Microcirculatory changes in venous leg ulcers using intermittent electrostimulation of common peroneal nerve.

OBJECTIVE: Activation of the venous muscle pumps of the leg by intermittent transdermal neuromuscular stimulation of the common peroneal nerve has been previously shown to augment venous and arterial flow in patients with leg ulcers. This study aims to establish if microcirculation in the wound bed and periwound area are augmented by the activation of a neuromuscular electrostimulation device (NMES) (Geko, Firstkind Ltd., UK). METHOD: In this self-controlled, observational study, laser speckle contrast imaging was used to map and quantify microcirculatory flow in the wound bed and periwound area of patients with venous leg ulcers (VLU). Values of flow and pulsatility in these locations were compared with the NMES device, both active and inactive. RESULTS: A total of 16 patients took part in the study. Microvascular flux increased by 27% (p=0.014) in the wound bed, and by 34% (p=0.004) in the periwound area, when the NMES device was activated. Pulsatility increased by 170% (p<0.001) in the wound bed and 173% (p<0.001) in the periwound area when the device was activated. CONCLUSION: Intermittent electrostimulation of the common peroneal nerve substantially increased both microcirculatory flux and pulsatility in the wound bed and in the periwound area of the VLUs of patients in this study. This provides a plausible mechanistic explanation for its reported efficacy in healing VLUs.

Hyperbaric Oxygen Therapy in Management of Diabetic Foot Ulcers: Indocyanine Green Angiography May Be Used as a Biomarker to Analyze Perfusion and Predict Response to Treatment.

SUMMARY: The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The effectiveness of far-infrared irradiation on foot skin surface temperature and heart rate variability in healthy adults over 50 years of age: A randomized study.

BACKGROUND: Far-infrared irradiation (FIR) is used in the medical field to improve wound healing, hemodialysis with peripheral artery occlusive disease, and osteoarthritis but seldom used in ameliorating poor lower extremity circulation. The purpose of this study was to evaluate the effect of FIR on changes in foot skin surface temperature (FSST) and autonomic nerve system (ANS) activity to evaluate its effectiveness in improving lower limb circulation. METHODS: A randomized controlled study was conducted. Subjects (n = 44), all over the age of 50 years and satisfying the inclusion criteria, were randomly allocated into 2 groups. The intervention group received FIR on a lower limb for 40 minutes and the control group received no intervention. Left big toe (LBT), right big toe (RBT), left foot dorsal (LFD), right foot dorsal (RFD) surface skin temperature, autonomic nervous activity, and blood pressure were assessed. RESULTS: The main results were skin surface temperature at the LBT increased from 30.8 ±â€Š0.4°C to 34.8 ±â€Š0.4°C, at RBT increased from 29.6 ±â€Š0.4°C to 35.3 ±â€Š0.4°C and LFD increased from 31.9 ±â€Š0.3°C to 36.4 ±â€Š0.4°C, RFD increased from 30.7 ±â€Š0.3°C to 37.7 ±â€Š0.2°C. FIR caused a significant increase of the FSST ranging in a 4°C to 7°C increase after 40 minutes irradiation (P < .001). The ANS low-frequency (LF) and high-frequency (HF) activity showed a statistically significant increase in the FIR group (P < .05) but not the LF/HF ratio. CONCLUSION: FIR significantly increased the FSST from between 4°C and 7°C after 40 minutes irradiation, which might improve lower extremity circulation and regulation of ANS activity.

Immediate Effects of Self-Thai Foot Massage on Skin Blood Flow, Skin Temperature, and Range of Motion of the Foot and Ankle in Type 2 Diabetic Patients.

