Footwear for the neuropathic patient: offloading and stability

Patients' Buying Behavior for Non-Reimbursed Off-Loading Devices Used in Diabetic Foot Ulcer Treatment-An Observational Study during COVID-19 Pandemic from a Romanian Physical Therapy Unit

Diabetic foot ulcer non-reimbursed treatment depends on multiple factors, including the patient's buying behaviors. Factors affecting buying behaviors for the removable off-loading devices are not completely understood. The aim of this study was to investigate the patients' buying behaviors of the removable off-loading devices and their influence on the DFU treatment outcomes remotely monitored during the COVID-19 pandemic. In this prospective observational study, 45 patients affected by diabetic peripheral neuropathy, with/without peripheral arterial disease, with foot ulcers treated with removable devices were remotely monitored. Prefabricated removable cast walkers, insoles, and therapeutic footwear were the proposed off-loading methods. Patients affected by high blood pressure (p = 0.018), peripheral arterial disease (p = 0.029), past amputations (p = 0.018), and ulcer on the left foot (p = 0.007) bought removable cast walkers. Rural provenience (p = 0.011) and male (p = 0.034) did not buy a removable walker. The healing rate was 69.4%, while the median healing time was 20 weeks. High blood pressure negatively influenced healing time (p = 0.020). Patients who bought the most efficient treatment method for DFUs were females from urban provenience, with amputation in the past, with peripheral arterial disease, and with high blood pressure.

Using a contralateral shoe lift to reduce gait deterioration during an offloading fast-walk setting in diabetic peripheral neuropathy: A comparative feasibility study

AIMS

Diabetic peripheral neuropathy (DPN) is a predictor of foot ulcers and leads to sedentary behaviour. This comparative study evaluated gait and feasibility of a 20-minute fast walk, at 40-60% of cardiopulmonary capacity, in individuals with DPN wearing an offloading boot and a contralateral shoe balancer.

METHODS

Gait parameters were measured with inertial sensors on 32 individuals (group with DPN [n = 16], group with diabetes but without DPN [n = 9], and a group without diabetes/DPN [n = 7]). Feasibility was assessed by feedback on perceived effort and adverse events. Gait outcomes were compared between groups with or without a shoe balancer using one-way ANOVAs.

RESULTS

The three groups were equivalent in terms of activity level and age and gender except for the body mass index. Both groups with diabetes exhibited minimal decreased gait speed (p > 0.005) and the DPN group exhibited increased double-support percentage (+4.6%, p = 0.01) while walking with an offloading boot and contralateral shoe balancer. The use of a contralateral shoe balancer reduced gait asymmetry. Lower physical activity level was associated with further gait deterioration in all groups. Few adverse events were reported, and 91% of participants reported that the proposed activity would be feasible daily.

CONCLUSIONS

The offloading boot deteriorated gait function, but a contralateral shoe balancer minimized its impact, especially in the context of physical activity in people with diabetes and DPN.

Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers

BACKGROUND

Non-removable knee-high devices are the gold-standard offloading treatments to heal plantar diabetic foot ulcers (DFUs). These devices are underused in practice for a variety of reasons. Recommending these devices for all patients, regardless of their circumstances and preferences influencing their ability to tolerate the devices, does not seem a fruitful approach.

PURPOSE

The aim of this article is to explore the potential implications of a more personalized approach to offloading DFUs and suggest avenues for future research and development.

METHODS

Non-removable knee-high devices effectively heal plantar DFUs by reducing plantar pressure and shear at the DFU, reducing weight-bearing activity and enforcing high adherence. We propose that future offloading devices should be developed that aim to optimize these mechanisms according to each individual's needs. We suggest three different approaches may be developed to achieve such personalized offloading treatment. First, we suggest modular devices, where different mechanical features (rocker-bottom sole, knee-high cast walls/struts, etc.) can be added or removed from the device to accommodate different patients' needs and the evolving needs of the patient throughout the treatment period. Second, advanced manufacturing techniques and novel materials could be used to personalize the design of their devices, thereby improving common hindrances to their use, such as devices being heavy, bulky, and hot. Third, sensors could be used to provide real-time feedback to patients and clinicians on plantar pressures, shear, weight-bearing activity, and adherence.

CONCLUSIONS

By the use of these approaches, we could provide patients with personalized devices to optimize plantar tissue stress, thereby improving clinical outcomes.

Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity

Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.

