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  • 1.
    Alnemo, John
    et al.
    Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences. University Health Care Research Center.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. 1Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications2019In: 8th International symposium on diabetic foot: Absttaract book, 2019, p. 117-117, article id P35.05Conference paper (Other academic)
    Abstract [en]

    Background: Therapeutic shoes can prevent diabetic foot reulcerations but their use is complicated by the fact that shoes have psychological and social meanings, which is believed to put a larger burden on women than men. The aim was to compare attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications.

    Methods: A questionnaire was posted to 1230 people with diabetes who had been fitted with therapeutic shoes. Women's and men's answers were compared using t-tests, Mann-Whitney U tests and chi-square tests with Fischer's exact tests. P-values < 0.05 were considered statistically significant.

    Results: Questionnaires from 443 (36.0%) respondents (294 men, 149 women, mean age 69.2 years) were analyzed. More men than women (p < 0.05) had paid employment (20.4% vs 9.4%), had someone who reminded them to wear their therapeutic shoes (27.6% vs 10.0%), and had a history of foot ulcers (62.9% vs 46.3%) or minor amputation (17.7% vs 6.7%). More women than men received disability pension (18.8% vs 10.2%). Women reported worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes to the appearance and price of therapeutic shoes and how they felt about wearing them in public. Other comparisons were non-significant: other shoe attributes, education, diabetes type, current foot ulcers, major amputations, satisfaction with shoe services, understanding of neuropathy as a risk factor, locus of control regarding ulcer healing, belief in the shoes' efficacy to prevent and heal ulcers, worries about ulcer healing and new ulcerations, self-efficacy, depression, shoe use/adherence, paying a fee for therapeutic shoes, and social support.

    Conclusions: Men had worse foot complications. Women had worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes toward therapeutic shoes. Clinicians should pay more attention to their female patients' concerns. Future research and development should focus on improving the weight and appearance of therapeutic shoes, particularly for women. Research is also needed on how to facilitate the adaption and reevaluation process where patients change from viewing shoes purely as items of clothing to also viewing them as medical interventions

  • 2.
    Alnemo, John
    et al.
    Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences. University Health Care Research Center.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics.
    Are the left and right limbs unequally affected by diabetic foot complications?2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 140-140, article id P45.04Conference paper (Other academic)
    Abstract [en]

    Aim: There is some debate about laterality for diabetic foot complications, that is, whether the right and left limbs are unequally affected. Coxon and Gallen (1) found that more amputations were performed on the right limb and Evans et al. (2) interpreted this in the context of foot dominance: they found that most foot ulcers occured on the dominant limb (which for most people is the right one) and speculated that the dominant limb may be more exposed to mechanical stresses and injuries. However, Demetriou et al. (3) did not find any laterality in foot ulcer location. The aim was to investigate laterality for foot ulcers and amputations. Methods: A questionnaire was posted to 1245 people who had diabetes, experience of using therapeutic shoes, and who had attended one of two prosthetics and orthotics clinics during a 12 months’ period. The number of ulcers or amputations on the right and left limb were compared with a two-sided chi-square test. Results: 469 (37.7%) questionnaires were returned. 118 (25.2%) participants reported unilateral foot ulcers, 54 (11.5%) reported unilateral minor amputation, and 21 (4.5%) reported unilateral major amputation. There was no statistically significant right-left difference in foot ulcers, minor amputations or major amputations (Table 1, p-values 0.713-1.000). Conclusions: Our results do not support the hypothesis about laterality for foot ulcers and amputations.

  • 3. Alnemo, John
    et al.
    Tranberg, Roy
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Are the left and right limbs unequally affected by diabetic foot complications?2019Conference paper (Other academic)
  • 4.
    Amer, Ahmed
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden.
    Jarl, Gustav M
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro County Council, Örebro, Sweden.
    Hermansson, Liselotte M. N.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro County Council, Örebro, Sweden.
    The effect of insoles on foot pain and daily activities2014In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 38, no 6, p. 474-480Article in journal (Other academic)
    Abstract [en]

    BACKGROUND:

    Foot pain decreases individuals' ability to perform daily activities. Insoles are often prescribed to reduce the pain which, in turn, may promote return to normal activities.

    OBJECTIVES:

    To evaluate the effects of insoles on foot pain and daily activities, and to investigate the relationship between individuals' satisfaction with insoles and actual use of them.

    STUDY DESIGN:

    A 4-week pre-post intervention follow-up.

    METHODS:

    Brief Pain Inventory, International Physical Activity Questionnaire and Lower Extremities Functional Status were used as outcome measures. Client Satisfaction with Device was used in the follow-up.

    RESULTS:

    A total of 67 participants answered the questionnaires (81% women). Overall, a reduction in Pain Severity (p = 0.002) and Pain Interference (p = 0.008) was shown. Secondary analyses revealed a significant effect only in women. No changes in daily activities (Walking, p = 0.867; Total Physical Activity, p = 0.842; Lower Extremities Functional Status, p = 0.939) could be seen. There was no relation between Client Satisfaction with Device measures and duration of insole use. A difference in sex was shown; women scored higher than men on Pain Severity.

    CONCLUSION:

    Insoles reduce pain and pain interference with daily activities for women with foot pain. Satisfaction with the insoles is not a predictor of actual insole use. The effect of insoles on activity performance needs further study.

    CLINICAL RELEVANCE:

    This study provides evidence for prescribing insoles to people with foot pain. Nonetheless, insoles are not enough to increase their physical activity level in the short term. Satisfaction with insoles and duration of use are not correlated and cannot be inferred from each other.

  • 5.
    Amer, Ahmed
    et al.
    University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Kakooza-Mwesige, A.
    Department of Paediatrics & Child Health, Makerere University College of Health Sciences, Kampala, Uganda; Mulago Hospital, Kampala, Uganda; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Center, Region Örebro County, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    Tumwine, J. K.
    Department of Paediatrics & Child Health, Makerere University College of Health Sciences, Kampala, Uganda; Mulago Hospital, Kampala, Uganda.
    Forssberg, H.
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Eliasson, A.-C.
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Hermansson, Liselotte
    Örebro University, School of Health Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    The Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG). Part II: Psychometric properties2018In: Child Care Health and Development, ISSN 0305-1862, E-ISSN 1365-2214, Vol. 44, no 4, p. 562-571Article in journal (Refereed)
    Abstract [en]

    Background: The Pediatric Evaluation of Disability Inventory (PEDI) has been recommended as a gold standard in paediatric rehabilitation. A Ugandan version of PEDI (PEDI-UG) has been developed by culturally adapting and translating the original PEDI. The aim of this study was to investigate the psychometric properties of the PEDI-UG in Ugandan children by testing the instrument's rating scale functioning, internal structure, and test-retest reliability.

    Methods: Two hundred forty-nine Ugandan children (125 girls) aged 6 months to 7.5 years (Mean = 3.4, SD = 1.9) with typical development were tested using the PEDI-UG. Forty-nine children were tested twice to assess test-retest reliability. Validity was investigated by Rasch analysis and reliability by intraclass correlation coefficient.

    Results: The PEDI-UG domains showed good unidimensionality based on principal component analysis of residuals. Most activities (95%) showed acceptable fit to the Rasch model. Six misfit items were deleted from the Functional Skills scales and one from the Caregiver Assistance scales. The category steps on the Caregiver Assistance scales' rating scale were reversed but functioned well when changed from a 6-point to 4-point rating scale. The reliability was excellent; intraclass correlation coefficient was 0.87-0.92 for the domains of the Functional Skills scales and 0.86-0.88 for the domains of the Caregiver Assistance scales.

