cooperation throughout the treatment program, am putation of the insensitive foot because of chronic ulceration may become a dark memory from the medical past.
1. Harris RI, Beath T: Canadian Army Foot Survey. Toronto, Na tional Research Council of Canada, 1947
SELECTED BIBLIOGRAPHY 1. Brand PW: Insensitive Feet: A Practical Handbook on Foot Problems in Leprosy. London, The Leprosy Mission, 1977 2. Miner KM, Shipley DE, Enna CD: Rehabilitation of the paralytic drop foot in Hansen's disease. Phys Ther 55:378-381, 1975 3. Shipley D, Miner K: The role of physical therapy in foot problems. In McDowell F, Enna C (eds): Surgical Rehabilitation in Lep rosy. Baltimore, Williams & Wilkins Co, 1974, pp 301-313
Temperature Assessment of the Insensitive Foot HARRY T. BERGTHOLDT, MS
Temperature assessment has proven valuable in detecting areas of inflammation in the insensitive limb. Monitoring the inflammatory response to the stresses of footwear and walking has worked as a "pain substitute." In conjunction with other evaluation methods, the results of temperature assessment can be used to reduce the incidence of injury and ulceration in the insensitive foot. A review of principles and methods, a presentation of a case study, and a discussion will elaborate upon the concepts of temperature assess ment. Key Words: Decubitus ulcer, foot, inflammation, physical therapy.
Temperature assessment is an excellent method of early detection and monitoring of damage to the insensitive foot. In a limb with normal sensation, a gradual increase in inflammation is usually prevented by the individual immediately responding to pain by resting, evaluating the foot or shoe, or consulting with a physician. The person with an insensitive but func tional limb may continue to traumatize the inflamed tissue without being aware of the ensuing damage. Progressive injury of this nature frequently leads to ulceration. Therefore, evaluation measures are essen tial to anticipate excessive trauma and to monitor changes regularly, until inflammatory responses have subsided. Temperature assessment measures have been used with considerable success in accomplishing this goal.
Mr. Bergtholdt is Deputy Chief of the Physical Therapy Depart ment, US Public Health Service Hospital, Carville, LA 70721.
18
REVIEW
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
REFERENCES
2. Beach R: Measurement of extremity volume by water displace ment. Phys Ther 57:286-287, 1977
Recording an individual's core temperature has long been recognized by those in the medical profes sion as an important aspect of routine physiological monitoring. Core temperature, although not a diag nostic tool in itself, provides valid information when it is used in conjunction with other medical infor mation, just as temperature assessment of the insen sitive limb has become a most valuable procedure in prevention of ulceration when used in conjunction with other clinical data.1,2 Measuring skin temperature has been used for many years as an evaluative technique in peripheral vascular disease.3 Most recently, skin temperature measurement has received renewed interest as the field of infrared thermography has advanced. Ther mography has been found helpful in areas such as: screening breast cancer, studying carotid artery insuf ficiency, detecting deep vein thrombosis, and evalu-
PHYSICAL THERAPY
METHOD
Temperature can be assessed by several methods. An experienced clinician can usually detect differ ences of approximately 2°C by careful palpation. Thermisters* or thermocouples costing approximately $200 are accurate recording devices that, when touched to a specific skin area for 10 to 15 seconds, give a numerical display of the temperature. These instruments are valuable as well as practical in a physical therapy clinic. A radiometerf is an infrared emission detector that gives a visual display of skin temperature without touching the skin. Costing over $1,000, this unit is rapid and allows for an accurate spot temperature reading, but has a limited scanning capability. Infrared thermography,^: the most expen sive method, is quick and is an excellent tool to scan areas such as the plantar surface of the feet. The unit uses a gray-scale monitoring system to display the skin temperature. Warm areas are white and cool areas are progressively darker. The actual tempera ture of any area can be determined with an isotherm display system using a superimposed bright line on the display screen to determine temperatures of spe cific areas. The superimposed bright light can be adjusted to an area of interest and the temperature can be read from a scale at the bottom of the display system (Fig. 1). The surface temperature of skin varies greatly from one body location to another. The most distal aspects of the extremities are cool, and muscular areas with good blood supplies are warmer than bony regions. A thermogram (picture of thermal patterns) taken of the plantar surface of normal feet shows that the arches are several degrees Celsius warmer than the heels or toes (Fig. 2). Normal skin temperature of the feet is variable, depending on factors such as outside temperature, room temperature, and the emotional state of the individual. The body's thermal symmetry allows for comparison between various body parts. Meaningful information from skin temperature mea surements can be obtained by comparing the temper ature of an inflamed area to that of the contralateral
* TRI-R, J.A. Preston Corp, 71 Fifth Ave, New York, NY 10003. f Mikron Infrared Thermometer, Mikron Instrument Co, Inc, Midland Park, NJ 07432. $ AGA Thermovision, AGA Corp, Secaucus, NJ 07094.