Effects of offloading devices on static and dynamic balance in patients with diabetic peripheral neuropathy: A systematic review

Patients with diabetic peripheral neuropathy (DPN) usually have reduced somatosensory information and altered perception in feet and ankles. Somatosensory information acts as feedback for movement control and loss of somatosensation leads to altered plantar pressure patterns during gait and stance. Offloading devices are used to reduce peak plantar pressure and prevent diabetic foot ulcers. However, offloading devices can unfortunately have negative effects on static and dynamic balance. It is important to investigate these unwanted effects, since patient with DPN already are at high risk of falling and offloading devices could potentially increase this risk. The aim of this systematic review is to investigate the effects of plantar offloading devices used for ulcer prevention on their role in static and dynamic balance control in patients with DPN. PubMed and Embase were systematically searched using relevant search terms. After title selection, abstract selection, and full-text selection only five articles could be included for further analysis. Two articles included static balance measurements, two articles included dynamic balance measurements, and one article included both. Results suggested that static balance control is reduced when rocker bottom shoes and different insole configurations are used, however, toe-only rockers showed less evidence for reduced static balance control. There was no evidence for reduced dynamic balance control in combination with offloading devices. However, these results should be interpreted with care, since the number of studies was very small and the quality of the studies was moderate. Future research should evaluate balance in combination with different offloading devices, so that clinicians subscribing them are more aware of their potential unwanted consequences.

The apex angle of the rocker sole affects the posture and gait stability of healthy individuals

BACKGROUND

Rocker sole (RS) shoes have been linked to impaired postural control. However, which features of RS design affect balance is unclear.

RESEARCH QUESTION

Which RS design features affect standing balance and gait stability?

METHODS

This study utilized an intervention and cross-over design. Twenty healthy young adults (10 males and 10 females) participated in this study. Standing balance and gait stability were measured using a single force platform and three-dimensional motion analysis system, respectively. The experimental conditions included the control shoe and five RS shoes in the combination of apex position (%) and apex angle (degree) for RS50-95, RS60-95, RS70-95, RS60-70, and RS60-110. The main outcome measures were the area surrounding the maximal rectangular amplitude, mean path length, average displacement of the center of pressure along the lateral and anterior/posterior directions, and maximal center of pressure excursion as the standing balance and lateral margin of stability as the gait stability. Statistical analyses were conducted using a two-way split-plot analysis of variance with repeated measures (with RS design as the within-subject factor and sex as the between-subject factor) and the Bonferroni post hoc test (α = .05).

RESULTS

Regarding the mean path length, RS60-70 was significantly longer than the control shoe, and it showed a significantly increased lateral margin of stability. Thus, RS60-70 was shown to affect standing balance, limit of stability, and gait stability of the frontal plane during gait.

SIGNIFICANCE

These results suggest that the apex angle of the RS design feature affects standing balance and gait stability, and RS60-70 is detrimental to stability. Therefore, when RS with a small apex angle is prescribed, it is necessary to consider the patient's balance ability.

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices. We propose a Diabetic foot Offloading and Activity framework to guide future research to find the optimal balance between the positive and negative effects of weight-bearing activity in the context of foot ulcers. We hope such future studies will shed more conclusive light on the impact of weight-bearing activity on healing of plantar diabetic foot ulcers.

Health impacts of seated arm ergometry training in patients with a diabetic foot ulcer: protocol for a randomised controlled trial

INTRODUCTION

Once diagnosed with a diabetic foot ulcer (DFU), patients are advised to offload, keeping pressure off the foot in order to facilitate ulcer healing. An increase in offloading is often accompanied by reductions in physical activity which can worsen the overall health of patients.While unable to perform traditional forms of upright activity, one mode of exercise that would allow patients to be physically active while adhering to offloading instruction is seated arm ergometry. The merits of tailored aerobic exercise in DFU remain unexplored.

METHODS AND ANALYSIS

This is a prospective open-label randomised controlled trial. Participants will be randomised to one of two groups, an exercise intervention group or control. The intervention group are required to undertake arm ergometry training at a moderate intensity (65%-75% HRpeak), three times per week for 12 weeks as individually prescribed by an exercise physiologist, while the control group will continue to receive standard care alone. Assessment of outcome measures will occur at baseline and after the intervention period, these will include: a seated VO₂ peak test, a blood sample, a short physical performance battery, a dual-energy X-ray absorptiometry scan and completing a range of health-based questionnaires. The above will be used to determine: cardiorespiratory fitness, metabolic health, physical function, body composition and quality of life, respectively. Ulcer area will also be measured as an approximate marker of ulcer healing.

ETHICS AND DISSEMINATION

This trial has been approved by 'Yorkshire & The Humber-Leeds West Research Ethics Committee' (19/YH/0269). Trial results will be published in peer-reviewed journals and through conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN16000053. Registered in accordance with WHO Trial Registration Data Set (version 1.3.1).

The impact of diabetic foot ulcers and unilateral offloading footwear on gait in people with diabetes

BACKGROUND

Unilateral offloading footwear prescribed to patients with diabetic foot ulcers elevates one limb relative to the other, which may lead to limp and abnormal gait. This study investigated whether the unilateral foot ulcer and offloading combination negatively impacts gait function beyond diabetic peripheral neuropathy.

