Biomechanical aspects of diabetic foot disease: aetiology, treatment, and prevention.
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Biomechanical Phenomena↗
Biomedical subjects
J S Ulbrecht
Publications and source records attributed to J S Ulbrecht.
The use of running shoes to reduce plantar pressures in patients who have diabetes.
We compared the plantar pressures generated by walking in leather-soled Oxford-style shoes and by walking in inexpensive running shoes with those generated by walking in thin socks on a hard surface for thirty-nine individuals (thirteen who had diabetes and neuropathy, and thirteen who had diabetes without neuropathy, and thirteen who had neither diabetes nor neuropathy [controls]). Except for two anatomical regions, the plantar pressure associated with the Oxford-style shoes were not different from those associated with walking without shoes. In comparison, the inexpensive running shoes relieved plantar pressure in the forefoot and heel by a mean (and standard deviation) of 31 +/- 9.1 per cent, with the most relief occurring in the feet that had the highest pressures when they were unshod. There were significant reductions in pressure in all regions of the foot except for the midfoot (p < 0.01), and there were no significant differences between the groups. Individuals who have insensate feet should be discouraged from wearing leather-soled Oxford-style shoes because of the risk of ulceration due to elevated plantar pressures. Inexpensive running shoes should be viewed as the very minimally acceptable choice for footwear for these individuals if the feet are free of deformity.
Adult↗
While early amputation is not recommended, others may be encouraged to follow this course on the basis that amputation is 'inevitable'.
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Amputation, Surgical↗
Assessment and management of foot disease in patients with diabetes.
Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.
Anti-Bacterial Agents↗
Postural instability in patients with diabetic sensory neuropathy.
OBJECTIVE: Recent survey evidence suggests that sensory ataxia due to diabetic neuropathy may be a more frequent and serious problem than is commonly recognized. This view is further supported by research that confirms the major contribution of the somatosensory system to the control of posture. We therefore sought to determine the effects of significant diabetic distal symmetrical polyneuropathy on the control of posture. RESEARCH DESIGN AND METHODS: Fifty-one subjects, divided into three groups, participated in this study. Seventeen had diabetes and significant sensory neuropathy, 17 had diabetes and no neuropathy, and 17 had neither diabetes nor neuropathy. The subjects were matched across groups, and stringent exclusion criteria were applied. Postural stability during quiet standing was measured using a force platform. In addition to electrophysiological and quantitative sensory tests of neuropathy, a number of physical and functional characteristics were measured for all subjects. RESULTS: Postural instability was found to be significantly associated with sensory neuropathy, but not with diabetes per se. Patients with sensory neuropathy demonstrated between 66 and 117% more instability than did control subjects (depending on the testing condition). Based on multiple linear regression analyses, the most significant correlates of instability were the quantitative sensory measures of neuropathy and age. CONCLUSIONS: The loss of sensory perception secondary to diabetic distal symmetrical sensory neuropathy has a markedly detrimental effect on postural stability. The deficit is greatest when visual or vestibular cues are absent or degraded. Patients with neuropathy need to be informed of the postural consequences of this condition to limit the potential morbidity caused by falls.
Aging↗
Ulceration, unsteadiness, and uncertainty: the biomechanical consequences of diabetes mellitus.
Diabetes mellitus, which results from a failure of the endocrine system to control blood glucose levels within normal limits, affects approximately 15% of the population over the age of 65 in developed countries. Between 20-50% of people with diabetes for more than 10 years will experience symmetrical distal sensory neuropathy resulting in a progressive, distal to proximal, loss of sensation in the lower extremities. The most common consequence is plantar ulceration that too often results in partial or total amputation of the foot. While neuropathy is a major permissive factor, plantar ulcers occur at locations of high plantar pressures. The measurement of pressure using tools developed and refined in the field of biomechanics has been shown to be a valuable asset to the management of the foot at risk for ulceration. In particular, the use of in-shoe measuring techniques has the potential to revolutionize the prescription of therapeutic footwear. Biomechanical techniques have also helped to evaluate other consequences of diabetic neuropathy on the foot such as callus formation, foot deformity, limited joint mobility and bony abnormalities. The reduction of afferent information from the lower extremities implies a lack of active feedback thought to be necessary for the control of human movements such as posture and gait. Our results show that diabetic neuropathy results in a significant increase in sway during standing that is not compensated for by other sensory systems. The study of the sagittal plane movements of the same individuals walking on a treadmill showed little effect on the kinematic control of gait when compared to age matched nonneuropathic control groups. This may indicate the dominance of efferent input over afferent feedback during gait. We believe that the study of the biomechanical consequences of diabetes can act as a model for many other diseases that have yet to come under the scrutiny of a multidisciplinary team.
