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Hello All,
Does anyone have a standard for testing sites on the foot with this instrument? Colleagues, not all podiatrists I have to add, have varying opinions testing and I would like to produce a ( evidence based ) standard for use in my region. Can anyone help please?

http://www.diabeticfoot.org.uk/

The above site gives a diagram of the recommended sites of testing, hope this is what you are after.

I personally think that testing plantarly is pointless, and I realise it is the adopted standard. I am yet to hear an argument why we should test areas that are affected significantly by calluses (hence invalidating the results because of an individual's biomechanics).

I test only non-weightbearing areas and ensure I test all nerves.

Hence, lat. 5th toe, med 1st toe, lat 5th mTP, med 1st MTP, styloid, tub of navicular, med and lat malleolus.

I did a study (unpublished) a thousand years ago which (inflating my ego) showed these sites to be reliable and good indicators of neuropathy.

The normal arguments for testing plantarly is because this is the area of likely ulceration. Given the nerves travel elsewhere (non-plantarly) I choose to test these areas. I believe the job of the monofilament is to test nerve function not how thick your calluses are.

Matt

__________________
Matt Dilnot - Podiatrist
http://www.equusmedical.com

Hi Matt,
That sounds interesting and certainly makes sense.
Too often we tend to do things by rote and for me one of the big benefits of degree-level training is that we do question accepted examination techniques and procedures :) .
Not that you need to have a degree to do that of course, but exposure to plenty of well-sourced written material + research methods has to help!
Regards,
David

Not directly related to the first question, but this paper in JBJS:
4.5-Gram Monofilament Sensation Beneath Both First Metatarsal Heads Indicates Protective Foot Sensation in Diabetic Patients

Concluded that:
Certainly raises question about using the 10g on 10 or 3 sites when a 4.5g on one site may be enough

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

I want to Thank you for your comments. I had read an abstract on the paper re testing with 4.5g instrument, and I, like Matt, have difficulty understanding the plantar tests. Matt, perhaps you may still have a copy of your study in your archives? I, for one, would be interested to read it.

I'd also like to say Thank You for setting up this Forum. I work in the north of Scotland and find arenas like this invaluable for discussion with colleagues internationally.

Regards,
Sandra

I have just amazed myself by throwing together an abbreviated version of my paper and put it up on a blog of mine.

http://www.podiatryreview.com

Have not read through closely so don't be suprised by strange little quirks but you will get the drift.

Matt

__________________
Matt Dilnot - Podiatrist
http://www.equusmedical.com

Below is an extract from my PG thesis of 8 years ago. And from what I remember the sites that are now currently used were those that were initially used in the Birke and Simms article on people with Leprosy. They felt the monofilament would be better than a sharpened pencil, but still cheap enough to use in the sub-continent. The 1,3,5 toes, 1,3,5 MTPJ, Med/Lat arch, heel and dorsum test points have been validated somewhat by the Kumar etal study

More recently the Semmes-Weinstein monofilament has gained favour as a simple quantitative measure of sensory neuropathy. Although developed in the 1960s it was not widely used on diabetic feet until the 1980s. (Weinstein, 1993; Birke and Sims, 1986; Kumar, Fernando et al., 1991). The nylon filament will bend at a given force and then apply a constant pressure on the skin surface. Different thickness filaments provide a different skin pressure allowing a cutaneous pressure perception threshold to be established (Levin, Pearsall and Ruderman, 1978).
Many studies have shown the monofilaments to have both inter and intra examiner reliability. They have established normal results for the foot, along with abnormal results that put the neuropathic foot at risk of ulceration. Mooney (1992) defines normal sensation of the plantar surface of the heel at 4.16 (1.4g) for men and 4.09 (1.2g) for women with lower normals of 3.97 (0.8g) for men and 3.86 (0.7g) for women in the forefoot. Spivak (1994) defined normal sensation for the foot at 0.07g and Birke and Sims (1986) used 4.17 (1g) as a normal baseline. These variations on normal appear to be due to different testing procedures, sample populations and instrument calibration (Weinstein, 1993).
Birke and Sims, (1986) in a study of 132 neuropathic foot ulcerations found that no subject was able to sense a monofilament smaller than 6.10 (75g). From this information they established the 5.07 (10g) filament as the level of protective sensation. Kumar, Fernando and colleagues (1991) confirmed this in a large screening of 182 subjects with diabetes. No person with a foot ulceration could feel the 5.07 (10g) filament, concluding that monofilaments are an effective, inexpensive and simple screening device in identifying the ‘at risk’ foot. Other studies have supported these findings (Stevens, Edmonds, Foster and Watkins, 1992; Olmos, Cataland et al., 1995).
Recently an improved device with a rounded tip has become available that provides pressure alone and reduced pain, being called the Weinstein Enhanced Sensory Test (Weinstein, 1993; Spivak, 1994). This device is calibrated for increased reliability between instruments, but as a general screening tool the Semmes-Weinstein monofilament set has been shown to be more than adequate.

