Does Self-Reported Postural Instability Correspond with Objective Measures of Balance in Patients with Diabetic Neuropathy?

Postural Instability (PI) is common in patients with diabetic peripheral neuropathy (DPN) and is the strongest predictor of depression and non-adherence to foot ulcer treatment. However, as PI was assessed by self-report in PREVIOUS studies, some have challenged the accuracy of self-report in capturing PI. We therefore compared the quantified PI measures during walking to patients’ perception of their own unsteadiness, as measured with 2 item scale from the NeuroQoL questionnaire (alpha=.87). During walking, PI was quantified by the maxima and range of motion of the centre-of-mass and temporal spatial measures of step length, width and walking speed. Fifteen individuals with diabetes and no DPN (D: 56±2yrs, 78±3kg, 1.70±0.02m, 10:5 [M:F], Vibration Perception Thershold (VPT) 25) and 19 controls without diabetes (C: 56±2yrs, 79±3kg, 1.72±0.02m, 13:6 [M:F], VPT<25). Group N reported poorer balance than group C on NeuroQoL (D:10, N:6, C:10; [score/10]; p<0.05), and perception of balance correlated with individual vibration perception thresholds (r=0.6, p=<0.001). Group N walked slower (D:1.5, N:1.2, C:1.5; [m/s]; p<0.05) with shorter step lengths (D:73, N:65, C:77; [cm]; p<0.05), both variables also correlated with NeuroQoL perception of balance (r=0.6, p<0.001). Anterior range of motion for the centre of mass was also decreased in group N (D: 92, N:83, C:94; [cm]; p<0.05). Shortening step length is a commonly observed trait of patients with physiological weakness in walking. Shorter step length also explains the slower speed and a smaller range of motion of the centre of mass. As these parameters significantly correlate with individuals’ perception of balance, more research is needed to determine whether self-reported postural instability prompts individuals to walk slower, thereby contributing to balance control

A randomised feasibility study of serial magnetic resonance imaging to reduce treatment times in Charcot neuroarthropathy in people with diabetes (CADOM): A protocol

Background Charcot neuroarthropathy is a complication of peripheral neuropathy associated with diabetes which most frequently affects the lower limb. It can cause fractures and dislocations within the foot, which may progress to deformity and ulceration. Recommended treatment is immobilisation and offloading, with a below knee non-removable cast or boot. Duration of treatment varies from six months to more than one year. Small observational studies suggest that repeated assessment with Magnetic Resonance Imaging improves decision making about when to stop treatment, but this has not been tested in clinical trials. This study aims to explore the feasibility of using serial Magnetic Resonance Imaging without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot. A nested qualitative study aims to explore participants’ lived experience of Charcot neuroarthropathy and of taking part in the feasibility study. Methods We will undertake a two arm, open study, and randomise 60 people with a suspected or confirmed diagnosis of Charcot neuroarthropathy from five NHS, secondary care multidisciplinary Diabetic Foot Clinics across England. Participants will be randomised 1:1 to receive Magnetic Resonance Imaging at baseline and remission up to 12 months, with repeated foot temperature measurements and x-rays (standard care plus), or standard care plus with additional three-monthly Magnetic Resonance Imaging until remission up to 12 months (intervention). Time to confirmed remission of Charcot neuroarthropathy with off-loading treatment (days) and its variance will be used to inform sample size in a full-scale trial. We will look for opportunities to improve the protocols for monitoring techniques and the clinical, patient centred, and health economic measures used in a future study. For the nested qualitative study, we will invite a purposive sample of 10-14 people able to offer maximally varying experiences from the feasibility study to take part in semi-structured interviews to be analysed using thematic analysis. Discussion The study will inform the decision whether to proceed to a full-scale trial. It will also allow deeper understanding of the lived experience of Charcot neuroarthropathy, and factors that contribute to engagement in management and contribute to the development of more effective patient centred strategies. Trial registration ISRCTN, ISRCTN, 74101606. Registered on 6 November 2017, http://www.isrctn.com/ISRCTN74101606?q=CADom&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-searc

Patient and provider perspective of smart wearable technology in diabetic foot ulcer prevention : a systematic review

Background and Objectives: Smart wearable devices are effective in diabetic foot ulcer (DFU) prevention. However, factors determining their acceptance are poorly understood. This systematic review aims to examine the literature on patient and provider perspectives of smart wearable devices in DFU prevention. Materials and Methods: PubMed, Scopus, and Web of Science were systematically searched up to October 2021. The selected articles were assessed for methodological quality using the quality assessment tool for studies with diverse designs. Results: A total of five articles were identified and described. The methodological quality of the studies ranged from low to moderate. Two studies employed a quantitative study design and focused on the patient perspective, whereas three studies included a mixed, quantitative/qualitative design and explored patient or provider (podiatrist) perspectives. Four studies focused on an insole system and one included a smart sock device. The quantitative studies demonstrated that devices were comfortable, well designed and useful in preventing DFU. One mixed design study reported that patients did not intend to adopt an insole device in its current design because of malfunctions, a lack of comfort. and alert intrusiveness, despite the general perception that the device was a useful tool for foot risk monitoring. Two mixed design studies found that performance expectancy was a predictor of a podiatrist’s behavioural intention to recommend an insole device in clinical practice. Disappointing participant experiences negatively impacted the podiatrists’ intention to adopt a smart device. The need for additional refinements of the device was indicated by patients and providers before its use in this population. Conclusions: The current evidence about patient and provider perspectives on smart wearable technology is limited by scarce methodological quality and conflicting results. It is, thus, not possible to draw definitive conclusions regarding acceptability of these devices for the prevention of DFU in people with diabetes

