Educate Your Patients To Test At Home
Educate Your Patients To Test At Home
The American Diabetes Association’s 2017 Position Statement on diabetic neuropathy is unequivocal that early diagnosis is critical. “Screening for symptoms and signs of diabetic neuropathy is also critical in clinical practice, as it may detect the earliest stages of neuropathy, enabling early intervention… Assessment should include a careful history and either temperature or pinprick sensation for small-fiber function”. Virtually all health care professionals working and studying in this area express the view that anything that alters foot self-care behavior in diabetes has got to be a good thing. Testing sensation with a Medipin clearly represents the most simple and easily executed technique to perform in the home and empowers patients to participate in an important aspect of their own diabetic healthcare.
Utilizing the American Diabetes Association recommended procedure for pinprick testing to detect Loss of Protective sensation in Diabetic Peripheral Neuropathy a home testing kit of 12 Medipins is available for monthly testing at home. The procedure couldn’t be much simpler;
“A disposable pin should be applied just proximal to (before) the toenail on the dorsal (upper) surface of the hallux, (great toe) with just enough pressure to deform the skin. Inability to perceive pinprick over either hallux would be regarded as an abnormal test result”.
(Extract from: Comprehensive Foot Examination and Risk Assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists, Diabetes Care August 2008 vol. 31 no. 8 1679- 1685, p1681) http://care.diabetesjournals.org
View Patients Instruction Leaflet Below
The back of the pack has a calendar to record monthly results and a patient adopting the routine who discovers LOPS would potentially produce a calendar that looks like this;
Now when diabetes patients test themselves monthly they can report to you in the event of an abnormal finding. Detect LOPS before the annual check up. WHY WAIT?
FOR THE FUTURE
How The Standard, ADA Recommended, Test Could be superseded at home to offer an even earlier warning with CPC/PAC
At home Self-Testing Technique – The Diabetic Toes Test – utilizes a single application sufficient to indent the skin producing a simple, ‘binary’, yes/no response – sharp or not. This technique is a crude comparison designed to reveal only when sensation has deteriorated so far that patients can’t distinguish between a feeling of sharp or blunt. It represents the current standard recommended by the ADA but, inevitably, detects only extreme loss and higher ulceration risk. Very reliable, if a crude measure is the only requirement, but not the best option as an early warning.
Continuous Pinprick Comparison (CPC) or Pinprick Analogue Comparison (PAC) testing which seeks to quantify similarity in pinprick sensitivity between a ‘normal’ control area – such as the palmer side of the wrist - and that of the periphery (foot) by means of a Verbal Analogue Scale. In this case the patient uses pinprick to establish and ascribe an arbitrary numerical value of 5/10 to the sensation in the area representing their ‘normal’, which can be compared to the foot. The foot should feel the same as the wrist and subtle deterioration will be detected easily and quantified on the same scale. By recording the result monthly the patient can track any gradual loss over time.
This CPC/PAC test technique has so far been directed at clinicians only because it is more complex to perform though, logically, is consistent with justifiable evidence based physiology and is easily grasped where there is sufficient understanding. In order to introduce this to the patient population a stronger base of practical evidence would be helpful and this is to be gained through a pertinent study at an appropriate centre of excellence.
The ADA technique is simple and easy to convey to patients but ironically, not very compelling. It belongs to a group of 5 tests recommended by a specialist panel of experts who, themselves, subscribe to and promote, the current mood of professional controversy regarding the limitations to these and other tests in general which are claimed to achieve the same thing, It is, at best, for both the ADA and us, a compromise. In short it is simply our ‘safe’ and defensible option in that it is recognised and advocated but, when performed exactly as the ADA instructs, not that efficacious. More ironic is it that, despite being virtually unknown within the relevant healthcare professions, the available evidence strongly suggests even the ADA’s crude version of pinprick testing is, in all probability, superior to other tests recommended in the same group.
The actual revelation will be to utilise the conclusions from the completed CPC/PAC study for home testing. If the instructions can be conveyed simply to the home user there would suddenly be to hand a significantly more potent and logically compelling testing option where patients can really gauge their vulnerability risk dictated by pinprick integrity. Pinprick really is best for the verbal analogue scale as years of research show us.
It just can’t be done easily with alternative modalities, including monofilament and the sensory loss it detects develops earlier. Patients will be able to track their progress over the year with greater precision using a better-informed system for anticipating the development of increasing risk of ulceration - an even more reliable early warning. A patient performing the CPC/PAC technique routinely may produce a calendar as below:
The C-PAC test is compelling and has the potential to radically transform routine sensory testing for neuropathy efficiently, rapidly and inexpensively with this overlooked but elegant solution. It is most gratifying therefore that, fortunately, Prof Andrew Boulton’s team in Manchester, amongst the worlds foremost departments in this field and at the heart of advisory panels developing recommendations made for and adopted by the ADA have reviewed my detailed proposal and expressed interest in taking my study forward.