Diabetische voet: Podologie en het ... - Paul Borgions
Diabetische voet: Podologie en het ... - Paul Borgions
Diabetische voet: Podologie en het ... - Paul Borgions
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<strong>Diabetische</strong> Voet<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Borgions</strong> <strong>Paul</strong> MsC Pod<br />
Master in de <strong>Podologie</strong><br />
www.paulborgions.be<br />
<strong>Podologie</strong><br />
1 Erk<strong>en</strong>de Vlaamse opleiding aan<br />
de Arteveldehogeschool te G<strong>en</strong>t<br />
Bachelor niveau, vroeger A1<br />
KB publicatie 07 12 2001<br />
RIZIV nr sinds 15 03 2003<br />
Master of sci<strong>en</strong>ce in Podiatry<br />
Gegradueerde in de <strong>Podologie</strong><br />
Pedicure<br />
VOETEN<br />
Schoonheidsverzorg(st)ers<br />
Schoonheidsverzorg(st)ers<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Podoloog<br />
Podiatrist<br />
Medische pedicure<br />
<strong>voet</strong>verzorgster<br />
600.000 jaar geled<strong>en</strong> is de m<strong>en</strong>s gaan<br />
rechtop lop<strong>en</strong>.<br />
In één m<strong>en</strong>s<strong>en</strong>lev<strong>en</strong> br<strong>en</strong>g<strong>en</strong> onze<br />
<strong>voet</strong><strong>en</strong> ons gemiddeld 4 keer rond<br />
de wereld<br />
E<strong>en</strong> afstand van ongeveer 170.000 km<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Definitie<br />
De Podoloog houdt zich bezig met:<br />
de structuur,<br />
de functie <strong>en</strong><br />
de fysiopathologie van de <strong>voet</strong>,<br />
steeds gerelateerd aan<br />
de hogergeleg<strong>en</strong> lichaamssegm<strong>en</strong>t<strong>en</strong><br />
<strong>en</strong> <strong>het</strong> functioner<strong>en</strong> van de m<strong>en</strong>s in<br />
zijn totaliteit<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Wie kan er terecht bij de<br />
podoloog?<br />
Alle m<strong>en</strong>s<strong>en</strong> met klacht<strong>en</strong> thv<br />
de onderste ledemat<strong>en</strong><br />
Kinder<strong>en</strong><br />
Geriatische patiënt<strong>en</strong><br />
Diabetisch patiënt<strong>en</strong><br />
Reuma patiënt<strong>en</strong><br />
Sporters<br />
Patiënt<strong>en</strong> met<br />
dermatologische problem<strong>en</strong><br />
…<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
1
Ongeveer 110140 miljo<strong>en</strong> m<strong>en</strong>s<strong>en</strong><br />
wereldwijd hebb<strong>en</strong> diabetes ,<br />
wat de volg<strong>en</strong>de 25 jaar nog zal<br />
verdubbel<strong>en</strong><br />
(Gruber et al 1993; Reiber 1996; World Health Organisation 2001).<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
De grootste kost is hospitalisatie:<br />
–32,7 % van de totale kost (orale antidiabetes<br />
medicatie 2,7 %) (European Association for the Study of Diabetes 35th<br />
world congress in Brussels, Belgium 1999; Jonsson 1999; Peys 2000 )<br />
De meeste van de hospitalisaties zijn t<strong>en</strong><br />
gevolge van e<strong>en</strong> diabetische <strong>voet</strong><br />
In 31% van deze gevall<strong>en</strong> is de oorzaak slecht<br />
schoeisel (Dyck et al 1987, Foot care and amputation<br />
prev<strong>en</strong>tion in the U.K. 1999; Knowles 1998; Payne et al 1998; Foot care and<br />
amputation prev<strong>en</strong>tion in the U.K. 1999).<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Kinesitherapeut<br />
Arts<br />
………<br />
Podoloog<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Verpleegkundige<br />
Orthopedisch technieker<br />
Artsspecialist<br />
Arts specialist<br />
Bijv :Orthopedisch chirurg<br />
Endocrinoloog,<br />
plastisch chirurg,<br />
Dermatoloog, … .<br />
Diëtist<br />
In de meeste land<strong>en</strong> word<strong>en</strong> de m<strong>en</strong>s<strong>en</strong><br />
steeds ouder.<br />
tot 7 biljo<strong>en</strong> 65+ in 2020 (United<br />
Nations 1995).<br />
2/3 of type 2 diabetes 65+<br />
