Podiatric Medicine

Emphasis on Diabetic Patients

Karla De La MataDepartment of Biological Sciences

East Stroudsburg University

Spring 2014

Overview

Why feet?

Diabetes Mellitus

Gait Analysis & Plantar Pressure

Case Studies

Conclusion

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Why Feet?...

Amazing podiatric medical schools

Increasing need for Doctors of Podiatric Medicine (DPM)

Expert in the lower extremity

Conservative approach

Option to perform surgeries

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Diabetes is…

Type 1 (juvenile diabetes)- Approximately 10% are affected – not common- Immune system attacks β cells that produce

insulin- Daily administration of insulin required

Type 2 (adult-onset diabetes)- Approximately 90% are affected - Characterized by insulin resistance and/or relative

insulin deficiency ~ due to receptor- Being overweight/obese may play a role

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Facts About Diabetes

Age, family history, and ethnicity play a role in diabetes susceptibility

According to the International Diabetes Federation, there are 382 million people in the world with diabetes; 37 million in North America

By 2035 an estimated 592 million may be affected

North America spends an estimated 263 billion on diabetic care

Global killer – every 7 seconds someone dies

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Is there any good news..?

Many inexpensive and cost-effective interventions exist!

Proven strategies for improving the living environment, changing diet and increasing physical activity can reverse the pandemic.

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Gait Walking is an unconscious effort, but requires symmetry and

reproducible timing

Deviations from normal gait can hint at multiple disease pathologies

Diabetes affects feet through its impact on circulation and sensation a lack thereof leads to complications

Gait analysis studies for patients with diabetes vary

Results can be confusing and contradictory, BUT clear trends emerge

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Gait Analysis Diagram

comprised of 2 phases

A series of “controlled” falls

*point of reference is the right foot*

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Gait: Stance Phasefoot is in contact with the ground

4 Components

1 Heel Contact – R.heel contact, ends with tow off of L.foot

2 Midstance – toe off of L.foot and ends with heel lift of R.foot

3 Active Propulsion – heel lift of R.foot and ends with heel contact of L.foot

4 Passive Propulsion – heel contact of L.foot and ends with toe off of R.foot

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Gait: Swing Phasefoot is NOT grounded

During 2/3 of the stance phase, the opposite leg is in swing phase

1 Acceleration – provides foot clearance away from ground

2 Midswing – swing leg advances through and in front of the stance leg

3 Deceleration – leg in the swing phase must be slowed before heel strike

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Other Points of Analysis

1 Pelvic Tilt

2 Pelvic Rotation

3 Lateral Shift

4 Width of Base

5 Stride Length

6 Step Length

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Plantar Pressure & Gait

Repetitive mechanical stress & loss of protective sensation on the plantar surface of the foot are considered relevant factors in skin breakdown resulting in foot ulcerations…so let’s reduce the peak plantar pressure (PPP)…

Traditional view is that high PPP is bad and low PPP is good…is it this cut and dry ?

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Figure. Medial longitudinal arch functions during stance phase.

Plantar Pressure13

How a Diabetic’s Gait Differs

Decreased walking speed

Decreased step length

Decreased single limb support time

Decreased plantarflexion moments

Decreased step variability

Decreased knee and ankle mobility

Decreased ground reactive forces

Decreased joint angles

Increased width of base

Increased double stance support time

Increased time needed to complete gait cycle

Overall increase in energy expenditure

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Why does it differ?

Research has not confirmed casual relationships between gait and diabetes, but there are suspects – Neuropathy #1

Possible that proprioceptive deficits cause diabetics to walk more carefully

Studies comparing patients with and without diabetes aren’t clear regarding which gait alterations are specific to neuropathy and which affect those without neuropathy

The presence of other factors also impinge on normal gait

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How DPM’s help…

Comprehensive foot care programs reduce amputation rates by 45 – 85%

Use innovative treatments (i.e. HBOT)

Dedicated in executing treatments that are multi-faceted - guidelines must be followed

Podiatry assessments/treatments can be all-inclusive

Amount of research completed and in-progress is impressive

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Case 1: PLANTAR PRESSURE DISTRIBUTION IN DIABETIC NEUROPATHY PATIENTS WITH

A HISTORY OF FOOT ULCERS

Hypothesis: Even with healed ulcers, diabetic neuropathy patients with a history of ulceration would still show an altered distribution of plantar pressure

