interventions for endocrine. diabetes mellitus patient education patient and family education...

Interventions for Endocrine

Diabetes Mellitus

Patient Education

Patient and family education assumes a primary role in prevention• Blood Glucose Levels• Effects of exercise on blood glucose levels• Stress Management• Exercise logs• Proper foot ware and skin care• Vitals • Self monitoring Heart rate / BP• Perceived exertion

• Weight management

Blood Glucose Levels

Fasting blood glucose levels Normal <110 mg/dL Unsafe for exercise

Do not exercise if blood glucose is over 240 and Ketones (sign of fat metabolism) are present

Hemoglobin A1c Normal < 6.5%

Ketones Urinary ketone testing is important in patients

with type 1 diabetes Test strips are available at pharmacies

Estimated Average Glucose (eAG)

• Estimated Average Glucose (eAG) is a new way for patients to understand how well they are managing diabetes.

• Reduction of A1c by 1% = 10% reduction in relative risk of microvascular complications from DM

Self Monitoring of Blood Glucose (SMBG)

Self-monitoring of blood glucose (SMBG) is an important component to the control diabetes

SMBG has been recommended for people with diabetes in order to achieve a specific level of glycemic control and to prevent hypoglycemia

SMBG has become a standard of care in the management of diabetes.

Self monitoring of Blood Glucose (SMBG)

SMBG can aid in diabetes control by: Development of an individualized blood glucose

profile SMBG data can be helpful in creating or modifying the

diabetes management regimen Giving people with diabetes and their families

the ability to make appropriate day-to-day treatment choices in diet and physical activity as well as in insulin or other agents

Improving patients’ recognition of hypoglycemia or severe hyperglycemia

Enhancing patient education and patient empowerment regarding the effects of lifestyle and pharmaceutical intervention on glycemic control.

Performing Self-Monitoring of Blood Glucose (SMBG) by Diabetes Type

Type-1 diabetes Perform SMBG three or more times per day. Adjust intensity of monitoring to intensity of insulin

therapy. Perform SMBG three or more times every day

when multiple doses of insulin are administered every day.

Type-2 diabetes The exact frequency is undetermined. Perform SMBG at a sufficient rate to reach glucose

goals. If taking insulin therapy, perform SMBG three or

more times each day.Gestational diabetes mellitus

Perform SMBG three or more times each day. Data from the American Diabetes Association;3 DiPiro JT, et al., 2002;6and Mooradian AD, et al., 1998.8

Symptoms of Hypoglycemia

• Shakiness • Dizziness • Sweating • Hunger • Headache • Pale skin color • Sudden moodiness or behavior changes, such

as crying for no apparent reason • Clumsy or jerky movements • Seizure • Difficulty paying attention, or confusion • Tingling sensations around the mouth

Hypoglycemia Treatment

• The quickest way to raise blood glucose and treat hypoglycemia is with some form of sugar.

• Once you've checked blood glucose and treated hypoglycemia, wait 15 or 20 minutes and check blood glucose again.

• If blood glucose is still low and symptoms of hypoglycemia don't go away, repeat the treatment.

• Encourage the patient to eat your regular meals and snacks as planned to keep their blood glucose level up.

• If the patient passes out, get immediate medical attention.

Hypoglycemia Treatment

• Many people with diabetes like to carry glucose tablets. • Other sources of sugar or simple carbohydrates also work

well to treat hypoglycemia, such as fruit juice, hard candies, pretzels or crackers. • The important thing is to get at least 15-20 grams of sugars or

carbohydrates. • To treat hypoglycemia you should stick with something that

is mostly sugar or carbohydrates. • Foods that have a lot of fat as well as sugars and

carbohydrates, such as chocolate or cookies, do not work as quickly to raise blood glucose levels.

• Foods with 15 grams carbohydrates:– 4 oz (1/2 cup) of juice or regular soda– 2 tablespoons of raisins– 4 or 5 saltine crackers– 4 teaspoons of sugar– 1 tablespoon of honey or corn syrup

Hyperglycemia

• Hyperglycemia is the term for high blood glucose, happens when the body has too little insulin or when the body can't use insulin properly.

