178 Article

The Importance of Education in Diabetic Foot Care of Patients with Diabetic Neuropathy


H. M. Şen1, H. Şen2, M. Aşık2, A. Özkan1, E. Binnetoglu2, G. Erbağ2, H. I. Ö. Karaman1



Key words ▶ diabetes mellitus ● ▶ neuropathy ● ▶ diabetic foot ● ▶ education ●


Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1389981 Published online: October 14, 2014 Exp Clin Endocrinol Diabetes 2015; 123: 178–181 © J. A. Barth Verlag in Georg Thieme Verlag KG ­Stuttgart · New York ISSN 0947-7349 Correspondence Dr. H. Şen Çanakkale Onsekiz Mart ­University Medical Faculty Internal Medicine çomü tıp fakültesi hastanesi 17100 Çanakkale Turkey Tel.:  + 90/286/263 5950 Fax:  + 90/286/263 5957 [email protected]

 Neurology, Çanakkale Onsekiz Mart University Medical Faculty, Çanakkale, Turkey  Internal Medicine, Çanakkale Onsekiz Mart University Medical Faculty, Çanakkale, Turkey

Objective:  Our aim is to research the effect of the knowledge and routine gained from the diabetic foot (DF) care education program given to patients with Type 2 Diabetes Mellitus (DM) with diabetic neuropathy. Materials and Method:  A total of 104 patients with Type 2 DM and diabetic neuropathy par­ ticipated in a survey to evaluate standards of DF care, and knowledge of and behavior relating to personal care. The difference in knowledge and personal care between the group who had received education on diabetes and the group who had not was researched. Results:  A total of 42.3 % of patients reported receiving education about diabetes. The educa­ tion for Type 2 DM patients increased the fre­ quency of attending yearly check-ups (p:0.028),


The number of patients with diabetes mellitus (DM) throughout the world is dramatically increasing. A study by the World Health Organi­ zation (WHO) estimated that by 2025 there will be 300 million diabetic patients in the world [1]. For diabetic patients, in addition to chronic degenerative complications such as nephropa­ thy, retinopathy, neuropathy and atherosclero­ sis, foot ulcers developing due to neuropathy and peri­pheral artery disease leading to lower extremity amputations negatively affect the prognosis of the disease. Wounds due to dia­ betic foot (DF) are a significant health problem for diabetic patients. Patients with DM have a 15–25 % risk of develop­ ing diabetic foot ulcers (DFU) during their life­ time [2]. DF is an important complication for diabetic patients increasing mortality, causing morbidity and increasing the economic load of

Şen HM et al. The Importance of Education …  Exp Clin Endocrinol Diabetes 2015; 123: 178–181

and helped develop the habit of having doctors check their feet (p:0.004). When comparing the daily practice of those who had received edu­ cation about DF care with those who had not, positive effects of education were seen in all questions evaluating foot care, nail care and choice of shoe. The statistical analysis proved that the educated group were significantly better in terms of foot care such as using moisturizer (p:0.002) and using insoles (p:0.042). Conclusion:  Our study reveal that educating diabetic patients about foot care is an effective method to develop their knowledge. However we observed that this education is not provided to all diabetic patients. We believe that every dia­ betic patient should receive education from the moment of diagnosis and repeated education during check-ups by doctors will increase effec­ tiveness.

the disease [3–5]. Globally every year around 4 million new DFU develop [6]. DF is the most fre­ quent cause of limb amputation not linked to trauma [7]. DF is the reason for an amputation every 30 s globally. Thus a life of dependence on others and low quality of living awaits these peo­ ple [8]. At the same time after amputation the rate of mortality of patients increases [3]. In the pathogenesis of DFU neuropathy, vascular insufficiency, mechanical changes in the foot structure, infection and hyperglycemia play a role [9]. However the most important cause of development of DF is neuropathy and neuro­ pathy is present in 50 % of type 2 DM patients [10]. These people are at severe risk. 50 % of dia­ betic neuropathy patients are symptomatic with symptoms ranging from burning pain, stinging or tingling sensation, paresthesia, hyperesthesia, or deep aching pain. Half of patients have no symp­ toms and diagnosis of neuropathy is made when they apply with DFU [11].

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received 07.07.2014 first decision 22.08.2014 accepted 03.09.2014


Poor foot care is known to be a risk factor for foot problems, especially for diabetic individuals [12]. Recent studies have shown that education given to DM patients about foot health and self-care for feet has reduced the risk of DFU and the rates of amputation [13]. In the latest guidelines from the American Dia­ betic Association (ADA) it is recommended that diabetic patients be given education about foot care [14]. In this study we planned to evaluate the level of information about foot care and to research the effect of education on the personal habits of patients with diabetic neuropathy who have very high risk of foot ulcers.

