Monday, March 24, 2014

(LML) Effectiveness of sensory re-education in leprosy

Leprosy Mailing List – March 24 ,  2014 

Ref.:    (LML) Effectiveness of sensory re-education in leprosy 

From:  Karthikeyan G, Allahabad, Uttar Pradesh,  India


Dear Dr Schreuder,

 

Thank you for reposting my message on sensory re-education.  I am happy to give answers to the questions raised by Robert.

Question 1: I do not have exact number of patients with altered perception of object in hand. We never thought of this phenomenon so never kept any record. In our program we use 2 grams (protective sensation) to test sensation in palm. We do not use graded filament. We check 4 points for ulnar nerve and 6 points for median nerve.

Question 2: Typical patients who usually complain are those who are involved in work using small objects like writing-students, clerical job, using tools like screw driver etc. The heavy workers like farmers usually don’t complain of anything. Their typical complains are: “I don’t feel any control on object in my hand like pen, objects drops from hand, difficult to eat rice etc. Their intrinsic muscle grade are usually 4 and above. Sensation present with 2 grams.

We usually ignore their complaints because of their good muscle power and sensation. Therefore, we give strengthening exercise and activities to improve hand function.

It would be interesting to assess with graded monofilament to get a clear picture of their sensory level.

Question 3: We do not use any perceptual motor tests. We did not do any other sensory tests. I feel two-point discrimination test could have given some idea. 

Question 4: The study was from Japan and not Nigeria. Nakada M & Uchida H. Case Study of a Five-stage Sensory Reeducation Program. J Hand Ther, 1997; 10:232-239.

The case described has similar picture which we encountered with our patients.

We have not done any screening test to rule out other conditions which could cause altered perception of hand. Considering the educated population who complain this phenomenon, it is less likely to have any CNS dysfunction. However, my first priority is to see that, does the sensory re-education helps in recovery of sensation in hand? And to treat altered perception of object in hand is second priority.

Let me explain to you with my recent case for whom we started sensory re-education: 23 year old student, diagnosed with HD came to hospital with severe T1R and 2 months old nerve involvement of his bilateral ulnar-complete paralysis and median–partial paralysis of his motor function. His sensory status is described in a table given below. 

   

Nerve

Area

Right

Left

Point of assessment

Day 1

Day 8

Day 1

Day 8

Median

Base of thumb

Nil

300 gms

Nil

10 gms

 

Pulp of thumb

2

2 gms

4 gms

2 gms

 

Pulp of Index finger

4

4 gms

Nil

300 gms

Ulnar

Base of hypothenar

10 gms

10 gms

Nil

Nil

 

Head of 5th metacarpal

300 gms

10 gms

Nil

Nil

 

Pulp of little finger

4 gms

 4gms

Nil

Nil

Nil = Unable to feel any filament even 300 gms (6.65)

He was unable to identify any small objects like battery, paper clips, ball, coins etc. However, he was able to identify big sized ball and could say rough textured surface but unable to identify of what it is.

He was admitted for T1R and neuritis, was put on standard regimen of steroid. He underwent exercises for weak muscles and splints, assistive devices were given to facilitate his ADL. Sensory re-education was started on day 1 and continued for 8 days. Sensory re-education started using mirror image as explained by Rosen B & Lundborg G. 2005 (Scand J Plast Reconstr Surg Hand Surg, 39: 104-108). We used common items like Velcro, nut-bolts, shapes cut out of rubber sheets, mesh, paper clips etc. On day 8 sensory, motor and stereognosis was reassessed and the change in sensory status is given in above table. Both thenar muscles improved from grade 2 to 2+ or 3. Though he was not able to identify small objects but patient described that he is feeling something is placed in his hand. For example, object like battery he described as nut-bolt because it feels like metal. Also he described that, he is able to feel warm and cold water when he takes bath and brushes teeth.

I understand that improvement observed is not solely because of the sensory re-education as he is on steroid therapy which also could have helped. He was discharged on day 8 and could not continue therapy under supervision. However, we made a kit containing all the objects used in hospital for re-education and explained to continue at home and review after 2 weeks. I look forward to reassess him and continue sensory re-education to see the effect.

