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To evaluate plantar pressure in type 2 diabetic patients. Subjects and methods: 126 type 2 diabetic patients were treated in the National Hospital of Endocrinology (diabetic group); 40 non-diabetic patients (control group).
Journal of military pharmaco-medicine no6-2019 EVALUATING PLANTAR PRESSURE IN TYPE DIABETIC PATIENTS WHO VISITED TO THE NATIONAL HOSPITAL OF ENDOCRINOLOGY Pham Tuan Phuong1; Nguyen Thi Phi Nga2; Phan Viet Nga2 SUMMARY Objectives: To evaluate plantar pressure in type diabetic patients Subjects and methods: 126 type diabetic patients were treated in the National Hospital of Endocrinology (diabetic group); 40 non-diabetic patients (control group) Results: Right foot: Peak pressure index in control group was 334.06 ± 104.06 kpa which was significantly lower than in case group (386.39 ± 123.64 kpa) (p < 0.05); 21.4% of study subjects increased peak pressure The most increase st of the peak pressure was found at the bone foundation of the toe: (79.45%) and the lowest in nd the toe (15.1%) Left foot: Peak pressure index in control group was 316.43 ± 282.14 kpa which was significantly lower than in case group (392.85 ± 369.85 kpa) (p < 0.05); 33.3% of study subjects increased peak pressure, the most increase of the peak pressure in bone rd nd foundation of toe (44.4%), the lowest in bone foundation of toe (2.4%) Conclusion: Peak pressure of foot in sides in the position of total pressure in case group was significantly higher than that in control group with p < 0.05 Peak pressure index: the most increasing positions st were the bone foundation of the toe on the right side (79.4%) and the bone foundation of the rd toe on the left (44.4%) * Keywords: Type diabetes; Plantar pressure INTRODUCTION Diabetic disease has increased with time of prolonged disease, accompanied by increasing in complications of disease Foot ulcer complication is one of the most serious complications, affecting the life quality of patients Global rate of foot ulcer caused by diabetes was 6.3% In Vietnam, there were a lot of researches showed that percentage of diabetic patient with foot complication admitted to the hospital at the late period and percentage of amputating limbs was high, approximately 40% among the diabetic patients with foot disease Plantar injuries caused by diabetic disease are the consequence of many causes such as nervous wounds, blood vessel wounds, trauma and infection and they are closely combined sometimes injuries are able to take place independently Some studies showed that high pressured points in feet are closely related to the foot ulcer injuries Therefore, plantar pressure is a raised factor given to predict the foot injuries early in the diabetic patients National Hospital of Endocrinology 103 Military Hospital Corresponding author: Pham Tuan Phuong (bsphuong80@gmail.com) Date received: 15/06/2019 Date accepted: 05/08/2019 168 Journal of military pharmaco-medicine no6-2019 SUBJECTS AND METHODS height and weight measurement; BMI, measuring waist and hip sizes Subjects 126 type diabetic patients (diabetic group) and 40 healthy people (control group); study duration: from 2015 to 2018 Methods * Techniques used in research: - Interview, history question, clinical examination; blood pressure measurement, - Routine biochemistry tests: Blood glucose; HbA1c; liver function; kidney function; blood lipid - Using the plantar pressure measuring by machine of Emed A50 to measure 10 sections in feet (measuring indexes: Peak pressure; maximum force) RESULTS Table 1: Age distribution by study groups Age group Control group (n = 40) Diabetic group (n = 126) n % n % 20 - 29 years old 15.0 0.0 30 - 39 years old 13 32.5 12 9.5 40 - 49 years old 22.5 21 16.7 