Using the 6W Approach to Determine Risk for Offloading Intervention in the Pre- and Post-Ulcerative Patient Protection Status

bY James McGuire, DPM, PT, LPed, FAPWHc

It is essential that the various offloading devices available to the wound care professional are applied appropriately to redistribute destructive forces that develop in the diabetic or neuropathic foot during standing and ambulation.1,2 The 6 "W" approach was first introduced in an article in 20063 to help practitioners better understand the biomechanical risk profile of patients at risk for ulceration so that they could better choose between the various offloading interventions available for their everyday footwear.

The 6Ws included:

1. Who the patient is or their intrinsic physical characteristics
2. What the patient wears or their choice of footwear
3. When the patient walks or the amount of time spent standing and walking each day
4. Where the patient walks or the type of ambulatory activities a patient engages in
5. Why the patient walks or their compliance and motivation
6. The "Way" the patient walks or their specific gait characteristics

I recently placed each of these variables on a grid and gave them a relative numerical weight to determine a “6W Biomechanical Risk Assessment” score for that patient. The higher the score the greater the risk of tissue damage and the more aggressive our offloading approach must be (Table 1).

Patients with a risk of 0-3 may wear their normal footwear and need only be checked regularly (every 3-6 months) for changes in their risk status. Patients with a risk of 4-6 need total contact orthotic insoles and depth shoes to better redistribute focal plantar pressures and reduce their risk of ulceration. They should also be seen every 2-3 months for reassessment. Patients with a risk of 7-12 have a high risk for damage to the foot and in addition to bimonthly visits to their Podiatrist, require molded innersoles, sole modifications to the shoe, and behavioral interventions such as gait training, ambulatory aides, and counseling to change their approach to ambulation.

Better understanding biomechanical risk helps us avoid forcing patients with minimal risk of mechanical damage into an already overburdened federal diabetic shoe program. On the other hand it helps practitioners use a more aggressive offloading approach for patients with a higher mechanical risk for ulceration who need all the intervention they can get.


1. McGuire J, Pressure Redistribution Strategies for the Diabetic or At-Risk Foot: Part I. Advances in Skin & Wound Care. 19(4):213-221, May 2006.
2. McGuire J. Pressure Redistribution Strategies for the Diabetic or At-Risk Foot: Part II. Advances in Skin & Wound Care. 19(5):270-277, June 2006.
3. McGuire, J. Transitional Off-loading: An Evidence-Based Approach to Pressure Redistribution in the Diabetic Foot. Advances in Skin & Wound Care. (23)(4):175-188. April 2010.

About the Author
Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia. Dr. McGuire has over 30 years of experience in wound management and lectures both nationally and internationally in the areas of wound healing, diabetic foot management, off-loading, and biomechanics of the at-risk foot.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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