METHODS

Eighty-six participants were recruited in 3 groups: 12 with diabetic peripheral neuropathy and unilateral foot ulcers wearing offloading footwear (offloading group, age = 55.6 ± 9.5 years, BMI = 30.9 ± 4.5 kg/m²), 27 with diabetic peripheral neuropathy (neuropathy group, age = 64.3 ± 7.7 years, BMI = 30.9 ± 5.4 kg/m²), and 47 non-diabetic controls (non-diabetic group, age = 62.9 ± 16.1 years, BMI = 29.0 ± 6.0 kg/m²). Gait function was quantified during a habitual speed walking test using a validated wearable platform.

FINDINGS

The offloading group exhibited deteriorated gait function compared to the non-diabetic group (p < 0.005, Cohen's effect size d = 0.90-2.61). They also had decreased gait speed (p < 0.001, d = 1.79) and stride length (p < 0.001, d = 1.76), as well as increased gait cycle time (p < 0.001, d = 1.67) and limp (p < 0.050, d = 0.72-1.49) compared to the neuropathy group. The offloading group showed increased gait unsteadiness compared to the neuropathy group, but the difference did not reach statistical significance in our samples.

INTERPRETATION

This study demonstrated that while diabetic peripheral neuropathy deteriorates gait function, including increasing gait unsteadiness and limp, the diabetic foot ulcer and offloading combination magnifies the deterioration beyond diabetic peripheral neuropathy. These findings promote caution of the current standards of care for treating diabetic foot ulcers with offloading footwear. However, it is possible that a contralateral shoe lift may remedy deteriorated gait function and improve quality of life for unilateral offloading users.

Gait stability of diabetic patients is altered with the rigid rocker shoes

BACKGROUND

Rigid-rocker shoes may induce gait instability in diabetics, however, this is not clearly investigated. The present study investigates if rigid-rocker shoes influence diabetic gait stability.

METHODS

Fourteen non-neuropathic and nine neuropathic diabetics, plus eleven healthy young-adults were recruited. Full-body kinematic data was captured during walking. Experimental conditions included barefoot and three rocker-shoe designs according to the rocker angle, apex angle and apex position (R10: 10°, 80°, 60%; R15: 15°, 95°, 52%; R20: 20°, 95°, 60%). Sagittal and frontal stability margin, plus fear of fall were main outcome measures.

FINDINGS

Sagittal stability margin was not affected by health, however, was increased with R10 and R15 in non-neuropathic diabetics and healthy individuals (R² = 0.16). Variability of sagittal stability margin was not altered in neuropathic diabetics, but was increased with R15 and R20 in healthy participants, with R15 in non-neuropathic diabetics (R² = 0.12). Frontal stability margin (R² = 0.46) and its variability (R² = 0.39) were significantly increased in neuropathic and non-neuropathic diabetics compared to healthy individuals. Frontal stability margin was significantly higher with R15 in neuropathic diabetics, and with R20 in both non-neuropathic and healthy participants. Sagittal and frontal stability margin were strongly correlated with fear of fall in neuropathic diabetics.

INTERPRETATIONS

R15 and R20 might challenge gait stability of diabetics cause them restrict centre of mass motion thereby imposing a tighter control over walking. However, neuropathic diabetics generally walk very cautious due to neuropathy and increased fear of fall. Frontal stability margin, highly affected by health and experimental condition, is a more sensitive indicator of gait stability.

Acute Effect of Toe Cap Choice on Toe Deviation Angle and Perceived Pain in Female Professional Ballet Dancers

Several classical dance complex movements, such as pointe, require body weight to be supported properly to avoid risk of foot injury. Regarding the choice of toe cap for pointe shoes, it is unclear which type can better alleviate pain symptoms and toe deviation angle in dancers. The aim of the current crossover study was to investigate the acute effect of using different types of toe caps among well-trained professional dancers on pain perception and toe deviation angle. Ten young female professional dancers volunteered to participate in the study. Each participant was tested during two separate sessions with an interval of 72 h in between. Participants were tested in the two sessions with a standard commercial or a customized prototype toe cap, always with pointe shoes, and in randomized order. An anteroposterior X-ray examination was performed separately for each participant and a visual analogue scale for pain perception was administered following each situation (with a standard commercial or a customized prototype toe cap). Significant amelioration was obtained when a customized toe cap prototype was used both for toe deviation angle and for visual analogue scale. Use of a customized toe cap prototype compared to a standard one may acutely reduce both toe deviation angle and pain in elite female professional dancers.

Falls, Footwear, and Podiatric Interventions in Older Adults

Footwear is a modifiable risk factor for falls in older adults, including populations with metabolic disease, inflammatory arthritis, and neurodegenerative disease. Ill-fitting footwear, and specific design features, such as elevated heels and backless styles, can impair balance control and heighten the risk of falling. Although foot care is routine practice for some older adults to prevent ulceration (eg, diabetes) or relieve symptoms (eg, foot pain), new footwear interventions are emerging with the potential to ameliorate balance and walking impairments. Multifaceted podiatric interventions, which include appropriate footwear and importantly patient education, may have the capacity to reduce falls in older adults.

