Using a monofilament to check for sensory neuropathy
Whenever a new patient with a wound on the lower extremity attends our clinic we should do a monofilament test to check for sensoric peripheral neuropathy. Simply put: we should check whether the patient can sense touch under his/her feet. There are many conditions which 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 thought to be high in Africa becasue 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 there are many other conditions which 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 not only be caused by the viral infection itself but also through neurotoxic antiretroviral therapy. Other causes of PN are leprosy and a number of other infections, vitamine deficiencies and alcoholism. At the bottom of this chapter is a link to an article summarizing different causes of peripheral neuropathy.
Be aware that there are many forms of neuropathy - the major categories are sensory neuropathy, motoric neuropathy, sympathic neuropathy and painful neuropathy. A patient may have only one type of neuropathy or in severe cases all four categories combined. When we are using a monofilament to test whether the patient has feeling under his/her feet we are obviously testing 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. It was the neuropsychologist Sydney Weinstein and neurophysiologist Josephine Semmes who developed this simple but clever test in the USA in the 60`s. In the beginning they used hair from the tails of horses 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 " Semmes-Weinstein monofilament test" - this will 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 and that they used a considerable time to develop and validate this simple test which 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 ulcers of the foot. Click on the image above to get to a video which explains the procedure. Courtesy of IHSgov (The federal health program for american indians and alaska natives)
Why is it imprtant to check for sensoric neuropathy?
Sensory neuropathy of the feet means that the patient has decreased or no sensation of touch 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.
If you perform a monofilament test and discover that the patient has sensory neuropathy then you know without any doubt that the patient is at high risk to develop an ulcer of the foot. Most likely he/she already has an ulcer on the foot since you have the patient infront 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 or 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. Very often the patient is not aware himself that they have 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 definitely avoid walking barefoot - even isnide the house. The list of advice to these patients is quite long - the important part is that the patients are aware of the conditions 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 prorgam is a structured 5-step prorgram that in our opinion should be adopted globally in every country. At the end of this chapter we have summarized the essence of what the LEAP program is 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 sensoric 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 over how important it is to detect whether a patient has sensoric neuropathy and what signifcance 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 preventive measure in all of health care!
Note that there are other tests for checking for sensory neuropathy - for example using a tuning fork for testing whether the nerves can detect vibration ( we have written a seperate chapter on the tuning fork method). Another method is to test whether the sesnory nerves can detect changes in temperature. While the monofilament test certainly has some pitfalls it remains the number-1 test globally in detecting sensory neuropathy in the field of woundcare because it is sufficiently reliable, cheap and availabel everywhere.
Which patients should be screened with the monofilament test?
The international recommendation is that all diabetic patients should be checked at least once yearly for sensoric neuropathy. In many western health systems this is something that should be performed by the family doctor ( general practitioner). Unfortunately many international studies show that very often this is overlooked by family doctors and they concentrate on measuring HbA1c levels, cholesterol and bloodpressure but regularly forget checking the feet of their diabetic patients.
Once sensory neuropathy has been diagnosed the test does not really have to be repeated - the patient will most likely have sensory neuropathy for the rest of their lives. There are exceptions to this but in nearly all cases once the nerves have been damaged it is a permanent condition.
Besides diabetes there are many other conditions that warrant doing a monofilament test of the feet. Leprosy, HIV ( and antiviral treatment), poor peripheral circulation, alcoholism and vitamine deficiencies can aong 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 also and do a monofilament test aswell. 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 patients 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 foot rest 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 gram?
A monofilament is a nylon filament which is not braided - it only has one filament - therfore "mono". 10 grams refers to that a monofilament of given thickness will bend when you press on it with 10 grams of pressure. The tool is standardized in this way so that conditions for the test are the same whether you are working in Botswana , Lybia or Northern Canada. If we would use 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 detect it. When the method was developed in the 60`s the 10 gram nylon filament was found to give a reliable sensitivity/specificity aspect for detecting sensoric neuropathy and this 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 cheap there online but you may have to buy 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 peoples feet checked then this tool must be provided at a ridiculously cheap price - they should be readily available everywhere.
If a health organization is serious about preventing foot ulcers that are cause by loss of sensation to the feet than 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 of woundcare health workers use monofilaments handed out at events and congresses by producers of woundcare products. So - there is a lack of good quality but ridicolously 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 latest replace 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 enach patient. the alcohol will however, shorten the lifespan of the monofilament considerably as it weakens the material.
Figure 1 Monofilaments are available in a lot of varieties and qualities and prices vary signifcantly.
Figure 2 Note that not all types of monofilament are of acceptable quality. This model comes with 5 estra monofilament tips but most of them were already bent before having been used. When a monofilament is bent the strength required to ben 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 ptient that they have sensory neuropathy while this may not be the case.
