Fisioterapi Lepra
Fisioterapi Lepra
Fisioterapi Lepra
Summary
Objective: To determine the effectiveness of individualised rehabilitation
programmes intended to reduce disabilities in patients with Hansen’s disease.
Methodology: This is an interventional study (before and after), carried out among
ten leprosy patients whose previous multidisciplinary assessment (medical,
physiotherapy, and biomechanical) designated to them an individualised rehabilita-
tion programme according to the singular condition of each patient. Patients were
evaluated every three months for one year.
Results: 70% of participants were male, 60% of who presented disability Grade 2,
30% Grade 1 and 10% Grade 0. All patients had abnormalities in gait parameters
(step width and speed). Furthermore, 100% of patients displayed improvement in
flexibility, arch joint movement and strength.
Conclusions: The implementation of individualised rehabilitation programmes
allowed us to detect nerve damage. Early implementation of an individualised
rehabilitation programme may mitigate and/or prevent the progression of disability in
people affected by leprosy.
Keywords: Leprosy; Hansen’s disease; physiotherapy; electromyography; disability; neuropathy
Correspondence to: Cardona-Castro N, Instituto Colombiano de Medicina Tropical, Carrera 53ª̄#52 S-99,
Sabaneta, Antioquia, Colombia (e-mail: [email protected])
Introduction
This is an intervention study that compares the response of ten patients with leprosy after
implementation of an individualised rehabilitation programme.
STUDY POPULATION
The selection of this sample took into account the records of patients diagnosed with
Hansen’s disease in the last 10 years in the Aburra Valley, where are located Medellı́n, Itagüı́,
Envigado, Sabaneta, and Bello municipalities (Antioquia).
Effectiveness of an individual physical rehabilitation programme 357
EVALUATIONS
Medical evaluation
The medical evaluation established the degree of disability (in the eyes, hands and feet of the
patient) and the impairment of the peripheral nervous system using Semmes Weinstein
monofilaments (SW)13 to explore superficial sensitivity. Furthermore, the immune and
bacteriological status of patients was determined using the bacillary index following
previously established methods.14 An ELISA for IgM against phenolic glycolipid-1 (PGL-1),
and its relationship to neuritis, was evaluated.15 In addition, we looked for antecedent signs
and symptoms of leprosy reactions and relapses.
Physiotherapy evaluation
This evaluation was to determine the functionality of body structures essential in carrying out
of daily activities. To do this we evaluated flexibility, joint range of motion (JRM),
pallesthesia, records of strength (grip, gripper and extension) and the presence of intrinsic
muscle weakness in the hands and feet (Froment and Paper grip test).16
Biomedical evaluation
This assessment recorded the initiation of muscle activity and power through the signal
recording Root Mean Square (RMS), an indirect method to measure nerve conduction
velocity using FREEEMG equipment.1 We also evaluated the gait of these patients using the
VICON motion capture system.17 Finally, we evaluated the plantar (foot) pressure and foot
damage using a tekscan rug.16
INTERVENTION
ANALYSIS OF DATA
Data was analysed using Excel and SPSS 18.0 software. Analysis of the distribution variables
was performed using a Shapiro-Wilk test. Comparison of the qualitative variables (before and
after the rehabilitation programme) was performed through the x 2 de McNemar test.
Comparison of quantitative variables (before and after) was performed with a paired Students
t test or a Wilcoxon test taking into account the distribution of these variables. The
significance level of P , 0·05 was established for all analyses.
358
Table 1. Selecting individualised rehabilitation techniques according to the findings of the physical examination
Muscle shortening † Hands and feet Static self-stretching Complete response Maintenance with active exercises
† Shoulder girdle
† Pelvic girdle Incomplete response Proprioceptive Neuromuscular Facilitation
(PNF) self-stretching (hold-relax)
Limited range Synovial joints of Self-stretching and passive Complete response Maintenance with active exercises
of motion upper and lower limbs forced range of motion
Incomplete response Joint mobilization for small joints
Results
CHARACTERISTICS OF THE PATIENTS EVALUATED
70% of the patients were male with an average age of 56 years and an age range of 37– 78
years. 90% of the patients were classified as MB and 60% had disability Grade 2, 30%
disability Grade 1 and the remaining 10% were disability Grade 0. Further, 40% of the
patients had history of leprosy reaction Type 2, 50% exhibited high PGL-1 antibody titers,
and 60% showed positive bacillary index. Table 2 shows the demographic, clinical,
bacteriological and immunological stage of each patient evaluated.
