Improving foot self-care knowledge, self-efficacy, and behaviors in patients with type 2 diabetes at low risk for foot ulceration: a pilot study

The interplay between patients and healthcare professionals in a cross-sectoral setting in connection with the treatment and care of patients with diabetic foot ulcers: a realistic evaluation

BACKGROUND

Diabetes-related lower extremity complications such as diabetic foot ulcer (DFU) are a global disability burden. Treatment and care for patients with DFU call for a multisectoral approach that incorporates interdisciplinary care pathways. We aimed to explore the interplay between patients with DFU and healthcare professionals in cross-sectoral settings that address treatment and care and to determine "what works, for whom, and under what circumstances".

METHOD

The study was designed as a realistic evaluation. The data were generated from September 2022 to March 2023 and drew upon approximately 60 h of participant observation of 14 patients during the treatment and care of DFUs in their homes (primary care) and/or at outpatient clinics (wound specialist clinics in a hospital setting) in a Danish cross-sectoral setting. The Standards for Reporting Qualitative Research (SRQR) were applied in this study.

RESULTS

We identified three illuminating themes that described the interplay between patients with DFU and related healthcare professionals representing both primary and secondary health care systems: (1) humour is a relationship-enhancing element between nurses and patients; (2) support from patients' coping strategies promotes patient-centeredness and collaboration; and (3) patients and professionals occupy unnegotiated identity roles.

CONCLUSION

Our study led to a refined programme theory developed through the realistic evaluation process that allows us to propose an answer to the problem of "what works, for whom, and under what circumstances". The interplay between patients with DFU and healthcare professionals in a cross-sectoral setting for treatment and care is characterised by the use of humour as a relation-enhancing element and by improving support for patient coping strategies, which encourages healthcare professionals to promote health literacy. Future research should examine strategies for negotiating identity roles between patients with DFU and healthcare professionals to enhance collaboration, patient health literacy, and health promotion in cross-sectoral healthcare settings.

Educational Interventions on Diabetic Foot Self-Care: A Study Protocol for a Pragmatic Randomized Controlled Trial

Diabetic foot is one of the most serious complications of diabetes and foot ulcer recurrence has been associated with poor foot care. Educational programs may work as a vehicle for promoting knowledge and adequate foot self-care behaviors, reducing potential ulcerative complications in the diabetic foot, and promoting a better quality of life. This study protocol will analyze the impact of two different educational strategies - an instructive video (Experimental Group 1) compared to a foot care leaflet with real-time guided reading (Experimental Group 2) and standard care (Control Group) - on adherence and knowledge about diabetic foot care and patients' perception of their foot health. This study is a Pragmatic Randomized Controlled Trial of a non-pharmacological treatment. Participants need to have a diabetic foot diagnosis and attend a Diabetic Foot Multidisciplinary Consultation at two hospitals from the North of Portugal. Participants will be assessed at the first appointment of the diabetic foot consultation (T0), two weeks after (T1), and three months later, at follow-up (T2). Primary outcomes will be adherence and knowledge about diabetic foot care and general foot health. Secondary outcomes will be illness representations regarding diabetic foot. The results of this study will inform educational interventions to decrease diabetic foot ulcers, amputation rates, and the costs associated with both, contributing to foot care adherence and improve patient's quality of life.

Qualitative exploration of patient and healthcare professional perspectives on barriers and facilitators to foot self-care behaviors in diabetes

INTRODUCTION

Diabetic foot ulcers contribute significantly to morbidity and mortality associated with diabetes, but are preventable with good foot self-care. This study sought to explore the perspectives of patients and healthcare professionals (HCPs) on barriers and/or facilitators to foot self-care behaviors in diabetes and areas of consensus and/or tension between patient and HCP perspectives.

RESEARCH DESIGN AND METHODS

This was a sequential, qualitative study that used a hermeneutic phenomenological approach. Phase I involved nine in-depth, semi-structured patient interviews. Phase II involved seven in-depth semi-structured interviews with HCPs (podiatrists, diabetes nurses, foot health practitioners (FHPs) and general practitioners (GPs)). In phase III, findings from phases I and II were brought back to two patient interview groups (five patients in total) to try and identify any areas of consensus and tension between HCP and patient perspectives.

