Disabilities and deformities in leprosy patients and management
DISABILITIES AND DEFORMITIES INLEPROSY PATIENTS
"Leprosy work is not merely medicalrelief; it is transforming frustrationof life into joy of dedication, personalambition into selfless service" Mahatma Gandhi
REFERENCES:-----• IADVL• IAL• PARK’ Preventive and Social Medicine• Journals
TERMINOLOGY• `Impairments are defined as `problems in body function or structure such as a significant deviation or loss. An example of an impairment in body function would be loss of sensation; examples of impairments in body structure would be contractures and absorption.• A `deformity is a structural, usually visible, impairment.• A `defect could be either a functional or structural impairment.• `Disability is used as an umbrella term for impairments, activity limitations and participation restrictions.
Risk factors and Types Of Deformities• Risk factors are:-1) Type of Leprosy- more extensive and highly bacilliferous types carry a high risk if not treated early.2) No. of nerve trunk involved- more than three nerve trunk involvement increases the risk manifold.3) Attack of reaction and neuritis increases the risk.4) Duration of active disases- longer the disease remains untreated, greater the risk of disability.
• Types of Deformities:-Specific Deformities:- arise due to local infection with M.lepra like loss of eyebrows, nasal deformities. (face>hands=feet)Paralytic Deformities:- result from damage to motor nerves like claw finger, foot drop, facial palsy. (hands>feet>face)Anesthetic deformities:- results from insensitivity because of damage to sensory nerves like ulceration, mutilation. (feet>hands>face)
WHO Classification and GradingHANDS AND FEETGrade 0: no anaesthesia, no visible deformity or damage.Grade 1: anaesthesia present, but no visible deformity or damage.Grade 2: visible deformity or damage present.EYESGrade 0: no eye problem due to leprosy; no evidence of visual loss.Grade 1: eye problems due to leprosy present, but vision not severelyaffected as a result of these (vision: 6/60 or better; can count fingers at6 m).Grade 2: severe visual impairment (vision: worse than 6/60; inability tocount fingers at 6 m) also includes lagophthalmos, iridocyclitis andcorneal opacities.
Grade Degree of impairment Included ExcludedHands and feet0 No sensory impairment, Scars of healed ulcers, when no visible impairment sensation is normal1 Sensory impairment present, Scars of healed ulcers, when Scars of healed ulcers when no visible impairment sensation is impaired sensation is present Hands or feet following Minor skin cracks successful reconstructive surgery Muscle weakness without clawinga2 Visible impairments present Ulcers, severe cracks, severe atrophyaEyes0 No eye impairment; no visible or vision impairment b1 Eye impairment present Absence of (regular) Corneal sensation testing19 (vision: > 6/60) blink2 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 andautonomic nerve fibres supplying dermal andsubcutaneous structures are damaged. involving Peripheral nerve trunks– usually thosewhich are superficial or are in fibrocasseous tunnelsleading to dermato sensory loss and dysfunction ofmuscles.• Nerve involvement in leprosy can be said to occur in 5 stages:-- First two are recognized histologically while nextthree by clinical examination
Stages Charecteristics1 Parasitization A few leprae found in nerve2 Tissue response Host tissue response(TT to LL)+, bacilli+3 Clinical involvement Clinically thickened w or w/o pain. No NFD4 Nerve damage NFD+, recovery possible5 Nerve destruction Irreversible NFD, severe wasting + Posterior tibial nerve is the most frequently affected nerve followed by ulnar, median, lateral popliteal and facial.
Nerve Care Practice• AIM- to prevent permanent damage to nerve trunks• It involves- Recognizing acute or subacute “clinical neuritis” and treating it using steroid or other measures. Recognizing nerve function defect and instituting appropriate treatment without delay.‘Clinical neuritis’ is diagnosed when a nerve trunk showsmoderate to severe nerve pain. It may or may not beassociated with NFD and similarly NFD may or may not beassociated with clinical neuritis(Quiet Nerve Paralysis)
NERVE TENDERNESS SCALE-GRADE Clinical features0 No tenderness Palpation not poanful1 Mild tenderness Palpation hurts only when asked about it2 Moderate tenderness Palpation hurts even w/o asking3 Severe tenderness Palpation is very painful4 Very severe tenderness Pt. is apprehensive of palpationCategorization of pt. acc. To NFD and Clinical Neuritis- Nerve Function Deficit Clinical Neuritis Absent Present Absent A B Present C D
• Category A patients- pt is taught how to look for signs and symptoms ofneuritis.• Category B patients-(Neuritis +, no NFD) Start Prednisolone 40-80 mg daily 4 wks taper dose 5mg/wk upto 30mg 2-3 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 occur.• In BL and LL cases(neuritis due to ENL), one can wait for six weeks or even longer
• Category C patients- ( No neuritis,NFD+) Clinically, one may assume that the nerve trunkhas the potential to recover if NFD is :-• of recent onset - < 6 mnths involvement• incomplete- some sensibility is there• and if no severe muscle wasting present If NFD considered reversible:- prednisolone 30mg 4 wks then tapered off over 30 days. If NFD not recent:- prevent secondary impairement.