    Conclusion: The PEDI-UG has good to excellent psychometric properties and provides a valid measure of the functional performance of typically developing children from the age of 6 months to 7.5 years in Uganda. Further analysis of all items, including misfit and deleted items, in children with functional disability is recommended.

  • 6.
    Bus, Sicco A.
    et al.
    Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
    Armstrong, David G.
    Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California, US.
    Gooday, Catherine
    Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK; School of Health Sciences, University of East Anglia, Norwich, UK.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Caravaggi, Carlo
    Diabetic Foot Department, IRCCS Multimedica Group, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
    Viswanathan, Vijay
    MV Hospital for Diabetes, Chennai, India.
    Lazzarini, Peter A.
    School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia; Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia.
    International Working Group on the Diabetic Foot, (IWGDF)
    Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)2020In: Diabetes/Metabolism Research Reviews, ISSN 1520-7552, E-ISSN 1520-7560, Vol. 36, no Suppl 1, article id e3274Article in journal (Refereed)
    Abstract [en]

    The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

  • 7.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Changing concepts–changing minds: Ulysses contracts in the treatment of diabetic foot ulcers with non-removable offloading devices2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 89-89, article id P24.02Conference paper (Other academic)
    Abstract [en]

    Aim: To change concepts is important to change how clinicians and patients conceptualize and act on diabetic foot disease. Different concepts have been introduced for different purposes, e.g., “diabetic foot attack” to emphasize urgency (1), “in remission” to emphasize the high risk of reulceration (2), and “latent diabetic foot disease” to emphasize diabetic foot disease as a single process, encompassing both active and latent phases (3). The aim was to review and discuss conceptualizations of treatment with non-removable offloading devices.

    Methods: Review and analysis of literature.

    Results: The “forced compliance” concept has been used to denote the use of non-removable offloading devices as a means to secure a high level of compliance/adherence (4). However, this concept may be inappropriate for two reasons. First, the concept has a paternalistic connotation of patients obeying doctors, which is not compatible with viewing patients as partners in decision making. Second, the concept conveys the meaning of doctors as being active (“forcing” compliance) and patients as being passive (being “forced”). Although these connotations are unintended they still may counteract the active and long-term personal responsibility for self-care that we wish to stimulate in our patients. “Ulysses contracts” (originating from Homer’s Odyssey) denote freely made decisions that bind the person in the future. Conceptualizing non-removable offloading devices as Ulysses contracts rather than means to force compliance has two advantages. First, Ulysses contracts emphasize that patients make choices by free will. Second, the “forcing” (i.e., eliminating the alternative to be non-compliant/adherent in the future) does not happen between the doctor and patient, but between the patient’s current and future self. Hence, the patient remains an active and responsible agent during the treatment period which hopefully will spill over into the in remission periods, when removable devices are used and personal responsibility for adherence is crucial.

    Conclusions: Ulysses contracts could be a viable way to conceptualize treatment with non-removable offloading devices.

  • 8.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics.
    Commitment devices in the treatment of diabetic foot ulcers2019In: Journal of Foot and Ankle Research, ISSN 1757-1146, Vol. 12, no 1, article id 44Article in journal (Refereed)
    Abstract [en]

    Background: Non-removable offloading devices are recommended for the treatment of uncomplicated plantar diabetic foot ulcers because adherence to using removable devices is low. However, patients may not always understand how crucial the non-removability is to ulcer healing, leaving them with the impression that it is the device per se that heals the ulcer. Thus, after ulcer healing when patients return to using removable offloading devices, typically therapeutic footwear, they often return to a low level of adherence resulting in high reulceration rates. To change this pattern of behavior based on a misconception, we need to start with how we as clinicians are conceptualizing treatment with offloading devices.

    Non-removable offloading devices as commitment devices: Commitment devices are voluntary restrictions people put on their future selves to resist short-term temptations and achieve long-term goals. In this paper, it is suggested that a change from viewing non-removable offloading devices as means to force compliance, to viewing them as commitment devices could facilitate a change to a clinical thinking that emphasizes the importance of high adherence without compromising respect for patient autonomy.

    Conclusion: Viewing non-removable offloading devices as commitment devices seems to be a promising approach to emphasize the importance of adherence while respecting patient autonomy. Hopefully, patients' higher appreciation of the role of adherence can lead to higher adherence to using therapeutic footwear after healing and consequently to reduced reulceration rates.

  • 9.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Decision trees for risk stratification of the diabetic foot2018In: The Diabetic foot journal, ISSN 1462-2041, Vol. 21, no 4, p. 218-223Article in journal (Refereed)
    Abstract [en]

    Delays in referral from primary to specialist care are a common issue in the clinical management of diabetic foot (DF) disease and are associated with worse clinical outcomes. One of the reasons for the delays may be the complexity of risk stratification, which can leave clinicians who are not specialised in the DF uncertain about when to refer patients for specialist assessment. This article illustrates how risk stratification can be simplified with the use of decision trees. Two decision trees are given as examples: one based on the risk stratification system of the Scottish Diabetes Foot Action Group and one based on the National Institute for Health and Care Excellence guideline. Decision trees can be used to facilitate correct risk stratifications and the referral of people with DF complications, and thereby hopefully contribute to improved outcomes for people with DF disease.

  • 10.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Decision trees to facilitate risk stratification of the diabetic foot2019In: 8th International Symposium on diabetic foot: Abstract book, 2019, p. 72-72, article id P16.06Conference paper (Other academic)
    Abstract [en]

    Aim: Delays in referrals from primary care to specialist care clinics are a common issue in the clinical management of diabetic foot disease and are associated with worse clinical outcomes in terms of ulcer healing and major amputations (1-3). One reasons for the delays may be the complexity of risk stratification; a number of different risk factors, such as foot deformity, neuropathy and peripheral arterial disease, interact and influence the risk of developing diabetic foot complications. The aim was to illustrate how decision trees can be constructed to facilitate risk stratification.

    Methods: A decision tree (4) was created based on the risk stratification described in the guideline document by the National Institute for Health and Care Excellence (NICE) (5).

    Results: With the help of the decision tree in Figure 1, clinicians without specialised knowledge in diabetic foot disease can stratify all diabetic feet with only four decision points or less. This could facilitate accurate risk stratification and timely referral of patients.

    Conclusions: Even complex risk stratifications as the one described by NICE can be transformed into simple decision trees for use in busy clinics. Future studies should investigate whether the use of decision trees lead to more accurate risk stratifications and referrals, improving the outcomes for people with diabetic foot disease.

  • 11.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro, University, Örebro, Sweden.
    Is it necessary to restrict weight-bearing physical activity during treatment of diabetic foot ulcers?2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 108-108, article id P32.02Conference paper (Other academic)
    Abstract [en]

    Aim: Patients are often instructed to reduce their weight-bearing physical activity to promote healing of plantar foot ulcers, even when appropriate offloading devices are used. This limits working ability and daily activities but it is not clear whether this contributes to ulcer healing. The aim was to investigate whether reduced weight-bearing physical activity contributes to ulcer healing when offloading devices are used.

    Methods: A literature review was conducted.

