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Sökning: WFRF:(Jarl Gustav 1978 )

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1.
  • Hellstrand Tang, Ulla, 1956, et al. (författare)
  • Clinical guidelines recommending prosthetics and orthotics in Sweden : Agreement between national and regional guidelines
  • 2023
  • Ingår i: Prosthetics and Orthotics International. - : Sage Publications. - 0309-3646 .- 1746-1553.
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND: Despite the presence of both national and regional clinical practical guidelines (CPGs) in Sweden, no previous studies have investigated the quality of CPGs or the level of agreement between national and regional CPGs.OBJECTIVES: This study aimed to assess the quality of national CPGs recommending prosthetics and orthotics (P&O) and quantify the agreement between national and regional CPGs in Sweden.STUDY DESIGN: Literature Review.METHODS: National and regional CPGs were identified in public databases and by surveyed local nurse practitioners. Quality of the national guidelines was assessed by using AGREE II. Agreement between recommendations in the national and regional CPGs was quantified on a 4-grade rating scale ("similar," "partially similar," "not similar/not present," and "different").RESULTS: Of 18 national CPGs, 3 CPGs (CPGs of Diabetes, Musculoskeletal disorders, and Stroke) had 9 recommendations related to P&O. The Musculoskeletal disorders and Stroke CPGs had quality scores .60% in all domains, and the Diabetes CPG had scores .60% in 5 of 6 domains according to AGREE II. Seven regional CPGs for P&O treatment were identified. Three national recommendations (in Diabetes CPGs) showed "similar" content for all regions, and 2 national recommendations (in Diabetes CPGs) showed "not similar" content for all regions. The remaining recommendations (Diabetes, Musculoskeletal disorders, and Stroke CPGs) had varying agreement with regional CPGs. CONCLUSIONS: There is a limited number of national recommendations for treatment within P&O. There was variation in the agreement of P&O-related recommendations in national and regional CPGs, which might lead to unequal care throughout the national healthcare system.
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  • Jarl, Gustav, 1978-, et al. (författare)
  • Comment on van Netten, et al : Definitions and criteria for diabetic foot disease
  • 2020
  • Ingår i: Endocrinology, Diabetes and Metabolism. - : John Wiley & Sons. - 2398-9238.
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: The International Working Group on the Diabetic Foot (IWGDF) recently published updated definitions for the diabetic foot field. However, the suggested definitions of lower limb amputations differ from the definitions of the International Organization of Standardization (ISO), which may create problems when implementing the definitions. This paper compares and discusses the amputation definitions of IWGDF and ISO.Results: Despite many similarities, the IWGDF and ISO systems have some important differences. First, the IWGDF uses the term “minor amputation” which is value-laden, arbitrary and has been defined in several different ways in the literature. Second, the IWGDF system lacks descriptions of amputations distal or through the ankle, which may increase the risk for misclassification. Third, hip disarticulations and transpelvic amputations are not included in the IWGDF system.Conclusion: It is suggested that future updates of the IWGDF definitions should be aligned with those of ISO, to meet the goal of global consensus on terminology related to lower limb amputation. 
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  • Jarl, Gustav, 1978-, et al. (författare)
  • Nordic clinical guidelines for orthotic treatment of osteoarthritis of the knee: A systematic review using the AGREE II instrument
  • 2019
  • Ingår i: Prosthetics and Orthotics International. - : Ovid Technologies (Wolters Kluwer Health). - 0309-3646 .- 1746-1553. ; 43:5, s. 556-563
  • Tidskriftsartikel (refereegranskat)abstract
    • © The International Society for Prosthetics and Orthotics 2019. 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: Domain scores indicate that many guidelines have not sufficiently addressed stakeholder involvement (average score: 55%), applicability (20%) and editorial independence (33%) in the development process. Inter-rater agreement for assessors indicated ‘good’ agreement for clinical practice guidelines from Finland, Norway and Sweden (W = 0.653, p < 0.001; W = 0.512, p = 0.003 and W = 0.532, p = 0.002, respectively) and ‘strong’ agreement for the clinical practice guideline from Denmark (W = 0.800, p < 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.
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  • Jarl, Gustav, 1978-, et al. (författare)
  • Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers
  • 2023
  • Ingår i: Journal of Diabetes Science and Technology. - : Diabetes Technology Society. - 1932-2968. ; 17:1, s. 99-106
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND: Non-removable knee-high devices are the gold-standard offloading treatments to heal plantar diabetic foot ulcers (DFUs). These devices are underused in practice for a variety of reasons. Recommending these devices for all patients, regardless of their circumstances and preferences influencing their ability to tolerate the devices, does not seem a fruitful approach.PURPOSE: The aim of this article is to explore the potential implications of a more personalized approach to offloading DFUs and suggest avenues for future research and development.METHODS: Non-removable knee-high devices effectively heal plantar DFUs by reducing plantar pressure and shear at the DFU, reducing weight-bearing activity and enforcing high adherence. We propose that future offloading devices should be developed that aim to optimize these mechanisms according to each individual's needs. We suggest three different approaches may be developed to achieve such personalized offloading treatment. First, we suggest modular devices, where different mechanical features (rocker-bottom sole, knee-high cast walls/struts, etc.) can be added or removed from the device to accommodate different patients' needs and the evolving needs of the patient throughout the treatment period. Second, advanced manufacturing techniques and novel materials could be used to personalize the design of their devices, thereby improving common hindrances to their use, such as devices being heavy, bulky, and hot. Third, sensors could be used to provide real-time feedback to patients and clinicians on plantar pressures, shear, weight-bearing activity, and adherence.CONCLUSIONS: By the use of these approaches, we could provide patients with personalized devices to optimize plantar tissue stress, thereby improving clinical outcomes.
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5.
  • Alnemo, John, et al. (författare)
  • Are the left and right limbs unequally affected by diabetic foot complications?
