diabetic foot syndrome an indian perspective

1. DIABETIC FOOT
SYNDROME – An Indian
Perspective –
Apropriate technology
DR. ASHOK KUMAR DAS
DEAN, DIRECTOR-PROFESSOR
& HEAD,
DEPARTMENT OF MEDICINE,
JIPMER, PONDICHERRY

2. AGENDA
ISSUES
COST
CLASSIFICATION
HIGH RISK FOOT
CLINICAL
EVALUATION
 HISTORY
 PHY EXAM
LAB TECHNOLOGY
MANAGEMENT
 6 CONTROLS
 INDIAN PROBLEMS
& SOLUTIONS
DIABETIC FOOT
CLINIC
CONCLUSIONS

3. INTRODUCTION
FOOT PROBLEMS - AN IMPORTANT
CAUSE OF MORBIDITY IN DIABETIC
PEOPLE
2025 THERE EXPECTED TO BE 75
MILLION DIABETICS
150 MILION FEET

4. TYPES OF DIABETIC
FOOT
NEUROPATHIC FOOT
(COMMONEST)
ISCHEMIC FOOT

6. DIAGNOSIS OF A ‘HIGH
RISK’ FOOT
PERIPHERAL NEUROPATHY
SOMATIC
AUTONOMIC
PERIPHERAL VASCULAR DISEASE
PREVIOUS FOOT ULCERS
FOOT DEFORMITY
CLAW TOES
CHARCOT ARTHROPATHY

7. PRESENCE OF CALLUS
BLIND OR PARTIALLY SIGHTED
NEPHROPATHY
ELDERLY
POOR UNDERSTANDING OF
DIABETES
INABILITY TO FEEL SEMMES-
WEINSTEIN NYLON MONOFILAMENT

8. TECHNOLOGY &
DIABETIC FOOT
UTILISED MAINLY
SCREENING
DIAGNOSIS OF HIGH RISK FOOT
DIAGNOSIS OF EXTENT OF INVOLVEMENT
PROGNOSTICATION
TREATMENT OF DIABETIC FOOT

9. TECHNOLOGY &
DIABETIC FOOT…
HI TECH EDUCATION
AWARENESS & EDUCATION
PERSONS WITH DIABETES &
DIABETIC FOOT CARE PROVIDERS
viz…diabetic foot pressures & its
improvement with insoles etc.

10. TECHNOLOGY &
DIABETIC FOOT…
Quantification & research
Natural history of Diabetes & its
complications
Drug trials
Evidence based Diabetology Practice
viz …diabetic Neuropathy

11. AREAS & APPLICATION
OF TECHNOLOGY IN
DIABETES PRACTICE
2004Diabetic foot pressure studies:
out of shoe
in shoe
emed
pedomed
f-scan

12. Introduction of opticalpedobiographs &
development of computing technology
microprocessor like recording devices
provide—possibility of identifying patients at
risk of plantar ulceration
give basis for
foot wear prescription & adjustment
surgical intervention
Hi tech education

13. 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

14. CLINICAL ALGORITHM
R E V IE W R IS K F A C T O R S T A T U S
A 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 T R Y , F O O T W E A R
N O R IS K F A C T O R S
R E V IE W F R E Q U E N T L Y
A 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 T IO N
R E G U L A R P O D IA T R Y
C O N S ID E R N E E D F O R S P E C IA L F O O T W E A R
R IS K F A C T O R S
ID E N T IF IE D
A S S E S S E V E R Y D IA B E T IC F O R R IS K F A C T O R S

15. CLINICAL EVALUATION
ALWAYS PRECEDES ANY
LABORATORY INVESTIGATION
GOOD HISTORY AND THOROUGH
PHYSICAL EXAMINATION WILL
REDUCE NEED FOR MANY
UNNECESSARY AND COSTLY
INVESTIGATIONS