Associated Joint Pain With Controlled Ankle Movement Walker Boot Wear

Background:

Controlled ankle movement (CAM) walker boots may cause gait alterations and leg-length discrepancy. This study evaluates secondary site pain relating to immobilization in a CAM walker boot.

Methods:

Patients wearing a CAM walker boot were prospectively enrolled and evaluated for new or worsened secondary site pain. Surveys at four time points were completed to evaluate secondary site pain severity and its effect on function.

Results:

The study included 46 patients (mean age, 49 years). At transition out of the boot (mean, 4.2 weeks), 31 patients (67%) reported pain which was new or worse than at baseline. The sites most susceptible to pain were lower back, contralateral hip, and ipsilateral knee. Most pains (84%) began within the first 2 weeks of boot wear. Secondary site pain was less common after transition out of the boot: 18 patients (39%) at 1 month and 15 patients (33%) at 3 months.

Conclusion:

Secondary site pain after CAM walker boot wear is common. The frequency and severity of pain lessened after transition out of the boot. Yet, one-third of patients still had new or worsened secondary site pain 3 months after cessation of boot wear.

Methodological considerations of investigating adherence to using offloading devices among people with diabetes

Foot ulcers are a diabetic complication associated with significant morbidity, mortality, and amputation risk. Offloading devices prevent and heal foot ulcers, but adherence to using these devices is low. The reasons for nonadherence are unclear, and study results are difficult to compare due to methodological heterogeneity. This paper explores aspects of investigating adherence to using offloading devices among people with diabetes and provides recommendations for future studies, focusing on study designs, definitions of adherence, measurement methods, and conceptual frameworks. Most studies use a cross-sectional observational study design, limiting the potential to establish the temporal sequence between predictors and adherence, rule out confounding factors, and establish causality. Studies defining adherence as the length of time the device is worn have often used self-report to measure adherence, which may be unreliable. Studies using activity monitors to measure adherence have defined adherence as the number of steps taken with the device, which excludes weight-bearing activities where no steps are taken. Conceptual frameworks are not made explicit in the current quantitative research. It is concluded that future studies should use a longitudinal design with observational studies to identify patient groups prone to nonadherence and factors that influence adherence and experimental studies to evaluate interventions to improve adherence, focusing on these patient groups and factors. Furthermore, adherence should be defined in terms of relative adherence to using offloading devices during all weight-bearing activities, and objective measurement of adherence (using accelerometers and temperature monitors) should be used whenever possible. Clearly defined conceptual frameworks should guide the choice of factors to include in the study and the analysis of their interactions. By implementing these recommendations, research could provide a stronger evidence base in the future, supporting interventions to increase adherence and thereby improve outcomes for people with diabetic foot complications.

Decreasing an Offloading Device's Size and Offsetting Its Imposed Limb-Length Discrepancy Lead to Improved Comfort and Gait

OBJECTIVE

Patient adherence is a challenge in offloading diabetic foot ulcers (DFUs) with removable cast walkers (RCWs). The size and weight of an RCW, changes to gait, and imposed limb-length discrepancies may all discourage adherence. This study sought to determine whether RCW size and provision of a contralateral limb lift affected users' comfort and gait.

RESEARCH DESIGN AND METHODS

Twenty-five individuals at risk for DFUs completed several 20-m walking trials under five footwear conditions: bilateral standardized shoes, a knee-high RCW with shoe with or without an external shoe lift contralaterally, and an ankle-high RCW with shoe with or without an external shoe lift contralaterally. Perceived comfort ratings were assessed through the use of visual analog scales. Spatial and temporal parameters of gait were captured by an instrumented walkway, and plantar pressure was measured and recorded using pedobarographic insoles.

RESULTS

The bilateral shoes condition was reported to be most comfortable; both RCW conditions without the lift were significantly less comfortable (P < 0.01). In contrast to the ankle-high RCW, the knee-high RCW resulted in significantly slower walking (5.6%; P < 0.01) but greater offloading in multiple forefoot regions of the offloaded foot (6.8-8.1%; P < 0.01). Use of the contralateral shoe lift resulted in significantly less variability in walking velocity (52.8%; P < 0.01) and reduced stance time for the offloaded foot (2.6%; P = 0.01), but it also reduced offloading in multiple forefoot regions of the offloaded foot (3.7-6.0%; P < 0.01).

CONCLUSIONS

Improved comfort and gait were associated with the ankle-high RCW and contralateral limb lift. Providing this combination to patients with active DFUs may increase offloading adherence and subsequently improve healing.

