Saturday, August 31, 2013

(LML) ILEP survey research priorities of leprosy field workers

Leprosy Mailing List – August 31,  2013 

Ref.:  (LML) ILEP survey research priorities of leprosy field workers 

From: June Nash, London, UK


 

Dear Dr Schreuder,

 

 

The ILEP Technical Commission (ITC) is looking at research priorities. We would like to have input from people who are working in the leprosy field and in particular basic health workers. It would be helpful if people on the mailing list could give us their top three research priorities for leprosy in the future. If they had opportunities to ask that question to the basic health workers on their team and could also give their answers that would be very helpful.

 

People can contact me on this email j.nash@sky.com

 

Many thanks.

 

 

Yours sincerely,

 

June Nash

 

member of ILEP ITC

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) WHO Weekly Epidemiological Record

Leprosy Mailing List – August 31,  2013 

Ref.:  (LML)   WHO Weekly Epidemiological Record

From:  Premanshu Bhushan, New Delhi, India


 

Dear Dr Schreuder,

 

The WHO Weekly Epidemiological Record 8835 has been uploaded on WHO website (available here: http://www.who.int/wer/2013/wer8835.pdf ).This deals with the global leprosy situation. A careful perusal of the document however brings out a serious error. In previous weekly epidemiological records numbered wer8734 (available at :

 http://www.who.int/wer/2012/wer8734.pdf) and wer8636 (available at:  http://www.who.int/wer/2011/wer8636.pdf)   the prevalence and new case detection rates are similarly calculated. The prevalence of leprosy is calculated per 10 000 population while the annual new case detection rate is calculated per 100 000 population. The same formula is used in new report that is wer8835

 

Now let us take a look at the reported data in these three documents:

 

WER no:     8636

Total cases (Prevalence, rate per 10 000) : 192 246 (0.34)   

Annual new cases detected (rate per 100 000): 228 474 (3.93)

 

WER no:    8734

Total cases (Prevalence, rate per 10 000) : 181 941 (0.34)

Annual new cases detected (rate per 100 000): 219 075 (4.06)

 

WER no:    8835

Total cases (Prevalence, rate per 10 000) : 189 018 (0.33)

Annual new cases detected (rate per 100 000): 232 857 (0.40)

 

Obviously, it is a mistake because with the same denominator  and almost similar numerator the result cannot be so different. In my opinion new case detection rate should have been 4.0   instead of 0.4. 

 

I would request you to kindly bring it to the notice of respective authorities and members of LML. Such errors in the WHO report is a very serious issue as it is looked upon as being most authoritative world over. A correction or clarification of this mistake should be done as soon as possible. I am ready to be corrected if I am wrong in my conclusion.

 

Sincerely,

 

Dr. Premanshu Bhushan

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Friday, August 30, 2013

(LML) WHO Weekly Epidemiological Record

Leprosy Mailing List – August 30,  2013 

Ref.:    (LML) WHO Weekly Epidemiological Record

From:  Felicity Bonham, London, UK


Dear Pieter,

 

On behalf of Mr Doug Soutar, General Secretary of ILEP, please can I ask you to help spread the word that the latest data on leprosy has been published in today’s Weekly Epidemiological Record by the WHO: WER8835

 

Best regards,

 

Felicity

Felicity Bonham

PA to the General Secretary

International Federation of Anti-Leprosy Associations
Working together for a world without leprosy

Tel: +44 (0)20 7602 6925 – Fax: +44 (0)20 7371 1621 – Website: www.ilep.org.uk

 To get our updates, like us on Facebook: ILEPAntiLeprosy


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Thursday, August 29, 2013

(LML) SW monofilaments

Leprosy Mailing List – August 29,  2013 

Ref.:    (LML) SW monofilaments

From:  Anthony Nicholl, Bauru, São Paulo, Brazil


 

Dear Pieter,

We've been very pleased to see how much interest is being shown in the use of different sensory testing techniques. I am sending a copy of the SORRI-BAURU monofilament testing kit user's manual in the English version (see attached file), for you to make available to readers as you see fit. It has a lot of information and should be easier for many people to understand. This should also shortly be available on the products page of SORRI's website - (at present only in Brazilian Portuguese).

