Can't Stand the Pressure: The Association Between Unprotected Standing, Walking, and Wound Healing in People With Diabetes

Management of Diabetic Foot Ulcers with Two Forefoot Offloading Techniques: Case Series

ABSTRACT

Offloading is a key principle to healing diabetic foot ulcers. Nonremovable knee-high offloading devices are considered the criterion standard for offloading plantar forefoot ulcers. However, patients exhibit a limited tolerance for these devices, which contributes to a lack of use. In this case series describing two patients, the authors share two alternative offloading modalities for the treatment of diabetic plantar forefoot ulcers. One patient was managed using a football offloading dressing, and the other was managed with a modified felted football dressing. The football and modified felted football offloading dressings provide a cost-effective, less time-consuming application and often are a better-tolerated alternative to nonremovable knee-high offloading devices. Clinical findings support further investigation into dressing options tolerated by patients with improved adherence and optimal healing outcomes.

Offloading systems for the treatment of neuropathic foot ulcers in patients with diabetes mellitus: a meta-analysis of randomized controlled trials for the development of the Italian guidelines for the treatment of diabetic foot syndrome

AIM

To compare the effectiveness of commonly used offloading devices for the treatment of neuropathic foot ulcers in patients with diabetes mellitus. This meta-analysis (MA) has been performed for giving an answer to clinical questions on this topic of the Italian guideline on diabetic foot syndrome.

METHODS

The present MA includes randomized controlled studies (duration > 12 weeks) comparing, in patients with diabetes mellitus and non-infected neuropathic foot ulcer: any offloading device vs either no offloading device or conventional footwear; removable versus non-removable offloading devices; surgical procedure vs other offloading approaches. The primary endpoint was ulcer healing.

RESULTS

A total of 184 studies were identified, and 18 were considered eligible for the analysis. We found that: any plantar off-loading, when compared to the absence of plantar offloading device, is associated with a higher ulcer healing (MH-OR: 3.13 [1.08, 9.11], p = 0.04, I2 = 0%); total contact cast or nonremovable knee-high walker, compared to other offloading devices, had a higher ulcer healing rate (MH-OR: 2.64 [1.43, 4.89], p = 0.002, I2 = 51%); surgical offloading for active ulcers in combination with post-surgery offloading achieves higher ulcer healing rate when compared to offloading devices alone (MH-OR: 6.77 [1.64, 27.93], p = 0.008, I2 = 0%).

CONCLUSIONS

Any plantar offloading, compared to the absence of plantar offloading device, is associated with a higher ulcer healing rate. Total contact cast or nonremovable knee-high walker, compared to other offloading devices, is preferable. Surgical offloading for active ulcers, in combination with post-surgery offloading devices, achieves a higher ulcer healing rate when compared to other offloading devices alone. Further studies with a larger cohort of patients with diabetic neuropathic foot ulcers and extended follow-up periods are necessary.

Towards a Remote Patient Monitoring Platform for Comprehensive Risk Evaluations for People with Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) significantly affect the lives of patients and increase the risk of hospital stays and amputation. We suggest a remote monitoring platform for better DFU care. This system uses digital health metrics (scaled from 0 to 10, where higher scores indicate a greater risk of slow healing) to provide a comprehensive overview through a visual interface. The platform features smart offloading devices that capture behavioral metrics such as offloading adherence, daily steps, and cadence. Coupled with remotely measurable frailty and phenotypic metrics, it offers an in-depth patient profile. Additional demographic data, characteristics of the wound, and clinical parameters, such as cognitive function, were integrated, contributing to a comprehensive risk factor profile. We evaluated the feasibility of this platform with 124 DFU patients over 12 weeks; 39% experienced unfavorable outcomes such as dropout, adverse events, or non-healing. Digital biomarkers were benchmarked (0-10); categorized as low, medium, and high risk for unfavorable outcomes; and visually represented using color-coded radar plots. The initial results of the case reports illustrate the value of this holistic visualization to pinpoint the underlying risk factors for unfavorable outcomes, including a high number of steps, poor adherence, and cognitive impairment. Although future studies are needed to validate the effectiveness of this visualization in personalizing care and improving wound outcomes, early results in identifying risk factors for unfavorable outcomes are promising.

The Stress of Measuring Plantar Tissue Stress in People with Diabetes-Related Foot Ulcers: Biomechanical and Feasibility Findings from Two Prospective Cohort Studies

Reducing high mechanical stress is imperative to heal diabetes-related foot ulcers. We explored the association of cumulative plantar tissue stress (CPTS) and plantar foot ulcer healing, and the feasibility of measuring CPTS, in two prospective cohort studies (Australia (AU) and The Netherlands (NL)). Both studies used multiple sensors to measure factors to determine CPTS: plantar pressures, weight-bearing activities, and adherence to offloading treatments, with thermal stress response also measured to estimate shear stress in the AU-study. The primary outcome was ulcer healing at 12 weeks. Twenty-five participants were recruited: 13 in the AU-study and 12 in the NL-study. CPTS data were complete for five participants (38%) at baseline and one (8%) during follow-up in the AU-study, and one (8%) at baseline and zero (0%) during follow-up in the NL-study. Reasons for low completion at baseline were technical issues (AU-study: 31%, NL-study: 50%), non-adherent participants (15% and 8%) or combinations (15% and 33%); and at follow-up refusal of participants (62% and 25%). These underpowered findings showed that CPTS was non-significantly lower in people who healed compared with non-healed people (457 [117; 727], 679 [312; 1327] MPa·s/day). Current feasibility of CPTS seems low, given technical challenges and non-adherence, which may reflect the burden of treating diabetes-related foot ulcers.

