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Castro-Martins P, Marques A, Coelho L, Vaz M, Costa JT. Plantar pressure thresholds as a strategy to prevent diabetic foot ulcers: A systematic review. Heliyon 2024; 10:e26161. [PMID: 38390156 PMCID: PMC10882031 DOI: 10.1016/j.heliyon.2024.e26161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/22/2023] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Background The development of ulcers in the plantar region of the diabetic foot originates mainly from sites subjected to high pressure. The monitoring of these events using maximum allowable pressure thresholds is a fundamental procedure in the prevention of ulceration and its recurrence. Objective The aim of this review was to identify data in the literature that reveal an objective threshold of plantar pressure in the diabetic foot, where pressure is classified as promoting ulceration. The aim is not to determine the best and only pressure threshold for ulceration, but rather to clarify the threshold values most used in clinical practice and research, also considering the devices used and possible applications for offloading plantar pressure. Design A systematic review. Methods The search was performed in three electronic databases, by the PRISMA methodology, for studies that used a pressure threshold to minimize the risk of ulceration in the diabetic foot. The selected studies were subjected to eligibility criteria. Results Twenty-six studies were included in this review. Seven thresholds were identified, five of which are intended for the inside of the shoe: a threshold of average peak pressure of 200 kPa; 25 % and 40-80 % reduction from initial baseline pressure; 32-35 mm Hg for a capillary perfusion pressure; and a matrix of thresholds based on patient risk, shoe size and foot region. Two other thresholds are intended for the barefoot, 450 and 750 kPa. The threshold of 200 kPa of pressure inside the shoe is the most agreed upon among the studies. Regarding the prevention of ulceration and its recurrence, the efficacy of the proposed threshold matrix and the threshold of reducing baseline pressure by 40-80 % has not yet been evaluated, and the evidence for the remaining thresholds still needs further studies. Conclusions Some heterogeneity was found in the studies, especially regarding the measurement systems used, the number of regions of interest and the number of steps to be considered for the threshold. Even so, this review reveals the way forward to obtain a threshold indicative of an effective steppingstone in the prevention of diabetic foot ulcer.
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Affiliation(s)
- Pedro Castro-Martins
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Faculty of Engineering, University of Porto, Portugal
| | - Arcelina Marques
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Luís Coelho
- CIETI, ISEP, Polytechnic of Porto, Portugal
- INESC-TEC, Centre for Robotics in Industry and Intelligent Systems, Porto, Portugal
| | - Mário Vaz
- Faculty of Engineering, University of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - José Torres Costa
- Faculty of Engineering, University of Porto, Portugal
- Faculty of Medicine, University of Porto, Portugal
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Vossen LE, van Netten JJ, Bakker CD, Berendsen HA, Busch-Westbroek TE, Peters EJG, Sabelis LWE, Dijkgraaf MGW, Bus SA. An integrated personalized assistive devices approach to reduce the risk of foot ulcer recurrence in diabetes (DIASSIST): study protocol for a multicenter randomized controlled trial. Trials 2023; 24:663. [PMID: 37828618 PMCID: PMC10568814 DOI: 10.1186/s13063-023-07635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Preventing foot ulcers in people with diabetes can increase quality of life and reduce costs. Despite the availability of various interventions to prevent foot ulcers, recurrence rates remain high. We hypothesize that a multimodal treatment approach incorporating various footwear, self-management, and education interventions that matches an individual person's needs can reduce the risk of ulcer recurrence with beneficial cost-utility. The aim of this study is to assess the effect on foot ulcer recurrence, footwear adherence, and cost-utility of an integrated personalized assistive devices approach in high-risk people with diabetes. METHODS In a parallel-group multicenter randomized controlled trial, 126 adult participants with diabetes mellitus type 1 or 2, loss of protective sensation based on the presence of peripheral neuropathy, a healed plantar foot ulcer in the preceding 4 years, and possession of any type of custom-made footwear will be included. Participants will be randomly assigned to either enhanced therapy or usual care. Enhanced therapy consists of usual care and additionally a personalized treatment approach including pressure-optimized custom-made footwear, pressure-optimized custom-made footwear for indoor use, at-home daily foot temperature monitoring, and structured education, which includes motivational interviewing and personalized feedback on adherence and self-care. Participants will be followed for 12 months. Assessments include barefoot and in-shoe plantar pressure measurements; questionnaires concerning quality of life, costs, disease, and self-care knowledge; physical activity and footwear use monitoring; and clinical monitoring for foot ulcer outcomes. The study is powered for 3 primary outcomes: foot ulcer recurrence, footwear adherence, and cost-utility, the primary clinical, patient-related, and health-economic outcome respectively. DISCUSSION This is the first study to integrate multiple interventions for ulcer prevention into a personalized state-of-the-art treatment approach and assess their combined efficacy in a randomized controlled trial in people with diabetes at high ulcer risk. Proven effectiveness, usability, and cost-utility will facilitate implementation in healthcare, improve the quality of life of high-risk people with diabetes, and reduce treatment costs. TRIAL REGISTRATION ClinicalTrials.gov NCT05236660. Registered on 11 February 2022.
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Affiliation(s)
- Lisa E Vossen
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands.
| | - Jaap J van Netten
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Chantal D Bakker
- Department of Rehabilitation Medicine, Máxima Medisch Centrum Veldhoven, de Run 4600, 5504 DB, Veldhoven, the Netherlands
| | - Heleen A Berendsen
- Department of Rehabilitation Medicine, Reinier de Graaf Gasthuis Delft, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Tessa E Busch-Westbroek
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Edgar J G Peters
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, the Netherlands
| | - Louise W E Sabelis
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Rehabilitation Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, the Netherlands
| | - Marcel G W Dijkgraaf
- Epidemiology and Data Science, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Methodology, Amsterdam Public Health, Meibergdreef 9, Amsterdam, the Netherlands
| | - Sicco A Bus
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Jarl G, Rusaw DF, Terrill AJ, Barnett CT, Woodruff MA, Lazzarini PA. Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers. J Diabetes Sci Technol 2023; 17:99-106. [PMID: 35658555 PMCID: PMC9846383 DOI: 10.1177/19322968221101632] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- 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
- Gustav Jarl, PhD, University Health
Care Research Center, Örebro University Hospital, S-huset, vån 1,
Örebro, SE-701 85, Sweden.
| | - David F. Rusaw
- School of Health and Welfare,
Jönköping University, Jönköping, Sweden
| | - Alexander J. Terrill
- School of Mechanical, Medical and
Process Engineering, Queensland University of Technology, Brisbane, QLD,
Australia
- Centre for Biomedical
Technologies, Queensland University of Technology, Brisbane, QLD,
Australia
- Faculty of Health, Southern Cross
University, Gold Coast, QLD, Australia
| | | | - Maria A. Woodruff
- School of Mechanical, Medical and
Process Engineering, Queensland University of Technology, Brisbane, QLD,
Australia
- Centre for Biomedical
Technologies, Queensland University of Technology, Brisbane, QLD,
Australia
| | - Peter A. Lazzarini
- School of Public Health and
Social Work, Queensland University of Technology, Brisbane, Australia
- Allied Health Research
Collaborative, The Prince Charles Hospital, Brisbane, Australia
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Does in-shoe pressure analysis to assess and modify medical grade footwear improve patient adherence and understanding? A mixed methods study. J Foot Ankle Res 2022; 15:94. [PMID: 36564819 PMCID: PMC9789308 DOI: 10.1186/s13047-022-00600-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Medical grade footwear (MGF) with demonstrated plantar-pressure reducing effect is recommended to reduce the risk of diabetes-related foot ulceration (DFU). Efficacy of MGF relies on high adherence (≥ 80%). In-shoe pressure analysis (IPA) is used to assess and modify MGF, however, there is limited evidence for the impact on patient adherence and understanding of MGF. The primary aim of this study was to determine if self-reported adherence to MGF usage in patients with previous DFU improved following IPA compared to adherence measured prior. The secondary aim was to determine if patient understanding of MGF improved following in-shoe pressure analysis. METHODS Patients with previous DFU fitted with MGF in the last 12 months were recruited. The first three participants were included in a pilot study to test procedures and questionnaires. MGF was assessed and modified at Week 0 based on findings from IPA using the Pedar system (Novel). Patients completed two questionnaires, one assessing patient adherence to MGF at Week 0 and Week 4, the other assessing patient understanding of MGF before and after IPA at week 0. Patient understanding was measured using a 5-point Likert scale (strongly disagree 1 to strongly agree 5). Patient experience was assessed via a telephone questionnaire administered between Weeks 0-1. RESULTS Fifteen participants were recruited, and all completed the study. Adherence of ≥ 80% to MGF usage inside the home was 13.3% (n = 2) pre-IPA and 20.0% (n = 3) at Week 4. Outside the home, ≥ 80% adherence to MGF was 53.3% (n = 8) pre-IPA, and 80.0% (n = 12) at Week 4. Change in scores for understanding of MGF were small, however, all participants reported that undergoing the intervention was worthwhile and beneficial. CONCLUSIONS Self-reported adherence inside the home demonstrated minimal improvement after 4 weeks, however, adherence of ≥ 80% outside the home increased by 27%, with 80% of all participants reporting high adherence at Week 4. Participants rated their learnings from the experience of IPA as beneficial.
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Footwear and insole design parameters to prevent occurrence and recurrence of neuropathic plantar forefoot ulcers in patients with diabetes: a series of N-of-1 trial study protocol. Trials 2022; 23:1017. [PMID: 36527100 PMCID: PMC9755781 DOI: 10.1186/s13063-022-06968-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Foot complications occur in conjunction with poorly controlled diabetes. Plantar forefoot ulceration contributes to partial amputation in unstable diabetics, and the risk increases with concomitant neuropathy. Reducing peak plantar forefoot pressure reduces ulcer occurrence and recurrence. Footwear and insoles are used to offload the neuropathic foot, but the success of offloading is dependent on patient adherence. This study aims to determine which design and modification features of footwear and insoles improve forefoot plantar pressure offloading and adherence in people with diabetes and neuropathy. METHODS This study, involving a series of N-of-1 trials, included 21 participants who had a history of neuropathic plantar forefoot ulcers. Participants were recruited from two public hospitals and one private podiatry clinic in Sydney, New South Wales, Australia. This trial is non-randomised and unblinded. Participants will be recruited from three sites, including two high-risk foot services and a private podiatry clinic in Sydney, Australia. Mobilemat™ and F-Scan® plantar pressure mapping systems by TekScan® (Boston, USA) will be used to measure barefoot and in-shoe plantar pressures. Participants' self-reports will be used to quantify the wearing period over a certain period of between 2 and 4 weeks during the trial. Participant preference toward footwear, insole design and quality-of-life-related information will be collected and analysed. The descriptive and inferential statistical analyses will be performed using IBM SPSS Statistics (version 27). And the software NVivo (version 12) will be utilised for the qualitative data analysis. DISCUSSION This is the first trial assessing footwear and insole interventions in people with diabetes by using a series of N-of-1 trials. Reporting self-declared wearing periods and participants' preferences on footwear style and aesthetics are the important approaches for this trial. Patient-centric device designs are the key to therapeutic outcomes, and this study is designed with that strategy in mind. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000699965p. Registered on June 23, 2020.
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Keukenkamp R, van Netten JJ, Busch-Westbroek TE, Nollet F, Bus SA. Users' needs and expectations and the design of a new custom-made indoor footwear solution for people with diabetes at risk of foot ulceration. Disabil Rehabil 2022; 44:8493-8500. [PMID: 34846977 DOI: 10.1080/09638288.2021.2003878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To assess users' needs and expectations regarding custom-made indoor footwear, and to design such footwear with similar biomechanical efficacy and better usability compared to regular custom-made footwear in people with diabetes at risk for foot ulceration. MATERIALS AND METHODS Multidisciplinary systematic design approach. Needs and expectations regarding indoor footwear were evaluated via a questionnaire in 50 high foot ulcer risk people with diabetes using custom-made footwear. We systematically designed indoor footwear, and manufactured this for nine participants. Primary requirement was similar plantar pressure compared to participants' regular custom-made footwear. RESULTS Eighty-two percent of participants expressed a need for custom-made indoor footwear and 66% expected such footwear to increase their adherence. The custom-made indoor footwear had the same bottom construction as participants' regular custom-made footwear, but with softer and more light-weight upper materials. Peak pressures were similar or lower, while qualitative evaluation showed better usability and lower costs for indoor footwear. CONCLUSIONS People with diabetes at risk of foot ulceration expressed a clear need for custom-made indoor footwear, and expected such footwear to increase their adherence. Our indoor footwear design provides adequate pressure relief, with better usability, and can be produced at lower costs compared to regular custom-made footwear.Implications for rehabilitationPeople with diabetes at risk of foot ulceration express a need for special indoor footwear.We developed indoor footwear with similar offloading capacity as regular custom-made footwear.The indoor footwear is lighter in weight, easier to don/doff and lower in costs.At-risk people with diabetes expect this footwear to increase their footwear adherence.