( www.sorribauru.com.br )
or
(
http://sorribauru.wix.com/sorribauru-niptec )

 

 

Best wishes,

Anthony

A R J Nicholl

SORRI-BAURU

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) Is the detection of nerve function loss high on the agenda?

Leprosy Mailing List – August 29,  2013 

Ref.:   (LML) Is the detection of nerve function loss high on the agenda?
From:        S. Noto, Ragusa, Italy



Dear Pieter,

 

Thank you and all other contributors to the LML very much.  In my opinion the fact, that several of us have the detection of early nerve function loss high on the agenda, is not a proof that the situation is similar in the field.  In my experience (mostly in Africa) this key issue is much neglected. It is essential to assess loss of sensation as good as possible. In sophisticated area’s it may be sensory nerve conduction or evoked signals in the brain, but in the field it may be  a ballpoint, bristles or for example two point discrimination. But the most important is be aware, test and follow-up!! As far as I can see Graded Sensory Testing is the standard.

 

I value the initiative of Dr Narasimha Rao, from Hyderabad, India (LML – August 5,  2013) as a step forward to overcome an unsatisfactory situation. Do not leave sensory testing exclusively to physio- (occupational) therapist, nurse or leprosy assistant; also the leprosy supervisor and medical doctor (including dermatologist) should assess nerve function (ST and VMT) routinely.

 

Your sincerely,

 

Salvatore

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Sunday, August 25, 2013

(LML) SW monofilaments

Leprosy Mailing List – August 25 ,  2013 

Ref.:    (LML)  SW monofilaments and sensory testing

From:  Robert Jerskey, California, USA


 

Dear Pieter Schreuder,

I have enjoyed and greatly appreciated the ongoing discussions re: sensory testing---cogent and informative for me---including a broader historical perspective by Ben on the evolution of monofilaments and their use by investigators in the field.

I also appreciate the point raised by Wim van Brakel re: a sustainable and low cost source of the filaments.   I volunteer to follow up later with an update re: the manufacturer of the filaments and prospects of their distribution outside of the Northern market, e,g., in Africa, Asia; and even if via loose filaments that can be assembled locally.

Meanwhile, as mentioned earlier, those who are seeking the [loose] filaments for their programs/clinics are welcome to approach me---Tues, Wed., Thurs. at the Congress---and I will deliver.  [Importantly: filaments will include guidelines re: their proper calibration and application].  I might be more easily identified by one of the colorful vests---primarily black and red---from my wife's homeland of Nagaland which I will be wearing.

Looking forward to meeting old friends and new acquaintances at the Congress,

Robert

 

Robert Jerskey, LOTR, P.O.D. consultant, Regional Hansen's Disease Clinics in Los Angeles and San Diego

email: robjerskey@yahoo.com

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

(LML) To contribute towards the formulation of the WHO Action Plan on Disability

Leprosy Mailing List – August 25,  2013 

Ref.:   (LML)  To contribute towards the formulation of the WHO Action Plan on Disability

From:  Doug Soutar, London, UK


Dear Pieter,

On behalf of Mr Doug Soutar, General Secretary of ILEP, please can I ask you to post this item about the current opportunity to contribute towards the formulation of the WHO Action Plan on Disability to ensure better health care for people with disabilities, in line with the 66th WHA Resolution, through WHO’s online consultation: http://goo.gl/i3kzvw ?

Mr Soutar says: “This is a vital opportunity for ILEP Members and organisations of leprosy affected persons to have a say in the drafting of this key document and to ensure that the perspectives of those affected by leprosy are heard.”

 

Thank you.

