Biofeedback for foot offloading in diabetic patients with peripheral neuropathy.

AIMS: The reduction of high plantar pressure in diabetic patients with peripheral neuropathy is mandatory for prevention of foot ulcers and amputations. We used a new biofeedback-based method to reduce the plantar pressure at an at-risk area of foot in diabetic patients with peripheral neuropathy. METHODS: Thirteen diabetic patients (age 60.8 +/- 12.3 years, body mass index 29.0 +/- 5.0 kg/m(2)) with peripheral neuropathy of the lower limbs were studied. Patients with memory impairment were excluded. The portable in-shoe foot pressure measurement system (PEDAR) was used for foot offloading training by biofeedback. The learning procedure consisted in sequences of walking (10 steps), each followed by a subjective estimation of performance and objective feedback. The goal was to achieve three consecutive walking cycles of 10 steps, with a minimum of seven steps inside the range of 40-80% of the baseline peak plantar pressure. The peak plantar pressure was assessed during the learning period and at retention tests. RESULTS: A significant difference in peak plantar pressure was recorded between the beginning and the end of the learning period (when the target for plantar pressure was achieved) (262 +/- 70 vs. 191 +/- 53 kPa; P = 0.002). The statistically significant difference between the beginning of learning and all retention tests persisted, even at the 10-day follow-up. CONCLUSIONS: Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term.

Plantar pressure distribution in Type 2 diabetic patients without peripheral neuropathy and peripheral vascular disease.

AIMS: To evaluate the distribution of plantar pressure during walking on a level gradient in patients with Type 2 diabetes mellitus without any microvascular and macrovascular complications and to compare them with non-diabetic control subjects. METHODS: A group of 15 patients with Type 2 diabetes mellitus without either peripheral neuropathy or peripheral vascular disease (PVD), as well as without both diabetic retinopathy and nephropathy, was compared with a group of 15 non-diabetic subjects matched for age, sex, body weight and height. The plantar pressure and duration of plantar pressure were measured on big toe, 1st, 3rd and 5th metatarsal heads, and on the heel of both feet by Force Sensing Resistors sensors. The static contact plantar surface was measured by method of Harris footprints. RESULTS: The diabetic group showed a significant increase in peak plantar pressure at the level of the big toe [right foot 205 +/- 94 vs. 101 +/- 39 kPa (mean +/- SD), P = 0.01; left foot 165 +/- 61 vs. 104 +/- 43 kPa, P = 0.05] and 5th metatarsal head (right foot 160 +/- 68 vs. 97 +/- 32 kPa, P = 0.05; left foot 174 +/- 65 vs. 91 +/- 42 kPa, P = 0.02) with a significantly prolonged duration of plantar pressure at each step. Under the heel, the peak plantar pressure was significantly lower in the diabetic group (right foot 187 +/- 54 vs. 321 +/- 91 kPa, P = 0.05; left foot 184 +/- 63 vs. 298 +/- 110 kPa, P = 0.05). No significant differences were noted under 1st and 3rd metatarsal heads. The contact plantar surface was significantly reduced in the diabetic group compared with control subjects (right foot 118.2 +/- 10.8 vs. 141.5 +/- 12.7 cm2, P = 0.05; left foot 127.5 +/- 8.7 vs. 140.0 +/- 11.1 cm2, P = 0.05). CONCLUSIONS: We observed an anterior displacement of weight-bearing during walking on a level gradient as well as a reduced static contact plantar surface in diabetic patients without evidence of any complications compared with the non-diabetic control group. This could be a premature sign of peripheral neuropathy, which is not evaluated on clinical examination or quantitative sensory testing used in clinics.

Asthma outpatient education by multiple implementation strategy. Outcome of a programme using a personal notebook.

More than 10 years after publication, international guidelines remain poorly implemented. To better implement them, we need to develop new strategies adapted to the expectations of patients and health professionals outside hospital settings and to ensure better outpatient follow up in the community. We developed a bilingual education programme including a brochure designed to support an interdisciplinary health care network and measured hospitalisations (H), work absenteeism (WA), emergency visits (EV), asthma medication (AM) and quality of life (QL Juniper) before and 12 months after the intervention. All QL scores improved significantly in comparison with pre-intervention values. Health service use decreased dramatically when comparing the 12 months prior to and after the intervention(H: 35-8%, WA: 39-14%, EV: 88-53%). The final cost/benefit ratio of the programme was 1.96. Interdisciplinary implementation strategy of patient education is cost-effective, improves quality of life for asthmatics, and reduces strain on health services. Such a health care network does not require an expensive infrastructure and is better adapted to the reality and competences of clinical practice.

