DEFORMITIES IN LEPROSY

1. DEFORMITIES IN LEPROSY
PRESENTED BY DR PDIANGTY GIRI
SECOND YEAR PG

2. INTRODUCTION
• Leprosy deforms and disables but seldom kills.
• Prevention of impairments and disability (POID) is integral
part of the successful management of leprosy affected
persons as well as national leprosy eradication program.
The objectives of managing disabilities in leprosy, therefore,
are to prevent:
(1) onset of new disabilities, and
(2) worsening of existing disabilities
• Deformity is an alteration in the appearance and is usually
associated with some incapability especially if the limbs are
involved.
• Disability is actually an incapability of the patient and it may
exist even without any obvious disfigurement.

3. DISABILITIES AND DEFORMITIES IN
LEPROSY: TERMINOLOGY
• The term impairment is a term denoting the loss or abnormality
of the anatomical/physiological structure or function .It is
classified as:
• Primary impairment: Changes in the structures and functions of
the body tissues directly due to disease process like damage to
the nerve, e.g.:– Anesthesia of area supplied by the affected
nerve.
• Secondary impairment: Changes in the structures and function
of the body parts due to neglect, excessive use, careless and
improper care of parts with primary impairment, e.g.: Insensitive
hand or foot: Development of cracks, ulcer, septic hand/foot,
shortening of fingers/toes, even mutilation of hands or feet and
disorganization of foot or wrist.Weak/paralyzed parts: Joint
stiffness or formation of contractures.

4. • Disability, on the other hand, is the lack of ability to perform an
activity considered normal for a human being of the same age,
gender and culture.
• NERVE INVOLVEMENT
• Involvement of nerves produces loss of sweating, loss of
sensations and loss of motor power in its territory just distal to the
site of affection. Palpation reveals the enlargement of the nerve
and that clinical examination of sensory and motor loss is charted
in order to judge its recovery or downgrading.
• TESTING FOR NERVE DAMAGE
• Sensory Testing
• Motor Testing

5. Sensory examination

6. • PALPATION OF PERIPHERAL NERVE

12. • MOTOR EXAMINATION

16. WHO DISABILITY GRADING: OPERATIONAL DEFINATION
Terminology

18. WHO GRADING OF DISSABILITY 1998

19. WHO GRADING FOR DISABILITY 2011-2015

20. • While WHO grading system may give an indication to the status
on detection it does not measure the worsening or improvement
by disability prevention and medical rehabilitation program
longitudinally.
• Therefore, EHF score is used to grade the disability of the
individual organ separately and to give an overall disability
grade to the person as outlined below.
• EHF score is the sum of the individual disability grades. EHF
score i.e. sum of all the individual disability grades for two eyes,
two hands and two feet (0-12) is recorded at each visit.
• The EHF score is more sensitive to change over time than the
disability grade itself. An increase in the score, whether of an
individual organ or the overall score would indicate some new or
additional disability.

21. Deformities in Leprosy
• Deformities in leprosy arise due to tissue infiltration and nerve
damage.
• Loss of eyebrows, depressed nose and wrinkled skin of the face
are deformities due to tissue infiltration
• The nerve damage is due to leprous neuritis and reactions which
affects peripheral nerves at a particular site, resulting in paralysis,
of which the most common example being the claw hand
• Primary and Secondary Deformities
• Loss of sensation due to nerve damage is primary impairment
• Claw hand is also a primary impairment
• Secondary impairment/deformities are joint stiffness and volar
skin contractures in the hands, and ulcers due to anesthesia,
injury and neglect of self-care

24. DEFORMITIES OF HANDS
• Claw Hand
• Management of Hand Deformities
• Physical Measures
• Splints
• Grip-aids
• Reconstructive Surgery
DEFORMITIES OF FEET
Foot Drop and Claw Toes
Plantar Ulcers
Management
• If ulcer is present, rest is essential. All simple ulcers will heal, if
given sufficient rest

27. • Splints and Splinting
• Splints are external appliances which are worn over the affected part
of the body to hold it in a desired position. These can be made from
different materials.
• Splinting is done to achieve different objectives individually or in
combination, viz. to immobilize a part to relieve pain, to stabilize a
joint, to retain the joint/part after release of contracture in a particular
position.
• To prevent its movement in a particular direction and also to provide
continuous gradual stretching.
• Common splints in use for hand deformities are: gutter splints, finger
loop splints, opponens splints and adductor band.

