Does Compliance Hamper The Efficacy Of Removable Cast Walkers?

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By Brian McCurdy, Associate Editor

Compliance may be an issue for diabetic patients wearing removable cast walkers, according to the results of a recent study on activity patterns. A recent study in Diabetes Care assesses the activity patterns of those with diabetic foot ulcerations and finds those involved in the study did not have adequate plantar pressure relief for nearly 75 percent of the steps they were taking.
The study tracked 20 patients with neuropathic diabetic foot wounds, which were all classified as University of Texas grade 1 stage A. The patients each received a standard removable cast walker (Royce Medical) to relieve plantar pressure during ambulation. Researchers recorded total activity on computerized accelerometers that patients wore on their waists and correlated the activity to accelerometers that were attached to the cast walkers and which patients could not access.
Researchers had instructed patients to wear the casts continuously for seven days. Each patient took a mean 1,219.1 steps (+/-821.2) per day and researchers noted they walked “significantly more” while not wearing the removable cast walker than they did while wearing it. This resulted in the devices recording only 28 percent of the patients’ movement.
“This figure was quite remarkable to us as these patients were all walking on open plantar wounds,” says the study’s principal investigator, David G. Armstrong, DPM, the Director of Research and Education within the Department of Surgery, Podiatry Section at the Southern Arizona Veterans Affairs Medical Center.
He attributed the phenomenon to a lack of painful feedback, what the late Paul Brand, MD, called “the gift of pain,” due to neuropathy.

What Factors Affect Compliance?
Why were patients taking 72 percent of their steps without plantar protection? As co-author Brent Nixon, DPM, explains, the three major components of compliance are the patient’s environment, condition and motivation. Factors which could influence compliance are whether the patient lives alone, has to climb steps or lives in the city. Dr. Nixon says other considerations in a patient are blindness, depression and complicating medical conditions.
“I have found that I need to give the patient a gentle talk about his or her condition and the possibilities of the complications that can result in failure to comply,” notes Dr. Nixon, Chief of Podiatry in the Department of Surgery at the Southern Arizona Veterans Affairs Medical Center. “If absolute compliance is not possible, we do our best to console the patient.”
“I have worn TCCs and removable cast walkers, such as the Active Offloading Walker, for some 10 days at a time,” says Dr. Armstrong. “I can tell you that it’s a pain in the neck. If I didn’t have to wear it — if I wasn’t in pain — then I surely wouldn’t wear it. It is the same with our patients.”
To aid in compliance, Dr. Nixon says he provides patients “every useful aid necessary to unload the affected limb,” such as wheelchairs with leg extensions, crutches, walkers and motorized scooters. The key to such cast walkers is a well-padded, non-removable splint or cast, he notes.

A Proposal For An Instant TCC
In a recent editorial in Diabetes Care, Dr. Armstrong and study co-author Andrew Bolton, MD, propose using non-removable offloading devices for neuropathic patients needing plantar protection. Although the doctors note such devices have not been used because of a concern that total contact casts (TCCs) require expertise to use and can injure a neuropathic foot, they suggest using an instant total contact cast. Instant TCCs would be cast walkers that are made non-removable when they are wrapped in coban or plaster.
Instant TCCs would be advantageous because of their lower weight, ease of application and the fact that they are cheaper because the patient can use the same cast walker throughout treatment, according to Drs. Armstrong and Boulton.
“Only then, when we put together what we ‘take off the wound’ (pressure) with what we ‘put on’ the wound (advanced dressings and devices), will we see any real improvement in outcomes on a worldwide basis,” says Dr. Armstrong, a member of the Board of Directors of the American Diabetes Association.

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