RU2433783C2 - Method of estimating risk of diabetic foot syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, endocrinology, and can be used for estimating risk of diabetic foot syndrome. For this purpose temperature on sole surface of foot is measured in points of the greatest plantar pressure: above the first and fifth metatarsal bones, above heel bone, in the centre of sole and in the point of the greatest microtraumatisation: on the cushion of the first toe. Additionally measured is temperature on sole backside in point of the highest microtaumatisation. After that, termoasymmetry in points on right and left feet is determined. If thermoasymmetry of points on feet < 1.09°C, patient is not included in group of risk of diabetic foot syndrome. If reduction of temperature parameters in comparison with age norm in more than 2 points on foot is from 1.09°C to 2.2°C it indicates low risk, if it is from 2.3°C to 4.4°C -medium risk, if > 4.4°C - high risk of ischemic form of diabetic foot syndrome. If thremoasymmetry due to local increase of temperature or hyperthermia in 1 or more points of foot is < 2.2°C - low risk, from 2. 2°C to 4.4 °C - medium risk, if > 4.4°C - high risk of neuroischemic form of diabetic foot syndrome with local inflammation - initial stage of trophic ulcer formation.

EFFECT: method is simple in application and interpretation of results, makes it possible to detect patients of group with risk of diabetic foot syndrome during primary consultation with administration of adequate therapeutically-preventive measures.

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Description

The invention relates to medicine, namely to endocrinology, and can be used in the study of diabetic polyneuropathy (DPN) in patients with diabetes mellitus (DM).

The well-known method of “Home monitoring of foot temperature to prevent ulceration” (Home monitoring of foot skin temperatures to prevent ulceration) authors: L.A. Lavery, K.R. Higgins, D.R. Lanctot, G.P. Constantinides, R.G. Zamorano, D.G.Armstrong, K.A.Athanasiou, C.M.Agrawal. The essence of the method: for 6 months, a group of patients with diabetic foot syndrome (SDS), risk categories 2 and 3 (with a history of trophic ulcers and amputations of the lower extremities) performed morning and evening measurements of temperature on the feet using a skin thermometer (TempTouch; Xilas Medical San Antonio, TX).

However, this method is intended only to monitor the risk of re-ulceration in the feet of patients with diabetes with diabetes and requires a long daily temperature measurement by the patients themselves, which significantly reduces compliance. In addition, the skin thermometer used in this study is not available in the Russian Federation. For the initial diagnosis and risk assessment of the development of VDS, this method is not suitable.

The objective of the invention is a simple and effective risk assessment of VDS during initial treatment.

The problem is solved due to the fact that the temperature on the rear of the foot at the point of greatest microtraumatization is additionally measured, the thermo-asymmetry is detected at the points on the right and left feet: with the thermo-asymmetry of the points on the feet <1.09 ° C, the patient is not at risk for diabetic foot syndrome ; if the decrease in temperature, compared with the age norm at more than 2 points on the foot from 1.09 ° C to 2.2 ° C - a low risk, if from 2.3 ° C to 4.4 ° C - medium risk if> 4.4 ° C - high risk of ischemic form of diabetic foot syndrome; if thermo-asymmetry due to a local increase in temperature or hyperthermia in the 1st or more points of the foot <2.2 ° C - low risk, from 2.2 ° C to 4.4 ° C - medium risk, if> 4.4 ° C - high risk of a neuroischemic form of diabetic foot syndrome with local inflammation - the initial stage of trophic ulcer formation.

The method is carried out using a DT-635 electronic thermometer adapted for measuring plantar temperature (AND, Japan), widely available in the pharmacy network of the Russian Federation, at strictly defined points. To the points proposed in the prototype (on the sole: in the center, above the first toe, above the first and fifth metatarsal bones, above the calcaneus), a point is added to the rear of the foot (at the level of the middle third of the rear of the foot, in the projection of the third metatarsal bone) (Fig. .one). Figure 1 shows a diagram of measuring skin temperature on the feet: temperature measurement points are shaded, where 1 is the I finger, 2 is the I metatarsal bone, 3 is the V metatarsal bone, 4 is the center of the sole, 5 is the calcaneus, 6 is the rear of the foot. The points of greatest plantar pressure: above the first and fifth metatarsal bones, above the calcaneus, the points of greatest microtraumatization: on the tip of the first finger, on the back of the foot, the point in the center of the sole (point 4) is additional, because It is least often involved in the inflammatory process (with a significant flattening of the arch of the foot). When measuring skin temperature in patients with diabetes at the indicated points, the indicators are compared with the age normative corridor (figure 2). In this case, take into account the general decrease in temperature (on one or two feet) and the presence of “temperature asymmetries” - that is, the presence of a significant temperature difference (more than 2.2 ° C) at the points of greatest plantar pressure within one foot.

