Physiotherapy Management of Leprosy Patient with Bilateral Claw Hands

Understanding the Deformity

• Hyperextension at MCP joints (due to unopposed action of extensor digitorum communis)
• Flexion at PIP and DIP joints (due to loss of intrinsic-plus position)
• Ulnar nerve palsy = clawing predominantly of ring and little fingers (all four in combined palsy)
• Anaesthesia of the hands, making patients vulnerable to burns, cuts, and pressure injuries

Physiotherapy Management - Systematic Approach

1. Assessment (Before Treatment)

• Document nerve involvement: ulnar, median, or combined
• Sensory testing: monofilament testing (Semmes-Weinstein), two-point discrimination
• Motor testing: assess intrinsic muscle power (MRC grading), test Froment's sign
• Deformity grading: WHO disability grade (0, 1, 2); assess whether claw is mobile (flexible, correctable) or fixed (contracture present)
• Functional assessment: grip strength (dynamometer), pinch grip, ADL performance
• Check for trophic ulcers, skin integrity, and oedema

2. Prevention of Deformity Progression

A. Splinting (Core Intervention)

• The anti-claw splint (blocking MCP hyperextension) is the standard functional splint in leprosy - it allows patients to use their hands while preventing worsening of the deformity.
• Splints must be checked for pressure areas in anaesthetic hands, as they can cause undetected sores.

3. Exercise Therapy

A. Range of Motion (ROM) Exercises

• Passive ROM to all finger joints and wrist - prevents joint stiffness and capsular contracture, especially in paralysed parts
• Active-assisted ROM where partial movement remains
• Active ROM for available muscles (extrinsics are preserved; train patient to use them correctly)

B. Stretching Exercises

• Intrinsic stretching: Gently stretch the shortened intrinsics and volar plate
• PIP joint extension stretches: Essential to counteract PIP flexion contracture
• Thumb web space stretching: Prevents thumb adduction contracture (first web space)
• Wrist tendon stretches: Prevent tightness of wrist flexors/extensors

C. Strengthening Exercises

• Grip strengthening: Putty exercises, sponge squeezing, graduated resistance
• Pinch grip training: Lateral pinch, tip pinch, tripod pinch - using coins, pegs, small objects
• Extrinsic muscle training: Wrist extensors and flexors (these are intact in ulnar palsy); used to compensate
• Biofeedback and neuromuscular electrical stimulation (NMES): For weak intrinsic muscles to maintain tone and facilitate re-education

D. Nerve Gliding Exercises

• Ulnar nerve gliding exercises to maintain nerve mobility and reduce fibrosis along the nerve bed
• Performed gently; contraindicated in acute neuritis or reaction

4. Sensory Re-education and Protective Sensation Training

• Education: Teach the patient to use their vision to compensate for absent protective sensation (visual substitution)
• Protective measures: Always inspect hands daily for cuts, blisters, burns; use padded tools and gloves; avoid extremes of heat/cold
• Sensory re-education protocol (when partial sensation recovers): Texture identification, object recognition, moving-touch localisation - performed with eyes closed to retrain cortical sensory maps
• Skin and nail care: Daily oil massage (liquid paraffin or coconut oil) to prevent dryness and fissuring; soaking and debriding hyperkeratotic areas around anaesthetic skin

5. Wound and Ulcer Care

• Address any trophic ulcers present on hands
• Offloading pressure: Pressure-redistributing padding, modified tools
• Dressing and debridement as appropriate
• Educate patient on daily inspection (self-monitoring protocol)

6. Electrotherapy Modalities

Caution: All heat modalities must be used with strict temperature monitoring in anaesthetic hands to prevent thermal burns.

7. Functional Rehabilitation and ADL Training

• Activities of daily living (ADL) retraining: Dressing, eating, writing, personal hygiene using adapted techniques
• Assistive devices: Modified utensils with padded grips, button hooks, key holders
• Pre-vocational training: Adapted work tools; training in safe occupational techniques
• Grip and pinch retraining: Simulated daily tasks - picking up objects, pouring, folding

8. Pre- and Post-operative Physiotherapy (if Tendon Transfer is indicated)

• Achieve full passive mobility of all joints before surgery (no residual contracture)
• Teach patient isolated contraction of the donor tendon (e.g., FDS - flexor digitorum superficialis)
• Strengthen donor muscle to grade 4+

• Immobilise in lumbrical position: MCP at 90° flexion, IP joints straight, wrist neutral - for 3-4 weeks in POP cast
• After cast removal: Gentle ROM, progress to strengthening, retraining transferred tendon
• Continue splinting as needed during the rehabilitation phase

9. Psychological Support and Patient Education

• Counselling: Address social stigma, depression, and fear of isolation
• Leprosy is curable - reinforce this; encourage compliance with MDT (multi-drug therapy)
• Self-care training: Teach patient and family the complete self-care routine
• Community rehabilitation (CBR): Involve family members; link to community-level support and vocational training

Summary of Goals of Physiotherapy in Leprosy Claw Hand