Leprosy and physiotherapy 2011

LEPROSY [HANSEN’S DISEASE]

DR. D. N. Biddnbid@yahoo.com

Leprosy

Main features

• Chronic infectious disease – mycobacterium leprae

• Affects peripheral nerves / skin muscles. Eyes, bones, testes and internal organs

• 2 polar forms

Lepromatous……borderline….indeterminate…..tuberculoid

Signs

• Hypo pigmented patches

• Partial or total loss of cutaneous sensation in affected areas

• Thickened nerve

• Acid fast bacilli in skin or nasal smears

• Advanced disease; lumps in face, ears/ plantar ulcers/loss of fingers and toes/ nasal depression/ foot drop / claw toes etc

history

• Oldest disease• Lepra = scaly• Kushta roga- curse

• 1837 M leprae discovered by Hansen of Norway

• 60s and 70s discovered in Mice foot and armadillos

• 1980s mono to multi drug therapy

90% reduction in prevalence

Reasons for decrease in prevalence since 1966

• Improved management of cases

• Very low relapse rate

• High cure rates

• Absence of drug resistance

• Shorter duration of treatment with MDT

• Global Leprosy program moved from Geneva to Delhi in 2005 for SEAR has the highest numbers

WHO global strategy for decreasing disease burden and sustain leprosy control activities

• Sustain leprosy control activities in all endemic countries• Use case detection as the main indicator to monitor

progress• Ensure high quality diagnosis, case management,

recording and reporting in endemic countries• Strengthen routine referral services• Discontinue campaign approach• Tools and procedures that are home / community based,

integrated and socially appropriate for prevention of disabilities etc

• Promote Operational Research to improve implementation• Supportive working arrangements with partners at all

levels

http://mohfw.nic.in/National_Leprosy_Eradication_Programme/CURR_SIT.htm

Level of Elimination of leprosy (<1 case / 10K) on 31 Dec 2005

Annual new case detection rate 1.43 / 10K

Focus on High priority districts and blocks> 5 / 10K,

Disability rate 1.9%

Child proportion 10% (TN,AP, Bihar, Gujar,

Jharkand, Maharashtra, kerala, karnataka)

Epidemiological determinants- agent

• M leprae= acid fast. Extra and intra cellular• Bacterial load 1 gm of leproma- 2-7 billion• Pathogenic• Non pathogenic- M tb, BCG etc• Grows in animal= mouse / armadillos but not in

artificial medium• Source- all active cases. Esp lepromatous leprosy• Portal of exit- nose. Also ulcerated skin• Highly infections. Low pathogenic• Attack rate- 4.4 to 12% • symptomatic in 5 yrs

Epidemiological determinants- host

• Any age. Both sexes. 2.5yr baby too (active and spreading)

• Prevalence pool/ migration

• Inactivation of the disease

• Immunity – cell mediated

• Genetic factors- HLA linked genes influence the type of response

Epidemiological determinants- environment

• Presence of infectious cases• Overcrowding and lack of ventilation

Mode of transmission• Droplet• Contact• ? Insect vectors/ tattooing needles• Incubation period 3- 5 yrs for lepromatous and

less for Tuberculoid leprosy

Indian Classification

Indeterminate 1-2 patches. Sensory impairment

Bact

negative

Tuberculoid 1-2 well defined flat/ raised/hypo pig/ erythematous

Anaesthetic Bact

negative

Borderline 4 or more lesions others same as above. Usually progresses to lepromatous

anaesthetic positive

Lepromatous Diffuse infiltration or numerous other types

anaesthetic positive

Pure neuritic No skin lesion

Has only nerve involvement

negative

MADRID classification • Indeterminate• Tuberculoid -flat/ raised• Borderline• Lepromatous

RIDLEY JOPLING ( immuno histological)Tuberculoid TLBorderline Tuberculoid BTBorderline BBBorderline Lepromatous BLLepromatous LL

Clinical classification

• Pauci bacillary :1-5 lesions

• Multi bacillary: : More than 5 lesions

Obstacles

• lack of a specific and sensitive diagnostic tool,

• social stigma

• and the potential reservoir in armadilloes

Diagnosis

Clinical examination•Case taking /Interrogation•Physical examination

Bacteriological examination•Skin smear- active lesion, and ear lobe•Nasal smears or blows•Nasal scraping