16. HISTORY
VASCULAR / NEUROGENIC
CLAUDICATION
PREVIOUS ULCERATION /
AMPUTATION
PATIENT UNDERSTANDING OF DM &
COMPLICATIONS

17. PHYSICAL
EXAMINATION
SHAPE & DEFORMITIES
 TOE DEFORMITIES, NAIL DEFORMITIES
 HALLUX VALGUS, HALLUX RIGIDUS
 PROMINENT METATARSAL HEADS
 HAMMER TOE
 CHARCOT DEFORMITY
 CALLUS

18. SENSORY FUNCTION
 VIBRATION (128 HZ TUNING FORK)
 THERMAL PROPRIOCEPTION
 JOINT POSITION SENSE

19. MOTOR FUNCTION
 WASTING
 WEAKNESS
 LOSS OF ANKLE REFLEXES

20. AUTONOMIC FUNCTION
 REDUCED SWEATING
 CALLUS
 WARM FOOT
 DISTENDED DORSAL FOOT VEINS

21. VASCULAR STATUS
 FOOT PULSES
 PALLOR
 COLD FEET
 EDEMA

22. CLINICAL ASSESSMENT
- EIGHT COMPONENTS
NEUROPATHY
ISCHEMIA
DEFORMITY
CALLUS
OEDEMA
SKIN BREAKDOWN
INFECTION
NECROSIS

23. STAGING THE DIABETIC
FOOT
STAGE CLINICAL CONDITION
1 NORMAL
2 HIGH RISK
3 ULCERATED
4 CELLULITIC
5 NECROTIC
6 MAJOR AMPUTATION

24. LABORATORY
EVALUATION OF THE
VASCULAR SYSTEM
INDIRECT METHODS
DIRECT METHODS

26. INDIRECT METHODS
DOPPLER
ULTRASOUND
PHOTOPLETHYSM
O GRAPHY
PULSE VOLUME
RECORDING
LASER DOPPLER
FLUX
TRANSCUTANEOU
S OXYGEN
TENSION
ISOTOPE
CLEARANCE

27. DIRECT METHODS
DUPLEX SCANNING
MAGNETIC RESONANCE IMAGING
ARTERIOGRAPHY

28. DOPPLER ULTRASOUND
AND DOPPLER
PRESSURES
METHODS INCLUDE
DOPPLER SIGNAL WAVE FORM
ANKLE DOPPLER PRESSURE
ANKLE - BRACHIAL INDEX
DOPPLER SEGMENTAL PRESSURES

29. 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

30. DOPPLER SIGNAL WAVE
FORM
NORMAL ARTERIAL DOPPLER WAVE
FORM IS TRIPHASIC
SYSTOLIC UPWARD DEFLECTION
DIASTOLIC DOWNWARD DEFLECTION
SMALLER UPWARD AND DOWNWARD
DEFLECTION (DIASTOLIC FORWARD
FLOW)

31. 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

32. ABI
ABI OF 0.8 - 0.5 ---
 INTERMITTENT CLAUDICATION
ABI OF < 0.5 ---
 REST PAIN
A CHANGE OF 0.15 IS CONSIDERED
SIGNIFICANT

34. SEGMENTAL
PRESSURES
USED TO LOCALIZE VASCULAR
OBSTRUCTION
MEASUREMENTS WITH PNEUMATIC
CUFFS ARE MADE FROM
HIGH THIGH
LOW THIGH
BELOW KNEE
ANKLE LEVEL

35. PRESENCE OF GRADIENT
BETWEEN MEASUREMENTS
INDICATES A SIGNIFICANT
STENOSIS OR A COMPLETE
OCCLUSION IN THE ARTERIAL
SEGMENT BETWEEN THE TWO
CUFFS

36. 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

37. 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

38. 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

39. PHOTOPLETHYSMOGRA
PHY
USES A DIODE THAT EMITS INFRA-
RED LIGHT INTO THE TISSUE,
WHICH IS REFLECTED BACK FROM
THE BLOOD IN THE CUTANEOUS
MICROCIRCULATION
TWO MEASUREMENTS
TOE BLOOD PRESSURE
SKIN PERFUSION PRESSURE

