Tóm tắt Luận án Assessment of the plantar pressure in the relation with nerve conduction, and ankle - Brachial index (ABI) in type 2 diabetes patients

The study performed in 126 subjects, which was divided into two groups: The cases group included 126 type 2 diabetic patients and The control group included 40 individuals without diabetes. In this thesis, there was a difference of the age group; BMI; waist/hip, the biochemistry tests between the case and control group, because we collected the healthy individuals for the control group. This aimed to drawn the average plantar pressure of these to compare with the case group.

* Gender: in the case group, 68.3% male and 31.7% female. In the control, 65% male and 35% female. It was the same as the study of Chao xu et al in 2017, the normal plantar pressure measured by the Footscan machine in 32 individuals (46.9% female and 53.1% male).

* Age: There was many studies which confirmed the difference between age , sex and plantar pressure.

* BMI: The average BMI in this thesis was lower than Fernando et al study: the control 21.1 ± 2.16 and the case 22.96 ± 3.07

* The patient history: 50% patients were diagnosed before the symptom 10 years.

 

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tion and needle electrode. - The surveillance of EMG helps to evaluate the ability of electrical conduction of peripheral nerve. The concerned index are the peripheral motor potential time (or sensory), the conduction speed, the average potential time, and the frequency of F and H waves. 1.4. The vascular lesion in diabetic foot patients - The obstruction of the peripheral vascular is the second important cause of foot ulcer in diabetes. It is affected by the: adhesive level of platelets, number of monocytes, lipidemia, smooth muscle, calcium concentration This condition is much more severe in the high risk subjects such as: hypertension, smoking, obesity The mechanisms are: - Atherosclerosis - Vascular obstruction causing by the platelets - Less elasticity, less oxygenation, less nutrition 1.4.2. The evaluating the vascular lesion method of lower limbs - There are varieties of method which evaluate the lower limbs vasculopathy. In this study, the ABI was used, measured by the pulse Doppler handling machine. + Ankle-brachial index (ABI). + Vascular Doppler ultrasound 1.5. The studies of plantar pressure, nerve conduction index and ABI * The studies of plantar pressure - Yang Chang et al studied the change of plantar pressure in Chinese diabetic patients. The cross-sectioned study in 649 diabetic patients and 808 normal Chinese people who had got diabetes, all was measured by the EMED AT system. It showed that the total plantar pressure and its distribution were different. It could be a factor which contributes the foot ulcer. - In 2014 Fernando performed a cross-section study which compared the pressure in the diabetic patients with neuropathic and ulcerative foot complication. It showed that the plantar pressure in the diabetic patients with neuropathic complication and history of ulceration was higher than individuals without history of ulceration. - In 2014 Tuna Hakan, Birane Murat et al studied in 84 type 2 diabetic patients, showed the decrease of contact square and the increase of foot peak pressure in the more than 10 years diabetic patients. - In 2012, Anita Raspovic 1, Karl B Landorf showed the key role of plantar pressure reduction in the prevention and treatment of foot ulceration in diabetic patients. - A study of Madhale Milka D, Godhi Ashoc S in 2017 