• A major cause of complications with diabetes • Hyperglycemia happens from time to time to all

people who have diabetes. • Learn to identify the symptoms of hyperglycemia

so you can treat it quickly. • When high, patients can lower blood glucose

level by exercising, unless ketones are present in your urine.

What causes hyperglycemia?

• Type 1: Patient may not have given themself enough insulin.

• Type 2: Their body may have enough insulin, but it is not as effective as it should be.

• Patient ate more than planned or exercised less than planned.

• Stress from an illness, such as a cold or flu. • Other stress, such as family conflicts or work

or financial stress

Signs and Symptoms of Hyperglycemia

High blood glucose High levels of sugar in the urine Frequent urination Increased thirst

Ketoacidosis

• If you fail to treat hyperglycemia, ketoacidosis (diabetic coma) could occur.

• Ketoacidosis develops when the body doesn't have enough insulin. Without insulin, the body can't use glucose so the body breaks down fats to use for energy.• When the body breaks down fats, waste products called ketones

are produced. • The body cannot tolerate large amounts of ketones and

will try to get rid of them through the urine. Unfortunately, the body cannot release all the ketones and they build up in the blood, which can lead to ketoacidosis.

• Ketoacidosis is life-threatening and needs immediate treatment. Symptoms include:– Shortness of breath – Breath that smells fruity – Nausea and vomiting – Very dry mouth

Effects of exercise on blood glucose levels

Chronic hyperglycemia in both type 1 and 2 DM is considered to be a significant factor in the development of microvascular complications

Exercise improves glucose uptake and exercise training was shown to decrease insulin requirements.

Exercise increases sensitivity to insulin although mechanism is not well understood

Evidence

Investigation of effect on glycosylated hemoglobin, blood pressure, and body mass index of diabetes intensive education program in patients with type 2 diabetes mellitus Beyazit E, Mallaoglu M Am J Mens Health 2011; 5(4): 351-357

A Diabetes Intensive Education Program in Patients (DIEP) intervention program improved

systolic and diastolic blood pressure and glycemic control through patient self-management education, establishment of an individualized care plan, behavioral goal setting, and close surveillance of patients.

In this study, A1C levels decreased by 2% in the intervention group as compared with 0.1% in the control group.

Stress Management

Stress affects blood glucose levels A body under stress reacts by pumping stress

hormones into the blood. such as cortisol & norepinephrine

The hormones make the body release stored glucose and fat so the body has extra energy

The extra glucose can only be used if there is enough insulin

Stress hormones also effect the body’s ability to use insulin

Stress Management Basics

You can’t control stress only your reaction to stress

Concentrate on how you react!Deal with today, not yesterday or tomorrowListen to musicExerciseGet good restWrite in journalLearn to say no!Laugh

Exercise Logs

Patients should keep logs of the following when starting a new exercise program. Include: Blood glucose Ketones present Blood pressure Resting HR Exercise HR Perceived exertion Exercise time / distance

Date

Blood Glucose

Ketones present?

Blood pressure

Resting Heart rate

Exercise Heart rate

Perceived exertion

Exercise timeExercise mode

Exercise Log for ___________

Vitals

Blood Pressure At every visit Goal < 130/80

Heart rate Teaching patients how to monitor HR

○ Resting○ After warm up○ During exercise○ After exercise○ 5 minutes after completing

Self Monitoring

Blood pressure cuffs Automated

Heart rate monitors

Ratings of Perceived Exertion

RPE0

0.512345678910

Intensity LevelNothingVery, Very weakVery weakWeak (light)ModerateSomewhat strongStrong

Very strong

Very, very strong

Skin Care and Foot Ware

Wear shoes / footwear Inspect your skinTake care of your skinCheck your shoesSee health care provider

Inspect your skin

Look at your feet everyday Including bottoms of

feet and between toes Mirrors Magnifying glass Family members / CG

Look out for these things on your feet Blisters Sores Corns Calluses Red spots Swelling Drainage from sore Broken toenails Cracked skin Odor Pain

Diabetic Mirror Inspection Light with PolyCarbonate MirrorDiabetic Mirror Inspection Light with PolyCarbonate Mirror

