Diabetic foot primary prevention: Difference between revisions

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==Primary Prevention==
==Primary Prevention==
[[Foot]] [[ulcers]] can be [[Prevention (medical)|prevented]] by frequent [[physical examinations]], good [[foot]] [[hygiene]], [[diabetic sock]]s and shoes, and by avoiding [[injury]]. The following are some of the important steps for [[Prevention (medical)|primary prevention]] of [[diabetic foot]]:<ref name="pmid28614678">{{cite journal| author=Armstrong DG, Boulton AJM, Bus SA| title=Diabetic Foot Ulcers and Their Recurrence. | journal=N Engl J Med | year= 2017 | volume= 376 | issue= 24 | pages= 2367-2375 | pmid=28614678 | doi=10.1056/NEJMra1615439 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28614678  }} </ref><ref name="pmid9834731">{{cite journal| author=Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S | display-authors=etal| title=1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association. | journal=CMAJ | year= 1998 | volume= 159 Suppl 8 | issue=  | pages= S1-29 | pmid=9834731 | doi= | pmc=1255890 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834731  }} </ref><ref name="pmid9839111">{{cite journal| author=Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM| title=Preventive foot care in people with diabetes. | journal=Diabetes Care | year= 1998 | volume= 21 | issue= 12 | pages= 2161-77 | pmid=9839111 | doi=10.2337/diacare.21.12.2161 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9839111  }} </ref><ref name="pmid1425105">{{cite journal| author=Rith-Najarian SJ, Stolusky T, Gohdes DM| title=Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria. | journal=Diabetes Care | year= 1992 | volume= 15 | issue= 10 | pages= 1386-9 | pmid=1425105 | doi=10.2337/diacare.15.10.1386 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1425105  }} </ref><ref name="pmid8545495">{{cite journal| author=Mueller MJ| title=Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. | journal=Phys Ther | year= 1996 | volume= 76 | issue= 1 | pages= 68-71 | pmid=8545495 | doi=10.1093/ptj/76.1.68 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8545495  }} </ref><ref name="pmid10189538">{{cite journal| author=McGill M, Molyneaux L, Spencer R, Heng LF, Yue DK| title=Possible sources of discrepancies in the use of the Semmes-Weinstein monofilament. Impact on prevalence of insensate foot and workload requirements. | journal=Diabetes Care | year= 1999 | volume= 22 | issue= 4 | pages= 598-602 | pmid=10189538 | doi=10.2337/diacare.22.4.598 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10189538  }} </ref><ref name="Croxson2002">{{cite journal|last1=Croxson|first1=S.|title=Diabetes in the elderly: problems of care and service provision|journal=Diabetic Medicine|volume=19|year=2002|pages=66–72|issn=07423071|doi=10.1046/j.1464-5491.19.s4.12.x}}</ref><ref name="StumvollGoldstein2005">{{cite journal|last1=Stumvoll|first1=Michael|last2=Goldstein|first2=Barry J|last3=van Haeften|first3=Timon W|title=Type 2 diabetes: principles of pathogenesis and therapy|journal=The Lancet|volume=365|issue=9467|year=2005|pages=1333–1346|issn=01406736|doi=10.1016/S0140-6736(05)61032-X}}</ref>
{{See_also|Diabetic neuropathy primary prevention}}
*Control of [[blood sugar]] levels
 
