Leprosy Rehabilitation by Hemant Nandgaonkar

S/b Lecturer, Occupational Therapy Thank you Dr.Sharmila Patil & Dr.Ananta Kulkarni for referring patients for REHABILITATION. Patients will be evaluated, Problem areas listed ..………….and treatment goals set…...Different methods, modalities used for therapy. Please send to OPD 23 for regular therapy………..thanking you….....sincerely……………Nandgaonkar Hemant P © Nandgaonkar Hemant P

Rehabilitation in Leprosy Nandgaonkar Hemant P. Lecturer, Occupational Therapy, Padmashree Dr.D.Y.Patil College of Occupational Therapy, Nerul

DISEASE

DISABILTY

DAMAGE

REHABILITATION DESTITUTION

DEFORMITY

DEHABILITATION

DISADVANTAGE

REHABILITATION a bridge, spanning the gap between uselessness and usefulness, between hopelessness and hopefulness and despair and happiness.

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REHABILITATION Is concerned with the consequences of disease, which CAN NOT be cured completely Seeks to enable patients to reach and maintain an optimal level of functional abilities, despite the lasting presence of impairment „s goal is to preserve & restore the patient‟s autonomy & well being © Nandgaonkar Hemant P

Facts and figures Prevalence of disability in developing countries ---- 7 to 10% of population Global need for population ----- 2.5 to 3 % of the population could benefit from rehabilitation

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Levels of Rehabilitation Rehabilitation Medicine: Prevention, reduction & compensation of disability & handicap Prevention: Medicine, Elective Surgery, Occupational Therapy, Physical Therapy, protective footwear Reduction: reconstructive surgery, Occupational Therapy, Physical Therapy Compensation: wheelchair, orthopedic appliances, tools ÂŠ Nandgaonkar Hemant P

Levels of Rehabilitation Social Rehabilitation Active & passive programmes for social reintegration “Active”: functional training, schooling, vocational training (independence, progress) “Passive”: care institutions & homes (food & shelter) © Nandgaonkar Hemant P

Different Approaches Institution based rehabilitation Outreach services for rehabilitation

Community based rehabilitation

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Resources Individuals: patient, family, community Professionals: medical doctors & surgeons, Occupational Therapy, Physical Therapy, bioengineer & orthotists, psychologist, social worker & nurses ÂŠ Nandgaonkar Hemant P

Resources Technology: WC, crutches, tools for ADL, orthopedic appliances (prosthesis, Orthosis, braces, shoes) , high tech equipment (myoelectric prosthesis) Service delivery system: administrative and logistic support on district, state and national level Research and evaluation programmes ÂŠ Nandgaonkar Hemant P

ACCORDING TO ICIDH (W.H.O.-1980) IMPAIRMENT-Any loss or abnormality of psychological, physiological or anatomical structure or function. DISABILITY-Any restriction or lack of ability (resulting from impairement)to perform an activity in the manner of within considered normal for the human being.

ACCORDING TO ICIDH -2 (W.H.O.-1997) DISABILITY =ACTIVITY LIMITATION HANDICAP = PARTICIPATION RESTRICTION.

IMPAIRMENT PREVENTION

TREATMENT

Early case detection Treatment with MDT Nerve function assessment Preventative steroid treatment Health education for self care Provision of footwear and sunglasses

Steroid treatment Treatment of complications Septic surgery Reconstructive surgery Orthosis Counseling/ treatment of depression

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DISABILITY…ACTIVITY LIMITATION PREVENTION

TREATMENT

Prevention of impairment Treatment of impairment ADL training Occupational Therapy Vocational Training

Aids and appliances Prosthesis Reconstructive surgery Physical therapy ADL training Occupational Therapy Vocational Training

HANDICAPS…PARTICIPATION RESTRICTION PREVENTION

TREATMENT

Health education of Counseling/ treatment of person affected by depression leprosy Vocational training Minimize duration of Economic assistance admission Community counseling Minimize frequency of Sheltered work/ home admission Community counseling © Nandgaonkar Hemant P 15

