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Lazzarini PA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Bus SA. Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2024; 40:e3650. [PMID: 37292021 DOI: 10.1002/dmrr.3650] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU. METHODS We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed. RESULTS From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers. CONCLUSIONS Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.
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Affiliation(s)
- P A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - D G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA
| | - R T Crews
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University, North Chicago, Illinois, USA
| | - C Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
| | - G Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - K Kirketerp-Moller
- Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen, Denmark
- Steno Diabetes Center, Copenhagen, Denmark
| | | | - S A Bus
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Ababneh A, Edwards H, Lazzarini P, Finlayson K. A qualitative exploration of adherence to wearing removable cast walkers in patients with diabetic foot ulcers. J Wound Care 2023; 32:456-466. [PMID: 37405942 DOI: 10.12968/jowc.2023.32.7.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To explore adherence to wearing removable cast walkers (RCWs) among patients with diabetic foot ulcers (DFUs). METHOD A qualitative study was conducted by interviewing patients with active DFUs and using knee-high RCWs as their offloading treatment. The interviews were undertaken at two diabetic foot clinics in Jordan, using a semi-structured guide. Data were analysed through content analysis by developing main themes and categories. RESULTS Following interviews with 10 patients, two main key themes with a total of six categories were identified: theme 1-reporting of adherence levels was inconsistent, included two categories: i) a belief in achieving optimal adherence, and ii) non-adherence was often reported indoors; and theme 2-adherence was a consequence of multiple psychosocial, physiological and environmental factors, which included four categories: i) specific offloading knowledge or beliefs influenced adherence; ii) severity of foot disease influenced adherence; iii) social support benefitted adherence; and iv) physical features of RCWs (the usability of the offloading device) impacted adherence. CONCLUSION Patients with active DFUs reported inconsistent levels of adherence to wearing RCWs which, after deeper investigation, seemed to be due to participants' misperceptions of the optimal adherence. Adherence to wearing RCWs also seemed to be impacted by multiple psychosocial, physiological and environmental factors.
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Affiliation(s)
- Anas Ababneh
- Faculty of Nursing, Applied Science Private University, Amman, Jordan
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Helen Edwards
- School of Clinical Sciences, Queensland University of Technology, Australia
| | - Peter Lazzarini
- School of Clinical Sciences, Queensland University of Technology, Australia
| | - Kathleen Finlayson
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Australia
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Finco MG, Cay G, Lee M, Garcia J, Salazar E, Tan TW, Armstrong DG, Najafi B. Taking a Load Off: User Perceptions of Smart Offloading Walkers for Diabetic Foot Ulcers Using the Technology Acceptance Model. SENSORS (BASEL, SWITZERLAND) 2023; 23:2768. [PMID: 36904971 PMCID: PMC10006940 DOI: 10.3390/s23052768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
People with diabetic foot ulcers (DFUs) are commonly prescribed offloading walkers, but inadequate adherence to prescribed use can be a barrier to ulcer healing. This study examined user perspectives of offloading walkers to provide insight on ways to help promote adherence. Participants were randomized to wear: (1) irremovable, (2) removable, or (3) smart removable walkers (smart boot) that provided feedback on adherence and daily walking. Participants completed a 15-item questionnaire based on the Technology Acceptance Model (TAM). Spearman correlations assessed associations between TAM ratings with participant characteristics. Chi-squared tests compared TAM ratings between ethnicities, as well as 12-month retrospective fall status. A total of 21 adults with DFU (age 61.5 ± 11.8 years) participated. Smart boot users reported that learning how to use the boot was easy (ρ =-0.82, p≤ 0.001). Regardless of group, people who identified as Hispanic or Latino, compared to those who did not, reported they liked using the smart boot (p = 0.05) and would use it in the future (p = 0.04). Non-fallers, compared to fallers, reported the design of the smart boot made them want to wear it longer (p = 0.04) and it was easy to take on and off (p = 0.04). Our findings can help inform considerations for patient education and design of offloading walkers for DFUs.