A Scoping Review of Wearable Technologies for Use in Individuals With Intellectual Disabilities and Diabetic Peripheral Neuropathy

BACKGROUND

Individuals with intellectual disabilities (IDs) are at risk of diabetes mellitus (DM) and diabetic peripheral neuropathy (DPN), which can lead to foot ulcers and lower-extremity amputations. However, cognitive differences and communication barriers may impede some methods for screening and prevention of DPN. Wearable and mobile technologies-such as smartphone apps and pressure-sensitive insoles-could help to offset these barriers, yet little is known about the effectiveness of these technologies among individuals with ID.

METHODS

We conducted a scoping review of the databases Embase, PubMed, and Web of Science using search terms for DM, DPN, ID, and technology to diagnose or monitor DPN. Finding a lack of research in this area, we broadened our search terms to include any literature on technology to diagnose or monitor DPN and then applied these findings within the context of ID.

RESULTS

We identified 88 articles; 43 of 88 (48.9%) articles were concerned with gait mechanics or foot pressures. No articles explicitly included individuals with ID as the target population, although three articles involved individuals with other cognitive impairments (two among patients with a history of stroke, one among patients with hemodialysis-related cognitive changes).

CONCLUSIONS

Individuals with ID are not represented in studies using technology to diagnose or monitor DPN. This is a concern given the risk of DM complications among patients with ID and the potential for added benefit of such technologies to reduce barriers to screening and prevention. More studies should investigate how wearable devices can be used among patients with ID.

Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis

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.

Motivation communication training programme for healthcare professionals to support adherence in patients with diabetic foot ulcers: Proof of concept study

Patients with diabetic foot ulcers have poor adherence to treatment recommendations. However, the most effective way to support adherence in this population is unknown. This study aimed to assess the preliminary effectiveness of a motivation communication training programme for healthcare professionals working with these patients, using theory and evidence-based strategies.A proof-of-concept study using a non-randomised, controlled before-and-after design. Six podiatrists took part in the motivation communication training programme. Pre-training, observation was undertaken to examine the communication style currently used by podiatrists in routine consultations. Patients' (n = 25) perceptions of podiatrist autonomy support, self-determination for limiting weight-bearing activity and average daily step count were also assessed. Post training, observations and patient measures were repeated with a different group of patients (n = 24). Observations indicated that podiatrists exhibited a more need-supportive communication style (e.g., taking time to understand patients' perspectives) after undergoing the training programme. Patients in the post-training group reported higher levels of autonomy support, while self-determination to limit weight-bearing activity remained unchanged. Although the post-training group had a lower average daily step count, the difference was not statistically significant. This is the first study to investigate implementation of motivation communication strategies in routine consultations with patients with diabetic foot ulcers. Results suggest that training can enhance healthcare professionals' motivation communication skills with potential for addressing adherence issues, however, a larger cluster randomised controlled trial is necessary to confirm this.

A qualitative exploration of adherence to wearing removable cast walkers in patients with diabetic foot ulcers

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.

The Validity and Reliability of Self-Reported Adherence to Using Offloading Treatment in People with Diabetes-Related Foot Ulcers

Adherence to using offloading treatment is crucial to healing diabetes-related foot ulcers (DFUs). Offloading adherence is recommended to be measured using objective monitors. However, self-reported adherence is commonly used and has unknown validity and reliability. This study aimed to assess the validity and reliability of self-reported adherence to using removable cast walker (RCW) offloading treatment among people with DFUs. Fifty-three participants with DFUs using RCWs were included. Each participant self-reported their percentage adherence to using their RCW of total daily steps. Participants also had adherence objectively measured using dual activity monitors. After one week, a subset of 19 participants again self-reported their percentage adherence to investigate test-retest reliability. Validity was tested using Pearson's r and Bland-Altman tests, and reliability using Cohen's kappa. Median (IQR) self-reported adherence was greater than objectively measured adherence (90% (60-100) vs. 35% (19-47), p < 0.01). There was fair agreement (r = 0.46; p < 0.01) and large 95% limits of agreement with significant proportional bias (β = 0.46, p < 0.01) for validity, and minimal agreement for test-retest reliability (K = 0.36; p < 0.01). The validity and reliability of self-reported offloading adherence in people with DFU are fair at best. People with DFU significantly overestimate their offloading adherence. Clinicians and researchers should instead use objective adherence measures.

Offloading of Diabetic Neuropathic Plantar Ulcers: Secondary Analysis of Step Activity and Ulcer Healing

OBJECTIVE

Although it is well-known that offloading devices facilitate healing in people with diabetes and neuropathic plantar ulcers, little is known about how step activity affects healing. The purposes of this study were to compare: (1) healing outcomes (time to healing, percentage of ulcers healed); (2) healing rates by ulcer location; and (3) step activity (daily step count, daily peak mean cadence) among patients using either total contact casts (TCCs) or removable cast walker boots (RCWs).

METHODS

The study included 55 participants (TCC, 29; RCW, 26) with diabetes mellitus, peripheral neuropathy, and a Wagner grade 1 or 2 neuropathic plantar ulcer. Each participant wore an activity monitor for 14 consecutive days. Step activity and healing variables were assessed using independent t tests, Kruskal-Wallis, Kaplan-Meier, and Mantel-Cox log-rank tests.