40. 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

41. 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

42. PULSE VOLUME
RECORDER
SEGMENTAL PLETHYSMOGRAPH IS
USED
CHANGES IN EXTREMITY OR DIGIT
VOLUME THAT TAKES PLACE IN
RESPONSE TO ARTERIAL
PULSATION IS MEASURED

43. PULSE CONTOUR
NORMAL WAVE
PEAKED
BRISK
ANACROTIC AND
DICROTIC
DEFLECTIONS
DICROTIC NOTCH
ABNORMAL
WAVE
FLATTENED WAVE
ABSENCE OF
DICROTIC NOTCH
REDUCED
ANACROTIC /
DICROTIC
COMPONENTS

44. PULSE AMPLITUDE
ARTERIAL OCCLUSIVE DISEASE IS
MARKED BY DECREASE IN
AMPLITUDE OF THE PULSE WAVE
FORM
AMPLITUDE < 15 MM - FOOT PAIN
LIKELY ISCHEMIC
AMPLITUDE < 5 MM - FOOT ULCER
UNLIKELY TO HEAL

46. 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

47. LASER DOPPLER FLUX
ALSO CALLED VELOCIMETRY
PROVIDES A DIRECT &
CONTINUOUS MEASUREMENT OF
SKIN CAPILLARY BLOOD FLOW
VELOCITY
SENSITIVITY LESS THAN TCPO2

48. ISOTOPE CLEARANCE
133
XE GAS ISOTOPE TO MEASURE
SKIN BLOOD FLOW
FLOW RATES ABOVE 2.6 ML / 100
GM TISSUE CORRELATED WITH
GOOD HEALING

49. DUPLEX SCANNING
COMBINATION OF REAL TIME B
MODE SONOGRAPHY AND A PULSE
DOPPLER
ALLOWS 2-D VISUALIZATION OF
BLOOD VESSEL WITH
SURROUNDING TISSUES
DETECTS CALCIFIED PLAQUE,
ULCER, THROMBI, ANEURYSMS

50. 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

51. MAGNETIC RESONANCE
IMAGING
3-D RECONSTRUCTION OF
VESSELS POSSIBLE
LUMINAL NARROWING, CALCIFIED
PLAQUES AND THROMBI CAN BE
DETECTED
MR ANGIOGRAPHY - ROLE BEING
STUDIED

52. ARTERIOGRAPHY
INDICATIONS INCLUDE
DISABLING CLAUDICATION
ISCHEMIC REST PAIN
ICHEMIC ULCERATION
ISCHEMIC GANGRENE

53. DIGITAL
SUBSTRACTION
ANGIOGRAPHY
ADVANTAGES OVER ROUTINE
ARTERIOGRAPHY
HIGH CONTRAST RESOLUTION
IMPROVED ARTERIAL VISUALIZATION
LESS REQUIREMENT OF THE
RADIOCONTRAST DYE
REDUCED COST OF EXAMINATION

54. VASCULAR
EVALUATION - INDIAN
CONTEXTAT PRIMARY HEALTH CARE LEVEL,
CLINICAL EVALUATION OF UTMOST
IMPORTANCE
“ALWAYS INSPECT THE FOOT OF A
DIABETIC PATIENT”
PALPATE FOR THE PULSE - DORSALIS
PEDIS, POSTERIOR TIBIAL
IDENTIFY & REFER A HIGH-RISK FOOT TO
NEAREST TERTIARY CARE CENTRE

55. VASCULAR
EVALUATION AT AN
INDIAN TERTIARY CARE
CENTRETHOROUGH CLINICAL EVALUATION
ABI WITH DOPPLER ESSENTIAL AND
AFFORDABLE
INTEGRATED APPROACH- TO LOOK
FOR OTHER RISK FACTORS

