Examining characteristics of those who receive pedorthic services: A clinical audit.

Diabetes-related foot complications, including neuropathic plantar forefoot ulcers, are a significant contributor to morbidity and increased healthcare costs. This retrospective clinical audit examines the characteristics of people accessing pedorthics services who are at risk of neuropathic plantar forefoot ulcer (re)occurrence and the pathways and funding models used to access these services. A clinical record audit was conducted on all patients accessing a pedorthics service who had diabetes and neuropathy with a history of plantar forefoot ulceration. The data included demographics, diabetes and neuropathy duration, main forefoot pathology and other comorbidity, footwear and insole interventions, and health fund access status. A total of 70 patient records were accessed, and relevant data was extracted. The mean age of participants was 64.69 (standard deviation (SD) 11.78) years; 61% were male and 39% female. Duration of diabetes ranged from one to 35 years, with a mean of 14.09 years (SD 6.58). The mean duration of neuropathy was 8.56 (SD 4.16) years. The most common forefoot conditions were bony prominences at 71% (n = 50), rigid flat foot and limited joint mobility (53%, n = 37), and hallux abductovalgus at 47% (n = 33). All participants had hyperkeratosis; 34% (n = 24) had forefoot amputation, and around 34% (n = 24) had a history of digital amputation. Various publicly funded packages and private health insurance were accessed. This study investigates the sociodemographic and medical profiles of individuals with diabetes-related foot complexities prone to neuropathic plantar forefoot ulcers. It is the first to examine patients receiving pedorthic services, informing practitioner surveys and preventive care strategies. Understanding patient characteristics aids in optimising multidisciplinary care and reducing ulcer incidence. Further studies are warranted to explore the field to establish an effective multidisciplinary care approach between medical professionals, podiatrists and pedorthists to optimise patient outcomes.

Footwear and insole design parameters to prevent occurrence and recurrence of neuropathic plantar forefoot ulcers in patients with diabetes: a series of N-of-1 trial study protocol.

BACKGROUND: Foot complications occur in conjunction with poorly controlled diabetes. Plantar forefoot ulceration contributes to partial amputation in unstable diabetics, and the risk increases with concomitant neuropathy. Reducing peak plantar forefoot pressure reduces ulcer occurrence and recurrence. Footwear and insoles are used to offload the neuropathic foot, but the success of offloading is dependent on patient adherence. This study aims to determine which design and modification features of footwear and insoles improve forefoot plantar pressure offloading and adherence in people with diabetes and neuropathy. METHODS: This study, involving a series of N-of-1 trials, included 21 participants who had a history of neuropathic plantar forefoot ulcers. Participants were recruited from two public hospitals and one private podiatry clinic in Sydney, New South Wales, Australia. This trial is non-randomised and unblinded. Participants will be recruited from three sites, including two high-risk foot services and a private podiatry clinic in Sydney, Australia. Mobilemat™ and F-Scan® plantar pressure mapping systems by TekScan® (Boston, USA) will be used to measure barefoot and in-shoe plantar pressures. Participants' self-reports will be used to quantify the wearing period over a certain period of between 2 and 4 weeks during the trial. Participant preference toward footwear, insole design and quality-of-life-related information will be collected and analysed. The descriptive and inferential statistical analyses will be performed using IBM SPSS Statistics (version 27). And the software NVivo (version 12) will be utilised for the qualitative data analysis. DISCUSSION: This is the first trial assessing footwear and insole interventions in people with diabetes by using a series of N-of-1 trials. Reporting self-declared wearing periods and participants' preferences on footwear style and aesthetics are the important approaches for this trial. Patient-centric device designs are the key to therapeutic outcomes, and this study is designed with that strategy in mind. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000699965p. Registered on June 23, 2020.

Embodied experiences and existential reflections of the oldest old.

