The paper grip test for screening on intrinsic muscle paralysis in the foot of leprosy patients

Plantar intrinsic foot muscles provide structure to the foot during walking and thus regulate mechanical foot sole stresses. When paralyzed, for instance in leprosy patients with neuropathy of the distal part of the tibial nerve, there is a high prevalence of plantar ulceration and deformities, especially when muscle weakness goes together with loss of foot sole sensibility. These patients should get immediate care involving education, special footwear and reconstructive surgery before further foot impairment and deformity becomes manifest. Thus far, in leprosy patients little attention is paid to screening of plantar intrinsic muscles activity. This can be done with a new simple and non-invasive method, the Paper Grip Test (PGT). There are two variants for detecting intrinsic muscle weakness of the foot, PGT1 for the great toe and PGT2 for the combined lesser toes. In this study, 517 leprosy patients and 170 healthy volunteers were investigated with the PGT. Sensibility of the foot sole was tested by means of a 10 gram monofilament. Specificity to the PGT1 is found to be about 95.3% which is considered good for physical diagnostic tests. PGT2 is less specific than PGT1. Individual muscle power and understanding of the patient seems to influence the outcome of the test to a certain extent. Sensitivity can only be calculated when the diagnosis is confirmed by electromyography. Especially patients with anesthetic feet, females, older patients and patients with PN-, BB- or LL-types of leprosy appeared to have a higher prevalence of intrinsic foot muscle weakness. All results were analyzed by means of the bivariate Pearson correlation-analysis and proved to be statistically significant (p = < 0.05). It is concluded that the PGT1, more than the PGT2, is a useful screening test on the function of plantar intrinsic foot muscles in leprosy patients in hospitals and during fieldwork in developing countries.

Tendon transfer for triple nerve paralysis of the hand in leprosy.

Paralysis of ulnar, median and radial nerves is seen in less than 1% of those affected with leprosy. This condition is a particular challenge for the surgeon, physiotherapist, and patient. A retrospective chart review was conducted at the Green Pastures Hospital and Rehabilitation Centre (GPHRC) and Anandaban Leprosy Hospital (ALH) in Nepal, and results were graded by the system outlined by Sundararaj in 1984. Thirty-one patients were identified, and 21 charts were available for review. Excellent or good results were obtained in 93% of patients for wrist extension, 85% of patients for finger extension, 90% of patients for thumb extension, 71% of patients for intrinsic reconstruction, and 63% of patients for thumb opposition reconstruction. These results are reasonable but inferior to those obtained by Sundararaj in his study. Surgical intervention offers a very significant improvement in function in these very difficult hands. Intensive physiotherapy is required both pre- and postoperatively.

Arthropathy of the wrist in leprosy--what changes are caused by long-standing peripheral nerve palsy?

A radiographical screening study of 338 leprotic patients was performed. Clinically, according to a nerve score (NS) designed by us, 12.9% of 674 hands showed mild nerve palsy (NS 5 or 6), 75.9% moderate (NS 3 or 4), and 11.4% severe (NS less than 2). Twenty-nine hands of 26 patients (NS 4.2 on average) demonstrated abnormal changes of the wrist joint on radiographs. We classified them into four groups: (a) lunate collapse (four patients), (b) scaphoid nonunion (eight), (c) scaphoid cyst (three), and (d) trapezium OA (11). In the lunate collapse and the scaphoid nonunion groups, destructive and reconstructive changes as described by Eichenholtz were identified on plain film. These groups demonstrated remarkable instability of the stress and dynamic roentgenograms. In contrast, the scaphoid cyst and trapezium OA wrists showed neither fracture nor instability and fewer changes than the other two groups. We considered the destructive changes that had taken place in the lunate collapse and the scaphoid nonunion wrists to be neuroarthropathy due to long-standing nerve palsy.