to health economics; 2. to train professionals in foot examination techniques and diabetic foot care at the hospital and health centres;
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3. to implement a specialist diabetic foot clinic; 4. to spread the project to other Brazilian states.
The project was initially established in 1991 when the nurses were invited to educate patients and perform basic podiatry care, and in 1992 a weekly foot clinic was opened at the general diabetic and endocrine outpatient clinic at the hospital.17 There were no sophisticated procedures, with the key message being the mandatory removal of shoes/sandals and socks in order to detect those at risk of foot problems.
The success of the clinic was such that it soon accounted for 13% of all the annual appointments,8,17 and professionals from other health centres also started to be trained to implement a foot network in the health district of Taguatinga, near Brasilia.
In 1993, a better podiatric training was provided with the support of British and North American podiatrists during the first national foot workshop held in Brasilia and São Paulo, mainly based on the Malvern National Foot Conference in the United Kingdom.18 It was then agreed that a 2-day foot workshop was the way of motivating professionals, when theoretical and practical activities were organised (Table 32.2).
An intense participation of patients, who were willing to relate their own experience of dealing with deformities, amputation, ulcers and even difficulties to health care access for financial reasons and lack of resources, had a great impact among professionals who left the training period with enthusiasm and anticipated what it has been nowknown to be shared with professionals: a better holistic and psychological approach to diabetic patients with foot problems.12,17, 21
Table 32.2 Foot workshops: materials and methods applied
Methods Materials
Themes Neurological and vascular tests Epidemiology, social and economic 10-g monofilament aspects of foot problems Tuning fork 128 Hz Pathophysiology: neuropathy, Cottonwool peripheral arterial disease, roles of Pins biomechanics on ulcer development Hammer Ulcer management Handheld Doppler Screening techniques Monofilament, biosthesiometer (at the hospital only) Biomechanics Goniometer Harris mat, Pressure stat R Basic podiatry Callus removal, superficial ulcer Snippers debridement Scalpel Nail care, dressings, hydration Files, vegetable oils Prevention Proper shoe, daily inspection Education flowchart (based on the daily Family and patient education foot clinic activity) Organisation of basic foot care Practical Guidelines , International Consensus (from 1999)
Note: The themes for theoretical and practical activities have been adapted from the very successful foot workshops that took place in Malvern National Diabetic Foot Conference (United Kingdom), involving crucial issues to be discussed among health professionals, which have been enriched by diabetic patients’ participation.8
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EDUCATION AND SCREENING PROCEDURES Identification of foot complications is the main step towards prevention, and this is a message for specialist and general clinicians who deal with diabetic patients.
There are many reports on what to inquire about risk factors, and those most frequent as based on robust studies include previous history of ulcer and amputation, long duration of DM, poor glycaemic control, impaired vision, lack of education and inaccessibility to health care.21,22 Concerning the physical examination, as peripheral neuropathy is the main permissive factor among the several causes of ulceration in the limbs,23, 26 one should also search for insensitivity, deformities (clawed- and hammer toes, bone prominences) and signs of high plantar pressure (hyperkeratosis, callus) besides evaluation of footwear conditions.22 There are no barriers to identifying the at-risk diabetic foot, and this has been the main message to the professionals who have learned how to apply simple techniques, which include the assessment of plantar protective sensation employing the 10-g monofilament27,28,29 : this was used for the very first clinical activities after the project received financial support from the Brasilia branch of the Brazilian Endocrine Society, importing the instruments from Carville, United States.
Years later, the local government and the Ministry of Health itself provided the health professionals, after their training during the national foot workshop sessions, with tuning forks, education flowchart and the monofilaments used by the leprosy programme.
The participation of those professionals followed established criteria: a nurse and a doctor selected by each state health department or university would attend the training, and after returning to their services they would start the process of setting up basic foot outpatient clinics in their services and a further referral system following the model in Brasilia.8,30 In the past 4 years, the workshops have been linked to the scientific programmes of national meetings of Brazilian Diabetes and Endocrine societies with an active participation of well- known international speakers promoting the aim of saving the foot in the country: the success can be judged by the number of participants attending such meetings (Table 32.3).
Meanwhile, some teams have come to Brasilia for a week for training at the diabetic foot centre and some are currently attached to the orthotic and prosthetic department.8 The increase in the number of basic foot clinics has been impressive, although simple and mostly on an outpatient basis.
The latest estimates after the training in the Brazilian capital show how the scenario has changed: in 1992 there was only one foot clinic linked to the general diabetes clinic, and in 2005 the number reached 62 plus the foot centre in Brasilia (Figure 32.1), which has become a regional and national reference for the Ministry of Health.
Table 32.3 Project demonstration and workshop attendance: 1992, 2005
Workshops 38 Workshop participants (n) 4035 National congress/regional meetings and seminars 21 National congress/regional meetings and seminars participants 4950 Total estimate 8985
Note: The foot workshops were first held in Brasilia and São Paulo (1993) when the first podiatrists from the United Kingdom and the United States helped to teach basic podiatry. Since that time, the workshops have been either held in Brasilia or more recently linked to scientific meetings of both diabetes and endocrine Brazilian societies (mean attendance: 100 per workshop; 200 per meeting).
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Diabetic foot clinics: Outpatients foot Implementation clinics: 92/ 05 = 62 Brasilia in Brazil -- 1992 Foot centre = 01 Brasilia, DF
Figure 32.1 Brazilian foot clinics: spread from 1992 to 2005. The first basic foot clinic was set up in Brası́lia, in 1992, linked to the general diabetes outpatient clinic. Nowadays, there has been an impressive increase in the number of other outpatient foot clinics in the country, and the clinic in the Brazilian capital has become a foot centre and a national reference for training health professionals8