50 - 59 years old 12 30.0 62 49.2 ≥ 60 years old 0.0 31 24.6 Average 41.47 ± 10.10 54.19 ± 9.60 p < 0.05 < 0.05 - Case group: Study subjects were distributed in age groups and the group accounting for the highest percentage was 50 to 59 years old and no one was less than 30 years old - Control group: Study subjects in group from 30 to 39 years old accounted for the highest percentage and no one was above 60 years old Male Female Percent % Control group Diabetic group Diagram 1: Gender distribution by study groups Proportion of male was higher than female in control group and study group and this proportion was equivalent 169 Journal of military pharmaco-medicine no6-2019 Table 2: Features of the right plantar pressure by the study groups The right plantar peak pressure (kpa) Control group (n = 40) Diabetic group (n = 126) p Total force 334.06 ± 104.83 386.39 ± 123.54 < 0.05 Heel of foot 185.62 ± 40.04 198.17 ± 50.62 > 0.05 Mid foot 97.29 ± 26.07 107.84 ± 35.04 > 0.05 MH1 151.46 ± 75.52 166.08 ± 69.30 > 0.05 MH2 220.40 ± 52.20 248.09 ± 68.55 < 0.05 MH3 222.60 ± 47.15 246.37 ± 64.69 < 0.05 MH4 158.21 ± 32.91 187.78 ± 56.18 < 0.01 MH5 133.63 ± 73.13 160.45 ± 98.94 > 0.05 Big toe 270.33 ± 133.57 287.53 ± 148.65 > 0.05 Toe 121.21 ± 47.78 128.82 ± 55.87 > 0.05 Toe 3, 4, 85.19 ± 49.09 94.97 ± 50.37 > 0.05 (* MH1: Bone foundation of toe 1; MH2: Bone foundation of toe 2; MH3: Bone foundation of toe 3; MH4: Bone foundation of toe 4; MH5: Bone foundation of toe 5) - Peak pressure of all feet and peak pressure in areas of MH2, MH3, MH4 in diabetic group were higher than those in control group and this difference had statistical significance - Peak pressure in other areas of feet, the difference between diabetic group and control group was not statistical significant Table 3: Changing the right plantar pressure in the study group Peak pressure on the right feet (kpa) Diabetic group (n = 126) Decreasing Normal Increasing n % n % n % Total force 1.6 97 77.0 27 21.4 Heel of foot 18 14.3 70 55.6 38 30.2 Mid foot 11 8.7 83 65.9 32 25.4 MH1 0.8 25 19.8 100 79.4 MH2 15 11.9 70 55.6 41 32.5 170 Journal of military pharmaco-medicine no6-2019 MH3 17 13.5 65 51.6 44 34.9 MH4 12 9.5 57 45.2 57 45.2 MH5 4.8 94 74.6 26 20.6 Big toe 16 12.7 87 69.0 23 18.3 Toe 17 13.5 90 71.4 19 15.1 Toe 3, 4, 7.1 95 75.4 22 17.5 (* MH1: Bone foundation of toe 1; MH2: Bone foundation of toe 2; MH3: Bone foundation of toe 3; MH4: Bone foundation of toe 4; MH5: Bone foundation of toe 5) In subject group of increasing plantar peak pressure, positions of the bone foundation of the 1st toe and the 2nd toe accounted for the highest percentage and lowest percentage, respectively Table 4: Features of the left plantar pressure by study groups Control group Diabetic group (n = 40) (n = 126) Total force 316.43 ± 107.22 392.85 ± 129.21 < 0.001 Heel of foot 184.86 ± 41.13 209.77± 60.72 < 0.05 Mid foot 114.48 ± 35.65 103.14 ± 27.50 > 0.05 MH1 151.12 ± 49.56 182.21 ± 86.64 < 0.05 MH2 221.43 ± 52.21 262.50 ± 90.69 < 0.01 MH3 216.77 ± 36.09 251.42 ± 63.96 < 0.01 MH4 166.43 ± 37.28 179.93 ± 50.57 > 0.05 MH5 140.75 ± 62.48 146.80 ± 87.17 > 0.05 Big toe 237.29 ± 139.22 284.64 ± 133.54 < 0.05 Toe 143.36 ± 119.73 122.74 ± 56.32 > 0.05 96.73 ± 50.14 89.01 ± 51.40 > 0.05 The right plantar peak pressure (kpa) Toe 3, 4, p (* MH1: Bone foundation of toe 1; MH2: Bone foundation of toe 2; MH3: Bone foundation of toe 3; MH4: Bone foundation of toe 4; MH5: Bone foundation of toe 5) - Peak pressure of all feet, peak pressure in areas of foot heel, MH1, MH2 and MH3 in diabetic group were higher than those in control group and this difference had statistical significance - Peak pressure in other areas of feet in diabetic group were higher than those in control group but this