Take Care of Your Skin

Wash feet gently everydayDry feet wellLotions to soften dry skin (non alcohol based)Never treat corns, calluses or toe nails with sharp

instrumentsCut toenails straight acrossPadding / air circulationClean white socksDo not walk barefootNo heating pad to warm feet

Check your Shoes

Check every day before you put them onCheck size and widthDo not wear old worn out shoes or socksShop in afternoonBreak in new shoes gradually

See Health Care Provider

Get blood glucose under controlKeep regular appointments with DoctorCall your health care provider immediately if

you find a wound on your foot

American Diabetes Association, Clinical Practice Recommendations, 2011

• The physician should evaluate blood glucose control and disease complications.

• The patient with diabetes (type 1 or 2) should have the following: • An annual retinal eye exam. • Glycemic control: The A1C goal for patients in general is an A1C goal of <7%. A Hemoglobin A1C (HbA1c) test two times a year if stable glycemic control; quarterly in patients whose therapy has changed or who are not meeting glycemic goals. • An annual LDL-C screening performed, with a goal of <100mg/dl as the primary goal of therapy for adults. Very high-risk patients, LDL <70mg/dl. • Nephropathy screening should be performed annually to test for the presence of microalbuminuria in type 1 diabetic patients with diabetes duration of 5 years and in all type 2 diabetic patients, starting at diagnosis and during pregnancy.

Weight Management

BMI Classification 18.5 or less Underweight 18.5 to 24.99 Normal Weight 25 to 29.99 Overweight 30 to 34.99 Obesity (Class 1) 35 to 39.99 Obesity (Class 2) 40 or greater Morbid Obesity

Weight ManagementFor overweight patients, losing as little as

7-10 percent of body weight may improve many of the problems linked to being overweight, such as high blood pressure and diabetes.

Slow and steady weight loss of no more than 1-2 pounds per week is the safest way to lose weight. Too rapid weight loss can cause muscle loss rather

than fat. It also increases the chances of developing other problems, such as gallstones and nutrient deficiencies.

Making long-term changes in eating and physical activity habits is the only way to lose weight and keep it off!

Nutrition

Goals of nutrition education in diabetes management: To achieve and sustain blood glucose Blood pressure levels as near normal Maintain a lipid profile that decreases the risk for

developing CVD Prevent chronic complications Address individual nutrition needs Maintain the pleasure of eating

Referral to Register Dietitian

Nutrition Carbohydrates

Promoting healthful, quality carbohydrate sources such as whole grains, fruit, vegetables, and low-fat or non-fat dairy, rather than highly processed foods and sweets, makes good nutritional sense.

Using sweets and sugars in moderation is recommended, especially for individuals who need to lose weight

Nutrition Fats

Choose leaner meats Eat foods containing water-soluble fiber,

oatmeal or other whole grain oat cereal, dried beans, fruit, and vegetables

Use less added sauces and gravies Choose olive or canola oil, or trans fat– free,

soft tub margarines in place of solid spreads or butter.

Eat fish twice a week. Choose nonfat milk, 1% rather than 2% milk,

or whole milk.

Therapeutic Exercises

StrengtheningAerobicGraded Exercise Test

Where to start

Warm up and cool down period

Proper foot wareDiabetes identity braceletHydration is important to prevent elevation in

blood glucose and abnormal heart function

Benefits of Exercise

Decreases the risk factors for CADImproves lipid profileDecrease Blood pressureMay decrease body weight and body fat (esp.

intra-abdominal fat)Help prevent or delay the onset of type 2

diabetes

EXERCISE INTENSITY 41

Intensity of exercise can be summarized as follows: Light Intensity is 40-59% of max HR reserve.

This range is reserved for those starting an exercise program after years of inactivity.

Moderate Intensity is 60-74% of max HR reserve. This is the normal range for most people.

High or Vigorous Intensity is 75% and higher of the Max HR reserve. This level of effort is for athletes desiring a high

level of fitness.

What is maximum HR reserve?42

• Heart rate reserve (HRR) is a term used to describe the difference between a person's measured or predicted maximum heart rate and resting heart rate.

