Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research

Pin-prick (Medipin) assessment for neuropathy in diabetes: Prospective screening study in primary care

AIMS

Diabetic patients are at elevated risk of neuropathy; early detection is desirable to minimise the risk of complications. The Medipin pin-prick device was appraised as a screening tool for diabetic neuropathy.

METHODS

Prospective cross-sectional comparative screening study in primary care setting, involving 389 participants with type 2 diabetes mellitus. The Medipin pin-prick method, involving dorsal application on the hallux of both feet, was compared to 10 g monofilament testing.

RESULTS

The ternary and semi-quantitative approach for scoring Medipin pin-prick sensation give very similar results (Spearman rho 0.67, P < 0.001). A total of 59 % patients had no signs of neuropathy (sharp sensation), 38 % reported impaired sensation (dull sensation), and an absence of sensation occurred in 3 % of patients. For the monofilament dorsal method, the figures were 79 % no neuropathy, 14 % elevated risk, and 7 % neuropathy respectively, and with the monofilament plantar method 87 % of patients had no neuropathy and 13 % did. Correlation analyses showed that taller patients and those with existing neuropathic pain are at very modest increased risk of neuropathy.

CONCLUSIONS

The Medipin pin-prick device can identify diabetic neuropathy and detects (first signs of) neuropathy in relatively more patients than 10 g monofilament testing. The differential targeting of nerve types, namely predominant small (Medipin) versus large (monofilament) fibre, likely underpins the difference in outcomes.

Improvement in Protective Sensation: Clinical Evidence From a Randomized Controlled Trial for Treatment of Painful Diabetic Neuropathy With 10 kHz Spinal Cord Stimulation

BACKGROUND

Painful diabetic neuropathy (PDN) can result in the loss of protective sensation, in which people are at twice the likelihood of foot ulceration and three times the risk of lower extremity amputation. Here, we evaluated the long-term effects of high-frequency (10 kHz) paresthesia-independent spinal cord stimulation (SCS) on protective sensation in the feet and the associated risk of foot ulceration for individuals with PDN.

METHODS

The SENZA-PDN clinical study was a randomized, controlled trial in which 216 participants with PDN were randomized to receive either conventional medical management (CMM) alone or 10 kHz SCS plus CMM, with optional treatment crossover after 6 months. At study visits (baseline through 24 months), 10-g monofilament sensory assessments were conducted at 10 locations per foot. Two published methods were used to evaluate protective sensation via classifying risk of foot ulceration.

RESULTS

Participants in the 10 kHz SCS group reported increased numbers of sensate locations as compared to CMM alone (P < .001) and to preimplantation (P < .01) and were significantly more likely to be at low risk of foot ulceration using both classification methods. The proportion of low-risk participants approximately doubled from preimplantation to 3 months postimplantation and remained stable through 24 months (P ≤ .01).

CONCLUSIONS

Significant improvements were observed in protective sensation from preimplantation to 24 months postimplantation for the 10 kHz SCS group. With this unique, disease-modifying improvement in sensory function, 10 kHz SCS provides the potential to reduce ulceration, amputation, and other severe sequelae of PDN.

TRIAL REGISTRATION

The SENZA-PDN study is registered on ClinicalTrials.gov with identifier NCT03228420.

Concomitants of Diabetic Foot Ulcer - A Review

BACKGROUND

Diabetes mellitus leading to foot ulcer is a serious complication, and it is considered a global epidemic. Neuropathyand high blood glucose levels are the primary causes of foot ulcers. Fifteen percent of people with diabetes develop foot ulcers, and these foot disorders are the main cause of lower extremity amputation among such patients.

INTRODUCTION

Complications of diabetic foot, affecting the lower extremities are common and quite complex and life-threatening. This review focuses on the life-threatening factors associated with diabetic foot ulcers and also the diagnosing and preventive measures. Neuropathy assessment and the range of foot ulcers were accurately examined.

CONCLUSION

Novel therapies focusing on the vascularity of the lower limbs, infection control, and ischemic control are being developed to mainly treat nonhealing ulcers.

Interprofessional Validation of the Ipswich Touch Test in Adults With Diabetes: The Canadian Experience

OBJECTIVES

Diabetes can lead to loss of protective sensation (LOPS) in the feet. Identifying LOPS requires use of screening tests, such as the standard monofilament test (SMT) and the Ipswich Touch Test (IpTT). The aim of this validation study was to compare the SMT (criterion) with the IpTT (new test).

METHODS

Each participant was randomly tested using the SMT, IpTT and Neuropathy Disability Score to identify LOPS. Sixteen health-care providers assessed 8 participants in randomized order using a specific protocol.

RESULTS

The IpTT, compared with the SMT, demonstrated a specificity of 100% for all raters and a mean sensitivity of 93.8% for LOPS. Kappa coefficient was 0.97 for SMT and 0.83 for IpTT.

CONCLUSIONS

The IpTT can be used by health-care providers as an effective tool for screening for LOPS in people with diabetes. This study validated the IpTT to the SMT in identifying LOPS.

A randomized placebo-compared study on the efficacy of classical ayurvedic pharmaceutical form versus aqueous alcoholic extracts of Phyllanthus niruri Linn. Plus Sida cordifolia Linn. in patients of diabetic sensory polyneuropathy

BACKGROUND

In routine, Ayurveda practitioners prefer classical pharmaceutical form of herbal medicines in compare to modern extracts.

OBJECTIVE

To explore the difference of efficiency between whole drug powder of Phyllanthus niruri plus root decoction of Sida cordifolia and modern extracts of the same in compared to placebo in patients of diabetic poly-neuropathy.

MATERIAL AND METHODS

A randomized, partly-double-blinded, placebo-controlled trial evaluated the efficacy of two different pharmaceutical forms of herbal medicines over placebo in 90 patients (30 in each group) of diabetic sensory polyneuropathy for first three weeks period. After three weeks, active herbal medication groups were continued with their assigned medicaments for next 5 weeks period and all placebo-patients were randomized again into 2 groups of active medication and treated for next 8 weeks. Patients were assessed with Neuropathy Total Symptom Score 6 and sensation thresholds.

RESULTS

Significant effect of both form of herbal medicines over placebo was found in aching pain [F (2, 49) = 6.79, p = 0.002], allodynia [F (2, 59) = 6.74, p = 0.002], burning pain [F (2, 82) = 14.66, p < 0.0001], numbness [F (2, 77) = 16.37, p < 0.0001] and pricking pain [F (2, 50) = 14.23, p < 0.0001]. After the 8 weeks period, no significant difference was identified between the effect of both the herbal treatment on aching pain (U = 220, p = 0.03), allodynia (U = 421.5, p = 0.29), burning pain (U = 881.5, p = 0.846), numbness (U = 778, p = 0.92) and pricking pain (U = 260, p = 0.15).

CONCLUSION

Both herbal groups have significant effect to reduce NTSS-6 score in compare to placebo. No significant difference found between the effect of two different pharmaceutical forms of Phyllanthus niruri and S. cordifolia.

Pay-for-performance and continuity of care synergistically reduced amputation of lower extremity in patients with diabetes: a population-based cohort study

Background

Diabetic foot is a common and costly complication of diabetes. No existing study has looked at the effect of continuity of care on amputations of diabetes (DM) patients while considering pay-for-performance (P4P) participation. We investigated the impact of the P4P program and the continuity of care index (COCI) on the incidence of lower extremity amputations (LEA) among diabetics in Taiwan.

Methods

This was a population-based cohort study using insurance claims data from 1997 to 2013. We selected 15,650 DM patients in the P4P program along with age- and sex-matched non-P4P participants at a 1:4 ratio. Time-weighted average (TWA) of the COCI was calculated and included in the time-dependent Cox proportional hazard models to examine the impact of P4P and COCI on the risk of LEA, while controlling for individual and area level characteristics.

