Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research

Accuracy and durability of Semmes-Weinstein monofilaments: what is the useful service life?

OBJECTIVE

To evaluate the accuracy and effective service life of commercially available Semmes-Weinstein monofilaments with repetitive loading.

METHODS

We obtained 6 brands of Semmes-Weinstein monofilaments (SWM) from commercial vendors identified from the Internet and the federal registry. Five monofilaments of each brand were subjected to repeat loading cycles, allowed to rest over night and loaded again the next day. First, sets of five monofilaments were loaded 25 times for each of five days. Then sets of five monofilaments were subjected to 200 loading cycles a day for 15 days. A testing jig ensured each SWM was loaded perpendicular to a digital pressure plate. The buckling force was measured via the pressure plate to determine failure loads. Several statistical techniques were used to examine the behavior of the monofilaments over repeated loadings: time series analysis, ANOVA and nonparametric comparisons of load distributions.

RESULTS

The monofilaments tested were neither precise nor accurate. The plasticity of filaments increased with repeated loadings resulting in lower bending forces. Individual and average bending forces varied widely both within and between monofilament brands. All monofilaments showed a typical material failure pattern. Initially the bending force was high but rapidly decreased and then leveled out at levels 1-2g lower than the starting values. After resting over night, the initial bending force was again high but usually not as high as the previous day and bending forces decreased and then leveled out. Most monofilaments did not start at the accepted 10-g buckling force but varied by up to 30% (p<0.01). At best, monofilaments starting at the accepted 10±1g buckling force would remain within a usable range (9-11g) for 7-9 days or to evaluate 70-90 patients.

CONCLUSION

Commercially available SWM have significant variability within and between devices from different manufacturers. Their actual bending force varies widely from their designated 10g value. When used they have a short service life where the instrument is within 10% of their initial bending force which is not usually the stated 10g of force.

Prevalence of risk factors for foot ulceration in a general haemodialysis population

It is well documented that diabetic foot ulceration contributes to increased morbidity and mortality associated with renal replacement therapy. Much less is known about the risk of foot ulceration and lower limb amputation in the non-diabetic dialysis population. The aim of this study was to determine if the prevalence of risks factors for lower limb amputation in a stable haemodialysis population was greater in the diabetic cohort compared with the non-diabetic cohort. The study design is a prospective observational cohort study. Sixty patients attending a satellite haemodialysis unit in Cardiff were invited to have a comprehensive foot assessment as part of a Podiatry service review. The medical notes and hospital information system were used to identify the diabetic cohort. Patients were classified according to diabetic status (diabetic versus non-diabetic). The Renal Foot Screening Tool was developed to prospectively identify risk factors associated with foot ulceration. The assessment included peripheral neuropathy (PN), peripheral arterial disease (PAD) and foot pathology (FP). Fifty-seven patients gave informed verbal consent prior to inclusion. Risk factors for foot ulceration were recorded at baseline in the diabetic (n = 24) and non-diabetic (n = 33) groups and mortality data was revisited after a 3-year period. FP was identified in 79% of patients. Eighteen per cent of the non-diabetic patients had PN. PAD was identified in 45% of diabetic and 30% of non-diabetic patients. Forty-nine per cent of the total cohort had ≥2 of the 3 independent risk factors for foot ulceration (16/24 diabetic versus 12/33 non-diabetic). The presence of PAD and PN was predictive of mortality independent of age. The limitations of this study are its small sample size and patients were from a single satellite dialysis unit. There was a high prevalence of risk factors for foot ulceration in this population, which were not confined to the diabetic cohort. These findings suggest that non-diabetic patients on haemodialysis therapy are also at risk of developing foot ulceration. Further work on strategies to monitor and prevent FP in this high-risk cohort is needed to minimize morbidity and mortality associated with foot ulceration.

In-shoe Plantar Pressure Distribution in Nonneuropathic Type 2 Diabetic Patients in Singapore

BACKGROUND

We sought to establish the in-shoe plantar pressure distribution during normal level walking in type 2 diabetic patients of Chinese, Indian, and Malay descent without clinical evidence of peripheral neuropathy.

METHODS

Thirty-five patients with type 2 diabetes mellitus without loss of tactile sensation and foot deformities and 38 nondiabetic individuals in a control group had in-shoe plantar pressures collected. Maximum peak pressure and peak pressure-time integral of each foot were analyzed as separate variables and were masked into 13 areas. Differences in pressure variables were assessed by analysis of covariance, adjusting for relevant covariates at the 95% confidence interval.

RESULTS

No significant differences were noted in maximum peak pressures after adjusting for sex, race, age, height, and body mass. However, patients with diabetes mellitus had significantly higher mean ± SD pressure-time integrals at the right whole foot (309.50 ± 144.17 kPa versus 224.06 ± 141.70 kPa, P < .05) and first metatarsal (198.65 ± 138.27 kPa versus 121.54 ± 135.91 kPa, P < .05) masked areas than did those in the control group after adjustment.

CONCLUSIONS

Patients without clinical observable signs of foot deformity (implying absence of motor neuropathy) and sensory neuropathy had similar in-shoe maximum peak pressures as controls. This finding supported the notion that either component of neuropathy needs to be present before plantar pressures are elevated. Patients with diabetes mellitus demonstrated greater pressure-time integrals, implying that this variable might be the first clinical sign observable even before peripheral neuropathy could be tested.

