Diabetic Foot Ulcers (DFU) Diabetic Foot Ulcers (DFU)
Regional Skin Integrity & Wound Management Steering Committee &
Diabetic Foot Ulcer Education Shared Work Team
Fraser Health Fraser Health Regional Wound Education Regional Wound Education
A Person’s Life Experience A Person’s Life Experience
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
2
MODULE
3
Vision Vision
To reduce the prevalence and incidence of
diabetic foot ulcers with a person-centered and a team approach
Mission Mission
Establish a team approach to identify clients at risk for diabetic foot ulcer, to implement
prevention and management strategies in a timely manner by:
1. Utilizing the appropriate tools/resources
2. Identifying interdisciplinary team members’ roles
MODULE
3
Diabetic Foot Ulcers
2006 Revised: 2012 4
Ice Breaker / Pre-test
Ice Breaker / Pre-test
MODULE
3
Objectives Objectives
Describe the etiology & predisposing risk factors of Diabetes (DM)
Describe the strategies in the prevention and management of DFU with an interprofessional team approach
Describe the components of a vascular and neurological assessment of the foot
Perform foot inspection, foot wear
assessment & identify interventions used to reduce pressure
Select local wound care interventions
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
Diabetes (DM) Pandemic Diabetes (DM) Pandemic
The 6th leading cause of death in Canada in 2008
Every hour/every day, >20 Canadians are diagnosed with DM
2 million (6.4%) Canadians have DM in 2010, and projected to be 3.5 millions (9.9%) in 2020
Aboriginal populations are more at risk by 3-5 times
Rising obesity, sedentary lifestyles, aging population, and changes in ethnic mix attribute to increasing
prevalence and incidence
Source:
1.An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes Association (Dec 2009
2.Statistic Canada (2010) & An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes Association (Dec 2009)
MODULE
3
An Economic Tsunami:
An Economic Tsunami:
The Cost of Diabetes in Canada The Cost of Diabetes in Canada
Economic burden of diabetes in Canada was projected to be about $12.2 billion in 2010; nearly double its level in 2000
Cost of diabetes is expected to be $17 billion in 2020
Direct cost of diabetes accounts for 3.5%
of public healthcare spending and is likely to continue rising
Source: An economic tsunami: the cost of diabetes in Canada, Canadian Diabetes
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
8
Persons with Diabetes Mellitus Persons with Diabetes Mellitus
(DM) (DM)
15% of individuals with DM will develop foot ulcers (DFUs) during the course of the illness
50% of DFUs that heal re-occur
DFU accounts for 50% of lower limb amputations
50% of persons with an amputation will have a contralateral amputation within 3-5 years
The 3-year survival rates after DM-related
lower extremity amputation are 50% with the major cause of death being cardiovascular
disease
MODULE
3
Age Offload
Family Physician
SAM/LOPS Lifestyle
Sam, our client newly diagnosed with DM Sam, our client newly diagnosed with DM
A Team approach to Optimizing Health Status A Team approach to Optimizing Health Status
Footcare
Dietitian Nurses/CM
RCA/PCA/CHW Food Services
OT/PT/Rehab
Pharmacist Social Worker
Specialists
Recreation
Psychosocial Spiritual
Volunteers Management
Sam/Family
DM Educator
DM Control
Orthotist/Pedorthotist
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
10
Risk Factors For Ulcerations Risk Factors For Ulcerations
Age
Obesity
Duration and control of diabetes
Nephropathy
Retinopathy
Prior foot ulcers or amputations
Peripheral NeuropathyPeripheral Neuropathy
Peripheral Vascular Peripheral Vascular Disease
Disease
MODULE
3 ABCs ABCs ...of Optimizing Diabetes ...of Optimizing Diabetes
A1C - greater than 9% will affect
wound healing.
Recommended is less than 7%
Blood Pressure
Cholesterol
Diet
Exercise
Foot care-
Check both feet at each appointment
Shoes should be professionally fitted
Smoking
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
12
Feet for
Feet for L.I.F.E. L.I.F.E.
Lifestyle choices
Inspect your feet and footwear
Find professional assistance
Expect your feet to last a life time
MODULE
3
Diabetic Educators can Diabetic Educators can
help:
help:
Foot Care for Prevention
Wash feet daily + dry well
Avoid excessive heat – water, heating pads, etc.
