Review article

Peripheral neuropathy and the diabetic foot

La infección del pie diabético, sobre todo si se asocia a isquemia, es la causa más frecuente de amputación de la extremidad inferior en la población general, de ingreso hospitalario y de disminución de la calidad de vida en los diabéticos. El 15% de los diabéticos van a sufrir a lo largo de su vida una infección del pie, con una incidencia anual del 1-4%, precedida en más del 80% de los casos de una úlcera en el pie. Son infecciones complejas en cuyo pronóstico influyen muchos factores, dependientes de la úlcera (localización, extensión, cronicidad, amputación previa, grado de isquemia) y del paciente (edad, insuficiencia renal, tiempo de evolución de la diabetes, comorbilidad asociada), lo que hay que tener en cuenta a la hora de plantear su tratamiento. Las infecciones deben clasificarse en función de su gravedad (leves, moderadas-leves, moderadas-graves y graves). Su tratamiento es complejo y debe ser multidisciplinar; debe incluir desbridamiento, descarga, antibioticoterapia adecuada, revascularización y cura de la úlcera.

En este documento de consenso, fruto de la colaboración de la Sociedad Española de Angiología y Cirugía Vascular (SEACV), Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Quimioterapia (SEQ), Asociación Española de Cirujanos (AEC), Sociedad Española de Medicina de Urgencias y Emergencias (INFURG-SEMES) y Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), se desarrollan las pautas, basadas en la mejor evidencia disponible, de las infecciones de pie diabético, encaminadas a obtener la mayor eficacia clínica.

Diabetic foot infection, particularly if it is associated to ischaemia, is the most common cause of lower limb amputation, in the general population, of hospital admissions, and a decrease in the quality of life in diabetics. Of all diabetics, 15% of them are going to suffer from a foot infection during their life, with an annual incidence of 1-4%, preceded by a foot ulcer in more than 80% of cases. They are complex infections and the prognosis is influenced by many factors, depending on the ulcer (location, extension, whether chronic or not, previous amputation, ischaemia grade), and the patient (age, renal impairment, time of onset of diabetes, associated comorbidity). All these must be taken into account when establishing its treatment. The infections must be classified according to their severity (mild, moderate-mild, moderate-severe, and severe). Their treatment is complex and must be multidisciplinary and must include debridement, discharge, adequate antibiotic therapy, revascularisation, and treatment of the ulcer.

In this consensus document, produced in collaboration with the Spanish Angiology and Vascular Surgery Society (SEACV), the Spanish Society of Internal Medicine (SEMI), the Spanish Chemotherapy Society (SEQ), the Spanish Surgeons Association (AEC), the Spanish Society of Urgent Medicine and Emergencies (INFURG-SEMES) and the Spanish Society of Intensive and Critical Medicine and Coronary Care (SEMICYUC), the guidelines are developed based on the best available evidence on diabetic foot infections, aimed at achieving greater clinical efficacy.

This study was conducted to examine changes in plantar foot pressure variability, and foot contact time in a client with diabetic neuropathy, following a single massage therapy treatment focused on the lower limbs.

The research was a pre-test post-test case study, in which plantar foot pressure measurements were taken at baseline, and immediately following massage therapy treatment. The participant was purposefully selected from the client pool at Sutherland-Chan School of Massage Therapy, where the research was conducted.

The intervention involved a single massage therapy treatment of 80 min duration, focused on the lower limbs. The techniques applied followed principles as outlined in the standards of practice of the College of Massage Therapists of Ontario, and included Swedish and myofascial techniques, passive stretching, trigger point treatment and mobilization of the joints of the lower limb distal to the knee. Additionally, preparatory hydrotherapy was applied. All techniques were modified in relation to the client's clinical needs and presentation.

Outcome measures were coefficients of variation for mean peak pressures (MPP) for the full foot, the first metatarsophalangeal joint and the hallux; coefficients of variation for the mean value pressure picture (MVP), also for the full foot, the first metatarsophalangeal joint and the hallux; and foot contact time.

A significant increase in the variability of MPP and MVP (greater than 5%) below the hallux was noted. Additionally, there was a significant decrease in contact time (t(7)=58.207; p<0.001) following treatment. Other comparisons were not statistically significant.

The results suggest that the massage therapy intervention utilized increased the variability of pressure below the hallux of a participant with diabetic neuropathy, and also affected gait positively in terms of velocity and fluidity. Although this single case study is a preliminary investigation of the role, massage therapy may play in the management of clients with diabetic neuropathy, the results reflect a potential to improve mobility and reduce the incidence of neuropathic ulceration in the diabetic population.

To review the spectrum of foot problems in patients with diabetes and the underlying etiologic factors.

In this review, the term “diabetic foot disease” (DFD) will be used (previously referred to as simply “diabetic foot”). The relevant anatomy of the foot is discussed, the clinical evaluation and severity of DFD are outlined, and the role of both systemic control and local measures in the management of DFD is addressed.

