SEMINAR AGENDA

279 732 Advance Nursing Practice in Selected Areas II

Evidence Based of Risk Factors Related to Diabetic Foot Ulcer (DFU)

Presented to:
Dr. Nichapatr Putthicamin
Assoc. Prof. Dr. Darunee Jongudomkarn
Assoc. Prof. Dr. Kritaya Sawangchareon

Presented by:
Parliani 575060120-1

MASTER OF NURSING SCIENCE PROGRAM

FACULTY OF NURSING KHON KAEN UNIVERSITY
2015
 SEMINAR AGENDA

Date/time : March 30, 2015

Room No : 2403
Topic : Evidence Based of Risk Factors Related to Diabetic Foot Ulcer (DFU)

1. Seminar Leader:
Parliani 575060120-1

2. SeminarParticipants:
Asri 575060127-7
Ngatoiatu Rohmani 575060125-1
Romiko 575060118-8
Sukron 575060119-6
Suwarno 575060122-7
Tri Sumarsih 575060123-5
Yuyud Wahyudi 575060121-9

3. Advisor:
Dr. Nichapatr Putthicamin

4. Objectives:
After finishing the seminar, the participant will be:
a. Know about the evidence based of risk factors of Diabetic Foot Ulcer (DFU)
b. Know about the pathway of risk factors lead to DFU
c. Know about the categorize of risk factors od DFU which fit to theory in conceptual
framework
d. Know about the draft of risk factors and their tools instrument from the literatures
e. Know about the draft of the new tools assessment to predict DFU based on risk
factors in the evidence based
5. Process of the seminar
The process of seminar will be arranged in around 20 minutes, with some activities:
a. Introduction/Background time 3 minutes
b. Seminar on time 10 minutes
c. Summary time 2 minutes
d. Feedback and conclusion time 5 minutes

6. Questions/Issues for discussion

a. What are kinds of the evidence based of risk factors of Diabetic Foot Ulcer (DFU)?
b. What is the pathway of risk factors lead to DFU?
c. How to categorize of risk factors of DFU which fit to theory in conceptual
framework?
d. What is the draft of risk factors and their tools instrument from the literatures?
e. What is the draft of the new tools assessment to predict DFU based on risk factors in
the evidence based
 EVIDANCE BASED TABLE OF RISK FACTORS OF DIABETIC FOOT ULCER (DFU)
No Author/References
1 Lee, C.M., Chang, C.C.,
Chien, M.C., Li-Ju, L.,
Chyong, F.C., & Mei,
Y.C. (2013). The devil is
in the detail: Prevention of
diabetic foot ulceration in
rural area is possible.
Open Journal of
Nursing, 3, 257-264
Objective Methodology
The aim of study is to Population:
explore the causes of 49 Participants with DFU
foot ulceration and
practice foot self-care Inclusion criteria:
behaviors before and Subjects having been diagnosed
after diabetic foot as Type 2 Diabetes Mellitus
ulceration (DM) by a physician, with a
history of diabetic foot ulcers
but without major amputation,
and being willing to participate
in the study
Exclusion criteria:
Serious mental problem and
serious diabetes complications,
example above-ankle or major
amputation
Research Type:
Descriptive method
Design: Retrospective design
Data analysis:
a. Quantitative variables were
analyzed using the statistical
software package for
Windows (version 17;SPSS,
Inc, Chicago,IL, USA). P
value=0.05
b. Descriptive data and
frequency of patient’s
Tools/Measurements Finding
Demographic The finding of the study from
characteristic such as birth factors in 49 participants
year, gender, duration of with DFU
diabetes, history and
treatment of diabetes, a. Age with Mode = 62 years
history of debridement, old
years in education,
occupation, family and b. Duration of diabetes year
personal health history with Mode = 10 years
Foot self-care capability
and the reason for foot c. Michigan neuropathy
injuries : screening index with Mode
Five open and semi- =7
structured questions
Health status was
determined using the d. Factors percentage more
following four indicators than 50%
from the review chart: - Gender showed that Men
= 63.3%
a. Normal glycemic levels - Participants who still
and blood pressure work (farmers and
were defined by the fishermen) are 61.2 %
BHP (Bureau of Health - Past history of
Promotion) claudication is 71.5%
b. Waist circumference - Fasting blood glucose is
was used to measure 71.4%
central obesity, - HbA1C is 57.1%
measuring mid- - Waist circumferences that
abdominal distance are abnormal is 69.4%
between the last rib - Michigan neuropathy
margin and the iliac screening index is 100%
 reports from the semi-
structured questionnaire
were recorded as
percentages for qualitative
analysis
Factors Measured Related to
DFU:
a. Demographic characteristic
- Age
- Duration of diabetes
- Gender
- Education levels
- Past history of claudication
- Fasting blood glucose
- HbA1c
- Waist circumference
- Michigan neuropathy
screening index
- Check-up ankle brachial
index (ABI)
- Systolic blood pressure
- Diastolic blood pressure
- Types of treatment
- Regular medication
- History of smoke
- Doing exercise before
wound happen
- Self-protection indoor
footwear
- Self-protection outdoor
footwear
- Have u thought diabetes
foot care before wound
happen?
crest
c. Peripheral neuropathy
was assessed using the
Michigan neuropathy
screening instrument
(MNSI, range= 0 -10).
MNSI contains five
parameters:
- Appearance of feet
- Foot ulceration
- Vibration perception at
the great toe
- Ankle reflexes
- 10-g Semmes-
Weinstein
monofilament
d. Peripheral vascular
status was evaluated
from the patient’s chart
review, example: ABPI
Reliability and Validity
The accuracy and adequacy
of the above equipment and
semi-structured
questionnaire were
evaluated by a critical
review of literature,
professional critiques and
pilot trials that four experts
(2 plastic wound surgeons,
one metabolic
endocrinologist, and one
diabetic nurse) were
involved in the professional
critiques and a content
- Check-up ABI is 81.6%
- Systolic blood pressure
that more than equal 131
mmHg is 71.4%
- Diastolic blood pressure
that more than equal 85
mmHg is 79.6%
- Types of treatment that is
Oral Anti-diabetic Drug
(OAD) only is 59.2%
- Participants who doing
exercise before wound
happen which they are
irregular and never do it is
around 77.6%
- Self-protection indoor-
footwear is 85.7%
- Self-protection outdoor-
footwear is 61.2%
- The question that the
answer no (have you been
taught diabetes foot care
before wound happen?) is
65.3%
- Wound self –care after
wound happen is 67.3%
e. Factors percentage less than
50%
- Education levels that
equal and less than
primary is 44.9 %
- No regular medication is
12.2 %
- History of smoke that
current smoker is 44.9%
 - Wound self-care after validity index (CVI) of 0.87
wound happen was obtained
f. Significant factors
associated with
peripheral neuropathy (P
b. Test of factors associated Value=0.05)
with peripheral - Receiving
neuropathy (P debridement (P=0.03)
Value=0.05) - Past history of
- Gender amputation (P=0.01)
- Age - Doing exercise before
- Education levels wound happen
- Duration of diabetes (P=0.05)
- Receiving debridement
- Past history of g. Not significant factors
amputation associated with
- Received foot self-care peripheral neuropathy
education - Gender (P=0.20)
- Waist circumference - Age (P=0.66)
(WC) - Education levels
- HbA1C (P=0.15)
- Doing exercise before - Duration of diabetes
wound happen (P=0.27)
- Past history of - Received self-care
claudication education (P=0.11)
- Waist circumference
(P=0.94)
- HbA1C (P=0.66)
- Past history of
claudication (P=0.12)

2 Al-Kafrawy, N.A.E., The research aim is to Population: The measurement of this The finding of study are:
Ehab, A.B.E.M., Alaa, study the risk factors 100 Patients with diabetic foot. study are:
E.A.E.D., Osama, M.E., & for diabetic foot ulcers The selected patients were a. Comparison between
Omnia, M.A.Z. (2014). (DFUs) in Menoufia subdivided into two groups a) Physical examination diabetic patient with and
Study of risk factors of University Hospital (group 1: 50 patients with DFU using anthropometric without DFU in terms of
diabetic foot ulcers. and group II:50 patients without
Menoufia Medical DFU)
Journal, 27:28-34.
Doi:10.4103/1110- Inclusion criteria:
2098.132298 Patients with diabetes, type 1 or
type 2 with and without diabetic
foot
Exclusion criteria:
Patients with peripheral vascular
diseases because of non-diabetic
causes, patients with traumatic
foot ulcers, and patients with
joint disease
Research Type:
Descriptive
Statistical Methodology:
The data collected were
tabulated and analyzed using
statistical package for social
science, version 17.0 on an IBM
compatible computer
Types of statistic were
calculated:
a. Descriptive statistic
b. Analytic statistic
Qualitative data were
analyzed by X2 and
whenever one cell of the
expected was equal to or
less than 5, Fisher’s exact
test was used.
Quantitative data were
for measure such as demographic data and
BMI laboratory tests
b) Foot examination that 1) Significant data are:
included neurological - Duration of diabetes
assessment for diabetic (P<0.001)
retinopathy through - Serum cholesterol
touch sensation or (P=0.022)
sensory neuropathy that - Fasting blood glucose
was assessed using a 10 (P<0.001)
g Semmes-Weinstein - 2h postprandial blood
monofilament that was glucose (P<0.001)
constructed to buckle - HbA1c (P<0.001)
when a 10g force is - Smoker (P<0.001)
applied - Retinopathy
c) Vibration sense was (P<0.032)
checked for neuropathies 2) Not significant data are:
using a 128 Hz tuning - Age (P=0.381)
fork - BMI (P=0.092)
d) Patellar and ankle deep - Serum creatinine
tendon reflexes (P=0.761)
e) Vascular assessment - Serum albumin (0.091)
through palpation of - Serum triglycerides
dorsalis pedis and (0.473)
posterior tibial pulses - Sex (P=0.160)
f) Doppler examination of - Nephropathy
dorsalis pedis and (P=0.223)
posterior tibial arteries
with calculation of the
ankle brachial index
(ABI) b. Comparison between
diabetic patients with and
without foot ulcer in
terms of diabetic foot
examination with
significant is P value <
0.05
1) Significant data are:
 analyzed using the t-test - Previous foot ulcer is
(Student’s test) for high significant
comparison of quantitative (P<0.001)
variables among two - Previous amputation
independent groups and the is high significant
Mann-Whitney test (P<0.001)
(nonparametric test) for - Normal skin
comparison between two (P=0.009)
groups that were not - Foot deformities
normally distributed (P=0.009)
- Joint mobility
(P=0.002)
Factors measured: - Monofilaments
(P<0.001)
a. Demographic data and - Vibration sensation
laboratory tests (P<0.001)
- Age
- Pinprick sensation
- Duration of diabetes
(P<0.001)
- BMI 2) Not significance data are:
- Serum creatinine - Ankle reflexes
- Serum albumin (P=1.00)
- Serum cholesterol
- Serum triglycerides c. Comparison between both
- Fasting blood glucose
groups in terms of
- 2h postprandial blood vascular assessment with
glucose significant data are
- HbA1c - ABI (P<0.001)
- Sex - Doppler (P<0.001)
- Smoker
- Nephropathy (micro-
albuminuria)
- Retinopathy

