WHO Leprosy Module4 en

Neglected Tropical Diseases
Leprosy
Training for health workers on
skin NTDs
Module 4: Leprosy
Nerve Function assessment (NFA)
Learning objectives
By the end of this module, you should be able to:
• Know the importance of nerve function assessment in

leprosy
• Know sensory and voluntary muscle testing of peripheral

nerves involved in leprosy and documenting the findings
• Know the WHO Grading of Disability for leprosy

Content
1. Nerve Function assessment (NFA) - Nerve function

impairment
2. Nerve damage in leprosy (Nerve function loss )
3. Nerve Function assessment (NFA)
4. WHO Grading of Disability for leprosy
- Nerve function impairment
Nerve function impairment is defined as clinically
detectable impairment of nerve function i.e.
• loss of modalities of sensation
• muscle paralysis or weakness,
• loss of autonomic function such as loss of
sweating)
If there is nerve function impairment, it necessitates

intervention
Nerve Function assessment (NFA)
Importance of NFA:
• Nerve function assessment is necessary to detect early
nerve impairment in leprosy, before it causes visible
deformity
• When nerve function impairment is not detected and

treated within 6 months of onset, nerve damage can
become irreversible and can cause permanent disability
• All programmes and clinics, treating leprosy, should

assess nerve function at regular intervals
2. Nerve damage in leprosy (Nerve function loss)
• Can occur in any leprosy patient
• Can occur before, during and after completion of a full

course of MDT
• Patients with higher risk of nerve damage include:

a. All MB Patients
b. PB and MB patients with impaired nerve
function at the time of diagnosis
(higher risk of further damage)
6
Nerve function loss (continued)
Eyes, hands and feet are affected due to peripheral nerve
function loss.
• Eyes:
– muscle weakness
– risks associated with ineffective closure of eye-lids
– loss of sensation cornea, dryness and watering
• Hands:
– loss of sensation (associated with dryness injuries,
wounds and ulcers)
– muscle weakness or muscle paralysis
• Feet:
– loss of sensation (associated with dryness injuries,
wounds and ulcers)
– muscle weakness or muscle paralysis
7
Nerve Function assessment includes:

● Test for sensations of the hands and feet (Sensory Test -
ST)
● Test for muscle weakness or paralysis of hands, feet and

eyes (Voluntary muscle test – VMT)
● Watch for regular blinking
● Test for vision impairment (eyes)

Nerve Function assessment (Continued)
Sensory testing:
• Sensory testing should be done with Semmes Weinstein
monofilaments wherever possible. (If not available, an
instrument such as the tip of a ball-point pen may be used)
Documenting Sensory Testing
Minimum number of
points usually tested in
the hands and feet.
Method of testing specific muscles (Voluntary
Muscle Testing or VMT)
Purpose of VMT:
1. To establish baseline motor function of a nerve
2. To monitor the progression or deterioration of nerve

function while on Management
3. To identify muscles that can be used for tendon transfers in

reconstructive surgery
The following factors are important in accurate VMT:

1. Patient position
2. Fixation of part to be tested
3. Prevention of trick movements
VMT - Method of testing specific muscles
Facial nerve: Orbicularis Oculi muscle
Test lid gap and eye closure
1. The patient is told to gently close the eye. If there is a lid

gap present, it is a sign of muscle paralysis. The lid gap is
measured with a scale and the measurement of the gap is
noted.
2. If there is no lid gap and the patient is able to close the eye
fully, it indicates that the muscle is not paralysed.
VMT- Method of testing specific muscles
(continued)
Facial nerve: Orbicularis Oculi muscle
Test lid gap and eye closure
3. The next step is to check if the muscle is weak or strong.
4. Gentle pressure is applied to try and open the eye, against the
muscle that is working to keep the eye closed
5. If even this very gentle pressure to open the eyelid is

successful, the muscle is graded as weak
VMT - Method of testing specific muscles (continued)
Ulnar nerve
Testing “little finger out
(continued)
Ulnar nerve: Testing “little finger out
Method:
1. The hand needs to be supported on a flat surface, with the
palm facing up
2. The patient is asked to take the little finger out, away from
the remaining fingers. The little finger should not be
extended or bent back. The finger should be straight when
this test is being done.
3. If it can be moved full range, the pressure should be

applied at the base of little finger (at the level of the PIP
joint ) to push the little finger back in.
4. Grade the muscle power as ‘S’, ‘W’ or ‘P’.