Risk assessment of SDS was carried out in patients with diabetes after a comprehensive study, including the detection of violations of tactile, pain, temperature, vibration sensitivity and assessment of the reflex sphere. After measuring the temperature on the plantar surface of the foot and on the back of the foot, the presence of thermal asymmetry was assessed: with thermal asymmetry of points on the feet <1.09 ° C, the patient is not at risk for diabetic foot syndrome; if the decrease in temperature, compared with the age norm at more than 2 points on the foot from 1.09 ° C to 2.2 ° C - a low risk, if from 2.3 ° C to 4.4 ° C - medium risk if> 4.4 ° C - high risk of ischemic form of diabetic foot syndrome; if thermo-asymmetry due to a local increase in temperature or hyperthermia in the 1st or more points of the foot <2.2 ° C - low risk, from 2.2 ° C to 4.4 ° C - medium risk, if> 4.4 ° C - high risk of a neuroischemic form of diabetic foot syndrome with local inflammation - the initial stage of trophic ulcer formation.

When developing the method, the study was carried out in the control (82 people) and the main (152 people) groups. Group 1 - control: individuals in a state of relative health who do not have diabetes (according to the history and studies of blood sugar levels):

Group 1a - 47 (57%) people: healthy young volunteers from 19 to 31 years old, average age - 21.55 ± 3.07 [95% CI: 19-23] years, including men (29 people) - 62%, age - from 19 to 31 years old, average age - 22.41 ± 3.46 [95% CI: 19-24] years; women (18 people) - 38%, age - from 19 to 24 years, average age - 20.17 ± 1.58 [95% CI: 19-20] years, where CI is the confidence interval.

Group 1b - 35 (43%) people: healthy volunteers of middle and older age - from 40 to 65 years old, average age - 47.2 ± 6.85 [95% CI: 41-49] years; including men (15 people) - 43%, age - from 40 to 60 years, average age - 46.2 ± 5.41 [95% CI: 41-48] years; women (20 people) - 57%, age - from 40 to 64 years, average age - 47.95 ± 7.81 [95% CI: 41.5-54.5] years.

Group 2 - the main: patients with mild, moderate and severe diabetes, in a state of compensation, subcompensation and decompensation.

2a subgroup - 72 people. (47%) patients with type 1 diabetes, age - from 18 to 60 years, average age - 32.10 ± 10.98 [95% CI: 22-39] years, including men - 51% (37 people) , age - from 19 to 60 years, average age - 32.2 ± 10.1 [95% CI: 24-38] years; women - 49% (35 people), age - from 19 to 60 years, average age - 32.03 ± 11.98 [95% CI: 21-42] years.

Subgroup 2b - 80 patients with type 2 diabetes, the age ranged from 34 to 77 years, the average age was 54.63 ± 8.18 [95% CI: 48-60] years; including men - 46% (37 people), age - from 43 to 71 years, average age - 53.61 ± 6.72 [95% CI: 48-57] years, women - 54% (43 people. ), age - from 34 to 77 years, average age - 55.72 ± 9.14 [95% CI: 49-62] years.

The study was carried out at a standard ambient temperature of + 20- + 22 ° C, in the position of the patient lying on his back according to the developed scheme (figure 1), with the results of the study entered in the study map.

According to the results of the study, in the control group, a decrease in the distal skin temperature in young people was revealed compared with the temperature in older people, which corresponds to physiological characteristics (Table 1).

Table 1. Skin temperature on the feet in the control group of observation (t ° C) Temperature measuring points Control group 1a
(n ₁ = 47) t ° С Control 16 group
(n ₂ = 35) t ° С one 2 3 1 - I finger 30.25 ± 3.47
[95% CI: 26.55-32.9] ° C 33.63 ± 3.36
[95% CI: 30.9-35.95] ° C

one 2 3 2 - I metatarsal bone 31.16 ± 2.92
[95% CI: 28.1-33.3] ° C 33.06 ± 2.66
[95% CI: 31.25-35.1] ° C 3 - V metatarsal bone 30.62 ± 3.24
[95% CI: 27.8-33.2] ° C 32.98 ± 3.78
[95% CI: 28.55-36.0] ° C 4 - center of the sole 32.04 ± 2.22
[95% CI: 29.95-34.15] ° C 33.71 ± 1.57
[95% CI: 32.1-35.5] ° C 5 - calcaneus 31.06 ± 2.93
[95% CI: 28.6-33.15] ° C 32.73 ± 3.57
[95% CI: 29.7-36.8] ° C 6 - rear foot 33.73 ± 1.93
[95% CI: 32.55-35.85] ° C 35.42 ± 0.87
[95% CI: 35.05-36.15] ° C

