Managing paralysis, especially during lepra reactions

A patient's nerves are involved early in tuberculoid and borderline leprosy, and later and less severely in lepromatous leprosy. This involvement can be slow, progressive, and irreversible. Or it can can occur suddenly during a Type One (see below).

Paralysis, whether slow or sudden, involves his nerves selectively: (1) His facial nerve, so that he cannot close his eye (lagophthalmos, 30.3). (2) His ulnar nerve at his elbow or wrist, so that his hand becomes clawed. (3) His median nerve at his wrist, so that he cannot oppose his thumb. (4) His radial nerve, so that his wrist drops (in the arm the ulnar nerve is most often affected, then the median, then the radial). (5) His lateral popliteal nerve at the neck of his fibula, so that he cannot dorsiflex his foot (''foot drop'). (5) His posterior tibial nerve behind his ankle, so that the intrinsic muscles of his foot become paralysed, his toes toes clawed, and his sole anaesthetic.

Both kinds of lepra reaction can cause paralysis, but need different management:

Type One reactions (also called non-lepromatous, reversal, or upgrading reactions) often cause sudden reversible paralysis in treated BT, BB, BL and rarely in LL leprosy. They make all the leprosy lesions in his skin and nerves swell acutely. His nerves become suddenly paralysed, and feel large and soft. They may be painless, or tender. His skin lesions may ulcerate, and the fibrosis that results may lead to a contracture. Recovery may take months, so don't let a contracture develop meanwhile! The sustained physiotherapy described below will prevent it. If he has an acute paralysis (but not otherwise), give him steroids for 6 to 12 weeks, as described below.

Type Two reactions are also called ''erythema nodosum leprosum' (ENL) reactions and occur in 50% of treated LL patients and occasionally in untreated LL or treated BL patients. During a few hours a crop of painful erythematous papules develop, typically on the extensor surfaces of his limbs, but in severe attacks over much of his body except his scalp. His skin may be thickened, especially over the backs of his hands and on his legs, where contractures may form. Meanwhile, his nerves are painful, and become steadily paralysed. Unfortunately, they are less likely to recover than after a Type One reaction. Give him clofazimine in high doses, and aspirin. If he has a severe acute episode, you can, if necessary, give him a short (10 to 21 days) course of steroids. If you prolong it, he is liable to all the long-term consequences of steroid therapy.

LEPROSY LEPRA REACTIONS SUPPRESSION is indicated if a lepra reaction has caused paralysis, or uveitis (30.2). Continue the patient's antileprotic drugs in both types of reaction.

Suppress his Type One reactions with steroids for 6 to 12 weeks, or as long as there is activity. Start with a maximum of 30 mg of prednisolone daily in the mornings. As soon as the acute stage of reaction (swelling, redness, and pain) has subsided, gradually reduce his steroids, even if there is no sign of nerve-function returning. Reduce the dose by 5 mg daily each successive week (30 mg of prednisolone daily for a week, then 25 mg daily for a week[...], until you are giving none).

His nerves may start to recover within 3 weeks, or they may not improve for 3 months, or a year, or longer. Meanwhile, manage them as described below.

Suppress Type Two reactions with clofazimine and aspirin or thalidomide (provided there is no possibility of pregnancy), as long as there continues to be any sign of them, however slowly improvement takes place. If you are going to use steroids, give him (or her) a short course only. Some contributors consider that the risks of steroids outweigh their benefits.

PHYSIOTHERAPY [s7]IN LEPROSY A limb which is paralysed by leprosy needs physiotherapy to strengthen its muscles and prevent contractures, especially if paralysis is recent, actively progressing, or possibly only temporary, as in either type of leprosy reaction. Particular physiotherapy for his eyes (30.2), hands (30.4), and feet (30.5) is described elsewhere.

As long as there are signs of weakness, someone, preferably the patient himself, must put all his paralysed joints through their full range of movement each day, even if they cannot be actively maintained in their positions of function.

Protect his paralysed muscles by splinting his joints in their positions of function during sleep, and never allow a muscle to be overstretched. Make sure he does active physiotherapy to retain the mobility of all his joints. Even if all the intrinsic muscles of his hand are paralysed, it will be more useful to him if its joints are kept mobile with the daily exercises in Fig. 30-3. Start this protection the first day you diagnose a reaction.

When he shows signs of recovery, as shown by his pain decreasing, his nerves becoming softer, and his sensation and motor function returning, he must: (1) increase his range of active movement and strengthen his muscles with carefully graded active exercises. And, (2) practise any skilled coordinated movements that he will need later when he returns to his normal life. Tell him to start his exercises as soon as the acute symptoms of neuritis have subsided. Begin by doing each exercise 5 times, increasing to a maximum of 30 times, repeated 3 to 5 times daily. Teach him to do his exercises himself at home: but if he is to have reconstructive surgery, he may need more intensive preparation.