Search Results
Background
Ankle position sense may be reduced before the appearance of the clinical manifestation of diabetic peripheral neuropathy. This is known to impair gait and cause falls and foot ulcers. Early detection of impaired ankle proprioception is important because it allows physicians to prescribe an exercise program to patients to prevent foot complications.
Methods
Forty-six patients diagnosed as having type 2 diabetes mellitus and 22 control patients were included in the study. Presence of neuropathy was assessed using the Michigan Neuropathy Screening Instrument (MNSI). Level of foot care awareness was determined using the Nottingham Assessment of Functional Footcare (NAFF). Joint position sense was measured using a dynamometer.
Results
Mean absolute angular error (MAAE) values were significantly higher in the neuropathy group compared with the control group (P < .05). Right plantarflexion MAAE values were significantly lower in the group without neuropathy compared with the group with neuropathy (P < .05). No correlation was found between MAAE values (indicating joint position sense) and age, educational level, disease duration, glycemic control, NAFF score, and MNSI history and examination scores in the groups with and without neuropathy (P > .05). Educational level and disease duration were found to be correlated with NAFF scores.
Conclusions
Increased MNSI history scores and increased deficits in ankle proprioception demonstrate that diabetic foot complications associated with reduced joint position sense may be seen at an increased rate in symptomatic patients.
Motivational Interviewing by Podiatric Physicians
A Method for Improving Patient Self-care of the Diabetic Foot
Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes. Despite agreement that diabetic foot self-care is a key factor in prevention of ulcers and amputation, there has only been limited success in influencing these behaviors among patients with diabetes. While most efforts have focused on increasing patient knowledge, knowledge and behavior are poorly correlated. Knowledge is necessary but rarely sufficient for behavior change. A key determinant to adherence to self-care behavior is clinician counseling style. Podiatrists are the ideal providers to engage in a brief behavioral intervention with a patient. Motivational interviewing is a well-accepted, evidence-based teachable approach that enhances self-efficacy and increases intrinsic motivation for change and adherence to treatment. This article summarizes some key strategies that can be employed by podiatrists to improve foot self-care. (J Am Podiatr Med Assoc 101(1): 78–84, 2011)
Background:
We investigated whether a forefoot off-loading postoperative shoe (FOPS) alters standing posture, ankle muscle activity, and static postural sway and whether any effects are altered by wearing a shoe raise on the contralateral side.
Methods:
Posture, ankle muscle activity, and postural sway were compared in 14 healthy participants wearing either a FOPS or a control shoe with or without a contralateral shoe raise. Participants were tested under different sensory and support surface conditions. Additionally, reductions in peak pressure under the forefoot while walking were assessed with and without a contralateral shoe raise to determine whether the FOPS continued to achieve its primary off-loading function.
Results:
Compared with the control condition, wearing a FOPS moved the center of pressure posteriorly, increased tibialis anterior muscle activity, and reduced ankle plantarflexor activity. These changes decreased when a contralateral shoe raise was added. No difference in postural sway was found between footwear conditions. Forefoot peak pressure was always reduced when wearing the FOPS.
Conclusions:
The posterior shift in center of pressure toward and behind the ankle joint axis is believed to result in the increase in tibialis anterior muscle activity that now acts as the primary stabilizer around the ankle. Instability may, therefore, increase in patients with weak tibialis anterior muscles (eg, diabetic neuropathy) who need to wear offloading devices for ulcer management. We suggest that the addition of a contralateral shoe raise fitted with a FOPS may potentially be beneficial in maintaining stability while off-loading the forefoot in this patient group. (J Am Podiatr Med Assoc 103(1): 36–42, 2013)
Background:
We investigated plantar loading asymmetry during gait in American Indians with and without diabetes and with diabetes and peripheral neuropathy.
Methods:
A convenience sample of 96 American Indians with and without diabetes was divided into three groups: 20 with diabetes and peripheral neuropathy, 16 with diabetes without peripheral neuropathy, and 60 with no history of diabetes (control group). Plantar loading was measured during barefoot walking across a pressure platform. Five trials were collected per foot during level walking at a self-selected speed using the two-step method. Asymmetry in peak pressure-time integral and peak plantar pressure were calculated from ten plantar regions and compared among groups.
Results:
Significant pressure-time integral asymmetry occurred across the forefoot regions in American Indians with diabetes and peripheral neuropathy compared with the other two groups. Significant peak plantar pressure asymmetry occurred in the third metatarsal region in both groups with diabetes (with and without peripheral neuropathy) compared with the control group.