pointing on the plantar pressure evaluation measured by the machine Novel, performed in 110 Indian patients, who was separated into 4 groups (normal: 30 subjects, type 2 diabetic patients: 30 patients, type 2 diabetic patients with the peripheral complication: 19 patients; diabetic patients with foot ulceration: 31 patients) showed the significance of plantar pressure observation in prevention and reduction the foot ulceration in type 2 diabetic patients. * The researches of ABI - In 2011, Nghi Tran Bao and Dung Ho Thuong researched the diagnosis value of ABI index and the risk factor in the peripheral artery disease of the lower limb in the diabetic patients, the cross-section study showed: the sensitivity and specificity of ABI in the peripheral artery disease diagnosis was 90,9 % and 91,0%, respectively. - In 2012 Bao Le Hoang and Dao Nguyen Thi Bich performed in 153 type 2 diabetic patients. It showed that the proportion of ABI 1,3: 2,6%. - In 2018 Ngan Nguyen Thi and Nhan Nguyen Thi performed a research of the risk factors, ABI, Doppler ultrasound of lower limb artery in the diabetic patients, this cross section study in the Internal Medicine Department of Hue Central Hospital. It showed that 26,3% diabetic patients with ABI 1,3. * The research of peripheral nervepathy - In 2012 Kha Ton That and Hung Nguyen Trong studied about peripheral neuropathy in 84 type 2 diabetic patients. It showed the 100% patients with abnormal EMG. - In 2015 Banach M et al studied the benefits of nerve conduction mesurement in diabetic patients with polyneuropathic. It showed that 57% patients with the abnormalities in EMG diagnosis and decrease amplification of sensory and mortor conduction of lower limb. - In 2015 Prasad N et al studied in 40 type 2 diabetic patients, average age 2,28±1,51 years old. It showed the decrease of nerve conduction between the diabetic patients 54,32±6,03m/s in comparison with non diabetic patients 59,52±6,51m/s. - In 2016 Truong Pham Cong, Vinh Hoang Trung performed a prospective cross section study in 53 type 2 diabetic patients in Ho Chi Minh city. It showed that the proportion of objective sensory abnormality increases with the prolong of diagnosis and untrollable HbA1c level. The sensory and motor conduction amplification measured in the median nerve was positive correlation; the potential motor and sensory conduction time measured in the median nerve was negative correlation with HbA1c. The conduction amplification and velocity measured in the tibia nerve was negative correlation with HbA1c. Chapter 2: SUBJECTS AND METHODOLOGY 2.1. Subjects The patient group (the case): 126 patient with type 2 diabetes, examined and treated in the National Hospital of Endocrinology. All of them was satisfied the inclusion and exclusion criteria. The controls: 40 healthy individuals who satisfied the inclusion and exclusion criteria. 2.1.1. Inclusion criteria * The criteria of the case: - Type 2 diabetic patients ≥ 30 years old with male and female. - Informed consent and accepted to joint the study - Enough the necessary data for the study * The control criteria: - Healthy individuals who had the casual examination ≥ 18 years old with male and female. - Without obesity or overweight - Without chronic diseases: shock, stroke, paralysis ... - Non-pregnancy woman - Informed consent and accept to joint the study - Enough the necessary data for the study. 