Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis

BACKGROUND

Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU.

METHODS

We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed.

RESULTS

From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers.

CONCLUSIONS

Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

AIMS

Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

MATERIALS AND METHODS

We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.

RESULTS

For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.

CONCLUSION

These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

Remaining Question: Does Exercise Improve Healing of Diabetic Foot Ulcers?

Even though it is reasonable to think that exercise is beneficial to diabetic foot ulcer healing, there are currently no exercise recommendations for this population. A systematic review published recently attempted to answer this question. However, because of both the scarce and heterogenous literature on the subject identified by the selected study design and the chosen quality appraisal tool that is too permissive and overestimates the treatment effects, no clinical recommendations can be drawn from this review. We advocate for research on this topic in order to obtain more direct evidence that exercise benefits wound healing, and to close the persistent gap of knowledge regarding the impact of exercise on diabetic foot ulcer wound healing.

Sensor-Assisted Wound Therapy in Plantar Diabetic Foot Ulcer Treatment: A Randomized Clinical Trial

BACKGROUND

Offloading is the cornerstone of treatment of plantar diabetic foot ulcers. It limits mobility with consequent psychological and cardiovascular side effects, and if devices are removed, healing is delayed.

METHODS

We developed three non-removable techniques with increasing offloading potential (multilayer felt sole, felt-fiberglass sole, or total contact casts with ventral windows) and sensors built within. Smartwatch and web apps displayed pressure, temperature, humidity, and steps. They alerted patients, staff, and a telemedicine center when pressure limits (125 kPa) were exceeded. Patients were advised to walk as much as they had done before the ulcer episode. To evaluate the potential of this intervention, we enrolled 20 ambulatory patients in a randomized clinical trial. The control group used the same offloading and monitoring system, but neither patients nor therapists received any information or warnings.

RESULTS

Three patients withdrew consent. The median time to healing of ulcers was significantly shorter in the intervention group compared with controls, 40.5 (95% confidence interval [CI] = 28-not applicable [NA]) versus 266.0 (95% CI = 179-NA) days (P = .037), and increasing ulcer area was observed less frequently during study visits (7.9% vs 29.7%, P = .033). A reduction of wound area by 50% was reached at a median of 10.2 (95% CI = 7.25-NA) versus 19.1 (95% CI = 13.36-NA) days (P = .2). Participants walked an average of 1875 (SD = 1590) steps per day in intervention group and 1806 (SD = 1391) in the control group.

CONCLUSIONS

Sensor-assisted wound therapy may allow rapid closure of plantar foot ulcers while maintaining patient's mobility during ulcer therapy.

Prescribing Home Digital Thermometry Coupled with Activity Dosing and Optimized Offloading to Prolong Diabetic Foot Remission: A Case Report

People with a history of diabetic foot ulcers (DFUs) experience diminished health-related quality of life and are at a 40% annual risk of DFU recurrence. Due to a fear of DFU recurrence, people in DFU remission participate less in physical activity and moderate-intensity exercise when compared to people with diabetes who have not had wounds. There is novel evidence to suggest that too little activity during DFU remission contributes to only low magnitudes of repetitive tissue loading creating a higher susceptibility to skin trauma during inadvertent high-activity bouts. Conversely, a hasty return to too much activity could lead to rapid recurrence. There is now high-level evidence from multiple meta-analyses to indicate that home-based foot temperature monitoring, coupled with activity modification and daily inspection of the feet for impending signs of ulceration, could reduce the risk of ulcer recurrence by 50%. There is little evidence, however, to guide the decision-making regarding the appropriate quantity and frequency of physical activity during DFU remission and the acceptability from the patient perspective. This has resulted in limited uptake of this novel intervention in clinical practice. Earlier, we proposed that activity can be dosed for people in foot ulcer remission, just like insulin or medication is dosed. Here, we describe a patient-centered approach to implementing home foot temperature monitoring coupled with daily foot checks and dosage-based return to physical activity in a patient in DFU remission, including his perspective. We believe using such an approach could maximize ulcer-free days in remission, thereby improving quality of life.

