June, 1963 P H Y S I O T H E R A P Y Page 3 THE LE P R O SY P R O B L E M IN S O U T H A F R IC A By H . W I L S O N , N a t . C e r t , o f P h y s i o t h e r a p y , P r e t o r i a a n d G . F. D O M M 1 S S E , M . B ., C h . B . , F . R . C . S . , E d . ‘•Jt c a n be j u s t i f i a b l y s t a t e d t h a t a c o u n t r y ’s s t a n d a r d o f c i v i li sa ti o n m a y be m e a s u r e d a l s o b y t h e e x t e n t a n d effi­ c i e n c y o f its r e h a b i l i t a t i o n s e rv i c e s .” T h e w o r d s a r e t h o s e o f t h e t h e n M i n i s t e r o f L a b o u r , th e H o n o u r a b l e S e n a t o r M r . J. d e K l e r k , a n d t h e y a r e q u o t e d f r o m " R e h a b i l i t a ­ t i o n ” , J u n e , 1961. T h e p r o b l e m in t h e R e p u b l i c is a f o r m i d a b l e o n e a n d o n e w h i c h u n d e r ex i s ti n g c o n d i t i o n s , m a y well be r e g a r d e d as in so lu bl e. T h e r e a r c a b o u t 1,000* k n o w n suf f er e rs f r o m ac ti v e l e p r o sy in o u r c o u n t r y — th i s fig ure i n c l u d e s all ra ces . T h e n u m b e r o f u n d i a g n o s e d ca se s is u n d e t e r m i n e d a n d f l u c t u a t ­ ing, a n d t h e p r o b l e m w h i c h th e s e ca s es c r e a t e is m a t e r i a l l y e x p a n d e d by t h e illegal influx o f fo re i g n n a t i v e s a c r o s s n e i g h b o u r i n g b o r d e r s . F r e s h ca s es o f l e p r o sy , t h a t is t o s a y , ca s es w h i c h ha v e e s c a p e d e a r l i e r d e t e c t i o n , a r e b e i n g a d m i t t e d t o W e s t f o r t I n s t i t u t i o n in P r e t o r i a at t h e r a t e o f 1 - 0 p a t i e n t s dail y. D i s c h a r g e s f r o m t h e I n s t i t u t i o n o c c u r at t h e r a t e o f J ■ 1 p a t i e n t s d a i l y ; it m a y t h u s b e se en t h a t t h e i n - p a t i e n t p o p u l a ­ t i o n at W e s t f o r t is b e i n g r e d u c e d at t h e r a t e o f 36■ 5 p a t i e n t s p e r a n n u m . Q u i t e r ec en t l y , t h e t o t a l n u m b e r o f i n m a t e s w a s r e d u c e d to 780 as a re su lt o f t h e r e p a t i i a t i o n o f a n u m b e r o f n a t i v e s t o t h e i r r e s p e c ti v e h o m e t e r r i t o r i e s o u t s i d e t h e R e p u b l i c . T h e s e fig ures se rve t o i l l u s t r a t e t h e fact t h a t t h e p r o b l e m is ver y r ea l, a n d t h a t a n y c o m p l a c e n c y w i t h r e g a r d t o t h e m a t t e r is b o t h m i s p l a c e d a n d un j u st i f i e d . T h e p o p u l a r beli ef t h a t le p r o s y m a y b e c u r e d b y t h e a d m i n i s t r a t i o n o f t h e S u l f o n e p r e p a r a t i o n s , a n d t h a t as a d i r e c t c o n s e q u e n c e , t h e p r o b l e m h as b e e n s o l v e d , is a n u n f o r t u n a t e a n d i n d e e d a d a n g e r o u s m i s c o n c e p t i o n . T h e a v e r a g e p e r i o d o f h o s p i t a l i s a ­ ti o n in o n e t y p e o f t h e d i s e a s e is n o less t h a n five y ea r s, while in t h e o t h e r it m a y b e as s h o r t as five m o n t h s . D e f o r m i t i e s a n d di sa b il i t i es n o t e d o n a d m i s s i o n o f t h e p a t i e n t t o h o s p i t a l , a r e f r e q u e n t l y o f a n i r re v e r s ib l e n a t u r e , t he e r a d i c a t i o n o f H a n s e n ’s b ac i l l u s n o t w i t h s t a n d i n g . T H E D I S A B L I N G L E S I O N S O F L E P R O S Y a r e as fo llows: 1. I m p a i r m e n t o f s e ns at io n in th e sk in o f t he h an d s an d the feet. T h i s is t h e p r e d o m i n a n t les ion , a n d ne rv e i n v o l v e m e n t o c c u r s in m ix ed n e r v e t r u n k s at de fi n ite sites o f p r e d i l e c t i o n , t h u s 1: (a) T h e u l n a r ne r v e, n e a r t h e e l b o w , (b) T h e m e d i a n n e r v e , n e a r t h e w ri st , (c) T h e l a t e r a l p o p i t e a l n er v e, n e a r t h e k n ee , (rf) T h e p o s t e r i o r ti b ial n er ve , n e a r t h e a n k l e , ( e ) B r a n h c e s o f t h e facial n e r v e , es p ec i al l y at t h e z y g o m a , ( / ) T h e r a d i a l n er ve , n e a r t h e el b o w . I n a d d i t i o n , n e r v e i n v o l v e m e n t o c c u r s in s k i n p a t c h e s a n y w h e r e o n t h e b o d y . N e r v e t r u n k s a r e in v o l v e d b y di r e c t i