Volume 59 / Number 1, January 1979
Fig. 1. Demonstration of the use of an isotherm display system. Thermogram of normal feet with superimposed dots of bright light indicating all areas that are 30° C, including a standard temperature source (circle between the feet kept at 30° C). Scale below feet indicates isotherm setting of 0.3, or 30° C.
site and measuring the temperature difference (AT). A AT greater than 1°C has been considered to be significant.7 Differences of up to 6 to 8°C are often seen on the feet when an injury or inflammation is present. Changes in the AT during a treatment regi men can provide an important guide to understanding the tissue response to the treatment. If the AT in creases, the area is probably receiving more stress than is tolerable, but if the AT decreases, the treat ment regimen is probably satisfactory. Controlled conditions are necessary for tempera ture assessment. A cool room (22-23 °C) is required, and the parts to be examined must be exposed and allowed to equilibrate with the room temperature for a minimum of 10 minutes. When shoes, socks, and dressings are first removed, the feet are warm. After several minutes of exposure to a cool room the normal tissues cool, leaving the inflamed areas warm and creating a difference in temperature between the dam aged area and its contralateral site. Repeated studies should always follow the same format. When moni toring the temperature of feet, it is best to perform the temperature assessment at the same time each day, preferably early in the morning. Our experience has shown that significantly warm areas following a day of stress will continue to be warm after a night's rest. Temperature assessment immediately following a stressful activity may be of value; however, the assessment following a night's rest has proven more 19
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
ating low back diseases.4 Sandrow and associates found thermography to be useful in early diagnosis of neuropathic arthropathy in the feet of diabetics.5 Goller and co-workers found a positive correlation between temperature variation and static pressure on several areas of the human body.6
CASE STUDY
valuable. The principles and methods of temperature assessment have been well documented elsewhere.8 The following case study will demonstrate several useful applications of temperature assessment in con junction with other insensitive limb management methods. These techniques and advantages of tem perature assessment have been reported previously.1'2
Fig. 3. Photograph of medial aspect of feet. Note asymmetry of instep of patient's right foot, corresponding to fractured metatarsal bones.
20
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
Fig. 2. Thermogram of normal feet. White denotes warmth, black denotes coolness, gray denotes in-between temperatures.
A fifty-year-old man with Hansen's disease had normal motor function but had surface anesthesia of both feet. After one of his regular jogging episodes, he felt mild discomfort deep in his right foot and decided to stop jogging. Several days later the discom fort ceased. Six months later, when he returned to the hospital for routine follow-up care, a bony prominence on the plantar surface of the right foot was noticed during examination of his feet (Fig. 3). A roentgenogram showed five metatarsal bone fractures of the right foot (Fig. 4). A thermogram of the plantar surface of the feet showed the right forefoot was 5°C warmer than the left, with the warmest area having a temper ature of 34°C, or 93.2°F (Fig. 5). The patient was shown the thermogram, and the significance of the increased heat was explained to him. Treatment of choice at that time consisted of modified shoes de signed to reduce the pressures on the metatarsal bones during ambulation. Approximately two months after the first visit (eight months following the injury), the patient re turned to the hospital. A thermogram at that time demonstrated a great improvement in the thermal pattern (Fig. 6). The temperature had returned to near normal, with a AT of less than 1°C and a temperature of 32°C (89.6°F) over the base of the fourth metatarsal bone. Roentgenograms showed cal lus formation. Proper care of the deformed foot was explained to the patient again. Objective evidence of improvement in the bone structure was explained to the patient, using the roentgenograms and the im proved thermogram. The importance of continued
PHYSICAL THERAPY
use of modified shoes was clearly explained to the patient. Five months later, the patient returned to the hos pital with a pin-hole-sized ulcer under the fourth metatarsal head. The area had a temperature of 36.0°C (96.8°F) and a AT of 7.0°C. The patient confessed he had not been wearing his modified shoes regularly. The ulcer healed in three weeks, while the patient walked minimally and in his modified shoes.
