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Biomedical subjects

W H van Brakel

Publications and source records attributed to W H van Brakel.

At least 19 recordsLinked to original sources
PubMed1999

Grading impairment in leprosy.

The aim of the paper is to discuss the concept of 'severity grading' in relation to impairment in leprosy, and to describe the use of an impairment sum score, the Eyes, Hands, Feet (EHF) score, as an indicator of the severity and the evolution of impairment over time. The use of an impairment sum score, the EHF score, is illustrated using data on impairment at diagnosis and after a 2-year interval from MB patients released from MDT in the Western Region of Nepal. The WHO 1988 'disability' grading scale (0-2, for both eyes, hands and feet--six sites) was used as a measure of impairment. For the analysis, the WHO grades for the six sites were summed to form an EHF score (minimum 0, maximum 12). The sensitivity to change over time of the EHF score was compared with that of the 'method of maximum grades'. Using the 'method of maximum grades', 509/706 patients (72%) appeared not to have changed in impairment status, compared with only 399 (56.5%) with the EHF score. Improvement or deterioration of impairment status was missed in 113 patients (16%). In 216/706 patients (30.6%), the changes detected with the EHF score were bigger than those revealed by the method of maximum grades. The six components of the WHO impairment grading may be added up to form a EHF sum score of impairment. This score can be used to monitor changes in impairment status in individuals or in groups. It should be recorded and reported at least at diagnosis and release from treatment. Reporting could be done as the 'proportion of patients with improved EHF score', 'stable EHF score' and 'EHF score worse', and 'proportion of patients without impairment', 'proportion with WHO grade 1' and 'proportion with WHO grade 2'. It is recommended that the concepts and terminology of the WHO International Classification of Impairments, Activities and Participation (ICIDH-2) be adopted in the field of leprosy, particularly for the areas of prevention of impairment and disability and rehabilitation. The 'WHO disability grade' should be renamed 'WHO impairment grade'.

Cohort Studies↗
PubMed1999

A scale to assess activities of daily living in persons affected by leprosy.

The aim of this study was to develop a scale for identifying disability among people in the rural areas of developing countries. The studies were carried out in the Green Pastures Hospital and the leprosy field programme of the Western Region of Nepal. With the help of staff experienced in working with people with disability, a 68-question questionnaire was made, based on the International Classification of Impairments, Activities and Participation (ICIDH-2). A survey was carried out of 269 people affected by leprosy who had impairments, as well as a sample of those who were unimpaired. The survey results were used to develop the questionnaire into a scale, using standard scale development methods. This included checking of criterion validity, discrimination and reliability and stability using weighted kappa statistics. Of the 68 questions, 38 were included in the second draft of the instrument. Eight questions were added to identify difficulty in relationships, about the use of aids and about occupation and employment. The sum score of the scale against the expert score gave a Spearman correlation coefficient of 0.72. Intra- and inter-interviewer reliability coefficients were 0.77 (95% CI 0.73-0.81) and 0.61 (95% CI 0.56-0.67), respectively. The stability test gave an overall kappa of 0.76 (95% CI 0.70-0.82). Four questions with particularly poor results were omitted from the final draft of the instrument. An interview-based instrument was developed for identifying limitations in activities of daily living (disability) in people living in a rural setting in a developing country--the Green Pastures Activity Scale (GPAS). The scale performed well during validity and reliability testing. It consists of 34 activity questions, five relationship questions, and three questions on the use of aids, occupation and employment.

Activities of Daily Living↗
PubMed1997

Functional sensibility of the hand in leprosy patients.

The aims of this cross-sectional comparative study was to compare the results of Semmes-Weinstein monofilament testing (SWM) and moving 2-point discrimination (M2PD) with four tests of functional sensibility: recognition of objects, discrimination of size and texture and detection of dots. Ninety-eight leprosy in- and outpatients at Green Pastures Hospital in Pokhara, Nepal were tested with each of the above tests and the results were compared to see how well they agreed. Using the tests of functional sensibility as reference points, we examined the validity of the SWM and M2PD as predictors of functional sensibility. There was definite, but only moderate correlation between thresholds of monofilaments and M2PD and functional sensibility of the hand. A normal result with the SWM and/or M2PD had a good predictive value for normal functional sensibility. Sensitivity was reasonable against recognition of objects and discrimination of textures as reference tests (80-90% and 88-93%), but poor against discrimination of size and detection of dots (50-75% and 43-65%). Specificity was high for most combinations of SWM or M2PD with any of the tests of functional sensibility (85-99%). Above a monofilament threshold of 2 g, the predictive value of an abnormal test was 100% for dot detection and 83-92% for textural discrimination. This indicates that impairment of touch sensibility at this level correlates well with loss of dot detection and textural discrimination in patients with leprous neuropathy. For M2PD the pattern was very similar. Above a threshold of 5 mm, 95-100% of affected hands had loss of dot detection and 73-80% had loss of textural discrimination. Monofilament testing and M2PD did not seem suitable as proxy measures of functional sensibility of the hand in leprosy patients. However, a normal threshold with monofilaments and/or M2PD had a good predictive value for normal functional sensibility. Above a monofilament threshold of 2 g and/or a M2PD threshold of 5 mm, textural discrimination was abnormal in most hands.