Materials and Methods

All type 2 DM patients at Canakkale Onsekiz Mart University Medical Faculty Internal Medicine and Diabetes monitoring clin­ ics were scanned for diabetic neuropathy. Neuropathy diagnosis for diabetic patients was made according to the neuropathic pain diagnostic questionnaire (DN4) and sensory examination [15]. The 104 type 2 DM patients with diabetic neuropathy were included in the study. Patients with diabetic neuropathy who have high risk of development of diabetic foot ulcers were included in the study as their foot care education is important. Patients were randomly included in the study during application to the clinic. Patients with dementia, psychosis, who were deaf, or had trouble answering the survey, were not included in the study. The demographic data of the patients, such as age, gender, education level, chronic diseases, and cigarette-alcohol use, were recorded. The DN4 test questions the presence of burning feeling in feet, painful feeling of cold, feeling electricity, tingling with pain, pins and needles, lack of feeling, accompanied by itching, localized touch hypoesthesia, needle hypoesthesia, and brushing causing or increasing pain in the painful area. Scoring of the DN4 of 4 or ▶  Table 1). The above indicates a diagnosis of neuropathic pain ( ●

Table 1  DN4 Questionnaire. DN4 Questionnaire PATIENT INTERVIEW Question 1. Does the pain have any of the following characteristics? 1. Burning 2. Painful sensation of cold 3. Electric shocks Question 2. Is the pain associated with any of the following symptoms in the same area? 4. Tingling 5. Pins and needles 6. Numbness 7. Itching PATIENT EXAMINATION Question 3. Is the pain located in an area where the physical examination may reveal one or more of the following characteristics? 8. Hypoaesthesia to touch 9. Hypoaesthesia to prick Question 4. In the painful area, can the pain be caused or increased by: 10. Brushing YES = 1 point NO = 0 points Patient’s score: _____/10 If the patient’s score is  ≥ 4, the test is positive. (sensitivity 82.9 %; specificity 89.9 %) Reprinted from Bouhassira D, et al.

degree of neuropathic pain in patients was evaluated using a visual analog scale (VAS) from 1–10. Those with neuropathic pain who showed pathological findings on the sensory examina­ tion, such as hypoesthesia, hyperesthesia, or slow deep tendon reflexes, were diagnosed with diabetic neuropathy. Patients were interviewed face-to-face during the survey. Patients were questioned on how long they had been diagnosed with diabetes, how many times they attended doctors due to diabetes in a year, was foot examination completed by doctors during their attendance and how many times they received edu­ cation about diabetic foot from doctors to date. Previous history of ulcers was questioned and the patients were examined for the presence of diabetic ulcers. Questions were then asked about foot examination of patients, foot care, use of shoes and nail care. The level of knowledge was evaluated by summing all the correct answers to questions with well-defined right and wrong answers according to current guidelines. The answers of those who had received education from doctors or diabetic nurses were compared with the answers of those who had not received any education.

Statistical analysis

The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 19. Categorical variables are given as proportions. Comparisons between groups were tested with Chi square test. Correlations were assessed with the SpearmenPearson correlation test.


The study included 104 patients (58 female, 46 male). The aver­ age age was 55.55  ±  13.3 years. The duration of DM was 10.37 ± 7.47 years on average and all patients had neuropathy. According to VAS score the average neuropathic pain was 4.66 ± 2.65. Patients examined by doctors an average of 4.19 ± 3.3 times per year. 15.4 % of patients replied “yes”, to the question “Were your feet examined during the visits”. While 8 patients (7.7 %) had a history of wounds on the foot, after examination 17 patients (16.3 %) were found to have foot ulcers. In our study 44 patients (42.3 %) had received education about diabetic foot care while 60 patients (57.7 %) did not receive any education. The survey results relating to daily foot care are given in  ▶  Table 2. ● The statistical analysis of those who received diabetic foot ­education found a significant correlation with attendance at yearly doctor check-ups, use of moisturizer, use of insoles and foot checks by doctors, shown in ●  ▶  Table 3. There was no diffe­ rence between the group who received education and those who did not in terms of answers about other foot care, nail care and shoe use.


In our study the rate of education about diabetic foot among dia­ betic patients with neuropathy was shown to be low. Again this patient group, where neuropathy is a major risk factor for the development of diabetic foot, the knowledge of foot care was insufficient and basic daily routines to prevent development of

Şen HM et al. The Importance of Education …  Exp Clin Endocrinol Diabetes 2015; 123: 178–181

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Article 179

Table 2  The survey results relating to daily foot care.