To the best of my knowledge sensory re-education is least practiced in leprosy as compared to nerve repair. With the advancement in sensory re-education after nerve repair, use of mirror image in sensory re-education, and brain plasticity there seems some hope, if not for all with sensory loss at least to the patient with early nerve damage.

I look forward to hear from experts in POD to share their experience in sensory re-education.


Thank you once again,

 

with kind regards,

 

Karthikeyan G,
Occupational Therapist,
The Leprosy Mission Hospital Naini
| Allahabad - 211008 | Uttar Pradesh | India.
Contact No: +91 99352 84315
| Skype: karthikeyan.ot 

 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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(LML) Effectiveness of sensory re-education in leprosy

Leprosy Mailing List – March 24 ,  2014 

Ref.:     (LML)  Effectiveness of sensory re-education in leprosy

From:  Dinkar D. Palande, Pondicherry, India


 

Dear Pieter,

 

I have seen this correspondence recently as I was away from Pondy. I am glad to see his (Kartikeya, LML March 15, 2014)  interest in this subject. I look forward to his reply to the observations of Robert Jerskey (LML March 16, 2014).

 

In the meantime I would like to encourage him in this difficult field of nerve recovery.

I have used extensively sensory re-orientation in nerve recovery after trauma and repair, after nerve excision and grafting in leprosy as also in nerve recovery especially after nerve decompression in leprosy. I have not published since many others starting with Wyn Parry have done lot of work on this topic.

 

What particularly interests me is his mention of altered perception. That does occur and there are many reasons for that in Leprosy. Here also sensory reorientation will help for basically that is retraining of the cognitive function. Purposive movements with a feedback are the key to recovery.

 

 

Kind regards

 

Dinkar D. Palande

 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

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Sunday, March 16, 2014

(LML) Effectiveness of sensory re-education in leprosy

Leprosy Mailing List – March 16 ,  2014 

Ref.:  (LML)  Effectiveness of sensory re-education in leprosy 

From:  Robert S. Jerskey, Carlsbad, California, USA


 

Dear Pieter,

I was pondering Mr. Karthikeyan's interesting request during the week.   Thank you for the gentle nudge.  

I have a few questions that might help me and perhaps other interested readers to get more than a glimpse of this particular patient population you are referring to, Karthikeyan:

1.  I read that you mention a number of patients with this phenomenon.   How many?   Any remarkable information to share from their records/charts?  Along with that, please state the criteria used for "recovery of touch", including which monofilament[s] and/or other instruments, and number and locale of sites on the hands tested.

2.  Would you be able to describe/illustrate, more specifically, the nature of the "disturbed perception" you are referring to.   That might be very helpful.

3.  Are there any other sensory tests, besides monofilament testing, and any perceptual-motor tests which you have recruited that lead to your findings?  They might also help shed some more light.

4.  Finally, would you please cite the case report from Nigeria you mention, e.g., abstract from Pubmed if available, or your choice narrative of it.

I imagine that you have examined and ruled out such factors as co morbidities; and that considerations such as the following are not in the picture: socio-cultural perception of body image, or challenges of ambiguity of language [in this case: Hindi, as you are based in central U.P.] in some contexts that might allude to symptoms of, for example, purely sensory via peripheral nerve impairment vs. a higher cortical sourced impairment, e.g., from a CNS lesion.

I look forward to following your and other's responses on this particular LML trail, after which I may be more informed to address your initial question re: sensory re education.   Thank you, Karthikeyan.


With warm greetings,

Robert

Robert S. Jerskey, LOTR, prevention of disability consultant
robjerskey@yahoo.com


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Saturday, March 15, 2014

(LML) Effectiveness of sensory re-education in leprosy

Leprosy Mailing List – March 15,  2014 

Ref.:   (LML)  Effectiveness of sensory re-education in leprosy

From:  Karthikeyan G, Allahabad, Uttar Pradesh, India


 

Dear LML readers,

 

 

Last week (March 9), Mr. Karthikeyan, an Occupational therapist working in India with The Leprosy Mission Trust India, sent you a LML message with a  request to share experience in the effectiveness of sensory re-education in leprosy.