 

Felicity

 Felicity Bonham

PA to the General Secretary

International Federation of Anti-Leprosy Associations
Working together for a world without leprosy

Tel: +44 (0)20 7602 6925 – Fax: +44 (0)20 7371 1621 – Website: www.ilep.org.uk

 To get our updates, like us on Facebook: ILEPAntiLeprosy


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Tuesday, August 20, 2013

(LML) Nerve impairment, sensory testing and M.leprae immune status

Leprosy Mailing List – August 20,  2013 

Ref.:   (LML) Nerve impairment, sensory testing and M.leprae immune status

From:  W. Theuvenet, Apeldoorn, the Netherlands


Dear All,

 

I have followed with great interest the discussion on sensory testing and from all correspondence it may be happily concluded that the issue of the early detection of nerve function loss is still high on the agenda of many clinicians. In the field one is often forced to use alternative tools but there seems no discussion that , when available, the use of Semmes Weinstein Monofilaments has preference when testing loss of sensation. Still, there are some pitfalls to the use of SWM as well and for those who are interested I have attached an article on the influence of humidity and temperature on the SWM.

 

In my daily practice I have noticed that EMG investigations are not sensitive enough to pick up early nerve function loss. For instance, in 25% of the patients with classical symptoms of a CTS (carpal tunnel syndrome) (for other peripheral neuropathies it is even worse) the EMG shows no abnormalities  while in those cases more than 90% will show function loss when using the SWM.

 

Dear Dr. Das, thank you again for your contribution. I am very much looking forward to hear of the results of your new study as conducted together with Drs Garbino, Barreto and Virmond.

 

Will you also use it for a prospective study on the effectiveness of nerve decompression? The need for such a nerve decompression study may come forward again in the next ILC in Brussels, unless a new magic bullet is presented to adequately treat (early) nerve function loss due to leprosy neuritis .

 

 

With best regards,

 

Willem Theuvenet, M.D., Ph.D

Plastic, Reconstructive and Hand Surgeon

Consultant for TLMI and NLR.


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

(LML) Nerve impairment, sensory testing and M.leprae immune status

Leprosy Mailing List – August 20,  2013 

Ref.:   (LML) Nerve impairment,  sensory testing and M.leprae immune  status

From:  D Porichha, Orissa, India


 

Dear Pieter,

This is regarding the different method of testing sensation of leprosy patients. Dr Das is adding an interesting dimension to the issue under direction. It is interesting because tissue damage is proportional to immune response than anything else.  

 

My responses need for some clarity are as follows:
1.      In leprosy in some areas there are dual procedures. For example in classification we have MB, PB for field and RJ system for institution/research/ may be better quality. For MB classification smear positivity and more than 5 patches. These are just to name the two. Hence whatever new improvement we are thinking I feel we should think to have such dual approach. For nerve function assessment ball pen is good enough, but say, for RCS (reconstructive surgery) evaluation SWM may be more suitable. For field use in leprosy either has equal validity in their own contexts.


2.      Coming to the status of immune reaction or its effect, an infected person may belong to any one of the following categories:
•       Presence M.leprae / AFB within the cell or tissue but no tissue repose- as phagocytosis has already taken place which is viewed often as innate immunity.
•       Perineural or neural infiltration of lymphocytes- indeterminate leprosy, probably a pre-sensitized state.
•       Polar lepromatous leprosy (P) - granulomatous but only innate immune reaction-no sensitization?
•       Tuberculoid leprosy (P)- strong delayed hypersensitivity- strongly sensitized.
•       Both types of reaction with no or under treatment.
•       Both types of reactions completed MDT but tissue containing antigens.


3.      Each of the groups is likely to give different results. Even if an ideal testing method is identified it will be difficult to correlate with the immune response nerve . My contention may be wrong.


Dr. D Porichha
Consultant,  LEPRA India, Bhubaneswar


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Monday, August 19, 2013

(LML) SW monofilaments

Leprosy Mailing List – August 19,  2013 

Ref.:   (LML) SW monofilaments

From:  Ben Naafs, Munnekeburen, the Netherlands


 

Dear Pieter,

 

I’m very pleased with the interest shown in sensory testing in leprosy. I would like to present a summary of the history of graded sensory testing with monofilaments. Everybody speaks of the Semmes-Weinstein monofilaments, though if I could choose I would preferably attribute the monofilaments to other persons.