56. LABORATORY
EVALUATION OF NERVE
FUNCTION
TESTS OF SENSORY FUNCTION
TESTS OF AUTONOMIC FUNCTION

57. TESTS OF SENSORY
FUNCTION
VIBRATION PERCEPTION
THRESHOLD
128 HZ TUNING FORK
REIDELL-SEIFFER GRADUATED
TUNING FORK
BIOTHESIOMETER
VIBRAMETER

58. TESTS OF SENSORY
FUNCTION (CONTD)
LIGHT TOUCH SENSATION
VON FREY HORSE HAIR
NYLON MONOFILAMENTS
THERMAL THESHOLDS
MARSTOCK STIMULATOR
MEDELEC
SENSORTEK
THERMOTEST

60. TESTS OF AUTONOMIC
FUNCTION
CARDIOVASCULAR TESTS
TESTS OF OTHER SYSTEMS
GI
SWEAT
PUPILLARY
NEURENDOCRINE

61. NERVE FUNCTION
EVALUATION- INDIAN
PERSPECTIVEAT PHC LEVEL, CLINICAL EVALUATION OF
LIGHT TOUCH WITH COTTON HAIR
VIBRATION WITH TUNING FORK AND
TEMP WITH WARM / COLD WATER
AT TERTIARY CENTRES,
BIOTHESIOMETRY AFFORDABLE AS
ALSO NYLON MONOFILAMENTS
FOR AUTONOMIC NEUROPATHY,
CARDIOVASCULAR TESTS WELL
DESCRIBED & EASY TO PERFORM

62. CARDIOVASCULAR
TESTS FOR AUTONOMIC
NEUROPATHY
HR RESPONSE TO VALSALVA
MANOEUVRE
HR RESPONSE TO STANDING UP
HR RESPONSE TO DEEP
BREATHING
BP RESPONSE TO STANDING UP
BP RESPONSE TO SUSTAINED
HAND-GRIP

63. NORMAL AND ABNORMAL
VALUES OF AUTONOMIC
FUNCTION TESTING
TEST NORMAL BORDER ABNORMAL
LINE
VALSALVA 1.2 1.11-1.2 <1.1
RATIO
HR VARIATION WITH
DEEP BREATHING 15/MIN 11-14/MIN <10/MIN
HR RESPONSE TO
STANDING 1.04 1.01-1.03 <1.0
BP FALL ON STANDING 10 MMHG11-29MMHG >30MMHG
BP TO HANDGRIP 16MMHG 11-15MMHG <10MMHG

64. AUTONOMIC Fn TESTS…
CARDIOVASCULAR TESTS EASY TO
PERFORM
NEEDS ONLY ECG,
SPHYGMOMANOMETER
COMPLICATED TESTS LIKE 24 HOUR
HR VARIABILITY etc ONLY FOR
ADVANCED RESEARCH, AND
PRACTICAL UTILITY LIMITED

65. 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

66. ASSESSMENT OF FOOT
PRESSURES
SIMPLE FOOT PRESSURE PADS
SOPHISTICATED
PEDOBAROGRAPHY
F.SCAN MAT SYSTEMS

67. AFFORDABLE INDIAN
ALTERNATIVES
PEDOBAROGRAPHY & F. SCAN MAT
SYSTEMS NOT FEASIBLE IN MOST
INDIAN HOSPITALS
REASONABLE, AFFORDABLE
ALTERNATIVES INCLUDE
HARRIS MAT
INKPAD SYSTEM
VIEW BOX

68. HARRIS MAT
PATIENT STEPS ON AN INKED MAT
WALKS ON A LONG SHEET OF
PAPER
FOOTPRINTS ANALYZED WITH
RESPECT TO PRESSURE POINTS