n v a s io n w i t h H a n s e n ’s bac illus o n t h e o n e h a n d a n d by t h e i s c h a e m i a a s s o c i a t e d wit h o e d e m a a n d p r e s s u r e b e n e a t h f i b r o u s b a n d s a n d t un ne ls , o n t h e o t h e r . L a t e r , a n d in c as es o f se v er e d e f o r m i ­ ties, t h e ne r v e fibres a r e d e s t r o y e d in c o n s i d e r a b l e m e a s u r e , a n d th e po ss i b i l i ty o f a n a n t i g e n - a n t i b o d y r e a c t i o n h a s b e e n su gg ested. C linic al re se a rc h is r e q u i r e d in r e g a r d t o t h e r ev er sib il ity o r ot h e r w i se o f t h e n e u r o l o g i c a l l es ion . O u r e x p e r i e n c e h a s be en t h a t w h e r e a s r e c o v e r y is n o t u n c o m m o n in t h e cas e o f t h e la t e r a l p o p l i t e a l n e r v e l es ion s, r e c o v e r y in u l n a r a n d m e d i a n ne rv e p a r a l y s i s is rare . T h e d i m i n u t i o n o f o e d e m a o f t h e n e r v e t r u n k , b r o u g h t a b o u t by t h e u s e o f s u i t a b l e s p li nt s , t h e a d m i n i s t r a t i o n o f *T hi s figure is s u p p l i e d b y t h e D e p a r t m e n t o f H e a l t h a n d is official. o r a l c o r t i c o s t c r o i d s a n d in t en si v e a p p l i c a t i o n o f p h y s i o ­ t h e r a p e u t i c m e a s u r e s , is t h o u g h t t o be r e s p o n s i b l e f o r m o s t o f t h e r e c o v e r y w h i c h h a s b e e n n o t e d , b u t a t r u e e s t i m a t e o f t h e r ec o v e r y o f t h e les ion is i m p o s s i b l e o n cli ni cal e x a m i n a ­ t i o n o n l y , a n d it is k n o w n t h a t 25 p e r c e n t o f t h e fi bres o f a n e r v e t r u n k m a y b e d e s t r o y e d o r r e n d e r e d a f u n c t i o n a l , w i t h o u t c o i n c i d e n t cli nical e v i d e n c e o f n e u r o l o g i c a l i n v o l v e ­ m e n t . 2 . M o t o r p a r a l y s i s involving the in tri n s ic mu sc les o f th e ha n d s , a n d r e s u l t i n g in c l a w h a n d d e f o r m i t y t o g e t h e r w i t h loss o f a b d u c t i o n a n d o p p o s i t i o n o f t h e t h u m b . T h e m e d i a n a n d t h e u l n a r n e r v e s a r e in v o l v e d sin gl y in a b o u t e q u a l p r o p o r t i o n , a n d t o g e t h e r in a s m a l l e r n u m b e r o f cas es. M u c h less f r e q u e n t l y , yet n o t u n ­ c o m m o n l y in o u r e x p e r i e n c e , t h e r a d i a l n e r v e is p a r a ­ lyse d, g iv i n g rise t o wr ist d r o p ( Fi gs . 1 a n d 2). . . . J F ig . I — C o m b in e d u ln a r a n d m e d ia n n e rv e p a r a ly s is , sh o w in g th e ty p ic a l " S im ia n h a n d " b u t w ith o u t h y p e r e x te n s io n a t th e m e ta c a r p o -p h a la n g e a l jo in ts . F ig . 2— U lnar n e rv e p a r a ly s is , sh o w in g ty p ic a l h y p e r e x te n s io n d e fo r m itie s a t th e m e ta c a r p o -p h a la n g e a l j o in ts a n d fle x io n d e fo r m itie s a t th e p r o x i m a l in te r p h a la n g e a l jo in ts . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y June, 1963 3 D irect d am age to the so ft tissues o f the hand by i n f il t r a t i o n o f t h e ti ssues d u r i n g p h a s e s o f r e a c t i o n ’. T h i s is a c o m m o n a n d re ve rsi bl e l e s io n, it inv ol ves p a r t i c u l a r l y t he s u b c u t a n e o u s ti ssues o f b o t h the p a l m a r a n d d o r s a l a s p e c t s o f th e h a n d , a n d t h e t e n d o n s h e a t h s w i t h i n t h e c a r p a l t u n n e l o r at t h e d o r s o ­ la t e r a l a s p e c t o f t h e l o w e r e n d o f th e r a d i u s ( t h e l o ng t e n d o n s o f t h e t h u m b ) . T h i s is a n i m p o r t a n t a n d less w e l l - k n o w n f e a t u r e o f lep ro sy , a n d it f re q u e n tl y re su lt s in t h e d e v e l o p m e n t o f c o n t r a c t u r e s . B e c a u s e it a p p e a r s t o b e a lesion o f lesser si g ni fi ca n ce t h a n s e n s o r y a n d m o t o r p a r a l y s i s , it t e n d s t o receive less s e r i o u s a t t e n t i o n ; b e c a u s e it is a s s o c i a t e d w it h o e d e m a , it is r e s p o n s i b l e fo r t h e i n s i d i o u s o n s e t o f c o n t r a c t u r e s in s u b c u t a n e o u s t i s s u e s , in t e n d o n s h e a t h s a n d in j o i n t c a p s u l e s ( Fi g. 3). be laid u p o n t h e v al u e o f th e e d u c a t i o n o f t h e B a n t u p a t i e n t , w h o p e r si s te n tly e x p o s e s h i m o r hersell to t he d a n g e r s o f t h e o p e n (ire w h i l e c o o k i n g , whil e s e e k i n g w a r m t h a n d whi le w a s h i n g a n d i r o n i n g p e r s o n a l effects. 6 . A bsorption o f d igits and ex trem ities. B o n e c h a n g e s in le p r o sy a r e o f t h r e e m a i n t ype s, t h u s : (a) I n v o l v e m e n t o f t h e b o n e in s e c o n d a r y infe cti on wi t h t r o p h i c u l c e r a t i o n ; (b) i n v o l v e m e n t o f t h e b o n e in d i s u s e a t r o p h y ( o s t e o p o r o s i s ) , a n d in t h e o s t e o p o r o s i s w h i c h o c c u r s in th e pr e se n c e o f s e p t ic le s io n s ; a n d (c) I n v o l v e m e n t o f t he b o n e in t h e g r a n u l o m a t o u s les io n o f l e pr os y . W h i l e thi s is n o t a c o m m o n f e a t u r e , it in v o lv es p a r t i c u l a r l y t h e p h a l a n g e s o f t h e fingers a n d it re su lt s in m u l t i p l e a r e a s o f b o n e d e s t r u c t i o n ; th e s e les ion s m a y he al w i t h co r t i c a l scl ero si s a n d t h i c k e n i n g a f t e r o n e y e a r o f su l f o n e t h e r a p y . 7. L ast, but not least, visual im pairm ent. T h e i n d iv id u al w h o po ss es se s n o r m a l tacti le sen sib il it y is a b l e t o c o n q u e r th e h a n d i c a p o f b l i n d n e s s in c o n s i d e r a b l e m e a s u r e . W h e n s e n s a t i o n s a r e lost o r i m p a i r e d in the e x t r e m i ti e s , t h e a d d i t i o n o f v isu a l i m p a i r m e n t gives rise t o di sa b il i t y w hi ch is w ell -n ig h i n s u p e r a b l e ; the vi ct im is c o n d e m n e d t o a s t a t e o f n ea r - h el p le ss n es s . f i g . 3— Inclin a tio n a n d o e d e m a o f th e le ft h a n d , ty p ic a l o f th e s o ft tiss u e in filtr a tio n w hich o c c u rs in th e re a c tiv e p h a s e s o j le p ro sy . T h is is a r e v e rs ib le lesion. 4. M o to r p aralysis involving the intrinsic m uscles o f the feet, a n d r e s u l t i n g in t h e d e v e l o p m e n t o f c l a w toes, h all ux val gu s, b u n i o n f o r m a t i o n a n d c al lo s iti es (Fig. 4). C l a w t oe a n d h a ll u x v a l g u s d e f o r m i t y in le p r o sy d e v e l o p in m u c h th e s a m e m a n n e r as s i m i l a r lesion s in n o n - l e p r o u s p a t i e n t s , es pe ci al ly w o m e n . In t h e lepe r, p a r a l y s i s o l the i n t r i n s i c m u s c le s o f t h e feet o c c u r s a s a resu lt o f m o t o r n er ve l es io ns , whi le in t h e n o n - l e p r o u s p a t i e n t , p s e u d o - p a r a l y s i s o f t h e i nt rin s ic s o c c u r s as a re su lt o f is c h a e m i a f r o m c o n ­ s tr ict iv e f o o t w e a r . T h e e n d re su lt s a r e th e sa n i e , ex c e p t i n g o n l y t h a t t h e feet o f l e p r o u s p a t i e n t s su ff er th e a d d i t i o n a l d i s a d v a n t a g e o f i m p a i r m e n t o f s e n s a t i o n , le a d i n g t o th e f o r m a t i o n o f vesicles, p r e s s u r e s o r e s a n d t r o p h i c ulcers. D r o p f o ot d e f o r m i t y f r o m i n v o l v e m e n t o f th e later al p o p l i t e a l n e r v e is a f r e q u e n t f e a t u r e o f l e p r o u s feet, a n d a d d s i m m e a s u r a b l y t o t h e p a t i e n t s d i s c o m f o r t b e c a u s e o f th e sp l i n t i n g w h i c h it n ec es sit at es . 5. S econ d ary deform ities o f hands and fe e t, t h e resul t ol d e l a y a n d negl ect in t he a p p l i c a t i o n o f t r e a t m e n t , ar e a t least a s i m p o r t a n t as t h e p r i m a r y les io n s, a n d in m a n y c as es o f neglect c o n s t i t u t e t h e d e t e r m i n i n g f a c t o r in th e m a n a g e m e n t o f th e cas e. D e f o r m i t i e s i n c l u d e c o n t r a c t u r e s o f t h e sk i n o n the flex or a s p e c t o f th e p a r a l y s e d t h u m b a n d fingers, c o n t r a c t u r e s o f t h e w e b o f t h e t h u m b r e s u l t i n g in i na b i l i t y t o a b d u c t a n d t o o p p o s e , a n d “ d a m a g e to a n d a b s o r p t i o n o f f in ger s d u e t o w o u n d s , t o sepsis, t o i n a b i l i t y t o g r a s p ev enl y w i t h t h e