Harnessing Digital Health Technologies to Remotely Manage Diabetic Foot Syndrome: A Narrative Review

Intelligent Care Management for Diabetic Foot Ulcers: A Scoping Review of Computer Vision and Machine Learning Techniques and Applications

Ten percent of adults in the United States have a diagnosis of diabetes and up to a third of these individuals will develop a diabetic foot ulcer (DFU) in their lifetime. Of those who develop a DFU, a fifth will ultimately require amputation with a mortality rate of up to 70% within five years. The human suffering, economic burden, and disproportionate impact of diabetes on communities of color has led to increasing interest in the use of computer vision (CV) and machine learning (ML) techniques to aid the detection, characterization, monitoring, and even prediction of DFUs. Remote monitoring and automated classification are expected to revolutionize wound care by allowing patients to self-monitor their wound pathology, assist in the remote triaging of patients by clinicians, and allow for more immediate interventions when necessary. This scoping review provides an overview of applicable CV and ML techniques. This includes automated CV methods developed for remote assessment of wound photographs, as well as predictive ML algorithms that leverage heterogeneous data streams. We discuss the benefits of such applications and the role they may play in diabetic foot care moving forward. We highlight both the need for, and possibilities of, computational sensing systems to improve diabetic foot care and bring greater knowledge to patients in need.

Assessing the effectiveness of targeted educational interventions on enhancing self-efficacy and foot care practices among diabetic women in Jordan

Background

Diabetic foot is a major public health issue, leading to increased morbidity and mortality among diabetic patients. This study aimed to evaluate the effectiveness of targeted health education interventions on self-efficacy and foot care practices among diabetic women in Jordan.

Methods

A pretest-posttest, quasi-experimental design was used to collect data from 76 diabetic women at a tertiary hospital in northern Jordan. Participants were assigned to three groups: a control group receiving standard care; Intervention Group 1, receiving standard care with weekly text reminders and follow-up calls; and Intervention Group 2, receiving the same components as Intervention Group 1, plus small group education sessions and hands-on foot care training. Generalized Estimating Equations models were used to assess the impact of the interventions on foot care practices and self-efficacy over an 8-week period.

Results

The findings revealed that participants in Intervention Group 2 demonstrated the most significant improvements in both foot care practices and self-efficacy. For foot care practices, Intervention Group 2 had adjusted odds ratios (aORs) of 2.5 (95% CI: 1.3-5.1) and 1.7 (95% CI: 1.2-2.9) when compared to the control group and Intervention Group 1, respectively. Similarly, for self-efficacy, the aORs for Intervention Group 2 were 2.7 (95% CI: 1.4-5.2) relative to the control group, and 1.8 (95% CI: 1.1-3.2) compared to Intervention Group 1.

Conclusion

Our study demonstrates that interactive educational approaches-featuring group discussions, real-time problem-solving, immediate feedback, and family support-can empower diabetic women to take a more active role in managing their foot health. Routine clinical care alone is insufficient to promote proactive foot care behaviors, highlighting the need for healthcare providers to incorporate educational materials tailored to the local cultural context into standard care to enhance patient outcomes.

Impact of ozone concentration on the treatment effectiveness of diabetic foot syndrome: a pilot single-centre study

Introduction

Diabetic foot syndrome (DFS) a severe complication of diabetes which can result in ulcers, infections, or tissue damage in the feet.

Aim

To compare the treatment effectiveness in patients with DFS using local O3 therapy depending on the O3 concentration.

Material and methods

The study included 50 patients, 24 male and 26 female ones, in the age range between 39 and 84 years, with DFS. In group 1 (25 patients), 30 µg/ml doses of ozone were applied, and in group 2 (25 patients) doses of 60 µg/ml. A total of 30 local ozone therapy procedures, lasting 30 min each, were performed in both groups, in two sessions (15 procedures), with a 4-week break between sessions. The effectiveness of wound healing was evaluated by computerized planimetry, and pain intensity was assessed with the use of the VAS scale.

Results

After treatment, a statistically significant reduction in the area of wounds and the intensity of pain was achieved in both groups. The median (IQR) wound size after treatment in group 1 was: 4.5 (4-5) cm2, and in group 2: 4 (3-4.5) cm2; (p = 0.027). The median (IQR) pain intensity (VAS) after treatment in group 1 was: 5 (4-5) points, and in group 2: 4 (3-4.5) points (p = 0.002).

Conclusions

The use of a higher concentration ozone increased the effectiveness of the therapy in terms of reducing the wound surface area and alleviating the pain. Therefore, the possibility of using higher ozone concentrations in the treatment of diabetic foot syndrome is worth considering.

How do patients and healthcare professionals experience foot examinations in diabetes care? - A randomised controlled study of digital foot examinations versus traditional foot examinations

BACKGROUND

Digital solutions in healthcare can facilitate and improve care. However, the experiences and the usefulness of using either digital foot examinations or traditional foot examinations need to be evaluated. The aims of the study were to evaluate: 1) The differences in patient experiences, having their foot examined supported by the Clinical Decision Support System as compared with having their foot examined in traditional practice, 2) How healthcare professionals, by using the digital tool, experienced the routine compared with performing the foot examination as in traditional practice.

METHODS

Of a total of 141 patients, 100 patients with diabetes were single-blind digitally randomised to one of two parallel arms: having their foot examined by a healthcare professional using a digital tool (n = 47) or having their foot examined as in traditional practice (n = 53) at the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients filled in a modified version of the National Patient Survey and the Orthotics and Prosthetics Users' Survey at study end. Two healthcare professionals, working at a Department of Prosthetics and Orthotics, answered surveys regarding the interaction between the patient and the certified prosthetist and orthotist.

RESULTS

Patients, aged 66 ± 13 years, perceived a high level of satisfaction with the service at the department, regardless of the method used. No significant differences between groups were found when evaluated by 27 questions in the National Patient Survey or by the Orthotics and Prosthetics Users' Survey, with scores of 67.17 ± 12.18 vs. 66.35 ± 16.52 (p = 0.78) for the intervention and control group respectively. For the same patient that healthcare professionals foot examined, the risk class was fully obtained when the risk to develop foot ulcers was assessed by using the digital tool, whereas only 2% of the patients were classified when foot assessed in traditional practice.