E<strong>en</strong> <strong>en</strong>orme verhoging van de incid<strong>en</strong>tie<br />
<strong>en</strong> preval<strong>en</strong>tie van niet insuline<br />
afhankelijke diabetes patiënt<strong>en</strong> <strong>en</strong><br />
sam<strong>en</strong> met hun, de gek<strong>en</strong>de complicaties<br />
(Audit Commission 2000; Currie et al 1997; Reav<strong>en</strong> 1988)<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Dr. Van Putt<strong>en</strong> (1999) asserts that 70% of all ulcers are<br />
the result of bad socks and shoes<br />
MacFarlane and Jeffcoate (1997) noticed in a group of<br />
subjects with diabetes that 59% had precipitating mostly<br />
due to rubbing from footwear or an accid<strong>en</strong>t.<br />
Edelson et al (1996) previously reported on the<br />
inadequacy with which the diabetic foot is evaluated in an<br />
inpati<strong>en</strong>t setting. The results reported here, also indicate<br />
the critical importance of adequate and appropriate<br />
footwear.<br />
Isakov et al (1992) reported that in 164 nontraumatic<br />
amputations for vascular reasons, just over two thirds<br />
developed a spontaneous ulcer while in the remaining<br />
subjects an initial lesion was selfinduced . The most<br />
common problems whereby illfitting shoes and injury from<br />
nail cutting.<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Poliklinische activiteit<strong>en</strong><br />
Huidproblematiek<br />
eelt<strong>en</strong>, wratt<strong>en</strong>, likdoorns, schimmel,...<br />
Orthoplastie<br />
orthese <strong>en</strong> prothese<br />
Onychoplastie <strong>en</strong> Orthonyxie<br />
nagelaanbouw <strong>en</strong> nagelcorrectie<br />
Nagelpathologie<br />
onychocriptosis<br />
onychomycosis<br />
onychogryphosis,..<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
2
PODOLOGISCH ONDERZOEK<br />
Anamnese<br />
Klinisch onderzoek<br />
Specifieke test<strong>en</strong><br />
Pulsaties A. tib. tib post <strong>en</strong> A. dors. pedis<br />
Gevoelsstoorniss<strong>en</strong><br />
Reflex<strong>en</strong><br />
Spierkracht<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Instrum<strong>en</strong>tele behandeling<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Poliklinische behandeling<br />
Instrum<strong>en</strong>tele<br />
behandeling<br />
Orthoplastie<br />
Vilttherapie<br />
Orthonyxie<br />
Onychoplastie<br />
…<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
3
HYPERKERATOSE ?<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
ULCUS NA VERWIJDEREN<br />
HYPERKERATOSE<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
VILTTHERAPIE<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
4
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
ORTHOPLASTIE : Ringorthese Ring orthese<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
ORTHOPLASTIE : Interdigitaal<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
5
Video Stapanalyse<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
BIOMECHANISCH ONDERZOEK<br />
Biomechanische<br />
meting<strong>en</strong><br />
(onbelast onbelast <strong>en</strong> belast) belast<br />
Stap Stap <strong>en</strong> loopanalyse<br />
Computergestuurde<br />
ganganalyse<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Verslag<br />
Verslag<br />
Computergestuurde ganganalyse<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
6
“Het PodoDynoGraphisch–Systeem”<br />
(PDG)<br />
FSR s<strong>en</strong>sors<br />
Force S<strong>en</strong>sing Resistor<br />
s<strong>en</strong>sor number –accuracy diagram of the PDG insoles, (Tavernier 1995).<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
gewone scho<strong>en</strong><strong>en</strong> AsicsTiger<br />
neutral<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Limited Joint Mobility<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Bij gebrek aan mobiliteit<br />
in <strong>het</strong> 1ste MPG zal er<br />
meer mobiliteit gezocht<br />
word<strong>en</strong> in <strong>het</strong><br />
interphalangiale gewricht<br />