b. Diabetic foot examination

- Previous foot ulcer
 - Previous amputation
- Normal skin
- Foot deformity
- Joint mobility
- Monofilaments
- Vibration sensation
- Pinprick sensation
- Ankle reflexes

c. Vascular assessment
- ABI
- Doppler

3 Pham, H., David, G.A., A multicenter Population: a. Neuropathy symptom a. Comparison between
Carolyn, H., Lawrence, prospective follow-up A total of 248 patients with score (NSS) non-ulcerated and
B.H., John, M.G., and study was conducted diabetes The neuropathic ulcerated patients with
Aristidis,V. (2000). to determine which symptoms were assessed significance levels of
Screening techniques to risk factors in foot Research type: by using a modified P=0.05
identify people at high screening have a high Prospective longitudinal mode neuropathy symptom 1) Significance Data
risk for diabetic foot association with the score (NSS) that was - Sex (P=0.000)
ulceration. Diabetes development of foot Statistical analysis: simplified from a version - Diabetes duration
Care, 23:606-611 ulceration The Minitab statistical package developed by Boulton. (P=0.019)
Version 12.0 (Minitab, State - Non-palpable pedal
Furthermore, this College, PA) for personal b. Neuropathy disability pulses (P=0.000)
study aimed to identify computers was used for score (NDS) - Maximal plantar
as many risk factors statistical analysis. The NDS was used to pressure (P=0.000)
as possible and to Comparison between patients quantify the severity of - STJ mobility (P=0.026)
develop a screening who developed and did not diabetic neuropathy - First MTPJ mobility
strategy that by develop foot ulceration were obtained from physical (P=0.000)
combining the made by using X2 tests for examination and was - NDS (P=0.000)
detection of 2 or more categorical variables. based on the - VPT (P=0.000)
risk factors, would For individual continuous examination of tendon - SWF (P=0.000)
provide the best tool variables, comparison were reflexes and sensory - Feet with high foot
for identifying the at- made by using 2-tailed Student’s modalities as previously pressure (P=0.000)
risk patient t test if assumptions of described - Feet with high NDS
normality were achieved or with Sensory tests included a (P=0.000)
Wilcoxon’s rank-sum test if pinprick with a pointed - Feet with high VPT
nonparametric hypothesis testing metal or wooden pin, (P=0.000)
was required light touch with a strip of - Feet with high SWF
cotton ball, vibration (P=0.000)
Factors measured: with a tuning fork, and 2) Not significant data:
temperature perception - Age
a. Age with a test tube filled - BMI
b. Sex with cold water - History of foot ulceration
c. BMI (P=0.062)
d. Diabetes duration c. Vibration Perception - Type of diabetes(P=0.36)
e. History of foot Threshold (VPT) - NSS
ulceration The study used a
f. Type of diabetes biothesiometer
g. Non-palpable pedal (Biomedical, Newbury,
pulses OH) to test the VPT.
h. Maximal plantar
pressure d. Semmes Weinstein
i. STJ mobility Monofilament (SWF)
j. First MTPJ mobility This study used a set of
k. NSS 8 SWFs that apply
l. NDS pressure from 1 to 100 g
m. VPT to evaluate the cutaneous
n. SWF perception threshold
o. Feet with high foot
pressure e. Maximal plantar foot
p. Feet with high NDS pressure
q. Feet with high VPT The F-Scan mat system
r. Feet with high SWF (Tekscan, Boston, MA)
was used to measure the
dynamic plantar foot
pressures

f. Joint mobility
The total range of
motion at the first

4 Madanchi, N., Ozra, T.M., The purpose of the Population:
Mohammad, P., Ramin, study is to investigate 873 DFU patients admitted
H., Bagher, L., & the characteristics of between 2002 and 2008 in two
Mohammaad-Reza, M.T. diabetic foot patients university hospitals
(2013). Who are diabetic and their foot ulcers
foot patients? A Research type:
descriptive study on 873 The descriptive with
patients. Journal of retrospective study
Diabetes & Metabolic
Disorders, 12:36 Data Collection:
Medical archives of the patients
were utilized and necessary data
was collected using a predesign
data collection sheet
Data analysis:
Data were analyzed using SPSS
software, version 15
Factors measured:
a. Basic demographic
characteristics:
metatarsophalangeal
joint (MTPJ) and the
subtalar joint (STJ) was
measured by using a
goniometer
g. Peripheral Vascular
Disease (PVD)
The diagnosis of PVD
was based on the
absence of foot pulses
and/or symptoms of
claudication or history of
bypass operation
a. Renal co-morbidity as The findings of study are:
presence of micro-
albuminuria, macro- a. Basic demographic
albuminuria, or end- characteristics:
stage renal disease - Gender with male
(58.1%) and female
b. Cardiovascular co- (41.9%)
morbidity as presence of - Age is about 25-87
hypertension or ischemic years old
heart disease - Duration of DM is
around 0-600 months
c. Ophthalmic co- - Positive family history
morbidity as presence of of DM (28.8%)
simple or proliferative
diabetic retinopathy or
cataract
b. Method of DM control
- Under treatment with
d. Pin Prick test to
oral hypoglycemic
temperature or
(43.99%)
superficial pain
- Patients were receiving
sensation or two-point
insulin (45.47%)
discrimination
- Patients were receiving
 - Gender
- Age
- Duration of DM
- Positive family history
of DM
b. Method of DM control
- Under treatment with
oral hypoglycemic
- Patients were receiving
insulin
- Patients were receiving
both oral hypoglycemic
agents and insulin
- Under no medication
c. Hemoglobin A1c (HbA1c)
d. Patient’s fasting blood sugar
during admission
e. Causes of patients’ previous
hospitalizations
- Previous DFU
- Cardiovascular
- Ophthalmic
- Uncontrolled sugar
Cerebrovascular
accident
- Renal
- Two or more of these
complications
e. Monofilament (10-g) for
seeing the decreasing of
sensation
f. Autonomic neuropathy
as presence of
unexplained orthostatic
hypotension, c. Mean hemoglobin A1C
gastroparesis, dyspepsia,
diabetic diarrhea or
constipation, neurogenic
bladder, erectile
dysfunction, vaginal or d. Mean patients’ first fasting
skin dryness
e. Causes of patients’ previous
f.
both oral hypoglycemic
agents and insulin
(2.29%)
- Under no medication
(8.25%)
(HbA1c) level was 9.51%,
and only 14.4% of the
patients had HbA1c < 7%
blood sugar during
admission was 198.7 mg/dl
hospitalizations
- Previous DFU (22.4%)
- Cardiovascular (9.8%)
- Ophthalmic (7.9%)
- Uncontrolled sugar
(3%)
- Cerebrovascular
accident (2.8%)
- Renal (2.4%)
- Two or more of these
complications (21.3%)
Prevalence of DM co-
morbidities in patients
- Renal (60.3%
- Cardiovascular (59.1%)

5 Clayton, W., and Tom,
A.E. (2009). A review of
the pathophysiology,
classification, and
treatment of foot ulcers in
diabetic patients. Clinical
Diabetes, Volume 27, no
2 classification and
The purpose of this - a. ABI is obtained by
review is to describe
the causes of lower-
extremity ulceration in
diabetic patients and to
identify common
methods of
treatment to aid
primary care providers
in determining
appropriate treatment
approaches for their
patients
measuring the systolic blood The major underlying causes
pressure in the ankles
(dorsalis pedis and posterior neuropathy and ischemic from
tibiall arteries) and arms
(brachial artery) using a
handheld Doppler and then
calculating the ration, the
ratio below 0.91 are
suggestive of obstruction
b.Loss of pressure sensation
in the foot has been
identified as a significant
predictive factor for foot
ulceration. A screening tool
in the examination of the
diabetic foot is the 10-gauge
monofilament
c.Surgical bypass is a
common method of
treatment for ischemic
- Retinopathy (40.9)
- Sensorimotor
neuropathy (27.5%)
- Autonomic neuropathy
(9%)
g. 74% of patients had
ischemic DFU, 17.4% had
neuropathic DFU, and 8.5%
had neuro-ischemic
a. Pathogenesis of Ulceration
are note to be peripheral
peripheral vascular disease
1) Neuropathy
More than 60% of diabetes
foot ulcers are the result of
underlying neuropathy
- Motor
Damage to the
innervations of the
intrinsic foot muscles
leads to an imbalance
between flexion and
extension of the
affected foot. This
produces anatomic foot
deformities that create
abnormal bony
prominences and
pressure points, which
limbs, and favorable long- gradually cause skin
term results have been breakdown and
reported. ulceration
- Autonomic
Autonomic neuropathy
leads to a diminution in
sweat and oil gland
functionality. As a
result, the foot loses its
natural ability to
moisturize the
overlying skin and
becomes dry and
increasingly
susceptible to tears and
the subsequent
development of
infection
- Sensation
The loss of sensation as
a part of peripheral
neuropathy exacerbates
the development of
ulcerations. As trauma
occurs at the affected
site, patients are often
unable to detect the
insult to their lower
extremity
2) Peripheral Vascular
Disease (PVD)
PVD is a contributing factor
to development of foot
ulcers in up to 50% of
causes.
Endothelial cell dysfunction
and smooth cell
abnormalities develop in
peripheral arteries as a
consequence of the
persistent hyperglycemic
state. This is a resultant
decrease endothelium-
derived vasodilators leading
to constriction. Further, the
hyperglycemia in diabetes
is associated with an
increase in thromboxane
A2, a vasoconstrictor and
platelet aggregation agonist,
which leads to an increased
risk plasma
hypercoagulability.
Smoking, hypertension and
hyperlipidemia are other
factors that are common in
diabetic patients and
contribute to the
development of PAD

b.Assessment of Diabetic
Foot Ulcers
The literature review
showed that a complete
history will aid in assessing
the risk for foot ulceration,
such as
- History of ulceration
or amputation
- Symptoms of
neuropathy
- Symptoms of PVD

