The Diabetic Neuropathies
The Diabetic Neuropathies
Patients with peripheral neuropathy are at higher risk of falling, and this problem may be particularly acute in diabetes. Among 60 diabetic patients over the age of 55 years old, over one-third had fallen in the prior year. Neuropathy, sensory loss, and distal weakness were major risk factors. Bedside gait examination may be a relatively insensitive predictor of fall risk. Patients with neuropathy often fall when walking on uneven or irregular surfaces, and formal gait evaluation should include these testing conditions. Any DSP patient, or patients with poor lower extremity strength or vibration perception should be counseled regarding fall risk and consideration given to possible gait evaluation and physical therapy intervention.
Foot ulceration and consequent digit, foot, or limb amputation remains a common diabetic complication. Among 248 diabetic patients followed prospectively in tertiary care podiatric clinic, foot ulcers developed in 29% of subjects and 19% of feet over a mean 30-month follow-up. DSP increases the risk of ulceration sevenfold and contributes to over 60% of lower extremity amputations in diabetic patients. The increased risk is due to a combination of lack of protective sensation, abnormalities in blood flow that are often compounded by peripheral artery disease, abnormal sweating, and poor wound healing. Ulceration and amputation risk is also related to duration of neuropathy and severity of hyperglycemia. Daily self-examination, with a foot mirror if necessary; podiatric consultation and maintenance for toenails and bunions; orthotic foot support, and use of protective, wide-based shoes with adequate toe box and ankle support are recommended for patients at risk for ulcers. If stasis ulcers develop, nonsurgical debridement, application of hydrogels, and empiric antibiotic coverage for wound flora are appropriate therapy.
Prevention of Neuropathy Complications: Falls and Ulcers
Patients with peripheral neuropathy are at higher risk of falling, and this problem may be particularly acute in diabetes. Among 60 diabetic patients over the age of 55 years old, over one-third had fallen in the prior year. Neuropathy, sensory loss, and distal weakness were major risk factors. Bedside gait examination may be a relatively insensitive predictor of fall risk. Patients with neuropathy often fall when walking on uneven or irregular surfaces, and formal gait evaluation should include these testing conditions. Any DSP patient, or patients with poor lower extremity strength or vibration perception should be counseled regarding fall risk and consideration given to possible gait evaluation and physical therapy intervention.
Foot ulceration and consequent digit, foot, or limb amputation remains a common diabetic complication. Among 248 diabetic patients followed prospectively in tertiary care podiatric clinic, foot ulcers developed in 29% of subjects and 19% of feet over a mean 30-month follow-up. DSP increases the risk of ulceration sevenfold and contributes to over 60% of lower extremity amputations in diabetic patients. The increased risk is due to a combination of lack of protective sensation, abnormalities in blood flow that are often compounded by peripheral artery disease, abnormal sweating, and poor wound healing. Ulceration and amputation risk is also related to duration of neuropathy and severity of hyperglycemia. Daily self-examination, with a foot mirror if necessary; podiatric consultation and maintenance for toenails and bunions; orthotic foot support, and use of protective, wide-based shoes with adequate toe box and ankle support are recommended for patients at risk for ulcers. If stasis ulcers develop, nonsurgical debridement, application of hydrogels, and empiric antibiotic coverage for wound flora are appropriate therapy.
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