2.1.2. The exclusion criteria * For the case: - Type 2 diabetic patients with the foot complication (ulceration more than level 3 and amputation) - Acute disease: shock, stroke - Pregnancy woman - Unconsented patients - Unable to measure the plantar pressure * For the controls: - Acute and chronic diseases - Overweight, obesity, pregnancy woman - Unconsented individuals - Unable to question all the necessary information 2.2. The methodology Design: Descriptive cross sectional study. Time: from 2015 to 2018. Place: - The case: patients with type 2 diabetes in National Hospital of Endocrinology - The controls: healthy individuals in Institute of Diabetes and Metabolism disorder. Diagnosis criteria of Diabetes: Vietnam National Endocrinology – Diabetes Association. Plantar pressure measurement: In this thesis, the plantar pressure of the control (TB ± 1SD) would be used as the criteria for comparing with the case. + The plantar pressure of case > TB ± 1SD of the control is considered as increase + The plantar pressure of case < TB ± 1SD of the control is considered as decrease The data analysis: using the softwear SPSS 22.0. + Logarithms technique to show the standard distribution before analysis + The avarage value define, standard deviation, median, avarage multiplies with the 95%CI + Comparison the averages by the T test. Chi-Square and Fissher Exact was employed to compare the difference %. + Nonparametric statistics to compare medians + Correlation coefficient + Regression line defined by the linear regression. Chapter 3: RESULTS 3.1. The characteristics of the subjects Table 3.1. The distribution of gender and age of subjects Age groups The controls (n = 40) The cases (n = 126) p n % n % 20 – 29 years old 6 15.0 0 0.0 < 0.05 30 - 39 years old 13 32.5 12 9.5 40 - 49 years old 9 22.5 21 16.7 50 – 59 years old 12 30.0 62 49.2 ≥ 60 years old 0 0.0 31 24.6 Average 41.47 ± 10.10 54.19 ± 9.60 < 0.05 - The cases: The most common was from 50-59 years old, there was no one under 30 years old. - The controls: The most common was from 30 to 39 years old, there was no one older than 60 years old. Graph 3.1. The distribution of the subjects regarding to gender Male was more prominent than female in case group, and equal in the control group. Table 3.2. Phân bố đối tượng theo yếu tố nguy cơ và giới của nhóm bệnh (n=126) Characteristics Female (n=40) Male (n=86) Total n % n % n % Smoking 0 0.0 13 15.1 13 10.3 Alcoholic abuse 0 0.0 13 15.1 13 10.3 Hypertension 12 30.0 30 34.9 42 33.3 Dyslipidemia 28 70.0 74 86.0 102 80.9 Time to diagnosis ≤ 5 years 12 30.0 17 19.8 29 23.0 > 5 – 10 years 11 27.5 23 26.7 34 27.0 > 10 years 17 42.5 46 53.5 63 50.0 The high proportion of male patients was smoker and alcoholic abuse The time to diagnosis > 10 years was the most common Hypertension took 33,3% patients Dyslipidemia was 80,9% patients, male and female was equal Table 3.3. The anthropometric characteristics Anthropometric Control (n=40) Case (n=126) p BMI 21.10 ± 2.16 22.96 ± 3.07 < 0.05 VB/VM 0.86±0.05 0.91 ± 0.05 < 0.05 The body weight, BMI, waist and hip, waist/hip of case group was higher than the control, statistical significance p< 0.05. Table 3.4. The biochemical tests of case group Biochemical Tests Control (n=40) Case (n=126) p Glucose 5.18 ± 0.51 10.80 ± 4.65 <0.001 HbA1c 5.26 ± 0.74 9.49 ± 4.34 <0.001 Cholesterol 4.77 ± 0.57 5.06 ± 2.17 >0.05 Triglyceride 1.35 ± 0.35 3.25 ± 4.74 <0.05 HDL-c 1.29 ± 0.35 1.22 ± 0.38 >0.05 LDL-c 2.87 ± 0.54 2.53 ± 0.94 <0.05 The triglyceride, LDL-C concentration in the case group was higher than control groups, statistical significance. 