28. • Gutter splint is in the form of a half cut tube (made of
thick, firm polyvinyl material) lined with felt and provided
with Velcro fasteners at its either ends. It is a static
splint.
• Loop splint consists of a loop of rexin or other suitable
soft material having an eyelet at its end. Through this
eyelet opening a rubber band is threaded and tied to
itself. The other end of rubber band is tied to a wrist
band at appropriate tension.
• Loop splint consists of a loop of rexin or other suitable
soft material having an eyelet at its end. Through this
eyelet opening a rubber band is threaded and tied to
itself. The other end of rubber band is tied to a wrist
band at appropriate tension

29. • Opponens splint is similar to loop splint, the loop here is wider to
accommodate for diagonal movement of the thumb.
• Adductor band consists of a straight band of appropriate
dimensions at either end of which Velcro fasteners are stitched.
• A simple spiral splint made out of 10 SWG galvanized steel wire
sheathed with thick rubber sleeve is easy to fabricate andcan be
used by patient anytime.
• Serial splinting involves repeated application of plaster of Paris
casts to PIP joint(s) of the fingers at regular intervals to
overcome the contractures gradually. The contracted finger is
passively stretched and held in that position by a plaster of Paris
cast, made by wrapping a wet plaster of Paris bandage (45 cm
long and 5 cm wide) so as to form four to five layers around PIP
joint, which is held in desired position till the cast is dry

30. • Where to use and Which Splint?
• When the palsy is just begun.
• Duration of Splinting
• Even though it is difficult to predict the duration of splinting
required for a particular case, majority of case have been
observed to improve in 8–12 weeks time
• Foot Drop
• Splinting for foot drop is aimed to prevent stretching of dorsiflexor
muscles of the foot and prevent contracture of tendo-Achilles. A
below knee slab of plaster of Paris, to keep the foot in neutral
position, is adequate.

31. • Alternatively a ‘Y’ strap with spring or single elastic strap can be
used to provide lift to the forefoot while walking, prevent
stretching of the dorsiflexors of the foot and prevent contracture
of tendo-Achilles.
• Facial Palsy
• The facial skin is appropriately splinted with hypoallergenic
adhesive tape strips so that lower lid is not sagging due to
gravity, and the angle of mouth is not deviated
• Splinting for Nerve Pain
• The affected limb is placed in a splint made of suitable and
easily available material so as to prevent the movement of
nerve (joint across which the nerve trunk takes its course) and
provide rest to the nerve. The joint is immobilized in such a
position that the nerve is relaxed

36. • Deep ulcers are less likely to respond to conservative treatment
and will need scraping (pairing) or scooping surgically, followed
by dressing and in a case of nonhealing ulcer, skin replacement
with graft or flaps will be required. However, majority of cases
need only self-care at home
• Surgery for Plantar Ulcers
• Footwear
• DEFORMITIES OF FACE
• Depressed Nose (Collapsed Nose)
• Wrinkled Face
• Loss of Eyebrows
• Lagophthalmos
• Ectropion

37. • FOOTWEAR
• Microcellular rubber footwear is considered the best for evenly
spreading out the body weight as well as preventing external
injuries with a hard sole. Criterion for its distribution was
standardized.
• First priority to those with ulcers and healed ulcers for next 3 years,
• Secondly to those with cracks and history of infection and swelling in
the feet off and on.
• Followed by all other cases
• If specialized footwear is not available, the insole of MCR also
can be used in patients own footwear, as an alternative. Finally, it
is necessary to explain to the patient that any footwear, which will
prevent injury, has to be used by them and they need to learn to
diagnose the initial symptoms of impending ulcerations by
looking at their feet, palpating for increase in temperature in
certain areas and any unusual swelling, on regular day-to-day
basis

38. • Lagopthalmos
• In the established cases, reconstruction may be in the form of
the temporalis musculofascial sling or gold implant in the upper
lid. Lateral tarsorrhaphy, though a simple procedure, often
shows an unsatisfactory outcome in terms of the eye closure

44. • HEALTH EDUCATION TO A PERSON AFFECTED WITH LEPROSY
• Advice to Patients on Completion of Multidrug Therapy
• Skin patches will take much longer time to disappear or get back the
original color and texture.
• Skin color will return to normal within few months of MB MDT when
dark coloration of the skin is due to clofazimine.
Reactions in the skin or nerves may occur in a few instances even after
completion of the treatment (after being cured).
• If the skin patches become reddish, if there is a sudden loss of
sensation in the hands or feet or weakness in the muscles, report back
immediately for a check-up.
• Tingling, numbness or heavy feeling is the initial sign of neural
damage. Do not neglect it and report for a check-up.