difference had no statistical significance 171 Journal of military pharmaco-medicine no6-2019 Table 5: Changing the left plantar pressure of study group Diabetic group (n = 126) Peak pressure on the left feet (kpa) Decreasing Normal Increasing n % n % n % Total force 1.6 82 65.1 42 33.3 Heel of foot 14 11.1 71 56.3 41 32.5 Mid leg 18 14.3 99 78.6 7.1 MH1 15 11.9 71 56.3 40 31.7 MH2 12 9.5 63 50.0 51 40.5 MH3 17 13.5 53 42.1 56 44.4 MH4 21 16.7 67 53.2 38 30.2 MH5 19 15.1 87 69.0 20 15.9 Big toe 2.4 97 77.0 26 20.6 Toe 0.0 123 97.6 2.4 Toe 3, 4, 24 19.0 84 66.7 18 14.3 (* MH1: Bone foundation of toe 1; MH2: Bone foundation of toe 2; MH3: Bone foundation of toe 3; MH4: Bone foundation of toe 4; MH5: Bone foundation of toe 5) In subject group of increasing plantar peak pressure, positions of the bone foundation of the 3rd toe and the 2nd toe accounted for the highest percentage and lowest percentage, respectively DISCUSSION Pressure is measured by total force provided for a unit of square area and calculated by dividing total number of force on square affecting area Plantar pressure is the impact force between the plantar and contact surface in daily activities In our research, we evaluated the right plantar on the peak pressure index as recorded in total overall in control group (334.06 ± 104.06 kpa) was significantly lower than that the diabetic group (386.39 ± 123.64 kpa), p < 0.05 The highest peak pressure in the position of big toe in control group (270.33 ± 133.57 kpa) was lower than in 172 case group (287.53 ± 148.65 kpa) and the lowest in the position of toe 3, 4, in control group (85.19 ± 49.09 kpa) also lower than diabetic group (94.97 ± 50.37 kpa), but there was no significant difference with p > 0.05; with 21.4% of subjects in diabetic group, increasing the plantar peak pressure in general increasing the highest increase was in the 1st metatarsus foundation (79.45%) and the lowest was in the 2nd metatarsus foundation (15.1%) Evaluating left the plantar on the peak pressure index in our research as recorded the total overall in control group (316.43 ± 282.14 kpa) was significantly lower than that in the Journal of military pharmaco-medicine no6-2019 diabetic group (392.85 ± 369.85 kpa) with p < 0.05 The highest peak pressure in the position of big toe in control group (237.29 ± 139.22 kpa) was lower than that in diabetic group (284.64 ± 133.54 kpa) which was a significant difference (p < 0.05) and the lowest in the position of toe 3, 4, in control group (96.73 ± 50.14) which was higher than that in diabetic group (89.0 ± 51.4 kpa), but there was no significant difference with p > 0.05; with 33.3% of subject group increased the plantar peak pressure, increased the most in the 3rd metatarsus foundation (44.4%), the lowest in the 2nd metatarsus position (2.4%) Therefore, it showed that the diabetic group had higher plantar pressure index than that in the control group, it was equivalent to some researches in the world Pataky Z et al (2003) reported the highest peak pressure in the big toe position was 220 ± 89 kpa and the lowest was in 5th metatarsus foundation (112 ± 22 kpa) [1] This result was lower than our research, because of the number of subjects participating to the study by Pataky Z was fewer than our research (11 patients) and their average age was high Lavery L.A, Armstrong D.G et al (2003) studied 1,666 diabetic disease patients with the peak pressure index was 86.6 ± 27.4 N/cm2+ [5] This result was higher than our study result, because study participants had higher average age and weight and longer disease detection time than our study Study by Pataky Z et al (2005) conducted on 30 diabetic patients and 15 non-diabetics people showed the result in diabetic patient group, increased peak