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Orlando G, Brown S, Jude E, Bowling FL, Boulton AJM, Reeves ND. Acute Effects of Vibrating Insoles on Dynamic Balance and Gait Quality in Individuals With Diabetic Peripheral Neuropathy: A Randomized Crossover Study. Diabetes Care 2024; 47:1004-1011. [PMID: 38536962 DOI: 10.2337/dc23-1858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/07/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE This study investigated the effects of vibrating insoles on dynamic balance and gait quality during level and stair walking and explored the influence of vibration type and frequency in individuals with diabetic peripheral neuropathy (DPN). RESEARCH DESIGN AND METHODS Twenty-two men with DPN were assessed for gait quality and postural and dynamic balance during walking and stair negotiation using a motion capture system and force plates across seven vibratory insole conditions (Vcs) versus a control (Ctrl) condition (insole without vibration). Vibration was applied during standing and walking tasks, and 15-min rest-stop periods without vibration were interposed between conditions. Repeated measures test conditions were randomized. The primary outcomes were gait speed and dynamic balance. RESULTS Gait speed during walking significantly improved in all Vcs compared with Ctrl (P < 0.005), with Vc2, Vc4, and Vc6 identified as the most effective. Gait speed increased (reflecting faster walking) during stair ascent and descent in Vc2 (Ctrl vs. Vc2 for ascent 0.447 ± 0.180 vs. 0.517 ± 0.127 m/s; P = 0.037 and descent 0.394 ± 0.170 vs. 0.487 ± 0.125 m/s; P = 0.016), Vc4 (Ctrl vs. Vc4 for ascent 0.447 ± 0.180 vs. 0.482 ± 0.197 m/s; P = 0.047 and descent 0.394 ± 0.170 vs. 0.438 ± 0.181 m/s; P = 0.017), and Vc6 (Ctrl vs. Vc6 for ascent 0.447 ± 0.180 vs. 0.506 ± 0.179 m/s; P = 0.043 and descent 0.394 ± 0.170 vs. 0.463 ± 0.159 m/s; P = 0.026). Postural balance improved during quiet standing with eyes closed in Vc2, Vc4, Vc6, and Vc7 (P < 0.005). CONCLUSIONS Vibrating insoles are an effective acute strategy for improving postural balance and gait quality during level walking and stair descent in individuals with DPN. These benefits are particularly evident when the entire plantar foot surface is stimulated.
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Affiliation(s)
- Giorgio Orlando
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
- Department of Sport and Exercise Sciences, Institute of Sport, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Steven Brown
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
- Department of Sport and Exercise Sciences, Institute of Sport, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Edward Jude
- Tameside and Glossop Integrated Care, National Health Service Foundation Trust, Ashton-under-Lyne, Manchester, U.K
| | - Frank L Bowling
- Department of Medicine, Manchester Royal Infirmary, Manchester, U.K
| | - Andrew J M Boulton
- Department of Medicine, Manchester Royal Infirmary, Manchester, U.K
- Diabetes Research Institute, University of Miami, Miami, FL
| | - Neil D Reeves
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
- Department of Sport and Exercise Sciences, Institute of Sport, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, Lancaster, U.K
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Shuang J, Haron A, Massey G, Mansoubi M, Dawes H, Bowling FL, Reeves ND, Weightman A, Cooper G. The effect of calcaneus and metatarsal head offloading insoles on healthy subjects' gait kinematics, kinetics, asymmetry, and the implications for plantar pressure management: A pilot study. PLoS One 2024; 19:e0303826. [PMID: 38758937 PMCID: PMC11101073 DOI: 10.1371/journal.pone.0303826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/01/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND The global number of people with diabetes is estimated to reach 643 million by 2030 of whom 19-34% will present with diabetic foot ulceration. Insoles which offload high-risk ulcerative regions on the foot, by removing insole material, are the main contemporary conservative treatment to maintain mobility and reduce the likelihood of ulceration. However, their effect on the rest of the foot and relationship with key gait propulsive and balance kinematics and kinetics has not been well researched. PURPOSE The aim of this study is to investigate the effect of offloading insoles on gait kinematics, kinetics, and plantar pressure throughout the gait cycle. METHODS 10 healthy subjects were recruited for this experiment to walk in 6 different insole conditions. Subjects walked at three speeds on a treadmill for 10 minutes while both plantar pressure and gait kinematics, kinetics were measured using an in-shoe pressure measurement insole and motion capture system/force plates. Average peak plantar pressure, pressure time integrals, gait kinematics and centre of force were analysed. RESULTS The average peak plantar pressure and pressure time integrals changed by -30% (-68% to 3%) and -36% (-75% to -1%) at the region of interest when applying offloading insoles, whereas the heel strike and toe-off velocity changed by 15% (-6% to 32%) and 12% (-2% to 19%) whilst walking at three speeds. CONCLUSION The study found that offloading insoles reduced plantar pressure in the region of interest with loading transferred to surrounding regions increasing the risk of higher pressure time integrals in these locations. Heel strike and toe-off velocities were increased under certain configurations of offloading insoles which may explain the higher plantar pressures and supporting the potential of integrating kinematic gait variables within a more optimal therapeutic approach. However, there was inter-individual variability in responses for all variables measured supporting individualised prescription.
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Affiliation(s)
- Jiawei Shuang
- School of Engineering, University of Manchester, Manchester, United Kingdom
| | - Athia Haron
- School of Engineering, University of Manchester, Manchester, United Kingdom
| | | | | | | | - Frank L. Bowling
- Faculty of Biology, School of Medical Sciences, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Neil D. Reeves
- Faculty of Science and Engineering, Department of Life Sciences, Manchester Metropolitan University, Manchester, United Kingdom
- Manchester Metropolitan University Institute of Sport, Manchester, United Kingdom
| | - Andrew Weightman
- School of Engineering, University of Manchester, Manchester, United Kingdom
| | - Glen Cooper
- School of Engineering, University of Manchester, Manchester, United Kingdom
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Barrett DW, Carreira J, Bowling FL, Wolowczyk L, Rogers SK. Improving duplex ultrasound methods for diagnosing functional popliteal artery entrapment syndrome. Scand J Med Sci Sports 2024; 34:e14592. [PMID: 38458973 DOI: 10.1111/sms.14592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES Popliteal artery entrapment syndrome (PAES) is a rare condition where musculoskeletal structures compress the popliteal artery (POPA) leading to vascular compromise. This study investigates the effect of dynamic plantar- and dorsi-flexion loading on POPA hemodynamic parameters to develop a robust diagnostic ultrasound-based protocol for diagnosing functional PAES. METHODS Healthy individuals (n = 20), recreational athletes (n = 20), and symptomatic (n = 20) PAES patients were consented. Triplex ultrasound imaging of lower limb arteries was performed (n = 120 limbs). Proximal and distal POPA's in dorsi-/plantar-flexion, in prone and erect positions, were imaged at rest and flexion. Peak systolic velocities (cm/s) and vessel diameter (antero-posterior, cm) was measured. RESULTS Distal vessel occlusion was noted across all three groups whilst prone during plantar-flexion (62.7%). POPA occlusion was only noted in the proximal vessel within the patient group (15.8%). When prone, 50% of control (n = 40 limbs), 70% of athletes (n = 40 limbs), and 65% of patients (n = 40 limbs) had distal POPA occlusion in plantar-flexion. When prone, recreational athletes (5%), and patients (12.5%) had distal POPA compression under dorsi-flexion. POPA occlusions with the patient in erect position were only noted in the symptomatic patient group under both dorsi-flexion (15.8%) and plantar-flexion (23.7%). CONCLUSION Compression of the POPA on ultrasound should not be the sole diagnostic criteria for PAES. POPA compression exists in asymptomatic individuals, primarily under prone plantar-flexion. To reduce false positives, ultrasound-based protocols should focus on scanning patients in the erect position only to diagnose PAES, rather than asymptomatic POPA compression. A distinction should be made between the two.
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Affiliation(s)
- David W Barrett
- Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Joao Carreira
- Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Frank L Bowling
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Manchester, UK
| | - Leszek Wolowczyk
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Manchester, UK
| | - Steven K Rogers
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Manchester, UK
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Ionac S, Rogers SK, Bondor CI, Bowling FL, Dragoi II, Ionac M. Lower Extremity Amputation and Peripheral Revascularisation Rates in Romania and Their Relationship with Comorbidities and Vascular Care. J Clin Med 2023; 13:52. [PMID: 38202058 PMCID: PMC10779533 DOI: 10.3390/jcm13010052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: This retrospective Romanian study aimed to calculate the rate of, and comparison between, amputation and revascularisation for patients with either cardiovascular or diabetic comorbidities. (2) Materials: In our hospital-based database, we analysed patient-level data from a series of 61 hospitals for 2019, which covers 44.9% of the amputation patients for that year. The national database is compiled by the national houses of insurance and was used to follow amputations and revascularisations between 2016 and 2021. (3) Results: During the six-year period, the mean number of amputations and revascularisations was 72.4 per 100,000 inhabitants per year for both groups. In this period, a decline in open-surgical revascularisation was observed from 58.3% to 47.5% in all interventions but was not statistically significant (r = -0.20, p = 0.70). The mean age of patients with amputation (hospital-based database) was 67 years. Of these patients, only 5.1% underwent revascularisation in the same hospital prior to amputation. The most common comorbidities in those undergoing amputations were peripheral arterial disease (76.8%), diabetes (60.8%), and arterial hypertension (53.5%). Most amputations were undertaken by general surgeons (73.0%) and only a small number of patients were treated by vascular surgeons (17.4%). (4) Conclusions: The signal from our data indicates that Romanian patients probably have a high risk of amputation > 5 years earlier than Western European countries, such as Denmark, Finland, and Germany. The prevalence of revascularisations in Romania is 64% lower than in the Western European countries.
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Affiliation(s)
- Stefan Ionac
- CerVasc, Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania;
| | - Steven K. Rogers
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Cosmina I. Bondor
- Department of Medical Informatics and Biostatistics, Iuliu Hațeganu University of Medicine and Pharmacy, 6 Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Frank L. Bowling
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Iulia Iovanca Dragoi
- CerVasc, Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania;
| | - Mihai Ionac
- Clinic of Vascular Surgery, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania;
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Dragoi II, Popescu FG, Bowling FL, Bondor CI, Ionac M. Patients' Buying Behavior for Non-Reimbursed Off-Loading Devices Used in Diabetic Foot Ulcer Treatment-An Observational Study during COVID-19 Pandemic from a Romanian Physical Therapy Unit. J Clin Med 2023; 12:6516. [PMID: 37892654 PMCID: PMC10607790 DOI: 10.3390/jcm12206516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Diabetic foot ulcer non-reimbursed treatment depends on multiple factors, including the patient's buying behaviors. Factors affecting buying behaviors for the removable off-loading devices are not completely understood. The aim of this study was to investigate the patients' buying behaviors of the removable off-loading devices and their influence on the DFU treatment outcomes remotely monitored during the COVID-19 pandemic. In this prospective observational study, 45 patients affected by diabetic peripheral neuropathy, with/without peripheral arterial disease, with foot ulcers treated with removable devices were remotely monitored. Prefabricated removable cast walkers, insoles, and therapeutic footwear were the proposed off-loading methods. Patients affected by high blood pressure (p = 0.018), peripheral arterial disease (p = 0.029), past amputations (p = 0.018), and ulcer on the left foot (p = 0.007) bought removable cast walkers. Rural provenience (p = 0.011) and male (p = 0.034) did not buy a removable walker. The healing rate was 69.4%, while the median healing time was 20 weeks. High blood pressure negatively influenced healing time (p = 0.020). Patients who bought the most efficient treatment method for DFUs were females from urban provenience, with amputation in the past, with peripheral arterial disease, and with high blood pressure.