Apply moisturizer (NOT between toes)
Cut toes nails straight across
Do NOT self treat corns, warts, etc.
Avoid bare feet + wear shoes that fit well
Seamless socks, no tight band
Check footwear for foreign objects
(Source: FH Diabetic Education Center)
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
14
Client Education: Early Detection Client Education: Early Detection
Inspect your feet daily
Check the bottoms of your feet
If needed ask your family to help or use a mirror
Be aware of signs of infection
Redness
Swelling
Warmer than surrounding skin
Discharge
MODULE
3
Client Education: Prompt Client Education: Prompt
Treatment Treatment
See your doctor for uninfected sores that don’t improve in 2-3 days
If signs of infection are present, seek medical attention immediately
Infection can raise blood sugar
Infection can move 2-3 times faster when blood sugar is high
Pain of an injury may not be felt
Follow treatment advice of your health care provider
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
16
Diabetes & Healthy Feet Diabetes & Healthy Feet
Canadian Association of Wound Care (CAWC) Public Information http://www.cawc.net/
An interactive public site that allows client to identify:
Personal self management plan
Questions to ask your doctor
Personal foot care team
Personal foot care plan
How to assess your feet
MODULE
3
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
18
Prevention & Treatment of DFUs Prevention & Treatment of DFUs
Take a careful history to determine general health, diabetic control, and complications
Ensure that the client is aware of the risks to feet associated with diabetes
Recognize that loss of protective
sensation (LOPS) is the greatest risk factor for the development of plantar ulcers
MODULE
3 Components of Foot Assessment Components of Foot Assessment
History:__________
Foot appearance &
structure: observe foot shape and any deformities
Gait: walking, ROM, balance
Neurologic:
sensation, tenderness, signs of hyperesthesia, paresthesia
Circulation: skin temp, pulses, cap refill,
Doppler, ABI (ankle brachial index)
Skin condition:
hydrated, dry,
macerated, fissures, cracks, edema
Infection
Footwear: indoor &
outdoor
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
Seconds Questions Physical Exam First 15
seconds
Are your feet ever numb?
*Look at the feet/shoes
*Visually examine the foot for skin condition, colour, calluses, toenail condition and structural deformities
Next 15
seconds Do they ever
tingle? *Palpate the foot for
temperature and ROM in general, but the big toe specifically
Final 30
seconds Do they ever burn?
Do they feel like insects crawling on them?
Check for sensory intactness, especially light tough using a 10-gram monofilament
20
Sixty Second Foot Exam Sixty Second Foot Exam
Shane Inlow, 2004 Shane Inlow, 2004
MODULE
3
Peripheral
Peripheral
Neuropathy Neuropathy
Metabolic origin
Possible theory
High blood sugars results in demyelination and subsequent lower conduction speed in the peripheral nerves
Type 1 diabetes: Rare in first 5 years of diagnosis
Type 2 diabetes: 8% have neuropathy at diagnosis
40% have neuropathy after 20 years diagnosis
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
22
Neuropathy Neuropathy
3 different types of neuropathy
Causatives of problems with diabetic foot
S ensory
A utonomic
M otor
MODULE
3 S S ensory Neuropathy ( ensory Neuropathy ( S S .A.M.) .A.M.)
Signs & Symptoms
Burning, tingling, numbness cramps
Paresthesia, hyperesthesia,
Loss of vibratory sensation
Loss of Protective Sensation (LOPS) can cause trauma:
Chemical trauma
Mechanical trauma
Thermal trauma
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
24
S S ensory Neuropathy & ensory Neuropathy & LOPS LOPS
L oss O f
P rotective
S ensation
MODULE
3
Why Why L L
ossossO O
ffP P
rotective rotectiveS S
ensationnsationcauses causes ulceration
ulceration
Poorly fitted shoes
Undetected foreign bodies
Improper nail trimming
Burns from hot water & heat appliances
Frostbite
Walking on structures and tissues that are destroyed
Self callous removal
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
26
Un-trimmed Nail Causing Pressure
Un-trimmed Nail Causing Pressure
( ( S S .A.M.) .A.M.)
