Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

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The other frequently reported method is the biothesiometer. This is a handheld devicewhich vibrates at 100Hz and connects by an electrical cord to a base unit whichallows the voltage to be increased by the operator through a range of 0 to 50V whichis displayed on a scale. This instrument is popular in specialist diabetes units but isinfrequently used in the primary care setting.Foot examination of people with diabetes is often inadequate. One study of peopleadmitted to a teaching hospital with diabetes foot problems reported that less than15% received a minimally competent lower limb examination as part of their routinecare (Armstrong et al, 1998).Evidence – Detection of Loss of Protective Foot SensationLoss of sensation to the 10g Semmes-Weinstein monofilament predicts footulceration and amputationIn a systematic review, Mayfield and Sugarman (2000) identified 6 prospectivestudies using the 10g Semmes-Weinstein monofilament and 4 using VPT to predictthe risk of foot ulceration and amputation. Among people who were unable to feel theSemmes-Weinstein monofilament which was tested in 1 to 4 sites including theplantar surface of the toes, metatarsal heads, insole, and heel, and the dorsum of thefoot, the odds ratio (OR) of increased risk of ulceration ranged from 4.1 (CI 1.89-8.87) to 18.4 (CI 3.83-88.47), and the relative risk (RR) of amputation ranged from2.2 (CI 1.5-3.1) to 9.9 (CI 4.8-21.0). Similarly, the risk of ulceration increased inpeople with VPT >25, with an OR ranging from 4.4 (CI 1.1-17.3) to 10.8 (CI 4.6-25.7).The following provides more details on studies included in the above systematicreview. In prospective studies, the 10g Semmes-Weinstein monofilament has emergedas the most sensitive test for peripheral neuropathy in predicting foot ulcer risk.Boyko and coworkers (1999) studied 749 US veterans with diabetes who werefollowed up for a mean of 3.7 years. 163 ulcers developed during the follow-up. Therisk of developing a foot ulcer was significantly higher for inability to perceive the10g Semmes-Weinstein monofilament at one or more of 9 sites (RR 3.37, CI 2.45-4.63; p
tendon reflexes (OR 6.48, CI 2.37–18.06), while absent vibration sensation was not asignificant independent risk factor (McNeely et al, 1995).In another prospective study of native American Indians, sensory status wasdetermined by the 10g Semmes-Weinstein monofilament applied to 8 points on theplantar surface of each foot. The 358 subjects were blindfolded and retested twicebefore being classified as insensate (if they consistently failed to feel the filament atone or more locations). 68 subjects were unable to feel the monofilament at screening.Among this group, there was a significantly increased risk of subsequent ulceration(OR 9.9, CI 4.8-21.0) and amputation (OR 17, CI 4.5-95.0) compared with those whoretained sensation (Rith-Najarian et al, 1992).In another case-control, 30 people with recent or current foot ulceration werecompared with 85 controls without a history of foot ulcer (Armstrong et al, 1998).The sensitivity and specificity of VPT testing assessed using a biothesiometer, the 10gSemmes-Weinstein monofilament and a 4-question verbal neuropathy score werecompared. Overall, VPT > 25V or four or more of eight imperceptible monofilamentsites had higher sensitivity (100%) and specificity (76.5%) than the symptom score.However combining the modalities increased specificity (88.2%) but sensitivitydecreased to 88.2%. Armstrong and coworkers recommend the monofilament as aninexpensive and reliable method for use in primary care, nursing or specialist practice.The different screening techniques to identify diabetic people at high risk of footulceration were compared by Pham and coworkers (2000) in 248 people who werefollowed up for 30 months. Foot ulcers developed in 73 people or 95 feet during thestudy. People with foot ulcer were more likely to be insensate to the 10g Semmes-Weinstein monofilament (p=0.000), had a higher neuropathy symptom score (NDS)(p=0.000), a high VPT (p=0.000), and high foot pressure (p=0.000) compared withpeople who did not develop a foot ulcer. Of these techniques, inability to feel themonofilament combined with high NDS had a sensitivity of 99% for foot ulcerdevelopment, while the best specificity of 78% was seen with the combination of highNDS and foot pressure. A multivariate analysis showed that significant factors fordeveloping foot ulcer were high NDS (OR 3.1, CI 1.3-7.6, p=0.013), high VPT (OR3.4, CI 1.7-6.8, p=0.001), inability to detect the monofilament (OR 2.4, CI 1.1-5.3,p=0.036), and high foot pressure (OR 2.0, CI 1.2-3.3, p=0.007). The authorsconcluded that clinical examination combined with testing with the 10g Semmes-Weinstein monofilament is the most sensitive test in identifying people at high risk forfoot ulceration.The 10g Semmes-Weinstein monofilament is clinically reliableIn 1,001 people attending a UK diabetes clinic, foot examination was performed withthe 10g Semmes-Weinstein monofilament, biothesiometer and pulse palpation(Klenerman et al, 1996). 229 people with an initial abnormal test were invited for asecond test. Of this group, 21.8% had loss of protective sensation as judged by theabsence of some or all protective sensation to the monofilament; 7.7% had absentpedal pulses and 4% had combined vascular and sensory loss. Between the twotestings the biothesiometer variation was considered clinically unacceptable. Theresults for palpation of pedal pulses were more stable, with 81% of people having thesame results for the posterior tibial pulse on the right, compared to 70% on the left43
Page 1: National Evidence Based Guidelinesf
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Page 24 and 25: Summary - Peripheral Vascular Disea
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and/or osteomyelitis; III - fore-fo
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Summary - Economic consequences•
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Section 13: Diabetes Foot ProblemsI
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Some ethnic groups are associated w
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Evidence Table: Section 13AuthorSoc
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Calle-Pascual AL, Duran A, Diaz A,
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Jannink MJ, van Dijk H, de Vries J,
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Moss SE, Klein R, Klein BE. The 14-
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Soulier SM, Godsey C, Asay ED, Perr
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Diabetes Foot Problems: General Ref
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McNeely MJ, Boyko EJ, Ahroni JH, St
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Diabetes Foot Problems: Other Refer
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Caputo GM, Cavanagh PR, Ulbrecht JS
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Garbalosa JC, Cavanagh PR, Wu G, Ul
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Lavery LA, Armstrong DG, Wunderlich
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Payne C. Regional variations of dia
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Tovi J, Svanborg E, Nilsson BY, Eng
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Criteria used to determine the suit
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QUESTIONS KEY WORDS NO.ARTICLESIDEN
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Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

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