Prevalence of the Appearance of Diabetic Ulcers in Patients With 3D Insole and LSCI.

Diabetes is a serious and chronic disease that affects more than 347 million people in the world. It is the leading cause of death by age and its prevalence is increasing annually throughout the world. Diabetes is a disorder that manifests itself with elevated blood glucose levels that may be the resultof a deficiency in insulin secretion or action, or a combination of both problems.

The "Diabetic foot" includes a number of syndromes in which the interaction of the loss of protective sensation by the presence of sensory neuropathy, the change in pressure points due to motor neuropathy, autonomic dysfunction and decreased Blood flow due to peripheral vascular disease can lead to the appearance of injuries or ulcers induced by minor traumas that go "unnoticed." This situation leads to significant morbidity and a high risk of amputation. It can be prevented with the application of prevention programs, based on the early detection of neuropathy, assessment of associated risk factors, along with the application of a structured program of education and treatment of risk factors.

PRIMARY OBJECTIVES: 1- Comparison of ulceration rates, decrease in amputation rates in the target population with intervention: LSCI, thermography and creation of personalized insoles versus the control group with assessment, treatment and follow-up, without the intervention of interest in the study. 2- Correlation between changes in perfusion and temperature detected in combination of LSCI and thermography to predict diabetic foot ulcers and the risk of having ulcers. Study Model: Parallel Assignment 1:1 . Patients with inclusion criteria and without exclusion criteria will be randomized into two groups with Randomization with sequence concealment, centralized in computer support. OxMaR (Oxford Minimization and Randomization) After signing the informed consent, the patients will be divided into two groups. Number of Arms 2 Masking: None (Open Label) A-GROUP WITH LSCI, 3D FOOT CREATOR FOLLOW UP B- GROUP WITHOUT LSCI, 3D FOOT CREATOR FOLLOW UP.

Regardless of the type of diabetes, failure to achieve optimal glycemic control over time can cause damage to large and small blood vessels, as well as nerves. This damage can affect the function of many body organs and interfere with wound healing. Diabetes is the leading cause of coronary artery disease, and the leading cause of new cases of blindness and kidney disease.

The incidence of foot ulcers in people with diabetes was 2.2% per year, and that having a history of foot ulcers or amputations was strongly associated with the risk of developing foot ulcers in the future.

Prevention of such traumatic events, along with early detection and treatment of foot problems, can reduce the incidence of foot ulceration and amputation. This can be achieved through a risk assessment program, self-care education, and regular reinforcement of that education. Diabetes not only affects the health of individuals but also their families, as well as represents a burden on society.

Research in recent years establishes that reducing contact pressure effectively reduces the incidence of diabetic foot ulcers. In various current scientific studies, methods have been proposed to optimize the distribution of stresses in the contact surfaces between the foot and the template by applying functional gradient structural properties.

Increased skin temperature of the feet is considered to be associated with diabetic peripheral neuropathy, while its decrease is related to the presence of arterial alterations in the foot.

Therefore, there is a higher temperature in the feet of subjects with diabetic peripheral neuropathy, since in diabetic peripheral neuropathy there is an increase in blood flow at the level of the microcirculation. This fact is justified because more heat is dissipated by vasodilation of the arteriovenous shunts, which depend on the control of the sympathetic nerve, causing alterations in thermoregulation. This increase in temperature occurs both on the plantar face and on the dorsal face of the foot, but it is on the back where the temperature increases the most due to the presence of arteriovenous shunts.

When contrasting the data of some publications on this fact, it can be seen how the temperature of the feet of the subjects with Diabetes Mellitus control (without the presence of diabetic peripheral neuropathy) is lower than the temperature of the subjects with Diabetes Mellitus who do present peripheral neuropathy diabetic.

The increase in local temperature is due to the inflammation itself and to the enzymatic autolysis of the tissues, prior to the appearance of an ulceration. An increase in temperature also occurs in subjects with inflammatory processes typical of Charcot arthropathy. The absolute temperatura values of the feet are not considered the best indicators by themselves, since factors such as age, gender or the presence of arteriopathies influence. However, the differences in temperatura between the same point on both feet are relevant, as they are significant at the clinical level.

Specifically, a difference of 2.2º C between the same point on both feet implies a significant/high risk of injury and/or imminent inflammation. The temperature rise may be present for up to a week before an ulcer occurs. If a temperature difference greater than 2.2 ºC is detected but there is no wound/dermal lesion at that point, acute Charcot arthropathy should be considered.

Furthermore, temperature differences correlate with radiological changes and with markers of bone remodeling. The rise in temperature is usually too subtle to be detected manually, so it is measured.

Currently, three temperature measurement systems are used, which are applied through two types of techniques: thermography and thermometry. Thermography tests are classified into infrared and thermosensitive liquid crystal overlays. Thermometry tests are divided into infrared and termal sensors.

