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special
shoes for Diabetics produced by Podartis
and inserts from Diapedia
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| Pressure
picture of neuropathic feet |
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| Pressure
picture of non-neuropathic feet |
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Pedography
as a diagnostic tool for early recognition
of altered pressure patterns in the individual
with diabetes.
In
the early 1980's, studies were first published
looking at the changes in dynamic pressure
distribution patterns of persons with diabetes.
Inspired by studies conducted in England with
the Pedobarograph, the first electronic pressure
distribution measuring system, Kirsch, Schaff,
and Seitz made their initial tests in Germany
(1983) to examine the pressure distribution
changes in neuropathic feet with a new measurement
technology.
Their new measurement system, known as emed
and developed by novel, was used in these
studies. For the first time, more precise
data could be provided with the emed capacitive
sensor technology. The neuropathic foot tests
clearly showed a difference when compared
to healthy feet.
In 1984 the Bundesministerium fuer Forschung
und Technologie (State Department for Research
and Technology) sponsored a project led by
Professor Mehnert and conducted by Dr. Dieter
Kirsch from the Munich Diabetes Research Group.
The Research Group examined more than 600
persons. The diabetics with neuropathy could
easily be identified from their specific foot
pressure patterns during dynamic loading.
It was documented that during the roll-over
process, the neuropathic forefoot displayed
increased and longer loadings than the healthy
forefoot. The neuropathic patients also exhibited
a "slap" gait. The load on the heel
and toes was lower than the unaffected feet.
Many neuropathic feet had substantially higher
localised pressures, particularly at the metatarsal
area, than the non-neuropathic feet.
With data analysis of the healthy control
group it was quickly determined that the non-diabetic,
due to various foot deformities, could record
similar pressure patterns to the neuropathic
diabetic. The frequency of the altered pressure
pattern in the patients with diabetes was
however substantially increased.
Additional testing procedures, such as temperature,
vibration and monofilament were used as complimentary
documentation. The result was significant.
If the pressure distribution showed a typical
change, the other monitoring tests recorded
changes as well. The pressure distribution
measurement procedure worked in conjunction
with these tests for outcome documentation.
It has been theorized for some time that the
areas of increased pressure on the diabetic
foot are the areas of highest risk for tissue
breakdown. Consequently, it was suggested
that a relationship between the absolute pressure
and the risk for tissue breakdown could be
established.
Currently there is no associated localized
pressure threshold, which guarantees tissue
breakdown. However, in recent studies it is
noted that 50 to 60 N/cm2, measured on a calibrated
emed platform can suggest a risk threshold.
The recorded localized maximum pressure is
dependent upon the sensor resolution and the
precision in calibration of the sensors. Therefore,
results from other research studies using
pressure distribution technology, can only
be directly compared if each sensor is carefully
calibrated.
A review of the pressure picture gives the
following basic information: The entire display
of the maximum pressure picture allows for
comparisons of foot regions. It may be necessary
to consider the duration of contact in addition
to the absolute pressures.
The Charcot foot displays higher pressures
in the midfoot region as compared to the typical
diabetic foot pattern. Pedography may aid
early detection of deformed feet and malfunction.
Naturally, the pressure picture of the neuropathic
diabetic patient can be influenced by foot
deformities and incorrect foot function. In
any case, the specific foot regions with higher
pressures indicate greater risk for tissue
breakdown.
In addition to the standard therapy for diabetic
patients, an altered load on the foot with
localized high pressures may require immediate
foot treatment with appropriate footwear and
pressure relieving orthotics.
Under no circumstances should these individuals
walk barefoot because plantar pressures will
increase dramatically and the foot is left
unprotected.
Shoes and orthotics should be fabricated by
a trained professional. The 1:1 hardcopy of
the pedography platform measurement provides
a baseline for the construction of the shoe
insert. The patient can then be measured inside
the modified shoe for quantification of the
load.
In-shoe pressure distribution measurement
systems were designed for that purpose. The
pedar system permits measurement of the area
between the plantar surface of the foot and
the shoe insert. With the pedar system the
patient can move freely, untethered from a
computer in a natural environment under real
life conditions.
The goal for the diabetic patient shoe insert
is to create a uniform pressure to prevent
localized high pressures. The patient should
be instructed to examine their feet on a regular
basis.
During the patient visit, the color display
and printout may be used to educate the individual
about the areas of concern.
Pedography is a quick measurement tool and
it does not place any burden on the individual's
feet. This is precisely why pressure assessment
is so valuable.
The objective for health professionals is
to reduce ulceration and amputation in the
diabetic population. Pedography is a cost
effective method to help reach this goal.
novel developed pedography systems for the
Diabetic Foot beginning in 1983. Intensive
research of novel partners around the world
generated valuable know-how about how to take
care of the Diabetic Foot and prevent ulceration
and amputation. novel continues to support
research in the area of Diabetic Foot.
The typical pressure pictures of neuropathic
feet show three factors:
1.
No definite roll-over process from heel
to midfoot to forefoot and finally to the
toes. The foot is typically in a;foot flat
position at ground contact and is characterized
by immediate forefoot loading. This pattern
can also be recognised from the center of
pressure line in the foot pressure picture
2.
The localized pressure values under the
3rd, 4th, 5th metatarsal heads are often
elevated in relation to other foot regions.
Pressure of 50 N/cm2 may be seen with the
emed 2 sensors/cm2 platform and in some
cases over 100 N/cm2 is recorded.
3.
The toes may be less pronounced or not visible
in the dynamic picture due to diminished
function.
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Treatment
for Diabetic Foot Ulcers
Cavanagh PR, Lipsky BA, Bradbury AW, Botek
G.
(The Lancet, pp. 1725-1735, Vol 366, Nov.
2005)
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