The Diabetic Foot - assessment and assistive devices

Abstract

Foot ulcers are a serious complication in diabetes and the most common factor leading to lower extremity amputation. The Swedish National Guidelines for Diabetes Care recommend an annual foot check for all 400,000 patients in the country, to identify patients at risk of developing diabetic foot ulcers (DFU). In the identified patients, preventive intervention and acute treatment should be initiated. Assistive devices, an annual foot check, risk classification of the feet, podiatry service, information and access to medical specialists should all be included in a well-designed prevention and care programme. However, there are regional differences in Sweden. The current lack of risk classification routines is leading to a situation in which patients at risk of developing DFU are likely not to be detected and, when they are detected, the necessary interventions may be delayed. This thesis focuses on health-care providers at departments of prosthetics and orthotics and methods that accurately assess the risk of developing DFU are presented. Moreover, the effects of assistive devices (foot orthoses and shoes) were evaluated. The patients that were studied in this thesis (n = 216) were all referred to a department of prosthetics and orthotics with the aim of being provided with protective assistive devices, as their feet were in the risk zone for developing DFU. Clinical tests, surveys and in-shoe pressure measurements were used to assess the type and frequency of risk factors that were present in the studied group. Several risk factors were found to be present, e.g. foot deformities, calluses and neuropathy. An eHealth tool, named the D-Foot, was constructed and its validity and reliability were assessed. The web program, the D-Foot, includes a series of foot assessments. After completing the assessments, an objective foot ulcer risk is displayed on the screen. The D-Foot gives recommendation for the prevention and care of DFU, based on the current guidelines. In-shoe pressure measurements showed that the plantar peak pressure using foot orthoses (prefabricated and custom-made) inserted in normal walking shoes was approximately 200 kPa under the sole of the foot. The individual variation in peak pressure was large. The conclusions of this thesis are that the D-Foot should be recommended as a clinical tool to assess the risk of foot ulcers in diabetes. Moreover, foot measurements and plantar pressure measurements are assessments that facilitate the provision of assistive devices. It is expected that early identification and rapid intervention with prevention and care will reduce the number of DFUs and amputations, leading to positive effects for the individual and society.