Bacterial Indexnumber of bacilli in oil immersion fields (OIF) in an

average microscopeHelp in monitoring

0 No bacilli 100 OIF

1+ 1 or<1 in each mic field

2+ Bacilli found in all the fields

3+ Many bacilli in all the fields

Bacterial Index= total of indices / number of sites examinedTotal number of + in 7 sites-4 skin lesions, 1 nasal swab, both ear lobes

Pauci bacillary 2Multibacillary>2

Solid -fragmented- granular percentage

• Indicator of patient's response to treatment during the first few months--

• 200 pink stained free standing bacilli have to be counted

• Total of Mis for all sites / number of sites+ average MI for the body.

Solid rods: Uniform staining of entire organism/ parallel sides, rounded end length 5 times the width - Viable

Solid -fragmented- granular are given separately

Better indicator of response

Foot pad culture

• Inoculate material into foot pads of mice

• Demonstrate its multiplication

• 10 times more sensitive than slit skin smears- 6-9 mths

• Macrophage culture: 3-4 wks

• Helpful to detect drug resistance

• Evaluate potency of anti leprosy drugs

• Viability of baciili during treatment

Histamine test

• Detecting at an early stage peripheral nerve damage due to leprosy

• Inject 0.1 ml of 1:1000 solution of histamine phosphate or chlorhydrate in hypo pigmented patches or anaesthetic patches flare response is lost

• Indeterminate leprosy

Biopsy• Of skin• Of nerve

Immunological tests• For detecting cell mediated immunity• Tests for humoral antibodies

CMI Tests : Lepromin TestLepromin is a suspension of killed M leprae obtained from infected

human or armadillo tissue. Mitsuda / DharmendraInject Lepromin O.1 ml inner aspect of forearm . Following intradermal inoculation, Read linke for PPD• early (48 h, Fernandez) reactions and late (3-4 wk, Mitsuda)

reactions may be seen.10 mm mild 15-20 mod >20 strong• The Mitsuda reaction, a granulomatous response to the antigen,

is more consistent. 3-4 weeks.Patients with TT or BT leprosy have strong positive (>10 mm) responses,

PATIENTS WITH L L DISEASE DO NOT RESPOND.The test is not useful in the diagnosis of leprosy because most of

the population in both areas of endemic and nonendemic disease are Mitsuda positive.

The lepromin test is a guide to the cell-mediated immunity of the individual.

CMI= cell mediated immunity

• lymphocyte transformation test (LTT) and

• lymphocyte migration inhibition test (LMIT).

Response decreases steadily in the progression from subpolar TT to subpolar LL leprosy

CMI tests…

Leprosy ControlMedical measures

1. Estimation of problem

2. Early case detection

3. Multi drug therapy

4. Surveillance

5. Immuno prophylaxis

6. Chemo prophylaxis

7. Deformities health education

Leprosy control ( contd)• Social support

• Program management

• Evaluation

GOALS

1. To interrupt transmission reduce incidence

2. To treat patients.. cure.. rehab

3. To prevent formation of associated deformities

Estimation of the problem

1. Epidemiological survey

2. Random sample surveys

Prevalence among all school age children x 4 = average prevalence in the community

II.Early case detection

Aim: identify and register all cases

• Involve primary health care workers• Active community participation

Methods• Contact survey- household• if 1 per 1000 Group survey..school/slum/military• if prevalence is10 or more per 1000 :Mass surveys

House to houseRecords; standardised:. Use WHO format

Iceberg disease

III Multi Drug therapy- MDT

• Mainstay of control

• Drug resistance leprosy due to monotherapy

• Relapse of disease

Therefore MDT. Shorter treatment

Objectives:

1. To interrupt transmission by sterilizing infectious patients as rapidly as possible by bactericidal drugs

2. To ensure early detection and treatment of cases to prevent deformities

3. To prevent drug resistance

Definitions

1. Case of leprosy- person showing clinical signs with or without bacteriological confirmation, and who has not completed MDT