[[Foot]] [[ulcers]] can maybe be [[Prevention (medical)|prevented]] by frequent [[physical examinations]], good [[foot]] [[hygiene]], [[diabetic sock]]s and shoes, and by avoiding [[injury]]. The following are some of the important steps for [[Prevention (medical)|primary prevention]] of [[diabetic foot]]:<ref name="pmid28614678">{{cite journal| author=Armstrong DG, Boulton AJM, Bus SA| title=Diabetic Foot Ulcers and Their Recurrence. | journal=N Engl J Med | year= 2017 | volume= 376 | issue= 24 | pages= 2367-2375 | pmid=28614678 | doi=10.1056/NEJMra1615439 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28614678  }} </ref><ref name="pmid9834731">{{cite journal| author=Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S | display-authors=etal| title=1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association. | journal=CMAJ | year= 1998 | volume= 159 Suppl 8 | issue=  | pages= S1-29 | pmid=9834731 | doi= | pmc=1255890 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834731  }} </ref><ref name="pmid9839111">{{cite journal| author=Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM| title=Preventive foot care in people with diabetes. | journal=Diabetes Care | year= 1998 | volume= 21 | issue= 12 | pages= 2161-77 | pmid=9839111 | doi=10.2337/diacare.21.12.2161 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9839111  }} </ref><ref name="pmid1425105">{{cite journal| author=Rith-Najarian SJ, Stolusky T, Gohdes DM| title=Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria. | journal=Diabetes Care | year= 1992 | volume= 15 | issue= 10 | pages= 1386-9 | pmid=1425105 | doi=10.2337/diacare.15.10.1386 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1425105  }} </ref><ref name="pmid8545495">{{cite journal| author=Mueller MJ| title=Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. | journal=Phys Ther | year= 1996 | volume= 76 | issue= 1 | pages= 68-71 | pmid=8545495 | doi=10.1093/ptj/76.1.68 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8545495  }} </ref><ref name="pmid10189538">{{cite journal| author=McGill M, Molyneaux L, Spencer R, Heng LF, Yue DK| title=Possible sources of discrepancies in the use of the Semmes-Weinstein monofilament. Impact on prevalence of insensate foot and workload requirements. | journal=Diabetes Care | year= 1999 | volume= 22 | issue= 4 | pages= 598-602 | pmid=10189538 | doi=10.2337/diacare.22.4.598 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10189538  }} </ref><ref name="Croxson2002">{{cite journal|last1=Croxson|first1=S.|title=Diabetes in the elderly: problems of care and service provision|journal=Diabetic Medicine|volume=19|year=2002|pages=66–72|issn=07423071|doi=10.1046/j.1464-5491.19.s4.12.x}}</ref><ref name="StumvollGoldstein2005">{{cite journal|last1=Stumvoll|first1=Michael|last2=Goldstein|first2=Barry J|last3=van Haeften|first3=Timon W|title=Type 2 diabetes: principles of pathogenesis and therapy|journal=The Lancet|volume=365|issue=9467|year=2005|pages=1333–1346|issn=01406736|doi=10.1016/S0140-6736(05)61032-X}}</ref>
*Control of [[blood sugar]] levels may help in both type 1<ref name="pmid35007329">{{cite journal| author=Boyko EJ, Zelnick LR, Braffett BH, Pop-Busui R, Cowie CC, Lorenzi GM | display-authors=etal| title=Risk of Foot Ulcer and Lower-Extremity Amputation Among Participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study. | journal=Diabetes Care | year= 2022 | volume= 45 | issue= 2 | pages= 357-364 | pmid=35007329 | doi=10.2337/dc21-1816 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35007329  }} </ref> and type 2<ref name="pmid30336205">{{cite journal| author=Goldman MP, Clark CJ, Craven TE, Davis RP, Williams TK, Velazquez-Ramirez G | display-authors=etal| title=Effect of Intensive Glycemic Control on Risk of Lower Extremity Amputation. | journal=J Am Coll Surg | year= 2018 | volume= 227 | issue= 6 | pages= 596-604 | pmid=30336205 | doi=10.1016/j.jamcollsurg.2018.09.021 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30336205  }} </ref> diabetes.
*Appropriate control of [[blood pressure]] and [[lipid|lipid profiles]]
*Appropriate control of [[blood pressure]] and [[lipid|lipid profiles]]
*[[Pressure]] offloading
*Proper [[foot]]wear (such as [[pressure]]-relieving [[foot]]wear)
**Although the comparison of custom shoes versus well-chosen and well-fitted athletic shoes is not clear.
*[[Pressure]] offloading insoles<ref name="pmid31773194">{{cite journal| author=Crawford F, Nicolson DJ, Amanna AE, Martin A, Gupta S, Leese GP | display-authors=etal| title=Preventing foot ulceration in diabetes: systematic review and meta-analyses of RCT data. | journal=Diabetologia | year= 2020 | volume= 63 | issue= 1 | pages= 49-64 | pmid=31773194 | doi=10.1007/s00125-019-05020-7 | pmc=6890632 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31773194  }} </ref>. In addition to custom orthotics, this includes received cork inserts and prefabricated insoles
* Silicone digital orthotics<ref name="pmid31773194"/><ref name="pmid19141719">{{cite journal| author=Scirè V, Leporati E, Teobaldi I, Nobili LA, Rizzo L, Piaggesi A| title=Effectiveness and safety of using Podikon digital silicone padding in the primary prevention of neuropathic lesions in the forefoot of diabetic patients. | journal=J Am Podiatr Med Assoc | year= 2009 | volume= 99 | issue= 1 | pages= 28-34 | pmid=19141719 | doi=10.7547/0980028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19141719  }} </ref>
 
