title: Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies.
abstract: OBJECTIVE
  Elevated dynamic plantar pressures are a consistent finding in diabetes patients with peripheral neuropathy with implications for plantar foot ulceration. This meta-analysis aimed to compare the plantar pressures of diabetes patients that had peripheral neuropathy and those with neuropathy with active or previous foot ulcers.
  
  
  METHODS
  Published articles were identified from Medline via OVID, CINAHL, SCOPUS, INFORMIT, Cochrane Central EMBASE via OVID and Web of Science via ISI Web of Knowledge bibliographic databases. Observational studies reporting barefoot dynamic plantar pressure in adults with diabetic peripheral neuropathy, where at least one group had a history of plantar foot ulcers were included. Interventional studies, shod plantar pressure studies and studies not published in English were excluded. Overall mean peak plantar pressure (MPP) and pressure time integral (PTI) were primary outcomes. The six secondary outcomes were MPP and PTI at the rear foot, mid foot and fore foot. The protocol of the meta-analysis was published with PROPSERO, (registration number CRD42013004310).
  
  
  RESULTS
  Eight observational studies were included. Overall MPP and PTI were greater in diabetic peripheral neuropathy patients with foot ulceration compared to those without ulceration (standardised mean difference 0.551, 95% CI 0.290-0.811, p<0.001; and 0.762, 95% CI 0.303-1.221, p = 0.001, respectively). Sub-group analyses demonstrated no significant difference in MPP for those with neuropathy with active ulceration compared to those without ulcers. A significant difference in MPP was found for those with neuropathy with a past history of ulceration compared to those without ulcers; (0.467, 95% CI 0.181- 0.753, p = 0.001). Statistical heterogeneity between studies was moderate.
  
  
  CONCLUSIONS
  Plantar pressures appear to be significantly higher in patients with diabetic peripheral neuropathy with a history of foot ulceration compared to those with diabetic neuropathy without a history of ulceration. More homogenous data is needed to confirm these findings.
authors.affiliation: Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Movement Analysis Laboratory, Institute of Sports and Exercise Science, James Cook University, Townsville, Queensland, Australia.
authors.forename: Malindu Eranga
authors.initials: ME
authors.lastname: Fernando
authors.affiliation: Movement Analysis Laboratory, Institute of Sports and Exercise Science, James Cook University, Townsville, Queensland, Australia.
authors.forename: Robert George
authors.initials: RG
authors.lastname: Crowther
authors.affiliation: Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
authors.forename: Elise
authors.initials: E
authors.lastname: Pappas
authors.affiliation: Allied Health Research Collaborative, Metro North Hospital & Health Service, Queensland Health, Brisbane, Queensland, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia.
authors.forename: Peter Anthony
authors.initials: PA
authors.lastname: Lazzarini
authors.affiliation: Department of Psychology, University of Stirling, Stirling, Scotland, United Kingdom.
authors.forename: Margaret
authors.initials: M
authors.lastname: Cunningham
authors.affiliation: Department of Internal Medicine, The Townsville Hospital, Townsville, Queensland, Australia.
authors.forename: Kunwarjit Singh
authors.initials: KS
authors.lastname: Sangla
authors.affiliation: School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia.
authors.forename: Petra
authors.initials: P
authors.lastname: Buttner
authors.affiliation: Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Golledge
mesh_terms: D003929:Diabetic Neuropathies / Q000503:physiopathology*; D005260:Female; D005528:Foot / Q000503:physiopathology*; D016523:Foot Ulcer / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D064887:Observational Studies as Topic; D011312:Pressure; D017594:Publication Bias; D016896:Treatment Outcome