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Affiliation(s)
- Renske Keukenkamp
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap J van Netten
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tessa E Busch-Westbroek
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frans Nollet
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sicco A Bus
- Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Shi QQ, Li PL, Yick KL, Jiao J, Liu QL. Influence of Contoured Insoles with Different Materials on Kinematics and Kinetics Changes in Diabetic Elderly during Gait. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12502. [PMID: 36231798 PMCID: PMC9566611 DOI: 10.3390/ijerph191912502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Alterations in the lower limb kinematics and kinetics of diabetic patients have been reported in previous studies. Inappropriate choices of orthopedic insole materials, however, fail to prevent diabetic foot ulcers and modify abnormal gait. The aim of this study was to quantitatively compare the effects of contoured insoles with different materials on the kinematics of and kinetics changes in the diabetic elderly during gait. METHODS There were 21 diabetic patients who participated in this study. Three-dimensional (3D) experimental contoured insoles constructed of soft (i.e., Nora Lunalastik EVA and PORON® Medical 4708) and rigid (i.e., Nora Lunalight A fresh and Pe-Lite) materials with Langer Biomechanics longitudinal PPT® arch pads were adopted. An eight-camera motion capture system (VICON), two force plates, and an insole measurement system-Pedar® with 99 sensors-were utilized to obtain the kinematics and kinetics data. The plug-in lower body gait model landmarks were used for dynamic data acquisition during gait. The corresponding data from five gait cycles were selected and calculated. RESULTS The range of motions (ROMs) of the ankle joint (p = 0.001) and knee joint (p = 0.044) were significantly influenced when the contoured insoles were worn in comparison to the barefoot condition. The joint moments of the lower limbs with maximum ankle plantarflexion during the loading response and maximum knee and hip flexions were significantly influenced by the use of contoured insoles with different materials in the diabetic elderly. The peak plantar pressure (PPP) of the forefoot (p < 0.001), midfoot (p = 0.009), and rearfoot (p < 0.001) was significantly offloaded by the contoured insoles during the stance phase, whilst the PPP of the rearfoot (p < 0.001) was significantly offloaded during the swing phase. CONCLUSIONS The contoured insoles, especially those constructed with soft materials, significantly offloaded the PPP during gait-hence accommodating certain abnormal gait patterns more effectively compared to going barefoot.
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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
| | - Jiao Jiao
- Dr. Stephen Hui Research Centre for Physical Recreation and Wellness, Hong Kong Baptist University, Hong Kong, China
| | - Qi-Long Liu
- School of Fashion and Textiles, The Hong Kong Polytechnic University, Hong Kong, China
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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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Muir BC, Li JS, Hudak YF, Kaufman GE, Cullum S, Aubin PM. Evaluation of novel plantar pressure-based 3-dimensional printed accommodative insoles - A feasibility study. Clin Biomech (Bristol, Avon) 2022; 98:105739. [PMID: 35987171 PMCID: PMC10786586 DOI: 10.1016/j.clinbiomech.2022.105739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/26/2022] [Accepted: 08/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Custom insoles are commonly prescribed to patients with diabetes to redistribute plantar pressure and decrease the risk of ulceration. Advances in 3D printing have enabled the creation of 3D-printed personalized metamaterials whose properties are derived not only from the base material but also the lattice microstructures within the metamaterial. Insoles manufactured using personalized metamaterials have both patient-specific geometry and stiffnesses. However, the safety and biomechanical effect of the novel insoles have not yet been tested clinically. METHODS Individuals without ulcer, neuropathy, or deformity were recruited for this study. In-shoe walking plantar pressure at baseline visit was taken and sensels with pressure over 200 kPa was used to define offloading region(s). Three pairs of custom insoles (two 3D printed insoles with personalized metamaterials (Hybrid and Full) designed based on foot shape and plantar pressure mapping and one standard-of-care diabetic insole as a comparator). In-shoe plantar pressure measurements during walking were recorded in a standardized research shoe and the three insoles and compared across all four conditions. FINDINGS Twelve individuals were included in the final analysis. No adverse events occurred during testing. Maximum peak plantar pressure and the pressure time integral were reduced in the offloading regions in the Hybrid and Full but not in the standard-of-care compared to the research shoe. INTERPRETATION This feasibility study confirms our ability to manufacture the 3D printed personalized metamaterials insoles and demonstrates their ability to reduce plantar pressure. We have demonstrated the ability to modify the 3D printed design to offload certain parts of the foot using plantar pressure data and a patient-specific metamaterials in the 3D printed insole design. The advance in 3D printed technology has shown its potential to improve current care.
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Affiliation(s)
- Brittney C Muir
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA; VA RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, USA.
| | - Jing-Sheng Li
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA; VA RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, USA
| | - Yuri F Hudak
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA; VA RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, USA
| | - G Eli Kaufman
- VA RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, USA
| | - Scott Cullum
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA; VA RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, USA
| | - Patrick M Aubin
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA; VA RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, USA
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10
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Zwaferink JBJ, Custers W, Paardekooper I, Berendsen HA, Bus SA. Effect of a carbon reinforcement for maximizing shoe outsole bending stiffness on plantar pressure and walking comfort in people with diabetes at high risk of foot ulceration. Gait Posture 2021; 86:341-345. [PMID: 33857799 DOI: 10.1016/j.gaitpost.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 03/15/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Different shoe design features can reduce peak plantar pressure to help prevent foot ulcers in people with diabetes. A carbon reinforcement of the shoe outsole to maximize bending stiffness is commonly applied in footwear practice, but its effect has not been studied to date. RESEARCH QUESTION What is the effect of a carbon shoe-outsole reinforcement on peak plantar pressure and walking comfort in people with diabetes at high risk of foot ulceration? METHODS In 24 high-risk people with diabetes, in-shoe regional peak pressures were measured during walking at a comfortable speed in two different shoe conditions: an extra-depth diabetes-specific shoe with a non-reinforced outsole and the same type of shoe with a 3-mm-thick full-length carbon reinforcement of the outsole. The same custom-made insole was worn in both shoe conditions. Walking comfort was assessed using a Visual Analogue Scale (0-10, 10 being highest possible comfort). RESULTS Significantly lower metatarsal head peak pressures (by a median 10-22 kPa) were found with the reinforced shoe compared to the non-reinforced shoe (p < .001). In >83% of cases with the reinforced shoe and >71% with the non-reinforced shoe metatarsal head peak pressures were <200 kPa. At the hindfoot, peak pressures were significantly higher (by a median 24 kPa) with the reinforced shoe (p = .001). No significant shoe effects were found for the toes. No significant shoe effects were found for walking comfort: median 6.1 for the reinforced shoe versus 5.6 for the non-reinforced shoe. SIGNIFICANCE Adding a full-length carbon reinforcement to the outsole of a diabetes-specific shoe significantly reduces peak pressures at the metatarsal heads, where ulcers often occur, in high-risk people with diabetes, and this does not occur at the expense of patient-perceived walking comfort.