Daily check for wounds on feet Daily washing of feet with warm water Careful drying between toes after washing Daily use of foot moisturizer Filing calluses, if present Do you walk barefoot? Do you continuously wear socks? Do you cut toenails weekly? Do you cut toenails straight across? Do you wear shoes that fit comfortably? Do you buy shoes when your feet are swollen? Do you use insoles? Do you check shoes for any objects before wearing?

Yes ( %)

No ( %)

80.8 71.2 69.2 35.6 21.2 40.4 50 69.2 76.9 92.3 27.9 18.3 77.9

19.2 28.8 30.8 64.4 78.8 59.6 50 30.8 23.1 7.7 72.1 81.7 22.1

Table 3  Evaluation of diabetic education with other parameters using the Spearmen-Pearson correlation test.

Attendance at yearly check-ups Use of moisturizer Use of insoles Feet checked by doctor



0.216 0.299 0.200 0.282

0.028 0.002 0.042 0.004

ulcers were lacking. The individuals who had received education about DM foot were significantly better in terms of personal foot care routines and frequency of attendance at yearly doctor check-ups. In our study diabetic foot education was not given to all patients and some routines of those given education remained insufficient. Patients given diabetic foot care education were again superior. Diabetic peripheral neuropathy is a heterogeneous disease including mononeuropathies, polyneuropathies, plexopathies and radiculopathies [16]. Peripheral neuropathy is observed in 48–50 % of diabetic patients [10, 17]. Peripheral neuropathy is one of the major risk factors for development of DFU and where DFU are present 82–92 % are also accompanied by neuropathy [18, 19]. Of patients with diabetic peripheral neuropathy 13 % have DFU [20]. In this study, similarly, 16.3 % of diabetic periph­ eral neuropathy patients were identified to have foot ulcers. Current guidelines recommend that all diabetic patients are scanned for foot ulcers once a year [14]. Treatment of lesions found in the early period can prevent complications. In our study when asked whether patients were scanned by doctors for dia­ betic foot yearly, 15.4 % reported they were. We believe the rea­ son for this low rate is that the family practitioner system in our country is inadequate and patients are not regularly monitored by a single physician. Again when asked if how many times they applied to the doctor due to diabetes in a year, patients reported 4.19 ± 3.31 times on average. This rate is comparable to the visit frequency recom­ mended in the guidelines. To prevent the development of DFU, initially education about foot care should be prioritized [14]. Understanding the impor­ tance of daily foot monitoring should be emphasized for diabetic patients at risk. The aim is to know the importance and the pos­ itive effects of appropriate foot care, including skin and nail care, and appropriate choice of shoes [21]. Diabetic committees ­recommend that all diabetic patients receive this education. In our study of patients with the major risk factor of peripheral

neuropathy, only 42.3 % said they received education about dia­ betic foot. We believe this low rate may be due to the number of patients per practitioner being too high in this country leading to insufficient time spent with each patient. At this point we are trying to close this gap with diabetic nurses. It is known that education on foot care given to diabetic patients improves daily foot care and reduces the development of DFU. Studies in recent years have shown that DF education reduces the rate of major amputations by 50 % [22]. Many studies have shown that diabetic foot education improves knowledge of foot care and develops practical routines. Vatankhah et al. in a survey study of the effectiveness of DF care education evaluated the knowledge levels of patients about DF care and also evaluated the application in practice. This study identified a significant improvement in foot care routine after education [23]. Lincoln et al. in another study of 172 diabetic patients evaluated DF educa­ tion 12 months later with a survey. While there was no differ­ ence between the group given education and the control group in terms of incidence of ulcer, the foot care routines of the group given education were significantly better than the control group [24]. In our study comparing the DF education group with the control group, all questions evaluating foot care, nail care and choice of shoe education were positive affected by education. The statistical analysis showed the educated group was signifi­ cantly better in terms of foot care routine including using mois­ turizer and insoles. In this study, different to previous studies, we showed that there were insufficiencies in the approach of doctors to diabetic foot. Development of diabetic foot is the most feared complication; however it is also the most frequently neglected issues. Doctors and nurses rarely receive official education on this topic [25]. However the most important way to prevent DF is through organizing and configuring structured education [10]. It is important that education programs informing about diabetic foot care and improving routines reach all diabetic individuals. From the first moment of diagnosis education is required by dia­ betic patients and we believe repeated education at doctor check-ups will be more effective. In our study only patients with neuropathy were evaluated. Dur­ ing long term monitoring patients diagnosed with diabetes mel­ litus should be given education regularly on every visit and be examined for development of neuropathy and diabetic foot ulcers. Prospective studies with more patients are required.

Conflict of interest: None. References

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The importance of education in diabetic foot care of patients with diabetic neuropathy.

Our aim is to research the effect of the knowledge and routine gained from the diabetic foot (DF) care education program given to patients with Type 2...
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