Using a monofilament to check for sensory neuropathy
Whenever a new patient with a wound on the lower extremity attends the clinic, we should do a monofilament test to check for peripheral sensory neuropathy. In other words - we have to check whether the patient can sense touch under their feet. Many conditions can impair the sensory nerves in the lower extremities - diabetes is the most common cause of this type of nerve damage globally. The prevalence of diabetic peripheral neuropathy (DPN) is high in Africa because of late detection of diabetes and sub-optimal glucose control. In a study performed at KCMC in Moshi, Tanzania (Amour et al. 2019), almost half of the patients attending a diabetic clinic at the hospital had DPN, many of them severe. Similar results are seen from studies in other African countries. DPN is a significant challenge in Africa, and it has been underreported for years. And we are just seeing the tip of the iceberg - if the prognosis for the prevalence of diabetes turns out as some studies predict, we are looking at a major challenge. Currently, there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless something is done (Godman et al. 2020).
While diabetes is the leading cause of peripheral neuropathy (PN) worldwide, many other conditions can give the same neurological symptoms. Peripheral neuropathy is, for example, the most frequent neurological complication in people living with HIV/AIDS. Neurological damage was identified to be caused by the viral infection itself and through neurotoxic antiretroviral therapy. Other causes of PN are leprosy and several other infections, vitamin deficiencies, and alcoholism. At the bottom of this chapter is a link to an article summarizing different causes of peripheral neuropathy.
There are many forms of neuropathy - the major categories are sensory neuropathy, motoric neuropathy, sympathetic neuropathy, and painful neuropathy. A patient may have only one type of neuropathy or, in severe cases, all four categories combined. When we use a monofilament to test whether the patient feels under their feet, we test the sensory neuropathy. So if you want to sound professional, use the term "sensory" to clearly show which type of neuropathy you are looking at. Simply saying that the patient has neuropathy is too general.
This was a digression because what we really want to talk about in this chapter is how to do a monofilament test to check for neuropathy. If you want to appear super correct, you should actually call this the Semmes-Weinstein test. The neuropsychologist Sydney Weinstein and neurophysiologist Josephine Semmes developed this clever but straightforward test in the USA in the '60s. In the beginning, they used hair from horses' tails for this test before using nylon monofilament. Horsehair had the disadvantage that it varies in thickness, and its elasticity is very dependent on room temperature and humidity - it was difficult to standardize the test with a natural filament like horsehair- hence the use of nylon.
If you do a literature search or google this test, we advise you to search for the "Semmes-Weinstein monofilament test" to give you the most relevant hits. In our everyday work, though, we usually just refer to the test as the "monofilament test." However, next time you hold a monofilament in your hand, think a second about Josephine Semmes and Sydney Weinstein. They used considerable time to develop and validate this simple test that is powerful enough to prevent the amputation of a foot.
Video 1 Everybody who treats patients with wounds should be able to perform a monofilament test. This is a very simple and cheap test, but the results can be of huge importance for preventing and treating, especially foot ulcers. Click on the image above to get to a video that explains the procedure. Courtesy of IHSgov (The federal health program for American Indians and Alaska natives)
Why is it important to check for sensory neuropathy?
Sensory neuropathy of the feet means that the patient has decreased or no touch sensation in the feet. It can be a severe sensory neuropathy to such an extent that the whole plantar side of the foot has no feeling whatsoever or just a slight sensory neuropathy where the sensation is slightly decreased.
Suppose you perform a monofilament test and discover that the patient has sensory neuropathy. In that case, you know that the patient is at high risk of developing a foot ulcer. Most likely, they already have an ulcer on the foot since you have the patient in front of you now!
Patients with severe peripheral sensory neuropathy will not be able to feel whether the shoes are too tight and are causing a blister. Neither will they feel whether they have a small stone in their shoe which they walk on all day ending in a catastrophic infected ulcer under the foot. They will not feel it if they have their feet too close to the fireplace and may suffer extensive burns on the feet without feeling pain. They have lost the sensory protection under their feet.
If you have a patient with sensory neuropathy, you have to give them thorough information on what to do / not to do. The patient is often unaware that he has numb feet - that may sound strange, but often the condition has taken many years to manifest, and many patients have become accustomed to this without thinking much of it.
