Lepr Rev (2016) 87, 355– 367

Effectiveness of an individual physical

rehabilitation programme in a group of
patients with Hansen’s disease

HÉCTOR SERRANO-COLL*, JOSÉ DAVID VÉLEZ**,

DIANA TROCHEZ***, JUAN CAMILO BELTRÁN*,
DANIELA SUANCA***, FELIPE MONSALVE** &
NORA CARDONA-CASTRO* , ****
* Instituto Colombiano de Medicina Tropical- Universidad CES,
Carrera 43 A#52 sur-99, Sabaneta, Antioquia, Colombia
** Facultad Fisioterapia – Universidad CES, Calle10 A#22-04
Medellı́n, Antioquia, Colombia
*** Facultad de Ingenierı́a Biomédica – Universidad Escuela de
Ingenierı́a de Antioquia-Universidad CES, Km 2 þ 200 Vı́a al
Aeropuerto José Marı́a Córdova Envigado, Colombia
**** Facultad de Medicina – Universidad CES, Calle10 A#22-04
Medellı́n, Antioquia, Colombia

Accepted for publication 27 July 2016

Summary
Objective: To determine the effectiveness of individualised rehabilitation
programmes intended to reduce disabilities in patients with Hansen’s disease.
Methodology: This is an interventional study (before and after), carried out among
ten leprosy patients whose previous multidisciplinary assessment (medical,
physiotherapy, and biomechanical) designated to them an individualised rehabilita-
tion programme according to the singular condition of each patient. Patients were
evaluated every three months for one year.
Results: 70% of participants were male, 60% of who presented disability Grade 2,
30% Grade 1 and 10% Grade 0. All patients had abnormalities in gait parameters
(step width and speed). Furthermore, 100% of patients displayed improvement in
flexibility, arch joint movement and strength.
Conclusions: The implementation of individualised rehabilitation programmes
allowed us to detect nerve damage. Early implementation of an individualised
rehabilitation programme may mitigate and/or prevent the progression of disability in
people affected by leprosy.
Keywords: Leprosy; Hansen’s disease; physiotherapy; electromyography; disability; neuropathy

Correspondence to: Cardona-Castro N, Instituto Colombiano de Medicina Tropical, Carrera 53ª̄#52 S-99,
Sabaneta, Antioquia, Colombia (e-mail: [email protected])

0305-7518/16/064053+13 $1.00 q Lepra 355

356 H. Serrano-Coll et al.

Introduction

Leprosy, also referred to as Hansen’s disease, is a chronic granulomatous infectious disease

caused by Mycobacterium leprae, a bacterium with a strong affinity for skin and peripheral
nerves.1 The disease results in nerve damage that is responsible for disabilities to the eyes,
hands and/or feet, each of which will have physical repercussions that may lead to societal
stigmatisation and rejection.2 Thus, physical disability is the most serious consequence of
the disease and negatively impacts patients economic and social standing. Therefore, it is
necessary to join efforts that aim to reduce the progression of nerve damage.3
Projections from the World Health Organization (WHO) indicate that between 2000 and
2020, five million new cases of leprosy will occur, with one million people having Grade 2
disabilities by 2020.4 In Colombia, leprosy is not considered a public health problem because
the prevalence of the disease (since 1997) is , 1/10000. However, in 2012, 11 of the 32
Colombian departments (34%) reported an increase in the incidence of leprosy from 0·12 to
4·73 cases per 100,000 inhabitants, including 30% of cases with a disability Grade of 1 and 2.5
In the face of this increase in Colombian leprosy cases, it has remained difficult to perform
neurological assessments (standardised, sequential and efficient) to determine the severity of
disabilities in leprosy patients.6
The neural disorder caused by M. leprae starts with an invasion of peripheral nerve fibres
through the interaction of the mycobacterial capsule glycoprotein phenolic glycolipid-1
(PGL-1) with the basal lamina of Schwann cells. This interaction results in irreversible
changes in neuronal function, adversely affecting the sensory fibres responsible for
exteroceptive sensitivity and alters skeletal muscle function, resulting in paralysis and muscle
atrophy in the hands and feet.7 – 10 It is notable that leprosy reaction Types 1– 2 are the leading
cause of deformities due to the inflammation and nerve damage caused by the disease.
Further, the neuritis that causes this immune event worsens the previously mentioned
neuropathy (sensory, motor or autonomic).11,12
The aim of this study is to evaluate the effectiveness of a rehabilitation programme
(Biomedical-physical) that focuses on the individual needs of leprosy patients. Our results
show, objectively, the importance of implementing new rehabilitation strategies aimed at
reducing the progression of disabilities associated with leprosy. Additionally, this study
explores the use of new methodologies that may impact the assessment and management of
this disease.

