DIABETIC FOOT

MEDICAL REHABILITATION
AND
PREVENTION

hendriko
 INTRODUCTION
There is a worldwide epidemic of diabetes. World
Health Organization stated that about 347 million
people suffer from diabetes

One of the most common and serious complications of

diabetes mellitus is ulceration of the foot

By 2030, there is a projected increase of 7.7% in the

worldwide prevalence of diabetes, with a 20% increase
in developed countries
Source: Thakral G., et al. Electrical Stimulation as an Adjunctive Treatment of Painful and Sensory Diabetic
Neuropathy. J Diabetes Sci Technol Vol 7, Issue 5, September 2013
 INCIDENCE
Diabetic peripheral neuropathy affects 60% to 70% of people with
diabetes

The incidence of lower limb amputations due to vascular disease has

increased in the United States by approximately 20% during the last
decade

More than 60% of nontraumatic lower limb amputations occur in

people with diabetes

Multdisciplinary clinics have demonstrated impressive reductons of

44% to 85% in the incidence of foot ulcers and lower limb amputations

Source: Kolodin EL, Vitale T, Gerber LH. Foot Disorders. In. DeLisas Physical Medicine & Rehabilitation. Principles
and Practice. 5th ed. Lippincot Williams & Wilkins, 2010. Philadelphia, USA
 DIABETIC FOOT IMPAIRMENT

Source: Turan Y., et al . Physical Therapy and Rehabilitation in Diabetic Foot. World J Exp Med 2015 May 20;
5(2): 130-139. ISSN 2220-315
 FUNCTIONAL LIMITATIONS
Persons with diabetes can develop peripheral
polyneuropathy with loss of positon sense and
weakness

These can lead to gait instability and falls

Persons with peripheral arterial disease are often

limited in community ambulaton and vocatonal
activities because of pain from claudication
Source: Esquenazi A, Talaty M. Gait Analysis: Technology and Clinical Application. In. Physical
Medicine and Rehabilitation. Braddom. 4th ed. Elsevier Saunders. PA. 2011
 GAIT ANALYSIS

Source: Esquenazi A, Talaty M. Gait Analysis: Technology and Clinical Application. In. Physical Medicine and Rehabilitation.
Braddom. 4th ed. Elsevier Saunders. PA. 2011
REHABILITATION PROBLEMS (ICF)

Source: Enderby P. Therapy Outcome Measures for Rehabilitation Professionals. 2nd ed. John Wiley &
Sons, Ltd. 2006.
 FUNCTIONAL ABILITY

Source: Skelton AD, Dinan-Young M. Ageing and Older People. In. Exercise Physiology in Special Populations.
Churchill Livingstone. 2008
REHABILITATION TREATMENT

Prevention Exercise

Orthotics Physical
Prosthetics Modalities
 PREVENTION
Rate of recurrent ulceration has been reported to be
28% in the first year, reaching up to 100% at 40 mo
Patients should be check their feet every day (including
with a mirror to see the bottoms) for the presence of
skin breaks, redness, swelling, callus or other problems
Prevention of diabetic foot ulcers begins with
screening for loss of protectve sensation with a brief
history and the Semmes-Weinstein monofilament
Should avoid walking on bare foot, or using flimsy or
poorly fitting sandals or slippers
Source: Turan Y., et al. Does Physical Therapy and Rehabilitation Improve Outcomes for Diabetic Foot Ulcers?
World J Exp Med 2015 May 20; 5(2): 130-139
 COMPONENTS OF PHYSICAL FITNESS

Source: Buckley JP, Hughes HR. Introduction. In. Exercise Physiology in Special Populations. Churchill
Livingstone. 2008
 EXERCISE TREATMENT

ROM &
Stretching
Buerger-Allen

Propriocepton

Balance & Coordinaton

Source: Turan Y., et al. Does Physical Therapy and Rehabilitation Improve Outcomes for Diabetic Foot Ulcers?
World J Exp Med 2015 May 20; 5(2): 130-139
 DEEP HEAT
The sound frequencies used in ultrasound therapy are typically 1.0 to 3.0 MHz (1
MHz = 1 million cps) at amplitude densities of 0.1 to 3 w/cm