  • 2019
  • Ingår i: 8th International symposium on diabetic foot. ; , s. 140-140
  • Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
    • Aim: There is some debate about laterality for diabetic foot complications, that is, whether the right and left limbs are unequally affected. Coxon and Gallen (1) found that more amputations were performed on the right limb and Evans et al. (2) interpreted this in the context of foot dominance: they found that most foot ulcers occured on the dominant limb (which for most people is the right one) and speculated that the dominant limb may be more exposed to mechanical stresses and injuries. However, Demetriou et al. (3) did not find any laterality in foot ulcer location. The aim was to investigate laterality for foot ulcers and amputations. Methods: A questionnaire was posted to 1245 people who had diabetes, experience of using therapeutic shoes, and who had attended one of two prosthetics and orthotics clinics during a 12 months’ period. The number of ulcers or amputations on the right and left limb were compared with a two-sided chi-square test. Results: 469 (37.7%) questionnaires were returned. 118 (25.2%) participants reported unilateral foot ulcers, 54 (11.5%) reported unilateral minor amputation, and 21 (4.5%) reported unilateral major amputation. There was no statistically significant right-left difference in foot ulcers, minor amputations or major amputations (Table 1, p-values 0.713-1.000). Conclusions: Our results do not support the hypothesis about laterality for foot ulcers and amputations.
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  • Alnemo, John, et al. (författare)
  • Attitudes and attributes of women and men using therapeutic shoes for diabetic foot complications
  • 2019
  • Ingår i: 8th International symposium on diabetic foot. ; , s. 117-117
  • Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
    • 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 69.2 years) 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
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  • Amer, Ahmed, 1984-, et al. (författare)
  • Cross-cultural adaptation and reliability of the Arabic version of Children's Hand-use Experience Questionnaire (CHEQ)
  • 2022
  • Ingår i: Hong Kong Journal of Occupational Therapy. - : Elsevier. - 1569-1861 .- 1876-4398. ; 35:1, s. 84-95
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Validated outcome measures are essential for assessment and treatment of children with disabilities. The Children's Hand-use Experience Questionnaire (CHEQ) was developed and validated for use in Western countries for children with unilateral hand dysfunction. This study aimed to perform a cross-cultural adaptation and investigate reliability for the Arabic CHEQ.Methods: Translation and cross-cultural adaptation were performed in four phases: (i) forward-translation and reconciliation with feedback from parents and typically developing children from Jordan (n = 14); (ii) backward-translation and review; (iii) cognitive debriefing with parents and/or their children with unilateral hand dysfunction (n = 17); and (iv) review and proofreading. In the psychometric analyses, 161 children from Jordan (mean age [SD] 10y 8 m [5y 8 m]; 88 males) participated. Internal consistency was evaluated with Cronbach's alpha. Test-retest reliability was evaluated in 39 children with intraclass correlation coefficient (ICC) and weighted kappa (kappa).Results: Synonyms of four words were added to accommodate for different Arabic dialects. On average, 93% of children with unilateral hand dysfunction and their parents understood the CHEQ items. One response alternative, 'Get help', to the opening question was unclear for 70% of the respondents and need further explanation. Two items about using a knife and fork were difficult to comprehend and culturally irrelevant. High internal consistency was demonstrated (Cronbach's alphas 0.94- 0.97) and moderate to excellent ICC (0.77-0.93). For 18 individual items, kappa indicated poor to good agreement (kappa between 0.28 and 0.66).Conclusions: After the suggested minor adjustments, the Arabic CHEQ will be comprehensible, culturally relevant and reliable for assessing children with unilateral hand dysfunction in Jordan.
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  • Amer, Ahmed, 1984-, et al. (författare)
  • The effect of insoles on foot pain and daily activities
  • 2014
  • Ingår i: Prosthetics and Orthotics International. - : Sage Publications. - 0309-3646 .- 1746-1553. ; 38:6, s. 474-480
  • Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
    • BACKGROUND:Foot pain decreases individuals' ability to perform daily activities. Insoles are often prescribed to reduce the pain which, in turn, may promote return to normal activities.OBJECTIVES:To evaluate the effects of insoles on foot pain and daily activities, and to investigate the relationship between individuals' satisfaction with insoles and actual use of them.STUDY DESIGN:A 4-week pre-post intervention follow-up.METHODS:Brief Pain Inventory, International Physical Activity Questionnaire and Lower Extremities Functional Status were used as outcome measures. Client Satisfaction with Device was used in the follow-up.RESULTS:A total of 67 participants answered the questionnaires (81% women). Overall, a reduction in Pain Severity (p = 0.002) and Pain Interference (p = 0.008) was shown. Secondary analyses revealed a significant effect only in women. No changes in daily activities (Walking, p = 0.867; Total Physical Activity, p = 0.842; Lower Extremities Functional Status, p = 0.939) could be seen. There was no relation between Client Satisfaction with Device measures and duration of insole use. A difference in sex was shown; women scored higher than men on Pain Severity.CONCLUSION:Insoles reduce pain and pain interference with daily activities for women with foot pain. Satisfaction with the insoles is not a predictor of actual insole use. The effect of insoles on activity performance needs further study.CLINICAL RELEVANCE:This study provides evidence for prescribing insoles to people with foot pain. Nonetheless, insoles are not enough to increase their physical activity level in the short term. Satisfaction with insoles and duration of use are not correlated and cannot be inferred from each other.
