Abstract
BackgroundAppropriate footwear for individuals with diabetes but no ulceration history could reduce the risk of first ulceration. However, individuals who deem themselves at low risk are unlikely to seek out bespoke footwear which is personalised. Therefore, our primary aim was to investigate whether group-optimised footwear designs, which could be prefabricated and delivered in a retail setting, could achieve appropriate pressure reduction, or whether footwear selection must be on a patient-by-patient basis. A second aim was to compare responses to footwear design between healthy participants and people with diabetes in order to understand the transferability of previous footwear research, performed in healthy populations.MethodsPlantar pressures were recorded from 102 individuals with diabetes, considered at low risk of ulceration. This cohort included 17 individuals with peripheral neuropathy. We also collected data from 66 healthy controls. Each participant walked in 8 rocker shoe designs (4 apex positions × 2 rocker angles). ANOVA analysis was then used to understand the effect of two design features and descriptive statistics used to identify the group-optimised design. Using 200 kPa as a target, this group-optimised design was then compared to the design identified as the best for each participant (using plantar pressure data).ResultsPeak plantar pressure increased significantly as apex position was moved distally and rocker angle reduced (p < 0.001). The group-optimised design incorporated an apex at 52% of shoe length, a 20° rocker angle and an apex angle of 95°. With this design 71–81% of peak pressures were below the 200 kPa threshold, both in the full cohort of individuals with diabetes and also in the neuropathic subgroup. Importantly, only small increases (<5%) in this proportion were observed when participants wore footwear which was individually selected. In terms of optimised footwear designs, healthy participants demonstrated the same response as participants with diabetes, despite having lower plantar pressures.ConclusionsThis is the first study demonstrating that a group-optimised, generic rocker shoe might perform almost as well as footwear selected on a patient by patient basis in a low risk patient group. This work provides a starting point for clinical evaluation of generic versus personalised pressure reducing footwear.
Highlights
Appropriate footwear for individuals with diabetes but no ulceration history could reduce the risk of first ulceration
Personalised therapeutic footwear has a wide range of different features that can be modified, this study focused on the outsole geometry of the rocker profile
The data identified that a stiff soled rocker shoe incorporating an apex position at 52% of shoe length was optimal for pressure reduction in three high-risk regions of the forefoot
Summary
Appropriate footwear for individuals with diabetes but no ulceration history could reduce the risk of first ulceration. Use of appropriate footwear by people with diabetes without prior ulceration is widely advocated [2,3,4] and motivated by a need to reduce plantar pressures that are one of the many risk factors for ulceration [5, 6]. At that stage adherence with footwear advice or prescriptions is known to affect ulcer healing and risk of reulceration, but effective behaviour change is often not achieved. This was demonstrated in a recent trial which observed a significant (19%) reduction in re-ulceration at 18-month follow, but only in the subgroup with good adherence and who wore customised footwear as recommended [7]. Changes in footwear choices and use prior to first ulceration might mitigate the risk of a first ulcer by reducing pressure and improve longer term adherence if ulcers do occur
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