DFD is linked with a wide variety of etiologic associations, pathologic forms, and clinical severity. The causes of DFD include such factors as diabetic neuropathy, vascular insufficiency, and the presence of underlying bone deformity. The pathologic forms range from superficial skin lesions, soft tissue infections, joint swellings, and deformities to frank necrosis and gangrene. The clinical severity ranges from mild, self-resolving disease to fulminant, rapidly progressive disease that usually eventuates in amputation. The heterogeneity of patients whose illness is grouped collectively under the diagnosis of DFD has contributed to the persisting confusion and controversy regarding the optimal classification system for diabetes-related foot problems and their appropriate management.

Optimal management of DFD involves a multimodality approach directed at regular foot care, blood glucose control, and early recognition of foot problems. Appropriate surgical management, administration of systemic antibiotics, and off-loading techniques are necessary to prevent the progression of DFD. (Endocr Pract. 2006;12:583-592)

It has been shown that high foot pressure in diabetic patients plays a crucial role in plantar ulcer development. The purpose of the study is to analyze the relationship between foot arterial pressures and plantar pressures in diabetic patients with both peripheral neuropathy vascular disease.

We have evaluated the relationship between foot arterial pressures and plantar pressure parameters (Peak Plantar Pressure, Foot-Floor Contact and Plantar Pressure Integral) in eleven diabetic patients with both peripheral neuropathy and peripheral vascular disease. Peripheral neuropathy was defined as a tuning fork score < 4/8 measured at the great toe and internal malleolus with a Tuning fork (Rydel-Seiffer® 128 Hz), the absence of both patellar and ankle reflexes and with a temperature discrimination more than +5 °C (Thermocross®). The peripheral vascular disease (PVD) was evaluated by Doppler technique. Peak Plantar Pressure (PPP) and Foot-Floor Contact (FFC) were measured by Force-Sensing Resistive© (FSR 174©) sensors under the 1^st, 3^rd and 5^th metatarsal heads as well as under the heel and big toe of both feet. The Plantar Pressure Integral (PPI) was defined by the integral of the pressure over the time.

We have found significant relationship between plantar pressure parameters (PPP, FFC, and PPI) under the first metatarsal heads and Doppler arterial pressures of both tibial posterior and dorsalis pedis artery. However, there was no relationship between Doppler arterial pressures and plantar pressure parameters (PPP, FFC, PPI) under 3^rd and 5^th metatarsal heads or under both the heel and the big toe.

According to our results, the peripheral vascular disease could contribute to the elevation of plantar pressures and to the prolonged duration of foot floor contact at each step in diabetic patients with both peripheral neuropathy and peripheral vascular disease. In such patients, severe ischaemia could lead to an increased risk of foot ulceration and consecutive lower extremity amputation.

Relation entre l'artériopathie périphérique des membres inférieurs et les pressions plantaires élevées chez des patients diabétiques avec pieds neuro-ischémiques

Il a été démontré que la pression plantaire élevée chez les patients diabétiques joue un rôle crucial dans le développement des ulcères plantaires. Le but de cette étude est d'analyser la relation entre les pressions artérielles du pied et les pressions plantaires chez les patients diabétiques avec une atteinte artérielle et une neuropathie périphérique.

Nous avons évalué la relation entre la pression artérielle du pied et les pressions plantaires (le pic de la pression plantaire, la durée du contact du pied au sol et l'intégrale de la pression plantaire par la durée du contact au sol) chez 11 patients diabétiques avec pieds neuro-ischémiques. La neuropathie périphérique a été définie par un score de pallesthésie < 4/8 mesuré au gros orteil et à la malléole interne par un diapason gradué (Rydel-Seiffer®_128 Hz) et par l'absence des réflexes rotuliens et achilléens ainsi qu'une discrimination à la chaleur de plus de 5 °C au Thermocross®. L'artériopathie périphérique (PVD) a été évaluée par Doppler. Le pic de la pression plantaire (PPP) et la durée du contact pied-sol (FFC) ont été mesurés à chaque pied par des capteurs FSR 174© (Force-Sensing Resistive© sensors) placés sous la tête des 1^er, 3^e et 5^e métatarsiens, sous le talon et gros orteil. La pression plantaire intégrale a été définie par la surface sous la courbe de la pression plantaire multipliée par la durée du contact au sol (PPI).

Nous avons trouvé une relation significative entre les paramètres des pressions plantaires (PPP, FFC et PPI) sous la tête du 1^er métatarsien et les pressions des artères tibiale postérieure et pédieuse mesurées au Doppler. Il n'y a pas de relation entre les pressions artérielles Doppler et les paramètres de pression plantaire (PPP, FFC et PPI) sous la tête des 3^e et 5^e métatarsiens ou sous le talon et gros orteil.

Selon nos résultats, l'artériopathie périphérique pourrait contribuer à l'élévation des pressions plantaires et à la durée prolongée du contact du pied au sol chez les patients diabétiques avec pieds neuro-ischémiques. Chez de tels patients, une ischémie sévère pourrait conduire à un risque important d'ulcération du pied et secondairement à une amputation de l'extrémité.