Provision Of Footwear Research Articles

Experiences of using a digital tool, the D-foot, in the screening of risk factors for diabetic foot ulcers

BackgroundIndividuals living with diabetes run an increased risk of developing diabetic foot ulcers (DFUs), leading to high costs to society and reduced quality of life for the individual. Regular screening is important to avoid complications.AimTo evaluate patients’ and clinicians’ experiences of using a digital tool, the D-Foot, in the screening of risk factors for developing DFUs. The secondary aims were to investigate whether patients had had their feet examined by a nurse or doctor during the past year, had been referred to podiatry and whether patients had received information about self-care.MethodsA prospective study was carried out, comprising 90 patients with diabetes visiting a Department of Prosthetics and Orthotics (DPO). Two Certified Prosthetists and Orthotists (CPOs) were included, and they assessed foot status and the risk of developing DFUs with the D-Foot software, prior to prescribing footwear. The quality of services at the DPO was assessed by the patients using the Orthotics and Prosthetics Users’ Survey (OPUS). The CPOs answered the System Usability Scale (SUS) before and after the study to assess the usability of the D-Foot.ResultsNo patient had risk grade 1. One (1%) patient had risk grade 2, 78 (87%) patients had risk grade 3 and 11 (12%) patients had risk grade 4. Patients reported high levels of satisfaction on eight of ten OPUS items and the two items with lower scores were not related to the use of the D-Foot. The two CPOs reported levels above the mean regarding usability both before (77.5 and 90) and after (70 and 97.5) using the D-Foot.ConclusionsPatients expressed a high level of satisfaction with the services when their feet were examined with the D-Foot prior to the provision of footwear. The CPOs found that the D-Foot system was usable. Several comments were made by patients and CPOs and will support the future development and testing of the D-Foot. There is a need to increase referrals for preventive podiatry and improve information on self-care for patients at risk of DFUs.Trial registrationClinicalTrials.gov ID: NCT04054804.

Musculoskeletal disorders, foot health and footwear choice in occupations involving prolonged standing

Occupations that involve prolonged periods of standing and maintaining an upright posture are associated with an increased risk of work-related musculoskeletal disorders (WMSD), particularly of the lower back and lower extremities. Identifying factors that impact WMSD is therefore important, but the foot and footwear have been largely ignored to date. Therefore, this study aimed to assess the prevalence of WMSD of the lower back and lower extremity with emphasis on foot health and the impact of footwear. A cross-sectional questionnaire was completed by 147 surgical workers who were standing for long periods in their working day. It assessed job demands, individual characteristics, WMSD prevalence, psychosocial factors and footwear, with a multivariate analysis to identify relationships between variables. Results found the low back was the most predominant area of WMSD (71%), but the foot had the second highest prevalence (55%). The plantar foot surface was the main region of foot pain with everyone that experienced foot pain reporting it under the heel, ball of foot or arch region. Footwear was recognised as an influencing factor on WMSD by the participants as well as by the multivariate analysis, highlighting the importance of exploring footwear to reduce WMSD. Footwear comfort, footwear fit, footwear choice and the provision of footwear by employers were all identified as important factors to consider in relation to WMSD and foot health. Relevance to industryFootwear is related to WMSD which are seen in the majority of workers undertaking prolonged standing. Employers of these workers and footwear suppliers should consider footwear comfort, particularly its fit and individual preference for footwear characteristics including underfoot cushioning and support. This should also include consideration of the range of footwear available and how it is selected by workers.

A toolkit for prosthetists and orthotists to facilitate progress in professional communication over the next 50 years.