Psychological and Biomechanical Aspects of Patient Adaptation to Diabetic Neuropathy and Foot Ulceration

PURPOSE OF REVIEW

The purpose of this review was to elucidate how psychological and biomechanical factors interrelate in shaping patients' experience with diabetic symmetric polyneuropathy (DSPN) and its sequela-diabetic foot ulceration (DFU).

RECENT FINDINGS

Recent findings emphasize the importance not only of neuropathic pain but also of other DSPN symptoms, such as unsteadiness. We highlight the negative spiral between unsteadiness, falls, and psychological distress. Moreover, unsteadiness is a key determinant of non-adherence to offloading resulting in the delayed DFU healing. While depression is an established predictor of incident DFU, findings linking depression and DFU healing remain inconclusive. Examination of physical activity in DFU development and healing represents the most recent application of research to this field. Research evidence indicates that DSPN markedly impairs physical and emotional functioning and suggests that there is an unmet need for the development of multifaceted interventions that address both psychological distress and biomechanical challenges experienced by patients with this debilitating complication of diabetes.

Assessment of plantar pressure in hindfoot relief shoes of different designs

BACKGROUND

Although there are several different concepts of hindfoot relief footwear, there are no studies on the extent of pressure reduction to be achieved by this footwear. Therefore, we sought to evaluate the reduction in plantar pressure to be achieved with two different hindfoot relief shoes.

METHODS

Ten healthy volunteers performed three trials at a self-selected speed. Peak pressure values in mass-produced shoes (normal gait) were considered as 100% and were compared with measurements in two differently designed hindfoot relief shoes. Foot portions were defined as heel (0%-15% of total insole length), hindfoot (16%-30%), midfoot (31%-60%), and forefoot (61%-100%).

RESULTS

Heel and hindfoot peak pressures were significantly reduced in both shoes compared with normal gait (P < .05), but the extent of peak pressure reduction under the heel and hindfoot varied significantly between the tested shoes. Midfoot peak pressure was not significantly reduced in tested shoes compared with baseline (P > .05) but differed significantly between the two shoes. Forefoot peak pressure was significantly reduced with one of the tested shoes (to a median 73% baseline; P = .004) but not with the other (median, 88% baseline).

CONCLUSIONS

Hindfoot relief shoes leave a considerable amount of peak pressure, predominantly under the hindfoot. The extent of peak pressure reduction for the heel and the hindfoot varies between different hindfoot relief shoes. Depending on the affected foot area, the kind of hindfoot relief shoe should be carefully chosen.

Role and Determinants of Adherence to Off-loading in Diabetic Foot Ulcer Healing: A Prospective Investigation

OBJECTIVE

Studies indicate that off-loading adherence is low in patients with diabetic foot ulcers (DFUs), which may subsequently delay healing. However, there is little empirical evidence for this relationship or the factors that influence adherence.

RESEARCH DESIGN AND METHODS

This prospective, multicenter, international study of 79 (46 from the U.K. and 33 the U.S.) persons with type 2 diabetes and plantar DFUs assessed the association between off-loading adherence and DFU healing over a 6-week period. Additionally, potential demographic, disease, and psychological determinants of adherence were examined. DFUs were off-loaded with a removable device (77% a removable cast walker). Off-loading adherence was assessed objectively by activity monitors. Patient-reported measures included Hospital Anxiety and Depression Scale (HADS), Neuropathy and Foot Ulcer Quality of Life (NeuroQoL) instrument, and Revised Illness Perception Questionnaire (IPQ-R).

RESULTS

Off-loading adherence was monitored for 35 ± 10 days, and devices were used during 59 ± 22% of subjects' activity. In multivariate analyses, smaller baseline DFU size, U.K. study site, and better off-loading adherence predicted smaller DFU size at 6 weeks (P < 0.05). Better off-loading adherence was, in turn, predicted by larger and more severe baseline DFUs, more severe neuropathy, and NeuroQoL foot pain (P < 0.05). In contrast, greater NeuroQoL postural instability predicted worse off-loading adherence (P < 0.001). HADS and IPQ-R measures were not significantly associated with off-loading adherence.

CONCLUSIONS

Off-loading adherence is associated with the amount of DFU healing that occurs, while postural instability is a powerful predictor of nonadherence. Clinicians should take this neuropathic symptom into consideration when selecting an off-loading device, as off-loading-induced postural instability may further contribute to nonadherence.

