Therapeutic Footwear for the Neuropathic Foot: An algorithm

Abstract

Neuropathy may bring about changes in form and function of the foot, which may lead to ulceration and progressive deformity. These manifestations often require specially adapted footwear. A comprehensive concept of the medical, functional, and technical requirements for this type of footwear is still lacking to date. In this article, we present an algorithm that should facilitate prescription and manufacture of adequate shoes. This algorithm attempts to establish a link between the requirements from a medical and functional point of view and the technical possibilities of orthopedic shoe technology. Diabetes Care 24:705-709, 2001T he neuropathic foot is characterized by loss of peripheral nerve function, which can be sensory, motor, autonomic or, usually, a combination of these. This loss of function causes changes in the form and function of the foot and may lead to ulceration and severe deformity, which eventually may result in amputation (1). Therefore, protection of the foot is of the greatest importance. In addition to a careful lifestyle, appropriate footwear is essential for achieving this protection (1,2).In medical literature on the neuropathic foot, much has been written about the prevention of complications. The importance of "good footwear" is stressed, though frequently without further specification (3,4). So far, research has focused only on parts of the problem, mostly pressure reduction (5-8), although in addition to peak pressure, the duration of maximum pressure and shear stress are also important (9 -11). Diabetic footwear has been discussed in descriptive articles (12, 13) and technical studies (8,14). However, the authors confine themselves to specific aspects like pressure distribution and rocker-bottom outsoles (8,14). A comprehensive conceptual approach for the management of the various aspects of this footwear problem is still lacking (15). The rationale behind footwear prescriptions is often unclear to patients and healthcare workers alike, and this can diminish compliance (3,16).The aim of this article is to describe the relationship between medical requirements and technical possibilities. For this purpose, we have developed an algorithm. A number of its components are evidencebased, but most are opinion-based, because testing the effects of therapeutic footwear is impossible without clear guidelines. This algorithm aims at establishing guidelines for clinical treatment and further research into this complex subject. REQUIREMENTS BASED ON MEDICAL FEATURESAltered biomechanics in the foot may lead to ulceration and progressive deformity (17). Here, we will only discuss the different features of a neuropathic foot. Because neuropathy commonly occurs in diabetes, we will also mention one of its consequences, limited joint mobility, which is not directly related to neuropathy (18). Sensory dysfunction Loss of sensory functionIn the long term, reduction of sensory function may lead to complete loss of sensation in the foot. We speak of loss of protective sensation when the patient is not aw...

Pé diabético: estratégias para prevenção

“…A avaliação dos pés constitui-se em passo fundamental na identificação dos fatores de risco que podem ser modificados, o que, conseqüen-temente, reduzirá o risco de ulceração e amputação de membros inferiores nas pessoas com diabetes (30) . Autores destacam que a diminuição da sensação protetora, caracterizada pela redução da sensação dolorosa de trauma na pele (3,(32)(33)(34)(35)(36)(37) , bem como a ausência parcial ou total do reflexo Aquileu (14,26,(38)(39) constituem sinais precoces de futuros processos ulcerativos nos pés, significando alto risco para o desenvolvimento de complicações. Ambas as alterações podem ser avaliadas mediante testes que utilizam vários tipos de instrumentos, desde os mais sofisticados aos mais simples.…”

“…Outro aspecto a se considerar na avaliação é a alteração biomecâ-nica ou osteoarticular dos pés (30,32,46) . Essa alteração poderá produzir deformidades estruturais (hálux valgo, pododáctilos em garra, pé plano, pé cavo), expondo os pés a uma distribuição anormal da pressão plantar em regiões, às vezes, não protegidas anatomicamente.…”

“…Embasado na experiência, pesquisador (32) indica características importantes a serem consideradas nos calçados terapêuticos, mediante o desenvolvimento de um algoritmo. Enfatiza que a palmilha, unicamente, influencia na distribuição da pressão, visto que a redução da fricção exigiria uma ótima fixação dos pés aos calçados.…”

The Effects of Various Orthotic Treatments on the Standing and Walking Performance of Diabetic Patients

“…Four articles examined the effect of rocker in shoes on the plantar pressure in which 2 articles were case control [29,30], 1 RCT [31], and 1 article review [32]. In this context, there are 4 articles that examined the impact of rocker on shoes with insoles where 2 articles were RCT [33,34], 1 article case control [6], and 1 systematic review [16]. Reported results of the studies show that using rocker is very effective on healing or preventing the diabetic foot ulcer, especially if the rocker is placed outside the shoes and standard insoles inside it.…”

Fifty years after Zamosky's article "Shoe modifications in lower-extremity orthotics"

“…Although national protocols [9] or disorder-specific algorithms [10] can be found, an international guideline for prescribing and providing shoe modifications is an important gap in the literature. To progress from tradition and clinical experience, evidencebased guidelines need to be developed.…”