Prevalence of standing plantar pressure distribution variation in north Asian Indian patients with diabetes mellitus: a study to understand ulcer formation

Factors associated with changes in plantar pressure of people with peripheral diabetic neuropathy

Abstract

Diabetic neuropathy is one of the main complications of Diabetes Mellitus, which can lead to loss of protective sensation, motor, and plantar pressure alteration, generating deformities, abnormal gait and mechanical trauma to the feet.

Objective

to evaluate the distribution of plantar pressure, sensorimotor changes, balance and associated factors to plantar pressure changes in people with peripheral diabetic neuropathy.

Method

Cross-sectional study conducted with individuals registered in the primary public health service of a city in the east of São Paulo - Brazil. The sample was composed by people with Diabetes Mellitus and Peripheral Neuropathy identified by the Michigan Screening Instrument. It were investigated variables such as sensory-motor changes, static and dynamic plantar pressure using baropodometry and balance using the Berg scale. A significance level of 5% was adopted for all tests used.

Results

Of the 200 individuals evaluated, 52.55% had no plantar protective sensitivity, the static evaluation did not demonstrated changes in the peak of plantar pressure, however in the dynamics the mean in the right foot was 6.0 (±2) kgf/cm2 and 6,7 (±1.62) kgf/cm2 on the left foot, the center of static pressure on the right foot was lower (10.55 ± 3.82) than on the left foot (11.97 ± 3.90), pointing hyper plantar pressure. The risk of falling was high, ranging from 8 to 56 points, with an average of 40.9 (±10.77).

Conclusion

The absence of protective plantar sensitivity, increased pressure, biomechanical changes lead to loss of balance and are predictive of complications in the feet due to diabetic neuropathy.

Index of Plantar Pressure Alters with Prolonged Diabetes Duration

INTRODUCTION

Diabetic foot ulcers develop with deviations in the distribution of plantar pressure. It is difficult to interpret any alteration in plantar pressure under different conditions of type 2 diabetes mellitus (T2DM). The aim of this study was to gain a better insight into the variations in plantar pressure with increased duration of diabetes.

METHODS

Plantar pressure was examined in 1196 participants with or without T2DM. Subjects with normal glucose tolerance (NGT) and impaired glucose tolerance (IGT) were assigned to control groups, and those with T2DM were divided into five groups according to diabetes duration (< 2 years, 2-5 years, 5-10 years, 10-15 years, and > 15 years). The clinical characteristics, plantar peak pressure, and pressure-time integral (PTI) were compared among the seven study groups, and factors associated with peak pressure and the PTI were analyzed.

RESULTS

At the hallux, peak pressure exhibited an upward trend in patients with T2DM within 5 years of diabetes duration, followed by a distinct downward slope with further progression of the disease (trend analysis, p  < 0.05). An uneven distribution of peak pressure was found at other locations, but this unevenness was ultimately lower than that in the two control groups (p  < 0.05). No obvious trend was noted for PTI among patients with different diabetes duration; however, those with diabetes for > 10 years manifested a significantly sharper increase in the PTI at the metatarsus (11.63 Ns/cm², p  < 0.05) and heel (14.12 Ns/cm², p  < 0.05) than at the hallux (8.76 Ns/cm²). A fluctuation in the PTI was also detected at the hallux and midfoot of diabetes patients, which was broadly flat when compared with that of the two control groups. The stepwise multiple regression analysis revealed that the variation in plantar pressure was independently associated with age, body mass index, and vibration perception threshold (VPT) (p  < 0.05).

CONCLUSIONS

There would appear to be an association between longer diabetes duration and decreased peak pressure for the hallux, suggesting that individuals with diabetes for > 10 years will have an increased PTI for the metatarsus and heel. The reduced pressure on the hallux is believed to be transferred to the metatarsus. Age, BMI, and VPT are distinct risk factors of abnormal plantar pressure.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Plantar pressure as a risk assessment tool for diabetic foot ulceration in egyptian patients with diabetes

BACKGROUND

Diabetic foot ulceration is a preventable long-term complication of diabetes. In the present study, peak plantar pressures (PPP) and other characteristics were assessed in a group of 100 Egyptian patients with diabetes with or without neuropathy and foot ulcers. The aim was to study the relationship between plantar pressure (PP) and neuropathy with or without ulceration and trying to clarify the utility of pedobarography as an ulceration risk assessment tool in patients with diabetes.

SUBJECTS AND METHODS

A total of 100 patients having diabetes were selected. All patients had a comprehensive foot evaluation, including assessment for neuropathy using modified neuropathy disability score (MNDS), for peripheral vascular disease using ankle brachial index, and for dynamic foot pressures using the MAT system (Tekscan). The studied patients were grouped into: (1) diabetic control group (DC), which included 37 patients who had diabetes without neuropathy or ulceration and MNDS ≤2; (2) diabetic neuropathy group (DN), which included 33 patients who had diabetes with neuropathy and MNDS >2, without current or a history of ulceration; and (3) diabetic ulcer group (DU), which included 30 patients who had diabetes and current ulceration, seven of those patients also gave a history of ulceration.

RESULTS

PP parameters were significantly different between the studied groups, namely, forefoot peak plantar pressure (FFPPP), rearfoot peak plantar pressure (RFPPP), forefoot/rearfoot ratio (F/R), forefoot peak pressure gradient (FFPPG) rearfoot peak pressure gradient (RFPPG), and forefoot peak pressure gradient/rearfoot peak pressure gradient (FFPPG/RFPPG) (P < 0.05). FFPPP and F/R were significantly higher in the DU group compared to the DN and DC groups (P < 0.05), with no significant difference between DN and DC. FFPPG was significantly higher in the DU and DN groups compared to the DC group (P < 0.05). RFPPP and FFPPG/RFPPG were significantly higher in the DU and DN groups compared to the DC group (P < 0.05) with no significant difference between the DN and DU groups (P > 0.05). FFPPP, F/R ratio, FFPPG, and FFPPG/RFPPG correlated significantly with the severity of neuropathy according to MNDS (P < 0.05). These same variables as well as MNDS were also significantly higher in patients with foot deformity compared to those without deformity (P < 0.05). Using the receiver operating characteristic analysis, the optimal cut-point of PPP for ulceration risk, as determined by a balance of sensitivity, specificity, and accuracy was 335 kPa and was found at the forefoot. Multivariate logistical regression analysis for ulceration risk was statistically significant for duration of diabetes (odds ratio [OR] = 0.8), smoking (OR = 9.7), foot deformity (OR = 8.7), MNDS (OR = 1.5), 2-h postprandial plasma glucose (2 h-PPG) (OR = 0.9), glycated hemoglobin (HbA1c) (OR = 2.1), FFPPP (OR = 1.0), and FFPPG (OR = 1.0).

CONCLUSION

In conclusion, persons with diabetes having neuropathy and/or ulcers have elevated PPP. Risk of ulceration was highly associated with duration of diabetes, smoking, severity of neuropathy, glycemic control, and high PP variables especially the FFPPP, F/R, and FFPPG. We suggest a cut-point of 355 kPa for FFPPP to denote high risk for ulceration that would be more valid when used in conjunction with other contributory risk factors, namely, duration of diabetes, smoking, glycemic load, foot deformity, and severity of neuropathy.