Biomechanical Phenomena↗
The effects of visual factors and head orientation on postural steadiness in women 55 to 70 years of age.
This study was designed to establish reference data for the effects of head position and visual conditions on the standing posture of healthy women ages 55 to 70. Center of pressure (CoP) data were analyzed using ANOVA models. Total CoP displacement was 45% greater (significant, p less than .05) when the subjects stood with their heads back and their eyes closed, as compared to standing looking straight ahead. Visual surrounds consisting of vertical visual cues resulted in less postural sway (PS) than surrounds made of horizontal visual cues (significant, p less than .05 for anteroposterior CoP range). Experimentally reduced visual acuity resulted in greater PS, while changes in ambient lighting and spatial frequency of visual cues affected PS minimally. These results suggest that a reduction in the height of shelving, and the provision of high-contrast visual cues and vertical geometric patterns are potential intervention strategies to optimize vestibular sensory input and visual orientational cues for the maintenance of stability during stance.
Aged↗
Problems with gait and posture in neuropathic patients with insulin-dependent diabetes mellitus.
Peripheral neuropathy secondary to diabetes mellitus is believed to cause postural instability and uncoordinated gait, although this is not well documented. Two groups of patients from the Pittsburgh Epidemiology of Diabetes Complications Study, matched for age and duration of Type 1 diabetes, but with significantly different vibratory sensation thresholds as determined by Vibratron II testing, were therefore surveyed. The mean ages were 32.9 and 31.9 years and durations of diabetes were 22.0 and 18.8 years for the neuropathic and control groups, respectively. Patients provided details of fall injuries, and perception of safety during standing and walking. Multiple linear and logistic regression models were used to account for potentially associated variables such as gender, retinopathy, and duration of diabetes. The neuropathic group had adjusted odds ratios for reported injuries during gait of 15.0 relative to the control group (95% confidence intervals 1.04-216.59). The neuropathic group also reported significantly lower scores (less safe, p = 0.004) than the control group on perceived safety in unusual conditions. It is concluded that peripheral neuropathy has an effect on gait and posture which is clinically significant and that this effect merits further biomechanical study in neuropathic patients.
Accidental Falls↗
The influence of visual factors on fall-related kinematic variables during stair descent by older women.
Despite the documented health hazards associated with stair descent, the mechanisms of falling on stairs remain relatively unexamined. The objectives of this study were to define kinematic variables that could be used to describe foot-stair spatial relationships during the mid-stair phase of stair descent, and to investigate the effects of various visual and environmental conditions on those variables in a group of 36 healthy women between the ages of 55 and 70. Foot clearance and foot placement were measured through high-speed film analysis. Clearance between the foot and the stair during swing phase was small under all visual conditions. Degraded visual acuity had a significant effect on cadence, foot placement, and foot clearance, but visual surround conditions did not. The kinematic variables used in this experiment may be helpful in future studies to assess the results of interventions aimed at reducing the frequency of falls on stairs.
Accidental Falls↗
Diabetes mellitus in American Indians: characteristics, origins and preventive health care implications.
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Diabetes Mellitus, Type 2↗
Risk factors in the diabetic foot. Recognition and management.