6 Iversen, M.M., Grethe,
S.T., Birgitte, S., Kristian,
M., Marit, G., Berit, R.,
Line, I.B., and Truls, O.
(2015). Is depression a
risk factor for diabetic
foot ulcers? 11-years
follow-up of the Nord-
Trondelag Health Study
(HUNT). Journal of
Diabetes and Its
The study aim is to Population:
prospectively examine Participants without diabetes,
whether depressive participant with diabetes not
symptom increase the reporting a foot ulcer, and
risk of diabetes and participants with diabetes
diabetic foot ulcer reporting a foot ulcer
Statistical analyses:
Descriptive statistic with mean
and standard deviation, t-test
and X2 tests were used to
- Smoking
- Inappropriate
footwear
- Presence of ulceration
or signs of infection
- The presence of callus
or nail abnormalities
- A temperature
different between feet
- Deformities
- Charcot arthropathy
- The dorsalis pedis
and posterior tibial
pulses should be
palpated and
characterized as
present or absent
- Claudication, loss of
hair, the presence of
pale, thin, shiny, or
col skin are physical
findings suggestive of
potential ischemia
- ABI
a. The Hospital Anxiety a. Baseline characteristic of
and Depression Scale the analysis sample
(HADS-D subscale) 1) Demographic
assessed depressive characteristic
symptom - Age with mean is
around 47 years
b. Height and weight were - Male gender (44.8%)
measured and body mass 2) Clinical factors
index (BMI) was - BMI with mean is
calculated as around 26.1 kg/m2
weight/height2 (kg/m2) - Serum glucose with
Complications, 29; 20-25 compare baseline characteristic
between subgroup.
Logistic regression analyses
were performed to estimate the
effect of depressive symptoms.
Analyses were also performed
using HADS-D as a continuous
variable. Statistical significance
was set as P<0.05, and analyses
were conducted using SPSS
version 20.0
Factors measured:
a. Characteristics of sample
1) Demographic characteristic
- Age
- Male gender
2) Clinical factors
- BMI
- Serum glucose
- Stroke
- Myocardial infarction
- Angina pectoris
- Any cardiovascular
disease
3) Assessment depression
- HADS-D
- HADS-D (≥8)
- HADS-D (8-10)
- HADS-D (≥11)
- Using anti-depressant
agents
- Combination of HADS
≥ 8 and/or use of anti-
depressant agents
mean 5.3 mmol/L
(blood sample were
c. Serum glucose was non-fasting
measured using an - Stroke (0.7%)
autoanalyzer (Hitachi - Myocardial infarction
Biocore Systems, (1.4%)
Thornhill, ON, Canada) - Angina pectoris (2.3%)
- Any cardiovascular
disease (3.6%)
3) Assessment of depression
- HADS-D with mean is
3.3
- HADS-D (≥8) (9.2%)
- HADS-D (8-10) (6.8%)
- HADS-D (≥11) (2.4%)
- Using anti-depressant
agents (2.7%)
- Combination of HADS
≥ 8 and/or use of anti-
depressant agents
(11.0)
b. Depressive symptoms as a
risk factor for diabetes
Odds for reporting diabetes
at follow up were
significantly higher among
individuals with a HADS-D
score ≥ 8 compared to
HADS-D < 8 at baseline
(OR 1.30 95%, CI: 1.07-
1.57)
c. Depressive symptoms as a
risk factor for DFU
 b. Depressive symptoms as a
risk factor for diabetes
c. Depressive symptoms as
risk factor for DFU
7 Molvear, A.K., Marit, G., The study is to Population:
Birgitte, E., Truls, O., determine the Diabetes patients with foot ulcer
Kristian, M., and proportion of people and without foot ulcer
Marjolein, M.I. (2014). with diabetes reporting
Journal of Diabetes and a history of foot ulcer Research type:
Its Complications, and investigate Cross sectional study
28:156-161 associated factors
healing time in the Statistical analyses:
Nord-Trondelag
Health Survey - T-test for continuous
(HUNT3), Norway variables.
- Chi-square tests for
nominal variables
- Fisher’s exact test instead
of chi-square when the
assumption of expected
counts was not met (for
variables peripheral
surgery and any
amputation)
- Logistic regression to
generate odds ratio and
95% CI to determine which
independent variables were
associated with a history of
foot ulcer
- Using SPSS version 19 (P
c. Self-reported eye a. Factors associated with
problems diagnosed by a history of foot ulcer (Socio-
doctor as due to diabetes demographic)
d. Macro-vascular 1) Significance data:
complications (history - Sex male (p=0.003)
stroke, myocardial - Marital status
infarction, angina (p=0.007)
pectoris and/or - Height (p=0.02)
peripheral surgery), 2) Not significance data:
history of amputation by - Age
questionnaires
e. Height, weight, and
waist circumference
were measured by b. Factors associated with
clinical examination history of foot ulcer (Life
f. BMI was calculated as style characteristic)
kilogram per meter 1) Significance data:
squared - BMI
g. Smoking was based on - Waist
the question “do you - Physical inactivity
smoke?” 2) Not significance data:
h. The study defined micro- - Smoke
albuminuria as an
albumin-creatinine ratio
> 3 mg/mmol in at least c. Factors associated with
two of three urine history of foot ulcer
samples. (Clinical characteristic)
1) Significance data:
 value= 0.05) - Insulin
- Duration of diabetes
2) Not significance data:
Factors measured: - HbA1c
- Ever used
a. Factors associated with
antihypertensive
history of foot ulcer
medication
1) Socio demographic
- Age
d. Factors associated with
- Sex male
history of foot ulcer (Micro-
- Marital status vascular complication)
- Height 1) Significance data:
2) Lifestyle characteristic
- Eye problems due to
- BMI
diabetes
- Waist - Any micro-vascular
- Physical inactivity complication
- Current smokers 2) Not significance data:
3) Clinical characteristic - Micro-albuminuria
- HbA1c
- Insulin
- Duration of diabetes
- Ever used e. Factors associated with
antihypertensive history of foot ulcer
medication (Macro-vascular
4) Micro-vascular complication)
complication 1) Significance data
- Micro-albuminuria - Self-reported stroke
- Eye problems due to - Self-reported
diabetes myocardial infarction
- Any micro-vascular - Self-reported angina
complication pectoris
5) Macro-vascular - Any macro-vascular
complication complication
- Self-reported stroke 2) Not significance data
- Self-reported - Peripheral vascular
myocardial infarction surgery
- Self-reported angina
 pectoris
- Peripheral vascular
surgery f. Any lower-limb amputation
- Any macro-vascular (p=0.03)
complication
6) Any lower-limb
Bivariate and multivariate in
amputation
characteristic

a. Significance data:
b. Bivariate and multivariate 1) Demographic
in characteristic - Age ≥ 75 years
1) Demographic (OR=2.1)
- Age - Male sex (OR=1.8)
- Gender - Height
- Height ≥176cm/≥162cm
2) Lifestyle (OR= 1.2)
- Current smoker 2) Lifestyle
- Waist - Current smoker
3) Clinical (OR=1.1)
- Duration of DM - Waist ≥ 102cm/ ≥
- Insulin 88cm (OR=1.6)
4) Vascular complication 3) Clinical
- Micro-vascular - Duration of diabetes ≥
complication 10years (OR=1.4)
- Macro-vascular - Insulin (OR=2.0)
complication 4) Vascular complication
- Micro-vascular
complications
(OR=1.3)
- Macro-vascular
complications
(OR=2.1)

8 Dubsky, M., Alexandra, The aim of this study Population a. End-stage renal disease Potential risk factors for ulcer
J., Robert, B., Vladimira, was to assess the 1200 patients with anew DFU (defined as needing recurrence:
F., Jelena, S., Nicolaas, frequency of ulcer for 12 months dialysis)
C.S., and Benjamin, A.L.
(2012). Risk factors for
recurrence of diabetic foot
ulcers: prospective follow-
up analysis in the
Eurodiale subgroup.
International Wound
Journal, 1742-4801.
Doi:10.1111/j.1742-
481X.2012.01022.x
recurrence in patients b. Overweight or obesity a. Significance data
with a healed DFU Research type: defined as a body mass - Osteomyelitis
followed up in our Prospective follow-up analysis index > 27 kg/m2 (p=0.0124)
centre for the 3 years during 3 year c. Chronic alcohol usage - Elevated CRP (> 5
after completing the defined as drinking more mg/l) (P=0.0454)
Eurodiale study, and to Statistical analysis: than 1 IU/day - Plantar location of
identify risk factors for d. PAD defined as an DFU
recurrence - X2 test ankle-brachial index (0.0001)
- Logistic regression (ABI) < 0.9 or the
absence of both foot b. Not significance data
pulses on the study foot - Age
Factor measured: e. Osteomyelitis diagnosed - Sex
a. Potential risk factors for by clinical features and - Poor glycemic control
ulcer recurrence plain X-ray finding (HbA1c >7.5%)
- Age f. Charcot foot diagnosed - Distance from hospital
by a presence of > 2C > 15 km
- Sex
difference in skin foot - Diabetes duration > 10
- Distance from hospital >
temperature between the years
15 km
two feet and plain X-ray - Diabetes treatment with
- Diabetes duration > 10
and/or radionuclide bone insulin
years
scan compatible with - Overweight (BMI > 27
- Diabetes treatment with
Charcot foot kg/m3)
insulin
g. DFU infections as - Smoking active
- Poor glycemic control
defined by the - Chronic alcohol usage
(HbA1c >7.5%)
International Working - End-stage renal disease
- Overweight (BMI > 27
Group on the Diabetic - Peripheral arterial
kg/m3)
foot disease
- Smoking active
h. Elevated C-reactive - Charcot foot
- Chronic alcohol usage
protein (CRP) level - Clinical signs of DFU
- End-stage renal disease
defined as > 5 mg/l infection
- Peripheral arterial
disease - Ulcer size > 5 cm2
- Osteomyelitis - Deep ulcer depth
- Charcot foot (subcutaneous)
- Clinical signs of DFU - Ulcer duration > 3
infection months
- Elevated CRP (> 5 - Foot deformity
 mg/l) - Previous ipsilateral
- Plantar location of DFU amputation
- Ulcer size > 5 cm2 - Previous contralateral
- Deep ulcer depth amputation
(subcutaneous) - Multiresistant
- Ulcer duration > 3 microorganisms
months - Days to complete
- Foot deformity healing
- Previous ipsilateral
amputation Multivariate stepwise logistic
- Previous contralateral regression- independent risk
amputation factors statistically
- Multiresistant significantly associated with
microorganisms ulcer recurrence (Significant
- Days to complete with OR>1)
healing
- Plantar location of the
ulcer (OR=2.15)
- Osteomyelitis
b. Multivariate stepwise (OR=1.64)
logistic regression- - HbA1c > 7.5%
independent risk factors (OR=1.4)
statistically significantly - CRP > 5 mg/l
associated with ulcer (OR=1.45)
recurrence
- Plantar location of the
ulcer
- Osteomyelitis
- HbA1c > 7.5%
- CRP > 5 mg/l