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Affiliation(s)
- Iulia Iovanca Dragoi
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania; (I.I.D.); (F.L.B.); (M.I.)
| | - Florina Georgeta Popescu
- Discipline of Occupational Health, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Frank L. Bowling
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania; (I.I.D.); (F.L.B.); (M.I.)
- Department of Surgery & Translational Medicine, Faculty of Medical and Human Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Cosmina Ioana Bondor
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Iuliu Hațieganu”, 8 Victor Babeș, 400000 Cluj-Napoca, Romania;
| | - Mihai Ionac
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania; (I.I.D.); (F.L.B.); (M.I.)
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Barrett DW, Carreira J, Bowling FL, Wolowczyk L, Rogers SK. The Importance of Patient Position When Defining Normal Versus Pathological Functionality in the Diagnosis of Popliteal Artery Entrapment Syndrome with Duplex Ultrasound. Eur J Vasc Endovasc Surg 2023; 65:760-761. [PMID: 36828257 DOI: 10.1016/j.ejvs.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023]
Affiliation(s)
- David W Barrett
- Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Joao Carreira
- Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Frank L Bowling
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK; Manchester Vascular Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Leszek Wolowczyk
- Manchester Vascular Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Steven K Rogers
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK; Manchester Vascular Centre, Manchester University NHS Foundation Trust, Manchester, UK.
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Rogers SK, Phair A, Carriera J, Ghosh J, Bowling FL, McCollum C. Feasibility and Accuracy of Measuring Carotid Plaque Volume (Burden) With Contrast-Enhanced Tomographic 3D Ultrasound and Ultrasound Image Fusion. Ann Vasc Surg 2023; 91:168-175. [PMID: 36563846 DOI: 10.1016/j.avsg.2022.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/15/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Stenosis severity has been the indication for carotid endarterectomy (CEA) for 4 decades, but the annual stroke risk in asymptomatic carotid stenosis >70% is under 2%. Atherosclerotic volume has emerged as a risk factor for future stroke, but needs to be measured noninvasively. Tomographic ultrasound (tUS) is a novel technology that assembles 3D images in seconds. We evaluated accuracy of measuring Carotid Plaque Volume (CPV) with tUS in patients undergoing CEA. METHOD Consecutive patients were imaged immediately before CEA by tUS and contrast-enhanced tUS (CEtUS). CPV was measured using tUS, CEtUS, and a fused images incorporating both tUS and CEtUS by trained vascular scientists. Precise volume of the endarterectomy specimen was measured using Archimedes technique. RESULTS Mean ± sd (range) CPV in 129 endarterectomy specimens was 0.75 ± 0.43 cm3 (0.10-2.47 cm3). Mean ± sd CPV measured by tUS (n = 114) was 0.87 ± 0.51 cm3, CEtUS (n = 104) was 0.75 ± 0.45 cm3 and with fusion (n = 95) was 0.83 ± 0.49 cm3. Differences between specimen volume and CPV measured by tUS (0.13 ± 0.24 cm3), CEtUS (-0.01 ± 0.21 cm3) or fusion (-0.08 ± 0.20) were clinically insignificant. Intra-/interobserver differences were minimal. CONCLUSIONS tUS accurately measures CPV with excellent intra-/interobserver agreement. CEtUS improves accuracy if precise CPV measurement is needed for research but tUS alone would be sufficient for population screening.
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Affiliation(s)
- S K Rogers
- University of Manchester, Manchester University NHS Foundation Trust, School of Medical Sciences, Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, Manchester, UK; Manchester University NHS Foundation Trust, Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester Academic Health Science Centre, Manchester, UK.
| | - A Phair
- University of Manchester, Manchester University NHS Foundation Trust, School of Medical Sciences, Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, Manchester, UK
| | - J Carriera
- Manchester University NHS Foundation Trust, Independent Vascular Services Ltd, Wythenshawe Hospital, Manchester Academic Health Science Centre, Manchester, UK
| | - J Ghosh
- University of Manchester, Manchester University NHS Foundation Trust, School of Medical Sciences, Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, Manchester, UK
| | - F L Bowling
- University of Manchester, Manchester University NHS Foundation Trust, School of Medical Sciences, Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, Manchester, UK
| | - C McCollum
- University of Manchester, Manchester University NHS Foundation Trust, School of Medical Sciences, Manchester Academic Health Science Centre, Faculty of Biology, Medicine and Health, Manchester, UK
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Coman H, Stancu B, Gâvan NA, Bowling FL, Podariu L, Bondor CI, Radulian G. Diabetes-Related Lower Extremity Amputations in Romania: Patterns and Changes between 2015 and 2019. Int J Environ Res Public Health 2022; 20:557. [PMID: 36612876 PMCID: PMC9819762 DOI: 10.3390/ijerph20010557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/24/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
Lower extremity amputations (LEAs) are a feared complication of diabetes mellitus (DM). Here we evaluated the recent trends in DM-related LEAs in Romania. We collected data from a national database regarding minor and major LEAs performed between 2015 and 2019 in patients with DM admitted to a public hospital. Absolute numbers of LEAs were presented by year, diabetes type, sex and age; incidence rates of LEAs in the general population were also calculated. Over the study period, 40,499 LEAs were recorded nationwide (83.16% in persons with type 2 DM [T2DM]); on average, the number of LEAs increased by 5.7%/year. This trend was driven by an increased number of LEAs in patients with T2DM; in patients with type 1 DM (T1DM), LEAs decreased over the study period. In patients with T2DM, the increase in minor LEAs was more pronounced than that in major LEAs. The overall number of LEAs showed an increasing trend with age (r = 0.72), which was most pronounced in patients aged ≥70 years. Men had a higher frequency of LEAs than women, regardless of DM type. These data support renewed efforts to prevent and decrease the burden of amputations among patients with DM.
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Affiliation(s)
- Horaţiu Coman
- Vascular Surgery Clinic, Cluj County Emergency Hospital, 400347 Cluj-Napoca, Romania
| | - Bogdan Stancu
- Second Department of Surgery, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | | | - Frank L. Bowling
- Developmental Biomedicine Research Group, The University of Manchester, Manchester M13 9PL, UK
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babeş” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Laura Podariu
- Vascular Surgery Clinic, Cluj County Emergency Hospital, 400347 Cluj-Napoca, Romania
- “Nicolae Stăncioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Cosmina I. Bondor
- Department of Medical Informatics and Biostatistics, “Iuliu Haţieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Gabriela Radulian
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucureşti, Romania
- “Prof. Dr. Nicolae Paulescu” National Institute for Diabetes, Nutrition and Metabolic Diseases, 030167 Bucuresti, Romania
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Dragoi II, Petrita T, Popescu FG, Alexa F, Barac S, Bowling FL, Reeves ND, Bondor CI, Ionac M. A Signal Processing Method for Assessing Ankle Torque with a Custom-Made Electronic Dynamometer in Participants Affected by Diabetic Peripheral Neuropathy. Sensors (Basel) 2022; 22:6310. [PMID: 36016070 PMCID: PMC9416663 DOI: 10.3390/s22166310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Abstract
Portable, custom-made electronic dynamometry for the foot and ankle is a promising assessment method that enables foot and ankle muscle function to be established in healthy participants and those affected by chronic conditions. Diabetic peripheral neuropathy (DPN) can alter foot and ankle muscle function. This study assessed ankle toque in participants with diabetic peripheral neuropathy and healthy participants, with the aim of developing an algorithm for optimizing the precision of data processing and interpretation of the results and to define a reference frame for ankle torque measurement in both healthy participants and those affected by DPN. This paper discloses the software chain and the signal processing methods used for voltage-torque conversion, filtering, offset detection and the muscle effort type identification, which further allowed for a primary statistical report. The full description of the signal processing methods will make our research reproducible. The applied algorithm for signal processing is proposed as a reference frame for ankle torque assessment when using a custom-made electronic dynamometer. While evaluating multiple measurements, our algorithm permits for a more detailed parametrization of the ankle torque results in healthy participants and those affected by DPN.
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Affiliation(s)
- Iulia Iovanca Dragoi
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Teodor Petrita
- Department of Communications, Politehnica University Timisoara, 2 Vasile Parvan, 300223 Timisoara, Romania
| | - Florina Georgeta Popescu
- Discipline of Occupational Health, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Florin Alexa
- Department of Communications, Politehnica University Timisoara, 2 Vasile Parvan, 300223 Timisoara, Romania
| | - Sorin Barac
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Frank L. Bowling
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
- Department of Surgery & Translational Medicine, Faculty of Medical and Human Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Neil D. Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Oxford Rd., Manchester M1 5GD, UK
- Institute of Sport, Manchester Metropolitan University, Manchester M1 5GD, UK
| | - Cosmina Ioana Bondor
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Iuliu Hațieganu”, 8 Victor Babeș, 400000 Cluj-Napoca, Romania
| | - Mihai Ionac
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
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Dragoi II, Popescu FG, Petrita T, Alexa F, Tatu RF, Bondor CI, Tatu C, Bowling FL, Reeves ND, Ionac M. A Custom-Made Electronic Dynamometer for Evaluation of Peak Ankle Torque after COVID-19. Sensors (Basel) 2022; 22:s22052073. [PMID: 35271220 PMCID: PMC8914901 DOI: 10.3390/s22052073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022]
Abstract
The negative effects of SARS-CoV-2 infection on the musculoskeletal system include symptoms of fatigue and sarcopenia. The aim of this study is to assess the impact of COVID-19 on foot muscle strength and evaluate the reproducibility of peak ankle torque measurements in time by using a custom-made electronic dynamometer. In this observational cohort study, we compare two groups of four participants, one exposed to COVID-19 throughout measurements and one unexposed. Peak ankle torque was measured using a portable custom-made electronic dynamometer. Ankle plantar flexor and dorsiflexor muscle strength was captured for both feet at different ankle angles prior and post COVID-19. Average peak torque demonstrated no significant statistical differences between initial and final moment for both groups (p = 0.945). An increase of 4.8%, p = 0.746 was obtained in the group with COVID-19 and a decrease of 1.3%, p = 0.953 was obtained in the group without COVID-19. Multivariate analysis demonstrated no significant differences between the two groups (p = 0.797). There was a very good test−retest reproducibility between the measurements in initial and final moments (ICC = 0.78, p < 0.001). In conclusion, peak torque variability is similar in both COVID-19 and non-COVID-19 groups and the custom-made electronic dynamometer is a reproducible method for repetitive ankle peak torque measurements.
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Affiliation(s)
- Iulia Iovanca Dragoi
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania; (I.I.D.); (F.L.B.); (M.I.)
| | - Florina Georgeta Popescu
- Discipline of Occupational Health, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
- Correspondence: (F.G.P.); (T.P.); Tel.: +40-745-384-732 (F.G.P.)
| | - Teodor Petrita
- Department of Communications, Politehnica University Timisoara, 2 Vasile Parvan, 300223 Timisoara, Romania;
- Correspondence: (F.G.P.); (T.P.); Tel.: +40-745-384-732 (F.G.P.)
| | - Florin Alexa
- Department of Communications, Politehnica University Timisoara, 2 Vasile Parvan, 300223 Timisoara, Romania;
| | - Romulus Fabian Tatu
- Department of Orthopaedics-Traumatology-Urology and Imagistics, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
| | - Cosmina Ioana Bondor
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Victor Babes, 400012 Cluj-Napoca, Romania;
| | - Carmen Tatu
- Department of Functional Sciences, Physiology, Center of Immuno-Physiology and Biotechnologies, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania;
| | - Frank L. Bowling
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania; (I.I.D.); (F.L.B.); (M.I.)
