Measuring adherence to wearing footwear for pain and deformity associated with inflammatory joint disease: A literature review
A report for the Health Research Council
Prepared by
Cynthia Otene-Strickland
Under the supervision of
Associate Professor Denise Wilson
AUT University
2014
Abstract
Adherence to footwear and foot orthoses is a major factor in the treatment intervention of inflammatory joint disease of Māori. This literature review focused on reviewing studies about ways of measuring adherence to wearing prescription footwear and foot orthoses for pain and deformity associated to inflammatory joint disease, like rheumatoid arthritis and gout. The strategy used in this study was a literature review of current evidence to identify research that has been done to measure adherence in patients with pain and deformity from inflammatory joint disease. The key findings were that there is limited evidence and studies that have been done on inflammatory joint disease. Studies on diabetes and measuring prescribed footwear adherence in diabetic patients were drawn on to gain methods of measuring adherence available. In conclusion it was found that more studies need to be conducted to prove ways of measuring adherence to pain and deformity in patients with inflammatory joint disease, particularly methods that are suitable for use with Māori patients. Developing e-technology that is simple yet informative for both podiatrists and patients will be a future direction for measuring adherence, which could be tested in future research.
Introduction
Māori have high prevalence rates of inflammatory joint disease (Winnard, Wright, & Taylor, 2012), particularly rheumatoid arthritis and gout. The incidence and prevalence of gout has increased worldwide and in New Zealand. Recent gout prevalence estimates for New Zealand (NZ) European adults are 3.2%, 6.1% for Māori adults and 7.6% for Pacific Island adults (Winnard et al., 2012). This inflammatory joint disease causes pain, impairment and disability as a result of the disease progression (Lindsay, Gow, & Vanderpyl, 2011; Rome, Supervalli, & Sanders, 2011). Gout has a predilection to affect the feet, particularly the first metatarsophalangeal joint (Dalbeth, Kalluru, & Aati, 2013). It causes tophaceous depositions that progress to stiffness and persistent aching of the involved joint(s). Tophaceous deposits in this weight-bearing area of the feet can cause gouty lesions that become hyperkeratotic, further increasing pain, impairment and disability (Rome et al., 2011). High and increasing hospital admissions for gout, combined with the burden of co-morbidities like diabetes, chronic kidney disease and cardiovascular disease, are important current issues for the New Zealand health system.
Rheumatoid arthritis and gout is prevalent among Māori (Winnard et al., 2012). Both these diseases severely impact quality of life, particularly with the development of foot deformities, foot pain and disability (Dalbeth, Petrie, & House, 2011). Gout, the most common form of inflammatory arthritis, has significant functional impacts (Lindsay et al., 2011). The increasing incidence and prevalence of gout is a worldwide phenomenon (Brook, Forsythe, & Smeeding, 2010; Zhu, Pandya, & Choi, 2011) that includes New Zealand (Winnard et al., 2012).
In New Zealand, gout has been reported to directly impact the ability of those affected to work which causes financial strains for the family, and reduces the quality of life of sufferers (Keith Rome et al., 2013). Gout and diabetes are common co–morbidities, and Māori particularly have high prevalence rates of both. Although they have tendency to exist together, there are differences in their pathophysiological presence – diabetes damages the microvascular vascular and neurological status in the lower limb, causing diminished sensation especially to pain (Ihaka, Bayley, & Rome, 2012). Gout, on the other hand, results in localised joint deposits, has a biochemical basis, and causes pain with increased uric acid levels (Rome et al., 2013).
Adherence to footwear and foot orthoses is a major factor in the treatment of inflammatory joint disease for Māori. Knowledge about adherence and what determines adherence is valuable in addressing issues related to footwear effectiveness, and can directly or indirectly reform footwear
prescription practice (Roelof et al., 2013). Measuring adherence to wearing footwear and orthoses can enable practitioners to assess how often the footwear and orthoses are being worn to support further treatment decisions and options (Roelof et al., 2013).
The main focus of this research was to review research that examined ways of measuring adherence to wearing prescription footwear and foot orthoses in patients with inflammatory joint disease with deformity, pain and impairment. Therefore, I aimed to identify and review studies about measuring adherence to wearing footwear for pain and deformity associated with inflammatory joint disease, like rheumatoid arthritis and gout. Studies that investigated diabetes and measuring footwear adherence were also utilised, particularly given the low number of studies looking specifically at the measurement of adherence. This enabled the identification of diabetic studies that measured adherence rates, and were included with the gout adherence studies. Given the high prevalence of go ut among Māori, adherence to prescription footwear and foot orthoses is an important health issue for Māori that needs to be urgently addressed to improve treatment and comfort for Māori suffering with gout. As mentioned earlier, gout has significant impacts on quality of life in general, work, and family finances. Measuring the use of footwear allows monitoring the use of footwear, and its ability, to make adaptations in order to improve adherence, and ultimately, quality of life.
Methods
A literature review provides an extensive outline of the key research findings on a particular topic. This section explains the research methods used to search the literature and gather the data for this report.
Search Strategy
Under the guidance of my supervisor, I reviewed online databases accessed through the AUT Library. The databases searched were Medline, EMBASE, CINAHL, EBSCO, Proquest, and AMED for studies that examined measuring adherence to footwear in patients suffering pain, disability, and impairment from inflammatory joint disease between 1960 and December 2013. Given the limited studies available on this topic, the search was then widened to include studies relating to diabetes and measuring adherence to footwear, although this literature was limited to those published within the previous five years. In addition to this search of health databases, hand searches of journals aided by the references cited in journal articles was also conducted. Key terms used (singularly and
in combination) included: measuring adherence to footwear, measuring compliance with footwear, pain, disability, impairment, inflammatory joint disease, gout, diabetes.
Studies were included in the review if they met the following inclusion criteria:
?Published in English language;
?Full text peer-reviewed articles;
?Participants had histories of foot conditions, like gout or foot complications secondary to diabetes; and
?Examined measuring adherence to wearing prescribed footwear or orthoses.
Studies excluded included those where no full text was available, and those involving surgical procedures, and/or healthy participants with no history of foot conditions.
Article titles and abstracts were screened for relevance, and those studies relating to footwear and foot orthoses adherence were retained. The literature found was then organised into themes, and summarised in a table (see Appendix 1). Identifying the themes involved grouping commonalities that existed in the ways adherence rates were measured.
Findings
Eight studies met the inclusion criteria and were subsequently reviewed. The common ways of measuring adherence included:
?Temperature based monitors
?Patient charts
?Patient diary
?Dual activity monitor
?Questionnaires
?Electronic mail survey
The following summarises the studies and their key findings related to footwear adherence.
Temperature Based Monitors
Temperature based monitors were used in studies to measure when participants’ footwear was on and off. There were 11 healthy and 14 neuropathic diabetic patients with high risk of foot ulceration in an observational study by Bus, Waaijman and Nollet (2012). This study used an in-shoe attached
monitor to measure when footwear was on and off, and in addition, participants kept a log for seven days and completed a questionnaire. The mean time difference between footwear on and off was used to calculate adherence. The adherence monitor showed good validity in measuring when footwear is used or not, meaning this device could have positive application in clinical practice and research. The self-reported log could have limited reliability as it relied on participants recording the data. Using an electronic recording device with the monitor could limit the burden of participants completing a written log.
A similar study conducted by Waaijman et al. (2013), objectively assessed adherence inpatients with high risk of ulcer recurrence and evaluated what determined adherence. Patients (n=107) with diabetes and neuropathy, a recently healed plantar foot ulcer, and custom made footwear were measured for their footwear use over seven consecutive days. The participants wore an in-shoe temperature based monitor and an ankle activity monitor to measure step count. Adherence was calculated as the percentage of steps that prescription footwear was worn. Waaijman et al. explained that significant determinants of higher adherence included lower BMI, severe foot deformity and more appealing footwear. The results from this study showed that adherence to wearing customised footwear are insufficient, which causes a threat to re-ulceration. Participants showed low adherence, particularly at home, which could then indicate the need for the inclusion of off-loading footwear for wearing indoors at home, or in the case of Māori when they are in wharenui. This study was limited by its very short term, and that it did not include any gout patients.
Patient Charts
An observational study by Chantelau and Haage (1994) recorded compliance by assessing daily the time of wearing protective shoes entered into patient charts. Fifty-one participants, accessed from a diabetic foot clinic, were given off-loading footwear that reduced peak plantar pressure load on the forefoot by 50%. They were followed for up to 4 years. This study found that wearing protective shoes for 60% of the daytime significantly reduced the ulcer relapse rate by 50%. Chantelau and Haage then concluded that protective footwear together with frequent foot care is essential in the prevention of neuropathic diabetic foot ulcer recurrence. This study was conducted on diabetic patients only, meaning that no gout patients were observed.