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Affiliation(s)
- Jennefer B J Zwaferink
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands
| | - Wim Custers
- Penders Voetzorg, Reinier De Graafweg 1, 2625 AD, Delft, the Netherlands
| | - Irma Paardekooper
- Penders Voetzorg, Reinier De Graafweg 1, 2625 AD, Delft, the Netherlands
| | - Heleen A Berendsen
- Department of Rehabilitation Medicine, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands.
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11
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D’Amico M, Kinel E, Roncoletta P, Gnaldi A, Ceppitelli C, Belli F, Murdolo G, Vermigli C. Data-driven CAD-CAM vs traditional total contact custom insoles: A novel quantitative-statistical framework for the evaluation of insoles offloading performance in diabetic foot. PLoS One 2021; 16:e0247915. [PMID: 33661973 PMCID: PMC7932531 DOI: 10.1371/journal.pone.0247915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 02/17/2021] [Indexed: 12/19/2022] Open
Abstract
Background Elevated plantar pressures represent a significant risk factor for neuropathic diabetic foot (NDF) ulceration. Foot offloading, through custom-made insoles, is essential for prevention and healing of NDF ulcerations. Objective quantitative evaluation to design custom-made insoles is not a standard method. Aims: 1) to develop a novel quantitative-statistical framework (QSF) for the evaluation and design of the insoles’ offloading performance through in-shoe pressure measurement; 2) to compare the pressure-relieving efficiency of traditional shape-based total contact customised insoles (TCCI) with a novel CAD-CAM approach by the QSF. Methods We recruited 30 neuropathic diabetic patients in cross-sectional study design. The risk-regions of interest (R-ROIs) and their areas with in-shoe peak pressure statistically ≥200kPa were identified for each patients’ foot as determined on the average of peak pressure maps ascertained per each stance phase. Repeated measures Friedman test compared R-ROIs’ areas in three different walking condition: flat insole (FI); TCCI and CAD-CAM insoles. Results As compared with FI (20.6±12.9 cm2), both the TCCI (7±8.7 cm2) and the CAD-CAM (5.5±7.3 cm2) approaches provided a reduction of R-ROIs mean areas (p<0.0001). The CAD-CAM approach performed better than the TCCI with a mean pressure reduction of 37.3 kPa (15.6%) vs FI. Conclusions The CAD-CAM strategy achieves better offloading performance than the traditional shape-only based approach. The introduced QSF provides a more rigorous method to the direct 200kPa cut-off approach outlined in the literature. It provides a statistically sound methodology to evaluate the offloading insoles design and subsequent monitoring steps. QSF allows the analysis of the whole foot’s plantar surface, independently from a predetermined anatomical identification/masking. QSF can provide a detailed description about how and where custom-made insole redistributes the underfoot pressure respect to the FI. Thus, its usefulness extends to the design step, helping to guide the modifications necessary to achieve optimal offloading insole performances.
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Affiliation(s)
- Moreno D’Amico
- SMART Lab (Skeleton Movement Analysis and Advanced Rehabilitation Technologies)—Bioengineering & Biomedicine Company Srl, Pescara, Italy
- Department of Neuroscience, Imaging and Clinical Sciences University G. D’Annunzio, Chieti-Pescara, Italy
- * E-mail:
| | - Edyta Kinel
- Department of Rehabilitation, Chair of Rehabilitation and Physiotherapy, University of Medical Sciences, Poznan, Poland
| | - Piero Roncoletta
- SMART Lab (Skeleton Movement Analysis and Advanced Rehabilitation Technologies)—Bioengineering & Biomedicine Company Srl, Pescara, Italy
| | - Andrea Gnaldi
- Guantificio Altotiberino Ecosanit Calzature Snc, Anghiari, Italy
| | - Celeste Ceppitelli
- Department of Medicine, Unit of Endocrinology and Metabolism, S. Maria della Misericordia, Perugia Hospital, Perugia, Italy
| | | | - Giuseppe Murdolo
- Department of Medicine, Unit of Endocrinology and Metabolism, S. Maria della Misericordia, Perugia Hospital, Perugia, Italy
| | - Cristiana Vermigli
- Department of Medicine, Unit of Endocrinology and Metabolism, S. Maria della Misericordia, Perugia Hospital, Perugia, Italy
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12
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Jones P, Davies MJ, Khunti K, Fong DTP, Webb D. In-shoe pressure thresholds for people with diabetes and neuropathy at risk of ulceration: A systematic review. J Diabetes Complications 2021; 35:107815. [PMID: 33280984 DOI: 10.1016/j.jdiacomp.2020.107815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/19/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In-shoe pressure thresholds play an increasingly important role in the prevention of diabetes-related foot ulceration (DFU). The evidence of their effectiveness, methodological consistency and scope for refinement are the subject of this review. METHODS 1107 records were identified (after duplicate removal) based on a search of five databases for studies which applied a specific in-shoe pressure threshold to reduce the risk of ulceration. 37 full text studies were assessed for eligibility of which 21 were included. RESULTS Five in-shoe pressure thresholds were identified, which are employed to reduce the risk of diabetes-related foot ulceration: a mean peak pressure threshold of 200 kPa used in conjunction with a 25% baseline reduction target; a sustained pressure threshold of 35 mm Hg, a threshold matrix based on risk, shoe size and foot region, and a 40-80% baseline pressure reduction target. The effectiveness of the latter two thresholds have not been assessed yet and the evidence for the effectiveness of the other in-shoe pressure thresholds is limited, based only on two RCTs and two cohort studies. CONCLUSIONS The heterogeneity of current measures precludes meta-analysis and further research and methodological standardisation is required to facilitate ready comparison and the further development of these pressure thresholds.