Materials and Methods

This is an intervention study that compares the response of ten patients with leprosy after
implementation of an individualised rehabilitation programme.

STUDY POPULATION

The selection of this sample took into account the records of patients diagnosed with
Hansen’s disease in the last 10 years in the Aburra Valley, where are located Medellı́n, Itagüı́,
Envigado, Sabaneta, and Bello municipalities (Antioquia).
 Effectiveness of an individual physical rehabilitation programme 357
EVALUATIONS

We performed five multidisciplinary evaluations (medicine, physiotherapy, biomedical

engineering) within a 3-month interval; one year elapsed between the first and fifth evaluation.

Medical evaluation
The medical evaluation established the degree of disability (in the eyes, hands and feet of the
patient) and the impairment of the peripheral nervous system using Semmes Weinstein
monofilaments (SW)13 to explore superficial sensitivity. Furthermore, the immune and
bacteriological status of patients was determined using the bacillary index following
previously established methods.14 An ELISA for IgM against phenolic glycolipid-1 (PGL-1),
and its relationship to neuritis, was evaluated.15 In addition, we looked for antecedent signs
and symptoms of leprosy reactions and relapses.

Physiotherapy evaluation
This evaluation was to determine the functionality of body structures essential in carrying out
of daily activities. To do this we evaluated flexibility, joint range of motion (JRM),
pallesthesia, records of strength (grip, gripper and extension) and the presence of intrinsic
muscle weakness in the hands and feet (Froment and Paper grip test).16

Biomedical evaluation
This assessment recorded the initiation of muscle activity and power through the signal
recording Root Mean Square (RMS), an indirect method to measure nerve conduction
velocity using FREEEMG equipment.1 We also evaluated the gait of these patients using the
VICON motion capture system.17 Finally, we evaluated the plantar (foot) pressure and foot
damage using a tekscan rug.16

INTERVENTION

The intervention consisted of an individual plan of domiciliary physical intervention. Each

patient was given a list of exercises and recommendations established by a physiotherapy
professional. The intervention plan was evaluated every 3 months for 1 year and was subject
to modifications that took into account neurological, physical and biomechanical follow-up
examinations of each patient. Table 1 shows the parameters used to develop the individual
rehabilitation plan based on the physical exam of each patient.18

ANALYSIS OF DATA

Data was analysed using Excel and SPSS 18.0 software. Analysis of the distribution variables
was performed using a Shapiro-Wilk test. Comparison of the qualitative variables (before and
after the rehabilitation programme) was performed through the x 2 de McNemar test.
Comparison of quantitative variables (before and after) was performed with a paired Students
t test or a Wilcoxon test taking into account the distribution of these variables. The
significance level of P , 0·05 was established for all analyses.
 358

Table 1. Selecting individualised rehabilitation techniques according to the findings of the physical examination

Phisycal findings Anatomy site Excercises Response Follow up

H. Serrano-Coll et al.

Muscle shortening † Hands and feet Static self-stretching Complete response Maintenance with active exercises
† Shoulder girdle
† Pelvic girdle Incomplete response Proprioceptive Neuromuscular Facilitation
(PNF) self-stretching (hold-relax)

Limited range Synovial joints of Self-stretching and passive Complete response Maintenance with active exercises
of motion upper and lower limbs forced range of motion
Incomplete response Joint mobilization for small joints

Strength † Grip Progressive resistive exercise Complete response Maintenance

† Gripper
† Extension Incomplete response Increase in load, frequency or volume

Parameters † Step length Dynamic balance exercises Complete response Maintenance

spatiotemporal † Step width on an unstable surface whit
of the gait † Velocity or without vision Incomplete response Destabilizations with a
† Cadence reduce base of support
 Effectiveness of an individual physical rehabilitation programme 359

Results
CHARACTERISTICS OF THE PATIENTS EVALUATED

70% of the patients were male with an average age of 56 years and an age range of 37– 78
years. 90% of the patients were classified as MB and 60% had disability Grade 2, 30%
disability Grade 1 and the remaining 10% were disability Grade 0. Further, 40% of the
patients had history of leprosy reaction Type 2, 50% exhibited high PGL-1 antibody titers,
and 60% showed positive bacillary index. Table 2 shows the demographic, clinical,
bacteriological and immunological stage of each patient evaluated.
Evaluation of sensitivity in the hands and feet showed that 90% of the patients displayed
evidence of anesthesia in these areas. As expected, we did not observe a recovery of
sensitivity in these areas after implementation of the rehabilitation programme.
When evaluating muscle flexibility in the upper and lower limbs, we found that 100% of
the patients, upon the first assessment, displayed some muscular contraction of the upper and
lower limbs. Implementation of our programme was effective in reducing the number of
retracted muscles in 100% of the participants (see Table 3).
Our results of the recovery of flexibility in the upper limbs (in 80% of the patients) and
lower limbs of (50%) are shown in Table 4.
With respect to the joint range of motion (JRM), the distal areas of the hands and feet
were affected in 60% of the participants upon first assessment. It is worth mentioning that the
rehabilitation programme was effective (100%) in reducing the JMR compromise in these
patients (see Table 3), being statistically significant in 40% of the cases (see Table 4).

Strength evaluation (grip, gripper, extension)

In comparing the records of strength (grip, gripper and extension) of each case, we observed
an improvement in 100% of the participants (see Table 3). Grip, gripper and extension
strength achieved statistically significant improvements in both hands after of the second
evaluation (see Table 5).

Table 2. Demographic characteristics and first evaluation of patients

Classification Disability Affected **History ELISA IgM Bacillary

Patients *Gender Age WHO grade area of reactions PGL-1 index

1 M 51 MB 2 Hands LR2 0·119 negative 0·2

2 F 73 MB 2 Feet NO 0·124 negative 0
3 M 54 MB 1 Hands-feet LR2 0·146 negative 0·8
4 M 56 MB 2 Hands-feet NO 0·176 positive 0·2
5 F 63 MB 1 Hands-feet LR2 0·126 negative 0
6 M 78 MB 2 Hands NO 0·2 positive 0·6
7 M 37 MB 1 Hands-feet NO 0·533 positive 0·8
8 M 54 MB 2 Hands LR2 0·473 positive 0
9 M 55 PB 2 Eye (cataract) NO 0·103 negative 0
10 F 40 MB 0 NA NO 0·555 positive 2·4

NA: not apply. *M: male. F: female.

**LR2: leprosy reactions type 2. NO: no reactions.
Table 3. Individualised response to the implementation of the rehabilitation programme
360

Retractions HR /HL Retractions LLR/LLL JRM Strength Increase***

Site and Site and

Patients/ number of number of
Physical muscles muscles Initial register Initial register
findings retracted Evolution** retracted Evolution** JRM * Evolution** of strength RH of strength LH RH LH

1 RH:7 85·8% of the RLL:6 50% of the retracted 13 Improving of Grip:204 N Grip:108 N Grip:296 N Grip:271 N
LH:7 retracted muscles LLL:6 muscle on the RLL 92·3% of the Gripper:5·9 kg Gripper:5·9 kg Gripper:3·2 kg Gripper:5·22 kg
H. Serrano-Coll et al.

