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 Table of Contents  
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 22

Continuous movement monitoring of daily living activities for prevention of diabetic foot ulcer: A review of literature

1 Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
2 Diabetes Unit, St. Jacopo Hospital, Pistoia, Italy
3 Tuscany Regional Health Agency, Florence, Italy
4 ANIMO Association, Reggello, Italy

Date of Submission16-Sep-2017
Date of Acceptance21-Dec-2017
Date of Web Publication12-Feb-2019

Correspondence Address:
Piergiorgio Francia
Department of Clinical and Experimental Medicine, University of Florence, Largo Brambilla 3, 50134 Florence
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2008-7802.252146

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Lower extremity ulcers represent the most ominous, feared, and costly complications of diabetes mellitus. The aim of this review is to highlight the role of daily life physical activities (PAs) and continuous movement monitoring (CMM) in the prevention of foot ulcers. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute, in turn, to the development of additional risk factors such as foot deformities and/or joint and muscular alterations. Moreover, a deficit of balance, posture abnormalities, followed by gait alterations, increases the risk of ulceration. PA can play a key role in the management of patients with diabetes and in the prevention of ulcers; however, even if it has been reported that some of these risk factors significantly improve after a few weeks of exercise therapy (ET), the real preventive role of ET has not yet been demonstrated. These uncertain results can occur due to some limitations in the management of the same relationship between PA and diabetic foot prevention. Technological advances during the last years enable timely management of overall daily PA. The use of these modern technologies and devices allows CMM assessment and description of daily PA even in the long term. The data collected from these devices can be used to properly manage patients' PA and thus contribute to the prevention of foot ulcers.

Keywords: Continuous movement monitoring, daily lifestyle, diabetic foot ulcer, exercise therapy, physical activity, prevention

How to cite this article:
Francia P, De Bellis A, Seghieri G, Tedeschi A, Iannone G, Anichini R, Gulisano M. Continuous movement monitoring of daily living activities for prevention of diabetic foot ulcer: A review of literature. Int J Prev Med 2019;10:22

How to cite this URL:
Francia P, De Bellis A, Seghieri G, Tedeschi A, Iannone G, Anichini R, Gulisano M. Continuous movement monitoring of daily living activities for prevention of diabetic foot ulcer: A review of literature. Int J Prev Med [serial online] 2019 [cited 2021 Feb 26];10:22. Available from: https://www.ijpvmjournal.net/text.asp?2019/10/1/22/252146

  Introduction Top

Diabetes mellitus (DM) is a metabolic disorder which is drastically increasing, making it one of the most important public health problems around the globe. Recent studies have found that the incidence of DM is increasing faster than in the past, and it is estimated that by 2035, almost 592 million people will be affected worldwide.[1]

Of the long-term complications that can affect DM patients, diabetic foot ulcers are most ominous and feared because the ulcers affect not only the patients' mobility and their overall well-being but can also increase morbidity and mortality in those with both type 1 and type 2 DM.[2],[3],[4]

The yearly incidence of diabetic foot ulcer in the DM population is around 4% in developed countries and even higher in developing countries where the lifetime risk of a patient to develop a foot ulcer rises to about 25%.[2],[5]

The severity of this phenomenon is also accentuated by the fact that only two-thirds of foot ulcers will ever heal. In addition, about one-third of patients with a recent history (1 year) of foot ulcer or amputation have a high risk of recurrence.[5],[6] Consequently, every 20 s, there is an amputation caused by diabetes somewhere in the world.[2]

The complexity of the multifactorial pathogenesis of diabetic foot ulcer makes patients difficult to treat.[5],[6],[7] The timely consideration of all this is important also in guaranteeing a proper treatment through physical activity (PA).

In this sense, since many years, several studies suggested that PA can concur in the prevention of diabetic foot by the treatment of its major risk factors.[8],[9],[10],[11],[12] In this article, “PA” means body movement generated by muscle contraction, whereas “exercise” means PA aimed at improving fitness or functional/motor deficits. Unstructured PA means “nonexercise” or daily living activities.[8],[13] Both structured and unstructured PA can be performed in an adapted and scheduled way to prevent diabetic foot.

