This thesis “Assessment of the plantar pressure in the relation with nerve conduction, and ankle-brachial index ABI in type 2 diabetes patients” aims to:1.. Assessment the plantar pressu
Trang 1The increase of diabetes prevanlence also accords to itscomplication It is the cause of cardiovascular accidents, blindness,renal failure, amputation and others which reduce life quality In
2015, the association of foot wound, the foot complication ofdiabetes has enormously affected the national economics, theprevalence in the developed country is about 2% to 4%, and could behigher in the developing country The worldwide rate of diabetic footulcer is 6,3%, male is higher than female, type 2 higher than type 1.The North America had highest prevalence 13%, then Australia3,0%; Asia 5,5%, Africa 7,1%, European 5,1% In India, about 5%diabetic patients have the foot wound The porpotion of amputation
in diabetic foot complication is 40% In the developping country likeEngland, 50% diabetics patients were admitted because of footwound Another research in 6000 patients showed that foot ulcer was20% and amputation was 2,5%
In many researches of the Vietnam National Hospital ofEndocrinology showed that the prevalence of late stage diabeticpatients with the foot and amputation complications was high (about40%)
The foot complication is the consequence of causes such as:nerves, vessels, injuries, trauma and infection The diabetic footcomplication mechanism is the close combination of three factors:vascular, nerve injuries and infection, sometimes these factors couldappear independently Some studies showed that the pressure points
of foot have a close relationship with the foot ulcer Therefore, theplantar pressure is the predictive factor in diabetic foot complicationpatients
However, there is no research which evaluates the change ofplantar pressure in term of recognization, prevention and reduce thefoot injuries of diabetic patients
Trang 2This thesis “Assessment of the plantar pressure in the relation with nerve conduction, and ankle-brachial index (ABI) in type 2 diabetes patients” aims to:
1 Assessment the plantar pressure and some nerve conduction index, ankle-brachial index in type 2 diabetes patients.
2 Evaluation the relation between the plantar pressure, nerve conduction index, ankle-brachial index and characteristics in type 2 diabetes patients.
The new contribution of the thesis:
- This thesis showed that the prevalence of increase plantarpressure measured in the base of the first toe in the diabeticpatients was 79,4% and base of the third toe was 44,4%
- The plantar pressure increased with the level of nerve injury Itwas statistically significant between the plantar pressure andthe potential nerve conduction
- The plantar pressure in diabetic patients increases with thelevel of peripheral artery (assessed by the ABI), significantlypositive correlation with the plantar pressure of the second,third and fifth toes (assessed by the ABI)
Structure of the thesis
This thesis includes 122 pages: Introduction 2 pages, Generaldescription 34 pages, Subjects and Methodology 21 pages, Result 30pages, Discussion 33 pages, Conclusion 1 page, Proposal 1 page, 52tables, 5 graphs, 1 map, 12 pictures, 122 references (33 Vietnamese,
Trang 31.1.2 Risk factors
The risks factors of type 2 diabetes are classified in four categories:genetics, human race, habits, lifestyle, and intermediate risks
Genetic factors
Human race (age, gender, race)
Lifestyle and habits relating risk factors
Obesity (distribution and related risk factors)
Inactivity
Diet
Others
- Stress
- Lifestyle: urbanization, modernization
- The factors which relate to the gestation such as: status ofdelivery, gestation diabetes, diabetes, the next generation of thediabetic patients, the uterus environment
1.1.3 The diagnosis criteria of diabetes
- Fasting plasma glucose (FPG) ≥ 7mmol/l (126mg/dl) Fasting atleast 8 hours before blood test Or