pressure in big toe (the right leg: 205 ± 94 kpa compared with 101 ± 39 kpa; left leg: 165 ± 61 kpa compared with 104 ± 43 kpa) in the 5th metatarsus foundation (the right plantar: 160 ± 68 kpa compared with 97 ± 32 kpa; the left plantar: 174 ± 65 kpa compared with 91 ± 42 kpa) in the heel of foot, peak pressure in diabetic case group was lower than control group (the right plantar: 187 ± 54 kpa compared with 321 ± 91 kpa; the left plantar: 184 ± 63 kpa compared with 298 ± 110 kpa) [4], and equivalent to our research Qui X, Tian D.H et al (2015) had prospective study on 65 type diabetic patients being monitored in years, at the time of enrollment, the highest maximum force was 179 (N) and the lowest in the position of toe - toe was 4.5 (N); the highest pressure in the 1st metatarsus foundation (160.7 kpa) and the lowest in position of toe - 5: 5.0 kpa [3] This result was lower than our research Tran Thi Ngoc Bang (2017) enrolled 102 type diabetic patients and the result showed that plantar peak pressure was 427.9 ± 120.9 kpa [6] In comparison with this study, our result was higher, because study subjects of Tran Thi Ngoc Bang had higher BMI In 2017, Halawa M.R et al enrolled 50 type diabetic patients and 30 people who were voluntary to participate, the result showed that static pressure and dynamic pressure in both of left and right feet of diabetic patients with nervous complication was higher than that in control group with p < 0.05 Static pressure and dynamic pressure in the left and right feet of diabetic patient group with nervous complication was higher than patient group without nervous complication with p < 0.05 [2], equivalent to our research 173 Journal of military pharmaco-medicine no6-2019 CONCLUSION - Plantar peak pressure index in sides in the position of total force of diabetic group was higher than control group with p < 0.05 - Peak pressure increased mostly in metarsus foundation in the area of the 3rd on the left index: positions of the area of the 1st (79.4%) and 44,4% metarsus foundation REFERENCE Pataky Z, Golay A et al Relationship between peripheral vascular disease and high plantar pressures in diabetic neuro ischemic patients Diabetes Metab 2002, 29, pp.489-495 Halawa M.R, Eid Y.M et al Relationship of planter pressure and glycemic control in type diabetic patients with and without 174 neuropathy Diabetes and metabolic syndrome: Clinical Research and Review 2017, pp.1-6 Qui X, Tian D.H et al Plantar pressure changes and correlating risk factors in Chinese patients with type diabetes: Preliminary year results of prospective study Chinese Medical Journal 128 (24), pp.3283-3392 Pataky Z, Assal J.P et al Plantar pressure distribution in type diabetes patients without peripheral and peripheral vascular disease Diabetes Medicine 2005, 22, pp.762-767 Lavery L.A, Armstrong D.G, Wunderlich R.P Predictive value of foort pressure assement as part of a population-based diabetes disease management program Diabetes Care 2003, 26 (4), pp.1069-1073 Muthuselvi, Shanthi M, Ethiya N Comparision of nerve conduction studies in geriatric normal and diabetic subjects IJSR 2015, (4), pp.1084-1086 ... foundation of toe 3; MH4: Bone foundation of toe 4; MH5: Bone foundation of toe 5) In subject group of increasing plantar peak pressure, positions of the bone foundation of the 3rd toe and the 2nd toe... MH2 22 1.43 ± 52. 21 26 2.50 ± 90.69 < 0.01 MH3 21 6.77 ± 36.09 25 1. 42 ± 63.96 < 0.01 MH4 166.43 ± 37 .28 179.93 ± 50.57 > 0.05 MH5 140.75 ± 62. 48 146.80 ± 87.17 > 0.05 Big toe 23 7 .29 ± 139 .22 28 4.64... 67 53 .2 38 30 .2 MH5 19 15.1 87 69.0 20 15.9 Big toe 2. 4 97 77.0 26 20 .6 Toe 0.0 123 97.6 2. 4 Toe 3, 4, 24 19.0 84 66.7 18 14.3 (* MH1: Bone foundation of toe 1; MH2: Bone foundation of toe 2; MH3: