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Characteristics of Plantar Pressure Distribution in Diabetes with or without Diabetic Peripheral Neuropathy and Peripheral Arterial Disease

Characteristics of Plantar Pressure Distribution in Diabetes with or without Diabetic Peripheral... Hindawi Journal of Healthcare Engineering Volume 2022, Article ID 2437831, 8 pages https://doi.org/10.1155/2022/2437831 Research Article Characteristics of Plantar Pressure Distribution in Diabetes with or without Diabetic Peripheral Neuropathy and Peripheral Arterial Disease 1,2 1,2,3 4 1,2 1,2 Zijun Cao, Fang Wang , Xuemei Li , Jun Hu , Yaoguang He , 1,2 and Jianguo Zhang College of Mechanical Engineering, Tianjin University of Science and Technology, Tianjin 300222, China Key Laboratory of Integrated Design and Online Monitoring, Light Industry and Food Machinery and Equipment,Tianjin, Tianjin300222, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil A„airs, National Research Centre for Rehabilitation Technical Aids,No. 1 Ronghuazhonglu,BDA, Beijing 100176, China NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Endocrinology InstituteTianjin Medical University, Tianjin 300134, China Correspondence should be addressed to Fang Wang; fwang@tust.edu.cn and Jianguo Zhang; jg-zh@tust.edu.cn Received 24 October 2021; Accepted 18 May 2022; Published 6 June 2022 Academic Editor: Gin-Shin Chen Copyright © 2022 Zijun Cao et al. €is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Excessive plantar pressure leads to increased risk of diabetic foot ulcers. Diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) have been considered to be associated with alterations in gait and plantar pressure in diabetic patients. However, few studies have diŽerentiated the eŽects with each of them. Objective. To investigate the plantar pressure distribution in diabetic patients, with DPN and PAD as independent or combined factors. Methods. 112 subjects were recruited: 24 diabetic patients with both DPN and PAD (DPN-PAD group), 12 diabetic patients with DPN without PAD (DPN group), 10 diabetic patients with PAD without DPN (PAD group), 23 diabetic patients without DPN or PAD, and 43 nondiabetic healthy controls (HC group). €e in-shoe plantar pressure during natural walking was measured. DiŽerences in peak pressure, contact area, proportion of high pressure area (%HP), and anterior/posterior position of centre of pressure (COP) were analysed. Results. Compared with HC group, in DPN-PAD group and DPN group, the peak pressures in all three forefoot regions increased signi˜cantly; in PAD group, the peak pressure in lateral forefoot increased signi˜cantly. €e contact area of midfoot in the DPN- PAD group decreased signi˜cantly. PAD group had larger HP% of lateral forefoot, DPN group had larger HP% of inner forefoot, and DPN-PAD group had larger HP% of total plantar area. €ere was a signi˜cant tendency of the anterior displacement of COP in the DPN-PAD group and DPN group. No signi˜cant diŽerences were observed between the D group and HC group. Conclusion. DPN or PAD could aŽect the plantar pressure distribution in diabetic patients independently or synergistically, resulting in increased forefoot pressure and the area at risk of ulcers. DPN has a more pronounced eŽect on peak pressure than PAD. €e synergistic eŽect of them could signi˜cantly reduce the plantar contact area of midfoot. nontraumatic limb amputation [1]. It is estimated that the 1. Introduction lifetime risk of a diabetic patient developing DFU could be as Diabetic patients are prone to many complications during high as 30% [2], and the recurrence risk within 5 years after the course of disease. Diabetic foot syndrome is one of the ulcer healing was 65% [3]. €e treatment and prevention of most serious chronic complications of diabetes mellitus, DFU is a worldwide concern. leading to foot ulcers or even lower extremity amputation. DFU is associated with multiple factors. €e main Diabetic foot ulcer (DFU) is the most common cause of pathophysiological factors include peripheral neuropathy, 2 Journal of Healthcare Engineering Previous studies have mainly focused on the plantar macroangiopathy, and the repetitive trauma caused by in- creased plantar pressure [4]. Other components include pressure in diabetic patients with neuropathy rather than vasculopathy. Moreover, few studies have removed the in- microangiopahy, callus, and foot deformity [5, 6]. /e physical trauma heals relatively rapidly in healthy foot tissue fluences of PAD in patients with DPN or removed the in- under appropriate conditions. However, the healing process fluence of DPN in patients with PAD. /us, there was a gap in diabetics is impaired, and the trauma is susceptible to in knowledge about how DPN and PAD affect plantar infection and eventually ulcers. pressure in diabetic patients independently or synergisti- Diabetic peripheral neuropathy (DPN) is a common cally. /e aim of this study was to investigate the charac- complication in diabetic patients. DPN could lead to re- teristics of in-shoe plantar pressure during natural walking in diabetic patients with DPN or PAD, more specifically, to duced peripheral sensation and compromised propriocep- tive feedback control of human locomotion [7]. Motor assess the plantar pressure parameters in diabetic patients “with DPN and PAD,” “with DPN without PAD,” “with neuropathy causes weakening muscle strength and altered gait. /e loss of protective sensitivity leads to reduction in PAD without DPN,” and “without DPN or PAD.” Identi- fying the changes in plantar pressure could contribute to the perception of pain and increased plantar pressure [8]. Rahman et al. [9] reported a decreased in-shoe peak pressure awareness of the risks of diabetic complications and help during shod walking in rearfoot in diabetics with DPN improve therapy interventions such as exercise programs or compared to healthy people. Guldemond et al. [10] reported therapy footwear. increased peak pressure in plantar forefoot region in dia- betics with DPN compared to diabetics without DPN during barefoot walking. In Gnanasundaram et al.’s study [11], 2. Materials and Methods diabetics with or without DPN had higher peak pressure in 2.1.Participants. 112 subjects were recruited in this study: 24 medial heel region compared to healthy people, while no diabetics with DPN and PAD (DPN-PAD group), 12 dia- significant differences were found between diabetics with betics with DPN and no PAD (DPN group), 10 diabetics and without DPN. /ese studies have shown differences in with PAD and no DPN (PAD group), 23 diabetics without pressure distribution between shod walking and barefoot either DPN or PAD (D group), and 43 nondiabetic healthy walking. Owings et al. [12] suggested that in-shoe pressure controls (HC group). Patients were recruited from Tianjin was a more realistic variable than barefoot pressure for the Medical University Chu Hsien-I Memorial Hospital. /e screening and examination of foot ulceration risk in diabetic study was approved by the Institutional Review Board of patients, considering that people wear shoes most of the time Tianjin University of Science and Technology. All experi- in daily activities. ments were performed in accordance with the World Peripheral arterial disease (PAD) is a progressive disease Medical Association’s Declaration of Helsinki. Subjects caused by the atherosclerosis that leads to ischemia of lower involved were informed of the research procedure and limb tissue and promotes the development of ulcers [13]. signed the informed consent. Demographic and anthro- /ere were 202 million PAD patients worldwide [14]. People pometric data of subjects are shown in Table 1. with diabetes have four times the risk of PAD than people Data of age, height, weight, and BMI were obtained from without diabetes [15], and two-thirds of chronic, nonhealing medical records or by interview. /e diagnosis of DPN and plantar ulcers have arterial insufficiency [16]. /e presence PAD and HbA1c levels were obtained from medical records of PAD and diabetes reduced mass and function via multiple of diabetes patients. Subjects were excluded if they had any mechanisms in synergistic way [17]. Altered spatiotemporal of the followings: current or a history of foot ulcers, foot gait parameters, such as decreased step length, cadence, and deformity, lower limb amputations in either limb, and velocity in patients with PAD, have been reported [18]. A unable to walk repeatedly unaided over a distance of 10 m. typical symptom of PAD is intermittent claudication, /e presence of intermittent claudication was not consid- characterized by the cramping pain in legs after short walks ered in PAD patients. In this study, the plantar pressure data [19]. Szymczak et al. [20] suggested that PAD patients with of subjects were collected for walking 10 meters, which was and without intermittent claudication have shorter step much shorter than the distance of the onset of intermittent length than healthy subjects. Cheung et al. [17] reported that claudication (usually a few hundred meters). In addition, patients with diabetes and PAD had significantly lower gait several studies have revealed altered gait parameters in PAD speed compared with subjects without diabetes or PAD, patients both with and without intermittent claudication while no such difference was found in the diabetics without [23, 24]. PAD and the PAD patients without diabetes. Pataky et al. [21] reported a significant correlation between plantar pressure under the first metatarsal head and Doppler arterial 2.2. Plantar Pressure Measurements and Statistical Analysis. pressure of both tibial posterior and dorsalis pedis artery in /e plantar pressure experiment was carried out with T&T diabetic patients with both peripheral neuropathy and Medilogic 5.8.1 measurement system (NORAXON, USA). vascular disease. Mantovani et al. [22] reported a higher /e dynamic sampling frequency was 300 Hz. Uniform flat pressure-time integral in diabetic patients with both pe- shoes and thin cotton socks with suitable sizes were assigned ripheral neuropathy and peripheral vasculopathy compared to subjects. All subjects walked 10 meters on a straight with nondiabetic patients. /ey suggested that the gait walkway with self-selected speed and stride length. pattern worsened with the severity of clinical impairment. Journal of Healthcare Engineering 3 Table 1: Demographic and anthropometric data of subjects. Variables DPN-PAD DPN PAD D HC Number (M/F) 24 (13/11) 12 (6/6) 10 (7/3) 23 (16/7) 43 (23/20) Age (years) 60.4 ± 7.6 55.0 ± 13.3 55.8 ± 15.0 54.4 ± 12.1 57.6 ± 15.4 Height (cm) 165.9 ± 8.6 166.5 ± 4.4 167.8 ± 6.7 168.2 ± 9.0 166.5 ± 6.9 Weight (kg) 68.4 ± 7.2 66.6 ± 12.8 76.4 ± 5.2 73.1 ± 11.1 67.1 ± 8.3 BMI (kg/m ) 24.9 ± 2.4 24.0 ± 4.2 27.2 ± 1.8 25.7 ± 2.5 24.2 ± 2.4 HbA1c (%) 8.6± 1.9 8.8± 1.7 8.4± 1.3 8.4± 1.9 — was the distance between the intersection point of butterfly Toes diagram and the zero position (initial contact position), as 0 to 100% of width shown in Figure 2. /e value of each subject was normalized Inner forefoot 80 to 100% of length by the foot length, and the ratios of each group were 66 to 100% of width Medial forefoot 60 to 80% of length calculated. 0 to 33% of width Statistical analysis was performed using SPSS software 60 to 80% of length 21.0 (IBM, USA). Mean and standard deviation of each group were calculated. Kolmogorov–Smirnov test was Lateral forefoot Midfoot performed to assess normal distribution. One-way ANOVA 33 to 66% of width 0 to 100% of width 60 to 80% of length was performed to analyse the differences of plantar pressures 30 to 60% of length between the four diabetic groups and control group, and the significant level of the differences was 0.05. Lateral heel Medial heel 50 to 100% of width 0 to 50% of width 3. Results 0 to 30% of length 0 to 30% of length 3.1. Absolute and Normalized Peak Pressure. /e absolute Figure 1: Segmented plantar regions. peak pressures are shown in Table 2. In each group, the peak pressure in inner forefoot was higher than that in medial forefoot and lateral forefoot, and the peak pressure in lateral heel was higher than that in medial heel. /e absolute peak pressures in all regions except midfoot were higher than 200 kPa. /e normalized peak pressures and the results of dif- ference analysis between groups are shown in Table 3. Compared with the HC group, the normalized peak pres- sures in all three forefoot regions in the DPN-PAD group and DPN group were significantly higher, and the peak pressure in lateral forefoot in PAD was significantly higher. No significant differences were observed between D group and HC group. Zero Position 3.2. Plantar Contact Area. /e normalized plantar contact Figure 2: Anterior/posterior position of COP. area is shown in Table 4. Compared with the HC group, the contact area of midfoot in the DPN-PAD group was sig- nificantly smaller. Although no significant differences were /e plantar pressure in steady gait cycle was included for observed in other groups, there was a tendency of decreasing analysis, and data of initial and terminal stage were excluded contact area of midfoot in the DPN group, PAD group and D to eliminate the effects of acceleration and deceleration. /e group. In addition, the experimental peak pressure distri- plantar area was segmented into 7 regions, namely, toes, bution during whole gait cycle of the subjects in different lateral forefoot, inner forefoot, medial forefoot, midfoot, groups is shown in Figure 3. DPN-PAD group had the lateral heel, and medial heel, respectively. /e schematic smallest contact area, especially in midfoot, which was image of plantar regions is shown in Figure 1. /e absolute consistent with the results in Table 4. Compared with the HC value and normalized (scale to body weight) value of peak group, there was also a decreasing tendency of contact area pressure, normalized plantar contact area (scale to total of midfoot in the DPN group and PAD group, particularly in plantar area), and the proportion of high pressure area (% the PAD group. HP) in segmented regions were calculated. High-pressure was defined as the absolute value above 200 kPa. /e trajectory of centre of pressure (COP) formed 3.3. Proportion of the High Pressure Area. /e HP% of butterfly diagram. /e anterior/posterior position of COP segmented plantar regions is shown in Table 5. Compared 4 Journal of Healthcare Engineering Table 2: Absolute value of peak pressures in segmented plantar regions. Region DPN-PAD DPN PAD D HC T 312.3± 141.3 264.3± 70.1 340.1± 64.6 294.4± 105.7 281.9± 106.7 LF 310.1± 120.1 325.6± 135.3 342.1± 114.3 262.9± 113.0 253.3± 90.8 IF 468.2± 121.2 524.1± 60.5 500.2± 128.4 422.6± 140.8 405.2± 120.3 MF 378.3± 109.9 372.7± 115.6 377.3± 125.6 341.9± 147.2 309.0± 102.1 M 143.6± 88.9 173.4± 104.8 129.7± 51.8 135.7± 74.4 155.0± 96.7 LH 456.1± 105.4 417.8± 93.1 454.3± 84.5 415.8± 124.8 422.2± 100.5 MH 439.5± 100.3 385.6± 87.7 422.9± 75.6 407.8± 123.7 410.5± 102.2 /e unit of peak pressure was kPa. Abbreviations: T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel. Table 3: Normalized (scale to body weight) value of peak pressures in segmented plantar regions. Normalized peak pressure P value Region DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC T 4.6± 2.1 4.1± 1.0 4.5± 0.9 4.0± 1.2 4.3± 1.7 0.514 0.633 0.701 0.483 ∗ ∗ ∗ ∗ ∗ ∗ LF 4.6± 1.8 4.7± 2.3 4.5± 1.5 3.6± 1.5 3.7± 1.2 0.035 0.039 0.045 0.688 ∗ ∗ ∗ ∗ IF 6.9± 1.7 7.6± 2.0 6.6± 1.7 5.8± 1.8 6.0± 1.4 0.043 0.021 0.320 0.597 ∗ ∗ ∗ ∗ MF 5.6± 1.4 5.8± 1.9 4.9± 1.8 4.6± 1.6 4.6± 1.3 0.010 0.019 0.556 0.975 M 2.1± 1.3 2.6± 1.5 1.7± 0.6 1.9± 1.0 2.3± 1.4 0.597 0.589 0.198 0.194 LH 6.7± 1.7 6.6± 2.0 6.0± 1.0 5.8± 1.8 6.4± 1.6 0.371 0.708 0.464 0.191 MH 6.5± 1.5 5.9± 1.3 5.5± 0.8 5.5± 1.3 6.1± 1.3 0.371 0.662 0.189 0.108 /e unit of peak pressure was kPa; the unit of body weight was kg. Values with indicate statistically significant difference(P< 0.05) compared with HC group. T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel. Table 4: Normalized value (scale to total plantar contact area) of contact area of segmented plantar regions. Normalized contact area (%) P value Region DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC T 17.5± 1.4 17.1± 1.9 16.8± 1.4 16.9± 2.1 17.4± 1.8 0.94 0.617 0.330 0.267 LF 7.0± 0.8 6.9± 1.1 6.8± 1.1 7.2± 1.1 7.0± 2.0 0.907 0.867 0.679 0.710 IF 9.8± 0.8 9.6± 0.6 9.5± 0.8 9.6± 0.7 9.6± 1.6 0.562 0.946 0.905 0.872 MF 9.0± 1.5 9.2± 1.5 9.3± 1.0 9.0± 1.2 8.7± 2.2 0.601 0.482 0.464 0.554 ∗ ∗ M 25.8± 4.1 26.7± 3.5 26.2± 3.8 26.8± 3.6 29.3± 4.9 0.005 0.101 0.217 0.097 LH 16.4± 2.3 16.6± 2.1 16.8± 1.5 16.4± 2.0 16.0± 3.4 0.555 0.529 0.459 0.573 MH 14.5± 1.2 13.7± 1.5 13.6± 1.6 14.1± 1.3 14.4± 2.7 0.883 0.382 0.363 0.581 Values with indicate statistically significant difference (P< 0.05) compared with HC. Abbreviations T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel; total � total plantar area. 040 80 120 160 200 240 280 320 360 400 kPa DPN-PAD subject DPN subject PAD subject D subject HC subject Figure 3: Peak plantar pressure distribution during the gait cycle. Journal of Healthcare Engineering 5 Table 5: HP% of segmented and total plantar regions. HP% (%) P value Region DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC T 13.1± 12.2 11.3± 7.5 16.2± 7.0 15.6± 11.7 11.6± 9.0 0.581 0.901 0.146 0.132 ∗ ∗ LF 28.1± 18.4 30.5± 20.7 32.1± 17.7 22.6± 22.0 20.0± 16.6 0.075 0.063 0.049 0.603 ∗ ∗ IF 55.6± 18.6 66.9± 15.1 59.5± 11.7 45.4± 19.7 51.8± 22.2 0.485 0.033 0.319 0.260 MF 32.5± 18.4 27.2± 15.1 22.4± 10.5 26.3± 18.5 26.0± 17.4 0.166 0.838 0.531 0.963 M 2.0± 4.0 2.3± 3.2 0.6± 1.0 1.1± 2.1 1.5± 3.0 0.637 0.440 0.338 0.517 LH 41.9± 13.5 36.6± 10.4 42.6± 12.5 36.8± 17.4 39.0± 14.5 0.427 0.607 0.482 0.595 MH 34.9± 11.0 31.2± 9.7 34.3± 8.9 33.9± 14.5 32.1 (10.0) 0.298 0.797 0.530 0.556 ∗ ∗ Total 25.1 (7.1) 24.0 (3.9) 24.7 (5.0) 22.1 (8.7) 21.4 (6.4) 0.035 0.204 0.147 0.729 Values with indicate statistically significant difference (P< 0.05) compared with HC. Abbreviations: HP% � proportion of high pressure (>200 kPa) area; T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel. Total is the proportion of high pressure area in the total plantar area. Table 6: Anterior/posterior position of COP in each group. Anterior/posterior position of COP (%) P value DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC ∗ ∗ ∗ ∗ 55.0± 2.6 54.6± 1.9 52.7± 4.4 52.4± 3.2 51.4± 3.0 0.001 0.002 0.285 0.224 Values with indicate statistically significant difference (P< 0.05) compared with HC. Abbreviations: T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel; total � total plantar area. with the HC group, the HP% of total plantar area in the of neuropathy and arterial disease did not further increase DPN-PAD group was significantly larger, while no signifi- the peak pressure. Although the difference of peak pressure in inner cant differences were found in segmented regions. /e significant increases were also observed in the inner forefoot forefoot in PAD group was not significant compared with in DPN group and lateral forefoot in PAD group. /ough HC group, it also showed increasing tendency and the the differences of HP% of lateral forefoot in DPN-PAD pressure level was close to that of DPN-PAD group. /is group and DPN group were not significant compared with suggested that the alteration of plantar pressure in diabetic the HC group, there was still a tendency of increase. No patients with PAD began in lateral forefoot, followed by significant differences were observed between the D group inner forefoot. Atherosclerosis resulted in insufficient oxy- and HC group. gen and nutrients. Long-term vasculopathy causes altered muscle morphology and mitochondrial function, resulting in decreased muscle strength [17]. Myers et al. [27] reported 3.4. Anterior/Posterior Position of COP. /e normalized the alteration of joint kinematics and kinetics in patients anterior/posterior position of COP is shown in Table 6. with PAD during pain-free walking compared with healthy Compared with the HC group, a significant increase was subjects. /ey found decreased dorsiflexor torque of ankle observed in the DPN-PAD group and DPN group. No during stance phase in PAD patients. In addition, the ki- significant differences were found in the other groups. nematic changes of greater ankle plantarflexion angle re- duced time to peak plantar flexion and increased time to peak dorsiflexion in patients with PAD resulted in altered 4. Discussion foot rotation [28]. /e alteration of plantar pressure in PAD As shown in Table 3, DPN or PAD could independently lead group was accompanied by these changes of gait parameters. to increased peak pressure in forefoot. Raspovic [25] re- To the author’s knowledge, the plantar contact area ported reduced motion at the ankle, less foot rotation, and during walking in these specific populations has not been less fist metatarsophalangeal joint movement in subjects reported. Pataky et al. [29] reported a significantly reduced contact area in diabetic patients without peripheral neu- with peripheral neuropathy and a history of plantar ulcer- ation. Gardner et al. [26] reported reduced swing phase and ropathy or peripheral arterial disease compared to nondi- abetic subjects. However, it was the contact area in static extended stance phase in PAD patients. /ese may lead to the accumulation of load in forefoot region as well as the standing position they investigated. As shown in Table 4 and increased plantar pressure. Significant increases of peak Figure 3, the contact area of midfoot in DPN-PAD patient pressures were observed in all three forefoot regions in DPN and PAD patient was relatively small, which may reflect a group, while only in lateral forefoot in