Limited Joint Mobility<br />
* 1ste Metatarsophalangiale gewricht :<br />
min. 65° dorsieflexie mogelijkheid<br />
* Tibiotalair gewricht :<br />
min. 10° dorsieflexie mogelijkheid<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
7
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
ZOOLTHERAPIE<br />
Zool ooltherapie therapie met ontlast<strong>en</strong>de padding<br />
na blauwdruk<br />
Functionele unctionele zooltherapie extrinsiek<br />
Na neutrale gipsafdruk<br />
Functionele unctionele zool intrinsiek <strong>en</strong> combinatie<br />
Na neutrale gipsafdruk<br />
Scho<strong>en</strong>advies<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
8
Support differ<strong>en</strong>t situations<br />
by specific tools<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
TOTAL CONTACT INSOLE<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
NEGATIEVE GIPSAFDRUK<br />
Onbelast<br />
STG neutraal<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Druk =<br />
kracht<br />
opp<br />
dus de druk verlaagt door :<br />
kleinere kracht<br />
<strong>en</strong> groter opp<br />
Hoe kunn<strong>en</strong> we hier mee omgaan ?<br />
total contact insole geeft groter opp<br />
zachte bodem >schokabsorptie > minder kracht<br />
kan in 1 zool gecombineerd word<strong>en</strong><br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
9
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
10
Functionele Zooltherapie<br />
De <strong>voet</strong>afdruk wordt<br />
g<strong>en</strong>om<strong>en</strong> met e<strong>en</strong> vacuüm<br />
systeem om e<strong>en</strong> correcte<br />
3Dim<strong>en</strong>sionelescan te<br />
mak<strong>en</strong> van e<strong>en</strong> belaste<br />
<strong>voet</strong> in de individueel<br />
aangepaste, meest ideale<br />
stand: de neutrale positie<br />
g<strong>en</strong>oemd. Er wordt<br />
rek<strong>en</strong>ing gehoud<strong>en</strong> met de<br />
kous<strong>en</strong> om e<strong>en</strong> perfecte<br />
realistische functionele<br />
zool te mak<strong>en</strong><br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Functionele Zooltherapie<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
SCHOENADVIES<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
11
motorische neuropathie<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
HAMERTEENTJES<br />
* atrofie intrinsieke<br />
<strong>voet</strong>spiertjes<br />
* geholp<strong>en</strong> door<br />
scho<strong>en</strong>gedrag<br />
Ontstok<strong>en</strong><br />
ulcus PIP<br />
gewrichtje.<br />
Worstvormig<br />
te<strong>en</strong>tje<br />
Botcontact<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Mean<br />
Peak<br />
%<br />
30<br />
20<br />
10<br />
0<br />
10<br />
20<br />
30<br />
1<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Verschill<strong>en</strong> bij <strong>het</strong> drag<strong>en</strong> van<br />
2<br />
Zones<br />
3<br />
4<br />
sportscho<strong>en</strong><strong>en</strong><br />
5<br />
6<br />
gewone scho<strong>en</strong><strong>en</strong> AsicsTiger neutral<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
12
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
te groot is echter te groot<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Risk<br />
Commercial shoes.<br />
Semi orthopaedic shoes<br />
Inlay sole<br />
Orthopaedic shoes<br />
Ortheses: e.g. orthoplasties<br />
made by podiatrists<br />
Total<br />
Van Acker K. 2001<br />
1<br />
0,17<br />
581<br />
0<br />
0%<br />
Risk 0: No neuropathy and no vascular disease<br />
Risk 1: Neuropathy pres<strong>en</strong>t but no other abnormalities<br />
Risk 2: Neuropathy and foot anomalies<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Risk 3: Previous amputation, previous ulceration, PVD, Charcot<br />
.<br />
0<br />
564<br />
97,07%<br />
3<br />
0,52%<br />
9<br />
1,55%<br />
4<br />
0,69%<br />
1<br />
86<br />
97,73%<br />
2<br />
2,27%<br />
0<br />
0%<br />
0<br />
0%<br />
88<br />
2<br />
72<br />
82,76%<br />
4<br />