The aim of this study was to learn more about the embodied experiences of people over 85 years and to gain a better understanding of how they make sense of the existential issues faced at this unique stage of life. This research is philosophically and methodologically underpinned by existential phenomenology, in particular embodiment theory, which allows exploration of everyday experiences and the personal meanings attributed to them. In-depth interviews with twenty purposively selected individuals were analysed using Interpretive Phenomenological Analysis. Findings indicated that ways of being, relationships with others and one's place in the world continue to evolve into late life. Gerotranscendence theory best encapsulates lived experiences, with salient features including an increased need for deep reflection, positive solitude and meaningful relationships, among other features. This research provides new insights into how identity, meaning and the experience of the broader lifeworld are influenced by corporeal ageing.

The Phenomenology of the Body After 85 Years.

The aim of this study was to describe the phenomenology of the body after 85 years, addressing the following question: What is the experience of the body at this age? Within the paradigm of existential phenomenology, this study was philosophically and methodologically underpinned by embodiment theory, positioning the body as the starting point for the exploration of lived experience. In-depth interviews with 20 purposively selected individuals were analyzed using van Manen's context-sensitive phenomenological orientation. Findings indicated that the body was experienced primarily in negative terms, as compromising engagement in meaningful activity, independence, safety, vitality, dignity, and identity. Participants coped with bodily changes through adaptation, humor, and acceptance. In addition, participants viewed their unreliable and at times unfamiliar body, as distinct from their sense of self. This research addresses the current lack of subjective accounts of bodily and embodied experiences in this group, combating assumptive views and contributing insightful understanding.

Footwear and insole design features that reduce neuropathic plantar forefoot ulcer risk in people with diabetes: a systematic literature review.

BACKGROUND: In people with diabetes, offloading high-risk foot regions by optimising footwear, or insoles, may prevent ulceration. This systematic review aimed to summarise and evaluate the evidence for footwear and insole features that reduce pathological plantar pressures and the occurrence of diabetic neuropathy ulceration at the plantar forefoot in people with diabetic neuropathy. METHODS: Six electronic databases (Medline, Cinahl, Amed, Proquest, Scopus, Academic Search Premier) were searched in July 2019. The search period was from 1987 to July 2019. Articles, in English, using footwear or insoles as interventions in patients with diabetic neuropathy were reviewed. Any study design was eligible for inclusion except systematic literature reviews and case reports. Search terms were diabetic foot, physiopathology, foot deformities, neuropath*, footwear, orthoses, shoe, footwear prescription, insole, sock*, ulcer prevention, offloading, foot ulcer, plantar pressure. RESULTS: Twenty-five studies were reviewed. The included articles used repeated measure (n = 12), case-control (n = 3), prospective cohort (n = 2), randomised crossover (n = 1), and randomised controlled trial (RCT) (n = 7) designs. This involved a total of 2063 participants. Eleven studies investigated footwear, and 14 studies investigated insoles as an intervention. Six studies investigated ulcer recurrence; no study investigated the first occurrence of ulceration. The most commonly examined outcome measures were peak plantar pressure, pressure-time integral and total contact area. Methodological quality varied. Strong evidence existed for rocker soles to reduce peak plantar pressure. Moderate evidence existed for custom insoles to offload forefoot plantar pressure. There was weak evidence that insole contact area influenced plantar pressure. CONCLUSION: Rocker soles, custom-made insoles with metatarsal additions and a high degree of contact between the insole and foot reduce plantar pressures in a manner that may reduce ulcer occurrence. Most studies rely on reduction in plantar pressure measures as an outcome, rather than the occurrence of ulceration. There is limited evidence to inform footwear and insole interventions and prescription in this population. Further high-quality studies in this field are required.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners.

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Life as Experienced Within and Through the Body After the Age of 85 Years: A Metasynthesis of Primary Phenomenological Research.

