Dosing Activity and Returning to Pre-Ulcer Function in Diabetic Foot Remission: Patient Recommendations and Guidance from the Limb Preservation Consortium at USC and The National Rehabilitation Center at Rancho Los Amigos

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality and healthcare costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility, decreased moderate intensity exercise when compared to people with diabetes without ulcers. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year following healing and the majority occurs in the first three months following wound healing. Hence this period after ulceration is called "remission" due to this risk for re-ulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate offloading and monitoring in people with a recently healed foot ulcer, foot reconstruction or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring which can identify dangerous "hot spots" prone to recurrence. By understanding areas at risk, it empowers patients to maximize ulcer-free days and to enable an improved quality of life. There is a current absence of high-quality evidence and standardized clinical algorithms for the post-ulcerative period. This perspective outlines this institution's unified strategy to treat patients in the remission period after ulceration. This approach utilizes the available evidence, identifies patient preferences, and relies on good clinical judgement for the best long-term outcomes for this patient population. Hence this position statement aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patient to ensure a safe transition to footwear and return to activity.