diabetic foot syndrome – an indian perspective – apropriate technology dr. ashok kumar das dean,...
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DIABETIC FOOT SYNDROME – An Indian Perspective – Apropriate technology
DIABETIC FOOT SYNDROME – An Indian Perspective – Apropriate technology
DR. ASHOK KUMAR DAS
DEAN, DIRECTOR-PROFESSOR & HEAD,
DEPARTMENT OF MEDICINE,
JIPMER, PONDICHERRY
AGENDA
ISSUES
COST
CLASSIFICATION
HIGH RISK FOOT
CLINICAL EVALUATION HISTORY PHY EXAM
LAB TECHNOLOGY
MANAGEMENT 6 CONTROLS INDIAN PROBLEMS
& SOLUTIONS
DIABETIC FOOT CLINIC
CONCLUSIONS
INTRODUCTION
FOOT PROBLEMS - AN IMPORTANT CAUSE OF MORBIDITY IN DIABETIC PEOPLE
2025 THERE EXPECTED TO BE 75 MILLION DIABETICS
150 MILION FEET
TYPES OF DIABETIC FOOT
NEUROPATHIC FOOT (COMMONEST)
ISCHEMIC FOOT
DIAGNOSIS OF A ‘HIGH RISK’ FOOT
PERIPHERAL NEUROPATHYSOMATICAUTONOMIC
PERIPHERAL VASCULAR DISEASEPREVIOUS FOOT ULCERSFOOT DEFORMITYCLAW TOESCHARCOT ARTHROPATHY
PRESENCE OF CALLUSBLIND OR PARTIALLY SIGHTEDNEPHROPATHYELDERLYPOOR UNDERSTANDING OF DIABETESINABILITY TO FEEL SEMMES-WEINSTEIN NYLON MONOFILAMENT
PRESENCE OF CALLUSBLIND OR PARTIALLY SIGHTEDNEPHROPATHYELDERLYPOOR UNDERSTANDING OF DIABETESINABILITY TO FEEL SEMMES-WEINSTEIN NYLON MONOFILAMENT
TECHNOLOGY & DIABETIC FOOT
UTILISED MAINLYSCREENING
DIAGNOSIS OF HIGH RISK FOOT
DIAGNOSIS OF EXTENT OF INVOLVEMENT
PROGNOSTICATION
TREATMENT OF DIABETIC FOOT
TECHNOLOGY & DIABETIC FOOT…
HI TECH EDUCATION
AWARENESS & EDUCATION
PERSONS WITH DIABETES & DIABETIC FOOT CARE PROVIDERS
viz…diabetic foot pressures & its improvement with insoles etc.
TECHNOLOGY & DIABETIC FOOT…
Quantification & research
Natural history of Diabetes & its complications
Drug trials
Evidence based Diabetology Practice
viz …diabetic Neuropathy
AREAS & APPLICATION OF TECHNOLOGY IN
DIABETES PRACTICE 2004Diabetic foot pressure studies:
out of shoe
in shoe
emed
pedomed
f-scan
Introduction of opticalpedobiographs & development of computing technologymicroprocessor like recording devicesprovide—possibility of identifying patients at risk of plantar ulcerationgive basis for foot wear prescription & adjustment surgical intervention Hi tech education
COST
FOOT COSTS A MAJOR COMPONENT OF DIABETES RELATED HEALTH-CARE EXPENDITURE
IN US, COSTS OVER $500 MILLION PER YEAR
IN UK, OVER £13 MILLION PER YEAR
CLINICAL ALGORITHM