Evaluation of sensitivity in the hands and feet showed that 90% of the patients displayed
evidence of anesthesia in these areas. As expected, we did not observe a recovery of
sensitivity in these areas after implementation of the rehabilitation programme.
When evaluating muscle flexibility in the upper and lower limbs, we found that 100% of
the patients, upon the first assessment, displayed some muscular contraction of the upper and
lower limbs. Implementation of our programme was effective in reducing the number of
retracted muscles in 100% of the participants (see Table 3).
Our results of the recovery of flexibility in the upper limbs (in 80% of the patients) and
lower limbs of (50%) are shown in Table 4.
With respect to the joint range of motion (JRM), the distal areas of the hands and feet
were affected in 60% of the participants upon first assessment. It is worth mentioning that the
rehabilitation programme was effective (100%) in reducing the JMR compromise in these
patients (see Table 3), being statistically significant in 40% of the cases (see Table 4).
1 RH:7 85·8% of the RLL:6 50% of the retracted 13 Improving of Grip:204 N Grip:108 N Grip:296 N Grip:271 N
LH:7 retracted muscles LLL:6 muscle on the RLL 92·3% of the Gripper:5·9 kg Gripper:5·9 kg Gripper:3·2 kg Gripper:5·22 kg
H. Serrano-Coll et al.
were improved on and 66·7% on the LLL affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:1·1 kg finger:0·57 kg finger:1·13 kg finger:1·7 kg
2 RH:6 83·4% of the RLL:4 50% of the retracted 5 Improving of Grip:217 N Grip:178 N Grip:77 N Grip:54 N
LH:6 muscles retracted LLL:4 muscles retracted 100% of the Gripper:3 kg Gripper:1·13 kg Gripper:4·3 kg Gripper:6·4 kg
were improved on were improved on affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH the RLL and the LLL finger:0·30 kg finger:1 kg finger:1·5 kg finger:0·8 kg
3 RH:4 100% of the RLL:6 100% of the retracted 0 Integrity of Grip:486 N Grip:514 N Grip:146·1 N Grip:146 N
LH:3 muscles retracted LLL:6 muscles on the RLL JRM were Gripper:9·1 kg Gripper:9·1 kg Gripper:0 kg Gripper:0 kg
were improved on and 75% on the LLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:2·3 kg finger:2 kg finger:0·18 kg finger:0·27 kg
4 RH:7 85·8% of the RLL:5 25% of the retracted 16 Improving of Grip:206 N Grip:179 N Grip:14 N Grip:33 N
LH:7 muscles retracted LLL:5 muscles on the RLL 62·5% of the Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg
were improved on and 75% on the LLL affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:1·13 kg finger:1·13 kg finger:1·02 kg finger:0·91 kg
5 RH:4 75% of the muscles RLL:5 80% of the retracted 0 Integrity of Grip:202 N Grip:214 N Grip:82 N Grip:131 N
LH:4 retracted were LLL:5 muscles were JRM was Gripper:4·5 kg Gripper:4·5 kg Gripper:2·27 kg Gripper:4·5 kg
improved on the improved on the RLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
RH and the LH and the LLL finger:1·3 kg finger:1·2 kg finger:0·52 kg finger:0·64 kg
6 RH:4 100% of the RLL:4 50% of the retracted 3 Improving of Grip:383 N Grip:344 N Grip:96 N Grip:127 N
LH:4 muscles retracted LLL:3 muscles on the RLL 100% of the Gripper:3·2 kg Gripper:4·5 kg Gripper:6 kg Gripper:4·5 kg
were improved on and 33.4% on the affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH LLL were improved finger:0·73 kg finger:1 kg finger:1·5 kg finger:1·3 kg
7 RH:2 100% of the RLL:3 83·4% of the retracted 0 Integrity of Grip:561 N Grip:534 N Grip:4 N Grip:23 N
LH:2 muscles retracted LLL:2 muscles on the RLL JRM was Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg
were improved on and 100% on the LLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:1 kg finger:1 kg finger:0·23 kg finger:0·23 kg
Table 3. continued
8 RH:4 100% of the RLL:6 83·4% of the retracted 6 Improving of Grip:293 N Grip:363 N Grip:127 N Grip:88 N
LH:4 muscles retracted LLL:6 muscles on the RLL 100% of the Gripper:3·2 kg Gripper:4·5 kg Gripper:5·5 kg Gripper:4·5 kg
were improved on and 100% on the LLL affected JMR Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:0·23 kg finger:0·34 kg finger:1·1 kg finger:1·8 kg