were improved on and 66·7% on the LLL affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:1·1 kg finger:0·57 kg finger:1·13 kg finger:1·7 kg
2 RH:6 83·4% of the RLL:4 50% of the retracted 5 Improving of Grip:217 N Grip:178 N Grip:77 N Grip:54 N
LH:6 muscles retracted LLL:4 muscles retracted 100% of the Gripper:3 kg Gripper:1·13 kg Gripper:4·3 kg Gripper:6·4 kg
were improved on were improved on affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH the RLL and the LLL finger:0·30 kg finger:1 kg finger:1·5 kg finger:0·8 kg
3 RH:4 100% of the RLL:6 100% of the retracted 0 Integrity of Grip:486 N Grip:514 N Grip:146·1 N Grip:146 N
LH:3 muscles retracted LLL:6 muscles on the RLL JRM were Gripper:9·1 kg Gripper:9·1 kg Gripper:0 kg Gripper:0 kg
were improved on and 75% on the LLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:2·3 kg finger:2 kg finger:0·18 kg finger:0·27 kg
4 RH:7 85·8% of the RLL:5 25% of the retracted 16 Improving of Grip:206 N Grip:179 N Grip:14 N Grip:33 N
LH:7 muscles retracted LLL:5 muscles on the RLL 62·5% of the Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg
were improved on and 75% on the LLL affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:1·13 kg finger:1·13 kg finger:1·02 kg finger:0·91 kg
5 RH:4 75% of the muscles RLL:5 80% of the retracted 0 Integrity of Grip:202 N Grip:214 N Grip:82 N Grip:131 N
LH:4 retracted were LLL:5 muscles were JRM was Gripper:4·5 kg Gripper:4·5 kg Gripper:2·27 kg Gripper:4·5 kg
improved on the improved on the RLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
RH and the LH and the LLL finger:1·3 kg finger:1·2 kg finger:0·52 kg finger:0·64 kg
6 RH:4 100% of the RLL:4 50% of the retracted 3 Improving of Grip:383 N Grip:344 N Grip:96 N Grip:127 N
LH:4 muscles retracted LLL:3 muscles on the RLL 100% of the Gripper:3·2 kg Gripper:4·5 kg Gripper:6 kg Gripper:4·5 kg
were improved on and 33.4% on the affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH LLL were improved finger:0·73 kg finger:1 kg finger:1·5 kg finger:1·3 kg
7 RH:2 100% of the RLL:3 83·4% of the retracted 0 Integrity of Grip:561 N Grip:534 N Grip:4 N Grip:23 N
LH:2 muscles retracted LLL:2 muscles on the RLL JRM was Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg Gripper:4·5 kg
were improved on and 100% on the LLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:1 kg finger:1 kg finger:0·23 kg finger:0·23 kg
Table 3. continued

Retractions HR /HL Retractions LLR/LLL JRM Strength Increase***

Site and Site and

Patients/ number of number of
Physical muscles muscles Initial register Initial register
findings retracted Evolution** retracted Evolution** JRM * Evolution** of strength RH of strength LH RH LH

8 RH:4 100% of the RLL:6 83·4% of the retracted 6 Improving of Grip:293 N Grip:363 N Grip:127 N Grip:88 N
LH:4 muscles retracted LLL:6 muscles on the RLL 100% of the Gripper:3·2 kg Gripper:4·5 kg Gripper:5·5 kg Gripper:4·5 kg
were improved on and 100% on the LLL affected JMR Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:0·23 kg finger:0·34 kg finger:1·1 kg finger:1·8 kg
9 RH:7 85·8% of the RLL:6 50% of the retracted 29 Improving of Grip:21·7 N Grip:297 N Grip:322 N Grip:89 N
LH:7 muscles retracted LLL:5 muscles on the RLL 82·8% of the Gripper:0 kg Gripper:0·8 kg Gripper:3·9 kg Gripper:8·3 kg
were improved on and 40% on the LLL affected JRM Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:0 kg finger:0·6 kg finger:1·3 kg finger:1 kg
10 RH:1 100% of the RLL:3 66·7% of the retracted 0 Integrity of Grip:314 N Grip:291 N Grip:18 N Grip:99 N
LH:1 muscles retracted LLL:2 muscles on the RLL JRM was Gripper:3·9 kg Gripper:3·5 kg Gripper:5·2 kg Gripper:4·2 kg
were improved on and 50% on the LLL preserved Extension I-II Extension I-II Extension I-II Extension I-II
the RH and the LH were improved finger:2 kg finger:1·6 kg finger:0·27 kg finger:0·7 kg