2. Pauci bacillary: A person with 1-5 skin lesions and/or only 1 nerve involvement

3. Multi bacillary ; A person having 6 or more skin lesions and /or more than1 nerve involvement

4. Adequate treatment: completion of regimen of multi drug therapy –

• 6 mthly doses within 9 mths for paucibacillary and • 12 mthly doses within 18 mths for multi bacillary

contd

Regular treatment: Received MDT for at least 2/3rd of the months in any interval of time

Newly diagnosed case- Diagnosed as a leprosy case and who has not taken MDT in the past

Defaulter case: A leprosy patient on MDT who has not collected treatment for 12 consecutive months

Relapsed case: successfully completed an adequate course of MDT and who subsequently develops new signs and symptoms of the disease, within during the surveillance period or thereafter.

Principles of treatment

1. Stop the infection with chemotherapy

2. Treat reactions

3. Educate the patient about leprosy

4. Prevent disability

5. Support patient socially and psychologically

DrugsName Description

Rifampicin Bactericidal -Hepatotoxic -Observe patient 1 hr after giving the drug

600mg -3 days1500 stat dose

Dapsone

DDS

Mild bactericidal.in 90 days make non infective

Haemolytic anemia, meth hb DDS syndrome

1-2 mg/kg; 100 mg OD

Clofazimine

CLF

Anti leprosy anti inflamm. Expensive. Red colouration

300 mg once a mth

Ethionamide/ protionamide

Bactericidal more expensive and toxic than DDS. Use if CLF is un acceptable

Quinalone-ofloxacin

Bactericidal. GI side effects

minocycline Inhibits bact protein synthesis CI children pregnancy

Clarithomycin Bactericidal. useful In LL

WHO Recommended regimensAdults

monthly / daily / bothMulti bacillary:

• Rifampicin-600mg monthly under supervision x 12 mths

• DDS 100 mg OD x 12 mths

• CLF 300 mg mthly supervised and 50 mg OD- for 12 mths

Pauci bacillary

• Rifampicin-600mg monthly x 6 months supervised

• DDS 100 mg OD x 6 mths

WHO Recommended regimensChildren

Multi bacillary:

• Rifampicin-450mg mthly under supervision x 12 mths

• DDS 50 mg OD x 12 mths

• CLF 150 mg mthly supervised and 50 mg alt days for 12 mths

Pauci bacillary

• Rifampicin-450mg x 6 mths supervised

• DDS 50 mg OD x 6 mths

Defaulters

• Not registered as new cases

Start a new course if she has red raised lesion/ new skin lesion/ new nerve involvement/ lepra nodules/ ENL or reversal reaction

• Drugs Shd be continued in pregnancy• Can be given to HIV positive persons• Tb, anemia

Lepra reaction

Immunologically mediated episodes. Involve nerves. Can cause deformities if not treated

1. Reversal – Type 1 Delayed Hypersensitivity reaction CMI. Usually in borderline BT BL BB cases.

2. Erythema nodosum leprosum- Type II (mild/severe) Immune complex deposition. BL and LL patients

Nodules, neuritis,High fever, ulcers and pustular, involve other organs-eye, testis, lymph node joints

• More with mono therapy than MDT• Treat with Prednisolone 12 weeks only. CLF

TYPE 1

Reversal reaction

TYPE 2 ENL

Relapse

Time interval Occurs with chemo and within 6 mths of stopping treatment

Only when chemo is discontinued after abt 5 mths

Onset Abrupt Slow Insidious

Old lesions Edematous, erythematous tender Not tender

New lesions Several appear Minimal

Ulceration May possible

Nerve involvement

Multiple+ painful and tender.Loss of nerve function

Single nerve. Painless

Gen condn May have fever jt pains. malaise Not usual

Response to steroids

Rapid Nil. Use Clofazamine

Surveillance To detect long term success and detect relapsePauci bacillary: Once an year x 2 yrsMulti bacillary : Once an year x 5 yrs

Immuno prophylaxisBCG vaccine – varying results 23-30-80%

Chemo prophylaxis

• DDS : 1-4 mg/kg for child contacts

protects 35-53%

Given 3 yrs or till index case becomes bact Neg.

ICRC – effective for 8 yrs

• Acdapsone : Inj once in 10 wks long term or short term 7 mths

• Rifampicin ??

