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W H Van Brakel

Publications and source records attributed to W H Van Brakel.

9 recordsLinked to original sources
PubMed2005

Risk factors for participation restriction in leprosy and development of a screening tool to identify individuals at risk.

The World Health Organisation International Classification of Functioning, Disability and Health defines participation as involvement in a life situation. Participation restrictions are problems experienced in any life situation, for example, in relationships or in employment. Our research explored risk factors for participation restrictions experienced by people affected by leprosy. Our objective was to develop a screening tool to identify individuals at risk. An initial round of qualitative fieldwork in eight centres in Nepal, India and Brazil identified 35 potential risk factors for participation restriction. These were then further assessed through quantitative fieldwork in six centres in India and Brazil. In all, 264 individuals receiving leprosy treatment or rehabilitation services made a retrospective assessment of their status at time of diagnosis. Their level of participation restriction was assessed using the Participation Scale. Regression analysis identified risk factors for participation restriction including fear of abandonment by family members (odds ratio 2.63, 95% CI 1.35-5.13) and hospitalization at diagnosis (3.98, 1.0-7.32). We recommend four consolidated items as the basis for a simple screening tool to identify individuals at risk. These are the physical impact of leprosy, an emotional response to the diagnosis, female gender and having little or no education. Such a tool may form the basis for a screening and referral procedure to identify newly diagnosed individuals at risk of participation restrictions and in need of actions that may prevent such restrictions.

Adolescent↗
PubMed2000

Peripheral neuropathy in leprosy and its consequences.

Leprosy causes a 'mononeuritis multiplex' of immunological origin that results in autonomic, sensory and motor neuropathy. When detected and treated early, primary impairments may be reversible. However, 11-51% of patients do not recover. In addition, 33-56% of newly registered patients already have clinically detectable impairments, often no longer amenable to drug treatment. Among new patients, 6-27% present with secondary impairments, such as wounds, contractures and shortening of digits. All patients with impairments should be taught methods to prevent further impairment and subsequent disability (POID). As the result of impairments, many people experience limitation of activities of daily living, which can be partially overcome with the help of assistive devices, training, and surgery. As a result of these limitations, because of visible impairments, or simply because of the diagnosis 'leprosy', many people are restricted in their participation in society. Many overcome activity limitations and participation restrictions without assistance, despite residual impairments. However, some require intervention, such as physical or occupational therapy, reconstructive surgery or temporary socioeconomic assistance. Information on these issues is not collected routinely, and the few tools that exist to measure the severity or extent of impairment have not been widely used, nor have they been used to generate cohort-based statistics. There are no agreed indicators for monitoring POID activities or rehabilitation interventions. Work in the general field of rehabilitation has resulted in the ICIDH-2, which provides a conceptual framework for rehabilitation and the entire area of 'consequences of health conditions'. Although experience to date is very limited, the conceptual framework appears appropriate to leprosy. Data on the prevalence and incidence of primary and secondary impairments have been reported from several countries, the link between impairments and activity limitations has been investigated, and a few studies of the magnitude of the need for rehabilitation have been reported. Research priorities include studies of methods to improve detection of autonomic, sensory and motor neuropathy; trials of alternative drugs or regimens for treating neuropathy; studies of the use of various POID-monitoring systems that may be derived from these; studies of the design and use of instruments to assess limitations of activities and restrictions on participation; assessments of needs for rehabilitation and the development of methods to do these; studies of the efficacy of various types of rehabilitation interventions for particular conditions; and studies of the cost-effectiveness of such interventions.

Activities of Daily Living↗
PubMed1998

Intertester reliability of manual muscle strength testing in leprosy patients.

This study reports the results of a study on the intertester reliability of manual muscle strength testing in leprosy patients with confirmed motor function loss of at least one nerve. Three testers graded the muscle strength of 72 patients in random order. Both hands and feet were graded. Strength was graded on a modified Medical Research Council Scale (9 points, 5, 4+, 4, 3+, 3, 2+, 2, 1, 0). The following movements were tested for strength: little finger and index finger abduction, intrinsic position of all four fingers, thumb abduction and opposition, foot dorsiflexion and eversion and extension of the big toe. The weighted kappa statistic was used to calculate the chance-corrected percentage of agreement between observers. Overall agreement for each of the 11 tests appeared to be good or very good (0.61-1.00). However, when data for hands or feet with normal strength or complete paralysis were excluded from the analysis, the reliability of the remaining mid-range scale was not acceptable (kappa 0.55-0.88, direct agreement range 11-41%). While the reliability of this scale could possibly be improved by special training, we feel that, for the evaluation of nerve function for leprosy patients with (suspected) nerve function loss, the extended 9-point VMT scale should only be used when direct intra- or intertester agreement is more than 80%.