- Plasma glucose after 2 hours ≥ 11,1 mmol/l (≥ 200mg/dl) withthe oral glucose tolerance test (WHO), 75 g glucose (anhydrousglucose) diluted in 200 ml water Or
- HbA1c ≥ 6,5 % (48mmol/mol), blood test approved by the NGSP and standardized in DCCT assay
Or
- Typical signs and symptoms of hyperglycemia (polyuria, polydipsia, polyphagia, lose weight), beside HbA1c, there are others tests have to be re-done to confirm the diagnosis The second time doing the test should be further from the first time 1-7 days
1.2 The plantar pressure
Trang 41.2.2 The factors of plantar pressure increasing
* Neurologic factors:
- Motor nerve: It seems to be the most important factor which
increases the plantar pressure
- Autonomic nerve: the disorder closely relates to the
degeneration of sensory nerve
* Peripheral vascularization: the peripheral vascular disease is
also important factor of increase plantar pressure
* Immobility of joint
* Other factors: Age, gender, weight, amputation, race
1.2.3 The consequence of plantar pressure increasing:
- Foot corn
- Foot deformity
- Foot ulceration
- Amputation
1.2.4 The solutions for reducing the plantar pressure
It is the first priority in the treatment
1.3 The neuropathies in diabetes
The neuropathy in diabetes: symptomatic reduction function of nerve fiber (pain, needling, numbness…) or asymptomatic (after ruling out other causes)
1.3.1 The classification of diabetic neuropathy:
- Peripheral neuropathy is the most important complication Theprevalence increases with the time of diagnosis With the type 2diabetes, the neuropathy usually appears at the time of diagnosis,even before years
- The diabetic neuropathy are sensory, motor, and autonomic
- Phân loại dựa theo kiểu hình tổn thương của hệ thần kinh ngoạibiên được sử dụng rộng rãi nhất, theo cách phân loại này, có thể phân chiacác bệnh thần kinh ngoại biên ra thành hai nhóm lớn là nhóm có triệuchứng phân bố đối xứng và nhóm có triệu chứng phân bố không đối xứng
Trang 51.3.2 The evaluating method of neuropathy lesion.
- Two basic techniques of electromyography diagnosis:surveillance of the nerve conduction and needle electrode
- The surveillance of EMG helps to evaluate the ability ofelectrical conduction of peripheral nerve The concerned index arethe peripheral motor potential time (or sensory), the conductionspeed, the average potential time, and the frequency of F and Hwaves
1.4 The vascular lesion in diabetic foot patients
- The obstruction of the peripheral vascular is the secondimportant cause of foot ulcer in diabetes It is affected by the:adhesive level of platelets, number of monocytes, lipidemia, smoothmuscle, calcium concentration … This condition is much moresevere in the high risk subjects such as: hypertension, smoking,obesity… The mechanisms are:
- Atherosclerosis
- Vascular obstruction causing by the platelets
- Less elasticity, less oxygenation, less nutrition…
1.4.2 The evaluating the vascular lesion method of lower limbs
- There are varieties of method which evaluate the lower limbsvasculopathy In this study, the ABI was used, measured by the pulseDoppler handling machine
+ Ankle-brachial index (ABI).
+ Vascular Doppler ultrasound …
1.5 The studies of plantar pressure, nerve conduction index and ABI
* The studies of plantar pressure
- Yang Chang et al studied the change of plantar pressure in
Chinese diabetic patients The cross-sectioned study in 649 diabeticpatients and 808 normal Chinese people who had got diabetes, allwas measured by the EMED AT system It showed that the totalplantar pressure and its distribution were different It could be a
factor which contributes the foot ulcer
- In 2014 Fernando performed a cross-section study whichcompared the pressure in the diabetic patients with neuropathic andulcerative foot complication It showed that the plantar pressure in
Trang 6the diabetic patients with neuropathic complication and history ofulceration was higher than individuals without history of ulceration.