MODULE
3 Monofilament Testing Monofilament Testing
Conducted with clients who have:
Diagnosis of diabetes and/ or diabetic foot ulcer
Numbness tingling, burning or a “crawling” sensation in either foot
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
28
Monofilament Testing
Monofilament Testing
MODULE
3 A A utonomic Neuropathy (S. utonomic Neuropathy (S. A A .M.) .M.)
Signs & Symptoms
Dry skin and/or sweaty feet leads to:
Fissures
Fungal infections
Poor skin integrity and increased entry for
infection
Hot or cold sensations in the feet
Diminished reflexes
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
30
Xerosis/Anhydrosis Fissures
A A utonomic Neuropathy (S. utonomic Neuropathy (S. A A .M.) .M.)
MODULE
3
Moisturizers to Protect Skin Moisturizers to Protect Skin
(S. (S. A A .M.) .M.)
Classified as:
Emollient – mixture of water and oil
Humectant – additives that attract and hold water (lactic acid, urea)
Occlusion – physical covering of the skin preventing water loss
Good moisturizer should?
Combine occlusion and humectant properties
e.g. Atractain
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
32
M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)
Neuropathy of the innervating motor neurons of the lower extremities
Distal to proximal cell death pattern
Intrinsic muscles of the foot are primarily involved
MODULE
3
Intrinsic muscle weakness:
Physical deformity of the foot
New pressure areas form
Altered gait
M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
34
Hammer Toe
Claw Toe
M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)
MODULE
3
Claw Toe Hammer Toe
M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
Fat Pad Migration
Fat Pad Migration (S.A. (S.A. M M .) .)
Clawing of the toes pulls the fat pads towards the toes
Uncovers the heads of the metatarsal bones
This removes the protective padding for the skin and
subcutaneous tissue
Pressure Pressure
MODULE
3
Intrinsic muscle
imbalance in the foot can cause the medial
longitudinal arch to increase
M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
38
The transverse arch of the forefoot can collapse, creating new pressure areas
1 2
2
M M otor Neuropathy (S.A. otor Neuropathy (S.A. M M .) .)
MODULE
3
How How M M otor Deformity otor Deformity Contributed To Ulcer?
Contributed To Ulcer?
1. Clawing of the foot / toes 2. Collapse of the arches
3. Migration of the fat pads All adds up to pressure
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
40
Deformities In The Foot:
Deformities In The Foot:
Where do you see the problem?
Where do you see the problem?
MODULE
3
Address Client Concerns Address Client Concerns
Related to
Related to SAM SAM
Activity of daily living (ADL)
Life styles
Diet
Work
Psychosocial/financial/emotional issues
Supports family, community, etc
Environmental issues
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
42
Self Management Self Management
Previous education
Foot care/footwear
Knowledge of
Personal risk factors and harm reduction
How to avoid foot trauma
When to access medical care
Behaviour
Adherence to diet, blood glucose monitoring, healthy lifestyle
choices
MODULE
3 Nutrition Nutrition
Optimal glycemic control
Adequate calories
Protein requirements 2-3 times normal
Supplement with multi- vitamins and minerals
Adequate hydration
Referral to dietitian
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
44
Role of Dietitian (RD) Role of Dietitian (RD)
Determines macro-/micro-nutrient needs
Modifies diet and/or recommend supplements if required
Provides education for optimizing glycemic control
Blood sugar / A1C
MODULE
3 Dietitian Referral Dietitian Referral
Diabetes Services
Clinics across Fraser Health, contact information and referral form available on
http://www.fraserhealth.ca/find_us/services/our_services?
&program_id=9557
Home Health Dietitian
Only available in Fraser North and East
Very limited access
Home visits only available to homebound clients who receive Home Health/Nursing Care
HealthLink BC
8-1-1
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
46
One Day, One Day,
Sam was surprised that...
Sam was surprised that...
His right foot was red, swollen, hot, and very painful
His GP referred him to ER suspecting of cellulitis or deep vein thrombosis
From his medical history, physical examination,
and lab/x-ray results, Sam was admitted for …
……Charcot FootCharcot Foot
Fracture caused by decreased structural
integrity of the bone as a result of hypervascularity of the mid foot osseous structures
MODULE
3
Age
Offload
Physician
VIP SAM/LOPS
Lifestyle
A Team Approach to Support Sam with A Team Approach to Support Sam with
CC
harcot Foot harcot Foot
Footcare
Dietitian Nurses/CM
RCA/PCA/CHW Food Services
OT/PT/Rehab
Pharmacist Social Worker
Specialists
Recreation
Psychosocial Spiritual
Volunteers Management
Sam/Family
DM Educator
DM Control
Charcot Foot
WCC/ET/WOCN
Orthotist/Pedorthotist
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
48
Risk Factors for Charcot Foot Risk Factors for Charcot Foot
1 in 680 person with diabetes (0.15%)
Many go undetected when clients do not
experience pain due to neuropathy
Risk factors :
Peripheral sensory neuropathy
Normal circulation
Preceding trauma, often minor, e.g.