He wrote: “I have seen the patients with recovered sensation (touch) after nerve damage due to leprosy, but their perception (cortical representation) of objects in hand seems to be disturbed. I am interested in sensory re-education after nerve damage in leprosy. I have found one case report from Nigeria, where they reported improvement after intervention. May I ask the readers to share their experience in the effectiveness of sensory re-education in leprosy? Karthikeyan G, Occupational Therapist,The Leprosy Mission Hospital Naini | Allahabad - 211008 | Uttar Pradesh | India.Contact No: +91 99352 84315 | E-mail: karthikot@hotmail.com | Skype: karthikeyan.ot | Website: www.tlmnaini.org?”

 

Anyone willing to give their advice?

 

Kind regards,

 

 

Pieter AM Schreuder

Editor LML

 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Friday, March 14, 2014

(LML) Leprosy and Slavery in Suriname

Leprosy Mailing List – March 14,  2014 

Ref.:   (LML)  Leprosy and Slavery in Suriname

From:   Stephen Snelders, Utrecht, the Netherlands


 

Dear readers,

 

 

Last month I attended a presentation about the history of leprosy in Suriname (South America) and in Indonesia. Dr. Stephen Snelders of the Descartes Centre for the History and Philosophy of the Sciences and the Humanities, Utrecht University, and the Julius Centre for Health Sciences of the University Medical Centre, Utrecht, The Netherlands agreed to our request to pay attention to his publication in LML. His article about Leprosy and Slavery in Suriname (see attached file) was published in Social History of Medicine, a journal concerned with all aspects of health, illness, and medical treatment in the past. Any question or comment you can contact Dr. Snelders by email: stephsnel@gmail.com.

 

Summary of above-mentioned article: “The skin disease boasie became a major health problem in the Dutch colony of Suriname from the 1740s–1750s onwards. European doctors attempted to come to a closer understanding of the disease, and established that it was identical to the leprosy of Antiquity and the Middle Ages. The Prussian surgeon and medical doctor Godfried Wilhelm Schilling (c. 1735 – after 1795) played a key role in this process. Schilling tried to give solutions to the medical and public health problems related to the disease. In particular, he had to mediate between the public interests of the colonial authorities, wishing to curb the spread of the disease, and the private interests of the local planter and slave-owning elite, concerned about financial losses. Schilling framed boasie as a disease of African origin, with strong racial and sexual overtones. This racial framing contributed to policies of isolation of boasie sufferers.

The disease was tainted with moral and cultural value judgments, as a health danger brought over byAfrican slaves, threatening the new Caribbean slave societies of the eighteenth centuries and ultimately the Dutch colonial empire itself. This framing of leprosy in racial terms was not a product of nineteenth century imperialism, Social Darwinism and bacteriology, but of the plantation economy and of a premodern Medicine”. Snelders S. Leprosy and Slavery in Suriname: Godfried Schilling and the Framing of a Racial Pathology in the Eighteenth Century. Social History of Medicine Advance Access  June 11, 2013; pages 1-19.

 

Kind regards,

 

Pieter AM Schreuder

Editor LML


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

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(LML) Righting Wrongs : Restoring Dignity

Leprosy Mailing List – March 14,  2014 

Ref.:   (LML)  Righting Wrongs : Restoring Dignity

From:  Deirdre Prins-Solani, South Africa


 

Dear LML readers,

 

I am pleased to present to you the much acclaimed presentation of Dr  M. Deidre Prins-Solani at the International Leprosy Congress, Brussels, September 2013.

 

Dr. M. Deirdre Prins-Solani is an  Independent Heritage and Cultural expert, member of IDEA and the International Coalition of Historic Sites of Exclusion and Resistance.

 

The presentation (see attached file) is called”: “Righting Wrongs : Restoring Dignity. Embracing Justice through Acts of Recognition”.

