***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Foot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy . AIM : To investigate the effects of strengthening , stretching , and functional training on foot rollover process during gait . Methods A two-arm parallel-group r and omized controlled trial with a blinded assessor was design ed . Fifty-five patients diagnosed with diabetic polyneuropathy , 45 to 65 years-old were recruited .  Exercises for foot-ankle and gait training were administered twice a week , for 12 weeks , to 26 patients assigned to the intervention group , while 29 patients assigned to control group received recommended st and ard medical care : pharmacological treatment for diabetes and foot care instructions . Both groups were assessed after 12 weeks , and the intervention group at follow-up ( 24 weeks ) . Primary outcomes involved foot rollover changes during gait , including peak pressure ( PP ) . Secondary outcomes involved time-to-peak pressure ( TPP ) and pressure – time integral ( PTI ) in six foot- areas , mean center of pressure ( COP ) velocity , ankle kinematics and kinetics in the sagittal plane , intrinsic and extrinsic muscle function , and functional tests of foot and ankle . Results Even though the intervention group primary outcome ( PP ) showed a not statistically significant change under the six foot areas , intention-to-treat comparisons yielded softening of heel strike ( delayed heel TPP , p=.03 ) , better eccentric control of forefoot contact ( decrease in ankle extensor moment , p<.01 ; increase in function of ankle dorsiflexion , p<.05 ) , earlier lateral forefoot contact with respect to medial forefoot ( TPP anticipation , p<.01 ) , and increased participation of hallux ( increased PP and PTI , p=.03 ) and toes ( increase in PTI , medium effect size ) . A slower COP mean velocity ( p=.05 ) , and an increase in overall foot and ankle function ( p<.05 ) were also observed . In most cases , the values returned to baseline after the follow-up ( p<.05 ) . Conclusions Intervention discreetly changed foot rollover towards a more physiological process , supported by improved plantar pressure distribution and better functional condition of the foot ankle complex . Continuous monitoring of the foot status and patient education are necessary , and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy . Trial registration Clinical Trials.gov Identifier : NCT01207284 , registered in 20th September 2010 PURPOSE To evaluate the effectiveness of home temperature monitoring to reduce the incidence of foot ulcers  in high-risk patients with diabetes . METHODS In this physician-blinded , 18-month r and omized controlled trial , 225 subjects with diabetes at high risk for ulceration were assigned to st and ard therapy ( St and ard Therapy Group ) or dermal thermometry ( Dermal Thermometry Group ) groups . Both groups received therapeutic footwear , diabetic foot education , regular foot care , and performed a structured foot inspection daily . Dermal Thermometry Group subjects used an infrared skin thermometer to measure temperatures  on 6 foot sites twice daily . Temperature differences > 4 degrees F between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized . RESULTS A total of 8.4 % ( n=19 ) subjects ulcerated over the study period . Subjects were one third as likely to ulcerate in the Dermal Thermometry Group compared with the St and ard Therapy Group ( 12.2 % vs 4.7 % , odds ratio 3.0 , 95 % confidence interval , 1.0 to 8.5 , P=.038 ) . Proportional hazards regression analysis suggested that thermometry intervention was associated with a significantly longer time to ulceration ( P=.04 ) , adjusted for elevated foot ulcer classification ( International Working Group Risk Factor 3 ) , age , and minority status . Patients that ulcerated had a temperature difference that was 4.8 times greater at the site of ulceration in the week before ulceration than did a r and om 7 consecutive-day sample of 50 other subjects that did not ulcerate ( 3.50+/-1.0 vs 0.74+/-0.05 , P=.001 ) . CONCLUSIONS High temperature gradients between feet may predict the onset of neuropathic ulceration and self-monitoring may reduce the risk of ulceration BACKGROUND Neuropathic foot ulcers are among the major health problems faced by patients with diabetes mellitus . OBJECTIVE To evaluate the preventive efficacy of a therapeutic education and protective footwear program in the incidence and recurrence of  neuropathic ulcers due to diabetes . METHODS Fifty-three patients with diabetes and neuropathy from a public healthcare unit in Porto Alegre , Rio Gr and e do Sul , took part in a clinical trial for two years . The participants were r and omly allocated to an intervention group ( n=30 ) or a control group ( n=23 ) . Therapeutic education was provided in group sessions , and protective footwear was supplied