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