The Use of mHealth Apps for the Assessment and Management of Diabetes-Related Foot Health Outcomes: Systematic Review.

BACKGROUND: Globally, diabetes affects approximately 500 million people and is predicted to affect up to 700 million people by 2045. In Australia, the ongoing impact of colonization produces inequity in health care delivery and inequality in health care outcomes for First Nations Peoples, with diabetes rates 4 times those of non-Indigenous Australians. Evidence-based clinical practice has been shown to reduce complications of diabetes-related foot disease, including ulceration and amputation, by 50%. However, factors such as a lack of access to culturally safe care, geographical remoteness, and high costs associated with in-person care are key barriers for First Nations Peoples in accessing evidence-based care, leading to the development of innovative mobile health (mHealth) apps as a way to increase access to health services and improve knowledge and self-care management for people with diabetes. OBJECTIVE: This study aims to evaluate studies investigating the use of mHealth apps for the assessment and management of diabetes-related foot health in First Nations Peoples in Australia and non-Indigenous populations globally. METHODS: PubMed, Informit's Indigenous Collection database, Ovid MEDLINE, Embase, CINAHL Complete, and Scopus were searched from inception to September 8, 2022. Hand searches of gray literature and reference lists of included studies were conducted. Studies describing mHealth apps developed for the assessment and management of diabetes-related foot health were eligible. Studies must include an evaluation (qualitative or quantitative) of the mHealth app. No language, publication date, or publication status restrictions were used. Quality appraisal was performed using the revised Cochrane risk-of-bias tool for randomized trials and the Health Evidence Bulletins Wales checklists for observational, cohort, and qualitative studies. RESULTS: No studies specifically including First Nations Peoples in Australia were identified. Six studies in non-Indigenous populations with 361 participants were included. Foot care education was the main component of all mHealth apps. Of the 6 mHealth apps, 2 (33%) provided functionality for participants to enter health-related data; 1 (17%) included a messaging interface. The length of follow-up ranged from 1-6 months. Of the 6 studies, 1 (17%) reported high levels of acceptability of the mHealth app content for self-care by people with diabetes and diabetes specialists; the remaining 5 (83%) reported that participants had improved diabetes-related knowledge and self-management skills after using their mHealth app. CONCLUSIONS: The findings from this systematic review provide an overview of the features deployed in mHealth apps and indicate that this type of intervention can improve knowledge and self-care management skills in non-Indigenous people with diabetes. Future research needs to focus on mHealth apps for populations where there is inadequate or ineffective service delivery, including for First Nations Peoples and those living in geographically remote areas, as well as evaluate direct effects on diabetes-related foot disease outcomes. TRIAL REGISTRATION: PROSPERO CRD42022349087; https://tinyurl.com/35u6mmzd.

Habitual Physical Activity of People with or at Risk of Diabetes-Related Foot Complications.

Regular physical activity is an important component of diabetes management. However, there are limited data on the habitual physical activity of people with or at risk of diabetes-related foot complications. The aim of this study was to describe the habitual physical activity of people with or at risk of diabetes-related foot complications in regional Australia. Twenty-three participants with diabetes from regional Australia were recruited with twenty-two participants included in subsequent analyses: no history of ulcer (N = 11) and history of ulcer (N = 11). Each participant wore a triaxial accelerometer (GT3X+; ActiGraph LLC, Pensacola, FL, USA) on their non-dominant wrist for 14 days. There were no significant differences between groups according to both participant characteristics and physical activity outcomes. Median minutes per day of moderate-to-vigorous physical activity (MVPA) were 9.7 (IQR: 1.6-15.7) while participants recorded an average of 280 ± 78 min of low-intensity physical activity and 689 ± 114 min of sedentary behaviour. The sample accumulated on average 30 min of slow walking and 2 min of fast walking per day, respectively. Overall, participants spent very little time performing MVPA and were largely sedentary. It is important that strategies are put in place for people with or at risk of diabetes-related foot complications in order that they increase their physical activity significantly in accordance with established guidelines.

Aboriginal and Torres Strait Islander Peoples' perceptions of foot and lower limb health: a systematic review.