69. INKPAD SYSTEM
LARGE INKPAD WITH A PLASTIC
COVER ON TOP TO PREVENT
STAINING OF PATIENT’S FOOT
FACILITY TO INSERT A PLAIN PAPER
BELOW THE INKPAD
PRESSURE BY PATIENT’S FOOT IS
TRANSMITTED TO THE PAPER AND
A FOOTPRINT OBTAINED

70. 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

72. OTHER LABORATORY
TESTS
BLOOD GLUCOSE LEVELS,
GLYCATED HEMOGLOBIN
TBA METHOD IN MOST INDIAN
SETTINGS
COMPLICATED METHODS OF
ASSESSMENT NOT
AVAILABLE/AFFORDABLE

73. Lab tests…
MICROPROTEINURIA
POSITIVE CORRELATION WITH PVD
‘SIGMA CHROMOGEN BLUE’ USED
COMMONLY FOR ESTIMATION
COMPLEX TESTS LIKE MICRO-
ALBUMINURIA, RIA, ELISA NOT
AVAILABLE EVEN AT MOST TERTIARY
CARE CENTRES IN INDIA

74. MANAGEMENT
MULTI-DISCIPLINARY APPROACH
ADVOCATED IN THE WEST
TEAM CONSISTS OF
 PHYSICIAN
 SURGEON
 PODIATRIST
 SPECIALIST NURSE
 ORTHOTIST
 RADIOLOGIST

75. IN INDIA
THE PRIMARY CARE DOCTOR IS
THE ONLY HELP AVAILABLE
ORTHOTIST, PODIATRIST,
SPECIALIST NURSE ALL
EXTREMELY SCARCE
THEREFORE, BASIC ASPECTS OF
ALL THESE FIELDS NEED TO BE
KNOWN BY EVERY PHYSICIAN

76. SIX ASPECTS OF
PATIENT TREATMENT
WOUND CONTROL
MICROBIOLOGICAL CONTROL
MECHANICAL CONTROL
VASCULAR CONTROL
METABOLIC CONTROL
EDUCATIONAL CONTROL

77. WOUND CONTROL
DEBRIDEMENT
REMOVES CALLUS & REDUCES
PLANTAR PRESSURES
TRUE DIMENSIONS OF ULCERS CAN
BE MEASURED
DRAINAGE OF EXUDATE
ENABLES DEEP SWAB FOR CULTURE
CONVERTS CHRONIC WOUND TO
ACUTE WOUND

78. SKIN GRAFT
DRESSINGS
DAILY
SHOULD BE EASY TO LIFT FOOT
GOOD EXUDATE CONTROL

79. DRESSINGS - TYPES
FILMS
CLEAR, WOUND INSPECTION EASY
FOAM
CUSHIONING EFFECT
HYDROCOLLOIDS
PATIENTS CAN BATHE
ALGINATES
USEFUL FOR PACKING DEEP WOUNDS

80. MICROBIOLOGICAL
CONTROL
NO UNIFORM AGREEMENT ON
ANTIBIOTIC POLICY
CLOXACILLIN + 3RD GEN
CEPHALOSPORINS COMMONLY
USED
CIPROFLOXACIN + CLOX - ANOTHER
USEFUL COMBINATION

81. IN NEURO-ISCHEMIC ULCERS,
MORE AGGRESSIVE ANTIBIOTIC
THERAPY REQUIRED AS
COMPARED TO PURE
NEUROPATHIC ULCERS
SEARCH AGGRESSIVELY FOR
OSTEOMYELITIS

82. MECHANICAL CONTROL
CORRECT FOOTWEAR
TENDING TO MINOR FOOT PROBLEMS
 ONYCHOGYPHOSIS (MONSTER NAIL)
 ONYCHOCRYPTOSIS (INGROWING TOE NAIL)
 ONYCHOMYCOSIS
 TINEA PEDIS
 CORNS, ETC

83. TREATMENT OF DEFORMITY & CALLUS
REDISTRIBUTION OF PLANTAR
PRESSURES IN NEUROPATHIC FOOT
TEMPORARY OFF-LOADING THE SITE OF
ULCER
USE OF CASTS
 AIRCAST (WALKING BRACE)
 TOTAL-CONTACT CAST
 SCOTCHCAST BOOT

