By Shalmali Pal
Convincing patients with diabetes to wear their prescribed footwear presents a challenge, but experts agree that encouraging patient compliance requires lower extremity clinicians to look beyond the disease and gain insight into the person being treated.
Genomes, epigenomes, pharmacogenomics–these are just some of the industry buzzwords today, as practitioners look to personalize medicine. A recent viewpoint column in JAMA Internal Medicine1 introduced another “ome”—the personome—and defined it as the “influence of the unique circumstances of the person.”
“Individuals are not only distinguished by their biological variability; they also differ greatly in terms of how disease affects their lives,” wrote Roy C. Ziegelstein, MD, a cardiologist at Johns Hopkins University School of Medicine in Baltimore, MD. “People have different personalities, resilience, and resources that influence how they will adapt to illness…”
Many lower extremity practitioners are familiar with the concept of individualized healthcare, particularly if they treat patients with diabetes. After all, what could be more personal than helping a patient choose a pair of custom-molded, prescription footwear that will become part of their daily lives?
But getting patients to comply with prescribed footwear presents a challenge. Studies have shown that footwear adherence is less than optimal among these patients. A 2014 study noted that, among 153 Dutch patients with diabetes presenting at a foot clinic, footwear use was low to moderate, with patients wearing the shoes for less than 60% of their daytime hours.2
Another study evaluated the thinking behind patient noncompliance, noting that those at risk for diabetic ulcerations often based their decision on the immediate risks and benefits of wearing the shoes. In other words, the threat of a future ulceration may not be enough to ensure compliance.3
LER: Foot Health checked in with practitioners to see how they handle this dilemma in real-world settings. They all agreed that encouraging patient compliance requires clinicians to look beyond the disease or disorder, and gain insight into the person being treated.
The time to talk
Complaints about aesthetics are common among patients who refuse to wear their prescribed footwear routinely. While experts agree diabetic footwear designs have improved over time, the shoes are still not likely to wind up in the pages of fashion magazines.
But Rob Sobel, CPed, cautioned against making assumptions about a patient’s fashion concerns based on gender. Sobel, the president of the Pedorthic Footcare Association and owner of Sobel Orthotics & Shoes in New Platz, NY, has found that aesthetic concerns are fairly equal between men and women, but that women may ultimately be more pragmatic.
“A big difference between men and women is that women are more likely to say, ‘OK, I have this issue, and this what I need to do to deal with.’ Men are not necessarily as willing to deal with the problem,” he explained. “They are often in denial and have the attitude of, ‘Those shoes are fine for other people, but I’m tougher than that. I’m bigger than this disease.’”
When faced with either form of noncompliance, Sobel suggests practitioners take time to talk to patients about their concerns.
“Maybe the patient’s focus is really on aesthetics and style,” Sobel said. “Let’s say she is determined to get a Mary Jane-style dress shoe, but that may not be appropriate because the shoe exposes too much of the foot, so she needs a shoe with more coverage. I’ll take the time to explain why I’m not inclined to give them the Mary Jane, instead of saying no without explanation.”
And, he said, don’t expect instant results.
“Patients are being asked to make some major changes to their lives because of this disease and, as practitioners, we have to accept that compliance may not be instantaneous,” Sobel said. “Just taking the time to hear them out can be useful.”
Robert P. Thompson, CPed, agreed that men, and men aged 50 years and younger in particular, can be resistant to wearing prescribed footwear because of a sense of invincibility. Thompson is a retired
pedorthist based in Birmingham, AL. He now serves as the executive director of the Institute for Preventive Foot Health.
While in practice, Thompson’s strategy was to refocus the patients’ attention on the comfort level of the shoes.
“I’d strongly encourage them just to try the shoes on, and once I’d get them into the footwear, they were always struck by the shoes’ comfort level,” he said. “Then we could shift the discussion to comfort rather than looks.”
Another driver of noncompliance is lifestyle, although the lack of adherence may not be intentional. For instance, a patient may wear the prescribed footwear outside the house, but abandon the shoes the minute they are home. The issue may be cultural—“outside” shoes are not worn indoors—or simply because patients assume the home is a safe environment.
