Physiotherapy in leprosy - notes

Leprosy DiseaseLeprosy DiseaseLeprosy is a chronic granulomatous disease caused by Mycobacterium leprae, an acid andalcohol fast bacillus. It is one of the most serious, disabling disease which attacks nerve and skin.Leprosy which is also called Hansens Disease is the commonest cause of peripheral neuritis andabout 20 million of the population is affected by it.Mode of spreadThe most important mode of spread of Mycobacterium leprae is by droplets from the sneeze ofleprosy patients, whose nasal mucosa is heavily infected. It is not certain whether the organismenters by inhalation or through the skin. The incubation period is between 2-5 years.The leprosy disease is common in tropical countries like Asia, Far East, Tropical Africa, Centraland South America and in some Pacific Islands. The disease is still endemic in Southern Europe,North Africa and the middle East.InfectivityIt is not absolutely sure how leprosy spreads from one person to another. We know that it ismuch less infectious than small-pox and many other diseases. Some people have such highresistance that they do not get infected by leprosy disease, no matter how closely they are incontact with any infectious person. Great majority of leprosy patients cannot infect other people.Even the few infectious patients are no longer infected if they have been taking adequatetreatment for 3-6 months, though they do need to continue drug treatment for a very long time.This fact shows that leprosy is not dangerous as most of the people think.It is a chronic infectious disease of only man and attacks mainly nerves and skin. It is diagnosedand treated with drugs and it can be controlled with little precautions, which reduce physicaldamage or disability from occuring. Leprosy disease may cause great emotional distress to thepatient and their families, and it may seiously affect the social life of the patient.Types of Leprosy DiseaseAll types of leprosy are caused by mycobacterium leprae. The amount of patients resistancedetermines whether he/she can get leprosy at all and if he can, then which type he will get.The three main types of leprosy are: • Tuberculoid • Borderline • Lepromatous 1

However, when treating neuritis it is necessary to divide borderline leprosy into 3 types makingfive types in all. These five types are: • Tuberculoid Leprosy(TL) • Borderline Tuberculoid(BT) • Borderline Borderline(BB) • Borderline Lepromatous(BL) • Lepromatous Leprosy(LL)According to the type and difference in resistance the skin sign changes. In tuberculoid, caseshave good resistance. Borderline cases have only fair resistance and lepromatous cases have littleor no resistance. Damage to hand and feet can occur in all three types, if the mycobacteriumleprae damages nerve trunk.Symptoms of Leprosy DiseaseBecause the bacteria that cause leprosy multiply very slowly, symptoms usually do not beginuntil at least 1 year after people have been infected. On average, symptoms appear 5 to 7 yearsafter infection. Once symptoms begin, they progress slowly.Leprosy disease affects mainly the skin and peripheral nerves Characteristic rashes and bumpsdevelop. Infection of the nerves makes the skin numb or the muscles weak in areas controlled bythe infected nerves. • Tuberculoid leprosy: A rash appears, consisting of one or a few flat, whitish areas. Areas affected by this rash are numb because the bacteria damage the underlying nerves. • Lepromatous leprosy: Many small bumps or larger raised rashes of variable size and shape appear on the skin. There are more areas of numbness than in tuberculoid leprosy, and certain muscle groups may be weak. Much of the skin and many areas of the body, including the kidneys, nose, and testes, may be affected. • Borderline leprosy: Features of both tuberculoid and lepromatous leprosy are present. Without treatment, borderline leprosy may become less severe and more like the tuberculoid form, or it may worsen and become more like the lepromatous form.The most severe symptoms result from infection of the peripheral nerves, which causesdeterioration of the sense of touch and a corresponding inability to feel pain and temperature.People with peripheral nerve damage may unknowingly burn, cut, or otherwise harm themselves.Repeated damage may eventually lead to loss of fingers and toes. Also, damage to peripheralnerves may cause muscle weakness that can result in deformities. For example, the fingers maybe weakened, causing them to curve inward (like a claw). Muscles may become too weak to flexthe foot—a condition called footdrop. Infected nerves may enlarge so that during a physicalexamination, doctors can feel them.Skin infection can lead to areas of swelling and lumps, which can be particularly disfiguring onthe face. 2

