Continuous Movement Monitoring of Daily Living Activities for Prevention of Diabetic Foot Ulcer: A Review of Literature

Curcumin Promotes Diabetic Foot Ulcer Wound Healing by Inhibiting miR-152-3p and Activating the FBN1/TGF-β Pathway

The objective of this study was to investigate the mechanism of curcumin in diabetic foot ulcer (DFU) wound healing. A DFU rat model was established, and fibroblasts were cultured in a high-glucose (HG) environment to create a cell model. Various techniques, including Western blot, RT‒qPCR, flow cytometry, Transwell, cell scratch test and H&E staining, were employed to measure the levels of relevant genes and proteins, as well as to assess cell proliferation, apoptosis, migration, and pathological changes. The results showed that miR-152-3p was overexpressed in DFU patients, while FBN1 was underexpressed. Curcumin was found to inhibit fibroblast apoptosis, promote proliferation, migration, and angiogenesis in DFU rats, and accelerate wound healing in DFU rats. In addition, overexpression of miR-152-3p weakened the therapeutic effect of curcumin, while overexpression of FBN1 reversed the effects of the miR-152-3p mimic. Further investigations into the underlying mechanisms revealed that curcumin expedited wound healing in DFU rats by restoring the FBN1/TGF-β pathway through the inhibition of miR-152-3p. In conclusion, curcumin can suppress the activity of miR-152-3p, which, in turn, leads to the rejuvenation of the FBN1/TGF-β pathway and accelerates DFU wound healing.

Photodynamic Therapy With RLP068 and 630-nm Red LED Light in Foot Ulcers in Patients With Diabetes: A Case Series

The management and healing of lower extremity ulcers have always been a complex health problem because the clinical course is typically chronic, the results are often poor, and the socioeconomic impact is considerable. The healing process of foot ulcers of people with diabetes is further hindered by the concomitant presence of obstructive arterial disease, neuropathy, and foot malformation. It is frequently associated with multiresistant infections and often results in micro/macro amputations. Photodynamic therapy employs a photosensitizer activated by light of a specific wavelength able to generate reactive oxygen species, which initiate further oxidative responses locally with components of the bacteria. The experience of the treatment center for the lower extremity ulcers in 17 persons with diabetes in Acerra (Italy) with photoactivated RLP068, reported here, corroborates the results of the clinical trials and of the previous case reports. In all cases, examined photodynamic therapy with photosensitizer RLP068 and red light at 630 nm was found to reduce lesion area and inflammation and to ensure the decrease of bacterial load, hence reducing treatment times and antibiotics use, improving patient outcomes, and reducing the incidence of amputations. The simultaneous combination of photodynamic therapy with other ancillary physical-based treatments such as therapeutic magnetic resonance or Bio-Electro-Magnetic-Energy-Regulation was observed to be safe, time-saving, and able to lead to faster healing.

Physiotherapeutic Interventions in Diabetic Foot Ulcer Management: A Case Report

Diabetic foot ulcers (DFUs) represent prominent complications arising from diabetes mellitus, characterized by the development of severe and persistent wounds involving the loss of epidermal and/or dermal layers, with the potential to extend into subcutaneous and underlying tissue structures. In the presented case, a 62-year-old male patient presented with complaints of pain and the emergence of blisters on the right foot, marked by an insidious onset and gradual progression in size, ultimately leading to ulcer formation subsequent to blister rupture. The patient had a medical history spanning 25 years of diabetes mellitus, accompanied by diminished range of motion and muscle strength in the affected foot. The primary goals in the management of DFU encompass addressing muscular weakness, skin manifestations, and any associated underlying health comorbidities. Central to this management approach lies the incorporation of physical therapy and rehabilitation modalities. The rehabilitation regimen designed for the patient was tailored to include targeted resistance exercises, infrared radiation therapy, and sensory integration therapy. Outcome measures, including the Numeric Pain Rating Scale (NPRS), World Health Organization Quality of Life questionnaire (WHO-QOL), and Diabetic Foot Self-Care Questionnaire (DFSQ-UMA), demonstrated substantial improvements, reflecting enhanced activities of daily living. This case underscores the pivotal role of incorporating physiotherapy into a comprehensive multidisciplinary approach for optimizing the management of DFUs. Such integration aims to improve patient outcomes and overall quality of life.

