Plantar pressures in diabetic patients with foot ulcers which have remained healed

NewsBot · Nov 26, 2009

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Plantar pressures in diabetic patients with foot ulcers which have remained healed.
Owings TM, Apelqvist J, Stenström A, Becker M, Bus SA, Kalpen A, Ulbrecht JS, Cavanagh PR.
Diabet Med. 2009 Nov;26(11):1141-6.

Aims The recurrence of foot ulcers is a significant problem in people with diabetic neuropathy. The purpose of this study was to measure in-shoe plantar pressures and other characteristics in a group of neuropathic patients with diabetes who had prior foot ulcers which had remained healed.

Methods This was an epidemiological cohort study of patients from diabetes clinics of two Swedish hospitals. From a database of 2625 eligible patients, 190 surviving patients with prior plantar ulcers of the forefoot (hallux or metatarsal heads) caused by repetitive stress were identified and 49 patients agreed to participate. Barefoot and in-shoe plantar pressures were measured during walking. Data on foot deformity, activity profiles and self-reported behaviour were also collected.

Results Mean barefoot plantar peak pressure at the prior ulcer site (556 kPa) was lower than in other published series, although the range was large (107-1192 kPa). Mean in-shoe peak pressure at this location averaged 207 kPa when measured with an insole sensor. Barefoot peak pressure only predicted approximately 35% of the variance of in-shoe peak pressure, indicating variation in the efficacy of the individual footwear prescriptions (primarily extra-depth shoes with custom insoles).

Conclusions We propose that the mean value for in-shoe pressures reported in these patients be used as a target in footwear prescription for patients with prior ulcers. Although plantar pressure is only one factor in a multifaceted strategy to prevent ulcer recurrence, the quantitative focus on pressure reduction in footwear is likely to have beneficial effects
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Admin2 · Nov 26, 2009

Related:
Other threads tagged with diabetic foot biomechanics
Other threads tagged with plantar pressures

NewsBot · Jul 11, 2012

Pedographic classification and ulcer detection in the diabetic foot.
Waldecker U.
Foot Ankle Surg. 2012 Mar;18(1):42-9.

BACKGROUND:
Plantar pressure is a cause of foot ulceration in diabetes. Attempts to determine a pressure threshold have failed. The aim of this study was to determine a pedographic classification to identify patients at risk for a foot ulcer.

METHODS:
210 diabetics and controls categorized into 4 groups with deformities of the forefoot were analyzed. For the pedographic measurement peak pressure, force and their integrals were analyzed using a percentage and an anatomic mask. A multivariant logistic regression analysis was performed.

RESULTS:
Logistic regression analysis using pedographic variables of a percentage mask revealed a combination of 4 variables (pressure time integral forefoot, peak pressure midfoot, pressure time integral heel, and peak pressure heel) identifying the foot ulcer with a sensitivity of 73% and a specificity of 87%. The analysis using an anatomic mask identified 8 variables (pressure time integral mask 4 (metatarsal 2), force mask 9 (2. toe), force time integral mask 8 (great toe), peak pressure mask 6 (metatarsal 4), pressure time integral mask 6 (metatarsal 4), peak pressure mask 8 (great toe), peak pressure mask 7 (metatarsal 5), and force mask 6 (metatarsal 4)) that characterized a pedal ulcer with a sensitivity of 95% and a specificity of 90%.

CONCLUSION:
This screening method identifies diabetics who are at risk for a foot ulcer.
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NewsBot · Aug 31, 2013

Risk Factors Correlated with Plantar Pressure in Chinese Patients with Type 2 Diabetes.
Qiu X, Tian DH, Han CL, Chen W, Wang ZJ, Mu ZY, Li X, Liu KZ.
Diabetes Technol Ther. 2013 Aug 28.

Background: Plantar pressure is a key factor for predicting ulceration in the foot of a diabetes patient.

Subjects and Methods: We recruited a group of 100 Chinese patients with type 2 diabetes and an age-, sex-, weight-, and height-matched group of 100 Chinese subjects without diabetes. We obtained plantar pressure data using a Footscan® gait system (RsScan International, Olen, Belgium) when the subjects with and without diabetes walked barefoot across a sensor platform. We recorded the maximum force, maximum pressure, impulse, pressure-time integral, and loading rate from 10 regions of the foot. We collected the data of 11 history-based variables, 10 anthropometric variables, and three metabolic variables regarding the clinical characteristics of the diabetes patients.