the PAD group. It reduction in plantar soft tissue. It has been reported that the seemed that DPN had a greater effect on peak pressure than presence of both diabetes and PAD could reduce muscle PAD. Similar to the DPN group, the peak pressures in the mass via multiple mechanisms synergistically [30, 31]. Long- term hyperglycemia and ischemia damage not only lower three forefoot regions in DPN-PAD group were significantly increased, but the pressure value was close. /e combination limb muscles but also plantar soft tissue. /inner and stiffer 6 Journal of Healthcare Engineering gradual process. /e significant changes in plantar pressure soft tissue is also associated with increased plantar pressure [32]. PAD causes reduced supply of oxygen and nutrients, occurred after the combination of DPN or PAD. However, the lack of significant differences between the resulting in alteration in histological characters of plantar soft tissue. Ischemia promotes the plantar soft tissue D group and HC group differs from Pataky’s [29]. /ey thickness under 1st and 5th metatarsal heads reduction [29]. found significant differences of peak pressure under the big /inner soft tissue could also contribute to higher plantar toe, 5th metatarsal head, and heel in diabetic patients pressure. /e elevated repetitive mechanical stress, in turn, without peripheral neuropathy or vasculopathy compared increases the fragility of microvessel and decreases blood with nondiabetic subjects. In this study, the absolute values flow, producing a vicious cycle [23]. of peak pressure in all three forefoot regions in the D group showed a tendency to increase, but the normalized values did In DPN group, no significant differences of segmented contact area were observed, but significant increase of peak not. /e inconsistent results suggested that the body weight of subjects should be a concern. Although an appropriate pressures were observed in all three forefoot regions. /is suggested that the increased peak pressure may not be due to range of body weight and BMI have been adopted as one of the inclusion criteria in many studies, the differences of body the altered contact area, but to the tendency of the anterior displacement of weight-bearing, which was confirmed by the weight in individuals still affected plantar pressure. In the results in Table 5. Compared with the HC group, all four study of Castro et al. [37, 38], the results of analysing ab- diabetic groups showed a tendency of the anterior dis- solute value of ground reaction force and plantar pressure placement of COP, and the significant differences were were different from the results of analysing normalized value observed in the DPN-PAD group and DPN group. Similar of ground reaction force and plantar pressure. /erefore, the conclusion was also presented in previous research. Melai absolute value could be used to indicate the magnitude of plantar pressure and evaluating the risk of ulceration, while et al. [33] observed a faster forward transfer of centre of pressure and consequently higher load in forefoot in patients the normalized value should be used in analysis of differ- ences between groups to subtract the effects of body weight. with DPN. Another important parameter analysed in this study was A potential limitation of this study is that the micro- vascular complications such as nephropathy and retinopathy the proportion of the high pressure area. Owings et al. [12] investigated the in-shoe plantar pressure in diabetic patients was not considered. Future research on potential factors with DPN and a history of DFU and suggested 200 kPa as a associated with macroangiopathy and microangiopathy reference in foot ulceration prevention. /is value was could be helpful to further understand the mechanism of the obtained from the position of healed ulcers in diabetic plantar pressure alteration in diabetic patients. /e current patients with a history of ulcers and was considered safe for results could be considered as a preliminary demonstration diabetic with or without a history of ulcers. It has been of the independent and synergistic effects of DPN and PAD on plantar pressure in diabetic patients. widely used in later studies as a threshold for classifying high pressure or as and optimization target for developing off- loading footwear [34–36]. As shown in Table 5, the HP% of 5. Conclusions the lateral forefoot in PAD group and the inner forefoot in DPN group was significantly larger than that in the HC /e current study provides the evidence for learning the group. Although there were no significant differences of independent or synergistic effects of peripheral neuropathy segmented HP% between the DPN-PAD and HC group, the and peripheral arterial disease on plantar pressure in diabetic HP% of total plantar area was significantly higher. More- patients. Identifying the changes in plantar pressure distri- over, a tendency of increasing HP% was also observed in all bution helps to carry out physical therapy interventions, such lateral forefoot and inner forefoot regions in DPN-PAD, as exercise program, offloading footwear, and therapeutic DPN, and PAD groups compared with the HC group, al- orthosis. /e alteration of plantar pressure in diabetic patients though the differences were not significant. /e HP% is was a gradual process, and significant changes occurred after positively associated with peak pressure in segmented the combination of DPN or PAD. DPN and PAD could plantar regions. Either peripheral neuropathy or peripheral independently affect plantar pressure in diabetic patients, arterial disease could independently cause increased plantar leading to higher pressure in forefoot and larger area at risk of pressure and high pressure area. /e combination of neu- ulcers. /e prevention and/or control of DPN and PAD and ropathy and vasculopathy did not cause further increases of the redistribution of plantar pressure from forefoot onto the peak pressure, but caused larger area of high pressure. whole foot should be highlighted in clinical practice. A noteworthy result in our study is that compared with the HC group, no significant differences of plantar pressure Data Availability parameters were observed in the D group. /e consistent results have been found in other study [11]. However, there /e raw/processed data required to reproduce these findings was a tendency of decreasing of contact area in the D group, cannot be shared at this time as the data also form part of an as shown in Table 4. /is may indicate that the alteration of ongoing study. soft tissue character occurred in the diabetic stage before the presence of complications. /e progressive effects of changes Conflicts of Interest in peripheral nervous system and vessels on the lower limb physiology making the changes in plantar pressure was a /e authors declare that they have no conflicts of interest. Journal of Healthcare Engineering 7 [15] M. Birrer, “Macroangiopathy in diabetes mellitus,” Vasa, Authors’ Contributions vol. 30, no. 3, pp. 168–174, 2001. [16] G. M. Caputo, P. R. Cavanagh, J. S. Ulbrecht, G. W. Gibbons, Zijun Cao, Fang Wang, and Xuemei Li are co-first authors. and A. W. 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Characteristics of Plantar Pressure Distribution in Diabetes with or without Diabetic Peripheral Neuropathy and Peripheral Arterial Disease