RH: Right Hand /LH: Left Hand /RLL: Right Lower Limb /LLL: Left Lower Limb.
*JRM: Joint Range of Motion affected.
**Evolution: results evidenced in the patient after applying the rehabilitation program.
***Increase: changes in strength records in the patient when comparing the initial assessment with the last assessment.
Effectiveness of an individual physical rehabilitation programme
361
362 H. Serrano-Coll et al.

Table 4. Effectiveness of individualised rehabilitation programme in improving sensitivity, flexibility and JRM when
comparing evaluation 1st with 5th

McNemar TEST (value P val.1- val.5)*

Flexibility JRM

Patients UL LL UL/LL

1 0·001 0·016 0
2 0·002 0·031 0·063
3 0·016 0·001 nc
4 0 0·5 0·002
5 0·031 0·008 nc
6 0·031 0·25 0·25
7 0·5 0·5 nc
8 0·008 0·001 0·031
9 0 0·063 0
10 0·5 0·125 nc

UL: upper limbs. LL: lower limbs. nc: no changes. Val: evaluations.
*Value P calculated comparing evaluation 1 vs evaluation 5.

Pallesthesia
As expected, we did not observe an affect in the deep sensory pathway in 92% of the
structures explored during the first assessment, 97% in the second, 96% in the third and 98%
in the fourth and fifth evaluation.

Froment test/paper grip test

The Froment and the paper grip test displayed variability in the results of these evaluations. It
is possible that the same person of the research team performed the exam. Given that, the
Froment test was positive in 30% of the patients for the right hand and 40% for left hand
(second assessment), 40% in right hand and 10% in left hand (fifth assessment). The Paper

Table 5. Effectiveness of individualised rehabilitation programme on strength (grip, gripper, extension) when
comparing evaluation 1st with rest of the evaluations

Comparison of average strength (Value P)

Extension strength
Grip strength Gripper strength (I-II finger)

Valuations Right Left Right Left Right Left

*Val.1-Val.2 0·235 0·037 0·279 0·463 0·375 0·343

Val.1-Val.3 0·032 0·01 0·007 0·01 0·005 0·011
Val.1-val.4 0·013 0·005 0·008 0·007 0·005 0·005
Val.1-val.5 0·009 0·000 0·012 0·011 0·005 0·005

Val: evaluations.
*P , 0·05.
 Effectiveness of an individual physical rehabilitation programme 363

grip test was positive in 20% of patients for both feet (second assessment) and 30% in the
right foot and 10% in left foot (fifth assessment).

Electromyography
Electromyographic records (RMS) showed statistically significant changes for one of the four
pairs of muscles in the evaluated upper limbs, corresponding to the flexor digitorum
superficialis muscle.

Gait biomechanics valuation

This test showed that in 80% of the patients, the longitudinal axis of gravity was normal with
a displacement average of 4·65 cm. Comparing this axis of gravity with the cadence and step
length of these parts were normal in 90% of the patients. Gait velocity was below average
(1·28 meters/second) in 100% of these patients.
The transversal axis of gravity was normal in 100% of the patients with a displacement
average of 2·64 cm. This axis of gravity was compared with the variable step width and we
observed that in 100% of patients this distance was outside the normal range.

Plantar pressures
This test showed that the area subjected to a greater pressure was the heel (79·6%) followed
by anterolateral eminence (12·2%) and anteromedial eminence (8·2%). We observed that
60% of the patients had alterations in the distribution of their plantar pressure levels. The
average maximum pressure for the right plant was 272 ^ 9·1 mmHg and in left plant was
265 ^ 5·8 mmHg.

