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Asian Leprosy Congress 2000
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at the leprosy conference at Agra......

Joy Mancheril, Hemant P.N., Ebenezer J. and A. A. Samy

Introduction :

Discussing the outcome measures in peripheral neuropathies, Molenear et al. stated ?believe that impairment measures give information on the biological effect of treatment, whereas disability and handicap measures give clinically important and patient relevant information showing whether a treatment improves the patient?unctional health.??t;br>
Leprosy cured persons with deformity or disabilities look forward to a ?mal??y-to-day living. It is a known fact that ?use?nd ?use?f insensitive and paralytic limbs are the main cause for deterioration of deformities and disabilities. The study examines the relationship between the ADL and the type and severity of deformity in leprosy patients.

To assess the severity of the impairment in a given individual and to monitor the success of prevention and treatment of impairment, requires an appropriate impairment measure. At the same time, measures to assess ADL and relevant social participation for people affected by leprosy should be developed. In leprosy, physical rehabilitation efforts have mainly centred on prevention and treatment of primary and secondary impairments. Despite preventive efforts in the management of leprosy a high proportion of patients are still presenting with nerve damage, with consequent deformities and increased risk of ulcer formation or other complications.

If prevention of impairment and disability (POID) is the principle aim then impairment and disability should be distinguished. Also making a patient appropriately independent instead of dependent or inappropriately independent, should be the target. Considering these factors, the ADL evaluation scale was devised with new type of scoring system, which stressed upon the evaluation of harmful ways of doing ADL. It was an interview-based assessment of ADL.

Objectives :

1. To find out the ADL status in leprosy patients with disabilities and deformities.
2. To adopt the new type of scoring for ADL evaluation in leprosy patients.
3. To find out correlation between WHO disability grade and ADL evaluation scale.
4. To find out which is the most affected area of ADL and needs intervention.

Methodology :

A revised version of the ICIDH (International Classification of Impairment, Disability and Handicap) was introduced in 1997 - the ICIDH-2. In this revised classification, the terms ?ability?d ?dicap?re replaced by the more intuitive and positive terms ?ivities?f daily living) and social ?ticipation?roblems in these areas are described as ?ivity limitation?d ?ticipation restriction?t;br>
According to these definitions, the well known WHO Disability grading scale does not grade disabilities but impairments. Hence, we refer to the WHO disability grade as the ?O impairment grade?

Specifically the study examines 209 leprosy patients with Grade-II deformities on the basis of International Classification of Impairments, Activities and Participation (ICIDH ????O 1997). (note ?? The severity of impairment was determined ?? applying the WHO deformity grade to each of the limbs and eyes and the scores are summed up. ADL evaluation was divided into three areas - self-care, work and leisure. Each of this sub-area was further represented by number of activities applicable to the patient. Work area was subdivided into home making tasks, meal preparation and service and work habits and attitudes. Work habits and attitudes were in turn represented by number of work characteristics like standing for long time, heavy lifting, handling sharp tools safely, strenuous eye activities etc. Leisure was similarly subdivided into hobbies and habits, spiritual activities.

While scoring, we had taken into consideration the independent and dependent aspect of an ADL activity, since it is the fact that it was a part of preventive rehabilitation. For this reason the scoring was further divided into appropriate ways of doing activities and inappropriate ways of doing activities, i.e. to say whether it is appropriately independent or inappropriately independent (note ??.

Further to determine the socio-economic status Kuppuswamy?ocio-economic scale ?an?s applied. (note ??. Thus the data about income, education and occupation was collected with respect to the individual leprosy patients.

Discussion :

Most of the patients are ?ppropriately independent? most of their ADL.

After detailed evaluation of ADL scores it was found that work area was the mainstay of the inappropriate ways of handling. This is so because doing repetitive nature of the job, standing for long time, working barefoot/hands, sharp tool handling etc. So work area rehabilitation should be the mainstay of concern along with other two areas. This work area may be home making tasks or meal preparation area for women or occupational area for men. Change of occupation is difficult in the urban set up and majority of the patients are unskilled workers. Hence occupation plays an important roll in deterioration of deformities.

The reasons for this can be viewed in context of social aspect of the disease. Loss of sensation and lack of education in taking care of insensitive limbs. Additionally, due to social ostracism they hesitate to ask for help.

Inappropriate intervention of leprosy workers in explaining the process of deformities or the lack of priority for detailed ADL evaluation also are contributory factors.

Leisure areas are not affected because most of these patients have no special leisure activities.

Conclusion :

The Activities of Daily Living (ADL) and the occupation of the patient are greatly altered by the type and gravity of their deformity and disability. Therefore ADL evaluation & intervention should be the regular part of the leprosy treatment. Occupation is the main determinant of the development of secondary deformities. Specifically patients belong to poorer section ??ecially semiskilled and unskilled workers engaged in heavy jobs. It is the most difficult area of intervention. Often change of occupation is not possible. Hence an individual approach need to be developed in teaching the patients ways and means to protect the limbs while doing their respective occupations.

POID cannot be a success without the proper way of handling or doing the ADL.This can happen only when we find time to study the individual patients ADL and suggest ways and means to prevent further deformities.

Just, the standardisation of ADL assessment will not help the patients in teaching self care and preventing deterioration of deformities. Because every individuals ADL varies from the other depending on various factors of particular socio-economic context.