» Caring for the diabetic foot remains a monumental task for those entrusted with providing care to the lower extremities.
Caring for the diabetic foot remains a monumental task for those entrusted with providing care to the lower extremities. A confluence of numerous factors affect the health of the diabetic foot. Although there is certainly an association between diabetic foot disease and physical activity engagement, this relationship is nuanced and still not fully understood. While too much weightbearing activity can result in the formation of diabetic foot ulcers or prohibit healing, activity avoidance is clearly problematic for overall health and likely detrimental to maintaining resilience of the soft tissue of non-ulcerated diabetic feet. As such, there is likely a “Goldilocks” paradigm in place in which there is a level (or range) of physical activity that is “just right” for each person. This issue’s two audio lectures dive into the challenges of determining that just right dosage of activity for each patient. They also explore timely themes pertaining to the diabetic foot, including COVID-19 and the concept of maintaining activity-rich days for those patients in diabetic foot disease “remission.”
This issue’s commentaries present critical reviews of the latest literature pertaining to managing and monitoring physical activity profiles of patients with diabetic foot disease. In addition to considering the implications of the literature for care providers and patients, the contributors to this issue also address the larger ecosystem of healthcare by considering the role of healthcare payers in promoting lower extremity health. A sampling of the topics addressed by the original manuscripts reviewed by commentators includes: quantification of physical activity profiles, recommendations for managing physical activity levels, advances in offloading the diabetic foot to ensure safe participation in physical activity, and the use of foot temperature monitoring as an early warning system for times when physical activity should be dialed back.
It has been my great privilege to serve as the Guest Editor for this issue of Foot and Ankle Quarterly, and I am immensely grateful to my colleagues that kindly accepted the invitation to join me on this adventure. The international team that has come together for this issue is an all-star roster of clinicians and academics within the field of the diabetic foot. I hope you as a reader will come away from this issue better enabled to partner with patients in managing that “just right” level of physical activity engagement for each patient at each phase of their journey with diabetic foot disease.
The ideas and opinions expressed in Foot and Ankle Quarterly are those of the authors and do not necessarily reflect those of the Editor or the Publisher. Publication of an advertisement or other product mentioned in Foot and Ankle Quarterly should not be construed as an endorsement of the product of the manufacturer’s claims. Readers are encouraged to contact the manufacturer with any questions about the features or limitations of the products mentioned. The Publisher does not assume any responsibility for any injury and/or damage to any persons or property arising out of or related to any use of the material contained in this periodical. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each device or of each drug to be administered to verify the dosage, the method and duration of administration, or contraindications. It is the responsibility of the treating physician or other healthcare professionals, relying on independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient.
Disclosure
Data Trace Publishing Company Continuing Education Mission Statement Data Trace Publishing Company is committed to providing high-quality print and internet-based enduring continuing education programs, including lectures, feature articles, and condensations and commentaries on current clinical podiatric topics and medical risk management topics which lead to improved delivery of patient care and help reduce the potential for medical errors. These programs are provided to meet the educational needs of the podiatric medical profession and thereby enhance the quality of patient care.
Program Objectives Foot and Ankle Quarterly (FAQ) is a unique program designed to help today’s podiatric physician manage an ever-increasing flow of information. After completing the Foot and Ankle Quarterly, Volume 33 program, the learner should be better able to: develop and refine a perspective on current treatment recommendations, updates, and advances pertinent to podiatric practice; evaluate the implications of the learned information as it pertains to the diagnosis and treatment of podiatric disorders and societal issues and barriers, and; apply current trends, standards, and best practices into learner’s own practice.
Data Trace Publishing Company Continuing Education Accreditation Statement Data Trace Publishing Company is approved by the Council on Podiatric Medical Education (CPME) as a provider of continuing education in podiatric medicine. Data Trace Publishing Company has approved this activity for a maximum of 6 continuing education contact hours (CECHs). Physicians should claim only the contact hours commensurate with the extent of their participation in the activity.
Estimated time to complete activity: 6 hours Date of release: May 10, 2022 Expiration Date: March 10, 2025 (unless further validated and extended by provider). For amended dates of activity expiration, please see FAQ Activity Effective Dates at www.datatrace.com).
Commercial Interests No commercial interest provided financial support for this continuing education activity.
CECH Note Participants of Volume 33, Issue 1 will receive a maximum of 6 CECHs for a correctly-completed CME Answer Form. In order to qualify for CECHs, a score of 70% or more must be achieved on the written examination material. Any participant who does not pass the first time may take the exam one additional time (within 90 days of receipt of results). One retake test may be taken for a fee of $15. You will be responsible for notifying your state of the number of contact hours you have received.
Participants are required to complete a course evaluation for use in developing future issues and to meet the unique educational needs of podiatric physicians.
