In people with diabetic neuropathy and a recently healed plantar foot ulcer, significant offloading can be achieved at high-risk foot regions by modifying custom-made footwear. These results provide data-driven directions for the design and evaluation of custom-made footwear for high-risk people with diabetes, and essentially mean that each shoe prescribed should incorporate those design features that effectively offload the foot.

Neuropathy may bring about changes in form and function of the foot, which may lead to ulceration and progressive deformity. These manifestations often require specially adapted footwear. A comprehensive concept of the medical, functional, and technical requirements for this type of footwear is still lacking to date. In this article, we present an algorithm that should facilitate prescription and manufacture of adequate shoes. This algorithm attempts to establish a link between the requirements from a medical and functional point of view and the technical possibilities of orthopedic shoe technology. Diabetes Care 24:705-709, 2001T he neuropathic foot is characterized by loss of peripheral nerve function, which can be sensory, motor, autonomic or, usually, a combination of these. This loss of function causes changes in the form and function of the foot and may lead to ulceration and severe deformity, which eventually may result in amputation (1). Therefore, protection of the foot is of the greatest importance. In addition to a careful lifestyle, appropriate footwear is essential for achieving this protection (1,2).In medical literature on the neuropathic foot, much has been written about the prevention of complications. The importance of "good footwear" is stressed, though frequently without further specification (3,4). So far, research has focused only on parts of the problem, mostly pressure reduction (5-8), although in addition to peak pressure, the duration of maximum pressure and shear stress are also important (9 -11). Diabetic footwear has been discussed in descriptive articles (12, 13) and technical studies (8,14). However, the authors confine themselves to specific aspects like pressure distribution and rocker-bottom outsoles (8,14). A comprehensive conceptual approach for the management of the various aspects of this footwear problem is still lacking (15). The rationale behind footwear prescriptions is often unclear to patients and healthcare workers alike, and this can diminish compliance (3,16).The aim of this article is to describe the relationship between medical requirements and technical possibilities. For this purpose, we have developed an algorithm. A number of its components are evidencebased, but most are opinion-based, because testing the effects of therapeutic footwear is impossible without clear guidelines. This algorithm aims at establishing guidelines for clinical treatment and further research into this complex subject. REQUIREMENTS BASED ON MEDICAL FEATURESAltered biomechanics in the foot may lead to ulceration and progressive deformity (17). Here, we will only discuss the different features of a neuropathic foot. Because neuropathy commonly occurs in diabetes, we will also mention one of its consequences, limited joint mobility, which is not directly related to neuropathy (18). Sensory dysfunction Loss of sensory functionIn the long term, reduction of sensory function may lead to complete loss of sensation in the foot. We speak of loss of protective sensation when the patient is not aw...

Objective. To evaluate the prevalence and 8-year course of forefoot impairments and walking disability in patients with rheumatoid arthritis (RA). Methods. A total of 848 patients with recent-onset RA from 1995 through the present were included. The patients were assessed annually. Pain and swelling of the metatarsophalangeal (MTP) joints, erosions and joint space narrowing of the MTP joints and first interphalangeal joints, and the Health Assessment Questionnaire walking subscale were analyzed using descriptive and correlational techniques. Results. Pain and swelling of >1 MTP joint was present in 70% of patients at baseline, decreasing to ϳ40 -50% after 2 years. The forefoot erosion score was >1 in 19% of the patients at baseline, and the prevalence of forefoot erosion increased to ϳ60% after 8 years, during which the mean forefoot erosion score increased from 1.3 to 7.9. At least mild walking disability was present in 57% of patients at baseline, stabilizing at ϳ40% after 1 year. Conclusion. The prevalence rates for pain and swelling of the MTP joints and walking disability are initially high and then stabilize, but the prevalence and severity of forefoot joint damage increase during an 8-year course of RA. The findings of this study quantitatively emphasize the importance of forefoot involvement in patients with RA.

Supported by evidence‐based guidelines, custom‐made footwear is often prescribed to people with diabetes who are at risk for ulceration. However, these guidelines do not specify the footwear design features, despite available scientific evidence for these features. We aimed to develop a design protocol to support custom‐made footwear prescription for people with diabetes and peripheral neuropathy. The population of interest was people with diabetes who are at moderate‐to‐high risk of developing a foot ulcer, for whom custom‐made footwear (shoes and/or insoles) can be prescribed. A group of experts from rehabilitation medicine, orthopaedic shoe technology (pedorthics) and diabetic foot research, reviewed the scientific literature and met during 12 face‐to‐face meetings to develop a footwear design algorithm and evidence‐based pressure‐relief algorithm as parts of the protocol. Consensus was reached where evidence was not available. Fourteen domains of foot pathology in combination with loss of protective sensation were specified for the footwear design algorithm and for each domain shoe‐specific and insole (orthosis)‐specific features were defined. Most insole‐related features and some shoe‐related features were evidence based, whereas most shoe‐related features were consensus based. The pressure‐relief algorithm was evidence based using recent footwear trial data and specifically targeted patients with a healed plantar foot ulcer. These footwear design and pressure‐relief algorithms are the first of their kind and should facilitate more uniform decision making in the prescription and manufacturing of adequate shoes for moderate‐to‐high‐risk patients, reducing variation in footwear provision and improving clinical outcome in the prevention of diabetic foot ulcers.

This study provides insight into employment-related concerns for people with HIV living in a Western country. It formed the basis for the key questions which were addressed in a multidisciplinary, evidence-based guideline "HIV and work". Finally, it gives leads for further scientific research and opportunities for improving the vocational guidance of people with HIV.