Dynamic Foot Pressure and Other Studies as Diagnostic and Management Aids in Diabetic Neuropathy
TL;DR: It is concluded that simple bedside investigations, such as measurement of the VPT alone, may be useful in identifying those patients at risk of foot ulceration, and foot pressure studies may then be used in such patients as a predictive and management aid by determining specific areas under the foot that are prone to ulcers.
Abstract: The pressures and loads under the feet during walking have been compared in three groups of 41 patients each, using a microprocessor-controlled optical system. Group A consisted of patients with diabetic neuropathy, group B of non-neuropathic diabetic patients, and group C of nondiabetic controls. Thirteen patients in group A had a history of neuropathic foot ulceration. Other investigations in the diabetic patients included motor conduction velocity (MCV) in the median and peroneal nerves, vibration perception threshold (VPT) in the great toes, the valsalva response (VR), skin resistance (SR), and the ankle pressure index (API). Fifty-one percent of neuropathic feet had abnormally high pressures underneath the metatarsal heads compared with 17% of the diabetic controls and 7% of nondiabetic subjects. All those feet with previous ulceration had abnormally high pressures at the ulcer sites. Of the other investigations, the VPT correlated most significantly with the presence of foot ulceration. In addition, a low median and peroneal nerve MCV, an abnormal VR, a high API, and the absence of sweating all correlated with the presence of foot ulceration. We therefore conclude that simple bedside investigations, such as measurement of the VPT alone, may be useful in identifying those patients at risk of foot ulceration. Foot pressure studies may then be used in such patients as a predictive and management aid by determining specific areas under the foot that are prone to ulceration.
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TL;DR: It is shown for the first time in a prospective study that high plantar foot pressures in diabetic patients are strongly predictive of subsequent plantar ulceration, especially in the presence of neuropathy.
Abstract: Foot ulceration results in substantial morbidity amongst diabetic patients. We have studied prospectively the relationship between high foot pressures and foot ulceration using an optical pedobarograph. A series of 86 diabetic patients, mean age 53.3 (range 17–77) years, mean duration of diabetes 17.1 (range 1–36) years, were followed-up for a mean period of 30 (range 15–34) months. Clinical neuropathy was present in 58 (67%) patients at baseline examination. Mean peak foot pressure was higher at the follow-up compared to baseline (13.5 kg·cm−2±7.1 SD vs 11.2±5.4, p 12.3) being present in 55 patients at follow-up and 43 at the baseline visit (p=NS). Plantar foot ulcers developed in 21 feet of 15 patients (17%), all of whom had abnormally high pressures at baseline; neuropathy was present in 14 patients at baseline. Non-plantar ulcers occurred in 8 (9%) patients. Thus, plantar ulceration occurred in 35% of diabetic patients with high foot pressures but in none of those with normal pressures. We have shown for the first time in a prospective study that high plantar foot pressures in diabetic patients are strongly predictive of subsequent plantar ulceration, especially in the presence of neuropathy.
656 citations
Cites background or result from "Dynamic Foot Pressure and Other Stu..."
...It is therefore not surprising that previous studies have identified measurement of VPT, a measure of large fibre function, as being strongly associated with risk of foot ulceration [ 4 , 20]....
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...Neuropathy and limited joint mobility have been found to be the two main aetiological factors of the high foot pressures that are often found in diabetic patients and are associated with foot ulceration [ 4-6 ]....
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...Previous studies [ 4 , 7, 8] have shown that foot ulcers are found at sites with high pressures but that in the absence of neuropathy high pressures alone do not lead to ulceration....
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...The first studies using foot pressure measurement systems in diabetic patients were all cross-sectional [ 4 , 7, 17] but nevertheless all showed a strong association between abnormal vertical loads under the foot and a history of neuropathic ulceration....
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TL;DR: With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.
Abstract: Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.
613 citations
TL;DR: A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation but these must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb and thus improve the quality of life for people with diabetes.
Abstract: A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation. These strategies must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb, and thus improve the quality of life for people with diabetes.
502 citations
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TL;DR: Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment, and Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound.
Abstract: Diabetic foot problems remain all too common and are likely to increase in prevalence over the next few decades. It has been estimated that an individual with diabetes now has a 25% risk of developing a foot ulcer at some time during their lifespan. A number of controversies are discussed in this chapter starting with the key question of the best screening methods for the “at risk foot” for ulceration. The key message is that simple clinical techniques of examination of the feet and lower limbs are probably the most accurate way to assess for further risk of foot lesions. A foot ulcer will normally heal if the circulation is intact, infection is treated and pressure is taken off the lesion. Physicians find it hard to believe that patients with large plantar foot lesions would actually walk on this lesion, but they forget that sensory loss in the diabetic foot permits walking without discomfort. Thus offloading is frequently neglected and if applied properly, will lead to satisfactory healing in most plantar neuropathic ulcers. In the area of infection, the key question is whether an ulcer is infected or colonized and this is discussed in some detail as is the differential diagnosis between osteomyelitis and Charcot neuroarthropathy. The use and abuse of expensive topical treatments is then discussed and finally the role of footwear in the prevention of recurrent ulcers is described.
