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Appendix 1

Facial assessment

Hand assessment

Foot assessment

Appendix 2

TABLE A2 Common adaptive / assistive devices used in leprosy

Name of the device

Indication

Brief description

Adapted spoon

APP4_3_1_RW1.png

Those with no grasp due to absorbed digits or complete paralysis of hand muscles

Device is made of a spoon attached to an aluminum cuff to facilitate the retention of the spoon in the hand while eating. This device can be adopted for a toothbrush and a comb.

Built-up spoon

APP4_3_1_RW2.png

Those with some grasp but inability to hold thin items such as a spoon or toothbrush during function movement

Soft material is padded around the spoon handle to facilitate grip for those with poor hand grasp. The same modifications can be done for a toothbrush, pen, shaving razors, and comb.

Nail cutting device

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Those with deformities; clawed fingers and thumb paralysis

Nail cutter is attached to stable base and cutter handle is broadened to facilitate easy cutting of nail.

Soap holder

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Those with paralyzed fingers and thumb or absorbed digits with difficulty in grasp

Soap is fixed into an aluminum holder, which is attached to a stable cuff around the palm to facilitate the retention of the soap in the hand. This device is rarely used.

Button hook

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Those with difficulty in fine motor activity due to paralysis and/or loss of sensation

A hook is fixed to a soft handle to facilitate buttoning, which is very challenging for those with thumb paralysis.

Writing aid

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Those with poor prehension (tripod) function with some pinch power

A soft rubber grip slips onto a pen or pencil to facilitate grip while writing.

Grip aids

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Those with absorbed digits with some grasp/prehension function

Made of a special material that takes the shape of the contact surface of the fingers to facilitate easy grasp.

Universal cuff

APP4_3_1_RW8.png

Those with poor or no grasp due to absorbed digits or paralysis of muscles of the hand

Those without fingers or loss of grasp

This device consists of a nylon or leather cuff around the palm with a pocket to insert a spoon, toothbrush, comb, etc.

Zipper puller

APP4_3_1_RW9.png

Those with poor prehension function

This device consists of a hook with a ring at one end to facilitate pulling a zipper.

Appendix 3

TABLE A3 Exercises recommended for peripheral nerve injuries*

Nerve

Major Muscle(s) affected

Active Exercise

Active Assisted Exercise

Passive Exercise

Facial

Orbicularis Occuli

Patient should try to tightly close eye, hold it for 10–20 counts, and then open it. Repeat 5 to 10 times hourly.

Patient should place index finger at lateral side of eye and gently pull eyelid laterally so that it closes.

Ulnar

Abductor digiti Minimi

Interossei

Lumbricals 4th & 5th

Flexor Digitorum Profundus 4th & 5th

Flexor Carpi Ulnaris

Patient is asked to adduct and abduct fingers as much as possible with palm placed on flat surface (thigh / table).

IP joints are flexed and extended while MCP joints are kept in flexion, wrist in neutral, and elbow in extension on soft padded surface.

MCP joints of affected hand are supported at 90 degrees by other hand, which is held in lumbrical position. From this position (MCP at 90 degrees flexion and wrist in neutral), interphalangeal joints of medial four fingers of affected hand need to be flexed and extended completely.

Hand is placed on thigh or soft flat surface, with palm facing up. Palm or hypothenar area of unaffected hand is used to gently straighten fingers. Once one cycle of exercise is over, other hand is lifted up and then exercise is done again. Repeat exercise at least 10 times every 2–3 hours. Oil or Vaseline can be used to soften hand.

Median

Abductor Pollicis Brevis

Extensor Digitorum Profundus 2 & 3rd

Oppones Pollicis Longus

Lumbricals 2nd & 3rd

Extended thumb of affected hand is moved into abducted position; position needs to be maintained for some time.

Support MCP joint of affected thumb with thumb and fingers of other hand:

With thumb fixed in above position, interphalangeal joint of thumb should be flexed and extended. Exercise will prevent contracture of IP joints of thumb.

Hand is placed on soft flat surface with palm facing up.

Extended thumb of affected hand is moved into opposition with other four fingers. Thumb is also actively moved into abduction position and this position is maintained for about 5 seconds. Repeat exercise at least 10 times every 2–3 hours.