RESULTS

Mean participant age was 55 (SD, 11) years. The percentage of ulcers healed was lower in the RCW group versus the TCC group (65% vs 93%). If healed, average healing rate was 77 (SD, 48) days in the TCC group and 138 (SD, 143) days in the RCW group. Survival distribution by ulcer location was different for RCW forefoot than other locations (132 ± 13 days vs 91 ± 15, 75 ± 11, and 102 ± 36 days for TCC forefoot, TCC-midfoot/hindfoot, and RCW-midfoot/hindfoot, respectively; χ2 = 10.69, P = .014). Average step count was 2,597 in the RCW group versus 1,813 steps in the TCC group (P = .07). The daily peak mean cadence for 20-, 30-, or 60-minute periods was greater with RCW use.

CONCLUSIONS

Step activity in participants with RCWs was increased compared with those with TCCs. Because of their potential to be easily removable, RCWs may impair ulcer healing by allowing greater step activity.

Rehabilitation for people wearing offloading devices for diabetes-related foot ulcers: a systematic review and meta-analyses

BACKGROUND

Offloading devices improve healing of diabetes-related foot ulcers (DFUs) but they can limit mobilisation. Rehabilitation during or after removal of these devices may promote physical activity in a population at risk of poor health outcomes for which inactivity is a reversible risk factor.

METHODS

This systematic review examined the effectiveness of rehabilitation interventions to promote physical activity during and/or after wearing an offloading device to treat diabetes-related foot ulcers. Searches using MESH terms and free-text combinations: 'foot ulcer', 'diabetic foot', 'casts, surgical', 'orthotic devices' were applied to MEDLINE, Embase, The Cochrane Library and clinical trial registers for randomised and observational studies published to September 2022. Methodological quality assessment of included studies was undertaken using the Cochrane Risk of Bias (RoB 2.0) and Risk of Bias In Non-randomised studies of Interventions (ROBINS-I) tools.

RESULTS

Of 3332 records identified, eight studies (441 participants), four clinical trials and four cohort studies, were included. None delivered or tested a structured rehabilitation programme, but all reported physical activity outcomes during or after device use. People wearing non-removable total contact casts were less active than those wearing devices (SMD -0.45; 95% CI - 0.87 to - 0.04; p = 0.03; I² 56%; 4 trials). Diabetes-related foot ulcers in people wearing total contact casts were more likely to heal compared to removable devices at 12 weeks (OR 2.69; 95% CI 0.97 to 7.45; p = 0.06; I² = 64%; 4 trials) and 20 weeks (OR 2.35; 95% CI 0.95 to 5.82; p = 0.07; I² = 65%; 4 trials).

CONCLUSIONS

Despite physical activity being low throughout off-loading treatment, no studies have specifically tested rehabilitation. There is a need to investigate the clinical and cost-effectiveness of rehabilitation programmes in this population. High quality trials are needed to provide robust evidence to support to rehabilitation after DFU treatment.

Taking a Load Off: User Perceptions of Smart Offloading Walkers for Diabetic Foot Ulcers Using the Technology Acceptance Model

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.

Physiotherapeutic interventions in the treatment of patients with diabetic foot ulcers: a systematic literature review

BACKGROUND

Diabetic foot ulcers are chronic wounds that are difficult to heal, with a high rate of recurrent hospitalizations. Due to its multifactorial complexity, treatment must be considered as multidisciplinary, with adjuvant therapy required to aid the healing process.

OBJECTIVES

To identify physiotherapeutic interventions for the treatment of diabetic foot ulcers through a systematic literature review.

DATA SOURCES

PubMed, Cochrane Library, SciELO and Web of Science were searched in April 2020.

STUDY SELECTION OR ELIGIBILITY CRITERIA

The inclusion criteria for this review were: randomised controlled trial published in the last 5 years; written in Portuguese, English or Spanish; subjects aged> 18 years with a diagnosis of diabetic foot ulcers; and physiotherapeutic intervention in combination with multidisciplinary wound management. The methodological quality was assessed using the PEDro scale.

RESULTS

Eight studies were included. Physiotherapists can treat diabetic foot ulcers using therapeutic exercises, electrotherapy, manual therapy and assistive technologies. All physiotherapeutic interventions were adjuvant to standard treatment for wounds provided by other health professionals. The main outcomes were wound size and healing time, with highly favourable results obtained for the experimental groups compared with the control groups.

CONCLUSIONS

Therapeutic exercise, electrotherapy, manual therapy and assistive technologies are physiotherapeutic modalities that, when combined with standard treatment, have been shown to be beneficial in the healing of diabetic foot ulcers.

Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers

BACKGROUND

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

PURPOSE

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

METHODS

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

CONCLUSIONS

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

Smart Offloading Boot System for Remote Patient Monitoring: Toward Adherence Reinforcement and Proper Physical Activity Prescription for Diabetic Foot Ulcer Patients

BACKGROUND

A critical factor in healing diabetic foot ulcers is patient adherence to offloading devices. We tested a smart offloading boot (SmartBoot) combined with a smartwatch app and cloud dashboard to remotely monitor patient adherence and activity. In addition, the impact of SmartBoot on balance, gait, and user experience was investigated.

METHODS

Fourteen volunteers (31.6±8.7 years; 64% female) performed natural activities (eg, sitting, standing, walking) with and without the SmartBoot for approximately 30 minutes. All participants completed balance tests, 10-meter walking tests at slow, normal, and fast pace while wearing the SmartBoot, and a user experience questionnaire. The accuracy of real-time adherence reporting was assessed by comparing the SmartBoot and staff observation. Center of mass (COM) sway and step counts were measured using a validated wearable system.

RESULTS

Average sensitivity, specificity, and accuracy for adherence and non-adherence were 90.6%, 88.0%, and 89.3%, respectively. The COM sway area was significantly smaller with the SmartBoot than without the SmartBoot regardless of test condition. Step count error was 4.4% for slow waking, 36.2% for normal walking, 16.0% for fast walking. Most participants agreed that the SmartBoot is easy to use, relatively comfortable, nonintrusive, and innovative.