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Affiliation(s)
- Petra Jones
- Leicester Diabetes Centre, Leicester General Hospital, University Hospitals of Leicester, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK.
| | - Melanie J Davies
- Leicester Diabetes Centre, Leicester General Hospital, University Hospitals of Leicester, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK; NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Leicester Diabetes Centre, Leicester General Hospital, University Hospitals of Leicester, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Daniel T P Fong
- School of Sport, Exercise and Health Sciences, Loughborough University, UK
| | - David Webb
- Leicester Diabetes Centre, Leicester General Hospital, University Hospitals of Leicester, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
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13
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Collings R, Freeman J, Latour JM, Paton J. Footwear and insole design features for offloading the diabetic at risk foot-A systematic review and meta-analyses. Endocrinol Diabetes Metab 2021; 4:e00132. [PMID: 33532602 PMCID: PMC7831212 DOI: 10.1002/edm2.132] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 12/25/2022] Open
Abstract
The aim of this systematic review was to identify the best footwear and insole design features for offloading the plantar surface of the foot to prevent foot ulceration in people with diabetic peripheral neuropathy. We searched multiple databases for published and unpublished studies reporting offloading footwear and insoles for people with diabetic neuropathy and nonulcerated feet. Primary outcome was foot ulcer incidence; other outcome measures considered were any standardized kinetic or kinematic measure indicating loading or offloading the plantar foot. Fifty-four studies, including randomized controlled studies, cohort studies, case-series, and a case-controlled and cross-sectional study were included. Three meta-analyses were conducted and random-effects modelling found peak plantar pressure reduction of arch profile (37 kPa (MD, -37.5; 95% CI, -72.29 to -3.61; P < .03), metatarsal addition (35.96 kPa (MD, -35.96; 95% CI, -57.33 to -14.60; P < .001) and pressure informed design 75.4 kPa (MD, -75.4 kPa; 95% CI, -127.4 to -23.44 kPa; P < .004).The remaining data were presented in a narrative form due to heterogeneity. This review highlights the difficulty in differentiating the effect of different insole and footwear features in offloading the neuropathic diabetic foot. However, arch profiles, metatarsal additions and apertures are effective in reducing plantar pressure. The use of pressure analysis to enhance the effectiveness of the design of footwear and insoles, particularly through modification, is recommended.
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Affiliation(s)
- Richard Collings
- School of Health ProfessionsFaculty of Health: Medicine, Dentistry and Human SciencesUniversity of PlymouthPlymouthUK
- Department of Podiatry, Torbay and South DevonNHS Foundation TrustPlymouthUK
| | - Jennifer Freeman
- School of Health ProfessionsFaculty of Health: Medicine, Dentistry and Human SciencesUniversity of PlymouthPlymouthUK
| | - Jos M. Latour
- School of Nursing and MidwiferyFaculty of Health: Medicine, Dentistry and Human SciencesUniversity of PlymouthPlymouthUK
| | - Joanne Paton
- School of Health ProfessionsFaculty of Health: Medicine, Dentistry and Human SciencesUniversity of PlymouthPlymouthUK
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14
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Ahmed S, Barwick A, Butterworth P, Nancarrow S. Footwear and insole design features that reduce neuropathic plantar forefoot ulcer risk in people with diabetes: a systematic literature review. J Foot Ankle Res 2020; 13:30. [PMID: 32498719 PMCID: PMC7271493 DOI: 10.1186/s13047-020-00400-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/22/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In people with diabetes, offloading high-risk foot regions by optimising footwear, or insoles, may prevent ulceration. This systematic review aimed to summarise and evaluate the evidence for footwear and insole features that reduce pathological plantar pressures and the occurrence of diabetic neuropathy ulceration at the plantar forefoot in people with diabetic neuropathy. METHODS Six electronic databases (Medline, Cinahl, Amed, Proquest, Scopus, Academic Search Premier) were searched in July 2019. The search period was from 1987 to July 2019. Articles, in English, using footwear or insoles as interventions in patients with diabetic neuropathy were reviewed. Any study design was eligible for inclusion except systematic literature reviews and case reports. Search terms were diabetic foot, physiopathology, foot deformities, neuropath*, footwear, orthoses, shoe, footwear prescription, insole, sock*, ulcer prevention, offloading, foot ulcer, plantar pressure. RESULTS Twenty-five studies were reviewed. The included articles used repeated measure (n = 12), case-control (n = 3), prospective cohort (n = 2), randomised crossover (n = 1), and randomised controlled trial (RCT) (n = 7) designs. This involved a total of 2063 participants. Eleven studies investigated footwear, and 14 studies investigated insoles as an intervention. Six studies investigated ulcer recurrence; no study investigated the first occurrence of ulceration. The most commonly examined outcome measures were peak plantar pressure, pressure-time integral and total contact area. Methodological quality varied. Strong evidence existed for rocker soles to reduce peak plantar pressure. Moderate evidence existed for custom insoles to offload forefoot plantar pressure. There was weak evidence that insole contact area influenced plantar pressure. CONCLUSION Rocker soles, custom-made insoles with metatarsal additions and a high degree of contact between the insole and foot reduce plantar pressures in a manner that may reduce ulcer occurrence. Most studies rely on reduction in plantar pressure measures as an outcome, rather than the occurrence of ulceration. There is limited evidence to inform footwear and insole interventions and prescription in this population. Further high-quality studies in this field are required.
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Affiliation(s)
- Sayed Ahmed
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
| | - Alex Barwick
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
| | - Paul Butterworth
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
| | - Susan Nancarrow
- School of Health and Human Sciences, Southern Cross University, Billinga, Queensland 4225 Australia
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15
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Zwaferink JBJ, Custers W, Paardekooper I, Berendsen HA, Bus SA. Optimizing footwear for the diabetic foot: Data-driven custom-made footwear concepts and their effect on pressure relief to prevent diabetic foot ulceration. PLoS One 2020; 15:e0224010. [PMID: 32324739 PMCID: PMC7179916 DOI: 10.1371/journal.pone.0224010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/03/2019] [Indexed: 01/22/2023] Open
Abstract
Aims To assess the effect of data-driven custom-made footwear concepts on plantar pressure relief to prevent diabetic foot ulceration. Methods Twenty-four neuropathic diabetic patients at high risk of foot ulceration were measured for in-shoe plantar pressures during walking in four data-driven custom-made footwear conditions, an athletic shoe and an off-the-shelf non-therapeutic shoe. Two evidence-based footwear conditions (Shoe-A; Insole-A) follow a scientific-based design protocol, are handmade, and use in-shoe plantar pressure guided optimization. One evidence-based insole condition (Insole-B) uses a barefoot plantar pressure and 3D foot shape-based computer-assisted design and manufacturing (CADCAM) routine. And one insole condition (Insole-C) uses a barefoot and in-shoe plantar pressure and 3D foot shape-based CADCAM design and optimization routine. Patient satisfaction was scored on walking comfort, shoe fit, weight and appearance. Results All data-driven footwear conditions significantly reduced metatarsal head peak pressure compared with the non-therapeutic shoe (17–53% relief). Shoe-A and Insole-A showed the lowest metatarsal head peak pressures (mean 112–155 kPa, 90–98% of cases <200 kPa), significantly lower than for Insole-B and Insole-C (mean 119–199 kPa, 52–100% <200 kPa). Patient satisfaction was not significantly different between footwear concepts. Conclusions This study proves the offloading efficacy of a scientific-based, handmade, and in-shoe plantar pressure data-driven approach to custom-made footwear design, and advocates its implementation to optimize diabetic footwear for plantar foot ulcer prevention.