• Category D patients:-(NFD +, neuritis+) Prednisolone 40-80 mg daily 2-3 wks reduce to maintenance dose in 3-4wks Maintenance dose 30mg daily 8-10 wksIf there is no improvement in neuritis within 3-7daysthen surgical decompression is required.To accelerate resolution of inflammation:- 1- splint affected nerve in slightly stretched position 2-supportive therapy like analgesics 3- short wave or microwave diathermy
• Nerve abscess is cold abscess occuring in a damaged fascicle usually in Tuberculoid Leprosy• Ocassionaly, ‘hot’ abscess occurs in ENL related neuritis Management :--• if nerve shows no NFD: wait and watch, 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: evacuate and excise the abscess.
Hand Problems in Leprosy Patients• Hands are affected because of damage to nerves supplying them or directly affected by reactional process(especially in BL, LL).• Ulnar nerve is affected most often than others.• In BL,LL cases usually Glove type extensive acral anesthesia occurs without significant motor involvement.• Therefore loss of sensibility in palm doesn’t necessarily indicate damage to nerve trunk, as it may also result from destruction of dermal nerve twigs.• Muscle weakness is sure sign of damage of nerve trunk.
Impairement Direct consequences Late consequencesDamage to somatic sensory Loss of sensibility Anestheticfibres deformities(ulcers,shortening of digits.)Damage to motor fibres Muscle paralysis ContractureDamage to sudomotor Dry skin Deep cracks, hand infectionsautonomic fibresLepra reaction Inflammatory odema, Severe fixed osteoporosis, bone deformities(specific destruction, pathological deformities,bizzare fractures deformities)
Sensory loss leads to:- Loss of perception of pain and heat deprives the hand of its protective mechanism. Motor activities become clumsy and difficult because muscle action is not fine tuned. Frequently injuries results in anesthetic deformities(shortening of digits).Dryness of Palmar skin :- Lack of sweating Cracks at digital creases
• Care of Insensitive Hand:- Skin care practices:- daily soaking hands in water for 15 min. rubbing palms vigorously apply liquid parrafin or vegetable oil Injury care practices:- precaution against burns while cooking using utensils with insulated handles daily inspection of hands using bulky bandages in case injury occurs
• Paralytic deformities of hand:-ulnar nerve supplies--- flexor carpi ulnaris medial half of flexor digitorum hypothenar muscles adductor pollicis and all interossei medial two lumbricalsmedian nerve supplies:--all flexor muscles of forearm thenar muscles first two lumbricals
• Ulnar palsy leads to:- Ulnar claw hand(hyper extended MCP and flexed PIP jts) Loss of adduction and abduction• Combined Ulnar and Median nerve palsy:- all intrinsic muscles are paralysed complete claw hand handling of objects become very difficultCorrective Surgery are:-- Lasso insertion Zancolli’s operation augment flexion forces at MCP jt Srinivasan’s operation Bunnell’s Brand augments extension forces at PIP jt Antia
• Specific Deformities of hand:- Banana Fingers (due to heavy infiltration) Shortening of fingers (due to resorption and fragmentation) “Reaction Hand” (when hand is involved in reactional states) Foci of ac. Inflammation develops which eventually resolves with dense fibrosis. Foci may be located in dorsal skin, s/c adipose tissue, in small muscles or in small bones. Lession in interossei leads to Swan Neck deformity. Rx. Start systemic corticosteroids therapy(30 mg), Initially hand is rested using splint in functional position Wax baths Active movements after subsidising acute phase
Massage and Exercises for Hands:-• Massage :- it should be done gently, after applying oil, place hand and gently stroke it with other.• 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)
Adductor Finger loop Gutter splintOpponens loopGrip Aids:--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
Foot Problem In Leprosy Patients• Common problems are:- Plantar ulceration Foot drop Fixed deformities of feet and toes Tarsal disorganisation.PLANTAR ULCERATION:-- found in 10% of patients manifestation of sensorimotor 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 and Types of feet ulcers: Stages--- First stage – threatened ulceration(dorsal puffiness, deep tenderness) Second stage – concealed ulceration(destruction of soft tissue has occurred) Third stage – open ulceration(necrosis blister open and exposed) Types--- Acute ulcer– frankly infected, purulent, covered with slough Chronis ulcer– indolent ulcer with hyperkeratotic edges, covered with granulation tissue Complicating ulcer– infection spread to deeper structure may lead to muscle paralysis, gas gangrene, tetnus or septicemia.