45. • Advice to Patients with Loss of Sensations in Hands and Feet
• Daily inspection of hands and feet for signs of injury.
• Keep the hands and feet moist
• Do not exert undue pressure while working
• Do not touch any hot objects without wrapping a cloth on your hands.
• Do not walk barefoot Use comfortable footwear without nails and
check your feet daily for injuries or burns.
Advice to Patients who have Deformities
• Follow advice meant for patients with loss of sensations.
• Carry out simple physiotherapy exercises at home to keep the joints
mobile.
• Deformity is a consequence of the disease and is often reversible or
mostly correctable.
• Deformity is not contagious and cannot transmit the disease.
• Do not allow deformities to worsen; get the specialist’s advice as soon
as possible.

47. • FACTORS AFFECTING THE ONSET AND PROGRESSION OF
DISABILITIES
• Age
• The deformities are more commonly seen in 20–40 years age group
probably because of the fact that self-limiting forms of disease occur in
younger age groups and the duration of disease is also shorter in them
• Sex
• The deformities are less common in females because of lower incidence of
disease.
• Duration of the Disease
• It has been observed that shorter the duration of active disease lesser the
number of deformities that develop later,because of better control of the
disease under treatment and lesser degree of involvement of nerves and
other body tissue

48. • Type of Disease and Immune Status
• The immunity to disease varies with the type of leprosy, being
maximum in tuberculoid variety and almost absent in lepromatous
leprosy
• Occupation
• Heavy manual labor and specific occupations causing repeated
trauma to an anesthetic part are likely to cause ulcerations which
may progress to mutilation
• Attitude of the Patient
• Living with anesthetic extremities is difficult. Patients, who do not
have clear concepts about the value of sensations and its
protective function preventing tissue damage, suffer more and
develop serious deformities
• Treatment
• Effectiveness of the antileprosy treatment in preventing the

49. • Availability of Medical Care
• Areas where adequate medical attention is available, the
deformities tend to be lesser in number and milder in form.
• Quiet Nerve Paralysis
• Clinically evident acute or subacute neuritis of nerve trunks is a
sign of impending paralysis. However, thickened nerve trunks quite
frequently become paralyzed without manifesting any nerve pain
and the damage is recognized only after it is physically manifest.
• CAUSATION OF DEFORMITIES
• The deformities can develop due to:
• Direct result of infiltration of tissues by M. leprae
• Muscle imbalance secondary to motor paralysis and Secondary effects of
impaired sensations and anesthesia.

50. • These factors operate singly or in combination in various patients
but to emphasize the individual contributions of each, these are
discussed separately.
• EFFECTS OF INFILTRATION OF TISSUES BY M. LEPRAE
• Nerve Damage
• Skin Damage
• When the skin and subcutaneous tissues are infiltrated, the collagen
and elastic fibers, which maintain the shape and form of skin, are
largely replaced by granulation tissue.The skin, first of all, looks
swollen and shiny but later when disease subsides it becomes
wrinkled and loose. The skin appendages are also destroyed leading
to the loss of hairs,sweat and sebaceous glands

51. • Oronasal Defects
• Nasal stuffiness develops first followed by superficial ulcers in nasal
mucosa due to trauma while picking the nose. These get secondarily
infected and repeated inflammatory episodes lead to the destruction
of nasal cartilage and scarring. The nasal tip is pulled posteriorly
presenting as typical nasal deformity with depressed dorsal crest
and anteriorly facing nostrils.
• Gynecomastia and Associated Changes
• Damage to Other Tissues
• Leprosy by itself does not cause gross bone destruction, but it does
cause bone to become fragile by trabecular absorption and
decalcification so that it is no longer able to withstand normal
strains. These changes are reversible and recalcification takes place
leaving functionally normal bones if adequate protection is given
during acute reactional episodes.