R E V IE W R IS K F A C TO R S TA TU SA T L E A S T A N N U A L L Y
G E N E R A L A D V IC E O N N A IL C A R E ,H Y G IE N E , P O D IA TR Y , F O O TW E A R
N O R IS K F A C TO R S
R E V IE W F R E Q U E N TL YA L W A Y S IN S P E C T F E E T
F O O T C A R E E D U C A TIO NR E G U L A R P O D IA TR Y
C O N S ID E R N E E D F O R S P E C IA L F O O TW E A R
R IS K F A C TO R SID E N TIF IE D
A S S E S S E V E R Y D IA B E TIC F O R R IS K F A C TO R S
CLINICAL EVALUATION
ALWAYS PRECEDES ANY LABORATORY INVESTIGATION
GOOD HISTORY AND THOROUGH PHYSICAL EXAMINATION WILL REDUCE NEED FOR MANY UNNECESSARY AND COSTLY INVESTIGATIONS
HISTORY
VASCULAR / NEUROGENIC CLAUDICATION
PREVIOUS ULCERATION / AMPUTATION
PATIENT UNDERSTANDING OF DM & COMPLICATIONS
PHYSICAL EXAMINATION
SHAPE & DEFORMITIES TOE DEFORMITIES, NAIL DEFORMITIESHALLUX VALGUS, HALLUX RIGIDUSPROMINENT METATARSAL HEADSHAMMER TOECHARCOT DEFORMITYCALLUS
SENSORY FUNCTION VIBRATION (128 HZ TUNING FORK) THERMAL PROPRIOCEPTION JOINT POSITION SENSE
MOTOR FUNCTION WASTING WEAKNESS LOSS OF ANKLE REFLEXES
AUTONOMIC FUNCTION REDUCED SWEATING CALLUS WARM FOOT DISTENDED DORSAL FOOT VEINS
VASCULAR STATUS FOOT PULSES PALLOR COLD FEET EDEMA
CLINICAL ASSESSMENT - EIGHT COMPONENTS
NEUROPATHY
ISCHEMIA
DEFORMITY
CALLUS
OEDEMA
SKIN BREAKDOWN
INFECTION
NECROSIS
STAGING THE DIABETIC FOOT
STAGE CLINICAL CONDITION
1 NORMAL
2 HIGH RISK
3 ULCERATED
4 CELLULITIC
5 NECROTIC
6 MAJOR AMPUTATION
LABORATORY EVALUATION OF THE VASCULAR
SYSTEM
INDIRECT METHODS
DIRECT METHODS
INDIRECT METHODS
DOPPLER ULTRASOUND
PHOTOPLETHYSMO GRAPHY
PULSE VOLUME RECORDING
LASER DOPPLER FLUX
TRANSCUTANEOUS OXYGEN TENSION
ISOTOPE CLEARANCE
DIRECT METHODS
DUPLEX SCANNING
MAGNETIC RESONANCE IMAGING
ARTERIOGRAPHY
DOPPLER ULTRASOUND AND DOPPLER PRESSURES
METHODS INCLUDEDOPPLER SIGNAL WAVE FORMANKLE DOPPLER PRESSURE ANKLE - BRACHIAL INDEXDOPPLER SEGMENTAL PRESSURES
DOPPLER USG - MOST WIDELY USED DEVICE
RANGES FROM A POCKET SIZE DEVICE TO LARGE, STATIONARY COMPLICATED DEVICE
AUDIBLE SIGNALS EVALUATED BY HEAD-PHONES OR LOUD SPEAKER
DOPPLER SIGNAL WAVE FORM
NORMAL ARTERIAL DOPPLER WAVE FORM IS TRIPHASICSYSTOLIC UPWARD DEFLECTIONDIASTOLIC DOWNWARD DEFLECTIONSMALLER UPWARD AND DOWNWARD
DEFLECTION (DIASTOLIC FORWARD FLOW)
ANKLE - BRACHIAL INDEX