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Affiliation(s)
- M. G. Finco
- Interdisciplinary Consortium for Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Gozde Cay
- Interdisciplinary Consortium for Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Myeounggon Lee
- Interdisciplinary Consortium for Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jason Garcia
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Elia Salazar
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Tze-Woei Tan
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - David G. Armstrong
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Bijan Najafi
- Interdisciplinary Consortium for Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Kang GE, Stout A, Waldon K, Kang S, Killeen AL, Crisologo PA, Siah M, Jupiter D, Najafi B, Vaziri A, Lavery LA. Digital Biomarkers of Gait and Balance in Diabetic Foot, Measurable by Wearable Inertial Measurement Units: A Mini Review. SENSORS (BASEL, SWITZERLAND) 2022; 22:9278. [PMID: 36501981 PMCID: PMC9735812 DOI: 10.3390/s22239278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/14/2022] [Accepted: 11/26/2022] [Indexed: 06/17/2023]
Abstract
People with diabetic foot frequently exhibit gait and balance dysfunction. Recent advances in wearable inertial measurement units (IMUs) enable to assess some of the gait and balance dysfunction associated with diabetic foot (i.e., digital biomarkers of gait and balance). However, there is no review to inform digital biomarkers of gait and balance dysfunction related to diabetic foot, measurable by wearable IMUs (e.g., what gait and balance parameters can wearable IMUs collect? Are the measurements repeatable?). Accordingly, we conducted a web-based, mini review using PubMed. Our search was limited to human subjects and English-written papers published in peer-reviewed journals. We identified 20 papers in this mini review. We found preliminary evidence of digital biomarkers of gait and balance dysfunction in people with diabetic foot, such as slow gait speed, large gait variability, unstable gait initiation, and large body sway. However, due to heterogeneities in included papers in terms of study design, movement tasks, and small sample size, more studies are recommended to confirm this preliminary evidence. Additionally, based on our mini review, we recommend establishing appropriate strategies to successfully incorporate wearable-based assessment into clinical practice for diabetic foot care.
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Affiliation(s)
- Gu Eon Kang
- Department of Bioengineering, Erik Jonsson School of Engineering & Computer Science, The University of Texas at Dallas, Richardson, TX 75080, USA
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Angeloh Stout
- Department of Bioengineering, Erik Jonsson School of Engineering & Computer Science, The University of Texas at Dallas, Richardson, TX 75080, USA
| | - Ke’Vaughn Waldon
- Department of Bioengineering, Erik Jonsson School of Engineering & Computer Science, The University of Texas at Dallas, Richardson, TX 75080, USA
| | - Seungmin Kang
- Department of Bioengineering, Erik Jonsson School of Engineering & Computer Science, The University of Texas at Dallas, Richardson, TX 75080, USA
| | - Amanda L. Killeen
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Peter A. Crisologo
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Michael Siah
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Daniel Jupiter
- Department of Biostatistics and Data Science, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA
| | - Bijan Najafi
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | | | - Lawrence A. Lavery
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Souza J, Escadas S, Baxevani I, Rodrigues D, Freitas A. Smart Wearable Systems for the Remote Monitoring of Selected Vascular Disorders of the Lower Extremity: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15231. [PMID: 36429951 PMCID: PMC9690814 DOI: 10.3390/ijerph192215231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/03/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
This systematic review aims at providing an overview of the state of the art regarding smart wearable systems (SWS) applications to monitor the status of patients suffering from vascular disorders of the lower extremity. Peer-reviewed literature has been analyzed to identify employed data collection methods, system characteristics, and functionalities, and research challenges and limitations to be addressed. The Medline (PubMed) and SCOPUS databases were considered to search for publications describing SWS for remote or continuous monitoring of patients suffering from intermittent claudication, venous ulcers, and diabetic foot ulcers. Publications were first screened based on whether they describe an SWS applicable to the three selected vascular disorders of the lower extremity, including data processing and output to users. Information extracted from publications included targeted disease, clinical parameters to be measured and wearable devices used; system outputs to the user; system characteristics, including capabilities of remote or continuous monitoring or functionalities resulting from advanced data analyses, such as coaching, recommendations, or alerts; challenges and limitations reported; and research outputs. A total of 128 publications were considered in the full-text analysis, and 54 were finally included after eligibility criteria assessment by four independent reviewers. Our results were structured and discussed according to three main topics consisting of data collection, system functionalities, and limitations and challenges.