BACKGROUND: Ongoing colonisation produces inequity in healthcare delivery and inequality in healthcare outcomes for Aboriginal and Torres Strait Islander Peoples. As a consequence, within the domain of lower limb health, foot disease has severe impacts for First Nations Peoples. Central to developing culturally safe healthcare and driving positive foot health change for First Nations Peoples, is the need for health professionals to develop understanding of First Nations perspectives of foot health. The aim of this systematic review was to evaluate studies investigating Aboriginal and Torres Strait Islander Peoples' perceptions of foot and lower limb health. METHODS: PubMeD, Ovid (Embase, Emcare, Medline), CINAHL, Informit Indigenous collection, and grey literature sources were searched to 23rd July 2021. We included any published reports or studies that examined Aboriginal and Torres Strait Islander Peoples' perceptions of foot and lower limb health, or meanings of, or attitudes to, foot and lower limb health. RESULTS: Four studies with a total of 1515 participants were included. Studies found that Aboriginal and Torres Strait Islander people self-assessed foot health with a demonstrated ability to perceive their feet as healthy relative to Western clinical measures of peripheral blood supply and neurological function. Footwear, including ill-fitting or lack of footwear was considered a contributing factor to reduced foot and lower limb health. Foot pain affected up to 60% of participants with up to 70% of foot pain untreated. Lack of access to culturally safe health care delivered by culturally capable health professionals was perceived to contribute to worse foot and lower limb health outcomes. CONCLUSIONS: Aboriginal and Torres Strait Islander Peoples' perceptions of foot and lower limb health are influenced by multiple complex interrelated factors. The limited number of studies in this area indicates ongoing failings to consult First Nations Peoples regarding their own lower limb and foot health. It is therefore essential that healthcare service and cultural capability implementation is led by Aboriginal and Torres Strait Islander Peoples in co-design. Urgent need for further research that exemplifies design and delivery of culturally safe care is required.

Release of the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary.

BACKGROUND: Developing since colonisation, Australia's healthcare system has dismissed an ongoing and successful First Nations health paradigm in place for 60,000 years. From Captain James Cook documenting 'very old' First Nations Peoples being 'far more happier than we Europeans' and Governor Arthur Phillip naming Manly in admiration of the physical health of Gadigal men of the Eora Nation, to anthropologist Daisy Bates' observation of First Nations Peoples living 'into their eighties' and having a higher life expectancy than Europeans; our healthcare system's shameful cultural safety deficit has allowed for an Aboriginal and Torres Strait Islander child born in Australia today to expect to live 9 years less than a non-Indigenous child. Disproportionately negative healthcare outcomes including early onset diabetes-related foot disease and high rates of lower limb amputation in Aboriginal and Torres Strait Islander Peoples contribute to this gross inequity. MAIN BODY: In 2020, the Australian Health Practitioner Regulation Authority released the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025 - empowering all registered health practitioners within Australia to provide health care to Aboriginal and Torres Strait Islander Peoples that is inclusive, respectful and safe, as judged by the recipient of care. This recently released strategy is critically important to the podiatry profession in Australia. As clinicians, researchers and educators we have a collective responsibility to engage with this strategy of cultural safety. This commentary defines cultural safety for podiatry and outlines the components of the strategy in the context of our profession. Discussion considers the impact of the strategy on podiatry. It identifies mechanisms for podiatrists in all settings to facilitate safer practice, thereby advancing healthcare to produce more equitable outcomes. CONCLUSION: Aboriginal and Torres Strait Islander Peoples access health services more frequently and have better health outcomes where provision of care is culturally safe. By engaging with the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy, all registered podiatrists in Australia can contribute to achieving equity in health outcomes for Aboriginal and Torres Strait Islander Peoples.

Efficacy of heel lifts versus calf muscle eccentric exercise for mid-portion Achilles tendinopathy (HEALTHY): a randomised trial.