A patient with sensory neuropathy of the feet should buy the most comfortable shoewear they can afford and have a habit of checking the shoes for small stones or other objects every time they take them on. They should also be advised to check for skin bruises underneath the feet every evening. If they are too stiff to check their own feet, they should get another family member to do so every day. Patients with severe sensory neuropathy should avoid walking barefoot - even inside the house. The list of advice to these patients is quite long - the important part is that the patients are aware of the condition and the high risk of developing foot ulcers which can be limb-threatening. We highly commend the American LEAP program (lower extremity amputation prevention program). The LEAP program is a structured 5-step program that, in our opinion, should be adopted globally in every country. At the end of this chapter, we have summarized the essence of the LEAP program and a link to the patient education pdf, which includes all you need to know to give your patients the best information.
In many western countries, patients with sensory neuropathy are entitled to subsidies for special shoes/ insoles. We are not aware of any African country that has introduced similar measures - if the patient needs special shoes/insoles in Africa, they will have to pay for these themselves.
Unfortunately, there are still very many caregivers that are not aware of how important it is to detect whether a patient has sensory neuropathy and what significance the monofilament test has. The test is so simple, cheap, and can save a limb by preventing ulcers of the feet because we have informed the patient and given them sensible advice. It is thought that up to 85% of diabetic foot ulcers could have been prevented if we were good at preventive measures. The monofilament test must be the most cost-effective preventative measure in health care!
Note that there are other tests for checking for sensory neuropathy, such as using a tuning fork to test whether the nerves can detect vibration ( we have written a separate chapter on the tuning fork method). Another method is to test whether the sensory nerves can detect temperature changes. While the monofilament test certainly has some pitfalls, it remains the number 1- test globally in detecting sensory neuropathy in wound care because it is reliable, cheap, and available everywhere.
Which patients should be screened with the monofilament test?
The international recommendation is that all diabetic patients be checked yearly for sensory neuropathy. In many western health systems, this should be performed by the family doctor ( general practitioner). Unfortunately, many international studies show that family doctors often overlook this. They concentrate on measuring HbA1c levels, cholesterol, and blood pressure but regularly forget to check the feet of their diabetic patients.
Once sensory neuropathy has been diagnosed, the test does not have to be repeated - the patient will most likely have sensory neuropathy for the rest of their lives. There are exceptions to this, but once the nerves have been damaged, it is a permanent condition in nearly all cases.
Besides diabetes, many other conditions warrant doing a monofilament test of the feet. Leprosy, HIV ( and antiviral treatment), poor peripheral circulation, alcoholism, and vitamin deficiencies can, among other causes, lead to sensory neuropathy.
A good rule for your clinical work is: whenever you have a patient complaining of a condition of the lower extremities, always take a look at their feet and do a monofilament test. This applies especially to patients attending your clinic with lower extremity ulcerations - take 2 minutes to do the test - you will on occasion find sensory neuropathy in patients where you never expected it - and your diagnosis may save the patient's limb someday.
Who should perform the test?
Everybody who treats wounds should be able to perform this simple test and should have access to a monofilament as a tool. If you regularly work with wounds on the feet but lack a monofilament, you will either have to make one on your own or get your management to order these asap.
What do we need to do the test correctly?
The patient should be able to relax while we are doing the test - i.e., have the patient in bed or on an examination bench, but a comfortable chair with a footrest is also a good alternative. The only tool you need is the standard 10-gram monofilament. What does monofilament mean, and what do they mean with 10 grams?
A monofilament is a nylon filament that is not braided - it only has one filament - therefore, "mono." Ten grams means that a monofilament of a given thickness will bend when you press on it with 10 grams of pressure. The tool is standardized so that conditions for the test are the same whether you are working in Botswana, Lybia, or Northern Canada. If we used a thicker nylon filament, patients with only slight neuropathy would detect this easier. If we used a very, very thin nylon filament, maybe even people with healthy feet would not feel it. When the method was developed in the 60s' the 10-gram nylon filament was found to give a reliable sensitivity/specificity aspect for detecting sensory neuropathy, which became the international standard.
Producing a monofilament must cost close to nothing. It must be more difficult to make a toothbrush. Most of the monofilaments available today come from China, and you can buy them reasonably cheaply online, but you may have to purchase large quantities. However, as the product advances through the distribution chain, the price increases exponentially, and paying 10 US dollars for a simple monofilament is piracy in our eyes. We are even more disappointed when we see that some diabetes patient organizations charge this price from their members for this simplest of tools. If we are serious about getting people's feet checked, then this tool must be provided at a ridiculously low price - they should be readily available everywhere.