The effect of immobilization devices and left-foot adapter on brake-response time

BACKGROUND

The ability to perform an emergency stop is essential for safe driving and can be represented by total brake-response time, reaction time, and braking time. Immobilization of the lower extremities is routinely performed for a variety of musculoskeletal conditions. This study sought to investigate the effect of immobilization with a left-foot driving adapter, a controlled-ankle-motion device, and a short leg cast on braking times. Our hypothesis was that there would be a significant difference in braking-time values between individuals utilizing a left-foot driving adapter or immobilization device and control individuals wearing normal footwear.

METHODS

A prospective, observational study was conducted to assess the effect of the immobilization devices on braking times. A driving simulator was used to assess total brake-response time, reaction time, and braking time in thirty-five volunteers. Volunteers were assessed while (1) wearing normal footwear (control group), (2) wearing a controlled-ankle-motion boot, (3) wearing a removable short leg cast, and (4) employing a left-foot driving adapter.

RESULTS

The mean total brake-response time was significantly increased as compared with that of the control group in all three study groups. The mean reaction time was significantly increased for the short leg cast and controlled-ankle-motion groups as compared with reaction time in the control group. The mean braking time was significantly increased in the controlled-ankle-motion and left-foot driving-adapter groups as compared with braking time in the control group.

CONCLUSIONS

Total brake-response time while wearing a controlled-ankle-motion boot or a short leg cast or while utilizing a left-foot driving adapter is significantly increased, or worsened, as compared with the response time while wearing normal footwear. This information may prove valuable to physicians when counseling patients on when it may be safe to return to driving.

The clinical use of the 10g monofilament and its limitations: a review

BACKGROUND

Diabetes mellitus is one of the most prevalent chronic diseases worldwide including Singapore. The 10g monofilament is commonly used by clinicians to examine diabetic patients for neuropathy due to its low cost and convenience. The aim of this literature review is to evaluate the use of the monofilament and the factors that affect its diagnostic value.

METHODS

A systematic search of AMED, Medline, EMBASE and Cinahl databases was conducted to identify English language articles from 1990 to 2009 which investigated the use of the monofilament.

RESULTS

A total of 34 studies were identified, consisting of 24 observational studies, 8 prospective studies, 1 review article and 1 randomised controlled trial. 6 recurrent themes emerged from these 34 studies.

CONCLUSIONS

The 10g monofilament remains a useful clinical tool for detecting severe neuropathy and hence identifying patients at increased risk of ulceration and amputation. However, a consensus on the protocol in the use of the monofilament needs to be reached. Further research regarding the effects of environmental conditions on the accuracy of the monofilament is also essential.

A survey of the management, control, and complications of diabetes mellitus in patients attending a diabetes clinic in Blantyre, Malawi, an area of high HIV prevalence

The aim of this study was to describe the current status of diabetes care in an urban diabetes clinic in Malawi and the prevalence of human immunodeficiency virus (HIV) in this population, investigating possible associations between HIV and diabetes. A systematic prospective survey of patients attending the diabetes clinic at a teaching hospital in Blantyre, Malawi was conducted. Six hundred twenty patients were assessed. Seventy-four percent had glycosylated hemoglobin (HbA1C) > 7.5%. Systolic blood pressure was > 140 mm Hg in 52% of patients. Hypertension was more common in patients with raised creatinine (P < 0.003), retinopathy (P = 0.01), and stroke (P < 0.0002). Microvascular complication rates were high, specifically nephropathy (34.7%), retinopathy (34.7%), and neuropathy (46.4%). HIV seroprevalence was 13.7%. HIV-positive subjects had a lower body mass index (BMI) and lower fasting blood sugar, and they were more likely to have albuminuria (48.0% versus 33.3%; P < 0.05). Control of glycemia and hypertension were poor, and microvascular complications were common. Nephropathy in diabetic patients may be affected by HIV status.

External validation and optimisation of a model for predicting foot ulcers in patients with diabetes

AIMS/HYPOTHESIS

In 2006 a risk stratification model was developed by Boyko et al. to predict foot ulceration in patients with diabetes, using seven commonly available clinical variables. We sought to validate and optimise this clinical prediction rule in a different setting.

METHODS

A retrospective cohort study was conducted on all patients with diabetes attending the podiatry section of a diabetic foot clinic at a tertiary hospital in Portugal (n = 360). Assessment at baseline included variables evaluated in the previous study and other relevant variables.

RESULTS

Type 2 diabetes was present in 98% of patients, 45% were men and (at baseline) the median age was 65 years. Median follow-up was 25 months (range 3-86), during which 94 patients (26%) developed a foot ulcer. Boyko's model had an area under the receiver operating curve of 0.83 (95% CI 0.78-0.88). The corresponding value for the optimised model, which included the footwear risk variable, was 0.88 (95% CI 0.84-0.91). Both models had high classification accuracy for prediction of foot ulceration. However, the optimised model tended to produce higher specificity and positive likelihood ratio values at all levels.

CONCLUSIONS/INTERPRETATION

This study confirmed that Boyko's proposed model has a high capacity to predict foot ulceration in diabetes patients of both sexes. Our results suggest that the inclusion of a further footwear variable could improve the model. Nevertheless, prospective validation in a larger population is still necessary.

Prediction of incident diabetic neuropathy using the monofilament examination: a 4-year prospective study

OBJECTIVE

To determine the specific monofilament examination score that predicts the subsequent 4-year incidence of diabetic neuropathy with the highest degree of diagnostic accuracy.

RESEARCH DESIGN AND METHODS

Longitudinal follow-up of 175 of 197 (89%) participants in the Toronto Diabetic Neuropathy Cohort without baseline neuropathy for incident neuropathy. We examined the baseline monofilament examination score (and other simple sensory screening tests) by receiver operating characteristic (ROC) curve analysis.