in accordance with individual prescriptions . The nonparametric Mann-Whitney test was used to determine differences in incidence and recurrence of ulceration between the groups . Life-table analysis and the Kaplan-Meier method were used to measure the duration of ulcer-free survival . RESULTS In the intervention group , the ulcer incidence rate was 38.1 % compared to 51.1 % in the control group . Among the participants who presented ulcers , 83 % were in the control group and 16.7 % in the intervention group . After one year , the participants in the intervention group had a 75 % chance of being ulcer-free , compared with 61 % in the control group , and these percentages reduced to 60 % and 52 % respectively after two years . There was a tendency toward shorter survival among the control group participants . CONCLUSION Although the proposed program lowered recurrence rates and increased the duration of ulcer-free survival , it was unable to prevent occurrence and recurrence of neuropathic ulcers due to diabetes Abstract Aims /hypothesisThis observer-blind , r and omised controlled trial was design ed to determine the effect of a foot care education programme in the secondary prevention of foot ulcers . Methods People with newly healed foot ulcers attending one of three specialist clinics were allocated to receive either targeted , one-to-one education or usual care , using a computer-generated r and om allocation sequence that had been prepared in advance but which was concealed from the clinical research er . The primary outcome was ulcer incidence at 12 months . Secondary outcomes were ulcer incidence at 6 months and incidence of amputation , mood ( Hospital Anxiety and Depression Scale ) and quality of life ( Diabetic Foot Ulcer Scale ) at 6 and 12 months . Protective foot care behaviours ( Nottingham Assessment of Functional Footcare ) were assessed at 12 months . Results There were 87 ( mean [ SD ] age 63.5 [ 12.1 ] years ) patients in the intervention group and 85 control patients ( mean [ SD ] age 64.9 [ 10.9 ] years ) . The groups were comparable at baseline . No significant differences ( p > 0.05 ) were observed between groups in ulcer incidence at either 6 months ( intervention 30 % , control 21 % ) or 12 months ( intervention 41 % , control 41 % ) . Recommended foot care behaviours at 12 months were better in the intervention than in the control group ( p = 0.03 ) , but education had no significant ( p > 0.05 ) effect on mood , quality of life or amputations . Conclusions /interpretationEven though the intervention was associated with improved foot care behaviour , there was no evidence that this programme of targeted education was associated with clinical benefit in this population when compared with usual care . The usefulness and optimal delivery of education to such a high-risk group requires further evaluation . Trial registration : Clinical Trials.gov NCT00729456 Funding : Diabetes UK project grant BACKGROUND We aim ed to investigate whether a home exercise for self-care program that consists of range of motion ( ROM ) , stretching , and strengthening exercises could improve ROM for foot joints and plantar pressure distribution during walking in diabetic patients to prevent diabetic foot complications . METHODS Seventy-six diabetic patients were recruited ( 38 with neuropathy and 38 without neuropathy ) . Neuropathy and nonneuropathy groups were r and omly divided into a home exercise group ( n = 19 ) and a control group ( n = 19 ) . Exercise groups performed their own respective training programs for 4 weeks , whereas no training was done in the control group . Total contact area and plantar pressure under six foot areas before and after the exercise program were measured . Ankle and first metatarsophalangeal joint ROM were measured before and after the exercise program . RESULTS In the exercise group , there were significant improvements in ROM for the ankle and first metatarsophalangeal joints ( P < .001 ) ; static pedobarographic values showed significant reduction in right forefoot-medial pressure ( P = .010 ) ; and significant decreases were seen in dynamic pedobarographic values of peak plantar pressure at the left forefoot medial ( P = .007 ) , right forefoot lateral ( P = .018 ) , left midfoot ( P < .001 ) , and right hindfoot ( P = .021 ) after exercise . No significant positive or negative correlation was found between the neuropathy and nonneuropathy groups ( P > .05 ) . CONCLUSIONS A home exercise program could be an effective preventive method for improving ROM for foot joints and plantar pressure distribution in diabetic patients independent of the presence of neuropathy Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system , but prevention thereof receives little attention . For every euro spent on ulcer prevention , ten are spent on ulcer healing , and for every r and omized controlled trial conducted on prevention , ten are conducted on healing . In this article , we argue that a shift in priorities is needed . For the prevention of a first foot ulcer , we need more insight into the effect of interventions and practice s already applied globally in many setting s. This requires systematic recording of interventions and outcomes , and well- design ed r and omized controlled trials that include analysis of cost-effectiveness . After healing of a foot ulcer , the risk of recurrence is high . For the prevention of a recurrent foot ulcer , home monitoring of foot temperature , pressure-relieving therapeutic footwear , and certain surgical interventions prove to be effective . The median effect size found in a total of 23 studies on these interventions is large , over 60 % , and further increases when patients are adherent to treatment . These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach , where attempts are made to assure treatment adherence . Effect sizes of 75 - 80 % may be expected . If such state-of-the-art integrated foot care is implemented , the majority of problems with foot ulcer recurrence in diabetes can be resolved . It is therefore time to act and to set a new target in diabetic foot care . This target is to reduce foot ulcer incidence with at least 75 % Background Diabetic foot ulcers are frequently related to elevated pressure under a bony prominence . Conservative treatment includes offloading with orthopaedic shoes and custom made orthotics or plaster casts . While casting in plaster is usually effective in achieving primary closure of foot ulcers , recurrence rates are high . Minimally invasive surgical offloading that includes correction of foot deformities has good short and long term results . The surgery alleviates the pressure under the bony prominence , thus enabling prompt ulcer healing , negating the patient ’s dependence on expensive shoes and orthotics , with a lower chance of recurrence . The purpose of this protocol is to compare offloading surgery ( percutaneous flexor tenotomy , mini-invasive floating metatarsal osteotomy or Keller arthroplasty ) to non-surgical treatment for patients with diabetic foot ulcers in a semi-crossover design ed RCT . Methods One hundred patients with diabetic neuropathy related foot ulcers ( tip of toe ulcers , ulcers under metatarsal heads and ulcers under the hallux interphalangeal joint ) will be r and omized ( 2:3 ) to a surgical offloading procedure or best available non-surgical treatment . Group 1 ( surgery ) will have surgery within 1 week . Group 2 ( controls ) will be prescribed an offloading cast applied for up to 12 weeks ( based on clinical considerations ) . Following successful offloading treatment ( ulcer closure with complete epithelization ) patients will be prescribed orthopaedic shoes and custom made orthotics . If offloading by cast for at least 6 weeks fails , or the ulcer recurs , patients will be offered surgical offloading . Follow-up will take place till 2 years following r and omization . Outcome criteria will be time to healing of the primary ulcer ( complete epithelization ) , time to healing of surgical wound , recurrence of ulcer , time to recurrence and complications . Discussion The high recurrence rate of foot ulcers and their dire consequences justify attempts to find better solutions than the non-surgical options available at present . To promote surgery , RCT level evidence of efficacy is necessary . Trial registration Israel MOH_2017–08 - 10_000719 . NIH : NCT03414216 Background Synthesis of multiple r and omized controlled trials ( RCTs ) in a systematic review can summarize the effects of individual outcomes and provide numerical answers about the effectiveness of interventions . Filtering of search es is time consuming , and no single method fulfills the principal requirements of speed with accuracy . Automation of systematic review s is driven by a necessity to expedite the 
    Output:
    
For the prevention of recurrent plantar foot ulcers , multiple RCTs with low risk of bias show the benefit for the use of daily foot skin temperature measurements and consequent preventative actions , as well as for therapeutic footwear that demonstrates to relieve plantar pressure and that is worn by the patient .
To prevent recurrence , some evidence exists for integrated foot care when it includes a combination of professional foot treatment , therapeutic footwear and patient education ; for just a single session of patient education , no evidence exists .
Surgical interventions can be effective in selected patients , but the evidence base is small .
The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong , but is small for the use of other , sometimes widely applied , interventions and is practically nonexistent for the prevention of a first foot ulcer and non-plantar foot ulcer