Figur 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 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 a optional re-usable handle available giving you even more accurate control. Click on the image above to get to the producers 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 i western countries but if you have a really 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 subsidied rate in Africa to make sure 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 a electronic scale availabel to do this. Place yur monofilament at an 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 he/she 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 nylon fishing line in the appropriate thickness and test it with the same method as described above.
Figure X We have been trawling the world wide web to find a cheap source of monofilaments. Apart from buing them directly from chinese producers at sites like aliexpress.com we foundthe american company medicalmonofilaments.com who sell 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 important 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 then it is obviosu that the patient has severe sensory neuropathy. We actually use the finger method ourselves - just to do a really quick check of the patients sensation at the start of the examination. Obviously- if the patient cannot even feel the 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 substitute a commercial 10 gram monofilament quite well. It seems that a nylon line of 0,5 millimter is most appropriate cut to 4 cm length. Obviously the longer the nylon filament is - the less force is required to bend it. You will have to experiment a little with the lengths- testing on an electronic scale - but several articles refer to a 4 cm lenght as being ideal. Note that 0,5 millimeter fishing line differs quite a bit in bending strengths between the different brands. But if your clinic cannot affort 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 somewhat more exact than holding the filament between your fingers when performing the test. Note: since 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 needle!) - the pink ones have adequate elasticity for the test. We havent tested them on an electronic scale yet and they can obviously not replace a true 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 horses tails. We are completly 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 strands of hair from several horses - they will have varying thickness and elasticy. Back at your clinic you cut them into shorter pieces and test them on the 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 X 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 elasticity 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 X two studies that show that using monofilament nylon fishing line cut to appropriate length can work well as an improvised monofilament to test for sensoric neuropathy. We particularly like the title of the first study by Parisi et al. from Brazil (2011) "Diabetic foot screening: study of a 3000 times cheaper instrument". You can click on each picture to get to a link of these articles.
Figure 5 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 foot rest. 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 are going to do and why the test is important.
Demonstrate on your own arm first how you ue the monofilament and that this is not at all painful. Then demonstrate it again using the inside of the patients lower arm where we usually have good sensory perception. This step is very important so that the patient can recognize what he/she should feel when you are testing the feet. Some demonstrate this on the patients 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 in a different way. In 2015 an international concensus 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 no longer is part of the test. The monofilament test concentrates on the forefoot which makes sense because sensory neuropathy will first develop in the end of the foot since the smallest nerves are affected first.
Ask the patient to close his/her eyes
Press the monofilament at an right angle to the skin ( 90 degree angle) with enough pressure that the filament bends to a "C" shape for one second.
You have to avoid areas with callus ( hard skin) and scars as these areas obviously not will be as sensitive to touch even though the patient has normal nerve function. You cannot do a monofilament test in an open wound either. If you have a situation where you for example have dry hard skin under the third metatarsal head then you an 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. In some recommendations it states 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 good method. Some patients wish they have normal sensitivity in their feet and might be obliged to answer "Yes, I feel it" although in reality they didnt 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 he/she should let you know when they think they feel the touch of the monofilament. We guarantee you that you will diagnose about 25% more patients with sensory neuropathy if you use the latter method! Remember, the patient should close his/her eyes during the examination.
As you perform the test you have to remember at how many sites the patient felt the monofilament. Since we are testing 4 sites on each foot that makes a total of 8 sites ( 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 indicatiove of severe sensory neuropathy. Many bpatients will be somewhere inbetween.
How do we interpret the results?
As mentioned earlier the results of the monofilament test are displayed as a fraction. For example 3/8 means that the patient felt the pressure form 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 he/she has 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 difficult to interpret. Especially in rural areas africans often have quite hard skin under the feet after years of walking in the bush and this 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 infact are healthy. So here you have to use your clinical experience aswell.
If you are unsure whether you can rely on your monofilament test in a particular case then 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 seperate chapter on this method under " practical skills". In most cases a tuning fork will probably not be available to you. If you often see patients with sensory neuropathy at your clinic you should defintiely 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)
If 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 cuase 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 then 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 originally was designed for patients with sensory neuropathy due to leprosy (which the program refers to as Hansens disease) but it 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 of relevance for your daily clinical practice but we need to give credit to those who have desigend 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 X A patient education brochure designed by the LEAP program with many excellent tips on how to prevent foot ulcers. Click on the image above to get to a pdf version of the brochure 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 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 that has lost sensation. In the absence of protective sensation, even normal 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 thereafter.
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 properly examine their feet on a daily basis.
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 toe nail problems (thick, tender, long, or discolored) is necessary to prevent potentially more serious problems.
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 toe 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 X 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 X Another useful resource is 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: