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“Self-care support in leg ulcer services should be the priority”


Venous leg ulcer recurrence is common. Many patients will develop at least three or more leg ulcers during their lifetime, and sometimes will have an ulcer that never heals. They often experience alternating periods of healed ulceration and open ulcers.

This disease process is similar to that of long-term conditions such as multiple sclerosis or rheumatoid arthritis. Venous leg ulceration is therefore recognised as a long-term condition.

Treatment focuses on encouraging self-care and empowering patients to lead as normal a life as possible, while aiming to achieve a healed ulcer.

While healing may be realistic in many cases, if the underlying problem is not corrected surgically, the ulcer is likely to recur. This cycle of healing and recurrence may result in frustration for practitioners and feelings of hopelessness for patients.

Practitioners need to tell patients with venous leg ulceration that they have a long-term, recurring condition and that, while treatment may heal their ulcer, it is likely the ulcer will return at some point. Not understanding this could be a reason why many patients refuse to wear compression hosiery once their ulcer has healed.

Interventions to encourage self-care, such as the Expert Patient Programme, which helps patients manage conditions with minimal dependence on health professionals, may be appropriate. EPP has been introduced as a way of managing many long-term conditions such as rheumatoid arthritis, diabetes and asthma, and has had promising clinical outcomes.

For venous leg ulcer patients, a self-care programme could be developed that encourages them to perform activities to minimise recurrence, such as wearing compression hosiery, leg elevation, ankle exercises and moderate exercise such as walking. Furthermore, it could equip patients with the skills to adapt their lives to living with the constant uncertainty that their ulcer may recur at any time.

Currently, many leg ulcer services are paid according to set outcomes, such as the number of ulcers healed and how many weeks it took them to heal. They receive very little financial reward for follow-up appointments or providing “well leg” services. As a result, when an ulcer has healed, patients are discharged, only to return when another ulcer has developed.

Given that venous leg ulceration is a long-term, recurring condition, this seems at odds with the government emphasis on encouraging self-care. A recurrent ulcer may be preventable if patients are taught self-care activities thought to prevent recurrence.

Within tissue viability services, there is a saying: “A venous leg ulcer patient is a patient for life.” Unfortunately, it would appear that current provision does not reflect this. Health professionals need to ensure that commissioners of services are aware of the long-term nature of venous leg ulceration and emphasise the importance of encouraging self-care in this client group.

Annemarie Brown is an independent tissue viability consultant at Tissue Viability Solutions, Essex


Readers' comments (4)

  • Many "ulcer" patients are lonely old ladies. Often obese and with multiple co-morbidities.

    The "ulcer" ensures on going human contact many do not wish their ulcer to be cured !

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  • many of these lonely old ladies no longer have the strength or will power to self care and appreciate human contact and the care of others. some have worked hard all of their lives and paid into the system and deserve to be treated with dignity, respect and to be given the care they need in their old age. those who prefer to maintain their independence and are able and willing to collaborate in self care, so be it. there must be room for both and to adapt care to meet patients' needs.

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  • How sad that those dear old ladies and sometimes men, need a life-affecting and sometimes painful, condition to get a bit of human company. In my younger days, neighbours helped one another-a hangover from when there was little domiscillory care, but today everyone reliles on the State to look after them and there is not enough man-power or finance to give much time to them, let alone provide a social life for them. Help the aged do quite alot and if the person can afford it (most cant) a companion can be purchased. Loneliness causes depression and lack of motivation-thus ulcers and other conditions are aggrevated. We need a culture of caring, in the community

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  • sally carson | 9-Oct-2013 12:47 pm

    I wrote the comment above yours and you add some very important points. it is sad indeed that we should expect to have to rely on the state as it is not entirely their role to fulfil all of the psycho-social needs of the elderly where there should be other alternatives with family, community and societal cohesion - much of which has broken down and developed into an entirely different manner of living.

    the other day I read a comment, which I hope was in jest, saying that you need a CRB in order to visit an elderly neighbour. Even though it was just an impression rather than fact it is a very sad and worrying reflection of our society.

    Any medical complaints besides ulcers will be aggravated and also healing could also be delayed by the conditions you mention.

    Some put the blame on the elderly for bringing the condition of loneliness on themselves but I find it a serious concern and one that is not always so easy to avoid. One can have plenty of acquaintances often of similar age and looking after an older person can be a very heavy and demanding charge.

    In my case, as a retiree and hopefully some way off needing care, my closest friends sadly all died young, other friends are scattered around the world as I spent my time in boarding school and then always living and working away from home although I am fairly open and usually integrate quite well wherever I am. My only relatives are two cousins and like other friends after raising their own families have spent all of their middle and early old age looking after parents and parents in law which is mainly left to the wife of a couple. they have had very little time to themselves or the financial resources to enjoy their own freedom after their children have left the nest as children, who they may also have had later in life, often need financial support for a long time to set them off on their careers and they may have to give some financial support to their elderly as well. they are also often exhausted so I most certainly would not expect any help or support from them once these duties are finished. I have also have my experiences of caring although sadly my parents died in their 80s, my dad suddenly while he was still independent and my Mum who needed my care but not for the prolonged period of the loved ones of some of my friends. This is why the so-called 'baby boomers' are also sometimes known as the sandwich generation.

    In other words two factors, and there are probably many more, which create this situation are having children later in life and possibly parents supporting them past their own retirement and the elderly staying fitter and living much longer. Many wish to keep them in their own homes for as long as possible as care homes can be costly and many fairly grim and most families now don't live nearby or have sufficient place to accommodate them.

    transport and the high costs of telephony and lack of mobility are other factors which can lead to loneliness and the fact that younger neighbours are often out for long hours every day and then understandably have other priorities at weekends.

    It has been well known that society and its demography has changed radically from the earlier days and it is said that the 'baby boomers' have seen more change than any other generation so far. Human beings have relied on their ability to adapt for millennia and we now need to accept that for some time we will now continue to have and increasingly older population and take the measures needed including considerable financial investment to accommodate it. there are some excellent communities being developed for the elderly but so far not enough but i believe the longer they can remain integrated in normal society spanning all the generations, instead of being segregated and largely abandoned, the better as after all they remain, just like everybody, else important members of our society who must be valued and respected as such as they still are in many other countries.

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