CONCLUSIONS

Regardless of the method used for the foot examination, patients perceived a high level of satisfaction with the services at the Department of Prosthetics and Orthotics. All the patients were risk classified in the intervention group. The healthcare professionals found that, by using the Clinical Decision Support System, the foot examination was structured and followed clinical guidelines. Furthermore, the documentation in the electronic health record was thorough, even though further improvements, such as integration with co-existing health record systems, were requested.

TRIAL REGISTRATION

Clinical Trials NCT03088566 , Registered 23 March 2017.

An overview of current developments and methods for identifying diabetic foot ulcers: A survey

Diabetic foot ulcers (DFUs) present a substantial health risk across diverse age groups, creating challenges for healthcare professionals in the accurate classification and grading. DFU plays a crucial role in automated health monitoring and diagnosis systems, where the integration of medical imaging, computer vision, statistical analysis, and gait information is essential for comprehensive understanding and effective management. Diagnosing DFU is imperative, as it plays a major role in the processes of diagnosis, treatment planning, and neuropathy research within automated health monitoring and diagnosis systems. To address this, various machine learning and deep learning‐based methodologies have emerged in the literature to support healthcare practitioners in achieving improved diagnostic analyses for DFU. This survey paper investigates various diagnostic methodologies for DFU, spanning traditional statistical approaches to cutting‐edge deep learning techniques. It systematically reviews key stages involved in diabetic foot ulcer classification (DFUC) methods, including preprocessing, feature extraction, and classification, explaining their benefits and drawbacks. The investigation extends to exploring state‐of‐the‐art convolutional neural network models tailored for DFUC, involving extensive experiments with data augmentation and transfer learning methods. The overview also outlines datasets commonly employed for evaluating DFUC methodologies. Recognizing that neuropathy and reduced blood flow in the lower limbs might be caused by atherosclerotic blood vessels, this paper provides recommendations to researchers and practitioners involved in routine medical therapy to prevent substantial complications. Apart from reviewing prior literature, this survey aims to influence the future of DFU diagnostics by outlining prospective research directions, particularly in the domains of personalized and intelligent healthcare. Finally, this overview is to contribute to the continual evolution of DFU diagnosis in order to provide more effective and customized medical care.

This article is categorized under:

Optimising wound monitoring: Can digital tools improve healing outcomes and clinic efficiency

BACKGROUND

Chronic wounds present significant challenges for patients and nursing care teams worldwide. Digital health tools offer potential for more standardised and efficient nursing care pathways but require further rigorous evaluation.

OBJECTIVE

This retrospective matched cohort study aimed to compare the impacts of a digital tracking application for wound documentation versus traditional manual nursing assessments.

METHODS

Data from 5236 patients with various wound types were analysed. Propensity score matching balanced groups, and bivariate tests, correlation analyses, linear regression, and Hayes' Process Macro Model 15 were utilised for a mediation-moderation model.

RESULTS

Digital wound tracking was associated with significantly shorter healing durations (15 vs. 35 days) and fewer clinic nursing visits (3 vs. 5.8 visits) compared to standard nursing monitoring. Digital tracking demonstrated improved wound size reduction over time. Laboratory values tested did not consistently predict healing outcomes. Digital tracking exhibited moderate negative correlations with the total number of nursing visits. Regression analysis identified wound complexity, hospitalizations, and initial wound size as clinical predictors for more nursing visits in patients with diabetes mellitus (p < .01). Digital tracking significantly reduced the number of associated nursing visits for patients with peripheral vascular disease.

CONCLUSION

These findings suggest that digital wound management may streamline nursing care and provide advantages, particularly for comorbid populations facing treatment burdens.

REPORTING METHOD

This study adhered to STROBE guidelines in reporting this observational research.

RELEVANCE TO CLINICAL PRACTICE

By streamlining documentation and potentially shortening healing times, digital wound tracking could help optimise nursing resources, enhance wound care standards, and improve patient experiences. This supports further exploration of digital health innovations to advance evidence-based nursing practice.

PATIENT OR PUBLIC CONTRIBUTION

This study involved retrospective analysis of existing patient records and did not directly include patients or the public in the design, conduct, or reporting of the research.

Assessing the influence of rural residence and economic distress on lower extremity risk stratification among diabetic foot ulcer patients utilizing the Wound, Ischemia, and Foot Infection (WIfI) classification system

OBJECTIVE

Diabetic foot ulcers (DFU) are a major sequela of uncontrolled diabetes with a high risk of adverse outcomes. Poor DFU outcomes disproportionately impact patients living in rural and economically distressed communities with lack of access to consistent, quality care. This study aimed to analyze the risk of geographic and economic disparities, including rural status and county economic distress, on the disease burden of DFU at presentation utilizing the SVS WIfI classification system.

METHODS

We conducted a retrospective review of 454 patients diagnosed with a DFU from 2011 to 2020 at a single institution's inpatient and outpatient wound care service. Patients >18 years old, with type II diabetes mellitus, and diabetic foot ulcer were included.

RESULTS

ANCOVA analyses showed rural patients had significantly higher WIfI composite scores (F(1,451) = 9.61, p = .002), grades of wound (F(1,439) = 11.03, p = .001), and ischemia (F(1,380) = 12.574, p = .001) compared to the urban patients. Patients that resided in at-risk economic counties had significantly higher overall WIfI composite scores (F(2,448) = 3.31, p = .037) than patients who lived in transitional economic counties, and higher foot infection grading (F(2,440) = 3.02, p = .05) compared to patients who lived in distressed economic counties. DFU patients who resided in distressed economic counties presented with higher individual grades of ischemia (F(2, 377) = 3.14, p = .04) than patients in transitional economic counties. Chi-Square analyses demonstrated patients who resided in urban counties were significantly more likely to present with grade 1 wounds (χ2(3) = 9.86, p = .02) and grade 0 ischemia (χ2(3) = 16.18, p = .001) compared to patients in rural areas. Economically distressed patients presented with significantly less grade 0 ischemia compared to patients in transitional economic counties (χ2(6) = 17.48, p = .008).