Why assess the temperature of the feet in Diabetes Mellitus? Diabetic ulcers generate a high economic cost, a high personal burden and carry an important social significance, both the process in which the injury is present and after the amputation suffered after a disastrous evolution of it.

However, its prevention is simple, economical and based on scientific evidence that supports it.

Prevention has a great impact since 75% of plantar ulcers can be prevented. Despite this, for every euro spent on prevention of plantar ulcers due to Diabetes Mellitus, 10 euros are used to cure them. One thing to keep in mind is that after the appearance of the first plantar ulcer in a patient with Diabetes Mellitus, the risk of recurrence is between 30-87% due to NPD. The arguments that justify the inclusion of thermal assessment in the neurological examination protocols of the feet of subjects with Diabetes Mellitus are the following: 1. First of all, the investigators must consider that the prevention of Diabetic Foot, it is currently based on exploration using two qualitative sensory tests with the Semmens-Weinstein 5.07 monofilament and the Rydel-Scheiffer 128 Hz graduated tuning fork, self-inspection by the patient and pulse palpation, not being the exploration of the temperature included. Effectiveness of preventive interventions for the appearance of ulcers in Diabetes Mellitus, being more effective the measurement of the temperature of the skin of the feet (once a day), advice and preventive footwear. These authors reinforce the suggestion of including temperatura measurement due to the short time of application in the exploratory screening with respect to preventive footwear. The importance of the heat resistance of the sole materials of footwear in subjects with Diabetes Mellitus is relevant since thermal perception is altered in them, and it must be taken into account that a temperature greater than 44º C generates a burn in the skin, with a temperature of 55º C, the burn occurs in 20 seconds and while, if the temperature is greater tan 60º C, only 3 seconds are needed for the burn to develop. Self-monitoring of temperatura (assessment of the same point in 2 feet) decreases the rate of appearance of ulcers.

There is a temperature interval, a difference of 2.2ºC between the two feet, which is used to control the appearance of lesions typical of Diabetic Foot. This interval, as a diagnostic test for infection, has a specificity of 25% and a sensitivity of 80% 40. With a temperature difference range of 1.35ºC, it is considered that urgent action is necessary28. Another argument is that the evaluation of the temperature of the feet is an effective and non-invasive technique. Its applicability is viable. Thermography is useful in detecting plantar ulcers with osteomyelitis. At a practical level, temperature control is an effective parameter to control bone consolidation and the evolutionary process of Charcot's disease, allowing a safe removal of immobilization.

The tendency to evaluate this parameter may be instruments with automatic storage of the processed data, with immediate obtaining of the calculation of the temperature differences The conclusions of this work are the following:

1. A difference of 2.2ºC at the same point on both feet of a subject indicates the appearance of lesions typical of Diabetic Foot, either ulceration if there is a lesion, or Charcot arthropathy.
2. The measurement of the temperature of the feet can be done by thermography and thermometry.
3. Scientific evidence indicates that controlling the temperature of the feet decreases the rate of ulcerations in Diabetes Mellitus.
4. The investigators advocate the inclusion of thermal assessment in the exploration protocol of subjects with Diabetes Mellitus, due to its effectiveness in preventing ulcerations as well as its short screening time.

Level of evidence related to the mechanism of action of the intervention in the planned clinical study population Diabetic foot ulcers (DFU) are a frequent complication, produced by sensory neuropathy and mechanical stress, it has been shown that the maximum plantar pressure (PPM) and the máximum pressure gradient (PPG) during walking are determining factors of these ulcers. In the clinical trial by Fernando ME et al., conducted in Australia, they evaluated plantar pressures in patients with active DFUs compared with patients with diabetes without a history of DFUs (diabetes controls) and people without diabetes (healthy controls), compared to those with 16 cases and 63 controls underwent plantar pressure measurement using an in-shoe pressure measurement software called Footscan® (F-scan), the cases had higher PPM in several sites: in the hallux, metatarsals and region midfoot compared to controls at follow-up. Plantar pressures assessed during walking were higher in patients with diabetes with UPD chronic than controls at various plantar sites, therefore offloading (relieving pressure) is necessary in patients with DFUs to facilitate healing.

Eligibility Criteria:
Inclusion Criteria:

1. The sample will include all the people who sign the informed consent.
2. Patients aged between 18 and 80 years.
3. Patients diagnosed with Diabetes Mellitus (more than 5 years from diagnosis), from the Department of Health Elche Hospital General.
4. Patients with Risk Level 2 and 3 according to the International Working Group on the Diabetic Foot - IWGDF.

Exclusion Criteria:

1. People who do not give their consent to participate in the study.
2. Patients who have previously had treatment with plantar orthoses or personalice insole.