*Regular [[Physical examination|examinations]]
*Regular [[Physical examination|examinations]]
**Studies recommend an annual [[Screening (medicine)|screening]] by the [[physician]] for every [[diabetes|diabetic]] [[patient]] older than 15 years old and more frequent for [[patients]] who are at risk (such as [[neuropathy]]).
**Studies recommend an annual [[Screening (medicine)|screening]] by the [[physician]] for every [[diabetes|diabetic]] [[patient]] older than 15 years old and more frequent for [[patients]] who are at risk (such as [[neuropathy]]).
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*[[Foot]]-care education:
*[[Foot]]-care education:
**Based on studies [[foot]]-care education combined with increased surveillance can reduce the [[incidence]] of serious [[foot]] problems. <ref name="pmid8498761">{{cite journal |author=Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F |title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial |journal=Ann Intern Med |volume=119 |issue=1 |pages=36-41 |year=1993 |pmid=8498761}}</ref>
**Based on studies [[foot]]-care education combined with increased surveillance can reduce the [[incidence]] of serious [[foot]] problems. <ref name="pmid8498761">{{cite journal |author=Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F |title=Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial |journal=Ann Intern Med |volume=119 |issue=1 |pages=36-41 |year=1993 |pmid=8498761}}</ref>
*Proper [[foot]]wear (such as [[pressure]]-relieving [[foot]]wear)
* Temperature-guided avoidance therapy<ref name="pmid21447666">{{cite journal| author=Arad Y, Fonseca V, Peters A, Vinik A| title=Beyond the monofilament for the insensate diabetic foot: a systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes. | journal=Diabetes Care | year= 2011 | volume= 34 | issue= 4 | pages= 1041-6 | pmid=21447666 | doi=10.2337/dc10-1666 | pmc=3064020 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21447666  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=22007067 Review in: Ann Intern Med. 2011 Oct 18;155(8):JC4-8] </ref>
**All major reviews recommend special [[foot]]wear for [[patients]] with a prior [[ulcer]] or with [[foot]] deformities.  
**One review added [[neuropathy]] as an indication for special [[foot]]wear.  
**Although the comparison of custom shoes versus well-chosen and well-fitted athletic shoes is not clear.
*Long term [[aerobic exercise]] decreases the risk of [[diabetic foot]] development.<ref name="pmid16798472">{{cite journal| author=Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F | display-authors=etal| title=Exercise training can modify the natural history of diabetic peripheral neuropathy. | journal=J Diabetes Complications | year= 2006 | volume= 20 | issue= 4 | pages= 216-23 | pmid=16798472 | doi=10.1016/j.jdiacomp.2005.07.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16798472  }} </ref>
*Long term [[aerobic exercise]] decreases the risk of [[diabetic foot]] development.<ref name="pmid16798472">{{cite journal| author=Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F | display-authors=etal| title=Exercise training can modify the natural history of diabetic peripheral neuropathy. | journal=J Diabetes Complications | year= 2006 | volume= 20 | issue= 4 | pages= 216-23 | pmid=16798472 | doi=10.1016/j.jdiacomp.2005.07.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16798472  }} </ref>
====Clinical practice guidelines====
A [[clinical practice guideline]] by the [https://iwgdfguidelines.org/%20International%20Working%20Group%20on%20the%20Diabetic%20Foot International Working Group on the Diabetic Foot] (IWGDF) recommended<ref name="pmid32176451">{{cite journal| author=Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN | display-authors=etal| title=Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). | journal=Diabetes Metab Res Rev | year= 2020 | volume= 36 Suppl 1 | issue=  | pages= e3269 | pmid=32176451 | doi=10.1002/dmrr.3269 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32176451  }} </ref>:
* screening for  loss of protective sensation (LOPS), peripheral artery disease (PAD). If a monofilament is not available, the Ipswich Touch Test (IpTT) can be used.
However, a [[systematic review]] by the [https://iwgdfguidelines.org/%20International%20Working%20Group%20on%20the%20Diabetic%20Foot International Working Group on the Diabetic Foot] (IWGDF) concluded<ref name="pmid31957213">{{cite journal| author=van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Rasmussen A, Sacco ICN | display-authors=etal| title=Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. | journal=Diabetes Metab Res Rev | year= 2020 | volume= 36 Suppl 1 | issue=  | pages= e3270 | pmid=31957213 | doi=10.1002/dmrr.3270 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31957213  }} </ref>:
* " Despite the importance of this topic, ulcer risk classification is only considered an intervention when a classification is linked directly to a strategy based on referral of patients for treatment.139 No such studies were identified. It remains crucial to better understand if the way in which we stratify risk is effective for ulcer prevention"
A prior systematic review had a similarly negative conclusion<ref name="pmid23280992">{{cite journal| author=Ozdemir BA, Brownrigg J, Patel N, Jones KG, Thompson MM, Hinchliffe RJ| title=Population-based screening for the prevention of lower extremity complications in diabetes. | journal=Diabetes Metab Res Rev | year= 2013 | volume= 29 | issue= 3 | pages= 173-82 | pmid=23280992 | doi=10.1002/dmrr.2383 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23280992  }} </ref>.