CONCLUSIONS

To our knowledge, this is the first smart offloading system that enables remote patient monitoring and real-time adherence and activity reporting. The SmartBoot enhanced balance performance, likely due to somatosensory feedback. Questionnaire results highlight SmartBoot's technical and clinical potential. Future studies warrant clinical validation of real-time non-adherence alerting to improve wound healing outcomes in people with diabetic foot ulcers.

Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers

AIMS

Patients' adherence to using knee-high offloading treatment is critical to effective healing of diabetes-related foot ulcers (DFUs). Previous studies have found that patients generally have low adherence to using removable knee-high offloading treatments, yet no study has investigated whether their adherence differs during daytime and nighttime. This study aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment during daytime and nighttime weight-bearing activities in people with DFUs.

METHODS

This was a secondary analysis of data collected from a multi-centre cross-sectional study investigating adherence to using knee-high RCWs among 57 participants with DFUs. All participants had multiple socio-demographic, physiological and psychosocial factors collected, before having their adherence to using RCWs during weight-bearing activity monitored over a 1-week period using the dual activity monitor method. Adherence data were categorised into daytime (06:00-18:00) and nighttime (18:00-06:00) periods and calculated separately. Multiple linear regression was used to identify factors associated with daytime and nighttime adherence.

RESULTS

Mean adherence to using RCW during weight-bearing activities in people with DFUs was higher during daytime compared with nighttime [39.9% (SD = 18.9) versus 20.4% (SD = 16.7), p < 0.001]. Factors independently associated with lower adherence during daytime were being male, longer diabetes duration, not having peripheral artery disease (PAD), and higher perceived RCW heaviness. Factors associated with lower adherence during nighttime were higher mean daytime steps, not having retinopathy and having dyslipidaemia.

CONCLUSIONS

Adherence to using RCWs during weight-bearing activities reduced significantly at nighttime compared with daytime among people with DFUs, and this was associated with different factors. Interventions to improve adherence, in research and clinical practice, should incorporate methods to target daytime or nighttime adherence specifically.

Mechanical and contact characteristics of foam materials within wound dressings: Theoretical and practical considerations in treatment

In the treatment of acute and chronic wounds, the clinical performance of a given foam-based dressing, and, ultimately, the wound healing and cost of care outcomes are strongly influenced by the mechanical performance of the foam material/s within that dressing. Most aspects of the mechanical performance of foam materials, for example, their stiffness, frictional properties, conformability, swelling characteristics and durability, and the overall mechanical protection provided by a foam-based dressing to a wound strongly depend on the microstructure of the foam components, particularly on their microtopography, density and porosity. This article, therefore, provides, for the first time, a comprehensive, self-inclusive compilation of clinically relevant theoretical and practical considerations, based on published analytical and experimental research as well as clinical experience related to the mechanical performance of foams in foam-based wound dressings. The current bioengineering information is useful for establishing understanding of the importance of mechanical properties of foams in foam-based dressings among clinicians and researchers in industry and academia, and other potential stakeholders in the wound care field, for example, regulators and buyers. This information is also particularly important for the development of standardised test methods for the evaluation of foam-based wound dressings and resulting standard mechanical performance metrics for these dressings.

Weight-bearing physical activity in people with diabetes-related foot disease: A systematic review

INTRODUCTION

Weight-bearing physical activity is important for people with diabetes-related foot disease but may also contribute to ulceration or delayed ulcer healing. No overview of weight-bearing activity of people at different stages of foot disease is available. We aimed to summarise quantitatively measured daily activity levels in people with diabetes-related foot disease.

METHODS

We systematically searched peer-reviewed literature for studies reporting objectively measured weight-bearing activity in people with diabetes-related foot disease. We calculated daily step counts' means (over studies) and weighted means (over participants). International Working Group on the Diabetic Foot (IWGDF) risk strata, different climates, and activity indoors versus outdoors were compared.

RESULTS

From 1247 publications, 27 were included. Mean steps/day in people with IWGDF risk 1/2: 6125 (12 studies; 345 participants; weighted mean: 5384). In IWGDF risk 3: 6167 (8 studies; 291 participants; weighted mean: 6239). In those with a foot ulcer: 4248 (6 studies; 186 participants; weighted mean: 4484). People living in temperate oceanic climates are more active compared to those in hotter or more humid climates (mean steps/day for no ulcer: 7712 vs. 5224 [18 studies]; for ulcer: 6819 vs. 2945 [6 studies]). People are more active indoors than outdoors (mean 4047 vs. 2514 [3 studies]).

CONCLUSION

Levels of weight-bearing physical activity are similar between people with diabetes at various risk levels for foot ulceration but lower for those with a foot ulcer. Weight-bearing activity differs depending on the climatological environment and is higher indoors than outdoors. These findings provide reference for intervention studies or for clinicians aiming to provide mobility advice in this population.

Comparing a non-removable total contact cast with a non-removable softcast in diabetic foot ulcers: A retrospective study of a prospective database

OBJECTIVE

Diabetic foot ulcers (DFUs) are mostly cured by an off-loading cast. Healing ratios of a non-removable Total Contact Softcast (TCS) were compared to a conventional Total Contact Cast (TCC), the latter reporting negative effects on lifestyle and transportation.