Exercise in adults admitted to hospital with diabetes-related foot ulcers: a pilot study of feasibility and safety

Background

Diabetes-related foot ulcers result in significant mortality, morbidity and economic costs. Pressure offloading is important for ulcer healing, but patients with diabetes-related foot ulcers are presented with a dilemma, because whilst they are often advised to minimise standing and walking, there are also clear guidelines which encourage regular, sustained exercise for patients with diabetes. To overcome these apparently conflicting recommendations, we explored the feasibility, acceptability and safety of a tailored exercise program for adults admitted to hospital with diabetes-related foot ulcers.

Methods

Patients with diabetes-related foot ulcers were recruited from an inpatient hospital setting. Baseline demographics and ulcer characteristics were collected, and participants undertook a supervised exercise training session comprising aerobic and resistance exercises followed by prescription of a home exercise programme. Exercises were tailored to ulcer location, which complied with podiatric recommendations for pressure offloading. Feasibility and safety were assessed via recruitment rate, retention rate, adherence to inpatient and outpatient follow up, adherence to home exercise completion, and recording of adverse events.

Results

Twenty participants were recruited to the study. The retention rate (95%), adherence to inpatient and outpatient follow up (75%) and adherence to home exercise (50.0%) were all acceptable. No adverse events occurred.

Conclusions

Targeted exercise appears safe to be undertaken by patients with diabetes-related foot ulcers during and after an acute hospital admission. Recruitment in this cohort may prove challenging, but adherence, retention and satisfaction with participation in exercise were high.

Trial registration

The trial is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12622001370796).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-023-00616-0.

Rehabilitation for people wearing offloading devices for diabetes-related foot ulcers: a systematic review and meta-analyses

BACKGROUND

Offloading devices improve healing of diabetes-related foot ulcers (DFUs) but they can limit mobilisation. Rehabilitation during or after removal of these devices may promote physical activity in a population at risk of poor health outcomes for which inactivity is a reversible risk factor.

METHODS

This systematic review examined the effectiveness of rehabilitation interventions to promote physical activity during and/or after wearing an offloading device to treat diabetes-related foot ulcers. Searches using MESH terms and free-text combinations: 'foot ulcer', 'diabetic foot', 'casts, surgical', 'orthotic devices' were applied to MEDLINE, Embase, The Cochrane Library and clinical trial registers for randomised and observational studies published to September 2022. Methodological quality assessment of included studies was undertaken using the Cochrane Risk of Bias (RoB 2.0) and Risk of Bias In Non-randomised studies of Interventions (ROBINS-I) tools.

RESULTS

Of 3332 records identified, eight studies (441 participants), four clinical trials and four cohort studies, were included. None delivered or tested a structured rehabilitation programme, but all reported physical activity outcomes during or after device use. People wearing non-removable total contact casts were less active than those wearing devices (SMD -0.45; 95% CI - 0.87 to - 0.04; p = 0.03; I² 56%; 4 trials). Diabetes-related foot ulcers in people wearing total contact casts were more likely to heal compared to removable devices at 12 weeks (OR 2.69; 95% CI 0.97 to 7.45; p = 0.06; I² = 64%; 4 trials) and 20 weeks (OR 2.35; 95% CI 0.95 to 5.82; p = 0.07; I² = 65%; 4 trials).

CONCLUSIONS

Despite physical activity being low throughout off-loading treatment, no studies have specifically tested rehabilitation. There is a need to investigate the clinical and cost-effectiveness of rehabilitation programmes in this population. High quality trials are needed to provide robust evidence to support to rehabilitation after DFU treatment.

