Evidence-based interventions for identifying candidate quality indicators to assess quality of care in diabetic foot clinics: a scoping review

BACKGROUND

Foot ulcers in people with diabetes are a serious complication requiring a complex management and have a high societal impact. Quality monitoring systems to optimize diabetic foot care exist, but a formal and more evidence-based approach to develop quality indicators (QIs) is lacking. We aimed to identify a set of candidate indicators for diabetic foot care by adopting an evidence-based methodology.

METHODS

A systematic search was conducted across four academic databases: PubMed, Embase CINAHL and Cochrane Library. Studies that reported evidence-based interventions related to organization or delivery of diabetic foot care were searched. Data from the eligible studies were summarized and used to formulate process and structure indicators. The evidence for each candidate QI was described in a methodical and transparent manner. The review process was reported according to the "Preferred Reported Items for Systematic reviews and Meta-Analysis" (PRISMA) statements and its extension for scoping reviews.

RESULTS

In total, 981 full-text articles were screened, and 322 clinical studies were used to formulate 42 candidate QIs.

CONCLUSIONS

An evidence-based approach could be used to select candidate indicators for diabetic foot ulcer care, relating to the following domains: wound healing interventions, peripheral artery disease, offloading, secondary prevention, and interventions related to organization of care. In a further step, the feasibility of the identified set of indicators will be assessed by a multidisciplinary panel of diabetic foot care stakeholders.

A multidisciplinary Delphi consensus to define evidence-based quality indicators for diabetic foot ulcer care

BACKGROUND

Valid measures to assess quality of care delivered to patients with diabetes suffering from diabetic foot ulcer (DFU) are scarce. This study aimed to achieve consensus on relevant and feasible quality indicators (QIs) among stakeholders involved in DFU care and was conducted as the second part of a Belgian QI selection study that sought to identify QIs for DFU care.

METHODS

A stakeholder panel, including caregivers from primary care and specialized disciplines active in diabetic foot care as well as a patient organization representative, was recruited. By using the RAND/UCLA Appropriateness Method, stakeholders were asked to rate a list of 42 candidate evidence-based indicators for appropriateness through a 9-point Likert scale. QIs were classified based on the median ratings and the disagreement index, calculated by the inter-percentile range adjusted for symmetry.

RESULTS

At the end of a three-phase process, 17 QIs were judged as appropriate. Among them, five were not previously described, covering the following topics: integration of wound care specialty in the multidisciplinary team, systematic evaluation of the nutritional status of the patient, administration of low-density lipoprotein-cholesterol lowering medication and protocolized care (implementation of care and prevention management protocols).

CONCLUSIONS

The identified evidence-based QIs provide an assessment tool to evaluate and monitor quality of care delivered to DFU patients. Future research should focus on their complementarity with the existing QIs and their implementation in clinical practice.

Which parameters predict correction of the intermetatarsal angle after first metatarsophalangeal fusion?

Fusion of the first metatarsophalangeal joint (MTPJ) is a commonly performed surgical procedure. Although the effect of first MTPJ fusion on reduction of Intermetatarsal angle (IMA) is well described, contributing factors remain unclear. The aim of this study was to identity predictive parameters for IMA reduction. Fifty-one patients (68 feet) who underwent a first MTPJ fusion and had an IMA greater than fourteen degrees were assessed retrospectively. The average age was 68 (31.4-79.3) years. Sixteen demographic and radiographic variables were evaluated using a multivariate regression analysis for association with change in IMA after surgery. The mean preoperative IMA was 16.11 (range, 14.0-22.5) degrees with a mean reduction of 4.95 (range, 0-17) degrees after surgery. Multivariate regression analysis revealed three significant independent predictors of the change in IMA. Increased preoperative IMA (β = .663, CI = .419, .908, P <.001), increased preoperative translation at base of MT1 (β = .490, CI = 0.005, .974, P = 0.039), and less postoperative translation in the fusion (β= -0.693, CI= -1.054, -.331, P= 0.002) significantly increased the amount of IMA reduction. Pre-operative IMA and translation at the base of the first metatarsal were positive predictors for correction of IMA after first MTPJ fusion. Translation at the level of the MTP I fusion was a negative predictor for the amount of IMA correction. Based on these findings, we recommend minimizing the lateral translation of the proximal phalanx relative to the metatarsal head to optimize IMA correction after MTPJ fusion.

