NEBULISER

DEFINITION
Nebulization is the process of medication administration via inhalation. It utilizes a nebulizer which transports medications to the lungs by means of mist inhalation.

TYPES OF NEBULISER-
There is a huge market for different types of nebulizers and each of them have some unique features although they all function in a similar way. Here are the two basic types of nebulizers available in the market:

STATIONARY NEBULISER – these are the nebulizers that are sturdy, rest on top of the table and they can provide durability as most of them come with a longer warranty period. They are cheaper than the mobile nebulizers and serve as a good aid for usage for children or elderly patients. Stationery nebulizers are mostly for indoor use only and are seldom used outdoors.

MOBILE NEBULISER – these nebulizers provide most mobility as they can be hand held and carried with the patient wherever they go. They have alternative power sources like batteries or auto adapters which enable them with usage at areas where there is no or limited access to AC power. Since they are mobile in nature, these nebulizers are lighter than the stationery ones and also smaller in size.

ULTRASONIC NEBULISER – Ultrasonic nebulizers deliver the medicine through high frequency vibrations in order to change the liquid medication into a mist to inhale and feel relaxed.

The fine mist is inhaled through an attached mask or the mouthpiece as the ultrasonic nebulizers doesn’t condense air, they function quietly and are small in size to fit into any container to begin the function. Being portable, compact and battery operated, they work fast when compared to other nebulizers and utilize the ultrasonic waves to aerosolize the liquid medication.

JET NEBULISER – A jet nebulizer is a machine which changes the prescribed liquid medicine into a fine mist to let the child or the patient breathes in through the mouthpiece or the face mask. It delivers the medicine directly to the inhaler’s lungs, making it easy to use.

These are less expensive and are usually in the form of a plastic cup which holds the medication and allows the air pass through the tube with the help of the compressor. Basically, jet nebulizers require electricity, frequently to function which is not advised safe to carry or depend on during travel. It produces loud sound and offers a range of particle sizes to change a liquid into a mist.

MESH NEBULISER – A Mesh Nebulizer is considered as the fastest working device and is more expensive when compared to the other nebulizers. It operates on a battery power supply and is quiet, efficient and well suits to the aerosolize solutions. It generates the mono-disperse aerosol particles of 4.5 to 5µm. It utilizes a vibrating membrane to generate the aerosol mist from the medication.

Available in a compact and portable body, it is perfect to carry while travelling and use in case of need. Besides this, Mesh nebulizer requires proper care, careful handling and intense cleaning as the membrane is more prone to get blocked and requires replacement many times in a year for proper function of inhalation process.

INDICATION
Nebulization therapy is used to deliver medications along the respiratory tract and is indicated to various respiratory problems and diseases such as:
•Broncho-spasms
•chest tightness
•Excessive and thick mucus secretions
•Respiratory congestions
•Pneumonia

CONTRAINDICATIONS
In some cases, nebulization is restricted or avoided due to possible untoward results or rather decreased effectiveness such as:
•Patients with unstable and increased blood pressure
•Individuals with cardiac irritability (may result to dysrhythmias)
•Persons with increased pulses
•Unconscious patients (inhalation may be done via mask but the therapeutic effect may be significantly low

EQUIPMENTS
•Nebulizer and nebulizer connecting tubes
•Compressor oxygen tank
•Mouthpies, Respiratory medication to be administered
•Normal saline solution

PROCEDURE

1.Position the patient appropriately, allowing optimal ventilation.

2.Assess and record breath sounds, respiratory status, pulse rate and other significant respiratory functions.

3.Teach patient the proper way of inhalation:

Slow inhalation through the mouth via the mouthpiece
Short pause after the inspiration
Slow and complete exhalation
Some resting breaths before another deep inhalation.

4.Prepare equipments at hand

5.Check doctor’s orders for the medication, prepare thereafter
6.Place the medication in the nebulizer while adding the amount of saline solution ordered
7.Attach the nebulizer to the compressed gas source
8.Attach the connecting tubes and mouthpiece to the nebulizer
9.Turn the machine on (notice the mist produced by the nebulizer)
10.Offer the nebulizer to the patient, offer assistance until he is able to perform proper inhalation (if unable to hold the nebulizer [pediatric/geriatric/special cases], replace the mouthpiece with mask.

COMPLICATIONS
Possible effects and reactions after nebulization therapy are as follows:
•Palpitations
•Tremors
•Tachycardia
•Headache
•Nausea
•Broncho-spasms (too mu

NEBULISERch ventilation may result or exacerbate Broncho-spasms)

•TEACHINGS
As nurses, it is important that we teach the patients the proper way of doing the therapy to facilitate effective results and prevent complications (demonstration is very useful). Emphasize compliance to therapy and to report untoward symptoms immediately for apposite intervention.

Auscultatory gap is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high and the reappearance of the sounds at a lower level.

Provide excellent clues to the physiological functioning of the body.
•Alterations in body flexion are reflected in the body temp, pulse, respirations and blood pressure.
•These data provide part of the baseline info from which plan of care is developed.
•Any change from normal is considered to be an indication of the person’s state of health.

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PNEUMOTHORAX AND PHYSIOTHERAPY MANAGEMENT

DEFINATION-
”A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall”. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax.
This condition can cause a steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, it can result in death.Very rarely both lungs may be affected by a pneumothorax.It is often called a collapsed lung, although that term may also refer to atelectasis.

TYPES OF PNEUMOTHORAX

TYPES OF PNEUMOTHORAX
TYPES OF PNEUMOTHORAX

The two basic types of pneumothorax are traumatic pneumothorax and nontraumatic pneumothorax. Either type can lead to a tension pneumothorax if the air surrounding the lung increases in pressure. A tension pneumothorax is common in cases of trauma and requires emergency medical treatment.

TENSION PNEUMOTHORAX
    TENSION PNEUMOTHORAX

TRAUMATIC PNEUMOTHORAX
Traumatic pneumothorax occurs after some type of trauma or injury has happened to the chest or lung wall. It can be a minor or significant injury. The trauma can damage chest structures and cause air to leak into the pleural space.

Examples of injuries that can cause a traumatic pneumothorax include:

Trauma to the chest from a motor vehicle accident
Broken ribs
A hard hit to the chest from a contact sport, such as from a football tackle
A stab wound or bullet wound to the chest
Medical procedures that can damage the lung, such as a central line placement, ventilator use, lung biopsies, or CPR
Changes in air pressure from scuba diving or mountain climbing can also cause a traumatic pneumothorax.
The change in altitude can result in air blisters developing on your lungs and then rupturing, leading to the lung collapsing.