Taking a Load Off: User Perceptions of Smart Offloading Walkers for Diabetic Foot Ulcers Using the Technology Acceptance Model

People with diabetic foot ulcers (DFUs) are commonly prescribed offloading walkers, but inadequate adherence to prescribed use can be a barrier to ulcer healing. This study examined user perspectives of offloading walkers to provide insight on ways to help promote adherence. Participants were randomized to wear: (1) irremovable, (2) removable, or (3) smart removable walkers (smart boot) that provided feedback on adherence and daily walking. Participants completed a 15-item questionnaire based on the Technology Acceptance Model (TAM). Spearman correlations assessed associations between TAM ratings with participant characteristics. Chi-squared tests compared TAM ratings between ethnicities, as well as 12-month retrospective fall status. A total of 21 adults with DFU (age 61.5 ± 11.8 years) participated. Smart boot users reported that learning how to use the boot was easy (ρ =-0.82, p≤ 0.001). Regardless of group, people who identified as Hispanic or Latino, compared to those who did not, reported they liked using the smart boot (p = 0.05) and would use it in the future (p = 0.04). Non-fallers, compared to fallers, reported the design of the smart boot made them want to wear it longer (p = 0.04) and it was easy to take on and off (p = 0.04). Our findings can help inform considerations for patient education and design of offloading walkers for DFUs.

A 12-Week Supervised Exercise Therapy Program for Patients with Diabetic Foot Ulcers: Program Development and Preliminary Feasibility

Exercise therapy helps improve glycaemic control and insulin sensitivity and may be relevant in treating patients with diabetic foot ulcers (DFUs). This study describes the development of a 12-week exercise therapy program for patients with DFUs and the preliminary feasibility of the program focusing on the program's inclusion, adherence, and safety. The development process is built on knowledge from a published systematic review on exercise for people with DFUs and a grounded theory study on the main concerns of people with DFUs regarding physical activity. The development involved doctors, wound care nurses, podiatrists, and feedback from patients and physical therapists using semi-structured interviews. The program was designed as a combination of aerobic and resistance training exercises. The aerobic exercise phase on the stationary bike of 30-minute duration was aimed at a moderate intensity. Resistance exercises were conducted with a 15-repetition maximum approach (four to five sets per trial) throughout the 12-week period. Three patients were included and received the exercise intervention. Except for recruitment and retention rates, acceptance levels were met for all other research progression criteria. Patients found the intervention relevant, wanted further guidance on continuing exercising, and would have liked the intervention closer to their home for example, a municipality setting. Although the exercise therapy program for patients with DFUs was developed in a thorough process with the inclusion of available evidence and the involvement of patients and other stakeholders conclusions on feasibility are limited due to the low recruitment rate. A reconsideration of the setting is needed in future exercise intervention studies.

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.

Mechanical and contact characteristics of foam materials within wound dressings: Theoretical and practical considerations in treatment

In the treatment of acute and chronic wounds, the clinical performance of a given foam-based dressing, and, ultimately, the wound healing and cost of care outcomes are strongly influenced by the mechanical performance of the foam material/s within that dressing. Most aspects of the mechanical performance of foam materials, for example, their stiffness, frictional properties, conformability, swelling characteristics and durability, and the overall mechanical protection provided by a foam-based dressing to a wound strongly depend on the microstructure of the foam components, particularly on their microtopography, density and porosity. This article, therefore, provides, for the first time, a comprehensive, self-inclusive compilation of clinically relevant theoretical and practical considerations, based on published analytical and experimental research as well as clinical experience related to the mechanical performance of foams in foam-based wound dressings. The current bioengineering information is useful for establishing understanding of the importance of mechanical properties of foams in foam-based dressings among clinicians and researchers in industry and academia, and other potential stakeholders in the wound care field, for example, regulators and buyers. This information is also particularly important for the development of standardised test methods for the evaluation of foam-based wound dressings and resulting standard mechanical performance metrics for these dressings.

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

INTRODUCTION

Weight-bearing physical activity is important for people with diabetes-related foot disease but may also contribute to ulceration or delayed ulcer healing. No overview of weight-bearing activity of people at different stages of foot disease is available. We aimed to summarise quantitatively measured daily activity levels in people with diabetes-related foot disease.