Background:In this celebratory issue of Prosthetics and Orthotics International, we review professional communication skills in the field of prosthetics and orthotics.Objective:We aim to reflect on communication skills in the past 50 years, to discuss developments in the coming 50 years, and to create a toolkit and research agenda to facilitate progress in professional communication in the next 50 years.Results:Despite being a key area in prosthetics and orthotics training programmes, we found no studies on professional communication with an experimental design published in Prosthetics and Orthotics International. As an alternative, we provide clinical reflections on the changes in professional communication in the past 50 years, and we discuss questionnaire-based and qualitative studies that provide evidence for the importance of communication in pedorthic footwear provision. In the coming 50 years, professional communication in the field of prosthetics and orthotics may be impacted by aging populations, global mobility, information technology, technological advances and emphasis on prevention. We discuss each of these topics. To facilitate progress in professional communication, we have created a toolkit with resources for prosthetics and orthotics professionals, prosthetics and orthotics students and other interested professionals.Conclusions:We hope this toolkit will inspire others to use, extend and implement it in their daily practice. As a research agenda, we strongly recommend undertaking research on interventions to improve professional communication and to study its effect on clinically meaningful outcomes.

Effect of awareness of being monitored on wearing of orthopaedic footwear.

To investigate the effect of awareness of being monitored on wearing time and adherence to wearing orthopaedic footwear. Quantitative assessment of wearing time was made using direct measurement with temperature sensors during the first 3 months after provision of footwear. Randomized controlled trial. Awareness that the temperature sensor is used for measuring wearing time. All 55 participants had a temperature sensor built into the medial arch of the left insole of their orthopaedic footwear. Participants were assigned randomly to either an "awareness group" (n = 25, mean age 67 years) and knew they were being monitored for wearing time, or a "no awareness group" (n = 30, mean age 65 years) and only knew their shoe temperature was being measured. Differences were assessed with a linear mixed model. Mean (standard deviation; SD) wearing time in the intervention group was 7.32 h/day (SD 4.2), and 6.11 h/day (SD 4.1) in the control group (p = 0.017). A significant interaction effect was found between awareness and pathology group on wearing time (p = 0.036). The difference was especially large (7.0 (SD 4.7) vs 2.4 (SD 2.2) h/day) in the subgroup of people with diabetes. Awareness of being monitored increases wearing time and wearing of orthopaedic footwear.

State of the art design protocol for custom made footwear for people with diabetes and peripheral neuropathy.

Supported by evidence‐based guidelines, custom‐made footwear is often prescribed to people with diabetes who are at risk for ulceration. However, these guidelines do not specify the footwear design features, despite available scientific evidence for these features. We aimed to develop a design protocol to support custom‐made footwear prescription for people with diabetes and peripheral neuropathy. The population of interest was people with diabetes who are at moderate‐to‐high risk of developing a foot ulcer, for whom custom‐made footwear (shoes and/or insoles) can be prescribed. A group of experts from rehabilitation medicine, orthopaedic shoe technology (pedorthics) and diabetic foot research, reviewed the scientific literature and met during 12 face‐to‐face meetings to develop a footwear design algorithm and evidence‐based pressure‐relief algorithm as parts of the protocol. Consensus was reached where evidence was not available. Fourteen domains of foot pathology in combination with loss of protective sensation were specified for the footwear design algorithm and for each domain shoe‐specific and insole (orthosis)‐specific features were defined. Most insole‐related features and some shoe‐related features were evidence based, whereas most shoe‐related features were consensus based. The pressure‐relief algorithm was evidence based using recent footwear trial data and specifically targeted patients with a healed plantar foot ulcer. These footwear design and pressure‐relief algorithms are the first of their kind and should facilitate more uniform decision making in the prescription and manufacturing of adequate shoes for moderate‐to‐high‐risk patients, reducing variation in footwear provision and improving clinical outcome in the prevention of diabetic foot ulcers.

Podiatry intervention versus usual care to prevent falls in care homes: pilot randomised controlled trial (the PIRFECT study)

