A Narrative Review of Clinical Decision Support Systems in Offloading Footwear for Diabetes-Related Foot Ulcers
This addresses fragmented prescription practices for diabetic foot ulcer care, though it is an incremental review and framework proposal.
The authors reviewed 45 studies on clinical decision support systems for prescribing offloading footwear to treat diabetic foot ulcers, finding fragmented approaches with limited personalization and evaluation. They proposed a five-part framework combining rules, optimization, and explainable machine learning to enable scalable, patient-centered systems.
Offloading footwear helps prevent and treat diabetic foot ulcers (DFUs) by lowering plantar pressure (PP), yet prescription decisions remain fragmented: feature selection varies, personalization is limited, and evaluation practices differ. We performed a narrative review of 45 studies (12 guidelines/protocols, 25 knowledge-based systems, 8 machine-learning applications) published to Aug 2025. We thematically analyzed knowledge type, decision logic, evaluation methods, and enabling technologies. Guidelines emphasize PP thresholds (<=200 kPa or >=25--30\% reduction) but rarely yield actionable, feature-level outputs. Knowledge-based systems use rule- and sensor-driven logic, integrating PP monitoring, adherence tracking, and usability testing. ML work introduces predictive, optimization, and generative models with high computational accuracy but limited explainability and clinical validation. Evaluation remains fragmented: protocols prioritize biomechanical tests; knowledge-based systems assess usability/adherence; ML studies focus on technical accuracy with weak linkage to long-term outcomes. From this synthesis we propose a five-part CDSS framework: (1) a minimum viable dataset; (2) a hybrid architecture combining rules, optimization, and explainable ML; (3) structured feature-level outputs; (4) continuous validation and evaluation; and (5) integration with clinical and telehealth workflows. This framework aims to enable scalable, patient-centered CDSSs for DFU care; prioritizing interoperable datasets, explainable models, and outcome-focused evaluation will be key to clinical adoption.