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April2014 Vol.51 Issue:      2 Table of Contents
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Correlation between Plantar Pressure and Plantar Microcirculation in Diabetic Peripheral Neuropathy Patients

Kadrya H. Battecha1, Waleed T. Mansour2, Gihan M. Ramzy3

Departments of Basic Science1, Neuromuscular Disorders and Its Surgery2; Faculty of Physical Therapy; Neurology3, Faculty of Medicine; Cairo University; Egypt



ABSTRACT

Background: Foot ulceration in patients with diabetic neuropathy is a major health problem, often leading to further complications. However neuropathy by itself is not the only factor responsible for ulceration; other abnormalities associated with this condition such as disturbed peak plantar pressures and impairments in micro-circulation have also been reported to play a crucial role. Objective: This study was done to investigate the effect of plantar pressure on plantar microcirculation in diabetic neuropathy patients. Methods: This study was conducted on two groups: group A (experimental group) consists of forty five patients presented clinically with diabetic peripheral neuropathy and group B (control group) consists of forty five normal subjects. RS scan foot plate system was used to measure the plantar pressure, while laser Doppler flow meter was used to investigate the plantar microcirculation. Results:  between subjects MANOVA showed that there is a significance difference between both groups in plantar pressure and microcirculation under the three studied points. While, Pearson correlation showed that there was a positive correlation between plantar pressure distribution and plantar microcirculation under heel, big toe and little toe in experimental group with no correlation between them in control group. Conclusion: Plantar pressure has an effect on microcirculation and so, it can be considered as one of the essential factors that cause foot ulceration in diabetic polyneuropathic patients. [Egypt J Neurol Psychiat Neurosurg.  2014; 51(2): 249-254

Key words: diabetic neuropathy, plantar pressure, microcirculation

 Correspondence to Kadrya H. Battecha, Department of Physical Therapy, Faculty of Physical Therapy, Cairo University, Egypt. Email: kadryabattechapt@gmail.com






INTRODUCTION

 

Neuropathies are the most common long-term complications of diabetes, affecting up to 50% of patients1.There are many subgroups of neuropathies; but, diabetic peripheral neuropathy (DPN) is the most common of all the diabetic neuropathies that affects up to 50% of older type II diabetic patients2. Patients with diabetes mellitus and peripheral nerve damage are at very high risk for developing neuropathic ulcer on planter surface of their feet that may lead to lower extremity amputation (LEA)3.

The loss of protective sensation secondary to neuropathy is considered an important factor for ulcer occurrence in this population. However neuropathy by itself is not the only factor responsible for ulceration. Other abnormalities associated with this condition such as peak plantar pressures and impairments in micro-circulation have also been reported to play a crucial role4. Diabetes disturbs the autonomic regulation of skin microcirculation, even in the absence of neuropathy.

 

Moreover, sensory diabetic neuropathy mainly affects unmyelinated primary afferent fibers5 and impairs the vasodilatation related to normally functioning unmyelinated C fibers6, 7. Because temperature and blood flow in cutaneous microcirculation are highly correlated8, skin temperature may have a major effect on skin blood flow response to applied pressure. Therefore, it was stated that the skin blood flow response to locally applied pressure would be impaired in diabetic patients because of the combined effects of their typically low skin temperature and diabetes-induced alterations of the vascular and nervous systems4.

Many complications of diabetes as limited joint mobility, foot deformities and abnormal gait result in an altered biomechanical loading of the foot with disturbed sensation on plantar foot pressures (mainly forefoot) and probably increased shear forces9.

Aim of work: This study was conducted to investigate the effect of disturbed plantar pressure on microcirculation in diabetic peripheral neuropathy patients.

 

PATIENTS AND METHODS

 

Study design and population:

This study was conducted on two groups:

Neurophysiologic methods:

 

Group A (experimental group) : consists of forty five patients with diabetic peripheral neuropathy( including 21 males and 24 females), their age ranged from 45-60 years with a mean age of (52.51±4.29 years), their post- prandial glucose level ranged between 150:350 mg/l, and presented clinically as thirty one patients who had sensory symptoms in the form of numbness, burning sensation, glove and stock hypothesia, nine patients with motor symptoms in the form of spasm of foot muscles and muscle weakness of lower limb and 5 patients with mixed sensory and motor symptoms.

