Nicolaas C Schaper

Maastricht University, Maestricht, Limburg, Netherlands

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Publications (168)577.37 Total impact

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    ABSTRACT: Diabetic polyneuropathy (DPN) is a common co morbidity in diabetic patients. It has been associated with diminished muscle strength, impaired mobility and decreased quality of life (QoL). The purpose of this study was to evaluate the acute and long term effect of a moderate intensive intervention on muscle strength, mobility and QoL in patients with DPN.
    11/2015; 9(3):126-127. DOI:10.1007/s12467-011-0077-5
  • 11/2015; 11(4):163-164. DOI:10.1007/s12467-013-0109-4
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    ABSTRACT: A previous study by Savelberg et al. indicated higher plantar flexion moments at 40% of the stance phase and simultaneously an increase in plantar loading in people with diabetic polyneuropathy. It was hypothesised that muscle weakness in the lower extremity caused by polyneuropathy can affect the ability to generate enough momentum during the first part of the stance phase to counter the forward momentum of the body and the roll off of the foot. This could lead to a faster forward transfer of the centre of pressure of the foot (COP) and consequently a higher forefoot loading. The current study sought to test this hypothetical cascade.
    11/2015; 9(3):127-128. DOI:10.1007/s12467-011-0079-3
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    ABSTRACT: Patiënten met diabetes mellitus hebben vaak klachten van het maag-darmkanaal, zoals misselijkheid, buikpijn en diarree. Eerdere studies toonden aan dat tot 75% van de patiënten met diabetes mellitus gastro-intestinale klachten kunnen hebben.
    07/2015; 10(2):66-67. DOI:10.1007/s12467-012-0024-0
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    ABSTRACT: Over the past decade, the National Action program Diabetes (NAD) was implemented in the Netherlands. Its aim was to introduce the Care Standard (CS) for diabetes by means of a specific implementation plan and piloting in several regions. This study aimed to provide insight into the implementation of the NAD as, coupled with the introduction of the CS, it may function as an example for similar approaches in other countries. A series of quantitative studies (participants 2010: N = 1726, participants 2013: N = 1370 & participants pilot regions 2013: N = 168) and qualitative studies (participants 2010: N = 18 and participants 2013: N = 4) was conducted among health care professionals (HCPs). In addition, two quantitative studies were conducted among type 1 and 2 patients (participants 2010: N = 573; participants 2013: N = 5056). Overall, positive changes in diabetes care were detected in the period 2010 - 2013. In 2013 significantly more HCPs were familiar with the CS (43.7 versus 37.6 %) and more HCPs perceived themselves to be working largely or completely in accordance with the CS (89.2 versus 79.0 %) than in 2010. A comparison of the results in specific pilot regions with the rest of the country revealed that HCPs in these regions scored significantly more positively on implementation and appreciation of the CS. This positive trend was reflected by the high levels of reported patient satisfaction and involvement in treatment. HCPs who were in possession of the CS had significantly better scores on the implementation of several elements of the CS than HCPs who were not in possession of the CS. The CS has become more prominent and embedded in daily health care practice. In retrospect the CS has provided momentum for the realization of various processes relating to the wider implementation of standards to improve the care for people with other chronic diseases in the Netherlands. Experiences with the NAD and CS underline the need to move towards an integrated multidisciplinary approach of diabetes care worldwide.