CONCLUSIONS

Our findings are the first to demonstrate the impact of geographic and economic disparities on the disease burden of DFU at presentation utilizing the SVS WIfI classification system. This may indicate need for improved multidisciplinary primary care prevention strategies with vascular specialists in these communities to mitigate worsening DFU and promote early intervention.

Development of a Digital Patient Assistant for the Management of Cyclic Vomiting Syndrome: Patient-Centric Design Study

BACKGROUND

Cyclic vomiting syndrome (CVS) is an enigmatic and debilitating disorder of gut-brain interaction that is characterized by recurrent episodes of severe vomiting and nausea. It significantly impairs patients' quality of life and can lead to frequent medical visits and substantial health care costs. The diagnosis for CVS is often protracted and complex, primarily due to its exclusionary diagnosis nature and the lack of specific biomarkers. This typically leads to a considerable delay in accurate diagnosis, contributing to increased patient morbidity. Additionally, the absence of approved therapies for CVS worsens patient hardship and reflects the urgent need for innovative, patient-centric solutions to improve CVS management.

OBJECTIVE

We aim to develop a digital patient assistant (DPA) for patients with CVS to address their unique needs, and iteratively enhance the technical features and user experience on the initial DPA versions.

METHODS

The development of the DPA for CVS used a design thinking approach, prioritizing user needs. A literature review and Patient Advisory Board shaped the initial prototype, focusing on diagnostic support and symptom tracking. Iterative development, informed by the design thinking approach and feedback from patients with CVS and caregivers through interviews and smartphone testing, led to significant enhancements in user interaction and artificial intelligence integration. The final DPA's effectiveness was validated using the System Usability Scale and feedback questions, ensuring it met the specific needs of the CVS community.

RESULTS

The DPA developed for CVS integrates an introductory bot, daily and weekly check-in bots, and a knowledge hub, all accessible via a patient dashboard. This multicomponent solution effectively addresses key unmet needs in CVS management: efficient symptom and impacts tracking, access to comprehensive disease information, and a digital health platform for disease management. Significant improvements, based on user feedback, include the implementation of artificial intelligence features like intent recognition and data syncing, enhancing the bot interaction and reducing the burden on patients. The inclusion of the knowledge hub provides educational resources, contributing to better disease understanding and management. The DPA achieved a System Usability Scale score of 80 out of 100, indicating high ease of use and relevance. Patient feedback highlighted the DPA's potential in disease management and suggested further applications, such as integration into health care provider recommendations for patients with suspected or confirmed CVS. This positive response underscores the DPA's role in enhancing patient engagement and disease management through a patient-centered digital solution.

CONCLUSIONS

The development of this DPA for patients with CVS, via an iterative design thinking approach, offers a patient-centric solution for disease management. The DPA development framework may also serve to guide future patient digital support and research scenarios.

Shengjihuayu formula ameliorates the oxidative injury in human keratinocytes via blocking JNK/c-Jun/MMPs signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

The reactive oxygen species (ROS) surge in the chronic wound tissue of diabetic ulcers (DUs) aggravates the inflammatory response. The oxidative stress state during inflammation will exacerbate inflammation and cause tissue damage, resulting in prolonged wound healing. Shengjihuayu Formula (SJHYF) is a renowned Chinese medicine prescription for treating chronic wounds in diabetic ulcers. Growing clinical evidence has demonstrated that SJHYF exhibits superior therapeutic efficacy and has a favorable safety profile. However, the underlying mechanisms by which SJHYF ameliorates oxidative damage under pathological conditions of DUs remain unclear.

OBJECTIVE

To investigate the cytoprotective properties of SJHYF on hydrogen peroxide (H2O2)-induced cell damage in human HaCaT keratinocytes and to explore its potential targets and molecular pathways in treating DUs using RNA-seq.

METHODS

HaCaT cells were incubated with H2O2 for 24 h to construct an oxidative stress cell model. Cell viability and proliferation were measured using the MTT and EdU assays, respectively. Cell migration was assessed using the scratch assay, and the fluorescence intensity of ROS was measured using the DCFH-DA probe. The chemical components of SJHYF were analyzed by UPLC-Q-TOF/MS, while the therapeutic effects of SJHYF on H2O2-induced HaCaT cells were analyzed using RNA-Seq. The potential target genes were validated using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). At the same time, the pathway phenotype expression of SJHYF on the protection of H2O2-induced HaCaT cells was explored using Western Blot.

RESULTS

The application of SJHY at a concentration of 0.25 mg/mL promoted cell proliferation, cell migration, and reduced ROS production. In addition, SJHYF was detected to have a total of 93 active compounds, including key components such as Galloyl-beta-D-glucose, Danshensu, Procyanidin B2, Catechin, and Alkannin. The RNA-seq analysis identified several core targets namely KRT17, TGM1, JUNB, PRDX5, TXNIP, PRDX1, HSP90AA1, HSP90AB1, HSPA8, and TNF-α. Western blot revealed the presence of the JNK/c-Jun/MMPs pathway and its related transcription factors.

CONCLUSION

SJHYF displays significant protective effects on H2O2-induced oxidative cell damage in HaCaT cells via blocking the JNK/c-Jun/MMPs pathway.

A Multi-Faceted Digital Health Solution for Monitoring and Managing Diabetic Foot Ulcer Risk: A Case Series

INTRODUCTION

Diabetic foot ulcers (DFU) are a devastating complication of diabetes. There are numerous challenges with preventing diabetic foot complications and barriers to achieving the care processes suggested in established foot care guidelines. Multi-faceted digital health solutions, which combine multimodal sensing, patient-facing biofeedback, and remote patient monitoring (RPM), show promise in improving our ability to understand, prevent, and manage DFUs.