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Hindawi Journal of Healthcare Engineering Volume 2022, Article ID 2437831, 8 pages https://doi.org/10.1155/2022/2437831 Research Article Characteristics of Plantar Pressure Distribution in Diabetes with or without Diabetic Peripheral Neuropathy and Peripheral Arterial Disease 1,2 1,2,3 4 1,2 1,2 Zijun Cao, Fang Wang , Xuemei Li , Jun Hu , Yaoguang He , 1,2 and Jianguo Zhang College of Mechanical Engineering, Tianjin University of Science and Technology, Tianjin 300222, China Key Laboratory of Integrated Design and Online Monitoring, Light Industry and Food Machinery and Equipment,Tianjin, Tianjin300222, China Key Laboratory of Human Motion Analysis and Rehabilitation Technology of the Ministry of Civil A„airs, National Research Centre for Rehabilitation Technical Aids,No. 1 Ronghuazhonglu,BDA, Beijing 100176, China NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Endocrinology InstituteTianjin Medical University, Tianjin 300134, China Correspondence should be addressed to Fang Wang; fwang@tust.edu.cn and Jianguo Zhang; jg-zh@tust.edu.cn Received 24 October 2021; Accepted 18 May 2022; Published 6 June 2022 Academic Editor: Gin-Shin Chen Copyright © 2022 Zijun Cao et al. €is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Excessive plantar pressure leads to increased risk of diabetic foot ulcers. Diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) have been considered to be associated with alterations in gait and plantar pressure in diabetic patients. However, few studies have diŽerentiated the eŽects with each of them. Objective. To investigate the plantar pressure distribution in diabetic patients, with DPN and PAD as independent or combined factors. Methods. 112 subjects were recruited: 24 diabetic patients with both DPN and PAD (DPN-PAD group), 12 diabetic patients with DPN without PAD (DPN group), 10 diabetic patients with PAD without DPN (PAD group), 23 diabetic patients without DPN or PAD, and 43 nondiabetic healthy controls (HC group). €e in-shoe plantar pressure during natural walking was measured. DiŽerences in peak pressure, contact area, proportion of high pressure area (%HP), and anterior/posterior position of centre of pressure (COP) were analysed. Results. Compared with HC group, in DPN-PAD group and DPN group, the peak pressures in all three forefoot regions increased signi˜cantly; in PAD group, the peak pressure in lateral forefoot increased signi˜cantly. €e contact area of midfoot in the DPN- PAD group decreased signi˜cantly. PAD group had larger HP% of lateral forefoot, DPN group had larger HP% of inner forefoot, and DPN-PAD group had larger HP% of total plantar area. €ere was a signi˜cant tendency of the anterior displacement of COP in the DPN-PAD group and DPN group. No signi˜cant diŽerences were observed between the D group and HC group. Conclusion. DPN or PAD could aŽect the plantar pressure distribution in diabetic patients independently or synergistically, resulting in increased forefoot pressure and the area at risk of ulcers. DPN has a more pronounced eŽect on peak pressure than PAD. €e synergistic eŽect of them could signi˜cantly reduce the plantar contact area of midfoot. nontraumatic limb amputation [1]. It is estimated that the 1. Introduction lifetime risk of a diabetic patient developing DFU could be as Diabetic patients are prone to many complications during high as 30% [2], and the recurrence risk within 5 years after the course of disease. Diabetic foot syndrome is one of the ulcer healing was 65% [3]. €e treatment and prevention of most serious chronic complications of diabetes mellitus, DFU is a worldwide concern. leading to foot ulcers or even lower extremity amputation. DFU is associated with multiple factors. €e main Diabetic foot ulcer (DFU) is the most common cause of pathophysiological factors include peripheral neuropathy, 2 Journal of Healthcare Engineering Previous studies have mainly focused on the plantar macroangiopathy, and the repetitive trauma caused by in- creased plantar pressure [4]. Other components include pressure in diabetic patients with neuropathy rather than vasculopathy. Moreover, few studies have removed the in- microangiopahy, callus, and foot deformity [5, 6]. /e physical trauma heals relatively rapidly in healthy foot tissue fluences of PAD in patients with DPN or removed the in- under appropriate conditions. However, the healing process fluence of DPN in patients with PAD. /us, there was a gap in diabetics is impaired, and the trauma is susceptible to in knowledge about how DPN and PAD affect plantar infection and eventually ulcers. pressure in diabetic patients independently or synergisti- Diabetic peripheral neuropathy (DPN) is a common cally. /e aim of this study was to investigate the charac- complication in diabetic patients. DPN could lead to re- teristics of in-shoe plantar pressure during natural walking in diabetic patients with DPN or PAD, more specifically, to duced peripheral sensation and compromised propriocep- tive feedback control of human locomotion [7]. Motor assess the plantar pressure parameters in diabetic patients “with DPN and PAD,” “with DPN without PAD,” “with neuropathy causes weakening muscle strength and altered gait. /e loss of protective sensitivity leads to reduction in PAD without DPN,” and “without DPN or PAD.” Identi- fying the changes in plantar pressure could contribute to the perception of pain and increased plantar pressure [8]. Rahman et al. [9] reported a decreased in-shoe peak pressure awareness of the risks of diabetic complications and help during shod walking in rearfoot in diabetics with DPN improve therapy interventions such as exercise programs or compared to healthy people. Guldemond et al. [10] reported therapy footwear. increased peak pressure in plantar forefoot region in dia- betics with DPN compared to diabetics without DPN during barefoot walking. In Gnanasundaram et al.’s study [11], 2. Materials and Methods diabetics with or without DPN had higher peak pressure in 2.1.Participants. 112 subjects were recruited in this study: 24 medial heel region compared to healthy people, while no diabetics with DPN and PAD (DPN-PAD group), 12 dia- significant differences were found between diabetics with betics with DPN and no PAD (DPN group), 10 diabetics and without DPN. /ese studies have shown differences in with PAD and no DPN (PAD group), 23 diabetics without pressure distribution between shod walking and barefoot either DPN or PAD (D group), and 43 nondiabetic healthy walking. Owings et al. [12] suggested that in-shoe pressure controls (HC group). Patients were recruited from Tianjin was a more realistic variable than barefoot pressure for the Medical University Chu Hsien-I Memorial Hospital. /e screening and examination of foot ulceration risk in diabetic study was approved by the Institutional Review Board of patients, considering that people wear shoes most of the time Tianjin University of Science and Technology. All experi- in daily activities. ments were performed in accordance with the World Peripheral arterial disease (PAD) is a progressive disease Medical Association’s Declaration of