BackgroundCommon foot problems are independent risk factors for falls in older people. There is evidence that podiatry can prevent falls in community-dwelling populations. The feasibility of implementing a podiatry intervention and trial in the care home population is unknown. To inform a potential future definitive trial, we performed a pilot randomised controlled trial to assess: (i) the feasibility of a trial of a podiatry intervention to reduce care home falls, and (ii) the potential direction and magnitude of the effect of the intervention in terms of number of falls in care home residents.MethodsInformed by Medical Research Council guidance on developing and evaluating complex interventions, we conducted a single blind, pilot randomised controlled trial in six care homes in the East of Scotland. Participants were randomised to either: (i) a three month podiatry intervention comprising core podiatry care, foot and ankle exercises, orthoses and footwear provision or (ii) usual care. Falls-related outcomes (number of falls, time to first fall) and feasibility-related outcomes (recruitment, retention, adherence, data collection rates) were collected. Secondary outcomes included: generic health status, balance, mobility, falls efficacy, and ankle joint strength.Results474 care home residents were screened. 43 (9.1%) participants were recruited: 23 to the intervention, 20 to control. Nine (21%) participants were lost to follow-up due to declining health or death. It was feasible to deliver the trial elements in the care home setting. 35% of participants completed the exercise programme. 48% reported using the orthoses ‘all or most of the time’. Completion rates of the outcome measures were between 93% and 100%. No adverse events were reported. At the nine month follow-up period, the intervention group per-person fall rate was 0.77 falls vs. 0.83 falls in the control group.ConclusionsA podiatry intervention to reduce falls can be delivered to care home residents within a pilot randomised controlled trial of the intervention. Although not powered to determine effectiveness, these preliminary data provide justification for a larger trial, incorporating a full process evaluation, to determine whether this intervention can significantly reduce falls in this high-risk population.Trial registrationClinicalTrials.gov identifier: NCT02178527; Date of registration: 17 June 2014.

Clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for falls prevention in older people: a multicentre cohort randomised controlled trial (the REducing Falls with ORthoses and a Multifaceted podiatry intervention trial).

Falls are a serious cause of morbidity and cost to individuals and society. Evidence suggests that foot problems and inappropriate footwear may increase the risk of falling. Podiatric interventions could help reduce falls; however, there is limited evidence regarding their clinical effectiveness and cost-effectiveness. To determine the clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for preventing falls in community-dwelling older people at risk of falling, relative to usual care. A pragmatic, multicentred, cohort randomised controlled trial with an economic evaluation and qualitative study. Nine NHS trusts in the UK and one site in Ireland. In total, 1010 participants aged ≥ 65 years were randomised (intervention, n = 493; usual care, n = 517) via a secure, remote service. Blinding was not possible. All participants received a falls prevention leaflet and routine care from their podiatrist and general practitioner. The intervention also consisted of footwear advice, footwear provision if required, foot orthoses and foot- and ankle-strengthening exercises. The primary outcome was the incidence rate of falls per participant in the 12 months following randomisation. The secondary outcomes included the proportion of fallers and multiple fallers, time to first fall, fear of falling, fracture rate, health-related quality of life (HRQoL) and cost-effectiveness. The primary analysis consisted of 484 (98.2%) intervention and 507 (98.1%) usual-care participants. There was a non-statistically significant reduction in the incidence rate of falls in the intervention group [adjusted incidence rate ratio 0.88, 95% confidence interval (CI) 0.73 to 1.05; p = 0.16]. The proportion of participants experiencing a fall was lower (50% vs. 55%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00; p = 0.05). No differences were observed in key secondary outcomes. No serious, unexpected and related adverse events were reported. The intervention costs £252.17 more per participant (95% CI -£69.48 to £589.38) than usual care, was marginally more beneficial in terms of HRQoL measured via the EuroQoL-5 Dimensions [mean quality-adjusted life-year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314 QALYs] and had a 65% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £30,000 per QALY gained. The intervention was generally acceptable to podiatrists and trial participants. Owing to the difficulty in calculating a sample size for a count outcome, the sample size was based on detecting a difference in the proportion of participants experiencing at least one fall, and not the primary outcome. We are therefore unable to confirm if the trial was sufficiently powered for the primary outcome. The findings are not generalisable to patients who are not receiving podiatry care. The intervention was safe and potentially effective. Although the primary outcome measure did not reach significance, a lower fall rate was observed in the intervention group. The reduction in the proportion of older adults who experienced a fall was of borderline statistical significance. The economic evaluation suggests that the intervention could be cost-effective. Further research could examine whether or not the intervention could be delivered in group sessions, by physiotherapists, or in high-risk patients. Current Controlled Trials ISRCTN68240461. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 24. See the NIHR Journals Library website for further project information.

