The gait features & plantar pressures of people with diabetic peripheral neuropathy & plantar foot ulcers

Fernando, Malindu Eranga (2017) The gait features & plantar pressures of people with diabetic peripheral neuropathy & plantar foot ulcers. PhD thesis, James Cook University.

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Abstract

Diabetes-related foot ulcers (DFUs) are a leading cause of morbidity and mortality worldwide. DFUs have been associated with lower physical, mental and social health that impacts on the overall functioning of individuals. The most significant contributing factor in the onset of DFUs is the development of diabetic peripheral neuropathy (DPN). DPN has been associated with biomechanical alterations in gait and elevated plantar pressures during gait. Although it was previously thought that elevated plantar pressures in the presence of DPN can lead to the development of DFUs, less was known about gait and plantar pressure in people during active ulceration. Therefore, despite international recommendations to offload plantar pressures to prevent the development of DFUs, the offloading requirements during active ulceration were less clearly established. This thesis sought to address this evidence deficiency though examining gait (joint angular kinematics, kinetics and temporal-spatial parameters) and plantar pressures in patients with active DFUs.

The five aims of the research contained in this thesis were: 1) to evaluate what was previously known about the gait and plantar pressure characteristics of people with DPN by performing a systematic review of observational studies; 2) to evaluate whether differences in plantar pressures exist between people with a history of DFUs (active and previous) compared to people with DPN without a history of DFUs by performing a meta-analysis of observational studies; 3) to determine whether available methodology could be used to obtain gait and plantar pressure data with adequate repeatability in people with active DFUs; 4) to prospectively assess whether gait and plantar pressures differ in people with active DFUs in comparison to healthy and diabetes controls without DFUs in a case-control study; and 5) to longitudinally evaluate whether plantar pressures change in people with active DFUs during follow-up compared to diabetes controls without DFUs. A series of studies was undertaken to achieve the above aims.

Overall, the results from the systematic reviews and meta-analyses contained in this thesis suggested that people with DPN have a significantly longer duration of time in the stance phase during walking and exhibit significantly elevated plantar pressures at multiple sites under their feet during walking compared to healthy and diabetes controls without DPN. Meta-analyses of previous observational studies suggested plantar pressures during walking were significantly higher in people with DPN with a history of DFUs compared to controls with DPN without a history of DFUs. However, there was noted to be a high level of heterogeneity and small sample sizes in studies comparing plantar pressures during walking in people with active DFUs compared to controls. The later finding suggested further research was needed regarding plantar pressures in patients with active DFUs. The prospective study on measurement reproducibility demonstrated that important gait and plantar pressure measurements could be reliably acquired in people with DFUs. Nearly all measures contributing to three-dimensional gait assessment and almost all plantar pressure measurements were within predefined acceptable limits.

The prospective case-control study demonstrated that when adjusted for age, sex and body mass index, people with active DFUs had a significantly smaller amount of plantar flexion, knee flexion and pelvic obliquity during walking compared to both control groups. People with active DFUs also had a significantly greater range of anterior-posterior ground reaction force, total vertical ground reaction force, slower walking speed and smaller step length compared to controls. The mean peak plantar pressures and pressure-time integrals measured under the toes and mid-foot during walking in people with DFUs were significantly higher than controls. The stance phase duration was also significantly longer in people with DFUs compared to both control groups. The longitudinal study suggested that when adjusted for age, sex, body mass index and the presence of DPN, patients with DFUs experienced higher mean peak plantar pressures under the toes and mid-foot and higher pressure-time integrals under the hallux, metatarsal 1, the mid-foot and rear-foot during walking, compared to controls, throughout follow-up.

An important and novel finding from the research contained in this thesis was that several gait characteristics were significantly different in people with active DFUs compared to controls. These included distinct joint angular kinematics (angles during the gait cycle) and higher kinetics (vertical and anterior-posterior ground reaction forces) during walking. The main clinical implication of the prospective research contained in this thesis was that plantar pressure offloading should be continued if a DFU develops both during and following an active episode of ulceration. This is on a background of findings from the two meta-analyses suggesting that plantar pressures are likely to be significantly higher in people with DPN prior to ulceration and following ulcer healing.

