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Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission

Patient Recommendations and Guidance from the Limb Preservation Consortium at USC and the Rancho Los Amigos National Rehabilitation Center

Malindu E. Fernando
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 PhD, MBBS, BHScience (Podiatry) Hons
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Stephanie L. Woelfel
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Diana Perry
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 DPM
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Bijan Najafi
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Tanzim Khan
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Charles DuBourdieu
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Laura Shin
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 DPM
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David G. Armstrong
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 DPM, MD, PhD
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Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called “remission” due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous “hotspots” prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.

Southwestern Academic Limb Salvage Alliance, Limb Preservation Program, Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA.

Interdisciplinary Consortium on Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.

Ulcer and Wound Healing Consortium, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.

Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA.

Rancho Los Amigos National Rehabilitation Center, Los Angeles, CA.

Department of Prosthetics and Orthotics, Rancho Los Amigos National Rehabilitation Center, Los Angeles, CA.

Corresponding author: David G Armstrong, DPM, MD, PhD, Keck School of Medicine of University of Southern California, 1520 San Pablo St, Health Sciences Campus, Los Angeles, CA. (E-mail: armstrong@usa.net)

Conflict of Interest: None reported.