evaluating and managing foot pain and neuropathy in diabetics dr. leslie goldenberg b.sc., m.d.,...
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Evaluating and Managing Foot Pain and Neuropathy in Diabetics
Dr. Leslie GoldenbergB.Sc., M.D., F.R.C.P.(C)., A.B.I.M., F.A.G.S
Medical Director, Walking Mobility ClinicsAssistant Professor, U of T Faculty of Medicine
PRESENTER DISCLOSURE
Dr. Leslie Goldenberg
Relationships with commercial interests: Medical Director of Walking Mobility Clinics
PROGRAM DISCLOSURE OF COMMERCIAL SUPPORT
Dr. Leslie Goldenberg
No commercial support
MITIGATION OF BIAS
Dr. Leslie Goldenberg
Not applicable
NEUROPATHY AND GAIT
NEUROPATHY AND GAIT
NEUROPATHIES
1. Sensory polyneuropathy clinically encompassing a spectrum from subclinical sensory loss to the totally asensate foot (distal symmetric small fiber neuropathy)
2. Autonomic neuropathy with trophic changes, distal hair loss and dry skin
3. Sensory motor polyneuropathy with distal weakness of longer duration (much less common than sensory neuropathy)
NEUROPATHIES
4. Painful distal sensory neuropathy
5.Painful proximal diabetic neuropathy or lumbosacral radiculoplexus neuropathy
6.Femoral neuropathy with diabetic amyotrophy associated with quadriceps wasting
NEUROPATHIES
7. Acute painful diabetic neuropathy (reversible insulin neuritis)
8. Single neuropathy especially of the peroneal and posterior tibialis nerve; third nerve, intercostal nerve roots and median nerve (mononeuropathy)
9. Local pressure palsies and entrapment neuropathies
NEUROPATHIES
10.Part of the syndrome of mononeuritis multiplex
11.Chronic inflammatory demyelinating polyneuropathy
12.Restless leg syndrome associated with diabetes
NEUROPATHIES
13.‘Too tall’ neuropathy
14. Acute quinolone neuropathy
LOCAL PRESSURE PALSIES & ENTRAPMENT NEUROPATHIES
Uni or bilateral peroneal palsy with foot drop
Tibial neuropathy in medial tarsal tunnel
Anterior tarsal tunnel syndrome
Plantar and calcaneal branch entrapments
Buttock sciatica/piriformis syndrome
TOXIC NEURITIS IN DIABETICS
Acute insulin neuritis
Acute Quinolone neuritis
Flagyl neuropathy
Statin induced neuropathy
Pyridoxine (Vitamin B6) neuritis
PROPRIOCEPTION
Role of proprioception and proprioceptive loss in balance
CLINICAL SCREENING ‘QUICKIES’:THE ONE MINUTE NEUROPATHY EXAM
1. Arise without arm recruitment
2. Heel and toe raises
3. Single leg balance
4. Assess sway with eyes closed – static gait
CLINICAL SCREENING ‘QUICKIES’:THE ONE MINUTE NEUROPATHY EXAM
5. Dynamic gait – tandem
6. Turn – Kneel – Deep tendon reflexes
7. Tuning fork – 10 gram pressure – light toe touch
8. Clues from visual inspection (autonomic, claw toes, intrinsic minus, trophic)
BLOOD TESTING SCREEN FOR NEUROPATHY CO-CONSPIRATORS ESR, ANA, ENA-Panel (SSA + Bab)
Serum protein Electrophoresis and Urine for light chains
HIV and Lyme Serology
Anti Hu antibodies
Cryoglobulins, Mercury, HbAIC, B12 and Pyridoxine
Urine porphyrins
NEUTRICEUTICAL THERAPY
B1 – Benfotiamine 600mg
B2 – Riboflavin 8mg
B6 – Pyridoxine 50-100mg
B12 – Methylcobalamine 4000ucg
R – alpha lipoic acid 300 units
Metanx (B6, B12, Folic Acid) combo
Neuropathy Support Formula
Consider B-50’s & B-100’s
Zinc 75mg tid, Vitamin C 500 mg/d
DIABETIC ULCERS – TOPICAL TRANSDERMALS
Clindoxyl gel or BenzaClin
Diltiazem 5%, 15%
Pentoxifyline 10%
Misoprostol 0.0024%, Phenytoin 5%
Timolol 0.5
Humulin 40 units/gram
Santyl collagenase
Iodosorb Inodine Flamazine
Polysporin complete, Ozonol antibiotic
Mupirocin 2% ointment
Metronidazole 1%, 2%
PCCA-PLO, Delivera, Lipoderm
PAINFUL NEUOPATHY – TOPICAL TRANSDERMALS
PCCA-PLO, Delivra, Lipoderm
Diclofenac 15% or Ketoprofen 20%
DMSO 5%
Ketamine 5%, Gabapentin 6%
Amitriptyline 10%
NNT – NUMBERS NEED TO TREAT
TCA’s – 1.4
NMDA antagonists – 1.8
Dilantin – 2.2
Tramadol – 3.3
Neurontin (gabapenin) – 3.7
Lyrica (pregablin) – 4.5
Capsaicin – 5.0
SSRI’s – 6.7