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

Best practice offloading treatments for diabetic foot ulcer healing, remission, and better plans for the healing-remission transition

Diabetes-related foot disease is arguably the world's least known major health problem and causes a disease burden larger than most well-known diseases, such as stroke and breast cancer. This burden is driven by people developing more severe stages of foot disease, such as foot ulcers and infections, and with that worsening quality of life. To reduce this burden, we need treatments that prevent more severe stages of foot disease and improve quality of life. Best practice offloading treatments have been found to be arguably the most effective existing treatments to heal and prevent diabetes-related foot ulcers and infections, but can worsen quality of life. Furthermore, high re-ulceration rates still occur with best practice offloading treatments after healing. This may be because of the gap in guideline recommendations on the transition from ulcer healing to ulcer remission when it comes to offloading treatments. In this paper, we review why we need offloading treatments and what are the best offloading treatments recommended by the latest international guidelines for healing and remission. Further, we propose plans for future best practice offloading treatments for the transition from healing-to-remission to help reduce re-ulceration rates and improve longer-term ulcer remission. These plans could be the catalyst for better transitioning patients from first ulcer presentation through healing and into long-term remission, and in turn delivering better quality of life, and lower diabetes-related foot disease burdens on patients, nations, and the globe in future.

Measuring 24-h use of time in people with a diabetes-related foot ulcer: A feasibility study

BACKGROUND

Physical activity (PA), sleep and sedentary time are now recognised as mutually exclusive and exhaustive parts of the 24-h day-if PA decreases, time spent sleeping, being sedentary or both must increase so that all components equate to 24 h. Recent advances in time-use epidemiology suggest that we should not consider time-use domains (PA, sleep and sedentary time) in isolation from each other, but in terms of a composition-the mix of time-use domains across the 24-h day. While interrelated daily activities are known to be important in the management of diabetes mellitus, few studies have investigated the interrelated daily activities in people with an active diabetes-related foot ulcer (DFU) and their impact on important outcomes such as wound severity, blood glucose control and health-related quality of life (HRQoL). This feasibility study aims to determine the acceptability and practicality of measuring 24-h use of time data in people with a DFU and its associations on important outcome measures for this population.

METHODS

Participants wore a wrist-worn accelerometer for two weeks and completed demographic and HRQoL questionnaires. Outcomes were participant engagement, reported levels of study burden and value and compositional data analysis as a methodological approach for evaluating 24-h use of time data.

RESULTS

Twenty-six participants reported low levels of study burden and rated the study value highly. The protocol appears feasible in terms of recruitment (81%) and retention rate (86%). On average, participants were relatively sedentary spending 747, 172 and 18 min in sedentary time, light physical activity and moderate-to-vigorous activity, respectively. Sleep appeared adequate with participants obtaining an average of 485 min, but quality of sleep was notably poor with average sleep efficiency of 75%. Compositional data analysis was able to quantify the integrated associations of 24-h use of time with HRQoL.

CONCLUSION

The protocol provides an acceptable method to collect 24-h use of time data in people with a DFU. Efforts to consider and analyse PA as part of a 24-h activity composition may provide holistic and realistic understandings of PA in this clinical population.

Adherence to wearing prescribed footwear in people at risk of diabetes-related foot ulcers

INTRODUCTION

Adherence to wearing prescribed footwear is paramount in reducing the risk of developing diabetes-related foot ulcers, but adherence is often lower than optimal. This study aimed to investigate predictors of footwear adherence and variations in adherence and activity in people at risk of diabetes-related foot ulceration.

METHODS

Sixty people at high foot ulcer risk were included. We measured the proportion of weight-bearing acitivity time the prescribed footwear was worn for seven days. Multiple linear regression and analysis of variance were used.

RESULTS

Mean overall adherence was 63%. Adherence was lower at home than away from home (59% vs. 74%), while activity was higher at home (2.2 vs. 1.2 h/day). Adherence was similar across activities (61%-63%). No variable predicted the overall adherence. Higher Hba1c predicted lower adherence at home (β = -0.34, p = 0.045, R2 = 11.6%). More daily steps predicted lower adherence away from home (β = -0.30, p = 0.033, R2 = 9.3%). Adherence and activity were highest in mornings (71%, 1.1 h) and afternoons (71%, 1.5 h), and lower in evenings (40%, 0.8 h) and at nights (9%, 0.1 h). Adherence was similar on weekdays and weekend days (63% vs. 60%), but activity was higher on weekdays (3.4 vs. 3.0 h).