9 Consultant. (2013). Risk The study believe that Methodology : - a. Direct and indirect causes
factors for Diabetic Foot a high percentages of Articles review of risk factors of DFU
Ulcers (DFU): the first DFU are preventable 1) Indirect factors that leads to
step in prevention,53(11) by recognizing the DFU through secondary
: 800-803 major factors that lead mechanism
to DFU and - Neuropathy
implementing 4 - Deformity
essential measures to - Peripheral artery
prevent these wounds disease
from occurring. - Venous stasis disease
- Glycosylation of
tissues
- Collagen vascular
disease
- Angiitis
2) Direct factors that leads to
DFU through an immediate
effect of the cause
- Deformity
- Trauma
- Charcot
neuroarthropathy
- Malunited fractures
- Osteoporosis
congenital anomalies

b. Recurrent condition in
risk factors for DFU
- Deformity
- Peripheral artery
disease
- History of previous
wound
- Previous amputation
- Neuropathy

c. The life style or other

conditions that may
contribute to DFU

10 Edo, A.E., Gloria, O.E.,
and Ignatius, U.E. (2013).
Risk factors, ulcer grade
and management outcome
of diabetic foot ulcers in a
Tropical Tertiary Care
Hospital. Nigerian
Medical Journal,
54(1):59-63. Doi:
10.4103/0300-
1652.108900
The aim of study is to Population:
determine the risk Diabetes patients with DFU
factors, ulcer grade,
and management Research type:
outcome of patients Prospective observational study
with diabetic foot ulcer
(DFU) managed in a Statistical analysis:
tropical tertiary
hospital - The study was using
SPSS version 16 and
Stata/IC 11.
- Comparison of means
was done using t-test for
continuous data and a
chi-square test for
categorical data
- Logistic regression
analysis was performed
to examine the
association of some risk
factors for Lower
Extremity Amputation
(LEA)
Factors measured:
a. Risk factors and co-
morbidities of DFU
- Obesity including
metabolic syndrome
- Smoking
- Diabetes mellitus
- Malnutrition
- Immobility
- Miscellaneous
a. Ulcer grade at a. Frequency of risk factors
presentation using and co-morbidities of
Wagner’s grading DFU
b. Peripheral neuropathy - Hypertension (50.8%)
was defined as - Peripheral Vascular
diminished or lack of Disease (PVD) (44.3%)
perception of - Peripheral Neuropathy
touch/pain stimuli (42.6%)
c. Loss of joint assessed - Visual impairment
using a 128 mHz (21.3%)
tuning fork - Erectile dysfunction
d. Peripheral vascular (14.75%)
disease was defined as - Diabetic Ketoacidosis
defined as the presence (DKA)/ Hyperglycemic
of diminished or absent hyperosmolar state
lower limb arterial (NHS) (8.2%)
pulsation on palpation - HIV (3.28%)
e. Visual impairment was - Nephropathy (1.64%)
defined as diminished - Previous DKA (3.28
vision resulting from %)
refractive errors,
cataracts
f. Diabetic foot ulcer was
defined as any full b. Frequency preceding
thickness ulcer below events of DFU
the ankle in any person - Spontaneous (52.46%
with diabetes mellitus - Puncture injury
(16.39%)
- Trauma (12.5%)
 - Hypertension - Tight foot wears
- Peripheral Vascular (8.20%)
Disease (PVD) - Thermal injury (6.56%)
- Peripheral Neuropathy - Pedicure injury
- Visual impairment (3.28%)
- Erectile dysfunction - Tinea pedis (1.64%)
- Diabetic Ketoacidosis - Rat bite (1.64%)
(DKA)/ Hyperglycemic
hyperosmolar state
(NHS)
- HIV
- Nephropathy
- Previous DKA

b. Preceding events of DFU

11 Altindas, M., Ali, K., Can,
C., Ugur, A.B., and
Guncel, O. (2011). The
Epidemiology of foot
wounds in patients with
diabetes: a description of
600 consecutive patients
in Turkey. The Journal of
Foot and Ankle Surgery,
50; 146-152
- Spontaneous
- Puncture injury
- Trauma
- Tight foot wears
- Thermal injury
- Pedicure injury
- Tinea pedis
- Rat bite
The study purpose is Population:
to describe the results 600 diabetes patients with foot
of 8-years of data wounds
collection and analysis
that involved 600 Research type:
patients with diabetes- A retrospective cohort study
related foot wounds
Factors measured:
a. Demographic
characteristic
- Gender
- Age
a. The Diabetic Foot a. Demographic
Evaluation Form characteristic
(DFEF) was used to - Gender with male
collect basic (68.17%)
demographic - Age with mean range
information, specific from 23 – 92 years old
clinical information - Mean duration of
related to vascular, diabetes mellitus is
neurological, and around 7.4 – 17.4 years
microbiological - Type of DM that type 2
characteristic (96.83%) and type 1
(3.17%)
b. The treating surgeon or
 - Duration of diabetes
- Type of diabetes
b. Vascular assessment
- Pulse present in
posterior tibial and c. The location of the foot
dorsalis pedis arteries
- Pulse present in dorsalis
pedis artery but not in
posterior tibial artery
- Pulse present in
posterior tibial artery
but not in dorsalis pedis
artery
- Pulse absent in posterior
tibial and dorsalis pedis
arteries
- Pulse present in d. Wound were
popliteal artery
- Pulse absent in popliteal
artery
- Pulse present in femoral
artery
- Pulse absent in femoral
artery
- Intermittent claudication
present e. The progression of
- Leg pain at rest present
c. Others
- Loss of Protective
Sensation (LOPS)
- Neuropathic
a member of the
surgeon’s team
collected the b. Vascular findings
information by means of - Pulse present in
patients interview and posterior tibial and
physical examination dorsalis pedis arteries
(30%)
- Pulse present in
wound, or wounds was dorsalis pedis artery
categorized as either but not in posterior
forefoot (distal to tibial artery (13%)
Lisfranc’s joint), - Pulse present in
midfoot (proximal to posterior tibial artery
Lisfranc’s joint but but not in dorsalis
distal to Chopart’s pedis artery (8%)
joint), or hindfoot - Pulse absent in
(proximal to Chopart’s posterior tibial and
joint) dorsalis pedis arteries
(49%)
- Pulse present in
categorized according popliteal artery (63%)
the level of tissue - Pulse absent in
penetration, defined as popliteal artery (37%)
soft tissue only - Pulse present in
(exclusive of joint femoral artery (81%)
structure, and bone or - Pulse absent in femoral
joint) artery (19%)
- Intermittent
claudication present
wound was defined as (23%)
acute (≤ 7 days - Leg pain at rest present
duration), subacute (15%)
(duration > 7 days but <
8 weeks), or chronic (≥ c. The causes of wounds
8 weeks duration) - LOPS (96%)
- Neuropathic ulcer
(36%)
 - Trauma
- Burn
- Skin and complication
of previous surgery,
such as nail cutting or
callus surgery
- Minor causes
12 Khalil, A.H.A., A. Zaki., The purpose of this Population:
A. Abdel. R., M.H. study is to examine the Diabetes patients
Megalla., N. Gaber., H. prevalence of diabetes
Gamal., and K.H. foot problems and Research type:
Rohoma. (2014). Primary related risk factors in A cross sectional study
Care Diabetes. Egypt
http://dx.doi.org/10.1016/ Statistical analysis:
j.pcd.2014.10.010
- Statistical analysis was
performed using SPSS
version 18.0
- Association between co
morbidities, skeletal
deformities and foot joints
mobility and the
development of diabetic foot
disorders was tested using
Chi square test
f. Arterial pulsation was
determined manually,
by means of the surgeon
palpating the femoral,
popliteal, dorsalis pedis,
and posterior tibial
arteries in the involved
extremity
g. Peripheral neuropathy
with loss of protective
sensation (LOPS) was
determined by the
absence of appreciation
of the 10-gram Semmes
Weinstein monofilament
at 3 or more contiguous
locations on the
involved foot
a. Symptom of neuropathy
using the diabetic
neuropathy symptoms
(DNS) score
b. The foot nails were
examined to detect
presence of nail
dystrophies, ingrowing
nails and
onychomychosis
c. Foot joint mobility was
assessed to detect
limited joint mobility
which was defined as
less than 50 degree of
- Trauma (19%)
- Burn (10%)
- Skin and complication
of previous surgery,
such as nail cutting or
callus surgery (3%)
- Minor causes (0.67%)
- No definitive causative
factor was identified
(23%)
a. Association between co-
morbidities and diabetic
foot disorder in diabetic
patients
1) Significance data
- Coronary artery
disease (P=0.001)
- Cerebrovascular
(P=0.009)
- Claudication
(P=0.005)
- Revascularization
(P<0.001)
- Renal transplantation
or dialysis (P=0.001)
- Laser
photocoagulation
- All risk factors significantly
associated with diabetes foot
complications (p<0.05) in
bivariate analysis were
included as independent
variables in a multivariate
logistic model with diabetic
foot complication as an
outcome variable
Factors measured:
a. Association between co-
morbidities and diabetic
foot disorder in diabetic
patient
- Hypertension
- Coronary artery disease
- Cerebrovascular
- Claudication
- Revascularization
- Renal transplantation or
dialysis
- Laser photocoagulation
b. Risk factors potentially
predicting diabetic foot
- Gender
- DM duration
- History of smoking
- Fissure
- Callus
- Hallux valgus
- Hammer toe
non-weight bearing (P<0.001)
passive dorsiflexion of
the hallux
d. The neurological status 2) Not significance data
of the foot was assessed - Hypertension
using 10g Semmes- (P=0.198)
Weinstein
Monofilament
examination b. Risk factors potentially
predicting diabetic foot
e. Peripheral vascular 1) Univariate logistic
status of the foot was regression (significance)
assessed by measuring
- Gender (OR=1.078)
Ankle Brachial Index - DM duration
(ABI) for dorsalis pedis
(OR=1.037)
and posterior tibial - History of smoking
arteries of both feet.
(OR=1.299)
- Fissure (OR=1.719)
f. Ankle pressure were - Callus (OR=1.168)
measured using a
- Hallux valgus
standardized Doppler (OR=1.182)
ultrasonic device
- Hammer toe
(OR=1.360)
g. ABI was calculated as - Flat foot (OR=1.557)
the ratio of higher of the - Charcot’s foot
two systolic pressure (OR=3.354)
(from posterior tibial - Limited joint mobility
and dorsalis pedis) at (OR=1.748)
the ankle to the higher - Monofilament
reading of the right and insensitivity
left brachial artery (OR=5.059)
pressure - ABI ≤0.9 (OR=1.541)
2) Multivariate logistic
h. Peripheral arterial regression
disease (PAD) was
 - Flat foot defined as an ABI of ≤ (Significance)
- Charcot’s foot 0.9 in at least one leg
- Limited joint mobility - DM duration
- Monofilament (P<0.001)
insensitivity - Fissure (P<0.018)
- ABI ≤0.9 - Charcot’s foot
(P<0.001)
- Limited joint mobility
(P=0.001)
- Monofilament
insensitivity (P<0.001)
- ABI ≤ 0.9 (P=0.035)