During the 20th century, and especially starting from the end of 1970s, the importance of investigating the qualitative or quantitative aspects of human movement for the prevention of foot ulcers has aroused more attention. The early studies were focused on analyzing foot plantar pressures and gait quality.[14],[15] The study of such parameters was possible thanks to advances in technology and the availability of new devices for the evaluation of the patient's movement and functional alterations (i.e., gait biomechanics–foot plantar pressure in static-dynamic conditions).[14],[15],[16],[17],[18] Subsequently, the assessment of daily life PA performed by patients with and without risk of developing diabetic foot ulcer has been carried out with different methods (questionnaires, pedometer, and accelerometer) [Table 1].[19],[20],[21],[22],[23],[24],[25],[26]
Table 1: Physical activity monitoring for the prevention of diabetic foot ulcer

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Nowadays, the use of even more advanced sensors, digital devices (sometimes similar to wristwatches), and their software allows a better patient's PA assessment and description along with continuous movement monitoring (CMM). CMM has been carried out with different devices, following different protocols, and provides targeted intervention at several levels in the process, leading to the development of foot ulcers in diabetic patients [Figure 1] and [Table 1].[23],[24],[25],[26],[29] The set of information collected from gait analysis and CMM allows a level of management of patients' PA not possible in the past.
Figure 1: “Three cornerstones” of physical activity management; the possible role of continuous movement monitoring in the prevention of diabetic foot ulcer

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The aim of this review is to highlight the role of the proper monitoring and management of structured and unstructured PAs as important methods of prevention against ulcers.

For this review, we searched the current medical literature through PubMed, MEDLINE, EMBASE, and Cochrane library databases. The topics searched were diabetic foot prevention, PA monitoring, exercise training, adapted PA published in English.

  Physical Activity And Diabetic Foot Prevention Top

Diabetic foot prevention begins with proper care of the patient at the time of diagnosis through treatment aimed at achieving good metabolic control [Figure 1]. This treatment involves patient education sessions on the role and importance of an active lifestyle.[8],[37] However, as well as nutrition, even PA can induce considerable variations in glycemic levels of patients with diabetes. This effect can limit metabolic control and become a barrier to exercise, especially in patients with type 1 diabetes (PA as risk factor for glycemic control).[32],[38] As a result, the management of a patient's PA is also to improve blood glucose control in addition to a better peripheral insulin action and the maintenance of a good body mass index.[8],[37]

CMM means that patients with diabetes have to be informed on PA performed and it provides indications on what has to be performed on the basis of data collected during the long-term monitoring.[8],[38] As a result, patients are more aware of managing appropriate food–liquid intake and/or drug therapy to achieve good metabolic control.[13],[20],[38] It has also been suggested that the evaluation of PA performed between main meals, in addition to that during 24 h, can enable patients to better orient themselves in their choices regarding glycemic management.[39]

It is important to consider that vigorous or prolonged PA can have significant acute effects on glycemic fluctuations that can be difficult to manage.[13],[37],[38],[40] All this hinders glycemic control.

In comparison to structured PA, daily life movement can usually be performed at light or moderate intensity so as not to excessively modify blood glucose values.[8],[37],[38],[40]

The improvement in glycemic control over time can be attained with CMM, providing knowledge of type, duration, intensity, and distribution of the activity performed. Each of these parameters can be set up or modified to achieve proper glycemia.[38],[41]

  Exercise Therapy And Diabetic Foot Prevention Top

Even if movement and especially gait are a key element of therapy for diabetic patients, it is important to consider that PA is, at the same time, stressful for feet and can cause foot lesions. For this, PA should be accurately assessed, monitored, and managed.

The early studies of this paradoxical “risk factor” (PA) focused on analyzing foot plantar pressures and gait quality and providing new information on gait and foot rollover alterations that patients with diabetes can show.[14],[15],[16],[42],[43]

According to these results, during the last 20 years, research studies were aimed at verifying diabetic patients' response to PA protocols [Table 2]. These studies demonstrated that targeted exercise therapy (ET) protocols can improve glycemic control, muscle strength, joint mobility, flexibility, and balance, in addition to gait abnormalities (gait speed and walking distance).[12],[43],[44],[45],[49],[50],[51],[52],[56],[58],[59]
Table 2: Studies on the effect of exercise program on patients with diabetes and risk of developing foot ulcers

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These studies have thus provided preliminary information of positive effects on foot rollover and plantar pressure distribution.[43],[46]

However, the limited use of PA/ET in the prevention of diabetic foot can be due to the lack of evidence on its preventive role. Since the results achieved seem to be temporary meaning that they are lost if the training is interrupted.[12],[44],[60],[61]

Further factors limiting the regular use of PA in the prevention of foot ulcers are as follows: patients' vulnerability and limited compliance, difficulty in performing the protocols routinely and for prolonged periods, feelings of tiredness, and fear of hypoglycemia.[12],[31],[32],[43],[44],[62],[63]

The lack of clear evidence on the preventive role of PA in diabetic foot requires further investigation.

Considering these problems in the use of PA, technologies available nowadays are possible solutions. Furthermore, thanks to the wide range of devices providing innumerable applications possibilities, such technologies monitoring daily PA by CMM can allow the definition of the proper treatment through structured or unstructured PA and clarify the preventive role of PA [Table 1].