Helsinki. Subjects caused by the atherosclerosis that leads to ischemia of lower involved were informed of the research procedure and limb tissue and promotes the development of ulcers [13]. signed the informed consent. Demographic and anthro- /ere were 202 million PAD patients worldwide [14]. People pometric data of subjects are shown in Table 1. with diabetes have four times the risk of PAD than people Data of age, height, weight, and BMI were obtained from without diabetes [15], and two-thirds of chronic, nonhealing medical records or by interview. /e diagnosis of DPN and plantar ulcers have arterial insufficiency [16]. /e presence PAD and HbA1c levels were obtained from medical records of PAD and diabetes reduced mass and function via multiple of diabetes patients. Subjects were excluded if they had any mechanisms in synergistic way [17]. Altered spatiotemporal of the followings: current or a history of foot ulcers, foot gait parameters, such as decreased step length, cadence, and deformity, lower limb amputations in either limb, and velocity in patients with PAD, have been reported [18]. A unable to walk repeatedly unaided over a distance of 10 m. typical symptom of PAD is intermittent claudication, /e presence of intermittent claudication was not consid- characterized by the cramping pain in legs after short walks ered in PAD patients. In this study, the plantar pressure data [19]. Szymczak et al. [20] suggested that PAD patients with of subjects were collected for walking 10 meters, which was and without intermittent claudication have shorter step much shorter than the distance of the onset of intermittent length than healthy subjects. Cheung et al. [17] reported that claudication (usually a few hundred meters). In addition, patients with diabetes and PAD had significantly lower gait several studies have revealed altered gait parameters in PAD speed compared with subjects without diabetes or PAD, patients both with and without intermittent claudication while no such difference was found in the diabetics without [23, 24]. PAD and the PAD patients without diabetes. Pataky et al. [21] reported a significant correlation between plantar pressure under the first metatarsal head and Doppler arterial 2.2. Plantar Pressure Measurements and Statistical Analysis. pressure of both tibial posterior and dorsalis pedis artery in /e plantar pressure experiment was carried out with T&T diabetic patients with both peripheral neuropathy and Medilogic 5.8.1 measurement system (NORAXON, USA). vascular disease. Mantovani et al. [22] reported a higher /e dynamic sampling frequency was 300 Hz. Uniform flat pressure-time integral in diabetic patients with both pe- shoes and thin cotton socks with suitable sizes were assigned ripheral neuropathy and peripheral vasculopathy compared to subjects. All subjects walked 10 meters on a straight with nondiabetic patients. /ey suggested that the gait walkway with self-selected speed and stride length. pattern worsened with the severity of clinical impairment. Journal of Healthcare Engineering 3 Table 1: Demographic and anthropometric data of subjects. Variables DPN-PAD DPN PAD D HC Number (M/F) 24 (13/11) 12 (6/6) 10 (7/3) 23 (16/7) 43 (23/20) Age (years) 60.4 ± 7.6 55.0 ± 13.3 55.8 ± 15.0 54.4 ± 12.1 57.6 ± 15.4 Height (cm) 165.9 ± 8.6 166.5 ± 4.4 167.8 ± 6.7 168.2 ± 9.0 166.5 ± 6.9 Weight (kg) 68.4 ± 7.2 66.6 ± 12.8 76.4 ± 5.2 73.1 ± 11.1 67.1 ± 8.3 BMI (kg/m ) 24.9 ± 2.4 24.0 ± 4.2 27.2 ± 1.8 25.7 ± 2.5 24.2 ± 2.4 HbA1c (%) 8.6± 1.9 8.8± 1.7 8.4± 1.3 8.4± 1.9 — was the distance between the intersection point of butterfly Toes diagram and the zero position (initial contact position), as 0 to 100% of width shown in Figure 2. /e value of each subject was normalized Inner forefoot 80 to 100% of length by the foot length, and the ratios of each group were 66 to 100% of width Medial forefoot 60 to 80% of length calculated. 0 to 33% of width Statistical analysis was performed using SPSS software 60 to 80% of length 21.0 (IBM, USA). Mean and standard deviation of each group were calculated. Kolmogorov–Smirnov test was Lateral forefoot Midfoot performed to assess normal distribution. One-way ANOVA 33 to 66% of width 0 to 100% of width 60 to 80% of length was performed to analyse the differences of plantar pressures 30 to 60% of length between the four diabetic groups and control group, and the significant level of the differences was 0.05. Lateral heel Medial heel 50 to 100% of width 0 to 50% of width 3. Results 0 to 30% of length 0 to 30% of length 3.1. Absolute and Normalized Peak Pressure. /e absolute Figure 1: Segmented plantar regions. peak pressures are shown in Table 2. In each group, the peak pressure in inner forefoot was higher than that in medial forefoot and lateral forefoot, and the peak pressure in lateral heel was higher than that in medial heel. /e absolute peak pressures in all regions except midfoot were higher than 200 kPa. /e normalized peak pressures and the results of dif- ference analysis between groups are shown in Table 3. Compared with the HC group, the normalized peak pres- sures in all three forefoot regions in the DPN-PAD group and DPN group were significantly higher, and the peak pressure in lateral forefoot in PAD was significantly higher. No significant differences were observed between D group and HC group. Zero Position 3.2. Plantar Contact Area. /e normalized plantar contact Figure 2: Anterior/posterior position of COP. area is shown in Table 4. Compared with the HC group, the contact area of midfoot in the DPN-PAD group was sig- nificantly smaller. Although no significant differences were /e plantar pressure in steady gait cycle was included for observed in other groups, there was a tendency of decreasing analysis, and data of initial and terminal stage were excluded contact area of midfoot in the DPN group, PAD group and D to eliminate the effects of acceleration and deceleration. /e group. In addition, the experimental peak pressure distri- plantar area was segmented into 7 regions, namely, toes, bution during whole gait cycle of the subjects in different lateral forefoot, inner forefoot, medial forefoot, midfoot, groups is shown in Figure 3. DPN-PAD group had the lateral heel, and medial heel, respectively. /e schematic smallest contact area, especially in midfoot, which was image of plantar regions is shown in Figure 1. /e absolute consistent with the results in Table 4. Compared with the HC value and normalized (scale to body weight) value of peak group, there was also a decreasing tendency of contact area pressure, normalized plantar contact area (scale to total of midfoot in the DPN group and PAD group, particularly in plantar area), and the proportion of high pressure area (% the PAD group. HP) in segmented regions were calculated. High-pressure was defined as the absolute value above 200 kPa. /e trajectory of centre of pressure (COP) formed 3.3. Proportion of the High Pressure Area. /e HP% of butterfly diagram. /e anterior/posterior position of COP segmented plantar regions is shown in Table 5. Compared 4 Journal of Healthcare Engineering Table 2: Absolute value of peak pressures in segmented plantar regions. Region DPN-PAD DPN PAD D HC T 312.3± 141.3 264.3± 70.1 340.1± 64.6 294.4± 105.7 281.9± 106.7 LF 