If improved outcome of ulcers , rather than reduced incidence , is the principal aim, then it is most likely that this will be best achieved by improving the knowledge, skills and coordination of professionals.
This aspect of the topic has not yet received much attention, although Connelly and colleagues demonstrated that much of the variation in the incidence of major amputation for diabetes in three towns in northern England could be attributed to differences in professional attitudes and beliefs concerning ulcer management.18 A change in behaviour of professionals may also have a significant impact on the incidence of new ulcers.
Del Aguila and colleagues19 have shown that health care providers have limited awareness of the potential for protective management in patients whose feet are at risk from either neuropathy or vascular disease, and this has been echoed in a recent report by Lawrence and colleagues.20 Others have judged that action or inaction by professionals is twice as likely to result in the presentation of a foot ulcer than anything that the patient does or does not do.21 There is evidence that education of health care professionals is associated with improved clinical practice with regard to preventive foot care (as opposed to actual ulcer incidence).
In an attempt to determine the effects of educating physicians, Bruckner et al.22 ran 1-day statewide workshops on diabetes foot care.
When reviewing, after an interval of 9 months, the records of the patients of the 560 clinicians who took part, they found better documentation of education, improved self-care and a trend towards reduced lower limb amputation.
O’Brien et al.23 also showed that lectures given to primary care physicians in Texas, United States , when combined with the instruction that clinic support staff should remove the socks and shoes of all diabetes patients who were placed in exam rooms , resulted in a significant increase in performance and documentation at 6 months of proper foot examination, from 14 to 62% and from 33 to 73%, respectively.
This confirms the observations made by Cohen, 20 years earlier.24 However, as with educational interventions for patients, no professional education programme has yet been shown to have a significant impact on either ulcer incidence or ulcer outcome22 , unless it was undertaken as part of a comprehensive programme of improving medical support in previously deprived communities with a particularly high baseline incidence of amputation.25 This is in contrast to the results of Plank and colleagues26 who demonstrated that the simple strategy of implementing routine podiatric supervision of those at greatest risk, independent of specific education, was associated with a significant reduction in ulcer recurrence.
There is a clear need for more research in this area.
Such work should probably acknowledge that it is inappropriate to require professionals in primary care to have detailed knowledge of ulcer aetiology and assessment , because non-specialists actually encounter relatively few ulcers in any one year.
They do, however, need to be able to identify the patient ‘at risk’ (see below) and all professional staff need to understand the importance and potential urgency of any newly presenting ulcer.
There should be agreed pathways for assessment and care, with appropriate early referral to specialist hospital clinics.
Patients
Educational initiatives for patients need to be considered under three headings: those with no special increase in risk, those at increased risk and those at much increased risk. Those at
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ISSUES TO BE ADDRESSED IN PLANNING AN EDUCATION PROGRAMME 147
increased risk are those with one identified risk factor (neuropathy or ischaemia or deformity), while those at greatly increased risk are those with two or more risk factors or those who have had a previous foot ulcer. The educational methods used will depend on the level of individual risk, and studies designed to determine the effectiveness of such interventions must take this into account.
Education of Patients with no Increased Risk
Prevention of neuropathy, ischaemia and deformity
Information imparted might include advice on the undisputed importance of maintaining good glycaemic control, and minimising vascular risk by not smoking, by taking exercise, dietary modification and, when appropriate, taking aspirin and lipid-lowering therapy. Education will not minimise the effects of any deformity that is congenital, or acquired as a complication of diabetes (such as neuropathy and Achilles tendon shortening), but patients should learn the importance of accommodating the deformed foot in appropriate footwear. Education given to younger people about pointed-toed shoes may in theory reduce the incidence of bunions in later life, but in practice it is likely to be ignored.
General foot care
Recommendations can be given concerning the general care of feet but it is unlikely that they will lead to a change in behaviour in the majority of those without special risk.