    Results: Three studies, published in four articles, were identified (Table 1). Saltzman et al. (1) found that taking more steps prolonged the time to ulcer healing, but the effect seemed rather small. Najafi et al. (2) found a negative correlation between step count and ulcer healing rate, but no correlation between standing time and healing rate. Crews/Vileikyte et al. (3,4) found no effect of number of steps taken on ulcer size after 6 weeks of treatment.

    Conclusions: There is limited evidence for recommending patients who use offloading devices to reduce weight-bearing physical activity to promote healing of plantar foot ulcers. Two out of three studies found a negative association between step count and ulcer healing but the clinical significance of this is uncertain. Future studies should investigate the effects of reducing weight-bearing physical activity from a broader perspective, including effects on ulcer healing, daily activities, health, and well-being.

  • 12.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics.
    Methodological considerations of investigating adherence to using offloading devices among people with diabetes2018In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 12, p. 1767-1775Article in journal (Refereed)
    Abstract [en]

    Foot ulcers are a diabetic complication associated with significant morbidity, mortality, and amputation risk. Offloading devices prevent and heal foot ulcers, but adherence to using these devices is low. The reasons for nonadherence are unclear, and study results are difficult to compare due to methodological heterogeneity. This paper explores aspects of investigating adherence to using offloading devices among people with diabetes and provides recommendations for future studies, focusing on study designs, definitions of adherence, measurement methods, and conceptual frameworks. Most studies use a cross-sectional observational study design, limiting the potential to establish the temporal sequence between predictors and adherence, rule out confounding factors, and establish causality. Studies defining adherence as the length of time the device is worn have often used self-report to measure adherence, which may be unreliable. Studies using activity monitors to measure adherence have defined adherence as the number of steps taken with the device, which excludes weight-bearing activities where no steps are taken. Conceptual frameworks are not made explicit in the current quantitative research. It is concluded that future studies should use a longitudinal design with observational studies to identify patient groups prone to nonadherence and factors that influence adherence and experimental studies to evaluate interventions to improve adherence, focusing on these patient groups and factors. Furthermore, adherence should be defined in terms of relative adherence to using offloading devices during all weight-bearing activities, and objective measurement of adherence ( using accelerometers and temperature monitors) should be used whenever possible. Clearly defined conceptual frameworks should guide the choice of factors to include in the study and the analysis of their interactions. By implementing these recommendations, research could provide a stronger evidence base in the future, supporting interventions to increase adherence and thereby improve outcomes for people with diabetic foot complications.

  • 13.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Methodological considerations of investigating adherence to using offloading devices among people with diabetic foot complications2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 90-90, article id P24.04Conference paper (Other academic)
    Abstract [en]

    Aim: Adherence to using offloading devices is often low (1) and studies on adherence are difficult to compare due to methodological heterogeneity. The aim was to explore aspects of investigating adherence and provide recommendations for future studies.

    Methods: A literature review was conducted of quantitative studies focusing on study designs, definitions of adherence, measurement methods, and conceptual frameworks.

    Results: Most studies are cross-sectional and observational, limiting the potential to rule out confounding and establish causality (Table 1). Studies defining adherence as wearing time often use self-report to measure adherence, which can be unreliable. Studies that measure adherence with activity monitors often define adherence as the number of steps taken with the device, which excludes weight-bearing activities where no steps are taken. Conceptual frameworks are not made explicit in current research.

    Conclusions: Future studies should be longitudinal; observational studies to identify non-adherent patient groups and factors that influence adherence, and experimental studies to evaluate interventions to improve adherence, focusing on these patient groups and factors. Adherence should be defined in terms of relative adherence to using offloading devices during all weight-bearing activities (walking, standing, etc.), and objective measurement of adherence should be used whenever possible. Conceptual frameworks should be defined to guide the choice of factors to include in the study and the analysis. Implementation of these recommendations could lead to a stronger evidence base in the future, supporting interventions to increase adherence and thereby improve outcomes for people with diabetic foot complications.

  • 14.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Predictors of adherence to using therapeutic shoes among people with diabetic foot complications2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 108-109, article id P32.03Conference paper (Other academic)
    Abstract [en]

    Aim: Therapeutic shoes can prevent diabetic foot ulcers but adherence to using them often is low. Studies are needed to identify nonadherent patient groups and factors affecting adherence, laying the groundwork for future interventions to improve adherence (1,2). The aim was to investigate predictors of adherence to using therapeutic shoes.

    Methods: A questionnaire was posted to 1245 people with therapeutic shoes because of diabetic foot complications. Variables that significantly correlated with adherence (Spearman’s correlation coefficient p<0.10) were entered into a stepwise linear multiple regression analysis where p-values <0.05 were considered statistically significant.*

    Results: 443 (35.6%) questionnaires were analyzed (66.4% men, mean age 69.2 years). On average, people used their therapeutic shoes 50.3% of daytime (SD 32.8%). Adherence was higher among people who did paid work, made consistent choices about what shoe type to wear, kept their therapeutic shoes visible in their home, and had put their conventional shoes away (Table 1).

    Conclusions: People not doing paid work may need extra support to improve adherence. The results provide insights in the mechanisms of adherence, where the establishment of new shoe wearing habits, daily cues to use therapeutic shoes, and daily temptations to wear conventional shoes seem important for adherence. Future studies should explore this further and develop interventions to improve adherence, focusing on these factors.

  • 15.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University , Örebro, Sweden; University Health Care Research Center Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Too little or too much fear and avoidance of activities: should we start learning from the other side?2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 133-134, article id P42.04Conference paper (Other academic)
    Abstract [en]

    Aim: Diabetic sensory neuropathy is a frustrating condition as lack of pain and symptoms reduce patients’ motivation to avoid activities, such as walking without shoes, that result in foot ulcers and counteract healing. Theoretical developments are needed to better understand patients’ situation and develop interventions to change counterproductive behaviors.

    Methods: A literature analysis was conducted.

    Results: The fear-avoidance model is a cognitive-behavioral account of why some people with acute pain develop chronic pain (1). Intriguingly, the situation of people with chronic pain mirrors the situation of people with diabetic neuropathy and foot ulcers; in chronic pain, counterproductive beliefs and behaviors transform acute pain into a vicious circle of chronic pain (Fig. 1a), in diabetic neuropathy, counterproductive beliefs and behaviors transform acute foot ulcers into a vicious circle of chronic foot ulcers (Fig. 1b). Thus, the situation of people with diabetic neuropathy could be described with a “no fear-avoidance model”, which as the fear-avoidance model could be used to guide research, educate patients, and develop interventions.

    Conclusions: The “no fear-avoidance model” seems promising for understanding people with diabetic neuropathy and for developing appropriate interventions, building on work on the fear-avoidance model. For example, interventions based on the fear-avoidance model (activity exposure with feedback, patient education using the model with individual beliefs and behaviors as examples, etc.) could be adapted for people with diabetic neuropathy. By this, we may be able to change inadequate beliefs and behaviors, resulting in more effective prevention and treatment of foot ulcers.

  • 16.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics; University Health Care Research Center.
    Alnemo, John
    Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences. University Health Care Research Center.
    Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications2019In: Journal of Foot and Ankle Research, ISSN 1757-1146, Vol. 12, article id 21Article in journal (Refereed)
    Abstract [en]

    Background: Therapeutic shoes can prevent diabetic foot reulcerations but their use is complicated by the fact that shoes have psychological and social meanings, which is believed to put a larger burden on women than men. The aim was to compare attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications.