If a health organization is serious about preventing foot ulcers caused by loss of sensation to the feet, they should hand out monofilaments free of charge! The LEAP program in the USA is one of few organizations where monofilaments are dispatched free of charge all over the USA. What a great initiative!
Even in Norway, monofilaments are not readily available everywhere, and most wound care health workers use monofilaments handed out at events and congresses by producers of wound care products. So - there is a lack of good quality but ridiculously cheap monofilaments globally - we sense a business opportunity here for a thrifty African company. If you are in a position to make such a product contact us - we can help you with the ideal design of the product and can use our network to distribute your monofilaments globally.
Note that a monofilament does not last forever - it should be replaced when it has a visible bend and, at the latest, replaced every 2-3 months. The most ideal is that you use a new monofilament for every patient to avoid contaminating the monofilament. This is not a realistic option at many workplaces because they only have one or two monofilaments lying around. In this case, you will have to wipe the monofilament down with alcohol between each patient. The alcohol will, however, shorten the lifespan of the monofilament considerably as it weakens the material.
Figure 1 Monofilaments are available in many varieties and qualities, and prices vary significantly.
Figure 2 Note that not all types of monofilament are of acceptable quality. This model comes with five extra monofilament tips, but most of them were already bent before having been used. When a monofilament is bent, the strength required to bend it more is less than 10 grams, and you will not get a reliable reading - you can risk having a false-positive result. In other words - a bent monofilament can result in you telling the patient that he has sensory neuropathy while this may not be the case.
Figure 3 It is generally advised to use one monofilament per patient- for hygienic reasons. We quite like this model made by medicalmonofilament.com in the USA - and it is the same model as used by the LEAP program. You can use the monofilament by holding the card between your thumb and index finger, but there is also an optional re-usable handle available, giving you even more accurate control. Click on the image above to get to the producer's website, where you also can order the product. The price is about 80 cents per monofilament which is acceptable if you are working at a clinic in western countries, but if you have a tight budget at your workplace - almost a dollar per monofilament is too high a price. Again, this important tool should be dispensed at a strongly subsidized rate in Africa to ensure that the test is available everywhere.
Figure 4 Did you know that you can check if your monofilament is of a standardized quality? Here is a simple trick to check your monofilament. Ideally, you should have an electronic scale available to do this. Place your monofilament at a right angle on the scale and press down until it buckles/bends. The value on the scale should be close to 10g ( +/- 1g is ok). In the example in the image above, almost 15g pressure was needed to bend the monofilament. This monofilament is not ideal for clinical use!. If we have to use more force to get the monofilament to bend - patients with early-onset neuropathy may still detect this. In other words, we can get false negative results - we can end up concluding that the patient has healthy feet while they may have sensory neuropathy in the early stages.
Note: if you do not have a monofilament available to you, you can try to get hold of a nylon fishing line in the appropriate thickness and test it with the same method described above.
Figure 5 We have been trawling the world wide web to find a cheap source of monofilaments. Apart from buying them directly from chinese producers at sites like aliexpress.com, we found the american company medicalmonofilaments.com sells a 20 pack of monofilaments for 13 US Dollars. With shipping the price will probably be around one US dollar /monofilament. They also sell the monogripper which is designed to hold the monofilaments in an ideal way. You can click on the image above to go to the producers website.
What can you do if you do not have a monofilament at hand?
A monofilament is such a cheap and essential tool that it should be found at every wound clinic. Paradoxically this is not the case. We have tested this at several wound clinics - asked the staff where the monofilament was, and it sometimes ended up with frantic searching in drawers under muffled " we know that it was here last week." All of your staff must know where to find the tool and how to use it.
But let us say for the sake of argument that you do not have a monofilament at hand. You could use other tools to test for sensory neuropathy like a tuning fork or a special temperature instrument - but if you do not have a monofilament, it is highly unlikely that you have one of the other tools.