310.1± 120.1 325.6± 135.3 342.1± 114.3 262.9± 113.0 253.3± 90.8 IF 468.2± 121.2 524.1± 60.5 500.2± 128.4 422.6± 140.8 405.2± 120.3 MF 378.3± 109.9 372.7± 115.6 377.3± 125.6 341.9± 147.2 309.0± 102.1 M 143.6± 88.9 173.4± 104.8 129.7± 51.8 135.7± 74.4 155.0± 96.7 LH 456.1± 105.4 417.8± 93.1 454.3± 84.5 415.8± 124.8 422.2± 100.5 MH 439.5± 100.3 385.6± 87.7 422.9± 75.6 407.8± 123.7 410.5± 102.2 /e unit of peak pressure was kPa. Abbreviations: T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel. Table 3: Normalized (scale to body weight) value of peak pressures in segmented plantar regions. Normalized peak pressure P value Region DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC T 4.6± 2.1 4.1± 1.0 4.5± 0.9 4.0± 1.2 4.3± 1.7 0.514 0.633 0.701 0.483 ∗ ∗ ∗ ∗ ∗ ∗ LF 4.6± 1.8 4.7± 2.3 4.5± 1.5 3.6± 1.5 3.7± 1.2 0.035 0.039 0.045 0.688 ∗ ∗ ∗ ∗ IF 6.9± 1.7 7.6± 2.0 6.6± 1.7 5.8± 1.8 6.0± 1.4 0.043 0.021 0.320 0.597 ∗ ∗ ∗ ∗ MF 5.6± 1.4 5.8± 1.9 4.9± 1.8 4.6± 1.6 4.6± 1.3 0.010 0.019 0.556 0.975 M 2.1± 1.3 2.6± 1.5 1.7± 0.6 1.9± 1.0 2.3± 1.4 0.597 0.589 0.198 0.194 LH 6.7± 1.7 6.6± 2.0 6.0± 1.0 5.8± 1.8 6.4± 1.6 0.371 0.708 0.464 0.191 MH 6.5± 1.5 5.9± 1.3 5.5± 0.8 5.5± 1.3 6.1± 1.3 0.371 0.662 0.189 0.108 /e unit of peak pressure was kPa; the unit of body weight was kg. Values with indicate statistically significant difference(P< 0.05) compared with HC group. T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel. Table 4: Normalized value (scale to total plantar contact area) of contact area of segmented plantar regions. Normalized contact area (%) P value Region DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC T 17.5± 1.4 17.1± 1.9 16.8± 1.4 16.9± 2.1 17.4± 1.8 0.94 0.617 0.330 0.267 LF 7.0± 0.8 6.9± 1.1 6.8± 1.1 7.2± 1.1 7.0± 2.0 0.907 0.867 0.679 0.710 IF 9.8± 0.8 9.6± 0.6 9.5± 0.8 9.6± 0.7 9.6± 1.6 0.562 0.946 0.905 0.872 MF 9.0± 1.5 9.2± 1.5 9.3± 1.0 9.0± 1.2 8.7± 2.2 0.601 0.482 0.464 0.554 ∗ ∗ M 25.8± 4.1 26.7± 3.5 26.2± 3.8 26.8± 3.6 29.3± 4.9 0.005 0.101 0.217 0.097 LH 16.4± 2.3 16.6± 2.1 16.8± 1.5 16.4± 2.0 16.0± 3.4 0.555 0.529 0.459 0.573 MH 14.5± 1.2 13.7± 1.5 13.6± 1.6 14.1± 1.3 14.4± 2.7 0.883 0.382 0.363 0.581 Values with indicate statistically significant difference (P< 0.05) compared with HC. Abbreviations T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel; total � total plantar area. 040 80 120 160 200 240 280 320 360 400 kPa DPN-PAD subject DPN subject PAD subject D subject HC subject Figure 3: Peak plantar pressure distribution during the gait cycle. Journal of Healthcare Engineering 5 Table 5: HP% of segmented and total plantar regions. HP% (%) P value Region DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC T 13.1± 12.2 11.3± 7.5 16.2± 7.0 15.6± 11.7 11.6± 9.0 0.581 0.901 0.146 0.132 ∗ ∗ LF 28.1± 18.4 30.5± 20.7 32.1± 17.7 22.6± 22.0 20.0± 16.6 0.075 0.063 0.049 0.603 ∗ ∗ IF 55.6± 18.6 66.9± 15.1 59.5± 11.7 45.4± 19.7 51.8± 22.2 0.485 0.033 0.319 0.260 MF 32.5± 18.4 27.2± 15.1 22.4± 10.5 26.3± 18.5 26.0± 17.4 0.166 0.838 0.531 0.963 M 2.0± 4.0 2.3± 3.2 0.6± 1.0 1.1± 2.1 1.5± 3.0 0.637 0.440 0.338 0.517 LH 41.9± 13.5 36.6± 10.4 42.6± 12.5 36.8± 17.4 39.0± 14.5 0.427 0.607 0.482 0.595 MH 34.9± 11.0 31.2± 9.7 34.3± 8.9 33.9± 14.5 32.1 (10.0) 0.298 0.797 0.530 0.556 ∗ ∗ Total 25.1 (7.1) 24.0 (3.9) 24.7 (5.0) 22.1 (8.7) 21.4 (6.4) 0.035 0.204 0.147 0.729 Values with indicate statistically significant difference (P< 0.05) compared with HC. Abbreviations: HP% � proportion of high pressure (>200 kPa) area; T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel. Total is the proportion of high pressure area in the total plantar area. Table 6: Anterior/posterior position of COP in each group. Anterior/posterior position of COP (%) P value DPN-PAD DPN PAD D HC DPN-PAD vs. HC DPN vs. HC PAD vs. HC D vs. HC ∗ ∗ ∗ ∗ 55.0± 2.6 54.6± 1.9 52.7± 4.4 52.4± 3.2 51.4± 3.0 0.001 0.002 0.285 0.224 Values with indicate statistically significant difference (P< 0.05) compared with HC. Abbreviations: T �toes; LF � lateral forefoot; IF � inner forefoot; MF � medial forefoot; M � midfoot; LH � lateral heel; MH � medial heel; total � total plantar area. with the HC group, the HP% of total plantar area in the of neuropathy and arterial disease did not further increase DPN-PAD group was significantly larger, while no signifi- the peak pressure. Although the difference of peak pressure in inner cant differences were found in segmented regions. /e significant increases were also observed in the inner forefoot forefoot in PAD group was not significant compared with in DPN group and lateral forefoot in PAD group. /ough HC group, it also showed increasing tendency and the the differences of HP% of lateral forefoot in DPN-PAD pressure level was close to that of DPN-PAD group. /is group and DPN group were not significant compared with suggested that the alteration of plantar pressure in diabetic the HC group, there was still a tendency of increase. No patients with PAD began in lateral forefoot, followed by significant differences were observed between the D group inner forefoot. Atherosclerosis resulted in insufficient oxy- and HC group. gen and nutrients. Long-term vasculopathy causes altered muscle morphology and mitochondrial function, resulting in decreased muscle strength [17]. Myers et al. [27] reported 3.4. Anterior/Posterior Position of COP. /e normalized the alteration of joint kinematics and kinetics in patients anterior/posterior position of COP is shown in Table 6. with PAD during pain-free walking compared with healthy Compared with the HC group, a significant increase was subjects. /ey found decreased dorsiflexor torque of ankle observed in the DPN-PAD group and DPN group. No during stance phase in PAD patients. In addition, the ki- significant differences were found in the other groups. nematic changes of greater ankle plantarflexion angle re- duced time to peak plantar flexion and increased time to peak dorsiflexion in patients with PAD resulted in altered 4. Discussion foot rotation [28]. /e alteration of plantar pressure in PAD As shown in Table 3, DPN or PAD could independently lead group was accompanied by these changes of gait parameters. to increased peak pressure in forefoot. Raspovic [25] re- To the author’s knowledge, the plantar contact area ported reduced motion at the ankle, less foot rotation, and during walking in these specific populations has not been less fist metatarsophalangeal joint movement in subjects reported. Pataky et al. [29] reported a significantly reduced contact area in diabetic patients without peripheral neu- with peripheral neuropathy and a history of plantar ulcer- ation. Gardner et al. [26] reported reduced swing phase and ropathy or peripheral arterial disease compared to nondi- abetic subjects. However, it was the contact area in static extended stance phase in PAD patients. /ese may lead to the accumulation of load in forefoot region as well as the standing position they investigated. As shown in Table 4 and increased plantar pressure. Significant increases of peak Figure 3, the contact area of midfoot in DPN-PAD patient pressures were observed in all three forefoot regions in DPN and PAD patient was relatively small, which may reflect a group, while only in lateral forefoot in the PAD group. It reduction