Quick treatment of a pneumothorax due to significant chest trauma is critical. The symptoms are often severe, and they could contribute to potentially fatal complications such as cardiac arrest, respiratory failure, shock, and death.

NON-TRAUMATIC PNEUMOTHORAX-
This type of pneumothorax doesn’t occur after injury. Instead, it happens spontaneously, which is why it’s also referred to as spontaneous pneumothorax.

There are two major types of spontaneous pneumothorax:
1.primary and 2. secondary.
1.Primary spontaneous pneumothorax (PSP) occurs in people who have no known lung disease, often affecting young males who are tall and thin.
2.Secondary spontaneous pneumothorax (SSP) tends to occur in older people with known lung problems.

Some conditions that increase your risk of SSP include:

  • Chronic obstructive pulmonary disease (COPD), such as emphysema or chronic bronchitis
  • Acute or chronic infection, such as tuberculosis or pneumonia
  • Lung cancer
  • Cystic fibrosis, a genetic lung disease that causes mucus to build up in the lungs
  • Asthma, a chronic obstructive airway disease that causes inflammation
  • Spontaneous hemopneumothorax (SHP) is a rare subtype of spontaneous pneumothorax. It occurs when both blood and air fill the pleural cavity Without any recent trauma or history of lung disease.

SYMPTOMS OF PNEUMOTHORAX
The symptoms of a traumatic pneumothorax often appear at the time of chest trauma or injury, or shortly afterward. The onset of symptoms for a spontaneous pneumothorax normally occurs at rest. A sudden attack of chest pain is often the first symptom.

Other symptoms may include:

  • A steady ache in the chest
  • Shortness of breath, or dyspnea
  • Breaking out in a cold sweat
  • Tightness in the chest
  • Turning blue, or cyanosis
  • Severe tachycardia, or a fast heart rate

RISK FACTOR FOR TRAUMATIC PNEUMOTHORAX
The risk factors are different for a traumatic and spontaneous pneumothorax.

Risk factors for a traumatic pneumothorax include:

  • Playing hard contact sports, such as football or hockey
  • Performing stunts that may cause damage to the chest
  • Having a history of violent fighting
  • Having a recent car accident or fall from a height
  • Recent medical procedure or ongoing assisted respiratory care

The people at highest risk for a PSP are those who are:

  • Young
  • Thin
  • Male
  • Between the ages of 10 and 30
  • Affected by congenital disorders like Marfan’s syndrome
  • Smokers
  • Exposed to environmental or occupational factors, such as silicosis
  • Exposed to changes in atmospheric pressure and severe weather changes
  • The main risk factor for SSP is having previously been diagnosed with a lung disease. It’s more common in people over 40.

DIAGNOSIS
Diagnosis is based on the presence of air in the space around the lungs. A stethoscope may pick up changes in lungs sounds, but detecting a small pneumothorax can be difficult. Some imaging tests may be hard to interpret due to the air’s position between the chest wall and lung.

Imaging tests commonly used to diagnose pneumothorax include:

An upright posteroanterior chest radiograph

CHEST RADIOGRAPH
CHEST RADIOGRAPH

A CT scan
A thoracic ultrasound

TREATMENT

Treatment will depend on the severity of condition. It will also depend on whether you’ve experienced pneumothorax before and what symptoms you are experiencing. Both surgical and nonsurgical treatments are available.Treatment options can include close observation combined with the insertion of chest tubes, or more invasive surgical procedures to resolve and prevent further collapse of the lung. Oxygen may be administered.

OBSERVATION-
Observation or “watchful waiting” is typically recommended for those with a small PSP and who aren’t short of breath. In this case, your doctor will monitor your condition on a regular basis as the air absorbs from the pleural space. Frequent X-rays will be taken to check if your lung has fully expanded again. doctor will likely instruct you to avoid air travel until the pneumothorax as completely resolved.

Routine physical activity hasn’t been shown to worsen or delay healing of a pneumothorax. However, it’s often advised that intense physical activity or high-contact sports be delayed until the lung is fully healed and the pneumothorax is gone.

A pneumothorax can cause oxygen levels to drop in some people. This condition is called HYPOXEMIA . If this is the case, doctor will order oxygen supplementation along with activity limitations.

DRAINING EXCESS AIR
Needle aspiration and chest tube insertion are two procedures designed to remove excess air from the pleural space in the chest. These can be done at the bedside without requiring general anesthesia.Needle aspiration may be less uncomfortable than placement of a chest tube, but it’s also more likely to need to be repeated.For a chest tube insertion, doctor will insert a hollowed tube between your ribs. This allows air to drain and the lung to reinflate. The chest tube may remain in place for several days if a large pneumothorax exists.

PLEURODESIS
Pleurodesis is a more invasive form of treatment for a pneumothorax. This procedure is commonly recommended for individuals who’ve had repeated episodes of pneumothorax.During pleurodesis, doctor irritates the pleural space so that air and fluid can no longer accumulate. The term “PLEURA” refers to the membrane surrounding each lung. Pleurodesis is performed to make your lungs’ membranes stick to the chest cavity. Once the pleura adheres to the chest wall, the pleural space no longer expands, and this prevents formation of a future pneumothorax.

Mechanical pleurodesis is performed manually. During surgery, your surgeon brushes the pleura to cause inflammation. Chemical pleurodesis is another form of treatment. doctor will deliver chemical irritants to the pleura through a chest tube. The irritation and inflammation cause the lung pleura and chest wall lining to stick together.

SURGERY
Surgical treatment for pneumothorax is required in certain situations. You may need surgery if you’ve had a repeated spontaneous pneumothorax. A large amount of air trapped in chest cavity or other lung conditions may also warrant surgical repair.There are several types of surgery for pneumothorax. One option is a THORACOTOMY. During this surgery, surgeon will create an incision in the pleural space to help them see the problem. Once your surgeon has performed a thoracotomy, they’ll decide what must be done to help you heal.

Another option is THORACOSCOPY, also known as video-assisted thoracoscopic surgery (VATS). surgeon inserts a tiny camera through chest wall to help them see inside your chest. A thoracoscopy can help surgeon decide on the treatment for pneumothorax. The possibilities include sewing blisters closed, closing air leaks, or removing the collapsed portion of lung, which is called a LOBECTOMY.