    BMC Health Services Research 06/2015; 15(1). DOI:10.1186/s12913-015-0883-3 · 1.66 Impact Factor
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    ABSTRACT: Hypertension and diabetes are both risk factors for cognitive decline, and individuals with both might have an especially high risk. We therefore examined linear and nonlinear (quadratic) associations of 24-h blood pressure (BP) with cognitive performance in participants with and without type 2 diabetes. We also tested the association of nocturnal dipping status with cognitive performance. This study was performed as part of the Maastricht Study, an ongoing population-based cohort study. Cross-sectional associations of 24-h BP (n = 713, of whom 201 had type 2 diabetes) and nocturnal dipping status (n = 686, of whom 196 had type 2 diabetes) with performance on tests for global cognitive functioning, information processing speed, verbal memory (immediate and delayed word recall), and response inhibition were tested using linear regression analysis and adjusted for demographics, vascular risk factors, cardiovascular disease, depression, and lipid-modifying and antihypertensive medication use. After full adjustment, we found quadratic (inverted U-shaped) associations of 24-h diastolic blood pressure (DBP) with information processing speed (b for quadratic term = -0.0267, P < 0.01) and memory (immediate word recall: b = -0.0180, P < 0.05; delayed word recall: b = -0.0076, P < 0.01) in participants with diabetes, but not in those without. No clear pattern was found for dipping status. This study shows that both low and high 24-h DBP are associated with poorer performance on tests of information processing speed and memory in individuals with type 2 diabetes. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
    Diabetes Care 05/2015; DOI:10.2337/dc14-2502 · 8.57 Impact Factor
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    ABSTRACT: The impact of physical inactivity and unhealthy diet on health is increasingly profound. Lifestyle interventions targeting both behaviors simultaneously might decrease the prevalence of overweight and comorbidities. The Dutch 'BeweegKuur' is a combined lifestyle intervention (CLI) in primary care, to improve physical activity and dietary behavior in overweight people. In a cluster randomized controlled trial, the (cost-) effectiveness of an intensively guided program has been compared to a less intensively guided program. This process evaluation aimed to assess protocol adherence and potential differences between clusters. In addition, sustainability (i.e. continuation of the CLI in practice after study termination) was evaluated. Existing frameworks were combined to design the process evaluation for our intervention and setting specifically. We assessed reach, fidelity, dose delivered and received, context and implementation strategy. Both qualitative and quantitative data were used for a comprehensive evaluation. Data were collected in semi-structured interviews with health care providers (HCPs, n = 25), drop-out registration by HCPs, regular questionnaires among participants (n = 411) and logbooks kept by researchers during the trial. Protocol adherence by professionals and participants varied between the programs and clusters. In both programs the number of meetings with all HCPs was lower than planned in the protocol. Participants of the supervised program attended, compared to participants of the start-up program, more meetings with physiotherapists, but fewer with lifestyle advisors and dieticians. The 'BeweegKuur' was not sustained, but intervention aspects, networks and experiences were still utilized after finalization of the project. Whether clusters continued to offer a CLI seemed dependent on funding opportunities and collaborations. Protocol adherence in a CLI was problematic in both HCPs and participants. Mainly the amount of dietary guidance was lower than planned, and decreased with increasing guidance by PT. Thus, feasibility of changing physical activity and dietary habits simultaneously by one intervention in one year was not as high as expected. Also the sustainability of CLI was poor. When a CLI program is started, re-invention should be allowed and maximum effort should be taken to guarantee long term continuation, by planning both implementation and sustainability carefully. Current Controlled Trials ISRCTN46574304 . Registered 23 December 2010.
    BMC Family Practice 03/2015; 16(37). DOI:10.1186/s12875-015-0254-5 · 1.74 Impact Factor
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    ABSTRACT: Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Diabetic Medicine 03/2015; 32(6). DOI:10.1111/dme.12749 · 3.06 Impact Factor
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    ABSTRACT: This cross-sectional study is one of the first to examine and compare the independent associations of objectively measured sedentary time, moderate to vigorous physical activity (MVPA) and fitness with cardio-metabolic risk factors. We studied 543 men and women (aged 18-49 years) from the NHANES 2003-2004 survey. Sedentary time and MVPA were measured by accelerometry. Fitness was assessed with a submaximal treadmill test. Cardio-metabolic risk factors included: waist circumference (WC), BMI, blood pressure, fasting glucose, HDL- and non HDL cholesterol, triglycerides (TG), and C-reactive protein (CRP). Sedentary time, MVPA and fitness were used as predictors for the cardio-metabolic outcomes in a multiple regression analysis. Standardized regression coefficients were computed. Results show that sedentary time was associated with HDL-cholesterol (β = -0.080, p = 0.05) and TG (β = 0.080, p = 0.03). These results became non-significant after adjustment for MVPA and fitness. MVPA was associated with WC (β = -0.226), BMI (β = -0.239), TG (β = -0.108) and HDL-cholesterol (β = 0.144) (all p < 0.05). These results remained significant after adjustment for sedentary time and fitness. Fitness was associated with WC (β = -0.287), BMI (β = -0.266), systolic blood pressure (β = -0.159), TG (β = -0.092), and CRP (β = -0.130) (all p < 0.05). After adjustment for sedentary time and MVPA these results remained significant. These differences in relative importance of sedentary time, MVPA and fitness on cardio-metabolic-risk are important in the design of prevention programs. In this population, the strength of the associations between MVPA and fitness with cardio-metabolic markers appeared to be similar; both MVPA and fitness showed independent associations with cardio-metabolic risk factors. In contrast, sedentary time showed no independent associations with cardio-metabolic risk after correction for fitness and MVPA.
