Dr Sue Benbow: Diabetes is one of the biggest health challenges facing the UK today.
Merseyside is no exception, with over 70,000 people already diagnosed with the condition
and the numbers are increasing year on year.
Disease of the foot is a complication of diabetes caused by either damage to the nerves or the
blood vessels that service the limbs.
But, worryingly, one in three people with diabetes don't realise that having the condition
puts them at increased risk of having an amputation.
The literature suggests that 15 per cent of the population with diabetes will experience
an ulcer during their lifetime, with 6 per cent having an amputation - a complication
that is both costly to the individual and to the NHS.
But if the incidence of ulcers and amputations could be reduced by intensive preventative
measures, there could be a significant saving to both the NHS and to the individual.
Diabetes is the commonest cause of non-traumatic amputation in the UK, with up to 80 per cent
of amputations being preceded by a foot ulcer.
However, ulceration and amputation should not be seen as an inevitable consequence of
diabetes.
Many foot ulcers and amputations could be prevented.
The early identification of the at-risk foot, combined with patient education and the application
of other preventative measures, as well as the rapid treatment of complications by the
multidisciplinary foot-care team, should help avoid this scenario.
So what are the principles of good foot care?
These should be - simple, visual examination of both feet at least once every year as an
essential management of the person with diabetes, no matter where they're seen.
All clinical staff seeing people with diabetes should be trained and competent in undertaking
a basic foot check.
The potential threat of active foot disease should also be recognised by non-specialist
health-care professionals.
Screening the foot is vital, but once assessed, the person should have the risk level classified
as low, increased or high current risk and, where necessary, action must be taken to reduce
future problems.
Where active foot disease is found, it requires a relevant history to be taken, a thorough
examination and immediate referral onwards to a multidisciplinary foot-care team with
the necessary skills in the management of the diabetic foot.
Helen Pendlebury: There are two main conditions that affect the foot due to diabetes.
These are peripheral neuropathy, which affects feeling and peripheral arterial disease, which
results in reduced circulation.
Diabetic peripheral neuropathy is defined as the presence of symptoms and/or signs of
peripheral nerve dysfunction in people with diabetes after the exclusion of other causes.
One of the symptoms of neuropathy can be the loss of protective sensation in the feet.
A person with loss of protective sensation could injure their foot and be completely
unaware of any resulting problems.
Peripheral arterial disease causes calcification, arterial narrowing and blockage of blood vessels,
which can result in reduced blood flow to the feet.
This can manifest itself in many ways and, in particular, it may cause pain when walking
or at rest and result in a reduced ability to heal.
To start a diabetic foot screening, sit the patient on the examination couch with their
shoes or socks or stockings removed.
Inform them that you are going to examine their feet and carry out a diabetic foot screening
to check their risk of developing any diabetic foot complications.
All the results of the baseline foot examination should be recorded on the baseline foot-screening
form or on the GP template.
Firstly, check if the patient has suffered any previous amputation.
The next stage of the screening process is to check the general shape of the feet for
any nail or foot deformities such as pes cavus, claw toes or hallux valgus, all of which could
increase the patient's risk of developing foot complications.
Check both feet for any areas of significant callus or dry skin, paying particular attention
to the heel area.
Check between the toes for problems such as athlete's foot, soft corns or fissures.
Check both feet for areas of ulceration and ask the patient if they have suffered any
previous ulceration.
Check if the patient is able to self-care.
This can be done by checking if the patient can reach their feet with ease and if they
are able to see their feet clearly.
Check if there are any other risk factors present, such as nail pathologies or inappropriate
footwear.
The next stage of the screening process is to check the patient's circulation to their
feet.
There are two pulses we look for in each foot - the dorsalis pedis and the posterior tibial.
To find the dorsalis pedis pulse, palpate the foot between the first and second metatarsals.
Note that the dorsalis pedis pulse is absent in about ten per cent of the population.
To find the posterior tibial, palpate the area behind the medial malleolus.
Record whether each pulse is present or absent.
Ask the patient if they are experiencing intermittent claudication - which is pain or tightness
in the calves on walking, relieved by stopping - or if they have had any previous vascular
intervention.
The next test we carry out is for diabetic neuropathy.
