The Bureau of Primary Health Care LEAP Program:

A comprehensive prevention program developed at the Gillis W. Long Hansen's Disease Center in Carville, LA designed to reduce lower extremity amputations in individuals with Diabetes Mellitus or any condition that results in loss of protective sensation in the feet.

The LEAP Program consists of five parts:
 

1. Annual Foot Screening;

2. Patient education;

3. Appropriate footwear selection;

4. Daily self inspection of the foot by the patient;

5. Management of simple foot problems.

Annual Foot Screening:

The foundation this prevention program is a foot screen that identifies patients who have lost "protective sensation". While it is well known that patients with diabetes frequently have vascular insufficiency in their extremities, the initial plantar wound 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 Diabetic Foot Screen is a brief examination that can be used to identify patients with a current acute foot problem or a foot at RISK of developing problems. The initial foot screen is a baseline on the patient that establishes: previous history of ulceration, weakness, deformity, and whether or not the patient has lost "protective sensation". A foot screen should be performed on all patients with diabetes during the initial visit and at least annually thereafter.

Once a patient has been identified as being "at RISK" you are going to have a patient for life. Have them come in at least four times a year to check their feet and shoes. Prevention depends on never waiting until problems develop!

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.

Videotapes and patient education materials on self inspection, skin care, nail care, callous care and shoe selection are available. The handouts, designed to reinforce the information in the videotapes, are valuable tools for the health care provider and the patient.

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. But in Diabetes Mellitus, if the patient has lost "protective sensation", poorly designed or improperly fitting shoes can cause serious foot injuries.

Once a patient has lost "protective sensation", they should never walk barefoot, even around the house. They will need special assistance in selecting the appropriate style and fit of shoes.

A patient with loss of "protective sensation", should never wear narrow toe shoes or boots, high heel shoes, shoes with vinyl tops, thongs, or any shoe that is too loose or too tight.

With the patient standing, both feet should be measured for shoe size using a Brannock type device - to check the length and width. Fit patients for shoes in the afternoon since the feet may be a little swollen then.

The patient should NOT wear their new shoes before coming back to have them checked for fit and style. They need to find out if the shoe store will accept returns or exchanges of shoes that have not been worn.

The shoe should fit the shape of the foot. There should be at least 1/2 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.

Everyone involved ? the patient, the family and the health care team ? need to recognize that most foot problems can be prevented by WEARING appropriately styled shoes that FIT.

Daily Self Inspection:

Daily self inspection is an integral part of the self management program. Every individual who has lost "protective sensation" (Risk Categories 1, 2 and 3) 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 a "pain warning system".

Early detection of a foot injuries (blister, redness or swelling), callous or toe nail problems (thick, tender, long or discolored) are necessary to prevent potentially more serious problems. Some problems should be reported immediately to a health care provider and others can be managed by the patient if they have been taught simple, basic self management techniques.

Management of Simple Problems:

In addition to causing loss of protective sensation, diabetes can also affect the autonomic nerves in the foot and lead to dry cracked skin, increasing the probability of foot injuries and wounds.

The prevention program acquaints the patient with management and prevention of dry skin. The patient is instructed in the proper technique of nail trimming, callous care and simple wound management.

If the patient is not able to self manage these simple problems, they will be followed in the Diabetic Foot Clinic on a regular basis for preventive care.

This prevention program emphasizes the importance of immediately reporting all injuries to the health care provider.