====Clinical Trials====
====Clinical Trials====
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   | accessdate = 2007-12-04
   | accessdate = 2007-12-04
}}</ref>
}}</ref>
*A [[meta-analysis]] by the [[Cochrane Collaboration]] concluded that "there is very limited evidence of the effectiveness of therapeutic shoes". <ref name="pmid10908550">{{cite journal |author=Spencer S |title=Pressure relieving interventions for preventing and treating diabetic foot ulcers |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002302 |year= |pmid=10908550 | doi=10.1002/14651858.CD002302}}</ref> However, the meta-analysis was published before the major trial that is in the table below.  
*A [[meta-analysis | meta-analyses]] by the [[Cochrane Collaboration]] conclude:
*A small and non-randomized trial showed the benefits of custom [[foot]]wear in [[patients]] with a prior [[foot]] [[ulcer|ulceration]], with a [[number needed to treat]] of 4 [[patients]].<ref name=pmid8721941">{{cite journal |author=Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G |title=Manufactured shoes in the prevention of diabetic foot ulcers |journal=Diabetes Care |volume=18 |issue=10 |pages=1376-8 |year=1995 |pmid=8721941}}</ref>  
** " There is no high-quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit."<ref name="pmid26299991">{{cite journal| author=Hoogeveen RC, Dorresteijn JA, Kriegsman DM, Valk GD| title=Complex interventions for preventing diabetic foot ulceration. | journal=Cochrane Database Syst Rev | year= 2015 | volume= | issue= 8 | pages= CD007610 | pmid=26299991 | doi=10.1002/14651858.CD007610.pub3 | pmc=8504983 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26299991  }} </ref>
*A major [[randomized controlled trial]] of specialized [[foot]]wear showed no benefit for [[patients]] with a prior [[foot]] [[ulcer|ulceration]] (see table below).<ref name="pmid12020336">{{cite journal| author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et  al.| title=Effect of therapeutic footwear on foot reulceration in  patients with diabetes: a randomized controlled trial. | journal=JAMA |  year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 |  doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336  }} </ref>
**  that "there is very limited evidence of the effectiveness of therapeutic shoes". <ref name="pmid10908550">{{cite journal |author=Spencer S |title=Pressure relieving interventions for preventing and treating diabetic foot ulcers |journal=Cochrane Database Syst Rev |volume= |issue= |pages=CD002302 |year= |pmid=10908550 |  doi=10.1002/14651858.CD002302}}</ref>
 