RESULTS

Incident diabetic neuropathy developed in 50 (29%) participants over a mean follow-up of 4.1 years (interquartile range 2.6-7.1 years). Although male sex, longer diabetes duration, taller height, and higher blood pressure at baseline were associated with incident neuropathy, the strongest association was with a lower baseline monofilament score (score out of 8 was 3.7 +/- 2.5 for incident neuropathy vs. 5.7 +/- 2.3 for those who did not develop neuropathy; P < 0.001). The optimal threshold score for risk of incident neuropathy was <or=5 sensate stimuli out of 8, with 72% sensitivity, 64% specificity, positive and negative likelihood ratios of 2.5 and 0.35, and positive and negative predictive values of 87 and 46%, respectively (chi(2) = 20.7, P < 0.001). Area under the ROC curve was significantly greater for the monofilament examination compared with that for other simple sensory tests.

CONCLUSIONS

A simple threshold of <or=5 sensate stimuli out of 8 discriminates 4-year risk of diabetic neuropathy with acceptable operating characteristics. Although there are limitations in its specificity for prediction of future neuropathy onset, the monofilament examination is appropriate as a simple diabetic neuropathy screening instrument generalizable to the clinical setting.

Foot Screening for Diabetics

Introduction: This study aims to evaluate the results of foot screening performed in a study population of 2137 diabetics (3926 feet) screened from 2006 to 2008 by the National University Hospital (NUH) multi-disciplinary team for diabetic foot problems. Materials and Methods: A standardised protocol was designed. Foot screening consisted of detailed history taking and clinical examination including assessment for sensory neuropathy by Semmes Weinstein monofilament (SWMF) and neurothesiometer and assessment of vasculopathy by ankle-brachial index (ABI) and total body irradiation (TBI). The foot screening was performed by a trained staff nurse. All patients were classified according to King’s College Classification. Results: Majority of the patients were in the fifth (27.9%) and sixth (30.0%) decades of life. Two thousand sixty-four had type II diabetes, and only 73 had type I diabetes. Neuropathy was found in 1307 (33.3%) feet based on 5.07 SWMF. Vasculopathy was recorded in 510 (13.0%) and 546 (13.9%) feet based on ABI <0.8 and TBI <0.7. According to King’s Classification, 1069 (50.0%) were Stage 1: Normal and 615 (28.8%) were Stage 2: At-Risk. Conclusion: Foot screening should be performed as early as possible to detect “At-Risk” feet and prevent the development of diabetic foot complications, thereby further reducing the risk of major amputations. Key words: “At-Risk” feet, Diabetic foot screening, King’s Classification

Cutaneous silent period changes in Type 2 diabetes mellitus patients with small fiber neuropathy

OBJECTIVE

Small myelinated (A-delta) and unmyelinated (C) somatic sensory fibers are initially affected and may be the earliest exhibited sign of neuropathy in glucose dysmetabolism. Cutaneous silent period (CSP) is an inhibitory spinal reflex and its afferents consist of A-delta nerve fibers. The aim of this study was to evaluate CSP changes in Type 2 diabetic patients with small fiber neuropathy.

METHODS

Forty-three patients and 41 healthy volunteers were included. CSP latency and duration, as well as CSP latency difference of the upper and lower extremities, were examined.

RESULTS

Nerve conduction studies were within normal limits in both groups. Lower extremity CSP latency was longer (122.1+/-15.5 vs. 96.4+/-6.4 ms; p<0.001), CSP duration was shorter (29.5+/-8.9 vs. 43.1+/-5.0 ms; p<0.001), and latency difference was longer (48.1+/-12.6 vs. 22.7+/-3.7; p<0.001) in patients than controls. The difference was more significant in patients with neuropathic pain. No significant difference existed in upper extremity on CSP evaluation.

CONCLUSION

The CSP evaluation together with nerve conduction study, has been demonstrated to be beneficial and performance of latency difference in addition to CSP latency and duration may be a valuable parameter in electrophysiological assessment of diabetic patients with small fiber neuropathy.

SIGNIFICANCE

An additional CSP evaluation may be considered in cases which nerve conduction studies do not provide sufficient information.

Clinical factors associated with gait alterations in diabetic patients

AIM

To identify clinical factors associated with gait alterations in patients with Type 2 diabetes.

METHODS

A sample of 76 diabetic patients underwent clinical examination and an outdoor gait assessment on tarred and cobblestoned terrains. We calculated respective differences in gait speed (performance measure) and gait variability (fall risk index) on changing terrains. Associations with clinical factors were investigated using correlation coefficients and linear regression analysis.

RESULTS

The mean walking speed on the tarred pathway was 4.5 +/- 0.6 km/h and 3.9 +/- 0.8 km/h on the cobblestone pathway (P < 0.001). The CVGCT increased from 2.6 +/- 0.9% on the tarred pathway to 5.1 +/- 2.8% on the cobblestone pathway (P < 0.001). Regression analysis showed that 36% of the decrease in gait speed was explained proportionally by the mean of maximal isometric lower limb strength (22.2%; P < or = 0.01), fear of falls (7.4%; P < or = 0.01) and participants' perceived vibration threshold (6.4%; P < or = 0.01). Moreover, mean maximal isometric strength explained 11.8% (P < or = 0.01) of the increase of the coefficient of variation of the gait cycle time when participants changed from tarred terrain to cobblestones.

