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
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