Objectives 

Steps in Rehabilitation of Leprosy

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Different Goals of Rehabilitation

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Importance of Activities of Daily Living assessment & intervention

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Splinting and adaptive devices © Nandgaonkar Hemant P

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Trunk nerves in the leg

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Deformities of Eyes / Face

Facial Palsy

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Deformities of Hand

FIX CLAW & ABSORPTION

CLAW FINGERS

MUSCLE WASTING

WRIST DROP

Deformities of Foot Absorption of toe Claw toe

Ulcer

Foot drop

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Assessment 

Condition

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Motion

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Sensibility

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Function

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Psycho Social Aspect © Nandgaonkar Hemant P

Condition Assessment 

Hand or extremity mass – Volumeter

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Finger Edema Circumferential measurements, external caliper

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Harris Grid for pressure points in lower extremity

Edema assessment 

Apply consistent pressure while measuring

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Use weights

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Frequency of Assessment

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Skin temperature (30 to 35 deg)

Motion Assessment Goniometric measurements 

Total active motion (TAM) and total passive motion (TPM)

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Torque-angle ROM

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Muscle testing © Nandgaonkar Hemant P

Ulnar

Median

Manual Muscle Test (VMT) Common Peroneal

Facial

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Testing sensations on hands & feet

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Sensibility assessment Semmes-Weinstein monofilaments

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Semmes-Weinstein monofilament

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Semmes-Weinstein monofilament     

2.83 – Green – NORMAL – Patient can recognize light touch & deep pressure 3.61 – Blue – Diminished light touch 4.31 – Purple – Diminished protective sensation 4.56 – Red – Loss of protective sensation 6.65 – Red Orange – Loss of all sensation except deep pressure © Nandgaonkar Hemant P

Shown is the monofilament mapping of the same patient as seen in the pin prick testing

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Sensibility assessment Two-Point Discrimination Test (2PD)

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Vibration testing

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Testing sensations

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Thermal testing

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Sensibility assessment

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Ninhydrin Test – based on sudomotor response, presence of sweat Wrinkle test – presence of skin moisture, Do not require patient interpretation or verbal response, Patients with cognitive or language problems, Young children, Whose motivation is suspect?

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Moberg pick up test

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EMG and NCV

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Why functional assessment? Evaluation of hand function or performance is important because the physical evaluation does not measure the patientâ&#x20AC;&#x2122;s ingenuity & ability to compensate for loss of strength, ROM, sensation, or presence of deformities The physical evaluation should precede the functional evaluation because awareness of physical dysfunction can result in a critical analysis of functional impairment & an understanding of why the patient functions as he or she does.

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Function assessment  

Grip strength Jamar Dynamometer

Function assessment 

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Pinch strength – thirty seven distinct pinches, pinchometer Clinical Evaluation

Dexterity assessment 

Dexterity – ability to manipulate objects with the hands rapidly & skillfully.

Dexterity assessment Manual/ gross dexterity was defined as the ability to make skillful, controlled arm- hand manipulations of larger objects. E.g. MRMT, MMDT  Finger / fine motor dexterity was defined as the ability to make rapid, skillful, controlled manipulative movements of small objects using primarily the fingers. E.g. Purdue Pegboard Test, O’Connor Finger Dexterity © Nandgaonkar Hemant P Test, RED test

GRASP

Cylindrical

Spherical

Hook

Intrinsic plus

PREHENSION

Palmar

Pad to lateral (key)

Tip to tip

Pad to pad

Lateral

FLAT HAND RELEASE

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Function assessment 

Assessment of daily living skills – interviews, observations, site visits

Simulated ADL assessment – Jebsen Test of Hand Function 

Return to work assessments – Valpar Work Samples,Job Analysis © Nandgaonkar Hemant P

CODE 1 A 1A - 1 1A - 2 1A - 3 1A - 4 1A - 5 1A - 6 1A - 7 1A - 8 1A - 9 1A - 10 B 1B - 1 1B - 2 1B - 3 1B - 4 1B - 5 1B - 6 1B - 7 1B - 8 1B - 9 1B - 10 C 1C - 1 1C - 2 1C - 3 1C - 4 1C - 5 1C - 6 1C - 7 1C - 8 1C - 9 1C - 10