Female↗
PubMed1996

Reference values for touch sensibility thresholds in healthy Nepalese volunteers.

A hundred and thirty-six apparently healthy volunteers between the ages of 16 and 67 were used to determine normative thresholds of tactile sensibility in the Nepali adult population. Tactile sensibility thresholds on standardized sites on hands and feet were assessed for two sensory tests: Semmes-Weinstein monofilaments (SWM) and moving-point discrimination (M2PD). Results are reported as the proportion of subjects able to feel a given threshold. The effect of age, sex, side, occupation, smoking habit and alcohol consumption on the results was examined with quantile regression. On the hand 200 mg seemed an appropriate threshold for 'normal' touch sensibility measured with monofilaments. About 99% (95% confidence interval 97-100) of individuals could detect this filament at all sites. A similar proportion could discriminate two points 4 mm apart which were moved from proximal to distal on the volar pad of the distal phalanx of the index and little finger. For the sole of the foot the thresholds were 2 g and 8 mm. Variability of results was greatest at the heel. Normal thresholds for tactile sensibility were higher than those published for the North American population. Monofilament thresholds suitable for screening were 200 mg (log number 3 center dot 61) and 2 g (log number 4 center dot 31) for hand and foot, respectively. For moving 2-point discrimination on the hand this threshold was 4 mm.

Adolescent↗
PubMed1996

Vasomotor reflex testing in leprosy patients, healthy contacts and controls: a cross-sectional study in western Nepal.

OBJECTIVE: To examine test characteristics of laser Doppler vasomotor reflex testing for leprosy and to determine the prevalence of abnormal responses in leprosy patients, healthy contacts and controls. DESIGN AND PARTICIPANTS: Cross-sectional study including 89 leprosy patients (mean age 35 years, 74% male), 36 healthy contacts (29 years, 64% male) and 47 controls (30 years, 68% male), for a total of 172 participants. SETTING: Leprosy hospital in an endemic region 200 km west of Kathmandu, Nepal. OUTCOME MEASURE: Finger-tip and toe-tip vasomotor reflexes elicited by inspiratory gasp were measured using a laser-doppler flow temperature technique. Results were expressed in per cent as the maximal reduction in bloodflow from baseline. RESULTS: For all 12 measurement sites there were highly significant (p > 0.0001 to < 0.004) differences between the three groups tested. Leprosy patients consistently had the lowest responses and controls the highest, with healthy contacts showing intermediate values. Thresholds defined as mean bloodflow reductions among controls minus 1.64 or minus 1.96 standard deviations provided optimal combinations of sensitivity and specificity. Using these cut-off values around 80% of leprosy patients, 50% of healthy contacts and 20% of controls had two or more abnormal reflexes (p < 0.0001 for differences between groups). CONCLUSIONS: In endemic regions, subclinical autonomic neuropathy may be an early but detectable marker for the risk of subsequent leprosy, making early treatment and prevention of transmission possible. Prospective studies are needed to establish the predictive value of abnormal vasomotor reflexes.

Adult↗
PubMed1994

Reactions in leprosy: an epidemiological study of 386 patients in west Nepal.