METHODS

Analysis of prospectively collected data for 2010-2017. Included were patients with a neuropathic DFU. Ischemic ulcers were excluded, as were Charcot arthropathy, non-plantar/non-forefoot ulcer location, and compliance issues. Patients with TCS were compared to TCC. Primary and secondary outcomes were healing ratio and healing time of DFU.

RESULTS

50 patients with 61 cast periods were included. Mean age was 63.7 ± 10.1 years. Overall successful ulcer healing was 71% (43/61). Except for depth of the DFUs, between-group patient characteristics were comparable; deeper DFUs were reported in the TCC group. This group reported 65% healed DFU (22/34), the TCS group 74% (20/27). Mean healing time was 8.4 weeks (95 %CI 5.9-10.8) for TCC and 5.5 weeks (95 %CI 4.2-6.9) for TCS (p = 0.052). Depth of the wound was a confounder.

CONCLUSIONS

TCS had a similar DFU healing ratio and a potentially clinically relevant effect (HR 1.47, 95 %CI 0.64-3.38) on healing time (ns). Ulcer depth is important for time to ulcer healing. A randomized study is recommended.

Factors associated with adherence to using removable cast walker treatment among patients with diabetes-related foot ulcers

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.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

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.

Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called "remission" due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous "hotspots" prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.

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

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

Photobiomodulation in diabetic wound healing: A review of red and near-infrared wavelength applications

The development of a painless, non-invasive, and faster way to diabetic wound healing is at the forefront of research. The complexity associated with diabetic wounds makes it a cause for concern amongst diabetic patients and the world at large. Irradiation of cells generates a photobiomodulatory response on cells and tissues, directly causing alteration of cellular processes and inducing diabetic wound repair. Photobiomodulation therapy (PBMT) using red and near-infrared (NIR) wavelengths is being considered as a promising technique for speeding up the rate of diabetic wound healing, eradication of pain and reduction of inflammation through the alteration of diverse cellular and molecular processes. This review presents the extent to which the potential of red and NIR wavelengths have been harnessed in PBMT for diabetic wound healing. Important research challenges and gaps are identified and discussed, and future directions mapped out. This review thus provides useful insights and strategies into improvement of PBMT, including its acceptance within the global medical research community.

Harnessing Digital Health Technologies to Remotely Manage Diabetic Foot Syndrome: A Narrative Review

About 422 million people worldwide have diabetes and approximately one-third of them have a major risk factor for diabetic foot ulcers, including poor sensation in their feet from peripheral neuropathy and/or poor perfusion to their feet from peripheral artery disease. The current healthcare ecosystem, which is centered on the treatment of established foot disease, often fails to adequately control key reversible risk factors to prevent diabetic foot ulcers leading to unacceptable high foot disease amputation rate, 40% recurrence of ulcers rate in the first year, and high hospital admissions. Thus, the latest diabetic foot ulcer guidelines emphasize that a paradigm shift in research priority from siloed hospital treatments to innovative integrated community prevention is now critical to address the high diabetic foot ulcer burden. The widespread uptake and acceptance of wearable and digital health technologies provide a means to timely monitor major risk factors associated with diabetic foot ulcer, empower patients in self-care, and effectively deliver the remote monitoring and multi-disciplinary prevention needed for those at-risk people and address the health care access disadvantage that people living in remote areas. This narrative review paper summarizes some of the latest innovations in three specific areas, including technologies supporting triaging high-risk patients, technologies supporting care in place, and technologies empowering self-care. While many of these technologies are still in infancy, we anticipate that in response to the Coronavirus Disease 2019 pandemic and current unmet needs to decentralize care for people with foot disease, we will see a new wave of innovations in the area of digital health, smart wearables, telehealth technologies, and “hospital-at-home” care delivery model. These technologies will be quickly adopted at scale to improve remote management of diabetic foot ulcers, smartly triaging those who need to be seen in outpatient or inpatient clinics, and supporting acute or subacute care at home.

Noninvasive Continuous Monitoring of Vital Signs With Wearables: Fit for Medical Use?

BACKGROUND

Wearables (= wearable computer) enable continuous and noninvasive monitoring of a range of vital signs. Mobile and cost-effective devices, combined with powerful data analysis tools, open new dimensions in assessing body functions ("digital biomarkers").

METHODS

To answer the question whether wearables are ready for use in the medical context, a PubMed literature search and analysis for their clinical-scientific use using publications from the years 2008 to 2018 was performed.

RESULTS

A total of 79 out of 314 search hits were publications on clinical trials with wearables, of which 16 were randomized controlled trials. Motion sensors were most frequently used to measure defined movements, movement disorders, or general physical activity. Approximately 20% of the studies used sensors to detect cardiovascular parameters. As for the sensor location, the wrist was chosen in most studies (22.8%).

CONCLUSION

Wearables can be used in a precisely defined medical context, when taking into account complex influencing factors.

The Role of Foot-Loading Factors and Their Associations with Ulcer Development and Ulcer Healing in People with Diabetes: A Systematic Review

We aimed to comprehensively and systematically review studies associating key foot-loading factors (i.e., plantar pressure, weight-bearing activity, adherence or a combination thereof) with ulcer development and ulcer healing in people with diabetes. A systematic literature search was performed in PubMed and EMBASE. We included studies if barefoot or in-shoe plantar pressure, weight-bearing activity or footwear or device adherence was measured and associated with either ulcer development or ulcer healing in people with diabetes. Out of 1954 records, 36 studies were included and qualitatively analyzed. We found low to moderate quality evidence that lower barefoot plantar pressure and higher footwear and device adherence associate with lower risk of ulcer development and shorter healing times. For the other foot-loading factors, we found low quality evidence with limited or contradictory results. For combined measures of foot-loading factors, we found low quality evidence suggesting that lower cumulative plantar tissue stress is associated with lower risk of ulcer development and higher ulcer healing incidence. We conclude that evidence for barefoot plantar pressure and adherence in association with ulcer outcome is present, but is limited for the other foot-loading factors. More comprehensive investigation in particularly the combination of foot-loading factors may improve the evidence and targeting preventative treatment.

Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review

AIM

To investigate whether ulceration, amputation and healing of foot ulcers in people living with diabetes are associated with psychosocial and behavioural factors.

METHODS

We searched MEDLINE, Embase, PsychINFO, CINAHL and The Cochrane Library to March 2019 for longitudinal studies with multivariable analyses investigating independent associations. Two reviewers extracted data and assessed risk of bias.

RESULTS

We identified 15 eligible studies involving over 12 000 participants. Clinical and methodological heterogeneity precluded meta-analysis, so we summarize narratively. Risk of bias was moderate or high. For ulceration, we found significantly different results for people with and without an ulcer history. For those with no ulcer history, moderate quality evidence suggests depression increases ulcer risk [three studies; e.g. hazard ratio (HR) 1.68 (1.20, 2.35) per Hospital Anxiety and Depression Scale (HADS) standard unit]. Better foot self-care behaviour reduces ulcer risk [HR 0.61 (0.40, 0.93) per Summary of Diabetes Self-Care Activities scale standard unit; one study]. For people with diabetes and previous ulcers, low- or very low-quality evidence suggests little discernible association between ulcer recurrence and depression [e.g. HR 0.88 (0.61, 1.27) per HADS standard unit], foot self-care, footwear adherence or exercise. Low-quality evidence suggests incomplete clinic attendance is strongly associated with amputation [odds ratio (OR) 3.84 (1.54, 9.52); one study]. Evidence for the effects of other psychosocial or behavioural factors on ulcer healing and amputation is very low quality and inconclusive.

CONCLUSIONS

Psychosocial and behavioural factors may influence the development of first ulcers. More high quality research is needed on ulcer recurrence and healing. (Open Science Framework Registration: https://osf.io/ej689).

Leveraging smart technologies to improve the management of diabetic foot ulcers and extend ulcer-free days in remission

The prevalent and long neglected diabetic foot ulcer (DFU) and its related complications rank among the most debilitating and costly sequelae of diabetes. Management of the DFU is multifaceted and requires constant monitoring from patients, caregivers, and healthcare providers. The alarmingly high rates of recurrence of ulcerations in the diabetic foot requires a change in our approach to care and to the vernacular in the medical literature. Our efforts should be directed not only on healing of open wounds, but also on maximizing ulcer-free days for the patient in diabetic foot remission. The increasing development and use of technology within every aspect of our lives represents an opportunity for creative solutions to prevent or better manage this devastating condition. In particular, recent advances in wearable and mobile health technologies appear to show promise in measuring and modulating dangerous foot pressure and inflammation to extend remission and improve the quality of life for these most complex patients. This review article discusses how harnessing wearables and digital technologies may improve the management and optimize prevention of DFUs by identifying high-risk patients for triage and timely intervention, personalizing prescription of offloading, and improving adherence to protective footwear. While still in their infancy, we envisage a future network of skin-worn, jewellery-worn, and implantable sensors that, if allowed to effectively communicate with one another and the patient, could dramatically impact measuring, personalizing, and managing how we and the patients we serve move through our collective world.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review

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.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

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.

Sensor-Based Daily Physical Activity: Towards Prediction of the Level of Concern about Falling in Peripheral Neuropathy

Concern about falling is prevalent and increases the risk of falling in people with peripheral neuropathy (PN). However, the assessment of concern about falling relies on self-report surveys, and thus continuous monitoring has not been possible. We investigated the influence of concern about falling on sensor-based daily physical activity among people with PN. Forty-nine people with PN and various levels of concern about falling participated in this study. Physical activity outcomes were measured over a period of 48 hours using a validated chest-worn sensor. The level of concern about falling was assessed using the falls efficacy scale-international (FES-I). The low concern group spent approximately 80 min more in walking and approximately 100 min less in sitting/lying compared to the high concern group. In addition, the low concern group had approximately 50% more walking bouts and step counts compared to the high concern group. Across all participants, the duration of walking bouts and total step counts was significantly correlated with FES-I scores. The duration of walking bouts and total step counts may serve as eHealth targets and strategies for fall risk assessment among people with PN.

Gait in People With Nonhealing Diabetes-Related Plantar Ulcers

BACKGROUND

Abnormalities in gait have been associated with high plantar pressures and diabetes-related plantar foot ulcers. Whether these are a transient response to the ulcer or are representative of long-term lower limb biomechanical abnormalities is currently unknown.

OBJECTIVE

The aim of this study was to examine whether 12 gait parameters identified as being associated with nonhealing diabetes-related plantar foot ulcers at baseline remained associated during a 6-month follow-up period.

DESIGN

This was a longitudinal observational case-control study.

METHODS

Gait assessments were performed at entry and twice during follow-up over a 6-month period in 12 participants with nonhealing diabetes-related plantar foot ulcers (case participants) and 62 people with diabetes and no history of foot ulcers (control participants) using a standardized protocol. Linear mixed-effects random-intercept models were used to identify gait parameters that consistently differed between case participants and control participants at all assessments after adjustment for age, sex, body mass index, presence of peripheral neuropathy, and follow-up time. Standardized mean differences (SMD) were used to measure effect sizes.

RESULTS

Five of the 12 gait parameters were significantly different between case participants and control participants at all 3 time points. Case participants had a more abducted foot progression angle (SMD = 0.37), a higher pelvic obliquity at toe-off (SMD = -0.46), a greater minimum pelvic obliquity (SMD = -0.52), a lower walking speed (SMD = -0.46), and a smaller step length (SMD = -0.46) than control participants.

LIMITATIONS

The limitations included a small sample size, the observational nature of the study, and the inability to evaluate the impact of gait on wound healing.

CONCLUSIONS

This study identified abnormal gait parameters consistently associated with nonhealing diabetes-related plantar foot ulcers. Further research is needed to test the clinical importance of these gait characteristics.

The Effect of Daily Use of Plantar Mechanical Stimulation Through Micro-Mobile Foot Compression Device Installed in Shoe Insoles on Vibration Perception, Gait, and Balance in People With Diabetic Peripheral Neuropathy

OBJECTIVE

People with diabetic peripheral neuropathy (DPN) have impaired gait and balance performance. The aim of this study is to investigate therapeutic effectiveness of mechanical stimulation through a wearable foot compression device equipped in a shoe insole on vibration perception, balance control and gait performance in people with DPN.

METHODS

Using a single-arm 4-week intervention study design, we examined effectiveness of daily use of shoes equipped with the foot compression device (Footbeat™, AVEX, Grand Junction, CO, USA) on improving vibration perception threshold (VPT_max), skin perfusion pressure (SPP), ankle brachial index (ABI), lower extremities edema (circumferences in the calf and ankle), and motor performance (postural sway with eyes open and closed conditions, and gait performance during normal, dual-task and fast walking). Thirty people with type 2 diabetes and symptoms of PN completed the experimental protocol.

RESULTS

Improvements in VPT_max (before = 27.4 V, after = 23.3 V, P = .007, d = 0.33, where d denotes effect size), center-of-mass sway in the mediolateral direction with both eyes open and closed conditions (before = 0.94 cm, after = 0.76 cm, P = .020, d = 0.47; before = 1.10 cm, after = 0.83 cm, P = .033, d = 0.66, respectively), and stride velocity for normal walking, dual-task walking and fast walking tasks (before = 0.87 m/s, after = 0.96 m/s, P = .017, d = 0.41; before = 0.75 m/s, after = 0.91 m/s, P = .001, d = 0.77; before = 1.10 m/s, after = 1.20 m/s, P = .043, d = 0.33, respectively) were found post treatment. There was no significant improvement in SPP, ABI, and circumferences in the calf and ankle.

CONCLUSIONS

Our findings suggest the wearable foot compression device may be effective for reducing neuropathic symptoms and enhancing motor performances in people with DPN.

Moderate-to-Vigorous-Intensity Physical Activity Observed in People With Diabetes-Related Foot Ulcers Over a One-Week Period

BACKGROUND

Regular moderate-to-vigorous-intensity physical activity results in health benefits in people with diabetes. No study has observed the moderate-to-vigorous-intensity physical activity typically performed by people with diabetes-related foot ulcers (DFU) in their everyday free-living environments. We observed the bouts, and accumulated time, spent doing moderate-to-vigorous-intensity physical activity in cases with DFU compared with diabetes-related peripheral neuropathy (DPN) and diabetes (DM) controls over a one-week period.

METHODS

This was a secondary analysis of a cross-sectional case-control study. Participants wore a multisensor device for >5 days (>22 hours per day). Primary outcomes included the number, duration (minutes) and intensity (metabolic equivalent tasks [METs]) of bouts of moderate-to-vigorous-intensity physical activity (defined as at least >3 METs for >10 consecutive minutes). Secondary outcomes included the total accumulated times spent doing moderate-to-vigorous-intensity physical activity (>3 METs) and doing sedentary-intensity activity (<1.5 METs). DFU subgroups with minor amputations and nonremovable offloading devices were also analyzed.

RESULTS

Overall, 15 DM, 23 DPN, and 27 DFU participants were included. All groups recorded similar low median daily numbers (0.33, 0.29, 0.25 numbers, respectively), duration (15, 17, 14 minutes), and intensity of daily bouts of moderate-to-vigorous-intensity physical activity (4.1, 4.3, 3.9 METs) (all, P > .1). Median accumulated daily time spent doing moderate-to-vigorous-intensity physical activity was also similar (40, 37, 36 minutes; P > .8). Those with DFU had more mean accumulated daily time spent doing sedentary-intensity activity (796 minutes) compared to DPN (720 minutes; P < .05), but not compared to DM (728 minutes; P < .08). DFU subgroups with minor amputations had more median accumulated daily time spent doing moderate-to-vigorous-intensity physical activity (66, 28 minutes; P < .05) and less mean time doing sedentary-intensity activity (745, 837; P < .05) than those without amputations.

CONCLUSIONS

People with DFU performed similar low numbers of daily bouts of moderate-to-vigorous-intensity physical activity to controls, but spend more time doing sedentary-intensity activities. Interventions that gradually increase the moderate-to-vigorous-intensity physical activity in people with DFU should be investigated.

Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management

Excessive stress on plantar tissue over time is one of the leading causes of diabetic foot ulcers among people with diabetic peripheral neuropathy. Plantar tissue stress (PTS) is a concept that attempts to integrate several well-known mechanical factors into one measure, including plantar pressure, shear stress, daily weight-bearing activity, and time spent in prescribed offloading interventions (adherence). Despite international diabetic foot guidelines recommending the measure of each of these individual mechanical factors in people with neuropathy, only recently has technology enabled their combined measurement to determine PTS. In this article we review the concept of PTS, the mechanical factors involved, and the findings of pivotal articles reporting measures of PTS in people with neuropathy. We also discuss key existing gaps in this field, including the lack of standards to measure and report PTS, a lack of practical solutions to measure shear stress, and the lack of PTS thresholds that may indicate benefit or detriment to people with neuropathy. To address some of these gaps, we propose recommended clinical and research standards for measuring and reporting PTS in people with neuropathy. Last, we forecast future clinical, research, and technological advancements that may use PTS to highlight the importance of this critical concept in the prevention and management of diabetic foot ulcers.