CONCLUSION

This study indicated that both physiological (strength and proprioception) and cognitive-behavioural factors (fear of falls) should be considered when treating diabetic patients with gait alterations. Therapists should apply these findings when developing specific fall prevention and treatment programmes.

The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy

OBJECTIVE

The purpose of this systematic review is to evaluate current evidence in the literature on the efficacy of Semmes Weinstein monofilament examination (SWME) in diagnosing diabetic peripheral neuropathy (DPN).

METHODS

The PubMed database was searched through August 2008 for articles pertaining to DPN and SWME with no language or publication date restrictions. Studies with original data comparing the diagnostic value of SWME with that of one or more other modalities for DPN in patients with diabetes mellitus were analyzed. Data were extracted by two independent investigators. Diagnostic values were calculated after classifying data by reference test, SWME methodology, and diagnostic threshold.

RESULTS

Of the 764 studies identified, 30 articles were selected, involving 8365 patients. There was great variation in both the reference test and the methodology of SWME. However, current literature suggests that nerve conduction study (NCS) is the gold standard for diagnosing DPN. Four studies were identified which directly compared SWME with NCS and encompassed 1065 patients with, and 52 patients without diabetes mellitus. SWME had a sensitivity ranging from 57% (95% confidence interval [CI], 44% to 68%) to 93% (95% CI, 77% to 99%), specificity ranging from 75% (95% CI, 64% to 84%) to 100% (95% CI, 63% to 100%), positive predictive value (PPV) ranging from 84% (95% CI, 74% to 90%) to 100% (95% CI, 87% to 100%), and negative predictive value (NPV) ranging from 36% (95% CI, 29% to 43%) to 94% (95% CI, 91% to 96%).

CONCLUSIONS

There is great variation in the current literature regarding the diagnostic value of SWME as a result of different methodologies. To maximize the diagnostic value of SWME, a three site test involving the plantar aspects of the great toe, the third metatarsal, and the fifth metatarsals should be used. Screening is vital in identifying DPN early, enabling earlier intervention and management to reduce the risk of ulceration and lower extremity amputation.

Foot problems and effectiveness of foot care education in children and adolescents with diabetes mellitus

OBJECTIVES

To assess foot care in paediatric and adolescent patients with diabetes mellitus and to evaluate the effectiveness of foot care education given to participants.

RESEARCH DESIGN AND METHODS

An 8-month prospective study of foot care in children and adolescents with type 1 and type 2 diabetes mellitus who attended diabetes clinics at the Royal Children's Hospital, Melbourne, where foot examination was performed at baseline and at follow-up. Patients and parents were given oral and written advice regarding foot care.

RESULTS

Five hundred and fifty-seven patients were examined at baseline, and 312 patients were reviewed at follow-up 3-6 months later. The majority of foot problems found at first assessment were potentially modifiable disorders of skin and nails (68.8%). The remainder (31.2%) were structural musculoskeletal disorders requiring referral to a podiatrist/orthotist. A total of 532 foot problems were recorded at baseline in a cohort of 557 patients and 161 foot problems at follow-up of 312 patients. Significant reduction of modifiable foot problems was seen at follow-up, particularly in those with longer duration of diabetes and in those whose body mass index was higher.

CONCLUSIONS

This study highlights the importance of foot examination and foot care advice for children and adolescents with diabetes. Larger prospective studies are required to establish prevalence and to optimize preventive interventions.

The diabetic foot

Diabetes is reaching epidemic proportions and with it carries the risk of complications. Disease of the foot is among one of the most feared complications of diabetes. The ultimate endpoint of diabetic foot disease is amputation, which is associated with significant morbidity and mortality, besides having immense social, psychological and financial consequences. As the majority of amputations are preceded by foot ulceration, it is crucial to identify those at an increased risk. Diabetic foot ulcers may develop as a result of neuropathy, ischaemia or both and when infection complicates a foot ulcer, the combination can become limb and life threatening. Structural abnormalities such as calluses, bunions, hammer toes, claw toes, flat foot and rocker bottom foot need to be identified and managed.

The management of ankle fractures in patients with diabetes

Patients with diabetes mellitus have higher complication rates following both open and closed management of ankle fractures. Diabetic patients with neuropathy or vasculopathy have higher complication rates than both diabetic patients without these comorbidities and nondiabetic patients. Unstable ankle fractures in diabetic patients without neuropathy or vasculopathy are best treated with open reduction and internal fixation with use of standard techniques. Patients with neuropathy or vasculopathy are at increased risk for both soft-tissue and osseous complications, including delayed union and nonunion. Careful soft-tissue management as well as stable, rigid internal fixation are crucial to obtaining a good outcome. Prolonged non-weight-bearing and subsequently protected weight-bearing are recommended following both operative and nonoperative management of ankle fractures in patients with diabetes.

Postural control following a self-initiated reaching task in type 2 diabetic patients and age-matched controls

Although the postural stability of diabetic patients is affected in the presence of polyneuropathy, it has been suggested that diabetes per se has no effect on balance control during quiet standing. However, recent studies have reported muscular mechanical deficits in patients with type 2 diabetes (T2D) that may be highlighted during a more destabilizing task than quiet standing. Therefore, the objective of this study was to compare non-diabetic and T2D subjects during a modified version of the functional reach (FR) test in order to discriminate differences in postural control associated with diabetes per se. Thirty subjects (15 non-diabetic and 15 T2D) were requested to stand on a force platform and to perform the FR test. Center of pressure velocity (V(COP)), root-mean-square (RMS) amplitude and range of the COP were calculated in the anterior-posterior direction during three specific periods of the FR performance: namely "before", "on-going" and "after". No significant difference between the non-diabetic subjects and the T2D subjects was found for the FR performance. However, T2D subjects had significantly higher V(COP), RMS and range of COP displacements for the "after" period compared to the non-diabetic group (p<0.05). These results suggest that T2D subjects without peripheral neuropathy may have difficulties regaining their stability after a self-initiated reaching task. Therefore, diabetes mellitus per se, could have a direct effect on postural control during standing after a self-induced forward reaching movement.

