The authors of a literature review published in the November issue of the Journal of the American Podiatric Medical Association have developed a consensus statement of guidelines and recommendations for off-loading in the management of diabetes-related foot ulcers (DFUs). After conducting a PubMed literature review of about 90 studies for evidence about off-loading of foot ulcers, the authors, nine multidisciplinary experts, drafted the statements and recommendations using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to assess quality of evidence and develop strength of recommendations for each consensus statement.
The authors conclude that adherence with off-loading increases the likelihood DFUs will heal, and current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. However, they noted that an increase in clinician use of effective off-loading is necessary. “Publishing this paper is intended to bridge the gap between evidence supporting the effectiveness of off-loading for diabetic foot ulcers and its use in clinical practice, and to guide the wound care decision-making process,” said Robert J. Snyder, DPM, MSc, professor and director of clinical research at Barry University School of Podiatric Medicine, and lead author of the guidelines.
The guidelines are as follows:
- Consensus Statement 1: The VIPs (vascular management, infection management and prevention, and pressure relief) are essential to DFU healing.
- Consensus Statement 2: Adequate off-loading increases the likelihood of DFU healing.
- Consensus Statement 3: For guidance on off-loading the Charcot foot, the panel endorses “The Charcot Foot in Diabetes” consensus report published in 2011 (Diabetes Care, vol. 34).
- Consensus Statement 4: Total contact casting is the preferred method for off-loading plantar DFUs, as it has most consistently demonstrated the best healing outcomes and is a cost-effective treatment.
- Consensus Statement 5: There currently exists a gap between the evidence supporting the efficacy of DFU off-loading and what is performed in clinical practice.
- Consensus Statement 6: The likelihood of DFU healing is increased with off-loading adherence.
- Consensus Statement 7: Advanced therapeutics are unlikely to succeed in improving wound-healing outcomes unless effective off-loading is obtained.
- Consensus Statement 8: The panel supports the development of a per-visit off-loading quality measure to address the gap between evidence of off-loading and its current use in clinical practice.