Other areas of the body may be affected by Leprosy Disease: • Feet: Sores may also develop on the soles of the feet, making walking painful. • Nose: Damage to the nasal passages can result in a chronically stuffy nose and nosebleeds and, if untreated, complete erosion of the nose. • Eyes: Damage to the eyes may lead to glaucoma or blindness. • Sexual function: Men with lepromatous leprosy disease may have erectile dysfunction (impotence) and become infertile. The infection can reduce the amount of testosterone and sperm produced by the testes. • Kidneys: The kidneys may malfunction. In severe cases, kidney failure may occur.During the course of untreated or even treated leprosy disease, the immune system may produceinflammatory reactions. These reactions can cause fever and inflammation of the skin, peripheralnerves, and, less commonly, the lymph nodes, joints, testes, kidneys, liver, and eyes. The skinaround bumps may swell and become red and painful, and the bumps may form open sores.People may have a fever and swollen lymph glands.Diagnosis of Leprosy DiseaseSymptoms (such as distinctive rashes that do not disappear, enlarged nerves, loss of the sense oftouch, and deformities that result from muscle weakness) provide strong clues to the diagnosis ofleprosy.Examination of a sample of infected skin tissue under a microscope (biopsy) confirms thediagnosis. Because leprosy bacteria do not grow in the laboratory, culture of tissue samples is notuseful. Blood tests to measure antibodies to the bacteria have limited usefulness becauseantibodies are not always present.Leprosy TreatmentThe good news is that leprosy is curable. In 1981, the WHO recommended the use of acombination of three antibiotics -- usually dapsone, rifampin, and clofazimine -- for treatment,which takes six months to a year or more. Certain cases may be treated with two antibiotics, butrifampin is a key component of either regimen. Since 1995, the WHO has provided these drugsfree of charge to all leprosy patients worldwide.During the course of treatment, the body may react to the dead bacteria with pain and swelling inthe skin and nerves. This is treated with pain medication, prednisone or thalidomide (underspecial conditions).Because some leprosy bacteria are resistant to certain antibiotics, doctors prescribe more thanone drug. The drugs chosen depend on the type of leprosy: • Multibacillary: The standard combination of drugs is dapsone, rifampin and clofazimine. People take rifampin and clofazimine once a month under a health care practitioners 3

supervision. They take dapsone plus clofazimine once a day on their own. This regimen is continued for 12 to 24 months, depending on the severity of the disease. • Paucibacillary: People take rifampin once a month with supervision and dapsone once a day without supervision for 6 months. People who have only a single affected skin area are given a single dose of rifampin, ofloxacin, and minocycline.Because the bacteria are difficult to eradicate, antibiotics must be continued for a long time.Depending on the severity of the infection and the doctors judgment, treatment continues from 6months to many years. Some doctors recommend lifelong treatment with dapsone for peoplewith lepromatous leprosy.Goals of Physical Therapy for Non-Surgical patients Of Leprosy Diseasethe major aim is to prevent or reduce complication, deformity and disability in body throughPhysical Therapy.MeansThe ways of reaching these Goals are- • By teaching the patient. • By treating and helping the patient.Teachings • What the disease of leprosy is? • The possible complications and deformities resulting from leprosy. • prevention of complication, deformities and disabilities.Treating and Helping • To respect themselves enough to take medication regularly and to take care of complications. • To protect their own anaesthetic hands, feets and eyes. • To keep their skin soft and supple. • To keep their joint flexible. • To preserve all posible movements of hands and feet. • To keep their muscles strong. • To use their hands, feet and eyes safely, in daily work.Goals of Physical Therapy for Surgical patients Of Leprosy Disease • To protect and prevent further damage and deformity. • To improve and restore function. • To improve appearance of hands, feet, face and eyes. 4