(Not significance)

- Gender (male)
(P=0.715)
- History of smoking
(P=0.220)
- Callus (P=0.377)
- Hallux valgus
(P=0.379)
- Hammer toe (P=0.113)
- Flat foot (P=0.231)

13 Zaine, N.H., Joshua, B., The primary aim of Population: a. Diabetes Mellitus was a. Demographic
Mauro, V., John, P.F., this study was to Type 1 and type 2 diabetes defined according to the - Age with median of
Lindy, B., and Kerry, H. evaluate the patients with foot ulcers criteria set by WHO that male is 65 years and
(2014). Characteristics of characteristics of are a fasting plasma women is 69.5 years
diabetic foot ulcers in diabetic foot ulcers in Research type: glucose ≥ 7.0 mmol/L - Gender male (66.2%)
Western Sydney, patients presenting to a Descriptive study (126 mg/dl) or 2-hour - Height with median 1.7
Australia. Journal of tertiary referral plasma glucose ≥ 11.1 meters
Foot and Ankle outpatient hospital Statistical analysis: mmol/l (200 mg/dl) - Weight with 84.5 kg of
Research, 7:39 setting in Western median score
Sydney, Australia - SPSS 21.0 (IBM SPSS b. A foot ulcer was defined - BMI (77.7% is more
Statistic for Windows, as a full-thickness than overweight)
The secondary Armonk, NY, USA) wound located distal to - Socioeconomic median
Aim was to evaluate - Continuous data were
the use of vascular compared using the Mann
investigation and off- Whitney U test and c. Peripheral neuropathy
loading modalities in proportions using the Chi
this high risk group Square (X2) test. With P<
patients 0.05
Factors measured:
d. PAD was assessed and
a. Demographic
- Age
- Gender
- Height
- Weight
- BMI
- Socioeconomic
- Nationality
- Marital status
- Duration of DM e. The socioeconomic
b. Medical history and
lifestyle risk factors of
Patients
- Neuropathy
- Hypertension
- Hyperlipidemia
- History of ulcer
- Retinopathy
- History of amputation
- Angina/Infarct
- Nephropathy
- Renal failure
- Claudication
- Cerebrovascular
Accident
- Transient ischemic
ankle (level of malleoli) is 996
- Nationality of
Australian born
was diagnosed by a (50.8%) and born
Podiatrist using a overseas is 49.2%
neurothesiometer, - Marital status with
128Hz tuning fork or 10 married (58.5%)
g monofilament - Duration of DM is with
median 17 years
diagnosed by measuring
toe pressures using a
photoplethysmography b. Medical history and
(Hadeco Smartdop 30 lifestyle risk factors of
EX vascular Ultrasound Patients
Dopppler). A toe 1) More than 50%
pressure of < 55 mmHg - Neuropathy (75.4%)
indicates PAD in a foot - Hypertension (67.2%)
- Hyperlipidemia
(54.9%)
status was based on the 2) Less than 50%
Australian Bureau of - History of ulcer
Statistic (ABS) (41.5%)
residential postcode - Retinopathy (39.5%)
method for general - History of amputation
Australian population (32.8%)
(mean index=1000) - Angina/Infarct (24.1%)
- Nephropathy (22.1%)
- Renal failure (13.3%)
- Claudication (11.3%)
- Cerebrovascular
Accident (10.8%)
- Transient ischemic
attack (7.7%)
- Charcot arthropathy
(5.6%)
- Smoking that smoker
 attack (14.5%) and ex-smoker
- Charcot arthropathy (42.6%)
- Smoking
14 Ahmad, W., Ishtiaq, A.K., The objective of this Population: a. X-ray foot was advised Findings:
Salma, G., Farhan, K.A., study was to identify Diabetes patients and diabetes to assess condition of
and Ihsanullah Khan. risk factors and their patients with foot ulcers underlying bones - Age is around 58.09
(2013). Risk factors for frequency in patients years old (mean)
diabetic foot ulcer. J presenting at Ayub Exclude population: - Gender male is 80.1%
Ayub Med Coll Teaching Hospital, Patients with medical co- - Duration of DM is 52%
Abbottabad; 25 (1-2): Abbottabad morbidity especially chronic more than 10 years old
16-8 heart failure and chronic renal - Glucose control (43.4%
failure were excluded from the had poorly controlled
study sugar)
- Distal pulse (62.8%
Research Type: patients both distal
Descriptive study pulse absent
- Sensory loss (40.8%)
Statistical analysis: - Osteomyelitis (42.9%)
SPSS-10 - Infection (85.7%)

Factors measured:

- Age
- Gender
- Duration of DM
- Glucose control
- Distal pulse
- Sensory loss
- Osteomyelitis
- infection
15 Deribe, B., Kifle, W., and The main objective of Population: a.Diabetes was diagnosed if a. Demographic variables
Gugsa, N. (2014). this study is to assess Diabetes patients the patients with fasting among diabetic patients
Prevalence and factors prevalence and factors plasma glucose level ≥ 126 with and without foot ulcer
influencing diabetic foot influencing diabetic Exclusion criteria: mg/dl or a 2-h post glucose 1) Significance
ulcer among diabetic foot ulcer among Diabetes patients who have level after a 75-g oral - Residence (P=0.001)
patients attending diabetic patients traumatic ulcer other than glucose tolerance test ≥ 200 - Age interval
Arbaminch Hospital, attending Arbaminch perceived risk factors such as mg/dl plus suggestive (P=0.038)
South Ethiopia. Journal hospital
Diabetes Metabolic,
2:322. Doi: 10.4171/2155-
6156.1000322
car accident were excluded from
the study
Research type:
A cross sectional study
Statistical analysis:
- SPSS version 16.0
- Chi-square and student
t-test
Factors measured:
a. Demographic variables
among diabetic patients
with and without foot ulcer
- Sex
- Residence
- Educational status
- Marital status
- Age interval
- Occupation
- Type of co-morbidity
- DM knowledge
- Attitude
- DM self-care practice
- Body Mass Index (BMI)
- Systolic blood pressure
- Diastolic BP
- Duration of DM
- Skin texture
- Sensory loss to vibration
- Use of ill-fitting shoes
- Callus of the feet
clinical manifestations
b.Diabetes self-care attitude
measured using statement
related to diabetic self-care.
Likert scale of attitude
measurement will be used to
classify patients to sat have
favorable attitude or
unfavorable attitude towards
diabetes self-care
c.Diabetic foot self-care is
defined as ability of patient
to perform self-care
activities that help the feet
to be healthy
d.Neuropathy is assessed
and determined from
patient’s medical history
meaning the patient’s
medical card was reviewed
for the presence of
neuropathy
e.Knowledge of patients’
relating to diabetes and self-
care practice will be
assessed by using ‘yes/no’
questions
f.Diabetic foot ulcer is non-
traumatic lesions of the skin
(partial or full thic kness) on
the foot of a person who has
- Occupation (p=0.002)
- Type of co-morbidity
(P=0.003)
- Attitude (P=0.02)
- Body Mass Index
(BMI) (P=0.003)
- Systolic blood
pressure (P=0.01)
- Diastolic BP
(P=0.024)
- Duration of DM
(P=0.001)
- Skin texture
(P=0.005)
- Sensory loss to
vibration (P=0.001)
- Use of ill-fitting shoes
(P=0.015)
- Callus of the feet
(P=0.004)
2) Not significance
- Sex (P=0.443)
- Educational status
(P=0.121)
- Marital status
(P=0.097)
- DM knowledge
(P=0.81)
- DM self-care practice
(P=0.54)

16 Nehring, P., Beata, M.R., The purpose of this Populations:
Monika, K., Agnieszka, study is to compare
S.K., Rafal, P., Grazyna, diabetic foot risk - Diabetes type 2 without Global consensus guidelines
B., & Waldemar, K. factors in diabetic type diabetic foot
(2014). Diabetic foot risk 2 and risk factors for - Diabetic foot
factors in type 2 diabetes diabetic in healthy - Healthy subjects
patient: a cross-sectional
case control study.
Journal of Diabetes & Exclusion criteria:
Individuals with dominating
Metabolic Disorder,
13:79 angiopathic of diabetic foot were diabetes complicated with
disqualified from the study
Research type:
Case control study
Statistical analysis:
- Logistic regression
- U Mann-Whitney
- T- student tests with
STATISTICA 9PL
(StatSoft,Inc)
Factors measured:
a.Diabetic foot risk factors in
type 2 diabetes patients
- Gender
- Age
- Diabetes duration
- Weight
- Height
- Waist circumference
diabetes mellitus
a. Diabetic foot was
diagnosed according to
on the management and
prevention of the diabetic
foot criteria, as an a wound,
infection and/or deep foot
tissues destruction localized
in lower limb below the
ankle in patients with
neuropathy and/or PAD
b. The diabetic foot type
was defined with
detailed physical
examination of
superficial sensation
impairment
c. Neuropathy was
evaluated using
Thermo-tip
(temperature),
monofilament (touch),
Neuro-tip (pain), and
Semmens-Weinstein
pitchfork (vibration)
d. The presence of pulse
was assessed on dorsal
pedis and tibial posterior
Factors measured:
a.Diabetic foot risk factors in
type 2 diabetes patients
1) Significance
- Gender male (OR=2.83)
- Diabetes duration
(OR=1.04)
- Weight (OR=1.04)
- Height (OR=1.08)
- Waist circumference
(OR=1.028)
2) Not significance
- Age (OR=0.94)
b.Risk factors for type
diabetes in general
population
(Significance)
- Weight (OR=1.035)
- Waist circumference
(OR=1.075)
- Hip circumference (OR=1.03)
- BMI (OR=2.49)
- Hyperlipidemia (OR=0.54)