Effects of thai foot massage on balance performance in diabetic patients with peripheral neuropathy: a randomized parallel-controlled trial

BACKGROUND Peripheral neuropathy is the most common complications of diabetic patients and leads to loss of plantar cutaneous sensation, movement perception, and body balance. Thai foot massage is an alternative therapy to improve balance. Therefore, the purpose of this study was to investigate the effects of Thai foot massage on balance performance in diabetic patients with peripheral neuropathy. MATERIAL AND METHODS Sixty patients with type-2 diabetes were recruited and randomly assigned into either the Thai foot massage or control groups. The Thai foot massage group received a modified Thai traditional foot massage for 30 min, 3 days per week for 2 weeks. We measured timed up and go (TUG), one leg stance: OLS), the range of motion (ROM) of the foot, and foot sensation (SWMT) before treatment, after the first single session, and after the 2-week treatment. RESULTS After the single treatment session, only the Thai foot massage group showed a significant improvement in TUG. After the 2-week treatment, both Thai foot massage and control groups showed a significant improvement of TUG and OLS (P<0.05); however, when comparing between 2 groups, the Thai foot massage group showed better improvement in TUG than the control group (p<0.05). The Thai foot massage group also showed significant improvements in ROM and SWMT after the 2-week treatment. CONCLUSIONS The results of this study suggest that Thai foot massage is a viable alternative treatment for balance performance, ROM of the foot, and the foot sensation in diabetic patients with peripheral neuropathy.

Diabetic foot ulcers: evaluation and management

Diabetic foot ulcers (DFUs) are a common complication of diabetes and present a significant health risk to patients, as well as impose a large economic burden. Evaluation for contributory factors that may impact general health or healing, such as hyperglycemia, peripheral artery disease, neuropathy, and nutritional status, is of the utmost importance. Management of DFUs requires involvement of a multidisciplinary team and a standardized approach to patient care. Standard therapy for DFUs includes offloading and debridement. Assessment and control of infection are critical, including determining the severity of the infection, which may drive therapeutic approaches. For recalcitrant ulcers, adjuvant therapies are used to hasten the healing process, and newer therapies are under investigation.

Plantar pressure in diabetic peripheral neuropathy patients with active foot ulceration, previous ulceration and no history of ulceration: a meta-analysis of observational studies

Aims

Elevated dynamic plantar pressures are a consistent finding in diabetes patients with peripheral neuropathy with implications for plantar foot ulceration. This meta-analysis aimed to compare the plantar pressures of diabetes patients that had peripheral neuropathy and those with neuropathy with active or previous foot ulcers.

Methods

Published articles were identified from Medline via OVID, CINAHL, SCOPUS, INFORMIT, Cochrane Central EMBASE via OVID and Web of Science via ISI Web of Knowledge bibliographic databases. Observational studies reporting barefoot dynamic plantar pressure in adults with diabetic peripheral neuropathy, where at least one group had a history of plantar foot ulcers were included. Interventional studies, shod plantar pressure studies and studies not published in English were excluded. Overall mean peak plantar pressure (MPP) and pressure time integral (PTI) were primary outcomes. The six secondary outcomes were MPP and PTI at the rear foot, mid foot and fore foot. The protocol of the meta-analysis was published with PROPSERO, (registration number CRD42013004310).

Results

Eight observational studies were included. Overall MPP and PTI were greater in diabetic peripheral neuropathy patients with foot ulceration compared to those without ulceration (standardised mean difference 0.551, 95% CI 0.290–0.811, p<0.001; and 0.762, 95% CI 0.303–1.221, p = 0.001, respectively). Sub-group analyses demonstrated no significant difference in MPP for those with neuropathy with active ulceration compared to those without ulcers. A significant difference in MPP was found for those with neuropathy with a past history of ulceration compared to those without ulcers; (0.467, 95% CI 0.181– 0.753, p = 0.001). Statistical heterogeneity between studies was moderate.

Conclusions

Plantar pressures appear to be significantly higher in patients with diabetic peripheral neuropathy with a history of foot ulceration compared to those with diabetic neuropathy without a history of ulceration. More homogenous data is needed to confirm these findings.

The effects of sandals on postural stability in patients with rheumatoid arthritis: an exploratory study

BACKGROUND

Rheumatoid arthritis results in postural instability, pain and functional limitations. As rheumatoid arthritis progresses, localised forefoot deformities such as hallux valgus and clawing of the lesser toes occur, leading to a high proportion of people with rheumatoid arthritis wearing sandals. Sandals may affect postural stability due to poor motion control. The aim was to assess two different open-toe sandals on postural stability in people with rheumatoid arthritis.

METHODS

Twenty women with rheumatoid arthritis were assessed in quiet standing under four conditions: (1) open-back sandal; (2) closed-back sandal; (3) own footwear and (4) bare feet. Postural stability was assessed as postural sway in the anterior-posterior and medial-lateral directions, with eyes open and eyes closed, using a pressure mat. Repeated measures analysis of variance tested the interaction effect of the footwear and eye conditions on anterior-posterior and medial-lateral sway.

FINDINGS

In eyes-open, there was no significant difference in anterior-posterior sway (P=.169) and medial-lateral sway (P=.325) for footwear conditions. In eyes-closed testing, compared with barefoot conditions, increased anterior-posterior sway was observed with participants' footwear (P<.0001), the open-back sandal (P=.005), and the closed-back sandal (P=.017). With eyes closed, increased anterior-posterior sway was also observed with the participants' footwear compared with the closed-back sandal (P=.041). Increased medial-lateral sway was observed with the closed-back sandal compared with bare feet (P=.014).

