Physiotherapy 118 (2023) 79–87

Systematic review
Physiotherapeutic interventions in the treatment of
patients with diabetic foot ulcers: a systematic literature ]]
]]]]]]
]]

review☆
⁎
Sabrina Medeiros , Alexandre Rodrigues, Rui Costa
School of Health Sciences, University of Aveiro, Aveiro, Portugal

Abstract
Background Diabetic foot ulcers are chronic wounds that are difficult to heal, with a high rate of recurrent hospitalizations. Due to its
multifactorial complexity, treatment must be considered as multidisciplinary, with adjuvant therapy required to aid the healing process.
Objectives To identify physiotherapeutic interventions for the treatment of diabetic foot ulcers through a systematic literature review.
Data sources PubMed, Cochrane Library, SciELO and Web of Science were searched in April 2020.
Study selection or eligibility criteria The inclusion criteria for this review were: randomised controlled trial published in the last 5 years;
written in Portuguese, English or Spanish; subjects aged > 18 years with a diagnosis of diabetic foot ulcers; and physiotherapeutic in-
tervention in combination with multidisciplinary wound management. The methodological quality was assessed using the PEDro scale.
Results Eight studies were included. Physiotherapists can treat diabetic foot ulcers using therapeutic exercises, electrotherapy, manual
therapy and assistive technologies. All physiotherapeutic interventions were adjuvant to standard treatment for wounds provided by other
health professionals. The main outcomes were wound size and healing time, with highly favourable results obtained for the experimental
groups compared with the control groups.
Conclusions Therapeutic exercise, electrotherapy, manual therapy and assistive technologies are physiotherapeutic modalities that, when
combined with standard treatment, have been shown to be beneficial in the healing of diabetic foot ulcers.
© 2022 The Authors. Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Diabetic foot ulcer; Therapeutic exercise; Electrotherapy; Manual therapy; Assistive technologies

Introduction Diabetic foot ulcers are considered a public health pro-

blem [5,6] because they result in recurrent hospitalisations
Diabetes mellitus is a condition with high prevalence, that require intensive treatment with high costs [2,4]. The
morbidity and mortality, to the point that it is considered a global prevalence of diabetic foot ulcers is 3–10% [7], with
worldwide epidemic [1,2]. Diabetic foot ulcers are one of an incidence rate of 1–7% within the diabetic population
the main complications of diabetes mellitus [3,4], and are once peripheral neuropathy develops [8]. Diabetic foot ul-
described as severe chronic wounds with a loss of epidermis cers are complicated by infections [1,2,5], peripheral vas-
and/or dermis, which can reach the subcutaneous and un- cular diseases or diabetic neuropathies [1,9]. Some of the
derlying tissues [5]. complications are reduced joint mobility [2,6,9], gait
changes [2,6] and pain [5,6], all of which decrease the
quality of life [4,6,9] and affect the activities of daily living
☆
Systematic review registration number PROSPERO CRD42020200042 [9]. Permanent healing is generally a difficult and time-
⁎
Correspondence to: School of Health Sciences, University of Aveiro, consuming process, as the healing phases are altered due to
Building 30, Agras do Crasto, Santiago University Campus, 3810-193
hyperglycaemia, which can result in a reduction of per-
Aveiro, Portugal.
E-mail address: [email protected] (S. Medeiros). ipheral blood flow to the wound [1,3,10].

https://doi.org/10.1016/j.physio.2022.09.006
0031-9406/© 2022 The Authors. Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
80 S.Medeiros et al. / Physiotherapy 118 (2023) 79–87