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Affiliation(s)
- Jennefer B. J. Zwaferink
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | | | | | - Heleen A. Berendsen
- Department of Rehabilitation Medicine, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Sicco A. Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- * E-mail:
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16
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Niemann U, Spiliopoulou M, Malanowski J, Kellersmann J, Szczepanski T, Klose S, Dedonaki E, Walter I, Ming A, Mertens PR. Plantar temperatures in stance position: A comparative study with healthy volunteers and diabetes patients diagnosed with sensoric neuropathy. EBioMedicine 2020; 54:102712. [PMID: 32304997 PMCID: PMC7163066 DOI: 10.1016/j.ebiom.2020.102712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/27/2020] [Accepted: 02/27/2020] [Indexed: 12/30/2022] Open
Abstract
Background Microcirculatory defects in diabetes are linked with neuropathy and the onset of diabetic foot syndrome. In this study we quantify pressure- and posture-dependent changes of plantar temperatures as a surrogate of tissue perfusion in healthy volunteers versus diabetes patients diagnosed with neuropathy in the absence of macroangiopathy. Methods Healthy volunteers (n = 31) as well as patients with diabetes diagnosed with severe polyneuropathy (n = 30) were enrolled in a clinical study to test for plantar temperature changes in the feet during extended episodes of standing. These lasted between 5 and 20 min each over 95 min, in between the participants were asked to take a seated position for 5 min and release the pressure from the feet. Major macroangiopathy was excluded before study enrolment. Custom-made insoles harbored temperature and pressure sensors positioned at eight preselected positions for recording. Findings In both subgroups a significant plantar temperature downshift occurred within 10 min of standing, which was especially detected during the initial 45 min of the study protocol. Comparisons between healthy volunteers and patients with diabetes revealed no differences in the magnitude of temperature downshifts during stance episodes. Pressure sensor recordings revealed that healthy volunteers intermittently released pressure during the longer stance episodes due to discomfort, whereas the patients with diabetes and polyneuropathy did not. Interpretation Our findings demonstrate a tight plantar temperature regulation following pressure exposure. In patients with diabetes and peripheral sensoric neuropathy the temperature drop is similar to healthy volunteers. Potentially, prolonged stance periods resulting in less perfused plantar tissue may remain unrecognized with polyneuropathy, whereas discomfort develops in healthy controls. Funding The study was supported by EFRE Förderung der Europäischen Union und Landesmittel des Ministeriums für Wirtschaft, Wissenschaft und Digitalisierung Sachsen-Anhalt (Vorhabennummer: ZS/2016/05/78,615 and ZS/2018/12/95,325). JK and PRM were supported by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) - project ID 97,850,925 - SFB854, AM by the Chinese Scholarship Council (CSC).
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Affiliation(s)
- Uli Niemann
- Faculty of Computer Science, Otto-von-Guericke University Magdeburg, Universitätsplatz 2, 39106 Magdeburg, Germany.
| | - Myra Spiliopoulou
- Faculty of Computer Science, Otto-von-Guericke University Magdeburg, Universitätsplatz 2, 39106 Magdeburg, Germany
| | - Jan Malanowski
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany
| | - Juliane Kellersmann
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany
| | | | - Silke Klose
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany
| | - Eirini Dedonaki
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany
| | - Isabell Walter
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany
| | - Antao Ming
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany
| | - Peter R Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, 39116 Magdeburg, Germany.
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17
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van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Rasmussen A, Sacco ICN, Bus SA. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3270. [PMID: 31957213 DOI: 10.1002/dmrr.3270] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022]
Abstract
Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non-controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot-related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight-bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non-existent for the prevention of a first foot ulcer and non-plantar foot ulcer.
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Affiliation(s)
- Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - 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, Universidade do Porto, Porto, Portugal
| | | | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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18
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Bus SA, Zwaferink JB, Dahmen R, Busch-Westbroek T. State of the art design protocol for custom made footwear for people with diabetes and peripheral neuropathy. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3237. [PMID: 31845547 PMCID: PMC7154634 DOI: 10.1002/dmrr.3237] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/12/2019] [Indexed: 01/06/2023]
Abstract
Supported by evidence-based guidelines, custom-made footwear is often prescribed to people with diabetes who are at risk for ulceration. However, these guidelines do not specify the footwear design features, despite available scientific evidence for these features. We aimed to develop a design protocol to support custom-made footwear prescription for people with diabetes and peripheral neuropathy. The population of interest was people with diabetes who are at moderate-to-high risk of developing a foot ulcer, for whom custom-made footwear (shoes and/or insoles) can be prescribed. A group of experts from rehabilitation medicine, orthopaedic shoe technology (pedorthics) and diabetic foot research, reviewed the scientific literature and met during 12 face-to-face meetings to develop a footwear design algorithm and evidence-based pressure-relief algorithm as parts of the protocol. Consensus was reached where evidence was not available. Fourteen domains of foot pathology in combination with loss of protective sensation were specified for the footwear design algorithm and for each domain shoe-specific and insole (orthosis)-specific features were defined. Most insole-related features and some shoe-related features were evidence based, whereas most shoe-related features were consensus based. The pressure-relief algorithm was evidence based using recent footwear trial data and specifically targeted patients with a healed plantar foot ulcer. These footwear design and pressure-relief algorithms are the first of their kind and should facilitate more uniform decision making in the prescription and manufacturing of adequate shoes for moderate-to-high-risk patients, reducing variation in footwear provision and improving clinical outcome in the prevention of diabetic foot ulcers.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jennefer B Zwaferink
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rutger Dahmen
- Amsterdam Rehabilitation Research Center, Amsterdam, The Netherlands
| | - Tessa Busch-Westbroek
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN, van Netten JJ. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3269. [PMID: 32176451 DOI: 10.1002/dmrr.3269] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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 prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention 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. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at-risk patient about appropriate foot self-care and treat any pre-ulcerative sign on the foot. Instruct moderate-to-high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non-surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high-risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days, and to reduce the patient and health care burden of diabetic foot disease.
