An Investigation into the Role of Plantar Foot Pressures in the Development of Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) remain a costly public health concern. A key risk factor for DFU development is abnormally high plantar pressure. However, several constraints are identified in the literature supporting the link between plantar pressure and DFUs, with little research considering pressure experienced throughout daily life. Providing feedback on plantar pressure to patients with diabetic peripheral neuropathy has shown promising results, however, little is known of its prolonged and continued use outside the laboratory setting. This thesis investigated the use of an intelligent insole system that provided continuous pressure feedback during daily life, to diabetes patients who were at high risk of DFU. An aim of the thesis was to investigate whether the provision of pressure feedback could reduce plantar pressure. In addition, through continuous pressure measurement and monitoring, the thesis aimed to examine pressure in the lead up to ulceration and establish which daily activities contributed to high pressure sustained. Diabetes patients who received pressure-feedback had reduced number of bouts of high plantar pressure compared to the control group, which became evident after a minimum learning period of 12 weeks. For those feet that ulcerated during the study, pressure was significantly greater (P < 0.05) at the forefoot in the three months leading up to DFU development compared to those remaining ulcer-free. Diabetes patients spent significantly more time being sedentary (66% vs 55%, P = 0.03) and significantly less time undertaking physical activity (27% vs 34%, P = 0.04) than non-diabetic controls. Furthermore, sedentary behaviour accounted for the highest proportion (56%) of sustained high pressure. This thesis provided a unique insight into plantar pressure experienced during the day-to-day life of diabetes patients at high risk of DFU development. Through continuous monitoring, the thesis was able to capture for the first time, increased plantar pressure in the lead up to ulceration and identify long periods of sedentary behaviour as a risk factor for DFU development. Continuous pressure-feedback was an effective intervention to reduce plantar pressure and the associated risk of ulceration

The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration – a comprehensive review

Diabetic foot ulcers (DFU) are a costly public health concern. The predominant risk factor, peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies, including orthotics and footwear, strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory-based environments, rather than during daily activity. Few studies investigated previous DFU location-specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight-bearing activities, where a lower ‘peak’ pressure might be applied on the foot over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time, such as pressure-time integral, could be a more relevant parameter than peak pressure. A few studies have indicated that providing pressure feedback to the patient might reduce plantar pressures, with an emerging potential use of smart technology. However, further research is required to determine the efficacy of this approach. Constraints of previous plantar pressure research may explain its low prediction ability for DFU as part of prospective studies. Further vertical and shear pressure analyses, across all weight-bearing activities and referring to location-specific pressures are required to improve our understanding of pressures resulting in DFUs and to help improve effectiveness of interventions, such as therapeutic footwear and pressure-feedback

"FootSnap": A New Mobile Application for Standardizing Diabetic Foot Images.

Background: We describe the development of a new mobile app called “FootSnap,” to standardize photographs of diabetic feet and test its reliability on different occasions and between different operators. Methods: FootSnap was developed by a multidisciplinary team for use with the iPad. The plantar surface of 30 diabetic feet and 30 nondiabetic control feet were imaged using FootSnap on two separate occasions by two different operators. Reproducibility of foot images was determined using the Jaccard similarity index (JSI). Results: High intra- and interoperator reliability was demonstrated with JSI values of 0.89-0.91 for diabetic feet and 0.93-0.94 for control feet. Conclusions: Similarly high reliability between groups indicates FootSnap is appropriate for longitudinal follow-ups in diabetic feet, with potential for monitoring pathology

An intelligent insole system with personalised digital feedback reduces foot pressures during daily life: An 18-month randomised controlled trial