52. • EFFECTS OF MOTOR PARALYSIS
• Motor paralysis results in loss of function performed by the
paralyzed muscle(s). Motor paralysis may also contribute to the
resorption of fingers by altering the gripping patterns
• EFFECTS OF ANESTHESIA AND ANALGESIA
• Inability to appreciate the temperature and pain sensations
causes damage to the hands and feet. The protective reflexes
are lost. The loss of pain allows the patient to use his burnt or
injured fingers as actively as if it were unwounded or uninfected.
• PREVENTION OF DISABILITIES
• Early case detection followed by full treatment is the most
important step to prevent and or to minimize nerve function
impairment (NFI).

53. • Early signs and symptoms of leprosy should be known well to the
community to promote self reporting in its early stages so that cure
is evident without the development of NFI.
• The deformities are surgically corrected if needed. Attempts need
to be made to provide a life with dignity and fellowship for the
severely disabled regardless of their physical condition.
• ANTICIPATING NERVE FUNCTION IMPAIRMENT
• We need to anticipate the impending neural damage and thereby
identify high-risk patients. These patients can then be given extra
attention and some form of prophylactic treatment.
• Risk factors have been identified, which can help in pointing out
cases that are more likely to develop reactive episodes and
NFI.15Previous nerve damage, multibacillary (MB) disease
especially borderline leprosy, multiple nerve trunk
involvement,pregnancy, inter-current illness like tuberculosis—all
canprecipitate a reactive episode.

54. • ROLE OF STEROIDS
• Steroids have been used to treat NFI, reactive episodes and
also as prophylactic agents against reactions. In a report, it was
concluded that 60% of patients who were treated with steroids
for NFI had useful recovery of sensory-motor functions
• ROLE OF NERVE TRUNK DECOMPRESSION
• The timing of nerve trunk decompression is not very clear.
• It has been reported that nerve damage of 3 months or lesser
duration and with muscle strength grade 3 or more has a
favorable prognosis.
• MONITORING AND SELF-REPORTING
• The patients can be taught to recognize reportable events like
changes in eyes and vision, sensory motor functions, and nerve
pain and to ask for help if required

55. • EVALUATION OF THE PATIENT AND ASSESSMENT OF
DISABILITY
• An assessment of disabilities and deformities in a patient is done
at the time of his first visit and recorded before starting the
treatment. This baseline information is helpful to assess the
response to therapy and nerve functions.27 A complete examination
is carried out to find out the condition of skin, nerve trunks,
sensory motor functions and joints. It is convenient to record this
information in charts, containing outline drawings of hands and
feet, so that these can be easily referred to in future, if required.
• ROLE OF PHYSIOTHERAPY
• Physiotherapy is an integral part of management of leprosy and is
needed to prevent the onset of disabilities and deformities and
also to arrest the progression of those if already developed

56. • It is required to relieve nerve pain and keep the integrity of muscle
fibers intact till they are reinnervated, if palsy has set in. It also helps
in the resolution of inflammation and edema of the extremities in
leprosy reaction and keeps the joints mobile.
• TECHNIQUES OF PHYSIOTHERAPY AS APPLIED TO LEPROSY
AFFECTED PERSONS
• Soaking in Water and Oil Application
• Exercises
• Splints and Splinting
• Claw Hand
• The splints used to manage finger clawing can be static, that is to
maintain the joint position or dynamic where some form of
mechanism is incorporated to exercise the fingers.

57. • Heat Therapy
• The physiologic effects of heat application are increased
collagen extensibility, decreased joint stiffness, relief of pain
and muscle spasm, increased blood flow and resolution of
inflammatory infiltrates, edema and exudates.
• Electrical Stimulation
• Transcutaneous electrical nerve stimulation (TENS) has been
widely used to treat acute and chronic painful conditions.It has also
been used in leprosy.High frequency, low intensity TENS activates
peripheral A beta fibers selectively, which blocks or modulates the
pain carrying inputs at the level of the dorsal horn of spinal cord.

58. • PREVENTION OF PROGRESSION OF DISABILITIES
• The components of this activity include early detection of nerve
damage and also the care for existing disabilities. Of these,
severity of nerve damage decides the actual clinical outcome.
• Problems faced by the patients having insensitive extremities
(hands and feet) are:
(1) problems of disuse or under use, (2) problems of misuse
and overuse and (3) problems of protection
• There is an inherent desire in these patients to perform and
behave like normal persons. As a, result, they are likely to
damage their hands and feet.

