A Randomized Pilot Study of improving Foot Care in Home Health Patients With Diabetes Novel Optical Techniques for Imaging Microcirculation in the Diabetic Foot. Diabetes Foot Self-care Practices in a Rural, Triethnic Population Shear-Reducing Insoles to Prevent Foot Ulceration in High-Risk Diabetic Patients Intensive education improves knowledge, compliance, and foot problems in type 2 diabetes. Foot Education Improves Knowledge and Satisfaction Among Patients at High Risk for Diabetic Foot Ulcer An integrated wound-care pathway, supported by telemedicine, and competent wound management - Essential in follow-up care of adults with diabetic foot ulcers Review article: Methodology for the ‘rapid review’ series on musculoskeletal injuries in the emergency department Foot Care: Knowledge Retention and Self-care Practices Evaluation of the Impact of Podiatrist Care in the Primary Prevention of Foot Problems in Diabetic Subjects A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable. Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting. Long-Term Effects of One Year of Intensified Podiatric Activities on Foot-Care Knowledge and Self-Care Habits in Patients With Diabetes Plantar fasciitis – to jab or to support? A systematic review of the current best evidence Reduction of Lower Extremity Clinical Abnormalities in Patients with Non-Insulin-Dependent Diabetes Mellitus Prevention of foot ulcers in patients with diabetes and end stage renal disease. Improving Foot Self-Care Behaviors With Pies Sanos Community-based care for chronic wound management: an evidence-based analysis. A systematic review of outcome tools used to measure lower leg conditions. Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting The effectiveness of exercise on recovery and clinical outcomes of soft tissue injuries of the leg, ankle, and foot: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. The pathway to foot ulceration in diabetes. Improving diabetes processes of care in managed care.
PURPOSE the purpose of this study was to test the effectiveness of an educational intervention to improve patients ' foot care knowledge , self-efficacy , and self-care practice s. METHODS A prospect i ve , r and omized , single center , 2-group design was used with a convenience sample of 40 home care patients from a Medicare-certified home health agency . Baseline measures of foot care knowledge , self-efficacy , and reported self-care practice s were obtained at study entry and 6 weeks later to control for foot care interventions provided during routine home care services . After obtaining the 6-week baseline measures , patients who were r and omized to the intervention group received individualized education about proper foot care . All patients were interviewed a third time 3 months after study entry to determine the effectiveness of the intervention . RESULTS The educational intervention improved patients ' knowledge , confidence , and reported foot care behaviors . CONCLUSIONS A brief , individualized educational intervention about st and ard foot care topics improved patients ' foot care knowledge and self-efficacy as well as reported self-care practice s. Incorporating such interventions into routine home care services may enhance the quality of care and decrease the incidence of lower-extremity complications BACKGROUND The most severe diabetic foot ulcers are those related with critical ischemia , which is primarily diagnosed with non-invasive diagnostics . However , these diagnostics have several disadvantages . For example , they only provide global indications of the (macro)level of ischemia . A potential solution can be found in novel optical imaging techniques for local assessment of the microcirculation in diabetic foot ulcers . This review provides an overview of these imaging techniques ( Laser Doppler Perfusion Imaging , Laser Speckle Contrast Imaging , Photoacoustic Imaging and Hyperspectral Imaging ) and their applicability for the diagnostic assessment of microcirculation in diabetic foot ulcers . METHOD For each technique , the following parts are described : a ) their technical background ; b ) general clinical applications ; and , c ) its application for microcirculation assessment in diabetic foot ulcers . Parts a-b are based on a narrative review of the literature , part c on a systematic review that was performed in the data base Scopus , covering the period from January 1 , 2000 to November 31 , 2017 . RESULTS Each of these techniques has specific advantages and disadvantages for imaging microcirculation . Potential clinical use depends on measurement aims , and clinical relevance . However , none of the techniques has a strongly established clinical relevance yet : we found a limited number of publications describing clinical outcomes . Future research is needed to determine which technique is the most clinical ly relevant for the assessment of microcirculation in diabetic foot ulcers . CONCLUSION Although promising , the currently available novel optical techniques need to be further improved technically and prospect i ve trials are necessary to evaluate their clinical value Purpose The purpose s of this study were to assess the level of foot self-care performed in a rural , multiethnic population of older adults and to identify factors associated with foot self-care . Methods The Evaluating Long-term Diabetes  Self-management  Among Elder Rural Adults study included a r and om sample of 701 African American , Native American , and white adults from 2 rural North Carolina counties . Participants completed in-home interviews , 5 foot selfcare practice s from the Summary of Diabetes Self-Care Activities ( SDSCA )  , functional status measures , and measures of education and support for foot care . Results Foot care practice s/behaviors reported at least 6 days/week ranged from 35.6 % for inspecting shoes to 79.2 % for not soaking feet . Four independent predictors of the SDSCA summary foot care index score were observed : having been shown how to care for feet ( P < .0001 ) , female gender ( P= .03 ) , having had a doctor check nerves in feet in past year ( P= .02 ) , and not receiving support caring for feet ( P = .0425 ) . Conclusions These findings indicate that educating patients about foot self-care may encourage routine foot care but that those dependent on either formal or informal support to perform foot care do so less frequently than those who perform it independently PURPOSE : To enhance the learner ’s competence with knowledge of the effectiveness of shear-reducing insoles for prevention of foot ulceration in patients with high-risk diabetes . TARGET AUDIENCE : This continuing education activity is intended for physicians and nurses with an interest in skin and wound care . OBJECTIVES : After participating in this educational activity , the participant should be better able to : 1 . Demonstrate knowledge of foot ulceration risk , risk factors , incidence , and prevention . 