Validation of a diabetic foot surgery classification

The purpose of this project was to evaluate associations of increasing diabetic foot surgery stage with postoperative outcome. This project, designed as a retrospective cohort model, was conducted at three large, urban referral-based diabetic foot clinics. The investigators abstracted medical records from 180 patients with diabetes, 76.1% male, aged 57.8 +/- 11.2 years, falling equally into four classes of a previously reported diabetic foot surgery classification system. These classes included class 1 (elective), class 2 (prophylactic), class 3 (curative) and class 4 (emergency). There was a significant trend towards increasing risk of ulceration/reulceration (chi2(trend) = 17.8, P = 0.0001), peri-postoperative infection (chi2(trend) = 96.9, P = 0.0001), all-level amputation (chi2(trend) = 41.7, P = 0.001) and major amputation (chi2(trend) = 8.6, P = 0.003), with increasing class of foot surgery. The results of this study suggest that a non vascular foot surgery classification system including variables such as the presence or absence of neuropathy, an open wound and acute infection may be predictive of peri- and postoperative complications. This may assist the surgeon in better identifying risk when determining a rationale for and type of surgery in persons with diabetes.

Ankle fractures in diabetics

Treatment of the diabetic patient with ankle fracture presents a unique set of challenges to the surgeon. The care of these patients should follow a multidisciplinary approach with a team of orthopedic and vascular surgeons, internists, anesthesiologists, nurses, and diabetic educators. Meticulous preoperative planning, intraoperative technique, and postoperative care can be decrease potential limb-threatening complications; however, complications will occur despite excellent care. Early recognition and treatment of preoperative complications is imperative. These patients require close attention for long periods, and the surgeon should plan on building a strong relationship with these patients.

Measuring sensation in the feet of patients with rheumatoid arthritis

OBJECTIVES

(1) To determine the test-retest reliability of monofilaments pressed against the skin as a method of assessing sensation in the feet of patients with rheumatoid arthritis (RA) and in controls using two grades of monofilaments; (2) to determine the stability of findings over 6 weeks; and (3) to calculate initial estimates of frequency of loss of sensation and to investigate its association with disease status.

METHOD

Clinical examination of the feet was undertaken in 51 patients with RA and 20 normal controls. Six sites on each foot were tested twice with both 10 g and 3 g research grade monofilaments and this was repeated after 6 weeks. Disease status was measured using the Disease Activity Score, the Health Assessment Questionnaire, visual analogue scales of pain, and the acute phase response using erythrocyte sedimentation rate and plasma viscosity.

RESULTS

Reproducibility was high for 3 g (kappa=0.73) and 10 g (kappa=0.75) monofilaments. The best balance between sensitivity (58.8%) and specificity (87.5%) for distinguishing the feet of patients from the feet of controls was using the 3 g filament and defining reduced protective sensation as being sensitive to less than 11 of 12 applications. Using this definition, the prevalence of reduced protective sensation is 59% in the patient group and 12.5% in the feet of controls. There was some variation in sensation over 6 weeks in the patient group, but this was not related to measures of clinical status.

CONCLUSION

The use of monofilaments in assessing sensation levels in the RA foot is repeatable and reproducible over a six-week period and requires only a short time to perform. The frequency of reduced sensation in the feet of patients with RA was greater than previously reported. Future studies should assess relationships with disease duration and inflammatory status.

Use of monofilament in the detection of foot lesions in older adults

The purpose of this study was to compare Semmes-Weinstein monofilament testing between elderly and young patients in both a diabetic and nondiabetic population. Monofilament mapping (10 g) was performed on 115 patients: 74 who were greater than 60 years of age (47 with diabetes) and 41 who were younger than 60 years (20 with diabetes). Sensations were assessed at 15 predefined pressure/risk points. Sensations were found to have perfect correlation between the same point on the left and right foot (r = 1.0) for each of the 15 points. The data for the 15 points were divided in 2 subsets: one for 8 points similar to a validated method and another with 7 new points on the dorsum and ankle area. Scores on both subsets differed significantly by age group (P < .0001) and diabetes status (P < .001), with older patients and patients with diabetes having higher scores. Analysis of covariance was used to estimate 15-point scores for the 4 combinations of age group and diabetes status, adjusting for foot ulceration, callus, deformity, and ischemia. In older patients without diabetes, each subset score was used to detect future neuropathy if 4 or more points were insensitive. The detections agreed in 37 of 47 cases. In all 10 cases of disagreement, the 7-point subset detected no neuropathy, suggesting that inclusion of the additional points could improve diagnostic specificity. The significant differences noted between young and old patients suggest the importance of aging-related changes, and raise questions about current scoring methods for detection of neuropathy in older adults with diabetes.

The effect of monochromatic infrared energy on sensation in patients with diabetic peripheral neuropathy: a double-blind, placebo-controlled study

OBJECTIVE

The purpose of this study was to determine the effect of monochromatic infrared energy (MIRE) on plantar sensation in subjects with diabetic peripheral neuropathy.