INTERPRETATION

Sandals may be detrimental to older women with well-established rheumatoid arthritis when eyes are closed. Further investigation is needed to evaluate the effect of sandals on dynamic tasks.

Effect of a forefoot off-loading postoperative shoe on muscle activity, posture, and static balance

BACKGROUND

We investigated whether a forefoot off-loading postoperative shoe (FOPS) alters standing posture, ankle muscle activity, and static postural sway and whether any effects are altered by wearing a shoe raise on the contralateral side.

METHODS

Posture, ankle muscle activity, and postural sway were compared in 14 healthy participants wearing either a FOPS or a control shoe with or without a contralateral shoe raise. Participants were tested under different sensory and support surface conditions. Additionally, reductions in peak pressure under the forefoot while walking were assessed with and without a contralateral shoe raise to determine whether the FOPS continued to achieve its primary off-loading function.

RESULTS

Compared with the control condition, wearing a FOPS moved the center of pressure posteriorly, increased tibialis anterior muscle activity, and reduced ankle plantarflexor activity. These changes decreased when a contralateral shoe raise was added. No difference in postural sway was found between footwear conditions. Forefoot peak pressure was always reduced when wearing the FOPS.

CONCLUSIONS

The posterior shift in center of pressure toward and behind the ankle joint axis is believed to result in the increase in tibialis anterior muscle activity that now acts as the primary stabilizer around the ankle. Instability may, therefore, increase in patients with weak tibialis anterior muscles (eg, diabetic neuropathy) who need to wear offloading devices for ulcer management. We suggest that the addition of a contralateral shoe raise fitted with a FOPS may potentially be beneficial in maintaining stability while off-loading the forefoot in this patient group.

Diabetic peripheral neuropathy and gait: does footwear modify this association?

BACKGROUND

Gait-related fall risk is the leading cause of mortality among patients with diabetes, especially those older than 65 years. Deterioration in balance and loss of protective sensation in lower extremities contribute significantly to fall risk in patients with diabetic peripheral neuropathy (DPN). This study aimed to explore the impact of neuropathy and foot ulcer on gait.

METHODS

We recruited 39 participants (age, 56.9 ± 8.2 years; body mass index, 29.6.3 ± 4.7 kg/m2), including 15 DPN patients without foot ulcers, 16 DPN patients with foot ulcers, and 8 healthy aged-matched controls. Patients with active foot ulcers wore an offloading device during gait examination, including removable cast walker.

RESULTS

Results suggest that neuropathy alters gait mainly by increasing gait initiation, gait variability (coefficient of variation of gait velocity), and double support (DS) time, while reducing knee range of motion and center of mass sway (p < .05). Interestingly, the presence of foot ulcer does not impact gait velocity (p > .1) but enhances some of the gait parameters such as gait variability and DS time.

CONCLUSIONS

This study demonstrates that neuropathy deteriorates gait, but the presence of foot ulcers does not alter gait parameters further than neuropathy. In addition, patients with foot ulcers demonstrated a better gait compared with DPN patients without ulcers. We speculate that offloading footwear may be enhancing the somatosensory feedback from sensate skin, thereby positively affecting gait parameters. A study with a larger sample is required to explore the effect of prescribed footwear in the DPN population in order to validate the findings of this research study.

A growing troubling triad: diabetes, aging, and falls

There is a significant and troubling link between diabetes (DM) and falls in the elderly. Individuals with DM are prone to fall for reasons such as decreased sensorimotor function, musculoskeletal/neuromuscular deficits, foot and body pain, pharmacological complications, and specialty (offloading) footwear devices. Additionally, there is some concern that DM patients are prone to have more severe problems with falls than non-DM individuals. Fractures, poorer rehabilitation, and increased number of falls are all concerns. Fortunately, efforts to mitigate falls by DM patients show promise. A number of studies have shown that balance, strength, and gait training may be utilized to successfully reduce fall risk in this population. Furthermore, new technologies such as virtual reality proprioceptive training may be able to provide this reduced risk within a safe training environment.

Impact of strut height on offloading capacity of removable cast walkers

BACKGROUND

Reducing weight-bearing stress to diabetic foot ulcers is critical to healing and commonly called offloading. Removable cast walkers are frequently used for offloading; however, patient compliance is often poor. Walkers commonly extend to the knee. Patients complain about walkers' weight and diminished balance with their use. This study compared the offloading capacity of walkers that varied by height. Heights included: knee, ankle, and shoe levels. To ensure a fair comparison the outsole and insole were standardized across the devices.

