Prevention of disability in leprosy: the different levels.

Prevention of disability in people affected by leprosy is primarily seen as prevention and management of impairments secondary to nerve function impairment. This article describes four different levels at which appropriate interventions may lead to the overall prevention of disability. These are--prevention of disease, timely diagnosis and adequate treatment of the disease, early recognition and adequate treatment of nerve function impairment and finally, prevention and treatment of secondary impairments due to nerve function loss.

Partnership for rehabilitation: looking beyond impairments.

Rehabilitation of leprosy-affected persons extends beyond the physical domain of prevention and treatment of impairments. A holistic rehabilitative approach should include addressing those problems that people may have in activities and difficulties that may prevent people from fully participating in social functions, i.e. being fully accepted as integrated members of the societies and communities to which they belong. This article highlights the activities of the Partnership for the Rehabilitation Program (PFR) of the International Nepal Fellowship (INF), Pokhara, Nepal. These activities aim to prevent, reduce or alleviate problems and difficulties that leprosy-affected persons may face in being respected and being contributing members of the communities of which they are a part.

Re-enablement of the neurologically impaired hand--2: surgical correction. report of a surgical workshop held at Green Pastures Hospital and Rehabilitation Centre, November 2004, Pokhara, Nepal.

The last half-century has seen tremendous advances in the surgical treatment of neuropathic conditions of the hand. Many of these procedures give clear benefit to patients and have been established by clinical practice and well-formulated assessment. However, much remains to be discovered, especially with respect to which procedures should be used on which hands, and the impact of various procedures on the ability to carry out activities of daily living. Increased communication between the 'West', where funding is available for well designed trials and where reference textbooks are usually published, and the 'East', where the surgery is most commonly performed, will undoubtedly lead to an even better understanding of the treatment of the neuropathic hand.

Leprosy acquired by inoculation from a knee injury.

This case study reports on the development of clinical leprosy in a young Caucasian female from a non-endemic country who contracted the disease while living in a leprosy endemic country. In the presentation and discussion, some relevant factors will be reviewed and discussed that may play a role in the transmission, susceptibility and clinical development of the disease.

Transformation of a leprosy hospital in Nepal into a rehabilitation centre: the Green Pastures Hospital experience.

Green Pastures Hospital for leprosy patients in Pokhara Nepal, was established in 1957 by the International Nepal Fellowship (INF) in a decade which saw the establishment of many similar hospitals in other leprosy endemic countries. In recent years, mainly due to significant improvements in leprosy control services and the wide implementation of multiple drug therapy (MDT) for all patients, many of these specialist hospitals have encountered 1) a decline in prevalence rate, 2) a large decline in the percentage of patients presenting with WHO grade 2 disability, 3) a decline in the previous indications for hospital admission, e.g. immunologically mediated reactions, and 4) a need to develop financial independence making them less dependent on donor agencies. In addition, the decision to change from specialist to general services opened up the possibility of using facilities and expertise for the rehabilitation of non-leprosy affected persons, whilst also moving towards the reduction of stigma and prejudice against patients with leprosy. This paper describes the process of 'transformation' of an established and well known leprosy hospital in Western Nepal from 1997 onwards into a general rehabilitation hospital. Careful preparation, with full involvement of existing staff and co-operation with other agencies in the hospital catchment area were key factors in what has now become a successful venture. Surgical procedures and orthopaedic appliance services for non-leprosy affected persons have increased in recent years and the introduction of a dermatology service has resulted in out-patient attendance rising from about 1000 in 1999 to 4500 in 2003. No evidence of reluctance to attend and use the facilities offered by this hospital because of stigma against leprosy has been encountered. Many of the changes described have been made in order to reduce financial dependence on donor sources of support, but the underlying reason for transformation is still based on the vision of the INF mission to work for and improve the condition of the marginalized in society.

Monitoring motor nerve function in leprosy patients.

Manual muscle strength testing has an important function in the management of leprosy patients. Its importance was first recognized in the 1960s, especially when following patients who were started on steroid treatment to monitor the nerve function and the effect of treatment. In those days, and still in many centres today, many or all muscles were tested that are innervated by the nerves that can be at risk in leprosy. The author argues that not all muscles innervated by the nerves at risk need to be tested and also that many muscles cannot be tested in isolation. A muscle charting form is presented which is suitable for screening purposes, and that also allows for more detail when motor function is impaired.

The international classification of impairments, disabilities and handicaps in leprosy-control projects.

