Summary

The Ipswich Touch Test (IpTT) is a novel test for neuropathy that is simple, safe and easily taught. The test involves lightly and briefly (1-2 seconds) touching the tips of the first, third and fifth toes of both feet with the index finger to detect a loss in sensation, and can be performed by patients and relatives alike in the comfort of their own home.

When used at home, the IpTT had a sensitivity of 78.3 per cent and specificity of 93.9 per cent. The likelihood that a positive test meant a person had neuropathy was 81.2 per cent, while the likelihood that a negative test meant someone didn’t have neuropathy was 92.8 per cent.

With clearly written instructions, this is a simple test can be used by non-professionals to assess for loss of protective sensation accurately. In addition, the test also serves as educational tool to teach patients and relatives about diabetes foot disease, with 96.8 per cent of respondents claiming their awareness levels increased.

Results

Challenge

Diabetes can lead to disease of the foot in up to 40 per cent of patients. These complications include damage to the nerves (diabetes neuropathy) and damage to the large blood vessels that serve the limbs (peripheral arterial disease) and can affect anyone with diabetes.

Current data suggests that amputation rates are set to rise, from over 5,000 in 2009/10 to more than 7,000 in 2014/15 in England. Amputation is not only devastating; it is expensive. In England it is estimated that nearly £700m is spent each year on foot ulcers and amputations and account for every £1 in £150 spent by the NHS in healthcare. However, 80 per cent of amputations are preventable by a variety of healthcare initiatives which include annual foot checks to screen for nerve damage, educating patients about foot care and improving standards of diabetes care delivery.

Given these statistics, the Ipswich Hospital NHS Trust set wanted to devise a project to involve the person with diabetes and their relatives in foot care by having them undertake the examination at home using the novel Ipswich Touch Test (IpTT). This test simply involves touching the toes with the index finger and has been shown in the clinic setting to be effective in detecting loss of sensation with a high degree of sensitivity and specificity comparable to existing screening techniques.

The project was designed to determine whether the test when done at home is sufficiently sensitive and specific in detecting neuropathy, whether patients and relatives find it an acceptable thing for them to be doing and whether it improves their awareness of diabetes foot disease. This project was carried out between September and December 2011 at The Ipswich Hospital NHS Trust.

Objectives

The project “The Ipswich Touch Test – screening for neuropathy at home” involves relatives and friends examining the feet of their diabetes patients using the Ipswich Touch test based on written instructions. We hope to determine:

• Whether the IpTT is an effective means to screen for diabetes neuropathy at home
• Whether it can serve as an educational tool to improve awareness of diabetes foot disease and empower patients and their relatives to be more involved in their foot care
• Whether people with diabetes, their friends and/or relatives find their involvement in foot examination acceptable.

Solution

Methodology of the IpTT: 
The test involves lightly and briefly (1-2 seconds) touching the tips of the first, third and fifth toes of both feet with the index finger in a designated sequence. Neuropathy is defined as the inability to feel the sensation in two or more areas (see Resources for video footage).

Patient selection: 
Type 1 and Type 2 diabetes patients between the ages of 18-85 attending the general diabetes clinic at The Ipswich Hospital NHS Trust were invited to take part. Patients unable to give consent or with a history of minor or major amputation were excluded.

Recruitment process: 
Invitation letters were sent to all eligible patients approximately two weeks prior to their annual review appointments along with detailed written instructions on how to carry out the IpTT and how to record the result on the enclosed record form (see additional attachment). Patients were asked to bring the record form with them when they attended for their annual review.

IpTT Validation: 
The IpTT was repeated at the clinic visit by a trained health professional (physician or diabetes specialist nurse) prior to inspecting the result obtained at home. A 10gm monofilament test was also carried out at the same six sites. The 10gm monofilament is currently the accepted gold standard to screen for neuropathy outside the laboratory. At the end of the clinic examination, patients were informed of the findings, how these relate to their finding at home, as well as their risk of foot disease and preventative measures they may need to take.

