Diabetes Chronic Complications - part 4 ppt

lignocaine Revisit coping strategies and psychological/psychiatric disease Consider complementary therapies Consider referral to specialist pain management team Figure 3.2 Treatment opti

 Hyperaesthesia – this is a heightened awareness of sensations or increasedsensitivity to stimulation, e.g brushing or stroking of the skin.

 Hypoaesthesia – this is a decreased sensitivity to stimulation

 Hyperpathia – this is a pain syndrome characterized by abnormally painfulreactions to stimuli

 Analgesia – this is the absence of pain to stimuli that would normally be painful

 Hypoalgesia – this is diminished pain in response to normally painful stimuli

 Hyperalgesia – this is an increased response to a stimuli that is not normallypainful

 Allodynia – this is the alteration of normal sensation into a painful or unpleasantsensation or pain due to a stimulus that does not usually provoke pain (IASP)

 Paraesthesiae – this is a difficult sensation to describe ‘Pins and needles’ is anaccurate if unscientific descriptor It is an important discriminator between

‘neuropathic pain’ and the ‘rest pain’ of peripheral ischeamia

Risk factors for the development of painful diabetic neurpathy

 Increased age

 Poor glycaemic control

 Increased duration of diabetes

 Smoking

 Other microvascular complications – established complications such as pathy or retinopathy

nephro- Abnormal lipid metabolism – low levels of high-density lipoprotein (HDL)

Assessment of foot pain

It is essential when assessing a patient with foot pain to take a detailed history.This should include detailed information about the type, frequency and nature of

the pain, precipitating and alleviating factors and other associated symptoms.37Adetailed past medical and medication history should be sought There should bespecific questioning about the presence of back pain and bowel/bladder function It

is essential to rule out other causes of foot/leg pain and the other causes ofperipheral neuropathy The pain may be severe and it is important to allow thepatient to express their feelings and for the listener to be empathetic Anassessment of the impact of symptoms should be made

A full physical examination should be carried out This should include a clinicalneurological assessment Pain is subjective and it may be important to identifytools that enable symptoms to be quantified.35,38 Pain questionnaires are widelyused to assist in the detection and measurement of severity of pain and in theevaluation of treatment Common questionnaires and tools in use include thefollowing:

 Visual analogue scale (VAS)38

– patients quantify their pain on a scale of 0 (nopain) to 10 (worst pain ever) This gives a quantitative assessment of the painseverity

 McGill pain questionaire39

– this questionnaire is able to quantify the qualityand severity of pain using four categories: sensory, affective, evaluative andmiscellaneous Descriptive terms are ranked by intensity

 DYCKS neuropathic staging38,39 – this takes into account the severity of painbut also grades the impact of ‘numbness’ and ataxia The grading takes intoaccount the impact on lifestyle’, e.g attending a physician for pain relief, effects

on work and recreational activities and need for medication

 LANNS neuropathic pain scale34

– this pain questionnaire takes into accountfunctional problems as well as pain perception

Management of neuropathic pain

There are a variety of treatments available for the management ofneuropathic pain However, success in alleviating all pain is unrealistic formany Frequently the goal is an improved quality of life, improved sleep and areduction in pain A 50 per cent reduction in pain severity may be a realistic andadequate goal The response to differing treatments will vary markedly betweenindividuals

Improvement in glycaemic control may help to prevent the development andprogression of neuropathic pain, and it is important to target a lowering of bloodglucose in those patients who have poor control Painful neuropathic symptomscan, however, worsen acutely in the context of both sudden deterioration and

sudden improvement in glycaemic control The aim should therefore be a gradualimprovement Patients with type 2 diabetes and poor glucose control despitemaximal oral hypoglycaemic agents should be commenced on insulin therapy.Neuropathic pain is usually a self-limiting condition but symptoms can last formany years It is important to inform sufferers about the cause and natural history

of the condition This information should include a careful explanation of differenttreatments, their effectiveness, potential side-effects and likely improvements It isessential that support networks are put in place for patients We have found that aneducation group involving patients, those that care for them and interested healthcare professionals is one way of achieving this This has the benefit of providingpeer support and also empowering patients with persisting pain to seek furthertreatment and support The authors have come to realize the importance ofinvolving patients in decision-making

It is common for patients to require a number of different treatments, eitheralone or in combination It is vital that treatment is continuously monitored andadjusted in order to maximize the beneficial effects This may prove difficult in abusy specialty outpatient setting but can be achieved more easily by involvingpatients in their management through self-titration of drug therapy and agreed careprotocols By establishing for patients an easy point of contact with an interestedhealth care professional, this benefit is further enhanced