The use of a uniform language, which includes definitions of terms, is very important in the field of health care. It is important to have a common language for educational, research and communication purposes. Classifications can play a major role in the development of uniform reporting and registration systems. The purpose of this article is to familiarize leprosy workers with two classifications that are in common use in health care, a classification of diseases and a classification used to describe the overall health status of a person, and to relate the 3 terms that are used in the latter classification, impairments, disabilities and handicaps, to leprosy.

Intertester reliability of manual muscle strength testing in leprosy patients.

This study reports the results of a study on the intertester reliability of manual muscle strength testing in leprosy patients with confirmed motor function loss of at least one nerve. Three testers graded the muscle strength of 72 patients in random order. Both hands and feet were graded. Strength was graded on a modified Medical Research Council Scale (9 points, 5, 4+, 4, 3+, 3, 2+, 2, 1, 0). The following movements were tested for strength: little finger and index finger abduction, intrinsic position of all four fingers, thumb abduction and opposition, foot dorsiflexion and eversion and extension of the big toe. The weighted kappa statistic was used to calculate the chance-corrected percentage of agreement between observers. Overall agreement for each of the 11 tests appeared to be good or very good (0.61-1.00). However, when data for hands or feet with normal strength or complete paralysis were excluded from the analysis, the reliability of the remaining mid-range scale was not acceptable (kappa 0.55-0.88, direct agreement range 11-41%). While the reliability of this scale could possibly be improved by special training, we feel that, for the evaluation of nerve function for leprosy patients with (suspected) nerve function loss, the extended 9-point VMT scale should only be used when direct intra- or intertester agreement is more than 80%.

Intraobserver and interobserver reliability of assessments of impairments and disabilities.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the interobserver and intraobserver reliability of assessments of impairments and disabilities. SUBJECTS AND METHODS: One physical therapist's assessments were examined for intraobserver reliability. Judgments of two pairs of therapists were used to examine interobserver reliability. Reliability was assessed by Cohen's kappa. RESULTS: Of the 42 impairments and disabilities assessed by the physical therapist in the intraobserver reliability study, kappa values could be calculated for 33 items. For 31 items (94%), kappa values ranged from .40 to .91, and 2 items (6%) had kappa values of less than .40. To determine interobserver reliability, 37 items were assessed in one practice. Kappa values could be calculated for 34 items, with 30 items (88%) having kappa values ranging from .41 to .80 and 4 items (12%) showing "poor" agreement. In the second practice, 47 items were assessed for interobserver reliability. Kappa values could be calculated for 40 items, with 11 items (27.5%) having kappa values ranging from .41 to .84. Poor agreement was shown for the remaining 29 items (72.5%). CONCLUSION AND DISCUSSION: Assessments of impairments and disabilities are potentially reliable. The differences between practices of the interobserver reliability study can be explained by the fact that one of the therapists did not receive training in the use of the assessment form. More generalizable conclusions will require further study with more subjects and therapists.

Impairments and disabilities--the difference: proposal for adjustment of the International Classification of Impairments, Disabilities, and Handicaps.

In this article, a proposal for adjustment of the Classification of Impairments and the Classification of Disabilities of the International Classification of Impairments, Disabilities, and Handicaps is presented. This proposal is a result of a project conducted by the Dutch National Institute for Research and Postgraduate Education in Physical Therapy. The project was executed in collaboration with the professional national organizations of five health professions: occupational therapy, chiropody, Cesar therapy (exercise therapy), Mensendieck therapy (exercise therapy), and physical therapy. The proposal includes reformulated definitions of impairment and disability, an inventory of the impairments and disabilities that are relevant for the health professions that participated in the project, a description of the domain of the Classification of Impairments and the Classification of Disabilities, a new subdivision for both classifications in chapters, and a set of "types of characteristics" and "characteristics" that subdivide the different chapters of the two classifications.

The effect of exercises on walking distance of patients with intermittent claudication: a study of randomized clinical trials.

BACKGROUND AND PURPOSE: There is no consensus about the indication for exercises for patients with intermittent claudication of the lower extremity and the characteristics of an exercise program to improve walking distance. The effect of walking is assessed by a systematic review of randomized clinical trials. METHODS: Literature databases were accessed using the relevant key words. The references of identified articles were screened for additional studies. A checklist was developed to screen the studies with respect to the variables of interest. A methodological assessment form was developed to assess the methodological quality of the studies (maximum possible score: 100). RESULTS: Eighty-two articles were identified, of which 21 studies were considered relevant for inclusion in the review. Following the analysis of the articles, 11 studies were for various reasons eliminated, leaving 10 studies for the systematic review. The score for methodological quality of the studies ranged from 47 to 75 (mean = 62.5, SD = 8.5). Percentage of improvement in walking distance or time ranged from 28% to 210% (mean = 105%, SD = 55.8%). CONCLUSION AND DISCUSSION: All studies showed that walking exercises improved walking distance in patients with intermittent claudication. Further research is needed to determine the optimal exercise program, the effect of adherence to the treatment protocol, and the duration of the effects following a formal exercise program.