17 Merza, Z & S. Tesfaye.
(2003). The risk factors
for diabetic foot
ulceration. The Foot, 13;
125-129
18 Hokkam, E.N. (2009).
Assessment of ristk
factors in diabetic foot
ulceration and their impact
on the outcome of the
disease. Primary Care
b.Risk factors for type
diabetes in general population
- Weight
- Waist circumference
- Hip circumference
- BMI
- Hyperlipidemia
The study or literature Review literatures
review will go through
the various risk factors
for diabetic foot
ulceration
The aims of the study Population:
is to identify risk 300 diabetic patients where 180
factors for diabetic diabetes patients with DFU and
foot ulcer and their 120 diabetes patients without
impact on the outcome DFU
of the disease
arteries
e. The criteria of
hyperlipidemia were
hipercholesterolaemia,
hipertrigliceridaemiaor
lipid-lowering
medications intake
Review literatures Risk factors of DFU in DM
a. Diabetic neuropathy
- Chronic sensorimotor
- Autonomic neuropathy
b. Peripheral vascular disease
(PVD)
c. Biomechanical factors
d. Previous foot ulceration
e. Poor glycemic control
f. Long duration of DM
g. Race
h. Smoking
i. Retinopathy
j. Nephropathy
k. Insulin use and history of
poor vision
l. Age and male sex
m. Other factors
- Weight
- Height
a. The socioeconomic a. Significance data of main
status was classifies risk factors for DFU
into low and accepted 1. Gender (male)
according to the (P=0.009)
monthly income of 2. Type 2 diabetes
each person (low ≤150 (P=0.02)
Diabetes, 3: 219-224. Research Method: L.E and accepted > 150 3. Previous ulcer
Doi: Prospective study L.E) mention in Egypt (P=0.003)
10.1016/j.pcd.2009.08.009 human development 4. Chronic medical illness
Factors measured: report prepared by (P=0.005)
United Nations 5. Foot examination
a. Age Development (P=0.002)
b. Duration of diabetes Programme 6. Low socioeconomic
c. Gender (male) b. A standard general state (P=0.01)
d. Type 2 diabetes health examination was 7. Ischemia (P=0.004)
e. Insulin use performed to all 8. Neuropathy (P=0.006)
f. Previous ulcer patients focusing on 9. Anemia (P=0.003)
g. Chronic medical illness measurement of height 10. Duration of diabetes
h. Foot examination and weight (without (P=0.004)
i. Smoking shoes) for calculation 11. Poor of glycemic
j. Low economic state of body mass index control (P= 0.006)
k. Ischemia (BMI) 12. Presence of infection
l. Neuropathy c. Sensory neuropathy (P<0.001)
m. Renal insufficiency was considered positive b. Not significance data of
n. Retinopathy if three or more sensory main risk factors for DFU
o. Anemia modalities were absent 1. Age
p. Glycemic control d. The patient was 2. Insulin use
q. Infection considered to have 3. Smoking
peripheral vascular 4. Renal insufficiency
disease that may affect 5. Retinopathy
the development of
ulcer if there was
absent pulsation of
either the dorsalis pedis
or posterior tibial
artery, or ankle-
brachial systolic blood
pressure index <0.80
e. Chronic renal
insufficiency was
stratified as creatinine
> 4.0 mg/dl, current

19 Crawford, F, et al,. (2013).
Protocol for a systematic
review and individual
patient data meta-analysis
of prognostic factors of
foot ulceration in people
with diabetes: the
international research
collaboration for the
prediction of diabetic foot
ulcerations (PODUS).
BMC Medical Research
Methodology, 13:22
dialysis or a history of
renal transplantation
f. Retinopathy was
assessed by one
independent
opthalmologist
The study undertook a Search strategy: - The most significance results
systematic review to Electronic search strategies were are Peripheral neuropathy and
determine the used to identify studies which excessive plantar pressure
predictive values of assessed the predictive value of
such features in diagnostic tests, signs and
estimating the risk of symptoms using MEDLINE
diabetic foot ulceration (1966-February 2005),
EMBASE (1980-March 2005),
CINAHL (1982-February 2005).
The electronic search strategy
was developed from clinical
MeSH headings and test words.
Inclusion criteria:
a. Published reports of cohort
or case-control studies that
evaluated the factors used
to predict diabetic foot
ulceration
b. All study participants free
of active foot ulceration at
the time of study entry
c. All study participants in
either study design had a
diagnosis of diabetes either
type 1 or type 2. The
outcome (reference
standard) was foot
ulceration
 Data Extraction:
Data were extracted from the
studies as absolute numbers and
as means with SDs to permit the
re-calculation of data as
weighted or standardized mean
differences and 95%Cls.

Statistical analyses:
The study present estimates of
effectiveness where there were
two or more reports for
individual predictive factors.
As the review focused on a
single outcome (diabetic foot
ulceration) groups of patients
were categorized into those who
ulcerated and those who did not.
Continuous outcomes, expressed
as means and SDs were pooled
as weighted mean differences
(WMD). Peak plantar pressure
was measured using different
dynamic platform-based
equipment system, and
consequently a standardized
mean difference (SMD) was
used to pool data. Tests for
heterogeneity was evident, a
random effects model was used.
20 Boulton et al. (2008). This article reviews - - Risk factors of DFU in this
Comprehensive foot aims is to review the study are:
examination and risk prevention of DFU in
assessment. Diabetes diabetes patients a. Previous amputation
Care,31 (8) And identify the risk b. Past foot ulcer history
c. Peripheral neuropathy
 factors of DFU, d. Foot deformity
screening test in e. Peripheral vascular
predict in DFU disease
f. Visual impairment
g. Diabetic nephropathy
(especially patients on
dialysis)
h. Poor glycemic control
i. Cigarette smoking
j. Past history
1) Ulceration
2) Amputation
3) Charcot joint
4) Vascular surgery
5) Angioplasty
6) Cigarette smoking
k. Neuropathic symptoms
l. Vascular symptoms
1) Claudication
2) Rest pain
3) Non-healing ulcer
m. Other diabetes
complications:
1) Renal (dialysis,
transplant)
2) Retinal (visual
impairment)

21 Rebolledo, F.A., Teran, S, The objective of this - - The risk factors for
& Jorge, E.P. (2011). The study is to make development of DFU in
pathogenesis of the pathogenesis of DFU diabetes patients are:
diabetic foot ulcer:
prevention and a. Physiopathology
Management. 1) hyperglycemia
Doi:10.5772/30325 b. Anatomical and structural
alterations
1) Peripheral sensory

22 Lavery, L.A., David,
G.A., Steven, A.V., Terri,
L, Q., & John, G.F.
(1998). Practical criteria
for screening patients at
high risk for diabetic foot
ulceration. Arch Intern
Med, 158; 157-162
The objective of this Population:
study is to evaluate The study used 76 case patients
risk factors for foot and 149 control subjects
ulcerations among
persons with diabetes Inclusion criteria:
mellitus
a. The presence of diabetes
mellitus based on World
Health Organization criteria
b. Evaluation by medicine and
ophthalmology services
within the past 3 months at
the time of enrollment
c. Glycosylated hemoglobin,
urinalysis, creatinine, and
blood urea nitrogen
laboratory studies performed
in the past 3 months, and
d. Age 18-80 years old
Exclusion criteria:
a. Patients with ulcers on the
ankle or leg
Research design:
neuropathy
2) Peripheral motor
neuropathy
3) Autonomic
neuropathy
c. Environmental influences
1) Limited joint mobility
2) The gait
Diabetes mellitus was Risk factors of DFU:
stratified into type 1 or 2 Univariate
based on the criteria
described by the National Significances:
Institutes of Health’s
National Diabetes Data a. Historical data
Group 1) Sex (male) (P<0.001)
2) Diabetes duration > 10
Renal function was stratified years (P<0.001)
using the following criteria: 3) Previous amputation
(P<0.001)
- No albuminuria (<20 4) ≥1 subjective
μg/min) vs micro- symptoms of
albuminuria (20-200 neuropathy (P<0.001)
μg/min) 5) Lower extremity
- Macro-albuminuria bypass (P<0.04)
(>200 μg/min) b. Diabetes comorbidities
- Chronic renal 1) Nephropathy
insufficiency (P<0.001)
(creatinine level > 350 2) Macro-albuminuria
μmol/L [>4.0 mg/dL] (P<0.001)
- Current dialysis 3) End-stage renal disease
- History of renal (P<0.003)
transplantation 4) Retinopathy (P<0.001)
5) History of retinopathy
(P<0.009)
The presence and severity of 6) Proliferative
diabetic retinopathy was retinopathy (P<0.005)
Case control
Statistical analyzes:
Logistic regression
Factors measured:
Univariate
a. Historical data
1) Sex
2) Diabetes duration > 10
years
3) Previous amputation
4) ≥1 subjective symptoms
of neuropathy
5) Lower extremity bypass
6) Current or past tobacco
use
7) Alcohol abuse
8) Intermittent claudication
b. Diabetes comorbidities
1) Nephropathy
2) Micro-albuminuria
3) Macro-albuminuria
4) End-stage renal disease
5) Retinopathy
6) History of retinopathy
7) Proliferative retinopathy
8) Glycosylated
hemoglobin
9) Impaired vision
10) Legally blind
c. Physical examination
1) Loss of protective
sensation
2) Plantar pressure
3) Hallux rigidus, hallux
assessed from centrally
graded retinal photographs
taken with a wideangle
camera
Retinopathy was classified
as none vs background or
proliferative
Proliferative retinopathy
was differentiated from
background retinopathy by
the presence of any
neovascularization, fibrous
proliferations, preretinal
hemorrhage, vitareous
hemorrhage, or
photocoagulation scars
Visual acuity was evaluated
using a Rosenbaum eye
chart at the standard
distance of 36 cm
Corrected vision was scored
as normal(<20/20), impaired
(20/25 to 20/200), or legally
blind (>20/200)
Peripheral neuropathy was
assessed using vibration
perception threshold testing c. Physical examination
at the distal great toe with
Biothesiometer (Biomedical
Instrument Co, Newbury,
Ohio)
7) Glycosylated
hemoglobin (P<0.001)
c. Physical examination
1) Loss of protective
sensation (P<0.001)
2) Plantar pressure
(P<0.001)
3) Hallux rigidus, hallux
vagus or rigid toe
deformity (P<0.001)
4) Ankle equinus
(P<0.005)
5) Limited subtalar joint
range of motion
(P<0.009)
Not significance
a. Historical data
1) Current or past tobacco
use (P=0.74)
2) Alcohol abuse (P=0.19)
3) Intermittent
claudication (P=0.08)
b. Diabetes comorbidities
1) Micro-albuminuria
(P=0.90)
2) Impaired vision
(P=0.97)
3) Legally blind (P=0.09)
1) Unable to see bottom of
foot ≥ 1 palpable foot
pulse (P=0.49)
2) Ankle-brachial index
>0.80 (P=0.1)
 vagus or rigid toe 3) Transcutaneous oxygen
deformity Peripheral vascular disease pressure < 30 mmHg
4) Ankle equinus was assessed by several (P=0.85)
5) Limited subtalar joint dichotomous variables
range of motion included the Rose
6) Unable to see bottom of intermittent claudication Multivariate
foot ≥ 1 palpable foot scale (history of claudication Significance
pulse =score >10 points), absence
7) Ankle-brachial index of palpable dorsalis pedis 1) Loss of protective
>0.80 and posterior tibial pulses in sensation (P<0.001)
8) Transcutaneous oxygen the foot, transcutaneous 2) History of amputation
pressure < 30 mmHg oxygen tension on the dorsal (P<0.02)
aspect of the first 3) Elevated plantar
intermetatarsal space (<30 lpressure (P<0.001)
Multivariate mmHg), and ankle-brachial 4) ≥1 subjective
systolic blood pressure (< symptoms of
a. Loss of protective sensation 0.08) neuropathy (P<0.02)
b. History of amputation 5) Hallux rigidus, hallux
c. Elevated plantar pressure To categorize forefoot vagus, toe deformity
d. ≥1 subjective symptoms of deformities in addition to (P<0.03)
neuropathy hallux rigidus evaluated the 6) Poor diabetes control
e. Hallux rigidus, hallux vagus, foot for the presence of (P<0.03)
toe deformity hallux valgus, 7) Duration of diabetes >
f. Poor diabetes control toecontractures (hammer- 10 years (P<0.04)
g. Duration of diabetes > 10 toe, claw toe or mallet toe 8) Sex (Male) (P<0.05)
years deformities), subluxation or
h. Sex dislocation of the
metatarsophalangeal joints
and prominent metatarsal
heads on the sole of the foot
 FACTORS ASSOCIATED WITH DFU BASED ON LITERATURE REVIEW