Results: Weight was identified as a determining factor for high plantar pressure. Height, the Neuropathy Symptom Score (NSS), and ankle-brachial index (ABI) were correlated positively with plantar pressure measurements, respectively. The sex, history of ulcer and callus, intima-media membrane of the lower limb blood vessels, and fasting blood glucose (FBG) could also explain a portion of the variability of the plantar pressure measurements. However, the correlations were low or weak.

Conclusions: High plantar pressure in diabetes patients could be predicted, in part, based on weight, height, NSS, ABI, sex, history of ulcer and callus, intima-media membrane of the lower limb blood vessels, and FBG. Therefore, interventions should be taken specifically before high plantar pressure emerges.
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NewsBot · Oct 16, 2013

Plantar Pressure Distribution Patterns of Individuals with Prediabetes in Comparison with Healthy Individuals and Individuals with Diabetes.
Robinson CC, Balbinot LF, Silva MF, Achaval M, Zaro MA.
J Diabetes Sci Technol. 2013 Sep 1;7(5):1113-1121.

BACKGROUND:
Since elevated mechanical stress along with loss of plantar protective sensation are considered relevant factors in skin breakdown resulting in diabetic foot ulcerations, the assessment of plantar pressure is important for the prevention of diabetic foot complications. Prediabetes subjects are at risk of chronic hyperglycemia complications, among them neuropathy, but information about plantar loading in this population is not available. We aimed to compare baropodometric parameters of individuals with prediabetes versus healthy persons and persons with diabetes mellitus (DM).
METHODS:
Baropodometric data from 73 subjects (15 with prediabetes (pre-DM), 28 with type 2 DM, 30 healthy) aged between 29 and 69 years of both genders were registered through a pressure platform with self-selected gait speed and first-step protocol. Peak plantar pressure, stance time, percentage of contact time, percentage of contact area and pressure-time integral were assessed in five plantar foot regions: heel, midfoot, metatarsals, hallux, and toes 2 to 5. Groups were compared by one-way analysis of variance with Scheffé post hoc (α = 0.05).
RESULTS:
Age, body mass index, gender, and arch height index did not differ between groups. Pre-DM and DM subjects presented increased peak pressure and pressure-time integral in metatarsals (p = .010; p > .001), as well as increased percentage of contact time in midfoot (p = .006) and metatarsals (p = .004) regions when compared with healthy subjects. Stance time was significantly higher (p = .017) in DM subjects.
CONCLUSIONS:
Pre-DM subjects seem to exhibit an altered plantar pressure distribution pattern similar to that often found in DM subjects
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NewsBot · Nov 29, 2013

Classification of forefoot plantar pressure distribution in persons with diabetes: a novel perspective for the mechanical management of diabetic foot?
Deschamps K, Matricali GA, Roosen P, Desloovere K, Bruyninckx H, Spaepen P, Nobels F, Tits J, Flour M, Staes F.
PLoS One. 2013 Nov 22;8(11):e79924. doi: 10.1371/journal.pone.0079924.

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.
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NewsBot · Feb 4, 2015

Predictors of Barefoot Plantar Pressure during Walking in Patients with Diabetes, Peripheral Neuropathy and a History of Ulceration.
Barn R, Waaijman R, Nollet F, Woodburn J, Bus SA.
PLoS One. 2015 Feb 3;10(2):e0117443. doi: 10.1371/journal.pone.0117443.

OBJECTIVE:
Elevated dynamic plantar foot pressures significantly increase the risk of foot ulceration in diabetes mellitus. The aim was to determine which factors predict plantar pressures in a population of diabetic patients who are at high-risk of foot ulceration.
METHODS:
Patients with diabetes, peripheral neuropathy and a history of ulceration were eligible for inclusion in this cross sectional study. Demographic data, foot structure and function, and disease-related factors were recorded and used as potential predictor variables in the analyses. Barefoot peak pressures during walking were calculated for the heel, midfoot, forefoot, lesser toes, and hallux regions. Potential predictors were investigated using multivariate linear regression analyses. 167 participants with mean age of 63 years contributed 329 feet to the analyses.
RESULTS:
The regression models were able to predict between 6% (heel) and 41% (midfoot) of the variation in peak plantar pressures. The largest contributing factor in the heel model was glycosylated haemoglobin concentration, in the midfoot Charcot deformity, in the forefoot prominent metatarsal heads, in the lesser toes hammer toe deformity and in the hallux previous ulceration. Variables with local effects (e.g. foot deformity) were stronger predictors of plantar pressure than global features (e.g. body mass, age, gender, or diabetes duration).
CONCLUSION:
The presence of local deformity was the largest contributing factor to barefoot dynamic plantar pressure in high-risk diabetic patients and should therefore be adequately managed to reduce plantar pressure and ulcer risk. However, a significant amount of variance is unexplained by the models, which advocates the quantitative measurement of plantar pressures in the clinical risk assessment of the patient.
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NewsBot · Apr 11, 2015