{| class="wikitable"
{| class="wikitable"
|+ Randomized controlled trials of interventions to prevent complications of diabetic foot.<ref name="pmid12020336">{{cite journal|  author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et  al.| title=Effect of therapeutic footwear on foot reulceration in  patients with diabetes: a randomized controlled trial. | journal=JAMA |  year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 |  doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336  }} </ref> <ref name="pmid8498761">{{cite journal|  author=Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild  DE et al.| title=Reduction of lower extremity clinical abnormalities in  patients with non-insulin-dependent diabetes mellitus. A randomized,  controlled trial. | journal=Ann Intern Med | year= 1993 | volume= 119 |  issue= 1 | pages= 36-41 | pmid=8498761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8498761  }} </ref> <ref name="pmid9472868">{{cite journal|  author=McCabe CJ, Stevenson RC, Dolan AM| title=Evaluation of a  diabetic foot screening and protection programme. | journal=Diabet Med |  year= 1998 | volume= 15 | issue= 1 | pages= 80-4 | pmid=9472868 |  doi=10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472868  }} </ref> <ref name="pmid18758747">{{cite journal|  author=Lincoln NB, Radford KA, Game FL, Jeffcoate WJ| title=Education  for secondary prevention of foot ulcers in people with diabetes: a  randomised controlled trial. | journal=Diabetologia | year= 2008 |  volume= 51 | issue= 11 | pages= 1954-61 | pmid=18758747 |  doi=10.1007/s00125-008-1110-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18758747  }} </ref>
|+ Randomized controlled trials of interventions to prevent complications of diabetic foot.<ref name="pmid12020336">{{cite journal|  author=Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C et  al.| title=Effect of therapeutic footwear on foot reulceration in  patients with diabetes: a randomized controlled trial. | journal=JAMA |  year= 2002 | volume= 287 | issue= 19 | pages= 2552-8 | pmid=12020336 |  doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12020336  }} </ref> <ref name="pmid8498761">{{cite journal|  author=Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild  DE et al.| title=Reduction of lower extremity clinical abnormalities in  patients with non-insulin-dependent diabetes mellitus. A randomized,  controlled trial. | journal=Ann Intern Med | year= 1993 | volume= 119 |  issue= 1 | pages= 36-41 | pmid=8498761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8498761  }} </ref> <ref name="pmid9472868">{{cite journal|  author=McCabe CJ, Stevenson RC, Dolan AM| title=Evaluation of a  diabetic foot screening and protection programme. | journal=Diabet Med |  year= 1998 | volume= 15 | issue= 1 | pages= 80-4 | pmid=9472868 |  doi=10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472868  }} </ref> <ref name="pmid18758747">{{cite journal|  author=Lincoln NB, Radford KA, Game FL, Jeffcoate WJ| title=Education  for secondary prevention of foot ulcers in people with diabetes: a  randomised controlled trial. | journal=Diabetologia | year= 2008 |  volume= 51 | issue= 11 | pages= 1954-61 | pmid=18758747 |  doi=10.1007/s00125-008-1110-0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18758747 }} </ref><ref name="pmid9405902">{{cite journal| author=Rönnemaa T, Hämäläinen H, Toikka T, Liukkonen I| title=Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects. | journal=Diabetes Care | year= 1997 | volume= 20 | issue= 12 | pages= 1833-7 | pmid=9405902 | doi=10.2337/diacare.20.12.1833 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9405902  }} </ref><ref name="pmid19141719">{{cite journal| author=Scirè V, Leporati E, Teobaldi I, Nobili LA, Rizzo L, Piaggesi A| title=Effectiveness and safety of using Podikon digital silicone padding in the primary prevention of neuropathic lesions in the forefoot of diabetic patients. | journal=J Am Podiatr Med Assoc | year= 2009 | volume= 99 | issue= 1 | pages= 28-34 | pmid=19141719 | doi=10.7547/0980028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19141719 }} </ref>
!  rowspan="2"|Trial!!rowspan="2"| Patients!!rowspan="2"|  Intervention!!rowspan="2"|Comparison  !!rowspan="2"|Outcome!!colspan="2"|Results!!rowspan="2"|Comment
!  rowspan="2"|Trial!!rowspan="2"| Patients!!rowspan="2"|  Intervention!!rowspan="2"|Comparison  !!rowspan="2"|Outcome!!colspan="2"|Results!!rowspan="2"|Comment
|-<br/>
|-<br/>
! Intervention!!Control
! Intervention!!Control
|-
|-
| Litzelman<ref name="pmid8498761"/><br/>1993|| 395 patients<br/>&bull;&nbsp;General medicine practice|| [[Patient]] and provider education||Usual care||&bull;&nbsp;Any [[foot]] lesion<br/> &bull;&nbsp;Serious [[foot]] lesions at one year|| Not reported||&bull;&nbsp;11%<br/>&bull;&nbsp;2.9%||<br/>&bull;&nbsp;Insignificant <br/>&bull;&nbsp;Significant reduction
| Litzelman<ref name="pmid8498761"/><br/>1993|| 395 patients<br/>&bull;&nbsp;General medicine practice|| [[Patient]] and provider education:<br/>&bull;&nbsp;"Nurse-clinicians conducted patient education sessions with "one to four patients, covering appropriate foot-care behaviors and footwear, using a commercially available slide and audiotape presentation [27] and pamphlets [28]. Behavioral contracts regarding desired foot-care behaviors were negotiated with each patient. Follow-up was done by telephone 2 weeks after the education sessions to remind patients about the contracted behavior. Additionally, postcard reminders, detailing the agreed-on behaviors, were sent at 1 and 3 months to patients in the intervention group."<br/>&bull;&nbsp;Prompts for "health care providers to ask patients to remove their footwear, to perform foot examinations, and to provide foot-care education at each visit. Physicians received an informational flow sheet providing patient-specific risk factors and foot-care practice guidelines for assessment, diagnostic work-up, treatment, and referral recommendations. "||Usual care||&bull;&nbsp;Any [[foot]] lesion<br/> &bull;&nbsp;Serious [[foot]] lesions at one year|| Rate not reported.<br/>OR for serious = 0.41 (p=0.05)||&bull;&nbsp;11%<br/>&bull;&nbsp;2.9%||<br/>&bull;&nbsp;Insignificant <br/>&bull;&nbsp;Significant reduction
|-
|-
| Lincoln<ref name="pmid18758747"/><br/>2008|| 172 patients<br/>&bull;&nbsp;Prior ulceration<br/>&bull;&nbsp;Specialist clinic|| Targeted, one-to-one education ||Usual care||Re-ulceration at<br/>&bull;&nbsp;1 year<br/>2 years|| &bull;&nbsp;30%<br/>&bull;&nbsp;41%||&bull;&nbsp;20%<br/>&bull;&nbsp;41%||&bull;&nbsp;Insignificant<br/>&bull;&nbsp;Insignificant
| Rönnemaa<ref name="pmid9405902"/><br/>1997|| 733 patients<br/>&bull;&nbsp;Primary care<br/>&bull;&nbsp;" Patients without recent visits to a podiatrist and without an obvious need for foot care"||"education and primary prevention measure" by podiatrist:<br/>"Education was given individually to every patient, taking into account each patient's age, occupation, earlier foot care habits, etc. Education included guidance concerning the use of proper footwear (socks, shoes), daily hygiene, cutting of toenails, use of emollient cream when necessary, avoidance of high-risk situations (e.g., exposure of the feet to hot environment, walking barefoot), and foot gymnastics. Preventive measures included gentle debridement of calluses, preparation of individual insoles, promotion of the use of emollient creams, treatment for ingrown toenails, guidance for foot gymnastics, etc. Foot gymnastics were aimed at increasing or maintaining muscle strength and joint mobility by regular training, e.g., walking on the heels and on the forefeet, flexing, extending, and spreading out the toes. The services of the podiatrists were free of charge to the patients."||Written instructions||Non-calceneal [[callus]]es at one year:<br/>&bull;&nbsp;Prevalence<br/>&bull;&nbsp;Size<br/>Knowledge||<br/><br/>&bull;&nbsp;40%<br/>&bull;&nbsp;Size reduction<br/>||&bull;&nbsp;48%<br/><br/>||<br/><br/>&bull;&nbsp; P < 0.001<br/>&bull;&nbsp;P = 0.009<br/>&bull;&nbsp;"significant improvements in knowledge and foot self-care scores"
|-
|-
| McCabe<ref name="pmid9472868"/><br/>1998|| 2002 patients<br/>&bull;&nbsp;High-risk<br/>&bull;&nbsp;General  diabetic clinic|| [[Screening (medicine)|Screening]] and referral to [[foot]]-care clinic if they had prior [[ulcer]], low [[ABI|ankle–brachial index]] (<0.75), or [[foot]] deformities||Usual care||&bull;&nbsp;[[ulcer|Ulceration]] within 2 years<br/>&bull;&nbsp;[[Amputation]] rates|| &bull;&nbsp;2%<br/>&bull;&nbsp;0.1%|| 4%<br/>1.2%||&bull;&nbsp;Insignificant<br/>&bull;&nbsp;Significant
| McCabe<ref name="pmid9472868"/><br/>1998|| 2002 patients<br/>&bull;&nbsp;<span style="color:red;font-weight:bold">High-risk</span><br/>&bull;&nbsp;General  diabetic clinic|| [[Screening (medicine)|Screening]] and referral to [[foot]]-care clinic if they had prior [[ulcer]], low [[ABI|ankle–brachial index]] (<0.75), or [[foot]] deformities||Usual care||&bull;&nbsp;[[ulcer|Ulceration]] within 2 years<br/>&bull;&nbsp;[[Amputation]] rates|| &bull;&nbsp;2%<br/>&bull;&nbsp;0.1%|| 4%<br/>1.2%||&bull;&nbsp;Insignificant<br/>&bull;&nbsp;Significant
|-
|-
| Reiber<ref name="pmid12020336"/><br/>2002|| 400 patients<br/>&bull;&nbsp;Prior [[ulcer|ulceration]]<br/>&bull;&nbsp;Excluded severe deformity||Therapeutic shoes||Usual [[foot]]wear|| Re-ulceration ||   15%|| 17%|| Insignificant difference
| Scirè<ref name="pmid19141719"/><br/>2009|| 167 patients<br/>&bull;&nbsp;<span style="color:red;font-weight:bold">High-risk</span><br/>&bull;&nbsp;"Neuropathic patients with deformities and localized hyperkeratosis in the forefoot"|| Podikon digital silicone padding orthoses||Usual care||&bull;&nbsp;[[ulcer|Ulceration]] within 3 months<ref name="pmid26340966"/><br/>&bull;&nbsp;Hyperkeratosis  within 3 months<ref name="pmid26340966"/>|| &bull;&nbsp;1.5%<br/>&bull;&nbsp;41%|| 15.4%<br/>84%||&bull;&nbsp;Significant<br/>&bull;&nbsp;Significant
|}
|}