    Methods: A questionnaire was posted to 1230 people with diabetes who had been fitted with therapeutic shoes. Women's and men's answers were compared using t-tests, Mann-Whitney U tests and chi-square tests with Fischer's exact tests. P-values<0.05 were considered statistically significant.

    Results: Questionnaires from 443 (36.0%) respondents (294 men, 149 women, mean age 69.2years) were analyzed. More men than women (p<0.05) had paid employment (20.4% vs 9.4%), had someone who reminded them to wear their therapeutic shoes (27.6% vs 10.0%), and had a history of foot ulcers (62.9% vs 46.3%) or minor amputation (17.7% vs 6.7%). More women than men received disability pension (18.8% vs 10.2%). Women reported worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes to the appearance and price of therapeutic shoes and how they felt about wearing them in public. Other comparisons were non-significant: other shoe attributes, education, diabetes type, current foot ulcers, major amputations, satisfaction with shoe services, understanding of neuropathy as a risk factor, locus of control regarding ulcer healing, belief in the shoes' efficacy to prevent and heal ulcers, worries about ulcer healing and new ulcerations, self-efficacy, depression, shoe use/adherence, paying a fee for therapeutic shoes, and social support.

    Conclusions: Men had worse foot complications. Women had worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes toward therapeutic shoes. Clinicians should pay more attention to their female patients' concerns. Future research and development should focus on improving the weight and appearance of therapeutic shoes, particularly for women. Research is also needed on how to facilitate the adaption and reevaluation process where patients change from viewing shoes purely as items of clothing to also viewing them as medical interventions.

  • 17.
    Jarl, Gustav
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden.
    Heinemann, Allen W.
    Rehabilitation Institute of Chicago, USA.
    Lindner, Helen Y.N.
    Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden.
    Norling Hermansson, Liselotte M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Northwestern University Feinberg School of Medicine, Chicago, USA.
    Cross-cultural validity and differential item functioning of theOrthotics and Prosthetics Users’ Survey with Swedish and Americanusers of lower limb prosthesisManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To investigate the cross-cultural validity of the Orthotics and Prosthetics Users’ Survey (OPUS), to investigate differential item functioning (DIF) in the OPUS related to sex, age, amputation level and amputated sides (unilateral or bilateral), and to determine the known-group validity of the OPUS.

    Design: Cross-sectional study design.

    Setting: 2 outpatient clinics in Sweden and 7 outpatient clinics in the United States.

    Participants: A total of 195 Swedish and 126 American adults using lower limb prosthesis.

    Interventions: Not applicable.

    Main Outcome Measure: 4 modules from the OPUS were used in this study, including the Lower extremity functional status (LEFS), Client satisfaction with device (CSD), Client satisfaction with services (CSS), and Health-related quality of life (HRQoL) modules. Items were scored on 4- or 5-level Likert scales, and a Rasch measure was calculated for each person and module.

    Results: The cross-cultural validity was satisfactory. Many items demonstrated DIF related to country and demographic characteristics, but the impact on mean person measures was negligible. The rating scales of the CSD and CSS needed adjustments, and the unidimensionality of the CSD and CSS was weak. The differences between the mean measures of known patient groups were statistically significant for age in the LEFS and for the level of amputation in the CSD.

    Conclusions: This study supports the validity of comparing OPUS measures between Sweden and USA and between patient groups with different demographic characteristics. The OPUS can, to some extent, discriminate between patient groups known to be different. The unidimensionality of the CSD and CSS modules is weaker than the other modules and these need further development and evaluation.

  • 18.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hellstrand Tang, Ulla
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Nordén, Erika
    Ottobock, Medical Care Sweden, Stockholm, Sweden.
    Johannesson, Anton
    Össur Clinics Scandinavia, Stockholm, Sweden.
    Rusaw, David Francis
    School of Health and Welfare, Jönköping University, Jönköping, Sweden.
    Nordic clinical guidelines for orthotic treatment of osteoarthritis of the knee: A systematic review using the AGREE II instrument2019In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 43, no 5, p. 556-563Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: High-quality clinical practice guidelines are necessary for effective use of resources both at an individual patient- and national-level. Nordic clinical practice guidelines recommendations for orthotic treatment of knee osteoarthritis vary and little is known about their quality.

    OBJECTIVES: The aim of the study was to critically evaluate the quality of clinical practice guidelines in orthotic management of knee osteoarthritis in the Nordic countries.

    STUDY DESIGN: Systematic review.

    METHODS: Four national clinical practice guidelines for treatment of knee osteoarthritis were assessed for methodological rigour and transparency by four independent assessors using the AGREE II instrument. Summary domain scores and inter-rater agreement (Kendall's W) were calculated.

    RESULTS:  Domain scores indicate that many guidelines have not sufficiently addressed stakeholder involvement (average score: 55%), applicability (20%) and editorial independence (33%) in the development process. Inter-rater agreement for assessors indicated 'good' agreement for clinical practice guidelines from Finland, Norway and Sweden (W = 0.653, p < 0.001; W = 0.512, p = 0.003 and W = 0.532, p = 0.002, respectively) and 'strong' agreement for the clinical practice guideline from Denmark (W = 0.800, p < 0.001).

    CONCLUSION: Quality of clinical practice guidelines for orthotic treatment of knee osteoarthritis in the Nordic region is variable. Future guideline development should focus on improving methodology by involving relevant stakeholders (e.g. certified prosthetist/orthotists (CPOs)), specifying conflicts of interest and providing guidance for implementation.

    CLINICAL RELEVANCE: The current review suggests that, for the Nordic region, there are areas of improvement which can be addressed, which ensure clinical practice guidelines are developed under stringent conditions and based on sound methods. These improvements would ensure knee osteoarthritis patients are receiving orthotic interventions based on appropriate guidance from published guidelines.

  • 19.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hermansson, Liselotte
    Örebro University, School of Health Sciences. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University Hospital, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    A modified walk-in clinic for shoe insoles: Follow-up of non-attendants2019In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 43, no 6, p. 597-600Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: = 1286), we found that a modified walk-in system reduced waiting times for prescription of shoe insoles by 40 days compared to scheduled appointments but resulted in a non-attendance rate of 17% compared to 6% for scheduled appointments.

    OBJECTIVES: To investigate the reasons for non-attendance at the modified walk-in clinic.

    STUDY DESIGN: This is a cross-sectional survey.

    METHODS: Unlike traditional walk-in clinics, a limited number of patients were invited each week from the waiting list to attend the modified walk-in clinic on pre-specified days during the following 5 weeks. A questionnaire was sent to 137 patients who did not attend the modified walk-in clinic, of whom 50 (36%) responded.

    RESULTS: The most frequently reported reasons for not attending were the following: could not attend on the suggested days and times (30%), had already received help (18%) and illness or other medical interventions (16%). The majority of these issues could have been overcome by rescheduling to a scheduled appointment.

    CONCLUSION: The main reason for not attending a modified walk-in clinic was that suggested days and times did not suit the patients. The option to reschedule the appointment needs to be clearly emphasized in the information provided to the patient.

    CLINICAL RELEVANCE: With clear information about rescheduling options, a modified walk-in clinic could be used to reduce waiting times for certain groups of patients.