Results

During four-year follow-up, 1816 subjects experienced LEA. The cumulative LEA hazard rate of the P4P group (n = 153) was significantly lower than that of the non-P4P group (n = 1663) (hazard ratio = 0.37, 95% CI = 0.31–0.43, p < 0.0001, by log-rank test). In the time-dependent Cox proportional hazard model, the adjusted hazard ratios (aHR) for the P4P group was 0.35, (p < 0.0001). With the low COCI (< 0.360) group as the reference, the aHR of LEA was 0.49 (p < 0.0001) for the middle COCI group, (p < 0.0001), and the aHR of LEA for the high COCI (≥0.643) group was 0.23 (p < 0.0001).

Conclusions

Participating in the P4P program and increasing COCI might reduce the risk of amputation for DM patients, independently and synergistically.

Diabetic foot ulcer in Southern Jordan: A cross-sectional Study of Clinical and Microbiological Aspects

Background

Materials and methods

Results

Conclusion

•

Diabetic foot ulcer is a common complication of diabetes.

•

This study is first of its kind in southern Jordan that combined clinical and microbiological aspects of diabetic foot ulcer.

•

The most frequent bacterial isolates from diabetic foot ulcers are gram negative bacteria.

•

Inappropriate previous use of antibiotics is the main determinant of multi-drug resistant isolates.

•

High rates of multi-drug resistant isolates in this study reflect the loose implementation of antibiotics dispensing regulations in Jordan.

Reliability of recommended non-invasive chairside screening tests for diabetes-related peripheral neuropathy: a systematic review with meta-analyses

The objective is to determine, by systematic review, the reliability of testing methods for diagnosis of diabetes-related peripheral neuropathy (DPN) as recommended by the most recent guidelines from the International Diabetes Foundation, International Working Group on the Diabetic Foot and American Diabetes Association. Electronic searches of Cochrane Library, EBSCO Megafile Ultimate and EMBASE were performed to May 2021. Articles were included if they reported on the reliability of recommended chairside tests in diabetes cohorts. Quality appraisal was performed using a Quality Appraisal of Reliability Studies checklist and where possible, meta-analyses, with reliability reported as estimated Cohen's kappa (95% CI). Seventeen studies were eligible for inclusion. Pooled analysis found acceptable inter-rater reliability of vibration perception threshold (VPT) (κ=0.61 (0.50 to 0.73)) and ankle reflex testing (κ=0.60 (0.55 to 0.64)), but weak inter-rater reliability for pinprick (κ=0.45 (0.22 to 0.69)) and 128 Hz tuning fork (κ=0.42 (0.15 to 0.70)), though intra-rater reliability of the 128 Hz tuning fork was moderate (κ=0.54 (0.37 to 0.73)). Inter-rater reliability of the four-site monofilament was acceptable (κ=0.61 (0.45 to 0.77)). These results support the clinical use of VPT, ankle reflexes and four-site monofilament for screening and ongoing monitoring of DPN as recommended by the latest guidelines. The reliability of temperature perception, pinprick, proprioception, three-site monofilament and Ipswich touch test when performed in people with diabetes remains unclear.

Foot Posture, Muscle Strength, Range of Motion, and Plantar Sensation in Overweight and Obese

The purpose of the study was to investigate the foot posture, ankle muscle strength, range of motion (ROM), and plantar sensation differences among normal weight, overweight, and obese individuals. One hundred and twenty-three individuals (42 normal weight, 40 overweight, and 41 obese) aged between 18 and 50 years participated in the study. Foot posture, ankle muscle strength, ROM, plantar sensation, and foot-related disabilities were evaluated. The relative muscle strength of left plantar flexors and invertors and light touch sensation of the left heel were significantly lower in obese individuals compared with overweight and normal weight (P < .016) individuals. Obese individuals had significantly reduced relative muscle strength of plantar flexors, dorsiflexor, and invertors, plantar flexion and inversion ROM in the left foot; and light touch sensation of the right heel compared with normal weight (P < .016) individuals. Foot Posture Index scores were significantly higher in obese individuals compared with overweight (P < .016) individuals. There were no significant differences in absolute muscle strength, vibration sensation, and foot-related disability scores among the 3 groups (P > .05). Obesity was found to have adverse effects on ankle muscle strength, ROM, and plantar light touch sensation. Vibration sensation was not affected by body mass index, and foot-related disability was not observed in obese adults.

What Is the Diagnosis in Patients with Type 2 Diabetes Who Have a Painful Shoulder? Results from a Prospective Cross-Sectional Study

Background: Patients with diabetes mellitus have higher risk of developing shoulder pathology. However, only adhesive capsulitis is addressed in shoulder pain guidelines as a disorder associated with diabetes. Yet, patients with diabetes are at risk of having several other shoulder disorders, including focal neuropathy. Our aim was to quantify the presence of shoulder disorders using physical examination and ultrasound imaging in patients with type 2 diabetes (T2DM) suffering from shoulder pain in general practice. Methods: In this prospective cross-sectional study, patients with T2DM who had had a painful shoulder for at least four weeks were included. Patients filled out a questionnaire and underwent a physical examination of the shoulders and feet and ultrasound imaging of the shoulder. Results: A total of 66 patients were included, of whom 40.9% (n = 27) had bilateral complaints resulting in 93 symptomatic shoulders. Subacromial pain syndrome was most frequently diagnosed by physical examination (66.6%, 95% CI 51.6–72.0%; p < 0.0001), while ultrasound imaging showed that subacromial disorders were statistically significantly the most prevalent (90.3%, 95% CI 81.9–95.2%). Only two patients (3%) were diagnosed with neuropathic shoulder pain. Conclusion: When choosing treatment, general practitioners should be aware that in patients with T2DM the subacromial region is most frequently affected.

Clinical Features and Rules of Chinese Herbal Medicine in Diabetic Peripheral Neuropathy Patients

OBJECTIVE

To analyse the clinical features of diabetic peripheral neuropathy (DPN) and employ data mining technology to explore the rules of Chinese herbal medicine (CHM) therapy.

METHODS

The clinical data of 216 patients with DPN and qi-yin deficiency syndrome were obtained, and the clinical features of the patients were assessed by cluster analysis. Relevant information was entered into the clinical diagnosis and treatment collection system, and data mining techniques were used to analyse the drug frequency, core CHM, CHM pair, and so on.

RESULTS

In this study, glycated haemoglobin (HbA1c) and homocysteine (HCY) were closely related to the pathogenesis of DPN. Overall, 162 patients had typical DPN syndrome characteristics, and we analysed 216 prescriptions, including 182 CHM. The frequencies of prescription of Astragalus membranaceus, Ligusticum wallichii, Poria cocos, and Radix Rehmanniae were greater than 45%. A Bayesian network analysis diagram showed that the 9 most common core CHM included Astragalus membranaceus, Ligusticum wallichii, Poria cocos, atractylodes rhizome, and Salvia miltiorrhiza Bge. According to the association rules of CHM, Radix Ophiopogon is used for Codonopsis pilosula; Astragalus membranaceus and atractylodes rhizome for Rehmannia are also frequently used. Astragalus membranaceus and Cinnamomi Ramulus or Ligusticum wallichii and Moutan bark were highly related to a decreased Michigan Diabetic Neuropathy Score.

CONCLUSION

HbA1c and HCY are related risk factors for DPN. Numbness is a typical syndrome characteristic. Astragalus membranaceus is a monarch CHM and is used most frequently.

Validity of Instrumented 360° Turn Test in Older Adults with Cognitive Impairment

AIMS

To examine concurrent and construct validity of inertial sensor 360°turn measures in relation with motion capture and mobility assessments in cognitively impaired older adults.

METHODS

Data was collected in 31 participants, mean age 85.2 (SD 5.2), during clockwise (CW) and counter clockwise (CCW) 360° turns using (1) APDM body-worn inertial sensors and (2) Qualisys 8-camera laboratory-based motion capture.

RESULTS

Absolute agreement between inertial sensor and motion capture measures was excellent for turn duration and turn peak velocity (ICC = 0.96-0.98). Strong to moderate correlations were present between inertial sensor turn measures and performance on the Timed Up and Go, Short Physical Performance Battery and 90-s Balance Test. ROC curve analysis of CCW 360° turn duration and turn peak velocity distinguished higher risk versus lower risk for mobility disability.