DeformitiesCause: • Disease process- eye brows, facial• Paralysis of muscles due to nerve damage-lag ophth, claw hand, foot

drop• Injuries infection of hands and feet- mutilation, corneal ulcer

Hands and feet Eyes

Grade 0 No anaesthesia. No visible deformity

No eye problem / vision defect

Grade I Anaesthesia+

No visible deformity

eye problem present

vision defect absent

Grade II Visible deformity/ damage Severe visual impairment, lag ophthalmos, iridocyclitis and corneal opacity

Plantar ulcer

Claw hands

Prevent these by lots of care …

Preventive rehabilitation

Health education- patient / family / public

Treat by prosthesis/ surgery

Protect people at risk

Social support

Key Messages Hypopigmented patch with loss of sensation could be leprosy Like any disease Leprosy is caused by germs Leprosy is non hereditary 80% do not spread to others It is completely curable Early detection and sustained treatment Become non infectious soon after treatment is commenced Need kindness and empathy Free treatment Not a poor man’s disease Community support is essential for eradication

17 states have achieved Leprosy elimination

7 more are nearing this

Female 34.77%

Child proportion is 13.77%

Multi bacillary 39.3%

Visible deformities 1.44%

Anti leprosy activities in India

• Leprosy mission• Hindu kushth Nivaran Sangh• Gandhi memorial• Sevagram• German leprosy Relief association• Damien Foundation• Danish• JALMA central institute in Agra• Central leprosy teaching and research

institute Chenglepet

Goals of Physical Therapy for Non-Surgical patients Of Leprosy Disease

The major aim is to prevent or reduce complication, deformity and disability in body through Physical Therapy.

Means

The ways of reaching these Goals are-

By teaching the patient.

By treating and helping the patient.

Teaching:

What the disease of leprosy is?

The possible complications and deformities resulting from leprosy.

prevention of complication, deformities and disabilities.

Treating and Helping:

To respect themselves enough to take medication regularly and to take care of complications.

To protect their own anesthetic hands, feet and eyes.

To keep their skin soft and supple.

To keep their joint flexible.

To preserve all possible movements of hands and feet.

To keep their muscles strong.

To use their hands, feet and eyes safely, in daily work.

Goals of Physical Therapy for Surgical patients Of Leprosy Disease

To protect and prevent further damage and deformity.

To improve and restore function.

To improve appearance of hands, feet, face and eyes.

Surgical Techniques used in Leprosy Disease:

Tendon Transfer: Moving the distal end of the tendon to a new place so that contraction of muscle belly will produce a needed movements used to replace paralysed muscles. Example- Transfer of fore-arm muscle to make finger movements.

Tendon Lengthening: Lengthening the tendon of a muscle to permit more movement and reduce contracture. Example- Tendo Calcaneus lengthening.

Capsulotomy: To loosen tight joint capsule often done with tendon lengthening and tendon transfer to improve range of motions. Tighten the loose joint capsule using suture.

Arthrodesis: Elimination of unstable and deformed joints.

Tenodesis: Attach a piece of tendon across the joint to reduce the movement. The tendon then act as ligament. Example- Tenodesis of MCP joint to prevent hyperextension.

Physical Therapy Goals: To increase and regain range of motion. Improve muscle strength particularly in muscles to be

transferred. Clean supple skin in areas of surgery. Teach home self care. Protect tissue during wearing. Prevent/reduce swelling. Muscle re-education after tendon transfer. Safe use of any new restored skill in work.

Physical Therapy Technique:

For increasing/regaining ROM: ROM can be increased by soaking the skin or part in warm water and then performing passive movement to the part affected.

To improve strength specially in tendon transfer: Active exercise in all part in which surgery is performed.

Clean supple skin: It is provided by soaking the part in soap water, rubbing off thick skin, oiling, self massage and protecting the part from infection.

Home care: teaching skin, hand, foot and eye care to groups and individuals and teaching the patients actual home care.

Protect tissue during healing: Rest, body position and POP cast.

Prevent/Reduce swelling: Elevation, active and passive exercise.

Muscle Re-education after tendon transfer: Teaching new restored skills in movements provided by tendon transfer.

Self restored skills in daily work: Teaching patient ot use any new skill safely in specific task. Providing hand, eye and foot protection.

THE END