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Sensory Foot Examination
Sensory foot examination
Neuropathy can be detected using
the 10g (5.07 semmes-weinstein) monofilament, tuning fork (128 Hz),
and/or cotton wisp.
Semmes-Weinstein monofilament
Sensory examination should
be done in a quiet and relaxed setting. First apply the monofilament
on the patient's hands (or elbow, or forehead) so the patients know
what to expect.
The patient must not be
able to see if and where the examiner applies the filament. The
three sites to be tested on both feet are indicated in figure 3.
Apply the monofilament
perpendicular to the skin surface. (Figure 4).
Apply sufficient force
to cause the filament to bend or buckle (figure 5)
The total duration of
the approach, skin contact, and removal of the filament should be
approximately 2 seconds.
Apply the filament along
the perimeter of 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 at the test side.
Press the filament to
the skin and ask the patient IF they feel the pressure applied (yes/no)
and next WHERE they feel the pressure applied (left/right foot).
Repeat this application
twice at the same site, but alternate this with at least one "sham"
application, in which no filament is applied. (Total three questions
per site).
Protective sensation is
present at each site if the patients correctly answers two out of
three. If two out of three answers are wrong, patient is considered
to be at risk of ulceration.
Encourage the patients
during testing.
Fig-3
Sites to be tested with the monofilaments
Fig-4
Fig-5
Application of the monofilaments
Fig-6
Tuning Fork
The sensory exam
should be done in a quiet and relaxed setting. First apply the tuning
fork on the patient's wrists (or elbow, or clavicle) so the patient
knows what to expect.
The patient must
not be able to see if and where the examiner applies the tuning
fork. The tuning fork is applied on a bony part on the
dorsal side of the distal phalanx of the first toe.
It should be applied
perpendicularly with a constant pressure. (See figure 6)
Repeat this application
twice, but alternate this with at least one "sham" application,
in which the tuning fork is not vibrating.
If the patient correctly
answers on at least two out of three tries, protective sensation
is present and at risk for ulceration with two incorrect answers
out of three.
If the patient
is unable to sense the vibrations at the big toe, the test is repeated
more proximally (malleolus, tibial tuberosity). Encourage the patient
during testing.
Easy to use foot screening assessment
sheet for clinical examination
The foot is at risk if any of the below are present
Deformity or bony
prominences
Yes/No
Skin intact
Yes/No
Neuropathy
Monofilament detectable
Tuning fork detectable
Cotton wool detectable
Yes/No
Yes/No
Yes/No
Abnormal
pressure, callus
Loss of joint mobility
Yes/No
Yes/No
Foot pulses
Posterior tibial artery felt
Dorsalis pedis artery felt
Discoloration on dependency
Yes/No
Yes/No
Yes/No
Any others
Previous ulcer
Amputation
Yes/No
Yes/No
Inappropriate footwear
Yes/No
Actions to be taken
Action recommended
Yes/No
Referral
Yes/No
LATEST DEVELOPMENT IN THE RELIEF
OF PAINFUL DIABETIC POLYNEUROPATHY
The use of pulsed galvanic stimulation
of large areas of hands, legs and feet, using silver mesh stocking electrodes
and the micro pulsed galvanic stimulator apparatus, has been tried in
a large number of patients with very good results in obtaining relief
(85 - 95%)