Patient Diaries
A single participant study undertaken over 4 days by Crews, Armstrong and Boulton (2009), used a patient diary to record time used wearing protective footwear along with hip mounted activity
monitors. These two methods were then compared to see if patients were over-recording in their diaries. The results from this study supported the use of an activity monitor approach for assessing compliance over the patient maintained diary, as activity monitors are not susceptible to incorrect patient recall. However, this study had a small sample size and did not include any gout patients.
Questionnaires
A cross-sectional multicentre study by de Boer et al. ( 2009) used 240 participants to describe the usage of assistive devices in rheumatoid arthritis patients. Questionnaires and semi-structured interviews were used to identify the possession and usage of the devices. The results showed that 8% of participants never wore the orthopaedic insole that they had been prescribed. The reasons for non-adherence were dissatisfaction with the device, impairment or disability, self-efficacy and the number of devices in possession. Overall satisfaction was high, although there was a highlighted need for systemic outcome evaluation by health professionals of the assistive devices in every individual case.
Electronic Mail Survey
An electronic mail survey was used in a study of 198 male cadets to assess compliance on wearing heel lifts over 8 weeks. This study, by Goss and Moore (2004), had a randomly selected control group, and used the heel lifts to prevent overuse injury during training. The cadets filled out the electronic mail survey and results proved that compliance with the use of the heel lifts was low. Goss and Moore warned health practitioners not to assume that devices are being worn. This study utilised healthy participants with leg length discrepancies, and included no gout patients.
Table 1
Ways of Measuring Adherence to Footwear and Prescribed Custom-Made Footwear MEASUREMENT TOOL METHOD STUDIES (n=8)
Temperature based monitors Monitor placed into footwear to measure
when footwear was on and off.
This study also involved patients keeping a
log and usability questionnaire.
Bus, Waaijman, & Nollet (2012)
Waaijman et al. (2013)
Patient charts Daily time of wearing protective or normal
footwear.
Compliance recorded on patient charts.
Chantelau & Haage (1994)
Patient diaries Compliance diary utilized by patient daily
entries. These entries included results
from activity monitor that was hip
mounted during walking hours.
Crews, Armstrong, & Boulton,
(2009).
Dual activity monitors Used diary and activity monitor to measure
and record activity while wearing
prescribed footwear device.
Crews, Armstrong, & Boulton
(2009).
Questionnaires Questionnaires and semi structured
interviews used to gain information around
the use and possession of custom
prescribed footwear devices.
de Boer et al. (2009).
Electronic mail surveys Electronic surveys sent to participants to
complete and return. Survey included
questions on wear time and activity.
Goss, D. L., & Moore, J. H.
(2004).
Conclusion
In conclusion, Māori have high prevalence rates of rheumatoid arthritis and gout. These diseases have severely impacts their quality of life, particularly with the development of foot deformities, foot pain and disability. Prescribed footwear is used to off-load peak plantar pressures from deformities. However, there is minimal evidence about how to measure if these off-loading
modalities are being used by the patient. This literature review revealed that there are studies that have used methods to measure adherence to prescribed footwear, although there were no studies about ways of measuring adherence to footwear for patients with pain and deformity associated with inflammatory joint disease. For Māori, inflammatory joint disease, such as gout, is yet another inequity they live with that compounds pain and reducing quality of life.
Future research needs to be conducted with Māori sufferers of inflammatory joint disease that measures adherence to prescribed footwear. A footwear based temperature monitor linked to an electronic application (APP) log could then be used to record information (with minimal burden for completion on participants), which also synchronises with the temperature based monitor (similar to some electronic activity monitors available). This e-technology APP could be developed for patients to not only record information about the time wearing prescribed footwear or orthoses, but also provide useful information for patients as feedback. Therefore, this would be an information device as well as a recording device that does not rely on patient data input.
Dissemination Plan
This report to the Health Research Council can be publically made available on their website, as well as making it available on the Māori and Pacific databases.
This report will be used to inform a poster presentation in forthcoming CMDHB science fest applications.
A report on this study will be shared at podiatry network meetings at CMDHB.
Acknowledgements
Ngā mihi ki a Ihoa o ngā mano, ki ōku Tupuna hoki mō ngā manaakitanga ki ahau.
Ngā mihi nui ki a Denise Wilson mō ōna manaakitanga, āwhina hoki ki ahau i roto I tēnei huarahi mātauranga. Nāna i ārahi i tiaki mai i ahau i roto i tēnei mahi. Nō reira ngā mihi nui ki a Denise Wilson.