DOPPLER PROBE USED TO MEASURE SYSTOLIC PRESSURE AT BRACHIAL ARTERY AND DORSALIS PEDIS/POSTERIOR TIBIAL ARTERY
NORMALLY, ANKLE PRESSURE / BRACHIAL PRESSURE = 1 OR SLIGHTLY ABOVE
ABI CORRELATES WITH SEVERITY OF ISCHEMIA
ABI
ABI OF 0.8 - 0.5 --- INTERMITTENT CLAUDICATION
ABI OF < 0.5 --- REST PAIN
A CHANGE OF 0.15 IS CONSIDERED SIGNIFICANT
SEGMENTAL PRESSURES
USED TO LOCALIZE VASCULAR OBSTRUCTIONMEASUREMENTS WITH PNEUMATIC CUFFS ARE MADE FROM HIGH THIGHLOW THIGHBELOW KNEEANKLE LEVEL
PRESENCE OF GRADIENT BETWEEN MEASUREMENTS INDICATES A SIGNIFICANT STENOSIS OR A COMPLETE OCCLUSION IN THE ARTERIAL SEGMENT BETWEEN THE TWO CUFFS
EXERCISE FOR DIAGNOSIS
CAN UNMASK OBSTRUCTION
CAUSES A DROP IN DOPPLER PRESSURES DISTAL TO OBSTRUCTION, AFTER EXERCISE
DIFFERENTIATES VASCULAR FROM NON-VASCULAR ETIOLOGY FOR CLAUDICATION
ANKLE DOPPLER PRESSURE
SEVERITY OF LOWER EXTREMITY ISCHEMIA
SYSTOLIC PRESSURE AT ANKLE
APPROPRIATE SIZED CUFF IS USED
POSTERIAL TIBIAL / DORSALIS PEDIS
THE HIGHER READING IS TAKEN
ANKLE DOPPLER PRESSURE
ABSOLUTE ANKLE PRESSURE IS THE BEST PREDICTOR OF LIMB VIABILITY
> 60 MM HG = 86% OF VIABLE LOWER EXTREMITIES
< 60 MM HG = 77% OF NON-VIABLE EXTREMITIES
PHOTOPLETHYSMOGRAPHY
USES A DIODE THAT EMITS INFRA-RED LIGHT INTO THE TISSUE, WHICH IS REFLECTED BACK FROM THE BLOOD IN THE CUTANEOUS MICROCIRCULATIONTWO MEASUREMENTSTOE BLOOD PRESSURESKIN PERFUSION PRESSURE
TOE BLOOD PRESSURE
FALSE HIGH DOPPLER PRESSURES IN CASE OF CALCIFIED VESSELS
ESPECIALLY USEFUL WHEN THE PATHOLOGY IN VESSELS IS BELOW THE ANKLE BUERGER’S DISEASE RAYNAUD’S PHENOMENON
LOWER LIMIT OF NORMAL FOR TOE PRESSURE IS 50 MM HG
SKIN PERFUSION PRESSURE
A GOOD PREDICTOR OF HEALING OF ULCER AND AMPUTATION SITES
SKIN PERFUSION PRESSURE OF 21 MM HG OR ABOVE FOUND TO CORRELATE WITH HEALING AND DECREASED COMPLICATION RATE OF THE AMPUTATION SITE
PULSE VOLUME RECORDER
SEGMENTAL PLETHYSMOGRAPH IS USED
CHANGES IN EXTREMITY OR DIGIT VOLUME THAT TAKES PLACE IN RESPONSE TO ARTERIAL PULSATION IS MEASURED
PULSE CONTOUR
NORMAL WAVEPEAKEDBRISK
ANACROTIC AND DICROTIC DEFLECTIONS
DICROTIC NOTCH
ABNORMAL WAVEFLATTENED WAVEABSENCE OF
DICROTIC NOTCHREDUCED
ANACROTIC / DICROTIC COMPONENTS
PULSE AMPLITUDE
ARTERIAL OCCLUSIVE DISEASE IS MARKED BY DECREASE IN AMPLITUDE OF THE PULSE WAVE FORMAMPLITUDE < 15 MM - FOOT PAIN LIKELY ISCHEMICAMPLITUDE < 5 MM - FOOT ULCER UNLIKELY TO HEAL
TRANSCUTANEOUS OXYGEN TENSION (TCPO2)