ACTIVITIES SELF-CARE FEEDING Eating with finger Cutting chapati with fingers Eating rice with fingers Eating western style (using fork, knife + spoon ) Eating rice with spoon Drinking fluid from glass/cup Eating on floor ( ) Eating on table Can serve self solids Can serve self liquids PERSONAL HYGIENE AND GROOMING Hair-combing with 2 hands ( plating/bun ) Teeth-brushing teeth/dentures gargling (Applying Masheri ) Nail care - clean fingernails, toenails trimming Shaving Blowing nose Applying make up Toilet - Indian style squatting, getting up from squatting Washing - pouring water Bathing applying soap washing UE washing LE washing face Care for menstrual periods DRESSING Put on blouse/shirt Remove blouse/shirt Put on pyjama/trousers/dhoti Remove pyjama/trousers/dhoti Put on sari Remove sari Making sari pleats Put on bra/baniyan Remove bra/baniyan Put on underwear/panty

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DEFINITIONS Dependent - Patient is unable to do any part of the activity. Independent Inappropriate - Patient is able to complete the activity with / without difficulty which may or will lead to reinforcement of abnormal porters or deformity predispose the body parts to ulcers etc. with such kind of performance of the activity. Independent Appropriate - Patient is able to complete the activity with or without adaptive equipment. The way of handling or performing the activity may or will not lead to deforming postures, ulcers or any other complications etc.

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WHO DISABILITY GRADE SITE EYE

GRADE I

GRADE II

Corneal anesthesia

lagophthlmos

FACE

anesthesia

facial

HAND

anesthesia on palm

mobile

FOOT

anesthesia on sole

mobile/

severe

vision loss

palsy claw/ fix claw fingers/ ‘z’

thumb wrist drop wasting of hand muscles fix claw toes foot drop ulcer/ wound on sole © Nandgaonkar Hemant P

CLASSIFICATION OF WORK LEVELS SEDENTARY WORK – requires a maximum lift of 10-1b, infrequently and occasional lifting and carrying of papers, small tools or, file folders sedentary work may require occasional walking or standing. LIGHT WORK - requires a maximum lift of 20-1b, with frequent lifting or carrying of up to 10-1b objects. If a great deal of walking, standing or pushing and pulling of arm or leg controls is required by the job, the job is classified at the light level even though the lifting requirements do not exceed 10-1b. MEDIUM WORK – requires a maximum lift upto 50-1b with frequent lifting and carrying of weights upto 25-1b.

CLASSIFICATION OF WORK LEVELS HEAVY WORK – requires a maximum lift of 100-1b with frequent lifting or carrying of objects weighing upto 50-1b. VERY HEAVY WORK – requires lifting objects greater than 100-1b with frequent lifting or carrying of objects weighing 50-1b or more. SOURCE : DIRECTORY OF OCCUPATIONAL TITLES (UNITED STATES DEPARTMENT OF LABOUR’S WORK LEVEL CLASSIFICATION SYSTEM.)

KUPPUSWAMY’S SOCIO ECONOMIC SCALE ‘URBAN’

EDUCATION

SCORE

.Professional degree, M.A., M.Sc., M. Com. Post graduate diploma; M.S.W. .B.A., B.SC., B.COM., D.M.E., D.H.M.S., B.P.N.A. .H.S.C., I.T.I., Intermediate, D.Ed. Post high school Diploma 5 .S.S.C., High School Certificate .Middle School complection .Primary School / Literate .Illiterate

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CLASSIFICATION FOR ADL SCORING (SEVERITY)

Mildly

Affected Moderately Affected Severely Affected Very Severely Affected

90.01% and above 65.01% to 90% 50.01% to 65% 50% and less.