Objectives: The purpose of this study was to investigate the immediate effects of self-Thai foot massages (STFMs) on the foot skin blood flow, the foot skin temperature, and range of motion (ROM) of the foot and ankle in type 2 diabetic patients with peripheral neuropathy. Design: A randomized crossover study. Subjects: Twenty five diabetic patients with peripheral neuropathy were recruited. Interventions: Participants were randomly assigned to either STFM or Thai foot massage (TFM) performed by a massage therapist; then, they were switched to the other group after a 1-week washout period. In both groups, the foot massage was performed in a seated position on the dominant lower leg and foot for 25 min. Outcome measures: Before and immediately after treatment, foot skin blood flow, foot skin temperature, and ROM of the foot and ankle were evaluated. Heart rate was measured throughout the treatment. Results: After a single treatment of the massage, foot skin blood flow and ROM of the foot and ankle significantly improved in both groups (p < 0.05). Foot skin temperature did not change in STFM, whereas it significantly increased in TFM. Heart rate significantly increased in STFM, whereas it tended to decrease in TFM. Conclusions: Both STFM and TFM by a massage therapist could improve foot skin blood flow and ROM of the foot and ankle in diabetic patients with peripheral neuropathy. An STFM could be a promising alternative treatment that patients can perform at home.

Hyperbaric oxygen therapy for severe blast injury of lower extremity after terrorist attack: case report.

More blast injuries are encountered in the civilian setting in recent years as terrorist attacks have increased globally. A 17-year-old male patient with severe blast injury of the right lower extremity was admitted to our department on the fifth day after a terrorist bombing attack. Initially he had been admitted to an emergency department with segmental tibia fracture and arterial injury (Gustilo IIIC). An amputation had been foreseen due to ischemia that persisted even after orthopedic fixation and revascularization interventions, followed by fasciotomy incisions. After consultation with our department hyperbaric oxygen (HBO2) therapy was administered twice daily for the first week. Ischemia improved prominently after 10 HBO2 sessions. HBO2 therapy was continued together with antibiotherapy and wound care. The patient underwent a total of 40 HBO2 sessions and two reconstructive operations and healed without amputation. Vascular injuries with concomitant orthopedic trauma cause most of the delayed amputations in bombing attacks since ischemia can persist at the microvascular level even though adequate treatments are applied. HBO2 corrects hypoxia at tissue level and so provides oxygen for the critically ischemic cells in the injured area. HBO2 also enhances host defense and decreases the ischemia reperfusion injury. In this case, HBO2 was effective in survival and functional recovery (salvage) of the extremity together with regular wound care, antibiotherapy and surgical repair.

Spectral analysis of the blood flow in the foot microvascular bed during thermal testing in patients with diabetes mellitus.

Timely diagnostics of microcirculatory system abnormalities, which are the most severe diabetic complications, is one of the major problems facing modern health care. Functional abnormalities manifest themselves earlier than the structural ones, and therefore their assessment is the issue of primary importance. In this study Laser Doppler flowmetry, a noninvasive technique for the cutaneous blood flow monitoring, was utilized together with local temperature tests and wavelet analysis. The study of the blood flow in the microvascular bed of toes was carried out in the control group of 40 healthy subjects and in two groups of 17 type 1 and 23 type 2 diabetic patients. The local temperature tests demonstrated that the diabetic patients have impaired vasodilation in response to local heating. The tendency for impaired low frequency pulsations of the blood flow associated with endothelial and neurogenic activities in both diabetes groups was observed. Local thermal tests induced variations in perfusion and its spectral characteristics, which were different in the groups under study. In our opinion, the obtained preliminary results can be a basis for further research and provide a deeper understanding of pathological processes that drive microvascular abnormalities caused by diabetes mellitus.

The association between cold hypersensitivity in the hands and feet and chronic disease: results of a multicentre study.

BACKGROUND: Cold hypersensitivity in the hands and feet (CHHF) is a common symptom in Korea and patients with CHHF complain of coldness in the hands and feet in an environment that is not considered cold by unaffected people. In traditional East Asian medicine, CHHF is believed to be accompanied by various diseases and symptoms, and is considered a symptom that needs active treatment. CHHF is used for pattern identification in the cold pattern, yang deficiency, and constitution. This study aimed to examine the differences in frequencies of chronic diseases with respect to the presence of CHHF. METHODS: Disease history, CHHF, body measurements, and blood test survey data from 6149 patients collected by 25 medical institutes in Korea were obtained from the Korean Medicine Data Center. The participants were divided into CHHF (n = 1909) and non-CHHF groups (n = 3017) according to the CHHF survey. The differences in frequencies of 18 diseases were analysed using chi-square tests, and the odds ratios (ORs) for each disease according to CHHF status were examined via logistic regression with adjustment for age, sex, and body mass index (BMI). RESULTS: Based on chi-square test results, the CHHF group showed a higher frequency of the following diseases: anaemia, hypotension, chronic gastritis, reflux oesophagitis, chronic rhinitis, dysmenorrhoea, and gastroduodenal ulcer. Diseases found in lower frequencies were as follows: hypertension, diabetes mellitus, impaired fasting glucose, dyslipidaemia, stroke, fatty liver, and angina pectoris. In addition, from the logistic regression with adjustment for age, sex, and BMI, the CHHF group showed a lower OR in diabetes mellitus and dyslipidaemia than the non-CHHF group, but a higher OR in degenerative arthritis, chronic gastritis, gastroduodenal ulcer, reflux oesophagitis, and chronic rhinitis. CONCLUSIONS: This study showed that CHHF is associated with chronic disease. Further large-scale prospective studies are needed to validate these associations.