e n t i r e s u r f a c e o f t he h a n d a n d t o th e use o f exc essive a n d u n r e a l i se d f o rc e by a n a e s t h e t i c fingers. A c u t e flexio n o f t he f in g er s a ls o e x p o s e s t h e k n u c k l e s t o i n j u r y w h i c h m a y l ead t o sep sis at t h e i n t e r - p h a l a n g e a l j o i n t s 1” . W i t h r e g a r d t o th e s e s e c o n d a r y d e f o r m i t i e s , e m p h a s i s m u st f i g 4— T h e d e fo r m ity w hich o c c u r s in th e f e e l a s a re su lt o f I th e p a r a ly s is o f th e f o o t in trin s ic m u sc le s. V e sic id a tio n a n d u lc e r a tio n cue c o m m o n c o n c o m ita n t lesions. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1963 P H Y S I O T H E R A P Y Page 5 t h e R O L E O F P H Y S J O T H E R A P Y I N L E P R O S Y : T h e p o t e n t i a l w h i c h p h y s i o t h e r a p e u t i c m e a s u r e s c a r r y for he relief o f t h e lot o f th e l e p e r is c o n s i d e r a b l e . In b o t h t h e o p h y l a c t i c a n d t h e r a p e u t i c fields, m u c h c a n be a c c o m ­ p l i s h e d a n d t he f o r m e r a r e p a r t i c u l a r l y r e w a r d i n g because the majority o f the disabling d eform ities o f leprosy are re adi ly p r e v en ta b le lesions. T h e irreve ri sib le n a t u r e o f t h e s e n s o r y c h a n g e s in t h e h a n d s a n d feet h a s a l r e a d y be en e m p h a s i s e d ; thes e c h a n g e s m u s t th e r e f o r e be a c c e p t e d as i ne vi tab le. T h e d i r e co n s e- a u e n c e s o f s e n s o r y i m p a i r m e n t m a y h o w e v e r be p r e v e n t e d , a n d p r e v e n t a t i v e t h e r a p y is the m o s t v a l u a b l e a n d the m o s t r ew a r d i n g c o n t r i b u t i o n w h i c h t h e p h y s i o t h e r a p i s t c a n m a k e t o w a r d s th e s o l u t i o n o f th e p r o b l e m . T h e scientific m e e t i n g o n r e h a b i l i t a t i o n in l e pr o sy , held u n d e r t he au s p i ce s o f t h e W o r l d H e a l t h O r g a n i s a t i o n in Vellore, M a d r a s , in N o v e m b e r , 1960 " w a s u n a n i m o u s in the o p i n i o n t h a t it h a s n o w b ee n e s t a b l i s h e d t h a t s t a n d a r d m e t h o d s o f p h y s i o t h e r a p y a n d r e c o n s t r u c t i v e s u r g e r y a r e a p p l i c a b l e t o le p ro sy p a t i e n t s , a n d t h a t th e r e su l t s o f su c h t r e a t m e n t a r e a t least as g o o d as t h o s e fo l lo w in g s i m i l a r t r e a t m e n t fo r o t h e r p a r a l y s i n g d i s e a s e s 1-’. Physiotherapy m easures include the follow ing: 1. T he e d u c a tio n o f th e v ic tim o f le p ro sy in re sp e c t o f h is o w n c o n d itio n . It w o u l d be difficult t o o v e r ­ e m p h a s i s e t h e i m p o r t a n c e o f th i s f u n c t i o n o f th e p h y s i o t h e r a p i s t , w h o s e d i l ig en t a n d p a t i e n t a p p l i c a t i o n o f first p r i n c i p le s m u s t c o n v i n c e e v e n t h e m o s t o b t u s e o f t h e i r value. P r e s u r e s o r e s a n d t r o p h i c ulce rs c o m m e n c e o n th e h a n d s a n d feet in t h e f o r m o f m i n o r a b r a s i o n s , cut s, s c ra t c h e s a n d vesicles, all o f w hi ch a r e a v o i d a b l e . T h o s e w h o d e d i c a t e t h e m se lv e s t o t h e a l l e v i a t i o n o f su ff eri ng in t h e leper, m u s t n e e d s i n c u l c a t e in th e m i n d s o f th e vi cti m s th e p r i n c i p le s a n d m e t h o d s o f skin hygien e, a n d t h e v al u e o f t h o s e s i m p l e m e a s u r e s w hi ch a r e d i r e c t e d at t he e l i m i n a t i o n o f t r a u m a t o a n d b r e a c h e s o f in se ns ib le c u t a n e o u s su r f a c e s . T h e use o f c l e a n h o se a n d p r o t e c t i v e f o o t w e a r is o f e q u a l i m p o r ­ tance . 