title: A systematic review and meta-analysis of off-loading methods for diabetic foot ulcers.
abstract: BACKGROUND
  Increased plantar foot pressure is one of several key factors that lead to diabetic foot ulcers. Multiple methods have been proposed to relieve this pressure and thus enhance wound healing and potentially prevent relapse. We aimed in this systematic review to find the best available evidence for off-loading methods.
  
  
  METHODS
  We searched MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus through October 2011. Pairs of independent reviewers selected studies and extracted data. Predefined outcomes of interest included complete wound healing, time to complete wound healing, amputation, infection, and relapse rates.
  
  
  RESULTS
  We identified 19 interventional studies, of which 13 were randomized controlled trials, including data from 1605 patients with diabetic foot ulcers using an off-loading method. The risk of bias in the included studies was moderate. This analysis demonstrated improved wound healing with total contact casting over removable cast walker, therapeutic shoes, and conventional therapy. There was no advantage of irremovable cast walkers over total contact casting. There was improved healing with half-shoe compared with conventional wound care. Therapeutic shoes and insoles reduced relapse rate in comparison with regular footwear. Data were sparse regarding other off-loading methods.
  
  
  CONCLUSIONS
  Although based on low-quality evidence (ie, evidence warranting lower certainty), benefits are demonstrated for use of total contact casting and irremovable cast walkers in the treatment of diabetic foot ulcers. Reduced relapse rate is demonstrated with various therapeutic shoes and insoles in comparison with regular footwear.
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn.
authors.forename: Tarig
authors.initials: T
authors.lastname: Elraiyah
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia (CONEVID), Lima, Peru.
authors.forename: Gabriela
authors.initials: G
authors.lastname: Prutsky
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia (CONEVID), Lima, Peru.
authors.forename: Juan Pablo
authors.initials: JP
authors.lastname: Domecq
authors.affiliation: Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece.
authors.forename: Apostolos
authors.initials: A
authors.lastname: Tsapas
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Nabhan
authors.affiliation: Phoenix VA Health Care System, Phoenix, Ariz.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Frykberg
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn; Department of Internal Medicine, University of Missouri, Columbia, Mo.
authors.forename: Belal
authors.initials: B
authors.lastname: Firwana
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn; Department of Internal Medicine, University of Missouri, Columbia, Mo.
authors.forename: Rim
authors.initials: R
authors.lastname: Hasan
authors.affiliation: Mayo Clinic Libraries, Mayo Clinic, Rochester, Minn.
authors.forename: Larry J
authors.initials: LJ
authors.lastname: Prokop
authors.affiliation: Evidence-based Practice Center, Mayo Clinic, Rochester, Minn; Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minn. Electronic address: murad.mohammad@mayo.edu.
authors.forename: Mohammad Hassan
authors.initials: MH
authors.lastname: Murad
mesh_terms: D000368:Aged; D002370:Casts, Surgical; D017719:Diabetic Foot / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012107:Research Design; D012775:Shoes