The Ministry of Health's updated Clinical Practice Guidelines - Diabetes Mellitus was recently launched on 23 July 2006. The aim of the guidelines is to ensure that all persons with diabetes undergo standard necessary evidence-based screening in order to manage diabetes and in some cases prevent complications associated with diabetes.

One of these preventable complications is the area of the foot and amputation. Amputation is one of the most feared complications of persons with diabetes. It is true that persons with diabetes have a greater risk of amputation (up to 70 times more likely than persons without diabetes) but that does not mean that all persons with diabetes will undergo amputation. What is the best way to avoid amputation

Studies show that a systematic screening, treatment and patient education protocol can reduce the lower extremity amputation rate by 44 to 85%. Early recognition and management of independent risk factors can prevent or delay adverse outcomes. This is the main focus of the "Prevention of Foot Complications" in the Clinical Practice Guidelines (CPG).

In short, the CPG instructs the primary physician with an easy to follow, systematic, yet comprehensive outline of screening, risk identification, treatment and patient education protocol which can be done in a clinical setting. In general, the CPG recommends that

1. All individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. That means, if you have diabetes and you have not had your feet checked - you need to. This is to be done during the initial diagnosis of your diabetes and following that, at least once a year.

2. The assessment of the feet involves risk identification, treatment and patient education appropriate to the level of risk. That means if you haven't been told if your feet are either At Risk" or "High Risk" and you haven't been told by your doctor, nurse or podiatrist what you need to do to manage existing foot problems, or prevent future foot problems, then you need to find out.

3 All patients, regardless of risk category, should receive ongoing education on footcare and footwear advice. Ensure that your doctor, nurse or podiatrist continues to counsel you on proper footcare and suitable footwear.

4 Patients identified with foot-related risk conditions should have access to a specialised footcare team which should includes diabetes specialist, podiatrist, physiotherapist trained in diabetes, diabetes nurse educator and vascular and orthopaedic surgeon. That means you need ready access to these people. Your primary physician / specialist may be able to coordinate this team.

5 Urgent referral to a specialised footcare team is needed in the presence of ulcerations, severe foot infection and gangrene. This means if something goes wrong - your foot needs to be checked by a specialist urgently.

Lastly, you play a very important role in saving your feet and legs from amputation.

It has been shown that well informed patients who are motivated to act with self-responsibility are the best defence against diabetic limb loss.

In this way, there is no reason why you would need to join the sad and unnecessary statistic of at least one leg and one toe being amputated (due to complications of diabetes) every day in Singapore.

 

Practical footcare guidelines has outlined in the Clinical Practice Guidelines)

 

 

DO's

 

 

Inspect Your Feet Everyday

  • Do look on top, underneath, in between toes, around heels.

  • Do look for cuts, scratches, abrasions or any broken skin

  • If found, do wash with saline, dress with dry sterile daily dressing.

  • If wound doesn't start to heal within 2 days. Do consult your doctor or podiatrist
     

Foot Hygiene

  •  Do wash feet daily using mild soap and warm water. Pay attention to areas in between toes.

  •  Do test water temperature with wrist or arm first to ensure that it is not too hot.

  •  Do pat dry especially on between toes.

  •  If feet are dry, do use moisturising cream nightly except in between toes.
     

Socks / Hosiery

  • Do ensure socks/stockings are not too tight

  • Do change socks/stockings daily.

  • Do ensure proper fit i.e. no bunching or wrinkling underneath.
     

General Hints

  • Do cut toenails straight across and not too short

  • Do seek help from your doctor, podiatrist or nurse educator if you are unsure of anything on your feet

  • Do exercise.

  • Do maintain good diabetes control.
     

Fitting

  • Do ensure a good fit One thumbnail width from the end of the longest toe to the end of the shoe.

  • Do wear shoes which are comfortable.
     

Style

  • Do wear closed-in shoes for protection. Sports shoes are deal however sports sandals are acceptable. Remember to check your feet regularly.

  • Do wear shoes with a rounded toebox.

  • Do wear shoes with laces or straps or buckles.
     

General Hints

  • Do check inside shoe for foreign objects, sharp seams, torn linings before you put on shoes.

  • Do "wear in" new shoes gradually e.g. 1 hour the 1st day, 2 hours the 2nd day, 3 hours the 3rd day until you can wear them through the day. Check feet for signs of rubbing - redness, blisters, pressure areas, open wounds.

  • Do alternate between 2 pairs of shoes i.e. use one pair for Mon. Wed, Fri, Sun and the other pair for Tues, Thurs, Sat.

  • Do clean and wash shoes regularly.

 

 

DON'Ts

 

Foot Neglect

  • Don't neglect your foot as small problems can turn into big problem quickly.
     

Bathroom Surgery

  • Don't cut hard skin, ingrown toenails yourself.

  • Don't use corn plasters and corn cures.
     

General Hints

  • Don't smoke

  • Don't walk barefoot. Always wear footwear inside and outside the house.
     

Fitting

  • Don't wear too tight or too loose shoes

  • Don't wear shoes which are required to stretch for a good fit.
     

Style

  • Don't wear slippers, flip-flops, thongs.

  • Don't wear shoes with pointy toes.

  • Don't wear shoes with high heels. The recommended height is 1 inch with a broad base.
     

General Hints

  • Don't sacrifice comfort and protection for the sake of fashion.

 

 

 

 

References
1 . Implementation of the St Vincent Declaration - Management of Diabetic Foot Disease. A National Clinical Guideline recommended for use in Scotland by Scottish Intercollegiate Guidelines Network (SIGN). March 1997:1.


2. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non insulin-dependent diabetes mellitus. Ann Inc Med 1993:119( 1 ): 36-41.


3. Standards of Medical Care in Diabetes - 2006.American Diabetes Association.


4. J.H.Aroni, Teaching FootCare Creatively and Successfully. Diabetes Spectrum vol 8 number 4. July/Aug 1995. p221.


5. Epidemiology & Disease Control Division Ministry of Health Singapore.