CONCLUSIONS

Inertial sensor 360° turn measures demonstrated concurrent and construct validity in relation to motion capture and mobility assessments.

Vitamin B12 Deficiency and Foot Ulcers in Type 2 Diabetes Mellitus: A Case-Control Study

OBJECTIVE

To assess the association between vitamin B12 deficiency and the development of diabetic foot ulcers (DFU) in type 2 diabetes mellitus (T2DM).

METHODS

This is a case-control study that enrolled 323 Saudi adults with T2DM randomly selected from the Jazan Diabetes & Endocrine Center, Saudi Arabia from January 1, 2019, to July 31, 2019. The sample included 108 newly diagnosed cases with DFU and 215 control participants with T2DM unaffected by and free of foot ulcers (1:2 ratio). Logistic regression analysis was performed to determine the DFU predictors and to examine the association of DFU and vitamin B12 deficiency.

RESULTS

The highest DFU rates were found among the male participants and the participants older than 45 years. Neuropathy, vasculopathy, vitamin B12 deficiency, poor glycemic control, poor feet self-care, Charcot foot, physical inactivity, and spending long time standing at work were significantly associated with DFU, and all except physical inactivity and spending long time standing at work were independent predictors of DFU. After adjustment for the covariates, vitamin B12 deficiency was significantly associated with DFU (odds ratio 3.1), indicating that the patients with T2DM and vitamin B12 deficiency had a three times higher risk of developing DFU than those with normal vitamin B12 levels.

CONCLUSION

Vitamin B12 deficiency had a significant association with DFU among the Saudi participants with T2DM. Establishing the causality and clarifying the biological role of vitamin B12 deficiency in DFU is important aims for future studies.

Measuring sensory and pain thresholds by Semmes-Weinstein monofilaments in patients with leg ulcers: a pilot study

OBJECTIVE

Pain is a common and disabling symptom in patients with leg ulcers. Clinical quantification of pain mostly depends on subjective pain reports, which do not reveal underlying mechanisms. The aim of this pilot study is to identify mechanisms underlying the pain in patients with leg ulcers by documenting alterations in pain processing using quantitative sensory testing.

METHODS

In nine ulcer patients the mechanical sensory thresholds and the mechanical pain thresholds were determined by Semmes-Weinstein monofilaments (SWM) at three different sites: on the contralateral (unaffected) leg, on the skin of the affected leg 10cm from the ulcer margin, and on the affected leg, close (1-2cm) to the ulcer margin. Besides the mechanical sensory thresholds and mechanical pain thresholds, pain at the site of the ulcer, using an 11-point numeric rating scale (NRS), was documented.

RESULTS

Mechanical sensory thresholds were increased in all subjects. Almost half (44%) of patients consistently showed allodynia at the unaffected site. The lowering of mechanical pain thresholds correlated with higher scores on the NRS.

CONCLUSION

All patients showed diminished touch and/or protective sensation, which might have contributed to ulcer development via (partial) loss of protective function. The allodynia at the unaffected site suggests the presence of central sensitisation of pain processing.

Perturbation-Induced Stepping Post-stroke: A Pilot Study Demonstrating Altered Strategies of Both Legs

Introduction: Asymmetrical sensorimotor function after stroke creates unique challenges for bipedal tasks such as walking or perturbation-induced reactive stepping. Preference for initiating steps with the less-involved (preferred) leg after a perturbation has been reported with limited information on the stepping response of the more-involved (non-preferred) leg. Understanding the capacity of both legs to respond to a perturbation would enhance the design of future treatment approaches. This pilot study investigated the difference in perturbation-induced stepping between legs in stroke participant and non-impaired controls. We hypothesized that stepping performance will be different between groups as well as between legs for post-stroke participants.

Methods: Thirty-six participants (20 persons post-stroke, 16 age matched controls) were given an anterior perturbation from three stance positions: symmetrical (SS), preferred asymmetrical (PAS−70% body weight on the preferred leg), and non-preferred asymmetrical (N-PAS−70% body weight on the non-preferred leg). Kinematic and kinetic data were collected to measure anticipatory postural adjustment (APA), characteristics of the first step (onset, length, height, duration), number of steps, and velocity of the body at heel strike. Group differences were tested using the Mann-Whitney U-test and differences between legs tested using the Wilcoxon signed-rank test with an alpha level of 0.05.

Results: Stepping with the more-involved leg increased from 11.5% of trials in SS and N-PAS up to 46% in PAS stance position for participants post-stroke. Post-stroke participants had an earlier APA and always took more steps than controls to regain balance. However, differences between post-stroke and control participants were mainly found when stance position was modified. Compare to controls, steps with the preferred leg (N-PAS) were earlier and shorter (in time and length), whereas steps with the non-preferred leg (PAS) were also shorter but took longer. For post-stroke participants, step duration was longer and utilized more steps when stepping with the more-involved leg compared to the less-involved leg.

Conclusions: Stepping with the more-involved leg can be facilitated by unweighting the leg. The differences between groups, and legs in post-stroke participants illustrate the simultaneous bipedal role (support and stepping) both legs have in reactive stepping and should be considered for reactive balance training.

Development of grading scales of pedal sensory loss using Mokken scale analysis on the Rotterdam Diabetic Foot Study Test Battery data

INTRODUCTION

Loss of sensation due to diabetes-related neuropathy often leads to diabetic foot ulceration. Several test instruments are used to assess sensation, such as static and moving 2-point discrimination (S2PD, M2PD), monofilaments, and tuning forks.

METHODS

Mokken scale analysis was applied to the Rotterdam Diabetic Foot Study data to select hierarchies of tests to construct measurement scales.

RESULTS

We developed 39-item and 31-item scales to measure loss of sensation for research purposes and a 13-item scale for clinical practice. All instruments were strongly scalable and reliable. The 39 items can be classified into 5 hierarchically ordered core clusters: S2PD, M2PD, vibration sense, monofilaments, and prior ulcer or amputation.

DISCUSSION

Guided by the presented scales, clinicians may better classify the grade of sensory loss in diabetic patients' feet. Thus, a more personalized approach concerning individual recommendations, intervention strategies, and patient information may be applied.

Lower limb vascular assessment techniques of podiatrists in the United Kingdom: a national survey

BACKGROUND

Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments.

METHODS

A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used.

RESULTS

Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient's general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed.

CONCLUSION

The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors.

Limbic and Basal Ganglia Neuroanatomical Correlates of Gait and Executive Function: Older Adults With Mild Cognitive Impairment and Intact Cognition

OBJECTIVE

This study aimed to examine differences in spatiotemporal gait parameters between older adults with amnestic mild cognitive impairment and normal cognition and to examine limbic and basal ganglia neural correlates of gait and executive function in older adults without dementia.

DESIGN

This was a cross-sectional study of 46 community-dwelling older adults, ages 70-95 yrs, with amnestic mild cognitive impairment (n = 23) and normal cognition (n = 23). Structural magnetic resonance imaging was used to attain volumetric measures of limbic and basal ganglia structures. Quantitative motion analysis was used to measure spatiotemporal parameters of gait. The Trail Making Test was used to assess executive function.

RESULTS

During fast-paced walking, older adults with amnestic mild cognitive impairment demonstrated significantly slower gait speed and shorter stride length compared with older adults with normal cognition. Stride length was positively correlated with hippocampal, anterior cingulate, and nucleus accumbens volumes (P < 0.05). Executive function was positively correlated with hippocampal, anterior cingulate, and posterior cingulate volumes (P < 0.05).

CONCLUSIONS

Compared with older adults with normal cognition, those with amnestic mild cognitive impairment demonstrated slower gait speed and shorter stride length, during fast-paced walking, and lower executive function. Hippocampal and anterior cingulate volumes demonstrated moderate positive correlation with both gait and executive function, after adjusting for age.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) discuss gait performance and cognitive function in older adults with amnestic mild cognitive impairment versus normal cognition, (2) discuss neurocorrelates of gait and executive function in older adults without dementia, and (3) recognize the importance of assessing gait speed and cognitive function in the clinical management of older adults at risk for dementia.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Concurrent Validity of Postural Sway Measures in Older Adults with Cognitive Impairment

Aims

To examine concurrent validity of inertial sensor (APDM ISway) versus force plate center of pressure (COP) measures of postural sway in cognitively impaired older adults.