RESULTS

Patient and HCP perspectives had several areas of alignment: concerns over consequences of diabetes complications; the importance of patient education and frustrations around aspects of health service delivery. There were also some notable tensions identified: mixed messaging from HCPs around whose responsibility patient foot health is; and who patients should initially consult following the development of a foot problem. Overall, patients expressed that motivation to undertake good foot self-care behaviors was generated from their lived experiences, and was enhanced when this aligned with the information they received from HCPs. HCPs appeared to attribute lack of patient motivation to lack of knowledge, which was not raised by patients.

CONCLUSIONS

This study has identified points of misalignment between the views of patients and practitioners that may help to explain why adherence to foot self-care among patients with diabetes is low. Our results suggest that better outcomes may stem from HCPs focusing on supporting autonomous motivation for self-care and enhancing the rationale through referencing patients' own experience rather than focussing on increasing patient knowledge. Renewed focus on consistency of messaging by HCPs around the roles and responsibilities relating to foot health in diabetes, and the benefit of foot-specific training being provided to non-foot specialist HCPs may also help to improve uptake and adherence to foot self-care behaviors in diabetes.

The Effect of Foot Care Education for Patients with Diabetes on Knowledge, Self-Efficacy and Behavior: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to synthesize randomized controlled trials on the impact of foot care education on knowledge, self-efficacy and behavior in patients with diabetes. A search was made using PubMed, Web of Science, Science Direct, Google Scholar, YOK National Thesis Center and Google Scholar electronic databases for studies published between March 2003-January 2022. The search medical subject headings (MeSH) terms were diabetic foot, knowledge, self-efficacy, and behavior. Studies suitable for the systematic review and the meta-analysis met the following criteria (PICOS): target participants would be diagnosed with diabetes (population), diabetic foot education (intervention), comparison of the group receiving diabetic foot care education and routine care education, and the control group receiving only routine care education (comparison), studies evaluating the levels of knowledge, self-efficacy and behavior (outcome), randomized controlled trials (study design). Twenty-six studies were included in systematic review. Three studies for knowledge, 5 studies for behavior, 8 studies for self-efficacy were included in the meta-analysis (total sample: 2534, experiment: 1464, control: 1071). All of the studies had low reporting bias. The mean duration of educations for knowledge was 5.2 months. This duration was 4.8 months for behavior and 4.5 months for self-efficacy. In the random effect (since the homogeneity test: P < .001, this model was used), there were significantly difference in terms of knowledge (standardized mean difference (SMD): 1.656, 95% [CI]: 1.014-2.299, P < .001), and behavior (SMD: 1.045, 95% CI: 0.849-1.242, P < .001). But no difference was observed in terms of self-efficacy (SMD: 0.557, 95%CI: -0.402-1.517, P > .05). The results of a systematic review of twenty-six studies and a meta-analysis of 9 studies showed that diabetic foot education improved the level of knowledge and behavior of patients with diabetes, while not affecting their self-efficacy. Educational interventions with long-term follow-up are needed to address the growing health care needs of patients with diabetes.

Occupational Therapy Practice Guidelines for Adults With Chronic Conditions

IMPORTANCE

Demand is increasing for occupational therapy practitioners to help the growing population of adults with chronic conditions manage their conditions.

OBJECTIVE

This Practice Guideline, which is informed by systematic reviews of the literature on the use of self-management interventions, is meant to guide occupational therapy practitioners' clinical decision making when working with community-dwelling adults with chronic conditions. The chronic conditions included heart disease, chronic lung conditions, diabetes, and kidney disease. The self-management interventions addressed ADLs and sleep and rest; IADLs; education, work, volunteering, leisure, and social participation; and the caregiver role.

METHOD

We reviewed, discussed, and integrated the clinical recommendations developed from four systematic reviews, supporting literature, and expert opinion to provide recommendations for practice.

RESULTS

A total of 102 articles were included in the systematic reviews, which served as the primary basis for the practice recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports clinical recommendations for the use of self-management interventions when working with clients with chronic conditions. We recommend the use of a multimodal approach that includes three components-education, goal setting, and problem solving-over an extended period to assist clients in establishing self-management habits and routines. On the basis of emerging evidence and expert opinion, we recommend that occupational therapy practitioners consider using a prevention approach, helping clients establish habits and routines, and emphasizing shared goal setting when addressing clients' self-management of chronic conditions. What This Article Adds: This Practice Guideline provides a summary of strong to moderate evidence that supports clinical recommendations for the use of self-management interventions with clients with chronic conditions. When guided by this evidence, occupational therapy practitioners are better able to help clients meet their occupational challenges.

