Ryan T Crews

Aims Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes‐related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. Materials and Methods We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient‐Intervention‐Control‐Outcome) format, undertaking a systematic review and meta‐analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including …

Background Offloading treatment is crucial to heal diabetes‐related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU. Methods We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight‐bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost‐effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta‐analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed. Results From 19,923 studies screened, 194 …

Aim: Adherence to offloading devices for diabetic foot ulcers (DFU) is poor and postural instability influences adherence. Prior research suggests an ankle-high removable cast walker (RCW) in tandem with a contralateral shoe lift might increase users’ balance relative to a traditional knee-high RCW without a lift. This study compared compensatory responses to perturbations under both conditions.Methods: Twenty-five individuals (48% male; age: 68±8 years) with diabetic peripheral neuropathy participated. Participants completed trials under three conditions: bilateral standardized shoes, knee-high RCW, and ankle-high RCW with contralateral shoe lift. Stepping thresholds (ST) were assessed for two types of perturbations: 1) From a stopped position, a treadmill rapidly accelerated at 3.5 m/s² to reach a set peak-velocity and then decelerated and stopped. The smallest peak-velocity to elicit a step was identified as …

Interprofessional education (IPE) aims to cultivate collaborative skills especially in health professional students and is implemented by an increasing number of educational programs. IPE is well received by both students and faculty members citing a wide range of benefits including improved learning, positive professional identity, and better patient care. However, the implementation of IPE may have a negative influence on an already overloaded basic and clinical science curriculum or can be impeded by several factors such as course content, time constraints and scheduling conflicts. In this study, we quantitatively evaluated the influence of IPE on students’ ability to learn in a basic science course. A total of 270 professional students from three different programs over two academic years participated in this randomized crossover study measuring anatomical knowledge acquisition during two learning activities …

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship …

According to a well-known proverb:“if you want to go fast, go alone; if you want to go far, go together.” When caring for the at-risk lower limb, going it alone may lead to the express lane to an amputation. Unfortunately, once an amputation is performed the next stop on the express lane is often death; the 5-year mortality is 46.2% following a diabetesassociated minor amputation and 56.6% following a diabetes-associated major amputation. 1 In 2014 the Society for Vascular Surgery published the WIfI (Wound, Ischemia, and foot Infection) classification system for staging lower extremities at-risk for amputation 2 and a subsequent metaanalysis of WIfI publications confirmed it to be predictive of one-year amputation risk. 3 The three risk-factors of WIfI inherently suggest the need for interprofessional collaborative efforts if at-risk limbs are to be preserved. In fact, before the publication of the WIfI classification system, several of its authors initiated concerted efforts to promote a podiatric and vascular surgery (‘Toe and Flow’) team approach to limb preservation. 4 This effort to extend the mileage traversed by at-risk limbs was a nascent recognition of the need to work collaboratively to save such limbs. The following searches, conducted on March 5th, 2021 in PubMed, and yielding only 56 and 54 publication hits, respectively (many duplicative), confirm the historical lack of a team approach to limb preservation.

BackgroundFall-risk assessments for patients with diabetes fail to consider reactive responses to balance loss. The purpose of this study was to assess the feasibility of using a simple clinical tool to evaluate the impact of diabetes and fall history on reactive balance in older adults.MethodsWe recruited 72 older adults with and without diabetes. Postural perturbations were applied by a waist-mounted spring scale. Stepping thresholds (STs) in the anterior and posterior directions were defined as the lowest spring-loads that induced a step. Balance was assessed via the National Institutes of Health Toolbox Standing Balance Test, and lower extremity sensation was assessed using vibratory perception threshold and Semmes-Weinstein monofilaments. Fall history over the past year was self-reported. Cox regressions and analysis of variance were used to compare hazard rates for stepping and observed STs between …

Diabetic foot ulcers (DFUs) represent a tremendous burden to health care systems. Offloading is one of the key tenants to healing DFU and knee-high irremovable offloading devices are considered the gold standard for offloading DFU. However, the gold standard is rarely utilized in clinical practice. Patients’ limited tolerance for such devices is one of a number of reasons that have been attributed to the lack of use of these devices. The practice of evidence-based medicine relies on shared decision making by pairing patients’ values and preferences with the best available evidence. The present case report reviews the process of a patient-centered approach to identify the best offloading option for a patient with DFU. In consultation with the patient, a series of modalities were evaluated for offloading 2 unilateral forefoot DFUs. It is suggested that optimizing DFU offloading outcomes at the population level will require …