Treatment of foot varicose veins: A study of 119 consecutive patients.

Objective To analyze the outcomes of 119 (188 feet) patients undergoing foot varicose vein phlebectomy with and without sclerotherapy between 2013 and 2015. Methods Legs and feet were treated in one single procedure. Clinical and ultrasound assessments were carried out at 7, 30, and 90 days for visualization of the sapheno-femoral and sapheno-popliteal junctions and the deep vein system. Results Mean age was 50 ± 12 years (25-79 years); 67 patients were female (56.3%). Median venous clinical severity score was 4 (range 2-5) before and 1 (range 0-2) at 90 days ( p < 0.001). Edema and transient paresthesia were the most frequent complications (13 (10.92%) and 11 (9.24%) patients, respectively). All complications were resolved at 90 days except one case of edema (resolved after 150 days with compression stockings and lymphatic drainage manual therapy). Conclusions Symptomatic foot varicose vein intervention was safe and effective. Further studies should focus on assessment of vein-specific quality of life questionnaires.

Effects of dietary nitrate supplementation on the response to extremity cooling and endothelial function in individuals with cold sensitivity. A double blind, placebo controlled, crossover, randomised control trial.

Individuals with cold sensitivity have low peripheral skin blood flow and skin temperature possibly due to reduced nitric oxide (NO•) bioavailability. Beetroot has a high concentration of inorganic nitrate and may increase NO-mediated vasodilation. Using a placebo-controlled, double blind, randomised, crossover design, this study tested the hypotheses that acute beetroot supplementation would increase the rate of cutaneous rewarming following a local cold challenge and augment endothelium-dependent vasodilation in cold sensitive individuals. Thirteen cold sensitive participants completed foot and hand cooling (separately, in 15 °C water for 2 min) with spontaneous rewarming in 30 °C air whilst skin temperature and cutaneous vascular conductance (CVC) were measured (Baseline). On two further separate visits, participants consumed 140 ml of either concentrated beetroot juice (nitrate supplementation) or nitrate-depleted beetroot juice (Placebo) 90 min before resting seated blood pressure was measured. Endothelial function was assessed by measuring CVC at the forearm, finger and foot during iontophoresis of 1% w/v acetylcholine followed by foot and hand cooling as for Baseline. Plasma nitrite concentrations significantly increased in nitrate supplementation compared to Placebo and Baseline (502 ± 246 nmol L-1; 73 ± 45 nmol L-1; 74 ± 49 nmol L-1 respectively; n = 11; P < 0.001). Resting blood pressure and the response to foot and hand cooling did not differ between conditions (all P > 0.05). Nitrate supplementation did not alter endothelial function in the forearm, finger or foot (all P > 0.05) compared to Placebo. Despite a physiologically meaningful rise in plasma nitrite concentrations, acute nitrate supplementation does not alter extremity rewarming, endothelial function or blood pressure in individuals with cold sensitivity.

Effect of Angelica acutiloba Extract on Blood flow Regulation in Stroke-prone Spontaneously Hypertensive Rats.