- Department of Surgery & Translational Medicine, Faculty of Medical and Human Sciences, University of Manchester, Oxford Rd., Manchester M13 9PL, UK
| | - Neil D. Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Oxford Rd., Manchester M1 5GD, UK;
| | - Mihai Ionac
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania; (I.I.D.); (F.L.B.); (M.I.)
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11
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Abbott CA, Chatwin KE, Rajbhandari SM, John KM, Pabbineedi S, Bowling FL, Boulton AJM, Reeves ND. Site-Specific, Critical Threshold Barefoot Peak Plantar Pressure Associated with Diabetic Foot Ulcer History: A Novel Approach to Determine DFU Risk in the Clinical Setting. Medicina (B Aires) 2022; 58:medicina58020166. [PMID: 35208490 PMCID: PMC8877109 DOI: 10.3390/medicina58020166] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/22/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives: Barefoot peak plantar pressures (PPPs) are elevated in diabetes patients with neuropathic foot ulcer (DFU) history; however, there is limited reported evidence for a causative link between high barefoot PPP and DFU risk. We aimed to determine, using a simple mat-based methodology, the site-specific, barefoot PPP critical threshold that will identify a plantar site with a previous DFU. Materials and Methods: In a cross-sectional study, barefoot, site-specific PPPs were measured with normal gait for patients with DFU history (n = 21) and healthy controls (n = 12), using a validated carbon footprint system. For each participant, PPP was recorded at twelve distinct plantar sites (1st–5th toes, 1st–5th metatarsal heads (MTHs), midfoot and heel), per right and left foot, resulting in the analysis of n = 504 distinct plantar sites in the diabetes group, and n = 288 sites in the control group. Receiver operator characteristic curve analysis determined the optimal critical threshold for sites with DFU history. Results: Median PPPs for the groups were: diabetes sites with DFU history (n = 32) = 5.0 (3.25–7.5) kg/cm2, diabetes sites without DFU history (n = 472) = 3.25 (2.0–5.0) kg/cm2, control sites (n = 288) = 2.0 (2.0–3.25) kg/cm2; (p < 0.0001). Diabetes sites with elevated PPP (>6 kg/cm2) were six times more likely to have had DFU than diabetes sites with PPP ≤ 6 kg/cm2 (OR = 6.4 (2.8–14.6, 95% CI), p < 0.0001). PPP > 4.1 kg/cm2 was determined as the optimal critical threshold for identifying DFU at a specific plantar site, with sensitivity/specificity = 100%/79% at midfoot; 80%/65% at 5th metatarsal head; 73%/62% at combined midfoot/metatarsal head areas. Conclusions: We have demonstrated, for the first time, a strong, site-specific relationship between elevated barefoot PPP and previous DFU. We have determined a critical, highly-sensitive, barefoot PPP threshold value of >4.1 kg/cm2, which may be easily used to identify sites of previous DFU occurrence and, therefore, increased risk of re-ulceration. This site-specific approach may have implications for how high PPPs should be investigated in future trials.
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Affiliation(s)
- Caroline A. Abbott
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M1 5GD, UK; (K.E.C.); (K.M.J.); (S.P.); (N.D.R.)
- Institute of Sport, Manchester Metropolitan University, Manchester M1 7EL, UK
- Correspondence: ; Tel.: +44-(0)161-247-1143; Fax: +44-(0)161-247-6831
| | - Katie E. Chatwin
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M1 5GD, UK; (K.E.C.); (K.M.J.); (S.P.); (N.D.R.)
| | - Satyan M. Rajbhandari
- Diabetes Centre, Chorley and South Ribble Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Chorley PR7 1PP, UK;
| | - Kanwal M. John
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M1 5GD, UK; (K.E.C.); (K.M.J.); (S.P.); (N.D.R.)
| | - Sushma Pabbineedi
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M1 5GD, UK; (K.E.C.); (K.M.J.); (S.P.); (N.D.R.)
| | - Frank L. Bowling
- School of Medicine, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester Royal Infirmary, Manchester M13 9PL, UK;
| | - Andrew J. M. Boulton
- Manchester Diabetes Centre, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester Royal Infirmary, Manchester M13 9PL, UK;
- Diabetes Research Institute, University of Miami, Miami, FL 33136, USA
| | - Neil D. Reeves
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M1 5GD, UK; (K.E.C.); (K.M.J.); (S.P.); (N.D.R.)
- Institute of Sport, Manchester Metropolitan University, Manchester M1 7EL, UK
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12
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Chatwin KE, Abbott CA, Rajbhandari SM, Reddy PN, Bowling FL, Boulton AJM, Reeves ND. An intelligent insole system with personalised digital feedback reduces foot pressures during daily life: An 18-month randomised controlled trial. Diabetes Res Clin Pract 2021; 181:109091. [PMID: 34653566 DOI: 10.1016/j.diabres.2021.109091] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/21/2021] [Accepted: 10/07/2021] [Indexed: 11/18/2022]
Abstract
AIMS High plantar pressure is a major risk factor in the development of diabetic foot ulcers (DFUs) and recent evidence shows plantar pressure feedback reduces DFU recurrence. This study investigated whether continued use of an intelligent insole system by patients at high-risk of DFUs causes a reduction in plantar pressures. METHODS Forty-six patients with diabetic peripheral neuropathy and previous DFU were randomised to intervention (IG) or control groups (CG). Patients received an intelligent insole system, consisting of pressure-sensing insoles and digital watch. Patients wore the device during all daily activity for 18-months or until ulceration, and integrated pressure was recorded continuously. The device provided high-pressure feedback to IG only via audio-visual-vibrational alerts. High-pressure parameters at the whole foot, forefoot and rearfoot were compared between groups, with multilevel binary logistic regression analysis. RESULTS CG experienced more high-pressure bouts over time than IG across all areas of the foot (P < 0.05). Differences between groups became apparent >16 weeks of wearing the device. CONCLUSIONS Continuous plantar pressure feedback via an intelligent insole system reduces number of bouts of high-pressure in patients at high-risk of DFU. These findings suggest that patients were learning which activities generated high-pressure, and pre-emptively offloading to avoid further alerts.
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Affiliation(s)
- Katie E Chatwin
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester M1 5GD, UK.
| | - Caroline A Abbott
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester M1 5GD, UK; Manchester Metropolitan University Institute of Sport, Manchester, UK
| | | | - Prabhav N Reddy
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Frank L Bowling
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Andrew J M Boulton
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; Diabetes Research Institute, University of Miami, 1450 N.W. 10th Avenue, Miami, FL 33136, USA
| | - Neil D Reeves
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester M1 5GD, UK; Manchester Metropolitan University Institute of Sport, Manchester, UK
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13
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Rashid ST, Cavale N, Bowling FL. A pilot feasibility study of non‐cultured autologous skin cell suspension for healing diabetic foot ulcers. Wound Repair Regen 2020; 28:719-727. [DOI: 10.1111/wrr.12844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Frank L. Bowling
- Manchester Royal Infirmary & University of Manchester Manchester UK
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14
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Abstract
Of all the late complications of diabetes, those involving the foot have traditionally required more face-to-face patient visits to clinics to treat wounds by debridement, offloading, and many other treatment modalities. The advent of the coronavirus disease 2019 (COVID-19) pandemic has resulted not only in the closing of most outpatient clinics for face-to-face consultations but also in the inability to perform most laboratory and imaging investigations. This has resulted in a paradigm shift in the delivery of care for those with diabetic foot ulcers. The approaches to this challenge in two centers with an interest in diabetic foot disease, including virtual consultations using physician-to-patient and physician-to-home nurse telemedicine as well as home podiatry visits, are described in this review and are illustrated by several case vignettes. The outcomes from these two centers suggest that we may be witnessing new possibilities in models of care for the diabetic foot.
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Affiliation(s)
- Laura Shin
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Frank L Bowling
- Division of Diabetes, Endocrinology & Gastroenterology, The University of Manchester, and Diabetes Centre, Manchester Royal Infirmary, Manchester, U.K
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Andrew J M Boulton
- Division of Diabetes, Endocrinology & Gastroenterology, The University of Manchester, and Diabetes Centre, Manchester Royal Infirmary, Manchester, U.K.
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
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15
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Chatwin KE, Abbott CA, Boulton AJ, Bowling FL, Reeves ND. The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration-A comprehensive review. Diabetes Metab Res Rev 2020; 36:e3258. [PMID: 31825163 PMCID: PMC7317473 DOI: 10.1002/dmrr.3258] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 12/19/2022]
Abstract
The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory-based environments, rather than during daily activity. Few studies investigated previous DFU location-specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight-bearing activities, where a lower "peak" plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight-bearing activities, referring to location-specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.
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Affiliation(s)
- Katie E. Chatwin
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & EngineeringManchester Metropolitan UniversityManchesterUK
| | - Caroline A. Abbott
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & EngineeringManchester Metropolitan UniversityManchesterUK
| | - Andrew J.M. Boulton
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Diabetes Research InstituteUniversity of MiamiMiamiFlorida
| | - Frank L. Bowling
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Neil D. Reeves
- Musculoskeletal Science & Sports Medicine Research Centre, Department of Life Sciences, Faculty of Science & EngineeringManchester Metropolitan UniversityManchesterUK
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16
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Price BL, Morley R, Bowling FL, Lovering AM, Dobson CB. Susceptibility of monomicrobial or polymicrobial biofilms derived from infected diabetic foot ulcers to topical or systemic antibiotics in vitro. PLoS One 2020; 15:e0228704. [PMID: 32069293 PMCID: PMC7028275 DOI: 10.1371/journal.pone.0228704] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 01/22/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetic foot ulcers can become chronic and non-healing despite systemic antibiotic treatment. The penetration of systematically-administered antibiotics to the site of infection is uncertain, as is the effectiveness of such levels against polymicrobial biofilms. We have developed an in vitro model to study the effectiveness of different treatments for infected diabetic foot ulcers in a wound-like environment and compared the activity of systemic levels of antibiotics with that for topically applied antibiotics released from calcium sulfate beads. This is the first study that has harvested bacteria from diabetic foot infections and recreated similar polymicrobial biofilms to those present in vivo for individual subjects. After treatment with levels of gentamicin attained in serum after systemic administration (higher than corresponding tissues concentrations) we measured a 0-2 log reduction in bacterial viability of P. aeruginosa, S. aureus or a polymicrobial biofilm. Conversely, addition of gentamicin loaded calcium sulfate beads resulted in 5-9 log reductions in P. aeruginosa, S aureus and polymicrobial biofilms derived from three subjects. We conclude that systemically administered antibiotics are likely to be inadequate for successfully treating these infections, especially given the vastly increased concentrations required to inhibit cells in a biofilm, and that topical antibiotics provide a more effective alternative.
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Affiliation(s)
- Bianca L. Price
- Division of Pharmacy and Optometry, Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Robert Morley
- Podiatric Surgery Dept, Buxton Hospital, Derbyshire Community Health Services NHS Foundation Trust, Bakewell, United Kingdom
| | - Frank L. Bowling
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Andrew M. Lovering
- Microbiology Department, Antimicrobial Reference Laboratory, Bristol, United Kingdom
| | - Curtis B. Dobson
- Medical Device Biology Group, Division of Pharmacy and Optometry, Faculty of Biology Medicine and Health (FBMH), University of Manchester, Manchester, United Kingdom
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17
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Malone M, Schwarzer S, Walsh A, Xuan W, Al Gannass A, Dickson HG, Bowling FL. Monitoring wound progression to healing in diabetic foot ulcers using three-dimensional wound imaging. J Diabetes Complications 2020; 34:107471. [PMID: 31859145 DOI: 10.1016/j.jdiacomp.2019.107471] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/02/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022]
Abstract
AIM 3D wound imaging has provided clinicians with even greater wound measurement options. No data is available to guide clinicians as to which 3D measurements may yield the most reflective marker of wound progression to healing. METHOD A prospective pilot study was undertaken to assess the accuracy of five 3D wound measurements that best reflect metrics of interest to clinicians. Twenty-one diabetic foot ulcers were enrolled from initial ulcer presentation, through to healing. The relationship between mean wound healing measurement variables was examined using linear regression and Pearsons correlation coefficient, in addition to assessing clinician inter-rater reliability of measurements using Intra-class correlation coefficients (ICC). RESULTS Statistical analysis demonstrated a linear healing slope for each wound measurement as having a value greater than R 0.70 and a statistical significance of p = 0.0001. This suggests that all five wound measurements are useful prognostic markers of wound progression to healing. Low variability of measurements between users indicates good inter-observer reliability. CONCLUSION 3D wound measurements demonstrate a linear correlation between the measurement and time to healing. This suggests they could be effective prognostic markers of a wounds progression to healing and closure. It may also provide important early identification of wounds not responding to standard care. Larger studies are required to validate our results.