According to the results of thermometry of the skin temperature of the feet in the control group, a corridor of normative indicators for measuring points on the feet was identified (Fig.2). Figure 2 shows this corridor, where the points of thermometry are indicated on the abscissa: 1 - I toe, 2 - I metatarsal bone, 3 - V metatarsal bone, 4 - center of the sole, 5 - calcaneus, 6 - rear of the foot; along the ordinate axis - temperature (° C); the solid line indicates the skin temperature corridor in young people, the dotted line indicates the skin temperature corridor in middle-aged and older people.

The general average thermometry in the main groups did not statistically significantly differ from those in the control groups (Table 2, Fig. 3). Figure 3 shows the corridor of normative indicators of skin temperature in patients with diabetes mellitus type 1 (a) and 2 (b), where the points of thermometry are indicated on the abscissa axis: 1 - I finger, 2 - I metatarsal bone, 3 - V metatarsal bone, 4 - the center of the sole, 5 - the calcaneus, 6 - the rear of the foot; along the ordinate axis is temperature (° С); the solid line indicates the skin temperature corridor in patients with diabetes mellitus, the dotted line indicates the skin temperature corridor in healthy volunteers of young (a) and middle (b) age. However, the values of each patient are of greater importance (see examples).

Table 2. Skin temperature on the feet in the main observation group (t ° C) Thermometry Results The main 2a group
(n ₃ = 72) t ° С The main 2b group
(n ₄ = 80) t ° С 1 - I finger 23.3 to 36.8
average 31.56 ± 3.86 ° C 23.6 to 36.9
average 31.75 ± 3.55 ° C 2 - I metatarsal bone 24.8 to 35.2
average 31.82 ± 3.51 ° C 24.4 to 36.7
average 32.09 ± 3.04 ° C 3 - V metatarsal bone 24.3 to 38.8
average 31.41 ± 3.49 ° C 25 to 36.7
average 31.92 ± 2.91 ° C 4 - center of the sole 25.6 to 36.7
average 32.39 ± 2.90 ° C 26.1 to 36.1
average 32.93 ± 2.09 ° C 5 - calcaneus 24.6 to 36.9
average 31.76 ± 3.26 ° C 26.1 to 36.6
average 32.48 ± 2.83 ° C 6 - rear foot 26 to 36.7
average 33.03 ± 2.91 ° C 26.8 to 36.6
average 34.37 ± 1.86 ° C

Of great importance is the presence of temperature asymmetry on the feet of patients with diabetes mellitus. In the control group, the maximum temperature asymmetry at the measurement points on the sole ranged from 0 to 2.9 ° C, the average was 1.09 ± 0.77 [95% CI: 0.6-1.35] ° C. In the main group, the temperature asymmetry at the points of the highest plantar pressure varied from 0 to 9.5 ° C, the average was 1.9 ± 1.92 [95% CI: 0.9-3.0] ° C.

If a patient with DPN has thermal asymmetry of points on the feet <1.09 ° C, the patient is not at risk for diabetic foot syndrome; if a decrease in temperature compared with the age norm at more than 2 points on the foot from 1.09 ° C to 2.2 ° C is a low risk, if from 2.3 ° C to 4.4 ° C - an average risk if> 4.4 ° C - high risk of ischemic form of diabetic foot syndrome; if thermo-asymmetry due to a local increase in temperature or hyperthermia in the 1st or more points of the foot <2.2 ° C - low risk, from 2.2 ° C to 4.4 ° C - medium risk, if> 4.4 ° C - high risk of a neuroischemic form of diabetic foot syndrome with local inflammation - the initial stage of trophic ulcer formation.

Example 1. Patient N., 65 years old, diagnosis: Type 2 diabetes mellitus, moderate, subcompensation.

After conducting a comprehensive study, we clarified the diagnosis of complications: Diabetic peripheral neuropathy of 2 degrees of severity, with a violation of temperature, tactile, pain sensitivity of 1 degree, with a violation of vibration sensitivity of 2 degrees.