Cross-Sectional Studies↗
PubMed1997

Progress of impairment scores following commencement of chemotherapy in multibacillary leprosy patients.

STUDY AIM: To investigate the progress of impairment over time in multibacillary (MB) leprosy patients. STUDY DESIGN: Retrospective cohort study. STUDY POPULATION: One-thousand-eighty-two MB patients newly registered in nine field clinics in the Western Region of Nepal between 1980 and 1993. METHODS: Data on impairment at diagnosis and at yearly intervals afterward were collected from patient records of MB patients already released from multidrug therapy (MDT). The World Health Organization (WHO) 1988 "disability" grading scale (0-2, for both eyes, hands and feet--six sites) was used as a measure of impairment. For the analysis we summed the WHO grading for the six sites into an eyes-hands-feet (EHF) sum score (minimum 0, maximum 12). The EHF score at 2 years of follow up was used to compute the main outcome measures: impairment at 2 years, yes or no, and deterioration of impairment compared with diagnosis. The combined effect of age, sex, classification and impairment status at diagnosis on the outcome was examined with logistic regression. RESULTS: At diagnosis, 55.8% of the patients had some impairment. This proportion decreased over 2 years to 43.9%. Among patients without initial impairment, 31/310 (10%) developed impairment during the study period. This was 81/396 (20.5%) among patients with impairment at diagnosis. The adjusted odds ratio (OR) for developing impairment was 1.87 [95% confidence interval (CI) 1.06-3.32] for patients with initial sensory impairment (WHO grade 1). and 1.98 (95% CI 1.15-3.4) for those with initial visible deformity (WHO grade 2). Among patients with impairment at diagnosis, 195/396 (49.2%) had improved after 2 years. CONCLUSIONS: The proportion of patients with impairment after 2 years of antileprosy treatment was 12% less than at diagnosis. Among patients without initial impairment, 10% had developed some impairment after 2 years. The risk of developing impairment was almost double for those with sensory impairment or visible deformity at diagnosis. For purposes of monitoring, evaluation and planning, both the proportion of patients with sensory impairment (WHO grade 1) and the proportion with visible deformity (WHO grade 2) should be reported at diagnosis and at release from treatment.

Adult↗
PubMed1996

Nerve function impairment in leprosy: an epidemiological and clinical study--Part 2: Results of steroid treatment.

This retrospective cohort study aimed to determine the progress of sensory and motor function during and after steroid treatment, and to identify any prognostic factors for the outcome of treatment. The study used one hundred and sixty-eight leprosy patients registered at Green Pastures Hospital, Pokhara, West Nepal, who were treated with one of four different corticosteroid regimens for impairment of nerve function. The function of the main peripheral nerve trunks affected in leprosy was assessed with a nylon filament to test touch thresholds (TST) and a manual voluntary muscle test (VMT) to quantify muscle strength. The TST and VMT scores at 3 months after initiation of steroid treatment served as the main outcome measure. The significance of potential prognostic factors was evaluated with logistic regression. At 3 months, the sensory and motor function of the majority of patients with 'recent' impairment ( = less than 6 months duration) had improved significantly (p < 0.01, Wilcoxon matched pairs signed-ranks test). The likelihood of 'good' recovery (prognosis) for both sensibility and motor function was directly related to the severity of the nerve damage at the beginning of treatment. Although nerve function improved in 30-84% (depending on the type of nerve) of patients, an active search for better methods of treatment and improved regimens is justified. The need for early assessment and treatment is stressed.

Adolescent↗
PubMed1996

Intra- and inter-tester reliability of sensibility testing in leprosy.

We conducted an intra- and inter-tester agreement study of three sensory screening tests used in nerve function assessment of leprosy patients: the Semmes-Weinstein monofilament (SWM) test, moving 2-point discrimination (M2PD), and the pin prick test. The weighted kappa (Kw) statistic was used as the reliability coefficient. The SWM had intra-observer Kws ranging from 0.83 to 0.92 and inter-observer Kws ranging from 0.76 to 0.89. The M2PD had intra- and inter-tester Kws ranging from 0.75 to 0.82 and 0.54 to 0.82, respectively. Inter-tester agreement for the pin prick test ranged from 0.45 to 0.85. There was evidence that the main source of variability between testers was testing skill and experience. Among the experienced physiotechnicians there was no significant difference between intra- and inter-tester reliability. We conclude that reliability of the SWM test was very good, closely followed by the M2PD test. Reliability of the pin prick test was less good than that of the SWM and M2PD, making it less suitable for serial testing.

Humans↗
PubMed1995

Integration of leprosy control into basic health services; an example from Nepal.

