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Title: Studies on the management of diabetic foot problems
Author: Oyibo, Samson Oghenetsovwe
ISNI:       0000 0004 2720 3457
Awarding Body: University of Manchester
Current Institution: University of Manchester
Date of Award: 2004
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Diabetic peripheral neuropathy affecting the lower limbs is a common debilitating complication of diabetes mellitus. A significant proportion of affected patients are plagued by severe intractable painful symptoms. In addition to this, the insensitive foot is prone to deformity, trauma and resultant foot ulceration. This thesis deals with the management of diabetic foot problems, with particular reference to painful diabetic neuropathy and foot ulceration. The treatment of painful diabetic neuropathy is far from satisfactory and present therapeutic agents are not without undesirable side effects. The first study (Chapter 3) examines the relationship between blood glucose excursions and pain in patients with symptomatic diabetic neuropathy. Twenty type 1 diabetic patients with peripheral neuropathy (10 painful and 10 painless) wore a continuous glucose monitoring system (CGMS) for 3 days. Symptomatic patients kept a daily pain score diary. Measures of glycaemic stability, the mean amplitude of glycaemic excursions (MAGE) and the M-value were calculated. The study demonstrated that patients with painful neuropathy have greater glucose flux and possibly poorer diabetes control, compared to patients with painless neuropathy. The use of electrical stimulation therapy such as transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS), have been shown to provide some benefit when used to treat painful diabetic neuropathy. In a previous open-labelled study, pulsed-dose electrical current delivered through stocking electrodes was shown to produce an 80% reduction in painful symptoms. In the second study (Chapter 4) a double blind, controlled crossover study was carried out to assess the efficacy of pulsed-dose electrical current delivered through stocking electrodes. Thirty patients with painful diabetic neuropathy were randomised to wear silver plated stocking electrodes for 8 hours a night for 6 weeks (pulsed electric current of 50 micro amps delivered by a microcomputer). The control, identical stockings received an insignificant current (5 micro amps). Pre-treatment, weekly and end-of-treatment pain and sleep-disturbance scores were recorded. This study demonstrated that although symptomatic relief occurred, this form of treatment was no more effective than control in the treatment of painful diabetic neuropathy, suggesting that placebo may play a significant role in electro-analgesia. For adequate management of foot ulcers a systematic approach is required. A foot ulcer classification system should aid in planning treatment strategies, monitoring treatment effectiveness, predicting clinical outcomes, and improving communication among healthcare providers. The third study (Chapter 5) examines wound classification systems and factors, which affect the outcome of diabetic foot ulcers. Diabetic patients with new foot ulcers presenting during a 12-month period, had demographics and ulcer characteristics recorded at presentation. Ulcers were followed up until an outcome was noted. This study demonstrated that ulcer area, a measure of ulcer size, predicts the outcome of foot ulcers and that its inclusion into a diabetic foot classification system will make that system a better predictor of outcome. In the fourth study (Chapter 6), two commonly used foot ulcer classification systems are compared as predictors of clinical outcome. Both the Wagner system (grade) and the University of Texas system (grade and stage) were applied to new foot ulcers at presentation, and ulcers were followed up until an outcome was noted. The study revealed that increasing stage, regardless of grade, is associated with increased risk of amputation and prolonged ulcer healing time. The University of Texas system, which combines grade and stage, is a better predictor of outcome. Therefore, strict glucose control should be the first step in the struggle for pain control in patients with painful diabetic neuropathy before other forms of therapy are employed. Additionally, the use of a robust, fully descriptive foot ulcer classification system, such as the University of Texas system should be employed in the management of diabetic foot ulcers. A systematic approach to foot care will aid in reducing the high incidence of lower limb amputations.
Supervisor: Andrew Boulton Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available