Leprosy Mailing List – September 4th, 2007
Ref.:
Care of the feet in leprosy and diabetes
From: Theuvenet W. J.,
Apeldoorn, The Netherlands.
Dear
Salvatore,
With great interest I have followed the discussion on the
prevention of ulcers in leprosy and diabetes mellitus and the valuable
contributions of Drs. Warren, Rao and Ryan.
Indeed ulceration is the most common
complication for which the patient presents him/herself at our
clinics. Most of their
discussion seems to focus on the prevention of ulcers by keeping the
skin well hydrated and many different protocols for this are
presented. There is no
doubt that additional protective footwear is needed in case of
associated loss of sensation.
Will these 2 steps prevent the recurrence of ulcers
effectively? I have my
very strong doubts. Have
any of the authors data on the recurrence rates of ulcers in their
clinic and perhaps more importantly; on the length of the ulcer-free
interval of each patient?
From my personal observation in the past 20 years I feel that
a third aspect of peripheral nerve function loss is mostly
overlooked, this is the loss of motor balance in the extremity
resulting in an abnormal gait which causes non-physiological peak
pressures.
When one examines a patient's gait on an even and uneven (sand?)
underground before examining the foot itself, one can often
detect abnormalities in the walking pattern which can predict the site
of inflammation and ulceration. After
this a more detailed examination of the motor balance of the foot and
specifically of the propriocepsis and of the strength of the extrinsic
and intrinsic muscles (paper grip-test) is essential. Only after this we will
have a proper picture of the functional anatomy (skin, sensation
and motor balance) of the foot, and of which abnormalities in this may
contribute to ulcer formation. A
proper examination can be learned by all motivated health workers and
most patients.
Fourthly, we need to assess the capability and motivation of
the patient to understand your analysis, to follow your advise on
preventive and therapeutic measures, and to educate other fellow
patients.
Fifthly; we need more data to improve on the prevention
of ulceration.
With
warm regards to you all,
Wim J.
Theuvenet, M.D., Ph.D.,
Plastic,
Reconstructive and Hand Surgeon,
Consultant
Regional Hospitals Apeldoorn, Deventer and Zutphen, The Netherlands.
Consultant
for the Netherlands Leprosy Relief and the Leprosy Mission Int.