PHYSIOTHERAPY MANAGEMENT

Indications for Physiotherapy

Lung collapse
Increased work of breathing
Thick sputum plugs predisposing to ventilation difficulty
Blood gas abnormalities
Sputum retention

Goals for Physiotherapy

To reinflate atelectatic lung areas
To improve distribution of ventilation
To increase oxygenation
Maintain airway clearance
Improve exercise tolerance

Physiotherapy Management
       To reduce work of breathing

  • Body positioning
  • Breathing control
  • Relaxation technique
    To improve ventilation
  • Localised thoracic expansion exercise
  • Sputum mobilisation techniques
  • Postural drainage
  • Deep breathing exercise
  • Percussion, shaking and vibrations
  • Sputum removal techniques
  • Coughing and huffing
  • Airway suctioning

Physiotherapy outcome evaluation includes

Respiratory rate
Breathing pattern
Sputum quantity
Ausculatation
Cough sound
Oxygen requirement
SpO2
Arterial blood gases
Chest x-ray changes
Muscle strength
Functional performance

LEPROSY

DEFINATION OF LEPROSY :

1 : A chronic infectious disease caused by a mycobacterium (Mycobacterium leprae) affecting especially the skin and peripheral nerves and characterized by the formation of nodules or macules that enlarge and spread accompanied by loss of sensation with eventual paralysis, wasting of muscle, and production of deformities — called also Hansen’s disease
2 : A morally or spiritually harmful influenceThe first system recognizes two types of leprosy: tuberculoid and lepromatous. A person’s immune response to the disease determines their type of leprosy.

The immune response is good and the disease only exhibits a few lesions (sores on the skin) in tuberculoid leprosy. The disease is mild and only mildly contagious.

The immune response is poor in lepromatous leprosy and affects the skin, nerves, and other organs. There are widespread lesions and nodules (large lumps and bumps). This disease is more contagious.

WHO categorizes the disease based on the type and number of affected skin areas. The first category is paucibacillary, in which five or fewer lesions with no bacteria are detected in the skin sample. The second category is multibacillary, in which there are more than five lesions, bacteria is detected in the skin smear, or both.

CLASSIFICATION OF LEPROSY :

Clinical studies use the Ridley-Jopling system. It has six classifications based on severity of symptoms. They are:

1. Intermediate leprosy: a few flat lesions that sometimes heal by themselves and can progress to a more severe type

2. Tuberculoid leprosy: a few flat lesions, some large and numb; some nerve involvement; can heal on its own, persist, or may progress to a more severe form.

3. Borderline tuberculoid leprosy: lesions similar to tuberculoid but smaller and more numerous; less nerve enlargement; may persist, revert to tuberculoid, or advance to another form.

4. Mid-borderline leprosy: reddish plaques, moderate numbness, swollen lymph glands; may regress, persist, or progress to other forms.

5. Borderline lepromatous leprosy: many lesions including flat lesions, raised bumps, plaques, and nodules, sometimes numb; may persist, regress, or progress.

6. Lepromatous leprosy: many lesions with bacteria; hair loss; nerve involvement; limb weakness; disfigurement; doesn’t regress.

TRANSMISSION OF LEPROSY :

Leprosy spreads through contact with the mucus of an infected person. This usually occurs when the infected person sneezes or coughs. The disease isn’t highly contagious. Close, repeated contact with an untreated person can lead to contracting leprosy.

The bacteria responsible for leprosy multiply very slowly. The disease has an incubation period (the time between infection and the appearance of the first symptoms) of up to five years. Symptoms may not appear for as long as 20 years.

According to the New England Journal of Medicine, an armadillo native to the southern United States can also carry and transmit the disease to humans.

SYMPTOMS :

 

BLISTER FORMATION IN LEPROSY

Symptoms mainly affect the skin, nerves, and mucous membranes (the soft, moist areas just inside the body’s openings).

The disease can cause skin symptoms such as:

A large, discolored lesion on the chest of a person with Hansen’s disease.
A large, discolored lesion on the chest of a person with Hansen’s disease.

Discolored patches of skin, usually flat, that may be numb and look faded (lighter than the skin around)
Growths (nodules) on the skin
Thick, stiff or dry skin
Painless ulcers on the soles of feet
Painless swelling or lumps on the face or earlobes
Loss of eyebrows or eyelashes
Symptoms caused by damage to the nerves are:

Numbness of affected areas of the skin
Muscle weakness or paralysis (especially in the hands and feet)
Enlarged nerves (especially those around the elbow and knee and in the sides of the neck)
Eye problems that may lead to blindness (when facial nerves are affected)
Enlarged nerves below the skin and dark reddish skin patch overlying the nerves affected by the bacteria on the chest of a patient with Hansen’s disease. This skin patch was numb when touched.
Enlarged nerves below the skin and dark reddish skin patch overlying the nerves affected by the bacteria on the chest of a patient with Hansen’s disease. This skin patch was numb when touched.

Symptoms caused by the disease in the mucous membranes are:

A stuffy nose
Nosebleeds
Since Hansen’s disease affects the nerves, loss of feeling or sensation can occur. When loss of sensation occurs, injuries such as burns may go unnoticed. Because you may not feel the pain that can warn you of harm to your body, take extra caution to ensure the affected parts of your body are not injured.

If left untreated, the signs of advanced leprosy can include:

Paralysis and crippling of hands and feet
Shortening of toes and fingers due to reabsorption
Chronic non-healing ulcers on the bottoms of the feet
Blindness
Loss of eyebrows
Nose disfigurement
Other complications that may sometimes occur are:

Painful or tender nerves
Redness and pain around the affected area
Burning sensation in the skin

LEPROSY DIAGNOSIS :

The diagnosis of leprosy is often established from the patient’s clinical signs and symptoms. A careful skin exam and neurologic exam will be undertaken by a health-care professional. If a laboratory is available, skin smears or skin biopsies may be obtained for a more definitive diagnosis. Skin smears or biopsy material that show acid-fast bacilli with the Ziel-Neelsen stain or the Fite stain can diagnose multibacillary leprosy. If bacteria are absent, paucibacillary leprosy can be diagnosed. Other less commonly used tests include blood exams, nasal smears, and nerve biopsies. Specialized tests can be done to place the patient in the more detailed Ridley-Jopling classification.

PREVENTION:

Early detection of the disease is important, since physical and neurological damage may be irreversible even if cured. Medications can decrease the risk of those living with people with leprosy from acquiring the disease and likely those with whom people with leprosy come into contact outside the home.However, concerns are known of resistance, cost, and disclosure of a person’s infection status when doing follow-up of contacts. Therefore, the WHO recommends that people who live in the same household be examined for leprosy and be treated only if symptoms are present.

The Bacillus Calmette–Guérin (BCG) vaccine offers a variable amount of protection against leprosy in addition to its target of tuberculosis. It appears to be 26 to 41% effective (based on controlled trials) and about 60% effective based on observational studies with two doses possibly working better than one. Development of a more effective vaccine is ongoing.

