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Course of diseases
Leprosy Nerve damage (primary impairment) Ulcers(secondary
impairment/deformity) walking difficulty (activity
limitation/disability)loss of job (participation restriction/handicap)
loss of social status(dehabilitation) forced to leave
home(destitution)
Eyes
0 No eye impairment; no
visible or vision impairment
b
1 Eye impairment present Absence of (regular) Corneal sensation testing19
(vision: > 6/60) blink
2 Severe visual impairment Unable to count ngers at 6 m Facial impairments due to
(vision: < 6/60) Lagophthalmos lepromatous leprosyc
Corneal opacities, uveitis19
Nerve Involvement
Nerve damage occurs in two settings-
In skin lesion small dermal sensory and autonomic nerve fibres supplying dermal and
subcutaneous structures are damaged
Involving Peripheral nerve trunks usually those which are superficial or are in fibrocasseous
tunnels are involved leading to dermato sensory loss and dysfunction
of muscles.
Radial Nerve Main trunk is affected in very few cases. When affected it can be rolled
as thickened cord in humeral groove, in the arm.
Sural nerve can be palpated on the back of leg, running along the lower portion of
Achilles tendon.
Lateral popliteal nerve at the neck of fibula,When affected can be palpated extending
proximally towards popliteal fossa in its course
Absent A B
Present C D
Category Apatients-Patent is taught how to look for signs and symptoms of neuritis.
Category B patients-(Neuritis +, no NFD)
Start Prednisolone 40-80 mg daily 4 wks
taper dose 5mg/wk upto 30mg2-3 wks and then taper it.
In BT leprosy cases (neuritis due to RR), if there is no significant
improvement in the clinical condition within 48-72 hrs then
immediate surgical decompression is required so that
haemperfusion to nerve can be improved and permit the drug to
reach the compressed segment
In BL and LL cases (neuritis due to ENL), thalidomide is very
useful and should be given if possible or one can wait for six weeks
or even longer
Others -integrity of sensory and motor function should be assessed daily to start with
and progressively less often so that one will be able to recognize the onset of
nerve damage
Management:--
If nerve shows no NFD: wait and watch, there is no urgency but nerve function should
be monitored closely drain abscess only if risk of sinus formation is there.
If nerve is considered irrecoverably damaged: same as above.
If NFD is considered likely to recover: drain the abscess, mopping out the necrotic
contents, gently removing adherent slough, evacuate and excise the abscess.
Assessment
Characteristic Comment
Past or present eye problem Danger of eye damage and loss of sight
Weakness of eyelid muscles
Anaesthesia of hand (palmar surface) Danger of damage to hand
Past or present ulceration or crack in
hand
Deformities in hand
"At-risk" group. Patients who have not yet developed impairments or disabilities but who
show any of the following characteristics should be assigned to the "at-risk" group. Such
patients are more likely to develop problems and disabilities than those in the "low-risk"
group and need to
be monitored. Remember that, in many cases, the risk of nerve damage is greater during the
first 6-12 months after starting anti-leprosy treatment.
Characteristic Comment
Multibacillary leprosy
"Low-risk" group. Patients with the following characteristics and patientswho are not
included in either of the two previous categories should be assigned to the "low-risk" group.
The likelihood of disability is low in these patients and they need only occasional checking.
Management surgical
Lasso's operation
Providing an independent flexor for the MCP joints (insertion of a transformed tendon)
D) Exercise:- press hand(flexed at MCP) against thigh and open flexed fingers with
other hand, take a soft rubber ball for squeezing
- In recent onset deformity, splints should be used. Four main types of
splints are used:-( delivered by H Workers)
Adductor Band splint(in splayed fingers)
Finger Loop Splint(maintain lumbricals in
position and strengthen small muscles of hand)
Opponens Loop Splint
Gutter Splint(in late cases with stiffness)
E) Grip Aid:- used after advanced deformities like absorption and amputation.
- Epoxy resins Grip Aids- applied on articles of work
- Instant Grip aid kit- immediate benefit in daily work
F) Physiotherapy
Foot Problem In Leprosy Patients
A) Paralytic deformity
1) Foot drop:--
About 1-5% of leprosy patients develop due to damage to lateral popliteal nerve.