2 . Apply knowledge gained from review ing this study and a literature review about the use of shear-reducing insoles to patient scenarios . ABSTRACT & NA ; OBJECTIVE : The objective of this study was to evaluate the effectiveness of a shear-reducing insole compared with a st and ard insole design to prevent foot ulceration in high-risk patients with diabetes . RESEARCH DESIGN AND METHODS : A total of 299 patients with diabetic neuropathy and loss of protective sensation , foot deformity , or history of foot ulceration were r and omized into a st and ard therapy group ( n = 150 ) or a shear-reducing insole group ( n = 149 ) . Patients were evaluated for 18 months . St and ard therapy group consisted of therapeutic footwear , diabetic foot education , and regular foot evaluation by a podiatrist . The shear-reducing insole group included a novel insole design ed to reduce both pressure and shear on the sole of the foot . Insoles were replaced every 4 months in both groups . The primary clinical outcome was foot ulceration . The authors used Cox proportional hazards regression to evaluate time to ulceration . RESULTS : There were 2 significant factors from the Cox regression model : insole treatment and history of a foot complication . The st and ard therapy group was about 3.5 times more likely to develop an ulcer compared with shear-reducing insole group ( hazard ratio , 3.47 ; 95 % confidence interval , 0.96–12.67 ) . CONCLUSIONS : These results suggest that a shear-reducing insole is more effective than traditional insoles to prevent foot ulcers in high-risk persons with diabetes Despite the established role of foot care education in diabetes management , reports evaluating such interventions are rare . The effectiveness of an intensive foot care intervention programme and a conventional one were therefore compared in Type 2 diabetes . The intensive group showed significantly greater improvements than the conventional group in foot care knowledge ( p less than 0.001 ) , compliance with the recommended foot care routine ( p = 0.012 ) , and compliance with the initial advice to consult  a podiatrist ( other than the project podiatrist ) for further treatment ( p = 0.008 ) . At the first follow-up visit the intensive group also showed a significantly greater reduction in the number of foot problems requiring treatment than the conventional group PURPOSE The purpose of this study was to evaluate an intensive diabetes foot education program for veterans at high risk for foot ulcer . METHODS We invited 100 consecutive patients with diabetes from a Department of Veterans Affairs Medical Center clinic who were insensate to the Semmes-Weinstein 5.07 monofilament to participate in a foot care education program . Two sessions were conducted by a nurse diabetes educator 3 months apart . Multiple educational approaches were used to teach patients foot self-examination , foot washing , proper footwear , and encouragement in enlisting proper physician foot care . Knowledge and satisfaction with care was measured before and after each visit . RESULTS The 34 patients who attended both education sessions improved their foot care knowledge over the course of the program . After the second session , the mean improvement over baseline was 14 % . These patients also reported improved satisfaction with foot care ; mean improvement was 33 % . CONCLUSIONS An intensive education program improved the foot care knowledge and behavior of high-risk patients . Those who adhered to a foot care education program were more satisfied with their foot care than prior to the program . Ways to improve accessibility of education sessions must be explored INTRODUCTION Diabetic foot ulcers are a feared complication of diabetes . Care delivered via telemedicine is suggested to be a more integrated care pathway to manage diabetic foot ulcers than traditionally delivered healthcare . Our aim was to explore patients ' experiences with telemedicine follow-up care as compared to traditional care . METHODS Interpretive description was used as an analysis strategy . Data were collected using individual semi-structured interviews in the context of a larger ongoing clustered r and omized controlled trial . Twenty-four patients ( 13 in the intervention group ; 11 in the control group ) , aged 38 - 88 years were purposively recruited from the RCT in order to obtain a diverse sample in terms of group composition ( intervention vs. control ) , age , gender , marital status , setting , and comorbidities present . The control group received traditional care . RESULTS Three themes emerged from the interpretive analysis : competence of healthcare professionals , continuity of care , and easy access . This was independed of types of follow-up that had limited impact on the patients ' follow-up experiences . Competence of healthcare professionals and continuity of care were crucial , because they can either enhance or jeopardize wound care . If these two latter factors were absent , patients would lose confidence in the wound care process . If this happened , patients pointed out that the expert knowledge of a specialist clinic was essential to receive good care . When telemedicine functioned optimally , telemedicine was an advantage in the treatment , because the images quickly captured changes in the wound healing that immediately could be corrected . Easy access is important for patients , but the importance of accessibility appears to be primary when the other two factors were present . CONCLUSION The best wound care pathway for patients with diabetes foot ulcers is depended on a combination of competence and professional skills in wound management , and continuity of care . If telemedicine is functioning as intended , it can be an important additional tool Musculoskeletal injuries are a common presentation to the ED , with significant costs involved in the management of these injuries , variances in care within the ED and associated morbidity . A series of rapid review papers were completed to guide best