MODIFIED CLARK ELECTRODE THAT MEASURES PARTIAL PRESURE OF O2 THAT DIFFUSES THROUGH SKIN
GOOD ULCER HEALING IF TCPO2 > 35 - 40 MM HG
POOR ULCER HEALING IF TCPO2 < 20 - 26 MM HG
LASER DOPPLER FLUX
ALSO CALLED VELOCIMETRY
PROVIDES A DIRECT & CONTINUOUS MEASUREMENT OF SKIN CAPILLARY BLOOD FLOW VELOCITY
SENSITIVITY LESS THAN TCPO2
ISOTOPE CLEARANCE
133XE GAS ISOTOPE TO MEASURE SKIN BLOOD FLOW
FLOW RATES ABOVE 2.6 ML / 100 GM TISSUE CORRELATED WITH GOOD HEALING
DUPLEX SCANNING
COMBINATION OF REAL TIME B MODE SONOGRAPHY AND A PULSE DOPPLERALLOWS 2-D VISUALIZATION OF BLOOD VESSEL WITH SURROUNDING TISSUESDETECTS CALCIFIED PLAQUE, ULCER, THROMBI, ANEURYSMS
COLOUR FLOW DOPPLER
DISPLAY OF FLOW IN VESSELS IN DIFFERENT COLOURS DEPENDING ON DIRECTION OF FLOW
ACCURACY OF 77% - 97%
TIME-CONSUMING AND NEEDS SKILL
MAGNETIC RESONANCE IMAGING
3-D RECONSTRUCTION OF VESSELS POSSIBLE
LUMINAL NARROWING, CALCIFIED PLAQUES AND THROMBI CAN BE DETECTED
MR ANGIOGRAPHY - ROLE BEING STUDIED
ARTERIOGRAPHY
INDICATIONS INCLUDEDISABLING CLAUDICATION ISCHEMIC REST PAIN ICHEMIC ULCERATION ISCHEMIC GANGRENE
DIGITAL SUBSTRACTION ANGIOGRAPHY
ADVANTAGES OVER ROUTINE ARTERIOGRAPHYHIGH CONTRAST RESOLUTION IMPROVED ARTERIAL VISUALIZATIONLESS REQUIREMENT OF THE
RADIOCONTRAST DYEREDUCED COST OF EXAMINATION
VASCULAR EVALUATION - INDIAN CONTEXT
AT PRIMARY HEALTH CARE LEVEL, CLINICAL EVALUATION OF UTMOST IMPORTANCE“ALWAYS INSPECT THE FOOT OF A DIABETIC PATIENT”PALPATE FOR THE PULSE - DORSALIS PEDIS, POSTERIOR TIBIALIDENTIFY & REFER A HIGH-RISK FOOT TO NEAREST TERTIARY CARE CENTRE
VASCULAR EVALUATION AT AN INDIAN TERTIARY
CARE CENTRETHOROUGH CLINICAL EVALUATION
ABI WITH DOPPLER ESSENTIAL AND AFFORDABLE
INTEGRATED APPROACH- TO LOOK FOR OTHER RISK FACTORS
LABORATORY EVALUATION OF NERVE FUNCTION
TESTS OF SENSORY FUNCTION
TESTS OF AUTONOMIC FUNCTION
TESTS OF SENSORY FUNCTION
VIBRATION PERCEPTION THRESHOLD128 HZ TUNING FORKREIDELL-SEIFFER GRADUATED
TUNING FORKBIOTHESIOMETERVIBRAMETER
TESTS OF SENSORY FUNCTION (CONTD)
LIGHT TOUCH SENSATIONVON FREY HORSE HAIRNYLON MONOFILAMENTS
THERMAL THESHOLDSMARSTOCK STIMULATORMEDELECSENSORTEKTHERMOTEST
TESTS OF AUTONOMIC FUNCTION
CARDIOVASCULAR TESTS
TESTS OF OTHER SYSTEMSGISWEATPUPILLARYNEURENDOCRINE
NERVE FUNCTION EVALUATION- INDIAN