Radial

Extensor Carpi Ulnaris

Extensor Carpi Radialis longus & Brevis

Extensor Digitorum Communis & Indicis

Keep wrist on edge of table, palm facing down. Ask patient to extend wrist and hold it for 30 seconds. Repeat exercise at least 10 times every 2–3 hours.

Two palms are placed in approximation with each other. From this position, wrist of normal hand is flexed to make affected wrist move into extension. Extension of paralyzed wrist should make it move to end ranges.

Other method of exercising wrist is to place it flat on surface and lift elbow perpendicular to wrist joint.

Lateral Popliteal

Tibialis Anterior

Extensor Digitorum Longus

Extensor Hallusis Longus

Patient sits high with legs not supported by ground. Foot is dorsiflexed and position is maintained for about 15 to 20 seconds. Repeat exercise at least 10 times every 2–3 hours.

Leg with paralyzed foot is placed over other leg and patient actively tries to dorsiflex foot on this gravity-eliminated plane.

Patient is positioned in long sitting (leg in extended position). Towel is placed over plantar surface over forefoot and patient holds edges of towel. When towel is pulled towards patient, foot is dorsiflexed and held in this position for about 10 seconds and then released.

Another exercise can be performed by standing about a foot in front of a wall, facing wall. Patient can lean forward with hands placed on wall for support. Position causes foot to dorsiflex. Repeat exercise at least 10 times every 2–3 hours.

Posterior Tibial

 

 

Patient is positioned with affected leg resting on other thigh. Patient can use hand to stretch toes passively and hold for 20 seconds.

* IP = Interphalangeal; MCP = Metacarpophalangeal

Appendix 4

TABLE A4A Pre- and post-operative assessment protocol of tendon transfer surgeries of hand*

 

Pre-Operative Assessment

Post-Operative Assessment

Ulnar Nerve

Median Nerve

Radial Nerve

Muscle Assessment

Abductors of little and index fingers

Intrinsic muscles

Flexor Digitorum Profundus – Ring and Little finger

Flexor carpi Ulnaris

Abductors and the opposers of thumb

Flexor Carpi Radialis

Intrinsic muscles

Flexor Digitorum Profundus – Index and middle finger

Pronator Teres

Palmaris Longus

Flexor Pollicis longus

Extensor carpi Radialis longus and brevis

Extensor carpi ulnaris

Extensor digitorum communis

Extensor pollicis longus

Extensor digiti minimi

Infection

Stitch abscess

Swelling

Adhesion

Loose tension

Tendon slipping

Pain

Sublimus Minus

Check Rein

Sensation

Sensory areas supplied by ulnar nerve

Sensory areas supplied by median nerve

Sensory areas supplied by radial nerve

Angle Measurements

Finger PIP angles in MCP flexion

Thumb MP and IP angles

Thumb web measurement

Thumb MP and IP angles

Wrist angles

Secondary Impairments

Assess for

  • Skin Contracture

  • Capsular Contracture

  • Long flexor tightness

  • Hooding

  • Guttering

  • Swan neck deformity

  • Extension Lag (DDE damage)

Assess for

  • Skin Contracture

  • Capsular Contracture

 

 

Functional Assessment

Grasp contact

Grasp strength

Pinch Contact

Pinch strength

9-hole peg boards

Other functional activities concerning the patients occupation:

  • Opening and closing jar

  • Picking up pebbles

  • Picking up cooked rice

  • Opening and closing big and small buttons

  • Opening and fastening zip

  • Counting paper

  • Drawing small and big shapes

  • Screening of Activity Limitation and Safety Awareness (SALSA) scale score

* PIP = Proximal Interphalangeal; MCP = Metacarpophalangeal; IP = Interphalangeal; DDE = Dorsal Digital Expansion

TABLE A4B Pre- and post-operative assessment protocol of tendon transfer surgeries of feet

 

Lateral Popliteal Nerve

 

Pre-Operative Assessment

Post-Operative Assessment

Muscle Assessment

Tibialis anterior

Tibialis posterior

Extensor Hallucis longus

Extensor digitorum longus

Infection

Stitch abscess

Swelling

Adhesion

Loose tension

Tendon slipping

Pain

Sensation

Sensory areas of the lateral popliteal and posterior tibial nerve

Angle Measurements

Ankle at rest

With Knee Extended

  • Active Dorsi / plantar flexion

  • Passive Dorsi / plantar flexion

With Knee Flexed (90º)

