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Diabetes testing best practise?

Discussion in 'Diabetic Foot & Wound Management' started by Tkemp, Aug 17, 2011.

  1. Tkemp

    Tkemp Active Member

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    My apologies if this has been covered already. I have checked other threads but could not find the answer.

    I would appreciate advice, opinions, feedback please.

    I've always carried out DM neuroloigcal testing as taught at Uni and am now confused by a colleague who states that half of it is not necessary or relevant.

    I check:
    Neurological 10g monofilament and neurotip (sharp/blunt) on IPJs, MTJs, Calc, dorsum (then dermatomes if required). Vibration perception on 1st apex & MTJ, 5th MTJ, both malleoli, then pat-fem if required.
    Muscle strength (for balance between legs, weakness, tremors, etc) of both feet and legs. Knee and ankle reflexes.
    Dermatological - colour, temp gradient, turgor, hydration, oedema, nails, hair growth.
    Vasc- with doppler the phasicity of PT & DP, SVPFT, if pulses palpable, intermittent claudication, night cramps, oedema.

    Then in my GP letters (to inform of test results and risk factors) I state my findings inc the locations of neuropathy, etc.

    My colleague feels palpating pulses, checking skin for colour, temp and hair growth, checking vibration perception and then 10g monofilament is adequate and that research proves other tests are not quantifiable and do not add to the diagnosis process.

    Obviously we both want what is best for the client and want to provide "gold standard" treatment, but I am confused as to whether I should continue to way I have over the past 3 years, or if I should streamline?

    (we both have the same time for appointments, so its not a matter of time)
  2. cperrin

    cperrin Active Member

    when doing our testing we are trying to fall in line with NICE CG10 -

    With this you only need to check if pedal pulses are palpable to get a confirmation of PVD, if we are concerned we will then go on to carry out a doppler and ABPI if necessary, if we can palpate the pulses there is no real need for a doppler at that point.

    With regard the neurological aspect, you are carrying out the correct test as it covers all the main nerve groups - 10g for A-β Motor and Sensory Fibres (TOUCH), 40g sharp for A-δ and non-myelinated C Fibres (PAIN) and tuning fork for A-β Motor and Sensory Fibres (VIBRATION). However you dont need to test the amount of sites that you do - main 'at risk' pressure areas are enough: 10g and 40g 1,3,5 Apex and MTPJ, tuning fork med. mal, 1st mtpj and hallux apex. There is no need to carry out reflexes as standard unless you have a concern to do so.

    Some good papers on all of this are:

    Lipsky, B. Armstrong, D. Singh, N. (2005) Preventing Foot Ulcers in Patients with Diabetes. Journal of the American Medical Association. 293 (2). 217-228

    Thivolet, C. Farkh, J el. Petiot, A. Simonet, C. Tourniaire, J. (1990) Measuring Vibration Sensations with Graduated Tuning Fork. Simple and Reliable Means to Detect Diabetic Patients at Risk of Neuropathic Foot Ulceration. Diabetes Care. 13. 1077-1080

    Young, M. (2008) A Perfect 10? Why the Accuracy of your Monofilament Matters. The Diabetic Foot Journal. 11 (3).

    Edit - Tkemp if you would like a copy of our diabetes review form pm your email and ill send you a copy
  3. fishpod

    fishpod Well-Known Member

    streamline ur doing to much not nessesary for apod to go this deep the medics generally manage the diabetic pt u just need to recognise the at risk pts and treat accordingly there are 1000snds of low risk pts who dont need al this it serves no purpose in private practice and would be awaste of resourses in nhs.
  4. Tkemp

    Tkemp Active Member

    I dont carry out all these tests for all patients. Only those with histroy of diabetes.
    Vascular tests are for those who have history of vascular conditions.
    Tests are annually, unless otherwise indicated.
    I work for Community Health in Rural Australia and GPs refer patients to our clinic for such testing.
    As a result of the testing we've had patients referred to vascular or neurological specialists eg. neuropathy which is in the L4, 5 dermatomes only and on specialist investigation has shown to be from nerve compression in the spine; queried DVT leading to hospital admission and treatment.

    Even in private practise, if you are concerned about a client or they have a history of medical conditions which impact on the health of the lower limb, then they should be initially assessed and monitored accordingly. Or so I believe.

    Thank you for the feedback though.
  5. fishpod

    fishpod Well-Known Member

    i meant low risk diabetic pts not none diabetic pts if i have concerns about a clients health i do not monitor i refer on as uk pods are not medically trained and have virtually no access to diagnostic testing in the nhs or p practice pods working for pcts cannot order x rays mri scans /ultasound scans or lab tests.HOWEVER IF YOU ARE BEING PAID for annual testing by the government of australia i would even record the colour of thier eyes for a fee if asked. ps spotting a dvt is fairly basic rock hard hot painful leg go to a/e immediatly do not pass go or collect 200 pounds. I GET AROUND 2 PTS PER YEAR WITH DVTS THEY ARE VERY GRATEFUL WHEN U SPOT IT AND ALWAYS THANK YOU FOR POTENTAILLY SAVING THIER LIVES
  6. Tkemp

    Tkemp Active Member

    Its not so much we carry out the service for a fee. It is part of our job contract and award level.
    I am UK trained and am allowed to monitor DM foot health, in conjunction with a MDT of DM Educaotr, Dietician, GP, physio. Due to regular appointments it is possible to assess for any deteriorations, etc. However, all clients are informed that if they notice a worsening of their conditions they are to see the GP or in emergencies attend the local hospital. We do not pretend to be Doctors and do not work outside of our scope of practise.
    With the tests, I have develpoed excellent working relationships with many of the local GPs and am able to write (or phone directly in emergencies) to request referral for tests or emergency admittance to hospital for ulcers with signs of systemic infection, gangrene, etc.
    The DVT in question was a warm hard lump by the knee, with the rest of the leg seemingly unaffected, but due to the history and doppler results I spoke to her GP and she was admitted for tests and it was a DVT.
    As you've said patients are grateful when we pick up on these conditions, and it is important though that we are alert for such changes and able to test as required.
    After all we are Podiatrists, not just nail cutters.

    My initial enquiry though was regarding the extent of testing required, not whether we should be testing as Podiatrists.
    Thank you for the information Chris, really appreciate it :)
  7. Tkemp

    Tkemp Active Member

    ... and obviously I cant spell today! Sorry.
  8. Katiebruce

    Katiebruce Member

    Confused over diabetes testing in podiatry practice. I offer this to patients but most say their GP does it. Is it expected of us to routinely test by trying to fit into an existing appointment.
  9. markjohconley

    markjohconley Well-Known Member

    Goodaye Tkemp, I have just been re-educated by a final year pod student; 'night cramps' if relieved by stretching and/or walking on cold floor is neurological etiologically not from vascular insufficiency.

    And I don't get how palpating pulsed is quantifiable??, all those patients with differing amounts of peripheral oedema affecting the tactile perception? of the pedal pulse, surely doppler waveform would be far more objective and quantitative.

  10. Tkemp

    Tkemp Active Member

    Hiya Katie,

    I find the GPs or practise nurses tend to check BGLs and 10g monofilament and leave it at that. They refer to us for full testing... at least that is what happens here.

    Thank you for the post, it is much what I wondered as some clients who are severly oedematous can only have their pulses located by doppler. However, as I have only a fraction of the experience of my colleague, I wanted to know if others agreed with this view.

  11. markjohconley

    markjohconley Well-Known Member

    For my part, a pleasure,

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