 

It was Von Frey in the 19th century who was the first one to use graded bristle testing. He used horse hairs. The first who used graded monofilaments consequently was as far as I know Weddell in the 40th and 50th. The first ones to use it in leprosy were students of his, Jamison (in the 70th) who used it in maculae and Pearson (again  in the 70TH) who introduced it in the follow up and diagnosis of reactions. He worked closely together with a physiotherapist, Jean Watson. Naafs was the first one to describe its use in the follow-up of neuropathy (70th) and in the follow-up of patients in the 80th . It was Judith Bell-Krotoski who really advocated it and made it popular. Later this was taken over in Brazil by Garbino as doctor and Linda Lehman as physiotherapist. Where Weddell used the monofilaments already in the 40th and 50th Semmes and Weinstein started its use in the 60th and 70th .

 

There is a difference in use by Pearson, Watson and Naafs and  later on by physiotherapist and revalidation specialists who took over the interest in the use of monofilaments. The former, for the hand used the graded bristles on the thenar and hypothenar only, to assess the function of median and ulnar nerves, avoiding maculae in those areas. Since Bell-Krotoski the whole hand was mapped, like later Semmes and Weinstein did for the foot. Such use is more tedious and gives mixed information, not only on the nerve trunks but about small nerves in the fingers and palm as well.

 

With many greetings,

 

Ben

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) SW monofilaments

Leprosy Mailing List – August 19,  2013 

Ref.:  (LML) SW monofilaments 

From: J Garbino, Bauru, São Paulo, Brazil 


Dear Pieter,

About Nerve Function Assessment and specifically the S-W monofilaments (SORRI Kit) we must consider that is the only one among the simple tests that are more appropriate to  nerve follow up because it can graduate the nerve sensory impairment, i.e., it is  semiquantitative.

We have compared some times to nerve conduction studies in leprosy neuropathy and in diabetes, all of the publications are available in the net :

-       MARCIANO LHSC, GARBINO JA. Comparação de Técnicas de Monitoração da Neuropatia Hanseniana: Teste de Sensibilidade e Estudo de Condução Nervosa.. Hansenologia Internationalis, 1994. SciELO.

 

-       SOUZA et al. Avaliação da neuropatia diabética: correlação entre sensibilidade cutânea dos pés, achados clínicos e eletroneuromiográficos. Acta Fisiátrica, 2005. SciELO.

 

-       MARCIANO et al. Avaliação do comprometimento neurológico e da prevalência da síndrome do túnel do carpo em pacientes portadores de diabetes mellitus tipo 2. Acta Fisiátrica, 2007.SciELO.

 

-       GARBINO JA, VIRMOND M, URA S, SALGADO MH, NAAFS B. A randomized clinical trial of oral steroids for ulnar neuropathy in type 1 and type 2 leprosy reactions. Arq Neuro-Psiquiatria, 2008. SciELO/ others 

Recently the Department of Neurophysiology - University of Heidelberg Medical School - compared the standard QST (test for  pain sensation (fibers C) and temperature (Aδ) respectively, gold pattern for thin fibers, to the SORRI- Bauru Kit showing a good equivalence that enables it to replacement of QST in the clinical daily practice because its competitive cost:

-       Comparability of mechanical detection and pain thresholds in Quantitative Sensory Testing (QST) using different devices. Doreen B. Pfau, DMD, Department of Neurophysiology, CBTM, Medical Faculty Mannheim, University of Heidelberg, Germany. 14TH World Congress on Pain, IASP, Milan, 2012.             

Because of the S-W monofilaments (SORRI Kit)  reliability, its low cost and scientific verified effectiveness it should be supported.