Effectiveness of a Transtheoretical Model-Based Foot Care Program in Improving Foot Care Behaviors and Self-Efficacy in Adults With Type 2 Diabetes: An Assessor-Blinded Randomized Controlled Trial

This study aimed to evaluate the effects of a transtheoretical model (TTM)-based foot care program on foot self-care behaviors and self-efficacy among adults with type 2 diabetes (T2DM). A prospective, assessor-blinded, randomized controlled trial was conducted between January 2020 and October 2020 at the endocrinology outpatient unit of a hospital in the north-west Turkey. The sample was composed of 51 adults with T2DM randomly allocated to the intervention group (n = 25) and control group (n = 26). The intervention group received the TTM-based foot care program during a 6-month period. The data were analyzed using the two-way repeated measure analysis of variance (ANOVA). After intervention, the intervention group's the diabetic foot care self-efficacy scale scores increased significantly at 3 and 6 months, compared with the control group. Similarly, the intervention group's the foot self-care behavior scale scores also increased significantly at 3 months and 6 months.

Self-Management Interventions to Improve Activities of Daily Living and Rest and Sleep for Adults With Chronic Conditions: A Systematic Review

IMPORTANCE

Chronic conditions often cause functional impairments in activities of daily living (ADLs) and rest and sleep, leading to decreased independence and self-efficacy.

OBJECTIVE

To aid occupational therapy practitioners in making informed decisions regarding self-management interventions to improve ADLs and rest and sleep for community-dwelling adults with chronic conditions.

DATA SOURCES

We identified literature published from 1995 to 2019 through searches of the Cochrane Database of Systematic Reviews, MEDLINE, PsycINFO, CINAHL, and OTseeker. Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to abstract and assess data quality and validity. The review followed American Occupational Therapy Association Evidence-Based Practice Project methodology. Studies addressing self-management interventions for community-dwelling adults ages 18 and older with chronic cardiovascular disease, Type 2 diabetes, heart disease, hypertension, chronic respiratory problems, or kidney disease were included.

FINDINGS

Fifteen articles met inclusion criteria and were categorized into ADLs and sleep. Strong evidence supports education to improve diabetic foot self-care. Low evidence addresses exercise and education to improve ADLs for people with heart disease and chronic obstructive pulmonary disease. Moderate evidence supports mind-body self-care education to enhance sleep.

CONCLUSIONS AND RELEVANCE

Occupational therapy practitioners working with adults with diabetes are encouraged to routinely offer education that includes discussion of risk factors and daily foot inspections and hygiene. When addressing sleep, education that addresses sleep hygiene, nutrition, relaxation techniques, and physical activity should routinely be provided to adults with chronic conditions. Further research is needed to understand the dosage needed. What This Article Adds: This systematic review supports the role of occupational therapy in providing self-management interventions to address ADLs and sleep for adults with diabetes and other chronic conditions.

A fact-finding survey on self-efficacy of foot care behaviour in patients with diabetes: Analysis using the Diabetes Study from the Center of Tokyo Women's Medical University 2017 (DIACET 2017)

Aim

We aimed to determine the association between self‐efficacy of foot care behaviour and chronic complications in Japanese patients with diabetes.

Methods

We conducted a cross‐sectional study based on a questionnaire survey of 4571 patients with type 1 and type 2 diabetes who had (a) given consent to participate in the Diabetes Study from the Center of Tokyo Women's Medical University: DIACET 2017, and (b) completed all the questions of the Japanese Version of Foot Care Confidence Scale (J‐FCCS), consisting of 12 statements.

Results

A greater proportion of respondents answered that they were not confident in determining the condition of corns and/or calluses and the condition of toenails. The J‐FCCS total scores of the patients with retinopathy (p <.001) and numbness or pain in the feet (p <.001) were significantly lower than those of the patients without these complications. In both the multiple regression analysis and logistic regression analysis, lower J‐FCCS was significantly associated with retinopathy and numbness or pain in the feet.

