
Podiatric Medicine
Emphasis on Diabetic Patients
Karla De La Mata
Department of Biological Sciences
East Stroudsburg Uni...
Overview
 Why feet?
 Diabetes Mellitus
 Gait Analysis & Plantar Pressure
 Case Studies
 Conclusion
2
Why Feet?...
 Amazing podiatric medical schools
 Increasing need for Doctors of Podiatric Medicine
(DPM)
 Expert in the...
Diabetes is…
 Type 1 (juvenile diabetes)
- Approximately 10% are affected – not common
- Immune system attacks β cells th...
Facts About Diabetes
 Age, family history, and ethnicity play a role in
diabetes susceptibility
 According to the Intern...
Is there any good news..?
 Many inexpensive and cost-effective
interventions exist!
Proven strategies for improving the l...
Gait
 Walking is an unconscious effort, but requires symmetry
and reproducible timing
 Deviations from normal gait can h...
Gait Analysis Diagram
comprised of 2 phases
A series of “controlled” falls
*point of reference is the
right foot*
8
Gait: Stance Phase
foot is in contact with the ground
4 Components
1 Heel Contact – R.heel contact,
ends with tow off of L...
Gait: Swing Phase
foot is NOT grounded
 During 2/3 of the stance phase,
the opposite leg is in swing phase
1 Acceleration...
Other Points of Analysis
1 Pelvic Tilt
2 Pelvic Rotation
3 Lateral Shift
4 Width of Base
5 Stride Length
6 Step Length
11
Plantar Pressure & Gait
 Repetitive mechanical stress & loss of protective
sensation on the plantar surface of the foot a...
Figure. Medial
longitudinal
arch functions
during stance
phase.
Plantar Pressure
13
How a Diabetic’s Gait Differs
 Decreased walking speed
 Decreased step length
 Decreased single limb support
time
 Dec...
Why does it differ?
 Research has not confirmed casual relationships between
gait and diabetes, but there are suspects – ...
How DPM’s help…
 Comprehensive foot care programs reduce amputation
rates by 45 – 85%
 Use innovative treatments (i.e. H...
Case 1: PLANTAR PRESSURE DISTRIBUTION
IN DIABETIC NEUROPATHY PATIENTS WITH
A HISTORY OF FOOT ULCERS
 Hypothesis: Even wit...
Case 2: EFFECTIVENESS OF INSOLES ON
PLANTAR PRESSURE REDISTRIBUTION
Figure. Definitions of foot
regions. MTH=metatarsal he...
Improvements To Be Made
 Make gait analysis more accessible and
“user-friendly”
 Try “ideal approach” when identifying t...
QUESTIONS?...
Thank You!
Bacarin, Tatiana A., Isabel C. Sacco, and Ewald M. Hennig. "Plantar pressure distribution patterns during gait in diabetic...
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Podiatric Medicine

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Seminar 2 at East Stroudsburg University

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Podiatric Medicine

  1. 1.  Podiatric Medicine Emphasis on Diabetic Patients Karla De La Mata Department of Biological Sciences East Stroudsburg University Spring 2014
  2. 2. Overview  Why feet?  Diabetes Mellitus  Gait Analysis & Plantar Pressure  Case Studies  Conclusion 2
  3. 3. 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 3
  4. 4. 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 4
  5. 5. 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 5
  6. 6. 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. 6
  7. 7. 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 7
  8. 8. Gait Analysis Diagram comprised of 2 phases A series of “controlled” falls *point of reference is the right foot* 8
  9. 9. Gait: Stance Phase foot 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 9
  10. 10. Gait: Swing Phase foot 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 10
  11. 11. Other Points of Analysis 1 Pelvic Tilt 2 Pelvic Rotation 3 Lateral Shift 4 Width of Base 5 Stride Length 6 Step Length 11
  12. 12. 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 ? 12
  13. 13. Figure. Medial longitudinal arch functions during stance phase. Plantar Pressure 13
  14. 14. 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 14
  15. 15. 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 15
  16. 16. 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 16
  17. 17. 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 17
  18. 18. 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. 18
  19. 19. 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
  20. 20. QUESTIONS?... Thank You!
  21. 21. 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

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