Conclusions:
Overall, American Indians with diabetes seemed to show greater asymmetry in plantar loading variables across the forefoot region compared with those in the control group. Specifically, individuals with diabetes and peripheral neuropathy had the greatest amount of forefoot pressure-time integral asymmetry. Significant peak plantar pressure asymmetry occurred in the third metatarsal region of the forefoot in those with diabetes with and without peripheral neuropathy. Loading asymmetry may play a role in the development of foot ulcers in the forefoot region of American Indians with peripheral neuropathy and diabetes. (J Am Podiatr Med Assoc 103(2): 106–112, 2013)
Background:
Metabolic disorders are known to alter the mechanical properties of tendons. We sought to evaluate the prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with type 2 diabetes mellitus (T2DM) without peripheral neuropathy.
Methods:
We recruited 43 patients with T2DM and 40 controls. Neuropathy was excluded with the Michigan Neuropathy Scoring Instrument. Bilateral ultrasonography of the Achilles tendon enthesis was performed.
Results:
Patients with T2DM had a higher prevalence of hypoechogenicity (26.7% versus 2.5%; P = .0001), entheseal thickening (24.4% versus 8.7%; P = .007), and enthesophytes (74.4% versus 57.5%; P = .02). No differences were found in the number of patients with erosions (1.2% versus 0%; P > .99), cortical irregularities (11.6% versus 3.7%; P = .09), bursitis (5.8% versus 3.7%; P = .72), or tears (2.3% versus 1.2%; P > .99). The mean ± SD sum of abnormalities was higher in patients with T2DM (1.5 ± 1.1 versus 0.7 ± 0.6; P < .0001), as was the percentage of bilateral involvement (72.1% versus 45.0%; P = .01). Mean ± SD thickness did not differ between patients and controls (4.4 ± 1.1 mm versus 4.2 ± 0.8 mm; P = .07).
Conclusions:
According to our data, there is an elevated prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with T2DM independent of peripheral neuropathy.
Background:
We developed a prototype of a novel thermochromic liquid crystal (TLC)–coated fabric with an extended temperature range and enhanced sensitivity. By incorporating color and pattern recognition into the fabric, rapid determination of the underlying pedal temperature is facilitated. The purpose of this study was to evaluate the accuracy of the TLC fabric as a potential diagnostic aid for identifying complications in the high-risk foot.
Methods:
The hands of 100 individuals were used to compare the mean maximum temperatures indicated by the fabric versus standard thermal camera images. Findings were statistically analyzed using a paired t test, with significance defined as P < .05.
Results:
Except for the tip of the thumb and regions in the palm, there were no statistically significant differences between mean maximum temperatures measured with the thermal camera and those detected with the TLC fabric. Minor differences were relatively consistent in all nine regions of the hand and were not considered to be clinically significant.
Conclusions:
Using direct visual analysis, we demonstrated that a novel TLC fabric could accurately map temperatures in the palmar surface of the hand. The findings support the continued development of a temperature-sensitive sock that can be used in the home to monitor for temperature changes that may indicate the onset of complications in the high-risk foot.
Background
Foot self-care is key in preventing morbidity in high-risk diabetic patients. Motivational interviewing (MI) is an approach to encourage behavior change by patients that can be used in medical settings. The goal was to explore how podiatric physicians promote self-care in such patients and whether they use MI techniques.
Methods
We conducted a 19-question online survey of US-based practicing podiatric physicians. Most answers were on a 5-point scale. The MI index was the sum of answers to five relevant questions.
Results
Of 843 podiatric physicians, 86% considered foot self-care to be very important for high-risk diabetic patients, and 90% felt that it was their role to discuss foot self-care with them; 49% felt that they had training and were successful in promoting behavior change, but most were definitely (38%) or possibly (46%) interested in learning more. Only 24% of respondents scored at least 15 of 20 on the MI index. Higher MI scores were associated with more face time and more time discussing foot self-care but were not related to podiatric physicians' age, sex, geographic location, percentage of time in surgery, or years in practice. Reported barriers to counseling were lack of reimbursed time and poor patient engagement.
Conclusions
Most podiatric physicians view self-care behavior among high-risk diabetic patients and their role in promoting it as very important; most feel already proficient, but only a few demonstrate MI skills; most are willing to learn more. Success in behavioral counseling, such as MI, is likely to require more time and may be encouraged by a move from fee-for-service to outcome-based reimbursement.