PERSPECTIVEAT PHC LEVEL, CLINICAL EVALUATION OF LIGHT TOUCH WITH COTTON HAIR VIBRATION WITH TUNING FORK AND TEMP WITH WARM / COLD WATERAT TERTIARY CENTRES, BIOTHESIOMETRY AFFORDABLE AS ALSO NYLON MONOFILAMENTSFOR AUTONOMIC NEUROPATHY, CARDIOVASCULAR TESTS WELL DESCRIBED & EASY TO PERFORM
CARDIOVASCULAR TESTS FOR AUTONOMIC
NEUROPATHYHR RESPONSE TO VALSALVA MANOEUVREHR RESPONSE TO STANDING UPHR RESPONSE TO DEEP BREATHINGBP RESPONSE TO STANDING UPBP RESPONSE TO SUSTAINED HAND-GRIP
NORMAL AND ABNORMAL VALUES OF AUTONOMIC
FUNCTION TESTINGTEST NORMAL BORDER ABNORMAL
LINEVALSALVA 1.2 1.11-1.2 <1.1
RATIOHR VARIATION WITH
DEEP BREATHING 15/MIN 11-14/MIN <10/MINHR RESPONSE TO
STANDING 1.04 1.01-1.03 <1.0BP FALL ON STANDING 10 MMHG 11-29MMHG >30MMHGBP TO HANDGRIP 16MMHG 11-15MMHG <10MMHG
AUTONOMIC Fn TESTS…
CARDIOVASCULAR TESTS EASY TO PERFORMNEEDS ONLY ECG, SPHYGMOMANOMETERCOMPLICATED TESTS LIKE 24 HOUR HR VARIABILITY etc ONLY FOR ADVANCED RESEARCH, AND PRACTICAL UTILITY LIMITED
INTERPRETATION
NORMAL - ALL FIVE NORMAL / 1 BORDERLINE
EARLY- ONE OF 3 HR TESTS ABNORMAL/ 2 BORDERLINE
DEFINITE- > 2 HR TESTS ABNORMAL
SEVERE- + > 1 BP TESTS ABNORMAL / BOTH BORDERLINE
ATYPICAL- ANY OTHER COMBINATION
ASSESSMENT OF FOOT PRESSURES
SIMPLE FOOT PRESSURE PADS
SOPHISTICATED PEDOBAROGRAPHY
F.SCAN MAT SYSTEMS
AFFORDABLE INDIAN ALTERNATIVES
PEDOBAROGRAPHY & F. SCAN MAT SYSTEMS NOT FEASIBLE IN MOST INDIAN HOSPITALSREASONABLE, AFFORDABLE ALTERNATIVES INCLUDEHARRIS MAT INKPAD SYSTEMVIEW BOX
HARRIS MAT
PATIENT STEPS ON AN INKED MAT
WALKS ON A LONG SHEET OF PAPER
FOOTPRINTS ANALYZED WITH RESPECT TO PRESSURE POINTS
INKPAD SYSTEM
LARGE INKPAD WITH A PLASTIC COVER ON TOP TO PREVENT STAINING OF PATIENT’S FOOTFACILITY TO INSERT A PLAIN PAPER BELOW THE INKPADPRESSURE BY PATIENT’S FOOT IS TRANSMITTED TO THE PAPER AND A FOOTPRINT OBTAINED
VIEW BOX
A VIEW BOX WITH A PLAIN GLASS ABOVE AND A MIRROR BELOW
A TUBE-LIGHT IS PLACED IN THE BOX FOR ILLUMINATION
WHEN THE PATIENT STANDS ON THE TOP, THE REFLECTION IN THE MIRROR CAN BE EASILY EXAMINED AND PRESSURE POINTS VISUALIZED
OTHER LABORATORY TESTS
BLOOD GLUCOSE LEVELS, GLYCATED HEMOGLOBINTBA METHOD IN MOST INDIAN
SETTINGSCOMPLICATED METHODS OF
ASSESSMENT NOT AVAILABLE/AFFORDABLE
Lab tests…
MICROPROTEINURIAPOSITIVE CORRELATION WITH PVD ‘SIGMA CHROMOGEN BLUE’ USED
COMMONLY FOR ESTIMATIONCOMPLEX TESTS LIKE MICRO-
