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Gibson TB, Driver VR, Wrobel JS, Christina JR, Bagalman E, DeFrancis R, Garoufalis MG, Carls GS, Gatwood J. Podiatrist care and outcomes for patients with diabetes and foot ulcer. Int Wound J 2013; 11:641-8. [PMID: 23374540 DOI: 10.1111/iwj.12021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 11/21/2012] [Accepted: 12/03/2012] [Indexed: 12/01/2022] Open
Abstract
We examined whether outcomes of care (amputation and hospitalisation) among patients with diabetes and foot ulcer differ between those who received pre-ulcer care from podiatrists and those who did not. Adult patients with diabetes and a diagnosis of a diabetic foot ulcer were found in the MarketScan Databases, 2005-2008. Multivariate Cox proportional hazard models estimated the hazard of amputation and hospitalisation. Logistic regression estimated the likelihood of these events. Propensity score weighting and regression adjustment were used to adjust for potentially different characteristics of patients who did and did not receive podiatric care. The sample included 27 545 patients aged greater than 65+ years (Medicare-eligible patients with employer-sponsored supplemental insurance) and 20 208 patients aged lesser than 65 years (non Medicare-eligible commercially insured patients). Care by podiatrists in the year prior to a diabetic foot ulcer was associated with a lower hazard of lower extremity amputation, major amputation and hospitalisations in both non Medicare-eligible commercially insured and Medicare-eligible patient populations. Systematic differences between patients with diabetes and foot ulcer, receiving and not receiving care from podiatrists were also observed; specifically, patients with diabetes receiving care from podiatrists tend to be older and sicker.
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Holmes C, Wrobel JS, MacEachern MP, Boles BR. Collagen-based wound dressings for the treatment of diabetes-related foot ulcers: a systematic review. Diabetes Metab Syndr Obes 2013; 6:17-29. [PMID: 23357897 PMCID: PMC3555551 DOI: 10.2147/dmso.s36024] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers are a major source of morbidity, limb loss, and mortality. A prolonged inflammatory response, extracellular matrix degradation irregularities, and increased bacteria presence have all been hypothesized as major contributing factors in the delayed healing of diabetic wounds. Collagen components such as fibroblast and keratinocytes are fundamental to the process of wound healing and skin formation. Wound dressings that contain collagen products create a biological scaffold matrix that supports the regulation of extracellular components and promotes wound healing. METHODS A systematic review of studies reporting collagen wound dressings used in the treatment of Diabetic foot ulcers was conducted. Comprehensive searches were run in Ovid MEDLINE, PubMed, EMBASE, and ISI Web of Science to capture citations pertaining to the use of collagen wound dressings in the treatment of diabetic foot ulcers. The searches were limited to human studies reported in English. RESULTS Using our search strategy, 26 papers were discussed, and included 13 randomized designs, twelve prospective cohorts, and one retrospective cohort, representing 2386 patients with diabetic foot ulcers. Our design was not a formal meta-analysis. In those studies where complete epithelialization, 58% of collagen-treated wounds completely healed (weighted mean 67%). Only 23% of studies reported control group healing with 29% healing (weighted mean 11%) described for controls. CONCLUSION Collagen-based wound dressings can be an effective tool in the healing of diabetic foot wounds. The current studies show an overall increase in healing rates despite limitations in study designs. This study suggests that future works focus on biofilms and extracellular regulation, and include high risk patients.