Due to its multifactorial complexity, treatment must be

considered as multidisciplinary [11,12]. In countries such as
Portugal and Brazil [5], apart from medicine, the nursing
team is the profession that has the greatest contact with this
patient group, providing standard treatment. Management
consists of local treatment of the wound by cleaning the
wound bed, applying an appropriate therapeutic option, and
secondary dressing, which may vary according to the evo-
lution and characteristics of the wound [5,13,14]; it also
includes the off-loading of wounds [15,16]. However,
treatment according to the guidelines is not always suc-
cessful, leading to a longer period of time for the ulcer to
heal, requiring different types of adjuvant therapy to assist
in the healing process [1,10].
The physiotherapeutic approach to ulcer treatment is
restricted and is not fully recognised; however, it can be
beneficial as there are several resources available that can
promote and accelerate tissue repair [5,11] through the
control of blood glucose level [9] and through modalities Fig. 1. Flow diagram – research and selection of bibliographic references.
with analgesic and biostimulant effects [13]. Little in- RCT, randomised controlled trial.
formation is available on the physiotherapeutic approach,
and a specific treatment protocol has not yet been estab-
lished for different types of wounds; as such, there is a need the PROSPERO website (Registration No.
to develop a protocol to assist in the healing process of CRD42020200042). Considering that the data sources (in-
diabetic foot ulcers [1,11,13]. tegrated articles) of the systematic literature review and the
According to the Physiotherapist Competence Profile, results obtained were independent and disaggregated by
validated by the Associaç ão Portuguesa de Fisioterapeutas wound type in the ‘Inclusion’ stage (Fig. 1), this article
[Portuguese Association of Physiotherapists] on 8 focuses on the results related to physiotherapeutic inter-
September 2020, the physiotherapist is a health professional ventions in the treatment of diabetic foot ulcers. These re-
with several relevant working strategies, including the use sults have not been reported in another paper included
of ‘repair and/or integumentary protection techniques’ and within the larger study.
‘techniques to facilitate lymphatic and arteriovenous cir- The methodological support for systematic literature
culation’ [17]. These strategies essentially consist of tech- reviews is structured according to the guidelines of the
niques that encourage the body to activate the healing Preferred Reporting Items for Systematic Reviews and
phases (i.e. to promote greater blood supply to the wound Meta-Analyses, which consists of a checklist with 27 items
bed) through the release of growth factors and other pro- and a flowchart with four phases [21].
ducts that are fundamental to the healing process [18–20]. The electronic databases PubMed, Cochrane Library,
Taking into account the complexity of the treatment of SciELO and Web of Science were searched in April 2020 in
diabetic foot ulcers and their associated problems, there is a English, Portuguese and Spanish. The descriptors selected
need to optimise their management and establish the best for the research were: physiotherapy, physical therapy,
physiotherapeutic interventions. Therefore, the research treatment, therapy, rehabilitation, and diabetic foot ulcer.
question in this study was ‘What physiotherapeutic-based Tables S1 to S4 (see online supplementary material) show
interventions have been proposed to aid the management of the search strategies used for each database.
foot ulceration in people with diabetes?’. In order to answer The inclusion criteria were: (i) articles written in
this question, a systematic review was carried out to iden- Portuguese, English or Spanish; (ii) randomised controlled
tify physiotherapeutic interventions for diabetic foot ulcers, trials published in the last 5 years; (iii) sample consisted of
with the outcomes being healing time and a reduction in the subjects aged > 18 years diagnosed with diabetic foot ul-
size of the affected area. cers; and (iv) physiotherapeutic treatment was combined
with a multidisciplinary team approach.
The exclusion criteria were: (i) incomplete text; (ii) in-
Methods clusion of totally dependent people; and (iii) patients with
wounds other than diabetic foot ulcers.
This article derives from a broader systematic literature The methodological quality of the studies was assessed
review on physiotherapeutic interventions in the prevention using the PEDro scale [22]. This scale presents acceptable
and treatment of chronic lower limb ulcers, including ve- interobserver reliability (intraclass correlation coefficient
nous ulcers and diabetic foot ulcers, which is registered on 0.68), and is specific for evaluating randomised controlled
 S.Medeiros et al. / Physiotherapy 118 (2023) 79–87 81