sprains or contusions
Foot deformities, prior amputations, joint
infections or surgical trauma disease
MODULE
3
Stages of Charcot Foot
Stages of Charcot Foot
BPR update 2010BPR update 2010Stage Description
0 Prodromal period: dermal flush/redness,
increase skin temperature, with or without local edema & bounding pulses. Evidence of foot
instability. X-ray evidence may be seen
1 Developmental stage: An acute destructive period that is induced by minor trauma resulting in fragmentation of bone and joint
dislocation/subluxation
2 Coalescence stage: Lessening of edema and healing of fractures
3 Reconstruction: Healing of bone and
remodeling on X-ray, and evidence of deformity
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
50
Charcot Foot With Ulceration Charcot Foot With Ulceration
Acute Charcot is a medical emergency
High risk for ulceration with re-occurrence
MODULE
3
Age
Offload
Physician
VIP SAM/LOPS
Lifestyle
A Team Approach to Support Sam
A Team Approach to Support Sam withwith
Diabetic Foot Ulcers (DFUs) Diabetic Foot Ulcers (DFUs)
Footcare
Dietitian Nurses/CM
RCA/PCA/CHW Food Services
OT/PT/Rehab
Pharmacist Social Worker
Specialists
Recreation
Psychosocial Spiritual
Volunteers Management
Sam/Family
DM Educator
DM Control
DFU
WCC/ET/WOCN
Orthotist/Pedorthotist
Prosthetics
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
52
Pathway To Assessment and Treatment Pathway To Assessment and Treatment
Of Person With Diabetic Foot Ulcers Of Person With Diabetic Foot Ulcers
Best Practice Recommendations for the Prevention and Treatment of Diabetic Foot Ulcers: Update 2006 - Heather L. Orsted, Gordon Searles, Heather Trowell, Leah Shapera, Pat Miller and John Rahman
Person with Diabetic Foot Ulcer
Treat the Cause
Vascular flow
Awareness of neuropathic changes
Pressure redistribution
Glycemic control
Lipid control
Client-centered Concerns
Adherence to plan of care
Quality-of-life issues related to lifestyle changes
Local Wound Care
Debridement
Callus and necrotic tissue Moisture Balance
Control exudate Inflammation/
Infection Control
Rule out/treat osteomyelitis
Edge of the Wound
Biological dressings
Adjunctive therapies
MODULE
3
Risk Factors Affecting DFU Healing Risk Factors Affecting DFU Healing
Nutrition
Ulcer history
Co-morbidities
Oxygenation
Smoking
COPD
Glucose Control
Hx of Diabetes>10yr
AIC greater than 9%
Foot care
Ability to assess feet
Footwear
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
54
Diabetic Foot Ulcer Assessment Diabetic Foot Ulcer Assessment
Address underlying cause and establish goal of treatment
VIP – 3 major components of assessment
V ascular Supply
I nfection
P ressure
MODULE
3
V V ascular Supply I I nfection P P ressure
15% of DFUs are related to peripheral vascular supply (Vascular supply)
Poor vascular supply and pressure often exist together to varying degrees within the ulcer etiology
V
ascular SupplyI
nfectionP
ressureMODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
56
VIP V : : V V ascular Supply ascular Supply
Compromised Arterial Flow Leads To Ulcerations
MODULE
3 The Vascular Assessment: The Vascular Assessment:
Thin atrophied skin
Loss of hair on the foot and ankle
Temperature of skin, feet
Thickened nails
Decreased or absent DP and PT pulses
Claudication
Pallor with elevation
Intolerance of elevation
Dependent rubour
Slow capillary re-fill (greater than 4
seconds)
But there is the catch……..
