Thesis (M.S.)--Michigan State University, 2006. / Includes bibliographical references (leaves 91-100). Also available online (PDF file) by a subscription to the set or by purchasing the individual file.

Thesis (M.S.)--Michigan State University, 2006. / Includes bibliographical references (leaves 91-100).

Introduction: Diabetic foot (DF) is a common complication in patients with diabetes mellitus. Due to arterial abnormalities and diabetic neuropathy, as well as a tendency to delayed wound healing, infection or gangrene of the foot is relatively common. Early study indicated Si-Miao-Yong-An (SMYA) decoction is the most chosen Chinese herbal formulae in the treatment of DF. The aim of this study is to assess the quality of current evidence, and systematic review the effectiveness and safety of SMYA decoction for the treatment of DF. Method: (1) Search strategy: a special protocol was designed, and electronic databases and hand-search materials were used for screening eligible trials. (2) Inclusive criteria: randomized controlled trials (RCTs) to examine the efficacy and/or safety of SMYA decoction in DF treatments were valid. (3)Data analysis: the Jadad’s scale was used to assess the quality of eligible trials. Result: Total 23 RCTs met the inclusion criteria. Among those, 1341 patients are involved, 702 patients were treated by SYMA decoction. 22 trails using SMYA decoction combined WM claimed that they showed a statistically significant advantages over the treatments using WM alone in reducing DF symptoms. Only 1 RCT reported adverse events related to SMYA decoction, but less than WM treatment. Conclusion: All available evidence points to the fact that SMYA decoction may benefit to those diabetes patients with foot problem. However, due to the poor quality of included trials, more high-quality trials are required to substantiate or refute these early findings.

Background: The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes. Methods: We reviewed new footwear publications, (international guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations. Result: We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate-or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate-or high-risk of foot ulceration to wear their footwear at all times, both indoors and outdoors. (6) Motivate people with diabetes at intermediate-or high-risk of foot ulceration (or their relatives and caregivers) to check their footwear, each time before wearing, to ensure that there are no foreign objects in, or penetrating, the footwear; and check their feet, each time their footwear is removed, to ensure there are no signs of abnormal pressure, trauma or ulceration. (7) For people with a foot deformity or pre-ulcerative lesion, consider prescribing medical grade footwear, which may include custom-made in-shoe orthoses or insoles. (8) For people with a healed plantar foot ulcer, prescribe medical grade footwear with custom-made in-shoe orthoses or insoles with a demonstrated plantar pressure relieving effect at high-risk areas. (9) Review prescribed footwear every three months to ensure it still fits adequately, protects, and supports the foot. (10) For people with a plantar diabetic foot ulcer, footwear is not specifically recommended for treatment; prescribe appropriate offloading devices to heal these ulcers. Conclusions: This guideline contains 10 key recommendations to guide health professionals in selecting the most appropriate footwear to meet the specific foot risk needs of an individual with diabetes.

Class of 2016 Abstract / Objectives: 1. To compare appropriateness of therapy and the time it takes for appropriate empiric antibiotic therapy to be given from when patients are first admitted for treatment of diabetic foot infection. 2. To compare the time it takes for physicians to “streamline” therapies or switch from empiric antibiotic therapy to specific antibiotics after culture results are obtained 3. To Compare the incidence of readmission within 30 days to the hospital after initial discharge. Methods: In this IRB approved, retrospective study, antibiotic therapy prescribing patterns before and after the distribution of a health network specific empiric antibiotic reference material were compared in patients admitted for diabetic foot infection. Patients were excluded if no antibiotic therapy prescribed, if under the age of 18 years, or if admitted for less than 48 hours (including time spent in the emergency department). The following data were collected and analyzed between the two groups: number of appropriate antibiotic therapy administered, timing of appropriate therapies relative to when appropriate culture samples were obtained if applicable, time it takes to streamline antimicrobial therapy, and the incidence of 30-day readmission. Results: A total of 400 patients were evaluated with 17 pre-intervention and 10 post-intervention patients who meet the inclusion criteria. The pre- and post- intervention groups did not show significant difference in demographics except for comorbid conditions (p=0.055). Overall, there was no significant difference between the pre- and post-intervention group on appropriate empiric therapy given (p=0.382), timing to streamline therapy (p=0.4035), and readmission rates (p=0.401). Conclusions: The health network specific empiric antibiotic recommendations reference material did not influence the timing and appropriateness of empiric antibiotic therapy in treatment of diabetic foot infections and the patient 30-day readmission rates.

