April 2014

Patients as people: Experts emphasize personal approach

In the moment: Diabetes

4ITM-diabetesshutterstock_lrBy Jordana Bieze Foster

The patient in the video, an older woman with diabetic neuropathy, is a dog lover. Her dog-shaped earrings give this away. And this just might be the most important thing for the clinicians treating her to know.

In the video, the patient talks about the benefits of her improved balance following an exercise intervention. She doesn’t mention fitness, or reduced risk of falls, or increased gait speed. She talks about being able to play tug-of-war in the yard with her dog.

“Since they have trouble even going outside, these patients avoid doing even very basic daily activities. So we need to find something personalized to motivate this patient,” said Bijan Najafi, PhD, who showed the video in March as part of a presentation at the Diabetic Foot Global Conference (DFCon) in Los Angeles. “This is the first step to get them to the point where they are more active.”

Najafi, who is director of the Interdisciplinary Consortium on Advanced Motion Performance at the University of Arizona in Tucson, and other presenters throughout the conference repeatedly underscored the need for clinicians to view each patient as an individual rather than as one more at-risk diabetic foot.

“We often think we’re going to educate patients, and when the patient is this very smart person with regard to healthcare it will be different. Nothing could be further from the truth,” said Grant H. Skrepnek, PhD, a health economist and an associate professor in the College of Pharmacy at the University of Oklahoma in Oklahoma City. “There are a number of variables that affect patients’ feelings about healthcare. We need to understand each patient as an individual.”

Sometimes, as in the video, this type of patient-centric approach to diabetic foot care involves determining each patient’s personal motivations. But sometimes it involves determining the degree of compromise needed to maximize compliance with interventions in a particular patient.

Najafi cited a 2012 study in which he and colleagues studied the offloading capabilities of walking boots that had lower-profile strut heights—and therefore were lighter and more comfortable—than traditional models (see “Rethinking device design to improve compliance”). They found that an ankle-high walker was associated with approximately 20% less peak pressure reduction than a knee-high walker, but, Najafi pointed out, in certain patients that might be an acceptable tradeoff.

“The shorter boot has 20% less offloading, but maybe that improves the quality of life of the patient,” he said. “We always blame the patient when they don’t have good compliance, but look what we are doing to their quality of life. If our interventions are not patient-centric, the patient won’t have good compliance.”

If mobility is important to a particular patient, that’s another area in which offloading expectations may need to be adjusted.

“The more mobility people have, the worse their pressure reduction is, so you have to compromise,” said Lawrence Lavery, DPM, a professor in the departments of plastic surgery, orthopaedic surgery, and physical medicine & rehabilitation at the University of Texas Southwestern Medical Center in Dallas.

Stability during gait is an additional factor that has to be balanced with offloading.

“If you’re not using the entire base of support for stability, then you are creating a risk of falls,” Najafi said. “You may heal the ulcer, but you may also put the patient at risk for a hip fracture.”

Stability is also important for patient quality of life, noted David Armstrong, DPM, MD, PhD, a professor of surgery and director of the Southern Arizona Limb Salvage Alliance at the University of Arizona.

“When you put someone in a total contact cast, that becomes the most stable-feeling limb, and they end up limping on the ‘wrong’ side. But if you give them a more normal gait, you increase pressure in some areas then too,” said Armstrong, a co-chair of the conference. “So now we’re trying to create a ‘relatively normal’ gait. Maybe they’ll be happier, and maybe that’s the most important thing.”


Crews RT, Sayeed F, Najafi B. Impact of strut height on offloading capacity of removable cast walkers. Clin Biomech 2012;27(7):725-730.

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