9 RH:7 85·8% of the RLL:6 50% of the retracted 29 Improving of Grip:21·7 N Grip:297 N Grip:322 N Grip:89 N
LH:7 muscles retracted LLL:5 muscles on the RLL 82·8% of the Gripper:0 kg Gripper:0·8 kg Gripper:3·9 kg Gripper:8·3 kg
were improved on and 40% on the LLL affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:0 kg finger:0·6 kg finger:1·3 kg finger:1 kg
10 RH:1 100% of the RLL:3 66·7% of the retracted 0 Integrity of Grip:314 N Grip:291 N Grip:18 N Grip:99 N
LH:1 muscles retracted LLL:2 muscles on the RLL JRM was Gripper:3·9 kg Gripper:3·5 kg Gripper:5·2 kg Gripper:4·2 kg
were improved on and 50% on the LLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:2 kg finger:1·6 kg finger:0·27 kg finger:0·7 kg
RH: Right Hand /LH: Left Hand /RLL: Right Lower Limb /LLL: Left Lower Limb.
*JRM: Joint Range of Motion affected.
**Evolution: results evidenced in the patient after applying the rehabilitation program.
***Increase: changes in strength records in the patient when comparing the initial assessment with the last assessment.
Effectiveness of an individual physical rehabilitation programme
361
362 H. Serrano-Coll et al.
Table 4. Effectiveness of individualised rehabilitation programme in improving sensitivity, flexibility and JRM when
comparing evaluation 1st with 5th
Patients UL LL UL/LL
1 0·001 0·016 0
2 0·002 0·031 0·063
3 0·016 0·001 nc
4 0 0·5 0·002
5 0·031 0·008 nc
6 0·031 0·25 0·25
7 0·5 0·5 nc
8 0·008 0·001 0·031
9 0 0·063 0
10 0·5 0·125 nc
UL: upper limbs. LL: lower limbs. nc: no changes. Val: evaluations.
*Value P calculated comparing evaluation 1 vs evaluation 5.
Pallesthesia
As expected, we did not observe an affect in the deep sensory pathway in 92% of the
structures explored during the first assessment, 97% in the second, 96% in the third and 98%
in the fourth and fifth evaluation.
Table 5. Effectiveness of individualised rehabilitation programme on strength (grip, gripper, extension) when
comparing evaluation 1st with rest of the evaluations
Extension strength
Grip strength Gripper strength (I-II finger)
Val: evaluations.
*P , 0·05.
Effectiveness of an individual physical rehabilitation programme 363
grip test was positive in 20% of patients for both feet (second assessment) and 30% in the
right foot and 10% in left foot (fifth assessment).
Electromyography
Electromyographic records (RMS) showed statistically significant changes for one of the four
pairs of muscles in the evaluated upper limbs, corresponding to the flexor digitorum
superficialis muscle.
Plantar pressures
This test showed that the area subjected to a greater pressure was the heel (79·6%) followed
by anterolateral eminence (12·2%) and anteromedial eminence (8·2%). We observed that
60% of the patients had alterations in the distribution of their plantar pressure levels. The
average maximum pressure for the right plant was 272 ^ 9·1 mmHg and in left plant was
265 ^ 5·8 mmHg.
Discussion
Patients included in this study had a late diagnosis of leprosy, likely due to their grade of
disability, reflecting the late diagnosis of leprosy in Colombia where , 70% of new cases are
MB.14 Of the patients in this study, 50% had positive bacillary index and IgM anti-PGL-1
titers. PGL-a is an important biomarker of neural damage as it interacts with the basal lamina
of Schwann cells.15
SENSITIVE EVALUATION
The recovery of sensitivity in the hands and feet after implementation of our programme had
a low effectiveness. This result is not surprising as the recovery of short-term sensitivity
is a complex process. In addition, to assess sensitivity in these areas, we used SW. Despite
being a sensitive instrument in the detection of peripheral neuropathy,19 SW has a subjective
interpretation—altered environmental conditions (such as temperature and humidity) at the
location of the evaluation can affect the bending of SW, possibly compromising the quality of
the results.20 Dros et al.20 considered this type of data ambiguous given the variation in
sensitivity (41% – 93%) and specificity (60 – 90%); SW lacks an adequate methodology for its
364 H. Serrano-Coll et al.
implementation and has no clear consensus on the appropriate thresholds regarding the
degree of neuropathic damage.