METHODS

Patients with a history of diabetic plantar foot ulcers were enrolled in a prospective cohort study and equipped with custom sensory insoles to track plantar pressure, plantar temperature, step count, and adherence data. Sensory insole data enabled patient-facing biofeedback to cue active plantar offloading in response to sustained high plantar pressures, and RPM assessments in response to data trends of concern in plantar pressure, plantar temperature, or sensory insole adherence. Three non-consecutive case participants that ultimately presented with pre-ulcerative lesions (a callus and/or erythematous area on the plantar surface of the foot) during the study were selected for this case series.

RESULTS

Across three illustrative patients, continuous plantar pressure monitoring demonstrated promise for empowering both the patient and provider with information for data-driven management of pressure offloading treatments.

CONCLUSION

Multi-faceted digital health solutions can naturally enable and reinforce the integrative foot care guidelines. Multi-modal sensing across multiple physiologic domains supports the monitoring of foot health at various stages along the DFU pathogenesis pathway. Furthermore, digital health solutions equipped with remote patient monitoring unlock new opportunities for personalizing treatments, providing periodic self-care reinforcement, and encouraging patient engagement-key tools for improving patient adherence to their diabetic foot care plan.

Stepping Forward: A Scoping Systematic Literature Review on the Health Outcomes of Smart Sensor Technologies for Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) pose a significant challenge in diabetes care, demanding advanced approaches for effective prevention and management. Smart insoles using sensor technology have emerged as promising tools to address the challenges associated with DFU and neuropathy. By recognizing the pivotal role of smart insoles in successful prevention and healthcare management, this scoping review aims to present a comprehensive overview of the existing evidence regarding DFU studies related to smart insoles, offloading sensors, and actuator technologies. This systematic review identified and critically evaluated 11 key studies exploring both sensor technologies and offloading devices in the context of DFU care through searches in CINAHL, MEDLINE, and ScienceDirect databases. Predominantly, smart insoles, mobile applications, and wearable technologies were frequently utilized for interventions and patient monitoring in diabetic foot care. Patients emphasized the importance of these technologies in facilitating care management. The pivotal role of offloading devices is underscored by the majority of the studies exhibiting increased efficient monitoring, prevention, prognosis, healing rate, and patient adherence. The findings indicate that, overall, smart insoles and digital technologies are perceived as acceptable, feasible, and beneficial in meeting the specific needs of DFU patients. By acknowledging the promising outcomes, the present scoping review suggests smart technologies can potentially redefine DFU management by emphasizing accessibility, efficacy, and patient centricity.

The Application of Digital Frailty Screening to Triage Nonhealing and Complex Wounds

OBJECTIVE

We investigated the association between the complexity of diabetic foot ulcers (DFUs) and frailty.

RESEARCH DESIGN AND METHODS

Individuals (n = 38) with Grade 2 Wagner DFU were classified into 3 groups based on the Society for Vascular Surgery risk-stratification for major limb amputation as Stage 1 at very low risk (n = 19), Stage 2 at low risk (n = 9), and Stage 3 to 4 at moderate-to-high risk (n = 10) of major limb amputation. Frailty status was objectively assessed using a validated digital frailty meter (FM). The FM works by quantifying weakness, slowness, rigidity, and exhaustion over a 20-second repetitive elbow flexion-extension exercise using a wrist-worn sensor. FM generates a frailty index (FI) ranging from 0 to 1; higher values indicate progressively greater severity of frailty. Skin perfusion pressure (SPP), albumin, and tissue oxygenation level (SatO2) were also measured. One-way analysis of variance (ANOVA) was used to identify group effect for wound complexity. Pearson's correlation coefficient was used to assess the associations with frailty and clinical endpoints.

RESULTS

Frailty index was higher in Stage 3 and 4 as compared to Stage 1 (d = 1.4, P < .01) and Stage 2 (d = 1.2, P < .01). Among assessed frailty phenotypes, exhaustion was correlated with SPP (r = -0.63, P < .01) and albumin (r = -0.5, P < .01).

CONCLUSION

Digital biomarkers of frailty may predict complexity of DFU and thus triage individuals who can be treated more simply in their primary clinic versus higher risk patients who require prompt referral to multidisciplinary, more complex care.

The quest for wellness: How to optimise self-care strategies for diabetic foot management?

Diabetic foot ulceration (DFU) is common and highly recurrent, negatively impacting the individuals' quality of life. The 2023 guidelines of the International Working Group on the Diabetic Foot emphasise that adherence to foot self-care recommendations is one of the most important factors in DFU prevention. These guidelines also briefly mention that depression and other psychosocial problems can hamper treatment and ulcer healing. Moreover, a new clinical question was added on psychological interventions for ulcer prevention, although the evidence regarding the role of psychological and social factors is still limited. To help the field progress, this narrative overview discusses how a stronger focus on psychological factors by both researchers and clinicians could improve the care for people at high DFU risk. The review starts with a testimony of a person living with DFU, explaining that for him, the absence of shared decision-making has been a key barrier to successful foot self-care implementation. Intervention studies that address patient-reported barriers are still scarce, and are therefore urgently needed. Furthermore, the key elements of psychological interventions found to be successful in managing diabetes are yet to be implemented in DFU risk management. Importantly, research evidence indicates that commonly advocated foot self-care recommendations may be insufficient in preventing DFU recurrence, whereas digital technology appears to effectively reduce recurrent DFU. More research is therefore needed to identify determinants of patient acceptance of digital technology.