  Physical Activity And Diabetic Foot Risk Factors Top

Diabetic foot lesions frequently occur in patients who show two or more simultaneous risk factors.[4] More than half of the patients with type 2 DM are affected by diabetic peripheral neuropathy (DPN) that can progressively induce motor dysfunction preceded by sensory deficits.[7],[10]

The neuromuscular problems (i.e., muscle weakness, reduced endurance, and loss of coordination) that may occur in patients with diabetes can worsen or lead to abnormalities in the biomechanics of the foot and of the whole body, in dynamic as well as in static postures.[42],[43],[64],[65] These impairments can also result in an abnormal foot rollover and plantar pressures, which significantly increase the risk of painless foot ulcer.[7],[35],[42],[43],[54],[57]

In addition to DPN, peripheral arterial disease plays an important role in the development of foot ulcers and can also negatively affect healing.[2],[4],[36] The presence of these complications indicates the patients at risk. It has been observed that about 50%–60% of all diabetic foot ulcers are ischemic or neuroischemic.[5] This condition can induce different functional limitations: minor gait speed, reduced walking distance, resting pain, and claudication.[51],[61],[66]

The presence of foot deformities and the importance of avoiding foot and leg trauma are other major risk factors to be considered in the PA management of diabetic patients.[2],[4],[7]

The same joint mobility of the lower limbs, usually evaluated at the ankle, and foot joints (subtalar and first metatarsophalangeal), can significantly decrease in patients with diabetes,[60],[67],[68],[69],[70] and this also contributes to the development of foot deformities and gait abnormalities.

Many factors concur to cause the development of structural abnormalities in diabetic patients. The presence of DPN, peripheral vascular disease (PVD), connective tissue alterations, and then deficit of balance, muscles strength, and biomechanics can trigger the development of foot deformities and ulcers due to the stress induced by the PA performed.[69],[70]

  Continuous Movement Monitoring and Major Risk Prevention Top

Even if PA can be fundamental in the prevention or treatment of major risk factors of the diabetic foot such as limited joint mobility or muscle weakness,[8],[44],[46],[48],[51],[53],[61] the presence of advanced DPN, in addition to PVD, seem cannot be significantly improved by ET and limit the possibility of full and long-lasting prevention or effective recovery from the other major risk factors (i.e., posture and biomechanical gait alterations).[12],[43],[61],[54]

As a result, it is important to begin the management of patients' PA as early as possible, starting from diabetes diagnosis. If, on the one hand, PA can have limited positive effects on DPN and PVD, on the other hand, their presence can explain the reason why, in individuals at risk, ET can have a limited positive effect on the maintenance of improvements over time.[12],[20],[60],[61]

It is important to underline that all due precautions must be taken into consideration in the management of a patient's daily PA designed to prevent the occurrence or recovery of ulcerative risk factors.[50],[56],[57],[61] In addition to leg trauma and falls, the disuse/overuse of muscles and connective tissues must be avoided.[56],[61],[71],[72]

The abnormal balance, posture, and gait biomechanics that patients at risk can show, in addition to the presence of foot deformities, may lead to overuse of some lower limb structures (i.e., muscle and connective tissue), while others cannot be involved during daily PA (disuse).[61],[72] In particular, the overuse of the foot and leg structures (i.e., Achilles tendon or plantar fascia) is mostly feared because it can contribute to the development of foot ulcer.[60],[72],[73]

In addition to this, the real effect of the improvement of patients' functional and motor deficits on their biomechanics and foot plantar pressures distribution is not yet clear; the short term in which they can be achieved can be a paradoxical risk for patients, leading to abnormal foot stress and overuse condition.[43],[46],[71],[72]

The patients' functional abilities and their quality of movement have to be checked (as well as lifestyle changes) so that instructions can be promptly adapted to the new needs identified. These evaluations have to be periodically repeated according to the patients' needs.

Once again, the results of postural and gait analysis can provide useful information on the management of daily PA. Such PA management based on the “three cornerstones” (CMM, posture–gait analysis, and muscle strength/joint mobility assessments) may ensure that the results achieved by an ET program are more long-lasting in patients [Figure 1].

  Continuous Movement Monitoring and Foot Plantar Pressure Top

The abnormal distribution and concentration of foot plantar pressure are one of the most feared causes of ulcer. Therefore, historically, the risk of plantar ulcers has been associated with the amount and type of the force exerted on the patient's foot.

Consequently, patients who are more active were considered to be at higher risk.[27],[28],[30],[34]

The CMM of daily lifestyle can be of great importance for its possible correlation with the total plantar pressure exerted on the feet. This estimation on long period foot pressures can be nowadays possible considering both the results of CMM and patients' foot pressure in static and dynamic conditions evaluated by the use of devices such as baropodometry, in-shoe pressure sensors, or instrumental walkways with a force platform.[Table 1].[19],[25],[28],[34],[42]

CMM can also highlight potentially harmful lifestyles such as those tending to concentrate or increased plantar foot stresses up to a dangerous degree and help patients modify their daily lifestyle to prevent ulcers.[19],[20],[24],[27]

However, it is worthy of attention that in the past decade, some studies, thanks to CMM, have not fully confirmed this correlation.[21],[23] It has been reported that patients with a history of ulceration are less active; one explanation being that higher variability in daily PA in less active patients could make them at higher risk for ulcers.[22],[23] These studies seem to suggest that patients' weakness and the possibility of developing foot ulcers are inversely associated with the level of daily PA performed.

