Effect of awareness of being monitored on wearing of orthopaedic footwear

Effects of Peer- or Professional-Led Support in Enhancing Adherence to Wearable Monitoring Devices Among Community-Dwelling Older Adults: Systematic Review of Randomized Controlled Trials

BACKGROUND

Despite the well-documented health benefits associated with wearable monitoring devices (WMDs), adherence among community-dwelling older adults remains low. By providing guidance on the purpose and benefits of using WMDs, facilitating goal-setting aligned with the device's features, promoting comprehension of the health data captured by the device, and assisting in overcoming technological challenges, peers and health care professionals can potentially enhance older adults' adherence to WMDs. However, the effectiveness of such support mechanisms in promoting adherence to WMDs among older adults remains poorly understood.

OBJECTIVE

The aims of this systematic review were to examine the effects of peer- or professional-led intervention programs designed to improve adherence to WMDs among community-dwelling older adults and to identify the intervention components that may positively influence the effects of the intervention.

METHODS

We conducted a comprehensive search across 7 electronic databases (Cochrane Central Register of Controlled Trials [CENTRAL], PubMed, EMBASE, PsycINFO, British Nursing Index, Web of Science, and CINAHL) to identify articles published between January 1, 2010, and June 26, 2023. We specifically targeted randomized controlled trials that examined the impact of peer- or professional-led interventions on enhancing adherence to WMDs among individuals aged 60 years and older residing in the community. Two independent reviewers extracted data from the included studies and assessed the potential risk of bias in accordance with the Cochrane Risk of Bias tool for randomized trials, version 2.

RESULTS

A total of 10,511 studies were identified through the database search. Eventually, we included 3 randomized controlled trials involving 154 community-dwelling older adults. The participants had a mean age of 65 years. Our review revealed that increasing awareness of being monitored and implementing the SystemCHANGE approach, a habit change tool focusing on personal goals and feedback, were effective strategies for enhancing adherence to WMDs among older adults. All of the included studies exhibited a low risk of bias.

CONCLUSIONS

By collaboratively designing specific goals related to WMDs with health care professionals, including nurses and physicians, older adults exhibited a higher likelihood of adhering to the prescribed use of WMDs. These goal-setting tools provided a framework for structure and motivation, facilitating the seamless integration of WMDs into their daily routines. Researchers should prioritize interventions that target awareness and goal-setting as effective approaches to enhance adherence to WMDs among older adults, thereby maximizing the realization of associated health benefits.

Objectively assessed long-term wearing patterns and predictors of wearing orthopaedic footwear in people with diabetes at moderate-to-high risk of foot ulceration: a 12 months observational study

BACKGROUND

Orthopaedic footwear can only be effective in preventing diabetic foot ulcers if worn by the patient. Robust data on long-term wearing time of orthopaedic footwear are not available, and needed to gain more insights into wearing patterns and associated factors (i.e. participants' demographic, disease-related characteristics, and footwear usability). We aimed to objectively assess long-term wearing patterns and identify factors associated with wearing orthopaedic footwear in people with diabetes at moderate-to-high risk of ulceration.

METHODS

People diagnosed with diabetes mellitus type 1 and 2 with loss of protective sensation and/or peripheral artery disease and prescribed with orthopaedic footwear were included and followed for 12 months. The primary outcome was mean daily wearing time, continuously measured using a temperature sensor inside the footwear (Orthotimer®). Adherence to wearing orthopaedic footwear was calculated as percentage of wearing time of a total assumed 16 h out-of-bed daytime, where adherence < 60% was a pre-determined non-adherent threshold. Wearing time patterns were assessed by calculating participants' wearing (in)consistency. One-way analyses of variance tested for wearing time differences between subgroups, weekdays, and weekend days. Factors potentially associated with wearing time were collected by questionnaires and medical files. Univariately associated factors were included in multivariate linear regression analysis.

RESULTS

Sixty one participants were included (mean (SD) age: 68.0 (7.4) years; females: n = 17; type 2 diabetes mellitus: n = 54). Mean (SD) overall daily wearing time was 8.3 (6.1) hours/day. A total of 40 (66%) participants were non-adherent. Participants with a consistent wearing pattern showed higher daily wearing times than participants with an inconsistent pattern. Mean (SD) wearing times were 12.7 (4.3) vs 3.6 (4.8) hours/day, respectively (P < 0.001). Mean (SD) wearing time was significantly higher (P < 0.010) during weekdays (8.7 (6.0) hours/day) compared to Saturday (8.0 (6.1) hours/day) and Sunday (6.9 (6.2) hours/day). In the multivariate model (R2 = 0.28), "satisfaction with my wear of orthopaedic footwear" was positively associated (P < 0.001) with wearing time. The other seven multivariate model factors (four demographic variables and three footwear usability variables) were not associated with wearing time.