practice for the assessment and management of common musculoskeletal injuries presenting to the ED . This paper presents the methodology used across the rapid review s. PubMed , CINAHL , EMBASE , TRIP and the grey literature , including relevant organisational websites , were search ed in 2015 . The search was repeated consistently for each topic area ( injuries of the foot and ankle , knee , h and and wrist , elbow , shoulder , lumbar spine and cervical spine ) . English- language primary studies , systematic review s and guidelines that were published in the last 10 years and addressed acute musculoskeletal injury management were considered for inclusion . Data extraction of each included article was conducted , followed by a quality appraisal . The extracted data from each article was synthesis ed to group similar evidence together . For each rapid review , the evidence has been organised in a way that a clinician can direct their attention to a specific component of the clinical cycle of care in the ED , such as the assessment , diagnostic tests , management and follow-up considerations from ED . The series of rapid review s are design ed to foster evidence -based practice within the ED , targeting the injuries most commonly presenting . The review s provide clinicians in EDs with rapid access to the best current evidence , which has been synthesis ed and organised to assist decision-making This study investigated the effectiveness of a " h and s-on " foot care teaching/learning approach for adults with diabetes . By r and om assignment , the control group received a lecture presentation on foot care , while the experimental group participated in a h and s-on session on foot care in addition to the lecture presentation . Data concerning the subjects ' foot care knowledge and skills , the condition of their feet , and their level of HbA1c were gathered prior to and six months after the foot care educational sessions . No significant increases in knowledge about foot care were observed in the experimental group . The experimental group reported improvements in inspecting and washing their feet on a daily basis , and in care of the toenails . No significant differences were observed in the status of the subjects ' feet . The HbAlc readings were significantly improved for both the experimental ( t=4.10 , df=10 , p=0.002 ) and control ( t=2.25 , df=9 , p=0.051 ) groups . A h and s-on educational session may improve foot care practice s temporarily . However , long term effects need to be studied to discern overall improvement of foot care practice s and physical status of the feet OBJECTIVE To evaluate the influence of podiatrist activities on the outpatient care of diabetic patients in terms of knowledge of diabetic foot care , self-care , and minor foot problems . RESEARCH DESIGN AND METHODS There were 733 patients , aged 10–79 years , identified from the national diabetes register . Patients without recent visits to a podiatrist and without an obvious need for foot care were r and omized into a podiatric care group ( education and primary prevention measures , n = 267 ) and a control group ( written instructions only , n = 263 ) . The patients were examined by an independent study podiatrist at baseline and after 1 year . RESULTS Patients in the podiatrist group had greater improvement in knowledge of diabetic foot care ( P = 0.004 ) and self-care ( P < 0.001 ) scores compared with control subjects . The prevalence of callosities in regions other than the calcaneal region decreased more ( P = 0.009 ) in the podiatrist group ( from 54.5 to 39.5 % ) than in the control group ( from 51.3 to 48.2 % ) , and the size of the callosities decreased more ( P < 0.001 ) in the podiatrist group than in the control group . Reduction in the prevalence of callosities was associated with younger age ( < 50 years ) . CONCLUSIONS Education and primary preventive measures provided individually by a podiatrist result in significant improvements in knowledge and foot self-care scores and in improvements in the prevalence of some minor foot problems . Long-term studies are needed to evaluate whether the intervention of podiatrists starting at an early phase would lead to a reduction in major foot problems Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system , but prevention thereof receives little attention . For every euro spent on ulcer prevention , ten are spent on ulcer healing , and for every r and omized controlled trial conducted on prevention , ten are conducted on healing . In this article , we argue that a shift in priorities is needed . For the prevention of a first foot ulcer , we need more insight into the effect of interventions and practice s already applied globally in many setting s. This requires systematic recording of interventions and outcomes , and well- design ed r and omized controlled trials that include analysis of cost-effectiveness . After healing of a foot ulcer , the risk of recurrence is high . For the prevention of a recurrent foot ulcer , home monitoring of foot temperature , pressure-relieving therapeutic footwear , and certain surgical interventions prove to be effective . The median effect size found in a total of 23 studies on these interventions is large , over 60 % , and further increases when patients are adherent to treatment . These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach , where attempts are made to assure treatment adherence . Effect sizes of 75 - 80 % may be expected . If such state-of-the-art integrated foot care is implemented , the majority of problems with foot ulcer recurrence in diabetes can be resolved . It is therefore time to act and to set a new target in diabetic foot care . This target is to reduce foot ulcer incidence with at least 75 % BACKGROUND While lower-extremity amputation ( LEA ) is a frequent complication of diabetes , effective strategies for the prevention of LEA in primary care setting s have not been extensively studied . METHODS This prospect i ve study of American Indians with diabetes in a rural primary care clinic was divided into three periods : the st and ard care period ( 1986 to 1989 ) , during which patients received foot care at the discretion of the primary care provider ; the public health period ( 1990 to 1993 ) , during which patients  were screened for foot problems and high-risk individuals received foot care education and protective footwear ; and the Staged Diabetes Management ( SDM ) period ( 1994 to 1996 ) , during which