OBJECTIVES: To compare the efficacy of in-shoe heel lifts to calf muscle eccentric exercise in reducing pain and improving function in mid-portion Achilles tendinopathy. METHODS: This was a parallel-group randomised superiority trial at a single centre (La Trobe University Health Sciences Clinic, Discipline of Podiatry, Melbourne, Victoria, Australia). One hundred participants (52 women and 48 men, mean age 45.9, SD 9.4 years) with clinically diagnosed and ultrasonographically confirmed mid-portion Achilles tendinopathy were randomly allocated to either a (1) heel lifts (n=50) or (2) eccentric exercise (n=50) group. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 12 weeks. Differences between groups were analysed using intention to treat with analysis of covariance. RESULTS: There was 80% follow-up of participants (n=40 per group) at 12 weeks. The mean VISA-A score improved by 26.0 points (95% CI 19.6 to 32.4) in the heel lifts group and by 17.4 points (95% CI 9.5 to 25.3) in the eccentric exercise group. On average, there was a between-group difference in favour of the heel lifts for the VISA-A (adjusted mean difference 9.6, 95% CI 1.8 to 17.4, p=0.016), which approximated, but did not meet our predetermined minimum important difference of 10 points. CONCLUSION: In adults with mid-portion Achilles tendinopathy, heel lifts were more effective than calf muscle eccentric exercise in reducing pain and improving function at 12 weeks. However, there is uncertainty in the estimate of effect for this outcome and patients may not experience a clinically worthwhile difference between interventions. TRIAL REGISTRATION NUMBER: ACTRN12617001225303.

Effect of different orthotic materials on plantar pressures: a systematic review.

BACKGROUND: The effect of different orthotic materials on plantar pressures has not been systematically investigated. This study aimed to review and summarise the findings from studies that have evaluated the effect of orthotic materials on plantar pressures. METHODS: We conducted a systematic review of experimental studies that evaluated the effect of foot orthotic materials or shoe insole materials on plantar pressures using in-shoe testing during walking. The following databases were searched: MEDLINE, CINAHL, Embase and SPORTDiscus. Included studies were assessed for methodological quality using a modified Quality Index. Peak pressure, pressure-time integral, maximum force, force-time integral, contact area, and contact time were variables of interest. Data were synthesised descriptively as studies were not sufficiently homogeneous to conduct meta-analysis. Standardised mean differences (Cohen's d) were calculated to provide the size of the effect between materials found in each study. RESULTS: Five studies were identified as meeting the eligibility criteria. All five studies were laboratory-based and used a repeated measures design. The quality of the studies varied with scores ranging between 20 and 23 on the modified Quality Index (maximum index score 28). The included studies investigated the effects of polyurethane (including PORON®), polyethylene (including Plastazote®), ethyl vinyl acetate (EVA) and carbon graphite on plantar pressures. Polyurethane (including PORON®), polyethylene (including Plastazote®) and EVA were all found to reduce peak pressure. CONCLUSION: Based on the limited evidence supplied from the five studies included in this review, some orthotic materials can reduce plantar pressures during walking. Polyurethane (including PORON®), polyethylene (including Plastazote®) and EVA reduce peak pressure beneath varying regions of the foot. Future well-designed studies will strengthen this evidence.

Corticosteroid injection for plantar heel pain: a systematic review and meta-analysis.