SELF-CARE AT HOME FOR LEPROSY

Prescribed antibiotics medications are the primary treatment for leprosy. Compliance with the full course of antibiotics is crucial to successful treatment.

Patients should also be educated to closely inspect their hands and feet for possible injuries sustained which may go unnoticed because of the loss of sensation.

1. Ulcers or tissue damage can result, leading to skin infections and disability.
2. Proper footwear and injury prevention should be encouraged.

LEPROSY TREATMENT:

Leprosy is a curable disease using the highly effective MDT (multidrug therapy).

In 1981, a World Health Organization Study Group recommended multidrug treatment with three medications: dapsone, rifampicin (Rifadin), and clofazimine (Lamprene).

This long-term treatment regimen cures the disease and prevents the complications associated with leprosy if started in its early stages.

The National Hansen’s Disease Programs (NHDP) currently recommends different treatment regimens for patients with tuberculoid and lepromatous leprosy.

NHDP recommendations:

1.Tuberculoid leprosy:

Twelve months of treatment using rifampin and Dapsone daily

2. Lepromatous leprosy
Twenty-four months of treatment using rifampin, dapsone, and clofazimine daily
The WHO recommended therapy for leprosy is given significantly shorter and less often, as this treatment policy is based upon practical considerations in countries with fewer medical resources. However, the relapses with treatment according to the WHO recommendations are significantly greater than those with the NHDP recommended therapy.

Individuals who develop type 1 or type 2 reactions may require other medications.

Type 1 reaction (reversal reaction):
Treatment may include the use of corticosteroids, salicylates, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Type 2 reaction (ENL):
Treatment may include the use of corticosteroids, salicylates, NSAIDs, clofazimine, and thalidomide (Thalomid).

SYRGICAL TREATMENT FOR LEPROSY:

There are various surgical procedures available for certain patients with leprosy. These surgical procedures are aimed at restoring function of affected body parts (for example, correcting clawed hand deformities) and to cosmetically improving areas damaged by the disease. Amputation of affected body parts is sometimes necessary. Surgery may also be necessary to drain a nerve abscess (pus collection) or to relieve the compression of nerves.

Some patients with leprosy may require psychological counseling, physical therapy, and occupational therapy.

DEFORMITIES IN LEPROSY:

Deformities occurring in leprosy:

1 .nose deformities
2. Face Deformities
3. Mask face, faces leonina, sagging face, lagophthaimos, loss of eye brows (supercilliary madorosis and eyelashes (ciliary madarosis),
4. ulcers and opacities, perforated nose, depressed nose, ear deformities, e.g. nodules on the ear and elongated lobules.

5. Hands deformities Hands deformitiesHands Deformities:

 

CLAW HAND DEFORMITY

Claw hand, wrist drop, ulcers, absorption of digits, thumb – web contracture, hollowing of the interossecus spaces and swollen hand.

6. Feet Deformities
Planter ulcer, foot drop, inversion of the foot, clawing of the toes, absorption of the toes, collapsed foot, swollen foot and callosities.

7. Other Deformities
Gynecomastia and perforation of the palate. All along it has commonly been believed that it is highly contagious and incurable. Even today, in spite of scientific information available about leprosy, it is deeply rooted in the minds of most people at all levels of society, with the result that social ostracism is apparent everywhere. This has led patients to hide their early lesions, and thereby delay treatment just at the period when they could be most speedily cured. Failure to appreciate the importance of the social and psychological factors has resulted in the failure of otherwise well conceived programs.

GOALS OF PHYSICAL THERAPY FOR NON-SURGICAL PATIENT’S OF LEPROSY DISEASE :

The major aim is to prevent or reduce complication, deformity and disability in body through Physical Therapy.

Means

The ways of reaching these Goals are-

By teaching the patient.
By treating and helping the patient.
Teachings

What the disease of leprosy is?
The possible complications and deformities resulting from leprosy.
prevention of complication, deformities and disabilities.
Treating and Helping

To respect themselves enough to take medication regularly and to take care of complications.
To protect their own anaesthetic hands, feets and eyes.
To keep their skin soft and supple.
To keep their joint flexible.
To preserve all posible movements of hands and feet.
To keep their muscles strong.
To use their hands, feet and eyes safely, in daily work

GOALS OF PHYSICAL THERAPY FOR SURGICAL PATIENTS OF LEPROSY:

To protect and prevent further damage and deformity.
To improve and restore function.
To improve appearance of hands, feet, face and eyLEPROSY AND SPLINT FOR HAND

Surgical Techniques used in Leprosy Disease

Tendon Transfer: Moving the distal end of the tendon to a new place so that contraction of muscle belly will produce a needed movements used to replace paralysed muscles. Example- Transfer of fore-arm muscle to make finger movements.
Tendon Lengthening: Lengthening the tendon of a muscle to permit more movement and reduce contracture. Example- Tendo Calcaneus lengthening.
Capsulotomy: To loosen tight joint capsule often done with tendon lengthening and tendon transfer to improve range of motions. Tighten the loose joint capsule using suture.
Arthrodesis: Elimination of unstable and deformed joints.
Tenodesis: Attach a piece of tendon across the joint to reduce the movement. The tendon then act as ligament. Example- Tenodesis of MCP joint to prevent hyperextension.
Physical Therapy Goals:

To increase and regain range of motion.
Improve muscle strength perticularly in muscles to be transferred.
Clean supple skin in areas of surgery.
Teach home self care.
Protect tissue during wearing.
Prevent/reduce swelling.
Muscle re-education after tendon transfer.
Safe use of any new restored skill in work.

PHYSICAL THERAPY TREATMENT::

For increasing/regaining ROM: ROM can be increased by soaking the skin or part in warm water and then performing passive movement to the part affected.
To improve strength specially in tendon transfer: Active exercise in all part in which surgery is performed.
Clean supple skin: It is provided by soaking the part in soap water, rubbing off thick skin, oiling, self massage and protecting the part from infection.
Home care: teaching skin, hand, foot and eye care to groups and individuals and teaching the patients actual home care.
Protect tissue during healing: Rest, body position and POP cast.
Prevent/Reduce swelling: Elevation, active and passive exercise.
Muscle Re-education after tendon transfer: Teaching new restored skills in movements provided by tendon transfer.
Self restored skills in daily work: Teaching patient ot use any new skill safely in specific task. Providing hand, eye and foot protection.

