2011-08-23

1

Dr. R. Gary Sibbald MD, FRCPC (Med, Derm), MACP, FAAD, M.Ed.

Professor Of Medicine / Public Health U. Of Toronto Director Of The International Interprofessional Wound Care Course

President Of The World Union Of Wound Healing Societies

Dr. Sibbald is:Company/ Agency Paid

Lecturers Advisory Board Members

ResearchParticipants

3M √ √ √

CIDA √

Coloplast √ √ √

Convatec √ √

Covidien √ √

Govt Ontario √

KCI √ √ √

J&J (Systagenix) √ √ √

Mölnlycke √ √ √

RNAO √ √

Stryker √ √

Objectives Participants will:

Focus on screening and prevention

Introduce the simplified 60 second screen to identify the person at high risk of a diabetic foot ulcer

Highlight appropriate foot care/ footwear to prevent skin complications

2011-08-23

2011-08-23

2

The Problem- Diabetic Foot Ulcers

2011-08-23 4

Global pandemic of Diabetes Developing countries on the frontline Person With Diabetes (PWD) has a

15-25% lifetime risk- Diabetic Foot Ulcer (DFU)

50-70% recurrence rate (5yrs)

Every 30 seconds a lower limbis lost to diabetes

The Problem- Diabetic Foot Ulcers

2011-08-23

Precedes amputation in 85% cases Average healing rates 11-14 weeks 14-24% proceed to amputation 1 yr amputation rate- 15% Cost to the health system - profound

The Problem- DFUs

2011-08-23

Issue Statistics

Person with diabetes 20x risk of a lower limb amputation

World wide lower extremity amputations

25-90% diabetic related

5 years after the first amputation •50% dead•50% second amputation

2011-08-23

3

The Financial Cost Diabetes & Foot complications

2011-08-23

Issue Cost Diabetes •10.9 billion US dollars

•3 billion UK pounds Diabetes related foot complications

252 Million UK pounds

Cost per Amputation •16.488 US dollars •66,215 US dollars

The Problem: Lower extremity amputation (LEA)

Region Country Data Used Incidence per 100,000 diabetic population

Europe Denmark Holstein et al, 2000

430

UK Rayman et al, 2004

285

North America USA Lavery et al, 2003 590

Africa NA NA

Asia NA NA

South America Brazil Spichler et al, 2001

181

Caribbean Barbados Hennis et al, 2004 936

Guyana Newark et al, 2007

478

2011-08-23 8

Ulcer Risk Factors : Person with Diabetes

2011-08-23

Ulceration

Potential Amputation

Neuropathy

Oxygen*Medication delivery

impaired

*Poor healing*Infection

Sensory loss of protective sensation

Autonomic skin, joints

Motor foot deformity, limited mobility joints

*Self care deficit *Poor glucose control*Improper footwear*Obesity

Peripheral Arterial Disease

2011-08-23

4

Who should be involved in the care of the person with

Diabetes ?

PATIENT Medical Internist –Endocrinologist

Surgeons/Family MD

Occupational Therapist

Dermatologist

Diabetic Educator/ Dietitian

Physiotherapist/Occupational Therapist

RehabAssistant/Foot Specialist

Clinic Nurses

VascularSurgeon

Plastic Surgeon

OrthopedicSurgeon

Radiologist

SocialWorker

Reception-Secretary

Neurologist

OrthotistPedorthist

Pharmacist

Prosthetist

FamilyDoctor

DIABETIC FOOT- AN INTERPROFESSIONAL TEAM APPROACH

Foot specialist

Clinical & Education Program

Best Practice Recommendations of the Canadian Association of Wound Care (CAWC)