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Najafi B, Crews RT, Wrobel JS. A Novel Plantar Stimulation Technology for Improving Protective Sensation and Postural Control in Patients with Diabetic Peripheral Neuropathy: A Double-Blinded, Randomized Study. Gerontology 2013; 59:473-80. [DOI: 10.1159/000352072] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 05/16/2013] [Indexed: 11/19/2022] Open
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Richer S, Cho J, Stiles W, Levin M, Wrobel JS, Sinai M, Thomas C. Retinal spectral domain optical coherence tomography in early atrophic age-related macular degeneration (AMD) and a new metric for objective evaluation of the efficacy of ocular nutrition. Nutrients 2012; 4:1812-27. [PMID: 23363992 PMCID: PMC3546609 DOI: 10.3390/nu4121812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 11/12/2012] [Accepted: 11/14/2012] [Indexed: 01/30/2023] Open
Abstract
Purpose: A challenge in ocular preventive medicine is identification of patients with early pathological retinal damage that might benefit from nutritional intervention. The purpose of this study is to evaluate retinal thinning (RT) in early atrophic age-related macular degeneration (AMD) against visual function data from the Zeaxanthin and Visual Function (ZVF) randomized double masked placebo controlled clinical trial (FDA IND #78973). Methods: Retrospective, observational case series of medical center veterans with minimal visible AMD retinopathy (AREDS Report #18 simplified grading 1.4/4.0 bilateral retinopathy). Foveal and extra-foveal four quadrant SDOCT RT measurements were evaluated in n = 54 clinical and ZVF AMD patients. RT by age was determined and compared to the OptoVue SD OCT normative database. RT by quadrant in a subset of n = 29 ZVF patients was correlated with contrast sensitivity and parafoveal blue cone increment thresholds. Results: Foveal RT in AMD patients and non-AMD patients was preserved with age. Extrafoveal regions, however, showed significant slope differences between AMD patients and non-AMD patients, with the superior and nasal quadrants most vulnerable to retinal thinning (sup quad: −5.5 μm/decade thinning vs. Non-AMD: −1.1 μm/decade, P < 0.02; nasal quad: −5.0 μm/decade thinning vs. Non-AMD: −1.0 μm/decade, P < 0.04). Two measures of extrafoveal visual deterioration were correlated: A significant inverse correlation between % RT and contrast sensitivity (r = −0.33, P = 0.01, 2 Tailed Paired T) and an elevated extrafoveal increment blue cone threshold (r = +0.34, P = 0.01, 2 Tailed T). Additional SD OCT RT data for the non-AMD oldest age group (ages 82–91) is needed to fully substantiate the model. Conclusion: A simple new SD OCT clinical metric called “% extra-foveal RT” correlates well with functional visual loss in early AMD patients having minimal visible retinopathy. This metric can be used to follow the effect of repleting ocular nutrients, such as zinc, antioxidants, carotenoids, n-3 essential fats , resveratrol and vitamin D.
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Wrobel JS, Marclay S, Najafi B. Golfing skill level postural control differences: a brief report. J Sports Sci Med 2012; 11:452-458. [PMID: 24149353 PMCID: PMC3737932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/22/2012] [Indexed: 06/02/2023]
Abstract
Golfers have better balance than their age-matched counterparts; however, it is uncertain if this persists during the swing as a function of skill level. The purpose of the study was to investigate dynamic postural control (center of mass (COM) motion) measured during different phases of the swing in golfers of varying proficiency. Eighteen healthy golfers were grouped by handicap: novice (no handicap, n = 7), intermediate (handicap 15-19, n = 7), and advanced (handicap 9-14, n = 4). Indoor testing was performed hitting 3 tee shots using a common driver. A five-camera (60 Hz) motion analysis system (9 markers) was used to extract kinematics data. There were no significant group differences in gender, age, or BMI. Advanced players had lower COM displacement with respect to address at the time of maximum arm speed (p = 0. 001) compared to intermediate (57%, p = 0.014) and novice (73%, p = 0.023). These changes persisted after COM distance and time normalization. Advanced golfers had improved COM linearity during the downswing (p < 0.001) compared to intermediate (30%, p = 0.029) and novice (51%, p < 0.001). Advanced players had decreased COM displacement at the time of maximum arm speed and a more linear COM path during the early downswing. Further study should focus on these changes during ball launch conditions. Key pointsStudies suggest that static and dynamic balance is important in golf. However, none have investigated dynamic postural control during the golf swing in golfers of varying proficiency.Our findings suggest advanced players demonstrated improved postural control at the point of maximum arm speed when compared to less skilled players. Furthermore, center of mass acceleration in advanced players is closer to impact than less-skilled players.We observed an increased center of mass linearity of trajectory during the early downswing for advanced players over novice players. We theorized this strategy may help advanced golfers to improve the economy of COM motion during golf swing and improve the performance of the shot.
