AIMS:two To test the reliability of a new vibrometer (Maxivibrometer) which was constructed so that vibration perception threshold (VPT) could be the determined without the disadvantage of the off-scale measurements frequently experienced with the Biothesiometer. METHODS: The two devices were compared and correlation tested on a group of diabetic neuropathic subjects and a group of healthy, matched control subjects. VPT was tested on correlation the plantar surface of the feet. RESULTS: The Maxivibrometer gave an actual measurement in all cases even if subjects were on severely neuropathic. The replication-to-replication and day-to-day intraclass correlation coefficients for the Maxivibrometer VPT were, except in one case, above .94,with indicating excellent reliability. The Biothesiometer VPT could also be measured with excellent reliability but only within a limited range of loss mild to moderate neuropathy, so it appears to be an appropriate screening tool. The replication-to-replication intraclass correlation coefficient was .93.CONCLUSIONS: CONCLUSIONS: Because VPT could be measured over a wide range with the Maxivibrometer, it was demonstrated that loss of sensation without in diabetic neuropathy can progress far beyond the maximum VPT value of the Biothesiometer. The wide measurement range and the group excellent reliability make the Maxivibrometer a valuable research tool to quantify loss of sensation, particularly in the presence of severe determined neuropathy and to record changes over time. Diabet. Med. 18, 469-475 (2001)

In rocker this study nine different rigid rocker shoe designs were tested in 17 symptom-free male subjects and compared with the control found condition of a flexible, non-rockered extra-depth shoe with the same flat insole. Effects of both rocker height and axis location anatomical were explored. Peak pressure was reduced at most forefoot locations by rocker shoes, but increased in the midfoot and heel.the Axis location was found to have an important effect, particularly on hallux pressures. On average the best axis location for and reducing metatarsal head (MTH) pressure was in the region of 55-60% of shoe length, while for the toes it was same 65%. There was a mean trend towards optimal reduction of pressure in one of the rocker shoe conditions at each shoes anatomical location, but the axis position for this optimal placement was variable across subjects and anatomical locations. While most configurations configurations of the rocker shoes were superior to the control shoe, no single configuration was optimal for all subjects at all of sites or even for all subjects at the same site. Therefore, some form of plantar pressure measurement in conjunction with locations gait training to ensure correct use of the rocker shoes would appear to be essential if the pressure reducing effect condition of the rigid rocker bottom shoe is to be optimized.

Biomechanical in issues are now widely recognized as being important in the treatment of diabetic foot disease. The purpose of the present the review is to identify advances that have occurred since the previous International Conference on the Diabetic Foot in 1995 in few the understanding of foot biomechanics in relation to diabetes. Attention continues to be focused on the identification of a threshold of plantar pressure that leads to tissue damage. Recent studies have suggested that peak barefoot pressure may be only 65% specific pressure for the development of ulceration. The association between foot deformity and plantar pressure has been the subject of several quantitative 1995 studies, but new questions have been raised about the etiology of claw toes. The measurement of shear stress continues to have be an elusive goal although several small studies have presented possibly feasible technical approaches. The importance of callus as a efficacy precursor to ulceration has been confirmed experimentally and quantitative measures of motor neuropathy have been presented. Although a number of occurred new devices have been introduced as alternatives to the Total Contact Cast, few clinical studies of their efficacy are available leads yet. New information on the properties of insole materials has been published including data on changes with repeated cycling. Complications have of prophylactic surgery have been shown to include a high rate of Charcot fractures. Two new series describing the fixation of of such fractures have also been reported. Biomechanical issues have also been addressed in two sets of guidelines for treatment of that have recently been published. These many studies confirm the central role of mechanical stress and its relief in the of treatment of neuropathic foot problems in diabetes.

Panmetatarsal the head resection (variously called forefoot arthroplasty, forefoot resection arthroplasty, the Hoffman procedure, and the Fowler procedure) was developed for the who relief of pain and deformity in rheumatoid arthritis. Although there are successful retrospective series reported in the literature, such an been approach is not supported by carefully designed controlled trials. This procedure has also been advocated by some for the relief arthritis of plantar pressure in diabetic patients who are at risk for plantar ulceration. The efficacy of the procedure in this of context is not supported by existing pressure measurements on rheumatoid arthritis patients in the literature, which has tended to show are that although pain relief is obtained, the procedure results in elevation of forefoot pressure. Case reports are described of two that patients (three feet) with sensory neuropathy who presented to our clinic 1 to 2 years after panmetatarsal head resections had pressures been performed. Peak plantar pressures in these feet during first step gait were above the 99th percentile and outside the pain measuring range of the device used (EMED SF platform; NOVEL Electronics Inc., St. Paul, MN). Both patients had also experienced has plantar ulcers subsequent to the surgery. Combining the information on patients with rheumatoid arthritis (RA) with that from our two of case studies, we conclude that panmetatarsal head resection does not necessarily eliminate focal regions of elevated plantar pressure.