Compliments,    

Jose Antonio Garbino

Clinical Neurophysiolgy - ILSL/Brasil


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Sunday, August 18, 2013

(LML) Nerve impairment, sensory testing and M.leprae immune status

Leprosy Mailing List – August 18,  2013 

Ref.:    (LML) Nerve impairment, sensory testing and M.leprae immune status  

From:  Pranab K Das, Univ. Birmingham, UK


Dear Pieter

As you are aware that I am an attentive follower of the LML based discussion forum . I was following the correspondences regarding the use of different techniques (ranging from SW filaments, ball point, pin pricks, cotton wool /birds' feather touch etc) for evaluating the loss of sensation as a measure of nerve impairment in leprosy. Since all these techniques seem to be useful in field use with varying degree, I am not sure whether such diagnostics had been studied in conjunction with patients' M. leprae specific immune/non(innate) immune status. In Bauru, I am contemplating to undertake a study (both longitudinal/retrospective) using multipronged approach which will include, para-medical , sonography/MRI/doppler, electro-physiology(as the main back bone), immune status, as well as immunopathological study for determining the most valid paramedical sets, to diagnose the nerve impairment in the field, with confidence.

In our study, should we rely on the data obtained by the use of SW filaments (as Dr Barreto, correspondence is also suggestive), as the most representative?

We are still in the planning stage to undertake this project with the initiative of Dr. Garbino, Dr Jason Barreto and Dr Marcos Virmond . Our main aim will be to have cohort double blind study, to establish the robustness of the data for diagnostic and prognostic purposes, which( i.e. double blind study) are mostly lacking in the field of leprosy.

I must admit after being 35 years in the field of leprosy although as a part timer, every day I am learning some useful tip, even in my old age.

BW.

Pranab K Das

Honorary Sr. Research Associate

Division Pathology(Neuropathology Unit),

Academin Medical Center-Univ.Amsterdam, NL;

Honorary Sr. Research Fellow, Div Infection and Immunity

(Clinical Immunology Unit), Colleges of Medical/Dental Sciences,

Univ. Birmingham, UK; and Chair Immunodeficiency/Inflammation,

Institute of Pediatrics, Univ Brescia, Italy.

emails: p.k.das@amc.uva.nl; p.k.das@bham.ac.uk; pran.k.das@gmail.com

 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder  editorlml@gmail.com

Saturday, August 17, 2013

(LML) Sensory testing

Leprosy Mailing List – August 17,  2013 

Ref.:    (LML)  Sensory testing

From:  Linda F. Lehman, Belo Horizonte, Brazil


 

Dear Pieter,

 

It has really been nice to hear from so many people about sensory testing.  

 

As I listen it seems that people need to be clear what they are wanting to accomplish with the testing and what is the objective of the testing:

-        1.   Diagnose Hansen's disease/leprosy(skin lesions);

-        2. Determine Protective sensory Loss in eyes/hands/feet which put them at Risk of injury if self-care and protection/footwear is not used;

-        3.  Early nerve function loss/change that when detected early and treated with Corticosteroids can get better and if not improving may need to be referred for surgery to decompress the nerve.  

 

One of the things I observe frequently in my supervision visits is that reactions and nerve function change is not being identified and/or treated adequately or treated so late the nerve function does not return.  It is recognized only after there are big changes and an ulcer.  I have seen several cases within the last 6 months that were diagnosed and with nerve function impairments but the worker only gave  MDT treatment thinking that this would be sufficient.  In busy clinics, often patient education and daily self-care practices are not adequately taught.  Self-care groups and empowering patients/families to recognize problems and take action are very important.

 

IN SUMMARY:

1.    We test cutaneous skin lesions to determine if it is leprosy or not.  Dr. Manuel Villarroel (neurologist) from Brasil did very interesting work on early sensory loss in single skin lesions.  Difficulty identifying small changes in temperature were first.  I am attaching an article that was published that readers may find interesting.  

2.    We monitor/test peripheral nerve function(eyes, hands & feet) in leprosy for three purposes:

·         TO IDENTIFY EARLY NERVE FUNCTION CHANGE or LOSS so other treatments can be started to preserve nerve function

·         TO MONITOR RESPONSES TO INTERVENTIONS (better, worse, unchanged) AND MAKE CHANGES IN TREATMENT IF NEEDED (ADL's -activities of daily living, Drug, Surgery, etc)

·         TO DETERMINE PERSONS AT RISK OF INJURY OR ULCER ("protective sensory loss determined by the ball point pen, clip, 10g filament)  This is NOT early nerve function loss but it tells us which persons are at RISK and are in need of good daily self-care practices, protective footwear, etc.   This is the WHO Grade 1, those at RISK for injury/ulcer.  The Diabetic foot program emphasis today is only to identify feet at risk of injury not early nerve function loss.  Limbs at Risk need protection and good self-care practices.