Discussion

Patients included in this study had a late diagnosis of leprosy, likely due to their grade of
disability, reflecting the late diagnosis of leprosy in Colombia where , 70% of new cases are
MB.14 Of the patients in this study, 50% had positive bacillary index and IgM anti-PGL-1
titers. PGL-a is an important biomarker of neural damage as it interacts with the basal lamina
of Schwann cells.15

SENSITIVE EVALUATION

The recovery of sensitivity in the hands and feet after implementation of our programme had
a low effectiveness. This result is not surprising as the recovery of short-term sensitivity
is a complex process. In addition, to assess sensitivity in these areas, we used SW. Despite
being a sensitive instrument in the detection of peripheral neuropathy,19 SW has a subjective
interpretation—altered environmental conditions (such as temperature and humidity) at the
location of the evaluation can affect the bending of SW, possibly compromising the quality of
the results.20 Dros et al.20 considered this type of data ambiguous given the variation in
sensitivity (41% – 93%) and specificity (60 – 90%); SW lacks an adequate methodology for its
364 H. Serrano-Coll et al.

implementation and has no clear consensus on the appropriate thresholds regarding the
degree of neuropathic damage.

FLEXIBILITY EVALUATION

The physiotherapy programme proved to be effective in restoring the amplitude of joint

movements in the upper and lower limbs, although improvement was greater in the upper
limbs than in the lower limbs. The participants of this study suffer from a high trophic
affection in the lower limbs which causes the elasticity of the muscle-tendon system and joint
mobility to be lower than in the upper limbs,21 potentially explaining the differences we
observed.
Although the effectiveness of stretching programmes in rehabilitation protocols has not
been established, it has been noted that these programmes generate physiological benefits
such as increased blood flow to the tissues, an increase in both the speed of muscle
contraction and in nerve transmission that may permit a greater capacity of execution of joint
movement and, as such, improves strength.22 Therefore, stretching routines could have a
positive impact on flexibility recovery in leprosy patients.

Joint range of motion (JRM) evaluation

The individualized physiotherapy programme was effective in recovering articular
movements given that we observed a reduction of the JRM committed. These findings are
related to improving muscle flexibility because less muscle strength will result in a greater
range of joint motion, mitigating disability and reducing the risk of injury.22,23

Strength evaluation (grip, gripper, extension)

In the records of strength (grip, gripper, extension), we observed improvement upon each
evaluation. These findings allowed us to infer that this type of programme improves
neuromuscular activation and promotes increased force through the gain of muscle mass,
thereby preventing the progression of functional limitations caused by leprosy.22

Pallesthesia
Deep sensitivity was preserved in the patients of this study given that the pallesthesia test with
tuning forks (128 – 256 Hz) was positive in over 95% of the patients, demonstrating that
leprosy only affected the superficial sensitivity transmitted through the spinothalamic
pathway.9

Froment test and paper grip test

The Froment test and Paper Grip test were used to detect intrinsic muscle commitment of the
hands and feet. These tests proved to be too subjective in their interpretation as too much
depended on patient attitude when executing movement as well as the interpretation of the
evaluator. Therefore, the interpretation of these tests was inconclusive. Other studies consider
dynamometry a promising method and more objective than these two tests in determining
intrinsic muscle strength of the hands and feet.16
 Effectiveness of an individual physical rehabilitation programme 365

Gait biomechanical evaluation

For the gait test it should be emphasised that the transverse axis of gravity was within the
normal limits (5 cm) in all patients but offset by its dependent variable (step width). In all
patients examined, this distance was outside the normal range (10 cm), having an average
distance of 18 cm. Furthermore, we observed that the gait velocity of these patients was below
the normal range (1·28 meters/second). Based on these results, we infer that leprosy patients,
despite preserving their deep sensitivity, may have alterations in balance and in some gait
parameters (step width and gait velocity) due to sensory disturbances and damage to the
plantar fascia. These findings are comparable to those of Cordeiro et al. which suggest that
plantar fascia sensory disturbances in patients with leprosy may be related to alterations in
gait.10 However, further research is required to validate these findings.

