Fw: Ref.: (LML) Detection of nerve damage in leprosy and timely treatment

 

Leprosy Mailing List – November 29,  2021

 

Ref.:  (LML) Detection of nerve damage in leprosy and timely treatment

 

From:  Ben Naafs, Munnekeburen, the Netherlands

 

 

Dear Pieter,

There are two things I'm concerned about and want to discuss. The gradual disappearance of the Graded Sensory Testing and the careful monitoring of the leprosy patients. The main arguments for this occurrence are the lack of time and the focus on diagnosis which is clearly also of extreme importance. However, when a patient has been diagnosed, he or she needs to get better. This was exactly the reason why I kept working in leprosy and leprosy research. At the time, in the early 1970s, there was careful monitoring of patients showing how they were deteriorating rather than improving under "care". I was shocked. And in the 80th and 90th thanks to introducing of careful monitoring of nerve damage and adequate timely action the situation improved. But the last 20 years there is a severe deterioration.

I want to reintroduce the use of monofilaments in leprosy as it was used by John Pearson in the early 1970s and later by me. The Graded Sensory Testing started out with the Von Frey's horsehair. Nowadays a nylon filament is in use called Semmes-Weinstein monofilament. But I'm pretty sure it was originally developed, in the 1950's, by one of my promoters, Oxford anatomist Prof Graham Weddell.

It's been years that I've been concerned about the way sensory testing is done today for the diagnosis of nerve damage and the follow-up of treatment. The way we introduced the monofilaments (see attached article), it was a very simple test for the nerve trunks and proved to be the most sensitive way to determine when to start an anti-reaction treatment. After all the most significant neural damage occurs in the nerve trunks. Most importantly, testing for it can be done by the doctor himself in his doctor's office.

After publication Graded Sensory Testing was soon adopted by physical therapists (Judith Bell-Krotoski, Linda Lehman) who were very interested in assessing hands and feet to prevent skin damage. This was done on quite a few testing points on the skin, and it required a lot of concentration and time from the researcher and the patient. The consequence was that it was done less and less, certainly when it disappeared from our armamentarium with the phasing out of leprosy services. It is not even produced at Sorri Brazil anymore (see how it was developed in an article by Linda Lehman, attached). Today you have to buy it from Carville USA. Elsewhere I noticed they are out of stock, and it is not known when they will be available again. The best way is to make them yourself. The use of ballpoint pen promoted by Jean Watson is more or less a desperate solution and only valuable in experienced hands, unlike the monofilaments.

The other problem I noticed is that most leprosy workers feel that it takes too much time to assess a leprosy patient, so they often leave the assessment to others or don't do the assessments at all.

How you should attend to your patients, including discovering impending nerve damage during follow-up, when you no longer have a well-trained physical therapist? The way I see it and do it.

Have the patient enter your doctor's office barefoot, bringing his/her shoes. Watch how he/she walks and check whether the shoes are appropriate. Have the patient stand in front of you and look at his/her toes, are hammertoes developing? Then have the patient sit and feel whether the soles of his/her feet are sweating and whether there are wounds. Do a simple 2-point discrimination test on forefoot and heel. This is just as sensitive as monofilaments and less time consuming. Test dorsiflexion of the feet and big toes. Then feel the nerves (lateral peroneal and posterior tibial) for enlargement, consistency, and tenderness. Then the hands : feel for sweat and test the feeling with the monofilaments, but only the thenar and hypothenar. Be careful not to test in a skin lesion. Note any increasing muscle atrophy. Do a Voluntary Muscle Test (VMT) for thumb abduction, ie movement of the thumb from the little finger upwards. For the little finger test the abductor digiti mini, then the little finger moves to the side. Feel the muscle for the contraction. Then palpate the nerves, ulnar and median. Study their face for asymmetry, do they blink and are their eyes in danger of sensory loss? Test the eye-closing force. Important is to ask them to close the eyes very lightly to see whether there is a small gap between the upper and lower eyelid because this is an early sign of loss of strength.

Record everything carefully. You can use a ready-made form or mention the deviations in your notes. All this can be done in 5-10 minutes. When he/she comes in, talk to the patient after you have prepared by reviewing your notes about the patient. Talk not only about the disease but about his or her family, work and problems too. Take personal notes. (These are private between you and the patient)

In this way, an increase in nerve damage can be detected early and the action is timely. The patient can get better instead of worse under your care, what happens too often nowadays.

Worried

Ben

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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