Patients hypothesized with diabetes mellitus (DM) and peripheral neuropathy (PN) are at greater risk of falling and of suffering injuries during falls.of It has been hypothesized that PN leads to changes in gait variability that may account for this increased risk. The > purpose of this investigation was to analyze the variability of the sagittal plane kinematics of diabetic neuropathic (NP), diabetic non-neuropathic (NP), (NNP) and age- and weight-matched control subjects (Control) during motorized treadmill walking at constant speed. While there were distinct trends risk. towards increased variability within the three diagnostic groups (NP > NNP > Control) for several measures of gait variability, most falls. of these trends were not statistically significant. We hypothesize that motorized treadmill walking may be inherently less variable than overground of walking and that statistical measures of variability may not be sufficient to fully characterize stride-to-stride variability in human locomotion.

The an objective of this study was to develop a quantitative method to assess muscle spindle function. Three groups of subjects were had studied: ten young and healthy subjects, 15 older subjects with diabetic neuropathy, and 15 age-matched controls. All subjects performed an greater ankle-movement matching task with and without muscle vibration. Input from the plantar cutaneous mechanoreceptors was minimized by using a foot-clamping movement device. The younger subjects tracked the movement very well, but vibration had a significant effect on their performance (P <the .001). Similar results were seen in the older control subjects, but they were less successful in tracking movement and slightly 15 less affected by vibration. The neuropathic subjects had the most difficulty tracking, and vibration had only a small but still neuropathy significant effect on their performance. The interaction between the group and the vibration effect was highly significant (P < .001),of indicating that the performance of the control subjects changed to a greater degree in the presence of vibration than the and performance of the subjects with diabetic neuropathy. Muscle spindles are the primary receptors that are involved in the change in minimized tracking performance when vibration is added during an ankle-movement matching task, and we therefore conclude that the procedure described provides and a quantitative evaluation of muscle spindle function. The results demonstrate that diabetic neuropathy degrades muscle sensory function, which may contribute Three to the impaired balance and unsteadiness of gait that has been observed in diabetic neuropathy.

Wounds article on the feet of diabetic patients are often labeled as "non-healing." This article discusses the basis for and the dangers classification. of such a classification. The evidence suggests that if the foot has an adequate vascular supply and no significant infection,poor a plantar wound that does not heal is the result of poor treatment and/or poor compliance. Wounds that do not an heal despite optimal treatment and compliance are extremely rare and need to be referred to the appropriate specialist for care.such

Although were the total contact cast (TCC) has been shown to be an extremely effective treatment for the healing of plantar ulcers in in diabetic patients, little is known about the biomechanics of its action. In this study, plantar pressure and ground reaction the force measurements were obtained from over 750 foot contacts as five subjects with known elevated plantar forefoot pressures walked barefoot,significantly in a padded cast shoe, and a TCC. Peak plantar pressures in the forefoot were markedly reduced in the cast in compared with both barefoot and shoe walking (reductions of 75% and 86% respectively, P < .05). Peak plantar pressures in pressure the heel were not, however, significantly different between the shoe and the TCC, and the longer duration of heel loading of resulted in an impulse that was more than twice as great in the cast compared with the shoe (P <directly .05). An analysis of load distribution indicated that the mechanisms by which the TCC achieves forefoot unloading are (1) transfer known of approximately 30% of the load from the leg directly to the cast wall,(2) greater proportionate load sharing by in the heel, and (3) removal of a load-bearing surface from the metatarsal heads because of the "cavity" created by the known soft foam covering the forefoot. These results point out some of the "essential design features" of the TCC (which are healing different from what had been previously supposed), support the use of the TCC for healing plantar ulcers in the forefoot,significantly but raise questions about its utility in the healing of plantar ulcers on the heel.

