Diabetes is widespread – millions of people worldwide are affected – yet its most common, and most dangerous complication, nerve damage in the feet, is often difficult to diagnose. It can develop painlessly for years, gradually taking away the ability to feel pain, heat or pressure. By the time a person develops a forefoot ulcer, damage may have been present for some time.
A novel screening tool developed by researchers in Ipswich provides a remarkably simple way to detect this sensory loss early using only a clinician’s finger-tip. The Ipswich Touch Test diabetes screening method offers healthcare professionals an accessible approach to identifying peripheral neuropathy in diabetic patients.
Understanding the Ipswich Touch Test Diabetes Screening
The Ipswich Touch Test was created at the Ipswich Hospital in the United Kingdom as a convenient, no equipment substitute for other methods of foot screening. The researchers needed a tool that could be used by any trained health care professional during the regular appointment of a diabetic, requiring no extra time and no special equipment.
What Is the Ipswich Touch Test?
The test is simple, very straightforward. It simply involves a gentle touch of various points on the patient’s toes with a finger tip to determine if the patient is feeling the contact. It was created to diagnose peripheral neuropathy—that is, nerve damage which diminishes or entirely removes protective sensation in the feet—in diabetics.
It’s extremely simple, requiring no devices, calibration, or extra clinic time. It was this rather extreme simplicity that attracted the attention of NHS diabetes teams, and of international health organizations, eager to find a low-cost screening alternative that can be carried out as part of annual diabetes foot checks.
Why Diabetic Foot Sensation Matters
Diabetic peripheral neuropathy affects the majority of all those with established diabetes. If nerve endings in the feet are dysfunctional, an individual can walk on a sharp object, develop a blister from an poorly fitting shoe, or burn the sole of their foot on the hot paving slab, and they will not feel anything. This painless state is actually extremely dangerous.
Without the ‘pain’ message, small wounds remain unnoticed, unnoticed wounds become infected ulcers, and in extreme circumstances amputation is necessary. Sensation testing on a regular basis is one of the most effective ways of preventing this progression.
When and Why the Ipswich Touch Test Is Used
Usually, healthcare staff will carry out a foot sensation screening as part of their annual diabetes review, but in more high-risk groups they may carry out the screening more regularly. The Ipswich Touch Test can be easily integrated into the annual review as it takes very little additional time on to an existing consultation. It has been shown to be practical for use in the community, in GP surgeries and even pharmacies.
Who Is at Risk and Should Be Tested
Not everyone with diabetes is equally at risk of foot problems. People who have had poorly controlled blood glucose for many years, who smoke, have kidney disease, or who have had a previous foot ulcer or amputation are greatly at higher risk. The longer you have had diabetes, the more vulnerable you are in the same way that the older you are the more sensation you tend to have, even without diabetes.
Aging also increases risk factors: the more they present, the more urgent testing becomes.
Clinical vs Home Use of the Test
This assessment is carried out by a trained nurse, podiatrist or doctor, as part of a formal foot examination in clinic. The findings are used as part of a more general risk stratifcation so that the frequency of the subsequent follow-up can be determined. Several diabetes educators and researchers have tried to determine whether trained family members/carers could carry out a modified version for use in the home, particularly in patients who are housebound and have difficulty attending hospital clinics.
Although home use shows great potential to extend coverage, it does have a role when the person undertaking the test has been given simple instructions about what to look for and when to refer.
How the Ipswich Touch Test Diabetes Assessment Works
The test itself is quite simple. The patient is kept comfortable either lying or sitting with closed eyes and is left for the performance of the test. The examiner lightly touches the tip of the index finger at six designated sites on both feet.
Step-by-Step Test Procedure
There are six sites on which touch sensitivity is tested, these are the tips of toes I, III, and V of each foot (bilaterally). The examiner strokes each of these six sites a single, short stroke of approximately one second duration, with each stroke being very light. The patient indicates whether or not they detected the touch by verbal response, “yes” in each case.
There is no pressure involved during testing, the examiner’s finger coming into contact with each site like a feather lightly brushing across the surface of the skin. The examiner notes the patient’s response for each site and how many sites they are able to feel. The entire process takes usually less than 2 minutes.
Interpreting Scores and What Results Mean
The six sites are either responded as “felt” or “not felt” (pg.100). if two or more of the six sites cannot be felt then the test indicates the likelihood of peripheral neuropathy and further medical investigation is needed, if less than two are cannot be felt then the test would be inconclusional and should be repeated. If three or more are cannot be felt there is a likely equivalent nerve destruction. The score achieved is not itself a diagnosis, but provides a screening pointer to the next level of investigation or care.
Accuracy, Benefits, and Limitations of the Ipswich Touch Test
Studies published in peer reviewed diabetic journals have looked into the effectiveness of this test when compared to other commonly employed screening methods. The results are quite promising, but not without complexities:
Comparison with Monofilament and Other Tests
The 10g monofilament remains the gold standard in protective foot sensation testing. Comparative studies between the two found that the Ipswich Touch Test works with approximately comparable sensitivity and specificity; it is a valid alternative rather than inferior replacement. Both tests measure important neuropathy equally well.
One advantages of the monofilament is the standard delivery of pressure, but you must procure and maintain the equipment. The fingertip test is free of this hurdle.
Strengths, Limitations, and Low-Resource Settings
The greatest advantage of the Ipswich Touch Test is how practical it is. It can be used in low resource settings such as clinics with a limited number of funds, out in the field in rural health posts, and in low income countries in which reliable low-cost monofilaments cannot be purchased in bulk. Its main weakness is its inconsistency; different examiners may exert slightly more or less pressure, which could influence the results.
It may also be less effective in discovering insidious neuropathy when using a neurological examination. However, for a population screening test at the public health level aimed at predicting foot ulceration in mostly moderate to severe neuropathy, it is sufficiently accurate to be of some utility.
What Happens After the Test and Protecting Your Feet
A positive screening result and altered or absent sensation is not a definitive conclusion. It is merely an initial step toward a holistic care plan.
Follow-Up, Referral, and Treatment Options
Following the detection of reduced sensation, the practitioner may organize a full podiatric foot assessment, look into blood glucose control and examine footwear. Additional neurological and vascular tests and imaging may then be undertaken depending on the clinical presentation, with the overall aim of understanding the level of damage and how to reduce future risk. Medication for treatment of neuropathic symptomatology may be prescribed where appropriate but presently there is no medication available that can reverse existing nerve damage – prevention and protection are therefore the only options.
Daily Foot Care Tips for People with Diabetes
Take care of your feet daily as soon as you develop neuropathy. Weekly eyeing up of the feet for bruising, redness, swelling or blisters in the morning as often there is no pain is a wise course of action. Wearing comfortable shoes with padding and not bare foot is important.
Feet need to be kept clean and moistened to prevent a breach of the skin providing a portal entry for infection. Attending all appointments with the diabetic team and making them aware of any foot changes ensure appropriate treatment is received.