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
58
The catch The catch
with a Person With Diabetes…
with a Person With Diabetes…
Intermittent claudication/rest pain may be absent
Palpable pedal pulse is a poor indicator of vascular status due to vessel calcification
Toe pressures or transcutaneous oxygen are the gold standard for determining the quality of peripheral arterial circulation of a person with diabetes
MODULE
3 V V ascular Supply ascular Supply
Occlusion of blood vessels can progress rapidly due to:
hyperlipidemia
hypertension
insulin resistance
hyperglycemia
increases in plaque formation and
coagulation
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
60
Review Vascular Disease (V.I.P) Review Vascular Disease (V.I.P)
How do we assess the foot and the limb?
Pedal pulse
Skin
Temp
Colour
Hair
Nails
Pain
Claudication
Rest Pain
MODULE
3 V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure
Infection makes healing
of an ulcer difficult or may be a causative factor in ulceration
Dry skin can lead to
infection and ulceration
What Signs and Symptoms Of Infection Do You See Here?
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
62
MODULE
3 Increased Bacterial Burden Increased Bacterial Burden
Non healing
Non-granulation
Friable or
hypergranulation
Slough
↑Exudate
Serous to purulent
Odour after cleansing
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
64
Localized Infection Localized Infection
Pain or wound pain↑
Induration>=2cm
↑Erythema>=2cm
↑Warmth
Wound deterioration
Purulent exudate
Wound may probe to bone
↑Spasticity/Dysreflex in persons with SCI
MODULE
3 Systemic Systemic I I nfection nfection
General Malaise
Fever
Rigor/Chills
Change in Behaviour
Change in Cognition
Unexplained elevation of blood sugars
Septic shock, multi-organ failure
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
66
V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure
Beware!
Symptoms of infection may be masked by decreased immune response common in diabetes
MODULE
3
Key features of diabetic foot infection:
History of worsening glucose control without explanation
New local pain
Increased WBC
V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
68
Neuropathic changes result in gait changes &
callous formations causing Pressure
Pressure is the primary cause of 85% of diabetic foot
V V ascular Supply ascular Supply I I nfection nfection P P ressure ressure
MODULE
3 P P ressure Related Forces ressure Related Forces
Compression – perpendicular force to the tissue
Friction – superficial transverse force between skin and contact surface
Shear – deeper transverse force between superficial and subcutaneous tissue
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
Braden Scale Braden Scale
Can be a useful tool to identify at risk client
1. Sensory Perception 2. Moisture
3. Activity 4. Mobility 5. Nutrition
6. Friction & shear
70
MODULE
3 P P ressure ressure
Pressure highest between soft tissue &
bony prominences
Plantar Metatarsophalangeal joints
Plantar 1st toe
Perimeter and plantar heel
Plantar, Dorsal and lateral surfaces of the digits and foot
New areas caused by deformityMODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
72
“Off-Loading the Diabetic Foot for Ulcer, Prevention and Healing”; P.R.
Cavanagh, S.A. Bus; Plast. Reconstr. Surg. 127 (Suppl.):248S, 2011.
A. Bare foot B. Flat insole C. Custom moulded insole
MODULE
3 P P ressure and Callous ressure and Callous
Long term or repetitive pressure, not high enough to cause immediate cell death, can result in the formation of callous
Callous increases the pressure directly to the underlying tissues, creating more callous, and leads to sufficient pressures to cause
ulceration
In the diabetic foot, callous increases the pressure directly to the underlying tissues, creating more callous, and leads to sufficient pressures to cause ulceration
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
74
Footwear, Pressure, Footwear, Footwear, Pressure, Footwear, Pressure, Footwear, Pressure…
Pressure, Footwear, Pressure…
MODULE
3
Key Criteria Key Criteria
For Appropriate Footwear For Appropriate Footwear
A wide toe box
Sufficient depth
Good arch support
Good fit
Grip
Cushioning
Lacing
Durability
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
76
Shoe Components Shoe Components
Toe Box
Arch Support Laces
Grip / Sole Foot Bed
Heel Counter
Seams / Ridges
MODULE
3
Activity: Foot Tracing
Activity: Foot Tracing
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
78
Recommendations for Appropriate Recommendations for Appropriate
Footwear Footwear
Utilize skilled shoe fitters, if possible
Shop for shoes in afternoon when feet are largest
Bring orthotics with you, if you wear them
Wear socks you normally wear
Bring old shoes so fitter can see pattern of wear
Inspect and eliminate pressure lines, both lateral and plantar
MODULE
3 Appropriate Footwear Appropriate Footwear
Consider:
Wound / ulcer location
S.A.M., V.I.P., and other risk factors
Environment of use
Finances
Compliance
Cognition
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
80
Coffee Break
MODULE
3
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
82
Managing Pressure Managing Pressure
Three Frameworks
1. Pressure Reduction – Immersion 2. Pressure Offloading – Non weight
bearing, cut outs, half shoes, crutches, etc
3. Alternating Pressure – powered or non powered surfaces, not applicable for plantar wounds
MODULE
3 OT Can Help OT Can Help
Assess pressure, shear, friction, positioning, and function
Recommendations for maximizing physical, cognitive, behavioral, environmental, and / or functional ability in relation to wound healing
Education on community resources (e.g.