CONCLUSION

Adherence levels and predictors thereof differed between adherence at home and away from home, so we suggest to treat them as different concepts. Due to the low explained variance, future studies should focus on other predictors such as psychological variables.

Plantar pressure measurement in diabetic foot disease: A scoping review

AIMS/INTRODUCTION

Patients with a healed diabetic foot ulcer (DFU) have a 40% risk of ulcer recurrence within a year. New and effective measures to prevent DFU recurrence are essential. We aimed to highlight emerging trends and future research opportunities in the use of plantar pressure measurement to prevent DFU recurrence.

MATERIALS AND METHODS

Our scoping review protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis - Scoping Review protocol. Peer-reviewed, English-language papers were included that addressed both plantar pressure measurement and diabetic foot disease, either as primary studies that have advanced the field or as review papers that provide summaries and/or opinion on the field as a whole, as well as specific papers that provide guidelines for future research and advancement in the field.

RESULTS

A total of 24 eligible publications were identified in a literature search using PubMed. A further 36 eligible studies were included after searching the references sections of these publications, leaving a total of 60 publications included in this scoping review.

CONCLUSIONS

Plantar pressure measurement can and will play a major role in the prevention of DFU. There is already a strong, albeit limited, evidence base in place to prove its benefit in reducing DFU recurrence. More research is required in larger populations, using remote monitoring in real-world settings, and with improved technology.

Capturing How the Accelerometer Measured Physical Activity Profile Differs in People with Diabetic Foot Ulceration

Diabetic Foot Ulcers (DFUs) are a major complication of diabetes, with treatment requiring offloading. This study aimed to capture how the accelerometer-assessed physical activity profile differs in those with DFUs compared to those with diabetes but without ulceration (non-DFU). Participants were requested to wear an accelerometer on their non-dominant wrist for up to 8days. Physical activity outcomes included average acceleration (volume), intensity gradient (intensity distribution), the intensity of the most active sustained (continuous) 5-120 min of activity (MXCONT), and accumulated 5-120 min of activity (MXACC). A total of 595 participants (non-DFU = 561, DFU = 34) were included in the analysis. Average acceleration was lower in DFU participants compared to non-DFU participants (21.9 mg [95%CI:21.2, 22.7] vs. 16.9 mg [15.3, 18.8], p < 0.001). DFU participants also had a lower intensity gradient, indicating proportionally less time spent in higher-intensity activities. The relative difference between DFU and non-DFU participants was greater for sustained activity (MXCONT) than for accumulated (MXACC) activity. In conclusion, physical activity, particularly the intensity of sustained activity, is lower in those with DFUs compared to non-DFUs. This highlights the need for safe, offloaded modes of activity that contribute to an active lifestyle for people with DFUs.

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 new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

The 1989 Saint Vincent Declaration established a goal of halving global diabetes-related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro-osteoarthropathy is more prevalent than previously thought. Most cases respond well to non-removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline-based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update)

AIMS

This is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline. This guideline is targeted at clinicians and other healthcare professionals.

MATERIALS AND METHODS

We followed the Grading of Recommendations, Assessment, Development and Evaluations methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature including, where appropriate, meta-analyses, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where (sufficient) evidence was not available, and a weighing of the desirable and undesirable effects of an intervention, as well as patient preferences, costs, equity, feasibility and applicability.

RESULTS

We recommend screening a person with diabetes at very low risk of foot ulceration annually for the loss of protective sensation and peripheral artery disease, and screening persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate persons at-risk about appropriate foot self-care, educate not to walk without suitable foot protection, and treat any pre-ulcerative lesion on the foot. Educate moderate-to-high risk people with diabetes to wear properly fitting, accommodative, therapeutic footwear, and consider coaching them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent plantar foot ulcer recurrence. Consider advising people at low-to-moderate risk to undertake a, preferably supervised, foot-ankle exercise programme to reduce ulcer risk factors, and consider communicating that a total increase in weight-bearing activity of 1000 steps/day is likely safe with regards to risk of ulceration. In people with non-rigid hammertoe with pre-ulcerative lesion, consider flexor tendon tenotomy. We suggest not to use a nerve decompression procedure to help prevent foot ulcers. Provide integrated foot care for moderate-to-high-risk people with diabetes to help prevent (recurrence of) ulceration.

CONCLUSIONS

These recommendations should help healthcare professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days and reduce the patient and healthcare burden of diabetes-related foot disease.

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.