Plantar Loading Reflects Ulceration Risks of Diabetic Foot with Toe Deformation.
Lu YC, Mei QC, Gu YD
Biomed Res Int. 2015;2015:326493

Diabetes has been one of the most common chronic diseases all over the world. The purpose of this study was to quantitatively assess the foot loading characteristics of diabetic patients with fifth-toe deformity through a comparative analysis with diabetic patients with healthy and normal feet. Six neuropathic diabetic female subjects with the fifth-toe deformation and six age-matched neuropathic diabetic controls without any feet deformities participated in the walking test. Dynamic barefoot plantar pressure was measured with Novel EMED force plate. Peak pressure and pressure-time integral for all 7 foot regions (rearfoot, midfoot, lateral forefoot, central forefoot, medial forefoot, great toe, and other toes) were collected. Peak pressure was significantly higher in the patients with toe deformity in rearfoot, central forefoot, and great toe regions compared with the control group. Meanwhile, loading sustaining period extended longer in great toe region of deformed group than in that of the control group, and the center of pressure was nearly in the big toe region during toe offstage. Diabetic patients with fifth-toe deformity could have plantar contact area reduction in the other toes part and increased loading to the great toe part. The result showed that fifth-toe deformity was associated with potential ulceration risk especially in hallux region.
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NewsBot · May 23, 2015

Evaluation of plantar pressure and force in diabetes using Tekscan F-Scan in-shoe foot force and gait analysis system
Ie Byung Park, Soojung Lee, Suneung Kim & Gyucheol Han
Endocrine Abstracts (2015) 37 EP532

Background: Evaluation of plantar pressure is useful for detecting functional abnormality of foot, especially in diabetic patients. The aim of this study was to evaluate plantar pressure and force in diabetic patients using Tekscan F-Scan in-shoe foot force and gait analysis system.

Methods: Plantar pressure and force were measured by selecting an area of interest under the six areas of the foot: hallux, first metatarsal, second metatarsal, 3–5 metatarsal, midfoot and heel based on previous reports. 65 diabetic patients and age-matched 25 controls were enrolled. Mean age of diabetic patients was 58.4±8.2 years, diabetic duration 8.39±5.26 years, and mean HbA1c 7.7±1.3%, and female 43.1% (28/65). Of the included 65 patients, 16 had diabetic polyneuropathy (DPN), 12 had cardiac autonomic neuropathy (CAN), 31 were without CAN, and 18 had inconclusive tests.

Results: Contact area distribution in diabetics were higher tendency than those in controls. Maximum force distribution was different between two group nearly all areas of foot, especially second metatarsal (109.4 N in DM vs 72.2 N in control, P<0.001) and condyle (307.4 N in DM vs 236.9 N in control, P<0.001). Pressure average distribution were similar differences between two groups. Right-to-left foot unbalancing of force and pressure in diabetics were showed compared with controls.

Conclusion: Evaluation of plantar pressure is useful for diabetic foot abnormalities. Plantar force and pressure distributions in diabetics are higher than those in controls, especially, in second metatarsal and condyle area. This method may be useful to detect diabetic foot and ulcerative disease early.
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NewsBot · Jun 19, 2015

Variation of plantar pressure in Chinese diabetes mellitus.
Yang C et al
Wound Repair Regen. 2015 Jun 17