RESEARCH DESIGN AND METHODS

In this randomized, double-blind, placebo-controlled study, 39 subjects with diabetic peripheral neuropathy completed the 8-week study. Subjects received 30 min of active or placebo MIRE three times a week for 4 weeks. Plantar sensation was tested with monofilaments at the beginning of the study (M1), following 4 weeks of treatment (M2), and after an additional 4 weeks of nontreatment (M3). The number of sites that could sense the 5.07 monofilament was totaled at M1, M2, and M3. Data were analyzed using a special repeated-measures statistic followed by a post hoc Tukey-Kramer test.

RESULTS

The average number of sites that patients could sense the 5.07 monofilament increased for both the active and placebo groups. There were significant gains from M1 to M2 (P < 0.002), no significant gains from M2 to M3 (P = 0.234), and significant gains from M1 to M3 (P < 0.002) for both the active and placebo groups. There were no significant differences between active and placebo groups at any measurement.

CONCLUSIONS

Thirty minutes of active MIRE applied 3 days per week for 4 weeks was no more effective than placebo MIRE in increasing sensation in subjects with diabetic peripheral neuropathy. Clinicians should be aware that MIRE may not be an effective modality for improving sensory impairments in patients with diabetic neuropathy.

A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes

PURPOSE

To assess the efficacy of a pharmacist-led, primary care-based, disease management program to improve cardiovascular risk factors and glycated hemoglobin (A(1C)) levels in vulnerable patients with poorly controlled diabetes.

METHODS

A randomized controlled trial of 217 patients with type 2 diabetes and poor glycemic control (A(1C) level >or=8.0%) was conducted at an academic general medicine practice from February 2001 to April 2003. Intervention patients received intensive management from clinical pharmacists, as well as from a diabetes care coordinator who provided diabetes education, applied algorithms for managing glucose control and decreasing cardiovascular risk factors, and addressed barriers to care. Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider. Outcomes were recorded at baseline and at 6 and 12 months. Primary outcomes included blood pressure, A(1C) level, cholesterol level, and aspirin use. Secondary outcomes included diabetes knowledge, satisfaction, use of clinical services, and adverse events.

RESULTS

For the 194 patients (89%) with 12-month data, the intervention group had significantly greater improvement than did the control group for systolic blood pressure (-9 mm Hg; 95% confidence interval [CI]: -16 to -3 mm Hg) and A(1C) level (-0.8%; 95% CI: -1.7% to 0%). Change in total cholesterol level was not significant. At 12 months, aspirin use was 91% in the intervention group versus 58% among controls (P <0.0001). Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients. There were no significant differences in use of clinical services or adverse events.

CONCLUSION

Our comprehensive disease management program reduced cardiovascular risk factors and A(1C) levels among vulnerable patients with type 2 diabetes and poor glycemic control.

Creation of a multidisciplinary, evidence based, clinical guideline for the assessment, investigation and management of acute diabetes related foot complications

AIMS

To design a multidisciplinary, evidenced-based, clinical guideline for the assessment, investigation and management of inpatients with acute diabetes related foot complications.

METHODS

A systematic search of both published (identified by searching all major electronic databases and hand searching key journals) and unpublished literature (derived from national and internationally recognized experts) identified 266 articles specific to diabetes related foot complications. Of these, 126 (47%) were assessed to be methodologically sound and clinically relevant. A narrative summary with the articles tabulated according to their level of evidence was prepared. A multidisciplinary expert group of health professionals, with a known interest and recognized expertise in diabetes related foot complications, was established to assess the evidence.

RESULTS

The multidisciplinary expert group used the identified literature and clinical experience to create a comprehensive, evidence-based, clinical guideline for the assessment, investigation and management of acute diabetes related foot complications. Included within the guideline is a novel, diabetes specific classification system, which codes for the presence/absence and severity of the four principle causative factors (Neuropathy, Vascular compromise, Ulceration and Infection) in the development of acute diabetes related foot complications.

CONCLUSION

Through the creation and implementation of this evidence-based clinical guideline, specific for acute diabetes related foot complications, it is hoped that health professionals will be better equipped to make informed decisions for this patient population. This may benefit the individual and health system through reductions in amputation rate, length of hospital stay and health expenditure.

Diabetic foot ulcer and multidrug-resistant organisms: risk factors and impact

AIMS

The primary objective was to characterize factors allowing the colonization of diabetic foot wounds by multidrug-resistant organisms (MDRO), and the secondary objective was to evaluate the influence of MDRO colonization/infection on wound healing.

METHODS

In 180 patients admitted to a specialized diabetic foot unit, microbiological specimens were taken on admission. Potential risk factors for MDRO-positive specimens were examined using univariate and multivariate analyses. Prospective follow-up data from 75 patients were used to evaluate the influence of MDRO colonization/infection on time to healing.

RESULTS

Eighteen per cent of admission specimens were positive for MDRO. MDRO-positive status was not associated with patient characteristics (age, sex, type of diabetes, complications of diabetes), wound duration, or wound type (neuropathic or ischaemic). In the multivariate analysis, the only factors significantly associated with positive MDRO status on admission were a history of previous hospitalization for the same wound (21/32 compared with 48/148; P = 0.0008) or the presence of osteomyelitis (22/32 compared with 71/148; P = 0.025). In the longitudinal study of 75 wounds, MDRO-positive status on admission or during follow-up (6 months at least or until healing, mean 9 +/- 7 months) was not associated with time to healing (P = 0.71).