Methods

Participants, mean age 85.6 (SD 4.8), were tested in 4 static standing conditions: (1) eyes open/normal base, (2) eyes open/narrow base, (3) eyes closed/normal base, and (4) eyes closed/narrow base. ISway and COP measures were collected.

Results

Strong correlations between ISway trunk sway smoothness [ISway JERK, (m ² /s ⁵ )] and COP path length (r = 0.67-0.85) and COP mean velocity (r = 0.77-0.87); also ISway total sway acceleration path length/trail duration [ISway PATH, (m²/s²)] and COP path length (r = 0.77-0.87) and COP mean velocity (r = 0.77-0.91). Increased sway was detected in narrow versus normal base and eyes closed versus open conditions (P = .001).

Conclusions

APDM ISway demonstrated concurrent validity to force-plate COP and changes in postural sway were detected between conditions.

Prevalence of ankle equinus and correlation with foot plantar pressures in people with diabetes

BACKGROUND

An association between equinus and plantar pressure may be important for people with diabetes, as elevated plantar pressure has been linked with foot ulcer development. To determine the prevalence of equinus in community dwelling people with diabetes and to examine any association between presence of equinus and forefoot plantar pressures.

METHODS

Barefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, non-weight bearing ankle range of motion and neuropathy status were assessed in 136 adults with diabetes (52.2% male; 47.8% with neuropathy; mean (standard deviation) age and diabetes duration: 68.4 (11.5) and 14.6 (11.1) years respectively).

FINDINGS

Equinus, when measured as ≤5° dorsiflexion, was present in 66.9% of the cohort. There was a significant correlation between an equinus and barefoot (r = 0.247, p = 0.004) and in-shoe forefoot pressure time integrals (r = 0.214, p = 0.012) and in-shoe forefoot alternate pressure time integrals (r = 0.246, p = 0.004). Significantly more males (p < 0.01) and people with neuropathy (p = 0.02) or higher glycated haemoglobin levels (p < 0.01) presented with an equinus.

INTERPRETATION

Community dwelling adults with diabetes have a high rate of ankle equinus which is associated with increased forefoot pressure time integrals and a two-fold increased risk of high in-shoe peak pressures. Clinical assessment of an ankle equinus may be a useful screening tool to identify adults at increased risk of diabetic foot complications.

How does a short period of exercise effect toe pressures and toe-brachial indices? A cross-sectional exploratory study

BACKGROUND

Whilst post exercise ankle-brachial indices (ABI) are commonly used to help identify peripheral arterial disease (PAD), the role of post exercise toe pressures (TP) or toe-brachial indices (TBI) is unclear. The aim of this study was to determine, in a population without clinical signs of PAD, the effect that 30 s of weight-bearing heel raises has on TP and TBI values. Additionally, the ability of resting TP and TBI values to predict change in post-exercise values using the heel raise method was investigated.

METHODS

Participants over the age of 18 with a resting TBI of ≥0.60 and ABI between 0.90 and 1.40, without diabetes, history of cardiovascular disease and not currently smoking were included. Following ten minutes of supine rest, right TP and bilateral brachial pressures were performed in a randomized order using automated devices. Participants then performed 30 s of weight-bearing heel raises, immediately after which supine vascular measures were repeated. Data were assessed for normality using the Shapiro-Wilk test. For change in TP and TBI values the Wilcoxon Signed-Rank Test was performed. For correlations between resting and change in post exercise values, the Spearman Rank Order Correlations were performed, and where significant correlation identified, a linear regression undertaken.

RESULTS

Forty-eight participants were included. A statistically significant decrease was seen in the median TP from resting 103.00 mmHg (IQR: 89.00 to 124.75) to post exercise 98.50 mmHg (IQR: 82.00 to 119.50), z = - 2.03, p = 0.04. This difference of 4.50 mmHg represents a 4.37% change and is considered a small effect size (r = 0.21). The median TBI also demonstrated a statistically significant decrease from resting 0.79 (IQR: 0.68 to 0.94) to post exercise 0.72 (IQR: 0.60 to 0.87), z = - 2.86, p = < 0.01. This difference of 0.07 represents an 8.86% change and is considered a small effect size (r = 0.29). Linear regression demonstrated that resting TBI predicted 22.4% of the variance in post exercise TBI, p = < 0.01, coefficients beta - 0.49.

CONCLUSIONS

Thirty seconds of weight-bearing heel raises resulted in a similar decrease in TBI values seen in longer periods of exercise. TP values also showed a decrease post exercise; however this was contrary to previous studies.

Validation of a weight bearing ankle equinus value in older adults with diabetes

Background

Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes.

Methods

Ankle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In-shoe and barefoot plantar pressure was recorded for the DA group. Spearman’s correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined.

Results

A weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure (r = 0.274, p = 0.005) and pressure-time integrals (r = 0.321, p = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p = 0.025) and pressure-time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p = 0.017) than the DA non equinus group.

Conclusions

We support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice.

The Necessity of the Simple Tests for Diabetic Peripheral Neuropathy in Type 2 Diabetes Mellitus Patients without Neuropathic Symptoms in Clinical Practice

Early recognition and appropriate management of diabetic peripheral polyneuropathy (DPNP) is important. We evaluated the necessity of simple, non-invasive tests for DPNP detection in clinical practice. We enrolled 136 randomly-chosen patients with type 2 diabetes mellitus and examined them with the 10-g Semmes-Weinstein monofilament examination, the 128-Hz tuning-fork, ankle-reflex, and pinprick tests; the Total Symptom Score and the 15-item self-administered questionnaire of the Michigan Neuropathy Screening Instrument. Among 136 patients, 48 had subjective neuropathic symptoms and 88 did not. The abnormal-response rates varied depending on the methods used according to the presence of subjective neuropathic symptoms (18.8% vs. 5.7%, P<0.05; 58.3% vs. 28.4%, P<0.005; 81.3% vs. 54.5%, P<0.005; 12.5% vs. 5.7%, P=0.195; 41.7% vs. 2.3%, P<0.001; and 77.1% vs. 9.1%, P<0.001; respectively). The largest abnormal response was derived by combining all methods. Moreover, these tests should be implemented more extensively in diabetic patients without neuropathic symptoms to detect DPNP early.

Weight bearing versus non-weight bearing ankle dorsiflexion measurement in people with diabetes: a cross sectional study

Background

Accurate measurement of ankle dorsiflexion is important in both research and clinical practice as restricted motion has been associated with many foot pathologies and increased risk of ulcer in people with diabetes. This study aimed to determine the level of association between non-weight bearing versus weight bearing ankle dorsiflexion in adults with and without diabetes, and to evaluate the reliability of the measurement tools.

Methods

One hundred and thirty-six adults with diabetes and 30 adults without diabetes underwent ankle dorsiflexion measurement non-weight bearing, using a modified Lidcombe template, and weight bearing, using a Lunge test. Pearson product-moment correlation coefficients, intraclass correlation coefficients (ICCs) with 95% confidence intervals, standard error of measurement and minimal detectable change were determined.

Results

There was a moderate correlation (r = 0.62–0.67) between weight and non-weight bearing tests in the non-diabetes group, and a negligible correlation in the diabetes group(r = 0.004–0.007). Intratester reliability was excellent in both groups for the modified Lidcombe template (ICC = 0.89–0.94) and a Lunge test (ICC = 0.83–0.89). Intertester reliability was also excellent in both groups for the Lidcombe template (ICC = 0.91) and a Lunge test (ICC = 0.88–0.93).

Conclusions

We found the modified Lidcombe template and a Lunge test to be reliable tests to measure non-weight bearing and weight bearing ankle dorsiflexion in adults with and without diabetes. While both methods are reliable, further definition of weight bearing ankle dorsiflexion normative ranges may be more relevant for clinical practice.