Ngā mihi anō ki a HRC mō tā rātou tautoko ki ahau.
Tēna rā koutou katoa.
SIGN OFF PAGE
This summer studentship report is representative of research conducted by the applicant, and has been reviewed and has been confirmed as satisfactory by the research supervisor
APPLICANT
Signed: Date:
28 February 2014
RESEARCH SUPERVISOR
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References
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Doi:10.1185/03007995.2010.533647
Bus, S. A., Waaijman, R., & Nollet, F. (2012). New monitoring technology to objectively assess adherence to prescribed footwear and assistive devices during ambulatory activity. Archives of Physical Medicine & Rehabilitation, 93(11), 2075-2079. doi:10.1016/j.apmr.2012.06.019
Chantelau, E., & Haage, P. (1994). An audit of cushioned diabetic footwear: Relation to patient compliance. Diabetic Medicine, 11(1), 114-116. doi:10.1111/j.1464-5491.1994.tb00240.x
Crews, R. T., Armstrong, D. G., & Boulton, A. J. M. (2009). A method for assessing off-loading compliance. Journal of the American Podiatric Medical Association, 99(2), 100-103. Dalbeth, N., Kalluru, R., & Aati, O. (2013 In press). Tendon involvement in the feet of patients with gout: A dual energy CT study. Annals of the Rheumatic Diseases, 72(9), 1545-1248.
doi:10.1136/annrheumdis-2012-202786
Dalbeth, N., Petrie, K., & House, M. (2011). Illness perceptions in patients with gout and the relationship with progression of musculoskeletal disability. Arthritis Care Research, 63, 1605-1612. doi:10.1002/acr.20570
de Boer, I. G., Peeters, A. J., Ronday, H. K., Mertens, B. J. A., Huizinga, T. W. J., & Vlieland, T. (2009).
Assistive devices: Usage in patients with rheumatoid arthritis. Clinical Rheumatology, 28(2), 119-128. doi:10.1007/s10067-008-0989-7
Goss, D. L., & Moore, J. H. (2004). Compliance wearing a heel lift during 8 weeks of military training in cadets with limb length inequality. Journal of Orthopaedic & Sports Physical Therapy, 34(3), 126-131.doi:10.2519/jospt.2004.34.3.126
Ihaka, B., Bayley, A., & Rome, K. (2012). Foot problems in Māori with diabetes. New Zealand Medical Journal, 125(1360), 48-56.
Lindsay, K., Gow, P., & Vanderpyl, J. (2011). The experience and impact of living with gout: A study of men with chronic gout using a qualitative grounded theory approach. Journal of Clinical Rheumatology, 17, 1-6. doi:10.1097/RHU.0b013e318204a8f9
Roelof, W., Renske, K., Mirjam, H., Wojtek, P., Frans, N., & Sicco, A. (2013). Adherence to wearing prescription custom made footwear in patients with diabetes at high risk for plantar foot ulceration. Diabetes Care, 36(6), 1613-1618. doi:10.2337/dc12-1330
Rome, K., Erikson, K., Ng, A., Gow, P., Sahid, H., & Williams, A. (2013). A new podiatry service for patients with arthritis. New Zealand Medical Journal, 126(1370), 70-77.
Rome, K., Stewart, S., Vandal, A. C., Gow, P., McNair, P., & Dalbeth, N. (2013). The effects of commercially available footwear on foot pain and disability in people with gout: A pilot study. BMC Musculoskeletal Disorders, 14, 278-278. doi:10.1186/1471-2474-14-278
Rome, K., Supervalli, D., & Sanders, A. (2011). Functional and biomechanical characteristics of foot disease in chronic gout: A case-control study. Clinical Biomechanics, 26, 90-94.
doi:10.1016/j.clinbiomech.2010.09.006
Waaijman, R., Keukenkamp, R., de Haart, M., Polomski, W. P., Nollet, F., & Bus, S. A. (2013).
Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration. Diabetes Care, 36(6), 1613-1618. doi:10.2337/dc12-1330 Winnard, D., Wright, C., & Taylor, W. (2012). National prevalence of gout derived from administrative health data in Aotearoa. Rheumatology, 51, 901-909.
doi:10.1093/rheumatology/ker361
Zhu, Y., Pandya, B., & Choi, H. (2011). Prevalence of gout and hyperuricaemia in the US general population. Arthritis Rheumatology, 63, 3136-3141. doi:10.1002/art.30520
Appendix 1
Summary of Literature
REFERENCE CONTEXT & PARTICIPANTS RESEARCH DESIGN & METHODS KEY FINDINGS LIMITATIONS RELEVANCE TO
Bus, Waaijman & Nollet (2012) Assessed the validity and
feasibility of a new temperature-
based adherence monitor to
measure footwear use.
n=11 healthy +
n=14 neuropathic diabetic
patients with high risk of foot
ulceration Observational study
In-shoe attached adherence monitor
to measure when footwear was on
and off.
Participants kept a log for 7 days and
completed a usability questionnaire
Mean time difference between
footwear on and off to calculate
adherence
The adherence monitor shows good validity in
measuring when footwear is used or not, and
is, together with instrumented monitoring of
walking activity, a feasible and objective
method to assess treatment adherence.
This method can have wide application in
clinical practice and research regarding
prescribed footwear and other body-worn
assistive devices.
No gout patients
Small observational study
Neuropathic diabetic high
risk patients not gout
patients.
Chantelau & Haage (1994) 51 diabetic patients with
recurrence of neuropathic foot
and who regularly attended a
diabetic foot clinic were
provided with protective
footwear to reduce peak plantar
pressure at the forefoot area by
50% (versus normal shoes), and
followed up for up to 4 years. Observational study
Compliance recorded by assesing daily
time of wearing protective shoes and
complicance recorded from the
entries in patients charts.
Wearing protective shoes for 60% of the
daytime significantly (p = 0.0002) reduced the
ulcer relapse rate by 50% in comparison with
shorter wearing times for these shoes.
Patients without ulcer relapses had foot care
significantly more frequently than patients
with relapse (p < 0.05).
It was concluded that cushioned protective
footwear with frequent foot care is essential
in the prevention of neuropathic diabetic foot
ulcer recurrence.
No gout patients
Errors in recording as patients
can misenter times into charts
or miss days.
No gout patients
No Māori patients
Crews, Armstrong, & Boulton (2009). Off-loading excessive pressure is
essential to healing diabetic foot
ulcers. However, many patients
are not compliant in using
prescribed footwear or off-
loading devices. We sought to
validate a method of objectively
measuring off-loading
compliance via activity
monitors..
Methods: For 4 days, a single subject
maintained a written compliance
diary concerning use of a removable
cast walker. He also wore a hip-
mounted activity monitor during all
waking hours. An additional activity
monitor remained mounted on the
cast walker at all times. At the
conclusion of the 4 days, the time-
stamped hip activity data were
independently coded for walker
compliance by the compliance diary
and by using the time-stamped walker
activity data
These results support the use of this dual
activity monitor approach for assessing off-
loading compliance. An advantage of this
approach versus a patient-maintained diary is
that the monitors are not susceptible to
incorrect patient recall or a patient's desire to
please a caregiver by reporting inflated
compliance. Furthermore, these results seem
to lend support to existing reports in the
literature using similar methods
Small sample size
Small sample ethnicity variance
No Gout patients
No Māori patients
14
de Boer et al. (2009) We describe the usage of various
assistive devices and identify
factors associated with usage in
patients with rheumatoid
arthritis (RA). Two hundred forty
patients with RA participated in
the study. A cross-sectional, multicentre study
was performed in three outpatient
rheumatology clinics in the
Netherlands. The main measures
were questionnaires and a semi-
structured interview regarding the
possession and usage of 21 common
assistive devices in the ISO9999
categories orthopaedic footwear,
personal care, mobility, household
and adaptations for housing. Potential
factors associated with usage included
sociodemographic variables, health
status, quality of life, coping
strategies, self-efficacy, outcome
expectations and satisfaction.
Out of 240 patients, 213 (89%) had one or
more assistive devices in possession (median
number of devices 3.0, interquartile range
3.0). The proportions of patients never using a
device in possession varied between 8% for
orthopaedic insoles and 23% for grab bars.
The main factors related to usage varied
among categories, but common determinants
were a specific impairment or disability,
satisfaction with the device or related
services, self-efficacy and the number of
devices in possession. In conclusion, in
patients with RA, possession rates are high,
with 23% or less of the devices in possession
being abandoned. Overall, satisfaction rates
were high. Factors associated with usage
varied among categories and comprised, apart
from the number of devices in possession and
variables related to health status, also aspects
of satisfaction with the device or related
services or self-efficacy. The latter findings
underline the need for a systematic evaluation
of the outcomes of assistive devices by
prescribing health professionals or suppliers in
every individual case.
