Physiotherapy management of leprosy patient with bilateral claw hands for 10 marks to pt cvts subject
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physiotherapy management leprosy bilateral claw hand CVS physiotherapy notes 10 marks
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https://arunalaya.com/leprosy-physiotherapy-nerve-rehab
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https://proceedings.ums.ac.id/apc/article/download/1145/1120
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Physiotherapy Management of Leprosy Patient with Bilateral Claw Hands
(For PT/CVTs Subject - 10 Marks Answer)
Introduction
Claw hand (main en griffe) in leprosy is caused by peripheral nerve damage - primarily the ulnar nerve (ring and little finger clawing) and median nerve (index and middle finger clawing). The intrinsic muscles of the hand (lumbricals and interossei) are paralyzed, leading to unopposed action of the extrinsic extensors, resulting in hyperextension at the MCP joints and flexion at the PIP/DIP joints. Bilateral involvement indicates damage to both nerves at both hands.
Physiotherapy is an integral component of the Disability Prevention and Medical Rehabilitation (DPMR) program in leprosy management.
Assessment Before Treatment
Before starting treatment, the physiotherapist should assess:
- Sensory status - presence of anaesthesia/hypoaesthesia using Semmes-Weinstein monofilaments
- Motor status - manual muscle testing (MMT) of intrinsic hand muscles
- Range of motion (ROM) - active and passive at MCP, PIP, DIP joints
- Trophic changes - skin dryness, ulcers, resorption of digits
- Degree of clawing - mobile (correctible passively) vs. fixed (contracture present)
- Grade of disability - WHO leprosy disability grading (Grade 0, 1, 2)
Aims of Physiotherapy
- Prevent contractures and further deformity
- Maintain/restore joint range of motion
- Strengthen weak muscles and re-educate muscles
- Protect anaesthetic hands from injury
- Promote functional independence in ADLs
- Educate the patient for long-term self-care
Physiotherapy Management
1. Patient Education and Self-Care (Most Important)
Since the hands are anaesthetic (loss of protective sensation), self-care education is the first and most critical component:
- Teach the patient to inspect hands daily for wounds, blisters, and burns
- Avoid holding sharp/hot objects without protection; use padded tools and gloves
- Soak and oil hands daily to prevent skin dryness and cracking
- Wound care for any trophic ulcers
- Educate about the "Think before you grip" principle
2. Splinting and Orthotic Management
Splinting is the cornerstone of claw hand management in leprosy.
| Type | Purpose | Example |
|---|---|---|
| Static/resting splint | Maintain corrected position at night; prevent worsening | Knuckle-bender/lively splint in neutral |
| Dynamic splint (Knuckle-bender splint) | Maintain MCP joints in slight flexion to counteract clawing; allows active movement | Spring-loaded MCP flexion splint |
| Serial splinting | Correct fixed contractures gradually | Progressive static splints changed every 1-2 weeks |
| Functional splint | Improve grip and pinch function during ADL | Opposition splint for thumb involvement |
The knuckle-bender (Bunnell) splint is the most commonly used dynamic splint - it flexes the MCP joints, allowing PIP/DIP extension via the long extensors, thereby correcting the claw posture during function.
3. Exercises
(a) Passive Range of Motion (PROM)
- Performed by the therapist or trained caregiver
- Gentle passive flexion-extension of MCP, PIP, DIP joints
- Prevents joint stiffness and adhesion formation
- Done daily, 2-3 sets of 10 repetitions each joint
(b) Active Range of Motion (AROM) / Active Assisted Exercises
- Patient actively moves the fingers within available range
- Tenodesis effect exercises: wrist flexion to produce finger extension, wrist extension to facilitate finger curl
(c) Intrinsic Muscle Strengthening
- "Intrinsic plus" exercises: MCP flexion with IP extension (the lumbrical action)
- Knuckle bending exercises against resistance
- Theraband / putty exercises for progressive resistive training
- Pinch and grip strengthening using resistive materials
(d) Stretching
- Passive stretching of the flexor digitorum superficialis and profundus if PIP contracture is developing
- Web space stretching for thumb adductor tightness
- Hold-relax (PNF) technique for contracted muscles
(e) Nerve Gliding Exercises
- Ulnar and median nerve gliding/mobilization exercises to maintain neural mobility and facilitate nerve regeneration
- e.g., Ulnar nerve: shoulder abduction, elbow flexion, wrist extension sequence
(f) Biofeedback and Muscle Re-education
- EMG biofeedback to help patients consciously activate residual intrinsic muscle activity
- Mirror therapy to facilitate neural re-learning
4. Electrotherapy Modalities
| Modality | Indication | Effect |
|---|---|---|
| TENS (Transcutaneous Electrical Nerve Stimulation) | Neuropathic pain | Pain relief |
| NMES/FES (Neuromuscular Electrical Stimulation) | Paralyzed intrinsic muscles | Maintain muscle bulk, prevent atrophy, facilitate re-innervation |
| Faradic electrical stimulation | Partial denervation (early nerve damage) | Muscle re-education |
| Galvanic stimulation | Complete denervation | Maintain muscle viability |
| Wax bath (paraffin wax therapy) | Stiff, dry, contracted hands | Improves circulation, softens skin, prepares for exercise |
| Ultrasound | Scar tissue/contracture management post-surgery | Collagen remodeling |
5. Sensory Re-Education
- Progressive tactile stimulation training using different textures, shapes, and surfaces
- Identification exercises (identify objects by touch with eyes closed)
- Protective sensation training - teaches compensatory strategies when normal sensation is absent
- Goal: improve functional use of hands and prevent injury from lack of feedback
6. Functional and Occupational Rehabilitation
- Training in modified ADL techniques (writing, buttoning clothes, eating)
- Adaptive equipment provision - built-up handles, key holders
- Vocational assessment and modification of work tasks
- Community-based rehabilitation (CBR) follow-up
- MCR (Microcellular Rubber) footwear if feet are also affected
7. Post-Surgical Physiotherapy (If Tendon Transfer Done)
In fixed, irreversible cases, a tendon transfer surgery (e.g., Zancolli procedure, Brand's ECRL transfer) may be performed before physiotherapy. Post-operatively, the physiotherapist:
- Protects the transferred tendon during the initial healing phase (3-4 weeks immobilization)
- Gradually introduces AROM and PROM
- Teaches the patient to re-learn the new tendon's function (muscle re-education)
- Progressive strengthening over 3-6 months
- Functional use training
Graded Progression of Treatment
| Phase | Focus |
|---|---|
| Acute/reactive phase | PROM only, splinting, wound care, edema management |
| Sub-acute phase | AROM, gentle strengthening, sensory education |
| Chronic/maintenance phase | Progressive resistance, functional training, vocational rehab |
Summary
The physiotherapy management of bilateral claw hands in leprosy is long-term and multi-modal. It combines:
- Protective education (to prevent injury in anaesthetic hands)
- Splinting (knuckle-bender splint to counteract clawing)
- Therapeutic exercises (PROM, AROM, strengthening, nerve gliding)
- Electrotherapy (NMES, TENS, wax bath)
- Sensory re-education
- Functional rehabilitation and ADL training
- Post-surgical rehab if tendon transfer is performed
Early intervention prevents disability progression. The goal is to restore maximum functional independence and quality of life in the leprosy-affected patient.
Sources: Park's Textbook of Preventive and Social Medicine (DPMR program); Arunalaya Leprosy Physiotherapy guide; Physiotattva - Claw Hand Rehab
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