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Jones K, Backhouse MR, Bruce J. Rehabilitation for people wearing offloading devices for diabetes-related foot ulcers: a systematic review and meta-analyses. J Foot Ankle Res 2023; 16:16. [PMID: 36966316 PMCID: PMC10039553 DOI: 10.1186/s13047-023-00614-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/13/2023] [Indexed: 03/27/2023] Open
Abstract
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.
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Affiliation(s)
- K Jones
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK.
| | - M R Backhouse
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
- University Hospitals Coventry Warwickshire NHS Trust, Coventry, UK
| | - J Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill, Coventry, CV4 7AL, UK
- University Hospitals Coventry Warwickshire NHS Trust, Coventry, UK
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Cook E, Laycock J, Acharya M, Backhouse MR, Corbacho B, Doherty L, Forward D, Hewitt C, Hilton C, Hull P, Kassam J, Maturana C, Mcdaid C, Roche J, Sivapathasuntharam D, Torgerson D, Bates P. Lateral compression type 1 fracture fixation in the elderly (L1FE): study protocol for a randomised controlled trial (with internal pilot) comparing the effects of INFIX surgery and non-surgical management for treating patients with lateral compression type 1 (LC-1) fragility fractures. Trials 2023; 24:78. [PMID: 36732808 PMCID: PMC9893645 DOI: 10.1186/s13063-022-07063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults. METHODS A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications. DISCUSSION The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019.
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Affiliation(s)
- Elizabeth Cook
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Joanne Laycock
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Mehool Acharya
- grid.416201.00000 0004 0417 1173Pelvic and Acetabular Reconstruction Unit, Southmead Hospital, Bristol, BS10 5NB UK
| | - Michael Ross Backhouse
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK ,grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Belen Corbacho
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Laura Doherty
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Daren Forward
- grid.240404.60000 0001 0440 1889Nottingham University Hospitals, Derby Road, Nottingham, NG7 2UH UK
| | - Catherine Hewitt
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Catherine Hilton
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - Peter Hull
- grid.24029.3d0000 0004 0383 8386Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ UK
| | - Jamila Kassam
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - Camila Maturana
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Catriona Mcdaid
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Jenny Roche
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Dhanupriya Sivapathasuntharam
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
| | - David Torgerson
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD UK
| | - Peter Bates
- grid.416041.60000 0001 0738 5466Bart’s Health NHS Trust, The Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB UK
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Filippou V, Redmond AC, Bennion J, Backhouse MR, Wong D. Capturing accelerometer outputs in healthy volunteers under normal and simulated-pathological conditions using ML classifiers .. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2020:4604-4607. [PMID: 33019019 DOI: 10.1109/embc44109.2020.9176201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Wearable devices offer a possible solution for acquiring objective measurements of physical activity. Most current algorithms are derived using data from healthy volunteers. It is unclear whether such algorithms are suitable in specific clinical scenarios, such as when an individual has altered gait. We hypothesized that algorithms trained on healthy population will result in less accurate results when tested in individuals with altered gait. We further hypothesized that algorithms trained on simulated-pathological gait would prove better at classifying abnormal activity. We studied healthy volunteers to assess whether activity classification accuracy differed for those with healthy and simulated-pathological conditions. Healthy participants (n=30) were recruited from the University of Leeds to perform nine predefined activities under healthy and simulated-pathological conditions. Activities were captured using a wrist-worn MOX accelerometer (Maastricht Instruments, NL). Data were analyzed based on the Activity-Recognition-Chain process. We trained a Neural-Network, Random-Forests, k-Nearest-Neighbors (k-NN), Support-Vector-Machines (SVM) and Naive Bayes models to classify activity. Algorithms were trained four times; once with `healthy' data, and once with `simulated-pathological data' for each of activity-type and activity-task classification. In activity-type instances, the SVM provided the best results; the accuracy was 98.4% when the algorithm was trained and then tested with unseen data from the same group of healthy individuals. Accuracy dropped to 52.8% when tested on simulated-pathological data. When the model was retrained with simulated-pathological data, prediction accuracy for the corresponding test set was 96.7%. Algorithms developed on healthy data are less accurate for pathological conditions. When evaluating pathological conditions, classifier algorithms developed using data from a target sub-population can restore accuracy to above 95%.