Fig. 5. Thermogram of plantar surface of feet six months following injury and no treatment.
Volume 59 / Number 1, January 1979
Temperature assessment at regular intervals during his hospital stay was used to evaluate the healing progress of the ulcer and especially to monitor the effects of the patient's increased activity after the ulcer healed. A thermogram taken six weeks after readmission demonstrated near-normal (temperature 32.5°C, 90.5°F, AT 1.0°C) tissue response to the stresses of walking in the modified shoes (Fig. 7). Reviewing with the patient the improvement in the
Fig. 6. Thermogram of plantar surface of feet eight months following injury and two months of treatment.
21
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Fig. 4. Roentgenograms of right foot: 4-16-74, prior to injury; 5-30-75, six months following in jury; 7-28-75, eight months following injury.
temperatures during this six-week period was an ex cellent tool in educating him. DISCUSSION
Routine evaluation of footwear for the insensitive foot has been instrumental in decreasing the incidence of ulceration; however, shoe evaluation is only one
REFERENCES
1. Bergtholdt HT, Brand PW: Temperature assessment and plantar inflammation. Lepr Rev, 47:211-219, 1976 2. Bergtholdt HT, Brand PW: Thermography: An aid in the man agement of insensitive feet and stumps. Arch Phys Med Rehabil 56:205-209, 1975 3. Winsor T: Peripheral Vascular Disease: An Objective Approach. Springfield, IL, Charles C Thomas, Publisher, 1959 4. Uematsu S (ed): Medical Thermography, Theory and Clinical Applications. Los Angeles, Brentwood Publishing Co, 1976
22
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
Fig. 7. Thermogram of plantar surface of the feet following six weeks of conservative treatment for plantar ulcer.
part of the total evaluation. No two people are exactly the same, and certainly not everyone has the same activity level. An excellent shoe modification with no subsequent ulceration on the feet of a sedentary in dividual is likely to be inadequate for an active individual. An active person is likely to receive several thousand more repetitions of a very low level of stress than will a sedentary person, which will damage the soft tissue, result in inflammation, and possibly lead to ulceration after repeated stress. Temperature as sessment may be used to monitor the reaction of tissues to footwear and also the level of repetitive stress. This is especially important in early ambula tion, when the tissues are fragile. The amount of stress on the feet must be increased gradually as tissue tolerance increases. Temperature assessment is valuable in a scheduled program to demonstrate changes in the temperature pattern. Often, increased activity by the patient or illfitting footwear can be detected by an increase in temperature. Appropriate measures can then be taken to prevent ulceration of the foot. The return to a normal temperature pattern assures the clinician and the patient that the modification was appropriate. Although temperature assessment has proven a valuable evaluative technique to aid the clinician in preventing ulcers on insensitive feet, its greatest value is in teaching the patient the importance of early injury recognition and of faithfully practicing daily self-care. Abnormal temperatures give him objective evidence of damage or potential damage. The patient quickly learns to appreciate the beneficial and harm ful changes in temperature and begins to take an active role in the prevention of his own ulcers. The patient's participatory role has proved to be a vital requirement in the care of insensitive feet.