The body is central to the experience of aging. In this metasynthesis, the authors located, analyzed, and reconceptualized phenomenological research on how life is experienced within and through the body after 85 years. Sandelowski and Barroso's metasynthesis method was employed. Seven databases were searched for primary phenomenological studies. After systematic screening and quality appraisal, 19 studies were included for review. Analysis was guided by Maurice Merleau-Ponty's existential philosophy of embodiment. Findings were organized using Max van Manen's reflective lifeworld existentials. Four ontological dimensions emerged, namely, being in a body (corporeality), being in time (temporality), being in place (spatiality), and being with others (relationality). Each dimension captures a distinct experiential dimension of this stage of the life course. The results suggest vast heterogeneity in the ontological experience of aging, supporting the view that diversity grows with age. The ability to adapt to multidimensional losses was identified as a source of resilience.

Factors associated with type of footwear worn inside the house: a cross-sectional study.

BACKGROUND: In specific populations, including those at risk of falls or foot ulcers, indoor footwear is an important aspect of preventative care. This study aims to describe the indoor footwear worn most over the previous year in a sample representative of the Australian inpatient population, and to explore the sociodemographic, medical, foot condition and foot treatment history factors associated with the indoor footwear worn. METHODS: This was a secondary analysis of data collected from inpatients admitted to five hospitals across Queensland, Australia. Sociodemographic information, medical history, foot conditions and foot treatment history were collected as explanatory variables. Outcomes included the self-reported type of indoor footwear (from 16 standard footwear types) worn most in the year prior to hospitalisation, and the category in which the self-reported footwear type was defined according to its features: 'protective', 'non-protective' and 'no footwear'. Multivariate analyses determined explanatory variables independently associated with each type and category. RESULTS: Protective footwear was worn by 11% of participants (including 4% walking shoes, 4% running shoes, 2% oxford shoes), and was independently associated with education above year 10 level (OR 1.78, p = 0.028) and having had foot treatment by a specialist physician (5.06, p = 0.003). Most participants (55%) wore non-protective footwear (including 21% slippers, 15% thongs/flip flops, 7% backless slippers), which was associated with older age (1.03, p < 0.001). No footwear was worn by 34% of participants (30% barefoot, 3% socks only). Those of older age (0.97, p < 0.001) and those in the most disadvantaged socioeconomic group (0.55, p = 0.019) were less likely to wear no footwear (socks or barefoot). CONCLUSIONS: Only one in nine people in a large representative inpatient population wore a protective indoor footwear most of the time in the previous year. Whilst having education levels above year 10 and having received previous foot treatment by a specialist physician were associated with wearing protective footwear indoors, the presence of a range of other medical and foot conditions were not. These findings provide information to enable clinicians, researchers and policymakers to develop interventions aimed at improving indoor footwear habits that may help prevent significant health burdens such as falls and foot ulcers.

Factors associated with wearing inadequate outdoor footwear in populations at risk of foot ulceration: A cross-sectional study.

BACKGROUND: Few studies have investigated if people at risk of foot ulceration actually wear the footwear recommended by best practice guidelines to prevent foot ulceration. This study aimed to investigate the prevalence of, and factors associated with, wearing inadequate outdoor footwear in those with diabetes or peripheral neuropathy in an inpatient population. METHODS: This was a secondary analysis of a multi-site cross-sectional study investigating foot conditions in a large representative inpatient population admitted into hospital for any medical reason on one day. A range of explanatory variables were collected from all participants including sociodemographic, medical and foot condition factors. The outcome variable for this study was the self-reported outdoor footwear type worn most by participants outside the house in the year prior to hospitalisation. The self-reported footwear type was then categorised into adequate and inadequate according to footwear features recommended in guidelines for populations at risk of foot ulceration. Logistic regression identified factors independently associated with inadequate footwear in all inpatient participants, and diabetes and neuropathy subgroups. RESULTS: Overall, 47% of a total of 726 inpatients wore inadequate outdoor footwear; 49% of the 171 in the diabetes subgroup and 43% of 159 in the neuropathy subgroup. Wearing inadequate outdoor footwear was independently associated (Odds Ratio (95% Confidence Interval)) with being female in the diabetes (2.7 (1.4-5.2)) and neuropathy subgroups (3.7 (1.8-7.9)) and being female (5.1 (3.7-7.1)), having critical peripheral arterial disease (2.5 (1.1-5.9)) and an amputation (0.3 (0.1-0.7)) in all inpatients (all, p<0.05). CONCLUSIONS: Almost half of all inpatients at risk of foot ulceration reported wearing outdoor footwear most of the time that did not meet recommendations for prevention. We found women were much more likely to wear inadequate footwear. More work needs to be done to increase the uptake of footwear recommendations in these populations to prevent foot ulceration.