The World Health Organization estimates that more than 422 million individuals have diabetes globally. 1–3 In United States, the Centers of Disease Control and Prevention estimates that more than 100 million adults have diabetes or prediabetes. 3 Diabetes has a large spectrum of associated complications with an estimated direct and indirect costs of more than $245 billion. 4 Costs associated with caring for diabetic foot complications constitute a large portion of this financial burden with up to one-third of the total costs for diabetes care being attributable to lower extremity care. 5 a Podiatric Surgery and Applied Biomechanics, Center for Lower Extremity Ambulatory Research (CLEAR), Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, USA; b Dr. William M. Scholl College of Podiatric Medicine at Rosalind …

With approximately one out of every three persons aged greater than or equal to 65 years falling each year, 1 falls present a tremendous challenge to health care systems. Recent estimates indicate that by 2030 older adults will incur 11.9 million fall injuries per year in the United States alone “unless effective interventions are implemented nationwide.” 1 As part of the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths & Injuries Initiative, an algorithm has been created to assist health care providers in fall risk screening, assessment, and intervention. 2 That algorithm specifically recommends referring patients to podiatrists when feet/footwear issues are identified. However, podiatrists are content experts in several

This thesis integrates a series of previously published papers centring around three interrelated themes addressing the complex relationship between diabetic foot ulcers (DFU) and physical activity engagement. The three foci of the thesis include: 1) ‘offloading’ DFU via specialized footwear that limit the application of physical stress to ulcers during weight bearing activity in order to promote healing; 2) monitoring and managing physical activity engagement of both patients at risk for DFU and patients with active DFU; 3) the heightened risk of falls in individuals at risk for DFU. A cohesive underlying foundation of the body of work contained within this thesis is an effort to help care providers and patients achieve better physical activity profiles. Offloading diabetic feet refers to the redistribution of physical stress away from sites at risk for or with active DFU. Thus, it is important to both prevent DFU but also to heal active DFU. This thesis includes two publications pertaining to the objective measurement of patient adherence to offloading modalities as well as two publications regarding the biomechanical assessment of devices used to offload DFU. The need for offloading is necessitated by the fact that individuals with DFU engage in weight bearing physical activity that can inflict physical trauma beyond the tolerance of the soft tissue of their feet, however, the relationship between physical activity and the formation as well as healing of DFU is not fully understood. A series of five publications concerning physical activity within patients with, or at risk for DFU are included in this thesis: two focus on improved monitoring of physical activity and three focus on …

BackgroundNumerous guidelines recommend pairing Semmes-Weinstein monofilament (SWM) testing with a secondary clinical test when screening for diabetic peripheral neuropathy, yet time is very limited in clinical practice. This study compared the time to complete and the diagnostic agreement of three vibratory sensation tests.MethodsSixty-five individuals (42% male; aged: 61 ± 12 years) were recruited. A single investigator administered the following tests bilaterally: 10-site SWM, traditional tuning fork (TTF), electronic tuning fork (ETF), and vibration perception threshold (VPT) via biothesiometer. Times to physically administer the tests were compared with a one-way repeated measures ANOVA. Cochran’s Q test was used to compare the varied tests’ diagnostic agreement.ResultsThe ANOVA indicated there were significant (P < .001, partial eta squared = .442) differences in time to complete the varied tests …

A plantar surface pressure offloading system includes an insole capable of coupling with a shoe and interfacing with a foot. A number of compressible bladders and pressure sensors are coupled to the insole. Each bladder has an adjustable compressibility, and each pressure sensor is configured to measure a pressure exerted on a respective portion of the foot. A controller of the system can perform, for each compressible bladder, a compressibility adjustment process including (i) receiving, from a respective pressure sensor associated with a respective bladder, a signal indicative of a pressure exerted on a respective portion of the foot,(ii) determining, based on the signal, that the pressure exerted on the respective portion of the foot exceeds a threshold pressure, and (iii) responsive to the determination, adjusting the compressibility of the respective bladder, thereby offloading pressure from the respective portion of …

The chapter emphasizes the importance of diabetic neuropathy‐related unsteadiness both as a key factor in generating depression in patients at high diabetic foot ulcer (DFU) risk and as an important determinant of non‐adherence to offloading in those with active DFUs. It examines the interplay between the psychological and biomechanical factors when considering high DFU risk patients’ engagement in physical activity. The chapter demonstrates that diabetic foot complications, and in particular, Charcot Neuroarthropathy, are associated with lower health status, especially in the physical domain. Moreover, diabetic foot ulceration is a source of DFU‐specific emotional disturbance and diminished quality of life (QoL). The chapter concludes with a discussion of the evidence base for the best approach to study QoL in DFU sufferers. Accumulating evidence suggests that psycho‐educational interventions …