I read with interest the articles by Lavery and Gazewood and by Mayfield and Sugarman in the November 2000 supplement to JFP.1,2 The authors recommend regular screening of patients with diabetes for neuropathy. Although there is clear evidence that sensory neuropathy is a powerful predictor of foot ulcer in these patients,3 I do not recommend routine screening in my patient population at a veteran’s hospital. On the contrary, I believe regular inspection of the feet, educating these patients about foot care, and aggressive treatment of underlying deformities, conditions, and diseases are important.4
Several arguments support my assertion. First, no diagnostic test should be employed unless a positive and a negative response will elicit a different action. I know of no specific therapy for neuropathy as an isolated finding except to avoid both going barefoot and wearing pointed shoes. The fact that a veteran’s hospital population is much older supports universal precautions. First, all patients with diabetes should be treated as neuropathic. Second, there are no data implying that neuropathy alone has a clinically significant prevalence. Third, somatic neuropathy causes and exacerbates deformities, such as intrinsic minus foot, hallux valgus, and hammer toes, and autonomic neuropathy predisposes the feet to abnormal sweating and cracking, which are forerunners of infection.3,5 Treating these consequences of neuropathy expectantly, regardless of its presence or absence, with special devices, shoes, and surgery, as well as treating limited joint mobility, onychomycosis, extensive callus formation, and hyperkeratosis prevents ulcers. Fourth, time saved from neurologic screening is better spent on inspection, education, and treatment. For now, I prefer the practical approach.
David A. Nardone, MD
Veterans Health Administration and
Oregon Health Sciences University
Portland
- Lavery L, Gazewood JD. Assessing the feet of patients with diabetes. J Fam Pract 2000; 49(suppl):S9-16.
- Mayfield JA, Sugarman JR. The use of the Semmes-Weinstein monofilament and other threshold tests for preventing foot ulceration and amputation in Persons with diabetes. J Fam Pract 2000; 49(suppl):S17-29.
- Boyko EJ, Ahroni JH, Stensel V, Forsberg, RC, Davignon DR, Smith DG. Diabetes Care 1999; 22:1036-42.
- Nardone DA. Preventing diabetic foot ulcers in the primary care setting: let’s get practical. Newsletter National Association of VA Ambulatory Care Managers, October 2000.
- Boulton AJM. The diabetic foot: neuropathic in etiology. Diabet Med 1990; 7: 852-58.
The Preceding Letter Was Referred To Drs Mayfield And Sugarman Who Responded As Follows:
We appreciate the opportunity to address Dr Nardone’s comments. Screening is justified when a disease has an asymptomatic stage with subsequent serious consequences, can be accurately identified during this asymptomatic stage, and has treatment that will avoid or minimize the adverse outcome.1 The articles in the JFP supplement described the asymptomatic stage and serious complications associated with neuropathy,2 the predictive ability of various testing modalities,3 and the effectiveness of treatment.4 The decision to screen a specific population includes the cost and benefits, available resources, and competing needs. Each physician must decide how to apply these principles to his or her practice.
Dr Nardone practices at a Veterans Health Administration (VHA) facility. The VHA has recently mandated that all patients with diabetes should receive an annual foot examination, including neuropathy screening. Data from 1483 veterans with diabetes in a general medicine clinic at the Seattle VHA facility found a prevalence of amputation of 6.6%; previous foot ulcer, 33.4%; severe hammer toe/claw toe deformity, 21.3%; clinician diagnosed peripheral vascular disease, 33.1%; and insensate to the 5.07 monofilament, 41.8%.5 Less than 25% had no foot risk factor (personal communication, Ed Boyko). If these data are generalizeable to the entire VHA population with diabetes, Dr Nardone’s suggestion to skip screening and provide treatment is very reasonable. However, in populations with lower prevalence of foot risk conditions periodic screening, with treatment for the few with abnormal findings, would be more efficient.
We would disagree with Dr Nardone’s concept of neuropathy management. The absence of sensation is one of the strongest risk factors for foot ulcerations and amputation and is more important than deformity and skin conditions in multivariate models.5 The impact of the loss of sensation on patient behavior and compliance is greatly underappreciated. Without the early warning and the dysphoric reinforcement of pain, patients will not realize they have a small lesion that needs immediate attention. Patients must be taught the significance of this loss and ways to use other sensory modalities (ie, eyes and hands) to monitor the well-being of their feet. The precipitating event for half to two thirds of all amputation is trauma from footwear when it is fitted improperly, broken in carelessly, or worn too long.3 Thus, patients must also be taught how to select and use footwear to avoid initial ulcers and re-occurrence.