A further complication of CMM is that also, the time spent in standing and sitting positions should be assessed.[26],[75] The amount of time spent in standing can correspond to a double walking activity in patients with DPN.[26] Therefore, the standing position is potentially dangerous in these patients because it could increase the risk of ulcer.[22],[23],[25],[26]

In this complex picture, CMM evaluation of daily PA can detect alarming factors such as a decrease in the daily PA performance. The understanding of causal factors of the reduced daily PA helps define preventive interventions. Similarly, a significant increase/change in PA intensity, duration, or distribution has to be carefully considered in patients at risk.

  Discussion Top

Currently, it is an important transitional moment for PA in the prevention of the diabetic foot. Timely attention should be given to the best uses for new PA assessment and monitoring devices in diabetes clinical practice.

To date, it has been demonstrated that most of the motor and functional deficits in DM patients significantly improve after short ET periods and patients can almost achieve the level of the healthy control group performance.[12],[47],[56],[58]

Patients can perform most of these activities as home-based exercise programs[44],[46],[51],[56] including weight-bearing and/or nonweight-bearing exercises according to the therapist's goals and the patient's needs.[12],[44],[55]

However, to date, the role of PA, mostly limited to ET in the prevention of foot ulcers, has not yet been fully clarified, and in-depth investigation is needed.[43],[61],[74]

In this context, the application possibilities of CMM open up new important perspectives and allow PA to be considered in its entirety.

However, on the one hand, if the 24-h monitoring of patients' PA is now possible through the use of devices showing an accuracy not previously achieved,[25],[33],[34],[75] on the other hand, it shows limitations that seem to hinder its application. Studies on CMM-involving patients with a history of foot ulcers or at risk have often been carried out with different devices providing several possibilities of evaluation.

CMM can help to evaluate the amount of daily foot stress, PA distribution, intensity, type, and duration and compare it to the lifestyle previously maintained.[19],[28],[29],[31],[75]

This approach may also be useful in determining what constitutes an unhealthy lifestyle, seasonal changes in leisure-time or working hours in addition to the location of activities to enhance patients' management. A full comprehension of these parameters requires repeating measurements several times a year.[48],[76]

Moreover, with the use of CMM, it can be possible to evaluate the effect of different treatment such as the use of protective foot devices. Indeed, CMM provides information on the amount and total time spent with the footwear and in-shoe devices worn.[27],[30],[34]

However, the use of devices for CMM evaluations involves costs, not only for buying the equipment but also for the involvement of specialized personnel and time for processing the data collected [Table 3].
Table 3: Pros and cons of continuous movement monitoring

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Moreover, different devices can provide varying results on the PA monitored. This involves a difficulty in analyzing the results achieved unless the same type of device is always used.[36]

It is important that CMM covers all 24 h in patients at risk. In fact, irregular monitoring can adversely affect the possibility to analyze PA performed since only a few minutes is needed to significantly modify the daily PA evaluation.

Although patients cannot wear a device continuously, they can fill out a log-book or diary to record the activities performed when the device is not worn. Special forms can help the patient to accurately register the activities performed.[24],[26],[33],[75]

Drawbacks to the use of new technology for CMM include the difficulty in assessing, understanding, and managing the lifestyle of patients at risk.

Therefore, to date, also in the case of CMM, the lack of prospective studies on larger sample size of patients at risk does not allow the definition of its real preventive impact. This can explain the currently limited use of such methods, despite their promising start.[20],[24]

Limitations of the study

This article provides a narrative review of studies without following the PRISMA guidelines for a transparent and complete reporting of systematic reviews and meta-analyses.[77] Some studies on movement monitoring in diabetic patients may not have been considered.

  Conclusions Top

Technological advances highlighted the application possibilities of devices for the evaluation and management of PAs. This allowed the proper management of daily life activities, well organized in quantity, intensity, type, and distribution, monitored by new CMM devices, to be a key element in the treatment of patients with diabetes. At the same time, further studies on the role of CMM and PA in the prevention of foot ulcers are needed to translate such type of monitoring into routine clinical practice. Currently, it is strongly recommended to define the role of CMM as cornerstone also in the prevention of diabetic foot.


We thank Mrs. G. Iannone for the technical and administrative support and Mrs. Mary Colonnelli for revising the English content.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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