Table 1.

Physical activity monitoring for the prevention of diabetic foot ulcer

Study (year)	General purpose	Study type	Sample size	Equipment and duration	Results and conclusion
Armstrong et al.[27] (2001)	To compare the effectiveness of three off-loading modalities to heal neuropathic foot ulcerations	Prospective longitudinal study	63 patients with DM and plantar foot ulcers	12 weeks. Pedometer	Patients treated with the total-contact casts were significantly less active than those treated with the half-shoe. There was not a significant difference in activity between patients treated with the total-contact casts and with the removable cast walkers
Armstrong et al.[24] (2001)	To evaluate the magnitude and location of patients’ activity level	Prospective longitudinal study	20 DM patients at high risk	1 week. Activity monitor	Patients were most active during the late morning and mid-afternoon hours. At home, the patients used the physician-approved shoes less than outside the home
Maluf and Mueller[19] (2003)	To compare the amount of weight-bearing activity and estimates of cumulative plantar tissue stress	Cross-sectional study with matched groups	20 patients with DPN with and without a history of foot plantar ulcer, 10 nondiabetic control subjects	1 week. Two-dimensional accelerometers and in-shoe pressure measurement	Patients with diabetes and a history of previous ulcers may be susceptible to plantar tissue injury even at relatively low levels of cumulative tissue stress
Lemaster et al.[21] (2003)	To determine whether weight-bearing activity increased the risk of foot ulcer	Prospective longitudinal cohort study	400 patients with DM and a prior history of foot ulcer	2 years. 24-h activity questionnaire	Increased weight-bearing activity did not increase the risk of foot reulceration
Armstrong et al.[23] (2004)	To evaluate the role of activity in the development of neuropathic foot ulceration	Prospective longitudinal study	100 DM patients at high risk	>25 weeks (or until ulceration). Accelerometer/pedometer	Individuals with diabetes who develop ulceration may actually have a lower overall daily activity than their nonulcerated counterparts, but the quality of that activity may be more variable
Kanade et al.[28] (2006)	To explore plantar loading of the surviving foot following unilateral transtibial amputation	Cross-sectional study with matched groups	21 patients with DPN and transtibial amputation; 21 patients with DPN without history of ulceration	8 consecutive days. Step watch activity monitors and in-shoe pressure measurement system	Adaptations in gait and level of walking activity affect the plantar pressure distribution and ultimately the potential risk of ulceration to the surviving foot
Najafi et al.[26] (2010)	To monitor spontaneous daily PA and examine both walking and standing activities	Prospective longitudinal study	13 patients with DPN	2 days. Body-worn sensor	Patients with DPN spent 13.5% of time in standing and 6.1% in walking. Walking may cover as little of a person’s daily PA and hence might not be representative of what the subject is doing during daily living activities
Van Schie et al.[29] (2011)	To evaluate the validity of the “step activity monitor” for assessing PA and the relation with the self-reported PA	Prospective longitudinal study	24 patients with DPN	2 days. Step activity monitor, step watch 3, and international PA questionnaire	Step activity monitor was shown to be a valid tool to assess PA
Waaijman et al.[30] (2013)	To objectively assess adherence to wearing prescribed custom-made footwear	Randomized controlled trial	107 DPN patients with a recently healed plantar foot ulcer	7 consecutive days. Temperature-based monitor and ankle-worn activity monitor	Adherence to wearing custom-made footwear is insufficient, particularly at home where patients exhibit their largest walking activity. This low adherence is a major threat for reulceration
Lim et al.[31] (2016)	To investigate the effect of an individualized multidisciplinary U-health care service combined with exercise monitoring and dietary feedback on glucose control	Randomized controlled trial	100 patients with type 2 DM assigned to a self-monitored blood glucose group or U-healthcare group	6 months. Glucometer and an activity monitor that automatically transferred test results to a hospital-based server	The HbA1c level was significantly decreased in the U-healthcare group compared with the self-monitored blood glucose group
Brazeau et al.[32] (2008)	To determine if there was an inverse relationship between sitting and step counts in a diabetes cohort	Prospective cohort study	The cohort included 198 T2DM adults	14 days. Pedometer, international PA questionnaire	There was a low correlation between sitting time and step counts
Dasanayake et al.[33] (2015)	To develop a method to detect the onset and end of exercise	Research study	16 adults with T1DM	2 days. Diary, accelerometer, heart rate monitor, and continuous glucose monitor	The method identified the onset and end of exercise in approximately 5 min, with an average blood glucose change of only - 6 mg/dL
Crews et al.[34] (2016)	To evaluate the role and adherence to off-loading	Prospective, multicenter study	79 patients with T2DM and active foot ulcer	6 weeks. Two concealed activity monitors	The presence of an independent relationship between the level of adherence to off-loading devices and the amount of DFU healing that occurs was detected. Neuropathic postural instability was found to be the strongest barrier to off-loading adherence
Crews et al.[25] (2017)	To assess the feasibility of objectively, synchronously, and continuously monitoring finely detailed PA and its location of occurrence	Pilot study	5 at risk and 5 actively ulcerated patients	3 days. Tri-axial accelerometer and GPS monitors	For DFU participant’s weight-bearing activity was 188% higher at home than away from home. At risk participants showed similar weight-bearing activity at home as active DFU participants
Kluding et al.[35] (2017)	To determine the impact of an intense lifestyle intervention on neuropathy progression and quality of life	Randomized controlled trial	140 type 2 DM patients with peripheral neuropathy	18 months of supervised exercise training. 7 days of actigraphy based counseling to reduce sedentary behavior	An intensive lifestyle intervention may be a sustainable, clinically effective approach for people with DPN that improves patients outcomes and can have an immediate impact on patient care
Jao et al.[36] (2017)	To evaluate the accuracy of 2 PA monitors	Cross-sectional study	31 patients with history of foot ulcer	14 weight-bearing and nonweight-bearing activities. Two PA monitors	Between PA monitors, there was an important difference in accuracy of weight-bearing activities

DM=Diabetes mellitus, DPN=Diabetic peripheral neuropathy, DFU=Diabetic foot ulcer, CMM=Continuous movement monitoring, HbA1c=Hemoglobin A1c, PA=Physical activity, GPS=Global Positioning System