Leprosy Mailing List – April 5, 2014
Ref.: (LML) Effectiveness of sensory re-education in leprosy
From: Grace Warren, Sidney, Australia
Dear Pieter,
I am so glad that Piet Both sent that article about sensory re-education (LML April 1, 2014). I must confess that I have not tried hard to re-educate sensory perceptors but feel I must share the experiences I have now had for many years with re-education of motor nerves.
Back in the 1960s, when I was learning leprosy we concentrated on the patients doing hand exercises to maintain their ability to function after the damage to motor nerves in the hands. The therapists who came to us at the Hong Kong Leprosarium early in the 1960s had little idea of what would help so we developed a series of 7 exercises aimed at maintaining the usefulness of hands. We found that if applied early with adequate anti-inflammatory therapy these exercises often meant the patient regained the function of the hand and it was no longer obviously clawed or was not as badly clawed as initially, and did not deteriorate further while exercising was continued.
Many years later dealing with hand deformities due to other causes - i.e not leprosy - e.g. CMT (Charcot–Marie–Tooth disease, a group of disorders of the peripheral nervous system characterised by progressive loss of muscle tissue and touch sensation across various parts of the body) has a similar picture of a clawed hand - I found that many CMT patients were able to re-educate the hand muscles to a functional degree. In CMT they may never get full strength ( weak flexors) but were often able to improve at least lumbrical action so that without any surgery they could return to a normal looking functional hand. Several of my patients were able to resume office jobs working with pins and papers after a few months of exercise ( one patient achieved it in a few weeks!) and maintained that ability for many years.
These hand exercises are published in my Book" Care of neuropathic foot" which will soon be available in the web if you do not already have it, or copies of the exercises that have been published in several places. We have also made it into a DVD so we can give to any patient to whom it may be helpful so they can see the exercises and teach themselves.
With the CMT patients with foot involvement, whom I saw in the 1990s I discovered some very interesting facts. If, in the patient with a definite foot drop, we transferred Tib. Posterior to the dorsum as a dorsiflexor he often got return of effective dorsiflexion in other muscles on that foot. Certainly he appeared to get no further muscle loss in the anti tibial muscles. And if he exercised both legs he often prevented the complete drop developing in the other foot.
I found that if a patient was seen when the ant Tib. Muscles had weakened but still could produce a flicker, and was taught strengthening exercises and rested at night in a splint to prevent marked plantar flexion which stresses the anterior tibial muscles he could often restore a practical dorsiflexion. This was in contrast to the routine therapy to put on night splints which may prevent gross plantar flexion but do not encourage strengthening on the anterior tibial muscles. It was most satisfying to see a number of younger siblings prevent the development of a full drop even though their muscles were already weak when they presented as the time an elder sibling came for reconstructive surgery. One teenager, we operated on the bad foot - one foot only at mothers request- and the Physio took him in hand and within 6 months of surgery the other foot had recovered enough so he could resume football without any surgery.
One can only assume that in CMT and in Leprosy, the all the fibres of any one nerve are not affected, and often there are enough functioning fibres to use, if the patient can learn to think function . This is so opposite to the traditional idea in CMT “Oh give him a foot drop splint at night and toe raising devise by day- and no effort to make him use what he has got”. Work here in Australia has also shown the Vit C in large doses helps to reduce the amount of dysfunction in motor neural deficit in CMT. We found in Thailand that adequate doses of B1 per day helped maintain nerve function in areas were polished rice is the staple and little attention is paid to supplementing for the fact that the same fields have been cultivated for years and not adequately fertilised.
Yes, these are simple ideas and I must confess I do not have documented records of trials but it certainly works. I have many CMT patients here in Australia who are convinced that the vitamin and mineral cocktail ( we regularly order) makes all the difference, in some indefinable way, to their general well being. The same as we found in Thailand that a good Multivitamins and mineral, with Vit B1 at 10 mgs reduced symptoms and problems for many patients. Quite as few of them have benefited from the same tendon transfers we use for leprosy and are very grateful for the increased function and acceptability that they now have. Many of our leprosy patients come for areas were their diet in compromised and I have long recommended the use of a good multivitamin and mineral to help improve the whole of the patients well being.
I would be fascinated to hear of others who have tried this and have any statistics to support or contradict what I am saying.
Grace Warren
Previously Travelling Adviser Leprosy and Reconstructive Surgery for the Leprosy Mission Asia
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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