When Ultrasound (US) therapy is used in musculoskeletal diseases at low frequencies

(such as 20-40 kHz), debridement effect becomes more prominent (concomitant
bactericidal and wound healing)

US can improve tssue repair by increasing protein synthesis, mast cell degranulation
and growth factor production, uptake of calcium and fibroblast mobility

US increases intracellular calcium and permeability of cell membrane which lead to

faster tissue healing at intensities of 0.5 to 0.75 w/c m2 with pulsed frequency of 20%

Source: El- Kader SMA, Ashmawy EM. Impact of Different Therapeutic Modalities on Healing of Diabetic Foot Ulcers.
Eur J Gen Med 2015; 12(4):319-325
 Extracorporeal shock wave therapy (ESWT)
It focuses strong sound waves on affected site using an ellipsoid-shaped
steel probe amount of energy 10-fold higher than delivered by
ultrasonic devices within 1 ms

it delivers high-amplitude, short, single, pulsatile, acoustic waves that

distribute their mechanical energy into the environment while passing
from the soft tissue to the bone

Recommendations for the treatment of diabetic foot ulcer are generally

administration at an energy level of 0.03 mjoul/mm2 twice weekly, 30
min @ foot, for a total of 6 applications, to achieve 100 pulses/cm2

Source: Turan Y., et al. Does Physical Therapy and Rehabilitation Improve Outcomes for Diabetic Foot Ulcers?
World J Exp Med 2015 May 20; 5(2): 130-139
 LASER
Laser can be used for acceleration of wound
healing as the biostmulaton of the
inflammatory phase
Altering the levels of various prostaglandins
Increasing ATP synthesis by enhancing electron
transfer in the inner membrane of the
mitochondria
Acceleration of collagen and fibroblasts synthesis
and vascularizaton of the healing tissue
Source: El- Kader SMA, Ashmawy EM. Impact of Different Therapeutic Modalities on Healing of Diabetic Foot Ulcers.
Eur J Gen Med 2015; 12(4):319-325
The most likely explanation for triggering remote responses following a localized light
exposure is the release of cytokines and growth factors into the circulation which are
responsible for systemic vasodilatation and formation of new capillaries

The induction of increased levels of cytokines such as IL-1, IL-2, IFN-, and TNF- after they
exposed leukocytes to 19 J/cm2 of a HeNe laser (Funk et al. (1992, 1993))

A direct or indirect interference of visible and infraredWavelengths with mitochondrial

components of the respiratory chain is part of the signal transduction pathway (Tiphlova
and Karu, 1989; Karu et al., 1993; Lubart et al., 1992)
 ELECTROTHERAPY
Electrical stimulation is typically administered at 30-
Hz frequency, at a pulse every 250 microseconds,
and 20-milliampere current, using 5 cm 5 cm
disposable carbonized electrodes, for 30 min three
times weekly

The current flows in one direction and has polarity

current. Through stimulation of the myelin-free pain
fibers, this current achieves paresthesia of both the
superficial and the deep skin layers
Source: Thakral G., et al. Electrical Stimulation as an Adjunctive Treatment of Painful and Sensory Diabetic
Neuropathy. J Diabetes Sci Technol Vol 7, Issue 5, September 2013
 WAVEFORMS OF ELECTRICAL STIMULATION IN
WOUND HEALING PHASE