Most activities of daily living and numerous modes of physical activity incorporate some form of ambulation, of which the foot and ankle constitute the first link in the kinetic chain. A change in foot or ankle structure may therefore have subsequent effects on the superincumbent joints of the human body such as the knee, hip and lower back. Plantar pressure and impulse measurements can therefore provide greater insight into the mechanics of the foot under load-bearing conditions with regards to the areas and regions of the foot that exhibit the largest pressure values and impulse figures. Hence, it is of importance to establish normative data so as to obtain a frame of reference to identify those individuals that fall outside these norms and may exhibit a larger probability of injury. Aim and Objectives: The primary aim was to identify and compare the plantar pressure distribution patterns and impulse values of students of a South African university of different gender and race groups. To realise this aim two specific objectives were set. The first was to determine whether height, weight, body mass index (BMI), gender, race, and the level of physical activity were related to the pressure and impulse values obtained, and the second was to generate reference tables from the normative data gathered. Method: The RS Footscan system was used to measure the pressure and impulse values of the foot. The characteristics that were analysed were height, weight, body mass index and the level of physical activity of the participant and their respective association with plantar pressure and impulse values obtained. This information was then used to establish normative data. A quasi-experimental study design utilising convenience sampling was implemented as the intention was to investigate as single instance in as natural a manner as possible. Convenience sampling was used with predefined inclusion and exclusion criteria. A total of 180 participants were utilised in this study and were subdivided as follows: Gender: Males (n = 90); Females (n = 90); Race: African black (n = 60); white (n = 60) and coloured (n = 60). Each race group therefore comprised of 30 males and 30 females respectively. The anthropometric profile of participants was as follows: Age (S.D.) = 22.21 (S.D. ± 2.93) years; Height (S.D.) = 169.69 (S.D. ± 8.91) cm; Weight (S.D.) = 66.97 (S.D. ± 12.01) kg; BMI (S.D.) = 23.16 (S.D. ± 3.15) kg/m2. Participants were asked to complete a questionnaire prior to testing that would identify all exclusion criteria consisting of: the presence of foot pain or deformity, acute lower extremity trauma, lower extremity surgery, exhibited problems of performance including eye, ear or cognitive impairment, diabetes mellitus or other neurological neuropathy, or the use of walking aids. Anthropometric measurements were then taken for those participants that qualified for the study. Participants were required to perform approximately five warm-up trials to familiarise themselves with the testing equipment before testing commenced. A total of ten successful trails were subsequently recorded for each participant, with three footprints being recorded per trial on the pressure platform, thereby comprising 30 footprints (15 left foot and 15 right foot) per participant that were analysed regarding pressure and impulse values. The two-step gait initiation protocol was implemented which was proven to be a valid and reliable means of assessing gait. Participants were instructed to walk at a comfortable walking speed between 1.19 – 1.60 m/s to ensure conformity between all participants as between-trial gait velocities were proven to be significantly variable. The foot was subdivided into ten anatomical areas focusing on the great toe, lesser toes, metatarsal 1, metatarsal 2, metatarsal 3, metatarsal 4, metatarsal 5, midfoot, medial heel and lateral heel. These ten areas were then grouped into one of three regions, namely the forefoot region (great toe, lesser toes, and all five metatarsal head areas), midfoot region (midfoot area), and rearfoot/heel region (medial and lateral heel areas). Once all relevant data was gathered, corrected and analysed it was used to establish normative data tables pertaining to the various gender and race groups. Results: Of the ten individual pressure and impulse areas, the second and third metatarsal heads demonstrated the highest mean peak pressure and impulse values. Once grouped into one of the three regions, the heel region was ascribed with the largest impulse and pressure values. It was established that statistically and practically significant racial pressure differences were apparent in the left and right forefoot and midfoot regions, with black and coloured individuals yielding the highest values, whereas white participants yielded the lowest. The same was true with regards to impulse figures in that both statistical and practical significant levels were established in the forefoot and midfoot regions. Black and coloured participants exhibited larger impulse values than the white participants. The level of physical activity was found to be associated with both pressure and impulse values over the various regions of the foot. Black individuals that were largely inactive as well as moderately active coloured participants yielded the highest pressure and impulse values, which were found to be statistically and practically significant over the forefoot regions. Conversely, white participants of all physical activity levels as well as coloured participants of both low and high physical activity levels exhibited the lowest pressure values over the forefoot region, which were also found to be statistically and practically significant. The anthropometric variables of height, weight and BMI were found to relate statistically to pressure and impulse values under the various regions of the foot, but none were found to be of any practical significance (r < .30). Conclusion: It was clearly established that both gender and race specific differences existed regarding plantar pressure and impulse values of the normal foot. Plantar pressure and impulse values were also associated with the level of physical activity of the individual, thereby indicating that the level of physical activity could be a contributing factor to altered pressure and impulse values. Anthropometric variables such as height, weight and BMI could not solely account for the variances observed in pressure and impulse. Further research is required to determine whether pressure or impulse values above or below those obtained predispose an individual to injury and to contrast between various activity or sporting codes and the effect of these on plantar pressure and impulse figures. Finally, from the collected data one was able to establish reference tables for the specific gender and race groups for both plantar pressure and impulse values. This enables one to classify individuals based on the pressure and impulse values generated.