  • 20.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics.
    Hermansson, Liselotte
    Örebro University, School of Health Sciences. Department of Prosthetics and Orthotics.
    A modified walk-in system versus scheduled appointments in a secondary-care prosthetic and orthotic clinic2018In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 42, no 5, p. 483-489Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Waiting is common in health care, delays intervention, and has negative effects on satisfaction with services.

    OBJECTIVES: To evaluate effects of a modified walk-in system, where patients were invited consecutively from the waiting list to attend the clinic on a walk-in basis, on waiting times, services, and work environment.

    STUDY DESIGN: Parallel-group trial.

    METHODS: In all, 1286 consecutive patients in need of shoe insoles were randomized to waiting lists for modified walk-in ( n = 655) or a scheduled appointment ( n = 631). Seven staff members also participated.

    RESULTS: The median indirect waiting time to first appointment was 40 days shorter for modified walk-in (135 days) than for scheduled appointment (175 days; p < 0.001); 17% of those randomized to modified walk-in did not attend the clinic compared to 6% for scheduled appointment ( p < 0.001). Mean direct waiting time in the waiting room was 9.9 min longer for modified walk-in than for scheduled appointment ( p < 0.001). Patients attending modified walk-in or a scheduled appointment reported similar levels of satisfaction with services. Staff reported more support from co-workers with modified walk-in than with scheduled appointment ( p = 0.041).

    CONCLUSION: The modified walk-in can reduce indirect waiting times without any substantial worsening of direct waiting times, service quality, or work environment. Studies are needed to investigate why many patients drop out from modified walk-in. Clinical relevance A modified walk-in system can cut the queues and create more timely interventions by reducing indirect waiting times. This system can therefore be recommended in secondary-care prosthetic and orthotic clinics to reduce patients' suffering from their health condition.

  • 21.
    Jarl, Gustav
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Centre for Rehabilitation Research, Örebro University, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    Holmefur, Marie
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Centre for Rehabilitation Research, Örebro University, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    Hermansson, Liselotte M. N.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Centre for Rehabilitation Research, Örebro University, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    Test-retest reliability of the Swedish version of the Orthotics and Prosthetics Users' Survey2014In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 38, no 1, p. 21-26Article in journal (Refereed)
    Abstract [en]

    Background: The Orthotics and Prosthetics Users' Survey consists of five modules to assess outcomes of orthotic and prosthetic interventions: lower extremity functional status, upper extremity functional status, client satisfaction with device, client satisfaction with services and health-related quality of life.

    Objectives: To investigate the test-retest reliability and calculate the smallest detectable difference for all modules of the Swedish Orthotics and Prosthetics Users' Survey.

    Study design: Test-retest reliability study design.

    Methods: A total of 69 patients at a Department of Prosthetics and Orthotics completed Orthotics and Prosthetics Users' Survey on two occasions separated by a 2-week interval, giving 18 answers on lower extremity functional status, 41 on upper extremity functional status, 53 on client satisfaction with device, 12 on client satisfaction with services and 67 answers on health-related quality of life. Raw scores were converted into Orthotics and Prosthetics Users' Survey units on a 0-100 scale. Intra-class correlation coefficients, Bland-Altman plots, common person linking plots and t-tests of person mean measures were used to investigate the reliability. The 95% confidence level smallest detectable differences were calculated.

    Results: The intra-class correlation coefficients ranged from 0.77 to 0.96 for the modules, and no systematic differences were detected between the response occasions. The smallest detectable differences ranged from 7.4 to 16.6 units.

    Conclusions: The test-retest reliability was satisfactory for all Orthotics and Prosthetics Users' Survey modules. The smallest detectable difference was large on all modules except the health-related quality of life module.

    Clinical relevance: The Orthotics and Prosthetics Users' Survey modules are reliable and, thus, can be recommended for repeated measurements of patients over time. Relatively large changes are needed to achieve statistical significance when assessing individual patients.

  • 22.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden; University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Law, Psychology and Social Work. University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Adherence to wearing therapeutic shoes among people with diabetes: a systematic review and reflections2016In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 10, p. 1521-1528Article, review/survey (Refereed)
    Abstract [en]

    Introduction: Therapeutic shoes are prescribed to prevent diabetic foot ulcers, but adherence to wearing the shoes is often poor.

    Aim: The aim of this study was to review the literature on factors that are associated with adherence to wearing therapeutic shoes and construct a model of adherence to aid future research and development in the field.

    Methods: We conducted a systematic search in PubMed, CINAHL, and PsycINFO for quantitative studies on factors associated with adherence to wearing therapeutic shoes among people with diabetes.

    Results: Six studies were included in the review. The studies focused mainly on patient-, therapy-, and condition-related adherence factors. There is some evidence (three to five studies) that sex, diabetes duration, and ulcer history are not associated with adherence. The evidence for or against the other factors was weak (only one or two studies) or conflicting.

    Conclusion: There is no conclusive evidence for using any factor to predict adherence to wearing therapeutic shoes, but there is some evidence against using certain factors for predicting adherence. Future studies should include a broader range of factors, including health system and social/economic factors, and they should investigate perceived costs and benefits of wearing therapeutic shoes in comparison with other shoes or no shoes. A seesaw model is presented illustrating the complex phenomenon of adherence. Further research is needed to identify factors associated with adherence to wearing therapeutic shoes, to enable the development of interventions to improve adherence and thereby reduce ulceration rates among people with diabetic foot complications.

  • 23.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences. University Health Care Research Centre, Region Örebro County, Örebro, Sweden.
    An alternative perspective on assistive technology: the Person-Environment-Tool (PET) model2020In: Assistive technology, ISSN 1040-0435, E-ISSN 1949-3614, Vol. 32, no 1, p. 47-53Article in journal (Refereed)
    Abstract [en]

    The medical and social models of disability are based on a dichotomy that categorizes people as able-bodied or disabled. In contrast, the biopsychosocial model, which forms the basis for the International Classification of Functioning, Disability and Health (ICF), suggests a universalistic perspective on human functioning, encompassing all human beings. In this article we argue that the artificial separation of function-enhancing technology into assistive technology (AT) and mainstream technology might be one of the barriers to a universalistic view of human functioning. Thus, an alternative view of AT is needed. The aim of this article was to construct a conceptual model to demonstrate how all human activities and participation depend on factors related to the person, environment, and tools, emphasizing a universalistic perspective on human functioning. In the Person-Environment-Tool (PET) model, a person's activity and participation are described as a function of factors related to the person, environment, and tool, drawing on various ICF components. Importantly, the PET model makes no distinction between people of different ability levels, between environmental modifications intended for people of different ability levels, or between different function-enhancing technologies (AT and mainstream technology). A fictive patient case is used to illustrate how the universalistic view of the PET model lead to a different approach in rehabilitation. The PET model supports a universalistic view of technology use, environmental adaptations, and variations in human functioning.

  • 24.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences.
    Beyond dichotomous thinking: a process perspective on diabetic foot disease2017In: Diabetic Foot & Ankle, ISSN 2000-625X, Vol. 8, no 1, article id 1380477Article in journal (Refereed)
    Abstract [en]

    Background: Diabetic foot (DF) disease causes severe suffering around the world, and appropriate self-care activities are needed to prevent and treat this condition. However, all too often, self-care activities are less than optimal and clinicians find themselves unable to influence them in a positive direction. Clinicians' and researchers' mental models of the DF tend to be dichotomous: either the patient has or does not have an active ulcer or other DF disease. This mode of thinking hides the long-term perspective of DF disease, where patients' previous experiences and expectations for the future influence their current behavior. Thus, there is a need for a different perspective on DF disease to better understand patients' perspectives and thereby improve self-care, leading to more effective prevention and treatment.