3.2 The change of plantar pressure and nerve conduction index, ABI in type 2 diabetic patients 3.2.1. The change of plantar pressure Table 3.5. Characteristics of peak pressure of right foot The peak pressure of right foot (kpa) Control (n=40) Case (n=126) p Total (kpa) 334.06 ± 104.83 386.39 ± 123.54 <0.05 Heel (kpa) 185.62 ± 40.04 198.17 ± 50.62 >0.05 Middle (kpa) 97.29 ± 26.07 107.84 ± 35.04 >0.05 MH1 (kpa) 151.46 ± 75.52 166.08 ± 69.30 >0.05 MH2 (kpa) 220.40 ± 52.20 248.09 ± 68.55 <0.05 MH3 (kpa) 222.60 ± 47.15 246.37 ± 64.69 <0.05 MH4 (kpa) 158.21 ± 32.91 187.78 ± 56.18 <0.01 MH5 (kpa) 133.63 ± 73.13 160.45 ± 98.94 >0.05 First toe (kpa) 270.33 ± 133.57 287.53 ± 148.65 >0.05 Second toe (kpa) 121.21 ± 47.78 128.82 ± 55.87 >0.05 3rd 4th 5th toes (kpa) 85.19 ± 49.09 94.97 ± 50.37 >0.05 The peak pressure of the whole foot and peak pressure of MH2, MH3, MH4 regions in the case group was higher than control group, statistical significance. The peak pressure of other regions in the foot was not significantly different. Table 3.6 The distribution of the foot peak pressure The peak pressure of the right foot Case ( n = 126) Decrease Normal Increase n % n % n % Total (kpa) 2 1.6 97 77.0 27 21.4 Heel (kpa) 18 14.3 70 55.6 38 30.2 Middle (kpa) 11 8.7 83 65.9 32 25.4 MH1 (kpa) 1 0.8 25 19.8 100 79.4 MH2 (kpa) 15 11.9 70 55.6 41 32.5 MH3 (kpa) 17 13.5 65 51.6 44 34.9 MH4 (kpa) 12 9.5 57 45.2 57 45.2 MH5 (kpa) 6 4.8 94 74.6 26 20.6 First toe (kpa) 16 12.7 87 69.0 23 18.3 Second toe (kpa) 17 13.5 90 71.4 19 15.1 3rd 4th 5th toes (kap) 9 7.1 95 75.4 22 17.5 In the increase foot peak pressure, the most common location was the first toe then the second toe. Table 3.7 The characteristics of peak left plantar pressure Peak left plantar pressure Control (n=40) Case (n=126) p Total (kpa) 316.43 ± 107.22 392.85 ± 129.21 <0.001 Heel (kpa) 184.86 ± 41.13 209.77 ± 60.72 <0.05 Middle (kpa) 114.48 ± 35.65 103.14 ± 27.50 >0.05 MH1 (kpa) 151.12 ± 49.56 182.21 ± 86.64 <0.05 MH2 (kpa) 221.43 ± 52.21 262.50 ± 90.69 <0.01 MH3 (kpa) 216.77 ± 36.09 251.42 ± 63.96 <0.01 MH4 (kpa) 166.43 ± 37.28 179.93 ± 50.57 >0.05 MH5 (kpa) 140.75 ± 62.48 146.80 ± 87.17 >0.05 First toe (kpa) 237.29 ± 139.22 284.64 ± 133.54 <0.05 Second toe (kpa) 143.36 ± 119.73 122.74 ± 56.32 >0.05 3th 4th 5th toes (kap) 96.73 ± 50.14 89.01 ± 51.40 >0.05 The whole plantar pressure, and peak pressure in the heel, MH1, MH2, MH3 in the case was higher than the control, statistical significance. The foot peak pressure of other regions in the case was not statistically different with the control. Table 3.8 The change of left foot peak pressure Left foot peak pressure Case ( n = 126) Decrease Normal Increase n % n % n % Total (kpa) 2 1.6 82 65.1 42 33.3 Heel (kpa) 14 11.1 71 56.3 41 32.5 Middle (kpa) 18 14.3 99 78.6 9 7.1 MH1 (kpa) 15 11.9 71 56.3 40 31.7 MH2 (kpa) 12 9.5 63 50.0 51 40.5 MH3 (kpa) 17 13.5 53 42.1 56 44.4 MH4 (kpa) 21 16.7 67 53.2 38 30.2 MH5 (kpa) 19 15.1 87 69.0 20 15.9 First toe (kpa) 3 2.4 97 77.0 26 20.6 Second toe (kpa) 0 0.0 123 97.6 3 2.4 3th 4th 5th toes (kap) 24 19.0 84 66.7 18 14.3 In the increase foot peak pressure, the pressure of the third toe was highest and the lowest was second toe. 3.2.2. The change of nerve conduction index Table 3.9. The nerve conduction index of common peroneal (fibular) nerve Index Right common peroneal nerve Left common peroneal nerve p Potential time (ms) (min – max) 10.53 ± 1.30 (7.6 – 15.3) 10.42 ± 1.25 (8.1 – 16.8) > 0.05 Amplitude (mV) (min – max) 3.95 ± 1.94 (0.5 – 8.9) 3.92 ± 1.69 (0.4 – 7.5) > 0.05 Velocity (m/s) (min – max) 44.13 ± 4.05 (33 – 56) 44.77 ± 3.63 (35 – 54) > 0.05 There was no statistically