This is to easily enable us to check if the patient's protective sensation is intact.
For this test, we use a 10-gram monofilament.
It is important that you only use reputable makes of monofilament, such as manufactured
by Bailey Instruments and Owen Mumford.
This will ensure the information you are collecting is accurate.
The monofilament must be rested for 24 hours after ten patients and replaced after 100
uses.
The advantages of this test are its simplicity, accuracy and low cost.
Studies have shown that inability to feel a 10-gram monofilament is a useful test as
a predictor of future occurrence of diabetic foot ulcers.
Inform the patient you are going to test the sensation in their feet with the monofilament.
Show the patient that it is not sharp by first testing it on their hand.
You may need to test it on the patient's elbow or forehead if the patient has neuropathy
affecting their hands.
Patients must have their eyes closed so they cannot see where the filament is being applied.
The monofilament should be applied perpendicular to the surface of the skin and with sufficient
pressure to cause a slight bend in the filament.
If it is kinked, it will need to be replaced.
Test on the plantar aspect of the first toes and the first and fifth metatarsal heads,
as demonstrated.
Avoid testing areas on the foot where there is callus present, areas of ulceration or
scar tissue.
You may have to test proximally or distally when any of these are present.
Do not make any repetitive contact or allow the monofilament to slide across the skin.
Press the filament to the skin and ask the patient if their feel pressure and next where
they feel the pressure being applied.
Clinician: Can you feel that?
Patient: Yep, like, underneath me big toe.
Clinician: Can you feel that?
Patient: Yep.
Underneath me little toe.
Clinician: Thank you.
Can you feel that?
Patient: Yep.
Underneath me other big toe.
Helen Pendlebury: Repeat this application twice at the same site, but alternate this
with at least one mock application in which no filament is applied.
Clinician: Can you feel that?
Patient: No.
Clinician: Can you feel that?
Patient: No.
Helen Pendlebury: This gives a total of three questions per site.
The total time from contact to removal of the monofilament should be approximately two
seconds in duration.
Protective sensation is present at each site if the patient correctly answers two out of
three applications.
Protective sensation is absent with two out of three incorrect answers and the patient
is considered to be at risk of ulceration.
Ask the patient if they are experiencing any pain or paresthesia, often described as tingling
or burning in their feet and record as appropriate.
The findings from these tests will enable the patient's risk category to be recorded
on the form.
Following the pathway with then determine if the patient needs to be referred to another
health-care professional, such as a podiatrist, or whether they can receive the appropriate
foot-health education and continue to be screened annually at the practice.
We are now going to carry out a simple diabetic foot screening on our patient in a clinical
situation.
Firstly we check that there have been no previous amputations.
We then check the general shape of the foot for any structural abnormalities.
Check for any callus, paying particular attention around the heel areas.
Check between the toes for any problems such as athlete's foot or fissuring.
Ask the patient if there has been any previous ulceration.
Check if the patient is able to self-care by being able to reach and see their feet
easily.
We then check the two pulses on either foot.
Firstly the dorsalis pedis and then the posterior tibial.
We are now ready to carry out the neurological test, using the monofilament.
We test the plantar aspect of the first toes and the first and fifth metatarsal heads,
recording as appropriate.
Clinician: Just going to check the sensation in your feet.
If I just show you this - it's a very light touch.
I'll just show you on the underside of your arm.
Smashing.
I'm going to touch different parts of your foot.
If you can just say "yes" when you feel it touching, just describe where you think it's
touched, OK?
Close your eyes for me as we do the test.
Can you feel that?
Patient: Yep, on my big toe.
Clinician: Can you feel that?
Patient: Yep, like, underneath me big toe.
Clinician: Can you feel that?
Patient: Yep.
Underneath me little toe.
Clinician: Thank you.
Can you feel that?
Patient: Yep.
Underneath me other big toe.
Clinician: Can you feel that?
Patient: Yep, underneath me big toe.
Clinician: Can you feel that?
Patient: No.
Clinician: Can you feel that?
Patient: Yep, underneath me little toe.
Clinician: Can you feel that?
Patient: Yep, like, underneath me big toe.
Clinician: Can you feel that?
Patient: No.