    International Journal of Environmental Research and Public Health 03/2015; 12(3):2330-2343. DOI:10.3390/ijerph120302330 · 2.06 Impact Factor
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    ABSTRACT: Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation. We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries. Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probing to bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively). For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
    Diabetes Care 02/2015; 38(5). DOI:10.2337/dc14-1598 · 8.57 Impact Factor
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    ABSTRACT: Objective: Microvascular dysfunction has been suggested as a possible underlying mechanism for the association between uric acid and various diseases, such as hypertension, renal disease and cardiomyopathies. We therefore analysed the association between serum uric acid and skin microvascular function, a model of generalized microvascular function. Methods: A cross-sectional study was performed in 610 individuals [51.8% men; mean age 58.7 +/- 8.6 years; 23.6% with type 2 diabetes (by design)] from The Maastricht Study. We assessed skin capillary density (capillaries/mm2) by capillaroscopy at baseline, after 4 min of arterial occlusion, and after 2 min of venous congestion. Capillary recruitment after arterial occlusion and during venous congestion was expressed as the absolute change in capillary density after recruitment and as the percentage change in capillary density from baseline. Results: Crude linear regression analyses showed that serum uric acid [per +1 standard deviation (SD) of 74 [mu]mol/l] was not associated with baseline capillary density [[beta] = -0.21 (95% confidence interval, 95% CI -1.61 to 1.19) P = 0.765], while an inverse association was found between uric acid and absolute change in capillary density after arterial occlusion [[beta] = -1.15 (95% CI -2.36 to 0.06) P = 0.062] and during venous congestion [[beta] = -1.41 (95% CI -2.68 to -0.14) P = 0.029]. However, after adjustment for sex, age and glucose metabolism status, these associations were no longer statistically significant. In addition, we found no association between uric acid and percentage capillary recruitment after arterial occlusion [[beta] = -1.66 (95% CI -3.97 to 0.65) P = 0.159] or during venous congestion [[beta] = -2.02 (95% CI -4.46 to 0.42) P = 0.104] in unadjusted analyses; multivariable analyses gave similar results. Conclusion: These results do not support the hypothesis that generalized microvascular dysfunction (as estimated in skin microcirculation) is the underlying mechanism for the association between uric acid and cardiovascular and renal diseases. The possibility that uric acid is associated with microvascular dysfunction in specific end-organs, for example heart or kidney, needs further investigation.