Identification, prevalence, and treatment of painful diabetic neuropathy in patients from a rural area in South Carolina

Diabetic peripheral neuropathy (DPN) represents significant burdens to many patients and the public health-care system. Patients with diabetes in rural areas have higher risk of developing complications and having less access to proper treatment. We studied a rural population of patients with diabetes who attended a pharmacist-led free clinic for a diabetic education program. Our objectives were to 1) determine the prevalence of DPN and painful diabetic neuropathy (p-DN) in patients with type 2 diabetes; 2) assess the proportion of patients with DPN and p-DN left undocumented upon physician referral to a pharmacist-led free clinic; and 3) determine the appropriateness of pain medication regimen. We performed a retrospective analysis of clinical records of patients from the Presbyterian College School of Pharmacy (PCSP) Wellness Center located in Clinton, SC. Diagnoses of DPN and/or p-DN were obtained from referral notes in the clinical records and compared with results from foot examinations performed in the free clinic and clinical features. Medication regimens were also obtained and compared using American Academy of Neurology (AAN) treatment guidelines. Within our study population (n=111), the prevalence of DPN was 62.2% (national average of 28%–45%) and that of p-DN was 23.4% (national average of 11%–24%). In p-DN patients (n=26), 53.8% (n=14) had a documented diagnosis of p-DN by the referring physician, and 46.2% (n=12) were identified by the pharmacists. A total of 95% (19 of 20) of the patients treated for p-DN received adequate pharmacological agents, though suboptimal as per clinical guidelines. More than 50% of the patients used subtherapeutic doses of their medications. Gabapentin was the most frequently used medication in our population (65.4%). Patients in rural South Carolina had a higher prevalence of DPN and p-DN with >60% undocumented cases of p-DN. More than 95% of treated patients did not receive optimum therapy according to AAN guidelines.

Footboards: Indigenous and Novel Method of Screening for Diabetes Peripheral Neuropathy - A Pilot Study

BACKGROUND

To validate the effectiveness of indigenously designed "footboard (FB)" in early diagnosis of diabetic peripheral neuropathy (PNP) by comparing it with Semmes-Weinstein monofilament (SWM) and vibration perception (VP).

MATERIALS AND METHODS

Two hundred and forty-four patients with diabetes were examined for PNP using SWM and 128 Hz tuning fork. The findings were compared with indigenously designed FBs with 1, 2, and 3 mm elevations.

RESULTS

Out of 108 patients who did not have protective sensation as per SWM, only 10 (9.2%) felt 1 mm board bearings, and out of 72 patients who did not feel vibration, only 8 (11.1%) felt 1 mm board bearings. Out of 136 patients who had protective sensation, 128 (94.11%) felt 2 mm elevated board bearings, and out of 172 patients who had VP, only 152 patients (88.3%) felt 2 mm board bearings. With SWM as standard, the sensitivities and specificities, respectively, were 63% and 90% (1 mm board), and 94% and 60% (2 mm board). With VP, the sensitivities and specificities, respectively, were 59% and 90% (1 mm board), and 88% and 61% (2 mm board).

CONCLUSIONS

FB, which simultaneously tests touch and pressure sensation, shows a high level of performance in detecting at-risk feet. FB may be simple, time-efficient, and inexpensive test for detection of neuropathy and needs further validation in a larger study.

A new diabetic foot risk assessment tool: DIAFORA

AIMS

This study aimed to derive a new model to classify subjects with diabetes and active diabetic foot ulcer by their risk of lower extremity amputation.

METHODS

A prospective cohort study was conducted that included all subjects with diabetic foot ulcer attending our Hospital Diabetic Foot Clinic from 2010 to 2013. Variables were collected at baseline. Subjects were followed up until healing, lower extremity amputation, death or for at least 3 months. Logistic regression was used to derive the new model, and the area under the receiver operating characteristic curve was assessed to propose the model with the greatest discrimination.

RESULTS

A total of 293 participants were included and followed for a median of 91 days. In 23.2% amputation was required, 5.1% died and 3.1% were lost. Our final model included the variables most commonly used in clinical practice for diabetic foot risk assessment (presence of neuropathy, foot deformity, peripheral arterial disease and previous foot complications) in addition to multiple diabetic foot ulcer, infection, gangrene and bone involvement. This model had an area under the receiver operating characteristic curve of 0.91 [95% confidence interval (CI) 0.87-0.95] and as classification of 0.89 (95% CI 0.84-0.93) for lower extremity amputation prediction. The high-risk group presented a positive likelihood ratio of 5 (95% CI 3-8) and predictive value of 58 (46-71). Only one minor lower extremity amputation occurred in the low-risk group.

CONCLUSIONS

We propose a new classification: diabetic foot risk assessment (DIAFORA). This classification was equally or more accurate for lower extremity amputation prediction in diabetic foot ulcer patients when compared with the existing ones.

Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease (DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy (DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.

Determinants of Slow Walking Speed in Ambulatory Patients Undergoing Maintenance Hemodialysis

Walking ability is significantly lower in hemodialysis patients compared to healthy people. Decreased walking ability characterized by slow walking speed is associated with adverse clinical events, but determinants of decreased walking speed in hemodialysis patients are unknown. The purpose of this study was to identify factors associated with slow walking speed in ambulatory hemodialysis patients. Subjects were 122 outpatients (64 men, 58 women; mean age, 68 years) undergoing hemodialysis. Clinical characteristics including comorbidities, motor function (strength, flexibility, and balance), and maximum walking speed (MWS) were measured and compared across sex-specific tertiles of MWS. Univariate and multivariate logistic regression analyses were performed to examine whether clinical characteristics and motor function could discriminate between the lowest, middle, and highest tertiles of MWS. Significant and common factors that discriminated the lowest and highest tertiles of MWS from other categories were presence of cardiac disease (lowest: odds ratio [OR] = 3.33, 95% confidence interval [CI] = 1.26–8.83, P<0.05; highest: OR = 2.84, 95% CI = 1.18–6.84, P<0.05), leg strength (OR = 0.62, 95% CI = 0.40–0.95, P<0.05; OR = 0.57, 95% CI = 0.39–0.82, P<0.01), and standing balance (OR = 0.76, 95% CI = 0.63–0.92, P<0.01; OR = 0.81, 95% CI = 0.68–0.97, P<0.05). History of fracture (OR = 3.35, 95% CI = 1.08–10.38; P<0.05) was a significant factor only in the lowest tertile. Cardiac disease, history of fracture, decreased leg strength, and poor standing balance were independently associated with slow walking speed in ambulatory hemodialysis patients. These findings provide useful data for planning effective therapeutic regimens to prevent decreases in walking ability in ambulatory hemodialysis patients.

Vascular assessment techniques of podiatrists in Australia and New Zealand: a web-based survey

Background

Podiatrists play a central role in conducting non-invasive vascular assessment in the lower extremity. This involves screening for signs and symptoms of peripheral arterial disease (PAD) and ongoing monitoring of the condition. Podiatric vascular assessment practices in Australia and New Zealand are currently unclear. Determining the clinical habits of Podiatrists is essential in identifying if there is a need for further education or support in performing accurate vascular assessments.

Methods

A web-based, secure, anonymous questionnaire was conducted of registered Podiatrists in Australia and New Zealand between 1 April and 31 July 2013. The questions examined clinician’s regular practices in vascular assessment, clinical indicators to perform and barriers in completing vascular assessment. Nominal logistic regression was performed to further examine years of experience and practice setting on clinical indicators to perform vascular assessment and types of assessment performed.

Results

Four hundred forty-seven podiatrists participated in the survey. Clinical indicators for vascular assessment, along with barriers and available equipment were examined and the results varied depending on the podiatrists’ geographical location, practice setting, and experience. Palpation of pedal pulses was the most frequently reported assessment (97 %) along with Doppler assessment (74 %). Pressure measurement was the least frequently reported vascular assessment method, with only 34 % undertaking ankle-brachial indices and 19 % completing toe-brachial indices. Public podiatrists reported more varied and complete vascular assessment compared to those in private practice. Lack of time was identified as the most frequently reported barrier (66 %) in performing vascular assessment, followed by lack of equipment (28 %). In New Zealand podiatrists, lack of equipment was much more of an issue than in Australian podiatrists.