Angelica acutiloba Kitagawa (Yamato Toki) is a herbal medicine known to exhibit various health effects. In this study, we used a rat model to examine the effects of two different Yamato Toki extracts on the blood flow response of the instep of the hind paw. Twelve-week- old male stroke-prone spontaneously hypertensive rats (SHRSP) were orally given 200 mg of a water extract of Yamato Toki (n=6), 200 mg of an ethanol extract of Yamato Toki (n = 6), 30 mg/kg of nicardipine (n = 6) as a positive control and saline (n = 6) as a negative control. Blood flow was monitored continuously for 0, 1, 3, 6 and 24 hours after treatment. Rats given 200 mg of the ethanol extract of Yamato Toki demonstrated significantly greater blood flow compared with control rats at I hour after treatment. An ethanol extract of Yamato Toki from Nara administrated orally can increase blood flow in SHRSP.

Microcirculation in the foot is augmented by neuromuscular stimulation via the common peroneal nerve in different lower limb postures: a potential treatment for leg ulcers.

AIM: Aim of the study was to examine the effects of the geko™ device (a portable electical nerve stimulator) on microcirculatory flow on the dorsum of the foot, and whether this is influenced by lower limb postures and application of a plaster cast. METHODS: This was a cross-sectional, healthy cohort, open label, physiological response study. In 10 healthy volunteers, aged 19 to 24 years, laser Doppler fluxmetry measurements were made on the dorsum of the foot in four postures: standing (weight bearing and non-weight bearing) and supine lying (with the lower limb horizontal and then elevated). Measurements of flux were made both at rest and during stimulation with the geko™ device applied over the common peroneal nerve, at 1 Hz for 5 minutes in each posture. Repeat measurement were made after the application of a below knee plaster cast. Measures of flux were compared to basal levels assumed to be in supine with limb horizontal, with no cast and an inactive geko™ device. RESULTS: The geko™ device was effective in increasing microcirculation on the dorsum of the foot in all four postures (mean difference =141%, 95% CI 70%-212%, P=0.001). This effect was more pronounced than that of using a plaster alone (Mean increase in flux of 73%, 95% CI 22%-125%, P=0.01) or variances due to the hydrostatic effects of different postures (mean difference 17-27.6%, P>0.05). There was a 2 to 3 fold increase in flux when stimulation was delivered in combination with the plaster cast. CONCLUSION: Stimulation using the geko™ device augments microcirculation in the foot. The response is greater in lying and non-weight bearing than weight bearing standing but the most striking effect is when stimulation is combined with a plaster cast. The geko™ offers a potential means of promoting conditions favourable for wound healing, where treatment using compression may be contraindicated, such as arterial/mixed aetiology ulcers.

Effects of a pulsatile electrostatic field on ischemic injury to the diabetic foot: evaluation of refractory ulcers.

AIMS: The macro- and microcirculation disease, in patients with type 2 diabetes mellitus (T2DM), induces ischemic wounds of the lower limbs. We have tried to reduce the aggregation of red blood cells and to improve the O2 supply to the tissues and speed the healing of ulcers in T2DM patients. METHODS: We enrolled 25 obese subjects without glucose intolerance (group A; BMI greater than 30 kg/m2), 20 obese adults intolerant to glucose (group B) and two subgroups, groups C and D, with T2DM and with leg ulcers. The groups A, B and C were treated with PESF. Body weight, O2 extraction, the capillary pulse, blood pressure and the surface of the ulcers were monitored. RESULTS: The technique PESF shows to have positive effects on the metabolism, on the reduction of body weight in the groups A and B, increasing extraction of O2 in group C and increase the speed of healing of wounds in group C compared to group D. In group A, there was a significant reduction in systolic and diastolic blood pressure. CONCLUSIONS: The technique PESF has affected the metabolic processes and the speed of wound healing ulcer in patients with T2DM.

Diabetic foot ulcers: Part II. Management.

The management of diabetic foot ulcers can be optimized by using an interdisciplinary team approach addressing the correctable risk factors (ie, poor vascular supply, infection control and treatment, and plantar pressure redistribution) along with optimizing local wound care. Dermatologists can initiate diabetic foot care. The first step is recognizing that a loss of skin integrity (ie, a callus, blister, or ulcer) considerably increases the risk of preventable amputations. A holistic approach to wound assessment is required. Early detection and effective management of these ulcers can reduce complications, including preventable amputations and possible mortality.

[Adjuvant treatment of diabetic foot]. / Trattamenti adiuvanti del piede diabetico.