    Journal of Hypertension 01/2015; DOI:10.1097/HJH.0000000000000583 · 4.22 Impact Factor
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    ABSTRACT: It has been hypothesized that arterial stiffness leads to generalized microvascular dysfunction and that individuals with type 2 diabetes mellitus (T2DM) are particularly prone to the detrimental effects of arterial stiffness. However, evidence for an association between stiffness and markers of generalized microvascular dysfunction is lacking. We therefore investigated the association between arterial stiffness and skin microvascular function in individuals without and with T2DM. Cross-sectional data were used of The Supplementation en Vitamines et Mineraux Antioxydants 2 (SUVIMAX2) Study (n = 284/62.2 years/48.6% women/0% T2DM (by design)) and The Maastricht Study (n = 737/59.7 years/45.2% women/28.8% T2DM (by design)). Arterial stiffness was determined by carotid-femoral pulse wave velocity (cfPWV). Skin capillaroscopy was used to determine capillary density at baseline, and during reactive hyperemia and venous congestion. Laser Doppler flowmetry was used to assess acetylcholine- and local heating-induced vasoreactivity, and skin flowmotion. In The SUVIMAX2 Study, cfPWV (per +1 SD) was not associated with baseline capillary density (regression coefficient: -0.48 (95% confidence interval: 2.37; 1.41)) or capillary recruitment during venous congestion (0.54% (-0.74; 1.81%)). In addition, cfPWV was not associated with acetylcholine (-0.02% (-0.14; 0.10%)) or local heating-induced vasoreactivity (0.03% (-0.07; 0.12%)). In The Maastricht Study, in individuals without T2DM, cfPWV was not associated with baseline capillary density (-1.20 (-3.17; 0.77)), and capillary recruitment during reactive hyperemia (1.22% (-0.41; 2.84%)) or venous congestion (1.50% (-0.25; 3.25%)). In addition, cfPWV was not associated with flowmotion (-0.01 (-0.07; 0.06)). Results were adjusted for age and sex. Additional adjustments for confounders did not materially change these results. Results were qualitatively similar in individuals with T2DM. Arterial stiffness is not associated with skin microvascular function, irrespective of the presence of T2DM. © American Journal of Hypertension, Ltd 2014. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
    American Journal of Hypertension 12/2014; DOI:10.1093/ajh/hpu246 · 3.40 Impact Factor
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    ABSTRACT: A valid non-wear algorithm for activity monitors is crucial to avoid the misclassification of sedentary time as non-wear time, and vice versa. Characteristics of the algorithm, such as time windows, should be well defined and tested. Furthermore, using tri-axial data might influence the algorithm's performance. This study assessed the optimal time window length in a non-wear algorithm for overweight adults, applied to tri-axial data from sixteen participants. Ten time windows, from 10 up to 120 min, were tested with a diary as a criterion measure. We assessed the bias in non-wear time, sensitivity and specificity. The optimal time window length was based on ten participants; the validation of this time window was carried out with six other participants. The time window of 20 min showed the highest and 120 min showed the lowest mean amount of correctly classified non-wear time, at 94% and 70% respectively. Sensitivity and specificity were considered optimal in the 20 min time window. Validation of this time window demonstrated a sensitivity and specificity of 86% and 83% respectively. A 20 min time window showed the best non-wear estimations. The current study utilized tri-axial raw data and 1 s epoch data which might have facilitated the application of a short time window and thereby decreased the risk of misclassifying non-wear.
    Physiological Measurement 10/2014; 35(11):2205. DOI:10.1088/0967-3334/35/11/2205 · 1.62 Impact Factor
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    ABSTRACT: OBJECTIVE Painful diabetic peripheral neuropathy (PDPN) is a common complication of diabetes mellitus. Unfortunately, pharmacological treatment is often partially effective or accompanied by unacceptable side effects, and new treatments are urgently needed. Small observational studies suggested that spinal cord stimulation (SCS) may have positive effects. RESEARCH DESIGN AND METHODS We performed a multicenter randomized clinical trial in 36 PDPN patients with severe lower limb pain not responding to conventional therapy. Twenty-two patients were randomly assigned to SCS in combination with the best medical treatment (BMT) (SCS group) and 14 to BMT only (BMT group). The SCS system was implanted only if trial stimulation was successful. Treatment success was defined as >= 50% pain relief during daytime or nighttime or "(very) much improved" for pain and sleep on the patient global impression of change (PGIC) scale at 6 months. RESULTS Trial stimulation was successful in 77% of the SCS patients. Treatment success was observed in 59% of the SCS and in 7% of the BMT patients (P < 0.01). Pain relief during daytime and during nighttime was reported by 41 and 36% in the SCS group and 0 and 7% in the BMT group, respectively (P < 0.05). Pain and sleep were "(very) much improved" in 55 and 36% in the SCS group, whereas no changes were seen in the BMT group, respectively (P < 0.001 and P < 0.05). One SCS patient died because of a subdural hematoma. CONCLUSIONS Treatment success was shown in 59% of patients with PDPN who were treated with SCS over a 6-month period, although this treatment is not without risks.
