Boulton Andrew J M
Manchester Diabetes Centre, 193 Hathersage Rd, Manchester M13 0JE, England.
J Am Podiatr Med Assoc. 2010 Sep-Oct;100(5):349-52. doi: 10.7547/1000349.
Throughout our medical training, we are taught how to manage patients who present with symptoms: perform a clinical examination, make a diagnosis, and develop a management plan. However, virtually no time is spent on teaching us how to manage patients who have no symptoms because they have lost the ability to feel pain, that is, patients with peripheral neuropathy. The lifetime incidence of foot ulceration in people with diabetes has been estimated to be as high as 25%, and a variety of contributory factors result in a foot being at risk for ulceration. Most important among these factors is peripheral neuropathy, or the loss of the ability to feel pain, temperature, or pressure sensation in the feet and lower legs. Up to 50% of older type 2 diabetic patients have evidence of sensory loss, putting them at risk for foot ulceration. If we are to succeed in reducing the high incidence of foot ulcers, regular screening for peripheral neuropathy is vital in all patients with diabetes. Those found to have any risk factors for foot ulceration require special education and more frequent review, particularly by podiatric physicians. The key message is, therefore, that neuropathic symptoms correlate poorly with sensory loss and that their absence must never be equated with lack of risk of foot ulceration. If we are to succeed in reducing the high incidence of foot ulceration and particularly recurrent ulceration, we must realize that with loss of pain there is also diminished motivation in the healing and prevention of injury.
在整个医学培训过程中，我们学习了如何治疗有症状的患者：进行临床检查、做出诊断并制定治疗方案。然而，几乎没有时间教我们如何治疗没有症状的患者，这些患者因为失去了疼痛感知能力，也就是患有周围神经病变。据估计，糖尿病患者足部溃疡的终生发病率高达25%，多种促成因素导致足部有溃疡风险。其中最重要的因素是周围神经病变，即足部和小腿失去疼痛、温度或压力感觉的能力。高达50%的老年2型糖尿病患者有感觉丧失的迹象，这使他们面临足部溃疡的风险。如果我们要成功降低足部溃疡的高发病率，对所有糖尿病患者定期筛查周围神经病变至关重要。那些被发现有任何足部溃疡风险因素的患者需要接受特殊教育并更频繁地复诊，尤其是由足病医生进行检查。因此，关键信息是，神经病变症状与感觉丧失的相关性很差，绝不能将无症状等同于没有足部溃疡风险。如果我们要成功降低足部溃疡尤其是复发性溃疡的高发病率，我们必须认识到，随着疼痛的丧失，愈合和预防损伤的动力也会减弱。
