DIABETIC FOOT SYNDROME – An Indian Perspective – Apropriate technology

DR. ASHOK KUMAR DASDEAN, DIRECTOR-PROFESSOR

& HEAD,DEPARTMENT OF MEDICINE,

JIPMER, PONDICHERRY

AGENDAISSUESCOSTCLASSIFICATIONHIGH RISK FOOTCLINICAL EVALUATION HISTORY PHY EXAM

LAB TECHNOLOGYMANAGEMENT 6 CONTROLS INDIAN PROBLEMS

& SOLUTIONS

DIABETIC FOOT CLINICCONCLUSIONS

INTRODUCTIONFOOT PROBLEMS - AN IMPORTANT CAUSE OF MORBIDITY IN DIABETIC PEOPLE2025 THERE EXPECTED TO BE 75 MILLION DIABETICS150 MILION FEET

TYPES OF DIABETIC FOOTNEUROPATHIC 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

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 EDUCATIONAWARENESS & EDUCATIONPERSONS WITH DIABETES & DIABETIC FOOT CARE PROVIDERS

viz…diabetic foot pressures & its improvement with insoles etc.

TECHNOLOGY & DIABETIC FOOT…

Quantification & researchNatural history of Diabetes & its complicationsDrug trialsEvidence based Diabetology Practice

viz …diabetic Neuropathy

AREAS & APPLICATION OF TECHNOLOGY IN

DIABETES PRACTICE 2004Diabetic foot pressure studies: out of shoe in shoeemedpedomedf-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

COSTFOOT COSTS A MAJOR COMPONENT OF DIABETES RELATED HEALTH-CARE EXPENDITUREIN US, COSTS OVER $500 MILLION PER YEARIN 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 EVALUATIONALWAYS PRECEDES ANY LABORATORY INVESTIGATIONGOOD HISTORY AND THOROUGH PHYSICAL EXAMINATION WILL REDUCE NEED FOR MANY UNNECESSARY AND COSTLY INVESTIGATIONS

HISTORYVASCULAR / NEUROGENIC CLAUDICATIONPREVIOUS ULCERATION / AMPUTATIONPATIENT UNDERSTANDING OF DM & COMPLICATIONS

PHYSICAL EXAMINATIONSHAPE & 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 CONDITION1 NORMAL

2 HIGH RISK

3 ULCERATED

4 CELLULITIC

5 NECROTIC

6 MAJOR AMPUTATION

LABORATORY EVALUATION OF THE VASCULAR

SYSTEM

INDIRECT METHODS

DIRECT METHODS

INDIRECT METHODSDOPPLER 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 DEVICERANGES FROM A POCKET SIZE DEVICE TO LARGE, STATIONARY COMPLICATED DEVICEAUDIBLE 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 INDEXDOPPLER PROBE USED TO MEASURE SYSTOLIC PRESSURE AT BRACHIAL ARTERY AND DORSALIS PEDIS/POSTERIOR TIBIAL ARTERYNORMALLY, ANKLE PRESSURE / BRACHIAL PRESSURE = 1 OR SLIGHTLY ABOVEABI CORRELATES WITH SEVERITY OF ISCHEMIA

ABIABI OF 0.8 - 0.5 ---

INTERMITTENT CLAUDICATION

ABI OF < 0.5 --- REST PAIN

A CHANGE OF 0.15 IS CONSIDERED SIGNIFICANT

SEGMENTAL PRESSURESUSED 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 DIAGNOSISCAN UNMASK OBSTRUCTIONCAUSES A DROP IN DOPPLER PRESSURES DISTAL TO OBSTRUCTION, AFTER EXERCISEDIFFERENTIATES VASCULAR FROM NON-VASCULAR ETIOLOGY FOR CLAUDICATION

ANKLE DOPPLER PRESSURE

SEVERITY OF LOWER EXTREMITY ISCHEMIASYSTOLIC PRESSURE AT ANKLEAPPROPRIATE SIZED CUFF IS USEDPOSTERIAL 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 PRESSUREFALSE HIGH DOPPLER PRESSURES IN CASE OF CALCIFIED VESSELSESPECIALLY 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 SITESSKIN 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 CONTOURNORMAL WAVEPEAKEDBRISK

ANACROTIC AND DICROTIC DEFLECTIONS

DICROTIC NOTCH

ABNORMAL WAVEFLATTENED WAVEABSENCE OF

DICROTIC NOTCHREDUCED

ANACROTIC / DICROTIC COMPONENTS

PULSE AMPLITUDEARTERIAL 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 SKINGOOD ULCER HEALING IF TCPO2 > 35 - 40 MM HGPOOR ULCER HEALING IF TCPO2 < 20 - 26 MM HG

LASER DOPPLER FLUXALSO CALLED VELOCIMETRYPROVIDES A DIRECT & CONTINUOUS MEASUREMENT OF SKIN CAPILLARY BLOOD FLOW VELOCITYSENSITIVITY LESS THAN TCPO2

ISOTOPE CLEARANCE133XE GAS ISOTOPE TO MEASURE SKIN BLOOD FLOW

FLOW RATES ABOVE 2.6 ML / 100 GM TISSUE CORRELATED WITH GOOD HEALING

DUPLEX SCANNINGCOMBINATION 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 DOPPLERDISPLAY OF FLOW IN VESSELS IN DIFFERENT COLOURS DEPENDING ON DIRECTION OF FLOWACCURACY OF 77% - 97%TIME-CONSUMING AND NEEDS SKILL

MAGNETIC RESONANCE IMAGING

3-D RECONSTRUCTION OF VESSELS POSSIBLELUMINAL NARROWING, CALCIFIED PLAQUES AND THROMBI CAN BE DETECTEDMR ANGIOGRAPHY - ROLE BEING STUDIED

