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Withers RV, Perrin BM, Landorf KB, Raspovic A. Offloading effects of a removable cast walker with and without modification for diabetes-related foot ulceration: a plantar pressure study. J Foot Ankle Res 2023; 16:27. [PMID: 37170147 PMCID: PMC10173588 DOI: 10.1186/s13047-023-00625-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/24/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Removable cast walkers (RCWs), with or without modifications, are used to offload diabetes-related foot ulcers (DRFUs), however there is limited data relating to their offloading effects. This study aimed to quantify plantar pressure reductions with an RCW with and without modification for DRFUs. METHODS This within-participant, repeated measures study included 16 participants with plantar neuropathic DRFUs. Walking peak plantar pressures at DRFU sites were measured for four conditions: post-operative boot (control condition), RCW alone, RCW with 20 mm of felt adhered to an orthosis, and RCW with 20 mm of felt adhered to the foot. RESULTS Compared to the control condition, the greatest amount of peak plantar pressure reduction occurred with the RCW with felt adhered to the foot (83.1% reduction, p < .001). The RCW with felt adhered to the foot also offered greater peak plantar pressure reduction than the RCW alone (51.3%, p = .021) and the RCW with felt adhered to an orthosis (31.4%, p = .009). CONCLUSION The largest offloading effect recorded was with the RCW with felt adhered to the foot. High-quality randomised trials are now needed to evaluate the effectiveness of this device for healing DRFUs.
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Affiliation(s)
- Rebekah V Withers
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086, Australia
| | - Byron M Perrin
- La Trobe Rural Health School, La Trobe University - Bendigo Campus, Flora Hill, 3552, Australia
| | - Karl B Landorf
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086, Australia
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, 3086, Australia.
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2
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Shi QQ, Li PL, Yick KL, Li NW, Jiao J. Effects of contoured insoles with different materials on plantar pressure offloading in diabetic elderly during gait. Sci Rep 2022; 12:15395. [PMID: 36100637 PMCID: PMC9470545 DOI: 10.1038/s41598-022-19814-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/05/2022] [Indexed: 01/22/2023] Open
Abstract
To investigate the effect of contoured insoles constructed of different insole materials, including Nora Lunalastik EVA, Nora Lunalight A fresh, Pe-Lite, and PORON Medical 4708 with Langer Biomechanics longitudinal PPT arch pads on offloading plantar pressure on the foot of the elderly with Type 1 or 2 diabetes during gait. Twenty-two elderly with Type 1 or 2 diabetes participated in the study. Their plantar pressure was measured by using an insole measurement system, while the participants walked 10 m in their bare feet or used each experimental insole in random order. The plantar surface was divided into four specific regions including the toes, forefoot, midfoot, and rearfoot. The mean peak pressure (MPP) and pressure-time integral (PTI) of ten steps with or without wearing one of the four insoles were analyzed on the dominant foot and the four specific plantar regions. After completion of the activities, the participants scored each insole from 1 (the least comfortable) to 10 (the most comfortable). The analysis of variance (ANOVA) factor of the insoles had significant effects on the MPP (P < 0.001) and PTI (P = 0.004) in the dominant foot during gait. Pairwise comparison results showed that the MPP and PTI in the dominant foot were significantly lower (P < 0.001) with PORON Medical 4708 than barefoot, Nora Lunalight A fresh, and Pe-Lite. Additionally, the insole materials had a significant effect for the forefoot (P < 0.001) and rearfoot (P < 0.001) in terms of the MPP and PTI compared with the barefoot condition during gait. Regardless of the plantar region, the MPP and PTI values were the lowest when PORON Medical 4708 was used as the insole material among four insole materials. Meanwhile, a significantly lower MPP and PTI can be found in the forefoot and rearfoot with the use of the four experimental insoles when compared with barefoot. The soft insole materials (i.e., PORON medical 4708 and Nora Lunalastik EVA) had a better performance than the rigid insole materials (i.e., Nora Lunalight A fresh, and Pe-Lite) on plantar pressure offloading for diabetic elderly.
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Affiliation(s)
- Qiu Qiong Shi
- School of Fashion and Textiles, The Hong Kong Polytechnic University, Hong Kong, China
| | - Pui Ling Li
- Laboratory for Artificial Intelligence in Design, Hong Kong, China
| | - Kit-Lun Yick
- School of Fashion and Textiles, The Hong Kong Polytechnic University, Hong Kong, China.
