Foot ulceration is the most common lower-extremity complication in patients with diabetes mellitus. This review considers the pathogenesis, treatment, and management of diabetic foot ulcers, including prevention of recurrence.

https://www.nejm.org/doi/suppl/10.1056/NEJMra1615439/suppl_file/nejmra1615439_appendix.pdf

Diabetic Foot Ulcers and Their Recurrence

Context:Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4%to 10%, the annual population-based incidence is 1.0%to 4.1 %, and the lifetime incidence may be as high as 25%. These ulcers frequently b ecome infected, cause great morbidity, engender considerable financial costs, an d are the usual first step to lower extremity amputation. Objective:To systemat ically review the evidence on the efficacy of methods advocated for preventing d iabetic foot ulcers in the primary care setting. Data Sources, Study Selection, and Data Extraction:The EBSCO, MEDLINE, and the National Guideline Clearinghous e databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles wer e also searched, along with the Cochrane Library and relevant Web sites. We revi ewed the retrieved literature for pertinent information, paying particular atten tion to prospective cohort studies and randomized clinical trials. Data Synthesi s:Prevention of diabetic foot ulcers begins with screening for loss of protecti ve sensation, which is best accomplished in the primary care setting with a brie f history and the Semmes-Weinstein monofilament. Specialist clinics may quantif y neuropathy with biothesiometry, measure plantar foot pressure, and assess lowe r extremity vascular status with Doppler ultrasound and ankle-brachial blood pr essure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify patients based o n risk and to determine the type of intervention. Educating patients about prope r foot care and periodic foot examinations are effective interventions to preven t ulceration. Other possibly effective clinical interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, debridement of c alluses, and certain types of prophylactic foot surgery. The value of various ty pes of prescription footwear for ulcer prevention is not clear. Conclusions:Sub stantial evidence supports screening all patients with diabetes to identify thos e at risk for foot ulceration. These patients might benefit from certain prophyl actic interventions, including patient education, prescription footwear, intensi ve podiatric care, and evaluation for surgical interventions.

Preventing foot ulcers in patients with diabetes

Control of balance is complex and involves maintaining postures, facilitating movement, and recovering equilib- rium. Balance control consists of controlling the body center of mass over its limits of stability. Clinical balance assessment can help to assess fall risk and/or determine the underlying reasons for balance disorders. Most func- tional balance assessment scales assess fall risk and the need for balance rehabilitation but do not differentiate types of balance deficits. A system approach to clinical bal- ance assessment can differentiate different kinds of bal- ance disorders and a physiological approach can deter- mine underlying sensorimotor mechanisms contribut- ing to balance disorders. Objective measures of balance using computerized systems and wearable inertial sensors can bring more sensitive, specific and responsive bal- ance testing to clinical practice.

http://disciplinas.stoa.usp.br/mod/resource/view.php?id=132603

The relevance of clinical balance assessment tools to differentiate balance deficits

This article reviews the evidence for cortical involvement in shaping postural responses evoked by external postural perturbations. Although responses to postural perturbations occur more quickly than the fastest voluntary movements, they have longer latencies than spinal stretch reflexes, suggesting greater potential for modification by the cortex. Postural responses include short, medium and long latency components of muscle activation with increasing involvement of the cerebral cortex as latencies increase. Evidence suggests that the cortex is also involved in changing postural responses with alterations in cognitive state, initial sensory-motor conditions, prior experience, and prior warning of a perturbation, all representing changes in "central set." Studies suggest that the cerebellar-cortical loop is responsible for adapting postural responses based on prior experience and the basal ganglia-cortical loop is responsible for pre-selecting and optimizing postural responses based on current context. Thus, the cerebral cortex likely influences longer latency postural responses both directly via corticospinal loops and shorter latency postural responses indirectly via communication with the brainstem centers that harbor the synergies for postural responses, thereby providing both speed and flexibility for pre-selecting and modifying environmentally appropriate responses to a loss of balance.

/pdf/cortical-control-of-postural-responses-55a0699gim.pdf

Cortical control of postural responses.

