Leprosy Mailing List – April 5, 2014
Ref.: (LML) Effectiveness of sensory re-education in leprosy
From: Robert Jerskey, California, USA
Dear Pieter,
I enjoyed reading the two correspondences posted last Monday [LML March 24, 2014: Dr. Dinkar Palande and Mr. G. Karthikeyan, respectively]. I greatly appreciate all the well crafted details, including the table, Mr. Karthikeyan submitted. Very, very informative.
I was able to locate and peruse the full article on sensory re-education cited (Nakada M & Uchida H., "Case Study of a Five-stage Sensory Re-education Program". J Hand Ther, 1997; 10:232-239). Indeed, the patient described in their case study--who is blind--was with considerable sensory loss in her left hand, e.g., not able to perceive the thickest of the monofilaments: 300 gm level [filament index number, or FIN, 6.65]. That said, they report how the 5 stage sensory re education program, well elucidated in the article, achieves some degree of success with that leprosy patient. They mention in the conclusion that "the most effective techniques of sensory re-education involved discrimination of an object's characteristics or materials by utilizing step-by-step proprioception and input sensory information" [pg. 238].
I italicized the word "proprioception" earlier because, due to the significant degree of sensory impairment, that sensory modality may be key, whether the patient is visually impaired or not---as apparently is the case with Mr. Karthikeyan's patient. The latter part of that sentence, "input sensory information" appears to be what is being well implemented for the 23 year old student, including his home exercise program with the kit. And, as he is being followed in Naini, Allahabad with occupational therapy; purposeful therapeutic activities, a cornerstone of O.T., engages, among other functions, the proprioceptive.
To reference the other March 24th posting: Dr. Palande cogently closes his post, "purposive movements with a feedback are the key to recovery". I would see that as an essential for any sensory re-education program.
In the Americas, at the L.A. and San Diego clinics we have used a range of textures and common items/objects with patients with less degree of sensory impairment, ie., mild-moderate. I can appreciate how integral proprioception would be as a key modality for those who are not able to even perceive the 300 gm filament. We follow a 52 year old patient at the San Diego clinic who is not able to perceive that filament at any site in either hand, and he clearly has cultivated that modality to help compensate for deep pressure sensory impairment amidst his activities of daily living.
I don't have, unfortunately, any novel strategies to contribute to such a methodical program in Naini, Allahabad underway for patients as the 23 year old student, but I would like to encourage the inclusion of the use of the 200 mg [0.2 gm] monofilament [FIN 3.61]* for all patients who receive a sensory assessment for the hand. If that 200 mg filament----1/10th the peak designated force on the target area of the skin vs. the 2 gm monofilament [FIN 4.31]---is systematically utilized with the others, patients with nerve function impairment, whether via silent neuritis or acute neuritis, may be identified much earlier on, and treated accordingly with corticosteroids. Less likely to have residual long term sensory impairment, or worse.
I, again, extend my appreciation to Mr. Karthikeyan and his colleagues with the work, investigations they are carrying out with sensory re-education in leprosy patients---a challenging area with a paucity of published literature as a touchstone, unlike re: trauma or nerve repair.
Friendly greetings to all.
Thank you,
Robert
Robert S. Jerskey, LOTR, prevention of disability consultant
*There have been a number of normative studies with the monofilaments on the hand [and the foot] in the Indian subcontinent over the years that have concluded that the 200 mg filament is the choice filament to begin the sequential order of graded monofilament testing for the hand**. With the exception of children, that was my conclusion for a normative study of 579 subjects in north and south India which I presented at the 1993 Congress in Orlando. I found the 70 mg filament [FIN 2.83] appropriate for children's hands.
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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