Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes
Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes
Background - Peripheral Neuropathy as a Risk FactorFifteen percent of people with diabetes will develop a foot ulcer during their lifetime(Reiber et al, 1998). Half of all non-traumatic amputations are performed in peoplewith diabetes (Pecoraro et al, 1990). Foot ulcers precede 84% of all lower limbamputations in diabetic people in the United States (Pecoraro et al, 1990). While thecause of ulceration is multifactorial, understanding the main factors in the aetiology ofthe ulcer will increase the likelihood of reducing ulceration and amputation despitethe rising prevalence of diabetes.In the UKPDS study damage to the peripheral nerves from prolonged hyperglycaemiaand its metabolic consequences was present in 12.3% at diagnosis and in 30% after 12years of diabetes (UKPDS 33, 1998). The commonest form is a distal symmetricalpolyneuropathy with a glove and stocking distribution of loss of sensation. Howeverthe loss of protective sensation is postulated to be the major factor in subsequentulceration. Coexistence of autonomic neuropathy can contribute partly by inducingdry skin and foot oedema (Boyko et al, 1999). Muscle wasting and foot deformityresulting from peripheral neuropathy are also thought to contribute to the risk ofulceration. Severe peripheral neuropathy can lead to joint disorganisation fromrepeated trauma with loss of protective sensation resulting in a Charcot joint (mostfrequently the tarsometatarsal joint). The resulting foot disorganisation and deformitycontribute to recurrent ulceration (Sims et al, 1988). However it is also clear thatprecipitating factors are also necessary for the development of diabetic foot ulcers.Knowing the relative risk of peripheral neuropathy as an underlying risk factor forulceration and amputation can help in targeting those with diabetes who are at riskand implementing preventative interventions to reduce subsequent ulceration andamputation (Shaw & Boulton, 1997).Evidence - Peripheral Neuropathy as a Risk FactorPeripheral neuropathy is associated with diabetic foot ulceration and amputationSeveral studies in people with Type 2 diabetes have related reduction of foot sensationand risk of ulceration or amputation.Coppini et al (1998) reported the incidence of foot ulcers or amputations in 405subjects without prior amputation attending St Thomas’ Hospital Diabetic Clinic. Therecords were examined retrospectively, and 20 people who developed foot ulcer oramputation over the 14 year follow-up period were each matched with 3 peoplewithout ulcers. The population was 60% males with cases being of similar mean ageto the controls (50.5 v 50.1 years) however they had a much longer duration ofdiabetes (9.7 v 4.1 years, p=0.02). A raised VPT at baseline was a predictor of footcomplications developing with OR 4.38 (CI 1.1-17.26, p=0.01).In 811 people with Type 2 diabetes in a community based cross-sectional study from37 UK general practices, neuropathy was diagnosed by clinical scoring. Thepopulation was 50% males with a mean age of 65.4 years (range 34-90 years) and hada duration of diabetes of 7.4 years (range 0-50 years). Those with neuropathy were12
significantly more likely to have a current or past ulcer than those without (9.8%versus 2.1%, p≤ 0.01) (Kumar et al, 1994). In a case-control study of people withdiabetes, 76 people with ulceration were compared with 149 control subjects who hadnever had a foot ulcer. People with an ulcer were similar to the control group in thatmost had Type 2 diabetes (95 v 93%) and were similar in age (52.7 v 51.8 years) butduration of diabetes was non-significantly longer in the ulcer group (14.5±9.1 v9.2±8.1 years). In multivariate analysis loss of protective sensation (VPT ≥25 V) hadan OR of 32.5 (no CI reported) for ulceration (p≤0.001) (Lavery et al, 1998).In a cross-sectional study of African Americans (14.3%), Hispanics (37.5%), andCaucasians (48.2%), Frykberg and coworkers (1998) found peripheral sensoryneuropathy (assessed by VPT or monofilament) independently predicted current orpast ulceration, OR 4.1 and 4.4 respectively (p
- Page 1: National Evidence Based Guidelinesf
- Page 4: Research OfficersMs Linda SmithPodi
- Page 7 and 8: 2.2 Issues for Foot Problems in Typ
- Page 9: • Aim to achieve the best possibl
- Page 14 and 15: proportion of subjects with a durat
- Page 16 and 17: and an OR 1.1-7.8. This study also
- Page 18 and 19: Summary - Peripheral Neuropathy as
- Page 20 and 21: Section 2: Diabetes Foot ProblemsIs
- Page 22 and 23: predicting risk of amputation, 2.9
- Page 24 and 25: Summary - Peripheral Vascular Disea
- Page 26 and 27: Section 3: Diabetes Foot ProblemsIs
- Page 28 and 29: Evidence - Foot Deformity and Previ
- Page 30 and 31: people with both LJM and neuropathy
- Page 32 and 33: Summary - Foot Deformity and Previo
- Page 34 and 35: Section 4: Diabetes Foot ProblemsIs
- Page 36 and 37: Also in the Seattle study, 67 peopl
- Page 38 and 39: Summary - Ulcer as a Risk Factor fo
- Page 40 and 41: Section 5: Diabetes Foot ProblemsIs
- Page 42 and 43: The other frequently reported metho
- Page 44 and 45: side; and 82% having the same resul
- Page 46 and 47: Evidence Table: Section 5Detection
- Page 48 and 49: Background - Clinical Detection of
- Page 50 and 51: pulse was bilaterally absent in 1.8
- Page 52 and 53: Evidence Table: Section 6AuthorClin
- Page 54 and 55: Background - Frequency of Foot Exam
- Page 56 and 57: Summary - Frequency of Foot Examina
- Page 58 and 59: Section 8: Diabetes Foot ProblemsIs
- Page 60 and 61: Behaviour assessment scores, measur
significantly more likely to have a current or past ulcer than those without (9.8%versus 2.1%, p≤ 0.01) (Kumar et al, 1994). In a case-control study <strong>of</strong> people withdiabetes, 76 people with ulceration were compared with 149 control subjects who hadnever had a foot ulcer. People with an ulcer were similar to the control group <strong>in</strong> thatmost had <strong>Type</strong> 2 diabetes (95 v 93%) <strong>and</strong> were similar <strong>in</strong> age (52.7 v 51.8 years) butduration <strong>of</strong> diabetes was non-significantly longer <strong>in</strong> the ulcer group (14.5±9.1 v9.2±8.1 years). In multivariate analysis loss <strong>of</strong> protective sensation (VPT ≥25 V) hadan OR <strong>of</strong> 32.5 (no CI reported) for ulceration (p≤0.001) (Lavery et al, 1998).In a cross-sectional study <strong>of</strong> African Americans (14.3%), Hispanics (37.5%), <strong>and</strong>Caucasians (48.2%), Frykberg <strong>and</strong> coworkers (1998) found peripheral sensoryneuropathy (assessed by VPT or mon<strong>of</strong>ilament) <strong>in</strong>dependently predicted current orpast ulceration, OR 4.1 <strong>and</strong> 4.4 respectively (p