    Diabetes Care 09/2014; 37(11). DOI:10.2337/dc14-0684 · 8.57 Impact Factor
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    ABSTRACT: http://www.biomedcentral.com/1471-2458/14/749/abstract (highly accessed) Health is associated with amount of daily physical activity. Recently, the identification of sedentary time as an independent factor, has gained interest. A valid and easy to use activity monitor is needed to objectively investigate the relationship between physical activity, sedentary time and health. We compared validity and reproducibility of physical activity measurement and posture identification of three activity monitors, as well as user friendliness.
    BMC Public Health 07/2014; 14(1):749. DOI:10.1186/1471-2458-14-749 · 2.32 Impact Factor
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    ABSTRACT: The Maastricht Study is an extensive phenotyping study that focuses on the etiology of type 2 diabetes (T2DM), its classic complications, and its emerging comorbidities. The study uses state-of-the-art imaging techniques and extensive biobanking to determine health status in a population-based cohort of 10,000 individuals that is enriched with T2DM individuals. Enrollment started in November 2010 and is anticipated to last 5-7 years. The Maastricht Study is expected to become one of the most extensive phenotyping studies in both the general population and T2DM participants world-wide. The Maastricht study will specifically focus on possible mechanisms that may explain why T2DM accelerates the development and progression of classic complications, such as cardiovascular disease, retinopathy, neuropathy and nephropathy and of emerging comorbidities, such as cognitive decline, depression, and gastrointestinal, musculoskeletal and respiratory diseases. In addition, it will also examine the association of these variables with quality of life and use of health care resources. This paper describes the rationale, overall study design, recruitment strategy and methods of basic measurements, and gives an overview of all measurements that are performed within The Maastricht Study.
    European Journal of Epidemiology 04/2014; 29(6). DOI:10.1007/s10654-014-9889-0 · 5.15 Impact Factor
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    ABSTRACT: Objective: Homozygous carriers of the apolipoprotein ε2 allele are at risk of type III hyperlipidemia, but do not necessarily develop this lipid disorder. In this study we investigated the role of circulating proprotein convertase subtilisin kexin type 9 (PCSK9), an important regulator of LDL receptor expression, in the development of this hyperlipidemic phenotype. Methods: In an observational study, plasma PCSK9 was measured in homozygous carriers of apolipoprotein ε2 (ε2/ε2; n=12), normal controls (n=72) and hypertriglyceridemic patients with familial combined hyperlipidemia (FCHL; n=38), who served as a hyperlipidemic reference group. Cholesterol, triglycerides and apolipoprotein B content in VLDL and LDL particles was determined by ultracentrifugation in ε2/ε2 and FCHL patients. Results: Median circulating PCSK9 levels did not differ between ε2/ε2 versus controls and hypertriglyceridemic FCHL patients (84.5 versus 82.0 and 84.9 ng/ml; p=0.2 and 0.6, respectively). Circulating PCSK9 was associated with total cholesterol and triglycerides levels in ε2/ε2 carriers (p<0.05). These associations were stronger in ε2/ε2 carriers when compared to controls (p for interaction = 0.01 and 0.02, respectively). A direct comparison with FCHL patients demonstrated a similar discrepancy for the association with plasma triglycerides and also VLDL apolipoprotein B, cholesterol and triglycerides (p for interaction = 0.01, 0.01, 0.03 and 0.03, respectively). Conclusions: plasma PCSK9 is associated with type III hyperlipidemia. Its strong relation with plasma triglycerides and total cholesterol distinguishes ε2/ε2 from controls and another type of dyslipidemia, which provides valuable information regarding the pathogenesis of this complex dyslipidemia. Furthermore, these results suggest that patients with type III hyperlipidemia may benefit from PCSK9 antagonizing therapy.