Innovations in plantar pressure and foot temperature measurements in diabetes

Plantar pressure and temperature measurements in the diabetic foot primarily contribute to identifying abnormal values that increase risk for foot ulceration, and they are becoming increasingly more integrated in clinical practice and daily life of the patient. While plantar pressure measurements have long been present, only recently evidence shows their importance in ulcer prevention, as a data-driven approach to therapeutic footwear provision. The long-term monitoring of plantar pressures with the option to provide feedback, when alarming pressure levels occur, is a promising development in this area, although more technical and clinical validation is required. Shear is considered important in ulcer aetiology but is technically difficult to measure. Innovative research is underway to assess if foot temperature can act as a useful surrogate for shear. Because the skin heats up before it breaks down, frequent monitoring of foot temperature can identify these warning signals. This approach has shown to be effective in preventing foot ulcers. Innovation in diagnostic methods for foot temperature monitoring and evidence on cost effectiveness will likely facilitate implementation. Finally, monitoring of adherence to offloading treatment using temperature-based sensors has proven to be a feasible and relevant method with a wide range of possible research and patient care applications. These innovations in plantar pressure and temperature measurements illustrate an important transfer in diabetic foot care from subjective to objective evaluation of the high-risk patient. They demonstrate clinical value and a large potential in helping to reduce the patient and economic burden of diabetic foot disease.

The perceived role of biomechanics in future footwear provision for European adults who are older, obese or who have diabetes

The perceived role of biomechanics in future footwear provision for European adults who are older, obese or who have diabetes

Data-driven directions for effective footwear provision for the high-risk diabetic foot.

Custom-made footwear is used to offload the diabetic foot to prevent plantar foot ulcers. This prospective study evaluates the offloading effects of modifying custom-made footwear and aims to provide data-driven directions for the provision of effectively offloading footwear in clinical practice. Eighty-five people with diabetic neuropathy and a recently healed plantar foot ulcer, who participated in a clinical trial on footwear effectiveness, had their custom-made footwear evaluated with in-shoe plantar pressure measurements at three-monthly intervals. Footwear was modified when peak pressure was ≥ 200 kPa. The effect of single and combined footwear modifications on in-shoe peak pressure at these high-pressure target locations was assessed. All footwear modifications significantly reduced peak pressure at the target locations compared with pre-modification levels (range -6.7% to -24.0%, P < 0.001). The metatarsal heads were most frequently targeted. Repositioning an existing (trans-)metatarsal pad in the shoe insole (-15.9% peak pressure relief), applying local cushioning to the insole (-15.0%) and replacing the insole top cover with Plastazote (-14.2%) were the most effective single modifications. Combining a new Plastazote top cover with a trans-metatarsal bar (-24.0% peak pressure relief) or with local cushioning (-22.0%) were the most effective combined modifications. In people with diabetic neuropathy and a recently healed plantar foot ulcer, significant offloading can be achieved at high-risk foot regions by modifying custom-made footwear. These results provide data-driven directions for the design and evaluation of custom-made footwear for high-risk people with diabetes, and essentially mean that each shoe prescribed should incorporate those design features that effectively offload the foot.

Data-driven directions for effective footwear provision in diabetic patients with a history of foot ulceration

Data-driven directions for effective footwear provision in diabetic patients with a history of foot ulceration

Australian Diabetes Foot Network: practical guideline on the provision of footwear for people with diabetes

Trauma, in the form of pressure and/or friction from footwear, is a common cause of foot ulceration in people with diabetes. These practical recommendations regarding the provision of footwear for people with diabetes were agreed upon following review of existing position statements and clinical guidelines. The aim of this process was not to re-invent existing guidelines but to provide practical guidance for health professionals on how they can best deliver these recommendations within the Australian health system. Where information was lacking or inconsistent, a consensus was reached following discussion by all authors. Appropriately prescribed footwear, used alone or in conjunction with custom-made foot orthoses, can reduce pedal pressures and reduce the risk of foot ulceration. It is important for all health professionals involved in the care of people with diabetes to both assess and make recommendations on the footwear needs of their clients or to refer to health professionals with such skills and knowledge. Individuals with more complex footwear needs (for example those who require custom-made medical grade footwear and orthoses) should be referred to health professionals with experience in the prescription of these modalities and who are able to provide appropriate and timely follow-up. Where financial disadvantage is a barrier to individuals acquiring appropriate footwear, health care professionals should be aware of state and territory based equipment funding schemes that can provide financial assistance. Aboriginal and Torres Strait Islanders and people living in rural and remote areas are likely to have limited access to a broad range of footwear. Provision of appropriate footwear to people with diabetes in these communities needs be addressed as part of a comprehensive national strategy to reduce the burden of diabetes and its complications on the health system.

