Much of the evidence for the effectiveness of patient education for the insensate patient is observational or obscured by inclusion with other interventions. Education to change behavior takes time and requires frequent reinforcement. Earlier identification provides the opportunity to maximize this low-cost, low-risk intervention of patient education. In our practices we teach all our insensate patients to examine their feet daily and select and use footwear properly. We encourage other primary care providers to adopt these simple interventions.
Jennifer A. Mayfield, MD, MPH
Jonathon R. Sugarman, MD, MPH
University of Washington
Seattle
- US Preventive Task Force. Guide to clinical preventive services. 2nd edition. Baltimore, Md: Williams & Wilkins; 1996:li-liii.
- Boulton AJM, Vileikyte L. The diabetic foot. J Fam Pract 2000; 49:S3-8.
- 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:S17-29.
- Rith-Najarian SJ, Reiber GE. Prevention of foot problems in persons with diabetes. J Fam Pract 2000; 49:S30-39.
- Boyko E, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer: the Seattle Diabetic Foot Study. Diabetes Care 1999; 22:1036-42.
Dr. Lavery Adds:
I strongly disagree with Dr Nardone’s arguments for neglecting to include sensory screening. As Dr Nardone suggests, peripheral sensory neuropathy is one of the most powerful predictors and risk factors for foot complications. Although there are ulcers and amputations in persons without neuropathy, it is one of the most common causes of lower extremity morbidity, and we need to know who has neuropathy and how severe it is to effectively educate and care for these patients.
Although there is no specific treatment that will reverse neuropathy, there are a number of different actions that should be performed in patients with diabetes in whom neuropathy is identified. The very limited time required to assess neuropathy will help identify patients who require therapeutic shoes and insoles, extensive and repeated foot care education, and regular foot evaluation. In a medical and economic environment where physician and support staff time is pushed to the limit (where even 1 wasted minute is excessive), prioritizing patients who need continual lower extremity surveillance and education is more practical than trying to treat every patient as if they had the same set of risk factors. Some patients need intensive professional care, while others only need to have their feet evaluated annually.
Prevention is effective, but we need to prioritize high-risk patients and direct our scarce resources to where they will have the greatest impact. Neuropathy has repeatedly been identified as one of the pivotal risk factors for ulceration and amputation in patients with diabetes. Screening for neuropathy is noninvasive, inexpensive, fast, and accurate and should be part of the routine care of patients with diabetes.
Lawrence Lavery, DPM, MPH
Diabetex Foot Care Center
San Antonio, Texas