The Grading or Index is NOT a Neurological examination/voluntary muscle test/sensory testing

Leprosy Mailing List – March 8^th, 2012 

Ref.:    The Grading or Index is NOT a Neurological examination/voluntary muscle test/sensory testing

From:  L F Lehman, Belo Horizonte, M G, Brazil.

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Dear Cairns,

Thank you for your message [LML March 6^th, 2012].  Yes, indeed the history of all is interesting. 

Dr. Palande can also give an important account of this early development as he was actually the originator, I believe of the idea, which than was adopted and adapted by W.H.O.  I do know talking with several of the persons involved in the beginning, the whole thing created quite a bit of discussion!

One other big areas of confusion is that many feel when they have done the Grading/Index they have done a "Neurological Examination – Voluntary muscle testing (VMT)".  It is important that readers clearly understand the Grading or Index is NOT a Neurological examination/VMT.  

Dr. Srinivasan [and Drs Schreuder and Naafs as well] points out that we need to combine Nerve palpation (pain responses) Sensory and Motor exams.  I am concerned that many programs have nerve palpation in one area of their clinical exam and then off in the physiotherapist part, the motor and sensory.  The Neurological exam is part of the Clinical exam and should combine all 3 parts.  Clinicians should know how to do and interpret results.  The neurological exam as well as education to help patients identify neurological changes is important.  Doing the Grading/Index each month may not be needed.  It is a concern that more time sometimes is spent on exams with little time spent working on self-care practice and education.  What is even more of a concern is that sometimes no action is taken when the exam results shows things have gotten worse.  The health team at times do not look at and/or do not know how to interpret the results.  Practice in interpretation and choosing what should be done is an important part of training/supervision.  Case studies can be helpful.

The other issue is that I see many programs record grading/indexes based on ONLY hand and foot exams and the eye is not even examined and/or perhaps the patient is asked "Do you see OK".  When I check the distance that fingers are counted, it varies greatly as people mark off the distance with their leg length of what they think is 6 meters.  It usually is less by at least a meter or 2.  

The quality of the Grading/Index has to be constantly monitored and clarified to try and get consistency.  Although it seems simple, I have seen it interpreted and additions slipped in without others knowing until close observation and inquiry is done.  I recall much effort was put into trying to get better definitions, clarity and consistency from 1997-2003 in Brazil.  National guidelines tried to include clearer definitions.   We worked hard at it and much improved however today this needs to be checked again.  I know this is something that all countries must monitor carefully.

Linda