Stroke survivors are at high risk for falls in all poststroke stages. Falls may have severe consequences, both physically and psychosocially. Individuals with stroke have an increased risk for hip fractures, and after such a fracture, they less often regain independent mobility. In addition, fear of falling is a common consequence of falls, which may lead to decreased physical activity, social deprivation and, eventually, loss of independence. Important risk factors for falls are balance and gait deficits. Stroke-related balance deficits comprise reduced postural stability during quiet standing and delayed and less coordinated responses to both self-induced and external balance perturbations. Gait deficits include reduced propulsion at push-off, decreased hip and knee flexion during the swing phase, and reduced stability during the stance phase. Interventions addressing these deficits can be expected to prevent falls more successfully. Preliminary evidence shows that task-specific exercise programs targeting balance and gait deficits can indeed reduce the number of falls in individuals with stroke. Technological advances in assistive devices are another promising area. More research is needed, however, to provide conclusive evidence of the efficacy of these interventions regarding the prevention of falls in individuals with stroke.

/pdf/falls-in-individuals-with-stroke-18f71l39al.pdf

Falls in individuals with stroke

A review of standing balance recovery from stroke.

Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study.

OBJECTIVE Custom-made footwear is the treatment of choice to prevent foot ulcer recurrence in diabetes. This footwear primarily aims to offload plantar regions at high ulcer risk. However, ulcer recurrence rates are high. We assessed the effect of offloading-improved custom-made footwear and the role of footwear adherence on plantar foot ulcer recurrence. RESEARCH DESIGN AND METHODS We randomly assigned 171 neuropathic diabetic patients with a recently healed plantar foot ulcer to custom-made footwear with improved and subsequently preserved offloading (∼20% peak pressure relief by modifying the footwear) or to usual care (i.e., nonimproved custom-made footwear). Primary outcome was plantar foot ulcer recurrence in 18 months. Secondary outcome was ulcer recurrence in patients with an objectively measured adherence of ≥80% of steps taken. RESULTS On the basis of intention-to-treat, 33 of 85 patients (38.8%) with improved footwear and 38 of 86 patients (44.2%) with usual care had a recurrent ulcer (relative risk −11%, odds ratio 0.80 [95% CI 0.44–1.47], P = 0.48). Ulcer-free survival curves were not significantly different between groups ( P = 0.40). In the 79 patients (46% of total group) with high adherence, 9 of 35 (25.7%) with improved footwear and 21 of 44 (47.8%) with usual care had a recurrent ulcer (relative risk −46%, odds ratio 0.38 [0.15–0.99], P = 0.045). CONCLUSIONS Offloading-improved custom-made footwear does not significantly reduce the incidence of plantar foot ulcer recurrence in diabetes compared with custom-made footwear that does not undergo such improvement, unless it is worn as recommended.

/pdf/effect-of-custom-made-footwear-on-foot-ulcer-recurrence-in-3p3ds7volj.pdf

Effect of Custom-made Footwear on Foot Ulcer Recurrence in Diabetes A multicenter randomized controlled trial

OBJECTIVE Recurrence of plantar foot ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for ulcer recurrence and to establish targets for ulcer prevention. RESEARCH DESIGN AND METHODS As part of a footwear trial, 171 neuropathic diabetic patients with a recently healed plantar foot ulcer and custom-made footwear were followed for 18 months or until ulceration. Demographic data, disease-related parameters, presence of minor lesions, barefoot and in-shoe plantar peak pressures, footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar foot ulcer recurrence. RESULTS A total of 71 patients had a recurrent ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98–27.57]), day-to-day variation in stride count (0.93 [0.89–0.99]), and cumulative duration of past foot ulcers (1.03 [1.00–1.06]). Significant independent predictors for those 41 recurrences suggested to be the result of unrecognized repetitive trauma were presence of minor lesions (10.95 [5.01–23.96]), in-shoe peak pressure 80% (0.43 [0.20–0.94]), barefoot peak pressure (1.11 [1.00–1.22]), and day-to-day variation in stride count (0.91 [0.86–0.96]). CONCLUSIONS The presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading footwear was a strong protector against ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic foot screening and ulcer prevention.

https://care.diabetesjournals.org/content/diacare/37/6/1697.full.pdf

Mirjam de Haart

Papers

A review of standing balance recovery from stroke.

Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study.

Effect of Custom-made Footwear on Foot Ulcer Recurrence in Diabetes A multicenter randomized controlled trial

Risk Factors for Plantar Foot Ulcer Recurrence in Neuropathic Diabetic Patients

Effects of visual center of pressure feedback on postural control in young and elderly healthy adults and in stroke patients.