VMT
Method of testing specific muscles (continued)
Median nerve: Testing ‘Thumbs Up

MEDIAN NERVE: Testing ‘Thumbs Up

Method
1. The hand is supported on a flat surface and the palm is positioned
facing up.
2. From this position, the patient is asked to lift the thumb up (ask the
patient to point the thumb towards his/her own nose). If there is no
movement possible, the muscle is graded as paralysed (P).
3. If the thumb is able to move full range, resistance is given over the
proximal phalanx in an effort to push the thumb down.
4. If the muscle is not able to move full range or if the muscle is not able to
function against the resistance provided, the muscle is graded as Weak
(W).
5. If the muscle is able to function by maintaining the position even with

the resistance given it is graded as Strong (S).
RADIAL NERVE: Testing “Wrist up”

RADIAL NERVE: Testing “Wrist up”
Method
1. The wrist should be supported by the examiners
hand, with palm facing down and fingers in a light fist
2. Ask the patient to take the wrist up and back as far

as possible
3. If it can be moved full range, then resistance should

be given on the back of the hand, pushing the hand
down.
VMT
Method of testing specific muscles (continued)
COMMON PERONEAL (LATERAL POPLITEAL) NERVE:
Testing “Foot up”
(continued)
COMMON PERONEAL (LATERAL POPLITEAL) NERVE:
Testing “Foot up”
Method:
1. Ask the patient to sit on a stool or chair.
2. Lift the foot off the ground and support at calf region.
3. Then ask the patient to dorsiflex his foot fully.
4. To test for weakness, push the foot downwards while the

patient tries to hold it in the test position.
5. Grade the muscle power as ‘S’, ‘W’, or ‘P’.

Recording the muscle strength
Muscle power
S = Strong
W = Weak
P = Paralysed
Score of the vision:

Counting fingers at
6 meters.
0 = Normal
1 = Blurred vision
2 = Unable to
count the fingers
4. WHO Grading of Disability for leprosy
Three-grade WHO disability grading system (0, 1, 2) has been in use for
measuring the magnitude of the problem and organizing physical
rehabilitation activities
Hands & Feet Eye
Grade 0 No disability found No eye problems due to leprosy; no
evidence of visual loss
Grade 1 Loss of sensation of hand Eye problem due to leprosy present,
and feet but no visible but vision not severely affected as a
deformity or damage. result (vision 6/60 or better; can count
fingers at six metres
Grade 2 Visible disability or visible Severe visual impairment ( Vision
damage present. worse than 6 / 60, inability to count
fingers at 6 meters )
Lagophthalmos
Iridocyclitis
Corneal Opacities
Recap
I. Nerve function assessment is necessary to detect early nerve

impairment in leprosy, before it causes visible deformity.
II. Nerve damage can occur before, during and after completion of a
full course of MDT.
III. Nerve Function assessment includes: Testing for sensations of the

hands and feet (Sensory Test) and testing for muscle weakness or
paralysis of hands, feet and eyes (Voluntary muscle test – VMT)
IV. Three-grade WHO disability grading system (0, 1, 2) is used for

measuring the degree of disability and organizing physical
rehabilitation activities.

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Neglected Tropical Diseases

• Know the importance of nerve function assessment in

• Know sensory and voluntary muscle testing of peripheral

• Know the WHO Grading of Disability for leprosy

1. Nerve Function assessment (NFA) - Nerve function

If there is nerve function impairment, it necessitates

• When nerve function impairment is not detected and

• All programmes and clinics, treating leprosy, should

• Can occur in any leprosy patient

• Can occur before, during and after completion of a full

• Patients with higher risk of nerve damage include:

Nerve Function assessment includes:

● Test for muscle weakness or paralysis of hands, feet and

● Watch for regular blinking

● Test for vision impairment (eyes)

2. To monitor the progression or deterioration of nerve

3. To identify muscles that can be used for tendon transfers in

The following factors are important in accurate VMT:

1. The patient is told to gently close the eye. If there is a lid

3. The next step is to check if the muscle is weak or strong.

5. If even this very gentle pressure to open the eyelid is

3. If it can be moved full range, the pressure should be

4. Grade the muscle power as ‘S’, ‘W’ or ‘P’.

Median nerve: Testing ‘Thumbs Up

MEDIAN NERVE: Testing ‘Thumbs Up

5. If the muscle is able to function by maintaining the position even with

RADIAL NERVE: Testing “Wrist up”

RADIAL NERVE: Testing “Wrist up”

2. Ask the patient to take the wrist up and back as far

3. If it can be moved full range, then resistance should

3. Then ask the patient to dorsiflex his foot fully.

4. To test for weakness, push the foot downwards while the

5. Grade the muscle power as ‘S’, ‘W’, or ‘P’.

Score of the vision:

I. Nerve function assessment is necessary to detect early nerve

III. Nerve Function assessment includes: Testing for sensations of the

IV. Three-grade WHO disability grading system (0, 1, 2) is used for

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