RESULTS & DATA ANALYSES TOTAL NO. OF PATIENTS - 209 Majority of them was male population.(61%) Almost 99% had right hand dominance. ADL status evaluation shows that work area was more severely affected than other two I.e.self care & leisure. Socio-economic status evaluation revealed that >50% were illiterate & mostly involved in unskilled & semiskilled type of occupation.(61%).Also,present work level of most of them was medium/heavy/very heavy.(70%).

RESULTS & DATA ANALYSES Work area involvement was correlating with type of occupation.(P<0.001) I.e. about 61.24% of population was doing unskilled/semiskilled type of occupation.Also,most of them were from middle & lower middle class category.The extent to which the ADL work area was affected was directly proportional to the present work level I.e. they were doing heavy/very heavy work at present.(P<0.001).

RESULTS & DATA ANALYSES WITH DOMINANT HAND AS A REFERENCE Out of hand involved cases 61% of population was with dominant hand involvement.In these cases also,work area was more severely affected & were belonging to unskilled & semiskilled type of occupation & doing medium/heavy/very heavy work at present.This means that there was definite correlation b/w these parameters & ADL work area. Finally,I found significant correlation b/w WHO impairment scale & ADL work/self care area.

CONCLUSION To conclude, detail ADL evaluation should be the matter of concern for the leprosy patients with Unskilled

semiskilled

occupation

type. Heavy or very heavy work level. Dominant hand involvement.

Rehabilitation Goals   

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Reduce or control edema Maintain or increase motion Maintain or increase function Maintain or enhance sensibility Control or decrease pain Maintain or improve physical daily living skills; return to work © Nandgaonkar Hemant P

Reduce or control edema The prevention and treatment of edema are of paramount importance during all phases of management.

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Effect of edema

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Restrictive scar Injury/infection

Prolonged Immobilization

Prolonged edema

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Techniques for reduction of edema -

Elevation Active motion Massage Intermittent compression Continuous Passive Motion Compressive bandages String wrapping Electrical modalities ÂŠ Nandgaonkar Hemant P

Maintain or increase motion Gliding Exercises Blocking exercises

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Exercises for hand deformities

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Exercises for lower extremity

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Maintain or increase motion Active and passive motion, joint play Extremity use

CPM, FES, TENS, BFB

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Isolated Exercises with Audio Visual Feedback

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Enabling Activities

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Purposeful Activity 

Intrinsic motivation

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Elicits adaptive response

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Promotes more coordination

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Better quality of movement © Nandgaonkar Hemant P

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Creative Recreational Adaptive Functional Therapy © Nandgaonkar Hemant P

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Splinting The Hand Needs Definition,Classification and Nomenclature

Definition

Made from a variety of materials, splints are external devices that are applied to treat upper-extremity problems resulting from injury, disease, birth defects, or the aging process. ÂŠ Nandgaonkar Hemant P

Splints serve one or more of four basic functions ď ˇ They may be used to 1.Support 2.Immobilize, or 3.Restrict a body part to allow healing after inflammation or injury to tendon, vascular, nerve, joint or soft tissue structures. 4.Correcting or preventing deformity is another function performed by splints. ÂŠ Nandgaonkar Hemant P

Hand Problems

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Hand Problems

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Classification  Dynamic splint  Static Splint  Serial Static Splint

 Static Progressive Splint © Nandgaonkar Hemant P

Dynamic Splints

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Dynamic Splints

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Dynamic Splint ď ˇ A dynamic splint includes a resilient component (elastic, rubber band, or spring), which the patient moves. Dynamic splints are designed to increase passive motion, to augment active motion by assisting a joint trough its range, or to substitute for lost motion. Dynamic splints generally include a static base on which to attach the movable, resilient components. E.g. radial cock up splint ÂŠ Nandgaonkar Hemant P

Static Splint ď ˇ A static splint has no resilient components & immobilizes a joint or part. Static splints are fabricated to rest or protect, to reduce pain, or to prevent muscle shortening or contracture. An example of static splint is a resting pan splint that maintains the hand in functional or resting position. ÂŠ Nandgaonkar Hemant P