A Survey on Impact of Internet of Medical Things Against Diabetic Foot Ulcer

INTRODUCTION: In this study, we explore the intricate domain of Diabetic Foot Ulcers (DFU) through the development of a comprehensive framework that encompasses diverse operational scenarios. The focus lies on the identification and classification assessment of diabetic foot ulcers, the implementation of smart health management strategies, and the collection, analysis, and intelligent interpretation of data related to diabetic foot ulcers. The framework introduces an innovative approach to predicting diabetic foot ulcers and their key characteristics, offering a technical solution for forecasting. The exploration delves into various computational strategies designed for intelligent health analysis tailored to patients with diabetic foot ulcers. OBJECTIVES: The primary objective of this paper is to present a technical solution for forecasting diabetic foot ulcers, utilizing computational strategies for intelligent health analysis. METHODS: Techniques derived from social network analysis are employed to conduct this research, focusing on diverse computational strategies geared towards intelligent health analysis for patients with diabetic foot ulcers. The study highlights methodologies addressing the unique challenges posed by diabetic foot ulcers, with a central emphasis on the integration of Internet of Medical Things (IoMT) in prediction strategies. RESULTS: The main results of this paper include the proposal of IoMT-based computing strategies covering the entire spectrum of DFU analysis, such as localization, classification assessment, intelligent health management, and detection. The study also acknowledges the challenges faced by previous research, including low classification rates and elevated false alarm rates, and proposes automatic recognition approaches leveraging advanced machine learning techniques to enhance accuracy and efficacy. CONCLUSION: The proposed IoMT-based computing strategies present a significant advancement in addressing the challenges associated with predicting diabetic foot ulcers. The integration of advanced machine learning techniques demonstrates promise in improving accuracy and efficiency in diabetic foot ulcer localization, marking a positive stride towards overcoming existing limitations in previous research.

Digital Health in Diabetes and Cardiovascular Disease

BACKGROUND

Digital health technologies are rapidly evolving and transforming the care of diabetes and cardiovascular disease (CVD).

PURPOSE OF THE REVIEW

In this review, we discuss emerging approaches incorporating digital health technologies to improve patient outcomes through a more continuous, accessible, proactive, and patient-centered approach. We discuss various mechanisms of potential benefit ranging from early detection to enhanced physiologic monitoring over time to helping shape important management decisions and engaging patients in their care. Furthermore, we discuss the potential for better individualization of management, which is particularly important in diseases with heterogeneous and complex manifestations, such as diabetes and cardiovascular disease. This narrative review explores ways to leverage digital health technology to better extend the reach of clinicians beyond the physical hospital and clinic spaces to address disparities in the diagnosis, treatment, and prevention of diabetes and cardiovascular disease.

CONCLUSION

We are at the early stages of the shift to digital medicine, which holds substantial promise not only to improve patient outcomes but also to lower the costs of care. The review concludes by recognizing the challenges and limitations that need to be addressed for optimal implementation and impact. We present recommendations on how to navigate these challenges as well as goals and opportunities in utilizing digital health technology in the management of diabetes and prevention of adverse cardiovascular outcomes.

Offloading and adherence through technological advancements: Modern approaches for better foot care in diabetes

OBJECTIVE

This manuscript aims to provide a review and synthesis of contemporary advancements in footwear, sensor technology for remote monitoring, and digital health, with a focus on improving offloading and measuring and enhancing adherence to offloading in diabetic foot care.

METHODS

A narrative literature review was conducted by sourcing peer-reviewed articles, clinical studies, and technological innovations. This paper includes a review of various strategies, from specifically designed footwear, smart insoles and boots to using digital health interventions, which aim to offload plantar pressure and help prevent and manage wounds more effectively by improving the adherence to such offloading.

RESULTS

In-house specially made footwear, sensor technologies remotely measuring pressure and weight-bearing activity, exemplified for example, through applications like smart insoles and SmartBoot, and other digital health technologies, show promise in improving offloading and changing patient behaviour towards improving adherence to offloading and facilitating personalised care. This paper introduces the concept of gamification and emotive visual indicators as novel methods to enhance patient engagement. It further discusses the transformative role of digital health technologies in the modern era.

CONCLUSIONS

The integration of technology with footwear and offloading devices offers unparallelled opportunities for improving diabetic foot disease management not only through better offloading but also through improved adherence to offloading. These advancements allow healthcare providers to personalise treatment plans more effectively, thereby promising a major improvement in patient outcomes in diabetic foot ulcer healing and prevention.

Data-driven digital health technologies in the remote clinical care of diabetic foot ulcers: a scoping review

Background

The availability and effectiveness of Digital Health Technologies (DHTs) to support clinicians, empower patients, and generate economic savings for national healthcare systems are growing rapidly. Of particular promise is the capacity of DHTs to autonomously facilitate remote monitoring and treatment. Diabetic Foot Ulcers (DFUs) are characterised by high rates of infection, amputation, mortality, and healthcare costs. With clinical outcomes contingent on activities that can be readily monitored, DFUs present a promising focus for the application of remote DHTs.

Objective

This scoping review has been conducted as a first step toward ascertaining fthe data-related challenges and opportunities for the development of more comprehensive, integrated, and individualised sense/act DHTs. We review the latest developments in the application of DHTs to the remote care of DFUs. We cover the types of DHTs in development and their features, technological readiness, and scope of clinical testing.

Eligibility criteria

Only peer-reviewed original experimental and observational studies, case series and qualitative studies were included in literature searches. All reviews and manuscripts presenting pre-trial prototype technologies were excluded.

Methods

An initial search of three databases (Web of Science, MEDLINE, and Scopus) generated 1,925 English-language papers for screening. 388 papers were assessed as eligible for full-text screening by the review team. 81 manuscripts were found to meet the eligibility criteria.

Results

Only 19% of studies incorporated multiple DHTs. We categorised 56% of studies as 'Treatment-Manual', i.e. studies involving technologies aimed at treatment requiring manual data generation, and 26% as 'Prevention-Autonomous', i.e. studies of technologies generating data autonomously through wearable sensors aimed at ulcer prevention through patient behavioural change. Only 10% of studies involved more ambitious 'Treatment-Autonomous' interventions. We found that studies generally reported high levels of patient adherence and satisfaction.

Conclusions

Our findings point to a major potential role for DHTs in remote personalised medical management of DFUs. However, larger studies are required to assess their impact. Here, we see opportunities for developing much larger, more comprehensive, and integrated monitoring and decision support systems with the potential to address the disease in a more complete context by capturing and integrating data from multiple sources from subjective and objective measurements.