5. Sandrow RE, Torg JS, Lapayowker MS, et al: Use of thermo graphy in early diagnosis of neuropathic arthropathy in feet of diabetics. Clin Orthop 88:31-33, 1972 6. Goller H, Lewis DW, McLaughlin RE: Thermographic studies of human skin subjected to localized pressure. Am J Roentgenol Radium Ther Nucl Med 113:749-754, 1971 7. Ryan J: Thermography. Australas Radiol 13:23-36, 1969 8. Gershon-Cohen J, Barnes RB: Thermography and its clinical applications. Ann NY Acad Sci 121:1-304, 1964
PHYSICAL THERAPY
1. Harris RI, Beath T: Canadian Army Foot Survey. Toronto, Na tional Research Council of Canada, 1947
SELECTED BIBLIOGRAPHY 1. Brand PW: Insensitive Feet: A Practical Handbook on Foot Problems in Leprosy. London, The Leprosy Mission, 1977 2. Miner KM, Shipley DE, Enna CD: Rehabilitation of the paralytic drop foot in Hansen's disease. Phys Ther 55:378-381, 1975 3. Shipley D, Miner K: The role of physical therapy in foot problems. In McDowell F, Enna C (eds): Surgical Rehabilitation in Lep rosy. Baltimore, Williams & Wilkins Co, 1974, pp 301-313
Temperature Assessment of the Insensitive Foot HARRY T. BERGTHOLDT, MS
Temperature assessment has proven valuable in detecting areas of inflammation in the insensitive limb. Monitoring the inflammatory response to the stresses of footwear and walking has worked as a "pain substitute." In conjunction with other evaluation methods, the results of temperature assessment can be used to reduce the incidence of injury and ulceration in the insensitive foot. A review of principles and methods, a presentation of a case study, and a discussion will elaborate upon the concepts of temperature assess ment. Key Words: Decubitus ulcer, foot, inflammation, physical therapy.
Temperature assessment is an excellent method of early detection and monitoring of damage to the insensitive foot. In a limb with normal sensation, a gradual increase in inflammation is usually prevented by the individual immediately responding to pain by resting, evaluating the foot or shoe, or consulting with a physician. The person with an insensitive but func tional limb may continue to traumatize the inflamed tissue without being aware of the ensuing damage. Progressive injury of this nature frequently leads to ulceration. Therefore, evaluation measures are essen tial to anticipate excessive trauma and to monitor changes regularly, until inflammatory responses have subsided. Temperature assessment measures have been used with considerable success in accomplishing this goal.
Mr. Bergtholdt is Deputy Chief of the Physical Therapy Depart ment, US Public Health Service Hospital, Carville, LA 70721.
18
REVIEW
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
REFERENCES
2. Beach R: Measurement of extremity volume by water displace ment. Phys Ther 57:286-287, 1977
Recording an individual's core temperature has long been recognized by those in the medical profes sion as an important aspect of routine physiological monitoring. Core temperature, although not a diag nostic tool in itself, provides valid information when it is used in conjunction with other medical infor mation, just as temperature assessment of the insen sitive limb has become a most valuable procedure in prevention of ulceration when used in conjunction with other clinical data.1,2 Measuring skin temperature has been used for many years as an evaluative technique in peripheral vascular disease.3 Most recently, skin temperature measurement has received renewed interest as the field of infrared thermography has advanced. Ther mography has been found helpful in areas such as: screening breast cancer, studying carotid artery insuf ficiency, detecting deep vein thrombosis, and evalu-
PHYSICAL THERAPY
METHOD
Temperature can be assessed by several methods. An experienced clinician can usually detect differ ences of approximately 2°C by careful palpation. Thermisters* or thermocouples costing approximately $200 are accurate recording devices that, when touched to a specific skin area for 10 to 15 seconds, give a numerical display of the temperature. These instruments are valuable as well as practical in a physical therapy clinic. A radiometerf is an infrared emission detector that gives a visual display of skin temperature without touching the skin. Costing over $1,000, this unit is rapid and allows for an accurate spot temperature reading, but has a limited scanning capability. Infrared thermography,^: the most expen sive method, is quick and is an excellent tool to scan areas such as the plantar surface of the feet. The unit uses a gray-scale monitoring system to display the skin temperature. Warm areas are white and cool areas are progressively darker. The actual tempera ture of any area can be determined with an isotherm display system using a superimposed bright line on the display screen to determine temperatures of spe cific areas. The superimposed bright light can be adjusted to an area of interest and the temperature can be read from a scale at the bottom of the display system (Fig. 1). The surface temperature of skin varies greatly from one body location to another. The most distal aspects of the extremities are cool, and muscular areas with good blood supplies are warmer than bony regions. A thermogram (picture of thermal patterns) taken of the plantar surface of normal feet shows that the arches are several degrees Celsius warmer than the heels or toes (Fig. 2). Normal skin temperature of the feet is variable, depending on factors such as outside temperature, room temperature, and the emotional state of the individual. The body's thermal symmetry allows for comparison between various body parts. Meaningful information from skin temperature mea surements can be obtained by comparing the temper ature of an inflamed area to that of the contralateral
* TRI-R, J.A. Preston Corp, 71 Fifth Ave, New York, NY 10003. f Mikron Infrared Thermometer, Mikron Instrument Co, Inc, Midland Park, NJ 07432. $ AGA Thermovision, AGA Corp, Secaucus, NJ 07094.