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  • Amer, Ahmed, 1984-, et al. (författare)
  • The Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG). Part II : Psychometric properties
  • 2018
  • Ingår i: Child Care Health and Development. - : John Wiley & Sons. - 0305-1862 .- 1365-2214. ; 44:4, s. 562-571
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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  • Amer, Ahmed, et al. (författare)
  • Validity and test-retest reliability of the Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG) in children and youth with cerebral palsy
  • 2023
  • Ingår i: Child Care Health and Development. - : John Wiley & Sons. - 0305-1862 .- 1365-2214. ; 49:3, s. 464-484
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND: Validity of the Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG) was previously investigated on typically developing children. This study aimed to investigate the validity, test-retest reliability and minimal detectable change (MDC) of the PEDI-UG in children and youth (C&Y) with cerebral palsy (CP).METHOD: A cross-sectional study design with 118 C&Y with CP (44.7% girls) aged 10 months-22.5 years were included in the study; 37 of them completed the PEDI-UG twice to investigate test-retest reliability, determined by calculating the intraclass correlation coefficient (ICC). Additionally, data from 249 typically developing children were used for differential item functioning (DIF) analysis. The validity of the PEDI-UG was investigated by Rasch analysis. The Kruskal-Wallis test and Spearman's correlation coefficient were calculated to investigate associations between PEDI-UG scores and external classification systems.RESULTS: The principal component analysis of residuals indicated unidimensionality in all domains. The ICC values were excellent (0.98-0.99), and the MDCs were less than 6 and 13 (on a 0-100 scale) for the functional skills and caregiver assistance parts, respectively. The four-category caregiver assistance rating scale fulfilled the criteria for the analysis of rating scale functioning. In total, 78 of 189 items in the functional skills domain and two items in the caregiver assistance domain demonstrated DIF between C&Y with CP and TD children. The Kruskal-Wallis test (p<0.05) and Spearman's correlation (coefficients of -0.93 to -0.78) supported the validity of PEDI-UG.CONCLUSION: The current diagnose-specific version of PEDI-UG demonstrates evidence for validity as a measure of ability in C&Y with CP in Uganda and other similar settings, being a promising tool for use in clinical practice and research. Conversion tables and MDC values are provided to facilitate clinical adoption of the measure.
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15.
  • Appelros, Peter, et al. (författare)
  • Comorbidity in Stroke-Survivors : Prevalence and Associations with Functional Outcomes and Health
  • 2021
  • Ingår i: Journal of Stroke & Cerebrovascular Diseases. - : Elsevier. - 1052-3057 .- 1532-8511. ; 30:10
  • Tidskriftsartikel (refereegranskat)abstract
    • OBJECTIVES: The purpose of this study was to evaluate the prevalence and impact of stroke-related comorbidity in a community-based sample of stroke survivors. We sought to find out which types of comorbidity that were most important with respect to the patients' functional outcomes and general health.MATERIALS AND METHODS: All stroke survivors (n = 330) living in a medium-sized Swedish municipality were included. Patient records were reviewed to determine the presence of comorbidities. A selection of patient reported outcomes were used to assess subjective symptoms, functional outcomes, and general health. Logistic regression models were used to investigate the association between comorbidities, residual symptoms, and subjective symptoms on the one hand, and functional outcomes and general health on the other hand.RESULTS: Hypertension (80%) was the most common cardiovascular risk factor. Ischemic heart disease was found in 18% and congestive heart failure in 10%. Of non-cardiovascular disorders, orthopaedic diseases were commonest (30%). Psychiatric disorders and cognitive impairment were present in 11% and 12% respectively. Hemiparesis is associated with both functional outcomes and general health. Additionally, orthopedic disorders, vertigo, cognitive impairment, nicotine use, chronic pulmonary disorders, and age, are associated with different functional outcomes. Psychiatric, orthopedic and neurological disorders are related to general health. The patient-reported outcome measure "feeling of tiredness" is important for many of the outcomes, while "feeling depressed" and "having pain" are associated with general health.CONCLUSIONS: Many medical conditions, several of which have received little attention so far, are associated with functional outcome and general health in stroke survivors. If the intention is to describe comorbidity relevant to function and general health in stroke patients, disorders that hitherto have received little attention, must be considered.
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  • Appelros, Peter, et al. (författare)
  • Comorbidity in stroke survivors in a medium-sized Swedish municipality
  • 2023
  • Ingår i: Brain Injury. - : Informa Healthcare. - 0269-9052 .- 1362-301X. ; 37:Suppl. 1, s. 135-136
  • Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
    • Objectives: The purpose of this study was to evaluate the prevalence and impact of stroke-related comorbidity in a community-based sample of stroke survivors. With respect to the patients’ functional outcomes and general health, we wanted to find out which types of comorbidity were most important.Materials and Methods: All stroke survivors (n = 330) living in a medium-sized Swedish municipality were included. To determine the presence of comorbidities patient records were reviewed. A selection of patient reported outcomes were used to assess subjective symptoms, functional outcomes, and general health. All patients were asked to answer a questionnaire, the Swedish Stroke Register (Riksstroke). Three questions from the questionnaire were used as additional measures of comorbidity. “Do you feel tired?,” “Do you have pain?” and “Do you feel depressed?” As outcome measures the patient reported measures from the Riksstroke questionnaire were used: * Do you still have problems after your stroke? * Have you been able to return to the life and activities you had before the stroke? * How is your mobility now? * Do you get help from someone when visiting the toilet? * Do you get help with dressing and undressing? * How do you assess your general health? Logistic regression models were used to investigate the association between comorbidities, residual symptoms, and subjective symptoms on the one hand, and functional outcomes and general health on the other hand.Results: Hypertension (80%) was the most common cardiovascular risk factor. Ischemic heart disease was found in 18% and congestive heart failure in 10%. Of non-cardiovascular disorders, orthopedic diseases were commonest (30%). Psychiatric disorders and cognitive impairment were present in 11% and 12% respectively. Logistic regression analyses found that hemiparesis was associated with both poorer functional outcomes and lower general health. Additionally, orthopedic disorders, vertigo, cognitive impairment, nicotine use, chronic pulmonary disorders, and older age, were also associated with poorer functional outcomes. Psychiatric, orthopedic and neurological disorders were associated with poorer general health. The patient-reported outcome measure “feeling of tiredness” was a predictor of both outcomes, while “feeling depressed” and “having pain” were associated with poorer general health.Conclusions: Many medical conditions, several of which have received little attention so far, are associated with poorer functional outcome and lower general health among stroke survivors. Future research into comorbidities relevant to function and general health in stroke patients could further focus on these disorders that hitherto have received little attention.