84. VASCULAR CONTROL
CAREFUL CLINICAL EXAMINATION
MANDATORY
SUPPLEMENTED BY ABI
ANGIOPLASTY / BYPASS IN NON-
HEALING ULCERS WITH
DOCUMENTED ARTERIAL STENOSIS

85. METABOLIC CONTROL
POOR GLYCEMIC CONTROL
DELAYED HEALING
IMMUNE SUPPRESSION
IMPAIRED RESPONSE TO INFECTION
LOOK FOR OTHER ASSOCIATED
METABOLIC PROBLEMS
HT, UREMIA, ACIDOSIS, ETC

86. EDUCATIONAL
CONTROL
CONTINUOUS EDUCATION OF
PATIENT ESSENTIAL
INFORMATION ACCORDING TO
STAGE
ENSURES PATIENT CO-OPERATION
& COMPLIANCE
LIST OF SIMPLE DOS AND DON’TS

87. DO
WASH FEET DAILY WITH MILD SOAP
& WATER
CHECK FEET DAILY
SEEK URGENT TREATMENT OF ANY
PROBLEMS
WEAR SENSIBLE SHOES
CHECK SHOES INSIDE AND
OUTSIDE BEFORE WEARING

88. 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

89. DONT
USE CORN CURES
USE HOT-WATER BOTTLES
WALK BAREFOOT
CUT CORNS OR CALLUSES BY
YOURSELF
DELAY IN SEEKING HELP FOR ANY
PROBLEM

90. MANAGEMENT
PROBLEMS IN INDIA
POOR PATIENT AWARENESS
DELAYED SEEKING OF HEALTH
CARE
POVERTY, LACK OF
AWARENESS/NEARBY FACILITIES
CULTURAL BELIEFS

91. INJURY PRONE FOOT
DIVERSE CAUSES
 RAT-BITE, INSECT BITE, ETC
 INJURY DURING AGRICULTURE/MANUAL
LABOUR
LACK OF SUFFICIENT FACILITIES
LACK OF TRAINED PERSONNEL
COST

92. SOME SOLUTIONS
EDUCATION
PRIMARY CARE PHYSICIAN
PATIENT
INNOVATE PRAGMATICALLY, EG:-
WASHED X-RAY FILM FOR ULCER
MEASUREMENT
INKPAD FOR FOOT PRESSURE
ASSESSMENT

93. 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

94. DANGER SIGNS - FOR
PATIENT AWARENESS
TO SEEK MEDICAL HELP IF
SWELLING
COLOUR CHANGE
PAIN / THROBBING
THICK HARD SKIN OR CORNS
BREAKS IN THE SKIN, INCLUDING
CRACKS, BLISTERS OR SORES

95. ORGANIZING
DIABETIC FOOT CLINIC
IDENTIFY DIAB ETIC FOOT AT RISK
INSPECTION
PALPATE FOOT PULSE
ANKLE JERK
CLASSIFY & STAGE
CALLUS REMOVAL
CONTROL

96. BARE MINIMUM
INSTRUMENTATION
SEMMES - WEINSTEIN MONOFILAMENT
BIOTHESIOMETER
POCKET DOPPLER
INKPAD

97. 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

98. Conclusions…
APPROPRIATE MULTI-DISCIPLINARY
MANAGEMENT BASED ON STAGING
MUCH WORK LEFT TO BE DONE IN
INDIA FOR RECOGNITION,
EVALUATION AND TREATMENT OF
DIABETIC FOOT

99. 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

100. Evaluation of Sensory
Function
Large Fibre Function
Vibration Perception Threshhold
Indian Biosthesiometer
Rs. 25,000 vs Rs. 50,000
Local Simmes Weinstein monofilament

101. 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

102. Net Working