Volume 59 / Number 1, January 1979
Fig. 1. Demonstration of the use of an isotherm display system. Thermogram of normal feet with superimposed dots of bright light indicating all areas that are 30° C, including a standard temperature source (circle between the feet kept at 30° C). Scale below feet indicates isotherm setting of 0.3, or 30° C.
site and measuring the temperature difference (AT). A AT greater than 1°C has been considered to be significant.7 Differences of up to 6 to 8°C are often seen on the feet when an injury or inflammation is present. Changes in the AT during a treatment regi men can provide an important guide to understanding the tissue response to the treatment. If the AT in creases, the area is probably receiving more stress than is tolerable, but if the AT decreases, the treat ment regimen is probably satisfactory. Controlled conditions are necessary for tempera ture assessment. A cool room (22-23 °C) is required, and the parts to be examined must be exposed and allowed to equilibrate with the room temperature for a minimum of 10 minutes. When shoes, socks, and dressings are first removed, the feet are warm. After several minutes of exposure to a cool room the normal tissues cool, leaving the inflamed areas warm and creating a difference in temperature between the dam aged area and its contralateral site. Repeated studies should always follow the same format. When moni toring the temperature of feet, it is best to perform the temperature assessment at the same time each day, preferably early in the morning. Our experience has shown that significantly warm areas following a day of stress will continue to be warm after a night's rest. Temperature assessment immediately following a stressful activity may be of value; however, the assessment following a night's rest has proven more 19
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
ating low back diseases.4 Sandrow and associates found thermography to be useful in early diagnosis of neuropathic arthropathy in the feet of diabetics.5 Goller and co-workers found a positive correlation between temperature variation and static pressure on several areas of the human body.6
CASE STUDY
valuable. The principles and methods of temperature assessment have been well documented elsewhere.8 The following case study will demonstrate several useful applications of temperature assessment in con junction with other insensitive limb management methods. These techniques and advantages of tem perature assessment have been reported previously.1'2
Fig. 3. Photograph of medial aspect of feet. Note asymmetry of instep of patient's right foot, corresponding to fractured metatarsal bones.
20
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
Fig. 2. Thermogram of normal feet. White denotes warmth, black denotes coolness, gray denotes in-between temperatures.
A fifty-year-old man with Hansen's disease had normal motor function but had surface anesthesia of both feet. After one of his regular jogging episodes, he felt mild discomfort deep in his right foot and decided to stop jogging. Several days later the discom fort ceased. Six months later, when he returned to the hospital for routine follow-up care, a bony prominence on the plantar surface of the right foot was noticed during examination of his feet (Fig. 3). A roentgenogram showed five metatarsal bone fractures of the right foot (Fig. 4). A thermogram of the plantar surface of the feet showed the right forefoot was 5°C warmer than the left, with the warmest area having a temper ature of 34°C, or 93.2°F (Fig. 5). The patient was shown the thermogram, and the significance of the increased heat was explained to him. Treatment of choice at that time consisted of modified shoes de signed to reduce the pressures on the metatarsal bones during ambulation. Approximately two months after the first visit (eight months following the injury), the patient re turned to the hospital. A thermogram at that time demonstrated a great improvement in the thermal pattern (Fig. 6). The temperature had returned to near normal, with a AT of less than 1°C and a temperature of 32°C (89.6°F) over the base of the fourth metatarsal bone. Roentgenograms showed cal lus formation. Proper care of the deformed foot was explained to the patient again. Objective evidence of improvement in the bone structure was explained to the patient, using the roentgenograms and the im proved thermogram. The importance of continued
PHYSICAL THERAPY
use of modified shoes was clearly explained to the patient. Five months later, the patient returned to the hos pital with a pin-hole-sized ulcer under the fourth metatarsal head. The area had a temperature of 36.0°C (96.8°F) and a AT of 7.0°C. The patient confessed he had not been wearing his modified shoes regularly. The ulcer healed in three weeks, while the patient walked minimally and in his modified shoes.