ARTERIOGRAPHYINDICATIONS 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 EVALUATIONABI WITH DOPPLER ESSENTIAL AND AFFORDABLEINTEGRATED 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 TESTSTESTS 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 <1.1RATIOHR VARIATION WITHDEEP 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

INTERPRETATIONNORMAL - ALL FIVE NORMAL / 1 BORDERLINEEARLY- ONE OF 3 HR TESTS ABNORMAL/ 2 BORDERLINEDEFINITE- > 2 HR TESTS ABNORMALSEVERE- + > 1 BP TESTS ABNORMAL / BOTH BORDERLINEATYPICAL- 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 MATPATIENT STEPS ON AN INKED MAT

WALKS ON A LONG SHEET OF PAPER

FOOTPRINTS ANALYZED WITH RESPECT TO PRESSURE POINTS

INKPAD SYSTEMLARGE 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 BOXA VIEW BOX WITH A PLAIN GLASS ABOVE AND A MIRROR BELOWA TUBE-LIGHT IS PLACED IN THE BOX FOR ILLUMINATIONWHEN 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

MANAGEMENTMULTI-DISCIPLINARY APPROACH ADVOCATED IN THE WESTTEAM CONSISTS OF PHYSICIAN SURGEON PODIATRIST SPECIALIST NURSE ORTHOTIST RADIOLOGIST

IN INDIATHE 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 CONTROLMICROBIOLOGICAL CONTROLMECHANICAL CONTROLVASCULAR CONTROLMETABOLIC CONTROLEDUCATIONAL CONTROL

WOUND CONTROLDEBRIDEMENTREMOVES CALLUS & REDUCES

PLANTAR PRESSURESTRUE DIMENSIONS OF ULCERS CAN

BE MEASUREDDRAINAGE OF EXUDATEENABLES DEEP SWAB FOR CULTURECONVERTS CHRONIC WOUND TO

ACUTE WOUND

SKIN GRAFTDRESSINGSDAILYSHOULD BE EASY TO LIFT FOOTGOOD EXUDATE CONTROL

DRESSINGS - TYPESFILMSCLEAR, WOUND INSPECTION EASY

FOAMCUSHIONING EFFECT

HYDROCOLLOIDSPATIENTS CAN BATHE

ALGINATESUSEFUL FOR PACKING DEEP WOUNDS

MICROBIOLOGICAL CONTROL

NO UNIFORM AGREEMENT ON ANTIBIOTIC POLICYCLOXACILLIN + 3RD GEN CEPHALOSPORINS COMMONLY USEDCIPROFLOXACIN + CLOX - ANOTHER USEFUL COMBINATION

IN NEURO-ISCHEMIC ULCERS, MORE AGGRESSIVE ANTIBIOTIC THERAPY REQUIRED AS COMPARED TO PURE NEUROPATHIC ULCERS

SEARCH AGGRESSIVELY FOR OSTEOMYELITIS

MECHANICAL CONTROLCORRECT FOOTWEARTENDING 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 CONTROLCAREFUL CLINICAL EXAMINATION MANDATORYSUPPLEMENTED BY ABIANGIOPLASTY / BYPASS IN NON-HEALING ULCERS WITH DOCUMENTED ARTERIAL STENOSIS

METABOLIC CONTROLPOOR GLYCEMIC CONTROLDELAYED HEALING IMMUNE SUPPRESSION IMPAIRED RESPONSE TO INFECTION

LOOK FOR OTHER ASSOCIATED METABOLIC PROBLEMSHT, UREMIA, ACIDOSIS, ETC

EDUCATIONAL CONTROLCONTINUOUS EDUCATION OF PATIENT ESSENTIALINFORMATION ACCORDING TO STAGEENSURES PATIENT CO-OPERATION & COMPLIANCELIST OF SIMPLE DOS AND DON’TS

DOWASH 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 SHOESBUY LACE-UP SHOES WITH PLENTY OF ROOM FOR TOESKEEP FEET AWAY FROM HEATSIT INSTEAD OF STANDINGCHANGE SOCKS FREQUENTLY

DONTUSE CORN CURESUSE HOT-WATER BOTTLESWALK BAREFOOTCUT CORNS OR CALLUSES BY YOURSELFDELAY IN SEEKING HELP FOR ANY PROBLEM

MANAGEMENT PROBLEMS IN INDIA

POOR PATIENT AWARENESSDELAYED 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 FACILITIESLACK OF TRAINED PERSONNELCOST

SOME SOLUTIONSEDUCATIONPRIMARY CARE PHYSICIANPATIENT

INNOVATE PRAGMATICALLY, EG:-WASHED X-RAY FILM FOR ULCER

MEASUREMENT INKPAD FOR FOOT PRESSURE

ASSESSMENT

HONING OF CLINICAL SKILLSEARLY IDENTIFICATION OF ‘HIGH RISK’ FOOT BY SCREENING EVERY DIABETICFOOTWEAR 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 & STAGECALLUS REMOVALCONTROL

BARE MINIMUM INSTRUMENTATION

SEMMES - WEINSTEIN MONOFILAMENT

BIOTHESIOMETER

POCKET DOPPLER

INKPAD

CONCLUSIONSDIABETIC FOOT - A WIDELY PREVALENT & COSTLY COMPLICATION OF DIABETESCLINICAL EXAMINATION OF FOOT - A MUST IN EVERY DIABETIC PATIENTSUPPLEMENTED 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 TCCTransformed 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 ThreshholdIndian 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 sensationMarstock Stimulator Thermal Discrimination Threshold measurementIndian EquipmentRs.2,00,000 vs Rs. 50,000

Net Working