Footcare in the dust…providing podiatry across the Kimberley

The Kimberley is a region in the north of WA which covers 423 517 square km’s (approximately twice the size of Victoria and three times that of England!). Although the Kimberley is a large geographical area the population is estimated at only 38 000 people who live in many remote locations right across the region. Thus providing reasonable healthcare services in this area often requires clients and care providers to travel long distances. Two of the main contributors to morbidity and mortality in the region are type II diabetes, and chronic kidney disease. Because of the high rate of foot complications associated with these disorders there are many people who require podiatric care, however, podiatric services in the Kimberley are limited and only three podiatrists cover this vast area. The podiatry team work out of many locations and with a variety of services to provide clinical podiatric care. The podiatrists also offer staff in-service and up-skilling, as well as community group education sessions on a range of topics and conditions at the many locations that they visit. The podiatrists travel to over 15 remote communities and five towns, to provide services and the tyranny of distance means that they often drive for long hours to provide these services. All equipment needed must be taken with them as there is no podiatry clinics already established. The focus of the service is on indigenous clients with chronic disease such as diabetes, and due to the limitations of the service, clients must meet an eligibility criteria. Over 2,600 occasions of service were provided in 2009 with 64% of clients being indigenous. The podiatrists are mainly involved with the assessment and management of foot problems related to chronic disease such as diabetes. The full range of podiatric care is provided, including wound management, general foot care, biomechanical assessment, minor nail surgery and the provision of footwear via Community Aids and Equipment Program or via donated footwear.

Foot Health Service Provision by the Australian Department of Veterans’ Affairs

In Australia, the Department of Veterans' Affairs provides podiatric medical services, including nail surgery and the provision of footwear and orthoses, for war veterans and their dependents. We sought to evaluate whether the provision of these interventions reduces the number of ongoing maintenance treatments. We used the database of the Department of Veterans' Affairs to document the number of major podiatric medical interventions (footwear, foot orthoses, nail surgery, and combinations of these interventions) for 1996-1997. The number of maintenance podiatric medical treatments provided in the 2 years before (1994-1996) and 2 years after (1997-1999) these interventions was then compared with a control group that did not receive any major interventions. Compared with the number of treatments in the 2 years before the interventions, in the subsequent 2 years there was a significant increase in the mean +/- SD number of maintenance treatments after receiving footwear only (10.4 +/- 5.8 versus 12.3 +/- 5.0), foot orthoses only (9.4 +/- 5.3 versus 12.2 +/- 4.6), nail surgery only (10.2 +/- 5.8 versus 13.2 +/- 4.4), and footwear plus foot orthoses (9.3 +/- 6.1 versus 13.3 +/- 5.5). In the control group, the mean number of treatments in 1994-1996 and 1997-1999 was 10.8 and 11.8, respectively. Provision of major podiatric medical interventions did not reduce the number of ongoing maintenance treatments received by veterans. However, owing to the inherent limitations of claims data, it is difficult to determine whether this finding is due to the limited efficacy of the interventions or to the policy structure of podiatric medical service provision in the Department of Veterans' Affairs.