Health Practitioners' Perceptions of Falls and Fall Prevention in Older People: A Metasynthesis.

Fall prevention has received a great deal of consideration and funding, however fall rates have not reduced accordingly. Health practitioners are key stakeholders in the process of implementing fall prevention evidence into their clinical assessment and management of older people at risk of falling. Investigating health practitioners' clinical experiences and perceptions has been identified as a means to enhance the translation of knowledge. Four databases were searched for studies exploring health practitioners' perceptions of falls and fall prevention. A metasynthesis of eight qualitative studies was conducted. The findings suggest that health practitioners face substantial barriers in the implementation of fall prevention practices. These include personal, interpersonal, and clinical barriers in addition to limitations of the research evidence. This knowledge hopes to enhance targeted dissemination of knowledge, reducing the research-practice gap and improving clinical outcomes for older people at risk of falls.

Self-reported physical activity in community-dwelling adults with diabetes and its association with diabetes complications.

AIMS: To describe the physical activity levels of an Australian community-based adult population with diabetes, and investigate the interaction between diabetes complications and physical activity. METHODS: Anthropometric, demographic, biochemical and self-reported physical activity measures (IPAQ) were performed. Associations and multiple regression analyses were undertaken between physical activity, known risk factors for diabetes complications, and history of cardiovascular disease (CVD), neuropathy and foot ulceration obtained from medical records. RESULTS: 240 participants were recruited (96% type 2 diabetes; age 68.7 ±â€¯10.5 y; 58% men; diabetes duration 14.3 ±â€¯11.4 y). Sixty seven percent of participants reported undertaking moderate or vigorous intensity exercise to recommended levels, and 29% reported no moderate-vigorous exercise. In addition to being associated with known demographic and biochemical risk factors and other complications, diabetes complications were also associated with different physical activity behaviours. Individuals with a history of CVD were more likely to participate in moderate-vigorous exercise and meet exercise guidelines, individuals with neuropathy undertook less walking and moderate intensity exercise, and those with a history of foot ulceration sat more and participated less in vigorous exercise. CONCLUSIONS: In Australian adults, the presence of diabetes complications may influence physical activity participation, and associate with characteristic physical activity approaches.

Independent factors associated with wearing different types of outdoor footwear in a representative inpatient population: a cross-sectional study.

BACKGROUND: Footwear can have both a positive and negative impact on lower limb health and mobility across the lifespan, influencing the risk of foot pain, ulceration, and falls in those at risk. Choice of footwear can be influenced by disease as well as sociocultural factors, yet few studies have investigated the types of footwear people wear and the profiles of those who wear them. The aim of this study was to investigate the prevalence and factors associated with outdoor footwear type worn most often in a representative inpatient population. METHODS: This study was a secondary data analysis of a cohort of 733 inpatients that is highly representative of developed nations' hospitalised populations; 62 ± 19 years, 55.8% male, and 23.5% diabetes. Socio-demographic, medical history, peripheral arterial disease, peripheral neuropathy, foot deformity, foot ulcer history, amputation history and past foot treatment variables were collected. Participants selected the footwear type they mostly wore outside the house in the previous year from 16 types of footwear. Multivariate logistic regression identified independent factors associated with outdoor footwear types selected. RESULTS: The most common outdoor footwear types were: running shoes (20%), thongs/flip flops (14%), walking shoes (14%), sandals (13%) and boots (11%). Several socio-demographic, medical history and foot-related factors were independently associated (Odds Ratio; 95% Confidence Interval)) with different types of footwear. Running shoes were associated with male sex (2.7; 1.8-4.1); thongs with younger age (0.95 for each year; 0.94-0.97), being female (2.0; 1.2-3.1) and socio-economic status (3.1; 1.2-7.6); walking shoes with arthritis (1.9; 1.2-3.0); sandals with female sex (3.8; 2.3-6.2); boots with male sex (9.7; 4.3-21.6) and inner regional (2.6; 1.3-5.1) and remote (3.4; 1.2-9.5) residence (all, p < 0.05). CONCLUSIONS: We profiled the types of outdoor footwear worn most in a large diverse inpatient population and the factors associated with wearing them. Sex was the most consistent factor associated with outdoor footwear type. Females were more likely to wear thongs and sandals and males boots and running shoes. Overall, this data gives insights into the socio-demographic, medical and other health factors that are related to footwear choice in a large diverse population primarily of older age.