SPLINT FOR LEG

 

 

DUPUYTREN’S CONTRACTURE AND PHYSIOTHERAPY MANAGEMENT

DUPUYTREN’S CONTRACTURE AND PHYSIOTHERAPY MANAGEMENT

Dupuytren’s contracture is a condition in which one or more fingers become permanently bent in a flexed position. It usually begins as small hard nodules just under the skin of the palm. It then worsens over time until the fingers can no longer be straightened. While typically not painful some aching or itching may be present.The ring finger followed by the little and middle fingers are most commonly affected. It can interfere with preparing food, writing, and other activities.

The cause is unknown. Risk factors include family history, alcoholism, smoking, thyroid problems, liver disease, diabetes, previous hand trauma, and epilepsy. The underlying mechanism involves the formation of abnormal connective tissue within the palmar fascia.Diagnosis is usually based on symptoms.

Initial treatment is typically with steroid injections into the affected area and physical therapy. Among those who worsen, clostridial collagenase injections or surgery may be tried.[ While radiation therapy is used to treat this condition, the evidence for this use is poor.The condition may recur despite treatment.

Dupuytren’s most often occurs in males over the age of 50.It mostly affects white people and is rare among Asians and Africans.In the United States about 5% of people are affected at some point in time, while in Norway about 30% of men over 60 years old have the condition. In the United Kingdom, about 20% of people over 65 have some form of the disease.It is named after Guillaume Dupuytren, who first described the underlying mechanism in 1833.

Contents :

Signs and symptoms
Related conditions Risk factors
Non-modifiable
Modifiable
Other condition
Diagnosis
Types
Stages
Treatment
Surgery
Prognosis
Postoperative care

Signs and symptoms

Dupuytren’s contracture of the right little finger. Arrow marks the area of scarring
Typically, Dupuytren’s contracture first presents as a thickening or nodule in the palm, which initially can be with or without pain. Later in the disease process, there is painless increasing loss of range of motion of the affected fingers. The earliest sign of a contracture is a triangular “puckering” of the skin of the palm as it passes over the flexor tendon just before the flexor crease of the finger, at the metacarpophalangeal (MCP) joint. Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected.The disease begins in the palm and moves towards the fingers, with the metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.

In Dupuytren’s contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren’s contracture decreases a person’s ability to hold objects. People may report pain, aching and itching with the contractions. Normally, the palmar fascia consists of collagen type I, but in Dupuytren sufferers, the collagen changes to collagen type III, which is significantly thicker than collagen type I.[citation needed]

Related conditions

Dupuytren’s contracture is related to a number of similar conditions that affect different areas of the body, including:

Garrod’s pads – nodules that develop on the back of the knuckles on the fingers
Ledderhose’s disease (plantar fibromatosis) – nodules and contractures that affect the foot
Peyronie’s disease – where the tissue of the penis is affected, causing it to become abnormally curved

Risk factors

Dupuytren’s contracture is a non-specific affliction but primarily affects:

Non-modifiable

People of Scandinavian or Northern European ancestry, it has been called the “Viking disease”, though it is also widespread in some Mediterranean countries (e.g., Spain and Bosnia Dupuytren’s is unusual among ethnic groups such as Chinese and Africans.
Men rather than women; men are more likely to develop the condition)
People over the age of 50; the likelihood of getting Dupuytren’s disease increases with age.
People with a family history (60% to 70% of those afflicted have a genetic predisposition to Dupuytren’s contracture)

Modifiable

Smokers, especially those who smoke 25 cigarettes or more a day
Thinner people (i.e., those with a lower than average body mass index)
Manual workers
Alcoholics

Other conditions

People with a higher-than-average fasting blood glucose level
People with previous hand injury
People with Ledderhose disease (plantar fibromatosis)
People with epilepsy (possibly due to anti-convulsive medication)
People with diabetes mellitus
People with HIV
In one study, those with stage 2 of the disease were found to have a slightly increased risk of mortality, especially from cancer.

Diagnosis

Types

According to the American Dupuytren’s specialist Dr Charles Eaton, there may be three types of Dupuytren’s disease:

Type 1: A very aggressive form of the disease found in only 3% of people with Dupuytren’s, which can affect men under 50 with a family history of Dupuytren’s. It is often associated with other symptoms such as knuckle pads and Ledderhose disease. This type is sometimes known as Dupuytren’s diathesis.

Type 2: The more normal type of Dupuytren’s disease, usually found in the palm only, and which generally begins above the age of 50. According to Dr Eaton, this type may be made more severe by other factors such as diabetes or heavy manual labour.

Type 3: A mild form of Dupuytren’s which is common among diabetics or which may also be caused by certain medications such as the anti-convulsants taken by people with epilepsy. This type does not lead to full contracture of the fingers and is probably not inherited.

Staging of Dupuytren’s disease.( TFD- Total flexion deformity )

Stage Deformity

0        No lesion
N       Palmar nodule without presence of contracture
1        TFD between 0° and 45°
2        TFD between 45° and 90°
3       TFD between 90° and 135°
4       TFD greater tha

Treatment

 

Currently, there is no cure for Dupuytren’s; however, the condition is not dangerous.

Although it varies from patient to patient, Dupuytren’s usually progresses very slowly and may not become troublesome for many years. In fact, for some patients, the condition may never progress beyond developing lumps in the palm.
If the condition progresses, your doctor may first recommend nonsurgical treatment to help slow the disease.

1. Nonsurgical Treatment

Steroid injection. Corticosteroids are powerful anti-inflammatory medications that can be injected into a painful nodule. In some cases, a corticosteroid injection may slow the progression of a contracture. The effectiveness of a steroid injection varies from patient to patient.

Splinting. Splinting is not known to prevent the progression of a finger contracture. Forceful stretching of the contracted finger may not be helpful and, in fact, could cause an injury to the finger or hand.
Splinting may be used after surgery for Dupuytren’s contracture to protect the surgical site; however, it is not known if it reduces the risk of recurrent contracture or tightening of the healing wound.

2. Surgical Treatment

If the contracture interferes with hand function, your doctor may recommend surgical treatment. The goal of surgery is to reduce the contracture and improve motion in the affected fingers.
There is no known cure for Dupuytren’s contracture; however, surgery is intended to “set back the clock” by reducing the restricting effect of the cords by either disrupting or removing them. Unfortunately, the healing tissues will form with the same potential to develop cords in the future—but the gains in hand function can still be substantial.
The surgical procedures most commonly performed for Dupuytren’s contracture are:

Fasciotomy
Subtotal palmar fasciectomy
Fasciotomy.

Treatment is indicated when the so-called table top test is positive. With this test, the person places their hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the table, leaving a space between the table and a part of the hand as big as the diameter of a ballpoint pen, the test is considered positive and surgery or other treatment may be indicated. Additionally, finger joints may become fixed and rigid.