Source: Ud-Din S, Bayat A. Electrical Stimulation and Cutaneous Wound Healing: A Review of Clinical Evidence. Healthcare
2014, 2, 445-467; doi:10.3390/healthcare2040445
 ORTHOTICS
The mainstay of treating plantar ulcers has been
with the use of total contact cast
It is believed to reduce plantar pressures at the
ulcer site
It is labor intensive, requires weekly applications
If improperly applied can result in significant
complicatons, including increased joint stiffness,
impaired mobility, abrasions, ulceration,
osteoporosis, and muscle atrophy
Source: Kolodin EL, Vitale T, Gerber LH. Foot Disorders. In. DeLisas Physical Medicine & Rehabilitation. Principles
and Practice. 5th ed. Lippincot Williams & Wilkins, 2010. Philadelphia, USA
 ORTHOTICS
The patient should be counseled on the
modality and the importance of compliance
with treatment protocols
Effective alternatives to TCC include
prefabricated total-contact posterior ankle-
foot orthoses, removable prefabricated
walking casts, wedged or half-soled shoes,
and total-contact sandals

Source: Kolodin EL, Vitale T, Gerber LH. Foot Disorders. In. DeLisas Physical Medicine & Rehabilitation. Principles
and Practice. 5th ed. Lippincot Williams & Wilkins, 2010. Philadelphia, USA
 SHOE MODIFICATION
Jenis Modifikasi Nama Alat
1. Modifikasi Eksternal Modifikasi Tumit 1. Cushioned heel
2. Heel Flare
3. External heel wedge
4. Extended heel
5. Shoe lift
Modifikasi Sol Eksternal 1. Rocker bar
2. Metatarsal bar
3. Sole wedge
4. Sole flare
5. Steel bar

Sumber: Rachmi A., et al. Pedoman Standar Pengelolaan Disabilitas. Wahyuni LK, Tulaar ABM. PERDOSRI. 2014
 SHOE MODIFICATION
Jenis Modifikasi
2. Modifikasi Internal
Modifikasi Tumit Internal
Modifikasi Sol Internal
Inserts
Nama Alat
1. Heel excavation
2. Internal heel wedge
1. Inner Sol Excavation
2. Bantalan Metatarsal
3. Scaphoid pad
4. Toe Crest
1. UCBL Inserts
2. Heel cup
3. Bantalan sesamoid
4. Bantalan longitudinal

Sumber: Rachmi A., et al. Pedoman Standar Pengelolaan Disabilitas. Wahyuni LK, Tulaar ABM. PERDOSRI. 2014
 SHOE MODIFICATION
Custom molded shoes can enhance ambulaton and unload pressure areas

Lateral and medial heel wedges may be used to control varus and valgus
deformities

Metatarsal bars can be placed on the outsole of the shoe to shift weight from the
metatarsal heads

This can be incorporated with an extended steel shank, which can be used to
decrease the magnitude of the toe break and facilitate roll off

When there is limited ankle motion, an ankle cushion heel can be added to provide
stimulated plantar flexion and aid in shock absorption
Source: Kolodin EL, Vitale T, Gerber LH. Foot Disorders. In. DeLisas Physical Medicine & Rehabilitation. Principles
and Practice. 5th ed. Lippincot Williams & Wilkins, 2010. Philadelphia, USA
 SHOE MODIFICATION
The shoes usually have a blucher style opening, lightweight, large and high
finger toe box and rocker bars, made from soft and flexible leather

Shoes with rocker bars reduce the ground reaction force and facilitate the
push-off phase of walking

Plastazote insoles may help ensure a homogenous distribution of the load

Heels soft pad and made from at least two materials of different densities,
with a robust edge and a capacity to absorb light shocks

The soles should be renewed every 6 to 12 mo

Source: Kolodin EL, Vitale T, Gerber LH. Foot Disorders. In. DeLisas Physical Medicine & Rehabilitation. Principles
and Practice. 5th ed. Lippincot Williams & Wilkins, 2010. Philadelphia, USA
 TAKE HOME MESSAGE
Outcomes have consistently been shown to be better
when patients with a diabetic foot ulcer are cared for a
mult or interdisciplinary approach
It may include Rehabilitaton experts
Therefore, every means possible should be used to try
to heal a diabetic foot ulcer, including exercise therapy,
footwear modifications and rehabilitation methods
The ultimate goals should be to lower amputaton
rates and help maintain good functon and quality of
life of our patients
terimakasih