Conclusion

Large variations exist in vascular assessment methods amongst Australian and New Zealand podiatrists. Some assessments being undertaken are potentially inadequate for accurate screening for PAD. There is a need for continuing education in vascular assessment to address the deficiencies in technique reported by some Podiatrists. A podiatry-relevant summary of broad international guidelines for PAD screening may be of use to improve utilisation and accuracy of screening methods to improve patient management.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-015-0130-5) contains supplementary material, which is available to authorized users.

Lower-limb amputation following foot ulcers in patients with diabetes: classification systems, external validation and comparative analysis

BACKGROUND

This study aimed to validate and compare the existing systems developed to stratify subjects with diabetic foot ulcers by risk of consequent lower extremity amputation.

METHODS

We conducted a prospective cohort study on a consecutive series of patients (mean age of 68 years; 64% male) with active ulcer who were attending our Hospital Diabetic Foot Clinic (n = 293) from January 2010 to March 2013. At baseline, we collected information on the participants' characteristics and the relevant variables. Afterwards, we assessed the predictive value of each variable and each system's prognostic accuracy for amputation occurrence.

RESULTS

During a median follow-up of 91 days (interquartile range of 98), ulcers healed in 62% of the subjects. Major amputation occurred in 7% and minor occurred in 17%. Previous ulcer or amputation, ulcer area, and gangrene were associated with amputation occurrence. Nephropathy, pulses number, ulcer aetiology, depth, and number were associated with risk of amputation. Systems typically presented sensitivity values ≥80% and negative likelihood ratios ≤0.5 for the highest risk group; area under the receiver operating characteristic curve ranged from 0.56 to 0.83 and positive likelihood ratios from 1.0 to 5.9. If one chose only major amputation as an outcome, positive predictive values were lower, and negative predictive values tended to be higher.

CONCLUSIONS

System stages, grades, scores, and/or prognostics were generally associated with amputation, presenting overall substantial accuracy values. Nevertheless, great improvement is possible. A multicentre study validating and refining the existing systems is needed to improve clinical decision-making in this area.

Effects of thai foot massage on balance performance in diabetic patients with peripheral neuropathy: a randomized parallel-controlled trial

BACKGROUND Peripheral neuropathy is the most common complications of diabetic patients and leads to loss of plantar cutaneous sensation, movement perception, and body balance. Thai foot massage is an alternative therapy to improve balance. Therefore, the purpose of this study was to investigate the effects of Thai foot massage on balance performance in diabetic patients with peripheral neuropathy. MATERIAL AND METHODS Sixty patients with type-2 diabetes were recruited and randomly assigned into either the Thai foot massage or control groups. The Thai foot massage group received a modified Thai traditional foot massage for 30 min, 3 days per week for 2 weeks. We measured timed up and go (TUG), one leg stance: OLS), the range of motion (ROM) of the foot, and foot sensation (SWMT) before treatment, after the first single session, and after the 2-week treatment. RESULTS After the single treatment session, only the Thai foot massage group showed a significant improvement in TUG. After the 2-week treatment, both Thai foot massage and control groups showed a significant improvement of TUG and OLS (P<0.05); however, when comparing between 2 groups, the Thai foot massage group showed better improvement in TUG than the control group (p<0.05). The Thai foot massage group also showed significant improvements in ROM and SWMT after the 2-week treatment. CONCLUSIONS The results of this study suggest that Thai foot massage is a viable alternative treatment for balance performance, ROM of the foot, and the foot sensation in diabetic patients with peripheral neuropathy.

Percutaneous injection of bone marrow mesenchymal stem cells for ankle non-unions decreases complications in patients with diabetes

PURPOSE

Clinical studies in diabetic patients have demonstrated that there is a high incidence of complications in distal tibia and ankle fracture treatments. One strategy to mitigate issues with wound healing and infection in diabetic patients is to use a percutaneous technique in which autologous, bone marrow-derived, concentrated cells are injected at the site of non-unions.

METHODS

Eighty-six ankle non-union in diabetic patients were treated with bone marrow mesenchymal stem cells (BM-MSCs) delivered in an autologous bone marrow concentrate (BMC). Clinical outcomes of the 86 diabetic non-union patients treated with BMC were compared with 86 diabetic matched non-unions treated with a standard bone iliac crest autograft.

RESULTS

Treatment with BMC promoted non-union healing in 70 among 86 diabetic patients (82.1 %) with a low number of complications. Of the 86 diabetic patients treated with iliac bone graft, 53 (62.3 %) had healing; major complications were observed: 5 amputations, 11 osteonecroses of the fracture wound edge and 17 infections.

CONCLUSIONS

In diabetic patients with ankle non-unions, treatment with BM-MSCs from bone marrow concentrate may be preferable in view of the high risks of major complications after open surgery and iliac bone grafting, and improved healing rates compared with standard iliac bone autograft treatment.

BE SMART: strategies for foot care and prevention of foot complications in patients with diabetes

BACKGROUND

Diabetic foot ulcers and lower extremity amputations are common complications of diabetes mellitus that are associated with substantial morbidity, loss of quality of life, disability, and a high social and economic burden. The implementation of strategies to prevent these complications is a key aspect of diabetes care.

OBJECTIVES

The objective of this article is to provide an overview of the available evidence on preventive diabetic foot care.

STUDY DESIGN

Literature review.

METHODS

Narrative review based on a thorough search of previous relevant studies, systematic reviews, and clinical guidelines on diabetic foot care published in English.

RESULTS

We describe diabetic foot care strategies that can be categorized within defined domains for the purpose of helping clinicians to remember them. We use the mnemonic "BE SMART" (Be aware of the risk factors, Educate patients and health providers, Structured clinical assessment, Metabolic evaluation and management, Assessment of Risk, and Team care) to organize these domains.

CONCLUSION

Diabetic foot ulcers and lower extremity amputations are potentially preventable complications. Clinicians taking care of patients with diabetes should know, understand, and remember the multiple aspects of diabetic foot care.

CLINICAL RELEVANCE

This review can be used as a reference source for those interested in the care of diabetic foot. It highlights the importance of risk factor recognition, education, a structured clinical and metabolic evaluation, and also the importance of assigning patients a risk category that can help guiding multidisciplinary management efforts.

Diabetic foot ulcers: evaluation and management

Diabetic foot ulcers (DFUs) are a common complication of diabetes and present a significant health risk to patients, as well as impose a large economic burden. Evaluation for contributory factors that may impact general health or healing, such as hyperglycemia, peripheral artery disease, neuropathy, and nutritional status, is of the utmost importance. Management of DFUs requires involvement of a multidisciplinary team and a standardized approach to patient care. Standard therapy for DFUs includes offloading and debridement. Assessment and control of infection are critical, including determining the severity of the infection, which may drive therapeutic approaches. For recalcitrant ulcers, adjuvant therapies are used to hasten the healing process, and newer therapies are under investigation.

Characteristics of a large cohort of patients with diabetes having at-risk feet and outcomes in patients with foot ulceration referred to a tertiary care diabetes unit

To identify in a large population cohort the clinical and biochemical characteristics of patients with diabetes at risk of foot ulceration and outcomes in those with foot ulcers. All patients with diabetes attending Baqai Institute of Diabetology and Endocrinology from January 2004 to April 2012 included in the study. Clinical, biochemical and socio-demographic data were collected and patients were categorised into those at no risk of ulceration, at risk of ulceration and those with foot ulcer, according to the University of Texas classification. Patients with foot ulceration followed for their final outcome, that is complete healing, persisted non-healed ulcer, lower extremity amputation, lost to follow-up or death. A total of 18 119 patients with diabetes underwent assessment, 3576 (19·7%) patients defined as at high risk for foot ulceration and 3731 (20·6%) presented with foot ulcer. Age, male gender, hypertension, higher glycated haemoglobin (HbA1c), history of smoking and presence of neuropathy were risk factors (P < 0·000) for foot ulceration. Amputation rate in patients with foot ulceration was significantly related to severity of ulceration at presentation. Preventive foot care practices were followed by 19·02% patients. One thousand eight hundred seventy three (50·2%) patients completely healed, 293 (11%) patients underwent amputation and 397 (10·1%) patients continued to be treated in the foot clinic. All patients with diabetes should be screened for neuropathy to identify those at risk of foot ulceration, as it is the major contributory factor for foot ulceration. The final outcome of foot ulceration was determined by the severity and grade of ulcer at presentation.