Provision of foot health services in rheumatology in the UK

To determine the provision of foot health services in rheumatology for the UK and Northern Ireland. Two hundred and sixteen rheumatology departments were surveyed by postal questionnaire. Questions covered the contribution of various disciplines to rheumatology out-patient clinics, and opinions on existing and potential services, with emphasis on foot health provision. Inter-regional variations were explored for eight UK regions. Valid responses were received from 170 respondents (78.7% response rate). More than 80% of out-patient departments reported having rheumatology nurse specialists included in the staff mix but fewer than half used other allied health professionals, such as podiatrists. One quarter of the departments had access to a podiatrist and in 18% there was a foot health service dedicated to rheumatology. Awareness of guidelines for referral or of standards of foot care provision was very low (6%). There was high satisfaction with the adequacy of provision of footwear and insoles (81-87%) but low satisfaction with the adequacy of basic foot care (48-52%). Regional variation was extremely high for the provision of basic foot care (0-73%), the non-English regions reporting poorer provision of service. Regional variation in the adequacy of foot health services was high and the non-English regions especially are failing to meet the foot health needs of rheumatology patients. Multidisciplinary care is generally well developed despite the composition of teams being highly variable. Fewer than half of rheumatologists reported that basic foot care needs were being met, although adequacy of provision of more advanced foot services is perceived to be better. The absence of nationally agreed standards and poor awareness of local standards may be detrimental to care in this patient group.

How can we reduce amputations?

Never in the history of diabetes has there been so much known about the diabetic foot and yet the number of amputations continues to rise in England, Scotland, Europe1 and the USA.2 Indeed, in the USA the number of amputations has increased from 36,000 in 1980 to 54,000 in 1990 and 86,000 in 1996. Doubtless the increase in the incidence of diabetes has played a role in these rather depressing statistics but the question remains: how can we reduce both the relative and absolute numbers of diabetes-related amputations? In fact, a number of major advances have taken place in the last decade. Diabetic foot programmes that enthusiastically promote preventive foot care, professional protective footwear, education of patients and staff, a multidisciplinary approach to healing ulcers with aggressive management of infection and ischaemia have achieved a substantial decrease in amputation rates.3 But the widespread application of these programmes has been hindered by misunderstandings, misconceptions and simple lack of awareness of advances in foot care. Accurate diagnosis of the neuropathic and the neuroischaemic foot; Efficient relief of the mechanical forces that have led to ulceration; Early diagnosis and aggressive treatment of infection; Regular debridement of ulcers and urgent removal of necrotic tissue from the infected foot; Revascularisation of the neuroischaemic foot with either angioplasty or bypass, if there is extensive tissue deficit or if ulceration does not respond to conservative treatment; The use of modern active wound healing techniques if ulcers do not respond to standard treatment; Tight control of blood glucose to accelerate healing and reduce infection; Early diagnosis of the Charcot foot and immobilisation of same to prevent deformity; Screening all diabetic patients for neuropathy, ischaemia, deformity and oedema, and education of those at risk to protect them from ulceration; The provision of diabetic foot care within a multidisciplinary foot clinic. How can we organise services such that there will be equitable access to a multidisciplinary clinic for all patients? What are the possibilities for an annual foot check for every patient? How can we make distal bypass surgery and distal angioplasty readily available to all patients? Is it right that in one instance a patient with a neuroischaemic foot can have a successful distal bypass and return to full mobility, and another with a similar foot have a below-the-knee amputation and possibly never walk again? Offloading of high pressures in the neuropathic foot is fundamental and the total contact cast may be regarded as a gold standard treatment. Why then is it used so infrequently within Europe and the USA? How far have we progressed with appropriate insoles and footwear? What educational strategies have been developed and proven to work in the diabetic foot? Should diabetic foot patients be admitted to the medical or surgical ward and, after admission, who should look after them? Who is responsible for the overall provision of footwear to all people with diabetes in a health district? The crucial task now is to address these and other questions and to debate how guidelines and consensus can be implemented and transformed into best clinical practice for all diabetic foot patients. We hope this will be facilitated by an ongoing Best Practice Round Table discussion to be held within the diabetesonestop.com website, in association with Practical Diabetes International. As a further step in the process, this year's Practical Diabetes International Foot Conference, to be held at the Royal College of Physicians, London, on 29 November 2001*, will be devoted to the theme of “How can we reduce amputations?” and the results of this debate will be published in the journal and on the web. We hope readers of this journal will attend the meeting and participate in the website discussion. There is good evidence that amputations can be reduced. There is a way, but it requires effort, time and resources. Do we really have the will or shall we just admit that the diabetic foot is too great a burden to bear?