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Fascione JM, Crews RT, Wrobel JS. Dynamic footprint measurement collection technique and intrarater reliability: ink mat, paper pedography, and electronic pedography. J Am Podiatr Med Assoc 2012; 102:130-8. [PMID: 22461270 DOI: 10.7547/1020130] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Identifying the variability of footprint measurement collection techniques and the reliability of footprint measurements would assist with appropriate clinical foot posture appraisal. We sought to identify relationships between these measures in a healthy population. METHODS On 30 healthy participants, midgait dynamic footprint measurements were collected using an ink mat, paper pedography, and electronic pedography. The footprints were then digitized, and the following footprint indices were calculated with photo digital planimetry software: footprint index, arch index, truncated arch index, Chippaux-Smirak Index, and Staheli Index. Differences between techniques were identified with repeated-measures analysis of variance with post hoc test of Scheffe. In addition, to assess practical similarities between the different methods, intraclass correlation coefficients (ICCs) were calculated. To assess intrarater reliability, footprint indices were calculated twice on 10 randomly selected ink mat footprint measurements, and the ICC was calculated. RESULTS Dynamic footprint measurements collected with an ink mat significantly differed from those collected with paper pedography (ICC, 0.85-0.96) and electronic pedography (ICC, 0.29-0.79), regardless of the practical similarities noted with ICC values (P = .00). Intrarater reliability for dynamic ink mat footprint measurements was high for the footprint index, arch index, truncated arch index, Chippaux-Smirak Index, and Staheli Index (ICC, 0.74-0.99). CONCLUSIONS Footprint measurements collected with various techniques demonstrate differences. Interchangeable use of exact values without adjustment is not advised. Intrarater reliability of a single method (ink mat) was found to be high.
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Najafi B, Barnica E, Wrobel JS, Burns J. Dynamic plantar loading index: understanding the benefit of custom foot orthoses for painful pes cavus. J Biomech 2012; 45:1705-11. [PMID: 22516856 DOI: 10.1016/j.jbiomech.2012.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 03/07/2012] [Accepted: 03/14/2012] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to evaluate a new method showing how custom foot orthoses (CFO) improve dynamics of plantar loading. The method is based on the probability distribution of peak pressure time series and is quantified using the Regression Factor (RF). RF is a least square regression slope between the experimentally observed plantar pressure magnitude probability distribution and a modeled Gaussian shape. Plantar pressure data from a randomized controlled trial of 154 participants with painful Pes Cavus were retrospectively re-analyzed. The participants were randomized to an active treatment group given CFO or a control group given sham orthoses. The location of 2(nd) Peak pressure as a percentage of stance time (P(Loc2)) and its magnitude (P(M2)) was also calculated. In addition, plantar pressure data were collected on 23 healthy volunteers with normal foot alignment and no foot pain. Results demonstrated Pes Cavus had a significantly lower RF than healthy participants (0.30 v. 0.51; p<10(-7)). P(M2) was reduced in both active and control groups. However, RF and the P(Loc2) were only changed in the active group (p<0.005) without any significant change in the control group (p>0.5). This study suggests that painful Pes Cavus alters the shape of probability distribution of plantar loading during walking and CFO are an effective therapeutic solution that can significantly improve it. Further use of the RF index and 2(nd) peak pressure location as an outcome measure for treatment of foot and ankle deformities is suggested.
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Wrobel JS, Davies ML, Robbins JM. Does open access improve the process and outcome of podiatric care? J Clin Med Res 2011; 3:101-5. [PMID: 21811539 PMCID: PMC3138405 DOI: 10.4021/jocmr545w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2011] [Indexed: 11/23/2022] Open
Abstract
Background Open access to clinics is a management strategy to improve healthcare delivery. Providers are sometimes hesitant to adopt open access because of fear of increased visits for potentially trivial complaints. We hypothesized open access clinics would result in decreased wait times, increased number of podiatry visits, fewer “no shows”, higher rates of acute care visits, and lower minor amputation rates over control clinics without open access. Methods This study was a national retrospective case-control study of VHA (Veterans Hospital Administration) podiatry clinics in 2008. Eight case facilities reported to have open podiatry clinic access for at least one year were identified from an email survey. Sixteen control facilities with similar structural features (e.g., full time podiatrists, health tech, residency program, reconstructive foot surgery, vascular, and orthopedic surgery) were identified in the same geographic region as the case facilities. Results Twenty-two percent of facilities responded to the survey. Fifty-four percent reported open access and 46% did not. There were no differences in facility or podiatry panel size, podiatry visits, or visit frequency between the cases and controls. Podiatry visits trended higher for control facilities but didn’t reach statistical significance. Case facilities had more new consults seen within 30 days (96%, 89%; P = 0.050) and lower minor amputation rates (0.62/1,000, 1.0/1,000; P = 0.041). Conclusions The VHA is the world’s largest managed care organization and it relies on clinical efficiencies as one mechanism to improve the quality of care. Open access clinics had more timely access for new patients and lower rates of minor amputations. Keywords Health care; Quality; Access; Evaluation; Delivery of health care; Amputation; Amputation prevention
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Victor BS, Jarboe TR, Hossack AC, Ennis DA, Nelson BA, Smith RJ, Akcay C, Hansen CJ, Marklin GJ, Hicks NK, Wrobel JS. Evidence for separatrix formation and sustainment with steady inductive helicity injection. PHYSICAL REVIEW LETTERS 2011; 107:165005. [PMID: 22107397 DOI: 10.1103/physrevlett.107.165005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Indexed: 05/31/2023]
Abstract
The first sustainment of toroidal plasma current of 50 kA at up to 3 times the injected currents, added in quadrature, using steady inductive helicity injection is described. Separatrix currents-currents not linking the helicity injectors-are sustained up to 40 kA. Decreases in the n=1 toroidal mode of the poloidal magnetic field at higher current amplifications indicate more quiescent, direct toroidal current drive. Results are achieved in HIT-SI (with a spheromak of major radius 0.3 m) during deuterium operations immediately after helium operation. These results represent a breakthrough in the development of this new current drive method for magnetic confinement fusion.
