Eficácia e eficiência das palmilhas na prevenção e reabilitação de ulceras plantares em pés neuropaticos na hanseníase e diabetes / Efficacy and efficiency of insoles in the prevention and rehabilitation of plantar ulcers in neuropathic feet in leprosy and diabetes

As neuropatias periféricas causadas pela hanseníase e diabetes podem causar perda de sensibilidade protetora, trofismo muscular e função autonômica da pele, e consequentemente deformidades em pés e desequilíbrios biomecânicos e da distribuição da pressão, gerando alto risco de desenvolvimento de úlceras plantares. Um dos meios para prevenir é o uso de palmilhas customizadas associadas ou não ao uso de calçados ortopédicos. O objetivo dessa revisão foi verificar a eficácia, eficiência das palmilhas na prevenção e reabilitação de úlceras plantares e conhecer novidades acerca do design e do material. Foram realizadas pesquisas nas plataformas PUBMED, LILACS, EMBASE e Cochrane e foram incluídos todos os modelos de artigos, livros, monografias, no total foram encontrados 17 estudos. Apesar das palmilhas serem eficazes no alívio de pressão plantar e na diminuição da incidência das ulceras plantares, neste estudo foi encontrado poucas evidências sobre inovações e durabilidade das palmilhas que levassem em conta o custo benefício e sua efetividade.

The effects of heel-elevated total contact insole on rearfoot pressure reduction in heel injury patients who had neurosensory impairment after receiving reconstructive flap operations.

OBJECTIVE: To evaluate the effects of a custom-molded heel-elevated total contact insole (TCI) on rearfoot pressure reduction and heel cushion for patients with heel-reconstruction. METHODS: Eleven patients with unilateral heel-reconstruction were recruited in this study. Maximal force and plantar pressures (peak pressure and pressure-time integral) at three different areas (heel Midfoot and forefoot) were measured under 3 randomized conditions (shoe-only flat insole and heel- elevated TCI) after wearing a heel-elevated TCI for 3 months. Ulceration inspection and pain intensity were evaluated before and 3 months after wearing a heel-elevated TCI Results: Pain intensity was decreased and walking velocity was improved in all patients (p<0.01), and ulcerations were completely healed in all of the five patients who had heel ulcers 3 months after wearing heel-elevated TCIs. Compared to shoe-only condition, the heel-elevated TCI was effectively reduced maximal force and plantar pressures in heel area (p<0.01) while part of the body weight was shifted from heel to midfoot and forefoot. Plantar pressures in heel area were more effectively reduced in the heel-elevated TCI than in the flat insole (p<0.05). CONCLUSION: These findings suggested that heel-elevated TCI provided more effective heel pressure reduction and shock absorption, and resulted in improvement of clinical symptoms.

Photographic image tissue characterization of the ulcerated diabetic foot during treatment: technical note / Caracterizacao tecidual de imagem fotografica durante tratamento do pe diabetico ulcerado: nota tecnica

Treatment of an ulcerated diabetic foot was documented photographically. We adapted the ultrasonographic tissue characterization (USTC or CATUS) technique to develop a photographic image tissue characterization (p-IMTC or CATIM) method. Five photographs, taken during medical treatment of an ulcerated diabetic foot following digital amputation, were quantified using imaging software designed to determine brightness intensity in grey scale images. The grey scale median (GSM) changed from 127 to 98; 86; 76; and 83 (out of 255) during follow-up. The area of lesion was estimated by number of pixels and reduced from 17.85 cm² to 12.44; 3.68; 2.11; and 0.15 cm². The percentage of total number of pixels showing granulation tissue increased from 11% to 34%; 56%; 62%; and 75%. p-IMTC quantified treatment progress. GSM quantified generalized changes in tissues, while the area of lesion and granulation tissue were documented quantitatively. Lesions, ulcers, wounds or other tissues can be analyzed using p-IMTC, allowing quantification, characterization and control of the progression of a condition or treatment.

Tratamento do pé diabético ulcerado é documentado fotograficamente. Adaptamos a técnica da caracterização tecidual ultrassonográfica (CATUS ou USTC) para análise da imagem fotográfica (CATIM ou p-IMTC). Cinco fotografias obtidas durante tratamento médico de pé diabético ulcerado, pós-amputação digital, foram quantificadas por software de imagem desenvolvido para caracterizar amplitudes de brilho em tons cinza. A mediana da escala cinzenta, ou Grey Scale Median (GSM), alterou de 127 para 98; 86; 76; e 83 durante o seguimento. Área da lesão, estimada por número de pixels, diminuiu de 17,85 para 12,44; 3,68; 2,11; e 0,15 cm². A porcentagem de número de pixels com granulação aumentou de 11% para 34%; 56%; 62%; e 75%. CATIM quantificou progresso do tratamento. GSM quantificou modificações generalizadas do tecido, a área da lesão foi estimada e a granulação foi documentada quantitativamente. Análises CATIM de lesões, úlceras, feridas, ou outros tecidos podem ser feitas, permitindo quantificação, caracterização e controle da evolução do agravo ou tratamento.