- Laboratory for Artificial Intelligence in Design, Hong Kong, China.
| | - Nga-Wun Li
- Laboratory for Artificial Intelligence in Design, Hong Kong, China
| | - Jiao Jiao
- Dr. Stephen Hui Research Centre for Physical Recreation and Wellness, Hong Kong Baptist University, Hong Kong, China
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3
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Shimbo K, Okuhara Y, Yokota K. Effectiveness of Flexor Tenotomy With a Transpositional Skin Flap for the Treatment of Severe Claw Toe Deformity With Mild-to-Moderate Joint Contracture. J Foot Ankle Surg 2021; 60:1290-1292. [PMID: 34272160 DOI: 10.1053/j.jfas.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 10/02/2020] [Accepted: 10/12/2020] [Indexed: 02/03/2023]
Abstract
Flexor tenotomy is the most effective for achieving healing and for the prevention of toe ulcer resulting from claw toe deformity. Although flexor tenotomy might be effective for a flexible claw toe, it might not provide benefits for severe claw toe deformity involving joint contracture. We devised a method involving the transfer of a flap to the skin defect caused by tenotomy, as severe claw toe deformity is associated with skin contracture. Although transpositional skin flap might increase the postoperative complication risks, it can be effectively used for severe claw toe deformity involving mild-to-moderate joint contracture.
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Affiliation(s)
- Keisuke Shimbo
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.
| | - Yukako Okuhara
- Department of Plastic and Reconstructive Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Kazunori Yokota
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
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4
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Lazzarini PA, Jarl G. Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:941. [PMID: 34577864 PMCID: PMC8471745 DOI: 10.3390/medicina57090941] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.
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Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane 4059, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane 4032, Australia
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, SE-70182 Örebro, Sweden;
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, SE-70182 Örebro, Sweden
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5
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Wang D, Ouyang J, Zhou P, Yan J, Shu L, Xu X. A Novel Low-Cost Wireless Footwear System for Monitoring Diabetic Foot Patients. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2021; 15:43-54. [PMID: 33296308 DOI: 10.1109/tbcas.2020.3043538] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Diabetic foot is one of the main complications of diabetes with the characteristics of high incidence and difficulty in treatment. Diabetic patients with peripheral neuropathy may develop foot ulcers, and in severe cases amputations are required and some may even die. Plantar pressure can be used to assess the risk of developing diabetic foot, but the existing plantar pressure monitoring methods are not suitable for long-term monitoring in daily life. This study presents a novel low-cost shoe system for daily monitoring of plantar pressure in diabetics. It includes an insole with pressure sensor array, which can dynamically monitor the plantar pressure and display the changes of plantar pressure in real time in the mobile phone to provide early warning for patients with high risk of diabetic foot. As for the sensor, copper and carbon black were adopted as the electrode and conductive filler respectively, enabling a mass production with low price. It was soft and bendable, meeting the performance needs of daily plantar pressure monitoring. All devices were encapsulated in shoes, and the data was transmitted wirelessly through Bluetooth, which did not affect the user's walking. After using random forest for feature selection, five classifiers were used to classify the plantar pressure of healthy people, diabetic patients without peripheral neuropathy, and diabetic patients with peripheral neuropathy collected by this system. The experimental results showed that the accuracy of the random forest classifier was the highest, reaching 94.7%, which indicated that the system could be useful for daily plantar pressure monitoring of diabetic patients.
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Korada H, Maiya A, Rao SK, Hande M. Effectiveness of customized insoles on maximum plantar pressure in diabetic foot syndrome: A systematic review. Diabetes Metab Syndr 2020; 14:1093-1099. [PMID: 32652497 DOI: 10.1016/j.dsx.2020.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Diabetic foot syndrome is a severe complication of type 2 diabetes mellitus with diabetic peripheral neuropathy. Increased maximum plantar pressure is a strong predictor that may be detrimental and cause a plantar ulcer. This present systematic review aims to evaluate the effectiveness of customized insoles on reducing maximum plantar pressure in diabetic foot syndrome. METHODS We conducted a systematic review (PubMed, Cochrane Database of Systematic Reviews, CINAHL, Pedro, Scopus) to summarize the evidence on the customized insole on maximum plantar pressure in diabetic foot syndrome. Randomized and non-randomized studies were included in the review. The quality of the included studies was assessed independently by the two review authors with the Modified Downs and Black checklist for the assessment of the methodological quality of both randomized and non-randomized studies. RESULTS A total of 1512 studies screened. After the exclusion criteria, 5 studies were included in the study. The outcome measure that was considered is maximum plantar pressure and pressure-time integral. CONCLUSIONS We concluded that the practice of customized insoles could significantly reduce maximum plantar pressure. While developing an insole, parameters like contoured insoles with shape and pressure based, weight-bearing position, and duration with good adherence to footwear application can significantly reduce maximum plantar pressure.