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  • Bus, Sicco A., et al. (författare)
  • Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)
  • 2020
  • Ingår i: Diabetes/Metabolism Research Reviews. - : John Wiley & Sons. - 1520-7552 .- 1520-7560. ; 36:Suppl 1
  • Tidskriftsartikel (refereegranskat)abstract
    • The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.
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  • Bus, Sicco A., et al. (författare)
  • Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)
  • 2024
  • Ingår i: Diabetes/Metabolism Research Reviews. - : American Physical Society. - 1520-7552 .- 1520-7560. ; 40:3
  • Tidskriftsartikel (refereegranskat)abstract
    • AIMS: Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.MATERIALS AND METHODS: We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.RESULTS: For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.CONCLUSION: These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.
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  • Gigante, Isabella, et al. (författare)
  • Offloading of diabetes-related neuropathic foot ulcers at Swedish prosthetic and orthotic clinics
  • 2023
  • Ingår i: Diabetes-Metabolism Research and Reviews. - : Wiley. - 1520-7552 .- 1520-7560.
  • Tidskriftsartikel (refereegranskat)abstract
    • Aims: This study aimed to assess (1) the use of different offloading interventions in Sweden for the healing of diabetes-related plantar neuropathic forefoot ulcers, (2) factors influencing the offloading intervention choice, and (3) the awareness of current gold standard offloading devices.Methods: An online questionnaire was distributed via SurveyMonkey to 51 prosthetic and orthotic clinics in Sweden.Results: Thirty-five (69%) practitioners responded to the questionnaire. Eighty-six percent of the practitioners provided modified off-the-shelf footwear combined with insoles to treat diabetes-related plantar neuropathic forefoot ulcers. A total contact cast (TCC) was provided by 20% of the practitioners, and a nonremovable knee-high walker was provided by 0%. Multiple practitioner-, patient-, intervention-, and wound-related factors were considered when practitioners provided offloading interventions to patients with this type of ulcer. The majority of the practitioners did not or were unsure whether they considered TCC or a non-removable knee-high walker to be the gold standard treatment.Conclusions: Practitioners mainly provided the offloading intervention that the International Working Group on the Diabetic Foot strongly recommends not be provided, namely, modified off-the-shelf footwear with insoles. In contrast, TCC and nonremovable knee-high walkers, as the gold standards, were vastly underutilised. Therefore, the pattern of providing offloading interventions was almost exactly opposite to the recommendations of evidence-based guidelines. Different factors were considered when providing offloading interventions to patients with diabetes-related plantar neuropathic forefoot ulcers. The practitioners' lack of awareness regarding gold standard devices may have contributed to the underutilisation of TCC and nonremovable knee-high walkers.
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  • Jarl, Gustav, 1978-, et al. (författare)
  • A model to facilitate implementation of the International Classification of Functioning, Disability and Health into prosthetics and orthotics
  • 2018
  • Ingår i: Prosthetics and Orthotics International. - London, United Kingdom : Sage Publications. - 0309-3646 .- 1746-1553. ; 42:5, s. 468-475
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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24.
  • Jarl, Gustav, 1978-, et al. (författare)
  • A modified walk-in clinic for shoe insoles : Follow-up of non-attendants
  • 2019
  • Ingår i: Prosthetics and Orthotics International. - : Sage Publications. - 0309-3646 .- 1746-1553. ; 43:6, s. 597-600
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND: = 1286), we found that a modified walk-in system reduced waiting times for prescription of shoe insoles by 40 days compared to scheduled appointments but resulted in a non-attendance rate of 17% compared to 6% for scheduled appointments.OBJECTIVES: To investigate the reasons for non-attendance at the modified walk-in clinic.STUDY DESIGN: This is a cross-sectional survey.METHODS: Unlike traditional walk-in clinics, a limited number of patients were invited each week from the waiting list to attend the modified walk-in clinic on pre-specified days during the following 5 weeks. A questionnaire was sent to 137 patients who did not attend the modified walk-in clinic, of whom 50 (36%) responded.RESULTS: The most frequently reported reasons for not attending were the following: could not attend on the suggested days and times (30%), had already received help (18%) and illness or other medical interventions (16%). The majority of these issues could have been overcome by rescheduling to a scheduled appointment.CONCLUSION: The main reason for not attending a modified walk-in clinic was that suggested days and times did not suit the patients. The option to reschedule the appointment needs to be clearly emphasized in the information provided to the patient.CLINICAL RELEVANCE: With clear information about rescheduling options, a modified walk-in clinic could be used to reduce waiting times for certain groups of patients.
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25.
  • Jarl, Gustav, 1978-, et al. (författare)
  • A modified walk-in system versus scheduled appointments in a secondary-care prosthetic and orthotic clinic
  • 2018
  • Ingår i: Prosthetics and Orthotics International. - : Sage Publications. - 0309-3646 .- 1746-1553. ; 42:5, s. 483-489
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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26.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Adherence and Wearing Time of Prescribed Footwear among People at Risk of Diabetes-Related Foot Ulcers : Which Measure to Use?
