Range of Motion and Plantar Pressure Evaluation for the Effects of Self-Care Foot Exercises on Diabetic Patients with and Without Neuropathy

et al. 2020

Background Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown. Methods The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self‐management; pre‐ulcer treatment; orthotic interventions; and foot‐ and mobility‐related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre‐ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables. Results We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self‐care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom‐made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot‐ and mobility‐related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting. Conclusions Structured education for patients and health care professionals, callus removal, custom‐made therapeutic footwear, and foot‐ and mobility‐related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.

Section: Structured Education Aimed At Health Care Professionalsmentioning

confidence: 99%

Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review

Netten

Sacco

et al. 2020

“…There is no direct evidence to suggest that foot‐related exercises prevent DFU, as studies on this topic are non‐existent. Various forms of foot‐related exercises are possible when aiming to improve modifiable risk factors for foot ulceration such as plantar pressure distribution, neuropathy symptoms, deficits in foot sensation, foot‐ankle joint mobility, and strength . These exercises can include stretching and strengthening of the foot and ankle musculature and functional exercises such as balance and gait exercises and are provided or supervised by physical therapists or similarly trained professionals.…”

Section: Treating Risk Factors For Ulcerationmentioning

confidence: 99%

“…These exercises can include stretching and strengthening of the foot and ankle musculature and functional exercises such as balance and gait exercises and are provided or supervised by physical therapists or similarly trained professionals. Multiple RCTs and non‐controlled studies have shown some benefit of these exercises on a range of modifiable risk factors for foot ulceration, including plantar pressure, foot and ankle range of motion, and neuropathy symptoms …”

Section: Treating Risk Factors For Ulcerationmentioning

confidence: 99%

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

Bus

Monteiro‐Soares

et al. 2020

374

609

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at‐risk patient about appropriate foot self‐care and treat any pre‐ulcerative sign on the foot. Instruct moderate‐to‐high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non‐surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high‐risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days, and to reduce the patient and health care burden of diabetic foot disease.

“…We therefore conclude that while foot‐ and mobility‐related exercises do not appear to help prevent foot ulcers, they can be considered safe to increase a patient's level of weight‐bearing activity without increasing the risk for ulceration. Other studies on this topic primarily aimed to reduce risk factors for ulceration, such as plantar pressure reduction or redistribution, but did not report ulcer outcomes . Considering the health advantages resulting from specific foot‐related exercises, or from general weight‐bearing activity, these interventions can be considered for this population.…”

Section: Discussionmentioning

confidence: 99%

“…Other studies on this topic primarily aimed to reduce risk factors for ulceration, such as plantar pressure reduction or redistribution, but did not report ulcer outcomes . Considering the health advantages resulting from specific foot‐related exercises, or from general weight‐bearing activity, these interventions can be considered for this population. However, no definitive conclusions can yet be drawn because of the limited evidence available, and further research is strongly advised.…”

Section: Discussionmentioning

confidence: 99%

Prevention of foot ulcers in the at‐risk patient with diabetes: a systematic review

Netten

Raspovic

et al. 2020

169

330

Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non‐controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot‐related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight‐bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self‐management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non‐existent for the prevention of a first foot ulcer and non‐plantar foot ulcer.