The document discusses disability prevention and management in leprosy. It defines key terms like impairment, deformity, and disability. It describes risk factors for deformities and classifications of nerve involvement. It discusses preventing impairments through early treatment, steroid use, nerve decompression, and self-care practices. Management involves assessing nerve function, physiotherapy including splinting and exercises, footwear, and corrective surgeries. Close monitoring and rehabilitation aims to restore function and independence.

1. Disabilities prevention and
management in leprosy
Dr.Dileep Saugat

2. Headings
1. Introduction
2. Definitions
3. Risk factors
4. Classification
5. Grading
6. Manifestations
7. Disability prevention
8. Management
9. Rehabilitation
4/10/2018 2

3. INTRODUCTION
• The main cause of socioeconomic
dehabilitation in leprosy is deformities
• Prevention of impairments and disability
(POID) is integral to the success of
management of leprosy affected persons
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4. "Leprosy work is not merely medical relief;
it is transforming frustration of life into
joy of dedication, personal ambition into
selfless service"
Mahatma Gandhi
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5. 4/10/2018 5

6. Impairments
• Loss or abnormality of the anatomical or
physiological structure and function.
• They are further classified as
–primary (e.g. facial disfigurement, nerve
and eye damage and personality disorders)
and
–secondary (e.g. ulcers, shortening of fingers
and toes, contractures and bone
destruction).
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7. Deformity
- The visible alteration in the form, shape or
appearance of body due to impairment produced
by the disease.
- E.g, loss of eyebrows or clawing of fingers.
Disabilities
– Lack of ability to perform an activity considered
normal for a human being.
– E.g., slipping of pen or objects from hands
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8. Handicap
disadvantages that limit or prevent from
fulfilling their normal role in society
Prevention of impairments and disabilities
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
Interventions that are aimed at preventing the
worsening of disabilities or deformities
already present when the disease is diagnosed
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9. RISK FACTORS FOR DEFORMITIES
• 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 diseases- longer the
disease remains untreated, greater the risk of
disability4/10/2018 9

10. • 5) Sex - less common in females
• 6) Immune status of the body
• 7) Occupation – heavy manual laborers are
more prone
• 8) Attitude of patients
• 9) Treatments – effectiveness of treatments in
preventing occurrences of deformities is still
debated
• 10) Availability of medical care
4/10/2018 10

11. 4/10/2018 11

12. 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)4/10/2018 12

13. 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 leading to dermato
sensory loss and dysfunction of muscles.
4/10/2018 13

14. • Stages of Nerve involements:-
–1) Parasitization A few leprae found in
nerve
–2) Tissue response
–3 )Clinical involvement Clinically thickened
nerves +/- pain. No NFD
–4 )Nerve damage NFD+, recovery possible
–5) Nerve destruction Irreversible NFD,
severe wasting +
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15. NOTE
• Posterior tibial nerve is the most frequently
affected nerve followed by ulnar, median,
lateral popliteal and facial.
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16. 4/10/2018 16

17. NERVE TENDERNESS SCALE-GRADE
0 - No tenderness, Palpation not painful
1 - Mild tenderness ,Palpation hurts only when
asked about it
2 - Moderate tenderness ,Palpation hurts even
w/o asking, not interfere with sleep,
aggravated by repeated use of limbs
3 - Severe tenderness, Palpation is very painful,
interferes with sleep, patient keeps limb
position at rest
4/10/2018 17

18. WHO Classification and Grading
HANDS AND FEET
Grade 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.
4/10/2018 18

19. EYES
Grade 0: no eye problem due to leprosy; no
evidence of visual loss.
Grade 1: eye problems due to leprosy
present, but vision not severely affected as
a result of these (vision: 6/60 or better; can
count fingers at 6 m).
Grade 2: severe visual impairment (vision:
worse than 6/60; inability to count fingers
at 6 m) also includes lagophthalmos,
iridocyclitis and corneal opacities.
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20. 4/10/2018 20

21. Nerve trunks involvements
• ULNAR
–MOTOR – clawing of ring and little finger
–SENSORY –
• Ulnar side of ring finger
• complete palmar aspect of little finger
• Hypothenar areas
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22. MEDIAN NERVE
–MOTOR – Loss of abduction –opposition of
thumb
–SENSORY –
• palmar aspect of thenar eminence
• Index and middle fingers
RADIAL NERVE
–MOTOR – Wrist drop
–SENSORY – dorsum of thumb web
4/10/2018 22

23. COMMON PERONEAL NERVE
–MOTOR – Foot drop
–SENSORY – dorsum of foot
POSTERIOR TIBIAL NERVE
–MOTOR – Clawing of toes
–SENSORY – Sole of foot
FACIAL NERVE
- Lagophthlmos
- paralysis of affected side
4/10/2018 23

24. MUSCULO-SKELETAL
• BONES – trabecular absorption and
decalcification
– Osteoporosis
– Pathological fracture
• Damage to tendon sheath and joint capsules
• Painful arthritis
4/10/2018 24

25. • OTHERS -:
–LARYNX –
•hoarseness of voice
–FACE –
•loss of eyebrows and other facial
hairs
–Hormonal imbalance
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26. 4/10/2018 26