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Affiliation(s)
- Julio Souza
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, 4200-450 Porto, Portugal
| | - Sara Escadas
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, 4200-450 Porto, Portugal
| | - Isidora Baxevani
- Department of Materials Science and Technology, University of Crete, 700 13 Iraklio, Greece
| | - Daniel Rodrigues
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, 4200-450 Porto, Portugal
| | - Alberto Freitas
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, 4200-450 Porto, Portugal
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Ababneh A, Finlayson K, Edwards H, Lazzarini PA. Factors associated with adherence to using removable cast walker treatment among patients with diabetes-related foot ulcers. BMJ Open Diabetes Res Care 2022; 10:10/1/e002640. [PMID: 35144940 PMCID: PMC8845212 DOI: 10.1136/bmjdrc-2021-002640] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/15/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Adherence to using knee-high offloading treatment is critical for healing diabetes-related foot ulcers (DFUs). However, few studies have investigated patients' adherence to using knee-high offloading treatment. We aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment among patients with DFUs. RESEARCH DESIGN AND METHODS In this multicenter cross-sectional study, we investigated adherence to using knee-high RCWs in 57 participants with DFUs. All participants were clinically examined for multiple sociodemographic, physiological, and psychosocial factors. Each participant's adherence level to using RCWs was then objectively measured using dual activity monitors (attached to the wrist and RCW) over a 1-week period. Multiple linear regression was undertaken to determine those factors independently associated with adherence levels. RESULTS The mean adherence level to using RCWs was 33.6% (SD 16.5) of weight-bearing activity. Factors independently associated with lower adherence levels were being male, longer diabetes duration, not having peripheral artery disease (PAD), and having higher perceived RCW heaviness (p≤0.05). No associations were found with psychosocial factors. CONCLUSIONS Patients with DFUs adhered to using their RCWs on average for only a third of their prescribed weight-bearing treatment duration. Factors linked to lower RCW adherence levels were being male, longer diabetes duration, not having PAD, and perceived heavier RCWs. These findings highlight the importance of using gold standard non-removable knee-high offloading device treatment. Furthermore, these findings suggest, when gold standard devices are containdicated, that these factors be considered when prescribing the second choice RCW offloading treatment to optimise adherence. Regardless, further longitudinal studies are needed to confirm these factors.
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Affiliation(s)
- Anas Ababneh
- Faculty of Nursing, Applied Science Private University, Amman, Jordan
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kathleen Finlayson
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Edwards
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Chermside, Queensland, Australia
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Lazzarini PA, Jarl G. Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:941. [PMID: 34577864 PMCID: PMC8471745 DOI: 10.3390/medicina57090941] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.
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Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane 4059, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane 4032, Australia
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, SE-70182 Örebro, Sweden;
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, SE-70182 Örebro, Sweden
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Samuelson KL, Kiefer CT, Wu SC, Crews RT. Changing Perspectives: Offloading a Patient With a Diabetic Foot Ulcer as Opposed to Offloading a Diabetic Foot Ulcer. Foot Ankle Spec 2021; 14:347-351. [PMID: 33287580 PMCID: PMC8180528 DOI: 10.1177/1938640020975620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetic foot ulcers (DFUs) represent a tremendous burden to health care systems. Offloading is one of the key tenants to healing DFU and knee-high irremovable offloading devices are considered the gold standard for offloading DFU. However, the gold standard is rarely utilized in clinical practice. Patients' limited tolerance for such devices is one of a number of reasons that have been attributed to the lack of use of these devices. The practice of evidence-based medicine relies on shared decision making by pairing patients' values and preferences with the best available evidence. The present case report reviews the process of a patient-centered approach to identify the best offloading option for a patient with DFU. In consultation with the patient, a series of modalities were evaluated for offloading 2 unilateral forefoot DFUs. It is suggested that optimizing DFU offloading outcomes at the population level will require concerted efforts to employ the best offloading solution at the individual patient level. Offloading modalities are necessitated to mitigate the physical stress imparted on DFU during the weightbearing activity that patients engage in. Success is likely to be maximized by maintaining a mind-set of treating individual patients with DFUs as opposed to simply treating DFUs.Levels of Evidence: Level V: Case report.
