role of physiotherapy in diabetic foot ulcer

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the role of physiotherapy for prevention and management of diabetic foot ulcers

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Presentation Transcript

Welcome : 

Welcome

Diabetic Foot UlcerRole of Physiotherapist : 

Diabetic Foot UlcerRole of Physiotherapist T. Senthilkumar M.P.T (Ortho).,M.I.A.P Asst. Professor Shanmuga College Of Physiotherapy

What is Diabetes Mellitus? : 

What is Diabetes Mellitus? Diabetes Mellitus is a group of metabolic disorders characterized by high levels of blood glucose resulting from defects in insulin production, or action, or both.

Types of Diabetes : 

Types of Diabetes Type 1 Type 2 Gestational Diabetes

The Need : 

The Need India has the largest number of diabetic patient (19.4 Million) - 1995 In 2025 this is projected as 57.2 million ie 114.4 million foot are at risk 40 – 70%- All lower extremity amputation are related to diabetes mellitus 85% - All diabetic related amputation are due to foot ulcers. 30 sec - Every 30 sec a leg is lost to diabetes somewhere in the world One in every six people with diabetes will have an ulcer during their life time. Ratio (1:6) Source: WHO Statistics on Diabetic Foot Ulcer

Contd.. : 

Contd.. 45% of diabetics will have peripheral vascular disease after 20 years After first below –knee amputation 42% of patients with lose the contra lateral limb within 1 year 11-40% of patients will die within first year of their below-knee amputations Source: WHO Statistics on Diabetic Foot Ulcer

The term diabetic foot has been coined to encompass a multitude of leg / foot presentation where the underlying disease is Diabetes Mellitus. : 

The term diabetic foot has been coined to encompass a multitude of leg / foot presentation where the underlying disease is Diabetes Mellitus. Diabetic Foot ?

Clinical triads : 

Clinical triads Peripheral neuropathy Peripheral vascular disease Mechanical factors (deformities)

Anatomy of the Foot : 

Anatomy of the Foot 26 – bones + (2-sesamoids) = 28 57- Joints 42- Muscles 107- ligaments In lifetime, its is estimated that a human being walks about 100,000m(1,50,000 KM) equaling to almost 4 times around the world

Why PVD & Peripheral Neuropathy is common in lower limbs than in upper limbs : 

Why PVD & Peripheral Neuropathy is common in lower limbs than in upper limbs A comparative lengthening of lower extremity Internal rotation to render the foot planti-grade Weight bearing got restricted to two instead of four limbs Our ability to see our plantar decreased significantly Great toe went further away from the body so its needs longest nerves and arteries

Bio & Patho mechanics of Diabetic Foot : 

Bio & Patho mechanics of Diabetic Foot

Phases of Gait Overview : 

Phases of Gait Overview Stance phase (62%) Contact period - heel contact (HC) to forefoot contact (FFC) Midstance period - forefoot contact (FFC) to heel off (HO) Propulsion period - heel off (HO) to toe off (TO) Swing phase (38%) early swing, late swing, double and single support

Normal Foot Function : 

Normal Foot Function Heel Strike The foot assists in shock absorption. The foot and leg are required to be a loose chain structure. Mid Stance The foot supports the entire body. A stable structure is required Propulsion The foot is required to adapt to the needs for propulsion. A rigid lever is required

Normal Foot Function contd.. : 

Normal Foot Function contd.. Heel Strike - Subtalar joint pronates and allows shock absorption Mid Stance – Subtalar joint comes to neutral position and acts as stable structure Propulsion – Subtalar joint supinates and acts as rigid lever

Abnormal Foot Function : 

Abnormal Foot Function

Slide 17: 

Sensory loss Trauma / Pressure / Stress / Heat Blisters / Wound Ulcer Tissue loss Autonomic dysfunction Dryness Cracks / Fissures / Callous Ulcer Tissue loss Motor Paralysis Altered biomechanics Contractures/Pressure/ blister/ wounds Ulcer Tissue Loss PAD Ischemia Ulcer Infection Tissue Loss

Factors affecting normal biomechanical loading in diabetic foot : 

Factors affecting normal biomechanical loading in diabetic foot Deformities Abnormal walking pattern Limited joint mobility Repeated plantar pressure Shear stress

PATHOGENESIS OF ULCERATION OF DIABETIC FOOT : 

PATHOGENESIS OF ULCERATION OF DIABETIC FOOT Impulse loading in diabetic neuropathy is very high at 1st MTP joint Increasing ground contact time due to LJM, soft and connective tissues changes, already existing deformities and scars of previous ulcers Due to autonomic neuropathy the recovery from anoxia and ischemia is delayed as the sympathetic denervation of the circulatory bed occurs This causes increased warmth and Erythema in the region of 1st/3rd/5th metatarsal heads This leads to progressive inflammation and exudates formed Continued walking with blisters promotes ulcers formation in the risk areas

Commonest deformities in diabetic foot : 

Commonest deformities in diabetic foot FLAT FEET (OVER PRONATION OF FEET) PES CALCANEUS PES EQUNIUS CLUB FOOT INSUFFICIENT PUSH OFF ACHILLES TENDINITIS PLANTAR FASCITIS HALLUX ABDUCTO VALGUS (BUNION) HALLUX RIGIDUS METATARSALGIA HAMMER TOE CALLUSES

High risk areas of diabetic foot : 

High risk areas of diabetic foot 1st Metatarsal Head 2nd and 3rd Metatarsal Head Between 4th and 5th MT Head Ball of the all toes Under 1 MTP joint Under MTP joints Lateral heel

CAUSATIVE FACTORS FOR NEUROPATHIC ULCERS : 

