Buruli ulcer - Management of Mycobacterium ulcerans disease
Rehabilitation
Objectives
This chapter will assist you to understand the importance and essential features of rehabilitation for patients who have undergone surgery for Buruli ulcer.
Physiotherapy
The physiotherapist or a health care provider with special training should teach patients and their families how to position a limb to prevent deformities, how to exercise affected joints, and how to use special devices (mostly splints) when they are needed.
Positioning
After surgery, a splint is often applied to hold a limb in a position that is good for function. The splint may be made of plaster of Paris, papier-mâché, plastic or wood. A pillow may be bandaged to a limb to hold it straight. After the wound has become stable (which may be before healing is complete), the patient should begin to move the limb, but it may be best to apply a splint at night to prevent a contracture. The surgeon will advise.
Exercises
Passive exercise means that the limb is moved without contraction of its own muscles
by the patient, physiotherapist or health care provider. This type of exercise commences
as soon as the positioning splint is removed, while the patient is too weak or has too
much pain to move the limb without help. The physiotherapist or health care provider
should commence movement slowly and gently to avoid excessive pain and stretching
of healing tissues.
Active exercise means that the patient moves the limb by contracting the limb’s own
muscles. This becomes easier as strength improves and pain lessens. Later, exercises
using weights, such as bags filled with rice, beans and/or sand are appropriate.
Special devices
If a prosthesis (artificial limb – Fig. 32) or an orthosis (brace, calliper or splint – Fig. 34) is necessary, the surgeon or the physiotherapist or health care provider will refer the patient to a centre where the required appliance is made.
If a limb has been amputated, the physiotherapist should teach the patient how to exercise the retained part and how to bandage the stump so that it assumes a shape that fits well into an artificial limb. Proper training to use the prosthesis or orthosis is absolutely essential.
Patients not needing (or awaiting) an artificial limb or calliper who have difficulty walking after surgery may need assistance to use a cane or crutches (Fig. 31).
Patients with hand deformities may find self-care difficult. A physiotherapist or an occupational therapist may fashion special devices which help to hold objects such as cups, spoons and combs (Fig. 33).
Prostheses
Limb prostheses (artificial limbs)
Services to provide limb prostheses (artificial limbs) exist in most countries but often only in major cities. Therefore, these services are often difficult to access from rural and remote areas. Find out where the services are available in your area and the procedures for accessing them.
Before referring a person to a prosthetic/orthotic centre, start as early as possible to prepare for the fitting of a prosthesis by initiating exercises to ensure that there are no contractures. Bandage the stump to achieve a satisfactory conical shape (see above).
Once the wound has healed, the stump is no longer swollen and the limb has no (or minimal) contractures, the person should be referred to the centre where the required artificial limb will be made. An impression of the stump is first taken. Trials of the semi-finished prosthesis follow and training in the use of the new limb should then commence. This normally takes 2–3 weeks but the time taken varies greatly. Much encouragement is needed and many adjustments to the prosthesis are often required.
After the patient has returned to his/her community, continued support from the health care provider is essential. The patient often needs to return to the specialist centre for adjustment of the artificial limb.
Eye prostheses
These prostheses are individually made using an impression taken from the affected area. This service may not be available in your area.
Orthoses
An orthosis is a device which supports a weakened limb or keeps a limb in a chosen position. Orthoses are referred to as splints, braces or callipers. They are sometimes needed after surgical treatment. Advice should be obtained from an orthopaedic centre. Making an orthosis is often similar to making a prosthesis.
Occupational therapy and vocational retraining
The physiotherapist or health care provider should advise persons whose disabilities interfere with their work where to go for appropriate training, which may involve the use of special devices.
Preventing stigmatization
In countries where people suffer rejection because of physical deformities, explain to the patient and family that others will not catch the disease and that the patient needs their help to recover and to become active again. A community leader may be able to help the person gain acceptance and thus involvement in social activities and work.
Education and other assistance
Admission to hospital may provide an opportunity to commence or to recommence educational courses. Arrangements should be made with the education sector to ensure that children’s schooling continues during hospitalization (Fig. 35). Agencies may support social rehabilitation (e.g. financial assistance or support to set up a small business).