Cutaneous microvascular reactivity in Charcot neuroarthropathy: a systematic review and meta-analysis.

BACKGROUND: To systematically evaluate the literature investigating the relationship between cutaneous microvascular reactivity in the foot of adults with diabetes-related Charcot neuroarthropathy compared to a non-Charcot adult control group. METHODS: A systematic search was conducted to June 2021 using the biomedical databases EBSCO Megafile Ultimate, Cochrane Library and EMBASE. Original research conducting comparative investigation of cutaneous microvascular reactivity in the foot of adults with diabetes and any pattern of acute or chronic Charcot neuroarthropathy and any non-Charcot adult control groups were included. A modified Critical Appraisal Skills Programme tool was used for quality appraisal. Cutaneous microvascular reactivity in diabetes-related Charcot neuroarthropathy data were synthesised and meta-analysis conducted where possible. RESULTS: The search strategy identified 1,684 articles, with seven eligible for inclusion. Included studies used various methodologies and equipment to assess cutaneous microvascular reactivity in 553 participants (162 with Charcot neuroarthropathy). Cutaneous microvascular reactivity in Charcot neuroarthropathy groups was impaired compared to uncomplicated diabetes groups. Meta-analysis investigating the difference in response to thermal hyperaemia demonstrated a significant difference in cutaneous microvascular reactivity between Charcot neuroarthropathy and peripheral neuropathy with a large, pooled effect size (SMD 1.46 95% CI: 0.89-2.02) and low heterogeneity (I2 = 4%, T2 = 0.01) indicating that the cutaneous microvascular response is more impaired in peripheral neuropathy than in Charcot neuroarthropathy. CONCLUSIONS: Charcot neuroarthropathy is associated with greater cutaneous microvascular reactivity in the periphery relative to diabetes cohorts with diabetes-related peripheral neuropathy alone. It is unknown if this occurs prior to, or as a result of, Charcot neuroarthropathy.

The ankle brachial index in people with and without diabetes: intra-tester reliability.

BACKGROUND: The ankle-brachial index (ABI) is widely used for determining the presence and severity of peripheral arterial disease (PAD), and current guidelines suggest it should be used to monitor possible progression in affected individuals. It is therefore important that the technique demonstrates adequate reliability for repeated measurements. Existing studies suggest that the ABI is reliable in the general population however, there is a lack of evidence for the reliability of the ABI in people with diabetes. The aim of this study was to investigate the intra-tester reliability of the ABI in people with and without diabetes. METHODS: Eighty-five participants (40 with and 45 without diabetes) underwent ankle and brachial systolic blood pressure measurements by a single clinician during two testing sessions. Intraclass correlation coefficients (ICC), their 95% limits of agreement, standard error of measurement and minimal detectable change were determined. RESULTS: Intra-tester reliability of the ABI was found to be good (ICC: 0.80), however sub-group analysis of participants with and without diabetes found that ABI was slightly less reliable in people with diabetes (ICC: 0.78) than in those without (ICC: 0.82). The relatively large limits of agreement (- 0.16 to 0.16), standard error of measurement (0.03 overall, 0.04 for the diabetes group), and minimal detectable change (0.08 overall, 0.11 for the diabetes group) suggest that a large change in ABI is required for it to demonstrate a true change rather than the result of measurement variability. The minimal detectable change for the ABI was 0.08 overall, and 0.11 for the diabetes group. CONCLUSIONS: The ABI demonstrated good reliability in all groups analysed. However, the wide limits of agreement and considerable standard error of measurement obtained support the use of multiple methods of vascular assessment for ongoing monitoring of lower limb vascular status.

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.

Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability.

BACKGROUND: Testing of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes. METHODS: Three podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year's clinical experience. The intra- (Cohen's К) and inter-rater (Cohen's or Fleiss' К) reliability of each test was determined. RESULTS: Fifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38-0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41-0.95, p < 0.01). The 10-site monofilament (К: 0.44-0.77) outperformed the 4-site test (К: 0.34-0.67) and the dampened tuning fork method (К: 0.41-0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52-0.57) and graduated methods (К: 0.50-0.57). CONCLUSION: We support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.

Pre-measurement rest time affects magnitude and reliability of toe pressure measurements.

OBJECTIVES: Toe pressures are used to evaluate lower extremity healing capacity and screen for peripheral arterial disease (PAD). Although toe pressures are commonly used clinically both as an independent measure and in the calculation of the toe-brachial index, the effect of pre-measurement rest duration on the magnitude and reliability of toe pressures is unknown. This study investigated the effect of pre-measurement rest duration on toe pressures. METHODS: Seventy community-based participants meeting guidelines for PAD screening were recruited. Systolic toe pressures either at the left or right hallux were manually measured using photoplethysmography following 5, 10 and 15 min of rest in a supine horizontal position. Testing was repeated 7-10 days later. RESULTS: A significant drop in toe pressure (3.86 mmHg) occurred between 5 and 10 min (p = 0.001). No significant change occurred between 10 and 15 min. Reliability after 5 min was excellent (intra-class correlation coefficient, ICC = 0.80, 95% CI 0.68-0.89), increasing slightly at 10 and 15 min (ICC = 0.86, 95% CI 0.77-0.92 and ICC = 0.82, 95% CI 0.69-0.89). CONCLUSIONS: Toe pressures stabilize after 10 min of rest in a supine horizontal position. Longer periods of pre-measurement rest did not improve reliability significantly.