• A more accurate target heart rate zone using Karvonen Formula: • THR = ((HRmax − HRrest) × % intensity) + HRrest

Maximum HR Example43

43 year old 220-43=177 (max HR)177 x .50 = 88 (light intensity)177 x .70 = 124 (moderate intensity)177 x .90 = 159 (high intensity)

Maximum HR Reserve Example44

43 year old with a resting heart rate of 68220-43=177 (max HR)177-68= 109 (HR reserve)109 x .50 + 68 =122 (light intensity)109 x .70 + 68 = 144 (moderate intensity)109 x .90 + 68 = 166 (high intensity)

Training Heart Rate Zone45

Exercise programs – Type 2 DM

3-5 days per weekFor the majority of type 2 DM, low to

moderate intensity (40-70% VO2 max)Minimum of 10-15 minutes each session with

goal of 60 minutesRisk and complication:

Acute Glycemic responses

Exercise and DM

IntensityIntensity HRHRmaxmax RPERPE

Very lightVery light <35<35 0-10-1

LightLight 35-5435-54 22

ModerateModerate 55-6955-69 33

HardHard 70-8970-89 4-64-6

Very HardVery Hard >90>90 7-87-8

MaximalMaximal 100100 9-109-10

Evidence

The effect of combined resistance and home-based walking exercise in type 2 diabetes patients Aylin K, Arzu D, Sabri S, Hadan TE, Ridvan A Int J

Diabetes Dev Ctries 2009; 29(4): 159-165

27 men and 11 women; The mean age of the participants was 54.3

years Exercise training that includes resistance training and

home-based walking could be safe, effective, and beneficial for patients with diabetes

Evidence

High-intensity resistance training improves glycemic control in older patients with type 2 diabetes Dunstan DW, Daly RM, Owen N, Jolley D, De Courten M, Shaw J,

Zimmet P Diabetes Care 2002; 25(10): 1729-1736

36 participantsTreatment Group 1 : High-intensity progressive

resistance training Treatment Group 2 : Control program (flexibility

exercise) This study demonstrated that a high-intensity resistance training

program was safe and well tolerated by older patients with type 2 diabetes and was effective in improving glycemic control and muscle strength

Evidence

The acute effects of in-patient physiotherapy program on functional capacity in type II diabetes mellitus Ozdirenc M, Kocak G, Guntekin R Diabetes Res Clin Pract 2004; 64(3): 167-172

Inclusion Criteria: Type II diabetes due to poor glycemic control, cardiac events, and/or foot

problems.

44 participants Treatment Group 1 : Exercise rehabilitation group. Control/Referent Group R : Non-exercise control group. Results:

Systolic and diastolic blood pressure decreased significantly in the exercise group, but not the control.

Distance walked during the 6-minute walk test increased significantly more in the exercise group then in the control group.

Estimated VO2max increased more in the exercise group

Acute Glycemic Response

Moderate intensity exercise increases glucose uptake by 2-3 mg/kg/min above usual requirements Replenish glycogen stores after exercise

To prevent hypoglycemia Time exercise to medication Good nutrition Glucose monitoring before and after exercise

Exercise Programs – Type 1 DM

Metabolic control before exercise AVOID exercise if fasting glucose > 240 mg/dl

and/or ketones are present Ingest CHO if glucose is < 100 mg/dl

Glucose monitoring before and after exercise May need to adjust insulin and/or food intake

Food intake Add CHO to avoid hypoglycemia Have CHO rich foods available during and after

exercise

Gait Training

Foot ware Diabetic shoes

Often wider and deeper to allow orthotics which are custom made

Diabetic socks Extend to the knee and provide firm support Well padded Absorb moisture