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Affiliation(s)
- Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde and CINTESIS-Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
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20
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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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21
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Lazzarini PA, Crews RT, van Netten JJ, Bus SA, Fernando ME, Chadwick PJ, Najafi B. Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management. J Diabetes Sci Technol 2019; 13:869-880. [PMID: 31030546 PMCID: PMC6955461 DOI: 10.1177/1932296819849092] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Excessive stress on plantar tissue over time is one of the leading causes of diabetic foot ulcers among people with diabetic peripheral neuropathy. Plantar tissue stress (PTS) is a concept that attempts to integrate several well-known mechanical factors into one measure, including plantar pressure, shear stress, daily weight-bearing activity, and time spent in prescribed offloading interventions (adherence). Despite international diabetic foot guidelines recommending the measure of each of these individual mechanical factors in people with neuropathy, only recently has technology enabled their combined measurement to determine PTS. In this article we review the concept of PTS, the mechanical factors involved, and the findings of pivotal articles reporting measures of PTS in people with neuropathy. We also discuss key existing gaps in this field, including the lack of standards to measure and report PTS, a lack of practical solutions to measure shear stress, and the lack of PTS thresholds that may indicate benefit or detriment to people with neuropathy. To address some of these gaps, we propose recommended clinical and research standards for measuring and reporting PTS in people with neuropathy. Last, we forecast future clinical, research, and technological advancements that may use PTS to highlight the importance of this critical concept in the prevention and management of diabetic foot ulcers.
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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, Australia
- Peter A. Lazzarini, PhD, School of Public Health and Social Work, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Brisbane, Queensland 4059, Australia.
| | - Ryan T. Crews
- Center for Lower Extremity Ambulatory Research (CLEAR), Dr William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Jaap J. van Netten
- Amsterdam UMC, Department of Rehabilitation, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Ziekenhuisgroep Twente, Department of Surgery, Almelo and Hengelo, the Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Sicco A. Bus
- Amsterdam UMC, Department of Rehabilitation, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Malindu E. Fernando
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | | | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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22
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Tang L, Wang L, Bao W, Zhu S, Li D, Zhao N, Liu C. Functional gradient structural design of customized diabetic insoles. J Mech Behav Biomed Mater 2019; 94:279-287. [PMID: 30933836 DOI: 10.1016/j.jmbbm.2019.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Abstract
Diabetic foot is a common and serious complication of diabetes, largely due to sensory neuropathy and excessive mechanical stresses. Studies have shown that reducing the contact pressure can effectively lower the incidence of diabetic foot. A new design method is proposed in this study for optimizing the stress distribution of the contact surfaces between the foot and the insole by applying functional gradient structural properties to the insole. Finite element analysis was employed for studying the contact mechanics, which laid the foundation for modulus readjustment during the optimization process. The moduli of the materials were correlated to the properties of the structural porous units. The customized insoles were manufactured using additive manufacturing technology and put into mechanical test. Results show that the designed insole helps in increasing the foot contact area by approximately 30% and reducing the peak contact pressure by 35%. Hence, the proposed method can be used to design customized insoles, particularly diabetic insoles, by offering better contact mechanics and good potential for reducing the severity of diabetic foot. The methodology is equally applicable to other designs involving optimization of material properties.
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Affiliation(s)
- Lei Tang
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, ShaanXi, China
| | - Ling Wang
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, ShaanXi, China
| | - Wannan Bao
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, ShaanXi, China
| | - Siyao Zhu
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, ShaanXi, China
| | - Dichen Li
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, ShaanXi, China.
| | - Ningxin'er Zhao
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, ShaanXi, China
| | - Chaozong Liu
- John Scale Centre for Biomedical Engineering, University College London, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
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23
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Telfer S, Bigham JJ. The influence of population characteristics and measurement system on barefoot plantar pressures: A systematic review and meta-regression analysis. Gait Posture 2019; 67:269-276. [PMID: 30391749 DOI: 10.1016/j.gaitpost.2018.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The measurement of plantar pressure distributions during gait can provide insights into the effects of musculoskeletal disease on foot function. A range of hardware, software, and protocols are available for the collection of this type of data, with sometimes disparate and conflicting results reported between individual studies. In this systematic review and meta-regression analysis of dynamic regional peak pressures, we aimed to test if 1) the system used to obtain the pressure measurements and 2) the characteristics of the study populations had a significant effect on the results. METHODS A systematic review of the literature was undertaken to identify articles reporting regional peak plantar pressures during barefoot walking. A mixed-effects modeling approach was used to analyze the extracted data. Initially, the effect of the system used to collect the data was tested. Following this, the effect of participant characteristics on the results were analyzed, using moderators of cohort type (defined as the primary health characteristic of the participants), age, sex, and BMI. RESULTS 115 participant groups were included in the analysis. Sufficient cohorts were available to test those that consisted of healthy individuals, and those with diabetes and diabetic neuropathy. Significant differences were found between results reported by studies using different pressure measurement systems in 8 of the 16 regions analyzed. The analysis of participant characteristics revealed a number of significant relationships between regional peak pressures and participant characteristics, including: BMI and midfoot plantar pressures; elevated forefoot pressures as a result of diabetic neuropathy; and sex-differences in regional loading patterns. CONCLUSIONS At the level of the literature, we confirmed significant effects of disease status, age, BMI, and sex on regional peak plantar pressures. Researchers and clinicians should be aware that measurements of peak plantar pressure variables obtained from different collection equipment are not directly comparable.
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Affiliation(s)
- S Telfer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, United States.
| | - J J Bigham
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, United States
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van Netten JJ, Lazzarini PA, Armstrong DG, Bus SA, Fitridge R, Harding K, Kinnear E, Malone M, Menz HB, Perrin BM, Postema K, Prentice J, Schott KH, Wraight PR. Diabetic Foot Australia guideline on footwear for people with diabetes. J Foot Ankle Res 2018; 11:2. [PMID: 29371890 PMCID: PMC5769299 DOI: 10.1186/s13047-017-0244-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022] Open
Abstract
Background The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes. Methods We reviewed new footwear publications, (inter)national guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations. Result We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate- or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate- or high-risk of foot ulceration to wear their footwear at all times, both indoors and outdoors. (6) Motivate people with diabetes at intermediate- or high-risk of foot ulceration (or their relatives and caregivers) to check their footwear, each time before wearing, to ensure that there are no foreign objects in, or penetrating, the footwear; and check their feet, each time their footwear is removed, to ensure there are no signs of abnormal pressure, trauma or ulceration. (7) For people with a foot deformity or pre-ulcerative lesion, consider prescribing medical grade footwear, which may include custom-made in-shoe orthoses or insoles. (8) For people with a healed plantar foot ulcer, prescribe medical grade footwear with custom-made in-shoe orthoses or insoles with a demonstrated plantar pressure relieving effect at high-risk areas. (9) Review prescribed footwear every three months to ensure it still fits adequately, protects, and supports the foot. (10) For people with a plantar diabetic foot ulcer, footwear is not specifically recommended for treatment; prescribe appropriate offloading devices to heal these ulcers. Conclusions This guideline contains 10 key recommendations to guide health professionals in selecting the most appropriate footwear to meet the specific foot risk needs of an individual with diabetes.