2. T he tim e ly re c o g n itio n o f in cip ien t s k in lesions. M i n o r in ju rie s o f a n a e s t h e t i c h a n d s a n d feet a r e o v e r ­ l o o k e d by t h e p a t i e n t . T h e i r r e c o g n i t i o n a n d t i m e o u s t r e a t m e n t by m e a n s o f rest, dr es s i n g s, p r o t e c t i v e s p li nt s a n d p h y s i o t h e r a p e u t i c m e a s u r e s ar e essen tial if sepsis, s c a r r i n g , c o n t r a c t u r e s a n d ev en s e q u e s t r a t i o n a r e t o be p r e v e n t e d . T h e u s u a l sites o f inj ury a r e the h a n d s , a n d t h e feet at t h o s e s u r f a c e a r e a s w h i c h b e a r m a x i m u m p r e s s u r e whi le w a l k i n g . I ll-fittin g f o o t w e a r c o n s t i t u t e s yet a f u r t h e r t r a u m a t i c f ac to r. W h e n th e sk in is c r a c k e d , sa l in e f o o t b a t h s a r e va l u ab l e, fo llowed by th e a p p l i c a t i o n o f zin c a n d c a s t o r oil o i n t m e n t . Ba dl y c r a c k e d feet r e s p o n d r a p i d l y t o thi s t r e a t m e n t a n d t he s ki n s o o n b e c o m e s t o u g h , s m o o t h a n d h e a lt hy . W a x b a t h s a r e o f m o r e v al u e in t h e ca s e o f th e h a n d s , a n d zinc a n d c a s t o r oil o i n t m e n t is us ed o n l y in i n t r a c t a b l e lesions. W a x b a t h s s h o u l d be used w i t h c a u t i o n b e c a u s e b u r n s o c c u r with e x t a r o r d i n a r y facility. T h e r e is loss o f p e r c e p t i o n in thes e c as es a n d it is k n o w n t h a t h e a t a s a p h y si c al f a c t o r is di ss ip at ed less r a p i d l y t h a n u n d e r n o r m a l c o n d i t i o n s f r o m its a r e a o f a p p l i c a t i o n , o w i n g t o t h e fact t h a t in le pr os y t her e is de l a y e d v a s o d i l a t a t i o n . P ar aff in w a x used in wax b a t h s for leper s s h o u l d h a v e a m e l t i n g p o i n t n o t e x c ee d in g 112° t o 115° F. E x ercise Exercises a r e g i v e n : (а) to r e d u c e e x is tin g c o n t r a c t u r e s (Fig . 5), (б) t o p r e v e n t th e d e v e l o p m e n t o f c o n t r a c t u r e s , (c) t o s t r e n g t h e n muscles. Fig. 5— S tr u c tu r a l c o n tr a c tu r e s h a v e o c c u rre d a t th u m b a n d fin g e r jo in ts o f th is h a n d . P re v e n tio n w o u ld h a v e b een e a sy . C u re is d iffic u lt, e v e n im p o ssib le . A w a r n i n g is issue d in r e g a r d t o th es e ex er ci se s, n a m e l y , th a t s p o n t a n e o u s f r a c t u r e s d u e t o n e u r o t r o p h i c b o n e a b s o r p t i o n , t o cys t f o r m a t i o n a n d t o s e c o n d a r y in f e c t i o n a r e n o t u n c o m m o n . T h is f a c t o r s h o u l d be b o r n e in m i n d , es p ec ia ll y w h e n a t t e m p t i n g t o r e d u c e c o n t r a c t u r e s . A ca r e f u l w a t c h s h o u l d be k e p t a ls o o n th e feet, for f r a c t u r e s a r e c o m m o n as a resu lt o f n o r m a l w e i g h t - b e a r i n g a n d su c h f r a c t u r e s p a s s u n n o t i c e d b e c a u s e o f a b s e n c e o f p a i n s e n s a ­ tion. A c o m m o n d e f o r m i t y in t h e h a n d s o f th e s e ca se s c o n ­ sists o f h y p er fl ex io n o f th e i n t e r p h a l a n g e a l a n d h y p e r ­ e x t e n s i o n o f t h e m e t a c a r p o - p h a l a n g e a l j o i n t s o f t he fingers. T h e d i l ig en t c o - o p e r a t i o n o f th e p a t i e n t is es se n t i al in the p r e v e n t i o n a n d t h e t r e a t m e n t o f th e s e d e f o rm it ie s . M a ssa g e and Splinting T h e negl ect ed h a n d c o m m o n l y p r es en t s wit h s h o r t e n e d c o n t r a c t e d fingers, d r y , c a l l o u s e d sk i n a n d d e e p c r a c k s in t he p a l m a r flexures. W o u n d s o f t h e h a n d a r e d r e s s e d , whil e t he fingers a r e lightly b a n d a g e d o v e r a r o u n d o b j e c t , a b o u t t h e size o f a te n n i s ball. M a s s a g e s wit h zinc a n d c a s t o r oil, s p l i n t i n g a n d exercises a r e c o m m e n c e d a s s o o n a s possible. T h e m o s t s a t i s f a c t o r y m e t h o d o f s p l i n t i n g th e fingers is a s f o l lo w s : A s t r i p o f o r t h o p a e d i c felt is laid a l o n g t h e d o r s u m o f t he finger, a n d a light p l a s te r - o f - p a r i s c y l i n d e r is a p p l i e d o v e r it. T h e finger is t h e n gen tl y held in the e x t e n d e d p o s i t i o n unt il t h e p l a s te r sets. P l a s t e r cy l i n d e r s R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) m u st be r em o v ed a n d re-a p p lie d a fte r e x erc ise e v e r y tw o to three d a y s. A n a ltern a tiv e m e th o d 2 is to m a k e a sp lin t o f £ in. p ersp e x , w h ich is a p p lied