title: The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review.
abstract: BACKGROUND
  Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot.
  
  
  METHODS
  A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques.
  
  
  RESULTS
  Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results.
  
  
  CONCLUSIONS
  This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure.
authors.affiliation: Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. s.a.bus@amc.uva.nl
authors.forename: S A
authors.initials: SA
authors.lastname: Bus
authors.forename: G D
authors.initials: GD
authors.lastname: Valk
authors.forename: R W
authors.initials: RW
authors.lastname: van Deursen
authors.forename: D G
authors.initials: DG
authors.lastname: Armstrong
authors.forename: C
authors.initials: C
authors.lastname: Caravaggi
authors.forename: P
authors.initials: P
authors.lastname: Hlavácek
authors.forename: K
authors.initials: K
authors.lastname: Bakker
authors.forename: P R
authors.initials: PR
authors.lastname: Cavanagh
mesh_terms: D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D017719:Diabetic Foot / Q000150:complications / Q000628:therapy*; D016523:Foot Ulcer / Q000517:prevention & control* / Q000628:therapy; D006801:Humans; D011312:Pressure; D001405:Reflex, Babinski; D012775:Shoes; D016474:Weight-Bearing