Preventative Sensor-Based Remote Monitoring of the Diabetic Foot in Clinical Practice

Diabetes and its complications, particularly diabetic foot ulcers (DFUs), pose significant challenges to healthcare systems worldwide. DFUs result in severe consequences such as amputation, increased mortality rates, reduced mobility, and substantial healthcare costs. The majority of DFUs are preventable and treatable through early detection. Sensor-based remote patient monitoring (RPM) has been proposed as a possible solution to overcome limitations, and enhance the effectiveness, of existing foot care best practices. However, there are limited frameworks available on how to approach and act on data collected through sensor-based RPM in DFU prevention. This perspective article offers insights from deploying sensor-based RPM through digital DFU prevention regimens. We summarize the data domains and technical architecture that characterize existing commercially available solutions. We then highlight key elements for effective RPM integration based on these new data domains, including appropriate patient selection and the need for detailed clinical assessments to contextualize sensor data. Guidance on establishing escalation pathways for remotely monitored at-risk patients and the importance of predictive system management is provided. DFU prevention RPM should be integrated into a comprehensive disease management strategy to mitigate foot health concerns, reduce activity-associated risks, and thereby seek to be synergistic with other components of diabetes disease management. This integrated approach has the potential to enhance disease management in diabetes, positively impacting foot health and the healthspan of patients living with diabetes.

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.

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.

Efficacy of a Self-managed Cooling Intervention for Pain and Physical Activity in Individuals With Recently Healed Chronic Venous Leg and Diabetic Foot Ulcers: A Randomized Controlled Trial

PURPOSE

This aim of this study was to evaluate the clinical efficacy of a self-managed cooling intervention in individuals with recently healed venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs) on pain reduction and physical activity improvement.

DESIGN

A 6-month longitudinal randomized controlled trial.

SUBJECTS AND SETTING

The sample comprised 140 individuals with previously healed VLU and DFU who received care in 3 outpatient wound centers in the Southeastern region of the United States. Participants were randomized to the MUSTCOOL or a placebo cooling patch intervention.

METHODS

The cooling and placebo interventions comprised cooling or cotton-filled patch application to recently healed skin for 30 minutes, 3 times weekly plus standard of care including compression and leg elevation (participants with VLU) or therapeutic footwear and hygiene (participants with DFU) over a 6-month period. Pain severity and intensity were measured with the Brief Pain Inventory and physical activity with the International Physical Activity Questionnaire, which assessed metabolic equivalent of tasks (METs) in minutes per week. Minutes in walking time per week were assessed with an accelerometer. Data were descriptively analyzed for difference changes in scores from baseline to 6 months post-intervention.

RESULTS

Data were analyzed for 81 participants randomized to cooling and placebo groups (VLUs, n = 26/29) and DFU (n = 12/16). Slight reductions in VLU pain severity (-0.5, -0.2) and interference (-0.4, -0.5) and minimal reductions in DFU pain severity (0, -0.1) and interference (0.4/0.1) were achieved. However, pain scores were low to moderate at baseline (mean 4, 0-10 with 10 worst pain possible) in both groups. For physical activity, the MET values showed low physical activity in both groups at baseline with slight improvements noted in VLU cooling and placebo groups (73/799) and DFU (1921/225), respectively. Walking time for the VLU groups improved by 1420/2523 minutes; the DFU groups improved 135/157 minutes, respectively. Findings for outcomes were not statistically significant within or between groups.

CONCLUSIONS

Application of the cooling pack compared to placebo was minimally efficacious in reducing posthealing pain and improving function in this posthealed ulcer population. However for pain, scores were initially low; thus outcomes on pain, while lower, were marginal.

TRIAL REGISTRATION

The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156), https://clinicaltrials.gov/ct2/show/NCT02626156 .

The Role of New Technological Opportunities and the Need to Evaluate the Activities Performed in the Prevention of Diabetic Foot with Exercise Therapy

The diabetic foot (DF) is one of the most feared conditions among chronic complications of diabetes, which affects a growing number of patients. Although exercise therapy (ET) has always been considered a pillar in the treatment of patients at risk of DF it is not usually used. Several causes can contribute to hindering both the organization of ET protocols for Diabetes Units and the participation in ET programs for patients at different levels of risk of foot ulceration. The risk of favoring the occurrence of ulcers and the absence of clear evidence on the role played by ET in the prevention of ulcers could be considered among the most important causes leading to the low application of ET. The increased availability of new technologies and in particular of systems and devices equipped with sensors can enable the remote monitoring and management of physical activity performed by patients. Consequently, they can become an opportunity for introducing the systematic use of ET for the treatment of patients at risk. Considering the complexity of the clinical conditions that patients at risk or with diabetic foot ulcer can show, the evaluation of how patients perform the ET proposed can consequently be very important. All this can contribute to improving the treatment of patients and avoiding possible adverse effects. The aim of this brief review was to describe that the use of new technologies and the assessment of the execution of the ET proposed allows an important step forward in the management of patients at risk.

Wound healing: potential therapeutic options

This review highlights the range of therapeutic options available to clinicians treating difficult-to-heal wounds. While certain treatments are established in daily clinical practice, most therapeutic interventions lack robust and rigorous data regarding their efficacy, which would help to determine when, and for whom, they should be used. The purpose of this review is to give a broad overview of the available interventions, with a brief summary of the evidence base for each intervention.