Paralysis of anterior group of muscles give rise to foot drop giving characteristic stepping
gait inwhich the outer part of forefoot make 1st contact to the ground and then rest of foot
slap down on ground. Paralysis lateral muscle group gives rise to loss of eversion which
normally transfer the body wt from lateral to medial part of foot hence leads to overloading
on outer part.
Rx
-If paralysis is recent; manage under Nerve Care therapy
-If paralysis is of >1 year duration; it is satisfactorily corrected by anterior
transposition of tibialis posterior tendon (Srinivasan operation)
-If surgical intervention is contraindicated; foot drop appliances like strap,
stops or springs are used which hold the foot at right angle, use drop foot
brace or toe raising device, exercise to prevent contracture of calf muscle
as such squatting or forward bending exercise
2) Claw deformity of Toe:-
Indicate plantar intrinsic muscle paralysis which increase the risk of ulceration under the
metatarsal head and the tip of the toes
Rx
oil massage
passive toe straightening exercise
dorsalizing the long flexor tendon distal to metatarsal phalyngeal
joint
arthrodesis of PIP joint
dorsal migration of toe with fixed hyperextension at
metacarpophalyngeal joint
B) Anesthetic deformities
PLANTAR ULCERATION:--
- found in 10% of patients
-manifestation of sensory motor deficit
-mostly in front part of sole in MTP joint
-augmented by infection through fissures and paralysis
of feet muscles(which counter the stress while walking)
Stages of ulceration
i. Threatened Ulceration (dorsal puffiness, deep tenderness)
ii. Concealed ulceration (destruction of soft tissues has occurred)
iii. Overt ulceration (necrosis blister open & exposed)
Types of Ulcer
Acute ulcer Frankly infected, swollen and hyperemic, copious discharge, base
covered with dirty slough
Chronic ulcer indolent ulcer with hyperkeratotic edges, scanty discharge, hard
fibrosed base with floor covered with unhealthy granulation tissue
Complicated ulcer Infection spread to deeper structure may lead to muscle paralysis, gas
gangrene, septicemia, osteomyelitis, septic arthritis, septic
tenosynovitis
Recurrent ulcer appears repeatedly
Risk of ulceration is increased in insensitive feet by a factor of 10-12 when there is intrinsic
muscle paralysis with loss of sensibility.
Mx.
ACUTE
-absolute bed rest no weight bearing, walking or standing
-limb elevation to prevent further tissue damage and permit the resolution of traumatic
inflammation
-if necrotic blister present avoid breaking of blister if felt necessary the blister may be
covered with sterile gauze
-Eusol bath, irrigation & dressing
-Remove slough
-Start antibiotics (treat information)
CHRONIC:
Aim:-to protect the ulcer during walking and to allow it to heal without interference
-plaster cast
-Protective foot wears
-Foot care practices: skin care, injury care, walking care
-superficial ulcer: strips of zinc oxide coated adhesive plaster laid directly
on the ulcer to cover it entirely
-large ulcer: split thickness graft then encasing the leg in plaster cast
-complicated ulcer: debridement where floor is curetted, sequestra are
removed
-Splinting of knee Rest to inflamed nerve, result in quicker healing &
dropped foot should be supported to hasten recovery
Stretching calf muscle
Prevention:--
Protective footwear:-(type depends on state of foot)
Feet with only sensory loss (no muscle paralysis), footwear should have tough
outer sole, should not rub against toes. Eg using automobile tyre side pieces.
-Any footwear can reduce the pressure upto 25%
-Appropriate footwear should have outer sole of
15-18mm thick and soft inner sole 18-22mm.
-Iron nails and buckles are to be avoided.
-Raja Model is most suitable one.
Rehabilitation
The basic concepts behind rehabilitation are that the persons affected with leprosy
should be restored back to normal social life or as near as possible.
Rehabilitation means restoration of economic productivity leading to economic
independence
Rehabilitation in the field of leprosy requires greater efforts than the rehabilitation in
other types of disabled persons because of the question of social acceptance
The task of removing public fear and at the same time maintaining public concern
and interest may be difficult but not impossible
Efforts to create a broad interest in the social problems of leprosy afflicted are
beginning to yield good results
Appropriate economic rehabilitation is provided eg sewing machines, handcrafts,
carpentry, kits for bicycle repair etc.