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Affiliation(s)
- Hrishikesh Korada
- Centre for Diabetic Foot Care and Research, Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Arun Maiya
- Department of Physiotherapy, Manipal College of Health Professions, Centre for Diabetic Foot Care and Research, Kasturba Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Sharath Kumar Rao
- Department of Orthopedics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Manjunath Hande
- Comprehensive Geriatric Clinic, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
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Lazzarini PA, Jarl G, Gooday C, Viswanathan V, Caravaggi CF, Armstrong DG, Bus SA. Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3275. [PMID: 32176438 PMCID: PMC8370012 DOI: 10.1002/dmrr.3275] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers. METHODS We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis. RESULTS We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia. CONCLUSION Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.
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Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social Work, Queensland
University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles
Hospital, Brisbane, Queensland, Australia
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of
Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine
and Health, Örebro University, Örebro, Sweden
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich
University Hospitals, Norwich, UK
- School of Health Sciences, University of East Anglia,
Norwich, UK
| | | | - Carlo F. Caravaggi
- Diabetic Foot Department, IRCCS Multimedica Group, Milan,
Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA),
Department of Surgery, Keck School of Medicine of University of Southern California
(USC), Los Angeles, California, USA
| | - Sicco A. Bus
- Amsterdam UMC, University of Amsterdam, Rehabilitation
Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Bus SA, Armstrong DG, Gooday C, Jarl G, Caravaggi C, Viswanathan V, Lazzarini PA. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3274. [PMID: 32176441 DOI: 10.1002/dmrr.3274] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.
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Affiliation(s)
- Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Carlo Caravaggi
- Diabetic Foot Department, IRCCS Multimedica Group, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
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van Netten JJ, Sacco ICN, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Bus SA. Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3271. [PMID: 31957306 DOI: 10.1002/dmrr.3271] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/01/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown. METHODS The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self-management; pre-ulcer treatment; orthotic interventions; and foot- and mobility-related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre-ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables. RESULTS We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self-care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom-made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot- and mobility-related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting. CONCLUSIONS Structured education for patients and health care professionals, callus removal, custom-made therapeutic footwear, and foot- and mobility-related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.
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Affiliation(s)
- Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech, and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde & CINTESIS-Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, VIC, Australia
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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10
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Nieto-Gil MP, Ortega-Avila AB, Pardo-Rios M, Gijon-Nogueron G. Effectiveness and Duration of Plantar Pressure Off-loading by Two Designs of Felt Padding: A Preliminary Study. J Am Podiatr Med Assoc 2019; 109:431-436. [PMID: 31755770 DOI: 10.7547/17-146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to observe the pressure changes in the felt padding used to off-load pressure from the first metatarsal head, the effects obtained by different designs, and the loss of effectiveness over time. METHOD With a study population of 17 persons, two types of 5-mm semicompressed felt padding were tested: one was C-shaped, with an aperture cutout at the first metatarsophalangeal joint, and the other was U-shaped. Pressures on the sole of the foot were evaluated with a platform pressure measurement system at three time points: before fitting the felt padding, immediately afterward, and 3 days later. RESULTS In terms of decreased mean pressure on the first metatarsal, significant differences were obtained in all of the participants (P < .001). For plantar pressures on the central metatarsals, the differences between all states and time points were significant for the C-shaped padding in both feet (P < .001), but with the U-shaped padding the only significant differences were between no padding and padding and at day 3 (P = .01 and P = .02). CONCLUSIONS In healthy individuals, the U-shaped design, with a padding thickness of 5 mm, achieved a more effective and longer-lasting reduction in plantar pressure than the C-shaped design.