The need for integration of vertical projects into the Basic Health Services (BHS) has been felt in Nepal since 1968. In 1987 it was decided to provide integrated BHS all over the country. The Nepal Leprosy Control Project (NLCP) was one of the vertical projects which had to be integrated from that year. In order to prepare the BHS staff for this new task the NLCP developed a Comprehensive Leprosy Training course. Besides adequate training, three other prerequisites for successful integration are: a) adequate supply of drugs and equipment; b) regular supervision and specialist referral facilities; and c) a well functioning BHS system in which to integrate. This article tries to assess to what extent these prerequisites have been met for leprosy control in Nepal. To do this, some results of an evaluation of the training are used as well as existing literature on the functioning of the BHS system. The first three prerequisites are not fully met, but problems and obstacles related to these are mainly due to problems in the last prerequisite: a not so well functioning BHS system. It was, therefore, recommended to continue a (semi)vertical support system of leprosy control in those districts where the BHS is not so well developed.

Health Personnel↗
PubMed1995

Use of facility-based assessment in the evaluation of a comprehensive leprosy training program in Nepal.

A facility-based assessment (FBA) was done to evaluate a comprehensive leprosy training program in Nepal. The training course was developed to prepare the Basic Health Services staff for integrated leprosy work. FBA is a coordinated set of data collection activities designed to determine the extent to which patients are properly diagnosed, treated, and cared for in the treatment facility. During the present evaluation, the data collection activities included: observation of health worker performance, exit interviews with leprosy patients, interviews with health workers, inventory of essential equipment and supplies, and collection of routine statistical data. The objectives of the training course were used as guidelines for the evaluation. Surveys and observation visits were done repeatedly and compared with a (untrained) control group. Different actors involved in leprosy care were used as informants, and different data collection methods were used which enabled cross-checking of the information. Part of the data collection activities was already routinely carried out. FBA proved to be a very useful and effective tool for the evaluation of a leprosy training program. Those parts of the training which need extra attention during the course itself as well as during refresher training and supervision visits became obvious.

Health Facilities↗
PubMed1994

Evaluation of sensibility in leprosy--comparison of various clinical methods.

In order to determine whether various sensibility tests, not in common use at our hospital, are appropriate for the neurological screening of leprosy patients, an extended nerve function assessment (NFA) was done on 50 in- and outpatients who had been diagnosed as suffering from leprosy (100 hands and feet). The nerve function assessment battery consisted of Semmes-Weinstein monofilament testing (SWMT), moving 2-point discrimination (M2PD). Pinprick (PP), position sense (PS), vibration sense (VS) and voluntary muscle testing (VMT). In addition the SWMT was performed on 637 hands and 634 feet of field patients' in order to get a better indication of the prevalence of sensory impairment as measured with the SWMT. The SWMT has been shown to be a sensitive test of peripheral nerve function, therefore the other tests were compared with the SWMT. Results are reported separately for the ulnar, median and posterior tibial nerve. Test sites were the pulp of the distal phalanx of the index finger, the little finger and the big toe. Correlation between the SWMT and each of the other tests proved statistically significant; the closest correlations were between the SWMT, M2PD and PP for both ulnar and median nerves (r > 0.7, F test > 100, p < 0.0001). It is argued that the first tests to show nerve function impairment (NFI) are the M2PD and the SWMT. VS and PS were also absent in a significant proportion of patients. Arguments are presented that this may indicate advanced NFI. Results are compared with other data currently available in the literature.

Adolescent↗
PubMed1994

Silent neuropathy in leprosy: an epidemiological description.

This paper presents epidemiological data on silent nerve function impairment in leprosy based on a retrospective study of 536 patients registered at Green Pastures Hospital, Pokhara, West Nepal. Because of the multiple possible aetiologies it is proposed that the clinical phenomenon should be named 'Silent Neuropathy' (SN). We defined this as sensory or motor impairment without skin signs of reversal reaction or erythema nodosum leprosum (ENL), without evident nerve tenderness and without spontaneous complaints of nerve pain (burning or shooting pain), paraesthesia or numbness. The functioning of the main peripheral nerve trunks known to be affected in leprosy was assessed using a nylon filament to test touch thresholds and a manual voluntary muscle test to quantify muscle strength. Almost 7% of new patients had SN at first examination. The incidence rate of SN among the 336 new patients who were available for follow-up was 4.1 per 100 person years at risk. In total, 75% of all SN episodes diagnosed after the start of chemotherapy occurred during the first year of treatment. During steroid treatment the sensory and motor function in nerves affected by SN improved significantly (p = 0.012, Wilcoxon matched-pairs signed ranks test) over a period of 3 months. The patients with more extensive clinical disease (3/9 or more body areas involved, more than 3 enlarged nerves or a positive skin smear) were found to be at increased risk of developing SN. We discuss 4 different possible aetiologies of SN: 1, Schwann cell pathology; 2, nerve fibrosis; 3, cell-mediated immune reaction; and 4, intra-neural ENL. Some epidemiological evidence is presented that suggests that SN cannot be equated with a 'reversal reaction expressing itself in the nerves'. It is recommended that all patients should have a nerve function assessment at every visit to the clinic at least during their first year of treatment. Regular nerve function assessment is essential to detect SN at an early stage and to prevent permanent impairment of nerve function.

Adolescent↗