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Affiliation(s)
- Katherine L. Samuelson
- Dr William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Chase T. Kiefer
- Dr William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Stephanie C. Wu
- Dr William M. Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Ryan T. Crews
- Dr William M. Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
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Reeves ND, Orlando G, Brown SJ. Sensory-Motor Mechanisms Increasing Falls Risk in Diabetic Peripheral Neuropathy. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57050457. [PMID: 34066681 PMCID: PMC8150714 DOI: 10.3390/medicina57050457] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/16/2021] [Accepted: 04/30/2021] [Indexed: 12/25/2022]
Abstract
Diabetic peripheral neuropathy (DPN) is associated with peripheral sensory and motor nerve damage that affects up to half of diabetes patients and is an independent risk factor for falls. Clinical implications of DPN-related falls include injury, psychological distress and physical activity curtailment. This review describes how the sensory and motor deficits associated with DPN underpin biomechanical alterations to the pattern of walking (gait), which contribute to balance impairments underpinning falls. Changes to gait with diabetes occur even before the onset of measurable DPN, but changes become much more marked with DPN. Gait impairments with diabetes and DPN include alterations to walking speed, step length, step width and joint ranges of motion. These alterations also impact the rotational forces around joints known as joint moments, which are reduced as part of a natural strategy to lower the muscular demands of gait to compensate for lower strength capacities due to diabetes and DPN. Muscle weakness and atrophy are most striking in patients with DPN, but also present in non-neuropathic diabetes patients, affecting not only distal muscles of the foot and ankle, but also proximal thigh muscles. Insensate feet with DPN cause a delayed neuromuscular response immediately following foot–ground contact during gait and this is a major factor contributing to increased falls risk. Pronounced balance impairments measured in the gait laboratory are only seen in DPN patients and not non-neuropathic diabetes patients. Self-perception of unsteadiness matches gait laboratory measures and can distinguish between patients with and without DPN. Diabetic foot ulcers and their associated risk factors including insensate feet with DPN and offloading devices further increase falls risk. Falls prevention strategies based on sensory and motor mechanisms should target those most at risk of falls with DPN, with further research needed to optimise interventions.
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Jarl G, van Netten JJ, Lazzarini PA, Crews RT, Najafi B, Mueller MJ. Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices? Diabetes Res Clin Pract 2021; 175:108733. [PMID: 33713722 DOI: 10.1016/j.diabres.2021.108733] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 11/17/2020] [Accepted: 02/18/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Dept of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands; School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
| | - Peter A Lazzarini
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Ryan T Crews
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University, North Chicago, IL, USA.
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Michael J Mueller
- Program in Physical Therapy and Department of Radiology, Washington University School of Medicine in St Louis, St. Louis, MO 63108, USA.
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Yalla SV, Crews RT, Patel NA, Cheung T, Wu S. Offloading for the Diabetic Foot: Considerations and Implications. Clin Podiatr Med Surg 2020; 37:371-384. [PMID: 32146989 DOI: 10.1016/j.cpm.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Offloading the diabetic foot remains the major consideration for ulceration prevention and healing. This narrative literature review presents a brief overview of current guidelines for offloading the diabetic foot and discusses the implications that come with offloading treatment modalities and their effects on the kinetic chain of the lower extremity. We also present the latest innovative studies from the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science that advance the knowledge in this field and provide avenues for future research opportunities.
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Affiliation(s)
- Sai V Yalla
- Podiatric Surgery and Applied Biomechanics, Center for Lower Extremity Ambulatory Research (CLEAR), Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, USA.
| | - Ryan T Crews
- Podiatric Surgery and Applied Biomechanics, Center for Lower Extremity Ambulatory Research (CLEAR), Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, USA
| | - Niral A Patel
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine & Science, 3333 Green Bay Road, North Chicago, IL 60064, USA
| | - Timothy Cheung
- School of Graduate and Postdoctoral Studies, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine & Science, 3333 Green Bay Road, North Chicago, IL 60064, USA
| | - Stephanie Wu
- Podiatric Surgery and Applied Biomechanics, Center for Lower Extremity Ambulatory Research (CLEAR), Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, USA
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Lazzarini PA, Jarl G, Gooday C, Viswanathan V, Caravaggi CF, Armstrong DG, Bus SA. Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3275. [PMID: 32176438 PMCID: PMC8370012 DOI: 10.1002/dmrr.3275] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers. METHODS We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis. RESULTS We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia. CONCLUSION Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.