Static Splint

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Physical agent modalities  Paraffin Wax bath  Hydrotherapy  Nerve stimulation and muscle stimulation

 Oil Massage © Nandgaonkar Hemant P

Serial Static Splint ď ˇ A serial static splint achieves a slow, progressive increase in range of motion by repeated remolding; each remolding positions the joint at its end of motion. The serial static splint has no movable, resilient components such as rubber bands or springs; it uses static forces along with remolding and repositioning to achieve its goal. A cylindrical cast designed to reduce a PIP joint flexion contracture through frequent removal and recasting is classic example of serial static splint. ÂŠ Nandgaonkar Hemant P

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Total End Range Time (TERT) Theory  suggest that the amount of increase in passive ROM of the stiff joint is directly proportional to the amount of time the joint is held at the end of its range  TERT theory states that if a joint held at the end of its range, the dense connective tissue around the joint grows. This lengthening of tissues increases ROM. The longer the joint is positioned at its end range, the greater the gain in mobility.  Serial static splinting or casting is used in the application of TERT theory in splinting.

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Static Progressive Splint ď ˇ Static progressive splints include a static mechanism that adjusts the amount or angle of traction acting upon a part. Frequently this mechanism is a turnbuckle, cloth strap, nylon line or a buckle. The static progressive splint is distinguished from the dynamic splint by its lack of a movable, resilient force. It is distinguished from a serial static splint in that its adjustment mechanism is built in, so it does not need to be remolded. E.g. Robert Jones splint ÂŠ Nandgaonkar Hemant P

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stress relaxation OR static progressive stretch therapy ď ˇ This approach elongates tissues through progressive incremental stretch. The static progressive stretch approach applies 30-minute sessions of splint wear with stretch increased every 5 minutes to the patient's tolerance to increase ROM Static progressive splints apply this theory by applying a low-load force that can be adjusted incrementally. ď ˇ These splints use method such as MERiT (Maximum End Range Time) components for gradual advancement of static stress on the splinted part. ÂŠ Nandgaonkar Hemant P

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What is the purpose of the splint?  Restrictive Splints  Immobilizing Splints  Mobilizing Splints

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Purposes of the Splints

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Purposes of the Splints

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Purposes of the splints

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The Splint classification system (SCS) The SCS defines splints according to series of 4 descriptors 1.Anatomic focus 2.Kinematic Direction 3.Primary Purpose 4.Inclusion of Secondary joints

The SCS The combination of the four descriptors accurately defines a splint without becoming lost in multitude of specific design options e.g.â&#x20AC;?cock-up splint Wrist extension immobilization splint,type 0 ÂŠ Nandgaonkar Hemant P

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The SCS ď ˇ Enhances communication between medical personnel by defining the important aspects of splints while leaving decisions about design options to those who actually fabricate splints.This allows therapists greater flexibility & use of their knowledge bases. ÂŠ Nandgaonkar Hemant P

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PROLIFERATIVE

ACUTE

CHRONIC

Static splinting

Serial Static Splinting Static Progressive splinting

Dynamic Splinting

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Mobile claw fingers (UN) FINGER LOOP SPLINTS

•Mobile claw fingers [Able to straighten the fingers passively] •Helps the fingers to do exercises, thereby prevents contractures

•Strengthens weak muscles of hand / fingers

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Purposes of splinting in PNI  To keep denervated muscles from remaining in an overstretched position  To prevent joint contractures  To prevent development of a strong substitution patterns  To maximize functional use of the hand

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Splinting Claw hand

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Common intervention for claw hand

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Splinting  Is the only technique that is able to apply gentle stress over a period of time sufficient length to allow collagen remodeling and tissue growth  Simple Purposeful Little Innovative Timely

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Maintain or enhance sensibility Sensory Reeducation Goal â&#x20AC;&#x201C; To improve or enhance useful sensation 1. 2.