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[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
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Latest revision as of 05:06, 31 January 2022

Diabetic foot Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2], Anahita Deylamsalehi, M.D.[3]

Overview

Foot ulcers can be prevented by frequent physical examinations, proper glycemic control, good foot hygiene, diabetic socks and shoes, and by avoiding injury. Studies recommend an annual screening by the physician for every diabetic patient older than 15 years old and more frequent for patients who are at risk (such as neuropathy). A careful examination should consist of a peripheral neuropathy assessment, which should be done by checking ankle reflexes, vibration, and sensation. A study showed the importance of using a 10-g Semmes-Weinstein monofilament with a 10 fold risk elevation of foot ulcer development and a 17 fold increase in amputation rate within a 32-month follow up in patients who had abnormal 10-g Semmes-Weinstein monofilament examinations.

Primary Prevention

Foot ulcers can maybe be prevented by frequent physical examinations, good foot hygiene, diabetic socks and shoes, and by avoiding injury. The following are some of the important steps for primary prevention of diabetic foot:[1][2][3][4][5][6][7][8]

  • Control of blood sugar levels may help in both type 1[9] and type 2[10] diabetes.
  • Appropriate control of blood pressure and lipid profiles
  • Proper footwear (such as pressure-relieving footwear)
    • Although the comparison of custom shoes versus well-chosen and well-fitted athletic shoes is not clear.
  • Pressure offloading insoles[11]. In addition to custom orthotics, this includes received cork inserts and prefabricated insoles
  • Silicone digital orthotics[11][12]

Clinical practice guidelines

A clinical practice guideline by the International Working Group on the Diabetic Foot (IWGDF) recommended[16]:

  • screening for loss of protective sensation (LOPS), peripheral artery disease (PAD). If a monofilament is not available, the Ipswich Touch Test (IpTT) can be used.

However, a systematic review by the International Working Group on the Diabetic Foot (IWGDF) concluded[17]:

  • " Despite the importance of this topic, ulcer risk classification is only considered an intervention when a classification is linked directly to a strategy based on referral of patients for treatment.139 No such studies were identified. It remains crucial to better understand if the way in which we stratify risk is effective for ulcer prevention"

A prior systematic review had a similarly negative conclusion[18].

