Piergiorgio Francia

The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer

AIMS Evaluation of how ankle joint mobility (AJM) can be useful in the identification of patients with diabetes at risk of foot ulcer (FU). METHODS Plantar and dorsal flexion of foot were evaluated using an inclinometer in 87 patients (54 type 2 and 33 type 1), and 35 healthy sex- and age-matched control subjects. Patients with diabetes were followed up for diagnosis of FU over the next 8 years and subsequently, patients were subdivided into: those without a history of FU (18 type 1 and 33 type 2), those who had a history of FU detected before baseline evaluation (14 type 2) and those who had history of first ulceration detected by the 8th year of the evaluation period (7 type 2). RESULTS Aging and diabetes caused a significant reduction in mobility of each of the movements investigated (p<0.001), whereas after adjusting for the confounding effect of age, diabetes specifically reduced plantar flexion (p<0.0001). AJM was significantly lower in those with history of previous FU compared to all the other groups (p<0.001). The first ulceration was detected in the same foot presenting lower AJM in 17 of the 22 subjects with diabetes with history of ulcer (77.27%). CONCLUSIONS Diabetes and aging reduce AJM although diabetes seems to reduce plantar flexion to a more specific extent. Reduced AJM is mostly associated with a previous history of FU. The evaluation of AJM is a valid and reliable ulcer risk scale that indicates which foot is at higher ulcer risk.

Diabetic Foot and Exercise Therapy: Step by Step The Role of Rigid Posture and Biomechanics Treatment

Lower extremity ulcers represent a serious and costly complication of diabetes mellitus. Many factors contribute to the development of diabetic foot. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute in turn to the growth of additional risk factors such as limited joint mobility, muscular alterations and foot deformities. Moreover, a deficit of balance, posture and biomechanics can be present, in particular in patients at high risk for ulceration. The result of this process may be the development of a vicious cycle which leads to abnormal distribution of the foots plantar pressures in static and dynamic postural conditions. This review shows that some of these risk factors significantly improve after a few weeks of exercise therapy (ET) intervention. Accordingly it has been suggested that ET can be an important weapon in the prevention of foot ulcer. The aim of ET can relate to one or more alterations typically found in diabetic patients, although greater attention should be paid to the evaluation and possible correction of body balance, rigid posture and biomechanics. Some of the most important limitations of ET are difficult access to therapy, patient compliance and the transitoriness of the results if the training stops. Many proposals have been made to overcome such limitations. In particular, it is important that specialized centers offer the opportunity to participate in ET and during the treatment the team should work to change the patient’s lifestyle by improving the execution of appropriate daily physical activity.

History, prevalence and assessment of limited joint mobility: from stiff hand syndrome to diabetic foot ulcer prevention

Background Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient’s condition and for the prevention of vascular disease and diabetic foot. Objectives The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers. Methodology An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications. Results Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient’s condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed. Conclusion Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

Type 1 diabetes, sport practiced, and ankle joint mobility in young patients: What is the relationship?

It is known that patients with diabetes can develop limited joint mobility (LJM) and that this can depend on the metabolic control maintained and the duration of the disease. The aims of this study were to verify the presence of ankle joint mobility (AJM) deficits in both plantar and dorsiflexion in young type 1 diabetic patients (T1D) considering also the possible role of sport practiced as a further factor, able to modify AJM.

A mathematical model of the effect of metabolic control on joint mobility in youngtype 1 diabetic subjects

Diabetes mellitus is a metabolic disorder representing one of the main problems for the global public health. The impairment of metabolic control can influence periarticular tissue and other major risk factors of limited joint mobility (LJM) also in young type 1 diabetic patients. LJM is a widespread phenomenon in diabetic patients and it is often characterized by ankle stiffness. In particular, a deficit of ankle joint mobility may occur with the onset of the disease; later, this deficit tends to deteriorate in presence of a poor glycemic control. We hypothesized a mathematical model of diabetes mellitus long-term effects, assuming that a reduced metabolic control affects joint mobility according with a Gaussian function: it requires some time for developing a reduction of joint mobility, that persists for a stable period, before fading out with time (in case metabolic control has been recovered). A non-linear optimization estimated the model parameters for obtaining the best fit over a set of patients. Results are in good accordance with empirical estimates: lack of control needs to persist for at least a few months before generating a sensible effect, that persists for up to one year.

Multi-gaussian Decomposition of the Microvascular Pulse Detects Alterations in Type 1 Diabetes

Among diabetic patients, microangiopathy represents a relevant cause of morbidity and mortality. Diabetes induces detrimental changes in the biomechanical characteristics of blood microvessels, and fuels the development of a dysfunctional vascularization. Since the structural properties of the circulatory system affect the microvascular pulse, the aim of this study was to detect these vascular alterations through a model-based quantitative analysis of its waveform. Baseline microvascular perfusion was recorded on the hallux with a laser Doppler flowmeter. 54 healthy subjects (age: 34 ± 26 years) and 22 type 1 diabetic (T1D) patients without known cardiovascular complications and smoking history (age: 34 ± 17 years) were compared. A novel multi-Gaussian decomposition algorithm was applied to reconstruct the heartbeat-related oscillations, which were evaluated according to normalized and physiologically-motivated shape descriptors. Eight out of the nine properties assessed significantly differed between the groups (p < 0.001), indicating that the proposed pulse modeling method is sensitive to the effects of T1D on the peripheral perfusion.