A Dutch study found that, among patients with diabetic neuropathy and a recently healed plantar foot ulcer, adherence to custom-made footwear was particularly insufficient at home, where patients’ walking activity was greatest.4
Study author Sicco Bus, PhD, senior investigator and head of the Human Performance Laboratory at the Academic Medical Center in Amsterdam, said noncompliance at home did not mean the patients were consciously willing to risk reulceration. It’s more likely that patients lacked awareness about the risk of reinjury.
Interventions to improve at-home adherence could include a pair of indoor offloading shoes based on the last of the outdoor prescribed footwear, Bus said. Depending on the status of their foot health and risk of injury, Sobel said he might recommend anything from a light slipper, to shield the feet from bacteria, to a more protective foot covering.
“Sometimes, over the years, patients will collect multiple pairs of insoles, many of which are lightly or completely unused. I’ll tell them to put the insole in their house shoes or even slippers, if possible. That way, they are getting the benefit even if they are not in their diabetic shoes,” he said.
Thompson said he would recommend a neoprene-based slip-on shoe for patients to wear indoors, or anywhere else where barefoot is the norm, if he suspected compliance would be low.
The lesson for practitioners is to be proactive and to have information about alternative at-home footwear options ready and available, rather than waiting for the patient to raise the issue.
Knowing that patients are still likely to go barefoot, experts agree that self-care and examination of the feet must be stressed. Patients need routine reminders about the importance of daily foot exams, inspecting the insides of shoes for pebbles or other potential irritants before donning them, and following clinician instructions regarding toenail trimming, retail pedicures, or foot massage.
Patients should consider socks as another way to protect the feet, and practitioners should inform them about the sock characteristics (ie, moisture-wicking, breathable, seamless, or padded) that are most appropriate for patients with diabetes, Thompson said.
“Socks can be a medical accessory. They serve a purpose–to absorb moisture and offer an extra layer for people who’ve lost the fat pads on their feet,” he said. “Don’t let socks be an afterthought.”
Data: Suitable or scary?
There is no shortage of data on the potential benefits of prescribed diabetic footwear when they are actually worn. For example, a guideline published by the International Working Group on the Diabetic Foot5 states that custom-made footwear is recommended for patients with diabetes, peripheral neuropathy, and foot deformity to prevent foot ulceration, infection, and amputation. In addition, footwear that does not meet the needs of these patients can increase ulcer risk by increasing foot pressures.
But is this information worth sharing with patients? Yes, experts say, but again, a personal approach is key.
Jennifer Grogg, EdD, an independent diabetes educator based in Tucson, AZ, suggested that practitioners do some patient profiling and then share the specific data that will mean the most to each individual. For instance, if the patient has been treated for a foot ulceration, studies on that particular issue will make more of an impression than general information on diabetic footwear. A patient with neuropathy may respond to an explanation of how the right shoes could help improve symptoms. And active patients may need to hear how wearing the footwear will allow them to continue their daily walks with friends or other ambulatory activities.
This approach “may mean taking more time with patients to find out what their interests are, what their daily lives are like, and then tailoring the information,” Grogg said.
Then there is the old scare tactic approach in which data can be used to convey the severity of the patient’s situation and frighten them into compliance. The experts have mixed thoughts on the “scaring into caring” method.
Sobel is not a fan. He prefers to convey that healthcare professionals are there to help, but that the patient needs to be an active member of that team. This may give the patient a sense of control over the situation, rather than feeling that the shoes are being thrust upon him or her.
“That doesn’t mean there isn’t a fight to get them to comply, but I don’t want to insult someone’s intelligence by making threats,” Sobel said.
Crystal Holmes, DPM, CWS, an assistant professor in the department of internal medicine at the University of Michigan in Ann Arbor, takes a similar tack. Typically she discusses the risks of not complying with prescribed footwear and lets patients make an educated decision. But if she still meets with resistance—especially when it comes to fashion concerns—Holmes will be blunter.
“I have to be candid with them: ‘Is the look of this shoe worth your lower extremity? Is it worth having an amputation? If the answer to that is yes, then please continue to do what you are doing. If the answer is no, then you need to make some modifications,’” she said.