Neuropathy is one of the main long term complications of diabetes affecting 30-50% of patients. It is the major contributing factor for foot ulceration with a life time risk which may be as high as 25%. Hence neuropathy leads to reduced pain and pressure perception, anatomic deformities and an impaired microcirculation. More specifically, unperceived minor trauma results in cutaneous injury which when combined with an inadequate pressure induced vasodilator response leads to tissue breakdown and ulceration. Once ulcers form, healing may be delayed or difficult to achieve, particularly if infection occurs in the deeper tissues and bone which can then lead to amputation. In the UK, South Asians (people originating from India, Pakistan and Bangladesh) have an excess mortality for coronary artery disease (CAD), stroke and end-stage renal disease when compared to white Europeans. However, it has been shown that South Asian people with type 2 diabetes in the UK are only one third as likely to have a foot ulcer compared with White European diabetic patients. This has been attributed to lower levels of peripheral neuropathy in Asians, but has not been systematically explored in detail. In the present study, both neurological and vascular deficits in a group of South Asian and European patients with type II diabetes have been assessed. The results demonstrate that: • South Asian diabetic patients have poorer glycaemic control, but paradoxically lower triglycerides. This finding may be relevant to the finding that they have a lower incidence of neuropathy, as triglycerides have been related to neuropathy and foot ulceration. • South Asians compared to Europeans have better small fibre function and a trend for better structure (Intra epidermal nerve fibre density and corneal nerve morphology) and large fibre function assessed with nerve conduction studies. • South Asians have higher foot skin oxygenation and hyperaemic blood flow response to heating. • South Asians have a thicker epidermis and a trend for a better capillary density. Therefore these alterations may protect South Asians from the development of foot ulceration.