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Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social Work, Queensland
University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles
Hospital, Brisbane, Queensland, Australia
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of
Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine
and Health, Örebro University, Örebro, Sweden
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich
University Hospitals, Norwich, UK
- School of Health Sciences, University of East Anglia,
Norwich, UK
| | | | - Carlo F. Caravaggi
- Diabetic Foot Department, IRCCS Multimedica Group, Milan,
Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA),
Department of Surgery, Keck School of Medicine of University of Southern California
(USC), Los Angeles, California, USA
| | - Sicco A. Bus
- Amsterdam UMC, University of Amsterdam, Rehabilitation
Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Ling E, Lepow B, Zhou H, Enriquez A, Mullen A, Najafi B. The impact of diabetic foot ulcers and unilateral offloading footwear on gait in people with diabetes. Clin Biomech (Bristol, Avon) 2020; 73:157-161. [PMID: 31986461 PMCID: PMC7183883 DOI: 10.1016/j.clinbiomech.2020.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/07/2020] [Accepted: 01/17/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Erica Ling
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; School of Health Professions, Baylor College of Medicine, Houston, TX, USA
| | - Brian Lepow
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - He Zhou
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Ana Enriquez
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Ashley Mullen
- School of Health Professions, Baylor College of Medicine, Houston, TX, USA
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.
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14
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Bus SA, Armstrong DG, Gooday C, Jarl G, Caravaggi C, Viswanathan V, Lazzarini PA. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3274. [PMID: 32176441 DOI: 10.1002/dmrr.3274] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.
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Affiliation(s)
- Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Carlo Caravaggi
- Diabetic Foot Department, IRCCS Multimedica Group, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Abstract
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.
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Crews RT, Candela J. Decreasing an Offloading Device's Size and Offsetting Its Imposed Limb-Length Discrepancy Lead to Improved Comfort and Gait. Diabetes Care 2018; 41:1400-1405. [PMID: 29666111 PMCID: PMC6014548 DOI: 10.2337/dc17-2584] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/26/2018] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ryan T Crews
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, Chicago, IL
| | - Joseph Candela
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, Chicago, IL
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Crews R, King A, Yalla S, Rosenblatt N. Recent Advances and Future Opportunities to Address Challenges in Offloading Diabetic Feet: A Mini-Review. Gerontology 2018; 64:309-317. [DOI: 10.1159/000486392] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/19/2017] [Indexed: 01/08/2023] Open
Abstract
Diabetic foot ulcers (DFU) are a substantial dilemma for geriatric individuals with diabetes. The breakdown in tissue associated with DFU is typically a result of repetitive cycles of physical stress placed on the feet during weight-bearing activity. Accordingly, a key tenet in healing as well as preventing DFU is the use of offloading footwear to redistribute physical stress away from high stress locations such as bony prominences. Over the last several years there has been a substantial amount of effort directed at better understanding and implementing the practice of offloading. A review of this work as well as relevant technological advances is presented in this paper. Specifically, we will discuss the following topics in association with offloading diabetic feet: achieving optimal offloading, dosing activity/physical stress, thermal monitoring to detect preulcerative tissue damage, adherence with offloading devices, and optimizing the user experience. In addition to presenting progress to date, potential directions for further advancement are discussed.
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Crews RT, Smith SR, Ghazizadeh R, Yalla SV, Wu SC. Preliminary Evaluation of a Cycling Cleat Designed for Diabetic Foot Ulcers. J Am Podiatr Med Assoc 2017; 107:475-482. [PMID: 27824259 PMCID: PMC5422142 DOI: 10.7547/15-198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Offloading devices for diabetic foot ulcers (DFU) generally restrict exercise. In addition to traditional health benefits, exercise could benefit DFU by increasing blood flow and acting as thermotherapy. This study functionally evaluated a cycling cleat designed for forefoot DFU. METHODS Fifteen individuals at risk of developing a DFU used a recumbent stationary bicycle to complete one 5-minute cycling bout with the DFU cleat on their study foot and one 5-minute bout without it. Foot stress was evaluated by plantar pressure insoles during cycling. Laser Doppler perfusion monitored blood flow to the hallux. Infrared photographs measured foot temperature before and after each cycling bout. RESULTS The specialized cleat significantly reduced forefoot plantar pressure (9.9 kPa versus 62.6 kPa, P < .05) and pressure time integral (15.4 versus 76.4 kPa*sec, P < .05). Irrespective of footwear condition, perfusion to the hallux increased (3.97 ± 1.2 versus 6.9 ± 1.4 tissue perfusion units, P < .05) after exercise. Infrared images revealed no changes in foot temperature. CONCLUSIONS The specialized cleat allowed participants to exercise with minimal forefoot stress. The observed increase in perfusion suggests that healing might improve if patients with active DFU were to use the cleat. Potential thermotherapy for DFU was not supported by this study. Evaluation of the device among individuals with active DFU is now warranted.