27. PREVENTION OF DISABILITIES
• Anticipating nerve function impairment
– Risk factors identification (mention)
• Use of steroids- to treat NFI, reactive episodes
• Nerve trunk decompression
• Care of eyes
– think and blink, spectacles, sheild, washed with clean
water, avoid rubbing
• Management of reactions
– Early recognition and tt
• Monitoring and self reporting
4/10/2018 27

28. Evaluation and Assessment
• Evaluation of nerve trunks
• Sensory and motor examination
• Voluntary muscle testing
• Monofilaments
4/10/2018 28

29. Role of physiotherapy
1. Soaking in water and oil application
2. Exercises: Active and assisted exercises,
passive exercises
3. Splints and splinting:
1) Claw hand
i. Adductor band splint : palsy has just began and little
finger is not able to adduct
ii. Loop splint: mobile finger clawing
iii. Opponens splint : if thumb is paralyzed
iv. Gutter splints : obvious contracture
4/10/2018 29

30. 2) Foot drop
i. Below knee slab of plaster of paris
ii. Y strap with string
iii. Single elastic trap
3) Facial palsy
i. Splinting with hypoallergenic adhesive tape strips so
that lower lid is not sagging due to gravity and angle
of mouth is not deviated.
4) Splinting for nerve pain
i. Joint is immobilized in such a way that nerve is
relaxed
4/10/2018 30

31. 4. Heat therapy
– Heating pads, hydrotherapy, paraffin baths
– Effects: increased collagen extensibility, decreased
joint stiffness, relief of pain and relaxation of
muscle spasm, increased blood flow, resolution of
inflammatory infiltrates, edema and exudates
– Wax bath : part to be treated is covered with
warm molten wax, for treatment of nerve pain
and stiff joints
4/10/2018 31

32. 5. Electrical stimulation
– Low frequency, high wavelengths currents are
used
– Uses: reduction of pain, stimulation of NM
function, stimulate the bone and soft tissue
swelling
– TENS (Transcutaneous electrical nerve
stimulation) is used
4/10/2018 32

33. Insensitive feet(with intrinsic muscle
paralysis):-
• 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 is required; add metatarsal bar
obliquely or molding the insole so that
pressure can be distributed evenly over entire
plantar surface.
4/10/2018 33

34. Care of Insensitive Hand:-
• daily soaking hands in water for 15 min.
• rubbing palms vigorously, apply liquid parrafin
or vegetable oil
• precaution against burns
• while cooking, use utensils with insulated
handles
• daily inspection of hands
• using bulky bandages in case injury occurs
4/10/2018 34

35. • Prevention of foot deformities:-
–Protective footwear:- Any footwear can
reduce the pressure upto 25%(type
depends on state of foot)
–footwear should have tough outer sole,
–should not rub against toes. Eg using
automobile tyre side pieces.
–Appropriate footwear should have outer
sole of - 15-18mm thick and soft inner sole
18-22mm.
– Iron nails and buckles are to be avoided.•
4/10/2018 35

36. • Orthosis like fixed ankle brace can also
be used that 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
4/10/2018 36

37. 4/10/2018 37

38. MANAGEMENT
Nerve Care Practice
AIM- to prevent permanent damage to nerve
trunks
It involves- (1) Recognizing acute or subacute
“clinical neuritis” and treating it using steroid
or other measures.
(2) Recognizing nerve function defect
and instituting appropriate treatment without
delay.
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39. ‘Clinical neuritis’ is diagnosed when a
nerve trunk shows moderate to severe
nerve pain.
It may or may not be associated
with NFD and similarly NFD may or may
not be associated with clinical neuritis
(Quiet Nerve Paralysis)
4/10/2018 39

40. CATEGORIZATION
• A – No clinical neuritis, no NFD
• B - Clinical neuritis+ , no NFD
• C – No clinical neuritis, NFD +
• D – Clinical neuritis + , NFD +
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41. Category A patients
• pt is taught how to look for signs and
symptoms of neuritis.
4/10/2018 41

42. Category B patients
• Start Prednisolone 40-80 mg daily 4 wks
,taper by 5mg/wk upto 30mg ,then ,
every2-3 wks
• In BT leprosy cases(neuritis due to RR), if
there is no significant improvement in
the clinical condition within 48-72 hrs,
immediate surgical decompression is
required.
• In BL and LL cases(neuritis due to ENL),
one can wait for six weeks or even longer4/10/2018 42

43. Category C patients
• assume that the nerve trunk has the potential
to recover if NFD is :-
–of recent onset ,< 6 months involvement
–incomplete- some sensibility is there
–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
impairment.
4/10/2018 43

44. Category D patients
• Prednisolone 40-80 mg daily 2-3 wks, reduce
to maintenance dose in 3-4wks
• Maintenance dose 30mg daily 8-10 wks
• If no improvement in neuritis within 3-7days,
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
4/10/2018 44

45. Nerve abscess
• if nerve shows no NFD: - wait and watch
• drain abscess only if
–risk of sinus formation is there.
–nerve is considered recoverably
damaged
4/10/2018 45