  • Active Dorsi / plantar flexion

  • Passive Dorsi / plantar flexion

Inversion and eversion at dorsiflexion

Inversion and eversion at plantar flexion

Functional Assessment

Navicular Height

Gait (123 pattern)

Whether able to walk short / long distances, run, climb stairs, and squat

SALSA Scale score

 

TABLE A4C Pre- and post-operative assessment protocol of tendon transfer surgeries of eye

 

Eye

Pre-Operative Assessment

Post-Operative Assessment

Muscle Assessment

Functioning of orbiculari occuli

Functioning of the transferred tendon “temporalis muscle”

Sensory assessment

Corneal Sensation – Blink

Lid gap in light closure (in millimeters)

Lid gap in tight closure (in millimeters)

Vision (Snellen’s E-Chart)

Lid gap in light closure (in millimeters)

Lid gap in tight closure (in millimeters)

Vision (Snellen’s E-Chart)

Other assessments

Ectropion

Entropion

Watering of the eye

Corneal Ulcer

Ectropion

Entropion

Watering of the eye

Corneal Ulcer

 

Appendix 5

TABLE A5 Surgical rehabilitation protocols

Surgical
Procedure

Pre-Operative
Rehabilitation

Post-Operative Rehabilitation

1st Week

2nd Week

3rd Week

4th Week

Extensor to Flexor 4 Tail Transfer (EF4T)

To gain isolation and full strength of ECRL, support hand in pronation and practice wrist extension without allowing finger or thumb movement.

To strengthen ECRL, do same action against resistance.

Isolate and do wrist extension with radial deviation, looking for MCP joint flexion and PIP extension in all fingers.

Use cylindrical splints for finger extension and lumbrical slab to reduce swelling.

Assess at end of 1st week.

MCP extension

Assess at end of 2nd week.

Start MCP and PIP joint flexion.

Assess at end of 3rd week.

Perform functional activities:

  • Grasping large progressing to smaller objects

  • Grasping light progressing to heavier objects

  • Picking up beans with fingers and thumb in lumbrical position

Assess at end of 4th week.

Extensor to Extensor 4 Tail transfer

 

Post-operative exercises are same as EF4T, except too much full wrist flexion should be avoided in post-operative period.

Palmaris Longus 4 Tail Transfer

Isolate PL by wrist flexion and hand cupping.

 

Sublimus Transfer

Ask patient to flex PIP joint of only long finger; all other fingers should be relaxed. MCP of long finger should be flat and DIP joint must be relaxed.

Post-operative exercises are same as above surgeries except care must be taken for “check-rein” and “sublimus-minus” deformities.

Lasso Procedure

Ask patient to flex PIP joint of only long finger; all other fingers should be relaxed. MCP of long finger should be flat and DIP joint must be relaxed.

Perform isolation exercises of transfer (FDS of long finger).

Flex and extend PIP and DIP joints while maintaining MCP joint in 55°.

Use POP slab when not exercising.

Assess at end of 1st week.

Flex and extend PIP and DIP joints while maintaining MCP joint in 55°.

Assess at end of 2nd week.

Perform coordination exercises.

Perform more extensions of MCP joints.

Change slab to one with MCP joints in 30° extension.

Assess at end of 3rd week.

 

Perform functional activities:

  • Grasping large progressing to smaller objects

  • Grasping light progressing to heavier objects

  • Picking up beans with fingers and thumb in lumbrical position

Assess at end of 4th week.

Sublimus Transfer

Ask patient to flex PIP joint of only long finger; all other fingers should be relaxed. MCP of long finger should be flat and DIP joint must be relaxed.

Perform isolation exercises of transfer (FDS of long finger).

Look for MCP joint flexion and PIP extension in all fingers.

Immobilize IP joints using POP cylindrical splints.

Assess at end of 1st week.

Perform MCP extension.

Assess at end of 2nd week.

Start MCP and PIP joint flexion.

Assess at end of 3rd week.

Perform functional activities:

  • Grasping large progressing to smaller objects

  • Grasping light progressing to heavier objects

  • Picking up beans with fingers and thumb in lumbrical position

Assess at end of 4th week.

Opponens
Replacement

To gain isolation and full strength of ring finger FDS, support hand in supination and practice PIP flexion of that finger. DIP joint and all other fingers must remain relaxed. Thumb web angle should be 40°.