Thompson said he had no qualms about sharing “horror stories” of patients whose lax foot care had serious consequences, or conveying what he called “violent numbers,” such as the finding that more than half of patients with diabetes who underwent a first amputation had a second one within five years.6
“I would make it a point to show them those kinds of scary, violent numbers. I would make it clear to them what the consequences could be if they chose not to protect and care for their feet. I wouldn’t sugarcoat that,” he said.
A trial done in Iran reported that patients with diabetes who underwent training on foot care, whether in a group setting or as individuals, had an increase in foot care self-efficacy, such as daily foot inspection, clinician visits, and, of course, using the right footwear.7
But, like the use of data, practitioners’ approaches to patient education differ.
Holmes said hers starts with the patient’s specific foot issues.
“Whenever I talk to patients about diabetic shoes, I try to educate them first on what their particular pathology is,” she said. “I think that is very important. If I have a patient who has diabetes, neuropathy, vascular disease, foot deformity, and a history of ulcerations, that conversation is going to be a lot different than one with a diabetic patient who has neuropathy and bunions but has never had an ulceration.”
Grogg advocates a whole-body approach. For example, a health education program that she and other healthcare providers conducted at an Air Force base was designed to show attendees that other health problems can stem from anomalies or stressors in the feet. While the attendees of this program were not exclusively patients with diabetes, the same approach is feasible, she said.
“Patients with diabetes are sometimes very focused on the disease itself; it’s almost a full-time job for them in terms of management, taking medications, going to see doctors, etc.,” Grogg said. “They may lose sight of the big picture and how changes they make in one area—diabetic footwear, new diet, increased activity—can be meaningful on a greater level.”
Sobel emphasized that practitioners must work together.
“Podiatrists, pedorthists, primary care physicians—we’ve got to work as a team. Don’t assume the other practitioner will take care of educating the patient,” he said. “It’s important for everyone to have essentially the same message to get that patient on board with treatment.”
A discussion of patient education wouldn’t be complete without technology and social media. Patients can now download apps that will guide them through a daily foot check, maintain a database of changes in foot health, and look up medical terminology. An app to track diabetic footwear compliance doesn’t yet exist, but could be a logical next step. And connecting with others online to discuss diabetic footwear and related issues could be another avenue to compliance, Thompson said.
To that end, practitioners may want to keep up with blogs or Facebook pages that their patients are using.
“Don’t discount the possibility that a discussion on a Facebook page could lead your patient to make the right decision about her footwear,” Thompson said. “Sometimes patients respond more openly to other people who are in the same situation they are.”
Patient usage of personal technology and social media to learn about diabetic footwear issues will depend on a number of factors–age, access to smartphones, and how tech savvy the patients are. But figuring out how an app or a social media site works may be an opportunity for older patients to connect with grandchildren or other young people in their lives, Grogg suggested.
Age alone is not necessarily a barrier to using gadgets, Thompson said.
“My mom is ninety-two,” he said, “and she just got her first iPad!”
Shalmali Pal is a freelance writer based in Tucson, AZ.
1. Ziegelstein R. Personomics. AMA Intern Med 2015;175(6):888-889.
2. Arts ML, de Haart M, Bus SA, et al. Perceived usability and use of custom-made footwear in diabetic patients at high risk for foot ulceration. J Rehabil Med 2014;46(4):357-362.
3. Paton JS, Roberts A, Bruce GK, Marsden J. Patients’ experience of therapeutic footwear whilst living at risk of neuropathic diabetic foot ulceration: an interpretative phenomenological analysis (IPA). J Foot Ankle Res 2014;7(1):16.
4. Waaijman R, Keukenkamp R, de Haart M, et al. Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration. Diabetes Care 2013;36(6):1613-1618.
5. Bakker K, Apelqvist J, Schaper NC, et al. International Working Group on Diabetic Foot Editorial Board. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012;28(Suppl 1):225-231.
6. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Harris MI, Cowie CC, Stern MP, et al, eds. Diabetes in America. 2nd ed. Bethesda, MD: National Institutes of Health;1995:409-428.
7. Seyyedrasooli A, Kobra P, Valizadeh L, et al. Self-efficacy in foot-care and effect of training: A single-blinded randomized controlled clinical trial. Int J Community Based Nurs Midwifery 2015;3(2):141-149.