Management and Prevention• Management:-- absolute bed rest and elevate foot eusol bath, irrigation, dressing remove slough or other draining procedures start antibiotics protective foot wearing• Prevention:-- Protective footwear:-(type depends on state of foot) Feet with only sensory loss(no muscle paralysis), footwer 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.• learn to take short steps
Insensitive feet(with intrinsic muscle paralysis):- these require a resilient, non collapsing, shock absorbing insole that will dampen the impact during walking Microcellular rubber is most suitable.In certain case where greater reduction of pressure isrequired; add metatarsal bar obliquely or molding theinsole so that pressure can be distributed evenly overentire plantar surface. Certain orthosis like fixed ankle brace can also be usedthat may transfer a part of load to leg. Foot Care Practices:-- similar to those done for hand soaking, scrubbing and smearing routinely corn and callosities are removed carefully identify ‘safe limits’ of walking
• Foot drop:-- About 1-2% of leprosy patients develop due todamage to lateral popliteal nerve. Paralysis of anterior muscles give rise to foot drop characteristic ‘stepping gait’ occurs in which ball of foot instead of heel hits the ground inversion foot leads to overloading on outer part.If paralysis is recent; manage under ‘Nerve Care’therapy.If paralysis is of >1 year duration; it is satisfactorilycorrected by anterior transposition of tibialis posteriortendon(Srinivasan’ operation)If surgical intervention is contraindicated; foot dropappliances like strap, stops or springs are used that holdfoot at right angle.
• Splinting of knee:- fig. 36.10 this allows rest to inflamed nerve and result inquicker healing.• Droped foot should be supported to hasten recovery. Splint• Stretching calf muscles: as in foot drop these are not used while walking so contracture may develop.
CONTRACTURES WITH ‘FOOT DROP’ IS TO STRETCHTHE HEEL CORDS BY LEANING FORWARD AGAINST AWALL OR BY SQUATTING WITH HEELS ON THEGROUND
Deformities of Face• Most of deformities on face occurs due to infilteration of facial skin but paralytic deformities can also occur(in borderline leprosy).• Deformities are:-- loss of eyebrows(madarosis) mega lobules of ear(Budhha ear) premature senility(strecthing of skin due to heavy infiltration lead to loss of elastic tissue, when infiltration regresses skin become redundant) Sunken Nose (due to infilteration in nasal mucosa in LL , granuloma formed erodes the supporting bony structure of nose).
Eye Problem• More commonly in BL and LL type leprosy.• Occurs due to:- Direct invasion- leprous conjuctivitis, scleritis and choroidal nodule. Acute iridocyclitis- due to immune complex deposition Damage to – facial nerve paralysis of eyelid muscles and lagophthalmos - trigeminal nerve loss of corneal sensation leads to exposure keratitis and corneal ulceration.Management- using spectacles,gogles or eyeshades. artificial tears and cover eyes during sleep treating ac iridocyclitis using topical corticosteroids surgical intervention for lagophthalmos or cataract
• Splint in facial palsy- use adhesive tape strips so that lower lid is not sagging due to gravity and angle of mouth isnt deviated• Gynecomastia: embarrassing enlargement of breast in males, usually bilateral due to hormonal imbalances because of testicular and liver damage.
GPAS(Green Pastures Activity Scale):-• It assess the daily routine of patients• Can help the nurse to pick up early deformityDaily activities are assessed as Interpersonal relationship For use of assistive devices4. Not difficult 4. No problem 4. Not necessary3.A bit difficult 3. Some problem 3. Not difficult2. Very difficult 2. More problem 2. Difficult1. Impossible 1. No relation 1. Very difficult
Economic Rehabilitation• Social ostracism is now on decrease following extensive education about leprosy.• Appropriate economic rehabilitation is provided eg sewing machines,handcrafts, carpentry ,etc.• CBR(community based rehabilitation) aims to overcome activity limitation and participation restriction and thus improving QOL for disabled.• WHO has endorsed the goal of reducing grade2 disabilities by 35% from baseline of2010