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Alcacer-Pitarch B, Backhouse MR, Gijon-Nogeron G, Biscontini D, Bonafede S, Ferreira A, Gatt A, Lescure Y, Nava T, Redmond AC. Provision of foot and ankle care services for people with rheumatic and musculoskeletal disease across Europe. Musculoskeletal Care 2019; 18:12-19. [PMID: 31802611 DOI: 10.1002/msc.1431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND The aim of the present study was to explore the variation in the provision of care for people with rheumatic and musculoskeletal diseases (RMDs), and foot and ankle problems between European healthcare systems. METHODS An electronic questionnaire was developed and piloted in seven countries prior to being distributed to the presidents of all 22 national health professionals in rheumatology associations within the European League Against Rheumatism (EULAR). Summary data were obtained using SPSS V22. Ethical approval was sought from the Medical Research Ethics Committee of University of Malaga (CEUMA-91-2015-H). RESULTS Sixteen questionnaires (73% response rate) were completed (Austria, Belgium, Czech Republic, Denmark, France, Hungary, Ireland, Italy, Malta, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the UK). All 16 respondents indicated that foot and ankle healthcare services were provided in their country, but only three countries had services specializing in RMD-related foot and ankle problems (the Netherlands, the UK and Malta). The professions providing care varied, depending on the pathology and the country. Foot and ankle pain was mostly treated by rheumatologists and physiotherapists; foot and ankle deformities by orthopaedic surgeons and orthotist/prosthetists; and foot and ankle ulcers by nurses. Services were predominantly delivered through the public sector, and in secondary care (hospital) settings. CONCLUSIONS Only three countries reported having specialist foot and ankle services addressing the needs of people with RMDs. Variation was seen in the professions which provided care between countries, and also between the foot and ankle pathologies cared for. There is a lack of clinical pathways and guidelines for the management of patients with RMD-related foot and ankle problems.
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Affiliation(s)
- Begonya Alcacer-Pitarch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michael Ross Backhouse
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Gabriel Gijon-Nogeron
- Podiatry Department, Faculty of Health Sciences, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga, Malaga,, Spain
| | - Devid Biscontini
- Rheumatology Unit, Azienda Ospedaliera Di Perugia, Umbria, Italy
| | | | - Andre Ferreira
- Department of Medicine and Surgery, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Alfred Gatt
- Faculty of Health Sciences, University of Malta, Msida, Malta
| | | | - Tiziana Nava
- Department of Translational Medicine and Surgery Program in Physical Therapy, Università Bicocca, Milan, Italy
| | - Anthony C Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Nelson A, Wright-Hughes A, Backhouse MR, Lipsky BA, Nixon J, Bhogal MS, Reynolds C, Brown S. CODIFI (Concordance in Diabetic Foot Ulcer Infection): a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England. BMJ Open 2018; 8:e019437. [PMID: 29391370 PMCID: PMC5879729 DOI: 10.1136/bmjopen-2017-019437] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To determine the extent of agreement and patterns of disagreement between wound swab and tissue samples in patients with an infected diabetic foot ulcer (DFU). DESIGN Multicentre, prospective, cross-sectional study. SETTING Primary and secondary care foot ulcer/diabetic outpatient clinics and hospital wards across England. PARTICIPANTS Inclusion criteria: consenting patients aged ≥18 years; diabetes mellitus; suspected infected DFU. EXCLUSION CRITERIA clinically inappropriate to take either sample. INTERVENTIONS Wound swab obtained using Levine's technique; tissue samples collected using a sterile dermal curette or scalpel. OUTCOME MEASURES Coprimary: reported presence, and number, of pathogens per sample; prevalence of resistance to antimicrobials among likely pathogens. Secondary: recommended change in antibiotic therapy based on blinded clinical