Electromyography evaluation
During the electromyography evaluation, comparison of the RMS records in the different
evaluations only showed statistically significant data for the flexor digitorum superficialis
muscle, which is innervated by the median nerve. While this may reflect an increase in the
activity of this muscle, it is not possible to conclude that there is a better neuroconduction
(indirectly) by the median nerve. Furthermore, we infer that recovery of intrinsic muscle
activity and nerve conduction may require rehabilitation programmes designed for the long-
term or, alternatively, surgical techniques (peripheral nerve decompression).24

Plantar pressures evaluation

This evaluation showed that the patients have a high risk of injury to plantar fascia. In
addition, Cordeiro et al. emphasised that the presence of trophic changes alongside
compromised protective sensitivity and increased plantar pressure level are important
predictors for ulcer formation in the soles of the feet.10 Therefore, it is necessary that these
patients use custom-made shoes and insoles to reduce pressure at the plant and prevent the
formation of plantar perforating.25

CHANGES IN THE PHYSIOTHERAPY PROGRAMMES

The physical programmes implemented by the physiotherapy team were initiated to aid in
the recovery of muscle flexibility, JMR and improved strength. The physiotherapy team
accomplished each of these objectives. Further, the team worked to improve functionality in
the hands and feet in order to provide an adequate grip, a better gait and improved balance in
these patients.

VIABILITY OF INDIVIDUAL PHYSICAL REHABILITATION PROGRAMMES

IN COLOMBIA

In Colombia there is no adequate approach to the management of disability by leprosy since

the information provided by the management guide on diagnosis, prevention and mitigation
of disability is often poor, ambiguous and lacking in scientific and budget support. In
addition, considering that the incidence of leprosy ranges from 350 – 500 cases per year, the
possibility of implementing such strategies, individualized physical rehabilitation is feasible
and easily implementable.
366 H. Serrano-Coll et al.

With this proposal for rehabilitation in leprosy, we remark that the programme should be
individual, since every patient has different damage or necessities. At this time of the
advanced medicine, other neuropathies as the diabetic neuropathy, are diagnosed, treated, and
rehabilitated with modern tools. In Colombia we have the development and personnel to
improve the rehabilitation and prevention programme for leprosy patients; however the
budget for these measures is not available.

Conclusions

This study found that implementation of an individualised rehabilitation programme in the

short-term proved to be effective in the recovery of motor skills in leprosy patients. Patients
of the programme showed improvements in muscle flexibility, in JMR and in strength.
Therefore, it can be inferred that this type of individualised physiotherapy programme can
generate an increase in the speed of muscle contractions, allowing a greater capacity of joint
movement and an improvement in strength. For this reason the variables of motor type
(flexibility, JMR, strength) should be studied with greater rigour to avoid the progression of
disabilities in these patients. In addition, changes were observed in some gait parameters and
balance that could be related to sensory alterations and trophic changes of the feet. However,
we need to go deeper into this type of research to validate these findings.

Acknowledgements

This project was partially financed by the Dirección de Gestión del Conocimiento de la
Universidad CES INV 022014002, by the Instituto Colombiano de Medicina Tropical –
Universidad CES, by the Escuela de Ingenierı́a de Antioquia – Universidad CES and by the
Physiotherapy Faculty of Universidad CES.
The authors wish to especially thank Dr. Wim Theuvenet for his assessment and discussion
on this project.
We appreciate the support as physiotherapists of Sara Hernández, Lucı́a Maya, Maria Isabel
Hernández Suárez, and Felipe Monsalve. Also the support as biomedical engineer of Nicolás
Gómez.

Conflict of Interests

The authors declare that there is no conflict of interest in relation with the publication of this
document.

Ethical considerations

This research was approved by the Ethical Committee of the Universidad CES. This research
was conducted according to international ethical norms issued by the World Health
Organization and the Pan American Health Organization endorsed by the Helsinki
Declaration, adopted in 1964 and the statutes given nationally by Resolution No. 008430 of
1993 the Ministry of health of Colombia that regulates health studies, this research is
considered minimal risk.
 Effectiveness of an individual physical rehabilitation programme 367

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