To investigate dynamic changes in plantar pressure in Chinese diabetes mellitus patients and to provide a basis for further preventing diabetic foot. This is a cross-sectional investigation including 649 Chinese diabetes mellitus patients (diabetes group) and 808 "normal" Chinese persons (non-diabetes group) with normal blood glucose levels. All the subjects provided a complete medical history and underwent a physical examination and a 75g oral glucose tolerance test. All subjects walked barefoot with their usual gait, and their dynamic plantar forces were measured using the one-step method with a plantar pressure measurement instrument; 5 measurements were performed for each foot. No significant differences were found in age, height, body weight, or body mass index between the two groups. The fasting blood glucose levels, plantar contact time, maximum force, pressure-time integrals and force-time integrals in the diabetes group were significantly higher than those in the non-diabetes group (p<0.05). However, the maximum pressure was significantly higher in the non-diabetes group than in the diabetes group (p<0.05). No difference was found in the contact areas between the two groups (P>0.05). The maximum plantar force distributions were essentially the same, with the highest force found for the medial heel, followed by the medial forefoot and the first toe. The peak plantar pressure was located at the medial forefoot for the non-diabetes group and at the hallucis for the diabetes group. In the diabetes group, the momentum in each plantar region was higher than that in the non-diabetes group; this difference was especially apparent in the heel, the lateral forefoot and the hallucis. The dynamic plantar pressures in diabetic patients differ from those in non-diabetic people with increased maximum force and pressure, a different distribution pattern and significantly increased momentum, which may lead to the formation of foot ulcers.
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NewsBot · Jun 12, 2019

Prediction of Peak Plantar Pressure for Diabetic Foot: The Regressional Model
AimeshHazariaArunMaiyaaIoannisAgourisbAshmaMonteirocShivashankarad
The Foot; 6 June 2019

Background
The increase in peak plantar pressure could be the most important etiological factor for pathogenesis of a Diabetic Foot. Thus the fate of a diabetic foot syndrome which is a clinical triad of neurological, vascular and musculoskeletal changes could be biomechanically predictive and preventive using clinical parameters. In the presence of peripheral neuropathy, certain clinical parameters could be severely altered resulting into increased peak plantar pressure. Therefore the aim of the study was to identify the most important clinical parameters for the prediction of peak plantar pressure between neuropathy and non-neuropathy type 2 diabetes mellitus participants.

Methodology
A total of 380 participants were recruited under the study and divided into two groups (190 each group). The cross-sectional study was conducted at Kasturba Hosipal, Manipal, India. Multiple regression analysis was performed to find the hyperplane of best fit. Stepwise regression was performed with (α entry = .15 and α removal = .2) to select the best subset of predictors.

Results
Adjusted R2 of the final model which included the predictors showed 90.8% variability for the dependent variable.

Conclusion
The findings from the regression analysis and suggested model was found be strongly significant in predicting the peak plantar pressure between neuropathy and non-neuropathy type 2 diabetes mellitus participants. Since higher values of peak plantar pressure is strongly associated with risk for future diabetic foot complications, it could be suggested that these clinical parameters could be very useful to assess and should be used in routine clinical practice very effectively.
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NewsBot · Sep 11, 2019

The insole materials influence the plantar pressure distributions in diabetic foot with neuropathy during different walking activities
MuhammadNoumanaTulayaDissaneewatebWipawanLeelasamranbSurapongChatpuna
Gait & Posture; 5 September 2019

Highlights
•The energy return is higher with CMI-B, especially at the midfoot and hindfoot.
•The maximum peak plantar pressure with CMI-B decreased, especially at the forefoot.
•The effective reduction occurred at the forefoot region when using CMI-B.
•The hallux showed a maximum increase in the contact area with CMI-B.
•The COP is lessened to the forefoot region and more centered to the midfoot with CMI-B.
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Background
Abnormal peak plantar pressure in neuropathic diabetic foot during walking activities is well managed through the use of appropriate design and material selection for the fabrication of custom made insoles (CMI). The redistribution of plantar pressure is possible by selecting an appropriate material for the fabrication of CMI. The walking activities may alter the plantar pressure distribution; which may differ while using CMI with different materials.

Objective
The objective of the study was to evaluate the effectiveness of CMI’s materials on plantar pressure distribution during different walking activities, in diabetic feet with neuropathy.

Methods
The study was conducted on sixteen diabetic neuropathic subjects. The subjects were provided with two types of CMI; CMI-A (Plastazote® and microcellular rubber) and CMI-B (Multifoam, Plastazote® and microcellular rubber). Maximum peak plantar pressure and plantar pressure distribution were determined by Pedar-X® sensor insole during level walking, ramp walking and stair walking.