    Objective: To present a novel framework, the process perspective on the DF, which can explain inadequate self-care behaviors not easily understood with a dichotomous perspective, and how they can be changed.

    Results: Three fictive clinical examples are used to illustrate how the process perspective on the DF can be used to understand how patients' previous experiences and expectations for the future influence their current behavior. In particular, this process perspective is used to understand how patients' beliefs and behaviors are sometimes self-reinforcing, resulting in stable behavior patterns, here referred to as 'DF cycles'. These cycles are quite common in clinical practice but are difficult to analyze using a dichotomous perspective on DF disease. The process perspective on the DF is used to analyze specific 'vicious' DF cycles of inadequate patient behavior and to find ways to transform them into 'virtuous' DF cycles, resulting in effective prevention and treatment.

    Conclusions: The process perspective on the DF seems suitable for understanding inadequate patient behaviors not easily understood with a dichotomous perspective on DF disease, opening up new avenues for clinical practice and research to help patients live a life with long remission phases, few relapses, and a high quality of life.

  • 25.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Lundqvist, Lars-Olov
    Örebro University, School of Health Sciences. University Health Care Research Center.
    Understanding patients: a process perspective on diabetic foot disease2019In: 8th International symposium on diabetic foot: Abstract book, 2019, p. 134-134, article id P42.03Conference paper (Other academic)
    Abstract [en]

    Aim: Diabetic foot self-care activities are often less than optimal and clinicians may find themselves unable to influence them in a positive direction. The aim was to present a novel framework, the process perspective on the diabetic foot, which can explain inadequate self-care behaviors and how they can be improved.

    Methods: A literature analysis was conducted.

    Results: The central principle of the process perspective is that diabetic foot disease is not a dichotomy (treatment and prevention) but a process over time, including alternating phases of active and latent diabetic foot disease (Fig. 1a). Thus, the patient is standing in the midst of a process, with a history of experiences and expectations for the future, all relevant to the patient’s current self-care behavior. A fictive patient case illustrates how the process perspective can be used to understand patients’ situation and how beliefs and behaviors are sometimes self-reinforcing, resulting in stable behavior patterns (‘diabetic foot cycles’), which are difficult to understand from a dichotomous perspective. The process perspective can be used to analyze ‘vicious’ diabetic foot cycles (Fig. 1b) of inadequate patient behavior and to find ways to transform them into ‘virtuous’ diabetic foot cycles (Fig. 1c), resulting in effective prevention and treatment.

    Conclusions: The process perspective on the diabetic foot seems suitable for understanding inadequate patient behaviors not easily understood with a dichotomous perspective, opening up new avenues for clinical practice and research to help patients live a life with long remission phases, few relapses, and a high quality of life.

  • 26.
    Jarl, Gustav M.
    Örebro University, School of Health and Medical Sciences.
    Den ortopedtekniska processen2011In: Ortopedteknik 2011, 2011Conference paper (Refereed)
  • 27.
    Jarl, Gustav M.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    The Orthotics and Prosthetics Users' Survey: translation and validity evidence for the Swedish version2014Doctoral thesis, comprehensive summary (Other academic)
  • 28.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Heinemann, Allen W
    Rehabilitation Institute of Chicago, Chicago IL, United States; Feinberg School of Medicine, Northwestern University, Chicago IL, United States.
    Lindner, Helen Y
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Hermansson, Liselotte M N
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Cross-cultural validity and differential item functioning of the Orthotics and Prosthetics Users’ Survey with Swedish and American users of lower-limb prosthesis2015In: Archives of Physical Medicine and Rehabilitation, ISSN 0003-9993, E-ISSN 1532-821X, Vol. 96, no 9, p. 1615-1626Article in journal (Refereed)
    Abstract [en]

    Objectives: To investigate the cross-cultural validity of the Orthotics and Prosthetics Users’ Survey (OPUS), to evaluate differential item functioning (DIF) related to country, sex, age, amputation level, and amputated side (unilateral, bilateral), and to determine known-group validity of the OPUS.

    Design: Survey.

    Setting: Outpatient clinics.

    Participants: The sample (NZ321) consisted of Swedish (nZ195) and U.S. (nZ126) adults using lower-limb prostheses.

    Interventions: Not applicable.

    Main Outcome Measures: Four OPUS modules were used: lower extremity functional status, client satisfaction with device (CSD), client satisfaction with services (CSS), and health-related quality of life. Rasch analysis was used to calculate measures for persons and items.

    Results: The cross-cultural validity was satisfactory. Many items demonstrated DIF related to country and demographic characteristics, but the impact on mean person measures was negligible. The rating scales of CSD and CSS needed adjustments, and the unidimensionality of CSD and CSS was weak. The differences between the mean measures of known patient groups were statistically significant for 2 out of 6 comparisons.

    Conclusions: This study supports the validity of OPUS measure comparisons between Sweden and the United States and between subgroups with different demographic characteristics. Some of the country-related DIF may reflect the different health care financing systems. The findings demonstrate that the OPUS can discriminate between certain patient groups. The results also challenge some of our preconceptions about persons with bilateral amputation, indicating that we might know these persons less well than we think.

  • 29.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro County Council, Örebro, Sweden.
    Heinemann, Allen W.
    Rehabilitation Institute, Chicago, USA; Nortwestern University Feinberg School of Medicine, Chicago, USA.
    Norling Hermansson, Liselotte M. N.
    Örebro University, School of Health and Medical Sciences. Centre for Rehabilitation Research, Örebro County Council, Örebro, Sweden; Department of Prosthetics and Orthotics, Örebro County Council, Örebro, Sweden.
    Validity evidence for a modified version of the Orthotics and Prosthetics Users' Survey2012In: Disability and Rehabilitation: Assistive Technology, ISSN 1748-3107, E-ISSN 1748-3115, Vol. 7, no 6, p. 469-478Article in journal (Refereed)
    Abstract [en]

    Purpose: To evaluate the validity of a modified version of the Orthotics and Prosthetics Users' Survey (OPUS) with persons using different prosthetic and orthotic (P&O) devices.

    Method: Two-hundred-and-eighty-two adults using prosthesis, orthosis, shoe insoles or orthopaedic shoes completed OPUS. OPUS comprises five modules - Lower and Upper Extremity Functional Status, respectively (LEFS and UEFS), Client Satisfaction with Device and Services, respectively (CSD and CSS), and, Health-Related Quality of Life (HRQoL). Eight new items were added to LEFS and six to UEFS. Rasch analysis was used for data analyses.

    Results: Rating scales functioned satisfactory after some modifications. All modules demonstrated a ceiling effect. Unidimensionality was satisfactory after deleting some items and dividing HRQoL into two subscales, although somewhat weak on CSD and CSS. Item reliability was excellent for all modules and person reliability good for all but CSD and CSS. Some items demonstrated differential item functioning related to sex and age, but the impact on person measures was small.

    Conclusions: This study supports the validity of a modified version of OPUS for persons using different P&O devices, but also reveals limitations to be addressed in future studies. OPUS could be useful in clinical rehabilitation and research to evaluate P&O outcomes.