comprehensive guidelines for diabetic foot management were adapted by the primary care clinicians to their practice s and were systematic ally implemented . RESULTS A total of 639 individuals contributed 4322 diabetic person-years during the three periods of observation . Patient sex distribution , mean age , and mean duration of diabetes were similar i the three periods . The average annual LEA incidence was 29/1000 diabetic person-years for the st and ard care period ( n = 42 ) , 21/1000 for the public health period ( n = 33 ) , and 15/1000 for the SDM period ( n = 20 ) , an overall 48 % reduction ( P = .016 ) . Overall , the incidence of a first amputation declined from 21/1000 to 6/1000 ( P < .0001 ) . CONCLUSIONS The customization and systematic implementation of practice guidelines by local primary care providers was associated with improved diabetic foot care outcomes . SDM has relevance to primary care organizations seeking to improve outcomes for patients with diabetes The purpose of this study was to evaluate the effectiveness of the activities of a podiatrist in the outpatient foot care of patients with diabetes . Patients from southwestern Finl and , ages 10 to 80 years , were selected from the national diabetes register . Those without a recent visit to a podiatrist and without any obvious need for foot care ( n=530 ) were r and omized into a podiatric care group ( individual counseling and primary prevention measures , n=267 ) and a control group ( written instructions only , n=263 ) . Knowledge of foot care and self-care habits were evaluated by means of structured interviews , and a podiatric examination  was performed at baseline and 1 and 7 years later . Compared with the baseline scores , the knowledge score was higher at the 7-year follow-up in both the podiatric and control group and similarly in men and women . Self-care score increased in men similarly in both treatment groups . The self-care score for women increased more in the podiatric group during the first year and the difference between the groups remained for up to 7 years . There were no significant differences between the groups in the podiatric findings Background : Plantar fasciitis is a common condition routinely managed by podiatrists in the community and is widely treated conservatively . Two commonly used treatments for plantar fasciitis are customized functional foot orthoses and corticosteroid injections . While common to clinical practice , the evidence base underpinning these treatment strategies is unknown . Therefore , the aim of this systematic review was to assess the effectiveness and safety of customized functional foot orthoses and corticosteroid injections in the treatment of plantar fasciitis . Methods : A systematic literature search was conducted . Experimental studies , in English , from 1998 to 2010 were accepted for inclusion in this review . The PEDro quality assessment tool and the National Health and Medical Research Council ’s hierarchy of evidence were used to assess the quality of the included studies . Results : Six r and omized controlled trials which met the selection criteria were included in this review . Four reported on customized functional foot orthoses and 2 on corticosteroid injections . Current best available evidence highlights that both customized functional foot orthoses and corticosteroid injections can lead to a decrease in pain associated with plantar fasciitis . Additionally , customized functional foot orthoses may also provide an additional benefit in terms of increased functional ability in patients with plantar fasciitis .  Corticosteroid injections may have side effects , especially pain ( from the injection ) . Conclusion : Both customized functional foot orthoses and corticosteroid injections can lead to reduction in pain associated with plantar fasciitis . While customized functional foot orthoses may increase the functional outcomes in patients with plantar fasciitis , corticosteroid injections may have side effects ( especially pain as a result of the injection ) , which may limit its acceptability Given that 14 million Americans have diabetes [ 1 ] , the common complications of this disorder , such as foot ulcers and lower extremity amputations , are of major concern to the medical community . Approximately 20 % of all diabetic patients hospitalized in the United States are admitted because of foot complications [ 2 , 3 ] . Furthermore , about 50 % of all nontraumatic amputations in the United States are done in patients with diabetes [ 1 , 4 ] . This proportion equates to about 55 000 amputations a year [ 1 ] or 59.7 amputations for every 10 000 persons with diabetes [ 5 ] . Patients who undergo an amputation are at greater risk for a second similar procedure on either the same or the other leg [ 6 , 7 ] . Yet , it has been estimated that about one half of the amputations in patients with diabetes , or about one fourth of the total amputations done in the United States , are preventable [ 1 , 4 ] . Recently , the focus has been on preventive strategies that minimize foot damage in diabetic patients and thereby reduce the rates of ulcers and amputations . These preventive strategies are based on two observations : first , that simple efforts on the part of the health care provider or patient can reduce the likelihood of subsequent amputation due to diabetes-associated foot disease [ 8 ] ; and second , that many of these simple procedures are not being systematic ally applied by health care providers or patients [ 9 ] . For example , studies indicate that physicians infrequently examine the feet of patients with diabetes [ 9 , 10 ] . Also , most patients with diabetes do not engage in simple foot-care assessment s to identify lesions requiring early treatment [ 11 ] . Preventive strategies are not systematic ally applied for several reasons : First , patients may not be aware of foot-care procedures or how to do them , or they may not believe that such procedures can make a difference ; second , podiatry and orthopedics services that could assist in foot salvage in diabetic patients may not be available ; and , finally , the health care system may make it difficult for patients or health care providers to examine the feet of patients with diabetes [ 10 ] . Several uncontrolled studies found that implementation of improved foot-care programs can significantly reduce lower extremity complications in patients with diabetes ; these studies showed a 44 % to 85 % reduction in the rate