  • 2023
  • Ingår i: Sensors. - : MDPI. - 1424-8220. ; 23:3
  • Tidskriftsartikel (refereegranskat)abstract
    • Adherence to prescribed footwear is essential to prevent diabetes-related foot ulcers. The aim was to compare different measures of adherence and wearing time of prescribed footwear with a reference adherence measure, among people with diabetes at high risk of foot ulceration. We followed 53 participants for 7 consecutive days. A temperature sensor measured wearing time of prescribed footwear and a triaxial accelerometer assessed weight-bearing activities. Subjective wearing time was self-reported. Reference adherence measure was proportion of weight-bearing time prescribed footwear was worn. We calculated Spearman's correlation coefficients, kappa coefficients, and areas under the curve (AUC) for the association between the reference measure and other measures of adherence and wearing time. Proportion of daily steps with prescribed footwear worn had a very strong association (r = 0.96, Κ = 0.93; AUC: 0.96-1.00), objective wearing time had a strong association (r = 0.91, Κ = 0.85, AUC: 0.89-0.99), and subjective wearing time had a weak association (r = 0.42, Κ = 0.38, AUC: 0.67-0.81) with the reference measure. Objectively measured proportion of daily steps with prescribed footwear is a valid measure of footwear adherence. Objective wearing time is reasonably valid, and may be used in clinical practice and for long-term measurements. Subjective wearing time is not recommended to be used.
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27.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Adherence to wearing therapeutic shoes among people with diabetes : a systematic review and reflections
  • 2016
  • Ingår i: Patient Preference and Adherence. - Albany, Auckland, New Zealand : Dove Medical Press. - 1177-889X. ; 10, s. 1521-1528
  • Forskningsöversikt (refereegranskat)abstract
    • Introduction: Therapeutic shoes are prescribed to prevent diabetic foot ulcers, but adherence to wearing the shoes is often poor.Aim: The aim of this study was to review the literature on factors that are associated with adherence to wearing therapeutic shoes and construct a model of adherence to aid future research and development in the field.Methods: We conducted a systematic search in PubMed, CINAHL, and PsycINFO for quantitative studies on factors associated with adherence to wearing therapeutic shoes among people with diabetes.Results: Six studies were included in the review. The studies focused mainly on patient-, therapy-, and condition-related adherence factors. There is some evidence (three to five studies) that sex, diabetes duration, and ulcer history are not associated with adherence. The evidence for or against the other factors was weak (only one or two studies) or conflicting.Conclusion: There is no conclusive evidence for using any factor to predict adherence to wearing therapeutic shoes, but there is some evidence against using certain factors for predicting adherence. Future studies should include a broader range of factors, including health system and social/economic factors, and they should investigate perceived costs and benefits of wearing therapeutic shoes in comparison with other shoes or no shoes. A seesaw model is presented illustrating the complex phenomenon of adherence. Further research is needed to identify factors associated with adherence to wearing therapeutic shoes, to enable the development of interventions to improve adherence and thereby reduce ulceration rates among people with diabetic foot complications.
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28.
  • Jarl, Gustav, 1978-, et al. (författare)
  • An alternative perspective on assistive technology : the Person-Environment-Tool (PET) model
  • 2020
  • Ingår i: Assistive technology. - New York, USA : Taylor & Francis. - 1040-0435 .- 1949-3614. ; 32:1, s. 47-53
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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29.
  • Jarl, Gustav, 1978-, et al. (författare)
  • An innovative sealed shoe to off-load and heal diabetic forefoot ulcers–a feasibility study
  • 2017
  • Ingår i: Diabetic Foot and Ankle. - : Taylor & Francis Group. - 2000-625X. ; 8:1
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Non-removable knee-high devices are the gold standard to treat diabetic foot ulcers located on the plantar forefoot, but they immobilize the ankle, which restricts daily life activities and has negative effects on joint functioning. Objective: To investigate the feasibility of sealing a therapeutic shoe to off-load and heal diabetic forefoot ulcers. Design: A case series of seven men with type 2 diabetes and a metatarsal head ulcer were prescribed therapeutic shoes and custom-made insoles. The shoe was sealed with a plastic band. Off-loading was assessed with the F-scan pressure measurement system. Adherence to wearing the shoe was assessed with a temperature sensor and by documenting the status of the seal. Results: The off-loading was effective and all ulcers healed. Median time to healing was 56 days (range 8–160). Complications were secondary ulcer (n=1) and plantar hematoma (n=1). Five of seven participants did not disturb the seal. Conclusions: Sealing a therapeutic shoe is a feasible way to off-load and heal forefoot ulcers. A controlled trial is needed to compare the effectiveness and safety of a sealed shoe to other non-removable devices. © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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30.
  • Jarl, Gustav, 1978-, et al. (författare)
  • An innovative sealed therapeutic shoe to off-load and heal diabetic forefoot ulcers
  • 2018
  • Konferensbidrag (refereegranskat)abstract
    • 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.
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31.
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32.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Beyond dichotomous thinking : a process perspective on diabetic foot disease
  • 2017
  • Ingår i: Diabetic Foot & Ankle. - : Taylor & Francis. - 2000-625X. ; 8:1
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Diabetic foot (DF) disease causes severe suffering around the world, and appropriate self-care activities are needed to prevent and treat this condition. However, all too often, self-care activities are less than optimal and clinicians find themselves unable to influence them in a positive direction. Clinicians' and researchers' mental models of the DF tend to be dichotomous: either the patient has or does not have an active ulcer or other DF disease. This mode of thinking hides the long-term perspective of DF disease, where patients' previous experiences and expectations for the future influence their current behavior. Thus, there is a need for a different perspective on DF disease to better understand patients' perspectives and thereby improve self-care, leading to more effective prevention and treatment.Objective: To present a novel framework, the process perspective on the DF, which can explain inadequate self-care behaviors not easily understood with a dichotomous perspective, and how they can be changed.Results: Three fictive clinical examples are used to illustrate how the process perspective on the DF can be used to understand how patients' previous experiences and expectations for the future influence their current behavior. In particular, this process perspective is used to understand how patients' beliefs and behaviors are sometimes self-reinforcing, resulting in stable behavior patterns, here referred to as 'DF cycles'. These cycles are quite common in clinical practice but are difficult to analyze using a dichotomous perspective on DF disease. The process perspective on the DF is used to analyze specific 'vicious' DF cycles of inadequate patient behavior and to find ways to transform them into 'virtuous' DF cycles, resulting in effective prevention and treatment.Conclusions: The process perspective on the DF seems suitable for understanding inadequate patient behaviors not easily understood with a dichotomous perspective on DF disease, opening up new avenues for clinical practice and research to help patients live a life with long remission phases, few relapses, and a high quality of life.