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Wrobel JS, Reiber GE. Time for a victory lap or time to raise the levees: a perspective on complication reduction and new-onset diabetes. Diabetes Care 2011; 34:2130-2. [PMID: 21868782 PMCID: PMC3161286 DOI: 10.2337/dc11-1069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, Defrancis RR, Wang S, Bagalman JE, Christina JR. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc 2011; 101:93-115. [PMID: 21406693 DOI: 10.7547/1010093] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We sought to examine the economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers by evaluating cost outcomes for patients with diabetic foot ulcer who did and did not receive care from a podiatric physician in the year before the onset of a foot ulcer. METHODS We analyzed the economic value among commercially insured patients and Medicare-eligible patients with employer-sponsored supplemental medical benefits using the MarketScan Databases. The analysis consisted of two parts. In part I, we examined cost or savings per patient associated with care by podiatric physicians using propensity score matching and regression techniques; in part II, we extrapolated cost or savings to populations. RESULTS Matched and regression-adjusted results indicated that patients who visited a podiatric physician had $13,474 lower costs in commercial plans and $3,624 lower costs in Medicare plans during 2-year follow-up (P < .01 for both). A positive net present value of increasing the share of patients at risk for diabetic foot ulcer by 1% was found, with a range of $1.2 to $17.7 million for employer-sponsored plans and $1.0 to $12.7 million for Medicare plans. CONCLUSIONS These findings suggest that podiatric medical care can reduce the disease and economic burdens of diabetes.
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Fleischer AE, Wrobel JS, Leonards A, Berg S, Evans DP, Baron RL, Armstrong DG. Post-treatment leukocytosis predicts an unfavorable clinical response in patients with moderate to severe diabetic foot infections. J Foot Ankle Surg 2011; 50:541-6. [PMID: 21621432 DOI: 10.1053/j.jfas.2011.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Indexed: 02/03/2023]
Abstract
Our aim was to determine whether post-treatment laboratory values could help to predict the clinical response in patients with advanced diabetic foot infections. One hundred and three consecutive patients hospitalized for moderate or severe diabetic foot infections at a large, university-affiliated hospital were identified and their records retrospectively reviewed. Definitive therapy during each patient's hospital course was defined as any foot surgery when additional major surgery was not anticipated or when a course of deep soft tissue and/or bone culture-specific antibiotics had been initiated. The clinical response was assessed at 90 days after the start of definitive therapy. A poor response was recognized as persistent infection at the initial or a contiguous site or when unplanned revision surgery or amputation was subsequently required. The peripheral white blood cell count, neutrophil count, erythrocyte sedimentation rate, and C-reactive protein levels measured shortly after initiating definitive therapy (i.e., post-treatment) were examined for their association with the clinical response using logistic regression models. A total of 38 patients with the complete compliment of laboratory and clinical follow-up aged 59.7 ± 12.3 years with a diabetes duration of 13.3 ± 9.1 years were included. Leukocytosis, defined as a white blood cell count >11,000 cells/μL, observed an average of 3 ± 1.4 days after treatment, was the single most important marker for predicting a poor clinical response, and the only significant study variable in both univariate and multivariate analyses (multivariate odds ratio 9.7, 95% confidence interval 1.0 to 92, p = .048). We conclude that leukocytosis observed shortly after initiating definitive therapy is predictive of an unfavorable clinical response by 90 days.