ALBUMINURIA, RIA, ELISA NOT AVAILABLE EVEN AT MOST TERTIARY CARE CENTRES IN INDIA
MANAGEMENT
MULTI-DISCIPLINARY APPROACH ADVOCATED IN THE WEST
TEAM CONSISTS OF PHYSICIAN SURGEON PODIATRIST SPECIALIST NURSE ORTHOTIST RADIOLOGIST
IN INDIA
THE PRIMARY CARE DOCTOR IS THE ONLY HELP AVAILABLEORTHOTIST, PODIATRIST, SPECIALIST NURSE ALL EXTREMELY SCARCETHEREFORE, BASIC ASPECTS OF ALL THESE FIELDS NEED TO BE KNOWN BY EVERY PHYSICIAN
SIX ASPECTS OF PATIENT TREATMENT
WOUND CONTROL
MICROBIOLOGICAL CONTROL
MECHANICAL CONTROL
VASCULAR CONTROL
METABOLIC CONTROL
EDUCATIONAL CONTROL
WOUND CONTROL
DEBRIDEMENTREMOVES CALLUS & REDUCES
PLANTAR PRESSURESTRUE DIMENSIONS OF ULCERS CAN
BE MEASUREDDRAINAGE OF EXUDATEENABLES DEEP SWAB FOR CULTURECONVERTS CHRONIC WOUND TO
ACUTE WOUND
SKIN GRAFT
DRESSINGSDAILYSHOULD BE EASY TO LIFT FOOTGOOD EXUDATE CONTROL
DRESSINGS - TYPES
FILMSCLEAR, WOUND INSPECTION EASY
FOAMCUSHIONING EFFECT
HYDROCOLLOIDSPATIENTS CAN BATHE
ALGINATESUSEFUL FOR PACKING DEEP WOUNDS
MICROBIOLOGICAL CONTROL
NO UNIFORM AGREEMENT ON ANTIBIOTIC POLICY
CLOXACILLIN + 3RD GEN CEPHALOSPORINS COMMONLY USED
CIPROFLOXACIN + CLOX - ANOTHER USEFUL COMBINATION
IN NEURO-ISCHEMIC ULCERS, MORE AGGRESSIVE ANTIBIOTIC THERAPY REQUIRED AS COMPARED TO PURE NEUROPATHIC ULCERS
SEARCH AGGRESSIVELY FOR OSTEOMYELITIS
MECHANICAL CONTROL
CORRECT FOOTWEAR
TENDING TO MINOR FOOT PROBLEMS ONYCHOGYPHOSIS (MONSTER NAIL) ONYCHOCRYPTOSIS (INGROWING TOE NAIL) ONYCHOMYCOSIS TINEA PEDIS CORNS, ETC
TREATMENT OF DEFORMITY & CALLUSREDISTRIBUTION OF PLANTAR PRESSURES IN NEUROPATHIC FOOTTEMPORARY OFF-LOADING THE SITE OF ULCERUSE OF CASTS AIRCAST (WALKING BRACE) TOTAL-CONTACT CAST SCOTCHCAST BOOT
VASCULAR CONTROL
CAREFUL CLINICAL EXAMINATION MANDATORY
SUPPLEMENTED BY ABI
ANGIOPLASTY / BYPASS IN NON-HEALING ULCERS WITH DOCUMENTED ARTERIAL STENOSIS
METABOLIC CONTROL
POOR GLYCEMIC CONTROLDELAYED HEALING IMMUNE SUPPRESSION IMPAIRED RESPONSE TO INFECTION
LOOK FOR OTHER ASSOCIATED METABOLIC PROBLEMSHT, UREMIA, ACIDOSIS, ETC
EDUCATIONAL CONTROL
CONTINUOUS EDUCATION OF PATIENT ESSENTIAL
INFORMATION ACCORDING TO STAGE
ENSURES PATIENT CO-OPERATION & COMPLIANCE
LIST OF SIMPLE DOS AND DON’TS
DO
WASH FEET DAILY WITH MILD SOAP & WATERCHECK FEET DAILYSEEK URGENT TREATMENT OF ANY PROBLEMSWEAR SENSIBLE SHOESCHECK SHOES INSIDE AND OUTSIDE BEFORE WEARING
Do…
HAVE FEET MEASURED WHEN BUYING SHOES