to th e p a lm a r su rfa ce o f th e finger a n d k e p t in p o sitio n b y m ea n s o f e la s to p la st stra p p in g . S everal se ts o f sp lin ts are n eed ed t o g a in p ro g ressiv ely greater d eg rees o f e x te n sio n . P ersp ex is e a s ily s o fte n e d b y h e a tin g , after w h ic h it ca n b e m o u ld e d t o a p la ster c a st o f th e finger req u irin g str a ig h te n ­ in g. R o u g h e d g e s o f perspex are r em o v ed w ith an em ery w h eel. The m o s t im p o rta n t e x e r c is e e m p lo y e d in th e c o rrectio n o f f in g e r d e fo rm itie s c o n sists o f the fo llo w in g : W ith th e w rist in e x te n sio n , th e m e ta c a r p o -p h a la n g e a l jo in ts are h eld in 9 0 ° fle x io n . T h e in te r-p h a la n g ea l jo in ts are then a ctiv ely ex te n d e d . I t is m o st im p o r ta n t t o a ch iev e th e fu llest p o s s ib le m ea su re o f co r r e c tio n o f d efo rm ity b e fo r e surgery fo r th e r e c o n str u c tio n /r e p la c e m e n t o f lu m b rica ls m ay b e c o n te m p la te d . T r a n sp o sed m u sc le s and te n d o n s are u n a b le to effect p o s t-o p e r a tiv e c o r r e c tio n o f finger d efo rm ity . In th is resp ect, th e v a lu e o f a d e q u a te and a ccu ra te n o te -ta k in g in c h r o n o lo g ic a l s e q u e n c e , c a n n o t b e ex a g g era ted . S p lin ts are n o t n o r m a lly u se d fo r th e w rists, b e c a u se o f th e d a n g e r o f pressu re so r e s in th e a b s e n c e o f p a in se n sa tio n . W h en u sed fo r c o n d itio n s su ch a s w rist d r o p and cla w h a n d s, th e y req u ire m e tic u lo u s su p erv isio n . D r o p f o o t req u ires s o m e ty p e o f f o o t su p p o r t, a n d fo u r ty p e s are u sed a t W e s tf o r t : 1. D o u b le b e lo w -k n e e iron s. 2. In s id e iro n a n d o u tsid e T -strap . T h e s e tw o ty p e s are o f p a rticu la r v a lu e , to m ale p a tie n ts w h o are a p t to b rea k sp lin ts o f lig h ter c o n ­ stru ctio n . 3. S w ed ish sty le O ’G o r m a n sp lin t, o f u s e in w o m e n o n ly . 4. A n im p r o v ise d sp rin g o r e la stic su p p o r t a tta c h e d t o th e w o o d e n s o le o f a sa n d a l at its o u te r e d g e , and to a lea th er b a n d a t b e lo w k n e e level. Splinting and infra-red radiation in selected cases R e a c tio n in le p r o s y is th o u g h t to b e an a llerg ic p h e n o ­ m e n o n w h ich d isp la y s v a ry in g m a n ife s ta tio n s in th e different fo rm s o f lep ro sy . In a ll ty p e s, o e d e m a o f ex tr e m itie s and n eu ritis o f sup erficial n erv es are u su a lly e n c o u n te r e d . T h e c o n stitu tio n a l fea tu re s o f rea ctio n in le p r o sy in c lu d e py r e x ia an d m a la ise, a n d th e se to g e th e r w ith p a in in th e affected ex trem ity m a y w ell c o m b in e t o ren d er th e p a tie n t u n w illin g an d u n c o -o p e r a tiv e . R e a c tio n is o f p a r tic u la r in te r e s t to p h y s io th e r a p ists w h en m a n ifest in a n y o n e o f th e fo llo w in g fo rm s: 1. A v io le n t r e a c tio n in th e p erip h era l n erv e tru nk s, a sso c ia te d w ith th e d e v e lo p m e n t o f se v e r e p a ra ly sis w ith in a m a tter o f d a y s or ev en o f h o u r s. In th e se c a se s p h y sio th e r a p y is e s se n tia l fo r th e p r ev en tio n o f r a p id -o n s e t d e fo r m itie s. 2. E r y th e m a N o d o s u m L e p r o su m , a r e a c tio n se en o n ly in le p r o m a to u s lep ro sy . S m a ll e r y th e m a to u s n o d u le s ra n g in g in d ia m e te r fro m 2 m m .-2 0 m m . ap p ea r in th e d erm is, ch iefly o n th e fa c e a n d e x trem ities. T h ey are p a in fu l o n p ressu re, a n d w h en a c c o m p a n ie d b y p erip h era l n e u r itis , m a y g iv e rise t o se v ere p a in s w h ich in turn fa v o u r s th e d e v e lo p m e n t o f co n tra ctu r es an d d e fo r m itie s. 3. P ersisten t o e d e m a o f th e h a n d s a n d fe e t, g iv in g rise to v e n o u s sta sis a n d th e ev en tu a l d e v e lo p m e n t o f d efo rm ity . S p lin tin g in th e p o sitio n o f fu n c tio n is o f p a ra m o u n t im p o r ta n c e . D u r in g th e a cu te p h a se su fficien t e x erc ise and p a ssiv e m o v e m e n t t o p rev en t co n