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Wrobel JS, Edgar S, Cozzetto D, Maskill J, Peterson P, Najafi B. A proof-of-concept study for measuring gait speed, steadiness, and dynamic balance under various footwear conditions outside of the gait laboratory. J Am Podiatr Med Assoc 2010; 100:242-50. [PMID: 20660874 DOI: 10.7547/1000242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This pilot study examined the effect of custom and prefabricated foot orthoses on self-selected walking speed, walking speed variability, and dynamic balance in the mediolateral direction. METHODS The gait of four healthy participants was analyzed with a body-worn sensor system across a distance of at least 30 m outside of the gait laboratory. Participants walked at their habitual speed in four conditions: barefoot, regular shoes, prefabricated foot orthoses, and custom foot orthoses. RESULTS In the custom foot orthoses condition, gait speed was improved on average 13.5% over the barefoot condition and 9.8% over the regular shoe condition. The mediolateral range of motion of center of mass was reduced 55% and 56% compared with the shoes alone and prefabricated foot orthoses conditions, respectively. This may suggest better gait efficiency and lower energy cost with custom foot orthoses. This tendency remained after normalizing center of mass by gait speed, suggesting that irrespective of gait speed, custom foot orthoses improve center of mass motion in the mediolateral direction compared with other footwear conditions. Gait intercycle variability, measured by intercycle coefficient of variation of gait speed, was decreased on average by 25% and 19% compared with the barefoot and shoes-alone conditions, respectively. The decrease in gait unsteadiness after wearing custom foot orthoses may suggest improved proprioception from the increased contact area of custom foot orthoses versus the barefoot condition. CONCLUSIONS These findings may open new avenues for objective assessment of the impact of prescribed footwear on dynamic balance and spatiotemporal parameters of gait and assess gait adaptation after use of custom foot orthoses.
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Sharkey AM, Goldkind A, Yong R, Chagares W, Wrobel JS. Multiuse 10-g monofilament contamination. Diabetes Care 2010; 33:e144. [PMID: 20980423 DOI: 10.2337/dc10-1171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Najafi B, Crews RT, Wrobel JS. Importance of time spent standing for those at risk of diabetic foot ulceration. Diabetes Care 2010; 33:2448-50. [PMID: 20682681 PMCID: PMC2963510 DOI: 10.2337/dc10-1224] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Despite the high cumulative plantar stress associated with standing, previous physical activity reports of diabetic patients at risk of foot ulceration have not taken this activity into account. This study aimed to monitor spontaneous daily physical activity in diabetic peripheral neuropathy (DPN) patients and examine both walking and standing activities as important foot-loading conditions. RESEARCH DESIGN AND METHODS Thirteen DPN patients were asked to wear a body-worn sensor for 48 h. Body postures (sitting, standing, and lying) and locomotion (walking, number of steps, and postural transition) were extracted. RESULTS Patients daily spent twice as much time standing (13±5%) as walking (6±3%). They spent 37±6% of time sitting and 44±8% lying down. The average number of steps per day was 7,754±4,087, and the number of walking episodes was 357±167 with maximum duration of 3.9±3.8 min. CONCLUSIONS The large portion of DPN patients' time spent standing with the feet loaded requires further consideration when treating and preventing foot ulcers.
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Abstract
BACKGROUND Diabetic foot complications represent significant morbidity and precede most of the lower extremity amputations performed. Peripheral neuropathy is a frequent complication of diabetes shown to affect gait. Glycosylation of soft tissues can also affect gait. The purpose of this review article is to highlight the changes in gait for persons with diabetes and highlight the effects of glycosylation on soft tissues at the foot-ground interface. METHODS PubMed, the Cochrane Library, and EBSCOhost on-line databases were searched for articles pertaining to diabetes and gait. Bibliographies from relevant manuscripts were also searched. FINDINGS Patients with diabetes frequently exhibit a conservative gait strategy where there is slower walking speed, wider base of gait, and prolonged double support time. Glycosylation affects are observed in the lower extremities. Initially, skin thickness decreases and skin hardness increases; tendons thicken; muscles atrophy and exhibit activation delays; bones become less dense; joints have limited mobility; and fat pads are less thick, demonstrate fibrotic atrophy, migrate distally, and may be stiffer. INTERPRETATION In conclusion, there do appear to be gait changes in patients with diabetes. These changes, coupled with local soft tissue changes from advanced glycosylated end products, also alter a patient's gait, putting them at risk of foot ulceration. Better elucidation of these changes throughout the entire spectrum of diabetes disease can help design better treatments and potentially reduce the unnecessarily high prevalence of foot ulcers and amputation.
