Neuropathic Ulcers for Students
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Transcript of Neuropathic Ulcers for Students
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Neuropathic Ulcers
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Introduction neuropathic ulcers
Also know as diabetic ulcers
Prevalence of diabetes, US = 18.2 million
Incidence of ulcers: 15%
25% Responsible for over 600,000 amputations/year
80% following a foot ulcers
51% of ulcers attained closure (1999)
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Physical therapy tests and
measures
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Assessment of Circulation
Pulses and capillary refill
Doppler Ultrasound or ankle-brachial index
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Assessment of sensory integrity
Semmes-Weinstein monofilaments
Light touch sensation varies with location
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Classification of neuropathic ulcers
Wagner classification system
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Classifying wounds
the 5PTmethod1. Pain
2. Position
3. (Wound) Presentation4. Periwound and structural changes
5. Pulses
6. Temperature
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Characteristics of neuropathic ulcers
Pain Absent or minimal
Position Plantar aspect of the foot
Areas of increased plantar pressure
Wound presentation Round, punched out lesion
Callus rim
Little or no drainage
Necrotic base uncommon
Periwound and structural changes Dry, cracked, callusedStructural deformities
Pulses Normal
Temperature Normal or increased
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Neuropathic ulcer
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Prognosis for neuropathic ulcer
Average healing time 1214 weeks
Great variability in healing rates
Better prognosis
Smaller, superficial (Wagner grade 1 or 2)
Decrease in size within 4 weeks of treatment
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Physical therapy interventions
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Coordination, Communication, and
Documentation
Team approach
Physician
Surgeon
Podiatrist Nutritionist/Diabetic educator
Endocrinologist
Orthotist Psychological counselor
Social worker
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Patient instructions
Disease process/medical management of DM
Role of exercise and safety guidelines
Risk factor reduction Proper shoe wear and foot care guidelines
Use of lotion, white cotton socks
Performing daily foot checks Toe nail care
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Precautions for neuropathic ulcers
1. Many patients do not show signs ofinfection when infected
2. Monitor for signs of hypoglycemia
Refer for medical testing
Bone scan or X-ray: suspected
osteomyelitis Wound culture and sensitivity: suspected
infection
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Local wound care
Offload ulcer
Callus: pared flush with epithelial surface
Petroleum-based moisturizer daily
Toe spacers Adjunct modalities
Negative pressure wound therapy
Ultrasound
Electrical stimulation
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Total contact casting
For grade 1 and 2 ulcers
Modified short leg casts Toes enclosed in the cast
Fiberglass casts walking heel or cast shoe
Assists wound healing Disperses weight bearing forces
Controls edema
Protection from trauma and microorganisms
Assists with patient adherence Contraindications: osteomyelitis, gangrene,
fluctuating edema, active infection, and ABI < 0.45 Precautions: patients with fragile skin
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Prescription, application, and
fabrication of devices and equipment
Temporary Footwear
Felt or foam inserts
Padded AFO
Walking shoes
Permanent Footwear
Fit ~ longer than the longest toe,
with snug heel fit
Last should match shape of foot Extra-depth toe box
Fit in the middle of the day
Break in shoes gradually
Soft, moldable materials withheel height < 1
Soft inserts may decreasepressure
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Characteristics of footwear
Characteristics Total contact cast Padded AFO Walking shoe
Ulcer grade 1,2 1,2,3,4 1,2,3,4
Removable No Yes Yes
Pressure distribution Total contact Insole to distribute pressure
Shear forces ---- - --
Rocker-bottom Yes Yes Yes
Enclosed toes Yes Yes Yes
Weight Moderate Heavy Light
Cosmesis Fair Fair Good
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Other physical therapy interventions
Therapeutic exercise
ROM exercises
Great toe extension
Talocrural dorsiflexion
Subtalar joint motion
Aerobic exercise
Glycemic control
Manual therapy
Gait and mobility training
PWB gait
Assistive device
Decrease plantar pressure Step-to pattern
Slower speed
Shuffling gait
Footwear modifications
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Medical interventions
Glycemic control
Pharmacologic management Paresthesias
Concomitant arterial insufficiency Antibiotic therapy
Cultures average four to five microbes
Broad-spectrum antibiotic: topically, orally, or
intravenously Radiological Assessment
X-rays and bone scan (gold standard)
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Surgical interventions
Debridement Large amounts of necrotic tissue or osteomyelitis
Incision and Drainage (I and D)
Antimicrobial bead implantation May be more effective than oral or intravenous antibiotic therapy
Surgery for abnormal foot function or tissue performance Joint arthroplasty
Tendon lengthening
Stabilization of Charcot deformities
Reduction of abnormal biomechanics
Revascularization surgery
Amputation Gangrenous, and grade 4 or 5 wounds