Despite the obvious improvements made in the field of diabetes therapy during this century [1] the quality of diabetes care has, in general, remained poor. The widespread failure to acknowledge the impact of patient education appears to evolve as the primary reason for this unsatisfactory situation. Despite the firm and well founded recommendations put forward by some of the pioneers of modem diabetology, e.g. Drs. E.P.Joslin and R.D. Lawrence in the 1920s, it has taken almost 50 years for the beneficial effects of patient education to have finally and unequivocally been proven. The recently developed strategies for a global approach to diabetes therapy which combines biomedical, psychosocial and educational elements represents an exemplary therapeutic model for the care of many chronic diseases. The complexities of diabetes and of diabetes careThe metabolic manifestations of diabetes mellitus oscillate from hypoglycaemia to hyperosmolar or ketoacidotic decompensation and coma. The long-term complications of the disease may involve almost all organs with disabling consequences from benign dysaesthesia of the legs to the total loss of pain sensation with the severe risk of foot lesions; from background diabetic retinopathy without any impairment of visual function to proliferative diabetic eye disease leading to blindness; from potentially reversible microproteinuria to endstage kidney failure; and from minor arterial insufficiency of the lower limbs to gangrene and amputations. The threat of acute and long-term complications as well as the need for daily monitoring (blood or urine glucose levels, foot care, blood pressure, etc.) represent a considerable psychological stress to diabetic patients and their families.Treatment of metabolic disturbances and care of diabetic patients are not simple. There are numerous factors involved in the control of blood glucose levels. Although the underlying cause of the disease is an endocrine disorder (i. e. the absolute or relative lack of insulin secretion and/or the insensitivity to insulin at the level of the liver and some peripheral tissues), many additional factors play important roles in regulating the level of glycaemia in diabetic patients. These include the nutritional status of the patients, their dietary habits, their emotional constitution and way of coping with the disease, their familial, professional and social environment and many others. There is a constant interaction between these factors, most of which keep fluctuating extensively even within the same day. Thus, physicians and patients often find it difficult to identify the factor(s) which might have been responsible for a deterioration of metabolic control. Because the majority of these factors are closely related to the patients' behaviour, it appears evident that the achievement of longterm metabolic control is the consequence of a complex process simultaneously involving psychosocial, endocrine, and pharmacological factors. Obtaining (near)normalization of glycaemia may require the patient to perform ...

Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term.

The foot off-loading by biofeedback leads to a safe and regular plantar pressure distribution without inducing any new 'at-risk' area under both feet.

We observed an anterior displacement of weight-bearing during walking on a level gradient as well as a reduced static contact plantar surface in diabetic patients without evidence of any complications compared with the non-diabetic control group. This could be a premature sign of peripheral neuropathy, which is not evaluated on clinical examination or quantitative sensory testing used in clinics.

The performance of the Rydel-Seiffer graduated tuning fork was examined in healthy subjects and in various groups of diabetic patients in order to evaluate its efficacy for identifying patients whose loss of vibration sensation may expose them to the risk of foot injury. Vibration perception score measured with the tuning fork declined with age (p less than 0.001) in the control subjects. It correlated well (r = -0.90, p less than 0.001) with the thresholds obtained with an electromagnetic instrument (Vibrameter) in diabetic patients, in whom vibration perception score was impaired compared with control subjects (4.0 +/- 1.8 (+/- SD) vs 5.4 +/- 1.4, p less than 0.001). Age-related Rydel-Seiffer tuning fork vibration sensation was impaired in 79% of 38 ulcerated feet of 26 patients. The tuning fork score was less than or equal to 4.0 in 95% of the ulcerated feet. We conclude that the Rydel-Seiffer graduated tuning fork is a suitable tool for screening for sensation loss and that diabetic patients with a tuning-fork score of less than or equal to 4.0 are vulnerable to ulceration.

These data suggest that contrast sensitivity deficits in diabetic patients without retinopathy are not solely explained by a diabetes-induced increases in lens optical density. Abnormalities of the retina or its neural connections occurring before the onset of clinically detectable retinopathy may be involved. Risk factors for these deficits are advanced age, high systolic blood pressure, and nephropathy.

This study was designed to assess whether concept maps used with diabetic patients could describe their cognitive structure, before and after having followed an educational programme. Ten diabetic patients, in Paris and Geneva, were interviewed and, during the interview, a concept map was drawn up by the researcher, using the patient's words. This was done on three different occasions: the first day of the educational programme (Pre-evaluation), the last day (Post 1) of a week of education, then 3 to 4 months after education (Post 2). Twenty-eight maps were analysed, using a grid that quantified and qualified the knowledge expressed (knowledge categories, concept links, exactitude) and the organization of that knowledge (hierarchization of concept, cross-links). The examples shown in the maps of the 10 patients gave an illustration of how knowledge was developed or maintained with education, and also showed some learning difficulties encountered by the patients, the changes or preservation of their beliefs and the patients' preoccupations. This study shows that concept maps can be a suitable technique to explore the type and organization of the patients' prior knowledge and to visualize what they have learned after an educational programme.

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