How sensitive and specific is continuous-wave Doppler for detecting peripheral arterial disease in people with and without diabetes? A cross-sectional study.

BACKGROUND: Continuous-wave Doppler is frequently used for detecting peripheral arterial disease in patients with diabetes; however, there is limited evidence investigating diagnostic accuracy. This study aimed to determine sensitivity and specificity of continuous-wave Doppler for detecting peripheral arterial disease in populations with, and without, diabetes and to investigate the influence of disease severity on sensitivity of continuous-wave Doppler for detecting peripheral arterial disease. RESULTS: Data from 396 participants were included. Using colour Duplex ultrasound as reference standard (N=66), printed continuous-wave Doppler waveform analysis sensitivity was 81.75% (95% confidence interval: 76.75 to 85.88) and specificity 89.34% (95% confidence interval: 82.62 to 93.67). Printed continuous-wave Doppler waveform analysis sensitivity for peripheral arterial disease was comparable to sensitivity calculated using angiography as the reference standard (81.67%; 95% confidence interval: 69.56 to 90.48). Sensitivity and specificity were unaffected by diabetes diagnosis (n = 176), sensitivity 82.76% (95% confidence interval: 74.86 to 88.55), and specificity 88.33% (95% confidence interval: 77.82 to 94.23). CONCLUSION: Continuous-wave Doppler is a fair assessment tool for peripheral arterial disease in a community-based sample with suspected peripheral arterial disease. Diagnostic accuracy of continuous-wave Doppler for peripheral arterial disease is unaffected by the presence of diabetes.

Diagnostic accuracy of the postexercise ankle-brachial index for detecting peripheral artery disease in suspected claudicants with and without diabetes.

The postexercise ankle-brachial index (ABI) is recommended in patients with normal resting ABI when peripheral artery disease (PAD) is suspected. The aims of this study were to determine the comparative diagnostic accuracy of the resting and postexercise ABI for detecting PAD, and, the effect of the presence of diabetes on these. Three methods of interpretation currently in use were also investigated: a reduction in postexercise ABI by >20% compared to resting ABI, an ABI value of ≤0.90 postexercise, or a reduction in systolic ankle pressure of >30 mmHg postexercise. This retrospective study used colour duplex ultrasound (CDU) as the reference standard. In 278 limbs (whole group), the resting ABI had an overall area under the curve (AUC) of 0.71, with the postexercise ABI yielding a similar diagnostic accuracy of AUC 0.72. In the non-diabetes group ( n=171), the resting ABI had an overall AUC of 0.74 and the postexercise ABI had a similar AUC of 0.76. In the diabetes group ( n=107), overall accuracy was reduced compared to the non-diabetes group, with the resting ABI having an overall AUC of 0.65 and the postexercise ABI yielding a similar accuracy with an AUC of 0.64. The overall diagnostic accuracy of the postexercise ABI for diagnosing PAD was not greatly improved compared to resting ABI. Given the lower overall diagnostic accuracy in the diabetes group, both the resting and the postexercise ABI results in diabetes populations should be interpreted with caution. There is a risk of undiagnosed disease if relying on these results alone to determine lower limb vascular status.

Venous Thromboembolism in Podiatric Foot and Ankle Surgery.