Wavelet Phase Coherence Between the Microvascular Pulse Contour and the Respiratory Activity

A wavelet phase coherence (WPC) analysis was conducted in order to evaluate the time-phase relationships between the respiratory activity and the pulse of the peripheral perfusion. The investigation involved a group of 21 young healthy subjects, aged from 20 to 30 years. Cutaneous perfusion was measured by laser Doppler flowmetry, while breathing was simultaneously monitored with a wearable chest band. A multi-Gaussian modeling algorithm was used to decompose the pulse waveform thus enabling the separate characterization of the forward-travelling systolic pulse and the diastolic components arising from vascular impedance mismatch. The WPC between model-derived shape features and the breathing rhythm was assessed, to determine whether their characteristic oscillations were somehow synchronized. In 17 subjects a significant degree of phase coherence was detected in the respiratory frequency band for the area beneath the diastolic phase of the cardiac pulse. This result indicates that the microvascular reflection waves exhibit a marked periodicity linked to the breathing activity.

Glycemic Control Maintained over Time and Joint Stiffness in Young Type 1 Patients: What Is the Mathematical Relationship?

Background: It is widely known that diabetes can induce stiffness and adversely affect joint mobility even in young patients with type 1 diabetes mellitus (T1D). The aim of this study was to identify a mathematical model of diabetes mellitus long-term effects on young T1D patients. Methods: Ankle joint mobility (AJM) was evaluated using an inclinometer in 48 patients and 146 healthy, sex- BMI-, and age-matched controls. Assuming time invariance and linear superposition of the effects of hyperglycemia, the influence of T1D on AJM was formalized as an impulse response putting into relationship past supernormal HbA1c concentrations with the ankle total range of motion. The proposed model was identified by means of a nonlinear evolutionary optimization algorithm. Results: AJM was significantly reduced in young T1D patients (P < .001). AJM in both plantar and dorsiflexion was significantly lower in subjects with diabetes than in controls (P < .001). The identified impulse response indicates that impaired metabolic control requires 3 months to bring out its maximum effect on the reduction of AJM, while the following long-lasting decay phase with the expected AJM recovery times, normally depends on the slow turnover of collagen. HbA1c concentration levels above 7.2% are sufficient to produce a reduction of ankle ROM. Conclusions: In young patients with T1D the lack of glycemic control over time affects AJM. HbA1c levels can serve as a relevant prognostic factor for assessing the progression of LJM in subjects with diabetes.

A mathematical model appraising the effect of metabolic control on joint mobility in young diabetic patients: a preliminary study

Objective. The impairment of glycemic control can induce limited joint mobility even in young type 1 diabetic (T1DM) patients. The aims of this study were to verify the presence of ankle joint mobility (AJM) deficits in young T1DM subjects and define a mathematical model of diabetes mellitus long-term effects on AJM. Methods. AJM was evaluated using an inclinometer in 37 patients and 53 healthy, sex- BMI- and age-matched controls. To set up the mathematical model, we assumed that reduced metabolic control affects AJM according to a lognormal function: requiring some time for development of a reduction of joint mobility, which then persists for a long period, before fading out over time (if glycemic control has been recovered). A non-linear optimization determined the model parameters to achieve the best fit for a series of patients. Results. Both plantar and dorsiflexion AJM was significantly lower in diabetic subjects than in controls (plantarflexion: 28.5°±7.5 vs 35.2°±6.5; dorsiflexion: 93.9°±16.0 vs 104.7±12.8; p<0.01). The defined model approximates the experimental data with good accuracy; after optimization, the lognormal curve obtained is in line with empirical estimates: lack of glycemic control needs to persist for at least a few months before producing a significant effect, that lasts up until one year. The fitting procedure indicated the optimal solution is p = (37; 30; 3:5; 6:7; 137); thus, the optimal _im(t) corresponds to the curve reported. Conclusion. AJM was significantly reduced in young T1DM patients. The mathematical model represents the experimental data accurately.

Tapentadol Prolonged Release Reduces the Severe Chronic Ischaemic Pain and Improves the Quality of Life in Patients with Type 2 Diabetes

This study has been performed in diabetic type 2 patients with pain due to peripheral artery disease (PAD) in order to evaluate the efficacy and tolerability of tapentadol prolonged release (PR). Methods. 25 patients with type 2 diabetes (13 F and 12 M) were admitted in the study. The evaluation of the analgesic efficacy of tapentadol PR was based on both the assessment of the intensity of the pain (NRS scale from 0 to 10) and the nature of the pain (DN4 questionnaire) and on assessment of the patients quality of life and state of health (SF-12 Health Survey). Study duration was 3 months: a baseline visit and follow-up included visits after 1 week, 1 month, 2 months, and 3 months. Results. At the beginning of the study, the mean intensity of the pain was 7.88 ± 1.17 on the NRS scale and at visit 2 it reduced in a statistically significant way; at the end of the treatment with tapentadol PR, the mean intensity was 2.84 points on the NRS scale. Conclusion. In type 2 diabetic patients with chronic severe pain due to PAD, tapentadol PR reduced pain intensity, improving the quality of life.