of lower extremity amputations [ 4 , 12 - 14 ] . A recent casecontrol study also supports the implementation of preventive strategies , such as foot care , use of protective footwear , and aggressive treatment of foot  infection by patients or health care providers , to decrease the risk for lower extremity amputation [ 15 ] . The intervention in our study was design ed to reduce the prevalence of risk factors for lower extremity amputations  in patients with noninsulin-dependent diabetes and involved the three major elements of a prevention program : the patient , health care providers , and the health care system . Specifically , we did a r and omized , controlled trial to determine whether a comprehensive foot-care intervention could improve patients ' knowledge and performance of appropriate foot care ; increase the number of referrals to specialty clinics such as the podiatry clinic ; increase the frequency of foot examinations by health care providers and the documentation of risk factors in the medical record ; and improve short-term patient outcomes such as skin and nail conditions known to be risk factors for ulcers and amputations . Methods Setting Our study , the design of which is summarized in Figure 1 , was done from April 1989 to March 1991 in the academic general medicine practice of the Regenstrief Health Center in Indianapolis , Indiana [ 16 ] . The practice is subdivided into four primary care teams ( labeled A , B , C , and D ) , each with its own nursing and clerical staff . Each team sees patients for eight half-day sessions per week , with each session staffed by one or two faculty internists and two to four housestaff . Teams A and C were r and omly assigned to the intervention group ; teams B and D were assigned to the control group . Previous studies in which this method of r and omization was used have shown no baseline interteam differences in patient characteristics and physician practice behavior and no effect of the team on the study outcome [ 16 - 19 ] . Figure 1 . Summary of the study design . Patient Identification and Recruitment The computerized Regenstrief Medical Record System [ 20 ] was used to identify approximately 3000 patients with noninsulin-dependent diabetes , as well as the date and time of their next appointment . Only patients with noninsulin-dependent diabetes who were seen at least two times in the preceding year by the same provider were included in the study . Additional criteria for inclusion were as follows : an age greater than 40 years ; a diagnosis of diabetes after 30 years of age ; a diagnosis of diabetes based on National Diabetes Data Group criteria [ 21 ] or the presence of disease requiring medication for the control of hyperglycemia ; an intention to obtain care at the general medicine practice for the next 2 years ; and a body weight that was either ideal or heavier than ideal . Exclusion criteria included pregnancy ; major psychiatric illness , including dementia ; terminal illness likely to cause death within 1 year ; renal failure ( serum creatinine > 440 mol/L ) ; previous bilateral amputations above or below the knee ; or an inability to provide any self-care . Patients of investigators involved in the protocol were also excluded from the study . Of the 728 eligible patients , 244 refused to participate , 89 enrolled in the study but failed to keep their appointments for assessment , and 395 were assessed by trained nurse-clinicians . Of the 395 patients assessed , 352 ( 89 % ) completed the study ; 43 patients ( 11 % ) did not complete the study for the following reasons : death ( 11 patients ) ; change of residence ( 15 patients ) ; illness ( 6 patients ) ; transportation problems ( 3 patients ) ; and miscellaneous reasons ( 8 patients ) . Patient Assessment Sample s for determining fasting plasma glucose , cholesterol , triglyceride , high-density lipoprotein , hemoglobin A1C , and C-peptide levels were obtained from enrolled patients and immediately transported to a certified laboratory for analysis . Patients gave a history and had a physical examination at study entry and approximately 1 year later ( mean , 11.8 1.5 months ) . These examinations focused on risk factors for amputation and were administered by two trained nurse-clinicians who were blinded to the patients ' experimental conditions . Foot-related data derived from the history and physical examination included the patient 's self-reported foot-care behaviors ; the quality of the patient 's examination of his or her feet ; the severity of any foot lesions ; and the presence of musculoskeletal abnormalities , dermatologic conditions , peripheral vascular disease , and peripheral neuropathy ( the neuropathy assessment included quantitative measures of pressure and temperature sensation ) . Patients were question ed about their regular foot-care routine and were asked to show how they examined their feet . During this self-examination , nurse-clinicians observed whether patients ' scrutinized the toenails , the soles of the feet , and the area between toes . Musculoskeletal and dermatologic abnormalities were assessed using st and ard definitions of findings such as callus , hammer toe , and Charcot foot [ 3 , 22 ] . The nurse-clinicians palpated the dorsalis pedis , posterior tibial , and femoral pulses bilaterally in their assessment for peripheral vascular disease . If a pulse was absent at any one of the six sites palpated , the assessment was considered abnormal . Foot lesions were rated for severity using the Seattle Wound Classification System [ 23 ] , which ranges from a grade of 1.1 ( absence of lesions ) to a grade of 10 ( entire foot or leg is gangrenous ) . In our study , a foot lesion was defined as any wound , with or without functional interruption of the protective cutaneous barrier , ranging from a superficial scratch to an ulcer involving the epidermis . A serious foot lesion was defined by a severity grade of at least 1.3 , which indicates a minor , nonulcerated lesion with clinical evidence of healing sufficient to close previous interruption of the cutaneous barrier [ 23 ] or a blister . Pressure and temperature sensations were measured using the 5.07-log ( 0.1 mg)-force Semmes-Weinstein monofilament and the thermal sensitivity testing apparatus , according to st and ard techniques [ 24 - 26 ] . Thermal sensitivity was considered abnormal if the patient had a value greater than 2 st and ard deviations from the mean value for a group of healthy persons without