BACKGROUND: The extent to which podiatric surgeons follow venous thromboembolism guidelines is unknown. The aim of this study therefore, was 2-fold: (a) to determine the rate of venous thromboembolism following podiatric surgery and (b) to investigate the factors that influence the use of thromboprophylaxis. METHODS: Data from 4238 patients who underwent foot and ankle surgery over 2 years were analyzed. Venous thromboembolism within the first 30 days following surgery was recorded using the Australasian College of Podiatric Surgeons surgical audit tool. Logistic regression analyses were undertaken to determine the factors that influenced thromboprophylaxis. RESULTS: Of the 4238 patient records, 3677 records (87%) provided complete data (age range 2-94 years; mean ± SD, 49.1 ± 19.7 years; 2693 females). A total of 7 venous thromboembolic events (0.2% rate) were reported. Operative duration and age (OR 12.63, 95% CI 9.47 to 16.84, P < 0.01), postoperative immobilization (OR 6.94, 95% CI 3.95 to 12.20, P < 0.01), and a prior history of VTE (OR 3.41, 95% CI 1.01 to 11.04, P = 0.04) were the strongest predictors of thromboprophylaxis. CONCLUSION: Podiatric foot and ankle surgery is associated with a low rate of venous thromboembolism. This may be due in part to the thromboprophylaxis regime implemented by podiatric surgeons, which closely aligns with current evidence-based guidelines. LEVELS OF EVIDENCE: Level II: Prospective cohort study.

Diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: a cross-sectional retrospective case-control study.

BACKGROUND: The resting systolic toe pressure (TP) is a measure of small arterial function in the periphery. TP is used in addition to the ankle-brachial index when screening for peripheral arterial disease (PAD) of the lower limb in those with diabetes, particularly in the presence of lower limb medial arterial calcification. It may be used as an adjunct assessment of lower limb vascular function and as a predictor of wound healing. The aim of this study was to determine the diagnostic accuracy of TP for detecting PAD in people with and without diabetes. METHODS: This was a retrospective case-control study. Two researchers extracted information from consecutive patient records, including TP measurements, colour Duplex ultrasound results, demographic information, and medical history. Measures of diagnostic accuracy were determined by receiver operating curve (ROC) analysis, and calculation of sensitivity, specificity, and positive and negative likelihood ratios. RESULTS: Three hundred and nintey-four participants with suspected PAD were included. In the diabetes group (n = 176), ROC analysis of TP for detecting PAD was 0.78 (95%CI: 0.69 to 0.84). In the control group (n = 218), the ROC of TP was 0.73 (95%CI: 0.70 to 0.80). TP had highest sensitivity when anatomical distribution of disease was both proximal and distal (diabetes group: 79.49%, the control group: 82.61%). TP yielded highest sensitivity in mild disease (50-75% stenosis) in diabetes group, (81.82%) and moderate disease (>75% stenosis) in control group (80.77%). CONCLUSIONS: Our findings indicate that TPs are useful to assist in diagnosing PAD in clinical practice, however, results should be interpreted with caution due to the small probability of PAD being present with a negative test.

Post-occlusive reactive hyperaemia of skin microvasculature and foot complications in type 2 diabetes.

AIMS: Diabetes-related microvascular disease has been implicated in the development of foot ulceration and amputation. Assessment of microvascular function may be effective in identifying those at risk of diabetic foot complications. We investigated the relationship between active or previous foot complication and post-occlusive reactive hyperaemia (PORH) measured by laser-Doppler fluxmetry (LDF) in people with type 2 diabetes. METHODS: PORH measures were obtained from the hallux apex in 105 people with type 2 diabetes. Associations were investigated between active or previous foot complication and PORH measures: time to peak (TtPeak) and peak as a percentage of baseline (P%BL). Multinomial logistic regression was used to determine the association of PORH with the likelihood of active foot ulcer or previous foot complication. RESULTS: For each second increase in TtPeak, the likelihood of a participant having a history of foot complication is increased by 2% (OR=1.019, p=0.01). This association was not reflected in people with an active foot ulcer (OR=1.003, p=0.832). P%BL was not found to be significantly different between those with a current or previous foot complication and those without (p=0.404). CONCLUSIONS: This investigation in a cohort with type 2 diabetes has demonstrated that longer TtPeak is associated with history of diabetic foot complications.