trials, which are frequently used in systematic literature [4,24–28]. In addition, all studies [4,24–28] provided point
reviews. This review included articles with a minimum measures and measures of variability for at least one key
score of five out of 10, as this has been shown not to affect outcome.
the conclusions of the review [23].
Using the above inclusion criteria, 1008 results were
identified in PubMed, 282 in Web of Science, 311 in Physiotherapeutic interventions in diabetic foot ulcers
Cochrane Library and 94 in SciELO, with a total of 1695
results. After removing duplicates (n = 524), 1171 articles The articles revealed four intervention modalities that
remained. Titles and abstracts were analysed, and this led to have been investigated and reported for the treatment of
the exclusion of 1080 articles because they did not meet the diabetic foot ulcers: therapeutic exercise, electrotherapy,
inclusion criteria. Next, the full-text of the remaining 91 manual therapy and assistive technologies (Table 1).
articles was analysed; two articles were excluded im- In one study [4], therapeutic exercise was combined with
mediately as the full-text was not available. In this step, all standard treatment, which included daily mobility exercises
articles were checked in detail to select those of interest to that became mobility and resistance exercises after the ulcer
the present study; 79 articles were excluded because they was healed. The experimental group performed five to 10
did not measure the outcomes of interest in the present exercises with plantarflexion, dorsiflexion, inversion, ever-
study, patients had ulcers of different aetiologies, the stu- sion, circumduction, and plantar and dorsal flexion of the
dies did not have a PEDro score ≥ 5, the studies were not toes, performed initially in the sitting position, but moving
randomised controlled trials, and some studies were clinical to the standing position after the ulcer healed. Ten to 15
trials. In summary, 12 studies met the inclusion criteria. As repetitions were performed twice per day for 12 weeks. The
the aim of this article was to focus on the treatment of control group received standard treatment alone. The in-
diabetic foot ulcers, the analysis will focus on the review of tervention resulted in a significant difference in ulcer size in
six studies (Fig. 1). the experimental group at Week 4 (12.63 cm2) and Week 12
(3.29 cm2).
For electrotherapy, three studies [24,27,28] investigated
Results the effects of radiofrequency, helium laser therapy, infrared
laser therapy and shock waves.
Characterisation of the studies Only one study [24] compared the effects of radio-
frequency with standard treatment for diabetic foot ulcers.
Table 1 shows the general characteristics of the studies The radiofrequency was pulsatile, with pulse width of 400
included in this review, and the quality assessment results μseconds, 70 pulses/second and average power of 23 W for
according to the PEDro scale are available in the online 30 min. This was applied three times per week for 6 weeks.
supplementary material. The control group received standard treatment alone. There
The PEDro quality assessment scale [23] was used to was a significant decrease in ulcer area and volume after
characterise study methodology. Subjects were distributed treatment in both groups; on comparison between the two
into groups at random in all six studies [2,24–28], and the groups, the result was significantly better in the experi-
distribution was blinded in four studies [24–26,28]. All mental group.
studies [4,24–28] had groups that were similar at baseline For laser therapy, only one study [27] compared the
when considering the most important prognostic indicators. effects of helium and neon laser therapy with infrared laser
All subjects and the physiotherapists who administered the therapy, both in combination with standard treatment. The
interventions were blinded in two studies [25,28]. (Table 2). parameters for the helium and neon laser were: wavelength
All studies [4,24–28] included local standard treatment 532 nm, power 20 mW, pulsed frequency 25 Hz, power
for ulcers, and differed only in terms of the physiother- density 15 mW/cm2, energy density 5 J/cm2, and applied for
apeutic modality. None of the studies combined two types 90 s/cm2. The parameters for the infrared laser were: wa-
of physiotherapeutic interventions in the same treatment velength 904 nm, power 20 mW, pulsed frequency 25 Hz,
plan in the experimental group, in order to verify their ef- power density 40 mW/cm2, energy density 6 J/cm2, spot
fects directly. size 1 cm2, and applied for 90 s/cm2. After 8 weeks of in-
The assessors who measured at least one outcome did so tervention, there was a greater reduction in the ulcer area in
blinded in two studies [25,28]. Three studies [4,26,27] had a the helium and neon laser therapy group compared with the
dropout rate < 15%. In three studies [25–27], all subjects infrared laser therapy group.
with complete results received treatment, or, when this was Only one article [28] reported treatment with shock
not the case, at least one of the primary outcomes received waves. This article consisted of two studies, each with an
‘intention-to-treat’ analysis. experimental group and a control group. Both studies had
The results of between-group statistical comparisons the same intervention plan and study duration, but there
were reported for at least one key outcome in all studies were variations in the application of the sessions, the
 82