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

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

Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.

Patients, carers and healthcare providers' perspectives on a patient-owned surveillance system for diabetic foot ulcer care: A qualitative study

Objective

Digital health has recently gained a foothold in monitoring and improving diabetes care. We aim to explore the views of patients, carers and healthcare providers (HCPs) regarding the use of a novel patient-owned wound surveillance application as part of outpatient management of patients with diabetic foot ulcers (DFUs).

Methods

Semi-structured online interviews were conducted with patients, carers and HCPs in wound care for DFUs. The participants were recruited from a primary care polyclinic network and two tertiary hospitals in Singapore, within the same healthcare cluster. Purposive maximum variation sampling was used to select participants with differing attributes to ensure heterogeneity. Common themes relating to the wound imaging app were captured.

Results

A total of 20 patients, 5 carers and 20 HCPs participated in the qualitative study. None of the participants have used a wound imaging app before. Regarding a patient-owned wound surveillance app, all were open and receptive to the system and workflow for use in DFU care. Four major themes emerged from patients and carers: (1) technology, (2) application features and usability, (3) feasibility of using the wound imaging application and (4) logistics of care. Four major themes were identified from HCPs: (1) attitudes towards wound imaging app, (2) preferences regarding functionality, (3) perceived challenges for patients/carers and (4) perceived barriers for HCPs.

Conclusion

Our study highlighted several barriers and facilitators from patients, carers and HCPs regarding the use of a patient-owned wound surveillance app. These findings demonstrate the potential of digital health and areas to improve and tailor a DFU wound app suitable for implementation in the local population.

Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers

BACKGROUND

Non-removable knee-high devices are the gold-standard offloading treatments to heal plantar diabetic foot ulcers (DFUs). These devices are underused in practice for a variety of reasons. Recommending these devices for all patients, regardless of their circumstances and preferences influencing their ability to tolerate the devices, does not seem a fruitful approach.

PURPOSE

The aim of this article is to explore the potential implications of a more personalized approach to offloading DFUs and suggest avenues for future research and development.

METHODS

Non-removable knee-high devices effectively heal plantar DFUs by reducing plantar pressure and shear at the DFU, reducing weight-bearing activity and enforcing high adherence. We propose that future offloading devices should be developed that aim to optimize these mechanisms according to each individual's needs. We suggest three different approaches may be developed to achieve such personalized offloading treatment. First, we suggest modular devices, where different mechanical features (rocker-bottom sole, knee-high cast walls/struts, etc.) can be added or removed from the device to accommodate different patients' needs and the evolving needs of the patient throughout the treatment period. Second, advanced manufacturing techniques and novel materials could be used to personalize the design of their devices, thereby improving common hindrances to their use, such as devices being heavy, bulky, and hot. Third, sensors could be used to provide real-time feedback to patients and clinicians on plantar pressures, shear, weight-bearing activity, and adherence.

CONCLUSIONS

By the use of these approaches, we could provide patients with personalized devices to optimize plantar tissue stress, thereby improving clinical outcomes.

Smart Offloading Boot System for Remote Patient Monitoring: Toward Adherence Reinforcement and Proper Physical Activity Prescription for Diabetic Foot Ulcer Patients

BACKGROUND

A critical factor in healing diabetic foot ulcers is patient adherence to offloading devices. We tested a smart offloading boot (SmartBoot) combined with a smartwatch app and cloud dashboard to remotely monitor patient adherence and activity. In addition, the impact of SmartBoot on balance, gait, and user experience was investigated.

METHODS

Fourteen volunteers (31.6±8.7 years; 64% female) performed natural activities (eg, sitting, standing, walking) with and without the SmartBoot for approximately 30 minutes. All participants completed balance tests, 10-meter walking tests at slow, normal, and fast pace while wearing the SmartBoot, and a user experience questionnaire. The accuracy of real-time adherence reporting was assessed by comparing the SmartBoot and staff observation. Center of mass (COM) sway and step counts were measured using a validated wearable system.

RESULTS

Average sensitivity, specificity, and accuracy for adherence and non-adherence were 90.6%, 88.0%, and 89.3%, respectively. The COM sway area was significantly smaller with the SmartBoot than without the SmartBoot regardless of test condition. Step count error was 4.4% for slow waking, 36.2% for normal walking, 16.0% for fast walking. Most participants agreed that the SmartBoot is easy to use, relatively comfortable, nonintrusive, and innovative.

CONCLUSIONS

To our knowledge, this is the first smart offloading system that enables remote patient monitoring and real-time adherence and activity reporting. The SmartBoot enhanced balance performance, likely due to somatosensory feedback. Questionnaire results highlight SmartBoot's technical and clinical potential. Future studies warrant clinical validation of real-time non-adherence alerting to improve wound healing outcomes in people with diabetic foot ulcers.

Investigating the effects of digital foot self-management program on enhancing self-efficacy and self-care behavior among community-dwelling older adults with type 2 diabetes: A randomized controlled trial

Introduction

Diabetic foot self-management intervention programs have been proven to positively influence individuals' behaviors in preventing diabetic foot ulcers. Using digital technologies to deliver programs can facilitate compliance with diabetes self-management programs. However, few studies have focused on the effects of such digital programs on improving the self-efficacy and behaviors of older adults with type 2 diabetes in the community.

Aim

To evaluate the effects of a digital foot self-management program on self-efficacy, self-care behavior, and Hemoglobin A1c levels.

Design

A single-blinded, randomized controlled trial was conducted.

Methods

The intervention program comprised a 4-week digital foot care program with one face-to-face education session, phone calls once weekly, and LINE messages (social media) three times per research nurse and a follow-up of three months. Patients in the control group received routine care.

Results

A total of 100 participants (n = 50 in the control and n = 50 in the intervention groups) completed the study with a mean age of 67.55 (SD = 11.17). The results showed significant improvements in self-efficacy (F = 2187.24, p < 0.01) and self-care behavior (F = 614.71, p < 0.01) in foot care between the groups. The Hemoglobin A1c levels showed a 0.41% reduction over time in the experimental group (t = -3.759; p < 0.01), whereas the control group showed a 0.06% reduction (t = -0.797, p > 0.05).

Conclusion

The newly developed digital foot self-management program was effective in community-dwelling older adult patients with type 2 diabetes.

Using Wearable Sensors to Measure Goal Achievement in Older Veterans with Dementia

Aligning treatment with patients' self-determined goals and health priorities is challenging in dementia care. Wearable-based remote health monitoring may facilitate determining the active participation of individuals with dementia towards achieving the determined goals. The present study aimed to demonstrate the feasibility of using wearables to assess healthcare goals set by older adults with cognitive impairment. We present four specific cases that assess (1) the feasibility of using wearables to monitor healthcare goals, (2) differences in function after goal-setting visits, and (3) goal achievement. Older veterans (n = 17) with cognitive impairment completed self-report assessments of mobility, then had an audio-recorded encounter with a geriatrician and wore a pendant sensor for 48 h. Follow-up was conducted at 4-6 months. Data obtained by wearables augments self-reported data and assessed function over time. Four patient cases illustrate the utility of combining sensors, self-report, notes from electronic health records, and visit transcripts at baseline and follow-up to assess goal achievement. Using data from multiple sources, we showed that the use of wearable devices could support clinical communication, mainly when patients, clinicians, and caregivers work to align care with the patient's priorities.

A review of non-invasive sensors and artificial intelligence models for diabetic foot monitoring

Diabetic foot complications have multiple adverse effects in a person's quality of life. Yet, efficient monitoring schemes can mitigate or postpone any disorders, mainly by early detecting regions of interest. Nowadays, optical sensors and artificial intelligence (AI) tools can contribute efficiently to such monitoring processes. In this work, we provide information on the adopted imaging schemes and related optical sensors on this topic. The analysis considers both the physiology of the patients and the characteristics of the sensors. Currently, there are multiple approaches considering both visible and infrared bands (multiple ranges), most of them coupled with various AI tools. The source of the data (sensor type) can support different monitoring strategies and imposes restrictions on the AI tools that should be used with. This review provides a comprehensive literature review of AI-assisted DFU monitoring methods. The paper presents the outcomes of a large number of recently published scholarly articles. Furthermore, the paper discusses the highlights of these methods and the challenges for transferring these methods into a practical and trustworthy framework for sufficient remote management of the patients.

Objective Assessment of Upper-Extremity Motor Functions in Spinocerebellar Ataxia Using Wearable Sensors

The study presents a novel approach to objectively assessing the upper-extremity motor symptoms in spinocerebellar ataxia (SCA) using data collected via a wearable sensor worn on the patient's wrist during upper-extremity tasks associated with the Assessment and Rating of Ataxia (SARA). First, we developed an algorithm for detecting/extracting the cycles of the finger-to-nose test (FNT). We extracted multiple features from the detected cycles and identified features and parameters correlated with the SARA scores. Additionally, we developed models to predict the severity of symptoms based on the FNT. The proposed technique was validated on a dataset comprising the seventeen (n = 17) participants' assessments. The cycle detection technique showed an accuracy of 97.6% in a Bland-Altman analysis and a 94% accuracy (F1-score of 0.93) in predicting the severity of the FNT. Furthermore, the dependency of the upper-extremity tests was investigated through statistical analysis, and the results confirm dependency and potential redundancies in the upper-extremity SARA assessments. Our findings pave the way to enhance the utility of objective measures of SCA assessments. The proposed wearable-based platform has the potential to eliminate subjectivity and inter-rater variabilities in assessing ataxia.

Patient and public involvement in mobile health-based research for hay fever: a qualitative study of patient and public involvement implementation process

BACKGROUND

Smartphones are being increasingly used for research owing to their multifunctionality and flexibility, and crowdsourced research using smartphone applications (apps) is effective in the early detection and management of chronic diseases. We developed the AllerSearch app to gather real-world data on individual subjective symptoms and lifestyle factors related to hay fever. This study established a foundation for interactive research by adopting novel, diverse perspectives accrued through implementing the principles of patient and public involvement (PPI) in the development of our app.

METHODS

Patients and members of the public with a history or family history of hay fever were recruited from November 2019 to December 2021 through a dedicated website, social networking services, and web briefing according to the PPI Guidebook 2019 by the Japan Agency for Medical Research and Development. Nine opinion exchange meetings were held from February 2020 to December 2021 to collect opinions and suggestions for updating the app. After each meeting, interactive evaluations from PPI contributors and researchers were collected. The compiled suggestions were then incorporated into the app, establishing an active feedback loop fed by the consistently interactive infrastructure.

RESULTS

Four PPI contributors (one man and three women) were recruited, and 93 items were added/changed in the in-app survey questionnaire in accordance with discussions from the exchange meetings. The exchange meetings emphasized an atmosphere and opportunity for participants to speak up, ensuring frequent opportunities for them to contribute to the research. In March 2020, a public website was created to display real-time outcomes of the number of participants and users' hay-fever-preventative behaviors. In August 2020, a new PPI-implemented AllerSearch app was released.

CONCLUSIONS

This study marks the first research on clinical smartphone apps for hay fever in Japan that implements PPI throughout its timeline from research and development to the publication of research results. Taking advantage of the distinct perspectives offered by PPI contributors, a step was taken toward actualizing a foundation for an interactive research environment. These results should promote future PPI research and foster the establishment of a social construct that enables PPI efforts in various fields.