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Affiliation(s)
- Ryan T. Crews
- Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, Center for Lower Extremity Ambulatory Research (CLEAR), North Chicago, IL
| | - Steven R. Smith
- HealthPartners Institute for Education and Research at Regions Hospital, St. Paul, MN
| | | | - Sai V. Yalla
- Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, Center for Lower Extremity Ambulatory Research (CLEAR), North Chicago, IL
| | - Stephanie C. Wu
- Department of Surgery, Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL
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Vileikyte L, Crews RT, Reeves ND. Psychological and Biomechanical Aspects of Patient Adaptation to Diabetic Neuropathy and Foot Ulceration. Curr Diab Rep 2017; 17:109. [PMID: 28942488 DOI: 10.1007/s11892-017-0945-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Loretta Vileikyte
- Department of Medicine, University of Manchester, Manchester, M13 9WL, UK.
| | - Ryan T Crews
- William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, M1 5GD, UK
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Crews RT, Yalla SV, Dhatt N, Burdi D, Hwang S. Monitoring Location-Specific Physical Activity via Integration of Accelerometry and Geotechnology Within Patients With or At Risk of Diabetic Foot Ulcers: A Technological Report. J Diabetes Sci Technol 2017; 11:899-903. [PMID: 27246669 PMCID: PMC5950978 DOI: 10.1177/1932296816651631] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Physical activity variability is a risk factor for diabetic foot ulcers (DFU). Geographic context may influence variability. This study developed initial methods for monitoring location-specific physical activity in this population. Secondarily, preliminary comparisons in location-specific physical activity were made between patients at risk versus patients with active DFU. METHODS Five at-risk and 5 actively ulcerated patients were monitored continuously for 72 hours with physical activity and GPS monitors. A custom algorithm time synchronized the 2 devices' data. RESULTS On average for all 10 subjects, 1.5 ± 2.1% of activity lacked a corresponding GPS location. 80 ± 11% of self-reported activity events per subject had a GPS identified location. The GPS identified locations were in agreement with the self-reported locations 98 ± 6% of the time. DFU participants' weight-bearing activity was 188% higher at home than away from home. At-risk participants showed similar weight-bearing activity at home as active DFU participants, however, at-risk participants had 132% more weight-bearing activity away-from-home. CONCLUSIONS Objectively monitoring location-specific physical activity proved feasible. Future studies using such methodology may enhance understanding of pathomechanics and treatment of DFU.
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Affiliation(s)
- Ryan T. Crews
- Center for Lower Extremity Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, North Chicago, IL, USA
- Ryan T. Crews, MS, CLEAR, William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064, USA.
| | - Sai V. Yalla
- Center for Lower Extremity Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, North Chicago, IL, USA
| | - Navdeep Dhatt
- Center for Lower Extremity Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, North Chicago, IL, USA
| | - Drew Burdi
- Center for Lower Extremity Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, North Chicago, IL, USA
| | - Sungsoon Hwang
- Department of Geography at DePaul University, Chicago, IL, USA
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Crews RT, Schneider KL, Yalla SV, Reeves ND, Vileikyte L. Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review. Diabetes Metab Res Rev 2016; 32:791-804. [PMID: 27155091 PMCID: PMC5466070 DOI: 10.1002/dmrr.2817] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/24/2016] [Accepted: 04/21/2016] [Indexed: 02/06/2023]
Abstract
Obesity and a sedentary lifestyle are common challenges among individuals at risk of diabetic foot ulcers. While substantial research exists on physical activity interventions in adults with diabetes, those at greatest risk for foot ulceration were often excluded or not well represented. Both at-risk patients and their clinicians may be hesitant to increase physical activity because of their perception of diabetic foot ulcer risks. Physical activity is not contraindicated for those at risk of diabetic foot ulcer, yet patients at risk present with unique barriers to initiating increases in physical activity. This review focuses upon the physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers. Offloading, diabetic peripheral neuropathy, depression, pain, self-efficacy and social support, diabetic foot ulcer risk-specific beliefs and emotions, and research to date on exercise interventions in this population are all discussed. Additionally, recommendations for implementing and researching physical activity interventions for individuals at risk for diabetic foot ulcer are provided. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ryan T Crews