Table 1
Characterisation of the studies: sample, objectives, inclusion criteria, intervention and study results.
Article Sample characterisation Objectives Inclusion criteria Intervention Results
Kadry et al. Experimental group (n = 20) To investigate the Diabetic foot ulcers for > 3 Duration: 6 weeks Significant decrease in ulcer area
(2016)[24] Age (mean, years) = 44 effectiveness of pulsed months Experimental group: and volume after treatment in both
Body mass index (mean, kg/m2) = 28.28 radiofrequency energy as a Radiofrequency and standard experimental and control groups
Initial ulcer area (mean, cm2) = 12.60 physiotherapeutic modality in treatment (P < 0.001). Significant between-
Control group (n = 20) the treatment of chronic lower Control group: Standard group difference after treatment in
Age (mean, years) = 44 years limb ulcers treatment ulcer area (P < 0.001) and volume
Body mass index (mean, kg/m2) = 27.99 (P = 0.010), with better results in
Initial ulcer area (mean, cm2) = 12.62 the experimental group
Joseph et al. Experimental group (n = 10) To investigate the therapeutic Fasting blood glucose Duration: 6 weeks Significant decrease (P < 0.05) in
(2016)[25] Gender = 60% male, 40% female effects of connective tissue ≥ 110 mg/dl, 2 h after a meal Experimental group: reduction of ulcer area in both
Age (mean, years) = 56 manipulation in diabetic foot ≥ 180 mg/dl; diabetic foot Connective tissue groups
Initial ulcer area (mean, cm2) = 4.15 ulcers ulcers that are not Grade 1 or manipulation and standard
HbA1c (%) = 7.19 2 on Wagner classification, or treatment
Control group (n = 10) Grade 1 or below on Control group: Standard
Gender = 40% male, 60% female University of Texas diabetic treatment
Age (mean, years) = 56 wound classification system
Initial ulcer area (mean, cm2) = 4.00
HbA1c (%) = 7.71
Najafi et al. Group with non-removable cast (n = 23) To report patterns of physical Age ≥ 18 years; neuropathic Duration: 7 weeks Most ulcers of the participants in
(2016)[26] Gender = 89% male, 11% female activity and their relationship plantar ulcer; ulcer that is not Group 1: Non-removable Group 1 had healed at 12 weeks
Age (mean, years) = 52 with the healing of diabetic infected or ischaemic cast and standard treatment (P = 0.038). Increase of standing
Body mass index (mean, kg/m2) = 30.8 foot ulcers protected with Group 2: Removable cast duration was the only significant
Initial ulcer area (mean, cm2) = 6.46 removable or irremovable and standard treatment healing predictor at 12 weeks
HbA1c (%) = 10.3 devices for pressure relief
Group with removable cast (n = 26)
S.Medeiros et al. / Physiotherapy 118 (2023) 79–87