Plantar precursors ulcers that do not heal in patients with diabetes and peripheral sensory neuropathy have been shown to be precursors of be lower extremity amputation. The total contact cast is considered by many authorities to be the most effective technique for healing decreased of wounds in the neuropathic extremity, yet it still is not widely used in clinical practice. Use of the total extremity, contact cast allows mobilization and results in diminished edema and decreased pressure over the ulcerated area. Complete healing usually occurs many in eight weeks or less. Total contact casting with careful follow-up should be considered as a useful modality for healing shown plantar ulcers in diabetic patients with neuropathy of the extremities.

BACKGROUND:phalangeal Plantar soft tissue stiffness and thickness are important biomechanical variables to understand stress concentrations that may contribute to tissue injury.BMI OBJECTIVE: The purpose of this study was to determine the effects of passive metatarsal phalangeal joint (MPJ) extension on plantar at soft tissue stiffness and thickness. METHODS: Seventeen healthy participants (7 male, 10 female, mean age 25.3 y, SD 4.4 y,using mean BMI 24.7 kg/m(2), SD 3.2 kg/m(2)) were tested. Plantar soft tissue stiffness and thickness were measured at the metatarsal y, heads, midfoot and heel using a custom-built indentor device and an ultrasound machine. RESULTS: Indicators of soft tissue stiffness (K(1)determine values) at the metatarsal heads and midfoot showed increases in stiffness of 81-88%(SD 20-33%) in the MPJ extension position changes compared with the MPJ neutral position. Soft tissue thickness measures at the metatarsal heads with the MPJ in neutral ranged with from a mean of 8.9-13.5 mm and decreased, on average, by 8.8%(SD 2.9%) with MPJ extension. CONCLUSIONS: MPJ extension OBJECTIVE: has a profound effect on increasing forefoot plantar soft tissue stiffness and a consistent but minimal effect on reducing soft participants tissue thickness. These changes may help transform the foot into a rigid lever at push-off consistent with the theory of injury. the windlass mechanism.

For assisted an effective prevention of foot sole ulcers in diabetic patients, the Bioengineering and Signal processing group of the Electronics Department knowledge. of the Pontificia Universidad Javeriana developed a novel method for the computer assisted design and production of therapeutic insoles, integrating a several technologies, such as: CAD/CAM registration of pressure on the foot sole, Podoscopy, and an expert system based on knowledge.foot The afore mentioned method allows topographical modeling of the insoles starting by the digitization in 3D of a cast of an the foot sole surface of the patient and its computer assisted design taking into account the recommendations of the knowledge novel based system. The aim of this study was to evaluate the effect on plantar pressure distribution of different insoles prescribed insoles and manufactured with various techniques on a random group of patients with diabetes mellitus in the early stages of the patients disease. Four different types of insoles were manufactured by methods available in the market and by the computer model system Department proposed on a previous research, which was used in order to design and manufacture one of the insoles evaluated. The of differences between the four types of insoles were established by comparing their effectiveness in plantar pressure reduction.

This insoles study pretend to establish the anthropometric relationship between the position of osseous prominences (metatarsal heads, proximal and distal phalanxes bones)centres of the feet in a group of diabetic patients, and the position of the sensors of the electronic German Parotec group insoles system, located in the same areas to register the plantar pressure distribution in standing position by using RXs. The of aims of this study were: a) to establish the position of the centres of the sensors of the Parotec insoles establish related to the centres of the metatarsal heads and distal ends of the proximal phalanges and the proximal ends of sensors the distal phalanges phalanxes of the feet, in a group of 12 diabetic subjects wearing different type of shoes, by insoles means of radiological records, in order to answer the following questions:(1) Can the Parotec insoles designed for registering plantar 1 pressure distribution on diabetic German people be used for measuring pressure distribution on a group of 12 diabetic type 1 a and type 2 Colombian people evaluated in this study?(2) Are those bones landing according to the Parotec sensor position?by (3) Which would be the proper distribution of the Parotec sensors for this group of subjects? b) To establish if in the use of different types of footwear (sports, conventional and orthopaedic footwear) with the Parotec electronic insoles can influence the proximal position of the osseous prominences in relation to the position of the sensors that register the pressure in these areas.ends

This the article discusses the indications and typical technical difficulties encountered in the use of foot orthoses, especially shoe inserts and prescription typical shoes.