Bottom-up approach to build a 'precision' risk factor classification for diabetic foot ulcer healing. Proof-of-concept

AIMS

Diabetic foot ulcers (DFU) have a complex multifactorial pathophysiology. It is crucial to identify essential prognostic variables to streamline therapeutic actions and quality-of-care audits. Although SINBAD and University of Texas (UT), the most frequently used prognostic classification systems, were prospectively validated, not all individual parameters were shown to have consistent associations with healing. In this study, we used a bottom-up approach relying on robust methods to identify independent predictors of DFU healing.

METHODS

1,664 DFU patients were included by 34 Belgian diabetic foot clinics (DFCs). Twenty-one patient- and foot-related characteristics were recorded at presentation. Predictors of healing were identified using multivariable Cox proportional hazard regression. Multivariable models were built using backward regression with multiple imputation of missing values and bootstrapping.

RESULTS

Five essential independent variables were identified: presentation delay, history of minor amputation, ulcer location, surface area and ischemia. This 5 variable-model showed a better performance compared to models based on existing classification systems.

CONCLUSIONS

A bottom-up approach was used to build a prognostic classification for DFU healing based on large databases. It offers new insights and allows to tailor the classification to certain clinical settings. These 5 parameters could be used as a 'precision classification' for specialized DFCs.

Foot and ankle kinematics in chronic ankle instability subjects using a midfoot strike pattern when running, including influence of taping

BACKGROUND

Investigate differences in multi-segment foot kinematics between controls and participants with chronic ankle instability during running with a midfoot striking pattern and to evaluate the effect of Low-Dye and High-Dye taping.

METHODS

Three-dimensional multi-segment foot kinematics of 12 controls and 15 participants with chronic ankle instability were collected while running barefoot, and in both taping conditions. Ranges of motion occurring at each joint, each sub phase of stance, were compared between groups and between taping conditions (0-dimensional inference). Kinematic data were also compared using one-dimensional statistical parametric mapping.

FINDINGS

The symptomatic group demonstrated while barefoot running a significantly decreased rearfoot dorsiflexion range of motion during the peak impact phase as well as a less dorsiflexed position from 6 to 12% of the running cycle. During the absorption and generation phase, the symptomatic group also showed a significantly increased rearfoot dorsiflexion and adduction motion as well as an increased midfoot inversion motion. In the peak impact phase of both taping conditions, a decreased midfoot inversion motion was found. The High-Dye taping resulted in a decreased rearfoot plantarflexion motion whereas the Low-Dye caused a decreased midfoot inversion motion.

INTERPRETATION

Persons with chronic ankle instability seem to have altered rearfoot and midfoot kinematics while running with a midfoot striking index. High-Dye taping seems to have better therapeutic features than Low-Dye taping.

Foot segmental motion and coupling in stage II and III tibialis posterior tendon dysfunction

BACKGROUND

Classification systems developed in the field of posterior tibialis tendon dysfunction omit to include dynamic measurements. Since this may negatively affect the selection of the most appropriate treatment modality, studies on foot kinematics are highly recommended. Previous research characterised the foot kinematics in patients with posterior tibialis tendon dysfunction. However, none of the studies analysed foot segmental motion synchrony during stance phase, nor compared the kinematic behaviour of the foot in presence of different posterior tibialis tendon dysfunction stages. Therefore, we aimed at comparing foot segmental motion and coupling in patients with posterior tibialis tendon dysfunction grade 2 and 3 to those of asymptomatic subjects.

METHODS

Foot segmental motion of 11 patients suffering from posterior tibialis tendon dysfunction stage 2, 4 patients with posterior tibialis tendon dysfunction stage 3 and 15 asymptomatic subjects was objectively quantified with the Rizzoli foot model using an instrumented walkway and a 3D passive motion capture system. Dependent variables were the range of motion occurring at the different inter-segment angles during subphases of stance and swing phase as well as the cross-correlation coefficient between a number of segments.

RESULTS

Significant differences in range of motion were predominantly found during the forefoot push off phase and swing phase. In general, both patient cohorts demonstrated a reduced range of motion compared to the control group. This hypomobility occurred predominantly in the rearfoot and midfoot (p<0.01). Significant differences between both posterior tibialis tendon dysfunction patient cohorts were not revealed. Cross-correlation coefficients highlighted a loss of joint coupling between rearfoot and tibia as well as between rearfoot and forefoot in both posterior tibialis tendon dysfunction groups.

INTERPRETATION

The current evidence reveals considerable mechanical alterations in the foot which should be considered in the decision making process since it may help explaining the success and failure of certain conservative and surgical interventions.

Foot segmental mobility during subphases of running: Comparative study between two striking patterns

OBJECTIVES

The literature lacks comparative data regarding foot segmental mobility in rearfoot (RFS) and midfoot striking (MFS) patterns. The aim of the study is to quantify the foot segmental mobility during distinct subphases of stance in presence of both striking patterns.

METHODS

Twelve participants were instructed to run barefoot at a constant speed of 3.3m/s on a 10-m walkway, while adopting a RFS and a MFS pattern. Multi-segment foot mobility during the impact phase, the absorption phase and the generation phase was subsequently calculated and compared between both conditions.

RESULTS

In the impact phase of the MFS trials, a higher sagittal plane range of motion was observed between shank and calcaneus (RFS=6.2°, MFS=14.5°, p<0.0001), between calcaneus and midfoot (RFS=1.9°, MFS=5.6°, p=0.002) as well as between the calcaneus and metatarsus (RFS=2.4°, MFS=4.9°, p=0.0015). In the absorption phase of the MFS trials, a higher frontal plane range of motion (RFS=1.3°, MFS=2.1°, p=0.004) and a lower sagittal plane range of motion (RFS=6.5°, MFS=4.3°, p=0.004) was observed between the calcaneus and metatarsus.

CONCLUSION

This study revealed that approximately 50% of the rearfoot range of motion has been observed in the midfoot when running with both striking patterns, although the highest ROM was observed in the rearfoot. This finding highlights that the rebounding effect of the human body results not only from absorption and generation within major joints of the lower limb but also from smaller joints in the foot.

3D Multi-segment foot kinematics in children: A developmental study in typically developing boys

BACKGROUND

The relationship between age and 3D rotations objectivized with multisegment foot models has not been quantified until now. The purpose of this study was therefore to investigate the relationship between age and multi-segment foot kinematics in a cross-sectional database.

METHODS

Barefoot multi-segment foot kinematics of thirty two typically developing boys, aged 6-20 years, were captured with the Rizzoli Multi-segment Foot Model. One-dimensional statistical parametric mapping linear regression was used to examine the relationship between age and 3D inter-segment rotations of the dominant leg during the full gait cycle.

RESULTS

Age was significantly correlated with sagittal plane kinematics of the midfoot and the calcaneus-metatarsus inter-segment angle (p<0.0125). Age was also correlated with the transverse plane kinematics of the calcaneus-metatarsus angle (p<0.0001).

CONCLUSION

Gait labs should consider age related differences and variability if optimal decision making is pursued. It remains unclear if this is of interest for all foot models, however, the current study highlights that this is of particular relevance for foot models which incorporate a separate midfoot segment.

Efficacy measures associated to a plantar pressure based classification system in diabetic foot medicine

AIMS

The concept of 'classification' has, similar to many other diseases, been found to be fundamental in the field of diabetic medicine. In the current study, we aimed at determining efficacy measures of a recently published plantar pressure based classification system.

METHODS

Technical efficacy of the classification system was investigated by applying a high resolution, pixel-level analysis on the normalized plantar pressure pedobarographic fields of the original experimental dataset consisting of 97 patients with diabetes and 33 persons without diabetes. Clinical efficacy was assessed by considering the occurence of foot ulcers at the plantar aspect of the forefoot in this dataset. Classification efficacy was assessed by determining the classification recognition rate as well as its sensitivity and specificity using cross-validation subsets of the experimental dataset together with a novel cohort of 12 patients with diabetes.

RESULTS

Pixel-level comparison of the four groups associated to the classification system highlighted distinct regional differences. Retrospective analysis showed the occurence of eleven foot ulcers in the experimental dataset since their gait analysis. Eight out of the eleven ulcers developed in a region of the foot which had the highest forces. Overall classification recognition rate exceeded 90% for all cross-validation subsets. Sensitivity and specificity of the four groups associated to the classification system exceeded respectively the 0.7 and 0.8 level in all cross-validation subsets.