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Affiliation(s)
- Matthew Malone
- High Risk Foot Service, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 2170, Australia; South West Sydney Limb Preservation and Wound Research, South Western Sydney Local Health District, Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia; Western Sydney University, School of Medicine, Infectious Diseases and Microbiology, Sydney, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia.
| | - Saskia Schwarzer
- High Risk Foot Service, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 2170, Australia; South West Sydney Limb Preservation and Wound Research, South Western Sydney Local Health District, Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia; Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia
| | - Annie Walsh
- High Risk Foot Service, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 2170, Australia; South West Sydney Limb Preservation and Wound Research, South Western Sydney Local Health District, Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia
| | - Wei Xuan
- Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia
| | - Abdulaziz Al Gannass
- National Guard Health Affairs, Department of Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hugh G Dickson
- High Risk Foot Service, Liverpool Hospital, Locked Bag 7103, Liverpool, NSW 2170, Australia; South West Sydney Limb Preservation and Wound Research, South Western Sydney Local Health District, Ingham Institute of Applied Medical Research, Liverpool, NSW 2170, Australia
| | - Frank L Bowling
- Central Manchester Foundation Trust, University of Manchester, UK
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18
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Alrdahe S, Al Sadoun H, Torbica T, McKenzie EA, Bowling FL, Boulton AJM, Mace KA. Dysregulation of macrophage development and phenotype in diabetic human macrophages can be rescued by Hoxa3 protein transduction. PLoS One 2019; 14:e0223980. [PMID: 31626638 PMCID: PMC6799902 DOI: 10.1371/journal.pone.0223980] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/02/2019] [Indexed: 01/10/2023] Open
Abstract
Controlled inflammatory responses of myeloid cells recruited to wounds are essential for effective repair. In diabetes, the inflammatory response is prolonged and augmented over time, with increased myeloid cells present in the wound that fail to switch from a pro-inflammatory phenotype to a pro-healing phenotype. These defects lead to delayed angiogenesis and tissue repair and regeneration, and contribute to chronic wound formation. In mouse models of diabetes, this aberrant phenotype is partially mediated by stable intrinsic changes to the developing myeloid cells in the bone marrow, affecting their maturation and polarization potential. Previous studies have shown that freshly isolated peripheral blood mononuclear cells from diabetic patients are more inflammatory than non-diabetic counterparts. However, the phenotype of macrophages from human diabetic patients has not been well characterized. Here we show that diabetic-derived human macrophages cultured for 6 days in vitro maintain a pro-inflammatory priming and hyperpolarize to a pro-inflammatory phenotype when stimulated with LPS and INF-ɣ or TNF. In addition, diabetic-derived macrophages show maturation defects associated with reduced expression of the RUNX1 transcription factor that promotes myeloid cell development. Targeting intrinsic defects in myeloid cells by protein transduction of the Hoxa3 transcription factor can rescue some inflammation and maturation defects in human macrophages from diabetic patients via upregulation of Runx1. In addition, Hoxa3 can modulate the levels of p65/NF-κB and histone acetyltransferase and deacetylase activity, as well as inhibit acetylation of the TNF promoter. Altogether, these results show a link between myeloid cell maturation and inflammatory responses, and that diabetes induces intrinsic changes to human myeloid cells that are maintained over time, as well as potentially therapeutic Hoxa3-mediated mechanisms of controlling the inflammatory response in diabetes.
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MESH Headings
- Adult
- Antigens, CD/genetics
- Antigens, CD/metabolism
- Antigens, Differentiation, Myelomonocytic/genetics
- Antigens, Differentiation, Myelomonocytic/metabolism
- Case-Control Studies
- Cell Survival/drug effects
- Cells, Cultured
- Core Binding Factor Alpha 2 Subunit/genetics
- Core Binding Factor Alpha 2 Subunit/metabolism
- Culture Media, Conditioned/chemistry
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/pathology
- Female
- Homeodomain Proteins/genetics
- Homeodomain Proteins/metabolism
- Humans
- Interleukin-6/analysis
- Leukocytes, Mononuclear/cytology
- Macrophages/cytology
- Macrophages/drug effects
- Macrophages/metabolism
- Male
- Middle Aged
- Phenotype
- Recombinant Proteins/biosynthesis
- Recombinant Proteins/isolation & purification
- Recombinant Proteins/pharmacology
- Tumor Necrosis Factors/analysis
- Tumor Necrosis Factors/metabolism
- Up-Regulation/drug effects
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Affiliation(s)
- Salma Alrdahe
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Hadeel Al Sadoun
- Stem Cell Unit, King Fahad Medical Research Center, Department of Laboratory Medical Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Saudi Arabia
| | - Tanja Torbica
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Edward A. McKenzie
- Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Frank L. Bowling
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Andrew J. M. Boulton
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Kimberly A. Mace
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- * E-mail:
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19
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Handsaker JC, Brown SJ, Petrovic M, Bowling FL, Rajbhandari S, Marple-Horvat DE, Boulton AJM, Reeves ND. Combined exercise and visual gaze training improves stepping accuracy in people with diabetic peripheral neuropathy. J Diabetes Complications 2019; 33:107404. [PMID: 31371130 DOI: 10.1016/j.jdiacomp.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/20/2019] [Accepted: 07/02/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Patients with diabetes and diabetic peripheral neuropathy (DPN) place their feet with less accuracy whilst walking, which may contribute to the increased falls-risk. This study examines the effects of a multi-faceted intervention on stepping accuracy, in patients with diabetes and DPN. METHODS Forty participants began the study, of which 29 completed both the pre and post-intervention tests, 8 patients with DPN, 11 patients with diabetes but no neuropathy (D) and 10 healthy controls (C). Accuracy of stepping was measured pre- and post-intervention as participants walked along an irregularly arranged stepping walkway. Participants attended a one-hour session, once a week, for sixteen weeks, involving high-load resistance exercise and visual-motor training. RESULTS Patients who took part in the intervention improved stepping accuracy (DPN: +45%; D: +36%) (p < 0.05). The diabetic non-intervention (D-NI) group did not display any significant differences in stepping accuracy pre- to post- the intervention period (-7%). DISCUSSION The improved stepping accuracy observed in patients with diabetes and DPN as a result of this novel intervention, may contribute towards reducing falls-risk. This multi-faceted intervention presents promise for improving the general mobility and safety of patients during walking and could be considered for inclusion as part of clinical treatment programmes.
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Affiliation(s)
- Joseph C Handsaker
- Research Centre for Musculoskeletal Science and Sports Medicine, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester, United Kingdom
| | - Steven J Brown
- Research Centre for Musculoskeletal Science and Sports Medicine, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester, United Kingdom
| | - Milos Petrovic
- Research Centre for Movement Sciences, Department of Physiotherapy, Faculty of Medicine, University of Iceland, Reykjavik, Iceland.
| | - Frank L Bowling
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Satyan Rajbhandari
- Lancashire Teaching Hospitals, Chorley and South Ribble Hospital, United Kingdom
| | - Dilwyn E Marple-Horvat
- Research Centre for Musculoskeletal Science and Sports Medicine, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester, United Kingdom
| | - Andrew J M Boulton
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Neil D Reeves
- Research Centre for Musculoskeletal Science and Sports Medicine, Department of Life Sciences, Faculty of Science & Engineering, Manchester Metropolitan University, Oxford Road, Manchester, United Kingdom
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20
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Abbott CA, Chatwin KE, Foden P, Hasan AN, Sange C, Rajbhandari SM, Reddy PN, Vileikyte L, Bowling FL, Boulton AJM, Reeves ND. Innovative intelligent insole system reduces diabetic foot ulcer recurrence at plantar sites: a prospective, randomised, proof-of-concept study. Lancet Digit Health 2019; 1:e308-e318. [PMID: 33323253 DOI: 10.1016/s2589-7500(19)30128-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prevention of diabetic foot ulcer recurrence in high risk patients, using current standard of care methods, remains a challenge. We hypothesised that an innovative intelligent insole system would be effective in reducing diabetic foot ulcer recurrence in such patients. METHODS In this prospective, randomised, proof-of-concept study, patients with diabetes, and with peripheral neuropathy and a recent history of plantar foot ulceration were recruited from two multidisciplinary outpatient diabetic foot clinics in the UK, and were randomly assigned to either intervention or control. All patients received an insole system, which measured plantar pressure continuously during daily life. The intervention group received audiovisual alerts via a smartwatch linked to the insole system and offloading instructions when aberrant pressures were detected; the control group did not receive any alerts. The primary outcome was plantar foot ulcer occurrence within 18 months. This trial is registered with ISRCTN, ISRCTN05585501, and is closed to accrual and complete. FINDINGS Between March 18, 2014, and Dec 20, 2016, 90 patients were recruited and consented to the study, and 58 completed the study. At follow-up, ten ulcers from 8638 person-days were recorded in the control group and four ulcers from 11 835 person-days in the intervention group: a 71% reduction in ulcer incidence in the intervention group compared with the control group (incidence rate ratio 0·29, 95% CI, 0·09-0·93; p=0·037). The number of patients who ulcerated was similar between groups (six of 26 [control group] vs four of 32 [intervention group]; p=0·29); however, individual plantar sites ulcerated more often in the control group (ten of 416) than in the intervention group (four of 512; p=0·047). In an exploratory analysis of good compliers (n=40), ulcer incidence was reduced by 86% in the intervention group versus control group (incidence rate ratio 0·14, 95% CI 0·03-0·63; p=0·011). In the exploratory analysis, plantar callus severity (change from baseline to 6 months) was greater in re-ulcerating patients (6·5, IQR 4·0-8·3) than non-re-ulcerating patients (2·0, 0·0-4·8; p=0·040). INTERPRETATION To our knowledge, this study is the first to show that continuous plantar pressure monitoring and dynamic offloading guidance, provided by an innovative intelligent insole system, can lead to a reduction in diabetic foot ulcer site recurrence. FUNDING Diabetes UK and Orpyx Medical Technologies.
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Affiliation(s)
- Caroline A Abbott
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK.
| | - Katie E Chatwin
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Philip Foden
- Medical Statistics Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Ahmad N Hasan
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK; Institute of Medical Science and Technology, University Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Chandbi Sange
- Diabetes Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Satyan M Rajbhandari
- Diabetes Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Prabhav N Reddy
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Loretta Vileikyte
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Frank L Bowling
- Division of Diabetes, Endocrinology & Gastroenterology University of Manchester, Manchester, UK
| | - Andrew J M Boulton
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Neil D Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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21
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Abstract
Doctoral-level study is increasingly popular for clinicians who wish to advance their clinical, research and academic career pathways. A range of alternatives to the traditional PhD are now well-established. This article aims to outline the different approaches and discuss some advantages and drawbacks of doctoral-level postgraduate study. By comparing the various doctoral programmes, the authors seek to clarify the issues for clinicians who may wish to embark on a future doctorate. Primary clinical or medical degrees are not discussed.
