Neglected Tropical Diseases

Leprosy
Training for health workers on
skin NTDs

Module 6B: Leprosy

Prevention and management of
disabilities due to leprosy –
Management of disabilities.
1
 Learning Objectives

By the end of this module, you should be able to:

• Understand management of disabilities of hands, feet and

eyes.

2
 Content

1. Management of insensitive hand and feet

2. Management of motor paralysed hands and feet
3. Management of ulcers of hands and feet
4. Management of disintegration of feet without ulceration
5. Management of the eye problems in leprosy
1. Management of insensitive hand
and feet
 Management of insensitive hand and feet
• Persons who have nerve damage (nerve function
impairment) should carry out daily ‘self-care’ activities.

• Self-care should be practiced at home while performing

activities of daily living.

• Self care helps in identifying problems early and seek

medical attention early.

(Refer Module 7 for details of Self-care of disabilities)

 Customised protective footwear for person
with insensitive feet

• Customised protective footwear with soft insole

(Microcellular Rubber), hard outer sole and adjustable
straps will help prevent excessive pressure and prevent
injury.

(Refer Module 7 for details of Self-care of disabilities)

2. Management of motor paralysed hands
and feet
 Management of motor paralysed hands and
feet

• The deformity is considered mobile when paralyzed

muscles and skin are soft and supple and movement in
the joints is possible
• If the deformed position is maintained for a long period
of time contractures can occur
• Contractures can hamper or prevent complete
correction of deformities by surgery
• It is therefore necessary to prevent contractures of the
muscles, tendons, skin and joints
 Management of motor paralysed hands and feet
(Continued)

Deformities can be kept mobile and contractures can be

prevented by
– Splinting
Cylindrical splint - indicated when there is interphalangeal joint
stiffness or contracture of fingers,
Thumb web spica - indicated when there is thumb web
contracture.

– Active and Passive exercises

vRefer persons with mobile deformities to a specialized

health centre for reconstructive Surgery
 Management of motor paralysed hands and
feet

Exercises:
Two types of physio excercises are
● Passive exercise: If the muscles are paralyzed because
of nerve damage, passive excercises are recommended.

● Active exercise: If the muscles are weak and not

paralyzed, active exercises are recommended to
strengthen the muscles.
 Management of motor paralysed hands and feet
(Continued)
Passive Exercise - weak or paralysed ulnar nerve
(Claw deformity)

● This exercise can also be called as massage

● The hand is placed on the thigh or on a soft flat surface, with the palm
facing up.
● The palm of the other hand is used to gently straighten the fingers.
● Once one cycle of the exercise is over, the other hand is lifted up and then
the exercise is done again.
● This can be repeated about 20 cycles for 4 to 5 times a day. This exercise
helps to prevent interphalangeal joint contractures.
Management of motor paralysed hands and feet
(Continued)
Median nerve paralysis (Loss of thumb abduction)
Passive Exercises for thumb muscles

● This exercise can be done by interlocking the thumb webs of both

the hands
● The normal hand is used to stretch the thumb web of the affected
hand.
● The thumb of the affected hand is moved away from the index
finger. This will help in stretching the thumb web and prevent thumb
web contractures).
● This can be repeated about 20 cycles for 4 to 5 times a day.
 Management of motor paralysed hands and feet
(Continued)
Radial nerve paralysis (Wrist drop)
Passive Exercise when wrist extensors are weak or paralysed

● The two palms are placed in approximation with

each other.
● From this position, the wrist of the normal hand is
flexed to make the affected wrist to move into
extension.
● The extension of the paralysed wrist should make it
move to the end ranges.
● The other method of exercising the wrist is to place
the wrist flat on a surface and the elbow is lifted
perpendicular to the wrist joint
● Repeat the exercise again for about 20 cycles for 4
to 5 times a day.
● The exercise will prevent wrist contracture from
developing
 Management of motor paralysed hands and feet
(Continued)
Lateral popletial nerve paralysis (Foot drop)
Exercises for Foot

Exercises when extensors of the ankle are weak or paralysed:

● The patient is positioned in long sitting. A towel is placed over the

plantar surface over the forefoot and the edges of the towel are
held by the patient.

● The towel is pulled towards the patient, so that the forefoot is pulled
into dorsiflexion. The foot is held in this position for about 10
seconds and then released.
 Management of motor paralysed hands and feet
(Continued)
Lateral popletial nerve paralysis (Foot drop)
Exercises for Foot (continued)

● Repeat the exercise again for about 20 cycles for 4 to 5

times a day.

● Another exercise that can be performed is by standing

about a foot in front of a wall, facing the wall. The
person can lean forward with the hands placed on the
wall for support. This causes the foot to dorsiflex.
 Management of motor paralysed hands and feet
(Continued)
Posterior Tibial nerve paralysis (Claw Toes)

Passive Exercise for Claw toes:

● The foot is placed over the other thigh with the affected leg in

crossed leg position.

● The toes of the foot are straightened manually.

● When the toes are straightened, the stretching force will prevent

the toes from becoming stiff in the clawed position

3. Management of ulcers of hands
and feet

17
 Management of ulcers of hands and feet

Management of ulcers includes:

Ø Management of simple ulcers

Ø Management of complicated ulcers

18
 Management of simple ulcers

• Simple ulcers can be managed at home and do not

require hospitalization.