A diabetic infected foot with erythema and fluctuation can suspect that the infection has passed the fascial compartmental, a condition that requires surgical drainage. Elective amputation may be considered for patients who have recurrent ulcers, irreversible loss of function or injuries that require long-term treatment in the hospital. If the diabetic infected foot appears ischemic it requires a treatment of revascularization. The outcome of revascularization is related with the extension of the damaged artery. The debridement removes the bacterial colonies, promotes granulation tissue and its reepithelialization, also facilitates the collection of samples for microbiological analyses. This procedure can be performed with the classic sharp instruments or with advanced autolytic dressings, maggots or ultrasonic equipment. The use of hyperbaric oxygen therapy in the treatment of infected diabetic foot is controversial because studies in this area are few and methodologically questionable. The same conclusion was reached also for the use of growth factors and skin substitutes.

The effect of a sweet potato, footbath, and acupressure intervention in preventing constipation in hospitalized patients with acute coronary syndromes.

Constipation is a common health problem that adversely affects quality of life and the prognosis of hospitalized patients with acute coronary syndromes (ACS). The purpose of this study was to develop and test the sweet potato/footbath/acupressure massage (SFA) intervention as a safe treatment for prevention of constipation and to increase satisfaction with bowel emptying in hospitalized patients with ACS. The study was a prospective, randomized controlled trial with a sample of 93 patients (SFA group, n = 44; usual care group, n = 49). Patients in the SFA group received SFA intervention combined with usual care. The results showed that there were statistical differences between the two groups in terms of (1) the incidence of constipation; (2) the use of laxatives and enemas; (3) patients' subjective satisfaction with their bowel emptying during hospitalization; and (4) sensation of incomplete evacuation and anorectal obstruction/blockade. The SFA intervention was more effective, economical, and practical than usual care alone in managing constipation and satisfaction with defecation in patients hospitalized with ACS.

Acute effects of warm footbath on arterial stiffness in healthy young and older women.

Acute systemic thermal therapy can improve arterial stiffness in both animals and humans. We examined and compared the effects of acute local thermal therapy (footbath) on an indicator of human arterial stiffness, cardio-ankle vascular index (CAVI), in 16 healthy young (29.4 ± 0.4 years) and 16 older (59.8 ± 1.7 years) women. Measurements were made at baseline (BL) and at 0 and 30 min after footbath in footbath trial, and at corresponding time points without footbath in control trial. In the footbath trial, subjects immersed their lower legs and feet in water for 30 min, with water temperature ranging from 41 to 43°C. The results showed that footbath elicited significant reductions in CAVI at 0 min compared to the same trial's baseline in both young and older groups (0.55 ± 0.07, P = 0.01 for young; 0.42 ± 0.15, P = 0.03 for older, respectively) with no changes found in the control trials. The percentage of CAVI change at 0 min was significantly greater in young women (91.9 ± 1.1%) compared to older women (96.5 ± 1.8%, P < 0.05). This study indicated that acute warm footbath results in transient improvement of systemic arterial stiffness in both healthy young and older women. Despite similar intervention, the percentage response of arterial stiffness to footbath was attenuated in older women.

Foam posturography: standing on foam is not equivalent to standing with decreased rapidly adapting mechanoreceptive sensation.

Standing on a foam surface is believed to exaggerate balance deficits by decreasing the reliability of somatosensory information from cutaneous mechanoreceptors on the plantar soles (i.e. base of feet) and by altering the effectiveness of ankle torque. The aim was to further document the nature of foam posturography testing by comparing between standing on foam and standing with decreased Rapidly Adapting Mechanoreceptive Sensation (RAMS). Sixteen healthy adults (mean age 20.8 years) were tested with posturography, standing with eyes open and closed on a solid surface and on foam, with and without decreased plantar RAMS. Standing balance was measured as torque variance and further analyzed by being divided into three spectral categories. Plantar cutaneous hypothermic anesthesia by ice-cooling was used to decrease RAMS. Plantar mechanoreceptive sensation was precisely determined with tactile sensitivity and vibration perception tests. Vibration perception was significantly decreased by hypothermic anesthesia, but tactile sensitivity was not. The anterior-posterior torque variance was significantly larger for frequencies less than 0.1 Hz under eyes closed conditions when standing on a solid surface with decreased RAMS compared to normal sensation. No effect of decreased RAMS was seen with eyes open on a solid surface, nor on foam with eyes open or closed. Decreased RAMS produced body sway responses on a solid surface that were different in spectral composition, amplitude, direction and that responded differently to vision compared with standing on foam. Hence, this study showed that RAMS contributes to postural control but reduction in RAMS does not produce a similar challenge as standing on foam.

