Effectively Offloading DFUs When Patients Experience Financial Challenges

  According to the Centers for Disease Control and Prevention, more than 29 million Americans have been diagnosed with diabetes. With 15% of those diagnoses including at least one diabetic foot ulcer¹ (DFU), it’s not surprising that DFUs remain one of the most common conditions treated each day among US wound clinics. Patients who are prescribed insulin and/or live with comorbid peripheral neuropathy, kidney disease, eye disease, or heart disease are at higher risk of an ulcer. Among those patients, about 25% require amputation.¹

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  The best tool wound care providers can give these patients is to assess their feet often in order to help patients, especially those experiencing neuropathy, identify DFUs and seek care as soon as possible. One of the most crucial concerns with healing DFUs is patient adherence. Although it may seem easy to the clinician, offloading can be rather difficult for patients to achieve because — let’s face it — many patients “don’t want to be inconvenienced” and/or financial barriers related to insurance and/or income may come into play. However, there are solutions that may help make care planning easier.

Appropriateness of TCC

  Total contact casting (TCC) is known for its ability to help patients maintain lifestyle without disrupting wound care and is considered by some to be the “gold standard” for reducing pressure.² However, it’s important to ensure that patients know they must walk in moderation with TCC. According to Snyder and Lanier, patients should limit walking to 1/3 of what is considered normal for them and never walk without the outer boot firmly secured to the cast, as that can result in the cast breaking or cracking as well as more financial demands, let alone additional wounds.² Additionally, providers should always ask each patient if a cast is loose, rubbing against skin, and/or if there’s any pain after application.

  Remember, as popular as TCC is among wound care providers, it's not always the best treatment for each patient from both a clinical and cost-effective standpoint. For example, if the patient’s DFU is on the right foot and he/she is actively driving an automobile, using a TCC can pose a safety threat and eventual physical and financial harm. Also, the outer boot that is required to be worn with the cast can be large and cumbersome, which doesn’t always work well if patients are petite and/or frail.

Considering Orthotic Shoes

  There are many orthotic shoes that can assist patients with offloading; however, most are denied by insurance in this author’s experience. As such, clinicians may need to consider orthotic shoes that are less expensive. One example is the Darco WCSTM Wound Care Shoe System for ulcerations that are Wagner Grade III or greater. This shoe offers four multidensity insoles that allow for customization of the sole to the location of the wound site on the plantar aspect.² It also has a leather upper-portion of the shoe that can be modified or cut for lateral pressure relief. A rocker bottom sole that is great for offloading metatarsal areas is another feature. This shoe is also great for long-term use due to its four multidensity insoles that allow for specifically targeted offloading. Sold in pairs, which lowers the cost of each shoe and better ensures there is no shoe-height difference when only wearing one shoe, the shoe is available in multiple sizes and ranges from $90-$125 depending on the durable medical equipment company or orthotic center.

  Another shoe option is the Globoped® Forefoot relief orthosis and the Globoped Heel relief orthosis. The forefoot relief shoe is a half-shoe that aims to relieve pressure on the forefoot and anterior midfoot by suspending half the foot in the air while supporting the posterior midfoot and heel. Other amenities include a soft inner lining, three straps that allow for customized comfort, and a forefoot shield that protects the foot from contact with objects. The heel-relief shoe is ready-made, offloads the posterior foot and heel, has four straps for added security, and has an adjustable hook and loop closure for comfort. Both shoes are lightweight and designed for either foot. In this author’s experience, many patients have shown adaptability with these two products due to reported ease in obtaining and applying them.

  Patients also experienced quicker healing rates in multiple clinics, according to this author’s experience, when implemented immediately with wound onset. The main drawbacks, however, are related to balance and gait issues. The patient’s ability to walk in any shoe prior to completing a purchase should be assessed. Another benefit may be to have patients wear socks with these shoes in order to reduce sliding and friction. Both shoes cost about $85-$100 and can be purchased by an orthotic center.

A Note On Knee Walkers

  There has been a lot of talk lately among wound care professionals about knee walkers as an alternative to traditional offloading. Patients have also shown interest in them as offloading resources, though they can be costly. Widely considered easier to use than crutches and less cumbersome than wheelchairs, knee walkers also provide comfort with increased ambulation. The first generations of these products were a bit stiff and difficult to maneuver, but those offered today are greatly improved. They now turn more easily with three-wheel design and swivel. Brakes, padded knee rests, and folding ability for easy storage in a car or on a bus are also key factors. Product cost has averaged about $300, but rental options may be more appropriate for some patients, with such prices typically varying from $90-$100 per month.

  Success hinges on the selection of an effective, convenient device for that particular patient who must be in agreement with proper treatment to help avoid amputation.³

Christina Le is director of clinical operations at Wound Care Advantage, Sierra Madre, CA.

References

1. American Podiatric Medical Association. Learn About Feet. Accessed online:www.apma.org/Learn/FootHealth.cfm?ItemNumber=981.

2. Snyder RJ, Lanier KK. Diabetes: Offloading difficult wounds. Lower Extremity Review. November 2009. Accessed online: https://lermagazine.com/article/diabetes-offloading-difficult-wounds.

3. Krasner D. In: Chronic Wound Care: The Essentials. 5th edition. HMP Communications. Chapter 20, p. 271-277. 2012.