significant difference of conduction between the right and left common peroneal nerves. Table 3.10 The conduction of tibia nerve Index Right tibia nerve Left tibia nerve p Potential time (ms) (min – max) 12,56 ± 1,61 (9,3 – 18,8) 12,41 ± 1,69 (8,7 – 19,3) > 0,05 Amplitude (mV) (min – max) 9,67 ± 6,80 (0,1 – 74) 8,84 ± 5,71 (0,3 – 60,2) > 0,05 Velocity (m/s) (min – max) 43,26 ± 4,69 (26 – 54) 42,85 ± 4,06 (29 – 53) > 0,05 There was no difference of conduction between the two groups p>0.05. Table 3.11 The conduction of saphenous nerve Index The right saphenous nerve The left saphenous nerve p Potential time (ms) (min – max) 2.43 ± 0.49 (1.5 – 4.1) 2.46 ± 0.48 (1.5 – 3.7) > 0.05 Amplitude (µV) (min – max) 11.59 ± 5.44 (0.1 – 24.6) 13.76 ± 7.72 (4 – 39.8) > 0.05 Velocity (m/s) (min – max) 53.49 ± 6.70 (34 – 85) 53.35 ± 5.30 (50 – 180) > 0.05 There was the difference between the left and right conduction (right > left). However, this difference was not statistically significant. Table 3.12. The superficial fibular nerve Index The right superficial fibular nerve The left superficial fibular nerve p Potential time (ms) (min – max) 2.15 ± 0.40 (1.4 – 4.1) 2.12 ± 0.38 (1.3 – 3.6) > 0.05 Amplitude (µV) (min – max) 9.82 ± 4.68 (4 – 25) 10.76 ± 5.50 (4 – 35) > 0.05 Velocity (m/s) (min – max) 55.78 ± 5.06 (42 – 69) 55.10 ± 5.57 (31 – 67) > 0.05 The conduction of the right was higher than the left. However, this difference was not statistically different p>0.05 3.2.3. The change of ankle-brachial index (ABI) Table 3.13. The distribution of ABI (n=126) Value range Ankle-brachial index Right Left Total n % n % n % ≤ 0.9 0 0 0.0 0.0 0 0.0 0.91 – 1.29 107 84.9 107 84.9 100 79.4 ≥ 1.3 19 15.1 19 15.1 26 20.6 There was no subject with ABI under 0.9; there was 20.6% subjects with ABI ≥ 1.3. 3.3 The relationship between the plantar pressure and nerve conduction, ABI and the characteristics of type 2 diabetic patients 3.3.1. The relationship between the plantar pressure index and characteristics of subjects Table 3.14 The distribution of plantar pressure in the respect of hypertension (n=126) The peak pressure (kpa) Right foot p12 Left foot p34 Non HP1 (n=84) Hypertension2 (n=42) Non HP3 (n=84) Hypertension4 (n=42) Total 384.4±119.6 395.9±143.2 >0.05 390.7±118 402.7±175.6 >0.05 Heel 196.6±50.6 205.6±51.3 >0.05 206.4±51.0 225.7±93.8 >0.05 Middle 106.0±36 116.4±29.3 >0.05 101.1±25.2 112.7±35.6 >0.05 MH1 166.0±73.8 166.3±43.7 >0.05 183.9±85.3 174.4±94.5 >0.05 MH2 247.3±64.9 251.9±85.4 >0.05 257.2±68.4 287.5±158.3 >0.05 MH3 246.4±63.7 246.4±70.9 >0.05 248.0±58.9 267.3±83.7 >0.05 MH4 188.2±58.1 185.9±47.3 >0.05 179.7±52.1 180.8±43.7 >0.05 MH5 162.0±104.7 152.9±66.9 >0.05 142.7±82.5 165.9±106.5 >0.05 First toe 285.7±136.6 296.4±199.8 >0.05 291.9±127.1 250.5±159.2 >0.05 2nd toe 126.9±56.8 137.8±51.6 >0.05 120.3±56.3 134.3±56.4 >0.05 3rd 4th 5th toes 93.5±51.0 102.0±47.7 >0.05 85.6±49.9 104.9±56.6 >0.05 There was no statistically significant difference of the foot peak pressure between hypertension and non-hypertension patients, p>0,05. Table 3.15 The distribution of peak plantar pressure according to the dyslipidemia (n=126) Peak pressure (kpa) Right foot p12 Left foot p34 Non1 (n=24) Dyslipidemia2 (n=102) Non1 (n=24) Dyslipidemia2 (n=102) Total 399.5±86.6 382.9±131.5 >0.05 365.4±70.1 398.3±139.4 >0.05 Heel 183.0±47.1 202.1±51.1 <0.05 182.7±49.6 216.5±61.8 <0.05 Middle 113.2±45.9 106.1±31.9 >0.05 97.7±35.1 103.9±25.0 >0.05 MH1 153.4±47.7 168.8±73.6 >0.05 165.2±59.6 187.1±91.7 >0.05 MH2 256.4±82.7 245.9±65.4 >0.05 268.0±74.7 