Conclusion

Foot care education that emphasizes a psychological approach in improving confidence associated with foot self‐care is important for patients with advanced complications of diabetes.

Behaviour change approaches for individuals with diabetes to improve foot self-management: a scoping review

BACKGROUND

Diabetes related foot complications are increasing in complexity, frequency and cost. The application of self-management strategies can reduce the risk of individuals developing foot complications. The type, range and nature of the literature focusing on interventions that support patients with diabetic foot self-management is unknown. This scoping review aimed to i) identify self-management actions and risky behaviour avoidance strategies within interventions, ii) map the theoretical functions through which these behaviour change interventions have an effect, iii) display gaps in the research.

METHODOLOGY

Arksey and Malley's (2003) 5 stage framework was followed to conduct the scoping study. This methodological framework was selected because it was developed specifically for scoping reviews and therefore offered clear methodological distinction from systematic review methodology. . Databases were searched from inception of the project until June 2020 supplemented by hand searching of reference lists. In total 988 papers were identified. These were independently screened by three reviewers, identifying 19 eligible papers. Data extraction and charting of data was independently conducted by three reviewers to identify study characteristics, self-management actions and risky behaviours. Data was charted against the COM-B (capability, opportunity, motivation, behaviour) model of behaviour to determine intervention function.

RESULTS

In total 25 different foot self-management actions and risk behaviours were classified into three themes; routine self-management, trauma avoidance and warning signs and actions. Inspect feet daily received the most attention. The majority of interventions focused on knowledge and skills, but overlooked taking action and decision making. Intervention mapping identified four primary intervention functions (education, persuasion, training and enablement) used to address deficits in capability, opportunity and motivation that positively improved foot self-management behaviour. No studies targeted first ulcer prevention, and most either did not measure or improve foot health outcomes.

CONCLUSION

This review charted the evidence for interventions promoting diabetic foot self-management through a theoretical behaviour change perspective. A core set of behaviour change activities and intervention functions associated with positive changes in behaviour were identified. This information will provide researchers with a useful basis for developing self-management interventions.

Effect of an Educational Intervention Based on Bandura's Theory on Foot Care Self-Efficacy in Diabetes: A Prospective Quasi-Experimental Study

The purpose of this study is to evaluate the foot care self-efficacy of diabetic foot patients and the effect of an educational intervention for improving it. This study was of a semi-experimental design and was conducted between January and December 2019 in a diabetic foot council of a university hospital. After power analysis to determine sample size, 33 participants meeting the inclusion criteria were included in the study. A Patient Identification Form and Diabetic Foot Care Self-Efficacy Scale (DFCSES) were used to collect data. Of the patients, 51.5% were male and the mean age was 54.91 ± 16.61 years. The mean score of DFCSES was 50.18 ± 20.88 before education and 72.67 ± 20.74 after education. The educational intervention has large effects on self-efficacy (d = 1.233), perceived knowledge level on diabetic foot (d = 1.102), perceived health status (d = 0.859), and perceived quality of life (d = 0.807). Educational intervention was found to be an effective way to improve foot care self-efficacy, perceived knowledge level on diabetic foot, perceived health status, and perceived quality of life.

Effectiveness of a theory-based foot care education program (3STEPFUN) in improving foot self-care behaviours and foot risk factors for ulceration in people with type 2 diabetes

AIMS

To evaluate the effectiveness of a theory-based foot care education intervention program (3STEPFUN) for people with type 2 diabetes at low risk of developing a foot ulcer.

METHODS

A controlled, pre-test/ post-test quasi-experimental design was used. From 119 participants, 60 participants in the control group received usual care and a foot care brochure. Those in the intervention group received (1) a small group intensive education and hands-on skills session; (2) a foot care kit and documents; and (3) three regular booster follow-up phone calls over 6 months. Generalised Estimating Equations models were undertaken to examine the impact of the intervention on outcomes over time.

RESULTS

The intervention group had significantly improved outcomes compared to the control group over 6 months in the following aspects: improved preventive foot care behaviour (p = 0.001); and decreased prevalence of foot risk factors for ulceration (i.e. dry skin, corns/ callus) (OR: 0.04, 95% CI 0.01 - 0.13, p < 0.001).

CONCLUSIONS

The study's findings provide evidence of 3STEPFUN on improving foot self-care behaviour and preventing minor foot problems. Further study with formal RCT design and longer follow-up time to examine the effects on decreasing foot ulcer incidence is recommended.

Challenges of foot self-care in older people: a qualitative focus-group study

Background

Foot health is an important aspect of general health, and it can be maintained and promoted through foot self-care. However, little is known about older people’s experiences of caring for their feet. The aim of this study was to gather knowledge about experiences of foot self-care from the perspective of healthy older people in order to improve their welfare and their management of foot health.

Methods

A qualitative descriptive design with focus groups was used. Seventeen older people recruited from daytime activity centres participated in the focus groups (n = 4). The data were analysed using inductive content analysis.

Results

The participants described their foot self-care as including various activities, but they were hindered by the following factors: physical (e.g. changes in nail structure), external (e.g. seeking help from multi-level professionals) and internal (e.g. related to ageing). Foot self-care was considered to be important, but it was not systematically carried out. The participants thought that health-care professionals neglected patients’ feet.

Conclusions

Older people use a variety of methods to care for their feet. However, several factors hinder their ability to do so. Older people need advice, education and support to maintain their foot health. Future research is needed to identify effective ways to support older people in foot self-care and improve their welfare as active citizens.

Cross-Validating a Structural Model of Factors Influencing Diabetes Self-Management in Chinese Americans with Type 2 Diabetes

Introduction: The purpose of this study was to cross-validate a structural model depicting the effects of individual and environmental factors on diabetes self-management in Chinese Americans with type 2 diabetes. Methodology: A cross-sectional survey was administered to a convenience sample of 209 Chinese Americans with type 2 diabetes in the Midwest of the United States. Structural equation modeling was used to cross-validate the model fit. Results: Provider–patient communication indirectly influenced self-management via belief in treatment. Knowledge indirectly influenced self-management via belief in treatment and self-efficacy. Social support indirectly influenced self-management via belief in treatment and knowledge. Discussion: This study demonstrated that the structural model, previously tested with Chinese diabetes patients in China, also fits Chinese Americans in the United States with few modifications. The cross-validated model provides a theoretical basis for developing culturally relevant diabetes self-management interventions for Chinese Americans, which may lead to health improvements in this ethnic population.

The effects of self-efficacy enhancing program on foot self-care behaviour of older adults with diabetes: A randomised controlled trial in elderly care facility, Peninsular Malaysia

BACKGROUND

Self-care behaviour is essential in preventing diabetes foot problems. This study aimed to evaluate the effectiveness of health education programs based on the self-efficacy theory on foot self-care behaviour for older adults with diabetes.

METHODS

A randomised controlled trial was conducted for 12 weeks among older adults with diabetes in elderly care facility in Peninsular Malaysia. Six elderly care facility were randomly allocated by an independent person into two groups (intervention and control). The intervention group (three elderly care facility) received a health education program on foot self-care behaviour while the control group (three elderly care facility) received standard care. Participants were assessed at baseline, and at week-4 and week-12 follow-ups. The primary outcome was foot-self-care behaviour. Foot care self-efficacy (efficacy expectation), foot care outcome expectation, knowledge of foot care and quality of life were the secondary outcomes. Data were analysed with Mixed Design Analysis of Variance using the Statistical Package for the Social Sciences version 22.0.

RESULTS

184 respondents were recruited but only 76 met the selection criteria and were included in the analysis. Foot self-care behaviour, foot care self-efficacy (efficacy expectation), foot care outcome expectation and knowledge of foot care improved in the intervention group compared to the control group (p < 0.05). However, some of these improvements did not significantly differ compared to the control group for QoL physical symptoms and QoL psychosocial functioning (p > 0.05).

CONCLUSION

The self-efficacy enhancing program improved foot self-care behaviour with respect to the delivered program. It is expected that in the future, the self-efficacy theory can be incorporated into diabetes education to enhance foot self-care behaviour for elderly with diabetes living in other institutional care facilities.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12616000210471.

The Impact of Three-month Training Programme on Foot Care and Self-efficacy of Patients with Diabetic Foot Ulcers

INTRODUCTION

Patient's self-efficacy in disease management and foot care is considered as an important indicator in controlling the complications of diabetes.

AIM

This study was aimed to determine the effect of three-month training programme on foot care and self-efficacy of patients with diabetic foot ulcers.

MATERIALS AND METHODS

A quasi-experimental study was conducted on 60 patients with diabetic foot ulcers in Jiroft Imam Khomeini hospital from January 2016 to May 2016. These patients were randomly divided into intervention and control groups (30 patients in each group). The research instrument was a questionnaire on demographic data, self-efficacy questions for patients with diabetes and a researcher made questionnaire of diabetic foot care. Training programmes for foot ulcers care and prevention of new ulcers formation and other aspects of the disease were implemented during three months in the test group. Data were analysed using descriptive and analytic statistical tests (Mann-Whitney U, paired t-test and Pearson correlation coefficient) by SPSS version 18.0 software.

RESULTS

The results showed statistically significant difference (p<0.001) in the score of self-efficacy between intervention group (182.25) and control group (93.56), and the foot care score was 47.43 in the intervention group and 30.18 in control group after the intervention. The average scores of self-efficacy and foot ulcers care significantly increased in the intervention group after training programme (p<0.001).

CONCLUSION

The results showed that the implementation of training programme has been able to increase the self-efficacy of patients and the rate of their foot ulcers care and the prevention of new ulcers and effectively reduce the complications in diabetic patients.

Nurses' Perceptions of Their Foot Health: Implications for Occupational Health Care

Nursing practice includes static standing and much walking causing strains to lower extremities. However, little is known about nurses' foot health and particularly their perceptions of their foot health. Therefore, in this study operating room nurses' perceptions of their foot health was investigated and promoting and hindering factors were identified. In total, 14 operating room nurses participated in in-depth interviews. The informants regarded foot health as part of general health and moreover a significant part of work well-being. Promoting factors for foot health were activity in sports and foot self-care as well as varying work conditions and seeing patients with severe foot conditions which served as a motivating factor to care for their own feet. On the contrary, hindering factors were unsuitable footwear, constant standing, and lack of motivation to care for their own feet. Based on this study, nurses' value their foot health which should be promoted. Nurses could benefit from annual foot health assessments and foot self-care education provided by occupational health professionals.

A self-efficacy education programme on foot self-care behaviour among older patients with diabetes in a public long-term care institution, Malaysia: a Quasi-experimental Pilot Study

OBJECTIVE

A pilot self-efficacy education programme was conducted to assess the feasibility, acceptability and potential impact of the self-efficacy education programme on improving foot self-care behaviour among older patients with diabetes in a public long-term care institution.

METHOD

A prequasi-experimental and postquasi-experimental study was conducted in a public long-term care institution in Selangor, Malaysia. Patients with diabetes aged 60 years and above who fulfilled the selection criteria were invited to participate in this programme. Four self-efficacy information sources; performance accomplishments, vicarious experience, verbal persuasion and physiological information were translated into programme interventions. The programme consisted of four visits over a 12-week period. The first visit included screening and baseline assessment and the second visit involved 30 min of group seminar presentation. The third and fourth visits entailed a 20-min one-to-one follow-up discussion and evaluation. A series of visits to the respondents was conducted throughout the programme. The primary outcome was foot self-care behaviour. Foot self-efficacy (efficacy-expectation), foot care outcome expectation, knowledge of foot care, quality of life, fasting blood glucose and foot condition were secondary outcomes. Data were analysed with descriptive and inferential statistics (McNemar's test and Wilcoxon signed-rank test) using the Statistical Package for the Social Sciences V.20.0.

RESULTS

Fifty-two residents were recruited but only 31 met the inclusion criteria and were included in the analysis at baseline and at 12 weeks postintervention. The acceptability rate was moderately high. At postintervention, foot self-care behaviour (p<0.001), foot self-efficacy (efficacy-expectation), (p<0.001), foot care outcome expectation (p<0.001), knowledge of foot care (p<0.001), quality of life (physical symptoms) (p=0.003), fasting blood glucose (p=0.010), foot hygiene (p=0.030) and anhydrosis (p=0.020) showed significant improvements.

CONCLUSION

Findings from this pilot study would facilitate the planning of a larger study among the older population with diabetes living in long-term care institutions.

TRIAL REGISTRATION NUMBER

ACTRN12616000210471; Pre-results.

Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review

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.