46. Paralytic deformities of hand
• Massage and Exercises for Hands:- Massage
gently, after applying oil, place hand and
gently stroke it with other.
• main types of splints used:
–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)
4/10/2018 46

47. • Corrective Surgery are:-
– Lasso insertion
– Zancolli’s operation augment flexion forces
at MCP jt
–Srinivasan’s operation
–Bunnell’s operation
– Brand’s augments extension forces at PIP jt
–Antia’s operation
–Fowler’s operation
4/10/2018 47

48. Foot Problem In Leprosy Patients
• 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)
4/10/2018 48

49. • Types-
(a)Acute ulcer– frankly infected, purulent,
covered with slough
(b)Chronic ulcer– indolent ulcer with
hyperkeratotic edges, covered with
granulation tissue
(c) Complicating ulcer– infection spread to
deeper structure may lead to muscle
paralysis, gas gangrene, tetanus or
septicemia.
4/10/2018 49

50. • Management:
– absolute bed rest
– elevate foot
– eusol bath,
– irrigation,
– dressing remove slough or
– other draining procedures
– start antibiotics
– protective foot wearing
4/10/2018 50

51. Management of Eye Problem
• using spectacles, goggles or eyeshades.
• artificial tears
• cover eyes during sleep
• treating acute iridocyclitis using topical
corticosteroids
• surgical intervention for lagophthalmos or
cataract
• Splint in facial palsy
4/10/2018 51

52. GPAS (Green Pastures Activity Scale):-
• It assess the daily routine of patients
• Can help the nurse to pick up early deformity
• Daily activities are assessed as
–1-Not difficult
–2-A bit difficult
–3-Very difficult
–4-impossible
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53. • Interpersonal relationship
– 1- no problem
– 2- some problem
– 3- more problem
– 4- no relation
• For use of assistive devices
– 1- not necessary
– 2 – not difficult
– 3 – difficult
– 4 – very difficult
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54. 4/10/2018 54

55. Definition
• The physical and mental restoration as far as
possible, of all treated patients to normal
activity, so that they may be able to resume
their place in the home, society and the
industry.
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56. Categorization
S.
No.
Deformity Socioeconomic
problems
Life condition
measures needed
Rehabilitation
1 Nil Nil Normal Nil
2 Yes Nil Normal Nil
3 Nil Yes Affected Psychological support,
counseling
4 Yes Threatened Threatened Investigation and suitable
rehabilitation
5 Yes Dislocated Seriously affected Investigation and suitable
rehabilitation
6 Yes Dislocated Seclusion and
destitution
No rehabilitation, only
food, shelter and general
life support4/10/2018 56

57. SERVICES
• Early detection, diagnosis and intervention
• Medical care and treatment
• Counseling and assistance
• Training in self care activities
• Provision of technical and mobility aids, and
other devices
• Special educational services
• Vocational rehabilitation service, vocational
training, placement in open or sheltered
employment
• Follow up4/10/2018 57

58. REHABILITATION INTERVENTIONS
• ANATOMICAL
–Deformities of hands Reconstructive
surgery
- Physiotherapy
–Foot drop Ankle – foot orthosis
–Amputation Prosthesis
• PSYCHOLOGICAL
–Depression Counseling
4/10/2018 58

59. • FUNCTIONAL
– Limitations to fine hand movements
Occupational therapy
– `Mobility limitations Crutches ,wheel chairs
• SOCIAL PARTICIPATION
– Stigma in family Counseling
– Exclusion from community functions
education, advocacy
– Children with disability Promoting inclusive
education
4/10/2018 59

60. • ECONOMIC
–Loss of employment / unemployment
- Vocational training
-Placement/reservation of
seats for disabled
–Poverty Micro-credit for self-
employment
4/10/2018 60

61. APPROACHES TO REHABILITATION
• INSTITUTIONAL BASED REHABILITATION (IBR)
• COMMUNITY BASED REHABILITATION (CBR)
Principles (PERS)
• Participation
• Empowerment
• Raising awareness
• Self-advocacy
• Partnership
• sustainability
4/10/2018 61

62. Pillars of CBR
1st : members of local community
2nd : Selected group of local volunteers who have
specific knowledge and skills in CBR
3rd : individuals and organizations outside the local
community who have resources for CBR along
with positive attitudes
Base : community development philosophy who
believes in the capability of community
Roof : Achievements of CBR when the community
takes responsibility of implementing its own
program
4/10/2018 62

63. Highlights of CBR
• Low cost strategy
• Can fit well within the current community
health or development project structures
• Will assist in preventing disease
• Helps to reduce unemployment and poverty
• It is a strategic way of improving the lives of
disabled people
4/10/2018 63

64. LEVEL OF INTERVENTION
• Patients
• Families of the patients
• Communities
• Government
• NGO
• Medical professionals, Allied health science
professionals, Educators etc
• Private sectors
4/10/2018 64

65. National program
• National Program for Rehabilitation of Persons
with Disabilities (NPRPD):
– Utilizes both approaches : CBR, IBR
– 4 tier system : Gram panchayat, Block, District and
state levels
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68. 68
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