No Factors References
1 Age Ref. 1.4.7.11.13.14.15.17.22
2 Duration of DM Ref. 1.2.3.4.7.10.11.12.13.14.15.16.17.22
3 Neuropathy Ref. 1.2.3.4.5.9.10.11.12.13.14.15.17.18.19.20.21.22
4 Gender (male) Ref. 1.3.4.7.11.13.15.16.17.18
5 Occupation Ref. 1.14
6 History of claudication Ref. 1
7 Fasting blood glucose Ref. 1.2
8 HbA1c Ref. 1.2.8
9 Waist circumference Ref. 1.7.16
10 Hypertension Ref. 1.13
11 Peripheral Vascular Disease Ref. 1.2.3.5.9.10.11.12.15.17.19.20
12 Irregular exercise Ref. 1
13 Footwear inappropriate Ref. 1.5.14.17
14 Poor of knowledge & practice Ref. 1.14.18
foot care
15 Serum cholesterol Ref. 2
16 2h postpradial blood glucose Ref. 2
17 Smoking Ref. 2.5.7.9.17.20
18 Retinopathy Ref. 2.4.10.17.20
17 Previous foot ulcer Ref. 2.4.5.9.17.18.19.20
20 Previous foot amputation Ref. 2.5.9.19.20.22
21 Deformity Ref. 2.5.9.20.22
22 Poor joint mobility Ref. 2.3.12.19.21
23 Plantar pressure Ref. 3.8.19.22
24 Family history Ref. 4
25 Un-control blood glucose Ref. 4.15.17.20.22
26 Cardiovascular Ref. 4
27 Renal disease/ Nephropathy Ref. 4.12.17.20
28 Cerebrovascular accident Ref. 4.12
29 Opthalmic Ref. 4
30 Symptom of neuropathy Ref. 5.22
31 Symptom of PVD Ref. 5
32 Infection Ref. 5.15
33 Callus Ref. 5.14
34 Charcot arthropathy Ref. 5.9.12
35 Trauma (finger) Ref. 1.9
36 Spontaneous blister Ref. 1.10
37 Burn Ref. 1
38 Depression Ref. 6
39 Height Ref. 7.13.16.17
40 Insulin Ref. 7.17
41 Micro-vascular Ref. 7
 No Factors References
42 Macro-vascular Ref. 7
43 Osteomyelitis Ref. 8.15
44 CRP Ref. 8
45 Osteoporosis Ref. 9
46 Mal-united fracture Ref. 9
47 Congenital abnormalities Ref. 9
48 Venous statis disease Ref. 9
49 Glycosylation of tissue Ref. 9
50 Collagen vascular disease Ref. 9
51 Angitis Ref. 9
52 Obesity Ref. 9
53 Malnutrition Ref. 9
54 Immobility Ref. 9.17
55 Miscalleneous Ref. 9
56 Dry, Cracked of foot skin Ref. 14
57 Residence : rural Ref. 14
58 Kidney disease Ref. 14
59 Fissure Ref. 12
60 Laser coagulation Ref. 12
61 Revascularization Ref. 12
62 Claudication Ref. 5.12
63 Coronary artery disease Ref. 12
64 Weight Ref. 13.16.17
65 Body Mass Index Ref. 13
66 Socio-economic Ref. 13.17.18
67 Marital status Ref. 13
68 Race Ref. 17
69 Biomechanical fracture Ref. 17
70 Type 2 DM Ref. 18
71 Chronic medical illness Ref. 18
72 Ischemic Ref. 18
73 Lower limb bypass procedure Ref. 19
74 Bio-molecular level/ Ref. 21
hyperglycemia
75 The Gait Ref. 21
 Depression Age Duration of DM Co-morbidities disease
(22) (1.3.8.11.15.17.19. 21.22) (1.2.3.8.11.13.14.15. (3.5.7.10.11.12.13.14.15.
Pathway of DFU 16.17.18.19.20.21) 16.18.21)
Diabetes Patients
Micro and Macro
vascular
Physical Un-controlled (19)
Inactivity blood sugar Neuropathy
(3.12.14) (1.3.5.11.15) (1.2.3.4.5.7.8.9.11.12.13.14.
Hyperglycemia 15.16.17.18.21)
(9) History of claudication
↓ Knowledge ↓ Foot practice (14)
(7.14.17) (7.14.17) ↑HbA1c
Smoking (10.14.16) Sensory Motoric Autonomy
(3.5.6.12.16.19
PVD (6) (6) (6)
(2.3.4.5.6.
Skin itching Scratching Non-traumatic 8.11.12.13
↓ Foot care the skin
(14) Injury .14.16.18) Loss of Foot muscle Diminution in
(14) (14) (14) sensation damaging sweat and oil
(6) (6) gland function
Thrombosis, (6)
Malnutrition Hypoproteinemia Edema vasoconstriction,
Dry skin (12) (12) (12) platelet
(3.17) Not aware Imbalance Loss of
aggregation of trauma between flexion moisturize skin
(6) (6) and extension of (6)
BMI
(21) the affected foot
(6)
Plasma Exacerbation Dry skin
Sex (male) Obesity coagulation injury (3.17)
(12) (6) (9) Deformities
(1.2.3.7.8.11.14.15.19.20.21)
Marital status (1.5.6.12.16)
(21) Impairment
Occupation (farmer) of tissue Fissures Callus
(14.17) perfusion Excessive (18) (6.17)
(3) Charcot foot
Socio-economic plantar pressure (6.12.18)
(3.7.21) (1.2.4.10)
Infection
Spontaneous Ischemic (6.11)
Blister (7)
(13.14) History of ulceration
Unclear (3.4.5.6.7.12.15.16)
Sources:
process History of amputation
(1.4.5.6.12.16)
1) Lavery et al., 199

Diabetic Foot Ulcer (DFU)

Sources:

1. Lavery et al., 1998

2. Pham et al., 2000
3. Merza & Tesfage, 2003
4. Crawford, Inkster, Kleijnan, &Fahey, 2007
5. Boulton et al., 2008
6. Clayton & Tom, 2009
7. Hokkam, 2009
8. Altindas et al., 2011
9. Rebolledo, Teran, & Jorge, 2011
10. Dubsky et al., 2012
11. Ahmad et al., 2013
12. Consultant, 2013
13. Edo, Gloria, & Ignatius, 2013
14. Lee et al., 2013
15. Madanchi et al., 2013
16. Al-Kafrawy et al., 2014
17. Deribe, Kifle, & Gogsa, 2014
18. Khalil et al., 2014
19. Molvear et al., 2014
20. Nehring et al., 2014
21. Zaine et al., 2014
22. Iversen et al., 2015
 Conceptual framework of study using RAM

Stimuli 23. Process Problem Impacts

Spontaneous blister Fissures

Dry skin Callus - Morbidity
Direct Ischemic Infection - Wound infection
Physiologic- - Disability
factors
24. Excessive plantar pressure History of ulceration physical
Deformity History of amputation (amputation)
Charcot foot - Depression
Contextual -
stimuli
Physical inactivity PVD
Un-controlled blood sugar Neuropathy
- Anxiety
Indirect Poor of foot care Age Self- - Denial
factors Smoking Duration of DM concept - Anger
High of HbA1c Co-morbidities disease
Malnutrition History of claudication - Feeling to suicide
BMI

Diabetes Mellitus
(DM) Diabetic Foot Ulcer
(Focal stimuli) (DFU)

- Impact of
Role quality of life
function - Negative role
Sex (male) in social
Residual Idiophatic Marital status
stimuli factors Occupation
Socio-economic - Increase cost
- Burden families’
Interdependence economic
- Government burden
- Long hospitalization