3. Recent Developments in Treatment

The recently developed treatments described below are intended to reduce a contracture and improve motion in the affected fingers by disrupting the tethering effect of the Dupuytren’s cords.

Enzyme Injection

The injection of an enzyme solution for treatment of Dupuytren’s contracture has recently been approved by the Federal Drug Administration. The enzyme, a collagenase, is administered on an outpatient basis by doctors who have been specifically trained in the technique.
To begin, your doctor will inject the enzyme directly into the cords in your hand. During the 24 to 72 hours following the injection, the enzyme will weaken/dissolve the contracted tissue.
The next step is performed under local anesthesia. Your doctor will manipulate and straighten your bent fingers to break or pull apart the restrictive cords. Often, this improves the contracture and increases range of motion in the fingers.
Enzyme injection typically results in less pain and swelling than major surgery. Although rare, the injection may cause an allergic reaction or flexor tendon rupture. Other potential complications are the same as those for surgery.
Early results for enzyme injection are promising, but long-term results and recurrence rates are not yet known.

4. Physiotherapy, massage and exercise before surgery

Physiotherapy may help relieve some of the pain and tension that patients feel in their hands or arms.

Massaging the palm of the hand and the forearm may help reduce the tension in the palmar fascia and the Palmaris Longus muscle (a muscle in most people’s arms that pulls on the fascia).

Physiotherapy will not remove the nodules, though some therapists can help with releasing tension in the arm and treating the tissues around the lumps to give relieve of pain and increase the range of movement. Physiotherapy can consist of massaging or exercises.

Some patients will wear splints to try slow down contracture, an example can be found on this page.

Acupuncture and reflexology are other treatments sometimes used to try slow or even reverse the progression.

Many consultants believe that physiotherapy will not stop the disease progress, but can help with the symptoms for a while.

Exercises are not commonly recommended and are unlikely to prevent contractures. However some patients do report good results, even if for a limited period of time until the condition worsens and they need further treatment.

Some treatments that have helped patients:

massaging the whole arm and hand to create good flow of fluid from the hand to the heart and from the heart to the hand.
gentle stretching exercises ( if stretching too vigorously you risk microtrauma to the fascia which can aggravate Dupuytren’s it should not be painful, at most a bit uncomfortable). Gentle stretching and holding the position for 10-15 seconds , then release and repeat 10 times is better and will tire the contracted strands more than brute force)
hot wax treatments to the hand or other warm applications, for many people applying heat or at least warmth first help to make exercises easier.
ultrasound treatment of the nodules to soften them and maybe reduce the pain
acupuncture
after heat treatment or ultrasound, massaging sideways over the palm may help to loosen the tissues a bit, with the other hand or done by a professional with tools made for tissue release techniques.
wearing night splints, the idea being that at night many people have their fingers slightly curved which makes it easier for the contracture to settle in a curved position.
for painful palms or nodules a lot of patients wear weightlifting gloves that are padded in the palm, to protect their hand and reduce the pain, and still have good grip
There are different type of exercises with different goals.

Remember that most exercises work best if you stretch until you feel resistance, NOT stretch until it really hurts. Hold that tension for 10-15 seconds, release and repeat 10 times.

Tendon Glide exercises : are meant to make the deep and superficial flexor tendons (the ones that bend your fingers) move separately. The are done by making different types of fists, as shown in the pictures here, going from a flat hand via fingers only bend at the hand joint to a fist with bend fingers to a fist with fingers straight.

TENDON GLIDE 1:

 

TENDON GLIDE 2

tendon glide 2

 

TENDON GLIDE 3 EXERCISE

tendon glide 3

 

TENDON GLIDE 4 EXERCISE

tendon glide 4

 

TENDON GLIDE  5 EXERCISE

tendon glide5

TENDON GLIDE 6 EXERCISE

tendon glide6

 

Range of motion exercises : can be to stretch the fingers and joints or to widen the reach of the fingers. A lot of websites will give ideas for this, especially sites for guitar or piano players. Some examples follow here:

To strengthen the fingers and increase the reach:

Place your hand against each other with the fingers stretches and the tips touching, try pushing the palms together as well. If you can get palms and fingertips touching, try to push the fingertips of one hand away with the tips of the other hand.
Place hand on a flat tabletop. Lift the palm off the table while keeping your fingers on the table, to stretch the joints between the hands and fingers.
Place the hand flat on the table and try to lift each finger up separately
With the hand flat on the table try to spread your fingers as wide as they will go. Then move each finger toward the thumb (start with the index finger) while holding the hand flat to create as much space between the fingers as you can each time. This exercise can be doe the other way around as well by moving each finger toward the little finger.
Hold you hand up, and make the thumb touch the tip of each finger in turning, creating a circle of the finger and thumb.

Gripping exercises

Use a folded up towel, or a sponge (cut to size of you want). Place it in your hand and squeeze tight, then release after 10 seconds and repeat. Soft exercise balls or babies toy balls work as well.

Exercises after the surgery:

Exercises may need to be done for up to 6 months. Repeat each one 10 times, do at least 3 times per day. It may be easier to do the exercises with the hand in lukewarm water, soapy or plain.

Please note exercising can be uncomfortable but should not be really painful. It is better to go gently, hold for 10 seconds and release, and try to get more movement slowly than to force the issue, that may do damage!

Any exercises where you use the other hand to push the joints (passive exercises) are best only started when the wound has healed and any scabs have come off.

Straightening the fingers: (note that a swollen finger will not straighten completely)

Finger Walking (Spreading the finger)s Rest palm on flat surface, move thumb to the side, slide one finger at the time toward the thumb.Finger Walking (Spreading the finger)s Rest palm on flat surface, move thumb to the side, slide one finger at the time toward the thumb.
Tendon Glide

Start with the hand open, make a fist by bending each joint one by one, then open the fist the same way.
Cat’s Paw– open hand wide, bend the fingertips but not the large knuckles, hold six seconds.
Making a fist (whole hand, try first around a ping pong ball or even small foam ball or sponge, later without anything between the fingers and the palm)

Making a fist finger by finger by using your other hand to bend the joints, passive exercises, only start these when the wound has healed and any scabs have come off.

Use the other hand to gently bend the affected finger at the large knuckle, hold for 10 seconds.

Complications.