CONCLUSIONS

Only one out of three people at moderate to high risk of foot ulceration were sufficiently adherent to wearing their orthopaedic footwear. Changing people's wearing behaviour to a more stable pattern seems a potential avenue to improve long-term adherence to wearing orthopaedic footwear. Investigated factors are not associated with daily wearing time. Based on these factors the daily wearing time cannot be estimated in daily practice.

TRIAL REGISTRATION

Netherlands Trial Register NL7710. Registered: 6 May 2019.

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.

Gait-Adaptability Training in People With Hereditary Spastic Paraplegia: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

In people with hereditary spastic paraplegia (HSP), reduced gait adaptability is common and disabling. Gait impairments result from lower extremity spasticity, muscle weakness, and impaired proprioception. The aim of this study was to assess the efficacy of a 5-week gait-adaptability training in people with pure HSP.

METHOD

We conducted a randomized clinical trial with a cross-over design for the control group, and a 15-week follow-up period after training. Thirty-six people with pure HSP were randomized to 5 weeks of (i) gait-adaptability training (10 hours of C-Mill training-a treadmill equipped with augmented reality) or (ii) a waiting-list control period followed by 5 weeks gait-adaptability training. Both groups continued to receive usual care. The primary outcome was the obstacle subtask of the Emory Functional Ambulation Profile. Secondary outcome measures consisted of clinical balance and gait assessments, fall rates, and spatiotemporal gait parameters assessed via 3D motion analysis.

RESULTS

The gait-adaptability training group (n = 18) did not significantly decrease the time required to perform the obstacle subtask compared to the waiting-list control group (n = 18) after adjusting for baseline differences (mean: -0.33 seconds, 95% CI: -1.3, 0.6). Similar, non-significant results were found for most secondary outcomes. After merging both groups (n = 36), the required time to perform the obstacle subtask significantly decreased by 1.3 seconds (95% CI: -2.1, -0.4) directly following 5 weeks of gait-adaptability training, and this effect was retained at the 15-week follow-up.

CONCLUSIONS

We found insufficient evidence to conclude that 5 weeks of gait-adaptability training leads to greater improvement of gait adaptability in people with pure HSP.

Custom-made footwear designed for indoor use increases short-term and long-term adherence in people with diabetes at high ulcer risk

INTRODUCTION

To explore changes in footwear adherence following provision of custom-made indoor footwear in people with diabetes at high risk for plantar foot ulceration and in possession of regular custom-made footwear.

RESEARCH DESIGN AND METHODS

Adherence indoors and outdoors was assessed objectively as percentage of steps custom-made footwear was worn, at baseline (in regular custom-made footwear), and at 1 and 12 months after providing custom-made indoor footwear (in both indoor and regular footwear). Primary group: participants with low (<80%) baseline indoor adherence; secondary group: participants with high (≥80%) baseline indoor adherence. Peak plantar pressures of the indoor footwear were compared with the regular custom-made footwear. Footwear usability was evaluated at 3 months via a questionnaire. At 12 months, ulcer recurrence was assessed through participant/prescriber reporting.

RESULTS

Of 31 participants, 23 had low baseline indoor adherence (<80%). Overall adherence in this group increased statistically significant from median 65% (IQR: 56%-72%) at baseline to 77% (60%-89%) at 1 month (p=0.002) and 87% (60%-93%) at 12 months (p<0.001). This was due to a significant increase in adherence indoors: baseline: 48% (21%-63%); 1 month: 71% (50%-83%) (p=0.001); and 12 months: 77% (40%-91%) (p<0.001). Mean peak plantar pressures were comparable between the indoor and regular custom-made footwear. Participants were positive about usability. One-year ulcer recurrence rate was 26%.

CONCLUSIONS

Footwear adherence increased in the short-term and long-term after provision of custom-made indoor footwear in people at high risk of diabetic foot ulceration with low baseline adherence, because they actively wore their newly provided indoor footwear inside their house. Footwear adherence may be helped by using both regular and indoor custom-made footwear in clinical practice; the effect on ulcer recurrence should be investigated in future trials.

The tip of the iceberg: an overview of diabetic foot disease

Diabetic foot disease is the leading cause of lower-extremity amputation globally and imposes a significant burden for healthcare services and patients alike. The main pathology is ulceration, due to neuropathy or peripheral arterial disease. The most frequent sign is ulceration on the foot. Ulceration needs to be referred to the multidisciplinary diabetic foot team promptly for a comprehensive management plan to be developed. Delay in referral is associated with poor outcomes. Management of diabetic foot ulceration is multifaceted, including offloading, revascularisation, infection control, debridement, glycaemic control and wound care. Management plans need to be patient focused and developed collaboratively across primary and secondary care settings.