Thus, those with intact peripheral circulation and sensation are unlikely to perceive the need to, for instance, inspect their feet carefully every day, to dry carefully between their toes or to adhere to any of the other (often unsubstantiated) advice that might be found in educational leaflets on foot care which are available.
Similarly, it is very unlikely that any study will ever be possible that will prove the utility or futility of such aspects of general advice , because the incidence of new ulceration is so low and the numbers needed to study would be prohibitive.
It seems, therefore, that the answer to this question will never be available.
Given that detailed information on foot care is unlikely to have a major impact on ulcer incidence in this group (and since the healing of any accidental injury is also unlikely to be a problem), professionals should bear in mind the potential adverse effects of giving instruction that is of limited use to the patient.
If the guidance is sufficiently far removed from the patient’s own foot care beliefs and health expectations, it may induce unnecessary alienation.
Particular thought should be given to the seemingly non-controversial advice that a patient should never go barefoot.
There is no reason why this advice should be given to someone whose circulation and sensation are intact.
There is, for instance, little point in advising young persons with uncomplicated type 1 diabetes not to go barefoot when they are about to go to a beach resort in the sun.
Not only are they at no increased risk if their sensation and circulation are intact, but they would not take any notice anyway.
Similarly, consideration should also be given to the validity of advice that people with uncomplicated diabetes should not go barefoot in their own home.
It should be borne in mind that the incidence of foot ulceration is very much lower in South Asian individuals living in the United Kingdom than it is in Caucasians,27 despite the fact that walking barefoot in the home is not uncommon in this group.
If the floor
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148 EDUCATION IN THE MANAGEMENT OF THE FOOT IN DIABETES
covering is good and uncluttered, it is possible (albeit unsubstantiated) that walking barefoot in the home may actually be beneficial (for those without either peripheral vascular disease or neuropathy) in the long term, by reducing any adverse effects of footwear.
Surveillance
People without any particular increase in risk should, however, be advised to ask their doctor or nurse to examine their feet for signs of neuropathy or ischaemia on a regular basis, in order to ensure that they remain complication free and without increased risk. It is recommended (but without evidence and mainly for ease of administration) that this be done annually. While there is no evidence that regular examination results in a short-term reduction in ulcer incidence,28 the practice will serve to emphasise the importance of foot care in later life.
Education of Patients at Increased Risk Those at increased risk (because of neuropathy or ischaemia or deformity) need to be advised that they are ‘at risk’. Evidence from the United Kingdom suggests that although the incidence of new ulceration in the total population with diabetes is of the order of 2% per year,29 the incidence in those with neuropathy exceeds 7%.30 More detailed information (such as the need for regular podiatry, appropriate footwear, avoidance of accidental injury) will depend on the individual problem and particular liability.
Surveillance
The persons with feet at risk should ideally examine their feet each day , if they are able to.
They should be encouraged to look for sores or unexpected changes and if they find them, they should seek professional help sooner rather than later.
If it is not possible for them to examine their feet themselves (for example, because of poor vision or limited mobility), it may be appropriate to ask them to enlist the help of a family member or friend.
It should, however, be borne in mind that neither the patients nor their helpers may like this idea.
The ‘at-risk’ foot also needs to be reviewed by the patient’s professional carer at intervals.
The length of the interval varies according to feasibility and need, but it is not always either necessary or desirable to insist (as some do) that the person’s feet should be inspected by the doctor or nurse at every visit.
While unsuspected (or undisclosed) ulcers will occasionally be detected, the primary purpose of such regular inspection is to reinforce the fact that the foot is ‘at risk’, and to emphasise the need for both appropriate protective behaviour and urgent assessment if any new lesion arises.
Foot inspection at every visit in this group will certainly do no harm and may be beneficial.
Nevertheless, a single study designed to document the benefit of more frequent foot examinations failed to demonstrate any benefit in terms of reduced incidence of amputation in a high-risk population.28
Advising other professional carers that the feet are at risk
The patients should be encouraged to advise all professionals involved in their care that their feet have been designated ‘at risk’. In an ideal world, this would then ensure that preventive