Fig. 5. Thermogram of plantar surface of feet six months following injury and no treatment.
Volume 59 / Number 1, January 1979
Temperature assessment at regular intervals during his hospital stay was used to evaluate the healing progress of the ulcer and especially to monitor the effects of the patient's increased activity after the ulcer healed. A thermogram taken six weeks after readmission demonstrated near-normal (temperature 32.5°C, 90.5°F, AT 1.0°C) tissue response to the stresses of walking in the modified shoes (Fig. 7). Reviewing with the patient the improvement in the
Fig. 6. Thermogram of plantar surface of feet eight months following injury and two months of treatment.
21
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
Fig. 4. Roentgenograms of right foot: 4-16-74, prior to injury; 5-30-75, six months following in jury; 7-28-75, eight months following injury.
temperatures during this six-week period was an ex cellent tool in educating him. DISCUSSION
Routine evaluation of footwear for the insensitive foot has been instrumental in decreasing the incidence of ulceration; however, shoe evaluation is only one
REFERENCES
1. Bergtholdt HT, Brand PW: Temperature assessment and plantar inflammation. Lepr Rev, 47:211-219, 1976 2. Bergtholdt HT, Brand PW: Thermography: An aid in the man agement of insensitive feet and stumps. Arch Phys Med Rehabil 56:205-209, 1975 3. Winsor T: Peripheral Vascular Disease: An Objective Approach. Springfield, IL, Charles C Thomas, Publisher, 1959 4. Uematsu S (ed): Medical Thermography, Theory and Clinical Applications. Los Angeles, Brentwood Publishing Co, 1976
22
Downloaded from https://academic.oup.com/ptj/article-abstract/59/1/18/4559358 by University of Texas at Dallas user on 03 February 2019
Fig. 7. Thermogram of plantar surface of the feet following six weeks of conservative treatment for plantar ulcer.
part of the total evaluation. No two people are exactly the same, and certainly not everyone has the same activity level. An excellent shoe modification with no subsequent ulceration on the feet of a sedentary in dividual is likely to be inadequate for an active individual. An active person is likely to receive several thousand more repetitions of a very low level of stress than will a sedentary person, which will damage the soft tissue, result in inflammation, and possibly lead to ulceration after repeated stress. Temperature as sessment may be used to monitor the reaction of tissues to footwear and also the level of repetitive stress. This is especially important in early ambula tion, when the tissues are fragile. The amount of stress on the feet must be increased gradually as tissue tolerance increases. Temperature assessment is valuable in a scheduled program to demonstrate changes in the temperature pattern. Often, increased activity by the patient or illfitting footwear can be detected by an increase in temperature. Appropriate measures can then be taken to prevent ulceration of the foot. The return to a normal temperature pattern assures the clinician and the patient that the modification was appropriate. Although temperature assessment has proven a valuable evaluative technique to aid the clinician in preventing ulcers on insensitive feet, its greatest value is in teaching the patient the importance of early injury recognition and of faithfully practicing daily self-care. Abnormal temperatures give him objective evidence of damage or potential damage. The patient quickly learns to appreciate the beneficial and harm ful changes in temperature and begins to take an active role in the prevention of his own ulcers. The patient's participatory role has proved to be a vital requirement in the care of insensitive feet.
5. Sandrow RE, Torg JS, Lapayowker MS, et al: Use of thermo graphy in early diagnosis of neuropathic arthropathy in feet of diabetics. Clin Orthop 88:31-33, 1972 6. Goller H, Lewis DW, McLaughlin RE: Thermographic studies of human skin subjected to localized pressure. Am J Roentgenol Radium Ther Nucl Med 113:749-754, 1971 7. Ryan J: Thermography. Australas Radiol 13:23-36, 1969 8. Gershon-Cohen J, Barnes RB: Thermography and its clinical applications. Ann NY Acad Sci 121:1-304, 1964
PHYSICAL THERAPY