METHODS

We systematically searched peer-reviewed literature for studies reporting objectively measured weight-bearing activity in people with diabetes-related foot disease. We calculated daily step counts' means (over studies) and weighted means (over participants). International Working Group on the Diabetic Foot (IWGDF) risk strata, different climates, and activity indoors versus outdoors were compared.

RESULTS

From 1247 publications, 27 were included. Mean steps/day in people with IWGDF risk 1/2: 6125 (12 studies; 345 participants; weighted mean: 5384). In IWGDF risk 3: 6167 (8 studies; 291 participants; weighted mean: 6239). In those with a foot ulcer: 4248 (6 studies; 186 participants; weighted mean: 4484). People living in temperate oceanic climates are more active compared to those in hotter or more humid climates (mean steps/day for no ulcer: 7712 vs. 5224 [18 studies]; for ulcer: 6819 vs. 2945 [6 studies]). People are more active indoors than outdoors (mean 4047 vs. 2514 [3 studies]).

CONCLUSION

Levels of weight-bearing physical activity are similar between people with diabetes at various risk levels for foot ulceration but lower for those with a foot ulcer. Weight-bearing activity differs depending on the climatological environment and is higher indoors than outdoors. These findings provide reference for intervention studies or for clinicians aiming to provide mobility advice in this population.

Prevention of Physical Risk and Rehabilitation of Muscle Injury in Sanda Competition

The Target. The purpose of this study is to explore the reduction of sports injury risk and verify the effective methods and means of athlete's muscle injury rehabilitation. Methods. In this study, 80 sanda athletes from a university were randomly selected as subjects, and the main parts of injury of all subjects were counted. After 12 weeks of muscle injury rehabilitation intervention, the pain, acute injury, and technical and tactical evaluation levels of subjects in the intervention group and the control group were compared. Results/Discussion. The overall performance of the 80 subjects' basic exercise ability was at a moderate level, and there was no significant difference between male and female subjects (P >0.05). After 12 weeks of rehabilitation intervention, there was no significant difference in the scores of shoulder joint flexibility, supine straight leg raising, and trunk stable support between male and female subjects in the intervention group in more than 7 sports (P >0.05). In the control group, there were significant differences in the scores of shoulder flexibility and trunk stability of male and female subjects (P < 0.05). Future research should further explore the effect of muscle injury rehabilitation on effectively reducing potential sports injuries and introduce advanced and effective medical rehabilitation methods.

Nanofiber-mediated sequential photothermal antibacteria and macrophage polarization for healing MRSA-infected diabetic wounds

Background

Diabetic wound healing remains a challenge because of its susceptibility to drug-resistant bacterial infection and its persistent proinflammatory state. Switching from proinflammatory M1 macrophages (Mφs) to proregenerative M2 dominant Mφs in a timely manner accelerates wound healing by coordinating inflammatory, proliferative, and angiogenic processes.

Methods

We propose a sequential photothermal antibacterial and subsequent M2 Mφ polarization strategy based on nanofibers (NFs) consisting of polydopamine (PDA) coating on curcumin (Cur) nanocrystals to treat Methicillin-resistant Staphylococcus aureus (MRSA)-infected diabetic wounds.

Results

The PDA/Cur NFs showed excellent photothermal conversion and antibacterial effects due to the PDA shell under laser irradiation, consequently resulting in the release of the inner Cur with the ability to promote cell proliferation and reinforce the M2 Mφ phenotype in vitro. In vivo studies on MRSA-infected diabetic wounds showed that PDA/Cur NFs not only inhibited MRSA infection but also accelerated the wound regeneration process. Furthermore, the NFs displayed the ability to promote the M2 Mφ phenotype with enhanced collagen deposition, angiogenesis, and cell proliferation.

Conclusion

Overall, the NFs displayed great potential as promising therapeutics for healing infected diabetic wounds through a sequential photothermal antibacterial and M2 Mφ polarization strategy.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12951-021-01152-4.

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.