The need for revision of the ICIDH: an example--problems in gait.

In this article a proposal is formulated for adjustment of the Classification of Impairments and the Classification of Disabilities of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH). This proposal is a product of a project from the Dutch National Institute of Research and Postgraduate Education in Physical Therapy. This project is conducted in close cooperation with the professional national organizations of five health professions. To give an indication of the kind of changes proposed, the disabilities and impairments necessary for classifying the complaints, the examination findings, the treatment goals and the treatment results in patients with gait problems are discussed.

Reflection on the definition of impairment and disability as defined by the World Health Organization.

The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) is gaining wide acceptance inside and outside the field of rehabilitation medicine. Impairment and disability are concepts which are often used interchangeably or defined differently. The World Health Organization (WHO) has defined impairment and disability in the ICIDH. In this article an analysis is made of these definitions and the characteristics that are given for the definitions. Based on this analysis, modifications for the definitions and characteristics of impairment and disability are suggested.

Handicap questionnaires: what do they assess?

BACKGROUND AND PURPOSE: There is an increasing need to get insight into the social and societal impact of chronic conditions on a person's life, i.e. person-perceived handicap. The purpose of this study is to report how current handicap questionnaires assess handicap. METHOD: A literature search using both Medline and the database of the Dutch Institute of Allied Health Professions (NPi) was conducted for handicap questionnaires. Questionnaires were included if addressing handicaps or life roles, environmental influences and social consequences of a disease. Excluded were questionnaires focusing on only impairments, disabilities or quality of life. RESULTS AND CONCLUSION: 20 questionnaires were identified. Handicap is not uniformly defined in these questionnaires. Based on different concepts, the various questionnaires encompass different domains and different aspects are emphasized in similar domains. Fourteen questionnaires assess society-perceived handicaps, and do not address the life roles, care needs or individual problem-experience. Six questionnaires are to some extent person-perceived, but a generic person-perceived handicap questionnaire could not be identified. It is concluded that development of a generic person-perceived handicap questionnaire is essential for adequate assessment of needs, outcome, and relevance of rehabilitation interventions from the individual's point of view.

Median nerve function after tendon transfer for ulnar paralysis.

This is a long term follow-up study of the median nerves of 128 leprosy patients who originally had pure ulnar palsy for which they had tendon transfers to correct claw hand. Of the thirty-one cases in which the carpal tunnel was not used as a pathway for tendon grafts, 16% developed median palsy in the subsequent years. Of the ninety-seven cases in which tendon grafts were passed through the carpal tunnel, 7% developed a transient median nerve palsy and 11% developed permanent median palsy. None of the median nerve palsies developed during the weeks or months of post-operative re-education or observation, but were noted at follow-up visits months or years later. It is concluded that the use of the carpal tunnel did not significantly affect the status of those high-risk median nerves in cases of leprosy.

Flexor digitorum superficialis tendon transfer for intrinsic replacement. Long-term results and the effect on donor fingers.

This study is a review of 127 hands in 100 patients in whom one or two FDS tendons were used to correct claw-hand deformity and/or loss of opposition of the thumb. In lumbrical replacement the results were graded as excellent in 16 hands (21%) and good in 43 hands (57%). For opponensplasty the results were excellent in 26 hands (32%) and good in 42 hands (51%). Possible defects that can develop in the donor finger are: swan-neck deformity, flexion posture of the DIP joint, not as part of the swan-neck deformity, check-rein deformity or flexion contracture, and insufficient finger flexion. Of the 158 fingers swan-neck deformity was seen in 15%, DIP flexion in 29%, check-rein deformity in 26% and insufficient finger flexion in 18%. The latter occurred with another defect. In 48 fingers (30%) no defects were observed.

A review of the biomechanics of intrinsic replacement in ulnar palsy.

The actions of the interossei and lumbricals are many and their loss causes significant impairment of hand function. Many procedures have been described to restore intrinsic function following ulnar nerve palsy. There are many biomechanical issues involved in tendon transfers, including choice of muscle-tendon unit, route, insertion site, tension and drag. The surgeon, therefore, should have a good understanding of biomechanical principles to ensure optimal results. In this article the principles of biomechanics are reviewed with specific reference to tendon transfers for intrinsic reconstruction in ulnar palsy, along with their practical implications.