Leprosy mailing list – August 17th, 2005
Ccn:
all.
Ref.:
plantar ulcer management.
From: L
Lehman, Brazil.
Dear Dr. Noto,
I would like to respond to Dr. Srinivasan´s issue of plantar ulcer
management (H Srinivasan, LML Aug. 15th, 2005). This
is a very important area and one that health education and self-care
training alone can not resolve.
It is important to have the
involvement of orthopaedics and plastic surgery but I think one of the
greatest needs is knowing how to indicate and provide
adequate footwear based on a better biomechanic evaluation.
This needs to include nursing, physical and occupational therapist,
shoemakers and orthotist in addition the surgeons. One also must
consider how to integrate this into the existing health system or
create an infrastructure
within the exiting health system which permits this to be sustained.
More adequate footwear needs to be more accessible and acceptable.
We are attempting to prevent and reduce plantar ulcers in Brazil
through the National ILEP project with the Ministry of Health.
The current systematic process was started in 1997 with BASICS of
providing simple EVA or microcellular innersoles, utilizing adequate
market shoes and dorsiflexion
assist orthosis when needed.
The last 3 years we have started including additional adaptations and
focused on developing persons within each 27 states to be of technical
support to training, supervision and footwear referral and
implementation. I utilized the
training of Dr. Hugh Cross during 3 trainings from 2003-2005. It was a
2 week training which trained a team (therapist and shoemaker).
They learned a simple
biomechanical evaluation which permitted them to indicate a specific
innersole or appliance modification which could be made and used
within a market sandal or
shoe. They also learned to make the appliances and evaluate
them. Many
states have started developing and implementing better footwear
programs within their states. There is still a lot of work to be
done. The results seen in supervision is that these adaptations,
if done right, are being accepted very
well, areas of callus are decreasing and simple ulcers are healing
even when the person walks. The process now is providing
supervision and follow up to ensure the process of implementation,
integration and expansion is done.
I found frequently inappropriate footwear was being indicated for
patients by surgeons and therapist. We found that there was a
need to challenge the thinking about footwear modifications used in
Hansen’s disease and
introduce additional options which include orthotics which improving
biomechanics in addition to distributing pressures better.
There still is a need for moulded innersoles and shoes for the foot
with great deformity. This needs to continue in addition to the
INCLUSION of these additional modifications for feet with a more
"normal appearance" that have
biomechanical alterations combined with the sensory loss that puts
them at high risk for developing ulcers.
I will be happy to share more
of this process with those interested. We hope to publish this
process and some of the results within the next year.
Best wishes,
Linda