Surgical Techniques used in Leprosy Disease • Tendon Transfer: Moving the distal end of the tendon to a new place so that contraction of muscle belly will produce a needed movements used to replace paralysed muscles. Example- Transfer of fore-arm muscle to make finger movements. • Tendon Lengthening: Lengthening the tendon of a muscle to permit more movement and reduce contracture. Example- Tendo Calcaneus lengthening. • Capsulotomy: To loosen tight joint capsule often done with tendon lengthening and tendon transfer to improve range of motions. Tighten the loose joint capsule using suture. • Arthrodesis: Elimination of unstable and deformed joints. • Tenodesis: Attach a piece of tendon across the joint to reduce the movement. The tendon then act as ligament. Example- Tenodesis of MCP joint to prevent hyperextension.Physical Therapy Goals: • To increase and regain range of motion. • Improve muscle strength perticularly in muscles to be transferred. • Clean supple skin in areas of surgery. • Teach home self care. • Protect tissue during wearing. • Prevent/reduce swelling. • Muscle re-education after tendon transfer. • Safe use of any new restored skill in work.Physical Therapy Technique: • For increasing/regaining ROM: ROM can be increased by soaking the skin or part in warm water and then performing passive movement to the part affected. • To improve strength specially in tendon transfer: Active exercise in all part in which surgery is performed. • Clean supple skin: It is provided by soaking the part in soap water, rubbing off thick skin, oiling, self massage and protecting the part from infection. • Home care: teaching skin, hand, foot and eye care to groups and individuals and teaching the patients actual home care. • Protect tissue during healing: Rest, body position and POP cast. • Prevent/Reduce swelling: Elevation, active and passive exercise. • Muscle Re-education after tendon transfer: Teaching new restored skills in movements provided by tendon transfer. • Self restored skills in daily work: Teaching patient ot use any new skill safely in specific task. Providing hand, eye and foot protection. • 5

PHYSIOTHERAPY IN LEPROSY ( H.D.)PHYSIOTHERAPY IN LEPROSY TREATMENT (The Hand)Physiotherapy and Reconstructive Surgery are two aspects of leprosy treatment for which thereshould be no need. If the disease is diagnosed in the very early stages and Multi Drug Therapy(MDT) started immediately, serious nerve damage and resultant deformities and disabilities canbe totally prevented. Unfortunately, physiotherapy is too often not started until many months oreven years after the first disabling symptoms are noticed. Sadly, in many cases, physiotherapy isnot even considered until reconstructive surgery is thought to be necessary.It is true to say that Hansen’s Disease (leprosy) and its treatment, more than any other healthproblem, brings all three specialists - Para-Medical Workers (PMW’s) / Nurses, Surgical staffand Physiotherapists - together in a very close cooperative, working relationship.Because the PMW is generally the first to make contact with the leprosy patient, he/she is oftenthe most logical one to initiate physiotherapy, perhaps in the field at a Control clinic.These few pages are designed to whet the appetite of physical therapists who are encouraged toaccess the Home Page of ILEP (International Federation of Anti-Leprosy Associations) at :-http://www.oneworld.org/ilepfor a more detailed study of this subject. In the bibliography, at end of these notes, I have listedsome helpful books and literature which make a more in-depth study of this subject.One basic fact to remember is that a insensitive or anaesthetic limb (finger, hand, foot etc.)which has been traumatised by any form of injury, must have REST if it is to heal. Often thesufferer is thought to have a incurable disease because, inspite of liberal applications of antibioticointments and the taking of so many pills, the ulcers etc. do not heal. All that may be necessary isREST. In this regard, pain is a blessing in disguise. Pain is the medium used by the body toinform the brain to give the affected member rest, but if the patient cannot feel and his/herdamaged sensory nerves fail to transmit the message to the brain, the injured limb etc. continuesto be further traumatised until often amputation is necessary. To provide rest, it may benecessary to use a splint, a Plaster of Paris (POP) Shoe , with “rocker”, to immobilize the foot, ora sling if the arm is involved. Where nerves are tender and inflamed, soft cotton-wool paddingmay be necessary to prevent any further damage. Sometimes, when the nerve is seriouslyswollen, the surgeon needs to incise the nerve sheath to prevent further damage to the nerve.Before a leprosy patient is referred to a physiotherapist, in a well organised Leprosy ControlProgramme, generally it is the PMW who carries out simple assessments. If the disease isdiagnosed in the early stages, a well trained PMW, in consultation with the physiotherapist, isable to provide all the treatment necessary to prevent disability and deformity. 6