After skin foot thermometry (Fig. 4), the risk of VDS was specified: the patient is not at risk for diabetic foot syndrome. Figure 4 presents the results of thermometry of the feet in patient N .: the temperature does not differ from the age norm, the same on both sides (<1.09 ° C), without significant temperature asymmetry, the patient is not at risk for diabetic foot syndrome. S - right foot, D - left foot.

Example 2. Patient W., 42 years old, diagnosis: Type 1 diabetes mellitus, moderate, subcompensation.

After conducting a comprehensive study, we clarified the diagnosis of complications:

Diabetic peripheral neuropathy of 2 degrees of severity, with violation of temperature sensitivity of 3 degrees, vibration sensitivity of 2 degrees.

After skin foot thermometry (Fig. 5), the risk of VDS was clarified: low risk of ischemic form of diabetic foot syndrome. Figure 5 presents the results of thermometry of the feet in patient Sh .: revealed a bilateral decrease in temperature on the feet, the same on both sides (from 1.09 ° C to 2.2 ° C compared with the age norm), but without significant temperature asymmetry, in conjunction with a violation of temperature and vibration sensitivity corresponds to a low risk of ischemic diabetic foot syndrome. S - right foot, D - left foot.

Example 3. Patient G., 55 years old, diagnosis: Type 2 diabetes mellitus, moderate, compensation.

After conducting a comprehensive study, we clarified the diagnosis of complications:

Diabetic peripheral neuropathy of 2 degrees of severity, with a violation of temperature, tactile, pain sensitivity and vibration sensitivity of 2 degrees.

After skin foot thermometry (Fig. 6), the risk of VDS was specified: the average risk of a neuroischemic form of diabetic foot syndrome. Figure 6 presents the results of thermometry of the feet of patient G.: a decrease in plantar temperature on the left foot (from 2.3 ° C to 4.4 ° C from the age norm) was noted, without significant temperature asymmetry within one foot (<1, 09 ° C), together with a violation of tactile, pain, temperature and vibration sensitivity, corresponds to an average risk of developing diabetic foot syndrome (neuroischemic form). S - right foot, D - left foot.

Example 4. Patient A., 42 years old, with a diagnosis of diabetes mellitus type 2, severe, subcompensation.

After conducting a comprehensive study, we clarified the diagnosis of complications: Diabetic peripheral neuropathy of 2 degrees of severity, with impaired temperature, tactile, pain and vibration sensitivity of 2 degrees.

After skin thermometry of the feet (Fig. 7), the risk of SDS was clarified: a high risk of the neuroischemic form of diabetic foot syndrome, with the initial stage of trophic ulcer formation (stage of local inflammation) in the heel on the right. Figure 7 presents the results of thermometry of the feet in patient A.: a decrease in temperature on the feet was detected (<1.09 ° C compared with the age norm), but the temperature asymmetry on the right foot was more than 4.4 ° C, in total with a violation of tactile, pain, temperature and vibration sensitivity corresponds to a high degree of risk of diabetic foot syndrome. S - right foot, D - left foot.

The proposed method allows for initial treatment to identify patients at risk of VDS with the appointment of adequate therapeutic and preventive measures. The method is simple to perform and interpret the results.

Claims (1)

A method for assessing the risk of diabetic foot syndrome, including measuring the temperature on the plantar surface of the foot at the points of greatest plantar pressure: above the first and fifth metatarsal bones, above the calcaneus, in the center of the sole and the point of greatest microtrauma: on the tip of the first finger, characterized in that it is additionally measured the temperature on the back of the foot at the point of greatest microtraumatization; thermo-asymmetry is detected at points on the right and left feet: with thermo-asymmetry of points on the feet <1.09 ° C, the patient is not included at risk for diabetic foot syndrome; if a decrease in temperature compared with the age norm at more than 2 points on the foot from 1.09 to 2.2 ° C is a low risk, if from 2.3 to 4.4 ° C - an average risk, if> 4 , 4 ° С - high risk of ischemic form of diabetic foot syndrome; if thermo-asymmetry due to a local increase in temperature or hyperthermia in the 1st or more points of the foot <2.2 ° C - low risk, from 2.2 to 4.4 ° C - medium risk, if> 4.4 ° C - high the risk of a neuroischemic form of diabetic foot syndrome with local inflammation is the initial stage of trophic ulcer formation.

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