have a life expectancy and get fatigued if used repeatedly for long periods without allow- ing the nylon to recover.12 The preferred method of using the monofilament is shown in Table 10.1.
The literature is equivocal about the definitive sites that must be tested for determining ulcer risk, and papers reporting 1, 14 sites on each foot have been published.13 However, there are sites that are common to virtually all publications, namely the plantar surface of the metatarsal heads and the big toe.
The rationale is that these sites most frequently ulcerate.
When testing, areas of scar tissue or callus should be avoided.14 There is no clear evidence on how many negative response sites implies an ‘at-risk’ foot.
However, some papers show that even one site with a negative response on each foot may indicate ‘at-risk’ status.13 Clearly, the more negative responses there are, the greater the risk.
In summary, when considering neuropathy screening in a busy general practice diabetes clinic, the sites that should be tested are the plantar surfaces of the big toe and a minimum of three metatarsal heads (four sites/foot).
Neuropathy is determined by the inability to detect the monofilament at one or more sites on each foot.
WHO SHOULD DO FOOT CARE SCREENING?
Anyone with the skills and competency to perform the testing safely should do foot care screening.
In most general practice diabetes clinics, a practice nurse involved in diabetes care will do the screening.
In some practices, testing is being performed by health care assistants who have had appropriate training and supervision.
In some parts of the United Kingdom, local podiatry services have contracted to provide a screening service for primary care.
In this model, podiatrists either attend the practice to do foot screening and provide basic foot education or send invitations for patients to attend the local podiatry department for this work.
In another model, foot screening is done at the same time as digital retinal photography in a mobile screening programme.15
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ACTIONS TO BE TAKEN AFTER FOOT EXAMINATION 127
One potential difficulty of involving trained podiatrists in primary screening in the commu- nity is shortage of podiatrists.
The author estimates that approximately half of the available hours of all trained podiatrists could be consumed in the process of primary care diabetic foot screening.
However, the expertise of trained podiatrists is vitally needed in the education and follow-up of people with ‘at-risk’ feet, and in the care of people with ulcers in multidisci- plinary foot teams.
Thus, it is in these areas that podiatry expertise should be concentrated, rather than in primary screening, which is a fairly routine process that less qualified personnel can effectively perform.
ACTIONS TO BE TAKEN AFTER FOOT EXAMINATION In this section, the actions to be taken, depending on the outcome of the foot examination, will be discussed.
If the foot is normal and, therefore, at low current risk of ulceration, the practitioner should reinforce general foot care education and advice (Table 10.2).
The patient should return for a repeat examination annually.
Patients who are determined to have at-risk feet must be referred to the specialist team.
The NICE guideline9 states that ‘Implementing a screening and foot protection programme for patients with risk factors for ulceration reduces morbidity and is cost effective’ and recommends that the following actions be performed: (1) inspect patients’ feet every 3, 6 months; (2) enhance foot care education (Table 10.3); (3) evaluate footwear; (4) review the need for further vascular assessment.
All these statements are given as evidence level D.
Table 10.2 General foot care and advice to be given to diabetic patients
Self-care and self-monitoring, including r daily examination of the feet for problems (colour change, swelling, breaks in the skin, pain or numbness); r footwear (the importance of well-fitting shoes and hosiery); r hygiene (daily washing and careful drying); r nail care; r dangers associated with practices such as skin removal (including corn removal); r methods to help self-examination/monitoring (e.g. the use of mirrors if mobility is limited).
When to seek advice from a health care professional? r if any colour change, swelling, breaks in the skin, pain or numbness is found; r if self-care and -monitoring is not possible or difficult (e.g. because of reduced mobility).
Possible consequences of neglecting the feet: r foot problems can often be prevented by good diabetes overall management as well as specific foot care; r prompt detection and management of any problems is important, and thus the importance of seeking help as soon as the problem is noticed; r complications of diabetes such as neuropathy and ischaemia can lead to foot problems such as ulcers, infections and, in extreme cases, gangrene and amputation.
From the NICE clinical guideline.9 Copyright, the National Institute for Health and Clinical Excellence.
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128 THE DIABETIC FOOT IN PRIMARY CARE
Table 10.3 Foot care advice and education to be given to patients with at-risk feet
If neuropathy is present, the resulting numbness means that problems may not be noticed, so extra care and vigilance is needed, and the following advice/precautions to keep the feet protected should be given: r not walking barefoot; r seeking help to deal with corns and callus; r dangers associated with over-the-counter preparations for foot problems (e.g. the corn cures); r potential burning of numb feet, checking bath temperatures, avoiding hot water bottles, electric blankets, foot spas and sitting too close to fires; r moisturise areas of dry skin.
Footwear advice to be given: r regular checking of footwear for areas that will cause friction or trauma; r seeking help from a health care professional if footwear causes difficulties or problems; r wearing specialist footwear that has been prescribed or supplied.
Additional advice about foot care on holiday: r not wearing new shoes; r planning adequate rest periods to avoid additional stress on feet; r if flying, walk up and down aisles; r use of sun block on feet especially on dry skin; r take a first-aid kit and cover any sore places with sterile dressing; r seek help if problems develop; r holiday insurance issues (ensure diabetes cover).
From the NICE clinical guideline.9 Copyright, the National Institute for Health and Clinical Excellence.
If the above review identifies patients at ‘high risk’, then the following actions are recom- mended: (1) frequent review every 1, 3 months; (2) intensified foot care education; (3) specialist footwear and insoles; (4) skin and nail care; (5) review of need for vascular assessment; (6) ensuring special arrangements for those people with disabilities or immobility.
One study has demonstrated the potential effectiveness of the above approach.
McCabe and colleagues describe a strategy for screening and intervention based on a trial of 2001 patients attending a hospital clinic.16 Patients were randomised to a control group (n = 1000), which continued to receive standard care in the routine diabetes clinic, and an index group (n = 1001).
The index group was screened for risk factors and patients found to be at increased risk (n = 259) were recalled.
Following a second assessment, 193 patients with foot deformities, vascular disease or a history of ulceration were entered into a foot protection programme with eligibility for weekly clinics providing chiropody and hygiene maintenance, hosiery and protective footwear.
When compared to the control group, the index group demonstrated non- significant trends in reduced ulceration and minor amputations, and statistically significant reductions in overall and major amputations.
Of those presenting with ulcers, significantly fewer progressed to amputation in the index group.
The foot protection programme was cost- effective in terms of major amputations prevented. (Cost of clinic £100 372; savings from avoiding 11 major amputations estimated at £12 000 each = £13 2000.) It is possible that broader inclusion criteria and increased compliance in the above study might have further improved the cost-effectiveness.