This paper presents epidemiological data on reversal reaction (RR) and erythema nodosum leprosum reaction (ENL) from a retrospective study of 386 leprosy patients newly registered at Green Pastures Hospital, Pokhara, West Nepal. The average follow-up time was 21 months. The prevalence of RR at first examination was 28% (23-32), and the prevalence of ENL reaction was 5.7% (2.3-9.2). The overall incidence rates among the 335 patients that were available for follow-up were 8.7 (6.5-12)/100 person years at risk (PYAR) for RR and 3.2 (1.5-6.7)/100 PYAR for ENL. Relapse of RR was common (1.4/patient). In all, 52% of RR were complicated by new nerve function impairment, against 59% of ENL reactions. The finding of other investigators that most RRs occur during the first year of treatment was confirmed by this study. The most significant risk factor for RR was extent of clinical disease measured by a count of body areas with clinical signs of leprosy. The risk of developing a RR for patients with 'extensive disease' (3 or more out of 9 body areas involved) was 10 times that of patients with limited disease (Rate Ratio 10 (1.3-76), p = 0.026). The study indicated that the following categories of patients in Nepal are at high or increased risk of developing a RR: 1, borderline patients during their first year of MDT; and 2, patients with more extensive clinical disease as described above.

Adolescent↗
PubMed1994

Nerve damage in leprosy: an epidemiological and clinical study of 396 patients in west Nepal--Part 1. Definitions, methods and frequencies.

A historic cohort study was performed to determine the prevalence and incidence rates of nerve function impairment (NFI) as demonstrated by sensory testing with a nylon monofilament and standard tests of motor function. The records of 396 new leprosy patients registering at Green Pastures Hospital, Pokhara, between January 1988 and January 1992 were analysed. The mean follow-up period was 21 months. In all, 36% (141/396) of patients had either sensory or motor function impairment at their initial examination. For each nerve the prevalence of sensory and motor impairment is reported separately. The posterior tibial nerve was the most frequently affected (sensory) nerve (21%). Sensory impairment of the ulnar nerve was found in 17% of the patients; 8.8% had sensory impairment of the median nerve. The overall incidence rate of motor function impairment was 7.5 (5.4-10) per 100 person years at risk (PYAR). Sensory impairment had a significantly higher rate of 13 (10-17)/100 PYAR (rate ratio (1.8 (1.2-2.7), p = 0.0076). Bl patients had a significantly higher incidence rate of nerve function impairment than BT patients (rate ratio 2.3 (1.4-3.7), p = 0.006). Altogether 152/396 (39%) of the patients required corticosteroid treatment for 'recent' or 'acquired' impairment, and 78 of the patients (20%) developed severe nerve function impairment during or after antileprosy treatment. Analysis of potential risk factors for nerve function impairment showed a significant association with the extent of clinical disease expressed as the number of body areas (out of 9) with primary or secondary signs of leprosy (rate ratio 5.0 (1.5-17), p = 0.0091). It was concluded that nerve function impairment is a serious problem, often occurring during or after multidrug therapy. The extent of clinical disease expressed as a count of body areas involved, or of skin or nerve lesions may identify patients who are at increased risk of nerve damage.

Adolescent↗
PubMed1992

The allocation of leprosy patients into paucibacillary and multibacillary groups for multidrug therapy, taking into account the number of body areas affected by skin, or skin and nerve lesions.

In Nepal, the setting up and maintaining of reliable services for slit-skin smears has proven difficult. A clinical classification system for leprosy has therefore been developed to assist in the allocation of patients to either paucibacillary or multibacillary groups for the purpose of multiple drug therapy (MDT), using 9 body areas: head (1), arms (2), legs (2), trunk (4). Patients with more than two areas of the body affected are grouped as multibacillary (MB) and those with only one or two areas affected are paucibacillary (PB). Using a computer simulation model and the data of 53 patients registered at Green Pastures Hospital (GPH) in Pokhara and 703 field patients from the Western Region, different clinical classification systems were evaluated with regard to their sensitivity, specificity, and predictive value for MB or PB classification, as compared with the histological classification for the GPH cases and the bacteriological classification for the field patients. The sensitivity and specificity of the body area system in present use were 93% and 39%, respectively. The low specificity is due to MB overclassification. The sensitivity of the WHO classification system without skin smear facilities is 73% (the difference with the body area system is significant: p < 0.05, McNemar's test). Our histology findings confirm previous publications indicating that, while some borderline-tuberculoid (BT) patients may outwardly have a 'PB appearance' and be skin-smear negative, their nerve biopsy and sometimes skin biopsy may show a 'MB' picture. This is the first publication discussing a 'body area system' for the purpose described, including diagrams of the areas used. In Nepal it has proved easy to use and teach and its use may be justified in other control programmes which implement MDT, particularly if slit-skin smear services are unreliable or nonexistent.

Adolescent↗