Utilidad de las plantillas conformadas / Benefits of insoles custom-made

Propuesta. Objetivar la utilidad de las plantillas instrumentadas en una consulta hospitalaria para la correcta prescripción de plantillas conformadas y la necesidad de revisión de las mismas hasta su adaptación. Diseño. Estudio prospectivo. Material y métodos. Se estudiaron 59 pacientes (53,7±13 años y predominio femenino, 74,6%). De 103 pies analizados, 67 (65%) presentaban dolor en antepié y 36 (35%) en medio-retropié (talalgia y/o fascitis plantar). Mediante plantillas instrumentadas (Biofoot/IBV, Valencia) se valoraron las presiones plantares basales y tras colocación de plantillas conformadas (picos máximos, PM y presiones medias, Pm) así como el dolor mediante EVA. Resultados. Tras una media de dos revisiones, se consiguieron unas plantillas conformadas que lograban una disminución de todas las presiones, aportando un alivio sintomático significativo (EVA basal de 64±18, final de 31±20, p<0,05), mayor en la patología del retropié. En las metatarsalgias, se redujeron significativamente los picos de presión del antepié (PM de 1.851,0kPa), y en las talalgias del retropié (PM de 1.357,2kPa), en un 16 y 45% respectivamente. Se logró un descenso de todas las presiones medias, significativo en la zona externa, retropié y antepié. No existió correlación entre la disminución de las PM y la disminución del EVA. Conclusión. Mediante plantillas, es posible lograr una mejoría sintomática en las algias plantares, cuando están bien conformadas, siendo necesarias varias correcciones incluso cuando se realizan con ayuda de mapa de presiones. Las plantillas instrumentadas son una buena herramienta de trabajo en la consulta que facilita la correcta prescripción y chequeo de las mismas (AU)

Proposal. To objective the usefulness of instrumented insoles for the prescription of the custom-made insoles and need of control. Design. Prospective study. Material and methods. We studied 59 patients (53.7±13 years and female predominance, 74.6%). From 103 feet examined, 67 (65%) had pain in forefoot and 36 (35%) in mid-hindfoot (heel pain and/or plantar fascitis). Using instrumented insoles (Biofoot/IBV Valencia), plantar pressures were assessed at baseline and after placement of custom-made insoles (peak PM and mean pressure, Pm) and pain by VAS. Results. After an average of two reviews, we got a few insoles that achieve a reduction of all the pressure, providing significant symptomatic relief (VAS baseline of 64±18, end 31±20, p<0.05), higher in the pathology of hindfoot. In metatarsalgias, were significantly reduced peak forefoot pressure (PM of 1851.0kPa), and the hindfoot in the heel pain (PM of 1357.2kPa) for 16% and 45% respectively. There was a decrease in all mean pressures, significant in the hindfoot and forefoot. There was no correlation between the reduction of PM and the decline in EVA. Conclusion. Using custom-made insoles, can be achieved symptomatic improvement in plantar algias where these are well formed, still needed several corrections of the same, even when performed with the aid of pressure map. The instrumented insoles are a good tool that facilitates the correct manufacture of the same (AU)

[International cooperation for prosthetics and orthotics in Myanmar].

"Effectiveness of the sole protection and the plantar ulcer treatment of Micro Cellular Rubber (MCR) sandals" was investigated as a part of research enterprise "Research concerning the diagnosis, treatment, and the prevention of disability of an effective Leprosy in Myanmar" of the international medical treatment cooperation for three years since 2007. Furthermore "Introduction of Orthotics for the footdrop" was recently attempted through those activities. We participated for two research items from 2007, and reported on the research content and the result. We discussed the ideal way of international technical support for the developing countries in the future. Conclusively we recognized further expected works in this field 1) to train more numbers of orthotic practitioners for MCR sandals; 2) to make them skillful; 3) to train Prosthetists and Orthotists (PO) in Myanmar leaders; and 4) to organize helpers in Japan including preparation for publishing guidelines for PO workers.