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Najafi B, Horn D, Marclay S, Crews RT, Wu S, Wrobel JS. Assessing postural control and postural control strategy in diabetes patients using innovative and wearable technology. J Diabetes Sci Technol 2010; 4:780-91. [PMID: 20663438 PMCID: PMC2909506 DOI: 10.1177/193229681000400403] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Currently, diagnosis of patients with postural instability relies on a rudimentary clinical examination. This article suggests an innovative, portable, and cost-effective prototype to evaluate balance control objectively. METHODS The proposed system uses low-cost, microelectromechanical sensor, body-worn sensors (BalanSens) to measure the motion of ankle and hip joints in three dimensions. We also integrated resulting data into a two-link biomechanical model of the human body for estimating the two-dimensional sway of the center of mass (COM) in anterior-posterior (AP) and medial-lateral (ML) directions. A new reciprocal compensatory index (RCI) was defined to quantify postural compensatory strategy (PCS) performance. To validate the accuracy of our algorithms in assessing balance, we investigated the two-dimensional sway of COM and RCI in 21 healthy subjects and 17 patients with diabetic peripheral neuropathic (DPN) complications using the system just explained. Two different conditions were examined: eyes open (EO) and eyes closed (EC) for duration of at least 30 seconds. Results were compared with center of pressure sway (COP) as measured by a pressure platform (Emed-x system, Novel Inc., Germany). To further investigate the contribution of the somatosensory (SOM) feedback to balance control, healthy subjects performed EO and EC trials while standing on both a rigid and a foam surface. RESULTS A relatively high correlation was observed between COM measured using BalanSens and COP measured using the pressure platform (r = 0.92). Results demonstrated that DPN patients exhibit significantly greater COM sway than healthy subjects for both EO and EC conditions (p < 0.005). The difference becomes highly pronounced while eyes are closed (197 +/- 44 cm(2) vs 68 +/- 56 cm(2)). Furthermore, results showed that PCS assessed using RCI is significantly better in healthy subjects compared to DPN subjects for both EO and EC conditions, as well as in both ML and AP directions (p < 0.05). Alteration in SOM feedback in healthy subjects resulted in diminished RCI values that were similar to those seen in DPN subjects (p > 0.05). DISCUSSION/CONCLUSION This study suggested an innovative system that enables the investigation of COM as well as postural control compensatory strategy in humans. Results suggest that neuropathy significantly impacts PCS.
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Wrobel JS, Chagares W, Stuck RM, Weaver F, Crews RT, Rapacki L, Paulson R, Armstrong DG. Creating a diabetes foot reminder-based registry using the electronic medical record. JOURNAL OF INNOVATION IN HEALTH INFORMATICS 2010; 18:283-7. [PMID: 22040855 DOI: 10.14236/jhi.v18i4.783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE We created a new diabetes foot examination clinical reminder to directly populate a foot risk registry and examined its accuracy versus administrative data. METHODS A pre- and post-test design assessed accuracy of coding foot risk and clinician acceptability. The intervention hospital's reminder was replaced with a dialogue tick box containing the International Diabetic Foot Classification System to populate risk using health factors. RESULTS There were no hospital agreement differences for each foot condition except diabetes and peripheral neuropathy, demonstrating higher agreement at the intervention hospital. There were no differences in service agreement adherence or consulting rates although both demonstrated significantly lower consulting rates at study end. The intervention hospital had a significantly lower patient cancellation rate (1% v. 5%, P=0.01) and better coding for grade 3 patients. The new reminder demonstrated high acceptability. CONCLUSIONS The registry system resulted in improved discrimination of the highest foot risk. Further testing is recommended.
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Norem N, Feuerstein C, Traverso V, Zomaya N, Crews R, Wrobel JS. Gait changes with the use of Heelys: a case study. J Am Podiatr Med Assoc 2009; 99:247-50. [PMID: 19448177 DOI: 10.7547/0980247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Heelys shoes are a novel athletic shoe with a concealed wheel. They have been popular among youths since their introduction in 2000. This case study serves as a first look into the biomechanical implications of Heelys shoes on gait. Pressure readings of the forefoot, midfoot, and rearfoot during ambulation in regular athletic-shoe walking, Heelys without the wheel walking, Heelys with the wheel walking, and Heelys skating with the wheel were recorded on a single subject using the Pedar X System. A visual gait analysis was also performed on the subject. The resulting data show increased forefoot and rearfoot pressure while walking with the Heelys with the wheel. The visual gait analysis showed a diminished heel strike and a more rapid forefoot loading. These results demonstrate that Heelys do in fact affect the biomechanics of gait.