The most frequently reported diabetic foot complication is plantar ulceration. Neuropathic fractures occur less often than plantar ulcers but usually result in major structural deformities of the feet. The primary risk factors for plantar ulceration are believed to be loss of protective sensation and the presence of high plantar pressures. Principal etiologic factors in the development of neuropathic fractures are hypothesized to be loss of protective sensation and bone demineralization. Major diabetic foot injuries are preventable by the use of comprehensive screening examinations and patient education. Patients at highest risk of injury should be seen more frequently and receive more extensive therapy. Successful management of plantar ulcerations is dependent on reduction of pressures under the foot and control of infection. Neuropathic fractures require long-term immobilization to promote healing followed by careful monitoring after removal of casts to prevent reinjury. Future research needs include prospective studies on risk factors and validation of treatment techniques.
Autonomic Nervous System Diseases↗
Clearance studies of oxytocin in humans using radioimmunoassay measurements of the hormone in plasma and urine.
Synthetic oxytocin (OT) was infused iv in four men at 3 mU/min, and the rate was doubled every 90 min for a total of three infusion periods. The mean (+/- SEM) OT MCR was 16.4 +/- 1.7 ml/kg X min and was independent of the rate of infusion. A method for measuring OT in urine was developed using an octadecasilyl-silica column for extraction of the hormone. The extracted residue was reconstituted in potassium phosphate buffer, pH 7.4, for RIA. The minimum detectable level of OT in urine was 0.2 microU/ml (defined as a bound to free ratio of approximately 90%). The mean recovery of OT was 77 +/- 2%. The mean (+/- SEM) concentration of endogenous OT in urine was 10.2 +/- 1.4 microU/ml. Endogenous OT in urine eluted from a reverse phase high pressure liquid chromatography column as a single peak of OT immunoreactivity in the position of synthetic OT. Urinary OT excretion during infusion of synthetic OT was linearly correlated with plasma OT concentration whether calculated as microunits of urinary OT per mg creatinine (r = 0.89) or urinary OT per min (r = 0.93). Mean urinary fractional clearance of OT (OT clearance/creatinine clearance) was 3.6% renal clearance of OT (5.5 ml/min or 0.43% of MCR). Thus, OT MCR was constant over a wide range of physiological plasma OT levels and was similar to MCR in pregnant women studied previously in this laboratory. Less than 1% of OT was cleared in urine. This study defines the relationship between urinary and plasma OT during steady state infusion of physiological concentrations of the hormone and indicates that measurements of OT in urine by RIA may prove helpful for pharmacokinetic and physiological studies of OT-related events in humans.
Adult↗
New developments in the biomechanics of the diabetic foot.
Biomechanical issues are now widely recognized as being important in the treatment of diabetic foot disease. The purpose of the present review is to identify advances that have occurred since the previous International Conference on the Diabetic Foot in 1995 in the understanding of foot biomechanics in relation to diabetes. Attention continues to be focused on the identification of a threshold plantar pressure that leads to tissue damage. Recent studies have suggested that peak barefoot pressure may be only 65% specific for the development of ulceration. The association between foot deformity and plantar pressure has been the subject of several quantitative studies, but new questions have been raised about the etiology of claw toes. The measurement of shear stress continues to be an elusive goal although several small studies have presented possibly feasible technical approaches. The importance of callus as a precursor to ulceration has been confirmed experimentally and quantitative measures of motor neuropathy have been presented. Although a number of new devices have been introduced as alternatives to the Total Contact Cast, few clinical studies of their efficacy are available yet. New information on the properties of insole materials has been published including data on changes with repeated cycling. Complications of prophylactic surgery have been shown to include a high rate of Charcot fractures. Two new series describing the fixation of such fractures have also been reported. Biomechanical issues have also been addressed in two sets of guidelines for treatment that have recently been published. These many studies confirm the central role of mechanical stress and its relief in the treatment of neuropathic foot problems in diabetes.
Biomechanical Phenomena↗
Insulinoma in a 94-year-old woman: long-term therapy with verapamil.
Several drugs can be used to control hypoglycemia caused by insulin-secreting pancreatic tumors but none are reliably efficacious or free of side effects. We report the case of a woman with an insulinoma who refused surgical intervention and was successfully treated with the Ca2+-channel blocker verapamil.
Adenoma, Islet Cell↗