Posts Tagged ‘diabetes’

Peripheral Neuropathy and Diabetic Foot Ulcers

April 3, 2014

 

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What is peripheral neuropathy?

One of the major complications associated with diabetes is peripheral neuropathy. This process of nerve damage gradually takes place after many years of having diabetes and uncontrolled blood sugar. The condition affects the sensory, motor, and autonomic nerves of the body. Muscle strength and balance are diminished with motor neuropathies. While autonomic neuropathies manifest as loss of hair and disfunctioning sweat glands in the lower extremity and can present as erectile dysfunction in very advanced cases. Sensory deficits, which include numbness, tingling or even pain, are often the first symptoms to develop. Many people that are developing the condition may not notice the gradual onset of symptoms. Diabetics may be unaware of of these gradual changes until their doctor informs them that they have the condition. Some may experience shooting pains in their feet that become worse at night, making it difficult to sleep.

 

Lack of sensation in the lower extremity can be very dangerous because it increases the risk of developing sores, open wounds and ulcers on the feet. If the wound becomes infected, there is a likelihood that the infection can spread and amputation of the affected limb may be necessary if it is not treated soon enough. Losing a limb becomes a large burden for patients in their daily activities and adds additional costs to their medical care. Because of this, it is recommended that a comprehensive foot exam be performed annually in all diabetics.

 

Muscle weakening associated with motor neuropathy acts as an added detriment because it can lead to development of foot deformities, such as hammertoes, bunions or limitation of motion in joints of the lower extremity. These defomities may rub on shoe gear and cause skin breakdown. Coupled with a numb foot, these deformities increase the patient’s risk of developing foot wounds.

 

Foot exam

The physical exam involves a thorough review of the skin health, blood supply, nerves and muscle strength of the lower extremity. The skin is assessed for hair growth, any discoloration and wounds. Diabetics have an increased risk of developing poor blood supply also known as peripheral vascular disease. This in turn greatly increases their risk of acquiring a dangerous infection and non-heeling wounds of the feet. The neurological portion of the exam involves measuring the patient’s ability to feel a small flexible fiber under their feet with their eyes closed. Additional testing evaluates their ability to detect vibratory sensation. Patients that develop peripheral neuropathy may not be able to tell the doctor when the bottom of their feet is touched with a monofilament. These patients are at an increased risk of developing unnoticed foot wounds.

 

Diabetic foot wounds – how are they treated?

Repetitive trauma to the foot leads to development of a hard callus, which increases pressure on the foot when the patient walks. The person with a numb foot continues to exert pressure on the callus, which forms a deeper wound that can subsequently lead to infection. An ulcer develops when a break of the skin occurs. The depth of the wound plays a large role in how serious the infection can be and how it can be managed. A rim of callus usually surrounds the wound. Once the wound becomes infected, the foot may become red, leak fluid, and may have a foul smell. As the infection progresses, thick yellow fluid can leak from the wound. It is important that callus and any wound is medically evaluated and appropriate medical treatment is started as soon as possible. Initial treatment involves debriding the wound to remove any dead tissue covering in order to expose the underlying healthy tissue in the wound. Any callus that surrounds the wound is also removed. A culture is obtained to find out which bacteria are involved with the infection so that appropriate medical therapy with antibiotics can be initiated. Negative pressure wound therapy a small vacuum placed over the wound can be used in some cases to quicken the healing process. Some of these infected ulcers may require intervenous antibiotics and hospitalization.

In addition to antibiotics and debridement pressure from the shoe and the ground must be reduced or eliminated to allow the wound to heal. Offloading pressure from the wound sight is accomplished in many ways. Sometimes a wheelchair or crutches are needed to completely remove weight from the foot. An orthotic or shoe insert with cutout areas under the wound can reduce pressure from causing additional damage. There are also many other ankle-foot braces and cast that remove pressure from the foot. One of these braces is the Bledso Boot. This boot has a layer of auto-molding foam in the foot bed, which reduces pressure on the wound. It also prevents movement at the ankle therefore reducing friction that can cause tissue breakdown. Another type of device made to eliminate pressure from the bottom of the foot is called the Toad Brace. This apparatus is molded to fit and grip around the top of the lower leg and the knee. This construct floats the foot off the ground and completely offloads the bottom of the foot. After the wound heals it will be necessary to use an offloading orthotic and a shoe designed to fit this inner sole.

If you have peripheral neuropathy, it is important to check your feet daily for wounds. Areas of your feet that receive high pressure may develop calluses, which increase the risk of a wound forming in that area. Seek help early from your doctor so that a proper treatment regimen can be started. A wound that is deep and does not heal leads to further complications, such as bone or systemic infection. Disregard for the condition of your feet, especially if you are diabetic, can lead to loss of a limb.

 

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Preventing Diabetic Foot Complications

December 28, 2009


Foot amputation is one of the most serious complications that diabetics may encounter.  Fortunately, diabetics do not have to bear the burden of keeping their feet healthy alone. Not all amputations associated with diabetes can be avoided, but with routine foot examinations by a podiatrist and daily self-examination of the feet by the patient, diabetic foot complications may be prevented. In order to thwart these complications, an understanding of how and why these problems occur must be recognized.

