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Jarl, G. (2019). Commitment devices in the treatment of diabetic foot ulcers. Journal of Foot and Ankle Research, 12(1), Article ID 44.
Open this publication in new window or tab >>Commitment devices in the treatment of diabetic foot ulcers
2019 (English)In: Journal of Foot and Ankle Research, ISSN 1757-1146, Vol. 12, no 1, article id 44Article in journal (Refereed) Published
Abstract [en]

Background: Non-removable offloading devices are recommended for the treatment of uncomplicated plantar diabetic foot ulcers because adherence to using removable devices is low. However, patients may not always understand how crucial the non-removability is to ulcer healing, leaving them with the impression that it is the device per se that heals the ulcer. Thus, after ulcer healing when patients return to using removable offloading devices, typically therapeutic footwear, they often return to a low level of adherence resulting in high reulceration rates. To change this pattern of behavior based on a misconception, we need to start with how we as clinicians are conceptualizing treatment with offloading devices.

Non-removable offloading devices as commitment devices: Commitment devices are voluntary restrictions people put on their future selves to resist short-term temptations and achieve long-term goals. In this paper, it is suggested that a change from viewing non-removable offloading devices as means to force compliance, to viewing them as commitment devices could facilitate a change to a clinical thinking that emphasizes the importance of high adherence without compromising respect for patient autonomy.

Conclusion: Viewing non-removable offloading devices as commitment devices seems to be a promising approach to emphasize the importance of adherence while respecting patient autonomy. Hopefully, patients' higher appreciation of the role of adherence can lead to higher adherence to using therapeutic footwear after healing and consequently to reduced reulceration rates.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Diabetes complications, Diabetic foot, Shoes, Patient compliance, Treatment adherence and compliance, Casts, surgical, Orthotic devices
National Category
Orthopaedics
Identifiers
urn:nbn:se:oru:diva-76445 (URN)10.1186/s13047-019-0355-9 (DOI)000483085000001 ()31452689 (PubMedID)2-s2.0-85070982474 (Scopus ID)
Available from: 2019-09-16 Created: 2019-09-16 Last updated: 2019-09-16Bibliographically approved
Jarl, G., Alnemo, J., Tranberg, R. & Lundqvist, L.-O. (2019). Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications. Journal of Foot and Ankle Research, 12, Article ID 21.
Open this publication in new window or tab >>Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications
2019 (English)In: Journal of Foot and Ankle Research, ISSN 1757-1146, Vol. 12, article id 21Article in journal (Refereed) Published
Abstract [en]

Background: Therapeutic shoes can prevent diabetic foot reulcerations but their use is complicated by the fact that shoes have psychological and social meanings, which is believed to put a larger burden on women than men. The aim was to compare attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications.

Methods: A questionnaire was posted to 1230 people with diabetes who had been fitted with therapeutic shoes. Women's and men's answers were compared using t-tests, Mann-Whitney U tests and chi-square tests with Fischer's exact tests. P-values<0.05 were considered statistically significant.

Results: Questionnaires from 443 (36.0%) respondents (294 men, 149 women, mean age 69.2years) were analyzed. More men than women (p<0.05) had paid employment (20.4% vs 9.4%), had someone who reminded them to wear their therapeutic shoes (27.6% vs 10.0%), and had a history of foot ulcers (62.9% vs 46.3%) or minor amputation (17.7% vs 6.7%). More women than men received disability pension (18.8% vs 10.2%). Women reported worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes to the appearance and price of therapeutic shoes and how they felt about wearing them in public. Other comparisons were non-significant: other shoe attributes, education, diabetes type, current foot ulcers, major amputations, satisfaction with shoe services, understanding of neuropathy as a risk factor, locus of control regarding ulcer healing, belief in the shoes' efficacy to prevent and heal ulcers, worries about ulcer healing and new ulcerations, self-efficacy, depression, shoe use/adherence, paying a fee for therapeutic shoes, and social support.