The impact of callosities on the magnitude and duration of plantar pressure in patients with diabetes mellitus. A callus may cause 18,600 kilograms of excess plantar pressure per day.

BACKGROUND: The importance of high peak plantar pressure (PP) in the development of foot ulcer is well known. However, few studies have analyzed the real impact of callosities on plantar pressure and ulcer formation. METHODS: The plantar pressure (PP) in patients with diabetes mellitus was studied in three groups, of a total number of 33 type 2 diabetic patients, without neuropathy or peripheral vascular disease: subjects with callus (A) (n = 10), subjects without callus (B) (n = 10), and a separate group of patients with callus which was submitted to callus removal (C) (n = 13). The plantar pressure (PP) parameters were measured by FSR 174 sensors and computer analyses were performed by LabView. RESULTS: Both maximum peak PP and duration of PP are significantly higher in patients with callus (peak PP: 314 +/- 52 kPa vs 128 +/- 16 kPa, p < 0.005; duration of PP: 621 +/- 27 ms vs 505 +/- 27 ms, p < 0.05). The intervention group C before and after callus removal showed an identical trend. Callus removal has decreased the peak PP by 58% (p < 0.001) and duration of PP has been decreased by 150 milliseconds by step (p < 0.05). CONCLUSION: This study has shown the deleterious role of callus and assuming that an average person walks about 10,000 steps a day, a callus may cause 18,600 kg of excess plantar pressure per day. In addition, this study has proven the importance of early and regular removal of hyperkeratotic tissue. Even more aggressive removal could be recommended in patients with neuropathy and peripheral vascular disease.

An analysis, using concept mapping, of diabetic patients' knowledge, before and after patient education.

This study was designed to assess whether concept maps used with diabetic patients could describe their cognitive structure, before and after having followed an educational programme. Ten diabetic patients, in Paris and Geneva, were interviewed and, during the interview, a concept map was drawn up by the researcher, using the patient's words. This was done on three different occasions: the first day of the educational programme (Pre-evaluation), the last day (Post 1) of a week of education, then 3 to 4 months after education (Post 2). Twenty-eight maps were analysed, using a grid that quantified and qualified the knowledge expressed (knowledge categories, concept links, exactitude) and the organization of that knowledge (hierarchization of concept, cross-links). The examples shown in the maps of the 10 patients gave an illustration of how knowledge was developed or maintained with education, and also showed some learning difficulties encountered by the patients, the changes or preservation of their beliefs and the patients' preoccupations. This study shows that concept maps can be a suitable technique to explore the type and organization of the patients' prior knowledge and to visualize what they have learned after an educational programme.

Bronchial asthma and self-management education: implementation of Guidelines by an interdisciplinary programme in health network.

UNLABELLED: Asthma is a chronic disease generating very high costs even for Switzerland. Self-management education (SME) is effective and recommended as an integral part of management in the most recent guidelines on asthma treatment. Its aim is to reduce morbidity [hospitalisations (H), lost workdays (LW), emergency consultations (EC)] and improve quality of life (QOL) in these patients. METHOD: Integrated programme with educational platforms (two-language booklet), SME in 66 patients (30 m, 36 f) with interdisciplinary quality team (pneumologists, primary care physicians, pharmacists, specialised nursing staff), QOL questionnaire. Measurement of morbidity parameters 12 months before and after SME. Measurement of QOL before and 12 months after SME. RESULTS: Hospitalisations fell from 35 to 8%*, EC from 88 to 53%*. and LW from 39 to 14%* (*p <0.001). Overall, SME resulted in a health cost saving of CHF 202,510 in terms of LW and CHF 131,200 in terms of days in hospital, i.e. a total of CHF 333,710. Costs saved per patient were CHF 5,056 per year. QOL improved with the following scores: overall QOL 4.5 +/- 0.9 to 5.2 +/- 0.9*; activities 4.5 +/- 0.9 to 5.2 +/- 0.9*; symptoms 4.2 +/- 1.1 to 5.2 +/- 1.1*; emotions 4.9 +/- 1.1 to 5.6 +/- 1*; environment 4.5 +/- 1.4 to 4.9 +/- 1.3* (*p <0.001). CONCLUSION: SME by interdisciplinary health network is effective. It brings a steep fall in costs for asthma treatment by cutting back hospitalisations and lost workdays and by improving the asthmatics' quality of life. It should be recognised and better supported by the health system.

A comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings.

OBJECTIVE: To compare patients with diabetes and new onset foot ulcers treated in Veterans Health Administration (VHA) and non-VHA settings. METHODS: The treatment of patients with new onset diabetic foot ulcers was prospectively monitored in three VHA and three non-VHA hospitals and outpatient settings until ulcer healing, amputation, or death. RESULTS: Of the 302 individuals enrolled in this study, 47% were veterans receiving VHA care. There were no significant differences between veterans and nonveterans in baseline wound classification, diabetes severity, or comorbid conditions. Veterans received significantly fewer sharp debridements, total contact casts, and custom inserts than their nonveteran counterparts, and they had significantly more x-rays, local saline irrigations, IV antibiotics, and prescriptions for bed rest. The percentage of amputations was higher in veterans but did not achieve statistical significance. CONCLUSIONS: Many commonly held stereotypes of veteran men were not found. Veterans and nonveterans with foot ulcers were similar in terms of health and foot history, diabetes severity, and comorbid conditions. There was considerable variation in treatment of diabetic foot ulcers between VHA and non-VHA care. Yet this variation did not result in statistically significant differences in ulcer outcomes.

Patient education in Switzerland: from diabetes to chronic diseases.

The Division of Therapeutic Education for Chronic Diseases at the University Hospital of Geneva has been playing an important role in the field of therapeutic patient education for more than 25 years. More than 16,000 patients have been hospitalised and an excess of 75,000 h have been spent with a rather novel interdisciplinary approach involving doctors, nurses, dieticians, psychologists, podiatrists and pedagogues. For the past 12 years, our division has held over 50 seminars of 1-week postgraduate training attended by over 3000 participants coming from more than 60 countries worldwide. In 1998, the faculty of medicine at the University of Geneva implemented a 3-year curriculum on therapeutic patient education leading to a postgraduate university diploma. In 1983, the WHO designated the Swiss teaching division as a WHO Collaborating Center for reference and research in diabetes education. In 1998, a WHO-Euro Working Group Report entitled "Therapeutic Patient Education. Continuing education programmes for health care providers in the field of prevention of chronic diseases" was published.

Revisiting the approach to treatment of long-term illness: from the acute to the chronic state. A need for educational and managerial skills for long-term follow-up.

The initial training of physicians and nurses is in the acute medical system, whether dealing with diagnosis or treatment of crises. This professional activity has gradually shaped the professional identity and is based on direct control, on avoiding risks and using therapeutic algorithms. When healthcare providers have to face chronic diseases and long-term follow-up strategies, this initial identity may often be counter-producing. This article describes the differences between the acute and chronic dimensions of diseases and treatments. Chronicity imposes on the healthcare provider a totally different way of functioning where he treats indirectly and should help the patient to manage the disease. Medical training has not put sufficient emphasis on the difference between those two approaches to disease. There is an urgent need for specific training in the strategies of management of long-term diseases.

Qualitative evaluation of courses intended for patients suffering from chronic diseases. New observation method for the continuous training of the healthcare team.

Experience has shown that when teaching patients, healthcare providers concentrate more on information concerning the illness rather than on the handling of treatment. Therapeutic education of patients imposes a precise structure on the pedagogic method and teaching aids. It is essential that, during their clinical practice, care-providers develop teaching methods which encourage a maximum of interaction to help patients learn to manage their own treatment. In this perspective, the authors propose 'analytical observation' as a method of training evaluation for healthcare providers. Three observation charts, as well as an analytical method for evaluation, have been devised. They have been tried and validated during a study whose principal objective was to measure quantitatively the impact of supervision of care-providers in the domain of therapeutic education of patients. The authors conclude that this method has a definite impact on the pedagogic progress of the care-providers. It makes it possible to record and to give a structure to the pedagogic follow-up (inspection, examination, testing) of care-providers. Since patient education plays a key role in therapeutic success, this type of methodology for training and evaluation conforms to the rigorousness essential to any therapeutic undertaking.

Patient education and diabetes research: a failure! Going beyond the empirical approaches.

A literature review of 37 papers cited by MEDLINE between 1986 and April 1996 under the terms "diabetes", "patient education" and "randomized" was carried out. The articles were analysed on the basis of a check list (Educational Procedure Check List), which contains 27 items grouped into 8 areas: study objectives, educational objectives, population, educational strategy, content, evaluation, outcome, final results. The results of our study show that authors do not describe the educational interventions that they have used; thus, we suggest that editors request randomized trial studies containing information on identification of patients' needs, elaboration of learning objectives, and planning and running of the program and the evaluation system used.

