CHAPTER VIII DISCUSSION

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1 Discussion 143 CHAPTER VIII DISCUSSION Disease Prameha has been elaborately discussed by ancient Indian Scientists with its etiology, pathogenesis, prognosis and treatment. Susruta termed it as Mahavyadhi (complicated diseases) Su.Su. 33/4. Charaka has mentioned that high calorie diet with lack of physical exercise said to be most potential causative factor for this disease which shows gravity of diabetes in relation to modern advanced era. Vasculopathy, neuropathy and infection are considered as three important predisposing factor known as classical triad resulting diabetic foot ulcer. Diabetic foot ulcer may even lead to amputation resulting in a grave physical disability and severe physio-psychological trauma to the patient. In India most of the patients are unaware regarding the seriousness of this disease. Study say diabetic foot often associated with hypertension with or without ischaemic heart disease (Mansour et al 2005). Again Retinopathy reported in 23% along with diabetic foot. (Scott et al 1995). The underlying cause of retinopathy may be microangiopathic pathology seen in diabetes mellitus. The indirect effect of retinopathy on diabetic foot is to be seriously noted that the poor vision and loss of sensation both hamper foot care by the patient and trauma during physical activity which is common may cause ulceration. It is also reported that end stage Renal disease (CKD) at about 2.6% present in diabetic patient with foot ulcer. Scott et al 1995

2 Discussion 144 Mansour et al (2005) reported proteinuria in 26.3% on their patient. Probably micro-angiopathy plays an important role in nephropathy. The deep seated foot infection no longer remain localized. It crosses all the anatomical barriers and progressing into the leg. The patients gradually show features of toxicity, septicaemia, shock and multi-organ failure. The gangrenous foot where medical treatment is quite helpless, even the leg amputation can not save the patient s life. Bormen et al (1990) in their study found amputation in type I diabetes 1% and in type II diabetes 0%; foot ulceration in type I diabetes 3% and in type II diabetes 0%. Young et al (1993) found an overall prevalence of 28.5% for peripheral neuropathy in diabetes. Pendsey et al (1994) from India reported the prevalence on peripheral vascular disease to be 3.8%. In Ayurveda disease like diabetic foot ulcer has not been described, but the disease Madhumeha, which is similar to diabetes mellitus has been described along with its complication like prameha pidakas, vrana, vidradhi, dustavrana etc. The pathogenesis of prameha pidakas and allied disorders is very interesting where Meda dhatu gets vitiated. The vitiated Meda dhatu represents dislipidaemia like disorder which is treated as main culprit for the vasculopathy and neuropathy lead to ulceration and infection. So drugs having Tikta Kashaya in Rasa, Ruksha in guna, Katu in vipaka and ushna in virjya have been selected which directly strikes vitiated Meda and by correcting it to normalcy the pathogenesis of the disease process reverts back. Thus the vasculapathy and neuropathy when corrected the complication like ulceration can not progress further. Of course once such complication develop these are mostly irreversible as per

3 Discussion 145 modern texts. So the concept of Ayurveda invites extensive study to establish its value in the present days. So considering Dosha-dushya involvement (etiopathogenesis) we needed the drugs having properties like vranarapaka, Raktasodhak or Krimighna (antiseptic or antimicrobial), Kapha-pitta-vata samak (correcting neuropathy), Twak doshahara or srotosodhak (correcting angiopathy), Sothahara (antiinflammatory), promehaghna (hypoglycaemic), Rasayana (rejuvanative/antioxidant) and Balya (immunomedulator). So considering all such prpoperties Guduci swaras along with other hypoglycemic drugs including insulin and regular dressing with Guduchyadi kwath have been jointly used for their clinical evaluation. It is also important to note here that in India, superstition with delayed reporting, use of ill fitted foot wear, bare foot walking, neuropathy leading to insensate foot, deformed foot; neuroischaemia with peripheral arterial diseases, cracked and fissured foot with or without callous/corn, any foot, immobility like foot drop, discolourisation of toes, associated fungal and bacterial infection of nail, foot without history of smoking and consumption alcohol, pattern, need special screening to rule out diabetes irrespective of any age group belong to any socio-economical status. To prevent recurrence of foot ulcer some measures should be followed strictly such as - a. Time to time reevaluation of the wound at the same site and other sites of the foot. b. Any corn/callous if seen, then self surgery (i.e. cutting of corn/callous) should be restricted. c. Timming of the nails should be done with nail cutter only.

4 Discussion 146 d. Any fungal infection of nails and foot should be treated immediately. e. The dry foot/cracks/fissures should be kept corrected using moisturizer at least at bed time. f. The foot should be kept clean as that of our face. g. Any surgical innervation should be performed after strict control of blood sugar level and after other related investigations when and where required. h. To protect the insensate foot from injuries, the person should be advised to use proper foot wear. They should never walk bare foot. The foot wear prescription will depend upon the stage of neuropathy, presence of deformity/or previous operations. The diabetic foot can be at various stages of risk of ulceration. The objectives of preventive foot wear are as follows- 1. Even distribution of planter pressure and relief of areas of excessive planter pressure. 2. Shock absorption 3. Reduction in friction and shear 4. Limiting joint motion 5. Accommodation of deformities. A varieties of foot wear are available or are tailor made according to the need for a particular patient. a. Diabetic Patient with normal response to monofilament test This type of patient needs to be educated about protecting the feet. The foot wear should have wide toe box, adequate depth & soft insoles of material like microcellular rubber, plastazoat or polymer & total heel counter. The sole should be rigid to prevent/reduce the pressure on the MTP points.

5 Discussion 147 b. Diabetic patient with positive filament test This is a foot at risk. The footwear should be of wide toe box, extra depth & molded insole & total heel counter. The footwear should be inspected at regular intervals to detect areas of increasing pressures. Any new area of pressure will required appropriate changes in the insoles. c. Person with diabetes with partially healed planter ulcer This type of patient requires orthowedge shoes with the site of wedge depending upon the site of the ulcer. A smaller ulcer can be managed with insole wing pad that can relieve the pressure on the ulcer bearing area significantly. d. Diabetic patient with foot deformity Here a specially molded total contact cradle insole in used. This is a composite made from 3-4 materials like polyethylene, plastazoat & cork-rubber. The molded insole is made from the plaster cast of the foot specially made for this purpose. This cradle insole should be fitted in the shoes with wide toe box & extra depth & rocker sole & complete heel counter. e. Diabetic patient with partially amputed foot This type of patient requires front filler of soft material in the shoes to fill the amputed portion with wide toe box & extra depth. Every person with diabetes should use footwear only with well fitting socks. Well fitting socks can reduce the shear force by 30%. Taking into account the cost of the footwear, a careful planning is required before prescribing footwear. We still lack in technologies to create & supply appropriate footwear to our diabetic patients. Correctly planned footwear can go a long way in preventing the injuries in a patient of diabetes.

6 Discussion 148 Commonly foot wears prescribes for Diabetic Foot Ulcer Patients

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