Group B (control group): consists of forty five age and sex matched normal subjects (including 22 males and 23 females). Their age ranged from 45-60 years with a mean age of (52.55±4.49 years).

After receiving an extensive explanation about the protocol, all participants gave informed consent to the study. Patients were recruited from the diabetes outpatient clinic in Kasr El-Aini Hospitals while the normal people were selected from the employee of physical therapy faculty.

 

Inclusion criteria:

1. All patients had type II diabetes and suffering from neuropathy especially in lower limb.

2. Duration of illness ranged between 10 years to 15 years of diabetes.

3. All participating patients required being able to walk 10 m unassisted.

 

Exclusion criteria:

All patients were excluded, if they had:

1. Respiratory or cardiac failure, neuropathy of non-diabetic origin, or peripheral vascular      disease.

2. Psychological disorder or tremor.

3.History of pedal ulcer, amputation and/or arthritis of lower limb, Osteoporosis or fractures of any bones of lower limb, gross musculoskeletal problems and significant scar tissue or calluses on the feet.

4. Received any vasodilator drugs.

 

Methods:

Instruments:

1) RS scan foot plate system: It was used to measure the absolute peak pressure under three areas on each foot that were first metatarsophalangeal, fifth metatarsophalangeal and centre of the heel.

 2) Laser Doppler flow meter: The PeriScan System is a Laser Doppler Perfusion Imaging system for non-invasive imaging of superficial tissue blood perfusion10. Laser Doppler perfusion imaging had also been shown to be a reliable method for characterizing microvascular changes in the human skin11.

Procedures:

-      The participants were asked to take off shoes and stand bare feet on the foot mark drawn on the force plate with erect back and straight knees and eyes forward to measure the static plantar pressure.

-      Then measurement of microcirculation (skin blood perfusion) was measured in these three points (big toe, little toe and mid heel) by laser Doppler flow meter instrument.

 

 

Statistical analysis

The data was coded and entered using the statistical package SPSS version 19. The data was summarized using descriptive statistics: mean and standard deviation for quantitative variables. Between subjects MANOVA was used to compare between control and experimental group. Pearson correlation was used to determine the relation between static plantar pressure and microcirculation under the three studied points in both groups.

 

RESULTS

 

A)     Subjects criteria:

 

Subjects’ age ranged from 45-60 years for experimental and control groups with mean of (52.51±4.29 years, 52.55±4.49years respectively), while, subjects’ weights ranged from 75-95 Kg with a mean of (82.86±6.3 Kg, 83±6.83 kg respectively) and heights ranged from160-175 cm with a mean of (166.9±4.69 cm, 167.04±5.04 cm respectively). Between subjects MANOVA showed that there is no significance difference between subjects in both groups at p- value =0.004(Table 1).

 

B)     Comparison of plantar pressure between control and experimental group:

Between subjects MANOVA was used to compare between the mean and SD of plantar pressure under the three studied points and it showed that there is a significance difference between both groups under the heel, big toe and little toe as p- value= 0.000. (Table 2)

 

C)     Comparison of microcirculation between control and experimental group:

There is a significance difference between both groups in microcirculation under the heel, big toe and little toe as shown in Table (3).

 

D)     Correlation between plantar pressure and microcirculation:

A statistically highly significant positive correlation was found between the plantar pressure and microcirculation under big toe, heel and little toe in experimental group (Table4). While there was no correlation was found between them under the three points in control group (Table 5).

 



 

Range

Mean+ SD

P- Value

 

 

Experimental group

Control group

Age(years)

45-60

52.51 ±4.29

52.55 ±4.49

0.96

Weight(kg)

75-95

82.86 ±6.3

83 ± 6.83

0.92

Height(cm)

160-175

166.9 ±4.69

167.04±5.04

0.94

Table 1. Mean &SD of subjects’ criteria of both groups.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2. Between subjects MANOVA of plantar pressure between control and experimental group.