CONCLUSIONS

The results of the current study support the use of the novel plantar pressure based classification system in diabetic foot medicine. It may particularly serve in communication, diagnosis and clinical decision making.

A Novel Method of Quantifying Gait Deviations Using Plantar Pressure Patterns

BACKGROUND

Comparing the dynamic pedobarographic patterns of individuals is common practice in basic and applied research. However, this process is often time-consuming and complex, and commercially available software often lacks powerful visualization and interpretation tools.

METHODS

We propose a simple method for displaying pixel-level pedobarographic deviations over time relative to a so-called reference pedobarographic pattern. This novel method contains four distinct automated preprocessing stages: 1) normalization of pedobarographic fields (for foot length and width), 2) temporal normalization, 3) a pixel-level z-score-based calculation, and 4) color coding of the normalized pedobarographic fields. Group and patient-level comparisons were illustrated using an experimental data set including diabetic and nondiabetic patients.

RESULTS

The automated procedure was found to be robust and quantified distinct temporal deviations in pedobarographic fields.

CONCLUSIONS

The advantages of the novel method cover several domains, including visualization, interpretation, and education.

A color-code based method for the interpretation of plantar pressure measurements in clinical gait analysis

Comparing plantar pressure measurements (PPM) of a patient following an intervention or between a reference group and a patient-group is common practice in clinical gait analysis. However, this process is often time consuming and complex, and commercially available software often lacks powerful visualization and interpretation tools. In this paper, we propose a simple method for displaying pixel-level PPM deviations relative to a so-called reference PPM pattern. The novel method contains 3 distinct stages: (1) a normalization of pedobarographic fields (for foot length and width), (2) a pixel-level z-score based calculation and, (3) color coding of the normalized pedobarographic fields. The methodological steps associated to this novel method are precisely described and clinical output illustrated. We believe that the advantages of the novel method cover several domains. The strongest advantage of the novel method is that it provides a straightforward visual interpretation of PPM without decreasing the resolution perspective. A second advantage is that it may guide the selection of a local mapping technique (data reduction technique). Finally, it may be easily used as education tool during the therapist-patient interaction.

Classification of forefoot plantar pressure distribution in persons with diabetes: a novel perspective for the mechanical management of diabetic foot?

Background

The aim of this study was to identify groups of subjects with similar patterns of forefoot loading and verify if specific groups of patients with diabetes could be isolated from non-diabetics.

Methodology/Principal Findings

Ninety-seven patients with diabetes and 33 control participants between 45 and 70 years were prospectively recruited in two Belgian Diabetic Foot Clinics. Barefoot plantar pressure measurements were recorded and subsequently analysed using a semi-automatic total mapping technique. Kmeans cluster analysis was applied on relative regional impulses of six forefoot segments in order to pursue a classification for the control group separately, the diabetic group separately and both groups together. Cluster analysis led to identification of three distinct groups when considering only the control group. For the diabetic group, and the computation considering both groups together, four distinct groups were isolated. Compared to the cluster analysis of the control group an additional forefoot loading pattern was identified. This group comprised diabetic feet only. The relevance of the reported clusters was supported by ANOVA statistics indicating significant differences between different regions of interest and different clusters.

Conclusion/s Significance

There seems to emerge a new era in diabetic foot medicine which embraces the classification of diabetic patients according to their biomechanical profile. Classification of the plantar pressure distribution has the potential to provide a means to determine mechanical interventions for the prevention and/or treatment of the diabetic foot.

Comparison of foot segmental mobility and coupling during gait between patients with diabetes mellitus with and without neuropathy and adults without diabetes

BACKGROUND

Reduction in foot mobility has been identified as a key factor of altered foot biomechanics in individuals with diabetes mellitus. This study aimed at comparing in vivo segmental foot kinematics and coupling in patients with diabetes with and without neuropathy to control adults.

METHODS

Foot mobility of 13 diabetic patients with neuropathy, 13 diabetic patients without neuropathy and 13 non-diabetic persons was measured using an integrated measurement set-up including a plantar pressure platform and 3D motion analysis system. In this age-, sex- and walking speed matched comparative study; differences in range of motion quantified with the Rizzoli multisegment foot model throughout different phases of the gait cycle were analysed using one-way repeated measures analysis of variance (ANOVA). Coupling was assessed with cross-correlation techniques.