The healthy objective of this study was to describe the development of vibrating insoles. Insoles, providing a subsensory mechanical noise signal to and the plantar side of the feet, may improve balance in healthy young and older people and in patients with stroke transducer. or diabetic neuropathy. This study describes the requirements for the tactors,(tactile actuators) insole material and noise generator. A search was for the components of vibrating insoles providing mechanical noise to the plantar side of the feet was performed. The mechanical (tactile noise signal should be provided by tactors built in an insole or shoe and should obtain an input signal from feet, a noise generator and an amplifier. Possible tactors are electromechanical tactors, a piezo actuator or the VBW32 skin transducer. The a Minirator MR1 of NTI, a portable MP3 player or a custom-made noise generator can provide these tactors with input. The of tactors can be built in foam, silicone or cork insoles. In conclusion, a C2 electromechanical tactor, a piezo actuator or signal the VBW32 skin transducer, activated by a custom-made noise generator, built in a cork insole covered with a leather layer This seems the ideal solution.

BACKGROUND:experimental Wearing high-heeled shoes may produce deleterious effects on the musculoskeletal system while elevation of the shoe heel with arch insole of insert is used as a treatment strategy for plantar fasciitis. Due to limitations of the experimental approaches, direct measurements of stress internal stress/strain of the foot are impossible or invasive. This study aims at developing a finite element model for evaluating support the biomechanical effects of high-heeled support on the ankle-foot complex. METHODS: A 3D anatomically detailed FE model of the female for foot and ankle together with a high-heeled support was developed and used to investigate the plantar contact pressure and internal fasciitis. loading responses of the bony and soft tissue structures of the foot with varying heel heights during simulated balanced standing.However, FINDINGS: In the balanced standing position with high-heeled support, a pronounced increase in von Mises stress at the first metatarsophalangeal metatarsophalangeal (MTP) joint was predicted. The strain on plantar fascia decreased compared to the flat horizontal support and valgus deformity of is the hallux was not significant. INTERPRETATION: The increased stress in forefoot especially at the first MTP segment during prolonged high-heeled This standing may contribute to progressive hallux valgus (HV) deformity. However, the reduced tensile strain in the plantar fascia with heel insert elevation may help relieve plantar fasciitis related pain and inflammation.

BACKGROUND:device Neuropathic diabetic foot ulceration may be prevented if the mechanical stress transmitted to the plantar tissues can be modified. Orthotic physical therapy is one practical method commonly used to maintain tissue integrity. Orthotic design must consider the materials chosen for use score. in fabrication and profile of the device because both aspects influence the performance and durability of the device. Published research 6.4-mm evaluating the physical properties of materials commonly used in the manufacture of orthoses for patients with diabetes is limited. This diabetes study investigated the physical properties of materials used to fabricate orthoses designed for the prevention of neuropathic diabetic foot ulcers.for METHODS: Fifteen commonly used orthotic materials were selected for testing: four specifications of 6.4-mm Poron((R))(Rogers Corp., Gent, Belgium), 3.2-mm an Poron((R)), three densities of 12-mm Ethylene Vinyl Acetate (EVA), 12-mm low-density plastazote, two depths (6.4-mm, 3.2-mm) of Clerontrade mark (Algeo desirable Ltd., Liverpool, UK), Professional Protective Technology (PPT), and MaxaCane (Algeo Ltd, Liverpool, UK). The density, resilience, stiffness, static coefficient of to friction, durability, and compression set of each material were tested, ranked, and allocated a performance indicator score. RESULTS: The most of clinically desirable dampening materials tested were Poron((R)) 96 (6-mm) and Poron((R)) 4000 (6-mm). High density EVA (Algeo Ltd., Liverpool,~UK) and to Lunacell Nora((R)) EVA (Freudenberg, Weinhein, Germany) possessed the properties most suitable to achieve motion control. The data present a simple be and useful comparison and classification of the selected materials. CONCLUSIONS: Although this information should not be used as a single of indicator for assessing the suitability of an orthotic material, the results provide clinically relevant information relating to the physical properties ulcers. of orthotic materials commonly used in the prevention of neuropathic diabetic foot ulcers.