review; adverse events; sampling costs. RESULTS 400 consenting patients (79% male) from 25 centres.Most prevalent reported pathogens were Staphylococcus aureus (43.8%), Streptococcus (16.7%) and other aerobic Gram-positive cocci (70.6%). At least one potential pathogen was reported from 70.1% of wound swab and 86.1% of tissue samples. Pathogen results differed between sampling methods in 58% of patients, with more pathogens and fewer contaminants reported from tissue specimens.The majority of pathogens were reported significantly more frequently in tissue than wound swab samples (P<0.01), with equal disagreement for S. aureus and Pseudomonas aeruginosa. Blinded clinicians more often recommended a change in antibiotic regimen based on tissue compared with wound swab results (increase of 8.9%, 95% CI 2.65% to 15.3%). Ulcer pain and bleeding occurred more often after tissue collection versus wound swabs (pain: 9.3%, 1.3%; bleeding: 6.8%, 1.5%, respectively). CONCLUSION Reports of tissue samples more frequently identified pathogens, and less frequently identified non-pathogens compared with wound swab samples. Blinded clinicians more often recommended changes in antibiotic therapy based on tissue compared with wound swab specimens. Further research is needed to determine the effect of the additional information provided by tissue samples. TRIAL REGISTRATION NUMBER ISRCTN52608451.
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Affiliation(s)
- Andrea Nelson
- School of Healthcare,
University of Leeds, Leeds, UK
| | | | - Michael Ross Backhouse
- Leeds Institute of Rheumatic and Musculoskeletal
Medicine, University of Leeds, Leeds, UK
| | | | - Jane Nixon
- Clinical Trials Research Unit,
University of Leeds, Leeds, UK
| | | | | | - Sarah Brown
- Clinical Trials Research Unit,
University of Leeds, Leeds, UK
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Abstract
INTRODUCTION Accurate identification of pathogens, rather than colonising bacteria, is a prerequisite for targeted antibiotic therapy to ensure optimal patient outcome in wounds, such as diabetic foot ulcers. Wound swabs are the easiest and most commonly used sampling technique but most published guidelines recommend instead removal of a tissue sample from the wound bed, which is a more complex process. The aim of this study was to assess the concordance between culture results from wound swabs and tissue samples in patients with suspected diabetic foot infection. METHODS AND ANALYSIS Patients with a diabetic foot ulcer that is thought to be infected are being recruited from 25 sites across England in a cross-sectional study. The coprimary endpoints for the study are agreement between the two sampling techniques for three microbiological parameters: reported presence of likely isolates identified by the UK Health Protection Agency; resistance of isolates to usual antibiotic agents; and, the number of isolates reported per specimen. Secondary endpoints include appropriateness of the empiric antibiotic therapy prescribed and adverse events. Enrolling 400 patients will provide 80% power to detect a difference of 3% in the reported presence of an organism, assuming organism prevalence of 10%, discordance of 5% and a two-sided test at the 5% level of significance. Assumed overall prevalence is based on relatively uncommon organisms such as Pseudomonas. We will define acceptable agreement as κ>0.6. ETHICS AND DISSEMINATION Concordance in diabetic foot ulcer infection (CODIFI) will produce robust data to evaluate the two most commonly used sampling techniques employed for patients with a diabetic foot infection. This will help determine whether or not it is important that clinicians take tissue samples rather than swabs in infected ulcers. This study has been approved by the Sheffield NRES Committee (Ref: 11/YH/0078) and all sites have obtained local approvals prior starting recruitment. STUDY REGISTRATION NRES Ref: 11/YH/0078, UKCRN ID: 10440, ISRCTN: 52608451.
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Affiliation(s)
| | | | | | | | | | - Jane Nixon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Sarah Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Janine Gray
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
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