BACKGROUND: Corticosteroid injection is frequently used for plantar heel pain (plantar fasciitis), although there is limited high-quality evidence to support this treatment. Therefore, this study reviewed randomised trials to estimate the effectiveness of corticosteroid injection for plantar heel pain. METHODS: A systematic review and meta-analysis of randomised trials that compared corticosteroid injection to any comparator. Primary outcomes were pain and function, categorised as short (0 to 6 weeks), medium (7 to 12 weeks) or longer term (13 to 52 weeks). RESULTS: A total of 47 trials (2989 participants) were included. For reducing pain in the short term, corticosteroid injection was more effective than autologous blood injection (SMD -0.56; 95% CI, - 0.86 to - 0.26) and foot orthoses (SMD -0.91; 95% CI, - 1.69 to - 0.13). There were no significant findings in the medium term. In the longer term, corticosteroid injection was less effective than dry needling (SMD 1.45; 95% CI, 0.70 to 2.19) and platelet-rich plasma injection (SMD 0.61; 95% CI, 0.16 to 1.06). Notably, corticosteroid injection was found to have similar effectiveness to placebo injection for reducing pain in the short (SMD -0.98; 95% CI, - 2.06, 0.11) and medium terms (SMD -0.86; 95% CI, - 1.90 to 0.19). For improving function, corticosteroid injection was more effective than physical therapy in the short term (SMD -0.69; 95% CI, - 1.31 to - 0.07). When trials considered to have high risk of bias were excluded, there were no significant findings. CONCLUSIONS: Based on the findings of this review, corticosteroid injection is more effective than some comparators for the reduction of pain and the improvement of function in people with plantar heel pain. However, corticosteroid injection is not more effective than placebo injection for reducing pain or improving function. Further trials that are of low risk of bias will strengthen this evidence. REGISTRATION: PROSPERO registration number CRD42016053216 .

Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial.

BACKGROUND: Plantar heel pain is a common foot complaint that causes significant disability and poorer health-related quality of life. Foot orthoses and corticosteroid injection are effective treatments for plantar heel pain; however, it is unclear whether one is more effective than the other. OBJECTIVE: The aim of this trial was to compare the effectiveness of foot orthoses and corticosteroid injection for plantar heel pain. METHODS: In this parallel-group, assessor-blinded, randomized clinical trial, participants received prefabricated, arch-contouring foot orthoses or a single ultrasound-guided corticosteroid injection. The primary outcome measure was the foot pain subscale of the Foot Health Status Questionnaire at 4 and 12 weeks. RESULTS: One hundred three participants aged 21 to 72 years (63 female) with plantar heel pain were recruited from the community and received an intervention. For the primary outcome of foot pain, corticosteroid injection was more effective at week 4 (adjusted mean difference, 8.2 points; 95% confidence interval: 0.6, 15.8 points). However, foot orthoses were more effective at week 12 (adjusted mean difference, 8.5 points; 95% confidence interval: 0.2, 16.8 points). Although these findings were statistically significant, the differences between the interventions did not meet the previously calculated minimal important difference value of 12.5 points. CONCLUSION: Corticosteroid injection is more effective than foot orthoses at week 4, but this effect does not last; and appropriately contoured foot orthoses are more effective than corticosteroid injection at week 12. However, patients may not notice a clinically worthwhile difference between the interventions. LEVEL OF EVIDENCE: Therapy, level 1b. J Orthop Sports Phys Ther 2019;49(7):491-500. Epub 26 May 2019. doi:10.2519/jospt.2019.8807.

Increasing preferred step rate during running reduces plantar pressures.

Increasing preferred step rate during running is a commonly used strategy in the management of running-related injuries. This study investigated the effect of different step rates on plantar pressures during running. Thirty-two healthy runners ran at a comfortable speed on a treadmill at five step rates (preferred, ±5%, and ±10%). For each step rate, plantar pressure data were collected using the pedar-X in-shoe system. Compared to running with a preferred step rate, a 10% increase in step rate significantly reduced peak pressure (144.5±46.5 vs 129.3±51 kPa; P=.033) and maximum force (382.3±157.6 vs 334.0±159.8 N; P=.021) at the rearfoot, and reduced maximum force (426.4±130.4 vs 400.0±116.6 N; P=.001) at the midfoot. In contrast, a 10% decrease in step rate significantly increased peak pressure (144.5±46.5 vs 161.5±49.3 kPa; P=.011) and maximum force (382.3±157.6 vs 425.4±155.3 N; P=.032) at the rearfoot. Changing step rate by 5% provided no effect on plantar pressures, and no differences in plantar pressures were observed at the medial forefoot, lateral forefoot or hallux between the step rates. This study's findings indicate that increasing preferred step rate by 10% during running will reduce plantar pressures at the rearfoot and midfoot, while decreasing step rate by 10% will increase plantar pressures at the rearfoot. However, changing preferred step rate by 5% will provide no effect on plantar pressures, and forefoot pressures are unaffected by changes in step rate.