Devices Walkers, canes, crutches

Balance Diabetic patients walk slower, with greater step

variability, and present higher plantar pressure than healthy controls

Stairs

Evidence

The gait and balance of patients with diabetes can be improved: a randomised controlled trial Allet L, Armand S, de Bie RA, Golay A, Monnin D, Aminian K, Staal JB,

de Bruin ED Diabetologia 2010; 53(3): 458-466

Type 2 diabetes and a clinical neuropathy. Clinical neuropathy was evaluated with a tuning fork on a 9 point scale. The average score for the intervention group was 3.23 and

the average score for the control group was 3.32

71 participants The gait speed and balance of diabetic patients with a vibration

perception of less than or equal to 4 can be improved with exercise intervention

Diabetic Neuropathy

Patient Education

Comprehensive foot care instructions Reduce amputations by 45-85%

Decrease weight bearing stressesDiabetic education

Diabetic Foot Prevention Program

Podiatric Care Regular visits, examinations,

and footcare Risk assessment Early detection and

aggressive treatment of new lesions


• Protective Shoes – Adequate room to protect from

injury; well cushioned walking sneakers, extra depth, custom-molded shoes

– special modifications as necessary.


• Pressure Reduction – Cushioned insoles, custom

orthoses, padded hosiery – pressure measurements

Computerized or Harris mat


Prophylactic Surgery Correct structural deformities

Hammertoes Bunions Charcot

Prevent recurrent ulcers over deformities

Intervene at opportune time


• Preventive Education – Patient education – need for daily

inspection and necessity for early intervention

– Physician education – significance of foot lesions, importance of regular foot examination, and current concepts of diabetic foot management

Modalities

PrecautionsHeat/ice over areas of decreased sensation

Anodyne Therapy

Utilizes near infrared light to precipitate the release nitric oxide (NO) from hemoglobin and endothelial cells

Nitric oxide activates enzymes which cause vasodilatation.

Used for diabetic neuropathic pain and may benefit hypoxic wounds.

http://mhhs.woundcenter.net/2005_SAWC_anodyne_case_report.pdf

Anodyne Therapy

Anodyne® Infrared Therapy Systems are medical devices that are indicated to increase circulation and reduce pain, stiffness, and muscle spasm

Anodyne therapy comes from the word anodyne, meaning a medical treatment that soothes or relieves pain. Anodyne therapy was first used in 1994.

Anodyne Therapy

Anodyne therapy is now being investigated for a number of uses, including diabetic neuropathy

All forms of Anodyne therapy use infrared light. Pads that emit the light are applied to the surface of the skin.

At times, Anodyne therapy will resolve symptoms in one or only a few sessions. For other individuals, however, ongoing Anodyne therapy may be necessary to experience relief from symptoms.

Evidence

Does anodyne light therapy improve peripheral neuropathy in diabetes? A double-blind, sham-controlled, randomized trial to evaluate monochromatic infrared photoenergy Lavery LA, Murdoch DP, Williams J, Lavery DC

Diabetes Care 2008; 31(2): 316-321

The authors concluded that there was no statistical evidence that anodyne therapy was effective in improving sensory perception compared with the sham treatment

Evidence

Reversal of diabetic peripheral neuropathy with phototherapy (MIRE) decreases falls and the fear of falling and improves activities of daily living in seniors Powell MW, Carnegie DH, Burke TJ Age Ageing 2006;

35(1): 11-16

Reversal of peripheral neuropathy and use of monochromatic near-infrared phototherapy (MIRE) at home contributed to a 78% decrease in falls, a 79% decrease in balance-related fear of falling, and a 72% increase in ADL

Evidence

The effect of monochromatic infrared energy on sensation in patients with diabetic peripheral neuropathy: a double-blind, placebo-controlled study Clifft JK, Kasser RJ, Newton TS, Bush AJ Diabetes

Care 2005; 28(12): 2896-2900

No significant difference was found between active and placebo monochromatic infrared energy in improving plantar sensation in patients with diabetic peripheral neuropathy

Evidence

Improvement of sensory impairment in patients with peripheral neuropathy Prendergast JJ, Miranda G, Sanchez M Endocr Pract 2004; 10(1): 24-30

21 patients with a diagnosis of diabetic peripheral neuropathy, 6 patients with neuropathy attributable to non-diabetic causes

All subjects received 10 forty-minute treatments of Anodyne Therapy over a two week time period. Anodyne treatments consisted of near infrared photoenergy (890 nm) that was pulsed at 292 times per second with a 50% duty cycle. Power density was 8 mW/cm2 with average power per pad at 480 mW.