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

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

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Toward Smart Footwear to Track Frailty Phenotypes-Using Propulsion Performance to Determine Frailty

Frailty assessment is dependent on the availability of trained personnel and it is currently limited to clinic and supervised setting. The growing aging population has made it necessary to find phenotypes of frailty that can be measured in an unsupervised setting for translational application in continuous, remote, and in-place monitoring during daily living activity, such as walking. We analyzed gait performance of 161 older adults using a shin-worn inertial sensor to investigate the feasibility of developing a foot-worn sensor to assess frailty. Sensor-derived gait parameters were extracted and modeled to distinguish different frailty stages, including non-frail, pre-frail, and frail, as determined by Fried Criteria. An artificial neural network model was implemented to evaluate the accuracy of an algorithm using a proposed set of gait parameters in predicting frailty stages. Changes in discriminating power was compared between sensor data extracted from the left and right shin sensor. The aim was to investigate the feasibility of developing a foot-worn sensor to assess frailty. The results yielded a highly accurate model in predicting frailty stages, irrespective of sensor location. The independent predictors of frailty stages were propulsion duration and acceleration, heel-off and toe-off speed, mid stance and mid swing speed, and speed norm. The proposed model enables discriminating different frailty stages with area under curve ranging between 83.2–95.8%. Furthermore, results from the neural network suggest the potential of developing a single-shin worn sensor that would be ideal for unsupervised application and footwear integration for continuous monitoring during walking.

Health Sensors, Smart Home Devices, and the Internet of Medical Things: An Opportunity for Dramatic Improvement in Care for the Lower Extremity Complications of Diabetes

OBJECTIVE

The prevalent and long-neglected diabetic foot ulcer (DFU) and its related complications rank among the most debilitating and costly sequelae of diabetes. With the rise of the Internet of medical things (IoMT), along with smart devices, the med-tech industry is on the cusp of a home-care revolution, which could also create opportunity for developing effective solutions with significant potential to reduce DFU-associated costs and saving limbs. This article discusses potential applications of IoMT to the DFU patient population and beyond.

METHODS

To better understand potential opportunities and challenges associated with implementing IoMT for management of DFU, the authors reviewed recent relevant literatures and included their own expert opinions from a multidisciplinary point of view including podiatry, engineering, and data security.

RESULTS

The IoMT has opened digital transformation of home-based diabetic foot care, as it enables promoting patient engagement, personalized care and smart management of chronic and noncommunicable diseases through individual data-driven treatment regimens, telecommunication, data mining, and comprehensive feedback tailored to individual requirements. In particular, with recent advances in voice-activated commands technology and its integration as a part of IoMT, new opportunities have emerged to improve the patient's central role and responsibility in enabling an optimized health care ecosystem.

CONCLUSIONS

The IoMT has opened new opportunities in health care from remote monitoring to smart sensors and medical device integration. While it is at its early stage of development, ultimately we envisage a connected home that, using voice-controlled technology and Bluetooth-radio-connected add-ons, may augment much of what home health does today.

An exploratory study on differences in cumulative plantar tissue stress between healing and non-healing plantar neuropathic diabetic foot ulcers

BACKGROUND

Mechanical stress is important in causing and healing plantar diabetic foot ulcers, but almost always studied as peak pressure only. Measuring cumulative plantar tissue stress combines plantar pressure and ambulatory activity, and better defines the load on ulcers. Our aim was to explore differences in cumulative plantar tissue stress between people with healing and non-healing plantar diabetic foot ulcers.

METHODS

We analyzed a subgroup of 31 patients from a randomized clinical trial, treated with a removable offloading device for their plantar diabetic forefoot ulcer. We measured in-device dynamic plantar pressure and daily stride count to calculate cumulative plantar tissue stress at the ulcer location and associated this with ulcer healing and ulcer surface area reduction at four weeks (Student's t and chi-square test for significance, Cohen's d for effect size).

FINDINGS

In 12 weeks, 68% (n = 21) of the ulcers healed and 32% (n = 10) did not. No statistically significant differences were found for cumulative plantar tissue stress, plantar pressure or ambulatory activity between people with healed and not-healed ulcers. Cumulative plantar tissue stress was 25% lower for people with healed ulcers (155 vs. 207 MPa·s/day; P = 0.71; Effect size: d = 0.29). Post-hoc analyses in the 27 patients who self-reported to be adherent to wearing the device showed that cumulative plantar tissue stress was 49% lower for those who reached ≥75% ulcer surface area reduction at four weeks (140 vs. 275 MPa·s/day; P = 0.09; d = 0.76); smaller differences and effect sizes were found for peak pressure (24%), peak pressure-time integral (30%) and ambulatory activity (26%); (P-value range: 0.14-0.97; Cohen's d range: 0.14-0.70).

INTERPRETATION

Measuring cumulative plantar tissue stress may provide insight beyond that obtained from plantar pressure or ambulatory activity alone, with regard to diabetic foot ulcer healing using removable offloading devices. These explorative findings provide baseline data for further studies on this relevant topic.

Recent Advances and Future Opportunities to Address Challenges in Offloading Diabetic Feet: A Mini-Review

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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