Self-awareness of foot health status in patients with Type 2 diabetes: the Fremantle Diabetes Study Phase II

A Review of Patient's Knowledge and Practice of Diabetic Foot Self-Care

Since diabetic foot ulcers (DFUs) are common among diabetes patients, it is essential to increase patients' knowledge and self-care practices to ensure early recognition and management and reduce amputation risk. Therefore, the goal of this review was to identify the range and level of knowledge of people with DFUs and the type of self-care they undertake. A literature review was conducted using the electronic databases PubMed and Google scholar with 'diabetic foot', 'self-care', 'practice' and 'behaviour' as searching keywords. The identification and selection process were conducted to sort the eligible papers through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The criteria are the original papers describing knowledge and practice in DFU; reporting knowledge and practice in their non-intervention studies; writing in English language; and publishing between years 2016 and 2022. The eligible papers were assessed using the strength of reporting observational studies in epidemiology (STROBE) checklist for appraising their quality. Twenty-two papers of 2,073 titles met the inclusion criteria and included in the review. The lowest and the highest quality score of included papers based on STROBE checklist are 11 and 26, respectively. The included papers showed various levels of knowledge from good to poor, which prominent the highest percentage are 88% (good knowledge) and 84.8% (poor knowledge). The majority of the foot-care activities found in the reviewed papers involved the following steps: washing, drying, applying moisturiser and trimming nails routinely. Those activity should be followed by checking the feet with a mirror for ulcers, looking for ingrown nails, choosing appropriate footwear, not walking barefoot and routinely consulting a healthcare provider. The knowledge levels were found variable and acceptable. Daily foot care, choosing the right footwear, foot activity and regular health checks should all be used to manage diabetes.

Falls, fear of falling, and related factors in patients with diabetic foot disease

BACKGROUND

Falls and fear of falling (FOF) are common in patients with diabetic foot disease (DFD).

PURPOSE

To understand the relationship between falls, FOF, and related factors in patients with DFD.

METHOD

We recruited 70 patients being treated for DFD at two hospitals in Korea. A structured questionnaire was used in investigating fall experience, FOF, and related factors.

RESULTS

Among the participants, 42.8 % fell in the past year, and FOF was reported in 57.1 %. Rates of "no caregiver," "DFD duration (>1 year)," and "burning pain" were higher in fallers than non-fallers. The rates of "older adults (≥65 years of age)," "unemployed," "not using assistive devices," "visual impairment," and "hearing impairment" were higher in patients with FOF than in those without FOF. However, the level of balance confidence was lower in patients with FOF.

CONCLUSIONS

The fall experience of patients with DFD was associated with the presence of their caregiver, disease-related factors, and foot pain symptoms, while FOF was related to age and fall-related factors.

Screening and diagnosis of diabetic polyneuropathy in clinical practice: A survey among German physicians (PROTECT Study Survey)

AIMS

We sought to obtain detailed information on the procedures and appraisal of screening for and diagnosing diabetic sensorimotor polyneuropathy (DSPN) in clinical practice.

METHODS

This cross-sectional survey included 574 physicians from 13 federal states across Germany who responded to a tripartite questionnaire.

RESULTS

The vast majority of the respondents reported to screen for DSPN at least once a year (87 %), while 65 % reported to examine the feet of DSPN patients at least twice a year. However, only 28 % and 20 % of the respondents used questionnaires and scores to assess the severity of neuropathic symptoms and signs, respectively. The rates of participants reporting that they do not use a standardized testing procedure were 58 % for pressure sensation, 62 % for pain sensation, and 54 % for thermal sensation. The rates of respondents reporting that they do not deploy a standardized assessment were 41 % for vibration sensation, 73 % for pressure sensation, 77 % for pain sensation, and 66 % for thermal sensation. Half of the physicians oriented themselves towards clinical guidelines when diagnosing DSPN.

CONCLUSIONS

Despite relatively high screening rates, the willingness to implement both standardized testing procedures and assessment and to follow guidelines is low among physicians when screening for and clinically diagnosing DSPN.

Uso de tecnologías de información y comunicación para promover la autogestión de ulceras por pie diabético

Introducción: El uso de las tecnologías de la información y comunicación en las intervenciones educativas de enfermería facilita los procesos de autogestión para lograr la adaptación en las condiciones crónicas de salud. Objetivo: Evaluar el efecto de una intervención educativa de enfermería para promover la autogestión en la prevención de ulceras por pie diabético en adultos diabetes mellitus tipo 2 en Colombia mediante la inclusión de las tecnologías de la Información y comunicación. Materiales y métodos: Estudio cuasi experimental con medición pre y post intervención realizado con 82 adultos que asistían a la consulta de enfermedades crónicas de un hospital de segundo nivel de atención en el departamento de Boyacá Colombia Los grupos fueron asignados aleatoriamente a los grupos experimental y comparación. Los datos fueron recolectados a partir de una ficha de caracterización y un cuestionario de autogestión. Resultados: No hubo diferencias significativas entre los dos grupos de experimental y comparación en términos de puntaje de autogestión, previo a la intervención. Sin embargo, el puntaje promedio de autogestión del grupo experimental fue significativamente mayor que el del grupo control 6 semanas después de la intervención (p<0.005) el resultado primario fueron los comportamientos de autogestión dados desde el cuidado de los pies. Se usaron las pruebas no paramétricas de Wilcoxon y Mann Whitney. Discusión: Las intervenciones de enfermería deben soportarse en enfoques teóricos propios de la disciplina, que permita visualizar resultados específicos, en este caso la autogestión la cual requiere de estrategias como el conocimiento, la habilidad y el soporte social que apoyaran la adaptación para las situaciones de enfermedad crónica. Conclusión: La intervención educativa a partir del uso de las tecnologías de la información y comunicación mejoro la autogestión para la prevención de heridas en pie diabético, logrando las personas un cambio en su comportamiento.

