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An overview of the new consensus document ‘Redefining and Demystifying Offloading for Diabetes Foot Care’

The term ‘offloading’ is widely used in the multidisciplinary management of foot disease in people with diabetes. However, it can be misrepresented by definition, as well as in terms of what it can actually deliver. Very often, it is associated with the application of casts and the precise vocabulary of basic components of ‘pressure redistribution’, ‘load sharing’ and ‘axial offloading’ are not in common use and, therefore, not always properly understood.

Following the publication of the work of the International Working Group on the Diabetic Foot in 2019 (Bus et al, 2019), The Scottish Diabetes Foot Action Group (SDFAG) had been considering how best to apply the principles of the working group. Through discussion, it was felt that a UK national consensus group should be established to consider how the knowledge and skills required to deliver holistic pressure management systems could be evolved.

The consensus group was convened on the first of May 2020 and was made up of healthcare professionals with a wide range of professional experience of managing foot disease in diabetes across medicine, podiatry, nursing, orthotics and orthopaedic practitioners delivering casting techniques.

The group decided that all aspects of pressure relief/pressure redistribution should be addressed and that the result of the work would be complementary to the IWGDF and also an aid to supporting the professional Capability Framework for Integrated Diabetic Lower Limb Care document in current circulation (Short-life Working Group, 2019). The title for this document decided by the group following wide discussion was to be Redefining and Demystifying Offloading for Diabetes foot Care.

Strategic intent
There was a realisation based on many years of experience by the healthcare practitioners dealing with active foot disease, that one of the most poorly implemented or adhered to aspects of the treatment of active disease was pressure management. It was, therefore, incumbent to examine the basic components of pressure management and relate these through robust evidence and clinical experience to enable clinicians to use the techniques most suited to the patient, service and geography across the UK and at the same time standardise the terminology used.

There was an aspiration that the document would encourage services that for a variety of reasons were not currently able to provide optimum pressure management strategies to review practice and possibly redesign their service to improve patient outcomes.

It was also recognised that the document would be a living and evolving process to allow for new techniques and devices to be considered. The driving force behind better understanding and delivery of pressure management would be  enhanced healing times giving patients the opportunity to have an  efficient  and smoother journey through their clinic experience and ultimately improve clinical outcomes. It would also allow the clinician’s time to review options and possibly review their strategies for onward referral if that was indicated.

The impact of COVID-19 was just starting to be realised at the time of the consensus meeting and as time went by during the writing process, it became more and more apparent that the delivery of clinical services and the management of foot disease would be dependent on the ability to provide pressure management techniques that were safe and reliable, often from a non-bespoke perspective. In some areas the application of casts were halted for fear of aerosol spray from plaster saws transmitting the virus. This meant that alternative off the shelf devices, made non-removable, had to be considered as a first-line intervention where formally a cast may have been applied.

The consensus document was an attempt to bring the key components of offloading to the appropriate healthcare professionals in an easily understood format supported by the evidence base.

It was considered that understanding the terms redistribution, load share and axial offloading was fundamental to making a choice on what were the most effective treatment modalities available, dependant on the geography, skills and service provision. The document highlighted the desired skillsets that a multidisciplinary team should provide and also what the optimum composition of the team should be.

Going forward, it is hoped that the consensus document can provide the information, knowledge and  reassurance of what devices and strategies can be provided to best suit the patients individual needs in a safe and effective manner.

Implementation
It is widely recognised that service design, knowledge and capabilities vary across the country. It would be folly to think that guidelines and consensus documents can facilitate change quickly, however, this document used in conjunction with the capability document (Munro et al, 2021) could provide the catalyst to allow a re-examination of resource and skills.

Despite the many challenges that COVID-19 pandemic has created, in particular, a reduction in face-to-face consultations, there is an opportunity during the recovery process to resume services with a fresh prospective and by using the basic components of this document revaluate a service framework with a focus of what load distribution can actually deliver.

Given the wide range of skills gained by the healthcare professionals that participated in the consensus document, it would be a timely opportunity to utilise their knowledge and encourage cooperation with disciplines that may currently not be present within multidisciplinary teams. It has been the desire of the SDFAG to have greater involvement with orthopaedic practitioners in particular, as greater integration within foot clinics would be beneficial in the upskilling and in the provision of casting techniques that are proven to be efficient in reducing healing times.