specialized ped-orthosis providers)
Basic education on basic shoe fitting
Problem solving when lower income and lack of funding are barriers to care.
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
84
Footwear / Offloading Options Footwear / Offloading Options
1. Total Contact Casts
2. Removable Cast Walkers 3. Half Shoes
4. Surgical Shoes 5. Healing Sandals
6. Over the Counter Orthopedic Shoes 7. Custom Made Shoes
8. Orthotics / Foot beds 9. Mobility Aides
MODULE
3 Total Contact Cast Total Contact Cast
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
86
Total Contact Cast Total Contact Cast
Advantages
Uniform distribution
of pressure over entire foot surface
Permits mobility
Protects foot from infection
Controls edema
High degree of client adherence
Gold standard in research
Disadvantages
Requires highly trained technicians to apply
safely and effectively
Potential to cause skin irritation an/or ulceration
Unable to assess the foot regularly
Contraindicated
with infection or drainage
Minimal client acceptance
MODULE
3 Removable Cast Walkers Removable Cast Walkers
XP Diabetic Walker™ System DH Offloading Walker™
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
88
Image of Pressure Mapping Image of Pressure Mapping Test Comparing a Patient’s Test Comparing a Patient’s
Own Footwear to a Own Footwear to a Removable Cast Walker Removable Cast Walker
Removable Air Cast / Cast Walkers Removable Air Cast / Cast Walkers
“Off-Loading the Diabetic Foot for Ulcer, Prevention and Healing”; P.R.
Cavanagh, S.A. Bus; Plast. Reconstr. Surg. 127 (Suppl.):248S, 2011.
MODULE
3
Removable Cast Walkers Removable Cast Walkers
Advantages
Allows for self-inspection and dressing changes
Improved comfort
Initial studies suggest close to TCC results
Can add custom foot bed to the boot
Disadvantages
Significant risk if over inflated- ischemia
Contraindicated for client’s with mobility and/or cognitive
impairments
Removable
Expensive
Contraindicated for heel ulcers
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
90
Half Shoes Half Shoes
Rear Foot Forefoot
DARCO HeelWedge™
DARCO OrthoWedge™
MODULE
3 Half Shoes Half Shoes
Advantages
Transfer pressure to mid and rear foot by eliminating prolusion
Low Cost
Disadvantages
Very unstable
High risk of falls
Does not fully offload or redistribute pressure
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
92
Surgical Shoes Surgical Shoes
DH Offloading Post-Op Shoe
DARCO APB™ All Purpose Boot DARCO MedSurg™ Shoe
MODULE
3
Surgical Shoe Surgical Shoe
Advantages
Low Cost
Accommodates Edema
Good for short term management
Disadvantages
Offloading is limited
Requires an orthotic or cushioning foot bed to be effective
Limits mobility
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
94
Healing Sandals Healing Sandals
DARCO Wound Care Shoe System™
Custom Sandal
MODULE
3
Healing Sandals Healing Sandals
Advantages
Moderate plantar pressure offloading
Complete pressure offloading of the top of the toes
Disadvantages
Require skilled and
experienced personnel to create and/or apply
Negative impact on mobility and balance
Limited durability
Expensive
Tall
MODULE
3
Diabetic Foot Ulcers 2006 Revised: 2012
96
OTC Diabetic Orthopaedic Shoes OTC Diabetic Orthopaedic Shoes
DARCO Gentle Step™
Pedors Black Classic
Pedors Classic Max