Comprehensive review on diabetic foot ulcers and neuropathy: Treatment, prevention and management

Table 1 Correlation between demographic factors and clinical outcomes

Demographic factors	Risk of DFU	Incidence of amputation/lower-extremity amputation	Healing time	Causes
Age	More	Higher	Longer	Longer duration of diabetes, the cumulative effects of hyperglycemia, and a higher prevalence of micro- and macrovascular complications
Sex	1.5 times more in male	1.4 to 3.5 times higher	Longer	Higher prevalence of PN, PAD, and cardiovascular disease
Race/ethnicity	More in Black, Hispanic, and other non-Whites than white groups	3 to 5 times higher	Longer	Unequal access to care manifests
Socioeconomic and geographic disparities	More	1.5 to 2.5 times higher	Longer	Lowest-income categories/lower education levels means disparities in access to care and biases in practice patterns
Overweight/obesity	No association	No association	Not defined	Not defined
Smoking	More	Higher	Longer	PN and PAD both

PN: Peripheral neuropathy; PAD: Peripheral arterial disease; DFU: Diabetic foot ulcer.

Table 2 Essential elements for sensorimotor polyneuropathy diagnosis in neurological basic assessment

Predictors	Test	Outcome
Pain perception	Pinprick testing such as 10-g monofilament and Semmes-Weinstein monofilament at the distal plantar sections of the big toe, the plantar side of metatarsals 1 or 2	Decreased distal symmetry sensation at least at one location
Temperature	Infrared thermometer (contact or noncontact) to generate thermal image	Raised temperature especially around DFUs
Vibration	Tuning fork test near the toes and fingers	VPT testing. Reference range vary between 5/8 or 6/8 according to age
Proprioception	Position perception when toes are moved passively by examiner e.g., at distal interphalangeal joints	Errors in detecting small amplitude movements
Autonomic muscle reactions	Achilles tendon reflex, patellar reflex	Decreased or lost in symmetrical way

VPT: Vibration perception threshold; DFU: Diabetic foot ulcer.

Table 3 Neuropathy signs score parameters

Signs (lower extremities and/or foot)	Focus of signs and symptoms	Relationship with time	Nighttime awakening
Cramps of muscles; debility feeling; pain; prickling sensation; scorching feeling; tingling	Foot; lower extremity; other locations	Only at night; only during the day; both, night and day	Yes/no

Table 4 Neuropathy deficiency score

Assessment category	Scoring
Achilles tendon reflex testing	Checking both sides for normal or deranged reflex
Assessment of blood supply to feet	Checking pulses on both sides
Perception of pain	Pain perception testing by using clinical tests on both sides
Temperature perception testing	On both sides by using clinical methods
Vibration perception	Checking on both sides for being normal or level of derangement

Table 5 Representation of techniques used for early diagnosis of diabetic foot ulcers

Techniques/tools	Assessment	Procedure	Utilization
Conventional tools		Direct physical examination	Help provide an assessment of the healing status of the wound
Footwear connected to computer	Pressure perception	Analyze risk factors for DFU based on recorded foot pressure	Use of footwear is considered good for identifying ulcerations, because there is a walking practice carried out by the patient
Biothesiometer or tuning fork	Vibration perception threshold testing	Vibration perception is tested over the pulp of the hallux	Patients who are at risk of DFU will feel relatively shorter vibration than normal people
Sudoscan medical device	Sudomotor/sweat glands function	Consist of a set of two electrodes for the feet and hands connected to a computer	Based on stimulation of sweat glands by low level voltage allowing evidence of sweat dysfunction that is not detectable under physiological conditions
Pinpricks		Inserted into pain receptors, namely the Meissner and Pacini nerves in the legs	Simple and can identify the risk of DFU well. Inability to perceive pinprick over either hallux would be regarded as an abnormal test result
3D thermal camera assessment system (e.g., FLIR or DSLR camera integrated smartphones)	Temperature perception	Helps in detecting the increase in temperature over the point of sole susceptible for ulcer	Help in taking preventive measures and stop further progression of disease. This is important to accelerate healing
DFU screening instrument; questionnaire/images, e.g., NeuDiaCan	Motor/sensitivity/autonomic, color segmentation of images	Allows the examination to be completed with an objective score	Help stratify the risk of diabetic foot and can be combined with standard nursing interventions

DFUs: Diabetic foot ulcers.

Table 6 Preventive care and different treatment plans for the management of diabetic foot ulcers

Management of DFUs	Preventive practices	Therapy strategies
		Non-invasive techniques	Invasive techniques
Methods	Self-screening; health care screening; podiatric care; selection of footwear; nutrition and psychological care; right foot care education	Wound dressing; antibiotics; hyperbaric oxygen therapy; right foot care education; shock wave therapy; topical growth factors; stem-cell therapy; -ve pressure wound therapy; laser therapy; larvae (maggot therapy); offloading methods; glycemic control; multidisciplinary care	Debridement; skin grafting; revascularization

Adopted from Intersocietal Peripheral Arterial Disease Guideline[104]. DFUs: Diabetic foot ulcers; -ve: Negative pressure.