Review paper: basic concepts to novel therapies: a review of the diabetic foot.

Diabetes mellitus is a global epidemic. Peripheral neuropathy and peripheral vascular disease are complications of diabetes mellitus and the primary causative factors for foot ulceration. Foot ulceration is the leading cause of hospitalization in people with diabetes mellitus. The burden of foot ulceration on health care systems and individual patients is immense. Despite conventional treatment, there persists a high incidence of amputation. A multidisciplinary approach is required to prevent ulcers. This review describes the etiology and risk factors for diabetic foot ulceration and a system for evaluating the diabetic foot. The assessment of neuropathy and the grading of foot ulcers are critically examined. This is important to allow for standardization in clinical trials. The management of diabetic foot syndrome is reviewed. The treatments to ensure vascular supply to the lower limb and control of infection as well as novel therapies, which are becoming available to treat nonhealing, "no-option" diabetic ulcers, are discussed.

Functional changes in microcirculation during hyperbaric and normobaric oxygen therapy.

OBJECTIVES: Treatment of cutaneous wounds is one of the many applications of hyperbaric oxygen therapy (HBO). However, the complex regulation of skin microcirculation during different phases of HBO is not completely understood. We therefore investigated skin microcirculation and oxygenation during HBO and normobaric oxygen (NBO) exposure. METHODS: Seven healthy volunteers were investigated using measurements of transcutaneous oxygen pressure (PtcO2), tissue spectrophotometry and laser Doppler flowmetry recorded simultaneously in the hand and foot during HBO and NBO in 2- and 4-mm depths. We defined tissue hypoxia as a PtcO2 below 30 mmHg. RESULTS: At the hand, in 2 mm depth, NBO induced a mild vasoconstriction (-37%, p=0.07), but a significant increase in PtcO2 (+380%, p<0.001). HBO induced a mild vasoconstriction (-45%, p=0.08), significantly increasing PtcO2 (+1430%, p<0.001). Hand changes in 2 and 4 mm were comparable. Foot changes were smaller than at the hand and more pronounced in 4 mm than in 2 mm depth during NBO and compression. No episodes of tissue hypoxia occurred at any time. CONCLUSIONS: In healthy subjects, NBO and especially HBO significantly improve tissue oxygenation, despite vasoconstriction. Differences in vascular regulation between hand and foot and especially at the latter site between 2 and 4 mm depth exist.

Extracorporeal shockwave treatment for chronic diabetic foot ulcers.

BACKGROUND: This prospective study compared extracorporeal shockwave treatment (ESWT) with hyperbaric oxygen therapy (HBO) in chronic diabetic foot ulcers. PATIENTS AND METHODS: Seventy-two patients with 72 chronic diabetic foot ulcers were randomly divided into two groups of similar demographics with 34 patients with 36 ulcers in the ESWT group and 36 patients with 36 ulcers in the HBO group. Patients in the ESWT group received 300 + 100/cm(2) impulses of shockwave at 0.11 mJ/cm(2) energy flux density every 2 wk for 6 wk, whereas patients in the HBO group received HBO daily for 20 treatments. The evaluations included clinical assessment of the ulcers with photo-documentation, blood flow perfusion scan, bacteriological examination, histological study, and immunohistochemical analysis. RESULTS: The overall results showed completely healed in 31%, improved in 58%, and unchanged in 11% for the ESWT group and 22% completely healed, 50% improved, and 28% unchanged for the HBO group. The ESWT group showed significantly better clinical results and local blood flow perfusion, higher cell concentration, and activity than the HBO group. On immunohistochemical analysis, the ESWT group demonstrated significant increases in endothelial nitric oxide synthase, vessel endothelial growth factor, and proliferation cell nuclear antigen expressions and a decrease in transference-mediated digoxigenin-deoxy-UTP nick end-labeling expression than the HBO group. CONCLUSIONS: ESWT appears to be more effective than HBO in chronic diabetic foot ulcers.