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Affiliation(s)
| | | | - Manuel Pardo-Rios
- Campus de los Jeronimos, Catolic University of Murcia, Murcia, Spain
| | - Gabriel Gijon-Nogueron
- Department of Nursing and Podiatry, University of Malaga, Malaga, Spain
- Instituto de Investigación Biomédica de Málaga (IBIMA), Malaga, Spain
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11
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Roslim R, Mok KL, Fatimah Rubaizah MR, Shamsul K, Tan KS, Amir Hashim MY. Novel Deproteinised Natural Rubber Latex Slow-recovery Foam for Health Care and Therapeutic Foam Product Applications. J RUBBER RES 2018. [DOI: 10.1007/bf03449175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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Raspovic A, Waller K, Wong WM. The effectiveness of felt padding for offloading diabetes-related foot ulcers, at baseline and after one week of wear. Diabetes Res Clin Pract 2016; 121:166-172. [PMID: 27721122 DOI: 10.1016/j.diabres.2016.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/12/2016] [Accepted: 09/16/2016] [Indexed: 11/25/2022]
Abstract
AIM Felt padding is used to offload diabetes-related foot ulceration although limited quality data exists to support its use. This study aimed to quantify pressure offloading from neuropathic plantar foot ulcers in a clinical setting, when felt padding is first applied and after wear. METHODS This study used a within-subjects, repeated measures design. Data was collected in a high-risk foot service. Peak plantar pressures, contact area and contact time were measured in 15 diabetes subjects with 16 non-complicated plantar neuropathic foot ulcers, with: no felt padding, newly applied felt padding and felt padding after one week of wear. RESULTS Statistically significant decreases in peak pressure of 49% and 32% were measured with newly applied felt padding (188.0kPa; p<0.001) and worn felt padding (248kPa; p=0.003) respectively, compared to no padding (367.2kPa). Worn felt offloaded 32% less pressure than new felt however this did not reach statistical significance (p=.069). Corresponding increases in contact area of 18% and 14% occurred with newly applied felt padding (156.9cm2; p<.001) and worn felt padding (150.6cm2; p=0.003) compared to no padding (132.5cm2). Contact time was constant across testing conditions. CONCLUSIONS New felt padding offloaded on average half the pressure applied to sites of plantar neuropathic ulceration, which reduced to one third after wear. Increased contact area under the foot is a possible mechanism contributing to pressure reduction. Further studies are required to evaluate effectiveness of felt padding directly on ulcer healing.
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Affiliation(s)
- Anita Raspovic
- Discipline of Podiatry and La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Melbourne 3086, Australia.
| | - Kate Waller
- Department of Podiatry and High Risk Foot Service, The Northern Hospital, 185 Cooper Street, Epping, Melbourne 3076, Australia.
| | - Wan Mun Wong
- Discipline of Podiatry and La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Melbourne 3086, Australia; Podiatry Department, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore.
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13
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Scott JE, Hendry GJ, Locke J. Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review. J Foot Ankle Res 2016; 9:25. [PMID: 27478505 PMCID: PMC4966795 DOI: 10.1186/s13047-016-0159-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/26/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diabetic toe ulcers are a potentially devastating complication of diabetes. In recent years, the percutaneous flexor tenotomy procedure for the correction of flexible claw and hammer-toe contraction deformities has been proposed as a safe and effective technique for facilitating the healing of toe-deformity related diabetic ulcers. The aim of this review is to critically appraise the evidence for the effectiveness of this surgical procedure in achieving ulcer healing, prevention of re-ulceration, and to summarise the rate of post-operative complications. METHOD A search of medical databases, was performed to locate relevant literature. Titles were screened prior to abstract and full text review to identify articles relevant to the research question. Search terms included truncations of "tenotomy", "toe", "hallux", "digit", "diabetes" and "ulcer". Peer reviewed primary research study designs specified as suitable for systematic reviews by the Centre for Reviews and Dissemination were included. Studies were excluded if they used a concurrent secondary procedure or included non-diabetic patients without reporting outcomes separately. Included studies were appraised for quality using the Methodological Index for Non-Randomised Studies tool. Levels of evidence were subsequently assigned to each outcome of interest (healing rate and prevention of re-ulceration). RESULTS From a total search yield of 42 articles, 5 eligible studies (all case series designs) were identified for inclusion. Included studies were of low-to-moderate methodological quality when assessed using the MINORS tool. A total of 250 flexor tenotomy procedures were performed in a total of 163 patients. Included studies generally reported good healing rates (92-100 % within 2 months) post-op follow-up), relatively few recurrences (0-18 % at 22 months median post-op follow-up), and low incidences of infection or new deformity. Transfer ulcers developing on adjacent areas as a result of shifted pressure were reported by several authors. The validity of these results is undermined by methodological limitations inherent to case series designs such as a lack of control groups, non-randomised designs, as well as inconsistent reporting of post-intervention follow-up periods. There was level 4 evidence for the flexor tenotomy procedure in facilitating ulcer healing and preventing re-ulceration. CONCLUSION More definitive research evidence is needed in this area to determine whether or not the flexor tenotomy is a safe and effective treatment option for people with, or at risk of developing diabetic toe ulcers. Whilst the available literature reports that the procedure may be associated with high healing rates, relatively low recurrence rates and low incidences of post-op complications, methodological limitations restrict the value of these findings.
