The complications of diabetes are associated with peripheral neuropathy, peripheral vascular disease, foot ulceration, minor and major amputation1 and increased mortality2
Patient A is a 56 year male, a self employed builder, who has had Type 1 diabetes for 35 years he does not smoke and drinks up to 15 units of alcohol a week, and has poor glycaemic control . He has a history of neuropathic foot ulcers and has had the left first toe amputated. A puncture wound caused a Left foot plantar ulceration. He remained off work for 6 months the ulcer was slow to improve (fig 1), conventional offloading was not tolerated due to ankle pain. The patient continued to attend the clinic and dress the foot himself. Due to economic hardship the patient wanted to return to work. To aid healing the PulseFlowDF device was considered (Fig 2). This device consists of a pair of anatomically correct left and right shoes with an offloading outer sole and generous Velcro straps to accommodate best fitting. The shoe design helps reduce shear forces and impact pressures during standing and walking. PulseFlow eliminates the leg length inequality that would normally occur if an offloading device was issued just for the affected side, by having a pair of shoes- this also reduces the potential of the patient developing joint pain in the knee, hip or lower back.
The shoe also has an intermittent plantar compression system (IPC) fitted to the ulcerated side; this consists of an air bladder located in the footwear sole under the inner longitudinal arch region of the ulcerated foot; this bladder inflates up to 160mmHg of pressure for one second every 20 seconds. Ultrasound examination (fig 3) has demonstrated the increase in volume and velocity of the peripheral blood flow3- thus reducing maceration and improving healing 4.
The concept of PulseFlow was explained to the patient and how to use the device, due to the patients’ work he could not use the device during the day, and so the patient was to use the boot in the evenings and weekends whenever he could. The patient was happy to try the device, and to continue to dress the foot as he had been. The patient was booked to return in one week to have the device fitted. During this period the patient had returned to work with out the knowledge of the clinical team. When the patient returned for the fitting the ulcer had significantly deteriorated (Fig 4).
The patient declined to be admitted due to his financial situation, he was commenced on a course of antibiotics. The patient was happy to continue with the care plan as had been agreed.
The patient on the whole complied with the care plan and used the PulseFlow device daily and also at weekends, he continued to work as a carpenter /builder. The patient dressed the foot with a foam dressing and attended the clinic once a week. There was continual incremental improvement in the lesion in the following weeks (Fig 6), the ulcer progressed further and closed.
The PulseFlow DF device was a relatively simple device to use for a patient that was working. Due to working access to the clinic was limited, the patient was able to continue with his normal dressings. The PulseFlow DF did not require any maintenance only recharging when required. The device proved easy to use in the evenings, and did not cause much disruption to the patient when it was being used.