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33.
  • Jarl, Gustav, 1978- (författare)
  • Changing concepts–changing minds : Ulysses contracts in the treatment of diabetic foot ulcers with non-removable offloading devices
  • 2019
  • Ingår i: 8th International symposium on diabetic foot. ; , s. 89-89
  • Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
    • Aim: To change concepts is important to change how clinicians and patients conceptualize and act on diabetic foot disease. Different concepts have been introduced for different purposes, e.g., “diabetic foot attack” to emphasize urgency (1), “in remission” to emphasize the high risk of reulceration (2), and “latent diabetic foot disease” to emphasize diabetic foot disease as a single process, encompassing both active and latent phases (3). The aim was to review and discuss conceptualizations of treatment with non-removable offloading devices.Methods: Review and analysis of literature.Results: The “forced compliance” concept has been used to denote the use of non-removable offloading devices as a means to secure a high level of compliance/adherence (4). However, this concept may be inappropriate for two reasons. First, the concept has a paternalistic connotation of patients obeying doctors, which is not compatible with viewing patients as partners in decision making. Second, the concept conveys the meaning of doctors as being active (“forcing” compliance) and patients as being passive (being “forced”). Although these connotations are unintended they still may counteract the active and long-term personal responsibility for self-care that we wish to stimulate in our patients. “Ulysses contracts” (originating from Homer’s Odyssey) denote freely made decisions that bind the person in the future. Conceptualizing non-removable offloading devices as Ulysses contracts rather than means to force compliance has two advantages. First, Ulysses contracts emphasize that patients make choices by free will. Second, the “forcing” (i.e., eliminating the alternative to be non-compliant/adherent in the future) does not happen between the doctor and patient, but between the patient’s current and future self. Hence, the patient remains an active and responsible agent during the treatment period which hopefully will spill over into the in remission periods, when removable devices are used and personal responsibility for adherence is crucial.Conclusions: Ulysses contracts could be a viable way to conceptualize treatment with non-removable offloading devices.
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34.
  • Jarl, Gustav, 1978- (författare)
  • Commitment devices in the treatment of diabetic foot ulcers
  • 2019
  • Ingår i: Journal of Foot and Ankle Research. - : BMC. - 1757-1146. ; 12:1
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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35.
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36.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Cross-cultural validity and differential item functioning of theOrthotics and Prosthetics Users’ Survey with Swedish and Americanusers of lower limb prosthesis
  • Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
    • Objective: To investigate the cross-cultural validity of the Orthotics and Prosthetics Users’ Survey (OPUS), to investigate differential item functioning (DIF) in the OPUS related to sex, age, amputation level and amputated sides (unilateral or bilateral), and to determine the known-group validity of the OPUS.Design: Cross-sectional study design.Setting: 2 outpatient clinics in Sweden and 7 outpatient clinics in the United States.Participants: A total of 195 Swedish and 126 American adults using lower limb prosthesis.Interventions: Not applicable.Main Outcome Measure: 4 modules from the OPUS were used in this study, including the Lower extremity functional status (LEFS), Client satisfaction with device (CSD), Client satisfaction with services (CSS), and Health-related quality of life (HRQoL) modules. Items were scored on 4- or 5-level Likert scales, and a Rasch measure was calculated for each person and module.Results: The cross-cultural validity was satisfactory. Many items demonstrated DIF related to country and demographic characteristics, but the impact on mean person measures was negligible. The rating scales of the CSD and CSS needed adjustments, and the unidimensionality of the CSD and CSS was weak. The differences between the mean measures of known patient groups were statistically significant for age in the LEFS and for the level of amputation in the CSD.Conclusions: This study supports the validity of comparing OPUS measures between Sweden and USA and between patient groups with different demographic characteristics. The OPUS can, to some extent, discriminate between patient groups known to be different. The unidimensionality of the CSD and CSS modules is weaker than the other modules and these need further development and evaluation.
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37.
  • Jarl, Gustav, 1978- (författare)
  • Decision trees for risk stratification of the diabetic foot
  • 2018
  • Ingår i: The Diabetic foot journal. - : S B Communications Group. - 1462-2041 .- 2514-5495. ; 21:4, s. 218-223
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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38.
  • Jarl, Gustav, 1978- (författare)
  • Decision trees to facilitate risk stratification of the diabetic foot
  • 2019
  • Ingår i: 8th International Symposium on diabetic foot. ; , s. 72-72
  • Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
    • Aim: Delays in referrals from primary care to specialist care clinics are a common issue in the clinical management of diabetic foot disease and are associated with worse clinical outcomes in terms of ulcer healing and major amputations (1-3). One reasons for the delays may be the complexity of risk stratification; a number of different risk factors, such as foot deformity, neuropathy and peripheral arterial disease, interact and influence the risk of developing diabetic foot complications. The aim was to illustrate how decision trees can be constructed to facilitate risk stratification.Methods: A decision tree (4) was created based on the risk stratification described in the guideline document by the National Institute for Health and Care Excellence (NICE) (5).Results: With the help of the decision tree in Figure 1, clinicians without specialised knowledge in diabetic foot disease can stratify all diabetic feet with only four decision points or less. This could facilitate accurate risk stratification and timely referral of patients.Conclusions: Even complex risk stratifications as the one described by NICE can be transformed into simple decision trees for use in busy clinics. Future studies should investigate whether the use of decision trees lead to more accurate risk stratifications and referrals, improving the outcomes for people with diabetic foot disease.
