2. "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. REFERENCES:-----
• IADVL
• IAL
• PARK’ Preventive and Social Medicine
• Journals
4. 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.
5. 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.
6. • 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)
7. 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.
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.
8. Grade Degree of impairment Included Excluded
Hands and feet
0 No sensory impairment, Scars of healed ulcers, when
no visible impairment sensation is normal
1 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
clawinga
2 Visible impairments present Ulcers, severe cracks,
severe atrophya
Eyes
0 No eye impairment; no
visible or vision impairment
b
1 Eye impairment present Absence of (regular) Corneal sensation testing19
(vision: > 6/60) blink
2 Severe visual impairment Unable to count ®ngers at 6 m Facial impairments due to
(vision: < 6/60) Lagophthalmos lepromatous leprosyc
Corneal opacities, uveitis19
9. 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.
• Nerve involvement in leprosy can be said to occur in
5 stages:--
First two are recognized histologically while next
three by clinical examination
10. Stages Charecteristics
1 Parasitization A few leprae found in nerve
2 Tissue response Host tissue response(TT to LL)+, bacilli+
3 Clinical involvement Clinically thickened w or w/o pain. No NFD
4 Nerve damage NFD+, recovery possible
5 Nerve destruction Irreversible NFD, severe wasting +
Posterior tibial nerve is the most frequently affected nerve
followed by ulnar, median, lateral popliteal and facial.
11. 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 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)
12. NERVE TENDERNESS SCALE-
GRADE Clinical features
0 No tenderness Palpation not poanful
1 Mild tenderness Palpation hurts only when asked about it
2 Moderate tenderness Palpation hurts even w/o asking
3 Severe tenderness Palpation is very painful
4 Very severe tenderness Pt. is apprehensive of palpation
Categorization of pt. acc. To NFD and Clinical Neuritis-
Nerve Function Deficit Clinical Neuritis
Absent Present
Absent A B
Present C D
13. • Category A patients-
pt is taught how to look for signs and symptoms of
neuritis.
• 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
14. • Category C patients- ( No neuritis,NFD+)
Clinically, one may assume that the nerve trunk
has 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.
15. • 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 wks
If there is no improvement in neuritis within 3-7days
then 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
16. • 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.
17. 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.
18. Impairement Direct consequences Late consequences
Damage to somatic sensory Loss of sensibility Anesthetic
fibres deformities(ulcers,shortening
of digits.)
Damage to motor fibres Muscle paralysis Contracture
Damage to sudomotor Dry skin Deep cracks, hand infections
autonomic fibres
Lepra reaction Inflammatory odema, Severe fixed
osteoporosis, bone deformities(specific
destruction, pathological deformities,bizzare
fractures deformities)
19. 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
20. • 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
21. • Paralytic deformities of hand:-
ulnar nerve supplies--- flexor carpi ulnaris
medial half of flexor digitorum
hypothenar muscles
adductor pollicis and all interossei
medial two lumbricals
median nerve supplies:--all flexor muscles of forearm
thenar muscles
first two lumbricals
22. • 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 difficult
Corrective 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
23. • 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
24. 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)
25. Adductor Finger loop Gutter splint
Opponens loop
Grip 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
26. 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)
27. • 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.
28. 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.
29. • 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
31. 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 is
required; add metatarsal bar obliquely or molding the
insole so that pressure can be distributed evenly over
entire plantar surface.
Certain 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
32. • Foot drop:--
About 1-2% of leprosy patients develop due to
damage 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 satisfactorily
corrected by anterior transposition of tibialis posterior
tendon(Srinivasan’ operation)
If surgical intervention is contraindicated; foot drop
appliances like strap, stops or springs are used that hold
foot at right angle.
33. • Splinting of knee:- fig. 36.10
this allows rest to inflamed nerve and result in
quicker 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.
34. CONTRACTURES WITH ‘FOOT DROP’ IS TO STRETCH
THE HEEL CORDS BY LEANING FORWARD AGAINST A
WALL OR BY SQUATTING WITH HEELS ON THE
GROUND
35. 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).
36. 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
37. • 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.
38. 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 Interpersonal relationship For use of assistive devices
4. Not difficult 4. No problem 4. Not necessary
3.A bit difficult 3. Some problem 3. Not difficult
2. Very difficult 2. More problem 2. Difficult
1. Impossible 1. No relation 1. Very difficult
39. 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
