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Background: Plantar pressure reduction with the use of cushioning materials play an important role in the clinical management of the diabetic foot. Previous studies in people without diabetes have shown that appropriate selection of the stiffness of such materials can significantly enhance their capacity to reduce pressure. However the significance of optimised cushioning has not been yet assessed for people with diabetic foot syndrome., Research Question: What is the potential benefit of using footwear with optimised cushioning, with regards to plantar pressure reduction, in people with diabetes and peripheral neuropathy?, Methods: Plantar pressure distribution was measured during walking for fifteen people with diabetic foot syndrome in a cohort observational study. The participants were asked to walk in the same type of footwear that was fitted with 3D-printed footbeds. These footbeds were used to change the stiffness of the entire sole-complex of the shoe; from very soft to very stiff. The stiffness that achieved the highest pressure reduction relative to a no-footbed condition was identified as the patient-specific optimum one., Results: The use of the patient-specific optimum stiffness reduced, on average, peak pressure by 46% (±14%). Using the same stiffness across all participants lowered the footwears' capacity for pressure reduction by at least nine percentile points (37% ± 17%); a statistically significant difference (paired samples t-test, t(13) = -3.733, p = 0.003, d = 0.997). Pearson correlation analysis indicated that patient-specific optimum stiffness was significantly correlated with the participants' body mass index (BMI), with stiffer materials needed for people with higher BMI (rs(14) = 0.609, p = 0.021)., Significance: This study offers the first quantitative evidence in support of optimising cushioning in diabetic footwear as part of standard clinical practice. Further research is needed to develop a clinically applicable method to help professionals working with diabetic feet identify the optimum cushioning stiffness on a patient-specific basis., Competing Interests: Declaration of Competing Interest Authors P. Chatzistergos and N. Chockalingam are named co-inventors in a relevant patent (International Application No. PCT/GB2018/052944)., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aims: Gait characteristics and balance are altered in diabetic individuals. Little is known about possible treatment strategies. This study evaluated the effect of a specific training program on diabetic patients' gait., Methods: A randomized controlled trial (N=71) with an intervention (IG) (N=35), and control group (CG) (N=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-oriented strengthening. Controls received no treatment., Results: After intervention the IG increased their habitual walking speed by 0.149ms(-1) (0.54kmh(-1)) on tarred terrain and by 0.169ms(-1) (0.61kmh(-1)) on the cobblestones. This significant treatment effect (p<0.001) decreased slightly at the six-month follow-up, but remained significant (p<0.001). In a similar manner, significant improvement was observed for cadence, gait cycle time and stance time on both terrains. All outcomes except stance time on the tarred terrain remained significant at the six-month follow-up. No significant effect was observed for stride length and the coefficient of variation of gait cycle time (on either surface) at the corrected significance level of p<0.004. CG patients' parameters all remained unchanged or progressively deteriorated compared to baseline values., Discussion: Cadence contributed 80%, whereas stride length only contributed 20% to the change of gait velocity. This may be due to the treatment or to diabetic patients' potential to regulate their cadence and stride length., Conclusion: A specific training program can improve diabetic patients' gait in a real life environment. A challenging environment highlights treatment effects on patients' gait better than an evenly tarred surface., (Copyright 2010 Elsevier B.V. All rights reserved.)

Background: Diabetes mellitus is one of the most common diseases worldwide and the number of patients is expected to increase dramatically in future. Plantar ulceration is partly caused by high plantar pressures and a major complication in diabetic patients., Purpose: The aim of this study was to investigate the pressure-relieving effects of two vacuum orthoses in patients with diabetes mellitus., Methods: Twenty patients with diabetes mellitus were included. They presented with plantar callosities but no ulceration. Exclusion criteria included the use of walking aids and other systemic diseases. Plantar pressure distribution was measured with sensor insoles (Pedar-X, Novel GmbH) during walking in two vacuum orthoses, a post-operative shoe and an off-the-shelf shoe as reference condition. Statistical analysis was conducted using Friedman and Wilcoxon signed-rank tests., Results: Significant differences in plantar pressure distribution were found between the four walking conditions. The contact area increased in the midfoot with the vacuum orthoses. Maximum force and peak pressures showed a significant decrease under the rearfoot and forefoot and increased in the midfoot area during walking with both vacuum orthoses. The high-cut vacuum orthosis revealed equal pressure relief under the forefoot and significantly lower rearfoot pressures compared to the post-operative shoe., Conclusions: The vacuum orthoses demonstrated a comparable pressure-relieving efficacy under the forefoot to post-operative shoes. Using vacuum orthosis significantly benefited re-distribution of plantar pressure and the roll-over process. Clinical significance of the pressure-relieving efficacy could not be confirmed in this investigation and has to be addressed in further studies.

Shoes with rocker bottom soles are utilized by persons with diabetic peripheral neuropathy to reduce plantar pressures during gait. This population also has a high risk for falls. This study analyzed the effects of shoes with rocker bottom soles on the postural response during perturbed stance. Participants were 20 healthy subjects (16 women, 4 men) ages 22-25 years. Canvas shoes were modified by the addition of crepe sole material to represent two forms of rocker bottom shoes and a control shoe. Subjects stood on a dynamic force plate programmed to move backward at a velocity that produced an automatic postural response without stepping. Force plate data were collected for five trials per shoe type. Sway variables for center of pressure (COP) and center of mass (COM) included: mean sway amplitude, sway variance, time to peak, anterior and posterior peak velocities, functional stability margin, and peak duration time. Compared to control, both the experimental shoes had significantly larger COP and COM values for mean sway amplitude, sway variance and peak duration. The functional stability margins were significantly smaller for the experimental shoes while their anterior and posterior peak velocities were slower and time to peaks were significantly longer. In young healthy adults, shoes with rocker bottom soles had a destabilizing effect to perturbed stance, thereby increasing the potential for imbalance. These results raise concerns that footwear with rocker bottom sole modifications to accommodate an insensate foot may increase the risk of falls.

Purpose: Forefoot offloading shoes (FOS) are commonly used in clinical practice for treatment of plantar forefoot ulcers in the diabetic foot. The aim of this study was to assess the offloading efficacy of four different FOS models in comparison with a cast shoe and control shoe., Methods: In-shoe plantar pressures were measured during walking in each of the six footwear conditions in 24 neuropathic diabetic patients at high risk for plantar foot ulceration. For each of six foot regions, peak pressure, pressure-time integral, and force-time integral were calculated. Load transfer diagrams were developed to assess the footwear mechanisms of action. Perceived walking comfort was measured using a visual analogue scale (VAS). All comparisons between conditions were tested at P<0.05., Results: Peak pressures and pressure-time integrals at the metatarsal heads and hallux regions were significantly reduced (by 38-58%) in all FOS models when compared with the control shoe. The FOS also relieved metatarsal head peak pressure to a significantly larger extent than the cast shoe (approximately 20%). The load transfer diagrams showed a major transfer of approximately 40% of forefoot load to the midfoot explaining the offloading efficacy of the FOS. Perceived walking comfort was significantly lower in the FOS (VAS score 2.7-5.9) when compared with the control shoe (VAS 8.2) and cast shoe (VAS 6.8)., Conclusions: The data showed that all FOS models were effective in their primary goal, relieving forefoot pressure in at-risk neuropathic diabetic patients. Therefore, these shoes may be effective in offloading and healing plantar forefoot ulcers, although the low comfort scores should be considered as this may potentially affect adherence to treatment.