Understanding Diabetic Foot Complications:
Diabetes causes an increase of sugar levels in the blood, which causes a process of “glycosylation” to be increased. Glycosylation is a normal process in the body that attaches chains of molecules to protein found in nerves, tendons, and cartilage.  Increased glycosylation, over time, begins to damage the function of these structures.

A vital function of nerves is the ability to convey pain, which allows us to recognize problems with our body. Due to the importance of pain as our body’s fire alarm, damaged nerves become a major risk factor for formation of diabetic foot wounds. Increased glycosylation of nerves leads to decreased pain sensation and therefore results in the loss of protective sensation. This situation becomes detrimental to diabetics, who are now unaware of small lacerations, wounds or callus on their feet that might lead to more serious complications such as ulcers and bone infections. If wounds are left untreated, they may result in amputation.

In addition to increased sugar levels, diabetics also tend to have high lipid concentrations in the blood. This produces the build up of plaque in the arteries, which results in poor circulation to tissues. Tissues depend on blood circulation for nutrients and oxygen to stay healthy and fight infections. Consequently, circulatory problems may not directly lead to ulcers on the feet, but exacerbates diabetic foot complications by creating a poor environment for wounds to heal.

The Role of the Podiatrist in Diabetic Foot Care:
Podiatric diabetic foot examinations are used to assess the risk of diabetic wounds and usually follow a methodical procedure that examines the entire foot from joint mobility and skin condition to nerve and vascular function.

Vascular Exam:
In a routine diabetic foot exam, circulation is determined by feeling for pulses in the feet. If pulses are not felt or are weak, then an ultrasound Doppler test may be used to listen and record the status of the pulses. If the Doppler test indicates poor circulation, the podiatrist may refer the patient to a vascular physician in order to treat the patient to enhance the blood circulation to the feet. The podiatrist may also observe any swelling, skin color changes, and cold temperature in the feet, as this may indicate poor circulation as well.

Neurological Exam:
In a neurological exam of the foot, the loss of protective sensation is assessed by using an instrument called a Semmes-Weinstein Monofilament, which is made out of a thin plastic wire. While the podiatrist touches the patient’s feet with the monofilament wire, the patient closes his or her eyes and tells the doctor whether or not they feel the instrument. An inability to feel the wire indicates that the patient cannot appropriately protect himself or herself from injury. These injuries can be cuts, callus or foreign body. It is important to note that neglecting the discovery of any of these injuries even for a single day can lead to an ulcer and later, an amputation.

Skin Exam:
During the skin exam, calluses, cracking, and nail conditions are noted and evaluated. Thick nails may result in painful ingrown nails or pressure soars that can harbor bacteria and lead to infections in the foot. . The condition of the skin is examined as well to ensure that there is no fungal growth, foreign bodies, and excessive moisture or dryness that promotes bacteria growth and skin deterioration.

Muscular Exam:
In order to prevent excessive pressure on the feet, bony prominences will be identified. The range of motion of joints is assessed by measuring joint motion with a tractograph. If there are painful bony prominences and decrease joint mobility, specialized diabetic shoes may be needed to provide extra depth for the feet and decrease friction against the skin. The combination of increased pressure and loss of protective sensation increases the risk of ulcers in diabetic patients. Additionally, muscle strength is evaluated in order to determine the stability of the foot. If muscle strength is found to be weak, bracing may be recommended to provide support.

The Role of the Diabetic Patient and Family Members in Diabetic Foot Care:
The responsibility of the diabetic patient and family members in preventing diabetic foot complications is just as important as the roles of the podiatrist. Here are tips to take care of diabetic feet:

1. Since diabetics are at risk of losing sensation in their feet, it is imperative that self-inspection of the feet is performed every day. If it is difficult to bend the knees to see the bottom of the foot, a magnifying mirror can be used. The mirror can be placed on the ground, while the patient looks to find any sores or foreign objects in the feet. If there are family members to assist the patient, they can inspect the feet for any wounds as well. If lesions are noted, the patient should see a podiatrist promptly to ensure timely and proper treatment of the wound.

2. Routine podiatric visits are important in maintaining diabetic foot health, especially since during these visits, calluses and nails can be debrided to relieve any excessive pressure to the feet. Furthermore, routine visits can provide early warning signals of impending problems, as detailed in this article.

3. Diet and blood sugar level should be controlled to decrease the progression of loss of protective sensation in the feet.

4. Daily foot hygiene should be incorporated into diabetic foot care. This includes washing the feet and changing socks daily. Making sure that the foot has adequate moisture, which can be ensured by moisturizing lotion. Be careful with over-moisturized feet for this may lead to the breakdown of skin.

5. Ensure that shoes fit comfortably to avoid pressure to the feet. When buying shoes, a wide toe box is advised.

6. Avoid walking barefoot to prevent stepping on foreign objects.

8. Be cautious when taking baths or going to steam rooms because with decreased sensation, the chances of getting burns increases. When taking baths, test the water first with a thermometer or your hand.