with poor wound healing?

>180 mg/dL (>10 mmol/L)

What are advanced glycosylated end-products?

glycosylated proteins that are harmful compounds formed when proteins or fats combine with sugars in the bloodstream (mediate radical damage/inflammation)

What are macrovascular effects of poor glycemic control?

- atherosclerotic-mediated CAD

- PAD

- cerebrovascular disease

What are the microvascular effects of poor glycemic control?

- nephropathy

- retinopathy

- neuropathy

the severity and complications of diabetes appears directly related to time and degree of glycemic control

What is the most common complication as a result of poor glycemic control?

peripheral neuropathy

Diabetic neuropathy is the primary cause of neuropathic ulcers due to what 3 types of neuropathy?

1. motor neuropathy

2. sensory neuropathy

3. autonomic neuropathy

What can motor neuropathy linked to neuropathic ulcers lead to?

balance issues, altered gait mechanics, intrinsic foot mm weakness and deformity (increases areas of excessive pressure)

What can sensory neuropathy linked to neuropathic ulcers lead to?

the prevention of detection of areas like the foot of abnormal and excessive pressure

What can autonomic neuropathy linked to neuropathic ulcers lead to?

leads to trophic skin changes like dry skin with abnormal skin responses to excessive pressure

What is formed prior to developing into a central ulceration?

a pre-ulcerative callus

What percentage of individuals with DM have an ulcer on the foot/ankle?

15%

What percentage of all LE amputations are d/t DM?

45%

What is the survival rate for individuals who have an LE amputation?

3 years

What are the characteristics of neuropathic ulcers?

1. pain

2. position (any area of increased pressure)

3. presentation

4. periwound (dry, cracked, callused)

5. exudate (low/moderate drainage)

6. pulses (diminished or absent)

7. temperature (autonomic dysfunction with warmth/edema or decreased impaired blood flow)

In the Wagner Ulcer grade classification for neuropathic ulcers, a score of "3" is associated with an increased risk of what?

osteomyelitis, abscess, or joint sepsis

What is a common observation in an individual with diabetes?

charcot foot deformity d/t laxity of the mm. and ligaments, the midfoot collapses

What monofilament thickness correlates to loss of protection sensation such as not being able to feel a small pebble in your show?

5.07 (10g)

What monofilament thickness is associated with decreased sensation?

1g (4.17)

What monofilament thickness is associated with absent sensation?

75g (6.10)

What is the best way to measure vascular integrity for individuals with diabetic neuropathy?

ankle brachial index**

can do capillary refill or pulse

What information can you gather from looking at an individuals shoes?

you will know if they are too tight, rubbing on certain areas, or potentially causing ulcers

What are important patient education talking points?

- glucose management (hypoglycemia concerns)

- offloading

- appropriate footwear

- daily foot inspections

- impaired vision or cognition

- discuss the "it doesn't hurt" disbelief

How do you go about offloading as a procedural intervention for diabetic neuropathy?

- TOTAL CONTACT CAST (gold standard)

- use of AD (walker for balance)

- orthotic/diabetic footwear wear schedule

With a diabetic ulcer, how should wound care be provided?

- typically need moisture adding dressings

- saucerization (to promote epithelialization)

look for signs of infection, HIGH RISK OF OSTEOMYELITIS

How does balance and fall prevention increase with diabetic ulcers?

increases 15-fold

How does aerobic exercise help individuals with diabetic ulcers?

- increased functional capacity

- secondary prevention with increased circulation

- help with correcting less efficient gait pattern

What are the advantages of a total contact cast?

- highest healing rates

- distributes pressure over entire plantar surface

- offloads foot completely

- can use with charcot foot

- protects foot from infection

- controls edema

- patient adhereance b/c its non removable

What are disadvantages of a total contact cast?

- cannot assess foot on daily basis

- impacts sleeping and bathing

- causes balance issues

- do not use if wound is infected OR pt has impaired vascular status

What is recommendation I for the DFU CPG?**

you MAY prescribe interventions to maintain CV health while minimizing weight bearing (can use AD if needed)

What is recommendation III for the DFU CPG?

you SHOULD prescribe a mod-to-vigorous intensity exercise program with aerobic and resistance training AFTER considering the pt's disease state and limits to exercise and depending on pt's physiological response in accordance to pt's preferences and resources

IIIb states you MAY use activity monitor-based counseling to increase PA

What is recommendation IV for the DFU CPG?

for a newly closed DFU, you MAY titrate tissue offloading by maintaining moderate to maximal offloading especially during the first 3 months using a wear schedule

According to recommendation IV in the DFU CPG, how long should a patient wear shoes when implementing a wear schedule?

twice daily for 1 hour each time

When using a wear schedule, when should the patient check their feet?

after 1 hour and after 20-30 mins, check feet to see if any redness is present

if there is no signs of redness, increase shoe wearing time to 1 hour at a time

What "unique" hygiene aspect should you educate patients on?

ensure drying between toes and do not put lotion between toes and cut toenails straight across

For diabetics, do you wear shoes even in the home?

yes! always wear shoes even when at home for protection IF they are not causing further damage

What is the goal HgbA1C for glycemic control?

<7%

What is the goal glucose levels before and meal and 1-2 hours after a meal?

before: 80-130 mg/dL

1-2 hours after: <180 mg/dL

If A1C increases by 1%, how does the amputation risk change?

increases 2-fold

When prescribing aerobic exercise or resistance training to individuals with DFU, what are the recommendations?

beginning at low-intensity and progressing to moderate intensity like brisk walking (pre-exercise clearance is not needed for asymptomatic individuals)

How many minutes/week of exericse is recommended for individuals with DFU? What should these individuals be aware of?

150 mins of mod exercise/week with no more than 2 consecutive days, can control glucose (start with 10 mins of AE and work up to 30 mins, no more than 2 days of rest)

MUST BE AWARE OF S/SX OF HYPOGLYCEMIA

How many days/week for resistance training and balance/flexibity for individuals with DFU?

2-3 days/week (RT on non-consecutive days)

What are the signs/symptoms of hypoglycemia?

- shakiness

- irritability

- intense hunger

- dizziness

- tachycardia

- sweating