Diabetic foot primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2], Anahita Deylamsalehi, M.D.[3]

Overview

Foot ulcers can be prevented by frequent physical examinations, proper glycemic control, good foot hygiene, diabetic socks and shoes, and by avoiding injury. Studies recommend an annual screening by the physician for every diabetic patient older than 15 years old and more frequent for patients who are at risk (such as neuropathy). A careful examination should consist of a peripheral neuropathy assessment, which should be done by checking ankle reflexes, vibration, and sensation. A study showed the importance of using a 10-g Semmes-Weinstein monofilament with a 10 fold risk elevation of foot ulcer development and a 17 fold increase in amputation rate within a 32-month follow up in patients who had abnormal 10-g Semmes-Weinstein monofilament examinations.

Primary Prevention

See also: Diabetic neuropathy primary prevention

Foot ulcers can maybe be prevented by frequent physical examinations, good foot hygiene, diabetic socks and shoes, and by avoiding injury. The following are some of the important steps for primary prevention of diabetic foot:

• Control of blood sugar levels may help in both type 1 and type 2 diabetes.
• Appropriate control of blood pressure and lipid profiles
• Proper footwear (such as pressure-relieving footwear)
  • Although the comparison of custom shoes versus well-chosen and well-fitted athletic shoes is not clear.
• Pressure offloading insoles. In addition to custom orthotics, this includes received cork inserts and prefabricated insoles
• Silicone digital orthotics

• Regular examinations
  • Studies recommend an annual screening by the physician for every diabetic patient older than 15 years old and more frequent for patients who are at risk (such as neuropathy).
  • A careful examination should consist of a peripheral neuropathy assessment, which should be done by checking ankle reflexes, vibration (by using a 128-Hz tuning fork), and sensation (by utilizing a 10-g Semmes-Weinstein monofilament).
  • A study showed the importance of using a 10-g Semmes-Weinstein monofilament with a 10 fold risk elevation of foot ulcer development and a 17 fold increase in amputation rate within a 32-month follow up in patients who had abnormal 10-g Semmes-Weinstein monofilament examinations.
    • There are different recommendations for appropriate examinations with the 10-g Semmes-Weinstein monofilament.
    • Generally it is recommended to asses all of the uncallused areas of the metatarsal heads (palmar surface).
    • Some others also recommend to assess at least 10 spots over the sole (toes to heel).
  • Daily foot examinations should be done by the patient him/herself.
• Prevention of infection
• Foot-care education:
  • Based on studies foot-care education combined with increased surveillance can reduce the incidence of serious foot problems.
• Temperature-guided avoidance therapy
• Long term aerobic exercise decreases the risk of diabetic foot development.

Clinical practice guidelines

A clinical practice guideline by the International Working Group on the Diabetic Foot (IWGDF) recommended:

• screening for loss of protective sensation (LOPS), peripheral artery disease (PAD). If a monofilament is not available, the Ipswich Touch Test (IpTT) can be used.

However, a systematic review by the International Working Group on the Diabetic Foot (IWGDF) concluded:

• " Despite the importance of this topic, ulcer risk classification is only considered an intervention when a classification is linked directly to a strategy based on referral of patients for treatment.139 No such studies were identified. It remains crucial to better understand if the way in which we stratify risk is effective for ulcer prevention"

A prior systematic review had a similarly negative conclusion.

Clinical Trials

• Clinical Evidence reviewed the topic and concluded "Individuals with significant foot deformities should be considered for referral and assessment for customized shoes that can accommodate the altered foot anatomy. In the absence of significant deformities, high quality well fitting non-prescription footwear seems to be a reasonable option".
• The National Institute for Health and Clinical Excellence has reviewed the topic and concluded that for patients who are at "high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer", "specialist footwear and insoles" should be provided.
• A meta-analyses by the Cochrane Collaboration conclude:
  • " There is no high-quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit."
  • that "there is very limited evidence of the effectiveness of therapeutic shoes".

Randomized controlled trials of interventions to prevent complications of diabetic foot.

Trial	Patients	Intervention	Comparison	Outcome	Results		Comment
					Intervention	Control
Litzelman 1993	395 patients • General medicine practice	Patient and provider education: • "Nurse-clinicians conducted patient education sessions with "one to four patients, covering appropriate foot-care behaviors and footwear, using a commercially available slide and audiotape presentation [27] and pamphlets [28]. Behavioral contracts regarding desired foot-care behaviors were negotiated with each patient. Follow-up was done by telephone 2 weeks after the education sessions to remind patients about the contracted behavior. Additionally, postcard reminders, detailing the agreed-on behaviors, were sent at 1 and 3 months to patients in the intervention group." • Prompts for "health care providers to ask patients to remove their footwear, to perform foot examinations, and to provide foot-care education at each visit. Physicians received an informational flow sheet providing patient-specific risk factors and foot-care practice guidelines for assessment, diagnostic work-up, treatment, and referral recommendations. "	Usual care	• Any foot lesion • Serious foot lesions at one year	Rate not reported. OR for serious = 0.41 (p=0.05)	• 11% • 2.9%	• Insignificant • Significant reduction
Rönnemaa 1997	733 patients • Primary care • " Patients without recent visits to a podiatrist and without an obvious need for foot care"	"education and primary prevention measure" by podiatrist: "Education was given individually to every patient, taking into account each patient's age, occupation, earlier foot care habits, etc. Education included guidance concerning the use of proper footwear (socks, shoes), daily hygiene, cutting of toenails, use of emollient cream when necessary, avoidance of high-risk situations (e.g., exposure of the feet to hot environment, walking barefoot), and foot gymnastics. Preventive measures included gentle debridement of calluses, preparation of individual insoles, promotion of the use of emollient creams, treatment for ingrown toenails, guidance for foot gymnastics, etc. Foot gymnastics were aimed at increasing or maintaining muscle strength and joint mobility by regular training, e.g., walking on the heels and on the forefeet, flexing, extending, and spreading out the toes. The services of the podiatrists were free of charge to the patients."	Written instructions	Non-calceneal calluses at one year: • Prevalence • Size Knowledge	• 40% • Size reduction	• 48%	•  P < 0.001 • P = 0.009 • "significant improvements in knowledge and foot self-care scores"
McCabe 1998	2002 patients • High-risk • General diabetic clinic	Screening and referral to foot-care clinic if they had prior ulcer, low ankle–brachial index (<0.75), or foot deformities	Usual care	• Ulceration within 2 years • Amputation rates	• 2% • 0.1%	4% 1.2%	• Insignificant • Significant
Scirè 2009	167 patients • High-risk • "Neuropathic patients with deformities and localized hyperkeratosis in the forefoot"	Podikon digital silicone padding orthoses	Usual care	• Ulceration within 3 months • Hyperkeratosis within 3 months	• 1.5% • 41%	15.4% 84%	• Significant • Significant

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