Prevent burns or other injuries Facilitate use of the affected hand in vision occluded functional activities ÂŠ Nandgaonkar Hemant P

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Maintain or enhance sensibility Sensory Reeducation - compensatory techniques Touch localization Shape discrimination Desensitization

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Maintain or improve physical daily living skills; return to work  ADL Training

 Encouraged to return to work as soon as possible

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Five intervention approaches to self care  Reduce the impairment  Build compensatory skills  Use assistive technologies  Change the task or task expectations  Use personal assistance

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Suggestions for making assistive devices/tool adaptations ď ˇ They can only assist, not replace what has been lost

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Guidelines 1. Locally available material 2. Cost effective 3. Individualized 4. Adapted to culture 5. Easy to use/lightweight/durable 6. Safe to use 7. Desirable to the person using 8. Should increase the independence 9. Replaceable 10. discontinued ÂŠ Nandgaonkar Hemant P

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Adaptive devices

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M-Seal Grip Aids

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Educate the patient to protect their insensitive hands, feet and eyes

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Hand and feet care

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Button Hook & zipper pull

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Cylindrical foam

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Causes for Sole wound

EXTERNAL

INTERNAL

• Thorn / nail prick

• Sustained pressure

• Injury / trauma

• Repeated stress

• Callous / bump

• Reduced surface

• Shoe bite - friction

• Inflammation

• Rat bite

• Ischemic necrosis

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Body weight FOOT BONE (Calcaneum) Joint capsule / ligaments

Muscles / blood vessels Sub-cutaneous / Fat

Thick sole skin

Hard surface

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Inflammation Ischemia

Necrosis

Body weight FOOT BONE (Calcaneum)

Hard surface

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Pressure

Area

Weight ÂŠ Nandgaonkar Hemant P

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MCR FOOTWEAR

EVEN DISTRIBUTION OF FORCES DURING WALKING MINIMISE SHEARING OF FORCES PROTECTS INSENSITIVE FEET FROM SECONDARY DEFORMITY

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SELF CARE :Care of feet

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Mobility devices

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Industrial Rehabilitation product lines Functional Capacity Evaluation Work hardening therapy Work conditioning Ergonomic consultation Job analysis Job simulation Job modification

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Intervention at the Work place  Hand held Tool design  Handle design  Workplace design  Work space  Worker position  Work surface  Task design © Nandgaonkar Hemant P

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Cooking mitt

When handling hot or extremely cold objects, cooking mitts should always be forearm length and well insulated. They should always be worn regardless of the patient's sensory level. The patient's hands should always be protected as well as the forearms due to the possibility of steam burns when ÂŠ Nandgaonkar Hemant P 147 involved in a cooking activity.

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Prosthesis

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Lower extremity prosthesis

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Therapy Concepts  Tissue Healing     

Anti-deformity Positioning The Myth of No Pain, No Gain Passive Range of Motion Can Be Injurious Judicious Use of heat Isolated exercise,

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Psychological factors affecting therapeutic outcomes

 Minor Trauma – large disability

 Adaptive response to hand impairment is influenced by body image as well as individual functional needs  The personal or symbolic meaning of the hand, self esteem, family and friend support systems, coping strategies all influence outcome  STIGMA

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Psychological factors affecting therapeutic outcomes     

Encourage patient to participate in their care Introduce yourself Maintain eye contact Listen well Use non medical terminology and instructional diagrams  Encourage some amiable conversation as appropriate © Nandgaonkar Hemant P

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Motivation  Motivation is the most important variable favorably influencing recovery.  Realistic expectations & appropriate communication that emphasizes education are also important.

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Learning and relearning motor skills is time consuming, requiring several hours a day of instruction, supervision and exercise

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Therapy  Involves understanding, use, and manipulation of the body’s normal healing process to attain the best possible rehabilitation outcomes  Its true when prescribing exercises or splints, purposeful activity  Follow “Therapy Concepts”  Hands off approach © Nandgaonkar Hemant P

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Challenge  Team work for professionals – Rehabilitation team: potential, goal, plan for rehabilitation

 Community and family support – Open mind & dedicated services

 Motivation of the patient – Staying power, vision, love

– Community based rehabilitation

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Thank you

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