Method: PP distribution recorded during barefoot gait to avoid influence of compounding factors (i.e. shoes)

CG: n=20 DN: n=17 DNU: n=10

Result: Velocities amongst the 3 groups were NOT significantly different. Peak pressure, especially the pressure-time integral, was different in all groups – highest in DNU sample

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Case 2: EFFECTIVENESS OF INSOLES ON PLANTAR PRESSURE REDISTRIBUTION

Figure. Definitions of foot regions. MTH=metatarsal head

Methods: Analyze gait in non-diabetic control group (n=8) and in a diabetic group (n=7) using various insoles

- Types of Insoles: shoe-only, flat insole, and three contoured insoles (non-weight, semi-weight, and full-weight-bearing)

Result: Insoles are affective! Peak pressure and pressure-time integral were highest in diabetic group. Semi-weight bearing insole was immediately effective.

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Improvements To Be Made

Make gait analysis more accessible and “user-friendly”

Try “ideal approach” when identifying the relationship between plantar pressure and ulceration

Increased patient education

QUESTIONS?...

Thank You!

Bacarin, Tatiana A., Isabel C. Sacco, and Ewald M. Hennig. "Plantar pressure distribution patterns during gait in diabetic neuropathy patients with a history of foot ulcers." Clinics 64.2 (2009): 113-19. Web. 1 Apr. 2014.

Cornwall, Mark W., and Thomas G. McPoil. "Relationship between static foot posture and foot mobility." Journal of Foot and Ankle Research 4.4 (2011): 1-9. Web. 2 Apr. 2014. <http://www.jfootankleres.com/content/pdf/1757-1146-4-4.pdf>.

DeBrule, Michael. "A Closer Look at Gait Analysis in Patients with Diabetes." Podiatry Today 27.3 (2014): 44-50. Web. 1 Apr. 2014. <http://www.podiatrytoday.com/closer-look-gait-analysis-patients-diabetes>.

Goldman, Sari, Devin Poonai, Oendrila Kamal, and Khurram H. Khan. "Emphasizing Proactive Gait Assessment in Patients with Diabetes." Podiatry Today 24.4 (2011): 20-26. Web. 1 Apr. 2014. <http://www.podiatrytoday.com/emphasizing-proactive-gait-assessment-patients-diabetes?page=1>.

Huang, Enoch T., and Javier La Fontaine. "HBOT: Is it worth it for DFU's?" Podiatry Today 27.3 (2014): 78-83. Web. 1 Apr. 2014. <http://www.podiatrytoday.com/point-counterpoint-hbot-it-worthwhile-dfus>.

International Diabetes Federation. N.p., n.d. Web. 16 Mar. 2014. <http://www.idf.org/>.

Khan, Tahir, and Ron Guberman. "Gait alterations associated with diabetic neuropathy." Lower Extremity Review Aug. 2012. Web. 6 Apr. 2014. <http://lowerextremityreview.com/article/gait-alterations-associated-with-diabetic-neuropathy>.

Ko, Mansoo. "Plantar pressure and gait in patients with diabetes." Lower Extremity Review Oct. 2010. Web. 2 Apr. 2014. <http://lowerextremityreview.com/article/plantar-pressure-and-gait-in-patients-with-diabetes>.

Liu, Rui, Ling Li, Mengliu Yang, Guenther Boden, and Gangyi Yang. "Systemic Review of the Effectiveness of Hyperbaric Oxygenation Therapy in the Management of Chronic Diabetic Foot Ulcers." Mayo Clinic 88.2 (2013): 166-75. Web. 6 Apr. 2014.

Normal and Abnormal Gait Series. YouTube, 2013. Web. 1 Apr. 2014. <http://www.youtube.com/watch?v=VYVyoFdJHdU>.

Tsung, Bonne, Ming Zhang, Arthur Mak, and Margaret Wong. "Effectiveness of insoles on plantar pressure redistribution." Journal of Rehabilitation Research & Development 41.6A (2004): 767-73. Web. 1 Apr. 2014.

Wu, Stephanie C., Vickie R. Driver, James S. Wrobel, and David G. Armstrong. "Foot ulcers in the diabetic patient, prevention and treatment." Vascular Health and Risk Management 3.1 (2007): 65-76. Web. 20 Apr. 2014. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994045/>.

REFERENCES