If you do not have a monofilament or other tool, you are still obliged to test for sensory neuropathy taking into consideration that your results may be flawed. However - if you use your fingers to touch the skin under the greater toe and under the metatarsal heads and the patient does not feel it, it is evident that the patient has severe sensory neuropathy. We actually use the finger method ourselves - just to do a really quick check of the patient's sensation at the start of the examination. If the patient cannot even feel your finger touching the skin, they will not feel a monofilament, and you can skip the test.
A nylon fishing line of the appropriate thickness can quite well substitute a commercial 10-gram monofilament. A nylon line of 0,5 millimeters is the most appropriate cut to 4 cm in length. Obviously, the longer the nylon filament is - the less force is required to bend it. You will have to experiment with the lengths- testing on an electronic scale - but several articles refer to a 4 cm length as ideal. Note that the 0,5-millimeter fishing line differs quite a bit in bending strengths between the different brands. But if your clinic cannot afford to buy commercial monofilaments regularly, this is probably the best workaround. You could make small paper pieces similar to the LEAP monofilaments and glue the nylon filament onto these. This will be more exact than holding the filament between your fingers when performing the test. Note: since the fishing line comes wrapped around a spool, it will have a slight natural bend to begin with, So here, you cannot use the rule - if it is bent, you have to discard it. The length you cut the filament has to compensate for the existing bend and still yield a 10-gram bend strength. Hopefully, the last sentence makes sense because we found it hard to explain this better. Anyway, using a fishing line is probably your best workaround solution. Several studies show that this is a viable solution.
You can use a venflon (without a needle!) - the pink ones have adequate elasticity for the test. We haven't tested them on an electronic scale yet, and they can obviously not replace an actual monofilament examination but as we always say- use what you have. But you have to interpret the results with care.
Remember that the original monofilament test by Semmes and Weinstein was done using hair from horse's tails. We are completely serious about this hack - if you cannot get hold of reasonably priced monofilaments - go to the nearest horse club or horse owner and ask if you can have some hair from horses' tails for limb saving purposes! Ideally, you should try hair strands from several horses - they will have varying thickness and elasticity. You cut them into shorter pieces at your clinic and test them on an electronic scale. And you use the ones which bend around 10g of pressure!
If you have any other workaround tips for the monofilament test- we would like to hear about it -send us an email!
Figure 6 A monofilament nylon fishing line of 0,5 mm thickness cut to 4 cm length will, in many cases, bend at around 10 grams pressure. Note that different brands of fishing line will have slightly different elasticities so you will have to experiment a little using different lengths of the brand available to you. If you can get hold of a black nylon fishing line that is even better as it is easier to visualize than the translucent types. Braided fishing line is not elastic and will not work for this purpose.
Figure 7 Two studies show that using a monofilament nylon fishing line cut to the appropriate length can work well as an improvised monofilament to test for sensory neuropathy. We particularly like the title of the first study by Parisi et al. from Brazil (2011), "Diabetic foot screening: a study of a 3000 times cheaper instrument". You can click on each picture to get to a link to these articles.
Figure 8 Left: Up to 2015, there were a confusing number of recommendations on where to place the monofilament when testing for sensory neuropathy. Right: Since 2015 these pressure points have been the international standrad- 4 points on each foot - under the great toes,under the first, third metatarsal and fifth metatarsal heads.
Step by step instructions on how to perform the monofilament test
Have the patient lying on an examination bench or a bed, but if that is not available, the patient can sit in a chair and have the feet elevated on some form of footrest. The important thing is to create a calm atmosphere. Remember that this can be a stressful situation for the patient. Especially for younger patients, the diagnosis "sensory neuropathy" may be seen as a defeat. Some patients know what poor prognosis follows this diagnosis!
Explain to the patient what you will do and why the test is important.
Demonstrate on your own arm first how you use the monofilament and that this is not at all painful. Then demonstrate it again using the inside of the patient's lower arm, where we usually have good sensory perception. This step is very important so that the patient can recognize what they should feel when you are testing the feet. Some demonstrate this on the patient's forehead, but it might seem more threatening to the patient if you approach the monofilament to the head!
First now you can go to the feet. Before 2015 the recommendations for which areas of the foot you should test with the monofilament were downright confusing, and everybody did it differently. In 2015 an international consensus concluded that we only need to test 4 areas on each foot: Under the greater toes, under the first, third, and fifth metatarsal heads. These represent common areas of pressure points in the foot. Note that the heel area is no longer part of the test. The monofilament test concentrates on the forefoot, which makes sense because sensory neuropathy will first develop at the end of the foot since the smallest nerves are affected first.