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39.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Fragile Feet and Trivial Trauma : Communicating the Etiology of Diabetic Foot Ulcers to Patients
  • 2023
  • Ingår i: Journal of the American Podiatric Medical Association (Print). - : American Podiatric Medical Association. - 8750-7315 .- 1930-8264. ; 113:1
  • Tidskriftsartikel (refereegranskat)abstract
    • People at risk for diabetic foot ulcer (DFU) often misunderstand why foot ulcers develop and what self-care strategies may help prevent them. The etiology of DFU is complex and difficult to communicate to patients, which may hinder effective self-care. Thus, we propose a simplified model of DFU etiology and prevention to aid communication with patients. The Fragile Feet & Trivial Trauma model focuses on two broad sets of risk factors: predisposing and precipitating. Predisposing risk factors (eg, neuropathy, angiopathy, and foot deformity) are usually lifelong and result in "fragile feet." Precipitating risk factors are usually different forms of everyday trauma (eg, mechanical, thermal, and chemical) and can be summarized as "trivial trauma." We suggest that the clinician consider discussing this model with their patient in three steps: 1) explain how a patient's specific predisposing risk factors result in fragile feet for the rest of life, 2) explain how specific risk factors in a patient's environment can be the trivial trauma that triggers development of a DFU, and 3) discuss and agree on with the patient measures to reduce the fragility of the feet (eg, vascular surgery) and prevent trivial trauma (eg, wear therapeutic footwear). By this, the model supports the communication of two essential messages: that patients may have a lifelong risk of ulceration but that there are health-care interventions and self-care practices that can reduce these risks. The Fragile Feet & Trivial Trauma model is a promising tool for aiding communication of foot ulcer etiology to patients. Future studies should investigate whether using the model results in improved patient understanding and self-care and, in turn, contributes to lower ulceration rates.
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40.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications
  • 2019
  • Ingår i: Journal of Foot and Ankle Research. - : Springer Science and Business Media LLC. - 1757-1146. ; 12
  • Tidskriftsartikel (refereegranskat)abstract
    • BackgroundTherapeutic 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.MethodsA 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.ResultsQuestionnaires 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.ConclusionsMen 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.
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41.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Gender differences in attitudes and attributes of people using therapeutic shoes for diabetic foot complications
  • 2018
  • Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
    • 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 69.2 years) 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.
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42.
  • Jarl, Gustav, 1978-, et al. (författare)
  • Incidence of lower-limb amputations in Sweden from 2008-2017
  • 2022
  • Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 64:2-3, s. 266-273
  • Tidskriftsartikel (refereegranskat)abstract
    • OBJECTIVES: This study examines the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes.DESIGN: Observational study using Swedish national register data.METHODS: We identified all initial amputations in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorized into three levels: High proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age-, sex- and region-specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex.RESULTS: The national annual incidence of LLAs was 22.1 per 100,000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI, 0.973-0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974-0.995) and low proximal amputations (0.973, 95% CI 0.962-0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974-1.014). Such declines in LLA incidence (all levels combined) were observed in 9 out of 21 regions. Compared to the national average and with adjustment for age, sex, diabetes and artery disease, the regional IRR varied from 0.85-1.36 for all LLAs, from 0.67-1.61 for high proximal amputations, from 0.50-1.51 for low proximal amputations and from 0.13-3.68 for partial foot amputations.CONCLUSIONS: The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant more research.
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43.
  • Jarl, Gustav, 1978- (författare)
  • Is it necessary to restrict weight-bearing physical activity during treatment of diabetic foot ulcers?
  • 2019
  • Ingår i: 8th International symposium on diabetic foot. ; , s. 108-108
  • Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract
    • Aim: Patients are often instructed to reduce their weight-bearing physical activity to promote healing of plantar foot ulcers, even when appropriate offloading devices are used. This limits working ability and daily activities but it is not clear whether this contributes to ulcer healing. The aim was to investigate whether reduced weight-bearing physical activity contributes to ulcer healing when offloading devices are used.Methods: A literature review was conducted.Results: Three studies, published in four articles, were identified (Table 1). Saltzman et al. (1) found that taking more steps prolonged the time to ulcer healing, but the effect seemed rather small. Najafi et al. (2) found a negative correlation between step count and ulcer healing rate, but no correlation between standing time and healing rate. Crews/Vileikyte et al. (3,4) found no effect of number of steps taken on ulcer size after 6 weeks of treatment.Conclusions: There is limited evidence for recommending patients who use offloading devices to reduce weight-bearing physical activity to promote healing of plantar foot ulcers. Two out of three studies found a negative association between step count and ulcer healing but the clinical significance of this is uncertain. Future studies should investigate the effects of reducing weight-bearing physical activity from a broader perspective, including effects on ulcer healing, daily activities, health, and well-being.
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44.
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45.
  • Jarl, Gustav M., 1978-, et al. (författare)
  • Cross-cultural validity and differential item functioning of the Orthotics and Prosthetics Users’ Survey with Swedish and American users of lower-limb prosthesis
  • 2015
  • Ingår i: Archives of Physical Medicine and Rehabilitation. - : Elsevier BV. - 0003-9993 .- 1532-821X. ; 96:9, s. 1615-1626
  • Tidskriftsartikel (refereegranskat)abstract
    • Objectives: To investigate the cross-cultural validity of the Orthotics and Prosthetics Users’ Survey (OPUS), to evaluate differential item functioning (DIF) related to country, sex, age, amputation level, and amputated side (unilateral, bilateral), and to determine known-group validity of the OPUS.Design: Survey.Setting: Outpatient clinics.Participants: The sample (NZ321) consisted of Swedish (nZ195) and U.S. (nZ126) adults using lower-limb prostheses.Interventions: Not applicable.Main Outcome Measures: Four OPUS modules were used: lower extremity functional status, client satisfaction with device (CSD), client satisfaction with services (CSS), and health-related quality of life. Rasch analysis was used to calculate measures for persons and items.Results: The cross-cultural validity was satisfactory. Many items demonstrated DIF related to country and demographic characteristics, but the impact on mean person measures was negligible. The rating scales of CSD and CSS needed adjustments, and the unidimensionality of CSD and CSS was weak. The differences between the mean measures of known patient groups were statistically significant for 2 out of 6 comparisons.Conclusions: This study supports the validity of OPUS measure comparisons between Sweden and the United States and between subgroups with different demographic characteristics. Some of the country-related DIF may reflect the different health care financing systems. The findings demonstrate that the OPUS can discriminate between certain patient groups. The results also challenge some of our preconceptions about persons with bilateral amputation, indicating that we might know these persons less well than we think.
