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 annual screening for every diabetic patient older than 15 years old by the physician and more frequent for patients who are at risk (such as neuropathy). A careful examinations should consist 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 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
Foot ulcers can 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:[1][2][3][4][5][6][7][8]
- Control of blood sugar levels
- Appropriate control of blood pressure and lipid profiles
- Pressure offloading
- Regular examinations
- Studies recommend annual screening for every diabetic patient older than 15 years old by the physician and more frequent for patients who are at risk (such as neuropathy).
- A careful examinations should consist 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 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 examination with 10-g Semmes-Weinstein monofilament.
- Generally it is recommended to asses all of the uncallused areas of the metatarsal heads (palmar surface).
- Some other also recommend to assess at least 10 spots over the sole (toes to heel).
- Daily foot examination should be done by the patient him/herself.
- Prevention of infection
- Foot-care education:
- Proper foodwear (such as pressure-relieving footwear)
- Aerobic exercise for long term decreases the risk of diabetic foot development.[10]
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".[11]
- 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. [12]
- A meta-analysis by the Cochrane Collaboration concluded that "there is very limited evidence of the effectiveness of therapeutic shoes". [13] However, the meta-analysis was published before the major trial that is in the table below.
- A small and non-randomized trial showed the benefits of custom footwear in patients with a prior footulceration, with a number needed to treat of 4 patients.[14]
- A major randomized controlled trial of specialized footwear showed no benefit for patients with a prior foot ulceration (see table below).[15]
| Trial | Patients | Intervention | Comparison | Outcome | Results | Comment | |
|---|---|---|---|---|---|---|---|
| Intervention | Control | ||||||
| Litzelman[9] 1993 |
395 patients • General medicine practice |
Patient and provider education | Usual care | • Any foot lesion • Serious foot lesions at one year |
Not reported | • 11% • 2.9% |
• Insignificant • Significant reduction |
| Lincoln[17] 2008 |
172 patients • Prior ulceration • Specialist clinic |
Targeted, one-to-one education | Usual care | Re-ulceration at • 1 year 2 years |
• 30% • 41% |
• 20% • 41% |
• Insignificant • Insignificant |
| McCabe[16] 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 |
| Reiber[15] 2002 |
400 patients • Prior ulceration • Excluded severe deformity |
Therapeutic shoes | Usual footwear | Re-ulceration | 15% | 17% | Insignificant difference |
Video: Diabetic Foot Care
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References
- ↑ Armstrong DG, Boulton AJM, Bus SA (2017). "Diabetic Foot Ulcers and Their Recurrence". N Engl J Med. 376 (24): 2367–2375. doi:10.1056/NEJMra1615439. PMID 28614678.
- ↑ Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S; et al. (1998). "1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association". CMAJ. 159 Suppl 8: S1–29. PMC 1255890. PMID 9834731.
- ↑ Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM (1998). "Preventive foot care in people with diabetes". Diabetes Care. 21 (12): 2161–77. doi:10.2337/diacare.21.12.2161. PMID 9839111.
- ↑ Rith-Najarian SJ, Stolusky T, Gohdes DM (1992). "Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria". Diabetes Care. 15 (10): 1386–9. doi:10.2337/diacare.15.10.1386. PMID 1425105.
- ↑ Mueller MJ (1996). "Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments". Phys Ther. 76 (1): 68–71. doi:10.1093/ptj/76.1.68. PMID 8545495.
- ↑ McGill M, Molyneaux L, Spencer R, Heng LF, Yue DK (1999). "Possible sources of discrepancies in the use of the Semmes-Weinstein monofilament. Impact on prevalence of insensate foot and workload requirements". Diabetes Care. 22 (4): 598–602. doi:10.2337/diacare.22.4.598. PMID 10189538.
- ↑ Croxson, S. (2002). "Diabetes in the elderly: problems of care and service provision". Diabetic Medicine. 19: 66–72. doi:10.1046/j.1464-5491.19.s4.12.x. ISSN 0742-3071.
- ↑ Stumvoll, Michael; Goldstein, Barry J; van Haeften, Timon W (2005). "Type 2 diabetes: principles of pathogenesis and therapy". The Lancet. 365 (9467): 1333–1346. doi:10.1016/S0140-6736(05)61032-X. ISSN 0140-6736.
- ↑ 9.0 9.1 9.2 Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F (1993). "Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial". Ann Intern Med. 119 (1): 36–41. PMID 8498761.
- ↑ Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F; et al. (2006). "Exercise training can modify the natural history of diabetic peripheral neuropathy". J Diabetes Complications. 20 (4): 216–23. doi:10.1016/j.jdiacomp.2005.07.005. PMID 16798472.
- ↑ Hunt D. "Foot ulcers and amputations in diabetes". Clin Evid: 455–62. PMID 16620415. Text " based on September 2005 search" ignored (help)
- ↑ "Scope: Management of type 2 diabetes: prevention and management of foot problems (update)" (PDF). Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems. National Institute for Health and Clinical Excellence. 20 February 2003. Retrieved 2007-12-04.
- ↑ Spencer S. "Pressure relieving interventions for preventing and treating diabetic foot ulcers". Cochrane Database Syst Rev: CD002302. doi:10.1002/14651858.CD002302. PMID 10908550.
- ↑ Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G (1995). "Manufactured shoes in the prevention of diabetic foot ulcers". Diabetes Care. 18 (10): 1376–8. PMID 8721941.
- ↑ 15.0 15.1 15.2 Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C; et al. (2002). "Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial". JAMA. 287 (19): 2552–8. PMID 12020336.
- ↑ 16.0 16.1 McCabe CJ, Stevenson RC, Dolan AM (1998). "Evaluation of a diabetic foot screening and protection programme". Diabet Med. 15 (1): 80–4. doi:10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K. PMID 9472868.
- ↑ 17.0 17.1 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ (2008). "Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial". Diabetologia. 51 (11): 1954–61. doi:10.1007/s00125-008-1110-0. PMID 18758747.