- Center for Lower Extremity Ambulatory Research (CLEAR) at Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
| | - Kristin L Schneider
- Department of Psychology, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Sai V Yalla
- Center for Lower Extremity Ambulatory Research (CLEAR) at Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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Crews RT, Shen BJ, Campbell L, Lamont PJ, Boulton AJM, Peyrot M, Kirsner RS, Vileikyte L. Role and Determinants of Adherence to Off-loading in Diabetic Foot Ulcer Healing: A Prospective Investigation. Diabetes Care 2016; 39:1371-7. [PMID: 27271185 PMCID: PMC4955934 DOI: 10.2337/dc15-2373] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 05/09/2016] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ryan T Crews
- Center for Lower Extremity Ambulatory Research at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University, Chicago, IL
| | - Biing-Jiun Shen
- Division of Psychology, Nanyang Technological University, Singapore
| | - Laura Campbell
- The Healing Foundation Centre, Faculty of Life Sciences, University of Manchester, Manchester, U.K
| | - Peter J Lamont
- Department of Medicine, University of Manchester, Manchester, U.K
| | | | | | - Robert S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, FL
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Piaggesi A, Goretti C, Iacopi E, Clerici G, Romagnoli F, Toscanella F, Vermigli C. Comparison of Removable and Irremovable Walking Boot to Total Contact Casting in Offloading the Neuropathic Diabetic Foot Ulceration. Foot Ankle Int 2016; 37:855-61. [PMID: 27083507 DOI: 10.1177/1071100716643429] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite its efficacy in healing neuropathic diabetic foot ulcers (DFUs), total contact cast (TCC) is often underused because of technical limitations and poor patient acceptance. We compared TCC to irremovable and removable commercially available walking boots for DFU offloading. METHODS We prospectively studied 60 patients with DFUs, randomly assigned to 3 different offloading modalities: TCC (group A), walking boot rendered irremovable (i-RWD; group B), and removable walking boot (RWD; group C). Patients were followed up weekly for 90 days or up to complete re-epithelization; ulcer survival, healing time, and ulcer size reduction (USR) were considered for efficacy, whereas number of adverse events was considered for safety. Patients' acceptance and costs were also evaluated. RESULTS Mean healing time in the 3 groups did not differ (P = .5579), and survival analysis showed no difference between the groups (logrank test P = .8270). USR from baseline to the end of follow-up was significant (P < .01) in all groups without differences between the groups. Seven patients in group A (35%), 2 in group B (10%), and 1 in group C (5%) (Fisher exact test P = .0436 group A vs group C) reported nonsevere adverse events. Patients' acceptance and costs were significantly better in group C (P < .05). CONCLUSIONS Our results suggest that a walking boot was as effective and safe as TCC in offloading the neuropathic DFUs, irrespective of removability. The better acceptability and lesser costs of a removable device may actually extend the possibilities of providing adequate offloading. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Alberto Piaggesi
- Sezione Dipartimentale Piede Diabetico, Dipartimento di Area Medica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Chiara Goretti
- Sezione Dipartimentale Piede Diabetico, Dipartimento di Area Medica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Elisabetta Iacopi
- Sezione Dipartimentale Piede Diabetico, Dipartimento di Area Medica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giacomo Clerici
- Centro per la Cura del Piede Diabetico, Istituto di Cura Città di Pavia, Pavia, Italy
| | - Fabio Romagnoli
- U.O.C. Centro Piede Diabetico, Istituto nazionale ricovero e cura anziani, Ancona, Italy
| | - Fabrizia Toscanella
- U.O. Piede Diabetico e ferite difficili. Casa di cura accreditata Villa Tiberia Roma, Roma, Italy
| | - Cristiana Vermigli
- Centro Regionale Specialistico per la Diagnosi e Cura del Piede Diabetico. Azienda Ospedaliero-Universitaria di Perugia, Perugia, Italy
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24
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Bus SA, van Deursen RW, Armstrong DG, Lewis JEA, Caravaggi CF, Cavanagh PR. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:99-118. [PMID: 26342178 DOI: 10.1002/dmrr.2702] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment. METHODS We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006. RESULTS We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches. CONCLUSIONS Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.