488 citations
TL;DR: The recurrence of foot ulcer as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers are evaluated.
Abstract: OBJECTIVE. To evaluate the recurrence of foot ulcers as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers. DESIGN. A prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer with a median follow-up of 4 years. SETTING. A multidisciplinary foot-care team. POPULATION. Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these patients, 468 healed either primarily (n = 345) or after minor or major amputations (n = 123) and 90 died before healing had occurred. Those 468 patients who healed were included in this prospective study from the time of healing. MAIN OUTCOME MEASURES. Patients were followed according to a standardized protocol with registration of foot lesions, amputation, morbidity and mortality. Clinical examination was performed twice yearly. RESULTS. After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively, had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant, respectively). Among patients with previous primary healing the cumulative amputation rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%, 35% and 48% among those who previously healed after amputation, irrespective of previous amputation level (P < 0.001 at all time-points). All amputations except three were initiated by a foot ulcer deteriorating to deep infection or progressive gangrene. The long-term survival ratio was lower among patients healed after previous amputation (80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%, 58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and P < 0.001 respectively). The mortality rate was twice as high among primarily healed and four times as high among patients with amputation compared to an age- and sex-matched Swedish population. CONCLUSION. These findings stress the need for life-long surveillance of the diabetic foot at risk and the necessity of preventive foot care among diabetic patients with previous foot lesions, and particularly among those who had had a previous amputation. (Less)
456 citations
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534 citations
TL;DR: It is suggested that this improvement in electrical function indicates improvement in nerve structure and that early effective control of the diabetic state would lead to a reduction in the incidence of serious nerve damage.
257 citations
TL;DR: The vertical forces acting on the sole of the foot in walking have been measured in diabetic patients with neuropathic ulcers using a load‐sensitive surface divided into 128 load cells, and compared with two groups of controls.
Abstract: The vertical forces acting on the sole of the foot in walking have been measured in 24 diabetic patients with neuropathic ulceration of the foot using a load-sensitive surface divided into 128 load cells, and compared with those in two groups of controls: (a), 21 diabetic patients with peripheral neuropathy but no ulceration and (b) 47 normal individuals. The results showed that the patients with neuropathic ulceration were significantly heavier, that diabetic patients with neuropathy, with or without ulceration, transmitted proportionally less force through the toes than normal individuals, and showed a medial shift of the force transmitted through the metatarsal heads. All plantar ulcers occurred at the site of maximum loading. The absolute force at the site of maximum loading was significantly greater in the patients with ulcers than in both control groups, through there was a considerable overlap. A significant difference remained even when the absolute force had been corrected for differences in toe loading and body weight, indicating that a further factor (or factors) must contribute to the development of these localized areas of high loading.
234 citations
TL;DR: Medial arterial calcification was much more common and extensive in the patients with neuropathy, occurring in the feet in 15 and in the hands in eight compared with in four and none of the controls respectively.
Abstract: X-ray examinations of the feet, knees, and hands were performed on 20 diabetics with severe neuropathy and 20 diabetics with no evidence of neuropathy but with a similar mean age and duration of diabetes. All were under 53 years old with no clinical evidence of peripheral vascular disease. Medial arterial calcification was much more common and extensive in the patients with neuropathy, occurring in the feet in 15 and in the hands in eight compared with in four (p less than 0.001) and none (p less than 0.001) of the controls respectively. Although there was some correlation between calcification and both proteinuria (p less than 0.05) and proliferative retinopathy (p less than 0.02), the association between calcification and neuropathy (p less than 0.001) was much stronger. Neuropathy, with sympathetic denervation of the smooth muscle of the tunica media, may be important in the aetiology of medial arterial calcification.
203 citations
TL;DR: An apparatus is described which gives a rapid and detailed picture of the distribution of pressure under the foot, this being displayed either as a continuous grey scale or a color contour map on a television monitor.
Abstract: An apparatus is described which gives a rapid and detailed picture of the distribution of pressure under the foot, this being displayed either as a continuous grey scale or a color contour map on a television monitor. Automatic analysis systems are outlined which enable the quantitation of the distribution of pressures and loads under the foot during standing and walking, utilizing computer techniques. The use of the static system is illustrated by the results of analytic procedures carried out on normal feet and in the assessment of surgical correction of a series of equino-varus feet in children suffering from spina bifida. The clinical application of the dynamic system is illustrated by the measurement of pressure/time curves encountered under the heel, the five metatarsal heads, and the great toe of a control group of feet and the feet of patients who had undergone metatarsophalangeal fusions, Keller arthroplasties, and Swanson arthroplasties.
145 citations