Diagnosis

The Ipswich Touch Test at home had 78% sensitivity and 94% specificity for detecting loss of foot sensation Clinical impact ratings:

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Sharma S, Kerry C, Atkins H, Rayman G. The Ipswich Touch Test: a simple and novel method to screen patients with diabetes at home for increased risk of foot ulceration. Diabet Med. 2014;31: 1100-3.

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Question

Commentary

Does the Ipswich Touch Test done by a nonprofessional in the home detect loss of foot sensation in patients with diabetes?

A patient with diabetes has about a 25% lifetime risk for a foot ulcer (1), and diabetic neuropathy is associated with an increased risk for ulceration (2). Early detection of loss of sensation in the feet allows clinicians to start a management plan, which includes improved metabolic control, education, and accommodative footwear. Detection of neuropathy at home could increase awareness of diabetic foot complications, engage patients in self-management of the diabetic foot syndrome, and potentially reduce ulceration. To date, however, insufficient evidence exists on the benefit of patient education in preventing diabetic foot ulcers (3).

Methods Design: Blinded comparison of Ipswich Touch Test done by a nonprofessional in the home with a standard 10-g monofilament assessment done by a clinician. Setting: Diabetes clinics at Ipswich Hospital, England, UK. Patients: 331 patients (mean age 60 y, 53% men) with diabetes. Patients with amputations were excluded. Description of test: Ipswich Touch Test done at home by a nonprofessional (friend, relative, or caregiver) following written instructions. The test comprised light touching of the tips of the patient's 1st, 3rd, and 5th toes of each foot with the tip of the tester's index finger for 1 to 2 seconds while the patient's eyes were closed. The patient indicated whether they felt the touch by responding right or left, and results were recorded on a foot diagram. Diagnostic standard: Pressure perception using the Neuropen (Owen Mumford, Chipping Norton, UK) standard 10-g monofilament, done by a trained health care provider (diabetologist, diabetes specialist nurse, or podiatrist). Patients had loss of sensation in their feet if there was no feeling at ≥ 2 of the 6 sites.

It is not unusual for patients to attend a clinic visit with a foot ulcer while being unaware of any trauma. The trial by Sharma and colleagues provides a realistic method to potentially interrupt this pattern. The study showed that home testing had good sensitivity and specificity compared with monofilament testing in the clinic. The nonblinding of clinicians to other patient characteristics is unlikely to have introduced bias in the results. The Ipswich Touch Test is simple to conduct and seems reliable. It is generalizable to a larger number of patients and caregivers and could reduce development of diabetic foot ulcers if coupled with preventive foot care (4). Aonghus O’Loughlin, MD Sean F. Dinneen, MD Galway University Hospitals and NUI Galway Galway, Ireland

Outcomes: Sensitivity, specificity, and likelihood ratios.

Main results 83* patients (25%) had loss of sensation in their feet. The Ipswich Touch Test had 78% sensitivity and 94% specificity for detecting loss of foot sensation compared with monofilament testing (Table). The area under the receiver-operating characteristic curve was 87%.

Test characteristics of Ipswich Touch Test for detecting loss of foot sensation in patients with diabetes† Test assessor

Sensitivity (95% CI)

Nonprofessional

78% (77 to 83)

Specificity (CI) LRⴙ 94% (91 to 96)

13

LRⴚ 0.23

†Diagnostic terms defined in Glossary. CI provided by author.

Conclusion

References 1. Boulton AJ, Armstrong DG, Albert SF, et al; American Diabetes Association; American Association of Clinical Endocrinologists. 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. 2008;31:1679-85. 2. Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors for diabetic foot ulceration: a systematic review. Diabetes Metab Res Rev. 2012;28:574-600. . 3. Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev. 2010(5):CD001488. 4. Arad Y, Fonseca V, Peters A, Vinik A. 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. 2011;34:1041-6.

In patients with diabetes, the Ipswich Touch Test done by a nonprofessional in the home detected loss of foot sensation. *Calculated from event rate in article. Source of funding: No external funding. For correspondence: Gerry Rayman, Ipswich Hospital NHS Trust, Ipswich, England, UK. E-mail [email protected]. 

姝 2015 American College of Physicians JC10 ACP Journal Club Downloaded From: http://annals.org/ by a Penn State University Hershey User on 05/27/2015

Annals of Internal Medicine

17 February 2015

ACP Journal Club: the Ipswich Touch Test at home had 78% sensitivity and 94% specificity for detecting loss of foot sensation.

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