Foot care is a cornerstone of diabetes care. However, there is very little evidence about the impact of specialist foot care by podiatrists or chiropodists on the risk of amputation. Current guidance recommends that podiatrists should be part of the multidisciplinary foot care team. However, this recommendation is based on observational studies. For this reason, the team from the University of Cork, Ireland, set out to review the evidence on the specific impact of podiatrists in foot care.
In people with diabetes, does care from a podiatrist reduce the risk of lower extremity amputation?
This systematic review in BMJ Open set out to summarise all of the available research addressing this question. The reviewers performed a thorough search of research databases as well as hand searching of journal to identify papers addressing this question. Two reviewers independently assessed the studies that they found.
Six studies were found that addressed the question, of which two were randomised trials. The reviewers pooled the data separately for the two randomised trials and the four observational studies.
Unfortunately, the confidence intervals around these estimates were so wide as to render the results meaningless.
What’s the alternative?
Presumably the benefit of seeing a podiatrist comes from what they do, not from the job title or the name on the door. However, the reviewers considered that previous reviews had failed to find good quality evidence for specific aspects of foot care interventions, such as patient education, or for integrated care models. Therefore it was worth looking at the specific role of the podiatrist.
At least this review tells us one thing: we need more research on the specific impage of interventions by podiatrists. Future studies are needed the focus on their role within the integrated care provided by a multidisciplinary team. These studies need to be large enough, and last long enough, for the benefits of specialist foot care to be measurable.
In short, research needs to catch up on clinical practice in this crucial area of diabetes care.
Limitations of this review
- The key limitation on this evidence is the low overall risk of amputation. With rare outcomes, we need lots of patients to see any benefit.
- The search was conducted in September 2011. Relevant studies may have been published since.
- The literature search did not use common synonyms for podiatry and was limited to MeSH headings. The review may have missed important studies, including ones not published in English.
Buckley CM, Perry IJ, Bradley CP & Kearney PM. Does contact with a podiatrist prevent the occurrence of a lower extremity amputation in people with diabetes? A systematic review and meta-analysis. BMJ Open 2013;3:e002331 doi:10.1136/bmjopen-2012-00233
Scottish Intercollegiate Guidelines Network. Management of diabetes. A national clinical guideline. March 2010.