Biofeedback can reduce foot pressure to a safe level and without causing new at-risk zones in patients with diabetes and peripheral neuropathy.

BACKGROUND: Plantar pressure reduction is mandatory for diabetic foot ulcer healing. Our aim was to evaluate the impact of a new walking strategy learned by biofeedback on plantar pressure distribution under both feet in patients with diabetic peripheral neuropathy. METHODS: Terminally augmented biofeedback has been used for foot off-loading training in 21 patients with diabetic peripheral sensory neuropathy. The biofeedback technique was based on a subjective estimation of performance and objective visual feedback following walking sequences. The patient was considered to have learned a new walking strategy as soon as the peak plantar pressure (PPP) under the previously defined at-risk zone was within a range of 40-80% of baseline PPP in 70% of the totality of steps and during three consecutive walking sequences. The PPP was measured by a portable in-shoe foot pressure measurement system (PEDAR(®)) at baseline (T0), directly after learning (T1) and at 10-day retention test (T2). RESULTS: The PPP under at-risk zones decreased significantly at T1 (165 ± 9 kPa, p < 0.0001) and T2 (167 ± 11, p = 0.001), as compared with T0 (242 ± 12 kPa) without any increase of the PPP elsewhere. At the contralateral foot (not concerned by off-loading), the PPP was slightly higher under the lateral midfoot at T1 (68 ± 8 kPa, p = 0.01) and T2 (65 ± 8 kPa, p = 0.01), as compared with T0 (58 ± 6 kPa). CONCLUSIONS: The foot off-loading by biofeedback leads to a safe and regular plantar pressure distribution without inducing any new 'at-risk' area under both feet.

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.

Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

Relationship between peripheral vascular disease and high plantar pressures in diabetic neuro-ischaemic patients.

BACKGROUND: It has been shown that high foot pressure in diabetic patients plays a crucial role in plantar ulcer development. The purpose of the study is to analyze the relationship between foot arterial pressures and plantar pressures in diabetic patients with both peripheral neuropathy vascular disease. METHODS: We have evaluated the relationship between foot arterial pressures and plantar pressure parameters (Peak Plantar Pressure, Foot-Floor Contact and Plantar Pressure Integral) in eleven diabetic patients with both peripheral neuropathy and peripheral vascular disease. Peripheral neuropathy was defined as a tuning fork score<4/8 measured at the great toe and internal malleolus with a Tuning fork (Rydel-Seiffer 128 Hz), the absence of both patellar and ankle reflexes and with a temperature discrimination more than +5 degrees C (Thermocross). The peripheral vascular disease (PVD) was evaluated by Doppler technique. Peak Plantar Pressure (PPP) and Foot-Floor Contact (FFC) were measured by Force-Sensing Resistive (FSR 174) sensors under the 1st, 3rd and 5th metatarsal heads as well as under the heel and big toe of both feet. The Plantar Pressure Integral (PPI) was defined by the integral of the pressure over the time. RESULTS: We have found significant relationship between plantar pressure parameters (PPP, FFC, and PPI) under the first metatarsal heads and Doppler arterial pressures of both tibial posterior and dorsalis pedis artery. However, there was no relationship between Doppler arterial pressures and plantar pressure parameters (PPP, FFC, PPI) under 3rd and 5th metatarsal heads or under both the heel and the big toe. CONCLUSION: According to our results, the peripheral vascular disease could contribute to the elevation of plantar pressures and to the prolonged duration of foot floor contact at each step in diabetic patients with both peripheral neuropathy and peripheral vascular disease. In such patients, severe ischaemia could lead to an increased risk of foot ulceration and consecutive lower extremity amputation.

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.

[Modification of some occlusion concepts in implant dentistry: thoughts inspired by clinical experience]. / Modification de certains concepts d'occlusion en implantologie. Réflexions dictées par l'expérience clinique.

Implantology is nowadays a common tool in dentistry. While studying a case and selecting the future restoration, implants have to be considered when possible. Due to the functional differences between an implant and a natural tooth, the classical occlusion principles need to be considered. The prostheses have to be built according to the magnitude and direction of the forces that will be applied on the abutments. The prosthetic work and the occlusal equilibration are different in a patient with implants than in a patient with natural dentition. The occlusal concept will not be the same in the case of single implants surrounded by natural teeth, in the case of a mixed implant-tooth-supported fixed reconstruction and in the case of a full fixed bridge on implants. The purpose of this paper is to discuss the clinical consequences of these differences.

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.

A new ambulatory foot pressure device for patients with sensory impairment. A system for continuous measurement of plantar pressure and a feed-back alarm.

Abnormal and excessive plantar pressure is a major risk factor for the development of foot ulcers in patients with loss of protective pain sensation. Repeated pressure with each step can result in inflammation at specific points, followed by ulcer formation. Patients with peripheral nerve disease are unable to prevent the development of such lesions, which often lead to amputation. For this reason, it has been suggested that a fundamental therapeutic intervention should be the reduction of high plantar pressure. We have developed a portable, battery-operated ambulatory foot pressure device (AFPD) which has two important functions: (1) to determine the areas of high plantar pressure, and (2) to provide an acoustic alarm, adjusted to a specific pressure load, which is triggered when weight-bearing exceeds the predetermined plantar pressure. A memory of plantar pressure parameters allows for downloading of the data and sequential analysis during the investigation period. Such an alarm device could replace the lack of pain sensation and may play an important role in the prevention of ulcer development and lower extremity amputation.

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.