FINANCIAL DISCLOSURE INFORMATION
It is the policy of Data Trace Publishing Company to ensure balance, independence, objectivity, and scientific rigor in all of its educational programs. All faculty, presenters, speakers, authors, and reviewers participating in any programs provided by Data Trace Publishing Company are expected to disclose any relevant financial relationships with CPME-defined commercial interests to the program audience. “Relevant financial relationships” are financial relationships of the individual (including those of the individual’s spouse or partner) in any amount occurring within the past 12 months that create a conflict of interest. A commercial interest is any organization manufacturing, producing, marketing, re-selling, or distributing healthcare goods or services consumed by or used on patients. The CPME mandates that the content of accredited activities be objective and independent of commercial bias. The intent of this policy is that readers may form their own judgements about the presentations, using independent review to resolve all identified conflicts of interest.
In addition to disclosing commercial relationships, faculty are advised of the following policies:
Each continuing education planner and author has submitted a Conflict of Interest Disclosure in order to identify relevant financial relationships and resolve conflicts.
Limitations on Data: Presenter will ensure, to the extent possible, meaningful disclosure of limitations on data (e.g., ongoing research, interim analyses, preliminary data, or unsupported opinion).
Discussion of Unapproved Uses: If unapproved (unlabeled) uses are discussed during the continuing education activity, the presenter will disclose when a product is not approved in the United States (and/or the nation where the activity takes place) for the use under discussion.
Data Trace Publishing Company has identified the option to disclose as follows:
The following authors have disclosed whether they or a member of their immediate family:
Will be receiving an honorarium for this activity
Within the past 12 months, had a financial or other significant relationship with a commercial organization that markets a product to which they willrefer as speaker or author:
Received monetary or other significant research support
Are or had been a paid consultant
Are or had been a full-time or part-time employee
Are or had been a paid or unpaid member of an advisory or similar board
Are or had been a member or on the Board of Trustees
Other
Within the past 12 months, had a financial or other significant relationship with a commercial organization that markets a product to which they will refer as speaker or author, BUT will not be recommending any of their products over similar competitor products
Within the past 12 months, had a financial or other significant relationship with a commercial organization that markets a product to which they willrefer as speaker or author, AND will be recommending one or more of their products over similar competitor products. Recommendation will be based on:
Exclusively on data and/or clinical experience not generated by the manufacturer or derived from manufacturer-sponsored studies
Data and/or clinical experience most of which were not generated by the manufacturer or derived from manufacturer-sponsored studies
Data and/or clinical experience, most of which were generated by the manufacturer or derived from manufacturer-sponsored studies
Exclusively on data and/or clinical experience generated by the manufacturer or derived from manufacturer or derived from manufacturer-sponsored studies
Have no conflicts to disclose
Article Authors and Lecturers
David G. Armstrong, DPM, MD, PhD (n.)
Virginie Blanchette, DPM, PhD (1. Data Trace Publishing Company)
Ryan T. Crews, PhD, CCRP (1. Data Trace Publishing Company)
Frank L. Bowling, DPM (n.)
Joseph Candela, DPM (n.)
Annabelle L. Dookie, DPM (n.)
Malindu E. Fernando, MBBS, PhD (1. Data Trace Publishing Company)
Crystal Holmes, DPM (n.)
Patricia Kluding, DPM (1. Data Trace Publishing Company)
Peter A. Lazzarini, PhD (n.)
Brian D. Lepow, DPM (n.)
Chia-Ding Shih, DPM (n.)
Neil D. Reeves, DPM (n.)
Dyane E. Tower, DPM (n.)
James Wrobel, DPM (n.)
FAQ Journal Planning Committee
Chrissy Wesolowski (formally Calvert) (n.)
Kimberly Collignon (n.)
Lauren Molander (n.)
Stephanie Wu, DPM, MSc (n.)