It was felt there should be a patient’s perspective as part of the consensus and our patient representative had personal experience of a number of load distribution and axial offloading modalities. The importance of balancing treatment with everyday life, which includes physical and mental health, is important. There is also a need for the healthcare professionals to be honest with patients in managing their expectations of healing times and outcomes. It is often the case that a number of strategies may be required to be employed as healing progresses, especially if treatment is protracted by other medical and social considerations. Environment and geographical considerations may prove troublesome in some parts of the UK when providing and delivering an effective and safe service.

The consensus document, therefore, demonstrated in a simple visual fashion, via the Rev counter on page 15, options that can be delivered by an appropriately trained healthcare professional taking into account clinician, and the patient’s capabilities and at the same time giving some indications as to the potential healing outcomes. This includes supported self-management as it is important to have the patient as fully engaged as possible in the healing process, as well as the management of remission following the successful outcome of a treatment regimen.

Education and the implementation of evidence based practice, improved clinical capabilities and supported self-management would be the desired outcome of adherence to the spirit of the consensus document. Through the use of specific and targeted vocabulary that identifies the principles being used, should help uniformity across services that would aid the collection of robust data and, therefore, inform evidence surrounding techniques and devices.

Members of the consensus group were invited to make some observations on the principle and outcomes of the document and these are set out overleaf.
This consensus document was required to draw together the rational for offloading, which is a key component to wound prevention and healing of ulcers in people with diabetes, while putting it into clinical practice. It offers clinicians the ability to gain confidence and reduce practice variation in effective selection of offloading device, by understanding the mechanics of the different devices, with a visual guide to each device.

Challenges may arise at a patient, professional and or organisational level when intending to use offloading to manage a diabetes-related foot complication. This document was prepared in an effort to make offloading more accessible to each of these parties by simplifying and encouraging consistent terminology, outlining an algorithm for offloading care and answering commonly expressed patient concerns. It is hoped it will better position healthcare professionals to advocate for improved offloading locally, on behalf of their patients, to ensure all persons living with diabetes-related foot complications are receiving best practice care.

As researchers, we were excited to take part in the making of this consensus document, which involved an expert group of multidisciplinary healthcare professionals, in addition to the perspective of a person with diabetes. The consensus document reflects the current published evidence and will inevitably be updated in the coming years to reflect new research developments in the management of foot ulcers associated with diabetes.

This consensus document is a timely addition to the evidence base. At a point in time where we have seen such diversity in how clinicians work and blurring of boundaries in who provides care for patients with lower-limb wounds, it is incredibly opportune to have access to a straightforward explanation of such a fundamental element of care. This document provides easily comprehendible explanations of both why and how offloading should be a routine part of care of the patient with a diabetic foot ulcer. It gives support to the specialist clinicians in selecting the appropriate mechanism to deliver offloading, but more importantly, to ensure non-specialists in this area understand why they must refer on to ensure their patents have access to this level of care.

Conclusion
During the discussions around this extremely important element of the multifactorial treatment of the diabetic foot, it became apparent that the membership of the multidisciplinary teams varies across the country. The skillsets and training sometimes vary due to geographical and service arrangements, however, the intention of the consensus document was to provide a tool to encourage a more informed platform for service delivery and also to enhance the  professions that have specific skills and knowledge in the field of casting and orthotics.

The consensus document offers the possibility of a fresh look at the components and knowledge required to enable the most appropriate and effective treatment delivered and implemented at the earliest possible opportunity to help ensure patient mobility, ulcer-free days and maintain quality of life.

Bus SA, Armstrong DG, Gooday C et al (2019) Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 36(Suppl 1): e3274
Munro W, Stang D, Fletcher J et al (2021) Redefining and Demystifying Offloading for Diabetes Foot Care. London: The Diabetic Foot Journal. Available at: https://bit.ly/3j35J8f (accessed 22.06.2021)
Short-life Working Group (2019) Capability Framework For Integrated Diabetic Lower Limb Care: A User’s Guide. London: OmniaMed Communications Ltd. Available at: https://bit.ly/2Sm3uCi (accessed 22.06.2021)

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