in plantar soft tissue. It has been reported that the seemed that DPN had a greater effect on peak pressure than presence of both diabetes and PAD could reduce muscle PAD. Similar to the DPN group, the peak pressures in the mass via multiple mechanisms synergistically [30, 31]. Long- term hyperglycemia and ischemia damage not only lower three forefoot regions in DPN-PAD group were significantly increased, but the pressure value was close. /e combination limb muscles but also plantar soft tissue. /inner and stiffer 6 Journal of Healthcare Engineering gradual process. /e significant changes in plantar pressure soft tissue is also associated with increased plantar pressure [32]. PAD causes reduced supply of oxygen and nutrients, occurred after the combination of DPN or PAD. However, the lack of significant differences between the resulting in alteration in histological characters of plantar soft tissue. Ischemia promotes the plantar soft tissue D group and HC group differs from Pataky’s [29]. /ey thickness under 1st and 5th metatarsal heads reduction [29]. found significant differences of peak pressure under the big /inner soft tissue could also contribute to higher plantar toe, 5th metatarsal head, and heel in diabetic patients pressure. /e elevated repetitive mechanical stress, in turn, without peripheral neuropathy or vasculopathy compared increases the fragility of microvessel and decreases blood with nondiabetic subjects. In this study, the absolute values flow, producing a vicious cycle [23]. of peak pressure in all three forefoot regions in the D group showed a tendency to increase, but the normalized values did In DPN group, no significant differences of segmented contact area were observed, but significant increase of peak not. /e inconsistent results suggested that the body weight of subjects should be a concern. Although an appropriate pressures were observed in all three forefoot regions. /is suggested that the increased peak pressure may not be due to range of body weight and BMI have been adopted as one of the inclusion criteria in many studies, the differences of body the altered contact area, but to the tendency of the anterior displacement of weight-bearing, which was confirmed by the weight in individuals still affected plantar pressure. In the results in Table 5. Compared with the HC group, all four study of Castro et al. [37, 38], the results of analysing ab- diabetic groups showed a tendency of the anterior dis- solute value of ground reaction force and plantar pressure placement of COP, and the significant differences were were different from the results of analysing normalized value observed in the DPN-PAD group and DPN group. Similar of ground reaction force and plantar pressure. /erefore, the conclusion was also presented in previous research. Melai absolute value could be used to indicate the magnitude of plantar pressure and evaluating the risk of ulceration, while et al. [33] observed a faster forward transfer of centre of pressure and consequently higher load in forefoot in patients the normalized value should be used in analysis of differ- ences between groups to subtract the effects of body weight. with DPN. Another important parameter analysed in this study was A potential limitation of this study is that the micro- vascular complications such as nephropathy and retinopathy the proportion of the high pressure area. Owings et al. [12] investigated the in-shoe plantar pressure in diabetic patients was not considered. Future research on potential factors with DPN and a history of DFU and suggested 200 kPa as a associated with macroangiopathy and microangiopathy reference in foot ulceration prevention. /is value was could be helpful to further understand the mechanism of the obtained from the position of healed ulcers in diabetic plantar pressure alteration in diabetic patients. /e current patients with a history of ulcers and was considered safe for results could be considered as a preliminary demonstration diabetic with or without a history of ulcers. It has been of the independent and synergistic effects of DPN and PAD on plantar pressure in diabetic patients. widely used in later studies as a threshold for classifying high pressure or as and optimization target for developing off- loading footwear [34–36]. As shown in Table 5, the HP% of 5. Conclusions the lateral forefoot in PAD group and the inner forefoot in DPN group was significantly larger than that in the HC /e current study provides the evidence for learning the group. Although there were no significant differences of independent or synergistic effects of peripheral neuropathy segmented HP% between the DPN-PAD and HC group, the and peripheral arterial disease on plantar pressure in diabetic HP% of total plantar area was significantly higher. More- patients. Identifying the changes in plantar pressure distri- over, a tendency of increasing HP% was also observed in all bution helps to carry out physical therapy interventions, such lateral forefoot and inner forefoot regions in DPN-PAD, as exercise program, offloading footwear, and therapeutic DPN, and PAD groups compared with the HC group, al- orthosis. /e alteration of plantar pressure in diabetic patients though the differences were not significant. /e HP% is was a gradual process, and significant changes occurred after positively associated with peak pressure in segmented the combination of DPN or PAD. DPN and PAD could plantar regions. Either peripheral neuropathy or peripheral independently affect plantar pressure in diabetic patients, arterial disease could independently cause increased plantar leading to higher pressure in forefoot and larger area at risk of pressure and high pressure area. /e combination of neu- ulcers. /e prevention and/or control of DPN and PAD and ropathy and vasculopathy did not cause further increases of the redistribution of plantar pressure from forefoot onto the peak pressure, but caused larger area of high pressure. whole foot should be highlighted in clinical practice. A noteworthy result in our study is that compared with the HC group, no significant differences of plantar pressure Data Availability parameters were observed in the D group. /e consistent results have been found in other study [11]. However, there /e raw/processed data required to reproduce these findings was a tendency of decreasing of contact area in the D group, cannot be shared at this time as the data also form part of an as shown in Table 4. /is may indicate that the alteration of ongoing study. soft tissue character occurred in the diabetic stage before the presence of complications. /e progressive effects of changes Conflicts of Interest in peripheral nervous system and vessels on the lower limb physiology making the changes in plantar pressure was a /e authors declare that they have no conflicts of interest. Journal of Healthcare Engineering 7 [15] M. Birrer, “Macroangiopathy in diabetes mellitus,” Vasa, Authors’ Contributions vol. 30, no. 3, pp. 168–174, 2001. [16] G. M. Caputo, P. R. Cavanagh, J. S. Ulbrecht, G. W. Gibbons, Zijun Cao, Fang Wang, and Xuemei Li are co-first authors. and A. W. 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Published: Jun 6, 2022

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