- In 2014 Tuna Hakan, Birane Murat et al studied in 84 type 2diabetic patients, showed the decrease of contact square and theincrease of foot peak pressure in the more than 10 years diabeticpatients
- In 2012, Anita Raspovic 1, Karl B Landorf showed the keyrole of plantar pressure reduction in the prevention and treatment offoot ulceration in diabetic patients
- A study of Madhale Milka D, Godhi Ashoc S in 2017 pointing
on the plantar pressure evaluation measured by the machine Novel,performed in 110 Indian patients, who was separated into 4 groups(normal: 30 subjects, type 2 diabetic patients: 30 patients, type 2diabetic patients with the peripheral complication: 19 patients;diabetic patients with foot ulceration: 31 patients) showed thesignificance of plantar pressure observation in prevention andreduction the foot ulceration in type 2 diabetic patients
* The researches of ABI
- In 2011, Nghi Tran Bao and Dung Ho Thuong researched thediagnosis value of ABI index and the risk factor in the peripheralartery disease of the lower limb in the diabetic patients, the cross-section study showed: the sensitivity and specificity of ABI in theperipheral artery disease diagnosis was 90,9 % and 91,0%,respectively
- In 2012 Bao Le Hoang and Dao Nguyen Thi Bich performed in
153 type 2 diabetic patients It showed that the proportion of ABI <0,91: 23,5%; ABI 0,91 – 1,3: 73,9%; and ABI > 1,3: 2,6%
- In 2018 Ngan Nguyen Thi and Nhan Nguyen Thi performed aresearch of the risk factors, ABI, Doppler ultrasound of lower limbartery in the diabetic patients, this cross section study in the InternalMedicine Department of Hue Central Hospital It showed that 26,3%diabetic patients with ABI < 0,9; 69,5% diabetic patients with ABIranged from 0,91 to 1,3 and 4,2% patients with ABI > 1,3
* The research of peripheral nervepathy
Trang 7- In 2012 Kha Ton That and Hung Nguyen Trong studied aboutperipheral neuropathy in 84 type 2 diabetic patients It showed the100% patients with abnormal EMG.
- In 2015 Banach M et al studied the benefits of nerveconduction mesurement in diabetic patients with polyneuropathic Itshowed that 57% patients with the abnormalities in EMG diagnosisand decrease amplification of sensory and mortor conduction oflower limb
- In 2015 Prasad N et al studied in 40 type 2 diabetic patients,average age 2,28±1,51 years old It showed the decrease of nerveconduction between the diabetic patients 54,32±6,03m/s incomparison with non diabetic patients 59,52±6,51m/s
- In 2016 Truong Pham Cong, Vinh Hoang Trung performed aprospective cross section study in 53 type 2 diabetic patients in HoChi Minh city It showed that the proportion of objective sensoryabnormality increases with the prolong of diagnosis and untrollableHbA1c level The sensory and motor conduction amplificationmeasured in the median nerve was positive correlation; the potentialmotor and sensory conduction time measured in the median nervewas negative correlation with HbA1c The conduction amplificationand velocity measured in the tibia nerve was negative correlationwith HbA1c
Chapter 2: SUBJECTS AND METHODOLOGY
2.1 Subjects
The patient group (the case): 126 patient with type 2 diabetes,examined and treated in the National Hospital of Endocrinology All
of them was satisfied the inclusion and exclusion criteria
The controls: 40 healthy individuals who satisfied the inclusionand exclusion criteria
2.1.1 Inclusion criteria
* The criteria of the case:
- Type 2 diabetic patients ≥ 30 years old with male and female
- Informed consent and accepted to joint the study
- Enough the necessary data for the study
* The control criteria:
- Healthy individuals who had the casual examination ≥ 18 yearsold with male and female
Trang 8- Without obesity or overweight
- Without chronic diseases: shock, stroke, paralysis
- Non-pregnancy woman
- Informed consent and accept to joint the study
- Enough the necessary data for the study
2.1.2 The exclusion criteria
* For the case:
- Type 2 diabetic patients with the foot complication (ulcerationmore than level 3 and amputation)
- Acute disease: shock, stroke
- Pregnancy woman
- Unconsented patients
- Unable to measure the plantar pressure
* For the controls:
- Acute and chronic diseases
- Overweight, obesity, pregnancy woman
Plantar pressure measurement: In this thesis, the plantar pressure
of the control (TB ± 1SD) would be used as the criteria forcomparing with the case
+ The plantar pressure of case > TB ± 1SD of the control isconsidered as increase
+ The plantar pressure of case < TB ± 1SD of the control is
considered as decrease
The data analysis: using the softwear SPSS 22.0.
Trang 9+ Logarithms technique to show the standard distribution beforeanalysis
+ The avarage value define, standard deviation, median, avaragemultiplies with the 95%CI
+ Comparison the averages by the T test Chi-Square andFissher Exact was employed to compare the difference %
+ Nonparametric statistics to compare medians
+ Correlation coefficient
+ Regression line defined by the linear regression
Chapter 3: RESULTS 3.1 The characteristics of the subjects
Table 3.1 The distribution of gender and age of subjects
Age groups
The controls (n = 40)
Trang 10The controls The case0
Graph 3.1 The distribution of the subjects regarding to gender
Male was more prominent than female in case group, and equal
in the control group
Table 3.2 Phân bố đối tượng theo yếu tố nguy cơ và giới của nhóm
- The time to diagnosis > 10 years was the most common
- Hypertension took 33,3% patients
- Dyslipidemia was 80,9% patients, male and female was equal
Table 3.3 The anthropometric characteristics
Anthropometric Control
(n=40)
Case
Trang 11BMI 21.10 ± 2.16 22.96 ± 3.07 < 0.05
The body weight, BMI, waist and hip, waist/hip of casegroup was higher than the control, statistical significance p< 0.05
Table 3.4 The biochemical tests of case group
3.2.1 The change of plantar pressure
Table 3.5 Characteristics of peak pressure of right foot
- The peak pressure of other regions in the foot was notsignificantly different
Trang 12Table 3.6 The distribution of the foot peak pressure
In the increase foot peak pressure, the most common locationwas the first toe then the second toe
Table 3.7 The characteristics of peak left plantar pressure
Peak left plantar
pressure
Control (n=40)
First toe (kpa) 237.29 ± 139.22 284.64 ± 133.54 <0.05
Second toe (kpa) 143.36 ± 119.73 122.74 ± 56.32 >0.05
3th 4th 5th toes (kap) 96.73 ± 50.14 89.01 ± 51.40 >0.05
- The whole plantar pressure, and peak pressure in the heel,MH1, MH2, MH3 in the case was higher than the control, statisticalsignificance
- The foot peak pressure of other regions in the case was not statistically different with the control
Table 3.8 The change of left foot peak pressure
Trang 13Left foot peak
In the increase foot peak pressure, the pressure of the third toe washighest and the lowest was second toe
3.2.2 The change of nerve conduction index
Table 3.9 The nerve conduction index of common peroneal
(fibular) nerve
Potential time (ms)
(min – max) 10.53 ± 1.30(7.6 – 15.3) 10.42 ± 1.25(8.1 – 16.8) > 0.05Amplitude (mV)
(min – max)
3.95 ± 1.94(0.5 – 8.9)
3.92 ± 1.69(0.4 – 7.5) > 0.05Velocity (m/s)
(min – max) 44.13 ± 4.05(33 – 56) 44.77 ± 3.63(35 – 54) > 0.05
There was no statistically significant difference of conduction between the right and left common peroneal nerves
Table 3.10 The conduction of tibia nerve
Index Right tibia nerve Left tibia nerve p
Potential time (ms)
(min – max)
12,56 ± 1,61(9,3 – 18,8)
12,41 ± 1,69(8,7 – 19,3)
>0,05Amplitude (mV)
(min – max)
9,67 ± 6,80(0,1 – 74)
8,84 ± 5,71(0,3 – 60,2)
>0,05Velocity (m/s)
(min – max)
43,26 ± 4,69(26 – 54)
42,85 ± 4,06(29 – 53)
>0,05