Clinical Trials

  • Clinical Evidence reviewed the topic and concluded "Individuals with significant foot deformities should be considered for referral and assessment for customized shoes that can accommodate the altered foot anatomy. In the absence of significant deformities, high quality well fitting non-prescription footwear seems to be a reasonable option".[19]
  • The National Institute for Health and Clinical Excellence has reviewed the topic and concluded that for patients who are at "high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer", "specialist footwear and insoles" should be provided. [20]
  • A meta-analyses by the Cochrane Collaboration conclude:
    • " There is no high-quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit."[21]
    • that "there is very limited evidence of the effectiveness of therapeutic shoes". [22]
Randomized controlled trials of interventions to prevent complications of diabetic foot.[23] [13] [24] [25][26][12]
Trial Patients Intervention Comparison Outcome Results Comment
Intervention Control
Litzelman[13]
1993
395 patients
• General medicine practice
Patient and provider education:
• "Nurse-clinicians conducted patient education sessions with "one to four patients, covering appropriate foot-care behaviors and footwear, using a commercially available slide and audiotape presentation [27] and pamphlets [28]. Behavioral contracts regarding desired foot-care behaviors were negotiated with each patient. Follow-up was done by telephone 2 weeks after the education sessions to remind patients about the contracted behavior. Additionally, postcard reminders, detailing the agreed-on behaviors, were sent at 1 and 3 months to patients in the intervention group."
• Prompts for "health care providers to ask patients to remove their footwear, to perform foot examinations, and to provide foot-care education at each visit. Physicians received an informational flow sheet providing patient-specific risk factors and foot-care practice guidelines for assessment, diagnostic work-up, treatment, and referral recommendations. "
Usual care • Any foot lesion
• Serious foot lesions at one year
Rate not reported.
OR for serious = 0.41 (p=0.05)
• 11%
• 2.9%

• Insignificant
• Significant reduction
Rönnemaa[26]
1997
733 patients
• Primary care
• " Patients without recent visits to a podiatrist and without an obvious need for foot care"
"education and primary prevention measure" by podiatrist:
"Education was given individually to every patient, taking into account each patient's age, occupation, earlier foot care habits, etc. Education included guidance concerning the use of proper footwear (socks, shoes), daily hygiene, cutting of toenails, use of emollient cream when necessary, avoidance of high-risk situations (e.g., exposure of the feet to hot environment, walking barefoot), and foot gymnastics. Preventive measures included gentle debridement of calluses, preparation of individual insoles, promotion of the use of emollient creams, treatment for ingrown toenails, guidance for foot gymnastics, etc. Foot gymnastics were aimed at increasing or maintaining muscle strength and joint mobility by regular training, e.g., walking on the heels and on the forefeet, flexing, extending, and spreading out the toes. The services of the podiatrists were free of charge to the patients."
Written instructions Non-calceneal calluses at one year:
• Prevalence
• Size
Knowledge


• 40%
• Size reduction
• 48%



•  P < 0.001
• P = 0.009
• "significant improvements in knowledge and foot self-care scores"
McCabe[24]
1998
2002 patients
• High-risk
• General diabetic clinic
Screening and referral to foot-care clinic if they had prior ulcer, low ankle–brachial index (<0.75), or foot deformities Usual care • Ulceration within 2 years
• Amputation rates
• 2%
• 0.1%
4%
1.2%
• Insignificant
• Significant
Scirè[12]
2009
167 patients
• High-risk
• "Neuropathic patients with deformities and localized hyperkeratosis in the forefoot"
Podikon digital silicone padding orthoses Usual care • Ulceration within 3 months[27]
• Hyperkeratosis within 3 months[27]
• 1.5%
• 41%
15.4%
84%
• Significant
• Significant