Individualised screening of diabetic foot: creation of a prediction model based on penalised regression and assessment of theoretical efficacy

AIMS/HYPOTHESIS

A large proportion of people with diabetes do not receive proper foot screening due to insufficiencies in healthcare systems. Introducing an effective risk prediction model into the screening protocol would potentially reduce the required screening frequency for those considered at low risk for diabetic foot complications. The main aim of the study was to investigate the value of individualised risk assignment for foot complications for optimisation of screening.

METHODS

From 2015 to 2020, 11,878 routine follow-up foot investigations were performed in the tertiary diabetes clinic. From these, 4282 screening investigations with complete data containing all of 18 designated variables collected at regular clinical and foot screening visits were selected for the study sample. Penalised logistic regression models for the prediction of loss of protective sensation (LOPS) and loss of peripheral pulses (LPP) were developed and evaluated.

RESULTS

Using leave-one-out cross validation (LOOCV), the penalised regression model showed an AUC of 0.84 (95% CI 0.82, 0.85) for prediction of LOPS and 0.80 (95% CI 0.78, 0.83) for prediction of LPP. Calibration analysis (based on LOOCV) presented consistent recall of probabilities, with a Brier score of 0.08 (intercept 0.01 [95% CI -0.09, 0.12], slope 1.00 [95% CI 0.92, 1.09]) for LOPS and a Brier score of 0.05 (intercept 0.01 [95% CI -0.12, 0.14], slope 1.09 [95% CI 0.95, 1.22]) for LPP. In a hypothetical follow-up period of 2 years, the regular screening interval was increased from 1 year to 2 years for individuals at low risk. In individuals with an International Working Group on the Diabetic Foot (IWGDF) risk 0, we could show a 40.5% reduction in the absolute number of screening examinations (3614 instead of 6074 screenings) when a 10% risk cut-off was used and a 26.5% reduction (4463 instead of 6074 screenings) when the risk cut-off was set to 5%.

CONCLUSIONS/INTERPRETATION

Enhancement of the protocol for diabetic foot screening by inclusion of a prediction model allows differentiation of individuals with diabetes based on the likelihood of complications. This could potentially reduce the number of screenings needed in those considered at low risk of diabetic foot complications. The proposed model requires further refinement and external validation, but it shows the potential for improving compliance with screening guidelines.

Polyneuropathy is inadequately treated despite increasing symptom intensity in individuals with and without diabetes (PROTECT follow-up study)

AIMS/INTRODUCTION

Despite its major clinical impact, distal symmetric polyneuropathy remains frequently undiagnosed and undertreated in clinical practice. We previously reported in the PROTECT Study that 70% of type 2 diabetes patients with distal symmetric polyneuropathy were unaware of having the latter condition.

MATERIALS AND METHODS

In the present follow up after 2.5 ± 0.7 years, 122 and 85 participants with and without type 2 diabetes, respectively, completed questionnaires to obtain information about the further course of disease and its management.

RESULTS

At follow up, 49 and 48% of the respondents with type 2 diabetes and without diabetes, respectively, reported that the intensity of paresthesia or numbness in the feet increased, whereas for burning and pain in the feet the corresponding percentages were 56 and 61%. However, 33 and 40% of the respondents with type 2 diabetes and without diabetes, respectively, reporting neuropathic symptoms at follow up did not receive any pharmacotherapy. Pharmacotherapy of neuropathic symptoms at follow up among participants with type 2 diabetes and without diabetes included mainly World Health Organization Step 1 analgesics (17% each; excluding acetylsalicylic acid), pregabalin/gabapentin (20 and 12%), vitamin B complex (13 and 22%), benfotiamine (13 and 2%), opioids (7 and 12%), antidepressants (4 and 5%) and α-lipoic acid (4 and 2%).

CONCLUSIONS

These findings point to insufficient care, inadequate treatment adherence or limited efficacy of treatments in patients with polyneuropathy, suggesting that effective measures should be implemented to correct these healthcare deficits.

Overcoming barriers to self-management: The person-centred diabetes foot behavioural agreement

OBJECTIVE

Behavioural agreements have been proposed as a clinical strategy for improving concordance with diabetes foot self-management practices, both for individuals 'At-risk' of, and with active, diabetes foot disease. This narrative review sought to explore the potential supportive role of person-centred diabetes foot behavioural agreements in promoting protective foot self-management behaviours among 'At-risk' individuals.