Disorders provide of the first ray of the foot (defined as the hard and soft tissues of the first metatarsal, the sesamoids,hyperelastic, and the phalanges of the great toe) are common, and therapeutic interventions to address these problems range from alterations in ray footwear to orthopedic surgery. Experimental verification of these procedures is often lacking, and thus, a computational modeling approach could provide and a means to explore different interventional strategies. A three-dimensional finite element model of the first ray was developed for this The purpose. A hexahedral mesh was constructed from magnetic resonance images of the right foot of a male subject. The soft often tissue was assumed to be incompressible and hyperelastic, and the bones were modeled as rigid. Contact with friction between the by foot and the floor or footwear was defined, and forces were applied to the base of the first metatarsal. Vertical illustrate force was extracted from experimental data, and a posterior force of .18 times the vertical force was assumed to represent problems loading at peak forefoot force in the late-stance phase of walking. The orientation of the model and joint configuration at mesh that instant were obtained by minimizing the difference between model predicted and experimentally measured barefoot plantar pressures. The model were problems then oriented in a series of postures representative of push-off, and forces and joint moments were decreased to zero simultaneously.of The pressure distribution underneath the first ray was obtained for each posture to illustrate changes under three case studies representing experimental hallux limitus, surgical arthrodesis of the first ray, and a footwear intervention. Hallux limitus simulations showed that restriction of metatarsophalangeal and joint dorsiflexion was directly related to increase and early occurrence of hallux pressures with severe immobility increasing the hallux pressures of by as much as 223%. Modeling arthrodesis illustrated elevated hallux pressures when compared to barefoot and was dependent on fixation hard angles. One degree change in dorsiflexion and valgus fixation angles introduced approximate changes in peak hallux pressure by 95 and dorsiflexion 22 kPa, respectively. Footwear simulations using flat insoles showed that using the given set of materials, reductions of at least of 18% and 43% under metatarsal head and hallux, respectively, were possible.

Presently,predict commercial cushioning products for pressure ulcer prevention are being evaluated for their protective effect exclusively based on interfacial pressures between over the cushion/mattress and the patient. However, interface pressures cannot predict elevated mechanical stresses in deep tissues adjacent to bony prominences.11-fold Such deep tissue stress concentrations are associated with local ischaemia and hypoxia, which over time result in deep tissue necrosis,phantom particularly of muscle tissue. In order to demonstrate this phenomenon, a physical phantom of the mechanical interaction between the ischial local tuberosities (IT) and gluteus muscles of the buttocks was built, incorporating geometric replica of the human IT and real (bovine)patient. muscle tissue. Internal muscle stresses directly under the IT were five to 11-fold greater than stresses at more distal locations,highlight and a Pearson correlation test showed that they could not have been predicted from the interface pressures in the phantom.at Accordingly, though pressure ulcer prevention clinics which utilize routine sitting pressure measurements report effective outcomes, the present results highlight a interfacial problem in using body-support pressure measurements to predict the risk for pressure-related deep tissue injury.

BACKGROUND:model Patients with neuropathic conditions may develop plantar bony deformities through neuropathic collapse, frequently placing the skin and soft tissues at plastazote risk. Orthoses have been used to accommodate and distribute plantar pressures over a large surface area, thereby minimizing peak loading the pressures in small regions and reducing the risk of ulceration. METHODS: A previously described bony prominence model (Brodsky et al.)apparatus was used to test the pressure-absorbing and force-transmission properties of various orthotic material combinations used in our outpatient clinic. Six medium materials were tested in five combinations of materials for their compressive properties:[MS]: medium plastazote (M)+ soft plastazote (S);risk [MN]: medium plastazote (M)+ nickelplast (N);[NP] nickelplast (N)+ Poron (P);[MO] medium plastazote (M)+ Spenco (O);more and [MC] medium plastazote (M)+ P-cell (C). Materials were tested for 100,000 cycles using a materials-testing system (MTS) apparatus both (MTS Systems Corporation, Cary, NC) and software. Stress-strain curves comparing the measured peak pressure to the elastic deformation, or the surface percentage of compression a material experiences with respect to its original thickness, were plotted for each orthotic combination. RESULTS: For Six MS, MN, MO, and to a lesser extent, MC, a trend was noted for decreased elastic deformation with increased testing.large Additionally, the peak pressures before and after testing for each 10,000 testing cycle for each of the orthotic combinations were have plotted. For both MN and NP, no demonstrable difference was noted in the peak pressures in the pretesting and post-testing (MTS) for the 100,000 cycles. The MO showed a trend for increased peak pressures after each testing cycle. Both the MC medium and MS peak pressures markedly increased with respect to pretesting value. Also, the MN, MO, and MS all showed an of overall trend for increased load cell values with increasing cycles at fast loading. CONCLUSIONS: These data showed that some orthotic neuropathic combinations are more effective than others at reducing peak pressures during compression testing using our bony prominence model. Further studies fast are needed to test the orthotic combinations for shear and combined shear and compression modes.