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Affiliation(s)
- Sharon Rees
- Associate Professor, Therapeutics, London South Bank University
| | - Karen Ousey
- Professor and Director, Institute of Skin Integrity and Infection Prevention, University of Huddersfield
| | - Kenneth Koo
- Surgical Registrar, Central Manchester Foundation Trust
| | - Naseer Ahmad
- Consultant Vascular Surgeon, Central Manchester Foundation Trust
| | - Frank L Bowling
- Reader in Translational Medicine, Faculty of Medical and Human Sciences, University of Manchester
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22
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Abstract
The excess risk of amputation in the diabetic population is well documented. However, approximately half of all amputations in England are in people that do not have diabetes - the remainder being mainly peripheral arterial disease. Whilst the prevalence of foot ulcers in the population without diabetes is significantly lower than their diabetic counterparts, the actual number of people with ulcers, and, therefore, the burden on services, is, the same. In addition to this inequality, the prevalence of amputation is greater in men than women and in the North of England compared with the South. We suggest that whilst diabetes is an important inequality to continue addressing, it is not the only one.
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Affiliation(s)
- Naseer Ahmad
- Manchester Royal Infirmary, Manchester, UK
- University of Manchester, Manchester, UK
| | | | | | - Frank L. Bowling
- Manchester Royal Infirmary, Manchester, UK
- University of Manchester, Manchester, UK
- Victor Babeș University, Timisoara, Romania
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23
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Azmi S, ElHadd KT, Nelson A, Chapman A, Bowling FL, Perumbalath A, Lim J, Marshall A, Malik RA, Alam U. Pregabalin in the Management of Painful Diabetic Neuropathy: A Narrative Review. Diabetes Ther 2019; 10:35-56. [PMID: 30565054 PMCID: PMC6349275 DOI: 10.1007/s13300-018-0550-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 12/18/2022] Open
Abstract
Pregabalin is a first-line treatment in all major international guidelines on the management of painful diabetic neuropathy (pDPN). Treatment with pregabalin leads to a clinically meaningful improvement in pain scores, offers consistent relief of pain and has an acceptable tolerance level. Despite its efficacy in relieving neuropathic pain, more robust methods and comprehensive studies are required to evaluate its effects in relation to co-morbid anxiety and sleep interference in pDPN. The sustained benefits of modulating pain have prompted further exploration of other potential target sites and the development of alternative GABAergic agents such as mirogabalin. This review evaluates the role of pregabalin in the management of pDPN as well as its potential adverse effects, such as somnolence and dizziness, which can lead to withdrawal in ~ 30% of long-term use. Recent concern about misuse and an increase in deaths linked to its use has led to demands for reclassification of pregabalin as a class C controlled substance in the UK. We believe these demands need to be tempered in relation to the difficulties it would create for repeat prescriptions for the many millions of patients with pDPN for whom pregabalin provides benefit.Plain Language Summary: Plain language summary available for this article.
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Affiliation(s)
- Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | | | - Andrew Nelson
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Adam Chapman
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Frank L Bowling
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Anughara Perumbalath
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Jonathan Lim
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Andrew Marshall
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Rayaz A Malik
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK.
- Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK.
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24
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Petrovic M, Maganaris CN, Bowling FL, Boulton AJM, Reeves ND. Vertical displacement of the centre of mass during walking in people with diabetes and diabetic neuropathy does not explain their higher metabolic cost of walking. J Biomech 2019; 83:85-90. [PMID: 30473134 DOI: 10.1016/j.jbiomech.2018.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 11/15/2018] [Accepted: 11/15/2018] [Indexed: 11/29/2022]
Abstract
People with diabetes display biomechanical gait alterations compared to controls and have a higher metabolic cost of walking (CoW), but it remains unknown whether differences in the vertical displacement of the body centre of mass (CoM) may play a role in this higher CoW. The aim of this study was to investigate vertical CoM displacement (and step length as a potential underpinning factor) as an explanatory factor in the previously observed increased CoW with diabetes. Thirty-one non-diabetic controls (Ctrl); 22 diabetic patients without peripheral neuropathy (DM) and 14 patients with moderate/severe Diabetic Peripheral Neuropathy (DPN), underwent gait analysis using a motion analysis system and force plates while walking at a range of matched speeds between 0.6 and 1.6 m/s. Vertical displacement of the CoM was measured over the gait cycle, and was not different in either diabetes patients with or without diabetic peripheral neuropathy compared to controls across the range of matched walking speeds examined (at 1 m/s: Ctrl: 5.59 (SD: 1.6), DM: 5.41 (1.63), DPN: 4.91 (1.66) cm; p > 0.05). The DPN group displayed significantly shorter steps (at 1 m/s: Ctrl: 69, DM: 67, DPN: 64 cm; p > 0.05) and higher cadence (at 1 m/s: Ctrl: 117 (SD1.12), DM: 119 (1.08), DPN: 122 (1.25) steps per minute; p > 0.05) across all walking speeds compared to controls. The vertical CoM displacement is therefore unlikely to be a factor in itself that contributes towards the higher CoW observed recently in people with diabetic neuropathy. The higher CoW in patients with diabetes may not be explained by the CoM displacement, but rather may be more related to shorter step lengths, increased cadence and the associated increased internal work and higher muscle forces developed by walking with more flexed joints.
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Affiliation(s)
- M Petrovic
- Research Centre for Musculoskeletal Science & Sports Medicine, School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, UK
| | - C N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University, UK
| | - F L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, UK
| | - A J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - N D Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, UK.
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25
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Hurlow JJ, Humphreys GJ, Bowling FL, McBain AJ. Diabetic foot infection: A critical complication. Int Wound J 2018; 15:814-821. [PMID: 29808598 PMCID: PMC7949853 DOI: 10.1111/iwj.12932] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/24/2018] [Accepted: 04/10/2018] [Indexed: 02/05/2023] Open
Abstract
The number of people in the world with diabetes has nearly quadrupled in the past 40 years. Current data show that 25% of these diabetics will develop a foot ulcer in their lifetime and that the cost of care for a diabetic foot ulcer (DFU) is over twice that of any other chronic ulcer aetiology. Microbial biofilm has been linked to both wound chronicity and infection. Close to 1 in 2 diabetics with a DFU are predicted to go on to develop a diabetic foot infection (DFI). The majority of these DFIs have been found to evolve even before the diabetic individual has received an initial referral for expert DFU management. Of these infected DFUs, less than half have been shown to heal over the next year; many of these individuals will require costly hospitalisation, and current data show that far too many DFIs will require extremity amputation to achieve infection resolution. The development of an infection in a DFU is critical at least in part because paradigms of infection prevention and management are evolving. The effectiveness of our current practice standards is being challenged by a growing body of research related to the prevalence and recalcitrance of the microbes in biofilm to topical and systemic antimicrobials. This article will review the magnitude of current challenges related to DFI prevention and management along with what is currently considered to be standard of care. These ideas will be compared and contrasted with what is known about the biofilm phenotype; then, considerations to support progress towards the development of more cost-effective protocols of care are highlighted.
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Affiliation(s)
- Jennifer J Hurlow
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
| | - Gavin J Humphreys
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
| | - Frank L Bowling
- Faculty of Medical & Human SciencesUniversity of ManchesterManchesterUK
- Manchester Foundation TrustDepartment of Diabetes & Vascular SurgeryManchesterUK
| | - Andrew J McBain
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
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26
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Chatwin KE, Abbott CA, Reddy PN, Bowling FL, Boulton AJM, Reeves ND. A Foreign Body Through the Shoe of a Person With Diabetic Peripheral Neuropathy Alters Contralateral Biomechanics: Captured Through Innovative Plantar Pressure Technology. INT J LOW EXTR WOUND 2018; 17:125-129. [DOI: 10.1177/1534734618784080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
High plantar pressure as a result of diabetic peripheral neuropathy is often reported as a major risk factor for ulceration. However, previous studies are confined to laboratories with equipment limited by cables, reducing the validity of measurements to daily life. The participant concerned in this case report was wearing an innovative plantar pressure feedback system as part of a wider study. The system allows for continuous plantar pressure monitoring and provides feedback throughout all activities of daily living. The participant concerned was a 59-year-old male with type 2 diabetes who presented with severe peripheral neuropathy. In addition, the right ankle had previously undergone fusion. Between monthly study appointments, the participant unknowingly had a screw embedded in his right shoe, while pressure was being recorded. Although no significant differences in pressure were present for the right foot with the embedded screw, the contralateral foot showed significantly higher pressure when the screw was embedded, compared with pre and post time periods. The increase in pressure on the contralateral foot is expected to result from the protrusion of the screw in the right shoe, causing a perturbation to balance and a shift in the center of pressure toward the contralateral side. This compensatory effect is likely to have been magnified by the limited mobility of the fused right ankle. These findings highlight the importance of checking both feet for ulcer risk, in the event of receiving high-pressure feedback. This innovative technology may improve our understanding of diabetic plantar foot ulcer development.
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27
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Markakis K, Faris AR, Sharaf H, Faris B, Rees S, Bowling FL. Local Antibiotic Delivery Systems: Current and Future Applications for Diabetic Foot Infections. INT J LOW EXTR WOUND 2018; 17:14-21. [PMID: 29458291 DOI: 10.1177/1534734618757532] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Foot infections are common among diabetic patients with peripheral neuropathy and/or peripheral arterial disease, and it can be the pivotal event leading to a minor or major amputation of the lower extremity. Treatment of diabetic foot infections, especially deep-seated ones, remains challenging, in part because impaired blood perfusion and the presence of biofilms can impair the effectiveness of systemic antibiotics. The local application of antibiotics is an emerging field in the treatment of diabetic foot infections, with demonstrable advantages. These include delivery of high concentrations of antibiotics in the affected area, limited systemic absorption, and thus negligible side effects. Biodegradable vehicles, such as calcium sulfate beads, are the prototypical system, providing a good elution profile and the ability to be impregnated with a variety of antibiotics. These have largely superseded the nonbiodegradable vehicles, but the strongest evidence available is for calcium bead implantation for osteomyelitis management. Natural polymers, such as collagen sponge, are an emerging class of delivery systems, although thus far, data on diabetic foot infections are limited. There is recent interest in the novel antimicrobial peptide pexiganan in the form of cream, which is active against most of the microorganisms isolated in diabetic foot infections. These are promising developments, but randomized trials are required to ascertain the efficacy of these systems and to define the indications for their use. Currently, the role of topical antibiotic agents in treating diabetic foot infections is limited and outside of routine practice.
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Affiliation(s)
| | | | | | - Barzo Faris
- 3 Central Manchester Foundation NHS Trust, Manchester, UK
| | | | - Frank L Bowling
- 1 Manchester Royal Infirmary, Manchester, UK.,5 University of Manchester, Manchester, UK
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28
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Petrovic M, Maganaris CN, Deschamps K, Verschueren SM, Bowling FL, Boulton AJM, Reeves ND. Altered Achilles tendon function during walking in people with diabetic neuropathy: implications for metabolic energy saving. J Appl Physiol (1985) 2018; 124:1333-1340. [PMID: 29420151 DOI: 10.1152/japplphysiol.00290.2017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The Achilles tendon (AT) has the capacity to store and release elastic energy during walking, contributing to metabolic energy savings. In diabetes patients, it is hypothesized that a stiffer Achilles tendon may reduce the capacity for energy saving through this mechanism, thereby contributing to an increased metabolic cost of walking (CoW). The aim of this study was to investigate the effects of diabetes and diabetic peripheral neuropathy (DPN) on the Achilles tendon and plantarflexor muscle-tendon unit behavior during walking. Twenty-three nondiabetic controls (Ctrl); 20 diabetic patients without peripheral neuropathy (DM), and 13 patients with moderate/severe DPN underwent gait analysis using a motion analysis system, force plates, and ultrasound measurements of the gastrocnemius muscle, using a muscle model to determine Achilles tendon and muscle-tendon length changes. During walking, the DM and particularly the DPN group displayed significantly less Achilles tendon elongation (Ctrl: 1.81; DM: 1.66; and DPN: 1.54 cm), higher tendon stiffness (Ctrl: 210; DM: 231; and DPN: 240 N/mm), and higher tendon hysteresis (Ctrl: 18; DM: 21; and DPN: 24%) compared with controls. The muscle fascicles of the gastrocnemius underwent very small length changes in all groups during walking (~0.43 cm), with the smallest length changes in the DPN group. Achilles tendon forces were significantly lower in the diabetes groups compared with controls (Ctrl: 2666; DM: 2609; and DPN: 2150 N). The results strongly point toward the reduced energy saving capacity of the Achilles tendon during walking in diabetes patients as an important factor contributing to the increased metabolic CoW in these patients. NEW & NOTEWORTHY From measurements taken during walking we observed that the Achilles tendon in people with diabetes and particularly people with diabetic peripheral neuropathy was stiffer, was less elongated, and was subject to lower forces compared with controls without diabetes. These altered properties of the Achilles tendon in people with diabetes reduce the tendon's energy saving capacity and contribute toward the higher metabolic energy cost of walking in these patients.
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Affiliation(s)
- M Petrovic
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University , Manchester , United Kingdom
| | - C N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University , Liverpool , United Kingdom
| | - K Deschamps
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven , Belgium
| | - S M Verschueren
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven , Belgium
| | - F L Bowling
- Faculty of Medical and Human Sciences, University of Manchester , Manchester , United Kingdom
| | - A J M Boulton
- Faculty of Medical and Human Sciences, University of Manchester , Manchester , United Kingdom.,Diabetes Research Institute, University of Miami , Miami, Florida
| | - N D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University , Manchester , United Kingdom
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29
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Abstract
BACKGROUND We describe the development of a new mobile app called "FootSnap," to standardize photographs of diabetic feet and test its reliability on different occasions and between different operators. METHODS FootSnap was developed by a multidisciplinary team for use with the iPad. The plantar surface of 30 diabetic feet and 30 nondiabetic control feet were imaged using FootSnap on two separate occasions by two different operators. Reproducibility of foot images was determined using the Jaccard similarity index (JSI). RESULTS High intra- and interoperator reliability was demonstrated with JSI values of 0.89-0.91 for diabetic feet and 0.93-0.94 for control feet. CONCLUSIONS Similarly high reliability between groups indicates FootSnap is appropriate for longitudinal follow-ups in diabetic feet, with potential for monitoring pathology.
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Affiliation(s)
- Moi Hoon Yap
- School of Computing, Mathematics and Digital Technology, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Katie E. Chatwin
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Choon-Ching Ng
- School of Computing, Mathematics and Digital Technology, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Caroline A. Abbott
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Frank L. Bowling
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - Satyan Rajbhandari
- Lancashire Teaching Hospitals, Chorley and South Ribble, Preston, Lancashire, UK
| | - Andrew J. M. Boulton
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
- Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Neil D. Reeves
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
- Neil D. Reeves, PhD, School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, M1 5GD, UK.
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30
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Petrovic M, Deschamps K, Verschueren SM, Bowling FL, Maganaris CN, Boulton AJM, Reeves ND. Altered leverage around the ankle in people with diabetes: A natural strategy to modify the muscular contribution during walking? Gait Posture 2017; 57:85-90. [PMID: 28578139 DOI: 10.1016/j.gaitpost.2017.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/08/2017] [Accepted: 05/16/2017] [Indexed: 02/02/2023]
Abstract
Diabetes patients display gait alterations compared to controls including a higher metabolic cost of walking. This study aimed to investigate whether differences in external moment arm (ExtMA) and effective mechanical advantage (EMA) at the ankle in diabetes patients could partly explain the increased cost of walking compared to controls. Thirty one non-diabetic controls (Ctrl); 22 diabetes patients without peripheral neuropathy (DM) and 14 patients with moderate/severe diabetic peripheral neuropathy (DPN) underwent gait analysis using a motion analysis system and force plates. The internal Achilles tendon moment arm length was determined using magnetic resonance imaging during weight-bearing and ExtMA was calculated using gait analysis. A greater value (P<0.01) for the EMA at the ankle was found in the DPN (0.488) and DM (0.46) groups compared to Ctrl (0.448). The increased EMA was mainly caused by a smaller ExtMA in the DPN (9.63cm; P<0.01) and DM (10.31cm) groups compared to Ctrl (10.42cm) These findings indicate that the ankle plantarflexor muscles would need to generate lower forces to overcome the external resistance during walking compared to controls. Our findings do not explain the previously observedhigher metabolic cost of walking in the DM and DPN groups, but uncover a new mechanism through which patients with diabetes and particularly those with DPN reduce the joint moment at the ankle during walking: by applying the ground reaction force more proximally on the foot, or at an angle directed more towards the ankle, thereby increasing the EMA and reducing the ankle joint moment.
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Affiliation(s)
- Milos Petrovic
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, UK.
| | - Kevin Deschamps
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgium.
| | | | - Frank L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, UK.
| | | | - Andrew J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, UK; University of Miami School of Medicine, Diabetes Research Institute, United States.
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, UK.
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31
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Almurdhi MM, Brown SJ, Bowling FL, Boulton AJM, Jeziorska M, Malik RA, Reeves ND. Altered walking strategy and increased unsteadiness in participants with impaired glucose tolerance and Type 2 diabetes relates to small-fibre neuropathy but not vitamin D deficiency. Diabet Med 2017; 34:839-845. [PMID: 28103405 DOI: 10.1111/dme.13316] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 12/17/2022]
Abstract
AIMS To investigate alterations in walking strategy and dynamic sway (unsteadiness) in people with impaired glucose tolerance and people with Type 2 diabetes in relation to severity of neuropathy and vitamin D levels. METHODS A total of 20 people with Type 2 diabetes, 20 people with impaired glucose tolerance and 20 people without either Type 2 diabetes or impaired glucose tolerance (control group) underwent gait analysis using a motion analysis system and force platforms, and detailed assessment of neuropathy and serum 25 hydroxy-vitamin D levels. RESULTS Ankle strength (P = 0.01) and power (P = 0.003) during walking and walking speed (P = 0.008) were preserved in participants with impaired glucose tolerance but significantly lower in participants with Type 2 diabetes compared with control participants; however, step width (P = 0.005) and dynamic medio-lateral sway (P = 0.007) were significantly higher and posterior maximal movement (P = 0.000) was lower in participants with impaired glucose tolerance, but preserved in those with Type 2 diabetes compared with the control group. Dynamic medio-lateral sway correlated with corneal nerve fibre length (P = 0.001) and corneal nerve branch density (P = 0.001), but not with vibration perception threshold (P = 0.19). Serum 25 hydroxy-vitamin D levels did not differ significantly among the groups (P = 0.10) and did not correlate with any walking variables or measures of dynamic sway. CONCLUSIONS Early abnormalities in walking strategy and dynamic sway were evident in participants with impaired glucose tolerance, whilst there was a reduction in ankle strength, power and walking speed in participants with Type 2 diabetes. Unsteadiness correlated with small-, but not large-fibre neuropathy and there was no relationship between vitamin D levels and walking variables.
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Affiliation(s)
- M M Almurdhi
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - S J Brown
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A J M Boulton
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M Jeziorska
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - N D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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Almurdhi MM, Reeves ND, Bowling FL, Boulton AJM, Jeziorska M, Malik RA. Distal lower limb strength is reduced in subjects with impaired glucose tolerance and is related to elevated intramuscular fat level and vitamin D deficiency. Diabet Med 2017; 34:356-363. [PMID: 27278802 PMCID: PMC5316421 DOI: 10.1111/dme.13163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 12/30/2022]
Abstract
AIM To quantify muscle strength and size in subjects with impaired glucose tolerance (IGT) in relation to intramuscular non-contractile tissue, the severity of neuropathy and vitamin D level. METHODS A total of 20 subjects with impaired glucose tolerance and 20 control subjects underwent assessment of strength and size of knee extensor, flexor and ankle plantar and dorsi-flexor muscles, as well as quantification of intramuscular non-contractile tissue and detailed assessment of neuropathy and serum 25-hydroxy vitamin D levels. RESULTS In subjects with impaired glucose tolerance, proximal knee extensor strength (P = 0.17) and volume (P = 0.77), and knee flexor volume (P = 0.97) did not differ from those in control subjects. Ankle plantar flexor strength was significantly lower (P = 0.04) in the subjects with impaired glucose tolerance, with no difference in ankle plantar flexor (P = 0.62) or dorsiflexor volume (P = 0.06) between groups. Intramuscular non-contractile tissue level was significantly higher in the ankle plantar flexors and dorsiflexors (P = 0.03) of subjects with impaired glucose tolerance compared with control subjects, and it correlated with the severity of neuropathy. Ankle plantar flexor muscle strength correlated significantly with corneal nerve fibre density (r = 0.53; P = 0.01), a sensitive measure of small fibre neuropathy, and was significantly lower in subjects with vitamin D deficiency (P = 0.02). CONCLUSIONS People with impaired glucose tolerance have a significant reduction in distal but not proximal leg muscle strength, which is not associated with muscle atrophy, but with increased distal intramuscular non-contractile tissue, small fibre neuropathy and vitamin D deficiency.
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Affiliation(s)
- M M Almurdhi
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - N D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A J M Boulton
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M Jeziorska
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Weill-Cornell Medicine-Qatar, Doha, Qatar
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Tavakoli M, Gogas Yavuz D, Tahrani AA, Selvarajah D, Bowling FL, Fadavi H. Diabetic Neuropathy: Current Status and Future Prospects. J Diabetes Res 2017; 2017:5825971. [PMID: 28770231 PMCID: PMC5523192 DOI: 10.1155/2017/5825971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/06/2017] [Indexed: 01/26/2023] Open
Affiliation(s)
- Mitra Tavakoli
- University of Exeter, Exeter, UK
- University of Manchester, Manchester, UK
- *Mitra Tavakoli:
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Almurdhi MM, Reeves ND, Bowling FL, Boulton AJM, Jeziorska M, Malik RA. Response to Comment on Almurdhi et al. Reduced Lower-Limb Muscle Strength and Volume in Patients With Type 2 Diabetes in Relation to Neuropathy, Intramuscular Fat, and Vitamin D Levels. Diabetes Care 2016;39:441-447. Diabetes Care 2016; 39:e184-5. [PMID: 27660129 PMCID: PMC5033084 DOI: 10.2337/dci16-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Monirah M Almurdhi
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Frank L Bowling
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Andrew J M Boulton
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Maria Jeziorska
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Rayaz A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K. Weill Cornell Medical College, Doha, Qatar
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Brown SJ, Handsaker JC, Maganaris CN, Bowling FL, Boulton AJM, Reeves ND. Altered joint moment strategy during stair walking in diabetes patients with and without peripheral neuropathy. Gait Posture 2016; 46:188-93. [PMID: 27131200 DOI: 10.1016/j.gaitpost.2016.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/16/2016] [Accepted: 03/10/2016] [Indexed: 02/02/2023]
Abstract
AIM To investigate lower limb biomechanical strategy during stair walking in patients with diabetes and patients with diabetic peripheral neuropathy, a population known to exhibit lower limb muscular weakness. METHODS The peak lower limb joint moments of twenty-two patients with diabetic peripheral neuropathy and thirty-nine patients with diabetes and no neuropathy were compared during ascent and descent of a staircase to thirty-two healthy controls. Fifty-nine of the ninety-four participants also performed assessment of their maximum isokinetic ankle and knee joint moment (muscle strength) to assess the level of peak joint moments during the stair task relative to their maximal joint moment-generating capabilities (operating strengths). RESULTS Both patient groups ascended and descended stairs slower than controls (p<0.05). Peak joint moments in patients with diabetic peripheral neuropathy were lower (p<0.05) at the ankle and knee during stair ascent, and knee only during stair descent compared to controls. Ankle and knee muscle strength values were lower (p<0.05) in patients with diabetic peripheral neuropathy compared to controls, and lower at knee only in patients without neuropathy. Operating strengths were higher (p<0.05) at the ankle and knee in patients with neuropathy during stair descent compared to the controls, but not during stair ascent. CONCLUSION Patients with diabetic peripheral neuropathy walk slower to alter gait strategy during stair walking and account for lower-limb muscular weakness, but still exhibit heightened operating strengths during stair descent, which may impact upon fatigue and the ability to recover a safe stance following postural instability.
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Affiliation(s)
- Steven J Brown
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom.
| | - Joseph C Handsaker
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
| | | | - Frank L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, United Kingdom
| | - Andrew J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, United Kingdom
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
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Handsaker JC, Brown SJ, Bowling FL, Marple-Horvat DE, Boulton AJM, Reeves ND. People with diabetic peripheral neuropathy display a decreased stepping accuracy during walking: potential implications for risk of tripping. Diabet Med 2016; 33:644-9. [PMID: 26172114 DOI: 10.1111/dme.12851] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
Abstract
AIM To examine the stepping accuracy of people with diabetes and diabetic peripheral neuropathy. METHODS Fourteen patients with diabetic peripheral neuropathy (DPN), 12 patients with diabetes but no neuropathy (D) and 10 healthy non-diabetic control participants (C). Accuracy of stepping was measured whilst the participants walked along a walkway consisting of 18 stepping targets. Preliminary data on visual gaze characteristics were also captured in a subset of participants (diabetic peripheral neuropathy group: n = 4; diabetes-alone group: n = 4; and control group: n = 4) during the same task. RESULTS Patients in the diabetic peripheral neuropathy group, and patients in the diabetes-alone group were significantly less accurate at stepping on targets than were control subjects (P < 0.05). Preliminary visual gaze analysis identified that patients diabetic peripheral neuropathy were slower to look between targets, resulting in less time being spent looking at a target before foot-target contact. CONCLUSIONS Impaired motor control is theorized to be a major factor underlying the changes in stepping accuracy, and potentially altered visual gaze behaviour may also play a role. Reduced stepping accuracy may indicate a decreased ability to control the placement of the lower limbs, leading to patients with neuropathy potentially being less able to avoid observed obstacles during walking.
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Affiliation(s)
- J C Handsaker
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - S J Brown
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - D E Marple-Horvat
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - A J M Boulton
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - N D Reeves
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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Almurdhi MM, Reeves ND, Bowling FL, Boulton AJM, Jeziorska M, Malik RA. Reduced Lower-Limb Muscle Strength and Volume in Patients With Type 2 Diabetes in Relation to Neuropathy, Intramuscular Fat, and Vitamin D Levels. Diabetes Care 2016; 39:441-7. [PMID: 26740641 PMCID: PMC5317239 DOI: 10.2337/dc15-0995] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/24/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Muscle weakness and atrophy of the lower limbs may develop in patients with diabetes, increasing their risk of falls. The underlying basis of these abnormalities has not been fully explained. The aim of this study was to objectively quantify muscle strength and size in patients with type 2 diabetes mellitus (T2DM) in relation to the severity of neuropathy, intramuscular noncontractile tissue (IMNCT), and vitamin D deficiency. RESEARCH DESIGN AND METHODS Twenty patients with T2DM and 20 healthy control subjects were matched by age, sex, and BMI. Strength and size of knee extensor, flexor, and ankle plantar and dorsiflexor muscles were assessed in relation to the severity of diabetic sensorimotor polyneuropathy (DSPN), amount of IMNCT, and serum 25-hydroxyvitamin D (25OHD) levels. RESULTS Compared with control subjects, patients with T2DM had significantly reduced knee extensor strength (P = 0.003) and reduced muscle volume of both knee extensors (P = 0.045) and flexors (P = 0.019). Ankle plantar flexor strength was also significantly reduced (P = 0.001) but without a reduction in ankle plantar flexor (P = 0.23) and dorsiflexor (P = 0.45) muscle volumes. IMNCT was significantly increased in the ankle plantar (P = 0.006) and dorsiflexors (P = 0.005). Patients with DSPN had significantly less knee extensor strength than those without (P = 0.02) but showed no difference in knee extensor volume (P = 0.38) and ankle plantar flexor strength (P = 0.21) or volume (P = 0.96). In patients with <25 nmol/L versus >25 nmol/L 25OHD, no significant differences were found for knee extensor strength and volume (P = 0.32 vs. 0.18) and ankle plantar flexors (P = 0.58 vs. 0.12). CONCLUSIONS Patients with T2DM have a significant reduction in proximal and distal leg muscle strength and a proximal but not distal reduction in muscle volume possibly due to greater intramuscular fat accumulation in distal muscles. Proximal but not distal muscle strength is related to the severity of peripheral neuropathy but not IMNCT or 25OHD level.
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Affiliation(s)
- Monirah M Almurdhi
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Frank L Bowling
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Andrew J M Boulton
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Maria Jeziorska
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Rayaz A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K. Weill Cornell Medical College, Doha, Qatar
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Handsaker JC, Brown SJ, Bowling FL, Maganaris CN, Boulton AJM, Reeves ND. Resistance exercise training increases lower limb speed of strength generation during stair ascent and descent in people with diabetic peripheral neuropathy. Diabet Med 2016; 33:97-104. [PMID: 26108438 DOI: 10.1111/dme.12841] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 12/18/2022]
Abstract
AIM To examine the effects of a 16-week resistance exercise training intervention on the speed of ankle and knee strength generation during stair ascent and descent, in people with neuropathy. METHODS A total of 43 people: nine with diabetic peripheral neuropathy, 13 with diabetes but no neuropathy and 21 healthy control subjects ascended and descended a custom-built staircase. The speed at which ankle and knee strength were generated, and muscle activation patterns of the ankle and knee extensor muscles were analysed before and after a 16-week intervention period. RESULTS Ankle and knee strength generation during both stair ascent and descent were significantly higher after the intervention than before the intervention in the people with diabetes who undertook the resistance exercise intervention (P < 0.05). Although muscle activations were altered by the intervention, there were no observable patterns that underpinned the observed changes. CONCLUSIONS The increased speed of ankle and knee strength generation observed after the intervention would be expected to improve stability during the crucial weight acceptance phase of stair ascent and descent, and ultimately contribute towards reducing the risk of falling. Improvements in muscle strength as a result of the resistance exercise training intervention are likely to be the most influential factor for increasing the speed of strength generation. It is recommended that these exercises could be incorporated into a multi-faceted exercise programme to improve safety in people with diabetes and neuropathy.
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Affiliation(s)
- J C Handsaker
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - S J Brown
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - C N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - A J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - N D Reeves
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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Tagoe MT, Reeves ND, Bowling FL. Is there still a place for Achilles tendon lengthening? Diabetes Metab Res Rev 2016; 32 Suppl 1:227-31. [PMID: 26452341 DOI: 10.1002/dmrr.2745] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 07/25/2015] [Accepted: 10/06/2015] [Indexed: 12/19/2022]
Abstract
Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.
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Affiliation(s)
- Mark T Tagoe
- West Middlesex University Hospital, Middlesex UK, University of Southampton, UK
| | - Neil D Reeves
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - Frank L Bowling
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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Abstract
In 2015, it can be said that the diabetic foot is no longer the Cinderella of diabetic complications. Thirty years ago there was little evidence-based research taking place on the diabetic foot, and there were no international meetings addressing this topic. Since then, the biennial Malvern Diabetic Foot meetings started in 1986, the American Diabetes Association founded their Foot Council in 1987, and the European Association for the Study of Diabetes established a Foot Study Group in 1998. The first International Symposium on the Diabetic Foot in The Netherlands was convened in 1991, and this was soon followed by the establishment of the International Working Group on the Diabetic Foot that has produced useful guidelines in several areas of investigation and the management of diabetic foot problems. There has been an exponential rise in publications on diabetic foot problems in high impact factor journals, and a comprehensive evidence-base now exists for many areas of treatment. Despite the extensive evidence available, it, unfortunately, remains difficult to demonstrate that most types of education are efficient in reducing the incidence of foot ulcers. However, there is evidence that education as part of a multi-disciplinary approach to diabetic foot ulceration plays a pivotal role in incidence reduction. With respect to treatment, strong evidence exists that offloading is the best modality for healing plantar neuropathic foot ulcers, and there is also evidence from two randomized controlled trials to support the use of negative-pressure wound therapy in complex post-surgical diabetic foot wounds. Hyperbaric oxygen therapy exhibits the same evidence level and strength of recommendation. International guidelines exist on the management of infection in the diabetic foot. Many randomized trials have been performed, and these have shown that the agents studied generally produced comparable results, with the exception of one study in which tigecycline was shown to be clinically inferior to ertapenem ± vancomycin. Similarly, there are numerous types of wound dressings that might be used in treatment and which have shown efficacy, but no single type (or brand) has shown superiority over others. Peripheral artery disease is another major contributory factor in the development of ulceration, and its presence is a strong predictor of non-healing and amputation. Despite the proliferation of endovascular procedures in addition to open revascularization, many patients continue to suffer from severely impaired perfusion and exhaust all treatment options. Finally, the question of the true aetiopathogenesis of Charcot neuroarthropathy remains enigmatic, although much work is currently being undertaken in this area. In this area, it is most important to remember that a clinically uninfected, warm, insensate foot in a diabetic patient should be considered as a Charcot foot until proven otherwise, and, as such, treated with offloading, preferably in a cast.
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Affiliation(s)
- K Markakis
- Manchester Royal Infirmary, Manchester, UK
| | - F L Bowling
- Manchester Royal Infirmary, Manchester, UK
- University of Manchester, Manchester, UK
| | - A J M Boulton
- Manchester Royal Infirmary, Manchester, UK
- University of Manchester, Manchester, UK
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Yap MH, Ng CC, Chatwin K, Abbott CA, Bowling FL, Boulton AJM, Reeves ND. Computer Vision Algorithms in the Detection of Diabetic Foot Ulceration: A New Paradigm for Diabetic Foot Care? J Diabetes Sci Technol 2015; 10:612-3. [PMID: 26468134 PMCID: PMC4773968 DOI: 10.1177/1932296815611425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Moi Hoon Yap
- School of Computing, Mathematics and Digital Technology, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Choon-Ching Ng
- School of Computing, Mathematics and Digital Technology, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Katie Chatwin
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Caroline A Abbott
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
| | - Frank L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - Andrew J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, Manchester, UK
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Abstract
Diabetes mellitus is associated with a series of macrovascular and microvascular changes that can manifest as a wide range of complications. Foot ulcerations affect ∼2-4% of patients with diabetes mellitus. Risk factors for foot lesions include peripheral and autonomic neuropathy, vascular disease and previous foot ulceration, as well as other microvascular complications, such as retinopathy and end-stage renal disease. Ulceration is the result of a combination of components that together lead to tissue breakdown. The most frequently occurring causal pathways to the development of foot ulcers include peripheral neuropathy and vascular disease, foot deformity or trauma. Peripheral vascular disease is often not diagnosed in patients with diabetes mellitus until tissue loss is evident, usually in the form of a nonhealing ulcer. Identification of patients with diabetes mellitus who are at high risk of ulceration is important and can be achieved via annual foot screening with subsequent multidisciplinary foot-care interventions. Understanding the factors that place patients with diabetes mellitus at high risk of ulceration, together with an appreciation of the links between different aspects of the disease process, is essential to the prevention and management of diabetic foot complications.
