Diabetic Foot Ulcers - Comparison of Cast Alternatives
Comparison ofRemovable Cast Walkers to the Total Contact Cast for the Treatment of Diabetic Foot UlcersCritically Appraised Topic (CAT) Summary
Diabetic Foot Ulcers (DFU)
2.3 million Canadians have diabetes today*
15% will develop a diabetic foot ulcer*
85% of all amputations are the result of a non-healing ulcer*
*National Diabetes Surveillance System: Diabetes in Canada 2009
Contributing Factors to DFU
Adapted from Lusardi and Neilson, page 544.
Treatment of Plantar DFU
Removal of Pressure
Gold Standard: Total Contact Cast (TCC)
Protects healing tissue
Cannot check wound
Alternatives for ulcer offloading
Custom Brace (AFO)
Removable cast walker (RCW)
Rebound Air Walker removable cast walker image courtesy of Ossur Canada.
Is the removable cast walker (RCW) as effective as the total contact cast (TCC) in the treatment of the plantar diabetic foot ulcer?
Summary of Best EvidenceKatz et al. (2005)Key Demographics
Summary of Best EvidenceKatz et al.Main Findings
Comparison of TCC and iRCW had similar outcomes for:
Proportion of people who had ulcers that healed
Median heal times
Time to don/doff: iRCW< TCC
Cost: iRCW< TCC
Implications for Practice
Best Practice Recommendations:
-> Remove the pressure
Fulltime use provides better outcomes
The RCW when made irremovable has similar outcomes when compared to the TCC
Studies are consistent with each other
Higher level studies (1b)
Studies are valid, reliable and relevant
Studies use small numbers
Studies are not blinded
Larger studies comparing TCC to RCW
Further study to compare RCW with and without custom insole
Implementation of results into clinical practice
-> make the RCW irremovable when using
Armstrong, D. G., Lavery, L. A., Wu, S., Boulton, A. J. M. (2005). Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. Diabetes Care, 28(3), 551-554.
Beuker, B. J., van Deursen, R. W., Price, P., Manning, E. A., van Baal, J. G., Harding, K. G. (2005). Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair and Regeneration, 13, 537-542.
Boninger, M. L., Leonard, J. A. (1996). Use of bivalve ankle foot orthosis in neuropathic foot and ankle lesions. Journal of Rehabilitation Research and Development, 33(1), 16-22.
Botros, M., Goett, K., Parsons, L. Menzildzic, S., Morin, C., Smith, T. Hoar, A., Nesbeth, H., McGrath, S. (2010). Best Practice Recommendation for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2010. Wound Care, 8(4), 6-40.
Bus, S. A., van Deursen, R. W., Armstrong, D. G., Caravaggi, C., Hlavacek, P., Bakker, K., Cavanaugh, P. R. (2008). The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes/Metabolism Research and Reviews, 24(Suppl 1), S162-S180. DOI:10.1002/dmrr.850.
Elftman, N. W. (2006). Orthotic management of the neuropathic limb. Physical Medicine and Rehabilitation Clinics of North America, 17, 115-157.
Fleischli, J. G., Lavery, L. A., Vela, S. A., Ashry, H., Lavery, D. C. (1997). Comparison of strategies for reducing pressure at the site of neuropathic ulcers. Journal of the American Podiatric Association, 87(10), 466-472.
Katz, I. A., Harlan, A., Miranda-Palma, B., Prieto-Sanchez, L., Armstrong, D. G., Bowker, J. H., Mizel, M. S., Boulton, A. J. M. (2005). A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care, 28(3), 555-559.
Lusardi, M. M., & Nielsen, C. C. (2007). Orthotics and prosthetics in rehabilitation. St. Louis, Missouri: Saunders Elsevier.
Maher, C. G., Sherrington, C., Herbert, R. D., Mosely, A. M., Elkins, M. (2003). Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy , 83(8), 713-721.
National Diabetes Surveillance System: Diabetes in Canada 2009. (2009). Report from the national diabetes surveillance system: Diabetes in Canada, 2009 No. HP32-2/1-2009. http://www.phac-aspc.gc.ca/publicat/2009/ndssdic-snsddac-09/pdf/report-2009-eng.pdf
PEDro Physiotherapy Evidence Database. The Centre for Evidence-Based Physiotherapy.http://search.pedro.org.au/pedro/browserecord.php?record_id=4580
Phillips, B., Ball, C., Sackett, D., Badenoch, D., Straus, S., Haynes, B., Dawes, M.(1998). Oxford Centre for Evidence Based Medicine – Levels of Evidence (March 2009) . Updated 2009 Howick, J. http://www.cebm.net/index.aspx?o=1025
Notice to Reader
This presentation was prepared to disseminate information as researched for the preparation of a Critically Appraised Topic (CAT) for a Masters Level Program, Evaluating Sources of Evidence. The information herein is for the sole purposes of sharing information on the specific topic.
Questions, concerns or requests for copies can be directed to: Linda LaaksoB.Sc.C.O.(c) at: www.customorthotic.ca