As with any surgery, there are risks associated with surgery for Dupuytren’s contracture. The likelihood of complications increases with the following:
The severity of the contracture
The number of contractures addressed in a single procedure
The presence of any other medical conditions

Possible risks and complications of surgery for Dupuytren’s include:

Pain
Scarring
Injury to nerves and/or blood vessels
Wound infection
Stiffness
Loss of sensation. Temporary loss of sensation may result from stretching nerves that have been contracted for a long time.
Loss of viability of a finger/loss of a finger (rare)

Prognosis

Dupuytren’s disease has a high recurrence rate, especially when a person has so called Dupuytren’s diathesis. The term diathesis relates to certain features of Dupuytren’s disease and indicates an aggressive course of disease

The presence of all new Dupuytren’s diathesis factors increases the risk of recurrent Dupuytren’s disease by 71% compared with a baseline risk of 23% in people lacking the factors. In another study the prognostic value of diathesis was evaluated. They concluded that presence of diathesis can predict recurrence and extension. A scoring system was made to evaluate the risk of recurrence and extension evaluating the following values: bilateral hand involvement, little finger surgery, early onset of disease, plantar fibrosis, knuckle pads and radial side involvement.

Minimally invasive therapies may precede higher recurrence rates. Recurrence lacks a consensus definition. Furthermore, different standards and measurements follow from the various definitions.[citation needed]

Post-operative care

Postoperative care involves hand therapy and splinting. Hand therapy is prescribed to optimize post-surgical function and to prevent joint stiffness.[citation needed]

Besides hand therapy, many surgeons advise the use of static or dynamic splints after surgery to maintain finger mobility. The splint is used to provide prolonged stretch to the healing tissues and prevent flexion contractures. Although splinting is a widely used post-operative intervention, evidence of its effectiveness is limited, leading to variation in splinting approaches. Most surgeons use clinical experience to decide whether to splint.Cited advantages include maintenance of finger extension and prevention of new flexion contractures. Cited disadvantages include joint stiffness, prolonged pain, discomfort, subsequently reduced function and edema.

A third approach emphasizes early self-exercise and stretching.

MULTIPLE SCLEROSIS

DEFINATION
Multiple sclerosis (MS) is a autoimmune disease characterised by inflammation,selective demylination and gliosis.it can cause both acute and chronic symptoms and can results in a significant disability and impaired quality of life.MS affects approximately 400,000 persons in the united states ; worldwild MS affects approximately 2.1 millian people.
It was first defined by the Dr.jean charcot in 1868 by its clinical ans pathological characteristics : paralysis and the cardinal symptoms of intension tremor, scanning speech and nystagmus later termed ”CHARCOT’S TRIAD”.
using the autopsy studies he identifies the areas of hardened plaques and termed the dieses sclerosis in plaques.

Specific symptoms can include double vision, blindness in one eye, muscle weakness, trouble with sensation, or trouble with coordination. MS takes several forms, with new symptoms either occurring in isolated attacks (relapsing forms) or building up over time (progressive forms). Between attacks, symptoms may disappear completely; however, permanent neurological problems often remain, especially as the disease advances.
Multiple sclerosis is a chronic disease that attacks the central nervous systrem, it affects the spinal cord , brain,and optic nerve.

Multiple sclerosis affects the nerve cells.

WHAT IS MS ?

In the CNS, nerve fibers are surrounded by a myelin sheath, which protects them. Myelin also helps the nerves conduct electrical signals quickly and efficiently. In MS, the myelin sheath disappears in multiple areas, leaving a scar, or sclerosis.
Multiple sclerosis means “scar tissue in multiple areas.”
The areas where there is no myelin or a lack of myelin are called plaques or lesions. As the lesions get worse, nerve fibers can break or become damaged. As a result, the electrical impulses from the brain do not flow smoothly to the target nerve.When there is no myelin, the fibers cannot conduct the electrical impulses at all. The messages from the brain to the muscles cannot be transmitted.

CAUSES:

The cause of multiple sclerosis is unknown. It’s considered an autoimmune disease in which the body’s immune system attacks its own tissues. In the case of MS, this immune system malfunction destroys myelin (the fatty substance that coats and protects nerve fibers in the brain and spinal cord).

Myelin can be compared to the insulation coating on electrical wires. When the protective myelin is damaged and nerve fiber is exposed, the messages that travel along that nerve may be slowed or blocked. The nerve may also become damaged itself.

It isn’t clear why MS develops in some people and not others. A combination of genetics and environmental factors appears to be responsible.

PATHOPHYSIOLOGY:
1 .In patients with MS the immune response triggers activation of immune cells that cross the blood brain barries. these cells activates the autoantigens, producing’‘ AUTO- IMMUNE CYTOTOXIC EFFECTS’‘ within the central nervous system. demylination slows neural transmission and cause nerve to fatigue rapidly.

2.demylinated areas eventually become filled with fibrous astrocytes and undergo a process called ”GLIOSIS”.

DISEASE COURSE:

Most people with MS have a relapsing-remitting disease course. They experience periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These relapses are followed by quiet periods of disease remission that can last months or even years.

Small increases in body temperature can temporarily worsen signs and symptoms of MS, but these aren’t considered disease relapses.

About 60 to 70 percent of people with relapsing-remitting MS eventually develop a steady progression of symptoms, with or without periods of remission, known as secondary-progressive MS.

The worsening of symptoms usually includes problems with mobility and gait. The rate of disease progression varies greatly among people with secondary-progressive MS.

Some people with MS experience a gradual onset and steady progression of signs and symptoms without any relapses. This is known as primary-progressive MS.

TYPES OF MS

There are four types of MS:

1.Clinically isolated syndrome (CIS): This is a single, first episode, with symptoms lasting at least 24 hours.

2.Relapse-remitting MS (RRMS): This is the most common form, affecting around 85 percent of people with MS and involving attacks of new or increasing symptoms.

3.Primary progressive MS (PPMS): Symptoms worsen progressively, without early relapses or remissions. Around 15 percent of cases are PPMS.

4.Secondary progressive MS (SPMS): After initial episodes or relapse and remission, the disease progresses steadily.

RISK FACTORS:

These factors may increase your risk of developing multiple sclerosis:

Age. MS can occur at any age, but most commonly affects people between the ages of 15 and 60.

Sex. Women are about twice as likely as men are to develop MS.

Family history. If one of your parents or siblings has had MS, you are at higher risk of developing the disease.

Certain infections. A variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes infectious mononucleosis.

Race. White people, particularly those of Northern European descent, are at highest risk of developing MS. People of Asian, African or Native American descent have the lowest risk.

Climate. MS is far more common in countries with temperate climates, including Canada, the northern United States, New Zealand, southeastern Australia and Europe.

Certain autoimmune diseases. You have a slightly higher risk of developing MS if you have thyroid disease, type 1 diabetes or inflammatory bowel disease.

Smoking. Smokers who experience an initial event of symptoms that may signal MS are more likely than nonsmokers to develop a second event that confirms relapsing-remitting MS.

