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Variability in Activity May Precede Diabetic Foot Ulceration

¹ Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, Chicago, Illinois
² Department of Surgery, Southern Arizona Veterans Affairs Medical Center, Tucson, Arizona
³ Department of Surgery, Texas A&M University, Temple, Texas
⁴ Department of Medicine, Manchester Royal Infirmary, University of Manchester, U.K

Address correspondence and reprint requests to David G. Armstrong, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd., North Chicago, IL 60064. E-mail: armstrong{at}usa.net

OBJECTIVE—To evaluate the role of activity in the development of neuropathic foot ulceration in individuals with diabetes.

RESEARCH DESIGN AND METHODS—We evaluated the first 100 consecutive individuals with diabetes (95.0% male, aged 68.5 ± 10.0 years with concomitant neuropathy, deformity, and/or a history of lower-extremity ulceration/partial foot amputation) enrolled in an ongoing prospective longitudinal activity study. Subjects used a high-capacity continuous computerized activity monitor. Data were collected continuously over a minimum of 25 weeks (or until ulceration) with daily activity units expressed as means ± SD.

RESULTS—Eight subjects ulcerated during the evaluation period of 37.1 ± 12.3 weeks. The average daily activity was significantly lower in individuals who ulcerated compared with individuals who did not ulcerate (809.0 ± 612.2 vs. 1,394.5 ± 868.5, P = 0.03). Furthermore, there was a large difference in variability between groups. The coefficient of variation was significantly greater in the ulceration group compared with the no ulceration group (96.4 ± 50.3 vs. 44.7 ± 15.4%, P = 0.0001). In the 2 weeks preceding the ulcerative event, the coefficient of variation increased even further (115.4 ± 43.0%, P = 0.02), but there was no significant difference in average daily activity during that period (P = 0.5).

CONCLUSIONS—The results of this study suggest that individuals with diabetes who develop ulceration may actually have a lower overall activity than their counterparts with no ulceration, but the quality of that activity may be more variable. Perhaps modulating the "peaks and valleys" of activity in this population through some form of feedback might prove to reduce risk for ulceration in this very-high-risk population.

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