Clinician: Can you feel that?
Patient: Yep.
Clinician: Whereabouts did that last one feel like?
Patient: Erm, underneath my little toe.
Clinician: That's great.
OK, you can open your eyes now.
Patient: Thanks.
Helen Pendlebury: Once you have completed the patient screening, you will enter all
the relevant findings on the baseline foot-screening form.
Following a diabetes foot screening, patients should be categorised into low risk, increased
risk, high risk or foot ulcer.
If a patient has palpable pulses and normal sensation, the left-hand side of the pathway
will be followed and the patient classified as low risk.
The patient should be encouraged to continue with their own foot care.
Low-risk verbal advice should be given and supported by a low-risk advice leaflet.
A diabetes foot screening should be completed annually.
Where a patient has neuropathy or absent foot pulses or has a risk factor which impacts
on foot health, such as inability to self-care, foot or nail deformity and pathological callus,
the patient should be categorised as increased risk.
This is the blue section on the foot-screening pathway.
All these factors require podiatry management.
The patient should be referred directly to the local podiatry department.
Following podiatry assessment and management plan, any advice will be supported with an
increased-risk advice leaflet.
Ideally, the management plans should be reviewed every three to six months and annual diabetes
foot screening will follow within the podiatry service.
Where a patient has neuropathy or absent foot pulses and foot deformity or pathological
callus, the patient should be categorised as high risk.
This is the yellow section of the pathway.
A high-risk advice leaflet for neuropathy or poor circulation or deformity is supplied
by a podiatrist in support of any verbal advice given following a podiatry appointment.
Ideally, the patient should be reviewed by a podiatrist every one to three months and
annual foot screening will ensue.
If a patient presents at a foot-screening consultation with a chronic or stable diabetes
foot ulceration, this represent the foot ulcer or red section of the pathway.
A foot-ulcer leaflet will be given followed by referral to the diabetes multidisciplinary
foot-care team and to the podiatry service.
Where a patient may present with critical ischaemia, spreading cellulitis, severe infection
or acute charcot osteoarthropathy, this is classed as a foot emergency.
Immediate referral should be made to A&E or admission arranged via the patient's GP.
The next available appointment should also be made at the multidisciplinary foot-care
team for further investigations and assessment.
This is as directed in red at the bottom of the pathway.
Fred: In my opinion, it's important for me to get my feet checked on a regular basis
because of the nerve damage that diabetes induces on your feet and it's important that,
on a day-to-day basis, I get a check done, but I also get a check done by a professional.
They can tell if there's anything that's actually going wrong with it that I can't detect.
Joan: I see annual foot screening as an essential in my diabetes care.
It means a lot to me and I do go regularly to get it done because, long term, as I say,
it can cause problems and, after this length of time, I prefer to keep problems away rather
than encourage them.
When I go for my foot-screening appointment, the podiatrist normally checks the nerve sensation,
checks the circulation and it's not painful, it's no problem and the maximum, I would say,
about ten minutes.
Fred: My immediate results with my foot screening are there and then and the other information
I need about that is given to me in that I might have to go and see somebody else for
further screening.
Joan: When the foot screening has been done, they normally give you the results at the
end of it, they usually say what risk you are, whether it's low, moderate or high risk.
And then you're given information on... you're given a leaflet about the risk factor involved
and you're also given advice on who to contact should there be a problem before your next
foot-screening appointment.
Fred: If you are a bit nervous about getting your feet screened, you actually don't need
to be nervous about it because it's quite a quick and easy process and it's important,
if you have got diabetes, that you're able to get it checked and your doctor will either
check it himself or herself or will pass you on to somebody, a podiatrist, who has a better
understanding of how the feet are and should work.
Joan: It's something that you really need to do because, long term, diabetes can have
horrendous complications and the sooner you do something, the better.
You know, it is very important, certainly from my viewpoint, and with doing what I've
been doing, I've now gone 50 years without...
with very few complications and I think that's been as a result of making sure that I get
screening for feet and any other areas that need checking.
Dr Sue Benbow: We hope that the production of this DVD will help both health-care professionals
and patients understand the importance of foot screening and that regular and correct
foot screening and risk stratification is an essential part of diabetes care.