  • 30.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences.
    Heinemann, Allen W
    Rehabilitation Institute, Chicago and Northwestern University Feinberg School of Medicine, Chicago, USA.
    Norling Hermansson, Liselotte M. N.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Validity of the Swedish version of Orthotics and Prosthetics Users’ Survey2010Conference paper (Refereed)
  • 31.
    Jarl, Gustav M
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hermansson, Liselotte M
    Örebro University, School of Health and Medical Sciences.
    Translation and linguistic validation of the Swedish version of Orthotics and Prosthtics User’s Survey2008In: 5th Regional Central European ISPO Conference, 2008Conference paper (Refereed)
  • 32.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hermansson, Liselotte M. N.
    Örebro University, School of Health and Medical Sciences.
    Översättning och språklig validering av svenska versionen av Orthotics and Prosthetics Users' Survey2009In: 8:e Nordiska ortopedtekniska kongressen 2009, 2009Conference paper (Refereed)
  • 33.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Holmefur, Marie
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Hermansson, Liselotte M N
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Test-retest reliability of the Orthotics and prosthetics users´ survey2013In: ISPO 2013 World Congress: Inclusion, Participation & Empowerment, 2013Conference paper (Refereed)
  • 34.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences.
    Norling Hermansson, Liselotte
    Örebro University, School of Health and Medical Sciences.
    Translation and linguistic validation of the Swedish version of Orthotics and prosthetics users’ survey2008Conference paper (Refereed)
    Abstract [en]

    There is a lack of Swedish instruments assessing outcome of orthotic and prosthetic services. The North American derived Orthotics and Prosthetics Users’ Survey (OPUS) consists of five questionnaires assessing common rehabilitation goals. It was translated to Swedish and validated linguistically. Thirty-nine persons answered the questionnaires and were systematically debriefed. In most cases the items were understood as intended. Words and expressions were changed if misunderstood or interpreted in different ways. The resulting Swedish version of OPUS showed acceptable linguistic validity. A study on construct validity and test-retest reliability is in process.

     

    1      Introduction

    Historically, Orthotic and Prosthetic (O&P) services in Sweden have been based on hands-on experience rather than science. Self-report instruments could be used to systematically evaluate the practice, but most of them are developed in English speaking countries and cannot be used in Sweden without translation and validation. Moreover, the only instruments available in Swedish are limited to the smaller group in O&P practice, namely prosthetic clients.

     

    The Orthotics and Prosthetics Users´ Survey (OPUS) was developed and validated in the USA to assess the outcome in both prosthetic and orthotic users [1]. The OPUS consists of five questionnaires assessing i) health related quality of life, ii) satisfaction with device, iii) satisfaction with services, iv) upper extremity function, and v) lower extremity function. If translated, OPUS could be a useful tool for studying the outcome of O&P services in Sweden. Still, validity problems can arise by using direct translations. Therefore, translations’ validity must be tested in the new cultural context.

     

    The aim was to translate OPUS to Swedish and test the linguistic validity in a Swedish context.

     

    2      Methods and subjects

    2.1. Methods

    A modified version of the translation process suggested by the WHO [2] was used. Four medical professionals (P/O, OT, PT, orthopaedic surgeon) independently translated OPUS to Swedish. The translations were merged to a single document by one of the authors (GJ). Translators and authors met twice to discuss the translations and a consensus version was created. A professional translator performed a back-translation to English. The English original, the Swedish consensus version, and the back-translation, were compared by one of the authors (GJ) and a new Swedish version was created.

     

    One intention with the Swedish version of OPUS was to use it for evaluation of insoles. However, many of these clients are relatively fit and a high ceiling effect could be expected in the lower extremity function part of OPUS. Therefore, eight new items assumed to be more difficult were added to the Swedish version of this particular questionnaire.

     

    Linguistic validation was performed by systematically debriefing the clients who answered the five questionnaires. Ten subjects answered each questionnaire (each subject completed one or two different questionnaires).

     

    2.2. Subjects

    Thirty-nine clients (27 women, 12 men, mean age 59,8) at the Department of Prosthetics and Orthotics, Örebro University Hospital, participated. Clients younger than 18 years, and clients unable to understand written Swedish, were excluded. The study was approved by the Regional Ethics Committee review board.

     

    3      Results

    Minor linguistic changes were made during the translation process. Most items were understood as intended but some words and expressions were changed because of misunderstandings or cultural differences between Sweden and the USA.

     

    4      Discussion

    The translation procedure used is well established and has been used in several studies. The quality of the translation was improved by involving people of different professions and experiences.

     

    5      Conclusion

    The translation and validation resulted in a Swedish version of OPUS that may be a reliable and useful contribution to outcome studies in Swedish O&P service. A study assessing construct validity and test-retest reliability is in process and preliminary results will be presented.

     

    6      References

    1.      Heinemann AW, Bode RK, et al. (2003). "Development and measurement properties of the Orthotics and Prosthetics Users' Survey (OPUS): a comprehensive set of clinical outcome instruments." Prosthet Orthot Int 27;3:191-206

     

    2.      WHO (2007). "Process of translation and adaptation of instruments."  2007: http://www.who.int/substance_abuse/research_tools/translation/en/.

     

  • 35.
    Jarl, Gustav M.
    et al.
    Örebro University, School of Health and Medical Sciences. Institution for Rehabilitation, Centre for Rehabilitation Research, Örebro; Örebro University Hospital, Örebro .
    Norling Hermansson, Liselotte Maria
    Institution for Rehabilitation, Centre for Rehabilitation Research, Örebro; Örebro University Hospital, Örebro.
    Translation and linguistic validation of the Swedish version of Orthotics and Prosthetics Users' Survey2009In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 33, no 4, p. 329-338Article in journal (Refereed)
    Abstract [en]

    There is an increasing need for outcome measures in the orthotic and prosthetic field and specifically a lack of outcome measures in Swedish. The Orthotics and Prosthetics Users' Survey (OPUS) was developed in the USA for assessment of the outcome of orthotic and prosthetic interventions, and could potentially also be used for shoe insoles and orthopaedic shoes. The aims of this study were to translate OPUS into Swedish and test the translated version's linguistic validity in a Swedish context. The Orthotic and Prosthetic Users' Survey was translated into Swedish and back-translated into English, following a modified version of the World Health Organization guidelines. After revision of the Swedish version, 39 Swedish clients (12 men, 27 women) answered the OPUS questionnaires and were systematically debriefed afterwards. Most items were understood correctly by the respondents, but some words and expressions had to be changed to avoid misunderstandings or unintended interpretations. The resulting Swedish version of OPUS, OPUS-Swe, showed acceptable linguistic validity and has potential for use in both clinical practice and scientific settings. Nevertheless, before OPUS-Swe can be fully implemented, its psychometric properties need to be evaluated.

  • 36.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden; University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Ramstrand, Nerrolyn
    CHILD research group, Department of Rehabilitation, School of Health and Welfare, Jönköping University, Jönköping, Sweden.
    A model to facilitate implementation of the International Classification of Functioning, Disability and Health into prosthetics and orthotics2018In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 42, no 5, p. 468-475Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The International Classification of Functioning, Disability and Health is a classification of human functioning and disability and is based on a biopsychosocial model of health. As such, International Classification of Functioning, Disability and Health seems suitable as a basis for constructing models defining the clinical P&O process. The aim was to use International Classification of Functioning, Disability and Health to facilitate development of such a model.

