Use of computed tomography and plantar pressure measurement for management of neuropathic ulcers in patients with diabetes.
BACKGROUND AND PURPOSE: Total contact casting is effective at healing neuropathic ulcers, but patients have a high rate (30%-57%) of ulcer recurrence when they resume walking without the cast. The purposes of this case report are to describe how data from plantar pressure measurement and spiral x-ray computed tomography (SXCT) were used to help manage a patient with recurrent plantar ulcers and to discuss potential future benefits of this technology. CASE DESCRIPTION: The patient was a 62-year-old man with type 1 diabetes mellitus (DM) of 34 years' duration, peripheral neuropathy, and a recurrent plantar ulcer. Although total contact casting or relieving weight bearing with crutches apparently allowed the ulcer to heal, the ulcer recurred 3 times in an 18-month period. Spiral x-ray computed tomography and simultaneous pressure measurement were conducted to better understand the mechanism of his ulceration. OUTCOMES: The patient had a severe bony deformity that coincided with the location of highest plantar pressures (886 kPa). The results of the SXCT and pressure measurement convinced the patient to wear his prescribed footwear always, even when getting up in the middle of the night. The ulcer healed in 6 weeks, and the patient resumed his work, which required standing and walking for 8 to 10 hours a day. DISCUSSION: Following intervention, the patient's recurrent ulcer healed and remained healed for several months. Future benefits of these methods may include the ability to define how structural changes of the foot relate to increased plantar pressures and to help design and fabricate optimal orthoses. (+info)
Toxic polyneuropathy of shoe-industry workers. A study of 122 cases.
The toxic polyneuropathy observed in a group of shoe-industry workers in Italy was clinically characterised by a symmetrical prevalently distal motor deficit, with occasional marked weakness of pelvic girdle muscles, and frequently by only subjective sensory symptoms; non-specific disturbances usually preceded neurological signs. Subclinical cases of 'minimal' chronic neuropathy, characterised by alterations of a neurogenic type in the EMG without a reduction of motor nerve conduction velocity, were also observed. Worsening of the clinical picture, with further lowering of nerve conduction velocity, was noted in some cases up to four months after removal from the toxic environment. In the most severe cases clinical recovery took up to three years. The electromyographic and electroneurographic features were consistent with a mixed axonal neuropathy, with clear prevalence of the damage in the distal part of the nerve (dying-back neuropathy). Volatile substances, such as n-hexane and other low boiling point hydrocarbons found in high percentage in solvents and glues, are suggested as the causative agent. (+info)
Acute systematic and variable postural adaptations induced by an orthopaedic shoe lift in control subjects.
A small leg length inequality, either true or functional, can be implicated in the pathogenesis of numerous spinal disorders. The correction of a leg length inequality with the goal of treating a spinal pathology is often achieved with the use of a shoe lift. Little research has focused on the impact of this correction on the three-dimensional (3D) postural organisation. The goal of this study is to quantify in control subjects the 3D postural changes to the pelvis, trunk, scapular belt and head, induced by a shoe lift. The postural geometry of 20 female subjects (X = 22, sigma = 1.2) was evaluated using a motion analysis system for three randomised conditions: control, and right and left shoe lift. Acute postural adaptations were noted for all subjects, principally manifested through the tilt of the pelvis, asymmetric version of the left and right iliac bones, and a lateral shift of the pelvis and scapular belt. The difference in the version of the right and left iliac bones was positively associated with the pelvic tilt. Postural adaptations were noted to vary between subjects for rotation and postero-anterior shift of the pelvis and scapular belt. No notable differences between conditions were noted in the estimation of kyphosis and lordosis. The observed systematic and variable postural adaptations noted in the presence of a shoe lift reflects the unique constraints of the musculoskeletal system. This suggests that the global impact of a shoe lift on a patient's posture should also be considered during treatment. This study provides a basis for comparison of future research involving pathological populations. (+info)
Clinical correlates of plantar pressure among diabetic veterans.
OBJECTIVE: To assess the relationship between diabetes characteristics, medical history, foot deformity, sensory neuropathy, and plantar foot pressure. RESEARCH DESIGN AND METHODS: There were 517 subjects from a cohort of diabetic veterans enrolled in a prospective study of risk factors for foot complications who contributed 1,017 limbs for study. We interviewed subjects to collect data on demographics, diabetes characteristics, and medical history. A research nurse practitioner performed a directed physical exam of the lower extremities, assessing foot deformities and including quantitative sensory testing with a 5.07 monofilament. In-shoe foot-pressure measurements were obtained with F-scan insoles on subjects wearing their own footwear while walking 10 m at their usual pace. RESULTS: In univariate analyses, significant associations were seen between at least one measure of plantar pressure and body mass, sex, race, age, insulin use, certain foot deformities, plantar callus, and sensory neuropathy. Diabetes duration, HbA1c, and history of foot ulcer or amputation were unrelated to plantar pressure. In multiple regression analyses, body mass measured as log (weight), insulin use, white race, male sex, plantar callus, and diabetes duration were significantly related to certain pressures. Foot deformities were related primarily to forefoot pressures. With high pressure at two or more sites defined as the outcome, only body mass remained statistically significant as a predictor of this outcome in a backwards elimination logistic regression model. CONCLUSIONS: High in-shoe plantar pressure in diabetic subjects can be predicted in part from readily available clinical characteristics. The mechanisms by which these characteristics may be related to plantar pressure require further study. (+info)
Change of footwear insulation at various sweating rates.