Medical therapies

We recommend the use of an algorithm to standardize the management ofneuropathic pain so that individual patients can receive benefit from all availabletreatments in an order that is most appropriate for achieving resolution ofsymptoms and improvement in quality of life (Figure 3.2)

Simple painkillers are rarely effective and their use should not be prolongedunless there is a rapid response to treatment

Topical agents

Capsaicin cream (0.075 per cent) is derived from the chilli pepper This is appliedthree to four times daily to symptomatic areas of the foot It is believed to workthrough depletion of substance P from nerve terminals

The use of this agent should be reserved for superficial discomfort and pain(burning, tingling etc.) Symptoms (particularly ‘burning’) may worsen for aperiod of 2–4 weeks following its initial use The full benefit of this treatment maynot be realized for 6 weeks It is essential that patients are well educated in the use

of this product in order for it to be effective Hands need to be washed before andimmediately after use Contact with eyes and inflamed or broken skin should be

Ineffective or partially effective

Ineffective or partially effective

Ineffective or partially effective

Ineffective or partially effective

Diagnosis

Consider reversible causes, e.g.

B12 deficiency and alchololism

Education and explanation Outline coping strategies and prognosis

Address poor glycaemic control

Prescribe simple analgesia, e.g paracetamol one month − early review if distressed

Involve physiotherapist where muscle weakness or reduced mobility exists

For superficial pain:

Try capsaicin cream (with detailed explanation of its use and side effects) or an

alternative topical application of Opsite spray.

Add or start tricyclic drug, i.e amitriptyline, or i mipramine with detailed

explanation of use and side effects

Six week course of maximum tolerated dose involving patients in self-titration of doses

Consider withdrawal of other oral therapies and introduce a phased course of

gabapentin or pregabalin

Consider use of tramadol as an add-on or subsititute therapy

Ineffective or partially effective

Ineffective or partially effective

Ineffective or partially effective

Consider substitution of tricyclics or gabapentin/pregabalin for carbamazepine or

Phenytoin therapy

Consider mechanical or invasive treatments, i.e TENS, nerve blocks,

sympathectomy, I.V lignocaine

Revisit coping strategies and psychological/psychiatric disease

Consider complementary therapies

Consider referral to specialist pain management team

Figure 3.2 Treatment options in the management of painful peripheral neuropathy

avoided It should not be used under tight bandages The patient should also avoidtaking a hot shower or bath immediately before or after applying the cream sincethis exacerbates the burning sensation.

‘Opsite’ spray is an alternative therapy that is sprayed directly onto the affectedarea gives some patients dramatic cooling relief of symptoms This therapy canunfortunately be somewhat messy, leaving a filmy residue on the skin surface thatcan be difficult to remove

Oral agents

Tricylcyclic antidepressant medication has, for many years, been a first linesystemic therapy that is effective in neuropathic pain Imipramine has beenshown to be beneficial in 60 per cent of symptomatic patients The initial startingdose is 25–50 mg increased in 25 mg increments every 1–2 weeks to a maximum

of 150 mg Amitriptyline as an alternative treatment with a similar dosing schedulehas proved to be similarly effective Side effects of the tricyclic group includesedation, dry mouth, urinary retention, postural hypotension and exacerbation ofglaucoma Treatment protocols can be drawn up to allow patients to self-titrateincreases in the dose of these drugs

Selective serotonin reuptake inhibitors such as paroxetine, citalopram andsibutramine have been used, but have not proved as effective as the tricyclics.Depression can be a common problem occurring in people with chronic pain and it

is thought that the antidepressant effect of these drugs may be the mechanism ofaction through which some benefit was observed.31

Anticonvulsants

Gabapentin (Neurontin) and its more recent successor pregabalin (Lyrica) arelicensed as oral agents for use in painful neuropathy The mode of action for thesedrugs is a blockage of neural transmission of pain pathways at the dorsal horns ofthe spinal cord Dose titration for gabapentin is in four stages over a 2 week period

A frequent maintenance dose is 600 mg three times daily Inadequate dose titration

of gabapentin will produce a sub-optimal response Common side-effects aredizziness and drowsiness

Pregabalin has a similar mode of action and appears to be as effective in thetreatment of neuropathic pain It may have benefits over its predecessor Dosetitration is simpler and quicker The drug is taken twice daily Benefits are seenwithin a week of therapy and improvements in sleep pattern changes are notice-able The usual final treatment dose is 300 mg twice daily

Carbamazepine and phenytoin have been used in the treatment of neuropathicpain but side effects are common and these drugs are now used less frequently.Sodium valproate has been used less widely

The use of opiate-based therapies is controversial in the management of anychronic pain These therapies typically cause a degree of dependence but may beadvocated in severe intractable cases Tramadol is a centrally acting opioidderiviative that is less addictive and has been shown to benefit some patientswith neuropathic pain A typical daily dose is 200–400 mg.