tr a c tu r e s is g iv en . Infra-red ra d ia tio n is o f c o n sid e r a b le v a lu e in r eliev in g p a in in o e d e m a to u s h a n d s a n d feet. Page 6 P H Y S I O T Therapy designed at the strengthening of the muscles In le p r o s y , as in o th e r c o n d itio n s affec tin g th e p erip h eral n erves su ch a s p o lio m y e litis, th e d e str u c tio n o f n erv es is o fte n in c o m p le te w ith th e resu lt th a t th e re is paresis rather than p a ra ly sis. E fforts a t in crea sin g th e stren gth o f th e r e m a in in g m u sc le fibres c o n stitu te stan d ard p h y sio -th e r a ­ p e u tic p ro ced u re. C o n sid e r a b le e m p h a sis sh o u ld be p laced o n fu n ctio n a l e x e r c ise s a n d a c tiv itie s , e.g . th e u se o f a d ra u g h t-b o a rd w ith c lo th e s p e g s o r hair c lip s fo r co u n te r s. T h e s e are clip p ed o n to m eta l ta g s o n th e b o a rd . In th e a b se n c e o f an o c c u p a tio n a l th e ra p ist, th is ta sk w ill fall t o th e lo t o f th e p h y sio th era p ist. It is im p o s sib le to p r o g n o stic a te d u rin g th e a c tiv e p h a se o f n erve in v o lv e m e n t, an d all n erve le s io n s m ust th erefore r ece iv e in te n siv e trea tm en t. It h as b een ou r e x p e r ie n c e that la tera l p o p lite a l n erv e le s io n s h a v e e n h a n ced p o w ers o f r eco v e ry w h e n co m p a r e d w ith le sio n s o f th e u ln ar a n d the m ed ia n nerves. E lec trica l stim u la tio n requires an a p p a ra tu s c a p a b le o f d eliv e r in g lo n g im p u lses (up to 1 ,0 0 0 m .se c s.) o f v ariab le w a v e fo rm a n d w ith a d ju sta b le, lo n g in te rv a ls. T h e current m u st b e d e p o la r ise d , as h ig h in te n sitie s are o fte n essen tia l. T h e sk in is h y p erse n sitiv e a n d ea sily d a m a g e d . A c u te n eu ritis is g en erally o f an in te rm itte n t n a tu re , and e lectrica l te sts a re n o t a lw a y s a r elia b le in d e x o f th e progress w h ich o c c u r s d u rin g trea tm en t. H o w e v e r , w h e n p a resis or p a ra ly sis is n o te d , m u s c le tests sh o u ld be perform ed regu ­ larly. D a ily a tte n tio n t o th e m u scles o f all c a se s in a la rg e in stitu ­ tio n is n o t p o ss ib le , a n d o u r e x p erien ce h as b een th a t tim e sp e n t o n c a se s o f ac u te p o ly n e u r itis h as b een m o r e rew ard in g th a n o n c a se s o f o th e r ty p e s o f n erve le sio n . Short wave diathermy S h o rt w a v e d ia th er m y is m o st c o m m o n ly u sed fo r n eu ritis, b u rsitis o f th e k n e e , an d te n d in itis at th e w rist a n d th e an k le. M ild d o se s and sh o r t p e r io d s o f trea tm en t are co n sid er ed sa fest. S h o r t-w a v e d ia th er m y is a b so lu te ly co n tr a -in d ic a te d in all c a se s o f E r y th em a N o d o s u m L e p r o su m , b eca u se it p ro d u ces a g g r a v a tio n o f th e lo c a l le s io n . F o r this r e a so n , le p r o m a to u s le p r o s y sh o u ld b e treated w ith c a u tio n , b e c a u se E .N .L . m ig h t w ell b e p resen t, a lb e it in u n r e c o g n isa b le form a t the tim e o f o n e ’s e x a m in a tio n ; sh o r t w a v e d ia th er m y e v e n in m ild d o sa g e , c o u ld p r o d u c e a se rio u s flare-u p o f this d is­ tressin g c o m p lic a tio n . Ultrasonic therapy T h is fo r m o f sh o r t-w a v e th erap y h a s n o t b een u sed at W e stfo r t I n s titu tio n , b u t fa v o u r a b le rep orts h a v e been rece iv e d fro m elsew h ere. | R o b e r t N . Z im m erm a n , C h ie f P h y sica l T h er a p ist at th e U .S . P u b lic H e a lth S ervice H o sp ita l a t C a rv ille, L o u isia n a s ta te s 3: “ In a p p ly in g u ltr a so u n d fo r n eu ritis, w e c o n sid e r n o t o n ly th e trea tm en t to th e n erve tru nk , b u t a lso g iv e th e r a p y to th e c o r r e sp o n d in g n erve r o o ts. W e h a v e b een su cc essfu l w ith d o sa g e s fro m -5 to 1 - 5 w a tts /c m s a lo n g th e n erve d istr ib u tio n fo r 4 -6 m in u tes, a n d c o r r e sp o n d in g n erv e r o o ts w ith d o sa g e s a n d d u r a tio n id e n tic a l w ith n erve d istrib u tio n tec h n iq u e . I w o u ld e stim a te th a t m o r e than 8 0 per c e n t o f o u r p a tie n ts