 

Some quotes from her presentation:

 

-           “There will come a time when it will not be possible to have first -  hand accounts – when voices of people who lived under much duress because of leprosy will no longer be heard. Now is the time to bear witness to these accounts and preserve them for future generations” Ymelda Beauchamp

-          “One of the great values of oral history is its ability to amplify the voices of communities, movements or individuals by taking them outside, by breaking their sense of isolation and powerlessness by allowing their discourse to reach other people and communities” Allisandro Portelli

-          “The identification of redressable injustice is not only what animates us to think about justice and injustice, it is also central to the theory of justice” Amartya Sen.

 

Kind regards,

 

 

Pieter AM Schreuder

LML editor

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

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(LML) Clinical leprosy course in Bangladesh

Leprosy Mailing List – March 14,  2014 

Ref.:    (LML) Clinical leprosy course in Bangladesh

From:  Ruth Butlin, Nilphamari, Bangladesh


Dear Dr. Schreuder,

 

The Leprosy Mission is going to run a course on clinical leprosy 15th to 19th June 2014 at DBLM hospital, Nilphamari, in NW Bangladesh. It is designed for doctors working at leprosy hospitals or in leprosy control programmes or for leprosy research projects. However other technical staff such as physiotherapists may also benefit from participation.

 

There will be plenty of practical work during the 5 day course and also an option of staying on for another week for visits to the hospital departments and field work, or for attending ward rounds with the regular hospital staff.

 

Facilitators include doctors and others experienced in leprosy work. Teaching will be in English.

Accommodation is available at the training centre  on the compound.

 

For further information, please contact Dr C Ruth Butlin on drruth@tlmbangladesh.org

 

Yours sincerely,

 

C Ruth Butlin


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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Sunday, March 9, 2014

(LML) Effectiveness of sensory re-education in leprosy

Leprosy Mailing List – March 9,  2014 

Ref.:   (LML)  Effectiveness of sensory re-education in leprosy

From:  Karthikeyan G, Allahabad, Uttar Pradesh, India


 

Dear Dr. Schreuder,


I am an Occupational therapist working in India with The Leprosy Mission Trust India.

I have seen the patients with recovered sensation (touch) after nerve damage due to leprosy, but their perception (cortical representation) of objects in hand seems to be disturbed.

Am interested in sensory re-education after nerve damage in leprosy. I have found one case report from Nigeria, where they reported improvement after intervention.

May I ask the readers to share their experience in effectiveness of sensory re-education in leprosy?

Thanking you,

With every good wishes,

Karthikeyan G,
Occupational Therapist,
The Leprosy Mission Hospital Naini
| Allahabad - 211008 | Uttar Pradesh | India.
Contact No:
+91 99352 84315 | E-mail: karthikot@hotmail.com | Skype: karthikeyan.ot | Website: www.tlmnaini.org 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com




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(LML) Leprosy patient with foot ulcer

Leprosy Mailing List – March 9,  2014 

Ref.:    (LML) Leprosy patient with foot ulcer

From:  Salvatore Noto, Bergamo, Italy



Dear Pieter,


Thank you very much for the comments by Wim Theuvenet, LML February 28, 2014.  Since last summer I have not seen the patient anymore.  Herewith my answers.


1. Have you checked the footwear that he used after discharge, perhaps ill fitting at the side of the ulcer?
The patient's shoes, that I saw, did not appear to be the cause of the ulcer.

2. Can there be a corpus alienum / exostosis/ bursitis in the deep that is playing up again? Ultrasound and X-ray done?
This investigations were not made at the time of the first ulcer.  Later on, when the ulcer relapsed other colleagues took care of the patient.  I lost contact with him.

3. There seems to be a rather dry skin with hyperkeratosis? Has he soaked, scraped and oiled?
This advice was given.

4. What is his residency status, any gain from being admitted ?
He had no job, income and, immigration documents.    A very difficult socio-economic position.  His admission to hospital was due to its recurrent reactional state. 

Yours sincerely,


Salvatore

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

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