Conclusions: Men had worse foot complications. Women had worse general health, lower internal locus of control regarding ulcer prevention, and more negative attitudes toward therapeutic shoes. Clinicians should pay more attention to their female patients' concerns. Future research and development should focus on improving the weight and appearance of therapeutic shoes, particularly for women. Research is also needed on how to facilitate the adaption and reevaluation process where patients change from viewing shoes purely as items of clothing to also viewing them as medical interventions.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Diabetes mellitus, Diabetic foot, Diabetes complications, Shoes, Patient compliance, Treatment adherence and compliance
National Category
Orthopaedics
Identifiers
urn:nbn:se:oru:diva-73768 (URN)10.1186/s13047-019-0327-0 (DOI)000463602200001 ()30976327 (PubMedID)
Note

Funding Agency:

Region Örebro County, Sweden 

Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2019-04-16Bibliographically approved
Jarl, G., Hellstrand Tang, U., Nordén, E., Johannesson, A. & Rusaw, D. F. (2019). Nordic clinical guidelines for orthotic treatment of osteoarthritis of the knee: A systematic review using the AGREE II instrument. Prosthetics and orthotics international
Open this publication in new window or tab >>Nordic clinical guidelines for orthotic treatment of osteoarthritis of the knee: A systematic review using the AGREE II instrument
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2019 (English)In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553Article, review/survey (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND: High-quality clinical practice guidelines are necessary for effective use of resources both at an individual patient- and national-level. Nordic clinical practice guidelines recommendations for orthotic treatment of knee osteoarthritis vary and little is known about their quality.

OBJECTIVES: The aim of the study was to critically evaluate the quality of clinical practice guidelines in orthotic management of knee osteoarthritis in the Nordic countries.

STUDY DESIGN: Systematic review.

METHODS: Four national clinical practice guidelines for treatment of knee osteoarthritis were assessed for methodological rigour and transparency by four independent assessors using the AGREE II instrument. Summary domain scores and inter-rater agreement (Kendall's W) were calculated.

RESULTS:  < 0.001).

CONCLUSION: Quality of clinical practice guidelines for orthotic treatment of knee osteoarthritis in the Nordic region is variable. Future guideline development should focus on improving methodology by involving relevant stakeholders (e.g. certified prosthetist/orthotists (CPOs)), specifying conflicts of interest and providing guidance for implementation.

CLINICAL RELEVANCE: The current review suggests that, for the Nordic region, there are areas of improvement which can be addressed, which ensure clinical practice guidelines are developed under stringent conditions and based on sound methods. These improvements would ensure knee osteoarthritis patients are receiving orthotic interventions based on appropriate guidance from published guidelines.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
Orthotic device, braces, orthosis, practice guidelines
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:oru:diva-75610 (URN)10.1177/0309364619857854 (DOI)31256710 (PubMedID)
Available from: 2019-08-20 Created: 2019-08-20 Last updated: 2019-08-20Bibliographically approved
Jarl, G. & Ramstrand, N. (2018). A model to facilitate implementation of the International Classification of Functioning, Disability and Health into prosthetics and orthotics. Prosthetics and orthotics international, 42(5), 468-475
Open this publication in new window or tab >>A model to facilitate implementation of the International Classification of Functioning, Disability and Health into prosthetics and orthotics
2018 (English)In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 42, no 5, p. 468-475Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The International Classification of Functioning, Disability and Health is a classification of human functioning and disability and is based on a biopsychosocial model of health. As such, International Classification of Functioning, Disability and Health seems suitable as a basis for constructing models defining the clinical P&O process. The aim was to use International Classification of Functioning, Disability and Health to facilitate development of such a model.

Proposed model: A model, the Prosthetic and Orthotic Process (POP) model, is proposed. The Prosthetic and Orthotic Process model is based on the concepts of the International Classification of Functioning, Disability and Health and comprises four steps in a cycle: (1) Assessment, including the medical history and physical examination of the patient. (2) Goals, specified on four levels including those related to participation, activity, body functions and structures and technical requirements of the device. (3) Intervention, in which the appropriate course of action is determined based on the specified goal and evidence-based practice. (4) Evaluation of outcomes, where the outcomes are assessed and compared to the corresponding goals. After the evaluation of goal fulfilment, the first cycle in the process is complete, and a broad evaluation is now made including overriding questions about the patient's satisfaction with the outcomes and the process. This evaluation will determine if the process should be ended or if another cycle in the process should be initiated.

CONCLUSION: The Prosthetic and Orthotic Process model can provide a common understanding of the P&O process. Concepts of International Classification of Functioning, Disability and Health have been incorporated into the model to facilitate communication with other rehabilitation professionals and encourage a holistic and patient-centred approach in clinical practice.

Clinical relevance: The Prosthetic and Orthotic Process model can support the implementation of International Classification of Functioning, Disability and Health in P&O practice, thereby providing a common understanding of the P&O process and a common language to facilitate communication with other rehabilitation professionals.