Gender = 96% male, 4% female

Age (mean, years) = 55
Body mass index (mean, kg/m2) = 27.8
Initial ulcer area (mean, cm2) = 10.13
HbA1c (%) = 10.3
Eraydin et al. Experimental group (n = 30) To investigate the effect of a Age between 20 and 80 years; Duration: 12 weeks Significant differences were found
(2017)[4] Gender = 50% male, 50% female therapeutic exercise feet diagnosis of type 2 diabetes Experimental group: between the sizes of diabetic foot
Age (mean, years) = 61 programme in the healing of mellitus; foot ulcers with a Therapeutic exercises: ulcers in the experimental group at
Body mass index (mean, kg/m2) = 31.36 diabetic foot ulcers in patients rating of 1 or 2 on Wagner mobility and resistance, with weeks 4 and 12 (P ≤ 0.05). Only
Initial ulcer area (mean, cm2) = 12.63 with type 2 diabetes classification; cannot have standard treatment week 12 was different at the
Initial ulcer depth (mean, cm) = 0.56 musculoskeletal disorders,
Table 1 (Continued)
Article Sample characterisation Objectives Inclusion criteria Intervention Results
HbA1c (%) = 10.36 heart disease or neurological Control group: Standard beginning in the control group
Control group (n = 30) diseases that could impair treatment (P = 0.000)
Gender = 73% male, 27% female ability to participate in the
Age (mean, years) = 66 study; cannot receive other
Body mass index (mean, kg/m2) = 28.58 treatments that may influence
Initial ulcer area (mean, cm2) = 24.67 ulcer healing
Initial ulcer depth (mean, cm) = 0.61
HbA1c (%) = 10.02
Tantawy et al. Helium and neon laser therapy group (n = 33) To compare the effects of Age between 50 and 60 years; Duration: 8 weeks After 4 weeks of intervention, there
(2018)[27] Gender = 76% male, 24% female helium and neon laser therapy body mass index 30 kg/m2; Group 1: Helium and neon were significant improvements in
Age (mean, years) = 55 with infrared laser therapy on cannot have a metabolic laser therapy and standard the ulcer surface area in both groups
Body mass index (mean, kg/m2) = 30.42 diabetic foot ulcers health problem such as treatment (P < 0.05).
Ulcer duration, months (mean) = 8.5 nephropathy, Group 2: Infrared laser After 8 weeks of intervention, there
Initial ulcer area (mean, cm2) = 10.2 cardiomyopathy, recent therapy and standard was a greater reduction in the ulcer
HbA1c (%) = 7.9 myocardial infarction, or lung treatment area in the helium and neon laser
Infrared laser therapy group (n = 32) problems therapy group than in the infrared
Gender = 81% male, 19% female laser therapy group, but this
Age (mean, years) = 56 difference was not significant
Body mass index (mean, kg/m2) = 29.34 (P > 0.05)
Ulcer duration, months (mean) = 9.1
Initial ulcer area (mean, cm2) = 9.5
HbA1c (%) = 7.6
Snyder et al. Study 1 To investigate the efficiency Have at least one diabetic Duration: 24 weeks A greater number of diabetic foot
(2018)[28] Experimental group (n = 107) of focal shockwave therapy as foot ulcer for ≥ 30 days; Study 1 ulcers had healed in week 20
Gender = 78% male, 22% female an adjunctive treatment for diabetes mellitus with HbA1c Experimental group (35.5% vs 24.4%; P = 0.027) and
S.Medeiros et al. / Physiotherapy 118 (2023) 79–87

Age (mean, years) = 60 diabetic foot ulcers ≤ 12%; able to take care of Shockwave therapy and week 24 (37.8% vs 26.2%;
Body mass index (mean, kg/m2) = 31.8 wounds at home; ulcer area standard treatment P = 0.023) in the experimental
Ulcer duration, weeks (mean) = 48.7 between 1 and 16 cm2; grade Control group Placebo group compared with the control
Initial ulcer area (mean, cm2) = 3.5 1 or 2 ulcer, stage A shockwave therapy and group. At 12 weeks, the
HbA1c < 7 (%) = 30.8 according to the University of standard treatment experimental group tended towards
HbA1c ≥ 7 (%) = 69.2 Texas diabetic wound Study 2 statistical significance (22.7%
Ankle brachial index = 1.01 classification system; ankle- Experimental group vs 18.3%)
Control group (n = 99) arm index between 0.7 and Intervention equal to Study 1
Gender = 84% male, 16% female 1.2, or toe pressure Control group Intervention
Age (mean, years) = 56 > 50 mmHg, or tcPo2 equal to Study 1
Body mass index (mean, kg/m2) = 31.6 > 40 mmHg
Ulcer duration, weeks (mean) = 69.5
83
 84 S.Medeiros et al. / Physiotherapy 118 (2023) 79–87

participants and the sample sizes. The studies lasted for 24

weeks, during which the experimental group received shock
waves with standard treatment, and the control group re-
ceived placebo shock waves with standard treatment. The
shock wave treatment parameters were: surface energy
density 0.123 mJ/mm2, 500 pulses/cm2 for 2–5 min, and 4
pulses per second. A greater number of diabetic foot ulcers
had healed by 20 weeks (36% vs 24%) and 24 weeks (38%
Results

vs 26%) in the experimental group compared with the

control group.
In the field of manual therapy, a single study [25] was
found on the manipulation of connective tissue. This study
compared the effects of a connective tissue manipulation
programme twice per week plus standard treatment with
standard treatment alone, applied for 6 weeks. The ulcer
Intervention

area reduced significantly in both groups.