Aims: High plantar pressure is a major risk factor in the development of diabetic foot ulcers (DFUs) and recent evidence shows plantar pressure feedback reduces DFU recurrence. This study investigated whether continued use of an intelligent insole system by patients at high-risk of DFUs causes a reduction in plantar pressures. Methods: Forty-six patients with diabetic peripheral neuropathy and previous DFU were randomised to intervention (IG) or control groups (CG). Patients received an intelligent insole system, consisting of pressure-sensing insoles and digital watch. Patients wore the device during all daily activity for 18-months or until ulceration, and integrated pressure was recorded continuously. The device provided high-pressure feedback to IG only via audio-visual-vibrational alerts. High-pressure parameters at the whole foot, forefoot and rearfoot were compared between groups, with multilevel binary logistic regression analysis. Results: CG experienced more high-pressure bouts over time than IG across all areas of the foot (P 16 weeks of wearing the device. Conclusions: Continuous plantar pressure feedback via an intelligent insole system reduces number of bouts of high-pressure in patients at high-risk of DFU. These findings suggest that patients were learning which activities generated high-pressure, and pre-emptively offloading to avoid further alerts

A peer-volunteer led active ageing programme to prevent decline in physical function in older people at risk of mobility disability (Active, Connected, Engaged [ACE]): study protocol for a randomised controlled trial

Background: The Active Connected Engaged [ACE] study is a multi-centre, pragmatic, two-arm, parallel-group randomised controlled trial [RCT] with an internal pilot phase. The ACE study incorporates a multi-level mixed methods process evaluation including a systems mapping approach and an economic evaluation. ACE aims to test the effectiveness and cost-effectiveness of a peer-volunteer led active ageing intervention designed to support older adults at risk of mobility disability to become more physically and socially active within their communities and to reduce or reverse, the progression of functional limitations associated with ageing. Methods/design: Community-dwelling, older adults aged 65 years and older (n = 515), at risk of mobility disability due to reduced lower limb physical functioning (Short Physical Performance Battery (SPPB) score of 4–9 inclusive) will be recruited. Participants will be randomised to receive either a minimal control intervention or ACE, a 6-month programme underpinned by behaviour change theory, whereby peer volunteers are paired with participants and offer them individually tailored support to engage them in local physical and social activities to improve lower limb mobility and increase their physical activity. Outcome data will be collected at baseline, 6, 12 and 18 months. The primary outcome analysis (difference in SPPB score at 18 months) will be undertaken blinded to group allocation. Primary comparative analyses will be on an intention-to-treat (ITT) basis with due emphasis placed on confidence intervals. Discussion: ACE is the largest, pragmatic, community-based randomised controlled trial in the UK to target this high-risk segment of the older population by mobilising community resources (peer volunteers). A programme that can successfully engage this population in sufficient activity to improve strength, coordination, balance and social connections would have a major impact on sustaining health and independence. ACE is also the first study of its kind to conduct a full economic and comprehensive process evaluation of this type of community-based intervention. If effective and cost-effective, the ACE intervention has strong potential to be implemented widely in the UK and elsewhere. Trial registration: ISRCTN, ISRCTN17660493. Registered on 30 September 2021. Trial Sponsor: University of Birmingham, Contact: Dr Birgit Whitman, Head of Research Governance and Integrity; Email: [email protected]. Protocol Version 5 22/07/22

Social Factors Key to Landscape-Scale Coastal Restoration: Lessons Learned from Three U.S. Case Studies