• Dressings can be done at home after ascertaining that it is

a simple ulcer.

• It is essential to give rest to the ulcer or rest to the limb (to

prevent stresses on the ulcer)

19
 Management of simple ulcers (continued)
Simple ulcers of the foot:
Rest : Can be
• bed rest,
• use of crutches or splinting or
• off-loading devices like plaster casts or appliances

Bed rest Using crutches Off-loading devices

Plaster costs 20
 Management of simple ulcers (continued)
Simple ulcers of the foot:
Plaster Cast
For the simple ulcer, plaster casts remain the most practical and
effective home based treatment. It is:
– rigid and therefore holds all tissues planes immobile
eliminating sheering stresses

– occlusive and therefore protects the simple ulcer from

repeated secondary infection.

– economical

• It can be applied at the house

21
 Management of simple ulcers (continued)
Simple ulcers of the foot:
Plaster casts

Moulded Double Rocker Shoes

(MDRS) Plaster

Plaster cast is:

• a plaster of Paris (POP) shoe which immobilises the
foot. It is provided with a double rocker board which
gives protection to the plaster.

• more stable to patient to walk on.

22
 Management of simple ulcers (continued)
Simple ulcers of the foot:

Plaster Casts

A plaster boot with a walking

heel or iron is strong enough
for the patient to walk

Below Knee (BK) Cast with

Bholer Iron Plaster
23
 Management of simple ulcers (continued)

Simple ulcers of the hand:

The hand should be rested in a sling.

If bulky dressings are used for the ulcer, it will not be necessary
to splint the hand.

24
 Management of complicated ulcers

§ Complications can include infected tenosynovitis or

osteomyelitis or infected arthritis

§ Malignant change usually manifests as Squamous Cell

Carcinoma

v Management of complicated ulcers require hospitalization

where medical and surgical facilities available. Refer the
person with complicated ulcer to a specialized health
centre.
25
 Management of complicated ulcers
Type of complication Management
Infection or purulent Debridement and immobilisation (rest), Elevation of
discharge from the ulcer affected part (hand/foot), Daily dressing and
Antibiotics.
Clear discharge from the Immobilisation (rest), Elevation of affected part
ulcer (hand/foot) and Daily dressings.
Slough (dead tissue in Debridement, Immobilisation (rest), Elevation of
the ulcer) affected (hand/foot), Daily dressings and
Antibiotics.
Sprouting granulation Biopsy to confirm whether the growth is malignant
tissue or growth of the or benign, dressings, immobilization and
ulcer debridement.

If malignancy is confirmed, then ablation (local

excision or amputation) surgery.

26
4. Management of disintegration of feet
without ulceration

27
 Management of “acute disintegration” of the
insensitive limb
• Immobilisation in a plaster cast and elevation for 1 month
• Once the swelling subsides (after one month) then change the
plaster cast
• Plaster cast for 3 months for the hand and wrist. Plaster cast for
4 months for the foot and ankle
• Remove the cast and take a mold for a fixed ankle brace for the
foot and reapply the cast for a month
• Remove cast and provide Fixed ankle brace for use for 1 year or
1½ years
• Re-evaluate after 1 year
 Secondary impairments Neuropathic limb
(continued)
Management of Chronic disintegration of Neuropathic limb:

This needs to be managed by special customized molded footwear

or surgery or both

Fixed Ankle Brace (FAB) Patellar Tendon Bearing

Brace (PTBB) 29
5. Management of the eye problems
in leprosy

30
 Management of Eye problems in leprosy

• Any eye complication due to leprosy is an emergency

• Eye complications can lead to blindness.

• Refer to a specialized health centre (Ophthalmologist)

Management of motor paralysed hands and feet
(Continued)
Passive Exercise for Facial Nerve – Orbicularis Oculi - Lagophthalmos

The commonest eye complication due to leprosy is lagophthalmos – the

eye cannot close completely. Explain to the patients they can overcome
this impairment by doing these passive and active exercises regularly

Passive Exercise for Lagophthalmos:

● Ask the patient to place the index finger

on the lateral side at the edge of the eye

● The person is told to gently pull laterally.

This will cause the eye to close
 Management of motor paralysed hands and feet
(Continued)
Active exercise for Facial Nerve – Orbicularis Oculi - Lagophthalmos

Active exercise for Lagophthalmos:

● The patient is asked to close the eye tight for 3 to 5 seconds.

● Then they must open the eye and after about 10 to 15 seconds, the

exercise should be repeated again

● This exercise will strengthen the Orbicularis oculi muscle.
 Recap
• Feet with loss of sensation in the part of the sole, and
paralysis of the small muscles are at risk of ulcers.
Therefore, all such patients should be wearing protective
footwear.

• Deformities can be kept mobile and contractures can be

prevented by splinting and exercises (active or passive).

• Simple ulcers of hand/feet can be managed at home.

• Management of complicated ulcers require hospitalization

where medical and surgical facilities available.

• Any eye complication due to leprosy is an emergency.

Refer to a specialized health centre (Ophthalmologist)