Anodyne therapy treatments significantly improve sensory impairment associated with peripheral neuropathy

Evidence

Improved sensitivity in patients with peripheral neuropathy: effects of monochromatic infrared photo energy DeLellis SL, Carnegie DH, Burke TJ J Am Podiatr

Med Assoc. 2005; 95(2): 143-147

The authors state that treatment with the monochromatic infrared photo energy (MIRE) was associated with improved foot sensation to the 5.07 Semmes-Weinstein monofilament in 1047 patients that were initially diagnosed with peripheral neuropathy.

Evidence

Restoration of sensation, reduced pain, and improved balance in subjects with diabetic peripheral neuropathy: a double-blind, randomized, placebo-controlled study with monochromatic near-infrared treatment Leonard DR, Farooqi MH, Myers S Diabetes Care

2004; 27(1): 168-172

Anodyne Therapy System treatments in subjects who have not progressed to profound sensory loss may result in at least temporary restoration of protective function.

Therapeutic Exercises

StrengtheningAerobicBalance

Precaution / ContraindicatedPrecaution / Contraindicated

Recommended ExercisesRecommended Exercises

Treadmill Prolonged walking Jogging Step exercises

Swimming Bicycling Rowing Chair exercises Arm exercises Other NWB exercise

Exercise with Peripheral Neuropathy

Gait Training

Off loadingAssistive devices

Crutches Cane

Orthotics Removable walker Charcot Restraint Orthotic Walker Half shoes Healing shoes Foot orthoses / shoe inserts

Effective for reducing peak plantar pressure under the MT heads

Good for prevention

Removable Walker

Padded removable AFO that immobilizes the ankle Has a rocker sole Includes pressure relieving insole Patient wears while walking Able to remove to inspect wound

Half Shoes

Wedges sole that ends proximal to the metatarsal heads

Places the ankle in a small amount of dorsiflexion to relieve MT head pressure

Eliminating toe offNot as effective as Removable WalkerNot effective with heel cord contractures

Healing Shoes

Post-op shoesNot recommended

while wound is still healing

Removable pressure relief insoles

Diabetes and Peripheral Neuropathy

30% of people with diabetes have some decreased sensation in their feet

Diabetic neuropathy impairs the motor and sensory function of the involved peripheral nerves

Impaired motor function Impaired muscle imbalances and can lead to foot

deformities Increased pressure under the metatarsal heads

Most common site for ulcerations

Impaired protective sensation Ulcers can develop due to repetitive microtrauma

Hammertoes

Deformity of the second, third or fourth toes. The toe is bent at the PIP, so that it resembles a

hammer. Hammertoes have flexion deformities of the PIP joint, and flexible MP

and DIP joints

Initially, hammertoes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.

People with hammertoe may have corns or calluses on the top PIP of that toe or on the tip of the toe.

They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.

Hammertoes Treatment

Conservative treatment starts with new shoes that have soft, roomy toe boxes.

Shoes should be one-half inch longer than the longest toe

Avoid tight, narrow, high-heeled shoes Sandals as long as they do not pinch or rub other

areas of the footToe exercises for HEP:

Gently stretch the toes manually Using toes to pick things up off the floor. Towel flat under your feet and use your toes to crumple it

Surgery if conservative measures fail

Surgical Correction of Hammertoe

Simple outpatient surgery with limited downtime. The best option is to fuse the deformed and

contracted digit in a straight position. This limits the need for future surgery and deformity

return. In certain cases, a removal of a small area of

bone in the deformity area will decrease pain and limit the need for a surgical waiting period that is found with fusions.

Although the toe is not as stable as with a fusion, in certain cases, an arthroplasty is the best option for some patients.

http://www.footankleinstitute.com

Bunions Hallux Valgus

The bunion is the enlarged medial prominence of the first MTP joint.