treated fo r this c o n d itio n h a v e had r e lie f fro m p a in w ith in a p erio d o f 3-5 d a y s.” E lse w h e r e 1 h e sta tes th a t u ltr a so u n d is m o r e b en eficial than a n y o th e r m o d a lity in a lle v ia tin g th e sy m p to m s o f a c u te n eu ritis in le p r o sy , a n d th a t th e p resen ce o f E .N .L . d o e s n o t c o n s titu te a c o n tr a -in d ic a tio n to its a p p lic a tio n . Summary and Conclusion D isc u s sio n o f th e n a tu re o f th e le s io n s o f lep ro sy h a s been o m itte d , in o rd er th a t their effects m a y rece iv e th e sp o tlig h t o f o u r a tte n tio n . W h e n v iew ed in this lig h t, it is cle a r th a t lep ro sy is a d ise a se in w h ich th e differen t sta g es o f th e d ise a se , and the ('C o n tin u ed on fo llo w in g p a g e 7 H E R A P Y June, 1963 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1963 P H Y S I O T H E R A P Y Page 7 nV a new approach to vasodilatation by the use of the potent new penetrative agent iN E W t 1 I -yJRubiguent F OR S P R A IN S , FIBROSITIS, ARTHRITIS, S T R A I N S A N D M U S C L E S P A S M R e g is te re d U ser o f T ra d e M a r k a n d D istr ib u to rs in S ou th A fric a : WYETH LABO RATO RIES (PTY.) LTD. Electron Avenue, Box 4 2 & 4 3 Isando, Transvaal. M ETH Y L N ICO TINATE in conjunction with the powerful vasodilator, histamine opens the way for the histamine to penetrate tissues rapidly. There it prom otes prolonged, pain-relieving hyperemia, com forting analgesia and soothing warmth. Formula H is ta m in e D ih y d r o c h lo r id e 0 • 1 % M e th y l N ic o tin a te 1 -0 % G ly c o l M o n o sa lic y la te 1 0 -0 % C a p sic u m O le o r e sin 0 - 1 % T h ese are in co rp o ra ted in a b la n d , c o sm e tic a lly p le a sa n t v eh icle. H o w S u p plied— T u b e s o f P r ic e — In e x p e n siv e — 5 / 6 O n e O u n ce. p er tube to y o u r p a tie n t. Continued f r o m p re c e d in g p a g e 6 ) a d van cem en t fro m sta g e t o sta g e are se en t o d e v e lo p b y a slo w and b y n o m ea n s in e x o r a b le p ro cess. W ith o u t th e lig h t w h ich su ch a d eta ile d co n sid e r a tio n sh ed s, w e are in clin ed t o a ss u m e t o o rea d ily th a t stru ctu ral ch anges in v o lv in g th e d ig its in a p r o cess o f d is s o lu tio n are prim ary, w h en in fa ct th e y are u su a lly se c o n d a r y to a num ber o f read ily a v o id a b le fa cto r s. W ith th e lig h t o f su ch rea lisa tio n , c o m e s th e su re k n o w le d g e th a t th e a v o id a b le factors are o f a stra ig h tfo rw a r d n a tu re , a n d th a t they are em in en tly a m e n a b le t o trea tm en t. T h e w orld p r o b le m in resp ect o f lep ro sy in v o lv e s n o few er than ten m illio n (and n o m o r e than 2 0 m illio n ) so u ls. T h e p ro b lem w ith in th e R e p u b lic is, n u m e r ic a lly sp ea k in g , a sm all o n e , b ut o n e w h ich is in in v erse p r o p o r tio n t o th e po te n tia l it bears a s a su b ject fo r sc ien tific resea rch , a n d a s a field in w h ich b o th th e m e d ic o and th e p h y sio th e r a p ist m ay m ake o u tsta n d in g c o n tr ib u tio n s. R E F E R E N C E S 1. “ Scien tific m e e tin g o n R e h a b ilita tio n in L e p r o sy ,” 1961. W .H .O . T e c h n ic a l R e p o r t S eries, N o . 2 2 1 , G e n e v a , 1961. 2. B r a n d , P. W . (1 9 5 9 ), in L e p r o s y in T h e o ry a n d P ra c tic e . E d itor, R . G . C o ch ra n e. P u b lish e d b y W righ t B r i s t o l . 3. Z im m e r m a n , R , N . (1 9 6 2 ). P erso n a l C o m m u n ic a tio n . 4. Z im m e r m a n , R . N . (1 9 6 1 ). “ U ltr a s o n ic s ,” S em in a r on L eprosy, U .S . P u b lic H e a lth S ervice H o sp ita l, C arville, L .A . T H A N K S A N D A C K N O W L E D G E M E N T S W e w ish to th a n k th e S ecretary fo r H e a lth , T h e D e p a r t­ m ent o f H e a lth , T h e R e p u b lic o f S o u th A fr ic a , an d the su p erin ten d en t, D r. A . R , D a v is o n , o f the W e stfo r t In stitu ­ tio n , P retoria, fo r p e r m issio n t o p u b lish th is article. A u th o r s, A p r il, 1963. BARF0RD & JONES (SURGICAL SUPPLY CO.) Makers of: ARTIFICIAL LIMBS and ORTHOPAEDIC APPLIANCES SURGICAL INSTRUMENT REPAIRERS. 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