59. • Management
• The patient needs to be properly examined and evaluated before a
tailored scheme for his rehabilitation can be worked out
• The evaluation includes, besides age and occupation, assessment
of residual sensory motor functions and psychological state to find
out his reaction and attitude toward his problems
• Proper counseling is done in several sittings and options are
suggested. It is for the patient to decide and choose the one that
suits him the best under the circumstances
• Health education is an important component of the management
scheme and key to success. It should start from the day patient is
brought under MDT umbrella and continue until he is ready to be
released from control

60. • Self-care is the responsibility of the individual who has NFI and he
is expected to carry this out on daily basis
• Constant use of proper fitting protective footwear is desirable. It is
not a must to go in for conventional MCR footwear since it is not
easily available in the market
• The physician must recognize the psychology of the person who
has lost sensations in their limbs. Even intelligent patients
continue to use their infected finger and continue to walk on
wounds destroying their feet
• We have to spend some time to explain to them the physiology,
pathology, mechanisms and psychology of their deformities and
encourage them to believe that their limbs can be saved with
some extra care

61. • DEFINITION
• Prevention of impairments and disabilities (POID) Interventions
that are aimed at preventing the occurrence of a new disability or
deformity not already present at the time when the disease is
diagnosed.
• Prevention of worsening of disabilities (POWD) Interventions that
are aimed at preventing the worsening of disabilities or deformities
already present when the disease is diagnosed.
• EPIDEMIOLOGY
• About 33%-56% of newly registered leprosy patients already have
clinically detectable NFI, often no longer amenable to MDT
• It was evident that the proportion of reaction showed an increase
of 75% among the patients with > 5 skin lesions and multiple
nerve trunk thickening at the time of registration. This analysis
stresses the need to focus attention on leprosy patients having > 5
skin lesions and multiple nerve thickening

62. INTERVENTION MODELS
Management of reaction or neuritis using a standard steroid
regimen
• Simple methods to identify early nerve function impairment and
treatment with a standard course of steroids
Management of disabilities using simple techniques for disability
care
• All patients with impairments should be taught methods to
prevent further impairment and residual impairments
• Leprosy workers and community volunteers (CVs) should be
given task oriented training in conducting a disability survey
using a simple survey proforma and in applying simple
adaptations like pre-fabricated splints grip-aids for hand
deformities and MCR footwear, mini plaster and ‘dressing’ kit for
foot deformities, besides conventional physiotherapy.

63. • METHODS OF ASSESSMENT
• For POID
• A retrospectively analyzed the records of 426 leprosy patients with
reactions treated using a standard steroid regimenunder field
conditions. This regimen comprised of an initial maximum dose of
60 mg of prednisolone (tapered down over 28 weeks) for acute
and silent neuritis, 40 mg (tapered down over 24 weeks) for skin
reactions (i.e. type I reaction) and 30 mg (similarly tapered off
within 16 weeks) for ENL (i.e. typeII reaction)
• This group was compared with another group of 350 patients with
reactions treated with arbitrary steroid regimens. With the
standard steroid regimen, significant improvement was observed
in sensory loss as compared with motor loss. Recurrences were
also less than with the arbitrary regimens (26%vs. 40%).

64. • For POWD
• There are no agreed indicators for monitoring POWD activities or
physical rehabilitation interventions
• An ongoing MDT programme in a Bombay slum identified 45
disabled leprosy patients who were offered POWD services at
their doorstep through CVs from the slum, under the supervision
of a trained paramedical worker.
• A questionnaire study indicated that 82% of family members and
neighbours acquired more knowledge about leprosy and actively
assisted in disability care of the patients in the study area as
compared to 66% in the control area where the leprosy workers
offered the POWD services at the clinic. The acceptance and
participation by family members was 78% in the study area and
54% in the control area

65. • The productivity loss in India due to deformity from leprosy was
assessed in a random sample of 550 leprosy patients from a
rural area and an urban area in Tamil Nadu.17 The conclusions
were that elimination of deformity would raise the probability of
gainful employment from 42.2% to 77.6%.

66. THANK YOU