The challenge is preserving nerve function so that the eyes, hands or feet are not "at risk" of further damage and complications.  For those who have "Protective Loss", the challenge is preventing further damage.

 

 

Linda


Linda F. Lehman, OTR/L MPH C.Ped

Technical Director, Programs

American Leprosy Missions

One ALM Way, Greenville, South Carolina 29601 USA

R. Castelo de Alenquer 390 Apt 302  Belo Horizonte, MG 31330-050 BRASIL

BRASIL Direct:  +55 31.3476.6842  +55 31.9637.5576

 

llehman@leprosy.org | www.leprosy.org

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

 

Friday, August 16, 2013

(LML) SW monofilaments and ball point pen

 

Leprosy Mailing List – August 16,  2013 

Ref.:    (LML) SW monofilaments and ball point pen

From:  Wim van Brakel, Royal Tropical Institute, Amsterdam, the Netherlands


Dear Pieter,

I would like to respond to the interesting discussion about use of the monofilament test (MFT) versus the ball point pen test (BPT). I will address three questions: what is the purpose of the these two tests, what scientific evidence exists of the reliability of either test, and what considerations should made regarding their use?

1. Purpose

Both tests are intended for screening of peripheral sensory nerve function. Neither was intended for testing sensation of skin lesions or for diagnosing leprosy. I don’t know of any studies that have compared these tests with the cotton wool test in terms of sensitivity, specificity and predictive value, but the consensus is that (a ‘wisp’ of) cotton wool is the preferred tool to test sensibility of skin lesions. It is obvious that the variability in pressure delivered by a touch or stroke of cotton wool would be much less than a touch with a stiff object such as a ballpoint pen. A thin monofilament (MFT) may be used effectively also (e.g. the green 50 mg filament), but this was not its original purpose. The INFIR cohort study found a good correlation between neurophysiological measures and MFT results, but this referred to nerve trunk lesions only; not to sensory impairment of skin lesion.

The ball point pen test (BPT) is not intended to be a replacement of the MFT, but to be a rapid screening test. I realize the very real operational constraints described by Dr. Cross, which may preclude the use of the MFT. However, the optimal procedure would be to conduct a quick BPT as a routine screening procedure during, and if necessary also in the first few years after MDT. If a patient does not feel the touches of the ballpoint pen adequately, s/he should be tested with the MFT. The MFT provides a semi-quantitative assessment of sensibility, which is much more suitable for monitoring over time than the BPT, which essentially only provides a ‘Yes/No’ answer. In practice, most leprosy programmes only use the BPT. This is much better than no test at all and should be seen as the minimum quality standard for prevention of disabilities. I would recommend adding the MFT, where possible, since this gives the health worker a simple, relatively inexpensive and more accurate means of monitoring the nerve function of his/her patients. The kind offer of Mr. Robert Jerskey to supply calibrated monofilaments to those who are interested at the ILC could be a step in the right direction for some. Of course, a sustainable and low-cost source needs to be established, especially in Africa and Asia.

2. Reliability

I agree with Dr. Cross that comparative reliability is an academic question if one of the two tests is not available. However, if the BPT would not be sufficiently reliable, then its use should not be recommended at all, even if no alternative were available. The inter-tester reliability of the MFT has been demonstrated repeatedly and is very good, with weighted kappa values usually exceeding 0.8 (i.e. chance-corrected agreement between the testers is 80% or better). Below are some of the publications; these refer only to the leprosy field, but others have found the same. 

Readers will notice that, fortunately, the BPT was also found to have very acceptable reliability, with coefficients only slightly below those of the MFT. Good news, therefore, for the many programme that currently have no alternative available.

