Leprosy Mailing List – February 5, 2017
Ref.: (LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.
From: Linda Lehman, Belo Horizonte, Brazil
Dear Pieter,
I have been following the Leprosy Listing comments on Monofilaments (MF) and ball point pen(BP) /clip testing for the last month with comments from many experts in the field. It always stimulates much good reflection and discussion. It all comes down to priorities and commitment to enable early detection of Nerve Function Impairment (NFI). I will comment on the following areas:
1. Priority for Disability Prevention
2. Using LOFT to discover Nerve Function Impairment
3. My 40yrs Experience with MF and BP pen/clip experience in work in the Americas, Africa and Asia in the field and reference centers
4. Share the Brazil experience adopting and using MF for sensory testing and the adoption of MF within National Leprosy Guidelines, training and monitoring activities
Priority for Disability Prevention
My question is, do we want to Prevent Disability? This requires BOTH early disease detection and Early Detection of NFI along with adequate treatment for the NFI.
Using “LOFT” to discover Nerve Function Impairment
Whether we use MF, ball point pens, clips we must remember to think of LOFT:
LISTEN carefully to the patient’s comments;
OBSERVE for atrophies, injuries, dryness, etc.;
FEEL for sweating, temperature difference; and
TEST sensory and motor function and take ACTION when NFI is identified.
My Experience with MF and BP /clip experience in work in the Americas, Africa and Asia in the field and reference centers
· Both require good training on testing technique, interpretation and using information to make decisions on treatment interventions (corticosteroids, surgery).
· Both require constant training and monitoring during field visits to assure NF evaluation is done, is done correctly, interpreted correctly and then that needed action is taken. It seems to be a never-ending job!
· BP pressures vary from 4g (rare) to over 300g depending on the person. Getting a consistent 10g pressure touch is rare and can improve with training. When BP not felt, motor function is usually involved, indicating advanced NFI. If not felt, we know the person is AT Risk for Injury.
Caution: Feeling BP does not mean sensation and nerve function are normal!
· MF are not perfect and have their limitations but are more repeatable and reliable than BP and paper clips. They can demonstrate change in NFI, if a series of filaments are used. Using 10g does not detect NFI early, it only tells us someone is AT RISK for injury. Feeling 10g does not mean sensation and nerve function are normal. The greatest limitation of MF is that they are not easily accessible or available.
Brazil Experience with MF
· Brazil is the 5th largest country (8,516 million km2) in the world and has over 30,000 new cases of leprosy each year. There are more than 5,500 municipalities in 26 states and 1 federal district.
· At the ILA China 2016 Congress I presented on a 24-year follow-up of using MF within the national Hansen’s disease control activities after MF kits were produced and available in Brazil. http://www.sorribauru.com.br/custom/462/uploads/English223.pdf
· Initially in 1983 only two locations in Brazil used imported MF kits and today MF kits are produced and used in all 27 federal states and district of Brazil.
· A Monkey Survey was done Aug 2016 with all Brazilian State HD Coordinators and the National Program. Results of data from 13 state coordinators and National program are as follows:
o MF in Leprosy: 100% in reference centers, 92% Primary Health Care, Other - Universities, private clinics and other non-leprosy services use MF (diabetes, neuropathies, research cancer, etc.).
o Most High endemic states. 75% of municipalities who attend HD use MF.
o All use 6 monofilament kits (0.05g, 0.2g, 2g, 4g, 10g, 300g). If only 1 filament is used, the 2g is used for both foot and hand, as oriented in Brazil National Hansen’s disease Guideline and 10g for the diabetic foot as oriented by the National Diabetic Foot program.
o When MF are used in government health services, it is part of the routine practice in leprosy and diabetes (93%) versus only with referral.
o MF have been a part of the Brazil National Leprosy Guidelines, training manuals and monitoring activities since 1998.
o MF use in leprosy programs was adopted due to the following factors:
§ Beliefs and knowledge of Professionals that MF testing detects and quantifies NFI best and is important to disability prevention.
§ MF are Accessible and Available IN COUNTRY.
§ Good quality control of produced MF Kits by producer.
§ Good durable MF Kit design for the field.
§ MF is initially complex to learn but possible with training and monitoring.
§ NFI Results and changes are easy to see with color coding.
§ Political commitment of National Leprosy Control Program of Brazil in adopting MF within routine leprosy control program.
TAKE HOME MESSAGE:
MF are best for detecting and monitoring NFI in the field but MF must be made accessible and available with good quality control production at a reasonable cost. It requires National and local political and professional commitments to include MF within guidelines, training and monitoring activities.
Linda F. Lehman, OTR/L MPH C.Ped
Senior Advisor for Morbidity Management & Disability Prevention
American Leprosy Missions
Reference Article:
Lehman, Linda Faye, Maria Beatriz Penna Orsini, and Anthony Robert Joseph Nicholl. "The development and adaptation of the Semmes-Weinstein monofilaments in Brazil." Journal of Hand Therapy 6.4 (1993): 290-297.
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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