261.2±94.8 >0.05 MH3 248.4±74.6 246.2±62.8 >0.05 261.2±61.2 249.1±65 >0.05 MH4 172.2±47.3 192.1±57.5 >0.05 165.6±49.7 183.1±50.6 >0.05 MH5 181.2±122.5 155.6±93.1 >0.05 141.2±92.3 144.6±78.8 >0.05 First toe 290.6±133.4 285.6±152.8 >0.05 274.0±104.2 288.8±139.7 >0.05 2nd toe 141.6±64.0 125.5±53.9 >0.05 124.4±54.1 122.0±57.3 >0.05 3rd 4th 5th toes 103.5±59.1 93.3±48.3 >0.05 98.9±63.3 86.3±48.4 >0.05 The foot peak pressure measured in almost point in the dyslipidemia group was no different with the non-dyslipidemia. Except in the heel, the pressure of the dyslipidemia one was statistically significant difference p<0.05. 3.4. The correlation between the plantar pressure index and potential time of lower limb nerves and ABI Potential time Foot pressure Graph 3.2. The correlation between the plantar pressure and the potential conduction time of the right common peroneal (fibular) nerve. The right plantar pressure had the positive correlation with the potential conduction time of common fibular nerve. r = 0.20 and p<0.05. Foot pressure Potential time Graph 3.3 The correlation between the total right plantar pressure and the potential conduction time of right common fibular nerve (n=126) The total right plantar pressure had the positive correlation with the potential conduction time of the common fibular nerve r=0.26 and p<0.05. Potential time Foot pressure Graph 3.4 The correlation between the total left plantar pressure and the potential conduction time of left common fibular nerve. (n=126) The total left plantar pressure had the positive correlation with the potential conduction time of the left common fibular nerve r = 0.23 and p<0.05 Foot pressure Potential time Graph 3.5 The correlation between the total left plantar pressure and the potential conduction time of the left tibia nerve (n=126) The total left plantar pressure had the negative correlation with the potential conduction time of the left tibia nerve r=0.2 and p<0.05 Table 3.16 The correlation between the peak plantar pressure and ABI (n=126) Index (Y) Correlation of peak right plantar pressure and ABI (x) Correlation of peak left plantar pressure and ABI (x) Y=ax+b r, p Y=ax+b r, p Total -0.07; >0.05 0.06; >0.05 Heel -0.042; >0.05 -0.04; >0.05 Middle 0.081; >0.05 0.17; >0.05 MH1 0.067; >0.05 0.01; >0.05 MH2 Y=28.38X+212.53 0.21; <0.05 0.17; >0.05 MH3 0.15; >0.05 Y=36.26X+206.4 0.23; <0.01 MH4 0.09; >0.05 0.06; >0.05 MH5 0.16; >0.05 Y=65.71X+64.48 0.28; <0.01 First toe -0.05; >0.05 -0.07; >0.05 Second toe 0.09; >0.05 0.09; >0.05 3th 4th 5th toes -0.05; >0.05 -0.01; >0.05 The peak pressure of MH2 right foot region, MH3 left foot region and MH5 left foot region had the positive correlation with the ABI in type 2 diabetic patients with p< 0.05. Chapter 4 DISCUSSIONS 4.1. The main characteristics of the subjects The study performed in 126 subjects, which was divided into two groups: The cases group included 126 type 2 diabetic patients and The control group included 40 individuals without diabetes. In this thesis, there was a difference of the age group; BMI; waist/hip, the biochemistry tests between the case and control group, because we collected the healthy individuals for the control group. This aimed to drawn the average plantar pressure of these to compare with the case group. * Gender: in the case group, 68.3% male and 31.7% female. In the control, 65% male and 35% female. It was the same as the study of Chao xu et al in 2017, the normal plantar pressure measured by the Footscan machine in 32 individuals (46.9% female and 53.1% male). * Age: There