diabetes ( warm > 2.04 C ; cool > 1.58 C ) . Practice Patterns of Health Care Providers Immediately after each scheduled visit , study patients had a structured interview [ 10 ] with a research assistant , who asked about foot self-examination and foot-care education given by health care providers ( the primary care physician or nursing personnel ) . In addition , a chart audit was conducted by a nurse-clinician who was blinded to the patients ' experimental condition . Information abstract ed from the medical record included the physician 's documentation of the findings from the history and physical examination ; any referral to podiatry , orthopedics , or vascular surgery clinics ; and diagnostic-test ordering related to the evaluation and treatment of diabetes-associated foot problems . Intervention The intervention cohort was exposed to several risk-reduction strategies . The nurse-clinicians conducted the patient education session with one to four patients , covering appropriate foot-care behaviors and footwear , using a commercially available slide and audiotape presentation [ 27 ] and pamphlets [ 28 ] . Behavioral contracts regarding desired foot-care behaviors were negotiated with each patient . Follow-up was done by telephone 2 weeks after the education sessions to remind patients This quasi-experimental pilot study used a convenience sample of 23 adult men and women with either Type 1 or Type 2 diabetes who received hemodialysis three times a week . The experimental group received a four-part intervention that included individual and group foot care education , foot assessment , and special shoes . Pre- and posttesting of foot care knowledge was done using the Siriraj question naire . Out of a possible score of 20 , those in the experimental group had a mean score of 15.3 versus 14.33 in the control group on the posttest . The nephrology nurse has the opportunity to play a role in early detection and intervention in clients with ESRD Participants who received Pies Sanos , a 15-min intervention design ed to improve diabetes self-efficacy and foot self-care behaviors in adult patients with type 2 diabetes who lived in a predominantly Mexican American community , performed more-complete foot self-care 1 month later in their homes . Recruited when they presented for nonurgent care to the emergency department in two community hospitals near the U.S .— Mexico border , participants were r and omized into one of three groups . At follow-up , there was a significant difference in observed foot self-care behaviors between groups , F(2 , 135 ) = 2.99 , p < .05 , as well as a significant difference within the intervention , t ( 47 ) = −4.32 , p < .01 , and control group , t ( 46 ) = −2.06 , p < .05 , for baseline and follow-up self-reported foot self-care behaviors . Baseline diabetes self-efficacy was significantly and positively correlated with both baseline ( r = .335 , p < .001 ) and follow-up ( r = .174 , p < .05 ) foot self-care behaviors UNLABELLED In August 2008 , the Medical Advisory Secretariat ( MAS ) presented a vignette to the Ontario Health Technology Advisory Committee ( OHTAC ) on a proposed targeted health care delivery model for chronic care . The proposed model was defined as multidisciplinary , ambulatory , community-based care that bridged the gap between primary and tertiary care , and was intended for individuals with a chronic disease who were at risk of a hospital admission or emergency department visit . The goals of this care model were thought to include : the prevention of emergency department visits , a reduction in hospital admissions and re-admissions , facilitation of earlier hospital discharge , a reduction or delay in long-term care admissions , and an improvement in mortality and other disease-specific patient outcomes .OHTAC approved the development of an evidence -based assessment to determine the effectiveness of specialized community based care for the management of  heart failure , Type 2 diabetes and chronic wounds .  PLEASE VISIT THE MEDICAL ADVISORY SECRETARIAT WEB SITE AT : www.health.gov.on.ca/ohtas to review the following reports associated with the Specialized Multidisciplinary Community-Based care series . Specialized multidisciplinary community-based care series : a summary of evidence -based analysesCommunity-based care for the specialized management of heart failure : an evidence -based analysis Community-based care for chronic wound management : an evidence -based analysis Please note that the evidence -based analysis of specialized community-based care for the management of diabetes titled : " Community-based care for the management of type 2 diabetes : an evidence -based analysis " has been published as part of the Diabetes Strategy Evidence Platform at this URL : http://www.health.gov.on.ca/english/providers/program/mas/tech/ohtas/tech_diabetes_20091020.htmlPLEASE VISIT THE TORONTO HEALTH ECONOMICS AND TECHNOLOGY ASSESSMENT COLLABORATIVE WEB SITE AT : http://theta.utoronto.ca/papers/MAS_CHF_Clinics_Report.pdf to review the following economic project associated with this series : Community-based Care for the specialized management of heart failure : a cost-effectiveness and budget impact analysis . OBJECTIVE The objective of this evidence -based review is to determine the effectiveness of a multidisciplinary wound care team for the management of chronic wounds . CLINICAL NEED CONDITION AND TARGET POPULATION Chronic wounds develop from various aetiologies including pressure , diabetes , venous pathology , and surgery . A pressure ulcer is defined as a localized injury to the skin/ and or underlying tissue occurring most often over a bony prominence and caused , alone or in combination , by pressure , shear , or friction . Up to three fifths of venous leg ulcers are due to venous aetiology . Approximately 1.5 million Ontarians will sustain a pressure ulcer , 111,000 will develop a diabetic foot ulcer , and between 80,000 and 130,000 will develop a venous leg ulcer . Up to 65 % of those afflicted by chronic leg ulcers report experiencing decreased quality of life , restricted mobility , anxiety , depression , and /or severe or continuous pain . MULTIDISCIPLINARY WOUND CARE TEAMS : The term ' multidisciplinary ' refers to multiple disciplines on a team and ' interdisciplinary ' to such a team functioning in a coordinated and collaborative manner . There is general consensus that a group of multidisciplinary professionals is necessary for optimum specialist management of chronic wounds stemming from all aetiologies . However , there is little evidence to guide the decision of which professionals might be needed form an optimal wound care team . EVIDENCE -BASED ANALYSIS METHODS LITERATURE SEARCH A literature search was performed on July 7 , 2009 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , OVID EMBASE , Wiley Cochrane , Centre for Review s and Dissemination/International Agency for Health Technology Assessment , and on July 13 , 2009 using the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , and the International Agency for Health Technology Assessment ( INAHTA ) for studies pertaining to leg and foot ulcers . A similar literature search was conducted on July 29 ' 2009 for studies pertaining to pressure ulcers . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with an unknown eligibility were review ed with a second clinical epidemiologist and then a group of epidemiologists until consensus was established . INCLUSION CRITERIA R and omized controlled trials and Controlled clinical Trials ( CCT ) Systematic review with meta analysis Population includes persons with pressure ulcers ( anywhere ) and /or leg and foot ulcersThe intervention includes a multidisciplinary ( two or more disciplines ) wound care team . The control group does not receive care by a wound care team Studies published in the English language between 2004 and 2009 EXCLUSION CRITERIA : Single centre retrospective observational studies OUTCOMES OF INTEREST Proportion of persons and /or wounds completely healedTime to complete healing Quality of LifePain assessment SUMMARY OF FINDINGS Two studies met the inclusion and exclusion criteria , one a r and omized controlled trial ( RCT ) , the other a CCT using a before and after study design . There was variation in the setting , composition of the wound care team , outcome measures , and follow up periods between the studies . In both studies , however , the wound care team members received training in wound care management and followed a wound care management protocol . In the RCT , Vu et al. reported a non-significant difference between the proportion of wounds healed in 6 months using a univariate analysis ( 61.7 % for treatment vs. 52.5 % for control ; p=0.074 , RR=1.19 ) There was also a non-significant difference in the mean time to healing in days ( 82 for treatment vs. 101 for control ; p=0.095 ) . More persons in the intervention group had a Brief Pain Inventory ( BPI ) score equal to zero ( better pain control ) at 6 months when compared with the control group ( 38.6 % for intervention vs. 24.4 % for control ; p=0.017 , RR=1.58 ) . By multivariate analysis a statistically significant hazard ratio was reported in the intervention group ( 1.73 , 95 % CI 1.20 - 1.50 ; p=0.003 ) . In the CCT , Harrison et al. reported a statistically significant difference in healing rates between the pre ( control ) and post ( intervention ) phases of the study . Of patients in the pre phase , 23 % had healed ulcers 3 months after study enrolment , whereas 56 % were healed in the post phase ( P<0.001 , OR=4.17 ) ( Figure 3 ) . Furthermore , 27 % of patients were treated daily or more often in the pre phase whereas only 6 % were treated at this frequency in the post phase ( P<0.001 ) , equal to a 34 % relative risk reduction in frequency of daily treatments . The authors did not report the results of pain relief assessment . The body of evidence was assessed using the GRADE methodology for 4 outcomes : proportion of wounds healed , proportion of persons with healed wounds , wound associated pain relief , and proportion of persons needing daily wound treatments . In general , the evidence was found to be low to very low quality . CONCLUSION The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared to persons not managed by a wound care team . The quality of evidence supporting these outcomes is low to very low meaning that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate BACKGROUND CONTEXT A variety of self-report and physical performance-based outcome measures are commonly used to assess progress and recovery in the lower leg , ankle , and foot . A requisite attribute of any outcome measure is its ability to detect change in a condition , a construct known as " responsiveness " . There is a lack of consistency in how responsiveness is defined in all outcome measures . PURPOSE The purpose of this study was to review the currently used recovery outcome measures for lower leg , ankle and foot conditions in order to determine and report recommended responsiveness values . METHODS A systematic literature search that included electronic search es of PubMed , CINAHL and SportD iscus as well extensive cross-referencing was performed in January , 2013 . Studies were included if each involved : 1 ) a prospect i ve , longitudinal study of any design ; 2 ) any condition associated with the lower leg , ankle or foot ; 3 ) a measure of responsiveness ; and 4 ) was an acceptable type of outcome measure ( eg . self-report , physical performance , or clinician report ) . The quality of the included articles was assessed by two independent authors using the responsiveness sub-component of the Consensus-based St and ards for the selection of health Measurement Instruments ( COSMIN ) . RESULTS Sixteen different studies met the inclusion criteria for this systematic review . The most commonly used outcome measures were the Foot and Ankle Ability Measure and the Lower Extremity Functional Scale . Responsiveness was calculated in a variety of methods including effect size , st and ardized response mean , minimal clinical ly important difference/ importance , minimal detectable change , and minimal important change . CONCLUSION Based on the findings of this systematic review there is a lack of consistency for reporting responsiveness among recovery measures used in the lower leg , ankle or foot studies . It is possible that the variability of conditions that involve the lower leg , ankle and foot contribute to the discrepancies found in reporting responsiveness values . Further research must be conducted in order to st and ardize reporting measures for responsiveness . LEVEL OF EVIDENCE 2a Abstract BACKGROUND : The established guidelines for a diabetes foot examination include assessing circulatory , skin , and neurological status to detect problems early and reduce the like-lihood of amputation . Physician adherence to the guidelines for proper examination is less than