 

Plantar  Pressure

Heel

Big toe

Little toe

 

 

mean±SD

P-value

mean±SD

P-value

mean± SD

Sig.

F

P-value

Experimental group

11.14±1.51

 

0.000٭

10.42±1.82

 

0.000٭

7.71±3.09

 

0.000٭

10.57

 

0.000٭

Control group

8.00±2.06

6.43±1.50

5.12±0.80

*Significant at p<0.01

 

Table 3: Between subjects MANOVA of microcirculation between control and experimental group.

 

 

Microcirculation

Heel

Big toe

Little toe

 

 

mean±SD

P-value

mean±SD

P-value

mean±SD

P-value

F

P

Experimental group

4.28±1.10

 

0.000٭

3.45±1.14

 

0.000٭

3.69±1.30

 

0.000٭

10.57

 

0.000٭

Control group

5.67±1.11

5.24±1.66

5.51±1.47

*Significant at p<0.01

 

Table 4: Correlation between plantar pressure and microcirculation under heel, big toe and little toe in experimental group.

 

Microcirculation

Heel

Big toe

Little toe

 

r

p- value

r

p- value

r

p- value

plantar pressure

 

0.809

0.001٭

0.691

0.001٭

0.861

0.001٭

*Significant at p<0.01

 

Table 5: Correlation between plantar pressure and microcirculation under heel, big toe and little toe in control group.

 

Microcirculation

Heel

Big toe

Little toe

 

r

p- value

r

p- value

r

p- value

plantar pressure

0.109

0.61

0.276

0.09

0.248

0.138

 


 

DISCUSSION

 

Limited joint mobility, foot deformities and abnormal gait result in an altered biomechanical loading of the foot with elevated plantar foot pressures and probably increased shear forces leading to foot ulcer and amputation especially with the presence of neuropathy9.

Previous studies have evaluated activity levels in relationship to ulceration. One of them studied activity in 400 subjects with diabetes and history of ulceration. The subjects who were “least active” (less than 4.5 hours a day of weight-bearing activity) were at most risk for re-ulceration. The subjects who were “most active” (greater than 7.5 hours a day of weight-bearing activity) had significantly reduced risk ofre-ulceration12.

Skin blood flow in response to locally applied pressure might be impaired in diabetic patients because of the combined effects of a typically low skin temperature and alterations in microcirculatory function, and could be worsened by neuropathy13. Previous study indicated that in response to applied local pressure, the skin blood flow over the anklebone decreased significantly from baseline, with much lower applied pressure in diabetic patients without neuropathy (7.5 mmHg) or with subclinical or clinical neuropathy (6.3 mmHg) than in matched control subjects (48.8 mmHg) studied in the same thermal conditions4.

A significant transient increase of skin blood flow was reported during local pressure application in the skin of humans14, 15. Because a skin temperature close to 34°C was considered the optimal temperature for the evaluation of skin vasomotor reflexes in the lower limb, the absence of pressure induced vasodilatation (PIV) in healthy subjects may be attributable to a low skin temperature. This suggests that the nervous receptors involved in the PIV development are mechano-thermal, and not only mechanical16.

Vasodilatation in diabetic subjects is attenuated in response to occlusive ischemia17, local heating to 44°C18, and indirect heating19. The inability of skin microcirculation in diabetic patients to respond normally to injury and even to non-noxious stimulation, such as the local pressure applied in the present study, may be an important factor in the development of ulceration20,21.

It has been shown that an acute glucose load in healthy subjects22 and glycemic dysregulation, such as that found in diabetes23, 24, 25, may lead to impaired vasodilation in both macro- and microcirculation. The PIV mechanism involves both nervous and microvascular tissues, which could be impaired together or separately in diabetes. Cacciatori et al (1997)26 observed that peripheral sympathetic adrenergic and cholinergic fibers undergo early alterations in diabetic patients, even when there is no clinical neuropathy. The dysregulation of skin neurovascular function, largely regulated by peripheral C fiber neurons, may be a component of the metabolic syndrome associated with type II diabetes27. Damage to unmyelinated C fibers in diabetic neuropathy would contribute to abnormalities in cutaneous blood flow28 and impairment of the vasodilatation related to those fibers6, 29.