Development of a comprehensive interprofessional diabetic foot program gram

Primary and secondary educational strategies

Best practice seminars

Skills: Doppler ABPI, skin temperature, conservative debridement

Prevention 60 sec. screen

IIWCC key opinion leader training

2011-08-23

2011-08-23

5

Person with Diabetic Foot Ulcer

Treat Cause

Local Wound Care

Patient-Centered Concerns

Superficial Infection /

Chronic Inflammation

Tissue-Debridement of

Devitalized tissueMoistureBalance

Edge-Non-healing WoundBiological Agents-

Growth FactorsSkin substitutes Acellular matrix

Skin Grafts-Full / Partial ThicknessAdjunctive Therapies (VAC)

Sibbald et al2006,20072011-08-23

Sibbald et al WBP, 2007,WHO 2010

Advances Sept 2011

Treat the Cause: Whole Patient

2011-08-23

A HbA1c: Target for Diabetes in Control is 7.0% and should be checked every 90 days

B Blood pressure: Target for PWD is 120 mm Hg systolic and 80 mm Hg diastolic

C Cholesterol: Cholesterol < 200mg/dL, LDL < 100 mg/dL, Triglycerides <150 mg/dL.

D Diet: > 5 daily servings of fruit and vegetables, > 6 daily servings of grain products, including whole grains, > 2 servings of oily fish per week, 25-30 grams of fiber per day, < 1 tsp salt.

E Exercise: Minimum of 30 minutes most (if not all) days

F Foot Care and Foot Wear: and Ulcer: VIPs

S No Smoking! One cigarette will decrease local circulation 30-50% for one hour!

Diabetes Control Priorities in Developing Countries1

Highest level priority: o Cost saving AND Highly feasible

Diabetes

o Foot care

o Glycemic control to HbA1c < 9%

o Blood pressure control to BP < 160/90

1) Narayan V, et al. Diabetes: The Pandemic and Potential Solutions. In: Jamison D, et al., editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006. p. 591-603.

2011-08-23

6

Break:Prevention: 1266 screenings GuyanaSouth America

2011-08-23

•History•Inspection abnormalities •Palpate pulse •Monofilament testing (4 out 10 negative)

Results of 60 second screeningITEM NO% YES%

Previous Ulcer 86.5 13.5

Previous Amp 95 5

Absent pulse 91.5 8.5

Stiffness ankle/toe 98.7 1.3

Active DFU 92.3 7.7

Ingrown toenail 81.7 18.3

Callus 77.7 22.3

Fissure 89.5 10.5

Neuropathy 76.6 23.4

REFERRED DFC 59.1 40.92011-08-23

Screening – high risk statusRisk factor Ulcer yearly

incidence/ rate %Odds ratio

(95%CI)

Group 0 (no PN, no PVD) 2%

Group 1

(PN, no PVD or deformity)

4.5% 2.4 (1.1.-5)

Group 2B (PVD) 13.8% 9.3 (5.7-15.2)

Group 3 PN/ PVD (history of ulcer or amputation)

32.2% 52.7(27.2-109.8)

2011-08-23

Lavery LA, et al. … classification system of the International Working Groupon the Diabetic Foot. Diabetes Care 31(1):154-6, 2008.

2011-08-23

7

60 Second Screen - History

1. Previous Ulceration 2. Previous Amputation

2011-08-23

60 Second Screen –Physical Examination

3. Deformity

2011-08-23

2011-08-23

8

60 Second Screen –Physical Examination

4. Pulses absent Dorsalis Pedis and /or Posterior Tibial

2011-08-23

60 Second Screen – Physical Examination- fixed joints

5.No movement large toe joint Limited Ankle joint dorsiflexon

2011-08-23

60 Second Screen –Foot Lesions6. Active Ulcer 7. Ingrown toenail

2011-08-23

2011-08-23

9

60 Second Screen – Foot Lesions

8. Calluses= increased pressure

2011-08-23

60 Second Screen –Foot Lesions9. Blisters

2011-08-23

10. Fissure

60 Second Screen –Foot Lesions 4th – 5th Toe Web Space Nails

2011-08-23

2011-08-23

10

60 Second Screen – Neuropathy

11.Mono filament ExamX all negative= 4/ 10

2011-08-23

X

X

X X

60 second screen video

2011-08-23

60 Second Screen – PlanPOSITIVE SCREENNeuropathy only

See in 6 monthsAll other +ve screens

Refer to next level facility

NEGATIVE SCREEN No referral See in 1 year

SCREENING KIT Sixty Second tool Monofilament Patients Practice Documentation Referral

2011-08-23

11

Physical Activity:How Does Exercise Help?