However, further research is needed to identify the required magnitude and most appropriate method of offloading pressure on the plantar surface of the foot during gait in people with active DFUs. Hence the future focus should be to define how to best: 1) optimize the offloading approach; 2) obtain good offloading adherence; and 3) monitor the appropriateness of offloading in people with DFUs.

(Throughout the Abstract the word 'significant' refers to the result of statistical tests and implies p-values less than 0.05.)

Item ID: 51101
Item Type: Thesis (PhD)
Keywords: biomechanics, diabetes complications, diabetes mellitus, diabetic foot disease, diabetic foot, diabetic neuropathies, diabetic peripheral neuropathy, electromyography, foot ulcer, foot ulceration, gait, locomotion, longitudinal studies, meta-analysis, movement analysis, offloading, peripheral diabetic neuropathy, plantar pressure, plantar ulcers, protocols, reproducibility of results, systematic review, Type 1 diabetes, Type 2 diabetes
Additional Information:

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 2: Fernando, Malindu, Crowther, Robert, Lazzarini, Peter, Sangla, Kunwarjit, Cunningham, Margaret, Buttner, Petra, and Golledge, Jonathan (2013) Biomechanical characteristics of peripheral diabetic neuropathy: a systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure. Clinical Biomechanics, 28 (8). pp. 831-845.

Chapter 3: Fernando, Malindu Eranga, Crowther, Robert George, Pappas, Elise, Lazzarini, Peter Anthony, Cunningham, Margaret, Sangla, Kunwarjit Singh, Buttner, Petra, and Golledge, Jonathan (2014) Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies. PLoS ONE, 9 (6). pp. 1-10.

Chapter 4: Fernando, Malindu Eranga, Crowther, Robert George, Cunningham, Margaret, Lazzarini, Peter Anthony, Sangla, Kunwarjit Singh, and Golledge, Jonathan (2015) Lower limb biomechanical characteristics of patients with neuropathic diabetic foot ulcers: the diabetes foot ulcer study protocol. BMC Endocrine Disorders, 15 (59). pp. 1-11.

Chapter 5: Fernando, Malindu, Crowther, Robert G., Cunningham, Margaret, Lazzarini, Peter A., Sangla, Kunwarjit S., Buttner, Petra, and Golledge, Jonathan (2016) The reproducibility of acquiring three dimensional gait and plantar pressure data using established protocols in participants with and without type 2 diabetes and foot ulcers. Journal of Foot and Ankle Research, 9 (4). pp. 1-12.

Chapter 6: Fernando, Malindu Eranga, Crowther, Robert G., Lazzarini, Peter A., Sangla, Kunwarjit S., Buttner, Petra, and Golledge, Jonathan (2016) Gait parameters of people with diabetes-related neuropathic plantar foot ulcers. Clinical Biomechanics, 37. pp. 98-107.

Chapter 7: Fernando, Malindu E., Crowther, Robert G., Lazzarini, Peter A., Sangla, Kunwarjit S., Wearing, Scott, Buttner, Petra, and Golledge, Jonathan (2016) Plantar pressures are higher in cases with diabetic foot ulcers compared to controls despite a longer stance phase duration. BMC Endocrine Disorders, 16 (51). pp. 1-10.

Chapter 8: Fernando, Malindu E., Crowther, Robert G., Lazzarini, Peter A., Yogakanthi, Saiumaeswar, Sangla, Kunwarjit S., Buttner, Petra, Jones, Rhondda, and Golledge, Jonathan (2017) Plantar pressures are elevated in people with longstanding diabetes-related foot ulcers during follow-up. PLoS ONE, 12 (8). pp. 1-17.

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Date Deposited: 11 Oct 2017 02:53
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1102 Cardiovascular Medicine and Haematology > 110201 Cardiology (incl Cardiovascular Diseases) @ 50%
11 MEDICAL AND HEALTH SCIENCES > 1103 Clinical Sciences > 110318 Podiatry @ 50%
SEO Codes: 92 HEALTH > 9201 Clinical Health (Organs, Diseases and Abnormal Conditions) > 920104 Diabetes @ 50%
92 HEALTH > 9201 Clinical Health (Organs, Diseases and Abnormal Conditions) > 920103 Cardiovascular System and Diseases @ 50%
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