Intravenous lignocaine has been shown to benefit some patients with intractableneuropathic pain It is not extensively used due to the need for close cardiacmonitoring A typical starting dose is 5 mg/kg body weight and it is typicallyinfused over 30–60 min Symptom relief may last for up to 15 days After thisperiod some physicians have found that the addition of oral mexilitine following agood response can offer additional benefit.40

Ketamine is an anaesthetic drug with good analgesic properties when used insub-anaesthetic dosage It is administered intramuscularly and may providetemporary pain relief for individuals with severe neuropathic pain There is,however, a high incidence of hallucinations and other transient psychotic effectsreported with this drug It is usually only considered for use where closemonitoring can be provided within a specialist setting

Other therapies

Spinal cord stimulation TENS machines may be beneficial for some, particularly

in those patients with pain localized to one limb only

Spinal nerve blocks have been used with mixed success but can be consideredafter an appropriate anaesthetic assessment from within a pain team

Complementary therapies

Complementary therapies can be used as an adjunct to conventional therapies Forsome individuals they can be useful in reducing the impact of this painfulcondition on quality of life and daily function.41

Complementary therapies for managing chronic pain can be split into three categories:physical treatments, relaxation and mind body techniques, and herbal remedies

 Physical approaches – these include therapeutic massage, chiropractic, ology, acupuncture and magnetic therapy There is emerging evidence of thesuccessful role of the use of acupuncture in treating painful diabetic neuro-pathy.41,46 It has been suggested that acupuncture works through stimulatingenergy flow through painful areas It is being used increasingly within the painclinic setting No untoward side effects have been reported Magnetic therapy isalso an emerging therapy in the UK It has been employed to treat a variety ofmedical conditions in Asia, predominantly China Magnetic insoles are one such

application They are thought to stimulate reflexology points in the foot to assist

in symptom reduction In one large study42there were statistically significantreductions in pain, burning, numbness and tingling Care should be taken ifemploying this technique When placed in the shoe the insole can raise the footand a larger toe box is required If the insole is not cut to the correct shape,pressure ulcers can also develop on the heel

 Relaxation techniques – relaxation techniques may help some to cope withchronic pain They can help to reduce stress and anxiety that can exacerbatepain Available therapies include hypnotherapy, meditation, music therapy,yoga, humour therapy and guided imagery

 Herbal medicines and aromatherapy – these have been used for many centuries

to treat pain Many of today’s most potent drug therapies are herbal derivativesand it is important not to underestimate their power when used in conjunctionwith more orthodox treatments A registered qualified herbalist should carry outthe preparation of any herbal remedy

Psychological support

When managing the chronic pain of peripheral neuropathy it is important toconsider whether psychological support may be required Depressive symptomsare common in this group.41There is a strong association between poor glycaemiccontrol and the prevalence of depression.43There is also evidence to link loss ofproprioception and balance in diabetic patients with an increased incidence ofdepression.43 Unfortunately there is a lack of appropriately trained clinicalpsychologists and others to deal with the psychological effects of chronic pain

in diabetes teams

For the sufferer the effects of trying to cope with symptoms include:

 apathy and self-imposed social isolation;

 an inability to perform the normal activities of daily living;

 disrupted sleep patterns;

 memory impairment;

 mood swings;

 feelings of isolation, frustration and despair;

 suicidal tendencies (reproduced from Diabetic Neuropathy – Under the light Booklet, The Neuropathy Trust, 2002.)

Spot-The symptoms of painful diabetic neuropathy may affect family and friends.Sleepless nights caused by neuropathic pain can disturb the household and leavethe sufferer weary and irritable This can affect relationships with partner, familyand friends.