Finally, assistive technologies, through the use of a cast,
were reported in a single study [26]. This study lasted for 7
weeks, and compared the effects of a non-removable cast
with a removable cast, both of which were combined with
years; Study 2, age ≥ 22 years
Exceptions: Study 1, age ≥ 18

standard treatment. Most of the ulcers in the non-removable

cast group healed by 12 weeks, while patients in the re-
movable cast group showed a significant inverse correlation
Inclusion criteria

between the duration of daily rest and the weekly rate of

healing.

Discussion

Therapeutic exercise, electrotherapy, manual therapy

and assistive technologies have been proposed previously to
aid in the management of diabetic foot ulcers.
Therapeutic exercise is used to treat individuals with
diabetes mellitus because it affects blood glucose level,
Objectives

decreases the amount of triglycerides, and increases insulin

sensitivity [9,29]. For individuals with diabetic foot ulcers,
it is common to think that the level of physical activity must
be reduced for the ulcer to heal. However, studies have
shown that a well-structured exercise programme that in-
cludes resistance training and aerobic training is safe, viable
Body mass index (mean, kg/m2) = 31.4

Body mass index (mean, kg/m2) = 31.6

and has positive effects on blood glucose regulation and

Ulcer duration, weeks (mean) = 44.6

Ulcer duration, weeks (mean) = 49.7

Initial ulcer area (mean, cm2) = 3.71

Initial ulcer area (mean, cm2) = 3.73

Initial ulcer area (mean, cm2) = 2.8

muscle strength in patients with diabetic foot ulcers, as well

Gender = 83% male, 17% female

Gender = 75% male, 25% female

as in patients at risk of developing them [29–31]. Mobility

Experimental group (n = 65)
Ankle brachial index = 1.04

exercises are also used in this population to promote joint

Sample characterisation

movement, increase blood flow to the area, and provide

Control group (n = 65)
Age (mean, years) = 59

Age (mean, years) = 57

HbA1c < 7 (%) = 33.3

HbA1c < 7 (%) = 34.9

HbA1c < 7 (%) = 20.6

HbA1c ≥ 7 (%) = 66.7

HbA1c ≥ 7 (%) = 65.1

HbA1c ≥ 7 (%) = 79.4

adequate perfusion to the wound [9].

In electrotherapy, the pulsed radiofrequency energy
produces heat and stimulates the cells of the epidermis to
trigger the cascade of cytokines, cyclins, growth factors and
Study 2

other genetic products associated with the healing process

[32]. The literature verifies that pulsed radiofrequency en-
Table 1 (Continued)

ergy can reduce the area of wounds in the lower extremities,

including venous ulcers, diabetic foot ulcers and pressure
ulcers [33]. Laser therapy is currently used as a therapeutic
Article

modality for tissue repair in patients with diabetic foot ul-

cers, when conventional treatment is ineffective. Tissue
 S.Medeiros et al. / Physiotherapy 118 (2023) 79–87 85

repair occurs due to photostimulation of the laser light,

which promotes a reduction in the inflammatory phase,
Snyder et al.
(2018)[28]
favouring angiogenesis and accelerating the tissue healing
process [18,34]. Shockwave therapy increases angiogenesis
and growth factor production, while decreasing inflamma-
X
X
X
X

X
X
X

8
tion in the wound bed and surrounding tissues [35]. Some
studies have shown that shockwave therapy can be an ad-
Tantawy et al.

junctive therapy to improve the healing of diabetic foot

(2018)[27]

ulcers [36].
Connective tissue manipulation is a manual therapy
technique that uses a shear force at the connective tissue
X
X

6
interfaces, stretching the elastic and viscous components of
the tissue. This manipulation has mechanical effects on the
peripheral vascular system, which causes vasodilation and
Eraydin et al.

increased blood flow in the peripheral areas. Although a

(2017)[4]

therapeutic effect has been reported in several studies, there

is a lack of conclusive evidence to support the theoretical
X
X

5
basis of the clinical benefits of connective tissue manip-
ulation in wound healing [37]. Assistive technologies, such
Najafi et al.

as casts, are used to provide support and protection to the

(2016)[26]

wound when carrying out exercise or physical activity. As

there is some concern that the load exerted on the foot is
X
X
X
X

excessive, a cast is used to assist in wound healing in pa-

tients with diabetic foot ulcers [16,38].
This review has some limitations. First, articles that did
Joseph et al.
(2016)[25]

not have full-text, and articles published in journals that are

not indexed online, were not included, and these could have
contributed to the findings. Also, some studies were not
X
X
X
X

