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Offloading for the treatment of the diabetic foot – a systematic review.

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OFFLOADING FOR THE TREATMENT OF DIABETIC FOOT ULCERS - A SYSTEMATIC REVIEW

 

1. BACKGROUND

•Diabetes is a chronic disease that can lead to a series of complications including the “diabetic foot”.1
•Both neuropathy that leads to a decrease or loss in protective sensation to pain and pressure, and peripheral vascular disease that causes poor blood flow to the feet, influence the development of diabetic foot ulcers.2,3
•If the foot is still subject to high pressures tissue damage will continue, preventing complete ulcer healing and even promoting ulcer recurrence2 Therefore use of offloading devices is critical for management of these wounds.3,4,5


2. METHODS

A systematic review of the literature was undertaken, using the guidance of the Cochrane Collaboration.


3. DEFINITION OF TERMS

Diabetic Foot Ulcers wounds that occur on the feet of people with type 1 and type 2 diabetes.  Diabetic foot ulcers usually occur on the bottom of the foot.6

Offloading is a treatment and prevention intervention with the objective of relieving, reducing or redistributing plantar pressure evenly, to avoid the concentration of high pressure in the feet and to protect pressure points.3,6


4. REVIEW QUESTION

What is the impact of offloading in the treatment of diabetic foot ulcers?


5. OBJECTIVES

•To identify the most effective offloading device for the treatment of the diabetic foot.
•To identify the strengths and limitations of different offloading devices.
•To determine the impact that offloading devices have in the quality of life of the patient.
 

6. INCLUSION & EXCLUSION CRITERIA

All studies, in English or Portuguese, where different types of casts, therapeutic shoes and other orthotic devices were compared and analysed in adult patients with only diabetic foot ulcers were included. Studies where participants were reported to have foot deformities and artropathies were excluded.


7. DATA EXTRACTION & QUALITY APPRAISAL

The information extracted included: author, date of study, title, source, study geographical location, research question/aim/objectives, care setting, type of wound, inclusion/exclusion criteria, sample size, patient characteristics, design details, study type, allocation, intervention details, outcome measures, analysis, results, conclusions and recommendations

Quality appraisal was undertaken using the risk of bias assessment from RevMan 5.2 tool for all randomized controlled trials retrieved. The EBL Critical Appraisal Checklist7 was used for the other quantitative studies retrieved.


8. DATA SYNTHESIS AND ANALYSIS

In all randomized controlled trials dichotomous data were analysed in terms of risk ratio, and continuous data were analysed in terms of mean differences and were presented in a forest plot.


9. SEARCH STRATEGY

Search terms:

•Diabetic foot, Foot orthoses/orthosis ; Casts/plaster; Casts/surgical; Casts; Orthosis/orthoses/orthotic devices; Shoes

14 studies met the inclusion criteria

Databases:

•CINAHL; Cochrane Library; Embase; Medline; Web of knowledge
 
 

10. RESULTS

•Twelve studies reported on healing rates. In general healing rates were higher with the Total Contact Casting (TCC) (p=0.02-p=0.05) and Instant Total Contact Casting (iTCC)  (P=0.03).
•Ten studies reported healing times. In general healing times were higher with the TCC and iTCCs (P<0.00001).


11. DISCUSSION

This systematic review has confirmed that casting is the first line of choice for the treatment of diabetic foot ulcers. studies need to address other factors such as cost, compliance and quality of life. These factors are of importance not only for clinical practice and management, but also for patients.

 

12. CONCLUSION

Offloading is a key treatment strategy for the management of diabetic foot ulceration and total contact casts were found to be the most effective devices to achieve ulcer healing. However, they are not without complications and further, their impact on cost, compliance and quality of life is not well understood.

 

13. REFERENCES

1.International Diabetes Federation Diabetes Atlas 5th Edition (Online) Available at: http://www.idf.org/atlasmap/atlasmap  (Accessed 4th of November 2012)
2.International Diabetes Federation (2012) What is Diabetes (Online) Available at: http://www.idf.org/diabetesatlas/5e/what-is-diabetes (Accessed 4th of November 2012)
3.Cavanagh P.R., Lipsky B.A., Bradbury A.W., Botek G. (2005) Treatment for diabetic foot ulcers. Lancet, 366, 1725-1735.
4.Lavery, A.L., Peters E.J.G, Armstrong D.G (2008) What are the most effective  interventions in preventing diabetic foot ulcers? International Wound Journal, 5(3), 435-433.
5.Van Deursen R. (2004) Mechanical Loading and Off-Loading of the Plantar Surface of the Diabetic Foot. Clinical Infectious Disease, 39 (Suppl. 2), S87-S91.
6.Edmonds M.E., Foster A.V.M. & Sanders L.J. (2008:85) A Practical Manual of Diabetic Foot Care. Blackwell Publishing, UK.
7.Glynn L. EBL Critical Appraisal Checklist (Online) Available at: http://www.hse.ie/eng/staff/Leadership_Education_Development/National_In... (Accessed 4th of March 2013).

 

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