Many different agents and techniques have been used to manage this condition

It is important to recognize that different individuals respond to different forms

of treatment Alternative therapies may be found to be effective for a givensufferer

3.4 The Organization of Foot Care

People with diabetes and those caring for them should be provided with easyaccess to a multidisciplinary diabetic foot care team This may take the form of the

‘gold-standard’ multidisciplinary foot clinic Alternatively this may be a team ofpeople who work closely together in settings that allow for easy communicationand direct access to each other’s specialist skills

There should be an organised programme of foot care that includes:

 continuous education of patients carers and staff;

 identification of patients with feet at high risk;

 provision of measures designed to reduce risk;

 streamlined communication between health care professionals that crossesboundaries of care

A diabetes foot care team can help to provide appropriate knowledge to each otherand to others who provide care outside the group Skills should be made easilyaccessible to patients and other health carers The group should produce anddisseminate practical guidelines on the avoidance, identification and management

of complications There should be clear pathways between primary and secondarycare.36,44

A multidisciplinary diabetic foot care team should incorporate a number of keyindividuals From the specialist setting there should be a minimum of oneindividual representing the following areas: specialist podiatry, specialist orthotics,diabetes nurse specialist, consultant diabetologist, vascular surgeon and orthopae-dic surgeon It may be beneficial to involve wound care/tissue viability nurses,plaster technicians and vascular/diabetes/medical admissions ward nurses Ideallythe group should cross the primary/secondary care boundary and incorporateprimary care nurse, physician and podiatrist There should also be a patientrepresentative

It is not feasible for all of these individuals to be involved in one disciplinary foot clinic However crucial leaders of the team should meet regularly

multi-to enhance the development of a co-ordinated diabetes foot care service.45 Themultidisciplinary foot care team should act as a focal point and resource forpatients and other health care professionals

The team of people caring for those with diabetes is much larger than these fewindividuals Extended team members include the patient carer, reception staff,pharmacist, microbiologist, physiotherapist, occupational therapist, clinical psy-chologist, pain specialist, radiologist and others

In order to meet the needs and achieve high standards of care for the person withdiabetes there needs to be continuing education for all in addition to effective

Person with diabetes, their family and partners

Diabetologist

Diabetes nurse specialist

Orthotist

Podiatrist

Plaster technician Vascular

surgeon

Vascular nurse specialist

Cardiologist Nephrologist

Pain specialists

Imaging specialists, podiatrists

Limb fitting services

Figure 3.3 The multidisciplinary foot team

communication between all of these individuals It is the responsibility of the team

to ensure that this happens

Although foot disease is a leading cause of hospital admission and expense,2itsprevention may increasingly lie in educating patients and staff away from thespecialist care setting We have also therefore helped indicate the links betweenprimary and secondary care to ensure that risk factors are recognized and actedupon and complications are managed effectively (Figure 3.3)

3.5 Conclusion

Care of the diabetic foot requires input before, during and following the opment of complications Prevention of foot ulceration can be optimized byeducating patients with diabetes about the use of appropriate footwear and byregular reinforcement of foot-care advice The annual, thorough inspection of feet

devel-is an essential part of a diabetic examination Standards should be in place to helpidentify at-risk feet A baseline foot assessment tool can serve this purpose Inparticular the feet of diabetic patients should be carefully examined for thepresence of deformities, callus, reduced blood supply and nerve damage

A good system of foot care should mean that the identification of an at-risk foottriggers the involvement of other health care professionals (orthotist, podiatrist,nurse and doctor) so that the risk of progression to a diseased foot is minimized.Ulceration of the diabetic foot depends on the presence of neuropathy and/orimpaired blood supply It is particularly likely to occur where high-pressure areasdevelop This can be due to the neuropathic process and/or areas of foot deformity.The development of excessive callus is frequently a predictive factor and can breakdown and lead to secondary ulceration

Impaired blood supply is due to atherosclerosis involving large vessels of bothlegs This is frequently distal and multisegmental, involving tibial and peronealblood vessels Areas of pressure that can lead to necrosis compound this reduction

in blood supply

Nerve damage leads to reduction in heat and pain sensation It also affects bloodsupply, resulting in diminished sweating Altered blood flow results in oedema andreduction in bone density Charcot disease can be a debilitating complication.Damage to the peripheral nerve fibres can lead to neuropathic pain This can be adifficult condition to treat Patients are educated about its cause and the naturalhistory of the condition They should receive detailed information about treatmentoptions and their likely effectiveness Systems should be put in place to enablemedication to be altered and optimized quickly and effectively

Optimal care of the diabetic foot is essential and can only be achieved throughclose collaboration of podiatrist, orthotist, nurse, physician and surgeon This canmost easily be carried out in a dedicated multi-disciplinary foot clinic Alterna-tively, there needs to be a system in place that enables easy dialogue and access

between these different specialties The development of an efficient system of carerequires the involvement of a dedicated group of individuals representing eachspecialty This allows for the development of local care pathways and systems tosupport the patient with diabetic foot disease Support networks should transcendany primary/secondary care boundaries.

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