Moisture inside the footwear can considerably affect the thermal insulation. In this study with a thermal foot model there was simulated three sweat rates (3, 5 and 10 g/h). Five types of footwear with various insulation levels (dry insulation from 0.19 to 0.50 m2. K/W) were tested. The footwear insulation reduction was calculated for 1.5 hour period. The reduction in insulation was related to sweating rate and initial insulation. The footwear with high insulation lost even in percentile more insulation than thin boots under the same conditions (9-19% at 3 g/h, 13-27% at 5 g/h and 19-36% at 10 g/h). A relationship between insulation decrease and sweating rate was established. An 8-hour sweating test (5 g/h) and a test for determining evaporative heat, losses were carried out in addition. The insulation reduction during the first 1.5 hours of the 8-hour test answered for more than half of the total reduction. (+info)
Effects of footwear on measurements of balance and gait in women between the ages of 65 and 93 years.
BACKGROUND AND PURPOSE: Footwear is not consistently standardized in the administration of the Functional Reach Test (FRT), Timed Up & Go Test (TUG), and 10-Meter Walk Test (TMW). This study was conducted to determine whether footwear affected performance on these tests in older women. SUBJECTS: Thirty-five women, aged 65 to 93 years, were recruited from assisted living facilities and retirement communities. METHODS: Each subject performed the FRT, TUG, and TMW wearing walking shoes, wearing dress shoes, and barefooted. Because of space constraints at the facilities where the testing was performed, 22 subjects performed the FRT and TUG on a linoleum floor and 13 subjects performed the tests on a firm, low-pile, carpeted floor. All 35 subjects completed the TMW on a firm, low-pile, carpeted floor. One-way repeated-measures analyses of variance (ANOVAs) and a Tukey Honestly Significant Difference test were used to compare the outcomes for the 3 footwear conditions, with separate ANOVAs conducted for the different floor surfaces for the FRT and TUG. RESULTS: Subjects performed better on the FRT when barefooted or wearing walking shoes compared with when they wore dress shoes, regardless of floor surface. Differences were found among all footwear conditions for the TUG performed on the linoleum floor and for the TMW. For these tests, the women moved fastest in walking shoes, slower barefooted, and slowest wearing dress shoes. CONCLUSION AND DISCUSSION: Footwear should be documented and should remain constant from one test occasion to another when the FRT, TUG, and TMW are used in the clinic and in research. Footwear intervention may improve performance of balance and gait tasks in older women. (+info)
Kinematic synergy adaptation to microgravity during forward trunk movement.
The aim of the present investigation was to see whether the kinematic synergy responsible for equilibrium control during upper trunk movement was preserved in absence of gravity constraints. In this context, forward trunk movements were studied during both straight-and-level flights (earth-normal gravity condition: normogravity) and periods of weightlessness in parabolic flights (microgravity). Five standing adult subjects had their feet attached to a platform, their eyes were open, and their hands were clasped behind their back. They were instructed to bend the trunk (the head and the trunk together) forward by approximately 35 degrees with respect to the vertical in the sagittal plane as fast as possible in response to a tone, and then to hold the final position for 3 s. The initial and final anteroposterior center of mass (CM) positions (i.e., 200 ms before the onset of the movement and 400 ms after the offset of the movement, respectively), the time course of the anteroposterior CM shift during the movement, and the electromyographic (EMG) pattern of the main muscles involved in the movement were studied under both normo- and microgravity. The kinematic synergy was quantified by performing a principal components analysis on the hip, knee, and ankle angle changes occurring during the movement. The results indicate that 1) the anteroposterior position of the CM remains minimized during performance of forward trunk movement in microgravity, in spite of the absence of equilibrium constraints; 2) the strong joint coupling between hip, knee, and ankle, which characterizes the kinematic synergy in normogravity and which is responsible for the minimization of the CM shift during movement, is preserved in microgravity. It represents an invariant parameter controlled by the CNS. 3) The EMG pattern underlying the kinematic synergy is deeply reorganized. This is in contrast with the invariance of the kinematic synergy. It is concluded that during short-term microgravity episodes, the kinematic synergy that minimizes the anteroposterior CM shift is surprisingly preserved due to fast adaptation of the muscle forces to the new constraint. (+info)
Long-term follow-up in diabetic Charcot feet with spontaneous onset.
OBJECTIVE: To assess the long-term results after Charcot breakdown with spontaneous onset in diabetic feet. RESEARCH DESIGN AND METHODS: This study was retrospective. A total of 115 patients (140 feet), 107 with acute deformity and 8 with chronic Charcot deformity, were followed for a median of 48 months (range 6-114). The routine treatment for acute cases was a weight-off regimen with crutches and foot protection with therapeutic shoes until skin temperature had normalized followed by increased weightbearing and the use of bespoke shoes or modification of conventional shoes. RESULTS: The incidence of Charcot deformity was 0.3%/year in the diabetic population investigated. About half of the patients were active in their jobs. Major complications were encountered in 5 (4%) of the patients that required surgical intervention: arthrodesis for unstable malaligned ankles in 3 subjects (1 bilaterally) and major amputation in 2 subjects for unstable ankle and pressure sores. Minor complications were recorded in 43% of subjects: new attacks of Charcot breakdown in 41 patients (36%) and/or foot ulceration in 43 patients (37%) that required minor surgical procedures for 11 patients. All healed except in 2 patients: 1 patient died before the Charcot fractures had healed, and 1 patient died with an unhealed ulcer. No patient lost the ability to walk independently. CONCLUSIONS: Major surgical procedures in only 4% were particularly related to patients with Charcot deformities in the ankle. Minor complications were recorded in about half of the patients. Lifelong foot care is required for diabetic patients with Charcot feet. (+info)