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.

Sensory testing with monofilaments in Hansen's disease and normal control subjects.

Sensory testing with Semmes-Weinstein filaments was conducted on: 112 normal subjects to determine the effects of age, gender and occupation on threshold perception, 27 Hansen's disease (HD) patients to determine inter-observer and intra-observer reliability of testing, and 101 patients with HD and a history of hand and/or foot ulceration to identify thresholds for injury risk. Filament thresholds were found related to age (p < 0.002) and occupation (p < 0.001) but not gender (p > 0.1). Inter-observer and intra-observer reliability was found to be high (intraclass correlation coefficient = 0.88-0.93). The 4.93 (7.0-7.7 g) filament had 97% sensitivity and 100% specificity for identifying a history of foot injuries, and the 4.17 (1.2-1.6 g) filament had 100% sensitivity and 100% specificity for identifying hand injuries.

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%.

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.

The Martin-Gruber innervated hand.

Two patients with a complete ulnar nerve lesion at the elbow and a median nerve lesion at the wrist secondary to leprosy neuropathy retained good function of the first dorsal interosseous and flexor pollicis brevis muscles. One patient also lacked the typical finger clawing associated with ulnar and median paralyses. These findings were attributed to the presence of Martin-Gruber anastomoses that were confirmed by nerve-conduction studies.