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Fascione JM, Crews RT, Wrobel JS. Association of footprint measurements and running training level, performance success, and training specificity. FOOTWEAR SCIENCE 2009. [DOI: 10.1080/19424280903535439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wrobel JS, Crews RT, Connolly JE. Clinical factors associated with a conservative gait pattern in older male veterans with diabetes. J Foot Ankle Res 2009; 2:11. [PMID: 19389247 PMCID: PMC2680835 DOI: 10.1186/1757-1146-2-11] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Accepted: 04/23/2009] [Indexed: 11/10/2022] Open
Abstract
Background Patients with diabetes and peripheral neuropathy are at higher risk for falls. People with diabetes sometimes adopt a more conservative gait pattern with decreased walking speed, widened base, and increased double support time. The purpose of this study was to use a multivariate approach to describe this conservative gait pattern. Methods Male veterans (mean age = 67 years; SD = 9.8; range 37–86) with diabetes (n = 152) participated in this study from July 2000 to May 2001 at the Veterans Affairs Medical Center, White River Junction, VT. Various demographic, clinical, static mobility, and plantar pressure measures were collected. Conservative gait pattern was defined by visual gait analysis as failure to demonstrate a heel-to-toe gait during the propulsive phase of gait. Results Patients with the conservative gait pattern had lower walking speed and decreased stride length compared to normal gait. (0.68 m/s v. 0.91 m/s, p < 0.001; 1.04 m v. 1.24 m, p < 0.001) Age, monofilament insensitivity, and Romberg's sign were significantly higher; and ankle dorsiflexion was significantly lower in the conservative gait pattern group. In the multivariate analysis, walking speed, age, ankle dorsiflexion, and callus were retained in the final model describing 36% of the variance. With the inclusion of ankle dorsiflexion in the model, monofilament insensitivity was no longer an independent predictor. Conclusion Our multivariate investigation of conservative gait in diabetes patients suggests that walking speed, advanced age, limited ankle dorsiflexion, and callus describe this condition more so than clinical measures of neuropathy.
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Klein EE, Crews RT, Wu SC, Wrobel JS, Armstrong DG. CLEAR Cleat: a proof-of-concept trial of an aerobic activity facilitator to reduce plantar forefoot pressures and their potential in those with foot ulcers. J Am Podiatr Med Assoc 2008; 98:261-7. [PMID: 18685045 DOI: 10.7547/0980261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Exercise has not been studied extensively in persons with active neuropathic diabetic foot wounds, primarily because a device does not exist that allows patients to exercise while sufficiently off-loading pressure at the ulcer site. The purpose of this project was to demonstrate a device that reduces cycling plantar forefoot pressure. METHODS Ten healthy participants rode a recumbent bicycle under three cycling conditions. While the left foot interaction remained constant with a standard gym shoe and pedal, the right foot was exposed to a control condition with standard gym shoe and pedal, gym shoe and specialized cleat, and gym shoe with an off-loading insole and specialized cleat. Pressure and contact area of the plantar aspect of the feet were recorded for a 10-sec interval once during each minute of each condition's 7-min trial. RESULTS The off-loading insole and specialized cleat condition yielded significantly lower (P < .01) peak pressure, contact area, and pressure-time integral values in the forefoot than the specialized cleat condition with gym shoe, which yielded significantly lower values (P < .01) than the standard gym shoe and pedal. CONCLUSION Modifications to footwear may alter plantar forefoot pressures, contact area, and pressure-time integrals while cycling. The CLEAR Cleat could play a significant role in the facilitation of fitness in patients with (or at high risk for) neuropathic wounds.