Statistical analysis: 
The results of the touch test at home by friends and relatives of diabetes patients were compared with those carried out by trained health professionals in the clinic. Moreover, the touch test at home was also compared with the 10gm monofilament to find sensitivity and specificity. All data was stored securely and analysed using SPSS® 19 software for non-parametric outcomes

Feedback methods: 
After completion of the test, patients were sent questionnaires asking for feedback about the test including their acceptance, ease of use, clarity of instructions and whether performing the test was helpful in increasing their awareness of diabetes foot complications.

Patient and Public interface: 
The project was discussed at the Suffolk Diabetes User Group (SDUG) meeting and received a favourable opinion.

Ethical approval: 
Ethical approval was obtained from REC using the proportionate review service

Learnings

Screening for peripheral neuropathy is an important means of detecting at risk diabetes feet. Simple measures like early diagnosis of neuropathy, improving awareness of foot diabetes, regular self-examination of feet and use of correct foot wear can prevent foot ulcerations and amputations in 80 per cent of cases.

The National Diabetes Inpatient Audit (NaDIA) in 2010 and 2011 showed respectively that only 27.5 per cent and 22.4 per cent of diabetes inpatients had their feet checked during the course of their hospital stay. Use of conventional and proven traditional bedside techniques like tuning forks, patellar hammers and 10gm monofilaments, though useful, have their limitations such as need for staff training, regular replacements and availability in busy clinical settings. The Ipswich Touch Test addresses all these limitations by being a simple, safe and easily taught method readily available ‘at hand’.

Use of IpTT in the clinical environment (in hospitals) 
A. At The Ipswich Hospital NHS Trust (Ipswich, England), the IpTT forms an integral part of the Foot of the Bed (FoB) form (see Resources for further information) wherein all diabetes inpatients have their feet examined within 24 hours of admission and this has increased to 85 per cent of all admissions currently. This enables detection of high risk feet which is then flagged to the diabetes foot team for remedial measures

B. NHS Diabetes, in liaison with The Ipswich Hospital NHS Trust and support from Sanofi is introducing a nationwide inpatient programme aimed at reducing the number of hospital acquired foot lesions in diabetes patients with the IpTT as an integral part of this programme. (See Resources for additional information)

Use of IpTT in the community 
A. Based on the favourable outcomes of this project, the IpTT is now being introduced by NHS Diabetes as ‘Touch The Toes Test’. This is part of the Putting Feet First campaign, which was launched at the Diabetes APC in March 2012 (see Resources for additional information).

Use of IpTT in the international arena
Due to the simple technique coupled with high effectiveness in the screening of diabetes nephropathy, the IpTT has now been used on a pilot basis in developing countries like Grenada and Pakistan and there has been expression of interest from other nations. We are currently formulating guidance on its use in these areas.

Challenges to further roll out
The IpTT is a very simple test, which can be performed with minimal training or instructions. Hence we introduced it using an implementation programme. For it to be successful in other Trusts will require adoption or development of a similar implementation programme. Furthermore, despite its simplicity, for its use overseas and particularly Third World countries will require local instruction and translation to the correct language. It would also require re-validation as barefoot walking may influence the sensitivity and specificity.

Evaluation

Firstly, there was a high concordance (98 per cent) between the IpTT in the hands of the friends and relatives compared to when trained health professionals performed it. This confirms that irrespective of the environment and the person performing the IpTT, with simple written instructions, comparable and sufficiently accurate screening results are obtained.

Secondly, in the hands of relatives and friends the sensitivity of 78.3 per cent implies that out of 100 patients with neuropathy, the IpTT at home could detect nearly 80 per cent of such patients. Similarly, of 100 normal diabetes patients devoid of neuropathy, the IpTT at home was able to exclude neuropathy in almost 94 per cent of patients. This sensitivity and specificity is no different from those reported for the 10gm monofilaments in other studies and indeed in our original assessment.

Thirdly, patient feedback suggested that the IpTT could easily be performed at home, based on the written instructions by friends and relatives without the need for specific training. This suggests that the IpTT can be used in larger populations simply by sending out instruction leaflets.

Finally, the IpTT was an effective means to improve awareness of diabetes foot disease among both patients and their friends and relatives.