CONCLUSION

MDROs are often present in severe diabetic foot wounds. About one-third of patients with a history of previous hospitalization for the same wound, and 25% of patients with osteomyelitis, had MDRO-positive specimens. This suggests that hygiene measures, or isolation precautions in the case of admission of patients presenting with these characteristics, should be aggressively implemented to prevent cross-transmission. Positive MDRO status is not associated with a longer time to healing.

4.5-gram monofilament sensation beneath both first metatarsal heads indicates protective foot sensation in diabetic patients

BACKGROUND

Loss of protective plantar foot sensation is the major cause of diabetic foot ulcerations and ultimate limb loss. Identification of patients without protective sensation can reduce the risk of unrecognized foot injury. The current recommended screening protocol requires 10-g monofilament testing of ten foot sites with use of a forced-choice paradigm. The objective of the present study was to determine whether testing of fewer than ten sites could provide accuracy comparable with that obtained by testing all ten sites.

METHODS

A cross-sectional comparative study of plantar sensory levels in diabetic subjects with and without plantar ulceration was conducted in a tertiary-care teaching hospital setting. We examined forty-seven diabetic subjects with a history of foot ulceration and forty-five diabetic subjects with no history of foot ulceration. Plantar sensory threshold values at five sites on the sole of each foot were measured with a quasi-continuous range of applied forces, and receiver operating characteristic analysis techniques were applied.

RESULTS

Screening on the basis of only the maximum force threshold for the left and right first metatarsal head sites provided comparable or better performance at high levels of sensitivity than did either the mean or the maximum force threshold across all ten sites. A sensory threshold of 4.5 g for both the left and right first metatarsal head sites predicted the risk of ulceration with a sensitivity of 100% and a specificity of 67%.

CONCLUSIONS

Testing of diabetic patients for protective sensation may be simplified to testing under both first metatarsal heads with a 4.5-g monofilament. If a patient cannot sense the application of a 4.5-g monofilament under either first metatarsal head, he or she probably has lost protective sensation and should be considered to be at risk for undetected injury.

Diabetic neuropathy: a review emphasizing diagnostic methods

Diabetic sensorimotor polyneuropathy (DSP) is the most common complication of diabetes. In order to manage DSP effectively, it is necessary to formulate an accurate diagnosis and monitor subjects regularly. This review of important aspects of the diagnosis of DSP starts with a conceptual framework that includes elements of DSP epidemiology, pathophysiology, and therapy. The emphasis of the review is to present our current understanding of diagnostic methods for DSP including their utility and limitations. Screening for DSP in the diabetes clinic can be achieved successfully using simple clinical tests. Clinical neurophysiological methods are necessary to exclude other diagnoses, stage severity, and monitor the course of DSP. Novel investigative techniques are highly promising, but their usefulness in the clinic setting remains limited at this time. This article presents an overview of diagnostic methods for DSP.

The clinical identification of peripheral neuropathy among older persons

OBJECTIVE

To identify simple clinical rules for the detection of a diffuse peripheral neuropathy among older outpatients.

DESIGN

Observational, blinded, controlled study.

SETTING

A tertiary-care electrodiagnostic laboratory and biomechanics laboratory.

PARTICIPANTS

One hundred research subjects, 68 with electrodiagnostic evidence of peripheral neuropathy, between the ages of 50 and 80 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

One examiner, unaware of the results of electrodiagnostic testing, evaluated Achilles' and patellar reflexes, Romberg testing, semiquantified vibration, and position sense at the toe and ankle in all subjects, and unipedal stance time and the Michigan Diabetes Neuropathy Score in a subset of subjects.

RESULTS

Significant group differences were present in all clinical measures tested. Three signs, Achilles' reflex (absent despite facilitation), vibration (128Hz tuning fork perceived for <10s), and position sense (<8/10 1-cm trials) at the toe, were the best predictors of peripheral neuropathy on both univariate and logistic regression (pseudo R(2)=.744) analyses. The presence of 2 or 3 signs versus 0 or 1 sign identified peripheral neuropathy with sensitivity, specificity, and positive and negative predictive values of 94.1%, 84.4%, 92.8%, and 87.1%, respectively. Values were similar among subgroups of subjects with and without diabetes mellitus. When other clinicians applied the technique to 12 more subjects, excellent interrater reliability regarding the presence of peripheral neuropathy (kappa=.833) and good to excellent interrater reliability for each sign (kappa range,.667-1.00) were shown.

CONCLUSION

Among older persons, the presence of 2 or 3 of the 3 clinical signs strongly suggested electrodiagnostic evidence of a peripheral neuropathy, regardless of etiology. Age-related decline in peripheral nerve function need not be a barrier to the clinical recognition of a diffuse peripheral neuropathy among older persons.

Evaluation of three screening tests and a risk assessment model for diagnosing peripheral neuropathy in the diabetes clinic

OBJECTIVE

with the aim of evaluating predictive power, three simple screening tests as alternates to nerve conduction tests for diagnosing diabetic peripheral neuropathy (DPN) were investigated. Results of the screening tests, along with the subjects' demographic and clinical characteristics, were planned as the variables for the development of a risk assessment tool for predicting DPN.

DESIGN

this is a cross-sectional multi-group comparison study. The study utilized a predictive model derived from one subset of the study population, and prospectively tested in the other subset to predict the presence of neuropathy.

SETTING

Diabetic Neuropathy Research Clinic of the Toronto General Hospital and University Health Network in Toronto, Ontario, Canada from June 1998 to August 1999.

SAMPLE POPULATION

data come from 478 subjects consisting of non-diabetic reference subjects, and patients with type 1 and type 2 diabetes mellitus.