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Affiliation(s)
- Frank L Bowling
- Manchester Royal Infirmary, University of Manchester, 193 Hathersage Road, Manchester M13 0JE, UK
| | - S Tawqeer Rashid
- Manchester Royal Infirmary, University of Manchester, 193 Hathersage Road, Manchester M13 0JE, UK
| | - Andrew J M Boulton
- Manchester Royal Infirmary, University of Manchester, 193 Hathersage Road, Manchester M13 0JE, UK
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Brown SJ, Handsaker JC, Bowling FL, Boulton AJM, Reeves ND. Diabetic peripheral neuropathy compromises balance during daily activities. Diabetes Care 2015; 38:1116-22. [PMID: 25765355 DOI: 10.2337/dc14-1982] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 02/17/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Patients with diabetes with peripheral neuropathy have a well-recognized increased risk of falls that may result in hospitalization. Therefore this study aimed to assess balance during the dynamic daily activities of walking on level ground and stair negotiation, where falls are most likely to occur. RESEARCH DESIGN AND METHODS Gait analysis during level walking and stair negotiation was performed in 22 patients with diabetic neuropathy (DPN), 39 patients with diabetes without neuropathy (D), and 28 nondiabetic control subjects (C) using a motion analysis system and embedded force plates in a staircase and level walkway. Balance was assessed by measuring the separation between the body center of mass and center of pressure during level walking, stair ascent, and stair descent. RESULTS DPN patients demonstrated greater (P < 0.05) maximum and range of separations of their center of mass from their center of pressure in the medial-lateral plane during stair descent, stair ascent, and level walking compared with the C group, as well as increased (P < 0.05) mean separation during level walking and stair ascent. The same group also demonstrated greater (P < 0.05) maximum anterior separations (toward the staircase) during stair ascent. No differences were observed in D patients. CONCLUSIONS Greater separations of the center of mass from the center of pressure present a greater challenge to balance. Therefore, the higher medial-lateral separations found in patients with DPN will require greater muscular demands to control upright posture. This may contribute to explaining why patients with DPN are more likely to fall, with the higher separations placing them at a higher risk of experiencing a sideways fall than nondiabetic control subjects.
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Affiliation(s)
- Steven J Brown
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K.
| | - Joseph C Handsaker
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Frank L Bowling
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, U.K
| | - Andrew J M Boulton
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, U.K
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
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Handsaker JC, Brown SJ, Bowling FL, Cooper G, Maganaris CN, Boulton AJM, Reeves ND. Contributory factors to unsteadiness during walking up and down stairs in patients with diabetic peripheral neuropathy. Diabetes Care 2014; 37:3047-53. [PMID: 25315208 DOI: 10.2337/dc14-0955] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although patients with diabetic peripheral neuropathy (DPN) are more likely to fall than age-matched controls, the underlying causative factors are not yet fully understood. This study examines the effects of diabetes and neuropathy on strength generation and muscle activation patterns during walking up and down stairs, with implications for fall risk. RESEARCH DESIGN AND METHODS Sixty-three participants (21 patients with DPN, 21 diabetic controls, and 21 healthy controls) were examined while walking up and down a custom-built staircase. The speed of strength generation at the ankle and knee and muscle activation patterns of the ankle and knee extensor muscles were analyzed. RESULTS Patients with neuropathy displayed significantly slower ankle and knee strength generation than healthy controls during stair ascent and descent (P < 0.05). During ascent, the ankle and knee extensor muscles were activated significantly later by patients with neuropathy and took longer to reach peak activation (P < 0.05). During descent, neuropathic patients activated the ankle extensors significantly earlier, and the ankle and knee extensors took significantly longer to reach peak activation (P < 0.05). CONCLUSIONS Patients with DPN are slower at generating strength at the ankle and knee than control participants during walking up and down stairs. These changes, which are likely caused by altered activations of the extensor muscles, increase the likelihood of instability and may be important contributory factors for the increased risk of falling. Resistance exercise training may be a potential clinical intervention for improving these aspects and thereby potentially reducing fall risk.
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Affiliation(s)
| | | | | | - Glen Cooper
- Manchester Metropolitan University, Manchester, U.K
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Brown SJ, Handsaker JC, Bowling FL, Maganaris CN, Boulton AJ, Reeves ND. Do patients with diabetic neuropathy use a higher proportion of their maximum strength when walking? J Biomech 2014; 47:3639-44. [DOI: 10.1016/j.jbiomech.2014.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 09/30/2014] [Accepted: 10/05/2014] [Indexed: 12/19/2022]
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Oates A, Bowling FL, Boulton AJM, Bowler PG, Metcalf DG, McBain AJ. The visualization of biofilms in chronic diabetic foot wounds using routine diagnostic microscopy methods. J Diabetes Res 2014; 2014:153586. [PMID: 24839608 PMCID: PMC4009286 DOI: 10.1155/2014/153586] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 02/14/2014] [Indexed: 12/31/2022] Open
Abstract
Diabetic foot wounds are commonly colonised by taxonomically diverse microbial communities and may additionally be infected with specific pathogens. Since biofilms are demonstrably less susceptible to antimicrobial agents than are planktonic bacteria, and may be present in chronic wounds, there is increasing interest in their aetiological role. In the current investigation, the presence of structured microbial assemblages in chronic diabetic foot wounds is demonstrated using several visualization methods. Debridement samples, collected from the foot wounds of diabetic patients, were histologically sectioned and examined using bright-field, fluorescence, and environmental scanning electron microscopy and assessed by quantitative differential viable counting. All samples (n = 26) harboured bioburdens in excess of 5 log₁₀ CFU/g. Microcolonies were identified in 4/4 samples by all three microscopy methods, although bright-field and fluorescence microscopy were more effective at highlighting putative biofilm morphology than ESEM. Results in this pilot study indicate that bacterial microcolonies and putative biofilm matrix can be visualized in chronic wounds using fluorescence microscopy and ESEM, but also using the simple Gram stain.
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Affiliation(s)
- Angela Oates
- Manchester Pharmacy School, The University of Manchester, Oxford Road, Manchester M13 9PT, UK
| | - Frank L. Bowling
- Department of Medicine Manchester Royal Infirmary, The University of Manchester, Oxford Road, Manchester M13 9PT, UK
| | - Andrew J. M. Boulton
- Department of Medicine Manchester Royal Infirmary, The University of Manchester, Oxford Road, Manchester M13 9PT, UK
| | | | | | - Andrew J. McBain
- Manchester Pharmacy School, The University of Manchester, Oxford Road, Manchester M13 9PT, UK
- *Andrew J. McBain:
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Malone M, Bowling FL, Gannass A, Jude EB, Boulton AJM. Deep wound cultures correlate well with bone biopsy culture in diabetic foot osteomyelitis. Diabetes Metab Res Rev 2013; 29:546-50. [PMID: 23653368 DOI: 10.1002/dmrr.2425] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 02/19/2013] [Accepted: 05/02/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Osteomyelitis is a major complication in patients with diabetic foot ulceration. Accurate pathogenic identification of organisms can aid the clinician to a specific antibiotic therapy thereby preventing the need for amputation. METHODS All diabetic patients with bone biopsy-confirmed osteomyelitis were included into the study: biopsies were performed either during surgical removal of infected bone or percutaneously under guided fluoroscopy through non-infected tissue. The depth and extent of the ulcer was assessed using a sterile blunt metal probe. Deep wound cultures were taken from the wound base after sharp debridement. RESULTS Of 66 cases of suspected osteomyelitis in 102 joints, 34 patients had both bone biopsies and deep wound cultures over the study period. Thirty two of 34 (94%), had a history of preceding foot ulceration, and in 25 of the cases a positive probe to bone test was recorded. In a high proportion of patients, at least one similar organism was isolated from both the deep wound culture and bone biopsy procedures (25 of 34 cases, 73.5%, p<0.001). When organisms were isolated from both wound cultures and bone biopsies, the identical strain was identified in both procedures in a significant proportion of cases (16 of 25 cases, 64%, p<0.001, total sample analysis in 16 of 34 cases, 47%). CONCLUSIONS Deep wound cultures correlate well with osseous cultures and provide a sensitive method in assessing and targeting likely pathogens that cause osseous infections. This will help aid the clinician in guiding antibiotic therapy in centers where bone biopsies may not be readily available.
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Affiliation(s)
- M Malone
- Podiatry Department, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia; Department of Surgery, Podiatric Surgery Unit, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
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Malone M, Gannass A, Descallar J, Bowling FL, Dickson HG. Pedal osteomyelitis in patients with diabetes: a retrospective audit from Saudi Arabia. J Wound Care 2013; 22:318-20, 322-3. [PMID: 24049816 DOI: 10.12968/jowc.2013.22.6.318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the characteristics of patients presenting to the emergency room and the specialist diabetes foot clinic with pedal osteomyelitis (PO). METHOD A retrospective study was conducted at a regional hospital. The charts of patients with suspected PO who presented during the period 1 January to 31 December 2011 were analysed. Demographics, biochemistry and microbiological data were obtained. Bone biopsies were performed by the attending clinician either during surgical removal of infected bone, or percutaneously under guided fluoroscopy through non-infected tissue. RESULTS Sixty-six cases of osteomyelitis affecting 102 joints were noted. The study population consisted of 44 men, mean age 62.9 +/- 1.3 years, and 22 women, mean age of 57.6 +/- 10.6 years. Gram-positive bacteria were the predominating pathogens (p < 0.05). Staphylococcus aureus was cultured in 36% of all bone biopsy cases. A predictive trend in HbA1c was observed,where every increase of 1% from the recommended level of 7% was associated with a 10% increase in the likelihood of receiving surgical intervention. CONCLUSION S. aureus infection is a major cause of osteomyelitis in interphalangeal joints of the feet of diabetic patients.There is an apparent association with patients who present with diabetic foot osteomyelitis and sub-optimal glycaemic control, requiring surgical intervention.
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Affiliation(s)
- M Malone
- High Risk Foot Clinic, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia.
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Clark RL, Bowling FL, Jepson F, Rajbhandari S. Phantom limb pain after amputation in diabetic patients does not differ from that after amputation in nondiabetic patients. Pain 2013; 154:729-732. [DOI: 10.1016/j.pain.2013.01.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 01/04/2013] [Accepted: 01/17/2013] [Indexed: 11/26/2022]
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Abstract
AIMS To compare the Ipswich Touch Test and the VibraTip with the Neuropathy Disability Score and the vibration perception threshold for detecting the 'at-risk' foot. METHODS We directly compared the Ipswich Touch Test and the VibraTip with both the Neuropathy Disability Score ≥ 6 and the vibration perception threshold ≥ 25 V indicating 'at-risk' feet in 83 individuals. RESULTS The vibration perception threshold and Neuropathy Disability Score tests exhibited almost perfect agreement with each other (P < 0.001). The VibraTip and Ipswich Touch Test results were identical (P < 0.001). The VibraTip and Ipswich Touch Test results also exhibited almost perfect agreement with the vibration perception threshold (P < 0.001) and the Neuropathy Disability Score (P < 0.001). CONCLUSIONS These two simple and efficient tests are easy to teach, reliable and can be used in any setting, and neither requires an external power source. We conclude that both the VibraTip and the Ipswich Touch Test are reliable and sensitive tests for identifying the 'high-risk' foot.
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