X
X
X

carried out with blinding, used inappropriate statistics for

within-group comparisons alone, and did not use intention-
Kadry et al.

to-treat analysis. Another limitation concerns the bias/error

(2016)[24]

of text sifting by a single reviewer, and the descriptors used

in the search may not have reached all the articles con-
X
X
X
X

cerning the offloading devices as physiotherapeutic practice

9. All subjects for whom outcome measures were available received the treatment
8. Measures of at least one key outcome were obtained from more than 85% of

or control condition as allocated, or, where this was not the case, data for at least

10. The results of between-group statistical comparisons are reported for at least
4. The groups were similar at baseline regarding the most important prognostic

differs by region and what is within the scope of practice

7. There was blinding of all assessors who measured at least one key outcome

11. The study provides both point measures and measures of variability for at

may not be reported with the key words used (i.e. ‘physical
therapy’ and ‘physiotherapy’).
6. There was blinding of all therapists who administered the therapy

Conclusion
Quality assessment results according to the PEDro scale.

one key outcome were analysed by ‘intention to treat’

Therapeutic exercise, electrotherapy, manual therapy

and assistive technologies are physiotherapeutic modalities
2. Subjects were allocated at random to groups

that, when combined with standard treatment, have positive

effects on the healing of diabetic foot ulcers. All phy-
the subjects initially allocated to groups

siotherapeutic interventions were complemented with

5. There was blinding of all subjects
1. Eligibility criteria were specified

standard treatment, which highlights the importance of a

multidisciplinary approach in the treatment of ulcers.
3. Allocation was concealed

In terms of the study outcomes, therapeutic exercise,

electrotherapy, manual therapy and assistive technologies
least one key outcome

were found to contribute to a reduction in ulcer area and a

one key outcome

reduction in healing time of the affected area.

This study adds knowledge about the importance of a
indicators

multidisciplinary approach in the assessment and treatment

Table 2

of patients with diabetic foot ulcers, including podiatrists,

Total

doctors, nurses, physiotherapists and psychologists. It also

86 S.Medeiros et al. / Physiotherapy 118 (2023) 79–87

allows health professionals to be aware of the scope of [12] Sorber R, Abularrage CJ. Diabetic foot ulcers: epidemiology and the
practice of physiotherapists in this field. role of multidisciplinary care teams. Semin Vasc Surg
Further research is needed to establish the effectiveness 2021;34:47–53.
[13] Santos J, Campelo M, Oliveira R, Nicolau R, Rezende V, Arisawa E.
of these interventions in the healing of ulcers. From there, it Effects of low-power light therapy on the tissue repair process of
will be possible to develop guidelines on the physiother- chronic wounds in diabetic feet. Photomed Laser Surg
apeutic management of diabetic foot ulcers. 2018;36:298–304.
[14] Mutlak O, Slam MA, Dfield NS. The influence of exercise on ulcer
healing in patients with chronic venous insufficiency. Int Angiol
Ethical approval: Not required. 2018;37:160–7.
[15] Monteiro RL, Sartor CD, Ferreira JSSP, Dantas MGB, Bus SA,
Sacco ICN. Protocol for evaluating the effects of a foot-ankle ther-
apeutic exercise program on daily activity, foot–ankle functionality,
and biomechanics in people with diabetic polyneuropathy: a rando-
Conflict of interest: None declared. mized controlled trial. BMC Musculoskelet Disord 2018;19:1–12.
[16] Everett E, Mathioudakis N. Update on management of diabetic foot
ulcers. Ann N Y Acad Sci 2018;1411:153–65.
[17] Associação Portuguesa de Fisioterapeutas. O Perfil de Competências
Appendix A. Supporting information do Fisioterapeuta. Oeiras: APFISIO; 2020. p.10–7.
[18] Perez-Favila A, Martinez-Fierro ML, Rodriguez-Lazalde JG, Cid-
Baez MA, Zamudio-Osuna MDJ, Martinez-Blanco MDR, et al.
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