    Clinical Science 12/2013; DOI:10.1042/CS20130556 · 5.63 Impact Factor
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    ABSTRACT: Objective Low health-related quality of life (HRQoL) has been consistently reported to be associated with poor prognosis for a variety of health outcomes in various settings. We aimed to evaluate whether HRQoL in patients presenting with new diabetic foot ulcers has prognostic significance for ulcer healing, major amputation and death.Research design and methodsWe followed 1088 patients with new diabetic foot ulcers presenting for treatment at one of the 14 centers in 10 European countries participating in the Eurodiale study, prospectively until healing (76.9%), major amputation (4.6%) or death (6.4%) up to a maximum of 1 year. At baseline, patient and ulcer characteristics were recorded as well as EQ-5D: a standardised instrument consisting of five domains and a VAS scale for use as a measure of HRQoL. The prognostic influence of the EQ-5D domains was evaluated in multivariable Cox regression analyses on the time-to-event data, adjusting for baseline clinical characteristics of the ulcer and co-morbidities.ResultsWhile predictive effects of HRQoL, adjusted for possible confounders, were absent for time to healing, decreased HRQoL especially in the physical domains were statistically significant for major amputation (Mobility, Self-Care, Usual Activities) and death (Self-care, Usual Activities, Pain/Discomfort).Conclusions Low HRQoL appears to be predictive for major amputation and death, but high HRQoL does not increase healing. Future studies into the influence of HRQoL on ulcer outcome are important in attempts to decrease treatment failure and mortality.
    Diabetes care 10/2013; 37(3). DOI:10.2337/dc13-1212 · 8.57 Impact Factor
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    ABSTRACT: Higher plantar pressures play an important role in the development of plantar foot ulceration in diabetic polyneuropathy and earlier studies suggest that higher pressures under the forefoot may be related to a decrease in lower leg muscle strength. Therefore, in this randomised controlled trial we evaluated whether lower-extremity strength training can reduce plantar pressures in diabetic polyneuropathy. This study was embedded in an unblinded randomised controlled trial. Participants had diabetes and polyneuropathy and were randomly assigned to the intervention group (n = 48) receiving strength training during 24 weeks, or the control group (n = 46) receiving no intervention. Plantar pressures were measured in both groups at 0, 12, 24 and 52 weeks. A random intercept model was applied to evaluate the effects of the intervention on peak pressures and pressure--time-integrals, displacement of center-of-pressure and the forefoot to rearfoot pressure--time-integral-ratio. Plantar pressure patterns were not affected by the strength training. In both the intervention and control groups the peak pressure and the pressure--time-integral under the forefoot increased by 55.7 kPa (95% CI: 14.7, 96.8) and 2.0 kPa.s (95% CI: 0.9, 3.2) over 52 weeks, respectively. Both groups experienced a high number of drop-outs, mainly due to deterioration of health status and lower-extremity disabilities. Plantar pressures under the forefoot increase progressively over time in people with diabetic polyneuropathy, but in this study were not affected by strength training. Future intervention studies should take this increase of plantar pressure into account and alternative interventions should be developed to reduce the progressive lower extremity problems in these patients.Trial registrationThis study was embedded in a clinical trial with trial number NCT00759265.
    Journal of Foot and Ankle Research 10/2013; 6(1):41. DOI:10.1186/1757-1146-6-41 · 1.83 Impact Factor

Publication Stats

3k Citations
577.37 Total Impact Points

Institutions

  • 1999–2015
    • Maastricht University
      • Department of Internal Medicine
      Maestricht, Limburg, Netherlands
  • 1992–2015
    • Maastricht Universitair Medisch Centrum
      • Central Diagnostic Laboratory
      Maestricht, Limburg, Netherlands
  • 2008
    • Malmö University
      Malmö, Skåne, Sweden
  • 2004
    • VU University Amsterdam
      Amsterdamo, North Holland, Netherlands
  • 1998
    • Academic Medical Center (AMC)
      Amsterdamo, North Holland, Netherlands
  • 1997
    • Radboud University Nijmegen
      Nymegen, Gelderland, Netherlands