neuropathic ulcers for students

8/10/2019 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

neuropathic ulcers for students

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