4,60%<br />
9<br />
10,34%<br />
2<br />
2,30%<br />
0<br />
0%<br />
87<br />
3<br />
543<br />
83,41%<br />
31<br />
4,76%<br />
34<br />
5,22%<br />
39<br />
5,99%<br />
4<br />
0,61%<br />
651<br />
Totals<br />
1.265<br />
40<br />
52<br />
45<br />
5<br />
1407<br />
13
Risk<br />
Commercial shoes.<br />
Semi orthopaedic shoes<br />
Inlay sole<br />
Orthopaedic shoes<br />
Ortheses: e.g. orthoplasties<br />
made by podiatrists<br />
Total<br />
Van Acker K. 2001<br />
4<br />
0,69%<br />
1<br />
0,17<br />
581<br />
0<br />
0%<br />
0<br />
0%<br />
Risk 0: No neuropathy and no vascular disease<br />
Risk 1: Neuropathy pres<strong>en</strong>t but no other abnormalities<br />
Risk 2: Neuropathy and foot anomalies<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
Risk 3: Previous amputation, previous ulceration, PVD, Charcot<br />
.<br />
0<br />
564<br />
97,07%<br />
3<br />
0,52%<br />
9<br />
1,55%<br />
1<br />
86<br />
97,73%<br />
2<br />
2,27%<br />
0<br />
0%<br />
88<br />
2<br />
72<br />
82,76%<br />
4<br />
4,60%<br />
9<br />
10,34%<br />
2<br />
2,30%<br />
0<br />
0%<br />
87<br />
3<br />
543<br />
83,41%<br />
31<br />
4,76%<br />
34<br />
5,22%<br />
39<br />
5,99%<br />
4<br />
0,61%<br />
651<br />
Totals<br />
1.265<br />
40<br />
52<br />
45<br />
5<br />
1407<br />
Educatie<br />
Educatie is e<strong>en</strong> lev<strong>en</strong>slang proces, dat sam<strong>en</strong> met regelmatige<br />
followup care, amputaties kan verminder<strong>en</strong> bij subject<strong>en</strong> die<br />
moet<strong>en</strong> lev<strong>en</strong> of ler<strong>en</strong> lev<strong>en</strong> met afwezigheid van symptom<strong>en</strong>,<br />
(PeterRiesch and Assal 1997).<br />
Stuart and Wiles (1997)<br />
– vond<strong>en</strong> in hun onderzoek door interview dat maar 2 van de 40 subject<strong>en</strong><br />
voldo<strong>en</strong>de k<strong>en</strong>nis hadd<strong>en</strong> omtr<strong>en</strong>t scho<strong>en</strong><strong>en</strong><br />
– Bij middel van <strong>en</strong>quete was dat 30 van de 40. E<strong>en</strong> duidelijk verschil met<br />
<strong>het</strong> intervieuw<br />
– Patiënt<strong>en</strong> zijn aan bepaalde “statem<strong>en</strong>ts””gewoon geword<strong>en</strong>, maar de<br />
relevante toepassing voor hun is soms ver weg Stuart and Wiles (1997)<br />
Bild et al 1989 , Malone et al 1989 , Delbridge (1983<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod <strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
risicogroep<br />
neuropathie<br />
orthopedische<br />
misvorming<br />
vaatlijd<strong>en</strong><br />
vroeger <strong>voet</strong>wonde<br />
of amputatie<br />
risico<br />
ne<strong>en</strong><br />
laag<br />
ne<strong>en</strong><br />
matig<br />
Maatregel<strong>en</strong> :<br />
vanaf risicogroep 1: grondige educatie<br />
vanaf risicogroep 2b: doorverwijzing naar e<strong>en</strong> gegradueerde<br />
podoloog <strong>Podologie</strong>(terugbetaling 2 x /jaar in risicogroep<strong>en</strong> <strong>Borgions</strong> <strong>Paul</strong> 2b Msc <strong>en</strong> 3 Pod :<br />
risicogroep op voorschrift noter<strong>en</strong> !).<br />
0<br />
ne<strong>en</strong><br />
ne<strong>en</strong><br />
ne<strong>en</strong><br />
1<br />
ja<br />
ne<strong>en</strong><br />
ne<strong>en</strong><br />
2a<br />
ja<br />
licht<br />
ne<strong>en</strong><br />
ne<strong>en</strong><br />
hoog<br />
2b<br />
ja<br />
zwaar<br />
ne<strong>en</strong><br />
ne<strong>en</strong><br />
zeer<br />
hoog<br />
3<br />
(één van de<br />
volg<strong>en</strong>de)<br />
Charcot<br />
ja<br />
ja<br />
extreem<br />
hoog<br />
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<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
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14
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<strong>Podologie</strong> <strong>Borgions</strong> <strong>Paul</strong> Msc Pod<br />
15
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