Improves insulin sensitivity

Increases sense of well-being

Increases flexibility and muscle strength

Prevent weight gain

Improves cardiovascular function

If hypertensive, helps to control high blood pressure

Improves cholesterol and other lipids

2011-08-23

No Smoking: Double indemnity Every cigarette will decrease the circulation in the leg or

foot up to 30% for an hour or increase sympathetic tone for 8 hours

2011-08-23

Foot ailment is the most common complication of diabetes that requires hospitalization.

High blood sugar can damage the nerves of your feet resulting in loss of sensation (numbness), tingling or burning to the feet, so there is no pain when there is an injury.

High blood sugar can also cause poor blood supply to the feet and so small injuries take a very long time to heal

Taking care of your feet can make a big difference in preventing foot problems and ultimately amputation. Your feet can last a life time.

How Does Diabetes Affect Your Feet

2011-08-23

2011-08-23

12

Pat dry between your toes each day

with a soft cloth, warm

water and mild soap.

Put some powder after

you wash them. Use powder that is mild and has

no scent

Use lotion for dry skin. Do not

put any lotion between your toes, or used

perfume lotion

Never walk barefooted

How to Care for Your Feet

2011-08-23

Look for colour changes such as blue, bright red or white (pale)

spots Keep your eyes

on your feet

Check your feet each day

for cuts, blisters or

sores.

Use a mirror, if necessary,

to see the bottom of your feet

You should look and touch to

ensure that there is no swelling nor tenderness

Check Your Feet Everyday

See your health care provider if you have a foot problem do not treat them yourself.

2011-08-23

Change your socks every day

Look inside your shoes

before you put them on (make sure nothing is

in them and make sure the lining in them are not torn)

Do not wear pointed or open –toed

shoes. Sandals or thongs may

cause problems.

Shoes should fit

well. There should be

enough room for

your toes to move

Footwear

2011-08-23

13

2011-08-23

How to Care for Your Feet

When infection is bad, part of the foot or leg may need to be amputated.

If you take good care of your feet, this does not have to

happen to you.

Shoes for Persons with Diabetes

2011-08-23

Good Shoe Featureslook for comfort & support

Extra depth Ventilation (natural material) Stretching material Seamless, lightweight

construction Arch support Room For Your Toes A Perfect fitting heel Thick sole

2011-08-23

2011-08-23

14

Tips on socks, too!

Light coloured, absorbent seamless Clean Loose fitting elastic but firm Increased length

2011-08-23

Get moving

Appropriate??

2011-08-23

1 2

3

4

34

Person with Diabetic Foot Ulcer

Treat Cause

Local Wound Care

Patient-Centered Concerns

Superficial Infection /

Chronic Inflammation

Tissue-Debridement of

Devitalized tissueMoistureBalance

Edge-Non-healing WoundBiological Agents-

Growth FactorsSkin substitutes Acellular matrix

Skin Grafts-Full / Partial ThicknessAdjunctive Therapies (VAC)

Sibbald et al2006,20072011-08-23

Sibbald et al WBP, 2007,2010WHO 2010

2011-08-23

15

Objectives Participants have:

Focused on screening and prevention

Introduced the simplified 60 second screen to identify the person at high risk of a diabetic foot ulcer

Highlighted appropriate foot care/ footwear to prevent skin complications

2011-08-23

Thank you!Together we can

make a difference!

2011-08-23