was many studies which confirmed the difference between age , sex and plantar pressure. * BMI: The average BMI in this thesis was lower than Fernando et al study: the control 21.1 ± 2.16 and the case 22.96 ± 3.07 * The patient history: 50% patients were diagnosed before the symptom 10 years. * The characteristic of biochemical tests in serum: because of the case group was in the treatment period, therefore the results of plasma glucose, HbA1c and dyslipidemia test was significantly higher than the control. Comparing to the study of Dien Le Thanh about the clinical characteristics and the EMG abnormality in the type 2 diabetic patients with 194 patients showed that: the average plasma glucose was 8.12 ± 2.26 mmol/l and HbA1c 7.56 ± 1.22 % lower than our study (10.8 ± 4.65 mmol/l; HbA1c: 9.49 ± 4.34 %). Hence, this study was similar with some in the world, the bio tests was fited into the developpment of disease. 4.2. The change of plantar pressure and nerve conduction index, ankle-brachial index. 4.2.1. The change of plantar pressure In this study, the machine Emed A 50 to measure the plantar pressure showed that the total plantar pressure of control group was 334.06 ± 104, 06 kpa, significantly lower with the case group 386.39 ± 123.64 kpa, p<0.05. The peak pressure mostly increased in the base of first toe 79.45% and lowest at the base of second toe 15.1%. Measuring the left peak plantar pressure showed that the control group (316.43 ± 282.14 kpa) lower than case group (392.85 ± 369.85 kpa), p<0.05. There was 33.3 subjects in the case group who had the increase of peak plantar pressure, most in the base of the third toe: 44.4%; and lowest at the second toe: 2.4%. In 1998 Amstrong D.G, Peter E.J.G et al studied the plantar pressure as the risk factor of foot ulceration, recored the pressure of ulceration individuals was 83.1 ± 24.7 N/cm2 equal to 831.0 ± 247.0 kpa, and non-ulceration group was : 62.7 ± 24.4 N/cm2 equal to 627.0 ± 244.0 kpa. This results was higher than ours (the right leg 386.39 ± 123.64 kpa and the left leg 392.85 ± 369 kpa), because the BMI of patients in Amstrong study was higher than ours 32.3 ± 6.2 kg/m2, average age 51.8 ± 10.4 years old; time to diagnosis of diabetes 9.2 ± 8.8 years. In 2015, Qui X, Tian DH et al studied the change of plantar pressure in the type 2 diabetic chinese patients, recored the highest pressure in the base of third toe was 16.070(N/cm2) equal to 160.7 Kpa and lowest at the base of the second to fifth toes 0.500(N/cm2) equal to 5.0 Kpa, lower than ours. In 2017 Halawa M.R et al studied the correlation between the change of plantar pressure and the blood glucose controllation in the tyoe 2 diabetic patients with or without neuropathy. It showed that HbA1C would not directly affect the change of plantar pressure, but indirectly reflect the status of neuropathy during the disease developpment, then the change of patient gaits. It also showed the positive correlation between the change of plantar pressure and the HbA1c. Summing up, this study showed the plantar pressure in the diabetic patients was higher than the control, this also fits in other researches in the world. 4.2.2. The change of the nerve conduction of lower limb There was no difference between the right and left leg in term of common fibular and tibia nerve conduction. There was the difference between the right and left leg in term of saphenous and common fibular nerve conduction. Assessment the sensory nerve at the superficial fibular ne

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