Effect of concurrent transcranial direct current stimulation on instrumented timed up and go task performance in people with Parkinson's disease: A double-blind and cross-over study

Transcranial direct current stimulation (tDCS) delivered to the dorsolateral prefrontal cortex (DLPFC) can improve mobility among people with Parkinson's disease (PD). Previous studies suggest that delivering tDCS during task performance might be beneficial. However, only a few studies explored the effect of combining tDCS with task. We investigated the effect of stimulating the DLPFC using anodal tDCS while performing a timed up and go (TUG) test and its sustained effects. In this sham-controlled, cross-over, and double-blind study, twenty participants with PD (age = 67.8 ± 8.3 years and 6 females) completed two sessions (anodal or sham tDCS), conducted in the randomized and counterbalanced manner, with at least a 1-week gap. Stimulation involved transferring 2 mA current through the DLPFC for 30 min. Single-trial of TUG test was performed under single- and dual-task conditions before, during, immediately after, 15 and 30 min after stimulation ceased. We estimated durations of completing different components of TUG. Phoneme verbal fluency task was given as the cognitive distractor during the dual-tasking. An improvement was observed in cognitive performance due to the tDCS condition (d = 0.7, p < 0.01) over time. However, we found no effect of tDCS condition on iTUG related outcomes under single- or dual-task conditions. In conclusion, DLPFC stimulation combined with task improved cognitive performance only, and the improvement was sustained after tDCS ceased. Future studies may investigate stimulating multiple brain regions to improve motor and cognitive performance.

A Survey of Human Gait-Based Artificial Intelligence Applications

We performed an electronic database search of published works from 2012 to mid-2021 that focus on human gait studies and apply machine learning techniques. We identified six key applications of machine learning using gait data: 1) Gait analysis where analyzing techniques and certain biomechanical analysis factors are improved by utilizing artificial intelligence algorithms, 2) Health and Wellness, with applications in gait monitoring for abnormal gait detection, recognition of human activities, fall detection and sports performance, 3) Human Pose Tracking using one-person or multi-person tracking and localization systems such as OpenPose, Simultaneous Localization and Mapping (SLAM), etc., 4) Gait-based biometrics with applications in person identification, authentication, and re-identification as well as gender and age recognition 5) “Smart gait” applications ranging from smart socks, shoes, and other wearables to smart homes and smart retail stores that incorporate continuous monitoring and control systems and 6) Animation that reconstructs human motion utilizing gait data, simulation and machine learning techniques. Our goal is to provide a single broad-based survey of the applications of machine learning technology in gait analysis and identify future areas of potential study and growth. We discuss the machine learning techniques that have been used with a focus on the tasks they perform, the problems they attempt to solve, and the trade-offs they navigate.

Distribution of Mobile Health Applications amongst Patients with Symptomatic Peripheral Arterial Disease in Germany: A Cross-Sectional Survey Study

Background: Broadly available digital and mobile health applications (also known as mHealth) have recently gained increasing attention by the vascular community, but very little is known about the dissemination and acceptance of such technologies in certain target populations. The current study aimed to determine the user behaviour and acceptance of such digital technologies amongst patients with peripheral arterial disease (PAD). Methods: A cross-sectional survey of consecutively treated inpatients at 12 university institutions, as well as one non-university institution, was conducted. All admitted patients with symptomatic PAD were surveyed for 30 consecutive days within a flexible timeframe between 1 July and 30 September 2021. The factors associated with smartphone use were estimated via backward selection within a logistic regression model with clustered standard errors. Results: A total of 326 patients participated (response rate 96.3%), thereof 102 (34.0%) were treated for intermittent claudication (IC, 29.2% women, 70 years in median) and 198 were treated for chronic limb-threatening ischaemia (CLTI, 29.5% women, 70 years in median). Amongst all of the patients, 46.6% stated that they had not changed their lifestyle and health behaviour since the index diagnosis (four years in median), and 33.1% responded that they were not aware of the reasons for all of their medication orders. Amongst all those surveyed, 66.8% owned a smartphone (IC: 70.6%, CLTI: 64.1%), thereof 27.9% needed regular user support. While 42.5% used smartphone apps, only 15.0% used mobile health applications, and 19.0% owned wearables. One out of five patients agreed that such technologies could help to improve their healthy lifestyle. Only higher age was inversely associated with smartphone possession. Conclusions: The current survey showed that smartphones are prevalent amongst patients with peripheral arterial disease, but only a small proportion used mobile health applications and a considerable number of patients needed regular user support. Almost half of the patients did not change their lifestyle and one third were not aware of the reasons for their medication orders, emphasising room for improvement. These findings can further help to guide future projects using such applications to identify those target populations that are reachable with digital interventions.

Patient and Provider Perspective of Smart Wearable Technology in Diabetic Foot Ulcer Prevention: A Systematic Review

Background and Objectives: Smart wearable devices are effective in diabetic foot ulcer (DFU) prevention. However, factors determining their acceptance are poorly understood. This systematic review aims to examine the literature on patient and provider perspectives of smart wearable devices in DFU prevention. Materials and Methods: PubMed, Scopus, and Web of Science were systematically searched up to October 2021. The selected articles were assessed for methodological quality using the quality assessment tool for studies with diverse designs. Results: A total of five articles were identified and described. The methodological quality of the studies ranged from low to moderate. Two studies employed a quantitative study design and focused on the patient perspective, whereas three studies included a mixed, quantitative/qualitative design and explored patient or provider (podiatrist) perspectives. Four studies focused on an insole system and one included a smart sock device. The quantitative studies demonstrated that devices were comfortable, well designed and useful in preventing DFU. One mixed design study reported that patients did not intend to adopt an insole device in its current design because of malfunctions, a lack of comfort. and alert intrusiveness, despite the general perception that the device was a useful tool for foot risk monitoring. Two mixed design studies found that performance expectancy was a predictor of a podiatrist's behavioural intention to recommend an insole device in clinical practice. Disappointing participant experiences negatively impacted the podiatrists' intention to adopt a smart device. The need for additional refinements of the device was indicated by patients and providers before its use in this population. Conclusions: The current evidence about patient and provider perspectives on smart wearable technology is limited by scarce methodological quality and conflicting results. It is, thus, not possible to draw definitive conclusions regarding acceptability of these devices for the prevention of DFU in people with diabetes.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.