Dr. Sibbald is: Company/ Agency Lecturers. Objectives Participants will:

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1 Dr. R. Gary Sibbald MD, FRCPC (Med, Derm), MACP, FAAD, M.Ed. Professor Of Medicine / Public Health U. Of Toronto Director Of The International Interprofessional Wound Care Course President Of The World Union Of Wound Healing Societies Dr. Sibbald is: Company/ Agency Paid Lecturers Advisory Board Members 3M CIDA Coloplast Convatec Covidien Govt Ontario KCI J&J (Systagenix) Mölnlycke RNAO Stryker Research Participants Objectives Participants will: Focus on screening and prevention Introduce the simplified 60 second screen to identify the person at high risk of a diabetic foot ulcer Highlight appropriate foot care/ footwear to prevent skin complications 1

2 The Problem- Diabetic Foot Ulcers Global pandemic of Diabetes Developing countries on the frontline Person With Diabetes (PWD) has a 15-25% lifetime risk- Diabetic Foot Ulcer (DFU) 50-70% recurrence rate (5yrs) Every 30 seconds a lower limb is lost to diabetes 4 The Problem- Diabetic Foot Ulcers Precedes amputation in 85% cases Average healing rates weeks 14-24% proceed to amputation 1 yr amputation rate- 15% Cost to the health system - profound Issue Person with diabetes The Problem- DFUs Statistics 20x risk of a lower limb amputation World wide lower extremity 25-90% diabetic related amputations 5 years after the first amputation 50% dead 50% second amputation 2

3 Issue Diabetes The Financial Cost Diabetes & Foot complications Diabetes related foot complications Cost per Amputation Cost 10.9 billion US dollars 3 billion UK pounds 252 Million UK pounds US dollars 66,215 US dollars The Problem: Lower extremity amputation (LEA) Region Country Data Used Incidence per 100,000 diabetic population Europe Denmark Holstein et al, UK Rayman et al, North America USA Lavery et al, Africa NA NA Asia NA NA South America Brazil Spichler et al, Caribbean Barbados Hennis et al, Guyana Newark et al, Ulcer Risk Factors : Person with Diabetes Peripheral Arterial Disease Neuropathy Oxygen *Medication delivery impaired Sensory loss of protective sensation Autonomic skin, joints Motor foot deformity, limited mobility joints *Poor healing *Infection *Self care deficit *Poor glucose control *Improper footwear *Obesity Ulceration Potential Amputation 3

4 Who should be involved in the care of the person with Diabetes? DIABETIC FOOT- AN INTERPROFESSIONAL TEAM APPROACH Reception- Secretary Vascular Surgeon Radiologist Foot specialist Social Worker Dermatologist Family Doctor Clinic Nurses Rehab Assistant/ Foot Specialist PATIENT Surgeons/ Family MD Diabetic Educator/ Dietitian Physiotherapist/ Occupational Therapist Prosthetist Orthotist Pedorthist Occupational Therapist Neurologist Medical Internist Endocrinologist Pharmacist Plastic Surgeon Orthopedic Surgeon Clinical & Education Program Best Practice Recommendations of the Canadian Association of Wound Care (CAWC) Development of a comprehensive interprofessional diabetic foot program gram Primary and secondary educational strategies Best practice seminars Skills: Doppler ABPI, skin temperature, conservative debridement Prevention 60 sec. screen IIWCC key opinion leader training 4

5 Person with Diabetic Foot Ulcer Treat Cause Tissue- Debridement of Devitalized tissue Local Wound Care Superficial Infection / Chronic Inflammation Patient- Centered Concerns Moisture Balance Edge-Non-healing Wound Biological Agents- Growth Factors Skin substitutes Acellular matrix Skin Grafts-Full / Partial Thickness Adjunctive Therapies (VAC) Sibbald et al WBP, 2007, WHO 2010 Advances Sept Sibbald et al 2006, Treat the Cause: Whole Patient A B C D E F S HbA1c: Target for Diabetes in Control is 7.0% and should be checked every 90 days Blood pressure: Target for PWD is 120 mm Hg systolic and 80 mm Hg diastolic Cholesterol: Cholesterol < 200mg/dL, LDL < 100 mg/dl, Triglycerides <150 mg/dl. Diet: > 5 daily servings of fruit and vegetables, > 6 daily servings of grain products, including whole grains, > 2 servings of oily fish per week, grams of fiber per day, < 1 tsp salt. Exercise: Minimum of 30 minutes most (if not all) days Foot Care and Foot Wear: and Ulcer: VIPs No Smoking! One cigarette will decrease local circulation 30-50% for one hour! Diabetes Control Priorities in Developing Countries 1 Highest level priority: o Cost saving AND Highly feasible Diabetes o Foot care o Glycemic control to HbA1c < 9% o Blood pressure control to BP < 160/90 1) Narayan V, et al. Diabetes: The Pandemic and Potential Solutions. In: Jamison D, et al., editors. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; p