Ask the patient to close their eyes.
Press the monofilament at a right angle to the skin (90-degree angle) with enough pressure that the filament bends to a "C" shape for one second.
You must avoid areas with callus ( hard skin) and scars as these areas will not be as sensitive to touch even though the patient has normal nerve function. You cannot do a monofilament test in an open wound if you have a situation where you, for example, have dry hard skin under the third metatarsal head; then you can test with the monofilament under the second metatarsal head- no problem.
Test all four points on one foot at a time before testing the other foot. Some recommendations state that you should ask the patient each time you press the monofilament on the skin: " Do you feel this? Yes or no?". We do not find this a suitable method. Some patients wish they had normal sensitivity in their feet and might be obliged to answer "Yes, I feel it," although, in reality, they didn't feel it. We find that the only reliable method is not to ask the patient each time you touch the skin with the monofilament. Instead, you inform the patient that they should let you know when they think they feel the touch of the monofilament. We guarantee that you will diagnose about 25% more patients with sensory neuropathy if you use the latter method! Remember, the patient should close their eyes during the examination.
As you perform the test, you have to remember how many sites the patient felt the monofilament. Since we are testing four sites on each foot, that makes a total of 8 locations ( provided that the patient is not amputated on one side). This means that the best score anyone can obtain is 8/8. In the worst-case scenario, the result is 0/8, which is indicative of severe sensory neuropathy. Many patients will be somewhere in between.
How do we interpret the results?
As mentioned earlier, the monofilament test results are displayed as a fraction. For example, 3/8 means that the patient felt the pressure from the monofilament at three out of eight sites.
The patient feels 0-3 of 8 points: most likely sensory neuropathy
The patient feels 4-6 of 8 points: possible sensory neuropathy
The patient feels 7-8 of 8 points: sensory neuropathy is unlikely
Remember that a patient does not have to have a perfect score - if the patient misses on only one site, this is considered quite normal. Even if the patient misses on two of the sites, you cannot be 100% sure that they have sensory neuropathy. As you see above, the interpretation of the test is not very rigid. Especially the group in the middle- those that only feel 4-6 /8 points can sometimes be challenging to interpret. Especially in rural areas, Africans often have quite hard skin under the feet after years of walking in the bush, which may seriously flaw your results. A patient with generally hard and dry skin on the whole sole of the foot may appear to have severe sensory neuropathy after a monofilament test while their nerves, in fact, are healthy. So here, you have to use your clinical experience as well.
If you are unsure whether you can rely on your monofilament test in a particular case, it is advisable to use another tool to check for sensory neuropathy. Checking the sense of vibration with a tuning fork is an excellent method to do this. We have written a separate chapter on this method under " practical skills." A tuning fork will probably not be available to you in most cases. If you often see patients with sensory neuropathy at your clinic, you should definitely invest in this tool - they can be bought for about 10 US Dollars at the cheapest sources.
What are the consequences?
Patients with a normal monofilament test should be tested again after a year ( and yearly from thereon)
Suppose we have found sensory neuropathy in a patient who does not have diabetes; we have to try to find the cause of the neuropathy. If we find neuropathy and you are not sure whether the patient has recently been checked for diabetes, you always always have to check this again! Could the cause be impaired arterial circulation? Ask the patient about alcohol use. We should also consider vitamin deficiencies - especially vitamin B deficiencies can cause neuropathy. Could the patient have leprosy or HIV? Sometimes we cannot find a specific cause, and this is called idiopathic sensory neuropathy.
When we have concluded that a patient has sensory neuropathy, this leads to a series of steps that have to be taken as a consequence of this finding. What a positive monofilament test really means is that the patient is at high risk of developing a foot ulcer at any time in the future.
The American LEAP program ( lower extremity amputation prevention program) has compiled an excellent 5 step program for patients where we have diagnosed sensory neuropathy. Note that the LEAP program, which was developed in 1992, was initially designed for patients with sensory neuropathy due to leprosy (which the program refers to as Hansen's disease) but has since been internationally adapted to all patients with peripheral sensory neuropathy. Actually, the LEAP program is a spin-off from the earlier Carville Diabetic Foot program - this is not relevant for your daily clinical practice, but we need to give credit to those who have designed the tools we are using today.