In the United States, extensive investments have been made to restore the ecological function and services of coastal marine habitats. Despite a growing body of science supporting coastal restoration, few studies have addressed the suite of societally enabling conditions that helped facilitate successful restoration and recovery efforts that occurred at meaningful ecological (i.e., ecosystem) scales, and where restoration efforts were sustained for longer (i.e., several years to decades) periods. Here, we examined three case studies involving large-scale and long-term restoration efforts including the seagrass restoration effort in Tampa Bay, Florida, the oyster restoration effort in the Chesapeake Bay in Maryland and Virginia, and the tidal marsh restoration effort in San Francisco Bay, California. The ecological systems and the specifics of the ecological restoration were not the focus of our study. Rather, we focused on the underlying social and political contexts of each case study and found common themes of the factors of restoration which appear to be important for maintaining support for large-scale restoration efforts. Four critical elements for sustaining public and/or political support for large-scale restoration include: (1) resources should be invested in building public support prior to significant investments into ecological restoration; (2) building political support provides a level of significance to the recovery planning efforts and creates motivation to set and achieve meaningful recovery goals; (3) recovery plans need to be science-based with clear, measurable goals that resonate with the public; and (4) the accountability of progress toward reaching goals needs to be communicated frequently and in a way that the general public comprehends. These conclusions may help other communities move away from repetitive, single, and seemingly unconnected restoration projects towards more large-scale, bigger impact, and coordinated restoration efforts

Abstracts from the NIHR INVOLVE Conference 2017

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Effects of Interventions to Improve Individual’s Adherence to Exercise Programs in people with Chronic Disease

MPT Systematic Reviews and Research Projects.Medicine, Faculty ofPhysical Therapy, Department ofUnreviewedGraduat

A Foreign Body Through the Shoe of a Person With Diabetic Peripheral Neuropathy Alters Contralateral Biomechanics: Captured Through Innovative Plantar Pressure Technology

High plantar pressure as a result of diabetic peripheral neuropathy is often reported as a major risk factor for ulceration. However, previous studies are confined to laboratories with equipment limited by cables, reducing the validity of measurements to daily life. The participant concerned in this case report was wearing an innovative plantar pressure feedback system as part of a wider study. The system allows for continuous plantar pressure monitoring and provides feedback throughout all activities of daily living. The participant concerned was a 59-year-old male with type 2 diabetes who presented with severe peripheral neuropathy. In addition, the right ankle had previously undergone fusion. Between monthly study appointments, the participant unknowingly had a screw embedded in his right shoe, while pressure was being recorded. Although no significant differences in pressure were present for the right foot with the embedded screw, the contralateral foot showed significantly higher pressure when the screw was embedded, compared with pre and post time periods. The increase in pressure on the contralateral foot is expected to result from the protrusion of the screw in the right shoe, causing a perturbation to balance and a shift in the center of pressure toward the contralateral side. This compensatory effect is likely to have been magnified by the limited mobility of the fused right ankle. These findings highlight the importance of checking both feet for ulcer risk, in the event of receiving high-pressure feedback. This innovative technology may improve our understanding of diabetic plantar foot ulcer development

Using systems mapping within the process evaluation of a randomised controlled trial of the ACE active ageing programme in England and Wales

Background: System mapping has mainly been used to develop theories and understanding of complex systems; to hypothesise how an intervention might work in a complex system or to inform intervention development. There are a few examples of the use of system mapping as part of process evaluation. In this paper, we describe an innovative approach to using system mapping as part of the process evaluation of a randomised controlled trial of the Active, Connected, Engaged (ACE) community-based active ageing programme. Method: Ten participatory workshops were held across three of the ACE sites (Cardiff, Stoke-on-Trent and Manchester, UK). These involved over 100 participants, volunteers and stakeholders (from National Health Service, statutory and voluntary sectors). Their aim was to gather area-specific information on participants’ barriers and facilitators to physical activity and the needs of peer volunteers and service providers; and create ‘baseline’ system maps before the launch of the programme in the three areas of ACE delivery. Results: System maps were produced showing the main outcome (physical activity) and the interactions between the key motivators and barriers described by older people, as well as ideas from stakeholders and volunteers about how these barriers can be addressed. Findings led to refinements to ACE intervention processes and the study’s logic model. Conclusions: System mapping helped to refine the ACE processes and fine-tune the logic model. The value of this approach will increase in the next phase when it will be used to explore any changes to the physical activity system including changes to stakeholders’ ways of working and collaborating to tackle barriers to activity following the completion of the ACE trial. Trial registration number: ISRCTN17660493