the individual patient lower extremity risk  |
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- the sensory exam should be done in a quiet and relaxed setting. the patient must not watch whole the examiner applies the filament.
- test the monofilament on the patient's hand so he/she knows what to anticipate.
- the five (or 10) sites to be tested are indicated on the accompanying screening form and a score of x/5 or x/10 can be given.
- apply the monofilament perpendicular to the skin's surface apply sufficient force to cause the filament to bend or buckle.
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- the total duration of the approach, skin contact, and departure of the filament should be approximately 1-1/2 seconds.
- apply the filament along the perimeter and not on an ulcer site, callus, scar or necrotic tissue. do not allow the filament to slide across the skin or make repetitive contact to the test site.
- press the filament to the skin such that it buckles at one of two times as you say "time one" or "time two". have patients identify at which time they were touched. randomize the sequence of applying the filament throughout the examination.
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-diabetes
-normal sensation
-+/- minor foot deformity
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yearly |
professionally fitted and accommodative |
footwear education |
2-3 months |
no restrictions.
encourage a regular exercise program. |
| moderate |
-diabetes
-loss of protective sensation
-no deformity
|
6 month |
professionally fitted and accommodative, with total contact insole depending on level of activity |
patient education |
6-8 weeks |
no restrictions as long as footwear and skin & nail care recommendations are followed. |
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-diabetes
-loss of protective sensation
-foot deformity with callous formation |
2-4 month |
professionally fitted and accommodative, with custom-molded foot orthosis |
patient education |
6-8 weeks |
emphasis on non-weight bearing activities such as swimming, biking, short walks (20 min. 2-3 times per day), weights and rowing. |
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-diabetes
-loss of protective sensation
-foot deformity
-history of ulceration and peripheral vascular disease |
1-2 month |
+/- custom footwear to accommodate the foot deformity |
patient education |
6 weeks |
gait retraining to take shorter steps. patients who are required to be on their feet for long preiods to perform the duties of their present job will need vocational counselling to assist with a career change. |
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- presence of an open wound or infection |
once a week as determined by the severity of the problem and the presence of other medical problems. |
special footwear with total contact inserts. air cast walking braces or total contact casting will be required to offload the foot wound site |
all the prescribed therapeutic measures must be reviewed with the patient and their caregivers during each follow up visit |
still must be attended to every 6 weeks so that other problems do not occur. |
walking must be kept to a minimum until the foot wound has almost healed. |
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- the signs of decreased blood flow to one's feet. this includes the presence of thickened, brittle nails, forefoot discoloration or rubor, shininess to the skin over the top of the foot and loss of hair from the toes and top of the foot skin.
- just walking as a form of exercise is not recommended. instead enjoy a variety of exercises such as biking, swimming, lightweights, rowing and short (15-20 minute) brisk walks and do a different activity each day.
- particular attention must be given to your feet when you notice an increase in foot, ankle or leg swelling since as this occurs, there is increased pressure to your skin caused by now ill-fitting walking shoes and in fact there is also a decrease in blood supply to the skin itself if the swelling is allowed to progress. therefore, it is essential that you seek immediate medical attention for progressive foot swelling.
- when walking, it is important that you try to walk through your (intermittent claudication) calf crampy pain as best as you can. by trying to walk even after your calf muscles start to arch, you are accelerating the development of collateral circulation in your legs to your feet. do the best that you can but don't hurt yourself. stop, rest and then try walking at a comfortable pace a bit further the next time.
- peripheral vascular patients must be aware of the significance of night pain especially when it occurs in your first toe. this pain is ischemic in nature secondary to the fact that in bed your foot is now in an elevated position and you are losing the benefit of gravity to assist in the delivery of blood to that digit.
you must report this to your doctor as the blood flow to your feet is now at a critically low level and peripheral vascular testing is required if it has not already been done.
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