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Affiliation(s)
- Jaap J van Netten
- 1School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD Australia.,Diabetic Foot Australia, Brisbane, QLD Australia.,Wound Management Innovation Cooperative Research Centre, Brisbane, QLD Australia
| | - Peter A Lazzarini
- 1School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD Australia.,Diabetic Foot Australia, Brisbane, QLD Australia.,Wound Management Innovation Cooperative Research Centre, Brisbane, QLD Australia.,Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD Australia
| | - David G Armstrong
- 5Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ USA
| | - Sicco A Bus
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Robert Fitridge
- Diabetic Foot Australia, Brisbane, QLD Australia.,7Vascular Surgery, The University of Adelaide, Adelaide, South Australia Australia
| | - Keith Harding
- 8University Dean of Clinical Innovation, Professor of Wound Healing Research, Cardiff University, Cardiff, UK
| | - Ewan Kinnear
- Diabetic Foot Australia, Brisbane, QLD Australia.,Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD Australia
| | - Matthew Malone
- Diabetic Foot Australia, Brisbane, QLD Australia.,9High Risk Foot Service, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW Australia
| | - Hylton B Menz
- 10Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC Australia
| | - Byron M Perrin
- Diabetic Foot Australia, Brisbane, QLD Australia.,11La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, VIC Australia
| | - Klaas Postema
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Jenny Prentice
- Diabetic Foot Australia, Brisbane, QLD Australia.,Wound Consultant, Trojan Health, Perth, WA Australia
| | - Karl-Heinz Schott
- 14School of Health and Human Sciences (Pedorthics) Southern Cross University Gold Coast Campus, Bilinga, QLD Australia
| | - Paul R Wraight
- Diabetic Foot Australia, Brisbane, QLD Australia.,15Diabetic Foot Unit, Royal Melbourne Hospital, Melbourne, VIC Australia
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25
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Bus SA, Maas JC, Otterman NM. Lower-extremity dynamics of walking in neuropathic diabetic patients who wear a forefoot-offloading shoe. Clin Biomech (Bristol, Avon) 2017; 50:21-26. [PMID: 28985487 DOI: 10.1016/j.clinbiomech.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 09/13/2017] [Accepted: 10/01/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND A forefoot-offloading shoes has a negative-heel rocker outsole and is used to treat diabetic plantar forefoot ulcers, but its mechanisms of action and their association with offloading and gait stability are not sufficiently clear. METHODS Ten neuropathic diabetic patients were tested in a forefoot-offloading shoe and subsequently in a control shoe with no specific offloading construction, both worn on the right foot (control shoe on left), while walking at 1.2m/s. 3D-instrumented gait analysis and simultaneous in-shoe plantar pressure measurements were used to explain the shoe's offloading efficacy and to define centre-of-pressure profiles and left-to-right symmetry in ankle joint dynamics (0-1, 1:maximum symmetry), as indicators for gait stability. FINDINGS Compared to the control shoe, peak forefoot pressures, vertical ground reaction force, plantar flexion angle, and ankle joint moment, all in terminal stance, and the proximal-to-distal centre-of-pressure trajectory were significantly reduced in the forefoot-offloading shoe (P<0.01). Peak ankle joint power was 51% lower in the forefoot-offloading shoe compared to the control shoe: 1.61 (0.35) versus 3.30 (0.84) W/kg (mean (SD), P<0.001), and was significantly associated with forefoot peak pressure (R2=0.72, P<0.001). Left-to-right symmetry in the forefoot-offloading shoe was 0.39 for peak ankle joint power. INTERPRETATION By virtue to their negative-heel rocker-outsole design, forefoot-offloading shoes significantly alter a neuropathic diabetic patient's gait towards a reduced push-off power that explains the shoe's offloading efficacy. However, gait symmetry and stability are compromised, and may be factors in the low perceived walking discomfort and limited use of these shoes in clinical practice. Shoe modifications (e.g. less negative heel, a more cushioning insole) may resolve this trade-off between efficacy and usability.
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Affiliation(s)
- Sicco A Bus
- Human Performance Laboratory, Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Josina C Maas
- Human Performance Laboratory, Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Nicoline M Otterman
- Human Performance Laboratory, Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Telfer S, Woodburn J, Collier A, Cavanagh P. Virtually optimized insoles for offloading the diabetic foot: A randomized crossover study. J Biomech 2017; 60:157-161. [DOI: 10.1016/j.jbiomech.2017.06.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 06/15/2017] [Accepted: 06/16/2017] [Indexed: 11/17/2022]
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The Role of Pressure Offloading on Diabetic Foot Ulcer Healing and Prevention of Recurrence. Plast Reconstr Surg 2017; 138:179S-187S. [PMID: 27556758 DOI: 10.1097/prs.0000000000002686] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND An increased plantar pressure is a causative factor in the development of plantar foot ulcers in people with diabetes mellitus, and ulcers are a precursor of lower extremity amputation. METHODS In this article, the evidence is reviewed that relieving areas of increased plantar pressure (ie, offloading) can heal plantar foot ulcers and prevent their recurrence. RESULTS Noninfected, nonischemic neuropathic plantar forefoot ulcers should heal in 6 to 8 weeks with adequate offloading. Recent meta-analyses and systematic reviews show that nonremovable knee-high devices are most effective. This is probably because they eliminate the problem of nonadherence with the use of a removable device. Studies show a large discrepancy between evidence-based recommendations on offloading and what is used in clinical practice. Many clinics continue to use methods that are less effective or have not been proven to be effective, while ignoring evidence-based methods. Strategies are proposed to address this issue, notably the adoption and implementation of recent international guidelines by professional societies and a stronger focus of clinicians on expedited healing. For the prevention of plantar foot ulcer recurrence in high-risk patients, 2 recent trials have shown that the incidence of recurrence can be significantly reduced with custom-made footwear that has a demonstrated pressure-relieving effect through guidance by plantar pressure measurements, under the condition that the footwear is worn. CONCLUSION This review helps to inform clinicians about effective offloading treatment for healing plantar foot ulcers and preventing their recurrence.
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