Often there are secondary lesser toe deformities (corns, calluses, hammertoes)

Treatment Shoe change: widen the toe box, Arch + heel support (bunion pads crowd shoe)

Bunion Xrays

Tightrope bunion procedure with re-alignment of the 1st metatarsal and the great toe position. Note metal anchors securing the Tightrope cord in place between the two bones

Drawing of bunion after surgery. Note the shift of the 1st metatarsal towards the second metatarsal for realignment of the column and fixation of the bones together with the two screws from top to bottom

Bunion Surgeries

http://www.footankleinstitute.com

Management of Acute Charcot Neuropathic Osteoarthropathy

Immobilization and reduction of stress are the mainstays of treatment for acute Charcot arthropathy

Complete Non-Weight bearing with the use of crutches There is an increase in pressure to the

contralateral limb predisposing it repetitive stress and ulceration or neuropathic fracture

Following a period of off-loading, a reduction in skin temperature and edema indicates the stage of quiescence at which point the patient progresses into the post-acute phase of treatment

Charcot Foot

Management of Acute Charcot Neuropathic Osteoarthropathy

Adjunctive treatment Bisphosphonate therapy

Bisphosphonates are specifically targeted to the skeleton but may even localize preferentially at sites of active bone resorption

to help expedite the conversion of the acute process to the quiescent, reparative stage

When it comes to using bisphosphonates during the acute phase of Charcot, the research is limited, but promising

Ancillary bone growth stimulation promote rapid consolidation of fractures

Management of Post-Acute Charcot Neuropathic Osteoarthropathy

Progression to protected weight bearing is permitted, usually with the aid of some type of assistive device

Application of total contact casts or other off-loading modalities Bi-valved cast: total contact casting (TCC) patellar tendon-bearing braces

Usually 4-6 months before returning to permanent foot ware

Bivalved Cast

is cut in half to detect or relieve pressure underneath, especially when a patient has decreased or no sensation in the portion of the body

Total Contact Casting (TCC)

The TCC employs a well-molded, minimally padded cast that maintains contact with the entire plantar aspect of the foot and lower leg.

Functions to mechanically unload the ulcer site and reduce the vertical shear stresses, redistributing the pressure of walking over the entire foot and lower leg.

The application: Requires a skilled technician considerable application time numerous applications over the

duration of plantar ulcer healing It has been well documented that

improper cast application can cause ulceration.

Evidence

Bone mineral density during total contact cast immobilization for a patient with neuropahtic (Charcot) arthropathy

Hastings MK, Sinacore DR, Fielder FA, Johnson JE Phys Ther 2005; 85(3): 249-256

Total contact casting as a treatment to resolve inflammation and protect the foot from additional trauma was supported by the decrease in skin temperature and edema during intervention period.

Loss of bone during cast immobilization and NWB indicates that the intervention may increase risk of future fractures.

Important to protect the foot as weight bearing activities progress and provide protective footwear. Individual started osteoporotic.

Patellar Tendon-Bearing Braces

Winged tibia plate is pre-formed to fit the tibia and support patellar tendon bearing

Unique rocker design allows patients to closely simulate a near normal gait without abnormal loads on any joints

Long-term PTB brace use, especially in the limited weight-bearing patient, should be regularly adjusted to ensure adequate brace fit.

Charcot Restraint Orthotic Walker

Custom moldedFully paddedThe weight-relieving AFO

minimizes the forces going through the foot.

The rocker bottom and the custom molded insert enhance healing and off-loading of the affected area.

Surgical Intervention

Reconstructive surgery may be considered if a deformity or instability exists that cannot effectively be controlled or accommodated by prescription footwear or bracing

The goal of any surgery undertaken on the Charcot foot is to create a stable, plantigrade foot that may be appropriately accommodated

Surgical Intervention – Con’t

If the arthropathy is identified in its early stages and NWB is instituted, surgery is usually unnecessary surgery in the acute stage is generally not advisable

due to the extreme hyperemia, osteopenia, and edema present

Surgical intervention during the acute phase, however, may be considered in the presence of acute subluxation without osteochondral fragmentation

Post Surgical

Following surgery, patients are immobilized until skin temperatures and postoperative edema normalize prolonged cast immobilization progress to a removable cast walker followed by permanent prescription footwear

Mean times from surgery to the wearing of therapeutic shoes have been reported in the range of 7 months.

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