Peripheral Neuropathy

Neuropathy affects 30-50% of patient population with diabetes and this prevalence tends to increase proportionally with duration of diabetes and dependant on control. Often presents as a loss of protective sensation. (LOPS) Gradual onset and progressive.

Peripheral Neuropathy May be due to a number of reasons or than Diabetes Alcoholism Systemic Lupus Erymatosus Multiple Sclerosis Renal failure Chronic back

Types of Neuropathy Neuropathy covers several areas Sensory Neuropathy Autonomic Neuropathy Motor Neuropathy Structural Abnormalities

Sensory neuropathy Loss of protective sensation can result in mechanical trauma/injury to tissues contributing to overloading tissues and tissue breakdown/ulceration. Sensory neuropathy often begins distally and progresses proximally. There is a diminished/loss of temperature, vibration, pressure and light touch Often starts in feet and legs

Symptoms of sensory neuropathy Pins and needles Burning/tingling sensation in feet Shooting pains Hypersensitivity hot feet at night time Difficulty tolerating shoes Loss of protective sensation Numbness

Testing methods Babinski sign Semmes Weinstein Monofilament 5.07 gm Reflex hammer Light touch, cotton wool ball Two point discrimination Temperature hot and cold Vibration testing 128c tunning fork Clonus

Peripheral Neuropathy

Test 10 different sites on both feet Test each area 3 times If 3 or more sites are not felt, it is classified as neuropathy being present.

Vibration testing Tuning fork 128 Hz Test over bony prominence Medal and lateral malleoli 1 st 3 rd and 5 th metatarsal heads testing for proprioception

Peripheral Neuropathy

THE DIABETIC FOOT

Autonomic Neuropathy Loss of functional homeostatic mechanisms eg: Sweat glands, atrophic sweat glands, arteriovenous shunting, atrophy of fibro fatty pad anhydrotic skin (very dry) Reduced Proprioception eg(awareness of body in space) Falls issue

Peripheral Neuropathy

Motor Neuropathy Muscle wasting of intrinsic muscles. Resulting in muscle imbalances between intrinsic and extrinsic muscles, contributing to deformities such as claw toes, hammer toes and plantar flexion deformities of metatarsal heads. Altered structure. Decreased stability.

Signs Foot slapping Toe scuffing Frequent falls Most common sign is weakness of toes and

Peripheral Neuropathy

Reflex testing Ankle jerk reflex Achilles tendon reflex document as: 0 = absent 1+ = diminished 2+ = normal 3+ = hyperactive 4+ = hyperactive with clonus;

reflexes can indicate neurologic or muscular dysfunction. Babinski sign

Peripheral Neuropathy

Structural Abnormalities Biomechanical assessment of Often significant sensory neuropathy Claw toes, hammer toes, Bunions Pes Planus or Pes Cavus, Increased pressure areas on. Charcot joint collapse associated with neuropathy red hot swollen

Peripheral Neuropathy

Prevention strategies Annual Foot Screening Monofilament to screen those at risk Those at risk to be seen 4 times per year to check feet and wear Patient Education Patient assumes personal responsibility partner with health care team Daily Self Inspection Early detection of injury, nail problems Footwear Selection Correct fit for length, width, box depth Management of Simple Foot Problems Autonomic neuropathy, cracks, dry skin Identify problems early and report

LOPS program(loss of protective sensation)

NORTON DISABILITY SCORE Right Left Vibration Perception Threshold 128-Hz tuning fork; apex of big toe: normal = can distinguish vibrating/ not vibrating Normal 0 Abnormal 1 Temperature perception on Dorsum of Foot Use tuning fork with beaker of ice/ warm water Pin Prick Apply pin proximally to big toe nail just enough to deform skin; Trial pair: sharp, blunt; Normal= can distinguish sharp/ not sharp Achilles Reflex Present 0 Present with reinforcement 1 Absent 2 NDS Total out of 10

References National Institute for Clinical Evidence http://www.nice.org.uk/ Scottish Collegiate Guidelines Network http://www.sign.ac.uk/guidelines/fulltext/116/index.html US Department of Health and Human Services - Health Resources and service Administration http://www.hrsa.gov/hansensdisease/leap Colaguiri et. Al., National Diabetes strategy and implementation Plan, Canberra, Australia 1998. McLennan et al., Improving wound-healing outcomes in ulcers. Expert Review of Endocrinology and Metabolism. 2007.

References The Australia (https://www.australia.org) Australian Diabetes Foot Network: management of diabetes-related ulceration a clinical update (https://www.mja.com.au/journal/2012/197/4/australian-diabetes-network-management-diabetes-related--ulceration) Monteiro-Soares M, et al. Risk stratification systems for ulcers: a systematic review. Diabetologia 2011;54:1190-9.+ http://www.diabetessa.com.au/type-2/-australian-type-2-diabetes-risk-assessmenttool.html?gclid=ciu4y63l1ducfysuvqodz8fxa Diabetic problems: prevention and management https://www.nice.org.uk/guidance/ng19/resources/--problems-prevention-andmanagement-pdf-1837279828933