It could be hypothesized that impairment in the mechanisms of vasodilatation underlying the PIV phenomenon, such as a reduction of release of local vasoactive mediators, may have implications for the pathophysiology of pressure ulcers. It has been shown that the release of neuropeptides, such as calcitonin gene-related peptide (CGRP), is diminished27, 30 and that endothelial-derived NO production is altered in diabetes31, 32.

It was demonstrated that major roles for CGRP and NO (particularly endothelial-derived NO) in PIV development the decreased production of these vasoactive mediators might partially explain the early decrease of skin blood flow at low applied pressures in diabetic patients33.

It was suggested that in individuals with diabetic peripheral neuropathy and diminished vascular status, the high heel-pressure levels commonly observed may result in a selective ulceration of the heel. Possibly, the techniques commonly used for the prevention of forefoot ulcerations, such as special shoes, may prevent heel ulcerations if redesigned to focus on heel-pressure reduction34.

 

Conclusion: There is a relation between the plantar pressure and microcirculation under big toe, heel and little toe in diabetic peripheral neuropathy patients. So this can explain that increase plantar pressure increase the incidence of foot ulcer under these three points due to the deficiency of microcirculation.

 

[Disclosure: Authors report no conflict of interest]

 

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21.    Walmsley D, Wales J, Wiles P. Reduced hyperaemia following skin trauma: evidence for an impaired microvascular response to injury in the diabetic foot. Diabetologia. 1989; 32:736 –9.

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الملخص العربى

دراسة مقارنة بين ضغط القدم والدورةالدموية الدقيقة فى مرضى الاعتلال العصبي السكري

القدم السكرى من المشاكل الرئيسية التى يعانى منها مرضى الأعتلال العصبى السكرى, والذى يؤدى أيضا الى مشاكل أخرى. ولكن التهاب الأعصاب ليس هوالسبب الوحيد للقدم السكرى فبعض العوامل الأخرى المصاحبة لهذا المرض مثل ارتفاع ضغط القدم ونقص الدورة الدموية الجلدية للقدم تلعب دوراهاما فى هذا. ولهذا فان الغرض من هذه الدراسة هودراسة أثرضغط القدم على الدورة الدموية الجلدية للقدم فى مرضىا لأعتلال العصبى السكرى.

خطوات البحث:أجريت هذه الدراسة على تسعين شخصا تم تقسيمهم الى مجموعتين مجموعة الدراسة و تضم خمسة و أربعون مريضا بالأعتلال العصبى السكرى و المجموعة الثانية (المجموعة الضابطة) وتضم خمسة و أربعون شخصا سليما. جميع الأشخاص تم اختيارهم عشوائيا من الجنسين (سبعة و أربعون من النساء, ثلاثة و أربعون من الرجال) وتراوحت أعمارهم بين 45- 60 سنة, و كانت أوزانهم بين 75-95 كيلو جرام  بينما كانت أطوالهم بين  160-175 سنتيميتر. و قد استخدم فى هذه الدراسة جهاز المسح الضوئى للقدم لقياس ضغط القدم و جهاز الليزر دوبلر لقياس الدورة الدموية الجلدية لثلاث نقاط (الكعب, الأصبع الكبير , و الأصبع الصغير).

النتائج: أسفرت النتائج عن أن هناك علاقة ايجابية بين ضغط القدم و الدورة الدموية الدقيقة  تحت الثلاث نقاط فى المجموعة الأولى التى تضم مرضى الأعتلال العصبى السكرى بينما لا توجد علاقة بينهم فى المجموعة الضابطة  . الإستنتاج: نستنتج من هذه الدراسة أن ضغط القدم له تأثير على الدورة الدموية الدقيقة للقدم, ولذلك يمكن وضعه من أهم و أخطر الأسباب و العوامل التى قد تسبب تقرح القدم ( القدم السكرى)  فى مرضى الأعتلال العصبى السكرى.

الكلمات الدالة: الأعتلال العصبى السكرى- ضغط القدم- الدورة الدموية الدقيقة للقدم



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