FINDINGS

Both cohorts with diabetes showed significantly lower motion values as compared to the control group. Transverse and sagittal plane motion was predominantly affected with often lower range of motion values found in the group with neuropathy compared to the diabetes group without neuropathy. Most significant changes were observed during propulsion (both diabetic groups) and swing phase (predominantly diabetic neuropathic group). A trend of lower cross-correlations between segments was observed in the cohorts with diabetes.

INTERPRETATION

Our findings suggest an alteration in segmental kinematics and coupling during walking in diabetic patients with and without neuropathy. Future studies should integrate other biomechanical measurements as it is believed to provide additional insight into neural and mechanical deficits associated to the foot in diabetes.

Changes in contact area characteristics of the ankle after a cartilage biopsy at the postero-medial rim of the talar dome

OBJECTIVE

Study the changes in local and generalized biomechanical characteristics of the ankle joint, associated with a well defined cartilage biopsy at the postero-medial rim of the talar dome, to evaluate its safety.

METHODS

Ten cadaver ankles were (sub-) physiologically loaded pre- and post-biopsy; in neutral position, 10 degrees of plantar-flexion (PF) and 10 degrees of dorsi-flexion (DF). Fuji film was used as transducer. Qualitatively, the coverage of the biopsy by the tibial plafond, and changes in the shape of the footprint were analyzed. Quantitatively, the pressure profile plot, normalized-tibio-talar contact area and the centroid position of pressure were examined. Results were reported as a mean for all specimens, and as individual values for every single specimen as well.

RESULTS

Mean results did not show significant changes, but those of some single specimens did. The majority of those changes were in PF. Some occurred in N, and besides two exceptions none occurred in DF. Two specimens did not show any change. One specimen showed an isolated quantitative change. Seven specimens showed both qualitative and quantitative changes. However, all changes were of low-magnitude and contact stresses did not show any rebound effect.

CONCLUSIONS

Although biopsies at the postero-medial rim of the talar dome did not induce on average significant changes in quantitative contact characteristics, few specimens did show some alterations. Currently, the investigated biopsy site seems safe, but long term follow-up studies in patients are needed for confirmation.

Inter- and intra-observer reliability of masking in plantar pressure measurement analysis

Plantar pressure measurement is an important tool in gait analysis. Manual placement of small masks (masking) is increasingly used to calculate plantar pressure characteristics. Little is known concerning the reliability of manual masking. The aim of this study was to determine the reliability of masking on 2D plantar pressure footprints, in a population with forefoot deformity (i.e. hallux valgus). Using a random repeated-measure design, four observers identified the third metatarsal head on a peak-pressure barefoot footprint, using a small mask. Subsequently, the location of all five metatarsal heads was identified, using the same size of masks and the same protocol. The 2D positional variation of the masks and the peak pressure (PP) and pressure time integral (PTI) values of each mask were calculated. For single-masking the lowest inter-observer reliability was found for the distal-proximal direction, causing a clear, adverse impact on the reliability of the pressure characteristics (PP and PTI). In the medial-lateral direction the inter-observer reliability could be scored as high. Intra-observer reliability was better and could be scored as high or good for both directions, with a correlated improved reliability of the pressure characteristics. Reliability of multi-masking showed a similar pattern, but overall values tended to be lower. Therefore, small sized masking in order to define pressure characteristics in the forefoot should be done with care.

Repeatability and contact stress gradient detection of sealed pressure-sensitive film when used in a physiological joint model

Sealed pressure-sensitive film is frequently used to record contact characteristics in physiological joints. However, the effect on the pressure-recording characteristics of sealing the film when used in these circumstances has never been studied. This study compares the coefficient of variation, the standardized coefficient of variation, the tangent and secant contact stress gradients, and the actual pressures between unsealed and sealed Fuji film, in a simplified physiological joint model with a full-thickness surface defect. Unsealed film and sealed film were loaded through a range of nominal loads and the resulting stains were analysed by use of custom-made macros for the ImageJ image-processing program. The coefficient of variation did not exceed 5.7 per cent (sealed film), and the standardized coefficient of variation did not exceed 1.8 per cent (unsealed and sealed film). Contact stress gradients did not differ significantly. The recorded pressure at the level of surface defects was always about 0.2 MPa higher in the case of sealed film, and therefore predictable. It is concluded that sealing the film will not change the pressure-recording characteristics.