Reducir la maceración de úlceras exudativas del pie diabético. Utilidad de una película barrera no irritante (Cavilon®) / Reducing skin maceration in exudative diabetic foot ulcers

Introducción: el exceso de exudado y su consecuente maceración constituye una de las causas de retraso en la cicatrización en las úlceras de pie diabético. El objetivo de nuestro estudio es demostrar la efectividad en la reducción de la maceración de la piel perilesional en úlceras exudativas de pie diabético aplicando una película barrera no irritante Cavilon® 3M® (PBNI). Material y métodos: estudio observacional que incluye 40 pacientes (29; 72,5% varones) diabéticos con úlceras exudativas de pie diabético y maceración perilesional, en los que se evalúa durante 30 días la efectividad de la aplicación de una PBNI para el control de la maceración y la evolución clínica de las lesiones. Resultados: a los 30 días de tratamiento el 70% de las lesiones presentó unos bordes sanos o con exudado bajo, con una mejoría significativa con respecto a las condiciones iniciales (día 0 n=8 vs día 30 n=28 p<0,05). La evolución de las variables clínicas relacionadas con la úlcera también fue favorable a lo largo del estudio. La presencia de tejido esfacelado mayor al 60% de la superficie de la úlcera en el día cero aparecía en 17 casos frente a dos en el día 30 (p<0,001). La aparición de tejido granulación pasó de 13 casos que presentaban más del 50% de fondo granulado de la úlcera el día de inclusión a 25 el día 30 (p<0,001). Discusión: la aplicación de un PBNI en el tratamiento de la maceración de úlceras exudativas de pie diabético demostró ser efectiva(AU)

Introduction: highly exudate and maceration is one of the causes of delay in diabetic foot ulcers healing. The purpose of our study was to demonstrate the effectiveness in the periwound skin maceration reduction with the use of no-sting barrier film (NSBF) (3M'99 Cavilon'99). Material and Methods: observational study, which includes 40 patients with diabetes (29, 72,5% males) who suffer diabetic foot ulcers with maceration and exudate. It was evaluated the application of NSBF during 30 days and its correlation with maceration control and clinical wounds progress. Results:70% of the ulcers were showed healthy edge or lower exudates after 30 days of treatment (Day 0 n=8 vs Day 30 n=28 p<0,05). Good evolutions of clinical variables were recorded through the study. Fibrin tissues upper 60% of the ulcer area were recorded in 17 cases at day 0 versus 2 cases in day 30 (p<0,001). Granulation tissue presence turned of 13 cases with upper 50% in wound bed at day 0 versus 25 cases at the end of the study (p<0,001). Discussion: the use of NSBF for the maceration management of highly exudates diabetic foot ulcers was demonstrated effective(AU)

Abordaje de una úlcera por presión con tendón expuesto / How to treat a bed sore with a tendon exposed

Las úlceras por presión (UPP) suponen un serio problema social, de salud y legal ya que implican serias consecuencias en la calidad de vida de la persona afectada y sus cuidadores, además de un enorme gasto sanitario, tanto a nivel de recursos materiales como humanos. Se expone el caso de una mujer de 84 años de edad, con una UPP estadio IV con tendón expuesto, cuyo abordaje interdisciplinar e integral desde Atención Primaria de Salud consiguió la resolución de la herida en 59 días(AU)

Bed sores are a serious social, health and legal problem since they imply serious consequences for the quality of life of the person affected and his/her caretakers; besides they create an enormous sanitary cost, both at the level of material as well as human resources. The author describes the case of an 84 year-old woman who has a stage IV bed sore with a tendon exposed; the interdisciplinary and integral treatment of her case by the Primary Health Care Center succeeded in curing her wound in 59 days(AU)

[Preventing high-risk diabetic foot ulceration by a new method of custom-made shoes in high-risk patients. Prospective study]. / Prévention des plaies du pied chez les diabétiques à haut risque par une méthode innovante d'appareillage par podo-orthèses sur mesure. Etude prospective.

BACKGROUND: The efficacy of custom-made shoes to prevent diabetic foot ulcerations is still unsatisfactory and specific conception is lacking. METHOD AND PATIENTS: We conducted a prospective study on 32 consecutive patients with diabetic mellitus, sensitive neuropathy and healed minor amputation of the foot. They were following a prevention program (education, medical consultation every month). They were treated by custom-made shoes in order to obtain a tested and effective load-off area (after trying and modifying a temporary footwear according to a simple qualitative test of the plantar pressure). RESULTS: At 1 year, 9% of patients presented a new foot ulceration and 3% new minor amputations of the foot. The custom-made shoes had very thick multiple layer total-contact soles (mean thickness 25 mm for a forefoot deformity and 40 mm for a mid-foot deformity). CONCLUSION: This new concept of custom-made shoes might be effective in enhancing the prevention of neuropathic ulcerations for high-risk patients. A randomized controlled trial would be needed to establish sound evidence supporting this new approach for therapeutic footwear.

