Adherence to Offloading Treatment for Diabetic Foot Disease
Diabetes & Metabolic Syndrome: Clinical Research & Reviews
Summary
This systematic scoping review examined the evidence on adherence to offloading treatment in people with diabetic foot disease. Analyzing 24 studies involving over 2,000 participants, the authors found significant variability in how adherence was defined and measured, with most studies relying on subjective self-reports. Objective measurements like step counters or temperature sensors were underused, present in only 25% of the studies. The review highlighted that adherence to offloading—defined as wearing prescribed footwear for at least 80% of daily steps or time—was consistently suboptimal, ranging from 28% to 60%. Importantly, the review emphasized that psychosocial factors such as stigma, footwear aesthetics, perceived need, and motivation played a larger role in non-adherence than biological factors alone. While the treatment's efficacy in preventing diabetic foot ulcers is well-established, very few interventions exist to promote adherence. Only one randomized controlled trial explored motivational interviewing as an adherence-boosting intervention, with limited long-term impact. The review concludes that despite offloading’s vital role in ulcer prevention and management, non-adherence remains widespread and understudied. It calls for future research to focus on long-term, objective adherence measurements and the development of psychosocial and behavioral interventions tailored to patients’ lived experiences.
Study Design
Interventions
Study Type
Outcomes
Duration and Size
Study Population
Age Range
Sex
Geography
Other Criteria
Methodology
This review employed a systematic scoping methodology in line with Arksey and O’Malley’s framework, Levac’s enhancements, and PRISMA-ScR guidelines. Five databases (MEDLINE, CINAHL, EMBASE, PubMed, EMCARE) were searched without date or geographic limitations. Eligible studies included adult participants with diabetes and prescribed foot offloading devices, focusing on adherence behaviors, measurement methods, influencing factors, and adherence-promoting interventions. Both qualitative and quantitative studies were included, although quality assessments were omitted due to the nature of the review.
A total of 24 studies were included, covering randomized trials, observational studies, and qualitative interviews. Data extraction followed JBI templates. The review did not conduct a meta-analysis but provided a thematic synthesis and categorized findings based on removable versus therapeutic footwear, adherence definitions, and subjective/objective measurement techniques. Biological and psychosocial factors were classified using Engel’s biopsychosocial model. One RCT explored motivational interviewing as an intervention to promote adherence.
Interventions
The primary interventions examined were removable cast walkers, therapeutic footwear (custom and prefabricated), and one behavioral intervention: motivational interviewing. Most studies focused on participants' natural behavior without direct intervention. Only one RCT tested motivational interviewing, combining standard education and structured counseling to promote adherence. While it showed short-term gains in compliance, effects waned at 3-month follow-up, suggesting the need for sustained psychosocial support. No pharmacologic or surgical interventions were assessed.
Key Findings
Adherence to foot offloading among people with diabetic foot disease is consistently suboptimal and poorly measured. Most studies relied on self-reported data, and only a few employed objective tools. Adherence ranged widely, with many patients using devices only 28% to 60% of the time. Psychosocial variables such as stigma, self-image, aesthetics, and motivation outweighed biological factors as barriers to adherence. There was only one reported intervention—a motivational interviewing RCT—which yielded temporary improvement. This review emphasizes the need for psychosocially-informed, patient-centered interventions to improve therapeutic adherence.
Comparison with other Studies
Compared to prior systematic reviews on diabetic foot ulcer (DFU) prevention, this review uniquely focused on adherence behaviors rather than clinical outcomes. It confirms earlier findings that offloading adherence is poor, echoing studies from rheumatoid arthritis populations where unattractive footwear also reduced compliance. However, this study adds depth by organizing influencing factors using Engel’s biopsychosocial model and highlighting psychosocial burdens. The inclusion of qualitative research enriches the narrative, surfacing patient perspectives often missing in prior reviews.
Other reviews of DFU interventions largely neglect behavioral and cultural factors. This review brings attention to shame, stigma, and knowledge gaps, calling for a paradigm shift in DFU management toward behavioral health. It aligns with research showing that wearable adherence improves with behavioral coaching in sleep apnea and other chronic diseases. Therefore, this work fills a critical knowledge gap and urges development of structured psychosocial interventions alongside offloading technologies.
Journal Reference
Racaru S, Bolton Saghdaoui L, Roy Choudhury J, Wells M, Davies AH. Offloading treatment in people with diabetic foot disease: A systematic scoping review on adherence to foot offloading. Diabetes Metab Syndr. 2022;16:102493. doi:10.1016/j.dsx.2022.102493
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