Offloading devices and therapeutic footwear are among the best-supported tools for healing and preventing diabetic foot ulcers, yet a device that is not worn cannot work. Adherence is therefore a clinical outcome in its own right. Foot ulcers also tend to return: in a landmark analysis of ulcer remission, Armstrong and colleagues reported that roughly 40% of patients had a recurrence within one year of healing (N Engl J Med, 2017). This article reviews what recent research shows about how consistently people use protective devices, and whether education and behavioural counselling improve it.
How Much Offloading Is Actually Happening?
Objective monitoring has shown a gap between prescription and use. In a prospective multicentre study of 79 people with type 2 diabetes and a weight-bearing ulcer, Crews and colleagues (Diabetes Care, 2016) found that participants were active about 6.7 hours per day but wore their offloading devices only about 59% of the time. Poorer adherence was predicted by larger ulcers, more severe neuropathy, and greater postural instability. Notably, better adherence independently predicted smaller ulcers at six weeks, while depression was not significantly associated with adherence in that cohort.
These findings matter because neuropathy removes the pain that would normally discourage walking on a wound. A person with loss of protective sensation may feel well enough to take off a cast-style boot or remove a removable device for short trips, and those unprotected steps can add up.
Does Patient Education Reduce Ulcers?
Education is a cornerstone of prevention, but the trial evidence is more modest than its reputation. The Cochrane review by Dorresteijn and colleagues (2014) included 12 randomised trials. Education improved short-term knowledge in five of eight trials measuring it and self-reported behaviour in seven of nine, but only five trials reported ulcer or amputation outcomes. One trial showed lower ulceration and amputation after a single group session, a second, lower-risk-of-bias trial did not replicate this, and the authors concluded that robust evidence supporting limited, stand-alone education was insufficient.
The International Working Group on the Diabetic Foot (IWGDF) 2023 prevention guideline (Bus and colleagues, Diabetes/Metabolism Research and Reviews, 2024) nonetheless recommends teaching at-risk people appropriate foot self-care, advising them to avoid walking barefoot or without suitable protection, and educating moderate- to high-risk individuals to wear properly fitting therapeutic footwear. The guideline pairs this with the prescription of footwear that has a demonstrated plantar pressure-relieving effect during walking. Education is best understood as one component of a prevention programme rather than a stand-alone solution.
Can Motivational Interviewing Improve Adherence?
Motivational interviewing, a collaborative counselling style intended to strengthen a person’s own reasons for change, has been proposed as a way to close the adherence gap. A systematic review by Binning, Woodburn, Bus, and Barn (Diabetes/Metabolism Research and Reviews, 2019) identified only five eligible studies, too heterogeneous to pool. One study using motivational interviewing alone showed a short-term benefit for footwear adherence; of four studies with motivational components within broader interventions, two reported effectiveness but both were at high risk of bias. The authors described the finding as an evidence gap.
A subsequent cluster-randomised trial tested a single podiatrist-led motivational interviewing consultation (Jongebloed-Westra and colleagues, Diabetes Research and Clinical Practice, 2023). Among 121 people with loss of protective sensation and/or peripheral artery disease who had been prescribed orthopaedic shoes, adherence was measured objectively as the percentage of steps taken while wearing the shoes, using insole temperature sensors and activity trackers. Mean adherence at three months was 60.9% in the usual-care group and 50.9% in the motivational interviewing group, and at six months 59.9% versus 49.5%. A single brief session therefore did not improve adherence, and adherence was somewhat lower in the intervention arm.
Interpreting the Evidence
Taken together, these studies suggest that adherence is a measurable and modifiable problem, but that simple interventions have not yet reliably solved it. Several practical points emerge. First, self-reported use may overestimate real use, so objective measures such as temperature sensors and activity monitors are increasingly used in research. Second, factors such as ulcer size, neuropathy severity, and balance impairment can make consistent device use physically harder, which suggests that barriers should be addressed as well as motivation. Third, single-session interventions appear insufficient; repeated, individualised reinforcement is a plausible direction, though it remains to be tested in adequately powered trials.
Key Takeaways
Patients wear prescribed offloading devices for well under the full time they are active, and better adherence is associated with better early healing. Education improves knowledge and self-reported behaviour in the short term, but evidence that it alone reduces ulcers or amputations is limited. Motivational interviewing has an uncertain evidence base, and the most recent randomised trial of a single consultation found no adherence benefit. Current guidelines continue to recommend education alongside appropriately designed footwear and regular risk-based screening.
References
- Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017.
- Crews RT, Shen BJ, Campbell L, et al. Role and determinants of adherence to off-loading in diabetic foot ulcer healing: a prospective investigation. Diabetes Care. 2016;39(8):1371-1377.
- Dorresteijn JAN, Kriegsman DMW, Assendelft WJJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev. 2014;(12).
- Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3651.
- Binning J, Woodburn J, Bus SA, Barn R. Motivational interviewing to improve adherence behaviours for the prevention of diabetic foot ulceration. Diabetes Metab Res Rev. 2019;35(2):e3105.
- Jongebloed-Westra M, Exterkate SH, van Netten JJ, et al. Cluster-randomized trial of motivational interviewing and adherence to orthopedic shoe wear in people with diabetes. Diabetes Res Clin Pract. 2023;204:110903.
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