SIMPLE PHYSIO ASSESSMENTS1. Detection of Sensory Deficit:-The most common way of identifying those areas where there is loss of feeling is to cover thepatient’s eyes and ask him/her to point to that part of the skin which is touched with a wisp ofcotton wool or a feather etc.. Patients may have areas of skin which manifest different forms ofinsensitive to either / or touch, pressure, heat / cold, pin prick etc.. The patient, with eyescovered, should be asked to point to those areas where the therapist touches. In this way, it ispossible to “map” or “chart” a leprosy patient’s body indicating areas involved.2. Detection of Muscle Weakness:-A) Hands:- Where the motor nerves ( ulnar, median and radial) have been affected, a simpleassessment can be made by asking the patient to extend all fingers. If the index and long fingerscan be straightened but not the ring and little finger, this is an indication that the ULNAR nerveis involved. This is the most common deformity in neglected Hansen’s Disease.If the patient can extend the ring and little fingers but not the index and long which remain bent,this indicates MEDIAN Nerve involvement. However, the therapist also needs to be aware of thepossibility of Carpal Tunnel Syndrome.If the patient is unable to straighten any of the four fingers which remain “clawed”, this indicatesboth ULNAR and MEDIAN nerve involvement and this also is a common deformity.Weakness of the INTRINSIC MUSCLES of the hand, due to Ulnar nerve involvement, isindicated when the patient is unable to spread the fingers apart and hold them in that positionagainst resistance.MEDIAN Nerve involvement is indicated when the patient is unable to oppose and rotate thethumb away for the palm of the hand. Complications of this form of Median nerve involvementcan often lead to THUMB WEB CONTRACTURE.RADIAL Nerve involvement is indicated when the patient is unable to extend the wrist againstresistance, resulting in the deformity of “Wrist Drop” .MEDIAN Nerve involvement is indicated when there is Atrophy of the THENAR MUSCLES ofthe palm of the hand and base of the thumb.ULNAR Nerve involvement is indicated when the HYPOTHENAR MUSCLES on the Ulnaraspect of the hand and the DORSAL MUSCLE between the index finger and thumb (first dorsalinterosseus) manifest atrophy.Please email me if you are interested in Simple Assessments of the Foot and Eye. 7

Suggested Reading material :-“Physical Therapy in Leprosy” by Ellen Davis Kelly Ph.D.- available from AMERICAN LEPROSY MISSIONS 1 ALM Way,Greenville, SC, 29601, 1-800-543-3131 -AMERICAN LEPROSY MISSIONS Email:- amlep@leprosy.org“Physiotherapy in Leprosy” by S.L.Kolumban, Chief of Physiotherapy, SchieffelinLeprosy Research Centre, Karigiri, India.“Handbook of Leprosy” by E.H. Jopling“Leprosy” by Anthony Bryceson and Roy E. Pfaltzgraff“A Manual of Leprosy” by R.H. ThangarajCLICK HERE TO ACCESS W.H.O. LEPROSY"http://www.ilep.org.uk/facts-about-leprosy/rehabilitation/ 8

Physiotherapy in leprosy - notes

by Dibyendunarayan Bid

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