The True Value of Diabetic Offloading Devices

We’ve all heard the old saying: an ounce of prevention is worth a pound of cure. When it comes to the progression of wounds, this is certainly true.

Consider diabetic foot ulcers. The stakes are high when it comes to these ailments. But, due to nerve damage, diabetics often find them difficult to recognize. Unfortunately, once deep infection sets in, serious consequences can arise—including foot and lower leg amputations.

That said, there are methods of eliminating foot ulcer-related complications. And they can be quite effective. Offloading devices are designed specifically to take pressure off of existing wounds, which can prevent amputations and other serious issues.

At this moment in health care history, solutions are critical. Diabetes rates are skyrocketing. Interventions that minimize some of the disease’s negative impacts will help practitioners improve the lives of patients in the years ahead. In this post, we’ll consider the value of offloading devices.

Diabetic foot ulcers: a critical issue

There’s no shortage of major issues facing Canada’s health care systems. Chronic disease rates are growing, bringing with them a myriad of new challenges. Managing diabetes and its (often grave and even fatal) consequences is one of them.

In 2016, there were an estimated 11 million Canadians living with diabetes and prediabetes. That’s 29% of the general population.

In Ontario, the numbers are similarly staggering. In 2015, there were approximately 1.5 million diabetic Ontarians, and 2.27 million who had predeiabetes. By 2025, those numbers are expected to reach 2.27 million and 2.54 million, respectively.

As a health care professional, you’re aware of just how serious these statistics are. From heart attacks to kidney disease and blindness, the complications of diabetes are both devastating and costly.

Most people who aren’t living with the disease don’t know much about diabetic foot ulcers. But these wounds are all too common—and they can drastically impact quality of life.

Of course, one of the biggest challenges associated with foot ulcers is making patients aware of the harm they can cause. Because nerve damage can reduce the pain associated with wounds, many diabetics don’t notice them—or seek help—until it’s too late.

Dire consequences may result: 85% of leg amputation are caused by non-healing diabetic foot ulcers. You may be aware of this statistic. But it certainly bears repeating.

Data on amputations in Canada is sparse. And according to some experts, current statistics are low. That said, existing estimates are still capable of shocking most people. As of 2009, there were 2,100 diabetic foot and leg amputations per year in Ontario.

While studies show that rates have held fairly steady in recent years, the increase in diabetes diagnoses threatens to change that. The costs are both human and monetary, since an amputation can be $70,000 per patient.

The solution: offloading devices

Many major health problems don’t have straightforward solutions. It’s not always clear which preventative measures a health care professional should suggest.

This lack of clarity can be frustrating. Because often, implementing evidence-informed solutions is the key to preventing future complications. The results can be measured not only in significantly lower health care costs, but in increased quality of life for patients.

Luckily, when it comes to diabetic foot ulcers, there are widely agreed-upon recommendations. Some of Ontario’s most credible health care organizations stand behind the use of offloading devices to prevent the progression of these wounds. These groups include the Registered Nurses of Ontario (RNAO), Wounds Canada, and the Canadian Association for Enterostomal Therapy (CAET).

As a professional who deals with chronic wounds, you’re likely aware of the problems that friction on the lower extremities can cause. Small wounds can quickly lead to deep infections—which can, of course, result in amputation.

The RNAO calls redistributing pressure on an ulcer “the most important intervention” in managing it, “without exception”. The right shoes or socks aren’t always enough to achieve this goal.

Often, offloading devices such as cast walkers or total contact casts are the key to dispersing pressure adequately. These devices usually range from $100 to $1,500. Compare that number to $70,000 dollars required to carry out an amputation.

Needless to say, implementing these devices when they’re needed can also have a impact on health care systems. By reducing the need for amputations and costly treatments, they can resulting in major savings. But if you work with patients who have chronic wounds, you know the greater value these devices provide. Quite simply, they help diabetics prevent events that could have huge, negative impacts on their lives.

Better outcomes, improved lives

The Ontario Health Technology Advisory Committee (OHTAC) recognizes the value of offloading devices. A recent assessment looked at three devices—total contact casts, removable cast walkers, and irremovable cast walkers.

The committee found that all three interventions “provide clinical benefit and value for money.” It also found that they are “consistent with patient values and preferences across the spectrum of management” of the type of ulcers it looked at.

For nurses, the most important outcomes have to do with people. It’s good to know that offloading devices can, in many instances, be part of patient-centred care plans. And because they can prevent wound progression and lead to healing, they go a long way toward improving quality of life.

One study found that, with the use of total contact casting, 89.5% of participants had ulcers that completely healed over 12 weeks. For those who used removable cast walkers, 65% were completely healed.

Of course, identifying at-risk patients is key, as is encouraging self foot examinations and regular check ups. And once a diabetic foot ulcer is recognized, further assessment is required in order to ensure that the right device is selected.

It goes without saying that these solutions should be part of a larger care plan. Like other serious wounds, diabetic foot ulcers are often best treated holistically. As part of a multidisciplinary team, you’re sure to achieve the most positive outcomes possible.

Unfortunately, despite positive results and the endorsement of many experts, offloading devices aren’t always used when they have the potential to help. It can take time for evidence-informed solutions to become accepted best practices.

In the war against diabetic foot ulcers, your knowledge and input are crucial. Be vocal about the benefits of offloading devices. You’ll help diabetic Canadians avoid serious health complications—and enjoy healthier feet.

Feature image courtesy of mmarchin

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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