A real-time plantar pressure feedback device for foot unloading.

OBJECTIVE: To develop and test a plantar pressure control device that provides both visual and auditory feedback and is suitable for correcting plantar pressure distribution patterns in persons susceptible to neuropathic foot ulceration. DESIGN: Pilot test. SETTING: Sports medicine laboratory in a university in France. PARTICIPANT: One healthy man in his mid thirties. INTERVENTIONS: Not applicable. Main outcome measures A device was developed based on real-time feedback, incorporating an acoustic alarm and visual signals, adjusted to a specific pressure load. Plantar pressure measured during walking, at 6 sensor locations over 27 steps under 2 different conditions: (1) natural and (2) unloaded in response to device feedback. RESULTS: The subject was able to modify his gait in response to the auditory and visual signals. He did not compensate for the decrease of peak pressure under the first metarsal by increasing the duration of the load shift under this area. Gait pattern modification centered on a mediolateral load shift. CONCLUSIONS: The auditory signal provided a warning system alerting the user to potentially harmful plantar pressures. The visual signal warned of the degree of pressure. People who have lost nociceptive perception, as in cases of diabetic neuropathy, may be able to change their walking pattern in response to the feedback provided by this device. The visual may have diagnostic value in determining plantar pressures in such patients. This pilot test indicates that further studies are warranted.

Plantar tissue stiffness in patients with diabetes mellitus and peripheral neuropathy.

OBJECTIVE: To determine if a difference exists in the plantar soft tissue of patients with diabetes mellitus (DM) and peripheral neuropathy (PN) compared with age-matched controls. DESIGN: Case-control study with a parallel 3-element 1-dimensional viscoelastic model developed to characterize indentation data. SETTING: Data collection performed in an academic physical therapy laboratory. PARTICIPANTS: Forty subjects were recruited into 2 groups (20 subjects with DM, PN, and history of plantar ulcers; 20 control subjects), matched for age (DM: 55.22+/-9.39 y; control: 55.91+/-10.97 y), gender (DM: 14 men, 6 women; control: 14 men, 6 women), and body mass index (DM: 32.96+/-8.39 kg/m(2); control: 32.58+/-7.69 kg/m(2)). INTERVENTIONS: The plantar soft tissue stiffness was measured over the first, third, and fifth metatarsals, and heel of each subject using an indentor system that accurately measures force/displacement (F/D) data. A parallel 3-element viscoelastic mechanical model was then used to transform the F/D data into values that were used to make stiffness assessments. MAIN OUTCOME MEASURE: The element coefficients of our model indicated the stiffness of the plantar tissue. RESULTS: The plantar tissue of the subjects with DM over the metatarsal heads was stiffer than the control population as indicated by one of the spring constants in the parallel 3-element model (first: 1.13+/-0.55 N/mm vs.72+/-.32 N/mm; third:.96+/-.32 N/mm vs.79+/-.17 N/mm; fifth:.90+/-.31 N/mm vs.69+/-.28 N/mm; P<.05). CONCLUSIONS: The plantar tissue of subjects with DM, PN, and a history of ulcers was stiffer than control subjects. However, additional research is needed to determine the relationship among increased soft tissue stiffness, plantar pressures, and skin breakdown.

Quality of life in patients with diabetic foot ulcers.

PURPOSE: To compare Quality of Life (QoL) between diabetic patients with (former or present) and without foot ulcers. METHODS: Two patient groups of comparable age, sex distribution, type distribution and duration of diabetes were studied. Fourteen patients with former or present, but clinically stable diabetic foot ulcers (DFUs) were studied. The control group was 24 unknown patients with DFUs. None of the participants had other diabetic complications or conditions that would potentially affect QoL. A diabetic foot risk score and QoL were assessed. QoL was scored with the RAND-36, the Barthel Score (ADL) and the Walking and Walking Stairs Questionnaire (WSQ). RESULTS: Marked and significant differences were found in physical functioning (p < 0.001), social functioning (p < 0.05), physical role (p < 0.001) and health experience (p < 0.05) between the two groups with the RAND-36 and the four subscales of the WSQ (all p < 0.001). On all these scales, QoL was significantly poorer in the study group. A correlation was found between the risk scores and QoL (physical functioning and physical role Spearman's r: -0.66, -0.56 and WSQ -0.63, -0.64, -0.67 and 0.71, respectively). CONCLUSION: Presence or history of DFUs has a large impact on physical role, physical functioning and mobility. Physical impairments especially influenced QoL. Probably, QoL can be increased by providing attention that will enhance mobility and by giving advice about adaptations and special equipment.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part I - general considerations and summary of results