OUTCOMES MEASURES

nerve conduction studies (NCS) comprised the primary defined outcome. The three screening sensory tests examined in the study were the Semmes-Weinstein 10 g monofilament examination (SWME), superficial pain sensation, and vibration by the on-off method.

RESULTS

the three screening tests are significantly and positively correlated with NCS. An increase in the number of insensate responses in the screening test is associated with an increase in the abnormal NCS score. The strength of the association between NCS and each sensory test was greater when the neuropathy severity stage of the subject was added to the model. Both the SWME and vibration by the on-off method tests demonstrated sufficient statistical power to differentiate non-diabetic control subjects from subjects with diabetes, as well as to differentiate subjects with diabetes with and without neuropathy. These two tests, when compared with NCS, also demonstrated acceptable diagnostic performance characteristics in terms of high sensitivity and specificity, total number of correctly predicted cases, and receiver-operating characteristic curves.

CONCLUSION

this data, through the development of a model involving training and validation sets, demonstrates that the knowledge of clinical risk factors alters the interpretation of sensory tests for DPN. This finding lends further support to the validity of simple sensory testing maneuvers in the conditional diagnosis of DPN. We recommend annual screening with either the SWME or vibration by the on-off method in the primary care and diabetes clinics.

Examining diagnostic tests: an evidence-based perspective

Diagnosis is an important aspect of physical therapist practice. Selecting tests that will provide the most accurate information and evaluating the results appropriately are important clinical skills. Most of the discussion in physical therapy to date has centered on defining diagnosis, with considerably less attention paid to elucidating the diagnostic process. Determining the best diagnostic tests for use in clinical situations requires an ability to appraise evidence in the literature that describes the accuracy and interpretation of the results of testing. Important issues for judging studies of diagnostic tests are not widely disseminated or adhered to in the literature. Lack of awareness of these issues may lead to misinterpretation of the results. The application of evidence to clinical practice also requires an understanding of evidence and its use in decision making. The purpose of this article is to present an evidence-based perspective on the diagnostic process in physical therapy. Issues relevant to the appraisal of evidence regarding diagnostic tests and integration of the evidence into patient management are presented.

Foot care practices, services and perceptions of risk among medicare beneficiaries with diabetes at high and low risk for future foot complications

A cohort of Medicare beneficiaries with diabetes was identified from inpatient and outpatient claims data and their risk for foot complications was estimated based on claims reflecting services for recent foot problems. A telephone survey of a random sample from this cohort was conducted to assess their foot care practices, barriers, and perceptions of risk. Eight percent of respondents reported a history of foot ulcers and 7% a history of lower extremity amputation. Based on claims data, 30% of respondents were at high risk for future foot complications. Compared to those at low risk, those at high risk were more likely to report having an annual foot exam, using protective footwear, and perceiving themselves to be high risk for future foot complications. However, 50% of those with claims indicating a high risk perceived themselves to be at low risk for future foot complications. Overall, 20% of respondents seldom checked their feet daily for sores or irritations. Among this group, 60% felt that it was unimportant and 9% reported they were limited by poor vision or physical problems. Our findings suggest that strategies are needed to improve the delivery of preventive foot care services to older persons with diabetes. Additionally, emphasis is needed to help individuals understand their risk and seek and perform appropriate preventive foot care.

Simple screening tests for peripheral neuropathy in the diabetes clinic

OBJECTIVE

The utility of rapid and reliable sensory tests appropriate for the diagnosis of neuropathy in the diabetes clinic, rather than as prognostic tools for the prediction of foot complications, has been unclear because of limitations inherent in previous studies. Although clinical practice guidelines recommend annual screening for neuropathy, they are unable to support specific recommendations for screening maneuvers because of a lack of evidence for the validity of screening tests in the medical literature. The objective of this study was to assess the operating characteristics of four simple sensory screening maneuvers as compared with standardized electrophysiological tests in the diagnosis of distal symmetrical polyneuropathy.

RESEARCH DESIGN AND METHODS

We assessed four simple tests (the 10-g Semmes-Weinstein monofilament examination [SWME], superficial pain sensation, vibration testing by the on-off method, and vibration testing by the timed method) in 478 subjects with independent blinded evaluations compared against the criterion standard of nerve conduction studies. We present receiver-operating characteristic (ROC) curves, positive and negative likelihood ratios, and sensitivity and specificity values for each test.

RESULTS

The four simple screening maneuvers reveal similar operating characteristics. Cutoff points by ROC curve analyses reveal that a positive or abnormal test is represented by five incorrect responses of eight stimuli applied. A negative or normal test is represented by one or fewer incorrect responses of eight stimuli applied. By these criteria, the point estimates of the positive likelihood ratios for vibration testing by the on-off method, vibration testing by the timed method, the SWME, and superficial pain sensation test are 26.6, 18.5, 10.2, and 9.2, respectively. The point estimates of the negative likelihood ratios are 0.33, 0.51, 0.34, and 0.50, respectively The screening tests showed comparable sensitivity and specificity results. The 10-g SWME, superficial pain test, and vibration testing by the on-off method are rapid, each requiring approximately 60 s to administer. The timed vibration test takes longer, and the interpretation is more complicated. The combination of two simple tests (e.g., the 10-g SWME and vibration testing by the on-off method) does not add value to each individual screening test.

CONCLUSIONS

Annual screening for diabetic neuropathy should be conducted using superficial pain sensation testing, SWME, or vibration testing by the on-off method. The reported operating characteristics for each sensory modality can be applied to positive findings on the physical examination of individual patients to predict the likelihood of neuropathy.