Place, publisher, year, edition, pages
London, United Kingdom: Sage Publications, 2018
Keywords
Disability and Health, International Classification of Functioning, Orthotics, prosthetics, rehabilitation, treatment outcomes
National Category
Other Health Sciences Orthopaedics
Research subject
Disability Science
Identifiers
urn:nbn:se:oru:diva-63977 (URN)10.1177/0309364617729925 (DOI)000444981600001 ()28905670 (PubMedID)2-s2.0-85041903423 (Scopus ID)
Available from: 2018-01-09 Created: 2018-01-09 Last updated: 2019-03-27Bibliographically approved
Jarl, G. & Hermansson, L. (2018). A modified walk-in system versus scheduled appointments in a secondary-care prosthetic and orthotic clinic. Prosthetics and orthotics international, 42(5), 483-489
Open this publication in new window or tab >>A modified walk-in system versus scheduled appointments in a secondary-care prosthetic and orthotic clinic
2018 (English)In: Prosthetics and orthotics international, ISSN 0309-3646, E-ISSN 1746-1553, Vol. 42, no 5, p. 483-489Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Waiting is common in health care, delays intervention, and has negative effects on satisfaction with services.

OBJECTIVES: To evaluate effects of a modified walk-in system, where patients were invited consecutively from the waiting list to attend the clinic on a walk-in basis, on waiting times, services, and work environment.

STUDY DESIGN: Parallel-group trial.

METHODS: In all, 1286 consecutive patients in need of shoe insoles were randomized to waiting lists for modified walk-in ( n = 655) or a scheduled appointment ( n = 631). Seven staff members also participated.

RESULTS: The median indirect waiting time to first appointment was 40 days shorter for modified walk-in (135 days) than for scheduled appointment (175 days; p < 0.001); 17% of those randomized to modified walk-in did not attend the clinic compared to 6% for scheduled appointment ( p < 0.001). Mean direct waiting time in the waiting room was 9.9 min longer for modified walk-in than for scheduled appointment ( p < 0.001). Patients attending modified walk-in or a scheduled appointment reported similar levels of satisfaction with services. Staff reported more support from co-workers with modified walk-in than with scheduled appointment ( p = 0.041).

CONCLUSION: The modified walk-in can reduce indirect waiting times without any substantial worsening of direct waiting times, service quality, or work environment. Studies are needed to investigate why many patients drop out from modified walk-in. Clinical relevance A modified walk-in system can cut the queues and create more timely interventions by reducing indirect waiting times. This system can therefore be recommended in secondary-care prosthetic and orthotic clinics to reduce patients' suffering from their health condition.

Place, publisher, year, edition, pages
Sage Publications, 2018
Keywords
Rehabilitation, lower limb orthotics, orthotics
National Category
Orthopaedics
Identifiers
urn:nbn:se:oru:diva-69230 (URN)10.1177/0309364617728120 (DOI)000444981600003 ()28905683 (PubMedID)2-s2.0-85041927809 (Scopus ID)
Note

Funding Agency:

Region Örebro County, Sweden

Available from: 2018-10-04 Created: 2018-10-04 Last updated: 2018-10-04Bibliographically approved
Jarl, G. & Lundqvist, L.-O. (2018). An alternative perspective on assistive technology: the Person-Environment-Tool (PET) model. Assistive technology
Open this publication in new window or tab >>An alternative perspective on assistive technology: the Person-Environment-Tool (PET) model
2018 (English)In: Assistive technology, ISSN 1040-0435, E-ISSN 1949-3614Article in journal (Refereed) Epub ahead of print
Abstract [en]

The medical and social models of disability are based on a dichotomy that categorizes people as able-bodied or disabled. In contrast, the biopsychosocial model, which forms the basis for the International Classification of Functioning, Disability and Health (ICF), suggests a universalistic perspective on human functioning, encompassing all human beings. In this article we argue that the artificial separation of function-enhancing technology into assistive technology (AT) and mainstream technology might be one of the barriers to a universalistic view of human functioning. Thus, an alternative view of AT is needed. The aim of this article was to construct a conceptual model to demonstrate how all human activities and participation depend on factors related to the person, environment, and tools, emphasizing a universalistic perspective on human functioning. In the Person-Environment-Tool (PET) model, a person's activity and participation are described as a function of factors related to the person, environment, and tool, drawing on various ICF components. Importantly, the PET model makes no distinction between people of different ability levels, between environmental modifications intended for people of different ability levels, or between different function-enhancing technologies (AT and mainstream technology). A fictive patient case is used to illustrate how the universalistic view of the PET model lead to a different approach in rehabilitation. The PET model supports a universalistic view of technology use, environmental adaptations, and variations in human functioning.