Results
The CMI-B lessened the maximum peak plantar pressure from the forefoot throughout the walking activities compared to CMI-A. The contact area was observed as lower using CMI-A compared to CMI-B, while performing walking activities.

Conclusion
CMI-B, with multifoam as an additional top layer, provided more effective peak plantar pressure reduction at forefoot and it had better plantar pressure distribution compared to CMI-A during level walking and ramp ascending in diabetic foot with neuropathy.
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NewsBot · Dec 9, 2020

In-shoe pressure thresholds for people with diabetes and neuropathy at risk of ulceration: A systematic review
Petra Jones et al
J Diabetes Complications. 2020 Nov 26

Introduction: In-shoe pressure thresholds play an increasingly important role in the prevention of diabetes-related foot ulceration (DFU). The evidence of their effectiveness, methodological consistency and scope for refinement are the subject of this review.

Methods: 1107 records were identified (after duplicate removal) based on a search of five databases for studies which applied a specific in-shoe pressure threshold to reduce the risk of ulceration. 37 full text studies were assessed for eligibility of which 21 were included.

Results: Five in-shoe pressure thresholds were identified, which are employed to reduce the risk of diabetes-related foot ulceration: a mean peak pressure threshold of 200 kPa used in conjunction with a 25% baseline reduction target; a sustained pressure threshold of 35 mm Hg, a threshold matrix based on risk, shoe size and foot region, and a 40-80% baseline pressure reduction target. The effectiveness of the latter two thresholds have not been assessed yet and the evidence for the effectiveness of the other in-shoe pressure thresholds is limited, based only on two RCTs and two cohort studies.

Conclusions: The heterogeneity of current measures precludes meta-analysis and further research and methodological standardisation is required to facilitate ready comparison and the further development of these pressure thresholds.
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NewsBot · Feb 28, 2022

Site-Specific, Critical Threshold Barefoot Peak Plantar Pressure Associated with Diabetic Foot Ulcer History: A Novel Approach to Determine DFU Risk in the Clinical Setting
Caroline A Abbott et al
Medicina (Kaunas). 2022 Jan 21;58(2):166

Background and Objectives: Barefoot peak plantar pressures (PPPs) are elevated in diabetes patients with neuropathic foot ulcer (DFU) history; however, there is limited reported evidence for a causative link between high barefoot PPP and DFU risk. We aimed to determine, using a simple mat-based methodology, the site-specific, barefoot PPP critical threshold that will identify a plantar site with a previous DFU. Materials and Methods: In a cross-sectional study, barefoot, site-specific PPPs were measured with normal gait for patients with DFU history (n = 21) and healthy controls (n = 12), using a validated carbon footprint system. For each participant, PPP was recorded at twelve distinct plantar sites (1st-5th toes, 1st-5th metatarsal heads (MTHs), midfoot and heel), per right and left foot, resulting in the analysis of n = 504 distinct plantar sites in the diabetes group, and n = 288 sites in the control group. Receiver operator characteristic curve analysis determined the optimal critical threshold for sites with DFU history. Results: Median PPPs for the groups were: diabetes sites with DFU history (n = 32) = 5.0 (3.25-7.5) kg/cm2, diabetes sites without DFU history (n = 472) = 3.25 (2.0-5.0) kg/cm2, control sites (n = 288) = 2.0 (2.0-3.25) kg/cm2; (p < 0.0001). Diabetes sites with elevated PPP (>6 kg/cm2) were six times more likely to have had DFU than diabetes sites with PPP ≤ 6 kg/cm2 (OR = 6.4 (2.8-14.6, 95% CI), p < 0.0001). PPP > 4.1 kg/cm2 was determined as the optimal critical threshold for identifying DFU at a specific plantar site, with sensitivity/specificity = 100%/79% at midfoot; 80%/65% at 5th metatarsal head; 73%/62% at combined midfoot/metatarsal head areas. Conclusions: We have demonstrated, for the first time, a strong, site-specific relationship between elevated barefoot PPP and previous DFU. We have determined a critical, highly-sensitive, barefoot PPP threshold value of >4.1 kg/cm2, which may be easily used to identify sites of previous DFU occurrence and, therefore, increased risk of re-ulceration. This site-specific approach may have implications for how high PPPs should be investigated in future trials.
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