Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission

Abstract

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality and healthcare costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility, decreased moderate intensity exercise when compared to people with diabetes without ulcers. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year following healing and the majority occurs in the first three months following wound healing. Hence this period after ulceration is called "remission" due to this risk for re-ulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate offloading and monitoring in people with a recently healed foot ulcer, foot reconstruction or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring which can identify dangerous "hot spots" prone to recurrence. By understanding areas at risk, it empowers patients to maximize ulcer-free days and to enable an improved quality of life. There is a current absence of high-quality evidence and standardized clinical algorithms for the post-ulcerative period. This perspective outlines this institution's unified strategy to treat patients in the remission period after ulceration. This approach utilizes the available evidence, identifies patient preferences, and relies on good clinical judgement for the best long-term outcomes for this patient population. Hence this position statement aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patient to ensure a safe transition to footwear and return to activity.

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

“…Based on 8 studies with 291 participants, 25,27,[36][37][38]41,42,46 we found a mean (over the total number of included studies) of 6167 steps per day (range: 4548 to 8450) in people at high risk of ulceration (IWGDF risk 3); the weighted mean, over the total number of participants included in these studies, was 6239 steps. Finally, based on 6 studies with 186 participants, [20][21][22]25,43,47 we found a mean (over the total number of included studies) of 4248 steps per day (range: 1219 to 8153) in people with a foot ulcer; the weighted mean, over the total number of participants included in these studies, was 4484 steps.…”

“…Reference checking resulted in an additional 3 publications, giving a total 27 publications from 21 studies. 14,[19][20][21][22][23][24][25][26][27][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48] In one publication, outcomes were reported as part of a guideline, yet without population characteristics. 47 We contacted the first author, who confirmed the correctness of the data and confirmed data was obtained from a subset of which population data were published elsewhere.…”

Australian guideline on offloading treatment for foot ulcers: part of the 2021 Australian evidence‐based guidelines for diabetes‐related foot disease

“…However, we do note that as recommended in the accompanying Australian guideline to prevent DFU there is moderate quality of supporting evidence for the use of medical grade footwear to prevent recurrence of DFU once healed [39]. Thus, we suggest that health professionals strongly consider arrangements to transition into medical grade footwear when healing is (nearly) achieved as per expert consensus guidelines [50] and refer the reader to the accompanying Australian guideline to prevent DFU [39]. Finally, while there is no literature to support their use as treatment to heal people with DFU, wheelchairs, knee scooters or electric scooters may be considered in these rare circumstances.…”

Diabetic Wound-Healing Science

“…Reports by the investigators found that patients optimally received one alert every 2 h, and a reduction of DFU recurrence was associated with the use of this smart sensor technology [ 276 , 277 ]. Recent guidelines for DFU prevention have incorporated regular monitoring of foot skin temperature to assess for early signs of inflammation and enable early intervention to prevent ulceration [ 278 ]. A number of other wearable devices have been created for thermal foot monitoring, including smart insole systems [ 279 , 280 ] and socks [ 281 , 282 ], though the efficacy of these wearables in DFU prevention or wound-healing monitoring need to be further tested.…”