    Proposed model: A model, the Prosthetic and Orthotic Process (POP) model, is proposed. The Prosthetic and Orthotic Process model is based on the concepts of the International Classification of Functioning, Disability and Health and comprises four steps in a cycle: (1) Assessment, including the medical history and physical examination of the patient. (2) Goals, specified on four levels including those related to participation, activity, body functions and structures and technical requirements of the device. (3) Intervention, in which the appropriate course of action is determined based on the specified goal and evidence-based practice. (4) Evaluation of outcomes, where the outcomes are assessed and compared to the corresponding goals. After the evaluation of goal fulfilment, the first cycle in the process is complete, and a broad evaluation is now made including overriding questions about the patient's satisfaction with the outcomes and the process. This evaluation will determine if the process should be ended or if another cycle in the process should be initiated.

    CONCLUSION: The Prosthetic and Orthotic Process model can provide a common understanding of the P&O process. Concepts of International Classification of Functioning, Disability and Health have been incorporated into the model to facilitate communication with other rehabilitation professionals and encourage a holistic and patient-centred approach in clinical practice.

    Clinical relevance: The Prosthetic and Orthotic Process model can support the implementation of International Classification of Functioning, Disability and Health in P&O practice, thereby providing a common understanding of the P&O process and a common language to facilitate communication with other rehabilitation professionals.

  • 37.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Örebro University Hospital, Örebro, Sweden; University Health Care Research Center, Region Örebro County, Örebro, Sweden.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    An innovative sealed shoe to off-load and heal diabetic forefoot ulcers: a feasibility study2017In: Diabetic Foot & Ankle, ISSN 2000-625X, Vol. 8, no 1, article id 1348178Article in journal (Refereed)
    Abstract [en]

    Background: Non-removable knee-high devices are the gold standard to treat diabetic foot ulcers located on the plantar forefoot, but they immobilize the ankle, which restricts daily life activities and has negative effects on joint functioning.

    Objective: To investigate the feasibility of sealing a therapeutic shoe to off-load and heal diabetic forefoot ulcers.

    Design: A case series of seven men with type 2 diabetes and a metatarsal head ulcer were prescribed therapeutic shoes and custom-made insoles. The shoe was sealed with a plastic band. Off-loading was assessed with the F-scan pressure measurement system. Adherence to wearing the shoe was assessed with a temperature sensor and by documenting the status of the seal.

    Results: The off-loading was effective and all ulcers healed. Median time to healing was 56 days (range 8-160). Complications were secondary ulcer (n = 1) and plantar hematoma (n = 1). Five of seven participants did not disturb the seal.

    Conclusions: Sealing a therapeutic shoe is a feasible way to off-load and heal forefoot ulcers. A controlled trial is needed to compare the effectiveness and safety of a sealed shoe to other non-removable devices.

  • 38.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics; University Health Care Research Center.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.
    An innovative sealed therapeutic shoe to off-load and heal diabetic forefoot ulcers2018Conference paper (Refereed)
    Abstract [en]

    Aim: The aim was to investigate the feasibility of using a therapeutic shoe, rendered irremovable,to off-load and heal forefoot ulcers. Non-removable knee-high off-loading devicesare gold standard to treat neuropathic forefoot ulcers. They do however immobilize theankle, affecting joint functioning and daily activities.

    Method: Seven men with diabetes type 2 since >10 years, sensory neuropathy and a metatarsalhead ulcer (table 1) were prescribed extra-depth therapeutic roller shoes and custom-madeinsoles adjusted to off-load the ulcer (fig. 1). Off-loading was assessed with anin-shoe plantar pressure system* measuring plantar peak pressures as the participantswalked. The shoe was then sealed with a plastic band and worn day and night like a cast.Adherence was assessed by documenting the status of the seal (intact/broken) whenchanging ulcer dressings.

    Results / Discussion: All ulcers healed, with a median time to healing of 8 weeks (range1-23). The median peak pressure on the ulcer was 116 kPa (range 62-192) when walkingwith the shoe. Five of seven participants respected the seal. Complications were secondaryulcer (n=1) and plantar hematoma (n=1). The most common complaint was difficulty todress (n=5).

    Sealed therapeutic shoes are an interesting avenue for future research; they include advantagesof non-removable knee-high devices as effective off-loading and high adherence,and overcome disadvantages as mobility restrictions and high costs.

    Conclusion: It seems feasible to seal a therapeutic shoe to off-load and heal forefoot ulcers.A randomized controlled trial is underway in which sealed shoes are to be comparedto total contact casting.

  • 39.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    An innovative sealed therapeutic shoe to offload and heal diabetic forefoot ulcers2019Conference paper (Other academic)
  • 40.
    Jarl, Gustav
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Tranberg, Roy
    Department of Orthopaedics, Institute of Clinical Sciences, the Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
    Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications2018Conference paper (Other academic)
    Abstract [en]

    Background: Therapeutic shoes can prevent diabetic foot reulcerations but their use is complicated by the fact that shoes have psychological and social meanings, which is believed to put a larger burden on women than men. The aim was to compare attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications.

    Methods: A questionnaire was posted to 1230 people with diabetes who had been fitted with therapeutic shoes. Women's and men's answers were compared using t-tests, Mann-Whitney U tests and chi-square tests with Fischer's exact tests. P-values < 0.05 were considered statistically significant.

    Results: Questionnaires from 443 (36.0%) respondents (294 men, 149 women, mean age 69.2 years) were analyzed. More men than women (p < 0.05) had paid employment (20.4% vs 9.4%), had someone who reminded them to wear their therapeutic shoes (27.6% vs 10.0%), and had a history of foot ulcers (62.9% vs 46.3%) or minor amputation (17.7% vs 6.7%). More women than men received disability pension (18.8% vs 10.2%). Women reported worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes to the appearance and price of therapeutic shoes and how they felt about wearing them in public. Other comparisons were non-significant: other shoe attributes, education, diabetes type, current foot ulcers, major amputations, satisfaction with shoe services, understanding of neuropathy as a risk factor, locus of control regarding ulcer healing, belief in the shoes' efficacy to prevent and heal ulcers, worries about ulcer healing and new ulcerations, self-efficacy, depression, shoe use/adherence, paying a fee for therapeutic shoes, and social support.

    Conclusions: Men had worse foot complications. Women had worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes toward therapeutic shoes. Clinicians should pay more attention to their female patients' concerns. Future research and development should focus on improving the weight and appearance of therapeutic shoes, particularly for women. Research is also needed on how to facilitate the adaption and reevaluation process where patients change from viewing shoes purely as items of clothing to also viewing them as medical interventions.

  • 41.
    Lazzarini, Peter A.
    et al.
    School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia; Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Gooday, Catherine
    Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK; School of Health Sciences, University of East Anglia, Norwich, UK.
    Viswanathan, Vijay
    MV Hospital for Diabetes, Chennai, India.
    Caravaggi, Carlo F.
    Diabetic Foot Department, IRCCS Multimedica Group, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
    Armstrong, David G.
    Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA.
    Bus, Sicco A
    Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
    Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review2020In: Diabetes/Metabolism Research Reviews, ISSN 1520-7552, E-ISSN 1520-7560, Vol. 36, no Suppl. 1, article id e3275Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers.

    METHODS: We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis.

    RESULTS: We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia.

    CONCLUSION: Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.

  • 42. Tranberg, Roy
    et al.
    Jarl, Gustav
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    An innovative sealed therapeutic shoe to offload and heal diabetic forefoot ulcers2019Conference paper (Other academic)
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