6 Break: Prevention: 1266 screenings Guyana South America History Inspection abnormalities Palpate pulse Monofilament testing (4 out 10 negative) Results of 60 second screening ITEM NO% YES% Previous Ulcer Previous Amp 95 5 Absent pulse Stiffness ankle/toe Active DFU Ingrown toenail Callus Fissure Neuropathy REFERRED DFC Screening high risk status Risk factor Ulcer yearly incidence/ rate % Group 0 (no PN, no PVD) 2% Odds ratio (95%CI) Group 1 (PN, no PVD or deformity) 4.5% 2.4 (1.1.-5) Group 2B (PVD) 13.8% 9.3 ( ) Group 3 PN/ PVD (history of ulcer or amputation) 32.2% 52.7 ( ) Lavery LA, et al. classification system of the International Working Group on the Diabetic Foot. Diabetes Care 31(1):154-6,

7 60 Second Screen - History 1. Previous Ulceration 2. Previous Amputation 3. Deformity 60 Second Screen Physical Examination 7

8 60 Second Screen Physical Examination 4. Pulses absent Dorsalis Pedis and /or Posterior Tibial 60 Second Screen Physical Examination- fixed joints 5.No movement large toe joint Limited Ankle joint dorsiflexon 60 Second Screen Foot Lesions 6. Active Ulcer 7. Ingrown toenail 8

9 60 Second Screen Foot Lesions 8. Calluses= increased pressure 60 Second Screen Foot Lesions 9. Blisters 10. Fissure 60 Second Screen Foot Lesions 4 th 5 th Toe Web Space Nails 9

10 60 Second Screen Neuropathy 11.Mono filament Exam X all negative= 4/ 10 X X X X 60 second screen video 60 Second Screen Plan POSITIVE SCREEN Neuropathy only See in 6 months All other +ve screens Refer to next level facility NEGATIVE SCREEN No referral See in 1 year SCREENING KIT Sixty Second tool Monofilament Patients Practice Documentation Referral 10

11 Physical Activity: How Does Exercise Help? Improves insulin sensitivity Increases sense of well-being Increases flexibility and muscle strength Prevent weight gain Improves cardiovascular function If hypertensive, helps to control high blood pressure Improves cholesterol and other lipids No Smoking: Double indemnity Every cigarette will decrease the circulation in the leg or foot up to 30% for an hour or increase sympathetic tone for 8 hours How Does Diabetes Affect Your Feet Foot ailment is the most common complication of diabetes that requires hospitalization. High blood sugar can damage the nerves of your feet resulting in loss of sensation (numbness), tingling or burning to the feet, so there is no pain when there is an injury. High blood sugar can also cause poor blood supply to the feet and so small injuries take a very long time to heal Taking care of your feet can make a big difference in preventing foot problems and ultimately amputation. Your feet can last a life time. 11

12 How to Care for Your Feet Pat dry between your toes each day with a soft cloth, warm water and mild soap. Put some powder after you wash them. Use powder that is mild and has no scent Use lotion for dry skin. Do not put any lotion between your toes, or used perfume lotion Never walk barefooted Check Your Feet Everyday Look for colour changes such as blue, bright red or white (pale) spots Keep your eyes on your feet Check your feet each day for cuts, blisters or sores. Use a mirror, if necessary, to see the bottom of your feet You should look and touch to ensure that there is no swelling nor tenderness See your health care provider if you have a foot problem do not treat them yourself. Footwear Shoes Change your socks every day Look inside your shoes before you put them on (make sure nothing is in them and make sure the lining in them are not torn) Do not wear pointed or open toed shoes. Sandals or thongs may cause problems. should fit well. There should be enough room for your toes to move 12

13 How to Care for Your Feet When infection is bad, part of the foot or leg may need to be amputated. If you take good care of your feet, this does not have to happen to you. Shoes for Persons with Diabetes Good Shoe Features look for comfort & support Extra depth Ventilation (natural material) Stretching material Seamless, lightweight construction Arch support Room For Your Toes A Perfect fitting heel Thick sole 13

14 Tips on socks, too! Light coloured, absorbent seamless Clean Loose fitting elastic but firm Increased length Get moving Appropriate?? Person with Diabetic Foot Ulcer Treat Cause Tissue- Debridement of Devitalized tissue Local Wound Care Superficial Infection / Chronic Inflammation Patient- Centered Concerns Moisture Balance Edge-Non-healing Wound Biological Agents- Growth Factors Skin substitutes Acellular matrix Skin Grafts-Full / Partial Thickness Adjunctive Therapies (VAC) Sibbald et al WBP, 2007,2010 WHO 2010 Sibbald et al 2006,

15 Objectives Participants have: Focused on screening and prevention Introduced the simplified 60 second screen to identify the person at high risk of a diabetic foot ulcer Highlighted appropriate foot care/ footwear to prevent skin complications Thank you! Together we can make a difference! 15