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Off-Loading Devices for People with Diabetic Neuropathic Foot Ulcers: A Rapid Qualitative Review

Last updated: July 13, 2020
Project Number: RC1286-000
Product Line: Rapid Response
Research Type: Device
Report Type: Summary with Critical Appraisal
Result type: Report

Question

  1. How do people living with type 1 or type 2 diabetes understand the use of offloading devices for the prevention and treatment of diabetic neuropathic foot ulcers? What are their experiences with these devices and how do they describe their expectations?
  2. How do people caring for (e.g., professional health care providers or family and friends) those living with type 1 or type 2 diabetes understand the use of offloading devices for the prevention and treatment of diabetic neuropathic foot ulcers?

Key Message

This rapid qualitative review analyzed 12 studies describing podiatrists’ and patients’ experiences using offloading devices. This review identified several challenges that patients face adhering to various offloading modalities. The most common challenges were mobility and autonomy, patients’ perceptions of the device effectiveness, and how offloading devices affected patients’ self-image and social interactions. First, patients cited how some offloading devices were heavy and difficult to use, which decreased their willingness to use them consistently in their daily lives. Patients also preferred not to use offloading devices in their homes because they were not designed for comfortable movement around the house. Second, patients who believed that the device provided quick ulcer healing were more likely to use offloading devices in the long-term. However, when patients’ expectations for healing were not met, their adherence to offloading decreased. Some patients were also concerned about how some devices may increase the risk of falls or cause new ulcers, particularly with devices that did not fully immobilize affected areas. Third, patients’ adherence depended on how their new self-image with the offloading device fit with family and community norms. Some patients viewed the device as a symbol of a disability that affected their social status in their communities, especially when strangers reacted negatively to the device in public. Patients needed time to reflect on how they would use the offloading device in their daily lives; adequate time enabled patients to accept a new self-image that incorporated offloading device use, thereby increasing adherence in the long-term. Patients also expressed challenges with purchasing offloading devices, particularly older patients who were on a fixed income and had to negotiate between broader self-management costs. Maintaining, repairing, and replacing offloading devices was also costly for these patients. Finally, this review found two studies examining podiatrists’ perspectives, which generally mirrored patients’ experiences and challenges using offloading devices. Podiatrists adopted two approaches to recommending offloading: an aggressive modality that was changed to a less aggressive version because of adverse outcomes, or a moderate modality that was changed to a more aggressive version because of slow healing.