Place, publisher, year, edition, pages
New York, USA: Taylor & Francis, 2018
National Category
Orthopaedics
Identifiers
urn:nbn:se:oru:diva-66705 (URN)10.1080/10400435.2018.1467514 (DOI)29676966 (PubMedID)
Available from: 2018-04-23 Created: 2018-04-23 Last updated: 2018-08-30Bibliographically approved
Jarl, G. & Tranberg, R. (2018). An innovative sealed therapeutic shoe to off-load and heal diabetic forefoot ulcers. In: : . Paper presented at 15th Annual Meeting of the Diabetic Foot Study Group (DFSG), Berlin, September 28-30, 2018.
Open this publication in new window or tab >>An innovative sealed therapeutic shoe to off-load and heal diabetic forefoot ulcers
2018 (English)Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Aim: The aim was to investigate the feasibility of using a therapeutic shoe, rendered irremovable,to off-load and heal forefoot ulcers. Non-removable knee-high off-loading devicesare gold standard to treat neuropathic forefoot ulcers. They do however immobilize theankle, affecting joint functioning and daily activities.

Method: Seven men with diabetes type 2 since >10 years, sensory neuropathy and a metatarsalhead ulcer (table 1) were prescribed extra-depth therapeutic roller shoes and custom-madeinsoles adjusted to off-load the ulcer (fig. 1). Off-loading was assessed with anin-shoe plantar pressure system* measuring plantar peak pressures as the participantswalked. The shoe was then sealed with a plastic band and worn day and night like a cast.Adherence was assessed by documenting the status of the seal (intact/broken) whenchanging ulcer dressings.

Results / Discussion: All ulcers healed, with a median time to healing of 8 weeks (range1-23). The median peak pressure on the ulcer was 116 kPa (range 62-192) when walkingwith the shoe. Five of seven participants respected the seal. Complications were secondaryulcer (n=1) and plantar hematoma (n=1). The most common complaint was difficulty todress (n=5).

Sealed therapeutic shoes are an interesting avenue for future research; they include advantagesof non-removable knee-high devices as effective off-loading and high adherence,and overcome disadvantages as mobility restrictions and high costs.

Conclusion: It seems feasible to seal a therapeutic shoe to off-load and heal forefoot ulcers.A randomized controlled trial is underway in which sealed shoes are to be comparedto total contact casting.

National Category
Orthopaedics Endocrinology and Diabetes
Identifiers
urn:nbn:se:oru:diva-69389 (URN)
Conference
15th Annual Meeting of the Diabetic Foot Study Group (DFSG), Berlin, September 28-30, 2018
Available from: 2018-10-08 Created: 2018-10-08 Last updated: 2018-10-08Bibliographically approved
Jarl, G. (2018). Decision trees for risk stratification of the diabetic foot. The Diabetic foot journal, 21(4), 218-223
Open this publication in new window or tab >>Decision trees for risk stratification of the diabetic foot
2018 (English)In: The Diabetic foot journal, ISSN 1462-2041, Vol. 21, no 4, p. 218-223Article in journal (Refereed) Published
Abstract [en]

Delays in referral from primary to specialist care are a common issue in the clinical management of diabetic foot (DF) disease and are associated with worse clinical outcomes. One of the reasons for the delays may be the complexity of risk stratification, which can leave clinicians who are not specialised in the DF uncertain about when to refer patients for specialist assessment. This article illustrates how risk stratification can be simplified with the use of decision trees. Two decision trees are given as examples: one based on the risk stratification system of the Scottish Diabetes Foot Action Group and one based on the National Institute for Health and Care Excellence guideline. Decision trees can be used to facilitate correct risk stratifications and the referral of people with DF complications, and thereby hopefully contribute to improved outcomes for people with DF disease.

Place, publisher, year, edition, pages
S B Communications Group, 2018
Keywords
Algorithms, Decision trees, Delays in care, Diabetic foot, Risk stratification
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:oru:diva-73675 (URN)
Available from: 2019-04-12 Created: 2019-04-12 Last updated: 2019-04-12Bibliographically approved
Jarl, G. (2018). Methodological considerations of investigating adherence to using offloading devices among people with diabetes. Patient Preference and Adherence, 12, 1767-1775
Open this publication in new window or tab >>Methodological considerations of investigating adherence to using offloading devices among people with diabetes
2018 (English)In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 12, p. 1767-1775Article in journal (Refereed) Published
Abstract [en]