Video: Diabetic Foot Care

{{#ev:youtube|DASvmFJeYX8}}

References

  1. Armstrong DG, Boulton AJM, Bus SA (2017). "Diabetic Foot Ulcers and Their Recurrence". N Engl J Med. 376 (24): 2367–2375. doi:10.1056/NEJMra1615439. PMID 28614678.
  2. Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S; et al. (1998). "1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association". CMAJ. 159 Suppl 8: S1–29. PMC 1255890. PMID 9834731.
  3. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM (1998). "Preventive foot care in people with diabetes". Diabetes Care. 21 (12): 2161–77. doi:10.2337/diacare.21.12.2161. PMID 9839111.
  4. Rith-Najarian SJ, Stolusky T, Gohdes DM (1992). "Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. A prospective evaluation of simple screening criteria". Diabetes Care. 15 (10): 1386–9. doi:10.2337/diacare.15.10.1386. PMID 1425105.
  5. Mueller MJ (1996). "Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments". Phys Ther. 76 (1): 68–71. doi:10.1093/ptj/76.1.68. PMID 8545495.
  6. McGill M, Molyneaux L, Spencer R, Heng LF, Yue DK (1999). "Possible sources of discrepancies in the use of the Semmes-Weinstein monofilament. Impact on prevalence of insensate foot and workload requirements". Diabetes Care. 22 (4): 598–602. doi:10.2337/diacare.22.4.598. PMID 10189538.
  7. Croxson, S. (2002). "Diabetes in the elderly: problems of care and service provision". Diabetic Medicine. 19: 66–72. doi:10.1046/j.1464-5491.19.s4.12.x. ISSN 0742-3071.
  8. Stumvoll, Michael; Goldstein, Barry J; van Haeften, Timon W (2005). "Type 2 diabetes: principles of pathogenesis and therapy". The Lancet. 365 (9467): 1333–1346. doi:10.1016/S0140-6736(05)61032-X. ISSN 0140-6736.
  9. Boyko EJ, Zelnick LR, Braffett BH, Pop-Busui R, Cowie CC, Lorenzi GM; et al. (2022). "Risk of Foot Ulcer and Lower-Extremity Amputation Among Participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study". Diabetes Care. 45 (2): 357–364. doi:10.2337/dc21-1816. PMID 35007329 Check |pmid= value (help).
  10. Goldman MP, Clark CJ, Craven TE, Davis RP, Williams TK, Velazquez-Ramirez G; et al. (2018). "Effect of Intensive Glycemic Control on Risk of Lower Extremity Amputation". J Am Coll Surg. 227 (6): 596–604. doi:10.1016/j.jamcollsurg.2018.09.021. PMID 30336205.
  11. 11.0 11.1 Crawford F, Nicolson DJ, Amanna AE, Martin A, Gupta S, Leese GP; et al. (2020). "Preventing foot ulceration in diabetes: systematic review and meta-analyses of RCT data". Diabetologia. 63 (1): 49–64. doi:10.1007/s00125-019-05020-7. PMC 6890632 Check |pmc= value (help). PMID 31773194.
  12. 12.0 12.1 12.2 Scirè V, Leporati E, Teobaldi I, Nobili LA, Rizzo L, Piaggesi A (2009). "Effectiveness and safety of using Podikon digital silicone padding in the primary prevention of neuropathic lesions in the forefoot of diabetic patients". J Am Podiatr Med Assoc. 99 (1): 28–34. doi:10.7547/0980028. PMID 19141719.
  13. 13.0 13.1 13.2 Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F (1993). "Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial". Ann Intern Med. 119 (1): 36–41. PMID 8498761.
  14. Arad Y, Fonseca V, Peters A, Vinik A (2011). "Beyond the monofilament for the insensate diabetic foot: a systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes". Diabetes Care. 34 (4): 1041–6. doi:10.2337/dc10-1666. PMC 3064020. PMID 21447666. Review in: Ann Intern Med. 2011 Oct 18;155(8):JC4-8
  15. Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F; et al. (2006). "Exercise training can modify the natural history of diabetic peripheral neuropathy". J Diabetes Complications. 20 (4): 216–23. doi:10.1016/j.jdiacomp.2005.07.005. PMID 16798472.
  16. Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN; et al. (2020). "Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)". Diabetes Metab Res Rev. 36 Suppl 1: e3269. doi:10.1002/dmrr.3269. PMID 32176451 Check |pmid= value (help).
  17. van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Rasmussen A, Sacco ICN; et al. (2020). "Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review". Diabetes Metab Res Rev. 36 Suppl 1: e3270. doi:10.1002/dmrr.3270. PMID 31957213.
  18. Ozdemir BA, Brownrigg J, Patel N, Jones KG, Thompson MM, Hinchliffe RJ (2013). "Population-based screening for the prevention of lower extremity complications in diabetes". Diabetes Metab Res Rev. 29 (3): 173–82. doi:10.1002/dmrr.2383. PMID 23280992.
  19. Hunt D. "Foot ulcers and amputations in diabetes". Clin Evid: 455–62. PMID 16620415. Text " based on September 2005 search" ignored (help)
  20. "Scope: Management of type 2 diabetes: prevention and management of foot problems (update)" (PDF). Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems. National Institute for Health and Clinical Excellence. 20 February 2003. Retrieved 2007-12-04.
  21. Hoogeveen RC, Dorresteijn JA, Kriegsman DM, Valk GD (2015). "Complex interventions for preventing diabetic foot ulceration". Cochrane Database Syst Rev (8): CD007610. doi:10.1002/14651858.CD007610.pub3. PMC 8504983 Check |pmc= value (help). PMID 26299991.
  22. Spencer S. "Pressure relieving interventions for preventing and treating diabetic foot ulcers". Cochrane Database Syst Rev: CD002302. doi:10.1002/14651858.CD002302. PMID 10908550.
  23. Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C; et al. (2002). "Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial". JAMA. 287 (19): 2552–8. PMID 12020336.
  24. 24.0 24.1 McCabe CJ, Stevenson RC, Dolan AM (1998). "Evaluation of a diabetic foot screening and protection programme". Diabet Med. 15 (1): 80–4. doi:10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K. PMID 9472868.
  25. Lincoln NB, Radford KA, Game FL, Jeffcoate WJ (2008). "Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial". Diabetologia. 51 (11): 1954–61. doi:10.1007/s00125-008-1110-0. PMID 18758747.
  26. 26.0 26.1 Rönnemaa T, Hämäläinen H, Toikka T, Liukkonen I (1997). "Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects". Diabetes Care. 20 (12): 1833–7. doi:10.2337/diacare.20.12.1833. PMID 9405902.
  27. 27.0 27.1