METHODS

Eleven diabetic subjects with moderate to high risk of ulceration were recruited. Subjects completed four 20 m walking trials. Subjects performed one trial with each walker and one trial with an athletic shoe. Primary outcomes focused on plantar loading and were measured by pressure insoles. Secondary outcomes were associated with gait kinematics as collected by body worn sensors.

FINDINGS

Significant differences were found for the peak pressure and pressure time integrals of the different footwear. All walkers performed better than the athletic shoe. The ankle and knee-high devices performed best. Center of mass rotation data showed a trend of the ankle walker yielding a smaller range of motion (18% medial/lateral and 22% anterior/posterior) than the knee level.

INTERPRETATION

The ankle-high walker was able to provide similar offloading capacities as the knee-high walker. The diminished weight, along with potentially improved stability, may result in improved compliance with ankle-high walkers. A study comparing the use of the two devices for treating ulcers is now suggested.

Diagnostics and treatment of the diabetic foot

Every 30 s, a lower limb is amputated due to diabetes. Of all amputations in diabetic patients 85% are preceded by a foot ulcer which subsequently deteriorates to a severe infection or gangrene. There is a complexity of factors related to healing of foot ulcers including strategies for treatment of decreased perfusion, oedema, pain, infection, metabolic disturbances, malnutrition, non-weight bearing, wound treatment, foot surgery, and management of intercurrent disease. Patients with diabetic foot ulcer and decreased perfusion do often not have rest pain or claudication and as a consequence non-invasive vascular testing is recommended for early recognition of ulcers in need of revascularisation to achieve healing. A diabetic foot infection is a potentially limb-threatening condition. Infection is diagnosed by the presence or increased rate of signs inflammation. Often these signs are less marked than expected. Imaging studies can diagnose or better define deep, soft tissue purulent collections and are frequently needed to detect pathological findings in bone. The initial antimicrobial treatment as well as duration of treatment is empiric. There is a substantial delay in wound healing in diabetic foot ulcer which has been related to various abnormalities. Several new treatments related to these abnormalities have been explored in wound healing with various successes. An essential part of the strategy to achieve healing is an effective offloading. Many interventions with advanced wound management have failed due to not recognizing the need for effective offloading. A multidisciplinary approach to wounds and foot ulcer has been successfully implemented in different centres with a substantial decrease in amputation rate.

Postural strategies in diabetes patients with peripheral neuropathy determined using cross-correlation functions

BACKGROUND

Although postural control strategies have been largely explored in diabetes patients with peripheral neuropathy, the literature on their postural control strategies related to peripheral neuropathy level and task complexity is still limited. The aim of this study is then to investigate how balance task difficulty influences postural strategies in diabetes patients with peripheral neuropathy.

SUBJECTS AND METHODS

Postural strategies and instability were evaluated in 25 diabetes patients during four standing tasks. The root mean square value of the anterior-posterior angular velocity, measured at the trunk and the ankle, was investigated and analyzed using cross-correlation functions (CCFs). Correlations between balance and clinical variables were analyzed.

RESULTS

A significant decrease in CCFs between trunk and ankles was observed under dynamic balance conditions. Correlations were observed between postural strategies and balance instability with the level of peripheral neuropathy and with hip and ankle strength.

CONCLUSION

Postural strategies are influenced by more demanding standing tasks and correlated with the level of peripheral neuropathy and strength of muscles in diabetes patients.

Investigation of standing balance in diabetic patients with and without peripheral neuropathy using accelerometers

BACKGROUND

Peripheral neuropathy is recognised to be the most symptomatic complication of diabetes and is also linked to postural instability. This study investigates balance instability in diabetic patients with and without peripheral neuropathy.

METHODS

Quiet standing balance was investigated using an accelerometric-based method in 24 diabetic patients (12 with and 12 without peripheral neuropathy) and compared with 12 control subjects. Accelerations were measured at lumbar and ankle levels using three accelerometers. Two standing conditions of 30s were evaluated (i.e., eyes opened, eyes closed). The range and root mean square values were calculated on the anterior posterior component of lumbar and ankle accelerations and for the medial lateral component of lumbar accelerations. Differences between parameters were compared between groups using ANOVA and post hoc comparisons.

FINDINGS

The diabetic patients with peripheral neuropathy show higher-range and root mean square values compared with those of control subjects and diabetic patients without peripheral neuropathy. Significant differences between groups have been detected for anterior posterior range of lumbar acceleration, which was significantly higher for diabetic patients with peripheral neuropathy, compared with those of others groups. Significant higher values for diabetic patients with peripheral neuropathy were also detected for anterior posterior range and root mean square of ankle accelerations compared with control subjects. Visual deprivation shows an increase in accelerometric parameters for each group.

INTERPRETATION

This study is the first to investigate the balance instability of diabetic patients using accelerometers. Results confirm that diabetic patients with peripheral neuropathy have greater postural instability with higher acceleration values than those of control group and diabetic patients without peripheral neuropathy.