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Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. J Foot Ankle Surg 2008; 48:39-46. [PMID: 19110158 DOI: 10.1053/j.jfas.2008.09.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Indexed: 02/08/2023]
Abstract
UNLABELLED The purpose of this investigation was to examine the value of using routinely available clinical and laboratory tests in combination to distinguish osteomyelitis from cellulitis in a diabetic population with mild to moderately infected forefoot ulcers. We conducted a case-control study of 54 diabetic patients with 54 locally infected ulcers admitted to a university-affiliated tertiary-care hospital over a 4.5-year period. A total of 30 clinical and laboratory characteristics obtained at admission were tested for their association with pathology-proven osteomyelitis using logistic regression techniques. Ulcer depth greater than 3 mm (univariate odds ratio 10.4, P = .001) and C-reactive protein greater than 3.2 mg/dL (univariate odds ratio 10.8, P < .001) were the most informative individual clinical and laboratory tests for differentiating osteomyelitis from cellulitis. Adding C-reactive protein also significantly improved upon the accuracy of the study's best clinical testing strategy (area under the curve improved from 0.80 to 0.88, P = .040). Strategies that combined ulcer depth with serum inflammatory markers proved most useful in detecting ulcerated patients with concomitant bone infections (sensitivity 100% [95% CI 89.7%-100%] for both ulcer depth greater than 3 mm or C-reactive protein greater than 3.2 mg/dL, and ulcer depth greater than 3 mm or erythrocyte sedimentation rate greater than 60 mm/h). We conclude that considering clinical and laboratory findings together can significantly improve our diagnostic accuracy for osteomyelitis in the diabetic foot. The specific combination of ulcer depth with serum inflammatory markers appears to be a particularly sensitive strategy that may allow for greater detection of early diabetic osteomyelitis. LEVEL OF CLINICAL EVIDENCE 3.
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Wrobel JS, Armstrong DG. Reliability and validity of current physical examination techniques of the foot and ankle. J Am Podiatr Med Assoc 2008; 98:197-206. [PMID: 18487593 DOI: 10.7547/0980197] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This literature review was undertaken to evaluate the reliability and validity of the orthopedic, neurologic, and vascular examination of the foot and ankle. METHODS We searched PubMed-the US National Library of Medicine's database of biomedical citations-and abstracts for relevant publications from 1966 to 2006. We also searched the bibliographies of the retrieved articles. We identified 35 articles to review. For discussion purposes, we used reliability interpretation guidelines proposed by others. For the kappa statistic that calculates reliability for dichotomous (eg, yes or no) measures, reliability was defined as moderate (0.4-0.6), substantial (0.6-0.8), and outstanding (> 0.8). For the intraclass correlation coefficient that calculates reliability for continuous (eg, degrees of motion) measures, reliability was defined as good (> 0.75), moderate (0.5-0.75), and poor (< 0.5). RESULTS Intraclass correlations, based on the various examinations performed, varied widely. The range was from 0.08 to 0.98, depending on the examination performed. Concurrent and predictive validity ranged from poor to good. CONCLUSIONS Although hundreds of articles exist describing various methods of lower-extremity assessment, few rigorously assess the measurement properties. This information can be used both by the discerning clinician in the art of clinical examination and by the scientist in the measurement properties of reproducibility and validity.
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Wu SC, Crews RT, Zelen C, Wrobel JS, Armstrong DG. Use of chlorhexidine-impregnated patch at pin site to reduce local morbidity: the ChIPPS Pilot Trial. Int Wound J 2008; 5:416-22. [PMID: 18205786 DOI: 10.1111/j.1742-481x.2007.00368.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Pin tract infection is one of the most common complications associated with the use of external fixation. While some studies have identified the potential benefit of chlorhexidine gluconate-impregnated polyurethane dressings to reduce the incidence of catheter-related bloodstream infections, we are unaware of any published studies that evaluate the effectiveness of similar technologies in reducing the risk for external-fixation-related pin tract infections. Therefore, the purpose of this study was to evaluate the effectiveness of chlorhexidine gluconate-impregnated polyurethane dressing in reducing percutaneous-device-related skin colonisation and local infections. In this initial retrospective cohort, data were abstracted for two groups of consecutive patients undergoing surgery involving external fixation at an interdisciplinary foot and ankle surgical unit. All patients received surgical treatment of their foot/ankle pathology along with application of a hybrid external fixator. Twenty patients (45% male, age 54.5 +/- 3.69 years) received chlorhexidine gluconate-impregnated polyurethane dressing and twenty (55% male, age 55.8 +/- 3.22 years) received standard pin care. There was a significantly higher rate of pin tract infection in patients who received standard pin care compared with those who received chlorhexidine gluconate-impregnated polyurethane dressings (25% versus 0%, P = 0.047). There was no significant difference in any of the descriptive study characteristics (age, gender, diabetes and presence of neuropathy). The results of this initial study suggest that chlorhexidine gluconate-impregnated polyurethane dressing may be effective to reduce the incidence of pin tract infections and help decrease morbidity associated with external fixation.
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