Try old action of PIP flexion of ring finger and watch for new action of thumb abduction / rotation.

Make sure while doing exercises that:

  • Other fingers and ring finger DIP joints are relaxed

  • There is no thumb tip flexion as transfer is used

  • MCP joint does not hyper extend

  • Check that rein deformity does not develop in ring finger

Apply thumb spica POP or cylinder POP to thumb along with anterior slab to hold it in abduction / opposition between treatments.

To strengthen transferred muscle:

  • Increase amount of exercise.

  • Provide less support for hand by changing position.

  • Perform action against gravity.

To improve coordination of transferred muscle:

  • Teach it to work together with fingers for pinch function.

  • Expect increased ROM.

  • Discard POP as good control is gained.

  • Continue anterior slab at night.

To train functional use of transferred muscle, activities may include

  • Picking up large objects, progressing to smaller ones.

  • Games such as ludo, Writing

  • Activities of daily living, especially those related to patient’s needs

Triple Nerve Palsy Correction – Restoration of wrist and finger extension

  • Restoration of wrist extension – Transfer of Pronator Teres to ECRB

  • Restoration of finger and thumb extension – FCR

  • Transfer to EDC and EPL

Perform isolated contraction of Pronator Teres (i.e., Pronation of forearm with all other muscles relaxed).

Perform isolated contraction of FCR (i.e., Flexion of wrist joint into radial deviation, with other muscles relaxed).

Patient does gentle exercises as taught pre-operatively.

Watch for wrist extension by graft when doing pronation and extension of fingers and thumb and when doing wrist flexion.

Apply post-operative anterior slab when not exercising.

Perform same exercises, but more strongly, change positions, hold for longer time.

If good control of graft, start gentle flexion of wrist, fingers, and thumb and supination and extension of elbow.

Continue exercises

Start functional activities as possible to prepare for lumbrical and opponens operation.

Temporalis Muscle Transfer (TMT)

Assess:

  • Face muscles, especially orbicularis occuli

  • Corneal sensation

  • Inter lid width of Lagophthalmos – light and tight closure

  • Strength of Temporalis muscle

  • Other assessments as for other surgery

  • Any eye complications, i.e., inflammation, ulcer.

Perform isolated contraction of temporalis muscles, i.e., biting.

Perform biting exercises on a hard substance, e.g., a piece of rubber or chewing gum, to strengthen temporalis muscle.

Liquid diet

Semi-solid diet

Normal diet

Start biting exercises and measure inter lid width when exercising.

Longer exercise sessions

Hold contraction for longer time

Bite on a hard substance

Tibialis Posterior Transfer (TPT)

Gain isolation of Tibialis Posterior.

Strengthen Tibialis Posterior by sitting with affected foot supported on opposite knee and practicing inversion.

Resistance may be given to medial side of foot.

To isolate transferred muscle:

  • Remind patient of pre-operative exercises.

  • As patient tries to do “old” action of inversion, watch for “new” action of dorsiflexion (exercise in same position as pre-operative). Movement may be a flicker at first.

  • Perform exercise with gravity eliminated.

To prevent damage or misuse of transferred tendon, provide back slab.

To strengthen transferred muscle:

  • Increase amount of exercise.

  • Sit with leg hanging down so that muscle is working against gravity.

To improve coordination of transferred muscle with associated leg muscles:

  • Perform partial weight-bearing exercises on parallel bars facing a mirror.

  • Transfer of weight that would be practiced on parallel bar would be side-to-side transference of weight and heel-to-toe transference of weight

Gain full weight bearing by decreasing, then removing, support of parallel bars, crutches, etc.

Encourage walking in all situations, progressing to:

  • Rough ground, slopes, steps

  • Longer distances

  • Hand ball games which distract patient’s attention from feet

* ECRL = Extensor Carpi Radialis Longus; MCP = Metacarpo Phalangeal; PIP = Proximal Interphalangeal; DIP = Distal Interphalangeal; ROM = Range of motion; POP = Plaster of Paris; FDS = Flexor Digitorum Sublimus; IP = Interphalangeal; FCR = Flexor Carpi Radialus; EDC = Extensor Digitorum Communis; EPL = Extensor Pollicis Longus

lepromatous leprosy
MDT
ROM
MB
RR
BI
PB
TT
BL
BT
LL
BB