This document summarizes evidence comparing the effectiveness of removable cast walkers (RCW) to total contact casts (TCC) for treating diabetic foot ulcers. It finds that RCWs can achieve similar healing outcomes to TCCs when made non-removable, reducing healing times and complication rates. While TCC application requires more expertise, RCWs are easier for patients to don and doff and have lower costs. The document recommends RCWs as an effective alternative to TCCs when used on a full-time basis.

1. Comparison ofRemovable Cast Walkers to the Total Contact Cast for the Treatment of Diabetic Foot UlcersCritically Appraised Topic (CAT) Summary Linda LaaksoB.Sc.,C.O.(c) www.customorthotic.ca

2. Diabetic Foot Ulcers (DFU) 2.3 million Canadians have diabetes today* 15% will develop a diabetic foot ulcer* 85% of all amputations are the result of a non-healing ulcer* *National Diabetes Surveillance System: Diabetes in Canada 2009

3. Contributing Factors to DFU Adapted from Lusardi and Neilson, page 544.

4. Treatment of Plantar DFU Removal of Pressure Gold Standard: Total Contact Cast (TCC) Redistribute pressure Protects healing tissue Disadvantages Specialized application Cannot check wound

5. Alternatives for ulcer offloading Custom Shoes Foot Orthoses Custom Brace (AFO) Removable cast walker (RCW) Surgical shoes/boots Rebound Air Walker removable cast walker image courtesy of Ossur Canada.

6. Is the removable cast walker (RCW) as effective as the total contact cast (TCC) in the treatment of the plantar diabetic foot ulcer?

7. Search Strategy

8. Selected Literature *Levels of evidence defined by Phillips et al. (1998).

9. Selected Literature

10. Summary of Best EvidenceKatz et al. (2005)Key Demographics

12. Median heal times

13. Complication ratesTime to don/doff: iRCW< TCC Cost: iRCW< TCC

14. Implications for Practice Best Practice Recommendations: -> Remove the pressure How? Consensus suggests: Fulltime use provides better outcomes The RCW when made irremovable has similar outcomes when compared to the TCC

15. Considerations Strengths Studies are consistent with each other Higher level studies (1b) Studies are valid, reliable and relevant Limitations Studies use small numbers Studies are not blinded

16. Next Steps Larger studies comparing TCC to RCW Further study to compare RCW with and without custom insole Implementation of results into clinical practice -> make the RCW irremovable when using

17. References Armstrong, D. G., Lavery, L. A., Wu, S., Boulton, A. J. M. (2005). Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. Diabetes Care, 28(3), 551-554. Beuker, B. J., van Deursen, R. W., Price, P., Manning, E. A., van Baal, J. G., Harding, K. G. (2005). Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair and Regeneration, 13, 537-542. Boninger, M. L., Leonard, J. A. (1996). Use of bivalve ankle foot orthosis in neuropathic foot and ankle lesions. Journal of Rehabilitation Research and Development, 33(1), 16-22. Botros, M., Goett, K., Parsons, L. Menzildzic, S., Morin, C., Smith, T. Hoar, A., Nesbeth, H., McGrath, S. (2010). Best Practice Recommendation for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2010. Wound Care, 8(4), 6-40. Bus, S. A., van Deursen, R. W., Armstrong, D. G., Caravaggi, C., Hlavacek, P., Bakker, K., Cavanaugh, P. R. (2008). The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes/Metabolism Research and Reviews, 24(Suppl 1), S162-S180. DOI:10.1002/dmrr.850. Elftman, N. W. (2006). Orthotic management of the neuropathic limb. Physical Medicine and Rehabilitation Clinics of North America, 17, 115-157.

18. Fleischli, J. G., Lavery, L. A., Vela, S. A., Ashry, H., Lavery, D. C. (1997). Comparison of strategies for reducing pressure at the site of neuropathic ulcers. Journal of the American Podiatric Association, 87(10), 466-472. Katz, I. A., Harlan, A., Miranda-Palma, B., Prieto-Sanchez, L., Armstrong, D. G., Bowker, J. H., Mizel, M. S., Boulton, A. J. M. (2005). A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care, 28(3), 555-559. Lusardi, M. M., & Nielsen, C. C. (2007). Orthotics and prosthetics in rehabilitation. St. Louis, Missouri: Saunders Elsevier. Maher, C. G., Sherrington, C., Herbert, R. D., Mosely, A. M., Elkins, M. (2003). Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy , 83(8), 713-721. National Diabetes Surveillance System: Diabetes in Canada 2009. (2009). Report from the national diabetes surveillance system: Diabetes in Canada, 2009 No. HP32-2/1-2009. http://www.phac-aspc.gc.ca/publicat/2009/ndssdic-snsddac-09/pdf/report-2009-eng.pdf PEDro Physiotherapy Evidence Database. The Centre for Evidence-Based Physiotherapy.http://search.pedro.org.au/pedro/browserecord.php?record_id=4580 Phillips, B., Ball, C., Sackett, D., Badenoch, D., Straus, S., Haynes, B., Dawes, M.(1998). Oxford Centre for Evidence Based Medicine – Levels of Evidence (March 2009) . Updated 2009 Howick, J. http://www.cebm.net/index.aspx?o=1025

19. Notice to Reader This presentation was prepared to disseminate information as researched for the preparation of a Critically Appraised Topic (CAT) for a Masters Level Program, Evaluating Sources of Evidence. The information herein is for the sole purposes of sharing information on the specific topic. Questions, concerns or requests for copies can be directed to: Linda LaaksoB.Sc.C.O.(c) at: www.customorthotic.ca