CONCLUSIONS

Healthcare professionals (HCPs) involved in diabetes foot risk stratification and management dedicate considerable time, effort and resources to the prevention of diabetic foot ulcers (DFU) and lower extremity amputation (LEA) and are uniquely placed to deliver person-centred diabetes self-management education and support (DSMES) interventions. Written, verbal and non-verbal agreements are consistent with a wider global move toward DSMES approaches, respectful of people's preferences, and supporting them to undertake protective self-care behaviours.

PRACTICE IMPLICATIONS

It is theorised that clear communication of the roles of the person with diabetes, their family or carers and HCPs may improve concordance with self-management behaviours. Rather than a punitive measure or means of facilitating discharge of 'non-concordant' individuals, person-centred behavioural agreements should be framed positively, as a means of delineating, prescribing and supporting individual diabetes foot-care responsibilities. This is an area worthy of further research.

Painful and painless neuropathies are distinct and largely undiagnosed entities in subjects participating in an educational initiative (PROTECT study)

AIMS

We conducted a nationwide educational initiative to determine the prevalence and risk factors of diagnosed and undiagnosed painful and painless distal sensory polyneuropathy (DSPN).

METHODS

Among 1850 participants, 781 had no history of diabetes (ND), 126 had type 1 diabetes (T1D), and 943 had type 2 diabetes (T2D). Painful DSPN was defined as polyneuropathy detected by bedside tests with pain and/or burning in the feet, while painless DSPN was defined as polyneuropathy with paresthesias, numbness, or absence of symptoms.

RESULTS

DSPN was detected in 48.2% of ND, 44.3% of T1D, and 55.3% of T2D subjects. DSPN was painful, painless, or atypical in 62.1, 24.8, and 13.1% of the participants. Painful DSPN was more severe than painless DSPN. Painful and painless DSPN were previously undiagnosed in 61.5 and 81.1% of the participants, respectively. In T2D subjects, painful and painless DSPN were associated with a higher and lower BMI, respectively. Among ND participants 39.2% had HbA1c levels indicating prediabetes/diabetes.

CONCLUSIONS

Around half of participants in an educational initiative had DSPN, 62% of whom had the painful entity that correlated with BMI in T2D. Since many cases of neuropathy and diabetes remain undiagnosed, effective strategies to timely detect both conditions should be implemented.

Prevention and treatment of diabetic foot ulcers

The rising prevalence of diabetes estimated at 3.6 million people in the UK represents a major public health and socioeconomic burden to our National Health Service. Diabetes and its associated complications are of a growing concern. Diabetes-related foot complications have been identified as the single most common cause of morbidity among diabetic patients. The complicating factor of underlying peripheral vascular disease renders the majority of diabetic foot ulcers asymptomatic until latter evidence of non-healing ulcers become evident. Therefore, preventative strategies including annual diabetic foot screening and diabetic foot care interventions facilitated through a multidisciplinary team have been implemented to enable early identification of diabetic patients at high risk of diabetic foot complications. The National Diabetes Foot Care Audit reported significant variability and deficiencies of care throughout England and Wales, with emphasis on change in the structure of healthcare provision and commissioning, improvement of patient education and availability of healthcare access, and emphasis on preventative strategies to reduce morbidities and mortality of this debilitating disease. This review article aims to summarise major risk factors contributing to the development of diabetic foot ulcers. It also considers the key evidence-based strategies towards preventing diabetic foot ulcer. We discuss tools used in risk stratification and classifications of foot ulcer.

High prevalence of diagnosed and undiagnosed polyneuropathy in subjects with and without diabetes participating in a nationwide educational initiative (PROTECT study)

AIMS

Since neuropathy screening may be underutilized in primary care practice, we conducted a nationwide educational initiative to determine the prevalence of diagnosed and previously undiagnosed polyneuropathy.

METHODS

Among 1017 individuals participating in the initiative, 983 with complete data were analyzed, 359 of whom had no diabetes by history (ND), 80 had type 1 diabetes, and 544 had type 2 diabetes. Polyneuropathy was assessed by history and foot examination including pressure, temperature, and vibration perception and was classified as possible, probable, and severe. Foot pulses and HbA1c were determined in subsets of participants.

RESULTS

Polyneuropathy was detected in 53.8% of ND, 43.8% of type 1, and 55.6% of type 2 diabetes subjects and was associated with higher age. In a subset of participants with polyneuropathy, the latter was declared as previously undiagnosed by 79.1% of ND, 35.7% of type 1, and 61.5% of type 2 diabetes participants. After adjustment for age and sex, prevalent polyneuropathy was associated with peripheral arterial disease.

CONCLUSIONS

More than half of subjects with and without diabetes participating in an educational initiative had polyneuropathy which was reported as previously undiagnosed by two thirds. Effective strategies to avoid underdiagnosis of neuropathy and to improve preventive foot care should be implemented.