No Classification Predictive
factors
1 Peripheral Neuropathy
(ref.1.2.3.4.5.7.8.9.10.12.17)
2 Peripheral Arterial Disease
(PVD)
(ref.2.5.9.10.11)
3 Depression
(ref. 6)
4 Physical inactivity
(ref.1.3.7.9)
5 Poor of foot care
(ref.14)
RISK FACTORS AND THEIR TOOLS TO MEASURE THEM
Sub of main factors Measurement (Tools) Explanation
a. Sensory a. Thermo-tip (ref. 16) Peripheral neuropathy (PN) is the
b. Motoric b. Monofilament 10 g (ref. 2.3.4. 5.11.12.16) most common component cause in
c. Autonom c. Neuro-tip (ref. 16) DFU (Boulton et al, 2008)
d. Semmens-Weinstein Pitchfork (ref. 16)
e. 128Hz Tuning Fork (ref. 2) The clinical exam for neuropathy
f. Neuro-thesiometer (ref. 13) or is to identify loss of protective
biothesiometer (Boulton et al, 2008) sensation (LOPS) (Boulton et al,
g. Michigan neuropathy screening instrument 2008)
(MNSI) (ref.1)
h. Neuropathy Symptom Score (NSS) (ref. 3)
i. Dismished or lack of perception of
touch/pain stimuli (ref.10)
j. Patient’s medical history (ref.15)
a. Photooplethysmography (Hadeco The ABI is simple and easily
Smartdop 30 EX vascular Ultrasound reproducible method of diagnosing
Doppler) (ref.13) vascular insufficiency in the lower
b. Ankle Brachial Index (ABI) (ref. 2.5.8.12) limbs (Boulton et al, 2008)
c. Palpation of dorsalis pedis and posterior
tibial (ref. 2.3.10.11.12.)
d. Patient’s chart review (ref.1)
The Hospital Anxiety and Depression Scale Depression is commonly
(HADS-D subscale) associated with suboptimal HbA1c
(Lukman et al, 2000; ref.6)
a. Irregular exercise a. Open question or interview (ref.7) “did Physical inactivity is defined as
b. Immobility you take regular exercise before wound doing exercise less than 1 hour per
appear?” (ref.1) a week (ref.7)
a. Foot care a. Semi-structured questions (ref.1) Poor of foot care is defined as
practice b. Joint mobility can be measured by inability of patient to perform foot
(ref.1.14) such as goniometer (ref.3) self-care activities that help feet to
joint mobility be healthy (ref.14) Or Physical
(ref.3) inactivity is defined as lack of foot
b. Foot care activities and foot care by
knowledge (ref. caregiver of patients.
 1)
c. Foot wear Lack of joint mobility means that
appropriate the condition of passive plantar
(ref.1) flexion and passive dorsi-flexion
(ref.3)
6 Smoking behavior a. Open question “do you smoke?” Smoking is a powerful risk factor
(ref. 2.6.9.12) for PAD promoting endothelial
dysfunction, and altering lipid
metabolism and coagulation (Lu
and Creager 2004; Shammas,
2007)
7 Malnutrition Malnutrition is the condition that
(ref. 9) occurs when the body does not
enough nutrients (National Library
of Medicine, 2013)
8 Deformity
(ref. 9)

9 Callus
(ref.12.15)
10 Fissures
(ref.12)

11 Excessive plantar pressure

(ref.3.7.17)

12 Spontaneous blister Blister is defined as a vesicle or

(ref.10) bulla of the skin that contain fluid
caused infection, irritation, or
burning (Mosby’s Medical
Dictionary, 2009)

13 Charcot foot The charcot foot will decrease

bone tissue resorption and changes
resorption lead to foot curve
alignment and tissue ulceration
(Nehring et al, 2013).
14 Claudication, loss of hair, Claudication is defined as pain
pale skin, cool skin caused by too little blood (Mayo
(ref.5) clinic, 2015)

15 Sex (male) Male or Female The males are more physically

(ref.3.4.11.12.13.14.15.16) active than females and spend
most of their time outdoors
performing weight-bearing
activities in Turkey (ref.11)
16 Age
(ref.6.13.14)

17 Marital status
(ref.6.13)

18 Occupation
(ref.15)

19 Socio-economic Australian Bureau of Statistic (ABS) method

(ref. 13) (Mean index=1000)

20 Body Mass Index (BMI) Height Antropometric (ref.2.16) The height related to increasing of
(ref. 6.13.15) (ref. 6. 16) demyelination comparing in
Weight individuals who have shorter lower
(ref. 13.16) limbs never fibers (ref.16)
Waist Circumference
(ref. 6.16)
21 Duration of diabetes
(ref. 2.6.12.16)
21 HbA1c Fasting blood glucose Laboratory test
(ref. 2.7) 2h-postpardial blood
glucose

23 History of ulceration
(ref.2.5.9)
24 History of amputation
(ref. 2.9)
25 Co-morbidities diseases
(ref.2.4.6.8.9.10.12.13)
 ASSESSMENT TOOL TO ASSESS RISK OF DIABETIC FOOT ULCER (DFU)
A. General Information

Name
Age
Gender
Marital status
Occupation
Socio-economic
Duration of DM

History of ulceration

History of amputation

B. Specific Assessment
1. Neuropathy
a. Sensory

b. Motoric

c. Autonomy

2. Peripheral Vascular Disease (PVD)

a. History of claudication

b. Absent pulse of dorsalis pedis

c. Absent pulse of posterior tibial

d. Ankle Brachial Index (ABI)

 3. Excessive plantar pressure

4. Spontaneous blister
Left
Right
Total

5. Depression
Level

C. Behavior Assessment
1. Physical inactivity

2. Smoking

3. Malnutrition

4. Poor of foot care

D. Laboratory Test

1. HbA1c (> Normal)

E. Co-Morbidities Disease
1. Retinopathy

2. Renal disease

3. Cardiovascular

4. Stroke

5. Osteomyelitis

6. Osteoporosis

7. Mal-united fracture

8. Hypertension

9. Coronary arterial disease

10. Cerebrovascular

11. Others…..
References:

Ahmad, W., Ishtiaq, A.K., Salma, G., Farhan, K.A., and Ihsanullah Khan. (2013). Risk factors for diabetic
foot ulcer. J Ayub Med Coll Abbottabad; 25 (1-2): 16-8

Al-Kafrawy, N.A.E., Ehab, A.B.E.M., Alaa, E.A.E.D., Osama, M.E., & Omnia, M.A.Z. (2014). Study of
risk factors of diabetic foot ulcers. Menoufia Medical Journal, 27:28-34. Doi:10.4103/1110-
2098.132298

Altindas, M., Ali, K., Can, C., Ugur, A.B., and Guncel, O. (2011). The Epidemiology of foot wounds in
patients with diabetes: a description of 600 consecutive patients in Turkey. The Journal of Foot
and Ankle Surgery, 50; 146-152

Boulton, A.J.M., David, G.A., Stephen, F.A., Robert, G.F., Richard, H., M. Sue, K., et al. (2008).
Comprehensive foot examination and risk assessment. Diabetes Care, volume 31, number 8

Clayton, W., and Tom, A.E. (2009). A review of the pathophysiology, classification, and treatment of foot
ulcers in diabetic patients. Clinical Diabetes, Volume 27, no 2

Consultant. (2013). Risk factors for Diabetic Foot Ulcers (DFU): the first step in prevention,53(11) : 800-
803

Crawford, F, et al,. (2013). Protocol for a systematic review and individual patient data meta-analysis of
prognostic factors of foot ulceration in people with diabetes: the international research
collaboration for the prediction of diabetic foot ulcerations (PODUS). BMC Medical Research
Methodology, 13:22

Deribe, B., Kifle, W., and Gugsa, N. (2014). Prevalence and factors influencing diabetic foot ulcer among
diabetic patients attending Arbaminch Hospital, South Ethiopia. Journal Diabetes Metabolic,
2:322. Doi: 10.4171/2155-6156.1000322

Dubsky, M., Alexandra, J., Robert, B., Vladimira, F., Jelena, S., Nicolaas, C.S., and Benjamin, A.L.
(2012). Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis in the
Eurodiale subgroup. International Wound Journal, 1742-4801. Doi:10.1111/j.1742-
481X.2012.01022.x

Edo, A.E., Gloria, O.E., and Ignatius, U.E. (2013). Risk factors, ulcer grade and management outcome of
diabetic foot ulcers in a Tropical Tertiary Care Hospital. Nigerian Medical Journal, 54(1):59-63.
Doi: 10.4103/0300-1652.108900

Iversen, M.M., Grethe, S.T., Birgitte, S., Kristian, M., Marit, G., Berit, R., Line, I.B., and Truls, O.
(2015). Is depression a risk factor for diabetic foot ulcers? 11-years follow-up of the Nord-
Trondelag Health Study (HUNT). Journal of Diabetes and Its Complications; 29; 20-25
Khalil, A.H.A., A. Zaki., A. Abdel. R., M.H. Megalla., N. Gaber., H. Gamal., and K.H. Rohoma. (2014).
Primary Care Diabetes. http://dx.doi.org/10.1016/ j.pcd.2014.10.010

Lee, C.M., Chang, C.C., Chien, M.C., Li-Ju, L., Chyong, F.C., & Mei, Y.C. (2013). The devil is in the
detail: Prevention of diabetic foot ulceration in rural area is possible. Open Journal of Nursing,
3, 257-264

Madanchi, N., Ozra, T.M., Mohammad, P., Ramin, H., Bagher, L., & Mohammaad-Reza, M.T. (2013).
Who are diabetic foot patients? A descriptive study on 873 patients. Journal of Diabetes &
Metabolic Disorders, 12:36

Molvear, A.K., Marit, G., Birgitte, E., Truls, O., Kristian, M., and Marjolein, M.I. (2014). Diabetes-
related foot ulcers and associated factors: results from the Nord-Trondelag Health Survey
(HUNT3) (2006-2008). Journal of Diabetes and Its Complications, 28:156-161

Nehring, P., Beata, M.R., Monika, K., Agnieszka, S.K., Rafal, P., Grazyna, B., & Waldemar, K. (2014).
Diabetic foot risk factors in type 2 diabetes patient: a cross-sectional case control study. Journal
of Diabetes & Metabolic Disorder, 13:79

Pham, H., David, G.A., Carolyn, H., Lawrence, B.H., John, M.G., and Aristidis,V. (2000). Screening
techniques to identify people at high risk for diabetic foot ulceration. Diabetes Care, 23:606-611

Shammas, N.W. (2007). Epidemiology, classification, and modifiable risk factors of peripheral arterial
disease. Vascular Health and Risk Management; 3(2) 229-234

Zaine, N.H., Joshua, B., Mauro, V., John, P.F., Lindy, B., and Kerry, H. (2014). Characteristics of
diabetic foot ulcers in Western Sydney, Australia. Journal of Foot and Ankle Research, 7:39