Disabilities prevention and management in leprosy

Hansen disease prevention and managment

1. Disabilities prevention and management in leprosy Dr.Dileep S augat

2. Headings Introduction Definitions Risk factors Classification Grading Manifestations Disability prevention Management Rehabilitation 3/29/2018 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 3/29/2018 3

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 3/29/2018 4

5. 3/29/2018 5 DEFINITIONS

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). 3/29/2018 6

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 3/29/2018 7

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 3/29/2018 8

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 disability 3/29/2018 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 3/29/2018 10

11. CLASSIFICATION 3/29/2018 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) 3/29/2018 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. 3/29/2018 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 + 3/29/2018 14

15. NOTE Posterior tibial nerve is the most frequently affected nerve followed by ulnar , median, lateral popliteal and facial. 3/29/2018 15

16. GRADING 3/29/2018 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 3/29/2018 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 . 3/29/2018 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. 3/29/2018 19

20. MANIFESTATIONS 3/29/2018 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 3/29/2018 21

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 3/29/2018 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 3/29/2018 23

24. MUSCULO-SKELETAL BONES – trabecular absorption and decalcification Osteoporosis Pathological fracture Damage to tendon sheath and joint capsules Painful arthritis 3/29/2018 24

25. OTHERS -: LARYNX – hoarseness of voice FACE – loss of eyebrows and other facial hairs Hormonal imbalance 3/29/2018 25

26. DISABILITY PREVENTION 3/29/2018 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 3/29/2018 27

28. Evaluation and Assessment Evaluation of nerve trunks Sensory and motor examination Voluntary muscle testing Monofilaments 3/29/2018 28

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

30. 2) Foot drop Below knee slab of plaster of paris Y strap with string Single elastic trap 3) Facial palsy 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 Joint is immobilized in such a way that nerve is relaxed 3/29/2018 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 3/29/2018 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 3/29/2018 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 . 3/29/2018 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 3/29/2018 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.• 3/29/2018 35

36. O rthosis 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 3/29/2018 36

37. MANAGEMENT 3/29/2018 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 . 3/29/2018 38

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) 3/29/2018 39

40. CATEGORIZATION A – No clinical neuritis, no NFD B - Clinical neuritis+ , no NFD C – No clinical neuritis, NFD + D – Clinical neuritis + , NFD + 3/29/2018 40

41. Category A patients pt is taught how to look for signs and symptoms of neuritis . 3/29/2018 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 longer 3/29/2018 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 . 3/29/2018 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 3/29/2018 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 3/29/2018 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) 3/29/2018 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 3/29/2018 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 ) 3/29/2018 48

49. Types- Acute ulcer – frankly infected, purulent, covered with slough Chronic ulcer – indolent ulcer with hyperkeratotic edges, covered with granulation tissue Complicating ulcer – infection spread to deeper structure may lead to muscle paralysis, gas gangrene, tetanus or septicemia . 3/29/2018 49

50. Management : absolute bed rest elevate foot eusol bath, irrigation , dressing remove slough or other draining procedures start antibiotics protective foot wearing 3/29/2018 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 3/29/2018 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 3/29/2018 52

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 3/29/2018 53

54. REHABILITATION 3/29/2018 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. 3/29/2018 55

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 support 3/29/2018 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 up 3/29/2018 57

58. REHABILITATION INTERVENTIONS ANATOMICAL Deformities of hands Reconstructive surgery - Physiotherapy Foot drop Ankle – foot orthosis Amputation Prosthesis PSYCHOLOGICAL Depression Counseling 3/29/2018 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 3/29/2018 59

60. ECONOMIC Loss of employment / unemployment - Vocational training -Placement/reservation of seats for disabled Poverty Micro-credit for self- employment 3/29/2018 60

61. APPROACHES TO REHABILITATION INSTITUTIONAL BASED REHABILITATION (IBR) COMMUNITY BASED REHABILITATION (CBR) Principles (PERS) Participation Empowerment Raising awareness Self-advocacy Partnership sustainability 3/29/2018 61

62. Pillars of CBR 1 st : members of local community 2 nd : Selected group of local volunteers who have specific knowledge and skills in CBR 3 rd : 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 3/29/2018 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 3/29/2018 63

64. LEVEL OF INTERVENTION Patients Families of the patients Communities Government NGO Medical professionals, Allied health science professionals, Educators etc Private sectors 3/29/2018 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 3/29/2018 65

66. THANK YOU 3/29/2018 66

67. 68 THANK YOU