FLEXIBILITY EVALUATION
Pallesthesia
Deep sensitivity was preserved in the patients of this study given that the pallesthesia test with
tuning forks (128 – 256 Hz) was positive in over 95% of the patients, demonstrating that
leprosy only affected the superficial sensitivity transmitted through the spinothalamic
pathway.9
Electromyography evaluation
During the electromyography evaluation, comparison of the RMS records in the different
evaluations only showed statistically significant data for the flexor digitorum superficialis
muscle, which is innervated by the median nerve. While this may reflect an increase in the
activity of this muscle, it is not possible to conclude that there is a better neuroconduction
(indirectly) by the median nerve. Furthermore, we infer that recovery of intrinsic muscle
activity and nerve conduction may require rehabilitation programmes designed for the long-
term or, alternatively, surgical techniques (peripheral nerve decompression).24
The physical programmes implemented by the physiotherapy team were initiated to aid in
the recovery of muscle flexibility, JMR and improved strength. The physiotherapy team
accomplished each of these objectives. Further, the team worked to improve functionality in
the hands and feet in order to provide an adequate grip, a better gait and improved balance in
these patients.
With this proposal for rehabilitation in leprosy, we remark that the programme should be
individual, since every patient has different damage or necessities. At this time of the
advanced medicine, other neuropathies as the diabetic neuropathy, are diagnosed, treated, and
rehabilitated with modern tools. In Colombia we have the development and personnel to
improve the rehabilitation and prevention programme for leprosy patients; however the
budget for these measures is not available.
Conclusions
Acknowledgements
This project was partially financed by the Dirección de Gestión del Conocimiento de la
Universidad CES INV 022014002, by the Instituto Colombiano de Medicina Tropical –
Universidad CES, by the Escuela de Ingenierı́a de Antioquia – Universidad CES and by the
Physiotherapy Faculty of Universidad CES.
The authors wish to especially thank Dr. Wim Theuvenet for his assessment and discussion
on this project.
We appreciate the support as physiotherapists of Sara Hernández, Lucı́a Maya, Maria Isabel
Hernández Suárez, and Felipe Monsalve. Also the support as biomedical engineer of Nicolás
Gómez.
Conflict of Interests
The authors declare that there is no conflict of interest in relation with the publication of this
document.
Ethical considerations
This research was approved by the Ethical Committee of the Universidad CES. This research
was conducted according to international ethical norms issued by the World Health
Organization and the Pan American Health Organization endorsed by the Helsinki
Declaration, adopted in 1964 and the statutes given nationally by Resolution No. 008430 of
1993 the Ministry of health of Colombia that regulates health studies, this research is
considered minimal risk.
Effectiveness of an individual physical rehabilitation programme 367
References
1
Véras LST, Vale RGS, Mello DB de et al. Degree of disability, pain levels, muscle strength, and
electromyographic function in patients with Hansen’s disease with common peroneal nerve damage. Rev Soc Bras
Med Trop, 2012; 45: 375 –379.
2
van Brakel WH, Sihombing B, Djarir H et al. Disability in people affected by leprosy: the role of impairment,
activity, social participation, stigma and discrimination. Glob Health Action, 2012; 5: 18394 - http://dx.doi.org/
10.3402/gha.v5i0.18394 (pages in PDF are 1–11).
3
Guerrero MI, Muvdi S, León CI. Delay in leprosy diagnosis as a predictor of disability in a cohort of patients in
Colombia, 2000-2010. Rev Panam Salud Pública Pan Am J Public Health, 2013; 33: 137 –143.
4
Richardus JH, Habbema JDF. The impact of leprosy control on the transmission of M. leprae: is elimination being
attained? Lepr Rev, 2007; 78: 330–337.
5
Cardona-Castro N. Leprosy in Colombia: post elimination stage? Lepr Rev, 2013; 84: 238 –247.