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Affiliation(s)
- Jennifer E. Scott
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - Gordon J. Hendry
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - John Locke
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
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Bus SA, van Deursen RW, Armstrong DG, Lewis JEA, Caravaggi CF, Cavanagh PR. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:99-118. [PMID: 26342178 DOI: 10.1002/dmrr.2702] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment. METHODS We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006. RESULTS We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches. CONCLUSIONS Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.
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Affiliation(s)
- S A Bus
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - R W van Deursen
- School of Health Care Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - D G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College of Medicine, Tucson, Arizona, USA
| | - J E A Lewis
- Cardiff and Vale University Health Board and Cardiff School of Health Science, Cardiff Metropolitan University, Cardiff, UK
| | - C F Caravaggi
- University Vita Salute San Raffaele and Diabetic Foot Clinic, Istituto Clinico Città, Studi, Milan, Italy
| | - P R Cavanagh
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Centre, Seattle, WA, USA
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Caravaggi P, Giangrande A, Berti L, Lullini G, Leardini A. Pedobarographic and kinematic analysis in the functional evaluation of two post-operative forefoot offloading shoes. J Foot Ankle Res 2015; 8:59. [PMID: 26516351 PMCID: PMC4625618 DOI: 10.1186/s13047-015-0116-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 10/21/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Forefoot offloading shoes are special orthopaedic footwear designed to protect and unload the injured part of the foot after surgery and for conservative treatments. The offloading action is often achieved by transferring plantar load to the rearfoot via rocker shoes with reduced contact area between shoe and ground. While these shoes are intended to be worn only for short periods, a compromise must be found between functionality and the risk of alterations in gait patterns at the lower limb joints. In this study, the pedobarographic, kinematic and kinetic effects of a traditional half-shoe and a double-rocker full-outsole shoe were compared to those of a comfortable shoe (control). METHODS Ten healthy female participants (28.2 ± 10.0 years) were asked to walk in three different footwear conditions for the left/right foot: control/half-shoe, control/full-outsole, and control/control. Full gait analysis was obtained in three walking trials for each participant in each condition. Simultaneously a sensor insole system recorded plantar pressure in different foot regions. Normalized root-mean-square error, coefficient of determination, and frame-by-frame statistical analysis were used to assess differences in time-histories of kinematic and kinetic parameters between shoes. RESULTS The half -shoe group showed the slowest walking speed and the shortest stride length. Forefoot plantar load was significantly reduced in the half-shoe (maximum force as % of Body Weight: half-shoe = 62.1; full-outsole = 86.9; control = 93.5; p < 0.001). At the rearfoot, mean pressure was the highest in the full-outsole shoe. At the ankle, sagittal-plane kinematics in the full-outsole shoe had a pattern more similar to control. CONCLUSIONS The half-shoe appears significantly more effective in reducing plantar load at the forefoot than a double-rocker full-outsole shoe, which is designed to reduce forefoot loading by using an insole with a thicker profile anteriorly as to maintain the foot in slight dorsiflexion. However, the half-shoe is also associated with altered gait spatio-temporal parameters, more kinematic modifications at the proximal lower limb joints and reduced propulsion in late stance.