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46.
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47.
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48.
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49.
  • Jarl, Gustav M., 1978-, et al. (författare)
  • Translation and linguistic validation of the Swedish version of Orthotics and Prosthetics Users' Survey
  • 2009
  • Ingår i: Prosthetics and Orthotics International. - : Ovid Technologies (Wolters Kluwer Health). - 0309-3646 .- 1746-1553. ; 33:4, s. 329-338
  • Tidskriftsartikel (refereegranskat)abstract
    • There is an increasing need for outcome measures in the orthotic and prosthetic field and specifically a lack of outcome measures in Swedish. The Orthotics and Prosthetics Users' Survey (OPUS) was developed in the USA for assessment of the outcome of orthotic and prosthetic interventions, and could potentially also be used for shoe insoles and orthopaedic shoes. The aims of this study were to translate OPUS into Swedish and test the translated version's linguistic validity in a Swedish context. The Orthotic and Prosthetic Users' Survey was translated into Swedish and back-translated into English, following a modified version of the World Health Organization guidelines. After revision of the Swedish version, 39 Swedish clients (12 men, 27 women) answered the OPUS questionnaires and were systematically debriefed afterwards. Most items were understood correctly by the respondents, but some words and expressions had to be changed to avoid misunderstandings or unintended interpretations. The resulting Swedish version of OPUS, OPUS-Swe, showed acceptable linguistic validity and has potential for use in both clinical practice and scientific settings. Nevertheless, before OPUS-Swe can be fully implemented, its psychometric properties need to be evaluated.
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50.
  • Jarl, Gustav M., 1978-, et al. (författare)
  • Translation and linguistic validation of the Swedish version of Orthotics and prosthetics users’ survey
  • 2008
  • Konferensbidrag (refereegranskat)abstract
    • There is a lack of Swedish instruments assessing outcome of orthotic and prosthetic services. The North American derived Orthotics and Prosthetics Users’ Survey (OPUS) consists of five questionnaires assessing common rehabilitation goals. It was translated to Swedish and validated linguistically. Thirty-nine persons answered the questionnaires and were systematically debriefed. In most cases the items were understood as intended. Words and expressions were changed if misunderstood or interpreted in different ways. The resulting Swedish version of OPUS showed acceptable linguistic validity. A study on construct validity and test-retest reliability is in process. 1      IntroductionHistorically, Orthotic and Prosthetic (O&P) services in Sweden have been based on hands-on experience rather than science. Self-report instruments could be used to systematically evaluate the practice, but most of them are developed in English speaking countries and cannot be used in Sweden without translation and validation. Moreover, the only instruments available in Swedish are limited to the smaller group in O&P practice, namely prosthetic clients. The Orthotics and Prosthetics Users´ Survey (OPUS) was developed and validated in the USA to assess the outcome in both prosthetic and orthotic users [1]. The OPUS consists of five questionnaires assessing i) health related quality of life, ii) satisfaction with device, iii) satisfaction with services, iv) upper extremity function, and v) lower extremity function. If translated, OPUS could be a useful tool for studying the outcome of O&P services in Sweden. Still, validity problems can arise by using direct translations. Therefore, translations’ validity must be tested in the new cultural context. The aim was to translate OPUS to Swedish and test the linguistic validity in a Swedish context. 2      Methods and subjects2.1. MethodsA modified version of the translation process suggested by the WHO [2] was used. Four medical professionals (P/O, OT, PT, orthopaedic surgeon) independently translated OPUS to Swedish. The translations were merged to a single document by one of the authors (GJ). Translators and authors met twice to discuss the translations and a consensus version was created. A professional translator performed a back-translation to English. The English original, the Swedish consensus version, and the back-translation, were compared by one of the authors (GJ) and a new Swedish version was created. One intention with the Swedish version of OPUS was to use it for evaluation of insoles. However, many of these clients are relatively fit and a high ceiling effect could be expected in the lower extremity function part of OPUS. Therefore, eight new items assumed to be more difficult were added to the Swedish version of this particular questionnaire. Linguistic validation was performed by systematically debriefing the clients who answered the five questionnaires. Ten subjects answered each questionnaire (each subject completed one or two different questionnaires). 2.2. SubjectsThirty-nine clients (27 women, 12 men, mean age 59,8) at the Department of Prosthetics and Orthotics, Örebro University Hospital, participated. Clients younger than 18 years, and clients unable to understand written Swedish, were excluded. The study was approved by the Regional Ethics Committee review board. 3      ResultsMinor linguistic changes were made during the translation process. Most items were understood as intended but some words and expressions were changed because of misunderstandings or cultural differences between Sweden and the USA. 4      DiscussionThe translation procedure used is well established and has been used in several studies. The quality of the translation was improved by involving people of different professions and experiences. 5      ConclusionThe translation and validation resulted in a Swedish version of OPUS that may be a reliable and useful contribution to outcome studies in Swedish O&P service. A study assessing construct validity and test-retest reliability is in process and preliminary results will be presented. 6      References1.      Heinemann AW, Bode RK, et al. (2003). "Development and measurement properties of the Orthotics and Prosthetics Users' Survey (OPUS): a comprehensive set of clinical outcome instruments." Prosthet Orthot Int 27;3:191-206 2.      WHO (2007). "Process of translation and adaptation of instruments."  2007: http://www.who.int/substance_abuse/research_tools/translation/en/. 
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