The Foot-and-mouth disease virus (FMDV) affects cloven-hoofed animals and is endemic in most parts of Africa, South America and southern Asia. South Africa is considered a FMDV-free zone but the virus is maintained within the wildlife in the Kruger National Park (KNP), making mitigation of outbreaks a high priority. Diagnostic methods are usually costly due to the high production cost of the reagents used, meaning that regular monitoring and diagnosis of animals around the KNP for FMDV is expensive due to the large amounts of serum continuously being tested. I propose an alternative plant expression platform for the local production of more cost effective diagnostic reagents capable of distinguishing between infected and vaccinated animals (DIVA). I selected the non-structural 3ABC polyprotein of FMDV to express, as it is a suitable candidate as a coating antigen in a competitive enzyme linked immunosorbent assay (C-ELISA) for the detection of neutralizing antibodies in livestock sera. I also chose other variations of the full polyprotein (3AB, 3AB1 and 3B) for expression as they have previously been shown to be effective in FMDV diagnosis. I also selected a second reagent to be expressed: this was the CRAb-FM27 single chain variable fragment (scFv), which binds a 3B epitope on the 3ABC polyprotein and has previously shown to be effective as a competing antibody in a C-ELISA. The 3B antigen and the scFv were successfully expressed and purified from N. benthamiana, which to my knowledge is the first time either has been shown. The plant produced scFv successfully bound the 3B antigen in an I-ELISA. Separately, the plant produced 3B antigen could be used to successfully differentiate FMDV infected and vaccinated guinea pig serum in an I-ELISA. However, testing of these reagents in tandem within a C-ELISA to DIVA sera was inconclusive, and further research is required to optimise C-ELISA conditions.

Artificial intelligence (AI) algorithms for gait analysis rely on properly identified foot strikes for step-based feature calculation. Smartphone signals collected during movement assessments, such as the 6-minute walk test (6MWT), have been used to train AI models for foot strike identification and fall risk classification in able-bodied populations. However, there is limited research in populations with more asymmetrical gait. People with lower limb amputation can have high gait variability, adversely affecting automatic step detection algorithms. Hence, fall risk models for lower limb amputees have relied on manual foot strike labelling to calculate step-based features for model training, which is inefficient and impractical for clinical use. In this thesis, decision tree and long-short term memory (LSTM) models were developed, optimized, and their performance compared for automated foot strike identification in an amputee population. Eighty people with lower limb amputations (27 fallers, 53 non-fallers) completed a 6MWT with a smartphone at the posterior pelvis. Automated and manually labelled foot strikes from the full 6MWT and from the first two minutes of data were used to calculate step-based features. A random forest model was used to classify fall risk. The best foot strike identification model was an LSTM with 100 hidden nodes in the LSTM layer, 50 hidden nodes in the dense layer, and batch size of 64 (99.0% accuracy, 86.4% sensitivity, 99.4% specificity, 82.7% precision). Automated foot strikes from the full 6MWT data correctly classified more fallers (55.6% versus 48.1%), whereas automated foot strikes from 2-minute data classified more non-fallers (90.6% versus 81.1%). Feature calculation using manually labelled foot strikes resulted in the best overall performance (80.0% accuracy, 55.6% sensitivity, 92.5% specificity). This research created a novel method for automated foot strike identification in lower limb amputees that is equivalent to manual labelling and demonstrated that automated foot strikes can be used to calculate step-based features for fall risk classification. Integration of the foot strike identification model into a smartphone application could allow for immediate stride analysis after completing a 6MWT; however, fall risk classification model improvement is recommended to enhance clinical viability.

No / The purpose of this article is determining if and how the kinematic relationship between adjacent body segments changes when an individual’s gait pattern is experimentally manipulated can yield insight into the robustness of the kinematic coupling across the associated joint(s). The aim of this study was to assess the effects on the kinematic coupling between the forefoot, rearfoot and shank during ground contact of running with alteration in foot strike pattern. Twelve subjects ran over-ground using three different foot strike patterns (heel strike, forefoot strike, toe running). Kinematic data were collected of the forefoot, rearfoot and shank, which were modelled as rigid segments. Coupling at the ankle-complex and midfoot joints was assessed using cross-correlation and vector coding techniques. In general good coupling was found between rearfoot frontal plane motion and transverse plane shank rotation regardless of foot strike pattern. Forefoot motion was also strongly coupled with rearfoot frontal plane motion. Subtle differences were noted in the amount of rearfoot eversion transferred into shank internal rotation in the first 10–15% of stance during heel strike running compared to forefoot and toe running, and this was accompanied by small alterations in forefoot kinematics. These findings indicate that during ground contact in running there is strong coupling between the rearfoot and shank via the action of the joints in the ankle-complex. In addition, there was good coupling of both sagittal and transverse plane forefoot with rearfoot frontal plane motion via the action of the midfoot joints.