Foot ulcers are a diabetic complication associated with significant morbidity, mortality, and amputation risk. Offloading devices prevent and heal foot ulcers, but adherence to using these devices is low. The reasons for nonadherence are unclear, and study results are difficult to compare due to methodological heterogeneity. This paper explores aspects of investigating adherence to using offloading devices among people with diabetes and provides recommendations for future studies, focusing on study designs, definitions of adherence, measurement methods, and conceptual frameworks. Most studies use a cross-sectional observational study design, limiting the potential to establish the temporal sequence between predictors and adherence, rule out confounding factors, and establish causality. Studies defining adherence as the length of time the device is worn have often used self-report to measure adherence, which may be unreliable. Studies using activity monitors to measure adherence have defined adherence as the number of steps taken with the device, which excludes weight-bearing activities where no steps are taken. Conceptual frameworks are not made explicit in the current quantitative research. It is concluded that future studies should use a longitudinal design with observational studies to identify patient groups prone to nonadherence and factors that influence adherence and experimental studies to evaluate interventions to improve adherence, focusing on these patient groups and factors. Furthermore, adherence should be defined in terms of relative adherence to using offloading devices during all weight-bearing activities, and objective measurement of adherence ( using accelerometers and temperature monitors) should be used whenever possible. Clearly defined conceptual frameworks should guide the choice of factors to include in the study and the analysis of their interactions. By implementing these recommendations, research could provide a stronger evidence base in the future, supporting interventions to increase adherence and thereby improve outcomes for people with diabetic foot complications.

Place, publisher, year, edition, pages
DOVE Medical Press Ltd., 2018
Keywords
research design, treatment adherence and compliance, patient compliance, orthotic devices, shoes, diabetic foot
National Category
General Practice Endocrinology and Diabetes
Identifiers
urn:nbn:se:oru:diva-69008 (URN)10.2147/PPA.S175738 (DOI)000444319800001 ()
Note

Funding Agency:

Region Örebro County, Sweden

Available from: 2018-09-25 Created: 2018-09-25 Last updated: 2018-09-25Bibliographically approved
Amer, A., Kakooza-Mwesige, A., Jarl, G., Tumwine, J. K., Forssberg, H., Eliasson, A.-C. & Hermansson, L. (2018). The Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG). Part II: Psychometric properties. Child Care Health and Development, 44(4), 562-571
Open this publication in new window or tab >>The Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG). Part II: Psychometric properties
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2018 (English)In: Child Care Health and Development, ISSN 0305-1862, E-ISSN 1365-2214, Vol. 44, no 4, p. 562-571Article in journal (Refereed) Published
Abstract [en]

Background: The Pediatric Evaluation of Disability Inventory (PEDI) has been recommended as a gold standard in paediatric rehabilitation. A Ugandan version of PEDI (PEDI-UG) has been developed by culturally adapting and translating the original PEDI. The aim of this study was to investigate the psychometric properties of the PEDI-UG in Ugandan children by testing the instrument's rating scale functioning, internal structure, and test-retest reliability.

Methods: Two hundred forty-nine Ugandan children (125 girls) aged 6 months to 7.5 years (Mean = 3.4, SD = 1.9) with typical development were tested using the PEDI-UG. Forty-nine children were tested twice to assess test-retest reliability. Validity was investigated by Rasch analysis and reliability by intraclass correlation coefficient.

Results: The PEDI-UG domains showed good unidimensionality based on principal component analysis of residuals. Most activities (95%) showed acceptable fit to the Rasch model. Six misfit items were deleted from the Functional Skills scales and one from the Caregiver Assistance scales. The category steps on the Caregiver Assistance scales' rating scale were reversed but functioned well when changed from a 6-point to 4-point rating scale. The reliability was excellent; intraclass correlation coefficient was 0.87-0.92 for the domains of the Functional Skills scales and 0.86-0.88 for the domains of the Caregiver Assistance scales.

Conclusion: The PEDI-UG has good to excellent psychometric properties and provides a valid measure of the functional performance of typically developing children from the age of 6 months to 7.5 years in Uganda. Further analysis of all items, including misfit and deleted items, in children with functional disability is recommended.

Place, publisher, year, edition, pages
John Wiley & Sons, 2018
Keywords
children, disability, PEDI, Uganda, validation studies
National Category
Pediatrics Psychology (excluding Applied Psychology)
Identifiers
urn:nbn:se:oru:diva-65823 (URN)10.1111/cch.12562 (DOI)000435441700007 ()29532497 (PubMedID)2-s2.0-85043570914 (Scopus ID)
Funder
Sida - Swedish International Development Cooperation AgencySwedish Research Council, 5925
Note

Funding Agencies:

Frimurare Barnhus Foundation  

African Population and Health Research Center (APHRC)  

International Development Research Center (IDRC)  

Ford Foundation  

Karolinska Institutet  

Belgian Technical Cooperation (BTC)  L07UGA023 

Available from: 2018-03-15 Created: 2018-03-15 Last updated: 2018-08-20Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-6410-2474

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