The five-step LEAP program is shown at the end of this chapter. We have also included a link to their website where you can download a pdf file on patient information for those diagnosed with peripheral sensory neuropathy. Note that the illustration for the monofilament test in this brochure has not been updated- it still shows the older version where we tested more than four sites on each foot.
Figure 9 A patient education brochure designed by the LEAP program with many excellent tips on preventing foot ulcers. Click on the image above to get to a pdf version of the booklet, which you can print out and give to your patients. The brochure is available in many different languages but currently not in any african languages. all copyrights: LEAP
Note: at the end of this chapter we have included a link to www.diabeticfoot.org.uk where you can find a link to another patient information leaflet -there we found one in Swahili. Ideally, you should use these to be inspired to design your own patient information guides which will be adaopted to the cultural setting you are working in and to the resources you and your patients have.
The Five-Step LEAP Program
STEP ONE: Annual Foot Screening
The foundation of this prevention program is a foot screening that identifies those patients who have lost protective sensation. The initial plantar ulcer usually results from an injury to a foot with lost sensation. In the absence of protective sensation, even regular walking can result in such injuries.
The LEAP Foot Screen uses a 5.07 monofilament, which delivers 10 grams of force, to identify patients with a foot at risk of developing problems. Perform an initial foot screen on all patients at diagnosis and at least annually after that.
To help prevent foot problems, at-risk patients should be seen at least four times a year. This is to check their feet and shoes to help prevent foot problems from occurring.
STEP TWO: Patient Education
Teaching the patient self-management skills is the second component of the LEAP Program.
Once taught simple self-management techniques, the patient assumes personal responsibility and becomes a full partner with the health care team in preventing foot problems.
STEP THREE: Daily Self-Inspection
Daily self-inspection is an integral part of the self-management program. Every individual who has lost protective sensation must regularly and adequately examine their feet daily.
Studies have shown that daily self-inspection is the single most effective way to protect feet in the absence of the pain warning system. Early detection of foot injuries (blister, redness, or swelling), callus, or toenail problems (thick, tender, long, or discolored) is necessary to prevent potentially more serious issues.
Some problems should be reported immediately to a health care provider while the patient can manage others if they have been taught simple, basic self-management techniques.
STEP FOUR: Footwear Selection
Shoes, like feet, come in a variety of styles and shapes. A person with normal sensation in their feet can wear almost any shoe style with little risk of injury. If the patient has lost protective sensation, poorly designed or improperly fitting shoes can seriously complicate the condition of the feet.
Once a patient has lost protective sensation, they should never walk barefoot, even around the house.
The patient should never wear narrow-toed shoes or boots, heeled shoes, shoes with vinyl tops, thongs, or any shoe that is too loose or too tight. This person will need special assistance in selecting the appropriate style and fit of shoes.
The shoe should fit the shape of the foot. There should be at least ½ inch between the longest toe and the end of the shoe. In a properly fitting shoe, a small amount of leather can be pinched up.
The patient, the family, and the health care team need to recognize that wearing appropriately styled shoes that fit can prevent most foot problems.
STEP FIVE: Management of Simple Foot Problems
In addition to causing loss of protective sensation, neuropathy can also affect the autonomic nerves in the foot. And this can lead to dry, cracked skin, increasing the probability of foot injuries and wounds.
This prevention program emphasizes the importance of reporting all injuries to the health care provider.
Date Last Reviewed: June 2019
Figure 11 We are impressed with the efforts of the LEAP program to prevent amputations! Did you know that they provide a free-of-charge online course for the comprehensive management of the neuropathic foot? You simply complete the registration form and they will send you a username and a password which will give you 24 hour access to the course materials. Click on the image above to get to this site. Note: the course involves modules and post-test which you have to complete withing two weeks to get a certificate of completion. We recommend you to only register if you know that you have some time available in the next two weeks! Otherwise postpone it to some time in the rainy season where you will spend more time indoors anyway! Left image source: shutterstock.
Figure 12 Another helpful resource is www.diabeticfoot.org.uk where we also found this patient information leaflet which was available in many languages - also Swahili. This sort of leaflet is something that you can easily modify to design your own patient information guides which will be adaopted to the cultural setting you are working in and to the resources you and your patients have. Click on the image above to get to their site. copyright: www.diabeticfoot.org.uk