References
Anonymous ‘Proceedings of a consensus development conference on standardized measures in diabetic neuropathy. Quantitative sensory testing. [Review]’ Neurology 42(9): 1829-31, 1992.
Birke, J. A. and Sims, D. S. ‘Plantar sensory threshold in the ulcerative foot’ Leprosy Review 57(3): 261-267, 1986.
Consensus Statement ‘Report and recommendations of the San Antonio conference on diabetic neuropathy.’ Diabetes 37(7): 1000-1004, 1988.
Kumar, S., Fernando, D. J. S., Veves, A., Knowles, M. J., and Boulton, A. J. M. ‘Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration’ Diabetes Research and Clinical Practice 13(1-2): 63-68, 1991.
Levin, S., Pearsall, G., and Ruderman, R. J. ‘Von Frey’s method of measuring pressure sensibility in the hand: An engineering analysis of the Weinstein-Semmes pressure aesthiometer.’ The Journal of Hand Surgery 3(3): 211-216, 1978.
Mooney, J. ‘Touch/pressure thresholds of the soles of the normal healthy adult foot’ Journal of British Podiatric Medicine 127-133, 1992.
Olmos, P. R., Cataland, S., O’Dorisio, T. M., Casey, C. A., Smead, W. L., and Simon, S. R. ‘The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with noninsulin-dependent diabetes.’ The American Journal of the Medical Sciences 309(2): 76-82, 1995.
Spivak, M. Weinstein enhanced sensory test and peripheral neuropathy Connecticut, Connecticut Bioinstruments Inc., 1994.
Stevens, M. J., Edmonds, M. E., Foster, A. V. M., and Watkins, P. J. ‘Selective neuropathy and preserved vascular responses in the diabetic Charcot foot’ Diabetologia 35(2): 148-154, 1992.
Weinstein, S. ‘Fifty years of somatosensory research’ Journal of Hand Therapy 6(1): 11-22, 1993.

dear matt & others, i'm at a loss, the studies conducted by boulton & others used the plantar sites so for these sites it is the (10 g) monofilament (and now the (4.5 g)??). Surely for other sites further studies are needed to establish the relevant pressure as a cut-off for "at risk" insensitivity.
thanks, mark conley

Hello all,

Pham and associates(2000) added to the work of previous authors. They used a 10g monofilament and concluded that clinical examination and a 5.07 (10g) SWF test are the two most sensitive tests in identifying patients at risk for foot ulceration.
They used the plantar aspect of the hallux to test, with the patient's eyes closed, but don't specify the number of applications to each site.

I wrote to WH van Houtum of the International Working Group on the Diabetic Foot (why re-invent the wheel!). The group had found no conclusive evidence as to how many sites,or which sites, to recommend. Which is probably why we're all having this discussion now.

Ref: Pham H, Armstrong DG, Harvey C, Harkless LB, Guirini JM, Veves A, Screening techniques to identify people at high risk for diabetic foot ulceration.Diabetes Care 2000;23:606-11.

Cheers
John