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

Background - Frequency of Foot ExaminationWhile people with diabetes who have peripheral neuropathy, foot deformity, historyof previous ulceration or amputation and/or PVD are a group at increased risk ofulceration and amputation, no studies have been done to assess the impact of thefrequency of examination on outcomes. It is generally accepted that regularsurveillance for foot problems is good clinical practice. The benefits of monitoringpeople with diabetes arise from the ability to detect feet at increased risk and from theidentification of specific foot problems which can be treated early which has thepotential to reduce subsequent morbidity.Evidence – Frequency of Foot ExaminationRoutine examination of the feet of people with diabetes is frequently notperformedThe lack of routine foot examination is a major issue in the care of people withdiabetes. A UK retropective survey (Deerochanawong et al, 1992) showed that 47%of people who were under the care of a hospital service for diabetes had incompletefoot examination and assessment. 15% of people with diabetes had their diabetes firstdiagnosed when they were admitted for amputation.In a New Zealand survey of 540 people with diabetes (Simmons et al, 1995), majorlesions (amputation, ulcer) and perdisposing lesions (callus or fugual infection) werepresent in 48.5% of people. However, 40% of people (n=214) reported they had nothad their feet examined over the previous 12 months.Wylie-Rosett et al (1995) reviewed foot examination in 350 people with diabetes(86% were black or Hispanic, mean age 57.7 years). A documented foot examinationwas defined as assessing at least two of the three components (circulation, skin andneurological status) of a foot examination. People had a mean duration of diabetes of8.8 years, but there was no indication of foot examination or referral for footexamination for 56% of people in their primary care clinics during a 2-year period.The optimal frequency of foot examination has not been established but there isgeneral international consensusAlthough regular foot examination is considered necessary in all people with diabetes,no studies were found which directly addressed the optimal frequency of footexamination in people with diabetes. However recommendations about the frequencyof foot examination have been made in several guidelines in Australia and overseas.The Australian guidelines include:• the New South Wales Department of Health ‘Guidelines for the ClinicalManagement of Diabetes Mellitus’ (1996) which suggests six monthly foot reviewof people with diabetes or at every visit for people in the “high risk foot” category• the ‘Systematic Review of Existing Evidence and Primary Care Guidelines on theManagement of Non-Insulin-Dependent Diabetes in Aboriginal and Torres StraitIslander Populations’ (Couzos et al, 1998) proposes that feet should be inspected54