BUY LACE-UP SHOES WITH PLENTY OF ROOM FOR TOES
KEEP FEET AWAY FROM HEAT
SIT INSTEAD OF STANDING
CHANGE SOCKS FREQUENTLY
DONT
USE CORN CURES
USE HOT-WATER BOTTLES
WALK BAREFOOT
CUT CORNS OR CALLUSES BY YOURSELF
DELAY IN SEEKING HELP FOR ANY PROBLEM
MANAGEMENT PROBLEMS IN INDIA
POOR PATIENT AWARENESS
DELAYED SEEKING OF HEALTH CAREPOVERTY, LACK OF
AWARENESS/NEARBY FACILITIES
CULTURAL BELIEFS
INJURY PRONE FOOTDIVERSE CAUSES
RAT-BITE, INSECT BITE, ETC INJURY DURING AGRICULTURE/MANUAL
LABOUR
LACK OF SUFFICIENT FACILITIES
LACK OF TRAINED PERSONNEL
COST
SOME SOLUTIONS
EDUCATIONPRIMARY CARE PHYSICIANPATIENT
INNOVATE PRAGMATICALLY, EG:-WASHED X-RAY FILM FOR ULCER
MEASUREMENT INKPAD FOR FOOT PRESSURE
ASSESSMENT
HONING OF CLINICAL SKILLS
EARLY IDENTIFICATION OF ‘HIGH RISK’ FOOT BY SCREENING EVERY DIABETIC
FOOTWEAR FOR INDIA AVOID BLACK COL (ASSO. WITH HANSEN’S) APPROPRIATE LOCALLY AVAILABLE
MATERIAL TAKING PATIENT INTO CONFIDENCE
DANGER SIGNS - FOR PATIENT AWARENESS
TO SEEK MEDICAL HELP IFSWELLINGCOLOUR CHANGEPAIN / THROBBINGTHICK HARD SKIN OR CORNSBREAKS IN THE SKIN, INCLUDING
CRACKS, BLISTERS OR SORES
ORGANIZING DIABETIC FOOT CLINIC
IDENTIFY DIAB ETIC FOOT AT RISK INSPECTIONPALPATE FOOT PULSEANKLE JERK
CLASSIFY & STAGE
CALLUS REMOVAL
CONTROL
BARE MINIMUM INSTRUMENTATION
SEMMES - WEINSTEIN MONOFILAMENT
BIOTHESIOMETER
POCKET DOPPLER
INKPAD
CONCLUSIONS
DIABETIC FOOT - A WIDELY PREVALENT & COSTLY COMPLICATION OF DIABETES
CLINICAL EXAMINATION OF FOOT - A MUST IN EVERY DIABETIC PATIENT
SUPPLEMENTED BY LAB EVALUATION FOR VASCULAR, NEUROLOGIC AND MECHANICAL STATUS
Conclusions…
APPROPRIATE MULTI-DISCIPLINARY MANAGEMENT BASED ON STAGING
MUCH WORK LEFT TO BE DONE IN INDIA FOR RECOGNITION, EVALUATION AND TREATMENT OF DIABETIC FOOT
India—Dr.Paul Brandt &TCC
PB while working at CMC amongst leprosy patients saw TCC
Transformed same exp. to diabetic foot Mx.
To day TCC is universaly accepted for Neuropathic Diabetic Foot Ulcer
Evaluation of Sensory Function
Large Fibre Function
Vibration Perception Threshhold
Indian Biosthesiometer
Rs. 25,000 vs Rs. 50,000
Local Simmes Weinstein monofilament
QST…
Assessment of small fibre function
Heat & Cold sensation
Heat Pain & Cold pain sensation
Marstock Stimulator
Thermal Discrimination Threshold measurement
Indian Equipment
Rs.2,00,000 vs Rs. 50,000
Net Working