33-1 Contributors
Guest Editor
Ryan T. Crews, PhD, CCRP
Dr. William M. Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, Chicago, IL
Contributors
David G. Armstrong, DPM, MD, PhD Professor of Surgery, Co-Director, University of Southern California Limb Preservation Program, Los Angeles, CA; Director, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine at the University of Southern California, Los Angeles, CA; Director, University of Southern California Center to Stream Healthcare in Place (C2Ship), Los Angeles, CA
Virginie Blanchette, DPM, MSc, PhD
Associate Professor, Podiatric Medicine Program, Université du Québec at Trois-Rivières (Canada), Board of Directors, Wounds Canada
Frank L. Bowling, BSc(Hons), PgD(Plast), MSc, DPM, PhD, DSc, FPRCPS, FRCPodS, FRCP Professor of Surgery and Translational Medicine, University of Manchester, Manchester, UK; Consultant Podiatric Surgeon, Manchester Foundation Trust; Adjunct/Visiting Professor of Surgery, Victor Babes University of Medicine and Pharmacy, Timișoara, Romania and Nicolae Testemitanu University of Medicine and Pharmacy, Chișinău, Moldova; International Advisory Board, World Health Organization (WHO)
Joseph Candela, DPM, PhD Staff Podiatrist, Department of Foot and Ankle Surgery, Major Health Partners, Shelbyville, IN
Annabelle L. Dookie, DPM, FACFAS Assistant Professor, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine, Chicago, IL; Fellow, American College of Foot and Ankle Surgeons; Diplomate, American Board of Podiatric Medicine
Malindu (Mal) E. Fernando, PhD, MBBS, BHsc (podiatry) Hons Visiting Fulbright scholar Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine of University of Southern California and at the Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Junior Doctor, The John Hunter Hospital, Newcastle, Australia; Adjunct post-doctoral research fellow, Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville, Australia; Conjoint Lecturer School of Medicine, University of Newcastle, Newcastle, Australia
Crystal Holmes, DPM, CWSP Podiatry Program Director, University of Michigan Medical School, Ann Arbor, MI; Past President, Michigan Podiatric Medical Association
Patricia Kluding, PT, PhD Professor and Chair, Department of Physical Therapy, Rehabilitation Science, and Athletic Training, Program Director, Doctor of Physical Therapy, University of Kansas Medical Center, Kansas City, KS
Peter A. Lazzarini, BAppSci, PhD Associate Professor, School of Public Health and Social Work, Queensland University Technology, Brisbane, Australia; Principal Research Fellow, Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia; Secretary, Offloading Working Group, International Working Group on the Diabetic Foot
Brian D. Lepow, DPM Assistant Professor of Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
Chia-Ding (JD) Shih, DPM, MPH, MA Assistant Professor, California School of Podiatric Medicine at Samuel Merritt University, Oakland, CA
Neil D. Reeves, PhD Professor of Musculoskeletal Biomechanics and Faculty Head of Research, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
Dyane E. Tower, DPM, MPH, MS, FACFAS, FACPM, FASPS Director of Clinical Affairs and Senior Medical Director, American Podiatric Medical Association, Bethesda, MD
James Wrobel, DPM, MS Staff Podiatrist, The Villages Health and University of Florida Health Central Florida, The Villages, FL
In This Issue
FEATURE ARTICLE: Physical Activity and the Diabetic Foot: Measuring What We Intend to Manage
Ryan T. Crews, PhD, CCRP
CONDENSATIONS and COMMENTARIES
Should Weightbearing Activity Be Reduced during Healing of Plantar Diabetic Foot Ulcers, Even when Using Appropriate Offloading Devices?
Commentary by Neil D. Reeves, PhD
Lower Resource Utilization for Patients with Healed Diabetic Foot Ulcers during Participation in a Prevention Program with Foot Temperature Monitoring
Commentary by James Wrobel, DPM
Mobility Advice to Help Prevent Re-Ulceration in Diabetes
Commentary by Peter A. Lazzarini, PhD
Innovative Intelligent Insole System Reduces Diabetic Foot Ulcer Recurrence at Plantar Sites: A Prospective, Randomized, Proof-of-Concept Study
Commentary by Dyane E. Tower, DPM
Short-Term Strength and Balance Training Does Not Improve Quality of Life but Improves Functional Status in Individuals with Diabetic Peripheral Neuropathy: A Randomized Controlled Trial
Commentary by Annabelle L. Dookie, DPM
Moderate-to-Vigorous-Intensity Physical Activity Observed in People with Diabetes-Related Foot Ulcers over a One-Week Period
Commentary by Joseph Candela, DPM, PhD
Ulcer-Free, Hospital-Free and Activity-Rich Days: Three Key Metrics for the Diabetic Foot in Remission
Commentary by Crystal Holmes, DPM
Physical Training and Activity in People with Diabetic Peripheral Neuropathy: Paradigm Shift
Commentary by Chia-Ding (JD) Shih, DPM, MPH, MA
Factors Associated with Wearing Inadequate Outdoor Footwear in Populations at Risk of Foot Ulceration: A Cross-Sectional Study
Commentary by Brian D. Lepow, DPM
Heel-Rise and Non-Weightbearing Ankle Plantar Flexion Tasks to Assess Foot and Ankle Function in People with Diabetes Mellitus and Peripheral Neuropathy
Commentary by Frank Bowling, DPM
AUDIO LECTURE 1: Physical Activity is Important for Those with Diabetic Peripheral Neuropathy
Patricia Kluding, PT, PhD
AUDIO LECTURE 2: Excessive Physical Activity Engagement by Those with Diabetic Foot Disease is a Bigger Concern than Engaging in Too Little
Malindu E. Fernando, MBBS, PhD, Virginie Blanchette, DPM, PhD and David G. Armstrong, DPM, MD, PhD