CAUSATIVE FACTORS FOR NEUROPATHIC ULCERS EXTRINSIC FACTORS Ill fitting footwear Barefoot walking Falls/accidents Objects inside shoes Thermal trauma Injury by sharp objects Home surgery INTRINSIC FACTORS Limited joint mobility Bony prominences Foot deformities Neuro-arthropathy Plantar callus Scar tissue Fissures

Clinical features of diabetic foot : 

Clinical features of diabetic foot SIGNS OF MOTOR NEUROPATHY Clawed toes Raised arch of foot Foot drop Intrinsic muscle wasting Other deformities SIGNS OF AUTONOMIC NEUROPATHY Dry skin Fissuring Distended dorsal veins Warm foot Increased blood flow Bounding pulses

Various Presentations of diabetic foot : 

Various Presentations of diabetic foot Fissures Abscesses Cellulitis Ulcers Gangrene Claw Toes Charcot foot

Wagner ulcer classification system : 

Wagner ulcer classification system

Role of Physiotherapy : 

Role of Physiotherapy

“The Whole problem is really one of mechanics not of Medicine”- Dr Paul Brand : 

“The Whole problem is really one of mechanics not of Medicine”- Dr Paul Brand

Assessment and Investigations : 

Assessment and Investigations History Neurological Examination (sensory) Foot Biomechanical Assessment Wound assessment Radiological Examination Pedobarography F - Scan

Examinations : 

Examinations 1. Touch and pressure - Semmes Weinstein Nylon Monofilament 10gm 2. Vibration Perception Threshold (VPT)- by tuning fork 3. Thermal thresholds i.e. sensation of heat and cold 4. Foot pressure measurements by pedobarograph 5.Reflex assessment by using tendon hammer

Foot Functional Assessment : 

Foot Functional Assessment Ask the patient to walk on the spot for a few seconds. Ask the patient to stop, stand still and look straight ahead. Look at the heel to see it turns in or out. Normal Heel Everted Heel Inverted Heel

Interventions : 

Interventions Prevention Therapeutic Exercises Health Education & Home care activities Splinting Modalities Footwear Orthosis Prosthesis

Prevention and Education : 

Prevention and Education Proper education about insensitive foot Regular examination of the sole of the foot Immediate reporting if there is any change in sensory perception or motor abnormality Checking nails for blood flow or any discoloration Check feet regularly for blood circulation, and blisters, callus, corns, wound

Contd…. : 

Contd…. Soak the feet for 20-30 minutes in cold water to keep the foot supple and smooth (especially those who have fissures and cracks) Dress the wound properly Give adequate rest to the affected part Avoid long distance walking Wear Proper Footwear

Aim of physiotherapist in diabetic foot clinic : 

Aim of physiotherapist in diabetic foot clinic To control and maintain blood glucose level To check the area at risk of foot ulcers and give utmost care to that risky areas To educate the foot care and prevention methods To advice proper footwear To educate do’s and don'ts during daily activities properly

Contd.. : 

Contd.. To advice proper foot splints To minimize neuropathic pain To prevent deformities To improve muscle power and prevent muscle wasting To increase range of motions, strength, endurance To prevent limited joint mobility

Means : 

Physiotherapy can help people to maintain good blood glucose control and achieve optimal weight Isotonic exercise like jogging, running, walking will benefit a person with diabetes LMJ mobility is corrected by teach active exercise to toes and foot Neuropathy pain to be corrected by the TENS and Interferential therapy HVPC (High voltage pulsed galvanic current) also used to enhance wound healing Electrical stimulation will enhance wound healing Means

Contd.. : 

Exercise - Burger-Allen exercises will facilitate and activate the blood circulation in lower extremities To teach Off Loading techniques that means train crutch walking, wheel chair training During off loading its necessary to prevent muscle wasting by active physio for leg & foot muscles To identify the excessive pressure areas and advice suitable foot wears To concentrate the dry skin to avoid that advice soaking training in cold water Contd..

Objectives of diabetic foot wear : 

Objectives of diabetic foot wear Relief of excessive plantar pressure Reduction of shock Reduction shear (frictional forces) Accommodation of minimal deformity Stabilization of deformity Preventing recurrence of ulcer

Total contact Cast is the appropriate way of resting the foot with diabetic plantar ulcer It Distributes weight along the entire plantar aspect of the foot. It Reduces shear forces normally present between the foot and shoe. It Produces shortened stride length and a decreased walking velocity. Splinting

Various types of Rocker Soles : 

Various types of Rocker Soles Mid rocker soles – to relieve pressure metatarsal Heel to toe rocker soles – fixed claw toes, hammer toes, calcaneal ulcers Toe only rocker soles – ulcer metatarsal heads Severe angle rocker sole – hallux rigidus, ulcer on the distal part of toe, hammer toe, ulcer metasal heads Negative heel rocker sole – fixed ankle in dorsiflexion

Do’s : 

Do’s Inspect the feet daily using mirror (especially b/w toes, pressure areas) Wash feet daily water Apply lotion, oil to feet after drying Avoid extremes of temperature Have your feet checked at each clinic visit Inspect shoes daily for defects/foreign bodies Change shoes often Regular skin and nail care

DONT’S : 

DONT’S Walk barefoot Smoke Step into the bath before checking water temperature Use heating pads Perform bathroom surgery Use chemical agent to treat corns or calluses Wear new shoes for more than an hour at a time

Conclusion : 

Conclusion Physiotherapist are likely to treat patients for diabetes related complications. Therapist may also have a role in preventing complications secondary to diabetes. So we are the peoples more responsible to treat and prevent the diabetic foot ulcers for diabetes patients “PREVENTION IS BETTER THAN CURE”

Thank You : 

Thank You