Computed tomography derived bone density measurement in the diabetic foot.

BACKGROUND: The accurate and reliable measurement of foot bone density is challenging and there is currently no gold standard technique. Such measurement is particularly valuable in populations at risk of foot bone pathology such as in those with long term diabetes. With research and development, computed tomography may prove to be a useful tool for this assessment. The aim of this study was to establish the reliability of a novel method of foot bone density measurement in people with diabetes using computed tomography. METHODS: Ten feet in people with diabetes were scanned with computed tomography twice with repositioning. Bone density (in Hounsfield units) was assessed in the trabecular and cortical bone in all tarsals and metatarsals. Reliability was assessed with intra-class correlation coefficients (95% confidence intervals), limits of agreement and standard error of measurement. RESULTS: The reliability of the trabecular density of most bones was excellent with intra-class correlation coefficients ranging from 0.68 to 0.91. Additionally, cortical bone density showed fair to good reliability at the talus (0.52), calcaneus (0.59), navicular (0.70), cuboid (0.69), intermediate cuneiform (0.46) and first metatarsal (0.61). CONCLUSIONS: The study established the reliability of a practical method of assessing the trabecular and cortical foot bone density using computed tomography scanning. This methodology may be useful in the investigation of foot bone disease occurring in diabetes and its early diagnosis, intervention and assessment of treatment efficacy. Further development of this method is warranted.

Peripheral sensory neuropathy is associated with altered postocclusive reactive hyperemia in the diabetic foot.

OBJECTIVE: This study examined whether the presence of peripheral sensory neuropathy or cardiac autonomic deficits is associated with postocclusive reactive hyperemia (reflective of microvascular function) in the diabetic foot. RESEARCH DESIGN AND METHODS: 99 participants with type 2 diabetes were recruited into this cross-sectional study. The presence of peripheral sensory neuropathy was determined with standard clinical tests and cardiac autonomic function was assessed with heart rate variation testing. Postocclusive reactive hyperemia was measured with laser Doppler in the hallux. Multiple hierarchical regression was performed to examine relationships between neuropathy and the peak perfusion following occlusion and the time to reach this peak. RESULTS: Peripheral sensory neuropathy predicted 22% of the variance in time to peak following occlusion (p<0.05), being associated with a slower time to peak but was not associated with the magnitude of the peak. Heart rate variation was not associated with the postocclusive reactive hyperemia response. CONCLUSIONS: This study found an association between the presence of peripheral sensory neuropathy in people with diabetes and altered microvascular reactivity in the lower limb.

Foot bone density in diabetes may be unaffected by the presence of neuropathy.

AIMS: Neuropathies are common complications of diabetes and are proposed to influence peripheral bone, principally via an altered vascular supply. This study aimed to determine the relationship between subtypes of neuropathy and vascular reactivity on foot bone density in people with diabetes. METHODS: A case-control observational design was utilised with two groups: those with diabetic peripheral large fibre neuropathy (n=23) and a control group with diabetes but without neuropathy (n=23). Bone density in 12 foot bones was determined with computed tomography scanning. Additionally, post-occlusive reactive hyperemia, presence of small fibre neuropathy and heart rate variability were determined. T-tests and hierarchical regression were used to examine the relationships among the variables. RESULTS: No difference in foot bone density was found between those with and those without large fibre neuropathy. Furthermore, no association between heart rate variability or reactive hyperemia and bone density was found. Small fibre neuropathy was associated with increased cuboid trabecular bone density (p=0.006) with its presence predictive of 14% of the variance. CONCLUSIONS: This study found no clear association between presence of diabetic neuropathies and foot bone density. Furthermore, vascular reactivity appears to have no impact on bone density.