Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies

Malindu Eranga Fernando; Robert George Crowther; Elise Pappas; Peter Anthony Lazzarini; Margaret Cunningham; Kunwarjit Singh Sangla; Petra Buttner; Jonathan Golledge

doi:10.1371/journal.pone.0099050

Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies

PLoS One. 2014 Jun 10;9(6):e99050. doi: 10.1371/journal.pone.0099050. eCollection 2014.

Authors

Malindu Eranga Fernando¹, Robert George Crowther², Elise Pappas³, Peter Anthony Lazzarini⁴, Margaret Cunningham⁵, Kunwarjit Singh Sangla⁶, Petra Buttner⁷, Jonathan Golledge⁸

Affiliations

¹ Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Movement Analysis Laboratory, Institute of Sports and Exercise Science, James Cook University, Townsville, Queensland, Australia.
² Movement Analysis Laboratory, Institute of Sports and Exercise Science, James Cook University, Townsville, Queensland, Australia.
³ Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
⁴ Allied Health Research Collaborative, Metro North Hospital & Health Service, Queensland Health, Brisbane, Queensland, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia.
⁵ Department of Psychology, University of Stirling, Stirling, Scotland, United Kingdom.
⁶ Department of Internal Medicine, The Townsville Hospital, Townsville, Queensland, Australia.
⁷ School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia.
⁸ Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia.

Abstract

Aims: Elevated dynamic plantar pressures are a consistent finding in diabetes patients with peripheral neuropathy with implications for plantar foot ulceration. This meta-analysis aimed to compare the plantar pressures of diabetes patients that had peripheral neuropathy and those with neuropathy with active or previous foot ulcers.

Methods: Published articles were identified from Medline via OVID, CINAHL, SCOPUS, INFORMIT, Cochrane Central EMBASE via OVID and Web of Science via ISI Web of Knowledge bibliographic databases. Observational studies reporting barefoot dynamic plantar pressure in adults with diabetic peripheral neuropathy, where at least one group had a history of plantar foot ulcers were included. Interventional studies, shod plantar pressure studies and studies not published in English were excluded. Overall mean peak plantar pressure (MPP) and pressure time integral (PTI) were primary outcomes. The six secondary outcomes were MPP and PTI at the rear foot, mid foot and fore foot. The protocol of the meta-analysis was published with PROPSERO, (registration number CRD42013004310).

Results: Eight observational studies were included. Overall MPP and PTI were greater in diabetic peripheral neuropathy patients with foot ulceration compared to those without ulceration (standardised mean difference 0.551, 95% CI 0.290-0.811, p<0.001; and 0.762, 95% CI 0.303-1.221, p = 0.001, respectively). Sub-group analyses demonstrated no significant difference in MPP for those with neuropathy with active ulceration compared to those without ulcers. A significant difference in MPP was found for those with neuropathy with a past history of ulceration compared to those without ulcers; (0.467, 95% CI 0.181- 0.753, p = 0.001). Statistical heterogeneity between studies was moderate.

Conclusions: Plantar pressures appear to be significantly higher in patients with diabetic peripheral neuropathy with a history of foot ulceration compared to those with diabetic neuropathy without a history of ulceration. More homogenous data is needed to confirm these findings.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Diabetic Neuropathies / physiopathology*
Female
Foot / physiopathology*
Foot Ulcer / physiopathology*
Humans
Male
Middle Aged
Observational Studies as Topic*
Pressure*
Publication Bias
Treatment Outcome

Grants and funding

Funding from the Queensland Government and National Health and Medical Research Council and The Townsville Hospital Private Practice Fund supported this work. JG holds a Practitioner Fellowships from the National Health and Medical Research Council, Australia (1019921). JG holds a Senior Clinical Research Fellowship from the Queensland Government. MF is currently supported by an Australian Postgraduate Award Scholarship at James Cook University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.