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Affiliation(s)
- Paolo Caravaggi
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Alessia Giangrande
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Lisa Berti
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Giada Lullini
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Alberto Leardini
- Movement Analysis Laboratory and Functional-Clinical Evaluation of Prostheses, Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
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16
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Song Q, Xu K, Yu B, Zhang C, Sun W, Mao D. Could Insoles Offload Pressure? An Evaluation of the Effects of Arch-supported Functional Insoles on Plantar Pressure Distribution during Race Walking. Res Sports Med 2015; 23:278-88. [DOI: 10.1080/15438627.2015.1040913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Qipeng Song
- Shanghai University of Sport, Shanghai, China
| | - Kaisheng Xu
- Shanghai University of Sport, Shanghai, China
| | - Bing Yu
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Cui Zhang
- Shandong Sports Science Research Center, Jinan, Shandong, China
| | - Wei Sun
- Shandong Sports Science Research Center, Jinan, Shandong, China
| | - Dewei Mao
- Shanghai University of Sport, Shanghai, China
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Lin TL, Sheen HM, Chung CT, Yang SW, Lin SY, Luo HJ, Chen CY, Chan IC, Shih HS, Sheu WHH. The effect of removing plugs and adding arch support to foam based insoles on plantar pressures in people with diabetic peripheral neuropathy. J Foot Ankle Res 2013; 6:29. [PMID: 23895323 PMCID: PMC3750449 DOI: 10.1186/1757-1146-6-29] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 06/18/2013] [Indexed: 01/02/2023] Open
Abstract
Background Removable plug insoles appear to be beneficial for patients with diabetic neuropathic feet to offload local plantar pressure. However, quantitative evidence of pressure reduction by means of plug removal is limited. The value of additional insole accessories, such as arch additions, has not been tested. The purpose of this study was to evaluate the effect of removing plugs from foam based insoles, and subsequently adding extra arch support, on plantar pressures. Methods In-shoe plantar pressure measurements were performed on 26 patients with diabetic neuropathic feet at a baseline condition, in order to identify the forefoot region with the highest mean peak pressure (MPP). This was defined as the region of interest (ROI) for plug removal.The primary outcome was measurement of MPP using the pedar® system in the baseline and another three insole conditions (pre-plug removal, post-plug removal, and post-plug removal plus arch support). Results Among the 26 ROIs, a significant reduction in MPP (32.3%, P<0.001) was found after removing the insole plugs. With an arch support added, the pressure was further reduced (9.5%, P<0.001). There were no significant differences in MPP at non-ROIs between pre- and post-plug removal conditions. Conclusions These findings suggest that forefoot plantar pressure can be reduced by removing plugs and adding arch support to foam-based insoles. This style of insole may therefore be clinically useful in managing patients with diabetic peripheral neuropathy.
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Affiliation(s)
- Tung-Liang Lin
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Huey-Min Sheen
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Chin-Teng Chung
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Sai-Wei Yang
- Institute of Biomedical Engineering, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan, Republic of China
| | - Shih-Yi Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Hong-Ji Luo
- School and Graduate Institute of Physical Therapy and Assistive Technology, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan, Republic of China
| | - Chung-Yu Chen
- Graduate School of Physical Education, National Taiwan University of Physical Education and Sport, No. 16, Sec. 1, Shuang-Shih Rd, Taichung 404, Taiwan, Republic of China
| | - I-Cheng Chan
- Department of Physical Medicine & Rehabilitation, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China
| | - Hsu-Sheng Shih
- Department of Physical Therapy, Fooyin University, 1 Jinxue Rd., Daliao Dist, Kaohsiung 83102, Taiwan, Republic of China
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec. 4, Taichung 407, Taiwan, Republic of China.,College of Medicine, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei 112, Taiwan, Republic of China.,Institute of Medical Technology, National Chung-Hsing University, 250 Kuo Kuang Rd, Taichung 402, Taiwan, Republic of China
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Miyan Z, Ahmed J, Zaidi SI, Ahmedani MY, Fawwad A, Basit A. Use of locally made off-loading techniques for diabetic plantar foot ulcer in Karachi, Pakistan. Int Wound J 2013; 11:691-5. [PMID: 23369009 DOI: 10.1111/iwj.12032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 12/14/2012] [Accepted: 01/02/2013] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to evaluate the effectiveness of applying locally made pressure off-loading techniques on plantar foot ulcer in individuals with diabetes. This prospective study of 70 diabetic patients was conducted at the foot clinic of Baqai Institute of Diabetology & Endocrinology. Plantar foot ulcer, stages 1A and 2A according to the University of Texas classification, was treated by using three off-loading techniques: modified foot wear (sandal), modified plaster of Paris cast with plywood platform and Scotchcast boot. The outcome was assessed at either complete wound healing (defined as complete epithelialisation) or at 12 weeks, whichever came first. Of the 70 patients, 24 were in modified foot wear group, 23 in modified plaster of Paris cast and 23 in Scotchcast boot group. There was almost equal proportion of patients healed within 12 weeks period treated with these three off-loading techniques, i.e. 22 (95·7%) for modified foot wear group, 19 (95%) for modified plaster cast and 18 (94·7%) for Scotchcast boot group. No significant difference was observed in median healing time and cumulative wound survival at 12 weeks in the three off-loading techniques. Modified foot wear group was the most cost effective ($7) amongst the three off-loading techniques. It is concluded that in this cohort, no significant difference in healing time was observed in the three off-loading techniques, although modified foot wear (sandal) was found to be a more cost-effective treatment modality.
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Affiliation(s)
- Zahid Miyan
- Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
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