Neuropathy-Related Unsteadiness and Psychosocial Outcomes in Diabetes—Preliminary Findings

Diabetes is a well-established risk factor for psychological distress and reduced quality of life (QoL). This may be part due to biomechanical challenges posed by diabetic peripheral neuropathy (DPN)-related unsteadiness leading to increased risk of falling and reduced physical activity (PA). This cross-sectional study explores relationships between physical (DPN-unsteadiness and PA) and psychosocial outcomes (depression, fear of falling [FoF], and QoL). The preliminary results of 15 type 2 DM people with DPN (age: 67 years; 13M; VPT 24V) indicate that quality of life (NeuroQoL) and depression (Hospital Anxiety and Depression Scale) are strongly associated with objective DPN-unsteadiness (Berg Balance test: r=-.64, p=.01 and r=.63, p=.01; respectively) and FoF (Falls Self-Efficacy Scale: r=.61, p=.02 and r=-.55 p=.03; respectively). Moreover, DPN-unsteadiness (Berg balance score: 47 ±6) and FoF are associated with reduced vigorous exercise PA levels (r=.53, p=.04 and r=-.51, p=.05; respectively), as well as total moderate PA levels (r=-.45, p=.09 and r=.45, p=.09; respectively); measured by General Practice Assessment Questionnaire. Finally, FoF correlates strongly with DPN-unsteadiness (r=-0.79, p<0.001), demonstrating a potential reason why balance impairment may have the negative impact upon PA and QoL. Whilst prospective data are needed to solidify these findings, the preliminary results are robust and support the strong links between the biomechanical impact of DPN and psychosocial outcomes, including depression and fear of falling, and reduced QoL. These data indicate that there is an unmet need for the development of multifaceted interventions that address both psychological distress and biomechanical challenges experienced by patients with this debilitating complication of diabetes

Increasing Patient Involvement in the Diabetic Foot Pathway: A Pilot Randomised Controlled Trial

Aims&nbsp; This pilot study aimed to explore whether the use of an intervention to increase shared decision-making (Decision Navigation) increased decision self-efficacy and foot-treatment adherence in patients with a diabetic foot ulcer.&nbsp; Methods&nbsp; Fifty-six patients with a diabetic foot ulcer were randomized to receive Decision Navigation (N= 30) or usual care (N= 26). Primary outcomes included decision self-efficacy, adherence to foot treatment as reported by the participant and adherence to foot treatment as reported by the clinician. Secondary outcomes included foot ulcer healing rate, health-related quality of life, decision conflict and decision regret.&nbsp; Results&nbsp; Despite participants rating Decision Navigation as very helpful, mixed analyses of variance revealed no differences in decision self-efficacy or adherence between those receiving Decision Navigation and those receiving usual care. There were no differences between groups with regards to the secondary outcomes, with the exception of decision conflict which increased over time (12 weeks) for those receiving Decision Navigation.&nbsp; Conclusions&nbsp; An intervention that facilitated patient involvement in treatment decisions did not have any impact on decisional confidence or adherence to foot treatment. This does not provide support for the suggestion that personalized care can improve health-related outcomes at this progressed stage of the patient's disease trajectory. We suggest that the diabetic foot population may benefit from interventions aimed at increasing motivation to engage with care pathways, centred on challenging personal controllability beliefs

Correlates of self-rated health in people with diabetic peripheral neuropathy: a longitudinal study.

AIM:Self-rated health, a measure of self-reported general health, is a robust predictor of morbidity and mortality in various populations, including persons with diabetes. This study examines correlates of self-rated health in adults with diabetic peripheral neuropathy (DPN). METHODS:Participants recruited from the UK and USA (n = 295; mean (± sd) age: 61.5 ± 10.7 years; 69% male; 71% type 2 diabetes) rated their health at baseline and 18 months. DPN severity was assessed using the neuropathy disability score and the vibration perception threshold. Validated self-report measures assessed neuroticism, DPN-symptoms of pain, unsteadiness and reduced sensation in feet, DPN-related limitations in daily activities, DPN-specific emotional distress and symptoms of depression. RESULTS:In the fully adjusted baseline model, younger age, presence of cardiovascular disease and higher depression symptom scores showed likely clinically meaningful independent associations with worse health ratings. Being at the UK study site and presence of nephropathy indicated potentially meaningful independent associations with lower baseline health ratings. These predictors were largely consistent in their association with health ratings at 18 months. CONCLUSION:Results identify independent correlates of health ratings among adults with DPN. Future research should investigate the clinical implications of associations and examine changes in these variables over time and potential effects on changes in health perceptions. If these associations reflect causal pathways, our results may guide interventions to target issues that are likely to have an impact on subjectively experienced health as an important patient-reported outcome in DPN care

Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study

© 2017 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK Aims: To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer. Methods: This multicentre, prospective, observational study reviewed participants’ data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants’ notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence. Results: In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06). Conclusions: Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers