100 March/April 2009 • Vol 99 • No 2 • Journal of the American Podiatric Medical Association The prescription of specialized footwear is common in the management of many foot problems, including the treatment and prevention of diabetic foot ulcers. Foot ulcerations are one of the most common mal- adies associated with diabetes and play a central role in the causal pathway to lower-extremity amputation. 1 An average of 79,200 nontraumatic lower-limb ampu- tations were performed annually on individuals with diabetes in the United States between 1999 and 2003. 2 Adler et al 3 noted that the odds ratio associat- ed with a first ulcer for a subsequent ipsilateral am- putation was 5.7 (95% confidence interval, 1.6–30.2). A key factor in healing and preventing diabetic foot ulcers is off-loading diabetic feet during weightbear- ing. 4, 5 Numerous modalities have been developed for this purpose, ranging from specialized casts to san- dals. 5, 6 The total-contact cast is recognized as the gold standard for healing ulcers. 5 Although some re- movable cast walkers (RCWs) off-loaded the plantar surface of the diabetic foot as effectively as the total- contact cast in the gait laboratory, 7, 8 the total-contact cast yielded higher healing rates and a shorter time to healing than did the RCW in a previous clinical trial. 9 In view of this fact, the primary difference in design (ie, removability) became the prime suspect to explain the varied outcomes. To investigate whether the difference in healing between the devices was attributable to noncompli- ance with the RCW, a study 10 was conducted compar- ing care with a total-contact cast versus an instant total-contact cast. The instant total-contact cast con- sisted of an RCW rendered irremovable by a single layer of fiberglass casting material wrapped around the walker. In this study, the instant total-contact cast and the total-contact cast yielded equivocal heal- ing results, thus supporting the hypothesis that lack of compliance was responsible for the diminished Background: Off-loading excessive pressure is essential to healing diabetic foot ulcers. However, many patients are not compliant in using prescribed footwear or off-loading devices. We sought to validate a method of objectively measuring off-loading compli- ance via activity monitors. Methods: For 4 days, a single subject maintained a written compliance diary concerning use of a removable cast walker. He also wore a hip-mounted activity monitor during all waking hours. An additional activity monitor remained mounted on the cast walker at all times. At the conclusion of the 4 days, the time-stamped hip activity data were inde- pendently coded for walker compliance by the compliance diary and by using the time- stamped walker activity data. Results: An intraclass reliability of 0.93 was found between diary-coded and walker monitor–coded activity. Conclusions: These results support the use of this dual activity monitor approach for assessing off-loading compliance. An advantage of this approach versus a patient-main- tained diary is that the monitors are not susceptible to incorrect patient recall or a pa- tientʼs desire to please a caregiver by reporting inflated compliance. Furthermore, these results seem to lend support to existing reports in the literature using similar methods. (J Am Podiatr Med Assoc 99(2): 100-103, 2009) *Scholl’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Sci- ence, Chicago, IL. Dr. Armstrong is now with University of Ari- zona College of Medicine, Tucson, AZ. †University Department of Medicine and Diabetes, Man- chester Royal Infirmary, Manchester, England. ‡Division of Endocrinology, Metabolism, and Diabetes, Uni- versity of Miami School of Medicine, Miami, FL. Corresponding author: Ryan T. Crews, MS, Scholl’s Cen- ter for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064. (E-mail: ryan.crews @rosalindfranklin.edu) A Method for Assessing Off-loading Compliance Ryan T. Crews, MS* David G. Armstrong, DPM, PhD* Andrew J.M. Boulton, MD†‡ ORIGINAL ARTICLES