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Affiliation(s)
- S A Bus
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - R W van Deursen
- School of Health Care Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - D G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, Arizona, USA
| | - J E A Lewis
- Cardiff and Vale University Health Board and Cardiff School of Health Science, Cardiff Metropolitan University, Cardiff, UK
| | - C F Caravaggi
- University Vita Salute San Raffaele and Diabetic Foot Clinic, Istituto Clinico Città, Studi, Milan, Italy
| | - P R Cavanagh
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Centre, Seattle, WA, USA
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25
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Kirsner R, Vivas A. Lower‐extremity ulcers: diagnosis and management. Br J Dermatol 2015; 173:379-90. [DOI: 10.1111/bjd.13953] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2015] [Indexed: 01/30/2023]
Affiliation(s)
- R.S. Kirsner
- Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine 1600 NW 10th Ave RMSB Room 2023‐A Miami FL 33136 U.S.A
| | - A.C. Vivas
- Department of Dermatology and Cutaneous Surgery University of Miami Miller School of Medicine 1600 NW 10th Ave RMSB Room 2023‐A Miami FL 33136 U.S.A
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26
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27
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Grewal GS, Bharara M, Menzies R, Talal TK, Armstrong D, Najafi B. Diabetic peripheral neuropathy and gait: does footwear modify this association? J Diabetes Sci Technol 2013; 7:1138-46. [PMID: 24124939 PMCID: PMC3876356 DOI: 10.1177/193229681300700506] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Gurtej S. Grewal
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Manish Bharara
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert Menzies
- Wound and Diabetic Foot Center, Department of Medicine, Hamad Medical Co., Doha, Qatar
| | - Talal K. Talal
- Wound and Diabetic Foot Center, Department of Medicine, Hamad Medical Co., Doha, Qatar
| | - David Armstrong
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
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Lin TL, Sheen HM, Chung CT, Yang SW, Lin SY, Luo HJ, Chen CY, Chan IC, Shih HS, Sheu WHH. The effect of removing plugs and adding arch support to foam based insoles on plantar pressures in people with diabetic peripheral neuropathy. J Foot Ankle Res 2013; 6:29. [PMID: 23895323 PMCID: PMC3750449 DOI: 10.1186/1757-1146-6-29] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 06/18/2013] [Indexed: 01/02/2023] Open
Abstract
Background Removable plug insoles appear to be beneficial for patients with diabetic neuropathic feet to offload local plantar pressure. However, quantitative evidence of pressure reduction by means of plug removal is limited. The value of additional insole accessories, such as arch additions, has not been tested. The purpose of this study was to evaluate the effect of removing plugs from foam based insoles, and subsequently adding extra arch support, on plantar pressures. Methods In-shoe plantar pressure measurements were performed on 26 patients with diabetic neuropathic feet at a baseline condition, in order to identify the forefoot region with the highest mean peak pressure (MPP). This was defined as the region of interest (ROI) for plug removal.The primary outcome was measurement of MPP using the pedar® system in the baseline and another three insole conditions (pre-plug removal, post-plug removal, and post-plug removal plus arch support). Results Among the 26 ROIs, a significant reduction in MPP (32.3%, P<0.001) was found after removing the insole plugs. With an arch support added, the pressure was further reduced (9.5%, P<0.001). There were no significant differences in MPP at non-ROIs between pre- and post-plug removal conditions. Conclusions These findings suggest that forefoot plantar pressure can be reduced by removing plugs and adding arch support to foam-based insoles. This style of insole may therefore be clinically useful in managing patients with diabetic peripheral neuropathy.
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Affiliation(s)
- Tung-Liang Lin
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Huey-Min Sheen
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Chin-Teng Chung
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Sai-Wei Yang
- Institute of Biomedical Engineering, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan, Republic of China
| | - Shih-Yi Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Hong-Ji Luo
- School and Graduate Institute of Physical Therapy and Assistive Technology, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan, Republic of China
| | - Chung-Yu Chen
- Graduate School of Physical Education, National Taiwan University of Physical Education and Sport, No. 16, Sec. 1, Shuang-Shih Rd, Taichung 404, Taiwan, Republic of China
| | - I-Cheng Chan
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Hsu-Sheng Shih
- Department of Physical Therapy, Fooyin University, 1 Jinxue Rd., Daliao Dist, Kaohsiung 83102, Taiwan, Republic of China
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China.,College of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan, Republic of China.,Institute of Medical Technology, National Chung-Hsing University, 250 Kuo Kuang Rd, Taichung 402, Taiwan, Republic of China
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A growing troubling triad: diabetes, aging, and falls. J Aging Res 2013; 2013:342650. [PMID: 23476773 PMCID: PMC3586503 DOI: 10.1155/2013/342650] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 01/11/2013] [Indexed: 11/17/2022] Open
Abstract
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.
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