Goss & Moore (2004) To examine compliance in
wearing heel lifts during 8 weeks
of military training in cadets
identified with limb length
inequalities. Background: Lack of
compliance can be blamed for
countless poor outcomes in the
medical community. Reported
compliance with intervention
protocols has been reported to
range from 11% to 95%. All 1100
new cadets in the class of 2005
were screened for a limb length
inequality. One hundred ninety-
eight out of 1100 cadets were
identified to have a limb length
inequality on physical exam and
volunteered to participate.
Cadets were randomly assigned Retrospective descriptive study.
All 1100 new cadets in the class of
2005 were screened for a limb length
inequality. One hundred ninety-eight
out of 1100 cadets were identified to
have a limb length inequality on
physical exam and volunteered to
participate. Cadets were randomly
assigned to a heel lift or control
group. Cadets in the heel lift group
were instructed to wear a heel lift at
all times throughout cadet basic
training to attempt to prevent
overuse injuries.
In an attempt to discern whether the
preventive intervention was
ineffective by design or if
noncompliance was to blame,
Cadet compliance was poor with the use of a
heel lift. Physical therapists throughout the
military often prescribe heel lifts, therapeutic
exercises, or medication and assume good to
excellent compliance. This study reminds
providers that good compliance should not be
assumed in any setting.
Leg length dexcrepancy
patients
Not Gout patients
15
to a heel lift or control group. investigators asked cadets via
electronic mail survey to report
compliance with heel lift wear as a
percentage (0%-100%)
Macfarlane & Jensen (2003) The use of diabetic footwear has
been shown to be effective in
reducing the incidence of
diabetic foot ulcerations. For
diabetic footwear to be most
effective, it must be worn at
least 60% of the time. All
reported rates of compliance fall
well short of this level. The style
and appearance of the shoe have
been commonly blamed for this
poor compliance. This study evaluates patients'
motivations and perceptions
regarding diabetic footwear.
Retrospective study
A patient's decision to use diabetic footwear is
based on the perceived value of the shoe and
not on the patient's previous history of foot
complications or the aesthetics of diabetic
footwear.
Diabetic populations No Gout or Rheumatoid
specific adherence
measurement factors
Rome et al (2013) The impact of gout on foot
function and biomechanics is
currently unknown. The aim if
this study was to describe the
effects of chronic gout upon
function and selected
biomechanical parameters
associated with gait. 25 patients with a history of gout
were compared with 25 age and
gender matched control participants
with no history of gout or other forms
of arthritis.
Patients with chronic Gout had higher levels of
general and foot-specific disability, pain and
impairment. There were lower peak plantar
pressures at the hallux of patients with
chronic gout and higher mid foot pressures.
Gout patients also walked slower with longer
step and stride lengths.
Not measuring adherence Proving that Gout is
associated with foot pain
and disability. Different toe
off stratergies may account
for functional changes and
pain associated with foot
problems in chronic gout.
Waaijman et al. (2013). OBJECTIVE-Prescription custom-
made footwear can only be
effective in preventing diabetic
foot ulcers if worn by the
patient. Particularly, the high
prevalence of recurrent foot
ulcers focuses the attention on
adherence, for which objective
data are non-existing. We
objectively assessed adherence
in patients with high risk of ulcer
recurrence and evaluated what
determines adherence. 107 patients with diabetes,
neuropathy, a recently healed plantar
foot ulcer, and custom-made
footwear, footwear use was
measured during 7 consecutive days
using a shoe-worn, temperature-
based monitor. Daily step count was
measured simultaneously using an
ankle-worn activity monitor. Patients
logged time away from home.
Adherence was calculated as the
percentage of steps that prescription
footwear was worn. Determinants of
adherence were evaluated in
multivariate linear regression analysis
Lower BMI, more severe foot deformity, and
more appealing footwear were significantly
associated with higher adherence.
CONCLUSIONS-The results show that
adherence to wearing custom-made footwear
is insufficient, particularly at home where
patients exhibit their largest walking activity.
This low adherence is a major threat for re
ulceration. These objective findings provide
directions for improvement in adherence,
which could include prescribing specific off-
loading footwear for indoors, and they set a
reference for future comparative research on
footwear adherence in diabetes.
Short term of study
Error in patient recording
Not Gout patients
16