The Queensland high risk foot form (QHRFF) - is it a reliable and valid clinical research tool for foot disease?

BACKGROUND

Foot disease complications, such as foot ulcers and infection, contribute to considerable morbidity and mortality. These complications are typically precipitated by "high-risk factors", such as peripheral neuropathy and peripheral arterial disease. High-risk factors are more prevalent in specific "at risk" populations such as diabetes, kidney disease and cardiovascular disease. To the best of the authors' knowledge a tool capturing multiple high-risk factors and foot disease complications in multiple at risk populations has yet to be tested. This study aimed to develop and test the validity and reliability of a Queensland High Risk Foot Form (QHRFF) tool.

METHODS

The study was conducted in two phases. Phase one developed a QHRFF using an existing diabetes foot disease tool, literature searches, stakeholder groups and expert panel. Phase two tested the QHRFF for validity and reliability. Four clinicians, representing different levels of expertise, were recruited to test validity and reliability. Three cohorts of patients were recruited; one tested criterion measure reliability (n = 32), another tested criterion validity and inter-rater reliability (n = 43), and another tested intra-rater reliability (n = 19). Validity was determined using sensitivity, specificity and positive predictive values (PPV). Reliability was determined using Kappa, weighted Kappa and intra-class correlation (ICC) statistics.

RESULTS

A QHRFF tool containing 46 items across seven domains was developed. Criterion measure reliability of at least moderate categories of agreement (Kappa > 0.4; ICC > 0.75) was seen in 91% (29 of 32) tested items. Criterion validity of at least moderate categories (PPV > 0.7) was seen in 83% (60 of 72) tested items. Inter- and intra-rater reliability of at least moderate categories (Kappa > 0.4; ICC > 0.75) was seen in 88% (84 of 96) and 87% (20 of 23) tested items respectively.

CONCLUSIONS

The QHRFF had acceptable validity and reliability across the majority of items; particularly items identifying relevant co-morbidities, high-risk factors and foot disease complications. Recommendations have been made to improve or remove identified weaker items for future QHRFF versions. Overall, the QHRFF possesses suitable practicality, validity and reliability to assess and capture relevant foot disease items across multiple at risk populations.

Evaluation of chemotherapy-induced peripheral neuropathy using current perception threshold and clinical evaluations

PURPOSE

Chemotherapy-induced peripheral neuropathy (CIPN) is increasing with introduction of new and combination cancer pharmacotherapies. This study evaluated associations between clinical and self-report measurements and current perception threshold (CPT), a neuroselective measure of sensory nerve function that may detect asymptomatic CIPN damage.

METHODS

Data for this secondary analysis were from a prospective, observational study using CPT to evaluate CIPN. Bivariate mixed models, accounting for the intraclass correlation between repeated patient assessments, were used to assess the relationship between CPT at each frequency (5, 250, and 2,000 Hz) and each subjective measure (Neuropathic Pain Scale, FACT-GOGntx) and objective measurement (quantitative sensory testing, deep tendon reflexes, and grip strength).

RESULTS

A total of 29 chemotherapy-naïve subjects with various cancer types had a mean age of 56.7 (SD 10.4); nine subjects developed CIPN grade >1 using NCI CTC-AE criteria. Cold detection thresholds were inversely associated with CPT 5 [b(95 % CI) = -2.5(-4.5, -0.5)] and CPT 2,000 [-7.5(-11.8, -3.3)] frequencies. FACT GOG-ntx quality of life (QoL) scale and neurotoxicity and function subscales were inversely associated with CPT 2,000 [-1.8 (-3.5, -0.05), -2.2 (-4.2, -0.2), and -5.4 (-9.8, -0.9), respectively], indicating worsening QoL, impairment, and function as hypoesthesia increases.

CONCLUSIONS

CPT 2,000 may identify impending worsening of patient-reported outcomes such as QoL.

Screening of diabetic foot in surgical inpatients: a hospital-based study in saudi arabia

Previous reports found that identification of diabetic patients at high risk of foot ulcers, and managing the risk factors early, lower extremity amputations could be prevented. The aim of this study is to determine the value of screening diabetics in estimating the risk of foot ulceration among surgical inpatients. This is a prospective study on all diabetic patients admitted to the surgical department, King Fahd Hospital of the University, Saudi Arabia, during the year 2011. Patients were screened for the presence of diabetic foot. They were classified according to the international working group on the diabetic foot into four grades [0 (lowest risk patients), 1, 2, 3 (highest risk patients)]. During the study period, 391 patients had diabetes mellitus (DM), of these 73 (19%) had active ulcer and were excluded from the study and the rest were screened. Grade 0 was in 174 (54.5%) patients, the rest were grades 1, 2, and 3. There was significant difference between low-risk groups (grades 0, 1) and high-risk groups (grades 2, 3) as regards age, smoking and duration of DM. This study indicates that prevalence of diabetic patients with risk of foot ulceration in surgical inpatients was high. Routine screening of diabetic foot is recommended specially in old patients.

Monofilament insensitivity and small and large nerve fiber symptoms in impaired fasting glucose

AIMS

To determine if diabetes or pre-diabetes is associated with monofilament insensitivity and peripheral neuropathy symptoms.

METHODS

The 10-g Semmes-Weinstein monofilament test and Michigan Neuropathy Screening Instrument symptom questionnaire were administered to participants in the Study of Women's Health Across the Nation - Michigan site (n=396). We determined the concordance of monofilament insensitivity and symptoms and used chi-square tests, ANOVA, and logistic regression to quantify the relationships among diabetes status, monofilament insensitivity and symptoms.

RESULTS

The prevalence of monofilament insensitivity was 14.3% and 19.4% of women reported symptoms of peripheral neuropathy. With monofilament testing, 11.7% of women with normal fasting glucose, 14.4% of women with impaired fasting glucose (IFG) and 18.3% of women with diabetes had monofilament insensitivity (p-value=0.33). For symptoms, 14.0% of women with normal fasting glucose, 16.5% of women with IFG and 31.2% of women with diabetes reported symptoms of peripheral neuropathy. Women who reported symptoms of small fiber nerve dysfunction alone were unlikely to have monofilament insensitivity. Compared to women with normal fasting glucose, women with diabetes were more likely to report peripheral neuropathy symptoms [OR 2.8 (95% CI: 1.5, 5.1)]. Women with diabetes were also more likely to report symptoms than women with IFG (p=0.02). There was no difference in the frequency of symptoms between women with normal fasting glucose and IFG.

CONCLUSIONS

Women with diabetes were more likely to report peripheral neuropathy symptoms. The prevalence of monofilament insensitivity and peripheral neuropathy symptoms did not differ between women with normal fasting glucose and IFG.

HIV peripheral neuropathy and foot care management: a review of assessment and relevant guidelines

Despite the decline in the incidence of central nervous system disease associated with HIV, distal sensory peripheral (DSP) neuropathy continues to be prevalent in this population, causing debilitating symptoms and affecting quality of life. Patients typically present with numbness, tingling, burning pain, and loss of sensation in the toes and soles of their feet. Although this complication causes loss of protective function and puts patients at elevated risk for injury, infection, and falls, foot care for people with HIV is often overlooked. This article reviews what is known about DSP neuropathy in HIV and discusses relevant foot care guidelines, adopted from the literature on other conditions associated with neuropathic foot disorders.

EMLA-Induced Skin Wrinkling for the Detection of Diabetic Neuropathy

Objective: To determine the usefulness of Eutectic Mixture of Local Anesthetic (EMLA)-induced stimulated skin wrinkling (SSW) to detect diabetic sensorimotor polyneuropathy (DSPN).

Research Design and Methods: Two hundred and ten diabetics were prospectively recruited (mean age 58.5 ± 12.7 years) from a large tertiary center from 2009 to 2011. EMLA was applied to the tips of digits 2, 3, and 4 and the degree of wrinkling graded. Diabetic Neuropathy Symptom (DNS) score, nerve conduction studies (NCS), Semmes–Weinstein monofilament (SWMF) tests, and vibratory perception thresholds (VPTs) testing were chosen as comparative clinical standards to diagnose length-dependent DSPN.

Results: Inter-rater agreement for two examiners of SSW was high, with Cohen’s weighted κ of 0.912 for the right hand, and 0.823 for the left. K measure of agreement of SSW with the NCS, DNS scores, SWMF testing, and VPT testing was 0.486, 0.243, 0.289, and 0.395 respectively. SSW was able to distinguish between normal and abnormal NCS and DNS results, with median scores of 3.333 vs. 1.667 (p < 0.0005); and 3.167 vs. 2.000 (p < 0.0005) respectively. Following receiver operating characteristic-analysis, at a cut-off point of <3 for an abnormal SSW test, sensitivity of SSW test for diagnosing DSPN using NCS as a reference standard was 81.3%, and specificity was 67.0%, on par with other testing methods.

Conclusion: SSW shows comparable sensitivity to other methods for detecting DSPN. Given its low cost and easy administration, SSW can be considered a useful alternative screening method for diagnosing diabetic neuropathy.

Bupivacaine digital blocks: how long is the pain relief and temperature elevation?

BACKGROUND

The goals of this study are threefold: (1) to determine what effect epinephrine has on the duration of bupivacaine finger block anesthesia; (2) to see whether the duration of action of bupivacaine on digital pain relief is the same duration as numbness to touch/pressure; and (3) to assess the fingertip temperature changes that result from bupivacaine digital blocks.

METHODS

The ring fingers of both hands of 44 volunteers were randomized to injection of bupivacaine with or without 1:200,000 epinephrine. The durations of time for digits to return to normal pain, touch, pressure sensation, and fingertip temperature were measured and recorded.

RESULTS

There were three main findings: (1) the pain block of bupivacaine lasts only half as long (15 hours) as the return to normal sensation (30 hours); (2) the effect of adding epinephrine to bupivacaine prolongs the duration of pain relief in a finger block for only an additional 1.5 hours; (3) in addition to pain relief, bupivacaine finger blocks cause fingertip hyperemia with consistent significant fingertip temperature elevation that lasts 15 hours.

CONCLUSIONS

The duration of bupivacaine pain relief is the clinically important factor that needs to be reported in bupivacaine trials. Patients should be informed that the return of pain will occur much sooner than the return of normal sensation. Adding epinephrine to bupivacaine does not add a clinically significant length of time to pain relief. Bupivacaine finger blocks provide prolonged hyperemia and pain block to fingertips, which may be useful in the treatment of acute frostbite.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Evaluation of patients' education on foot self-care status in diabetic patients

BACKGROUND

Skin problems caused by neuropathy and antipathy are common manifestations of diabetes. The most serious about such problem is the diabetic foot, which may lead to eventual ulceration and amputation, and will decrease a patient's quality of life dramatically.

OBJECTIVES

The aim of this study is to assess the level of foot self-care and foot conditions in diabetic patients, and to demonstrate the role of self-care education in diabetic foot care.

PATIENTS AND METHODS

A total of 80 diabetic patients were included in the study, all of whom had referred to "Yazd Diabetic Research Center." The levels of their foot self-care were recorded in pre-test questionnaires, and then all of the patients were visited and educated by a Dermatologist for their foot self-care on a monthly basis, after which their post-test results were recorded through a second administration of the same questionnaire. Eventually, data from the pre and post-test questionnaires were analyzed to identify the possible effects of education.

RESULTS

A total of 80 diabetic patients (34 males, 46 females) with a mean average age of 53.53 ± 10.19 and mean average duration of diabetes 12.42 ± 6.73 years were assessed. A significant increase in foot self-care through education was observed (baseline 27.06 ± 8.77, vs. post education 43.12 ± 8.77; P = 0.0001). After education, foot and nail lesions improved completely in 84% and 62.8%. Moreover, 77.8% of patients had suitable shoes and 79.6% had suitable socks.

CONCLUSIONS

Our findings showed that foot self-care education could improve knowledge and performance of patients about various foot problems, and was significantly important in preventing ulcers.

Validation and comparison of currently available stratification systems for patients with diabetes by risk of foot ulcer development

AIMS/HYPOTHESIS

There are five systems to stratify the risk for the development of a diabetic foot ulcer (DFU). This study aimed to prospectively validate all of them in the same cohort of participants to allow their direct comparison.

METHODS

A retrospective cohort study was conducted on all patients with diabetes but without an active DFU attending our podiatry section (n=364) from January 2008 to December 2010. Participants' characteristics and all variables composing the stratification systems were assessed at baseline. Follow-up was performed for 1 year or until DFU occurred.

RESULTS

Participants had a mean age of 64 years; 99.7% had type 2 diabetes and 48.6% were male. Median follow-up was 12 months (1-12) during which 33 subjects (9.1%) developed a DFU. Age, diabetes duration, foot deformity, peripheral vascular disease, diabetic peripheral neuropathy, previous DFU, and previous lower extremity amputation were associated with DFU occurrence. All systems presented greater DFU occurrence frequency as the risk group was higher (χ(2), P<0.001) and showed good diagnostic accuracy values, especially negative predictive value (≥ 95%) and area under the receiver operating curve (≥ 0.73). The lowest performance concerned positive predictive value (≤ 29.5%).

CONCLUSIONS/INTERPRETATION

All the currently available stratification systems show high accuracy to detect which patients will develop a DFU with no significant differences among them. Therefore, for diabetic foot screening and resource allocation, it would be desirable to have a single unified system, combining the available systems, prospectively validated in a multicenter context and testing the inclusion of novel predictive variables' pertinence.

Accuracy and durability of Semmes-Weinstein monofilaments: what is the useful service life?

OBJECTIVE

To evaluate the accuracy and effective service life of commercially available Semmes-Weinstein monofilaments with repetitive loading.

METHODS

We obtained 6 brands of Semmes-Weinstein monofilaments (SWM) from commercial vendors identified from the Internet and the federal registry. Five monofilaments of each brand were subjected to repeat loading cycles, allowed to rest over night and loaded again the next day. First, sets of five monofilaments were loaded 25 times for each of five days. Then sets of five monofilaments were subjected to 200 loading cycles a day for 15 days. A testing jig ensured each SWM was loaded perpendicular to a digital pressure plate. The buckling force was measured via the pressure plate to determine failure loads. Several statistical techniques were used to examine the behavior of the monofilaments over repeated loadings: time series analysis, ANOVA and nonparametric comparisons of load distributions.

RESULTS

The monofilaments tested were neither precise nor accurate. The plasticity of filaments increased with repeated loadings resulting in lower bending forces. Individual and average bending forces varied widely both within and between monofilament brands. All monofilaments showed a typical material failure pattern. Initially the bending force was high but rapidly decreased and then leveled out at levels 1-2g lower than the starting values. After resting over night, the initial bending force was again high but usually not as high as the previous day and bending forces decreased and then leveled out. Most monofilaments did not start at the accepted 10-g buckling force but varied by up to 30% (p<0.01). At best, monofilaments starting at the accepted 10±1g buckling force would remain within a usable range (9-11g) for 7-9 days or to evaluate 70-90 patients.

CONCLUSION

Commercially available SWM have significant variability within and between devices from different manufacturers. Their actual bending force varies widely from their designated 10g value. When used they have a short service life where the instrument is within 10% of their initial bending force which is not usually the stated 10g of force.