Recurrent plantar ulceration is a common and serious complication occuring consequent to impairment of the tibial nerve in leprosy patients. In spite of many therapies and long therapeutic course, it is extremely difficult to abolish this complication in many cases because of extensive skin and soft tissue cushion loss due to repeated infection. Since the early 70 we have been using microscopic surgical techniques to reconstruct the ulcerated area using eight types of the flaps. In this series of papers we review out experience. Post operatively, the flapes survived in all cases, the long term results have proved satisfactory, and recurrent ulceration occurred in only three patients

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part III - use of plantar skin or musculocutaneous flaps and anterior leg flap

Anatomical studies suggest that five types of plantar flaps namely, the lateral and medial plantar flaps, the Abductor hallucis, the Flexor digitorum brevis, and the Abductor digiti minimi myocutaneous flaps, can be incised from the central section of the sole. The advantages of a plantar flap are recognizable neurovascular bundles of the sole, wide calibre of constantly located blood vessels, identical histological structure of the donor and the recipient sites, hidden donnor site and absence of functional deficit. We have used the palntar flaps in seven cases. There has been no recurrence of ulceration in any of them during the follow up period of 12 to 108 month. An anterior leg flap based on the cutaneous branches of the anterior tibial artery, with firmly anchored vessels, a long pedicle with wide vessels may used not only as a free flap graft for reconstruction of moderate degree distant defects but also as a retrograde island flap graft for the reconstruction of adjacent tibial artery in five cases of plantar ulceration with satisfactoryresults. there was no recurrence of ulceration during the follow up period of 48 to 72 months

Patellar tendon bearing orthosis--application as adjunctive treatment in healing of lower-limb tissue loss.

OBJECTIVES: To assess the efficacy of the patellar tendon bearing orthosis (PTBO) as adjunctive treatment of patients with significant lower-limb ischaemia and tissue loss complicated by neuropathy. DESIGN, MATERIALS AND METHODS: Twelve consecutive patients (14 legs) with a variety of underlying conditions causing extensive lower limb tissue loss are described. Seven patients were diabetic. Six patients (seven legs) underwent vascular reconstruction procedures. CHIEF OUTCOME MEASURES: Wound healing and amputation rate. RESULTS: Eight patients had ulcer healing within 5 months, one at 18 months (patient with alcoholic neuropathy who was poorly compliant with treatment), one stopped using the PTBO at 3 months and was converted to protective footwear with healing, one died of a myocardial infarct 1 month after the PTBO was fitted (the ulcer was showing signs of healing), and one has just had surgery and been fitted with a PTBO. CONCLUSIONS: Early results from this anecdotal series are encouraging and a prospective study to determine the application of the PTBO in patients with neuropathic and neuropathic/ischaemic tissue loss is planned.

The effect of insoles in therapeutic footwear--a finite element approach.

Current practice in the prevention of recurrence of neuropathic foot ulcers is to prescribe accommodative in-shoe orthoses or insoles which reduce plantar pressure levels at locations of bony prominences, particularly under the metatarsal heads. To date, design of these orthoses has largely been a trial and error process. There is little quantitative information available regarding the effects of thickness and the influence of soft tissue characteristics on the cushioning effect of such interventions. The current paper investigated alterations in pressure under the second metatarsal head as a function of insole thickness and tissue thickness. Both experimental and quasi-static plane strain finite element approaches were employed. The orthoses chosen reduced plantar pressure by a maximum of approximately 30% and were more effective (on a percentage basis) in the setting of reduced sub-metatarsal tissue thickness. Peak normal stresses predicted by the FE models were, on average, within 5.9% of experimentally measured values for the normal tissue case and 8.1% for the reduced tissue case. The techniques presented represent a promising approach to understanding plantar cushioning and the principles involved in the design of therapeutic footwear for insensate feet.

Cost-effective footwear for leprosy control programmes: a study in rural Ethiopia.

A randomized, controlled trial of commercially available canvas shoes was carried out in a rural area of Ethiopia. Subjects with deformed and anaesthetic feet, most with ulceration, were given either canvas shoes or plastazote/moulded shoes and followed up for one year. Seventy-five percent of subjects with ulcers who used canvas shoes had no ulcer at the end of the study, while no significant change was noted in the plastazote group. The durability and acceptability of the shoes were also examined. Clients in remote areas who have no access to an orthopaedic workshop, but who have anaesthetic feet, with or without deformity, should have access to canvas shoes with an MCR insole. Two pairs are needed per year at a cost of US$6.7 per pair.