3. Considerations for use

The difficulty with the BPT is the consistency of the technique used. As Dr. Schreuder wrote as an editor’s note in Dr. Warren’s earlier contribution to this discussion, the correct technique is a very light touch, preferably one that does not produce any depression of the skin at all. This was published as consensus advice 10 years ago:

Watson JM, Lehman LF, Schreuder PA, van Brakel WH. Ballpoint pen testing: light touch versus deep pressure. Lepr Rev 2002; 73(4):392-393.

So, we should definitely not use the weight of the pen; even a light pen (e.g. the 4-g BIC pen) is too heavy to detect early sensory impairment. The threshold for normal sensation is measured in milligrams, rather than grams. In my experience, it is much easier to perform the test and control the pressure when holding the pen at an angle (~45 degrees) than perpendicular, particularly when testing the sole of the foot.

In this context, it may also be worth noting that a stroking movement (either with cotton wool or a filament) provides a much stronger sensory stimulus than a static touch. A static touch may be preferred for that reason, but the most important point is to be consistent in the method and use either static touches or gentle stroking, but not a mixture.

Monofilaments need replacing after varying lengths of time (as soon as the filament remains bent after testing). This is another reason why a sustainable source of standardised monofilaments is needed. It ought to be possible to develop this, since the MFT is also recognised as a test of choice to monitor diabetes-related neuropathy. This is a rapidly growing problem in many leprosy-endemic countries, which should ensure a future market for cheap, high-quality monofilament test kits.

 

With kind regards,

 

Wim van Brakel

Technical Advisor NLR

 

van Brakel WH, Khawas IB, Gurung KS, Kets CM, van Leerdam ME, Drever W. Intra- and inter-tester reliability of sensibility testing in leprosy. Int J Lepr Other Mycobact Dis 1996; 64(3):287-298.

 Anderson AM, Croft RP. Reliability of Semmes Weinstein monofilament and ballpoint sensory testing, and voluntary muscle testing in Bangladesh. Lepr Rev 1999; 70(3):305-313.

 van Brakel WH, Khawas IB, Gurung KS, Kets CM, van Leerdam ME, Drever W. Intra- and inter-tester reliability of sensibility testing in leprosy. Int J Lepr Other Mycobact Dis 1996; 64(3):287-298


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

Tuesday, August 13, 2013

(LML) Sensory testing peripheral neuropathy

Leprosy Mailing List – August 13,  2013 

Ref.:    (LML) Sensory testing peripheral neuropathy

From:  Grace Warren, Sidney, Australia



 Dear Pieter,

I note a few letters in the last 24 hours,  regarding recording of  abnormalities in sensory   perception .    

I wonder if you have ever seen my text book" The care of Neuropathic limbs"  that Prof Syd Nade ( orthopaedic surgeon) helped me get published in 1999. In it there is a lovely little cartoon showing the use of a open oval paper clip that is almost better than a pen as when the clip is part opened one has a blunt curved end and a flat cut end and one can make the patient point to where he feels the touch and say smooth or rough.   Often the patient can feel  touch , all be it vaguely- but cannot tell whether it is  sharp or blunt so has an abnormality of sensory perception  or he has misreference and points to the wrong spot. So here are two other methods of charting sensory abnormality  in a patient who says  Yes I can feel - but does not have a supply of the good filaments. I have managed to scan the illustration on to this email so it is there if you feel it worth including (see attached file).

For those who receive it   "Tropical  doctor" published an article by me  on October 2002, called " Practical Management of  neuropathic feet"  in which we  included the cartoon., and some other relevant  facts and diagrams  about  care of neuropathic limbs.

Good testing!!    Grace.

 

p/s   By  the way my text book " the care of neuropathic limbs " is no longer available from the publisher( who closed down) but I still have a few hundred copies that I  will gladly give to those who are really prepared to use it.,   When it was first published in 1999 the Leprosy Mission ordered an extra 500 laminated copies that we gave to leprosy hospitals and clinics round the world., But  I suspect I have the only remaining store now ,  and am trying to place them where they will be used properly,  instead of being recycled and destroyed.,


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com