Mobility advice to help prevent re-ulceration in diabetes

Clinicians and patients face a dilemma in understanding how best to resume walking after a healed diabetic neuropathic ulcer. The objectives of this brief review are to: provide context for the patient's health and mobility status; propose 5 suggestions to safely and effectively progress mobility following a healed foot ulcer; and to consider topics for future research to improve care in this area. Rates of ulcer recurrence and mortality are high, and activity is low following a diabetic foot wound. Medical and rehabilitation approaches have emphasized protection of the insensitive, fragile foot with the hope to prevent subsequent harm to the foot and person. In particular, the 1-2 months following wound unloading and "healing" have the greatest risk for ulcer recurrence. While early protection should be emphasized, a growing body of evidence suggests that over-protection of the foot and limited walking can be harmful, presumably because of the negative effects of prolonged immobility and stress protection. Multiple recent studies report the ability of exercise and walking to have a positive effect on various diabetic foot outcomes without additional harm. Much less is known about how an ulcerated foot can resume walking after the wound is healed. This review integrates available guidelines, evidence, and precautions to suggest advice on how best to resume and progress walking in this population at high risk for ulcer recurrence.

Cost-effectiveness of TLC-sucrose octasulfate versus control dressings in the treatment of diabetic foot ulcers

Objective:

Diabetes is one of the most widespread diseases in Germany. Common complications are diabetic foot ulcers (DFU), which are associated with a cost-intensive treatment and serious adverse events, such as infections, amputations. This cost-effectiveness analysis compares two treatment options for patients with DFU: a TLC-NOSF dressing versus a neutral dressing, assessed through a European double-blind randomised controlled trial (RCT), Explorer.

Methods:

The evaluation of the clinical outcomes was associated to direct costs (costs for dressings, nursing time, hospitalisation etc.) of both dressings, from the perspective of the statutory health insurance in Germany. Due to the long mean healing time of a DFU, the observation period was extended from 20 to 100 weeks in a Markov model.

Results:

After 20 weeks, and with complete closure as a primary endpoint, the model revealed direct treatment costs for DFU of €2,864.21 when treated with a TLC-NOSF dressing compared with €2,958.69 with the neutral control dressing (cost-effectiveness: €6,017.25 versus €9,928.49). In the Markov model (100 weeks) the costs for the TLC-NOSF dressing were €5,882.87 compared with €8,449.39 with the neutral dressing (cost-effectiveness: €6,277.58 versus €10,375.56). The robustness of results was underlined by several sensitivity analyses for varying assumptions. The frequency of weekly dressing changes had the most significant influence in terms of parameter uncertainty.

Conclusion:

Overall, the treatment of DFU with a TLC-NOSF dressing is supported from a health economic perspective, because both the treatment costs and the cost-effectiveness were superior compared with the neutral wound dressing.

Effect and Mechanism of the Bruton Tyrosine Kinase (Btk) Inhibitor Ibrutinib on Rat Model of Diabetic Foot Ulcers

BACKGROUND Diabetes causes damage to the soft tissue and bone structure of the foot, referred to as "diabetic foot". Ibrutinib is a Bruton tyrosine kinase (Btk) inhibitor, and the role and mechanism of ibrutinib on the diabetic foot have not been elucidated. MATERIAL AND METHODS Male Wister rats were randomly divided into 3 groups: control group, model group, and ibrutinib group. After 14 days, the ulcer wound size of each group was measured, and the ulcer healing rate was calculated. The level of inflammatory factors interleukin (IL)-1ß, tumor necrosis factor (TNF)-alpha, and IL-6 was detected by enzyme-linked immunosorbent assay (ELISA). Real-time polymerase chain reaction (PCR) was used to analyze the changes of Toll-like receptor 2 (TLR2) and TLR4. The expression of vascular endothelial growth factor (VEGF) and the RAGE (receptor for advanced glycation end product/NF-kappaB (nuclear factor-kappa B) pathway was detected by western blot. RESULTS Blood glucose, blood lipids, serum creatinine, and urea nitrogen (BUN) levels were increased in the model group, together with increased levels of IL-1ß, TNF-alpha, IL-6, as well as TLR2 and TLR4 expression, and there were significant differences compared with the control group (P<0.05). Meanwhile, the model group showed decreased VEGF expression and increased expression of RAGE and NF-kappaB. However, ibrutinib reduced blood sugar, blood lipids, creatinine, and urea nitrogen levels, inhibited the secretion of inflammatory factors, promoted ulcer healing, improved ulcer healing rate, decreased the expression of TLR2, TLR4, RAGE, and NF-kappaB, and increased VEGF expression; there were significant differences in the ibrutinib group compared with the model group (P<0.05). CONCLUSIONS The Btk inhibitor ibrutinib can upregulate VEGF expression, inhibit the expression of TLRs, inhibit the secretion of inflammatory factors, and promote the healing of diabetic foot ulcer possibly by regulating the RAGE/NF-kappaB pathway.