optimal . OBJECTIVE : Our objective was to increase compliance with the performance of a  proper foot examination  through a predominantly physician-directed interventional campaign . METHODS : The study consisted of 3 parts : a retrospective chart review to estimate background compliance , an educational intervention , and prospect i ve chart review at 3 and 6 months . A properly documented foot examination was defined as assessing at least 2 of the 3 necessary components . The educational intervention consisted of 2 lectures directed at resident physicians and a quality assurance announcement at a general internal medicine staff meeting . Clinic support staff were instructed to remove the shoes and socks of all diabetic patients when they were placed in exam rooms , and signs remiding diabetics were placed in each exam room . RESULTS : There was a significant increase in the performance of proper foot examination  over the course of the study ( baseline 14.0 % , 3 months 58.0 % , 6 months 62.1 % ; P<.001 ) . Documentation of any component of a proper foot examination also increased substantially ( 32.6 % , 67.3 % , 72.5 % ; P<.001 ) . Additionally , performance of each component of a proper exam increased dramatically during the study : neurological ( 13.5 % , 35.8 % , 38.5 % ; P<.001 ) , skin ( 23.0 % , 64.2 % , 69.2 % ; P<.001 ) , and vascular ( 14.0 % , 51.2 % , 50.5 % ; P<.001 ) . CONCLUSIONS : Patients with diabetes are unlikely to have foot examinations in their primary medical care . A simple , lowcost educational intervention significantly improved the adherence to foot examination guidelines for patients with diabetes INTRODUCTION Soft tissue injuries of the leg , ankle , or foot are common and often treated by exercise . The purpose of this study was to determine the effectiveness of  exercise  for the management of soft tissue injuries of the leg , ankle , or foot . METHODS A systematic review of the literature was conducted . We search ed five data bases from 1990 to 2015 . Relevant articles were critically appraised using Scottish Intercollegiate Guidelines Network ( SIGN ) criteria . The evidence from studies with low risk of bias was synthesized using the best- evidence synthesis methodology . RESULTS We screened 7946 articles . We critically appraised ten r and omized trials and six had a low risk of bias . The evidence suggests that for recent lateral ankle sprain : 1 ) rehabilitation exercises initiated immediately post-injury are as effective as a similar program initiated one week post-injury ; and 2 ) supervised progressive exercise plus education/advice and home exercise lead to similar outcomes as education/advice and home exercise . Eccentric exercises may be more effective than an AirHeel brace but less effective than acupuncture for Achilles tendinopathy of more than two months duration . Finally , for plantar heel pain , static stretching of the calf muscles and sham ultrasound lead to similar outcomes , while static plantar fascia stretching provides short-term benefits compared to shockwave therapy . CONCLUSIONS We found little evidence to support the use of early or supervised exercise interventions for lateral ankle sprains . Eccentric exercises may provide short-term benefits over a brace for persistent Achilles tendinopathy and plantar fascia stretching provides short-term benefits for plantar heel pain It should now be possible to achieve a reduction in the incidence of foot ulceration and amputations  as knowledge about pathways that result in both these events increases . However , despite the universal use of patient education and the hope of reducing the incidence of ulcers in high-risk patients , there are no appropriately design ed large , r and omized controlled trials actually confirming that education works . It has been recognized for some years that education as part of a multidisciplinary approach to care of the diabetic foot can help to reduce the incidence of amputations in certain setting s. Ultimately , however , a reduction in neuropathic foot problems will only be achieved if we remember that the patients with neuropathic feet have lost their prime warning signal — pain — that ordinarily brings patients to their doctor . Very little training is offered to health care professionals as to how to deal with such patients . Much can be learned about the management of such patients from the treatment of individuals with leprosy : if we are to succeed , we must realize that with loss of pain there is also diminished motivation in the healing of and prevention of injury OBJECTIVE To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practice s. RESEARCH DESIGN AND METHODS Nine practice s providing care to managed care patients were r and omly assigned as intervention or comparison sites . Intervention-site subjects had Annual Diabetes Assessment Program ( ADAP ) assessment s ( HbA(1c  ) , blood pressure , lipids , smoking , retinal photos , urine microalbumin , and foot examination ) at years 1 and 2 . Comparison-site subjects had ADAP assessment s at year 2 . At Intervention sites , year 1 ADAP results were review ed with subjects , mailed to providers , and incorporated into electronic medical records with guideline -generated suggestions for treatment and follow-up . Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessment s. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models . RESULTS Of 284 eligible subjects , 103 of 173 ( 60 % ) at the Intervention sites and 71 of 111 ( 64 % ) at the comparison sites participated ; 83 of 103 ( 81 % ) of the intervention-site subjects returned for follow-up at year 2 . Performance of the six recommended assessment s improved in intervention-site subjects at year 2 compared with year 1 ( 5.8 vs. 4.3 , P = 0.0001 ) and compared with comparison-site subjects at year 2 ( 4.2 , P = 0.014 ) . No significant changes were noted in intermediate outcomes . CONCLUSIONS The ADAP significantly improved processes of care but not intermediate outcomes . Additional interventions are needed to improve intermediate outcomes
Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practice s. Conclusion Preventing these complications , underst and ing the risk factors , and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program .
Introduction The purpose of this systematic literature review is to review published studies on foot care knowledge and foot care practice interventions as part of diabetic foot care self-management interventions .