6
Skacel M, Antunes SL, Rodrigues MM et al. The diagnosis of leprosy among patients with symptoms of
peripheral neuropathy without cutaneous lesions: a follow-up study. Arq Neuropsiquiatr, 2000; 58: 800–807.
7
Truman RW, Ebenezer GJ, Pena MT et al. The armadillo as a model for peripheral neuropathy in leprosy. ILAR J
Natl Res Counc Inst Lab Anim Resour, 2014; 54: 304– 314.
8
Chacha JJ, Sotto MN, Peters L et al. Peripheral nervous system and grounds for the neural insult in leprosy. An
Bras Dermatol, 2009; 84: 495–500.
9
Nascimento OJM. Leprosy neuropathy: clinical presentations. Arq Neuropsiquiatr, 2013; 71: 661–666.
10
Cordeiro TL, Frade MAC, Barros ARSB, Foss NT. Baropodometric Evaluations and Sensitivity Alterations in
Plantar Ulcer Formation in Leprosy. Int J Low Extrem Wounds, 2014; 13: 110 –115.
11
Nery JA, da C, Bernardes Filho F, Quintanilha J et al. Understanding the type 1 reactional state for early diagnosis
and treatment: a way to avoid disability in leprosy. An Bras Dermatol, 2013; 88: 787–792.
12
Lienhardt C, Fine PE. Type 1 reaction, neuritis and disability in leprosy. What is the current epidemiological
situation? Lepr Rev, 1994; 65: 9– 33.
13
Moraes A, Costa A. Avaliaçao Neurológica Simplificada. 2013; Fundaçao Alfredo da Matta.
14
Ministerio de Salud y Protección social Colombia. Guı́a de atención integral de la lepra [Internet]. 2012 [citado 18
de octubre de 2014]. Recuperado a partir de: http://www.minsalud.gov.co/Documentos%20y%20Publicaciones/
GUIA%20DE%20ATENCI%C3%93N%20DE%20LEPRA.pdf
15
Pandhi D, Chhabra N. New insights in the pathogenesis of type 1 and type 2 lepra reaction. Indian J Dermatol
Venereol Leprol, 2013; 79: 739 –749.
16
Soysa A, Hiller C, Refshauge K, Burns J. Importance and challenges of measuring intrinsic foot muscle strength.
J Foot Ankle Res, 2012; 5: 29.
17
Gait Analysis & Rehab – Qualisys Motion Capture Systems [Internet]. [citado 23 de septiembre de 2015].
Recuperado a partir de: http://www.qualisys.com/applications/biomechanics/gait-analysis-and-rehabilitation/
18
Kisner C, Allen L. Therapeutic exercise: foundations and techniques. 6th edition, Philadelphia, EEUU: Davis Plus
2012.
19
Ferreira TL, Alvarez RRA, Virmond M da CL. Validation of the questionnaire on hand function assessment in
leprosy. Rev Saúde Pública, 2012; 46: 435– 445.
20
Baraz S, Zarea K, Shahbazian HB, Latifi SM. Comparison of the accuracy of monofilament testing at various
points of feet in peripheral diabetic neuropathy screening. J Diabetes Metab Disord, 2014; 13: 19.
21
Muñoz J, Portocarrero R. Relación entre flexibilidad de los miembros inferiores y compensaciones posturales al
sostener la posición de «en dehors» en estudiantes de ballet de la UNMSM– 2013 [Internet]. [Lima -Perú]:
Universidad Nacional Mayor de san Marcos; 2013 [citado 15 de junio de 2015]. Recuperado a partir de: http://
cybertesis.unmsm.edu.pe/bitstream/cybertesis/3420/3/munoz_yj.pdf
22
Micheo W, Baerga L, Miranda G. Basic principles regarding strength, flexibility, and stability exercises. PM R,
2012; 4: 805–811.
23
Carneiro NH, Ribeiro AS, Nascimento MA et al. Effects of different resistance training frequencies on flexibility
in older women. Clin Interv Aging, 2015; 10: 531 –538.
24
Van Veen NHJ, Schreuders TAR, Theuvenet WJ et al. Decompressive surgery for treating nerve damage in
leprosy. A Cochrane review. Lepr Rev, 2009; 80: 3–12.
25
Tang SF-T, Chen CPC, Lin S-C et al. Reduction of plantar pressures in leprosy patients by using custom made
shoes and total contact insoles. Clin Neurol Neurosurg, 2015; 129 Suppl 1: S12–S15.