Applied Evidence
Is your patient on target? Optimizing diabetes management
As new evidence emerges and guidelines are frequently revised, optimizing diabetes treatment with an eye toward HbA1c, blood pressure, and lipid...
Neuropathic LOPS is easily detectable, yet it is linked to at least 75% of all nontraumatic diabetic amputations.20-23 Adiminished vibratory perception threshold (VPT) is one of the earliest indicators of neuropathic LOPS and is the best predictor of long-term lower extremity complications.1,24,25 However, VPT devices are expensive and time-consuming to operate, and they require training to ensure proper use. The Semmes-Weinstein monofilament is a well-documented alternative to VPT for predicting ulcer risk26-28 and has long been advocated as an essential component of a thorough foot exam.5 The 128 Hz tuning fork is another regularly used alternative.5 However, physicians would need to purchase one of these devices and receive training on how to use it, and, in the case of the monofilament, to regularly stock replacements to maintain accurate results.16
The Ipswich Touch Test (IpTT) is an alternative neurologic test that requires only the physician’s index finger. During the IpTT, the physician instructs the patient to close his or her eyes while the physician lightly rests his or her finger on each of the patient’s first, third, and fifth toes for 1 to 2 seconds (FIGURE 3). Patients are instructed to respond with a “yes” when they feel the physician’s touch. In a head-to-head trial, diagnostic results of the IpTT directly paralleled those of the monofilament in detecting LOPS; IpTT was also equally sensitive and specific (k=.88, indicating almost perfect agreement; P<.0001).29 The IpTT’s use of only 6 palpation points, constant availability, and accuracy make it a first-line neurologic test for rapidly screening the feet of a patient with diabetes.
Neuromuscular/musculoskeletal exam. Neuromuscular disturbances, such as a reduction in the strength of dorsiflexion and plantar flexion, may indicate a complicated neurologic compromise.5 In addition to being aesthetically problematic, musculoskeletal deformities such as a hammer toe, claw toe (FIGURE 4), or bunion can cause significant pain and/or gait disturbance, and can increase patients’ risk for ulceration.30 These deformities also may compromise patients’ general health and grossly escalate their risk of falls and resultant injuries.5,31 Therefore, patients who present with previously unreported musculoskeletal deformities should be referred to a specialist.31
Also screen patients for Charcot neuroarthropathy (FIGURE 5), a devastating complication that classically presents as a hot, red, swollen foot; the redness resolves upon elevation.32 Charcot neuroarthropathy is hypothesized to be a dysregulation of normal bone metabolism typically occurring secondary to diabetic neuropathy and repetitive minor trauma.33,34 This dysregulation leads to joint instability and disorganization of normal midfoot bone architecture.31,32 Charcot neuroarthropathy is an urgent pathology that requires management by a foot specialist.35
Vascular exam. PAD is particularly common in patients with diabetes and contributes to the development of impaired healing in up to half of foot ulcers.13,18,36-39 Bilateral femoral, popliteal, posterior tibial, or dorsalis pedis pulses should be assessed by palpation; a diminished or absent pulse is a key indicator of vascular compromise.40,41 An integrated care approach between foot specialists and vascular surgeons results in optimal treatment.
Patient education (1 minute)
It is imperative to include patients in their treatment process to reduce the likelihood of complications and, ultimately, decrease the incidence of amputations.12,42 Patient education improves patients’ self-reported home care behaviors, even at the most fundamental levels.43,44 TABLE 35,15,45 lists topics to cover during patient education.
Patients’ lack of understanding about self-care for diabetes is a common barrier to prevention.23 El-Nahas et al46 found a lack of appropriate education regarding diabetes was a factor in more than 90% of recurrent ulcers, which emphasizes the need for repeated education for at-risk patients.47,48 Involve all levels of medical staff in the effort to educate patients on the importance of foot screenings, both at home and in-office. Even with proper patient education, many patients may be in various stages of coping with this all-consuming yet frequently asymptomatic condition, which makes the need for repeated patient education even more critical.
Who to refer, and when
After completing the 3-minute foot exam, create a treatment and follow-up plan, focusing on the need for referral to a specialist. TABLE 4 outlines suggested indications, priorities, and timelines for referral based on ADA guidelines.5 It incorporates the ADA’s patient risk categories (very low, low, moderate, and high risk) and also provides a recommended frequency for patient follow-ups.