Teaching diabetic foot care effectively.

Patient education is a fundamental aspect of the management of foot ulcers in the patient with diabetes mellitus. Preventive measures have to be focused on the individual risk profile of the patient and on the chronology of appearance of symptoms. Teaching issues need to be adapted into the following three stages: A) before: prevention of foot ulceration in the at-risk patient; B) acute: prevention of extension of an existing ulcer; and C) after: prevention of recurrence.

The added value of therapy in diabetes: the education of patients for self-management of their disease.

The long-term success of diabetes therapy is strongly dependent on education of the patient. Considerable emphasis and effort has been directed at this dimension of treatment by healthcare providers (HCPs) in the field of diabetology. Education of patients is not aimed at making them more knowledgable about their disease, but to help them better manage their treatment and adapt the diabetes control to the constant changes in daily life. Patient education is a complex process, and many factors may interfere with the patient's understanding. There is growing awareness among HCPs that more knowledge and skill have to be acquired in the field of therapeutic education of patients.

Risk factors associated with contrast sensitivity loss in diabetic patients.

BACKGROUND: Psychophysical tests in patients with diabetes mellitus reveal deficits of central vision before the development of overt retinopathy. We evaluated the contrast sensitivity thresholds in 30 patients with type II diabetes mellitus and without retinopathy, taking into account the crystalline lens density. Risk factors for contrast sensitivity deficits were investigated. METHODS: Contrast sensitivity was compared in 30 aretinopathic diabetic patients and age-matched controls. Contrast thresholds were determined for stationary gratings at three spatial frequencies (6, 15, and 27 cycles/deg) and for mesopic (5 cd/m2) and low photopic (85 cd/m2) vision. Lens density was measured using a IntraOptics opacity lensmeter. RESULTS: Significant contrast sensitivity losses at all three spatial frequencies were observed in low photopic and mesopic vision in diabetic patients. The optical density of the lens in the diabetic group did not differ from that in the controls. Contrast sensitivity deficits were positively correlated with patient's age, systolic blood pressure and nephropathy at all three spatial frequencies. No relationship between cardiovascular autonomic neuropathy and contrast sensitivity defects was observed. CONCLUSIONS: These data suggest that contrast sensitivity deficits in diabetic patients without retinopathy are not solely explained by a diabetes-induced increases in lens optical density. Abnormalities of the retina or its neural connections occurring before the onset of clinically detectable retinopathy may be involved. Risk factors for these deficits are advanced age, high systolic blood pressure, and nephropathy.

Bridges, why and from where to where?

Therapeutic intervention for chronic diseases does not rely only on drugs but is also strictly dependent on how the patient has been informed about his disease and how he is able to master the various skills required by his treatment. Education therefore plays a fundamental role in the efficacy of control of those diseases. But what is education? Among the various possible definitions, one could be metaphorically illustrated by bridges. How to get the message across from the medical world to that of the patient, or, inside the medical professions from one group of providers to another. Different bridges may have different functions or roles. One is for commuting in the current daily life. Another one is to ensure vital needs. Bridges help also to discover new territories, but any new visitor may not always be welcomed in these new regions. Bridges need to be solidly constructed with a structure which can be methodologically described. This may help repair in case of problems. Patient education is a kind of bridge submitted to all sorts of forces and barriers which may interfere with the passage of knowledge and skills from the health care providers to the patient and his family.

The patients' voice: testimonies from patients suffering from chronic disease.

A medical congress brings together those doctors who are interested in the proposed theme of that particular congress. Within the congress 'Patient Education 2000' an unusual aspect was the presentation, in the form of posters, of the requirements of patients suffering from one of the diseases or conditions covered by the congress. On the one hand, these posters showed the impact of the illness; on the psychological aspect, within the family, within the professional and social lives as well as the financial aspect. On the other hand, the posters showed what the patients really wanted to say to the health care team. In this paper we present a synthesis illustrating certain significant examples.

Patients' experiences with their disease: learning from the differences and sharing the common problems.

Experiences and views of patients are presented concerning psychological, professional, family life, cognitive and financial aspects of the costs of several chronic diseases: arterial hypertension, autonomous dialysis, back pain, bronchial asthma, chronic obstructive pulmonary disease, colostomy, diabetes mellitus, epilepsy, laryngectomy, Parkinson's disease. The posters expressed what patients would really like to tell their doctors.