SYMPTOMS:

 

MS-Symptoms

Symptoms of MS vary considerably, depending on the location of the lesion.Early symptoms typically include minor visual disturbance, and paresthesias, progressing to numbness, weakness and fatigability.
Multiple sclerosis signs and symptoms may differ greatly from person to person and over the course of the disease depending on the location of affected nerve fibers.
They may include:
1.SENSORY- Altered sensations are far more common and can including paresthesias, numbness of face , body and extremities.
Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or the legs and trunk
2.VISION -Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
Prolonged double vision
”MARCUS GUNN PUPIL”
Scotoma
Optic neuritis
Nystagmus
INO-interneuclear ophthelmoplegia , produce lateral gaze palsy
Tingling or pain in parts of your body
Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign)
Tremor, lack of coordination or unsteady gait
Slurred speech
Fatigue
Dizziness
Headache.
trigeminal neuralgia
Paroxysmal limb pain
hyperpathia
chronic neuropathic pain
Musculoskeletal pain
Problems with bowel and bladder function
3.PAIN – Approximately 80% patients with MS experience pain.almost half experience pain.Anxiety and fear woersen the pain symptoms.
4.MOTOR-
Weakness
Spasticity

5.FATIGUE.
6.COORDINATION AND BALANCE-Ataxia
7.GAIT AND MOBILITY-Ataxic gait
8.SPEECH AND SWALLOWING-Dysarthria
9. COGNITIVE-In MS short term memory , attension and concentration ,information processing, executive functions, visuospatial functions affected.
10.DEPRESSION
11.EMOTIONAL-Pseudobulbar affect.
12.SEXUAL DYSFUNCTION.

13.UTTHOF’S SYMPTOMS

DIAGNOSIS:

Tests for MS include:

1.Neurological examination
2.MRI scanning
3.Evoked potentials
4.Lumbar puncture
5.Other tests
The neurologist will use specific criteria to diagnose MS, known as the McDonald criteria.

1-Neurological examination
Your neurologist will ask you lots of questions about your ‘history’, meaning your health problems and symptoms, now and in the past. This helps the neurologist get a better picture of you and can help identify any other problems that may explain current symptoms.

A physical examination checks for changes or weaknesses in your eye movements, leg or hand coordination, balance, sensation, speech or reflexes. Whilst a neurologist may strongly suspect MS at this stage, a diagnosis won’t be given until other test results confirm MS.

2-Magnetic Resonance Imaging (MRI)

DIAGNOSIS OF MS
DIAGNOSIS OF MS- ”BRIGHT SPOT”

An MRI scanner uses a strong magnetic field to create a detailed image of inside your brain and spinal cord. It is very accurate and can pinpoint the exact location and size of any inflammation, damage or scarring (lesions). MRI scans confirm a diagnosis in over 90 per cent of people with MS.

To get the image of a person’s brain and spinal cord they must lie down and enter a small tunnel in the centre of the MRI scanner. The process can take between 10 and 60 minutes and is painless, though some people can feel a little claustrophobic in the scanner. The Newcastle Upon Tyne Hospitals NHS Foundation Trust has produced a video which explains what to expect when you have an MRI

3-Evoked potentials tests
This painless test involves measuring the time it takes for your brain to receive messages from your eyes, ears and skin. Small electrodes are placed on your head. These check how your brain reacts to sounds you hear in headphones, patterns you see on a screen or sensations you feel on your skin. Messages to and from your brain will be slower if MS has damaged the myelin covering around some of your nerves.

4-Lumbar puncture
This is sometimes called a spinal tap. A needle is inserted in your lower back, into the space around your spinal cord. You have a local anaesthetic for this. A small sample of the fluid around your spinal cord is taken and tested for signs of MS. People with MS often have antibodies in this fluid. Antibodies show your immune system is active in your brain and spinal cord. This is something that isn’t seen in people who don’t have MS.

People often get headaches following a lumbar puncture. The medical staff should advise you on how to manage this. Lumbar punctures are used less now that MRI scans are more common.

5-Other tests
To rule out conditions that are similar to MS, other tests may also be done. These may include blood tests to reveal certain antibodies, and inner ear tests to check your balance.

The McDonald Criteria is distinguished by incorporating clinical evaluation with magnetic resonance imaging (MRI) scans in establishing MS. But, like an earlier approach, it too requires:

Evidence of damage to the central nervous system (CNS; the brain, spinal cord and optic nerves) that is “disseminated in time,” meaning damage that occurs on different dates;
Evidence of damage “disseminated in space,” or found on two or more parts of the CNS.

TREATMENT:

There is no cure for multiple sclerosis. Treatment typically focuses on speeding recovery from attacks, slowing the progression of the disease and managing MS symptoms. Some people have such mild symptoms that no treatment is necessary.

Treatments for MS attacks

1-Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are prescribed to reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, mood swings and fluid retention.
2-Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. Plasma exchange may be used if your symptoms are new, severe and haven’t responded to steroids.

Symptom: Sensory symptoms (parasthesias)
Numbness, tingling, pins and needles

Treatment
No treatment required unless interfering with function; medication if necessary; referral to PT/OT if necessary

Symptom: Primary pain
*Central neuropathic pain – continuous (dysesthesias)
Treatment
Medications:

tricyclic antidepressant medications (amitriptyline, nortriptyline, desipramine); antiepileptic medications (pregabalin, gabapentin)
Other:
topical appliation of capsaic acid cream;behavioral self-management (mindfulness,meditation)
hypnosis,cognitive behavior therapy

*Central neuropathic pain – intermittent (trigeminal neuralgia)
Treatment
Medications

First-line: carbamazepine
Alternate options: oxcarbazepine, lamotrigine, baclofen
Additional options with lower levels of evidence: phenytoin, clonazepam, valproic acid, intranasal lidocaine
Surgery:

radiofrequency rhizotomy; radiofrequency electrocoagulation; glycerol rhizotomy

Psychosocial Implications for each pain symptom
Clumsiness, balance problems, and loss of dexterity from sensory loss
Discomfort that is sometimes excruciating
Increase in fatigue caused by medications and interrupted sleep

NOTE: Many people are still told by doctors that MS does not cause pain, yet pain is a common symptom of MS that is distracting, depressing, and debilitating.

*Symptom: Secondary pain (musculoskeletal)
Resulting from poor posture/balance in ambulatory individuals or improper use/fitting of wheelchair

Treatment
Interventions:Referral to PT: gait and balance training; assessment of all seating (home, automobile, work, and wheelchair/scooter);
Medications:analgesics

PHYSICAL THERAPY MANAGEMENT:

Physical therapy can play an essential role in keeping a patient with MS active and functional within the community.While there is no cure for multiple sclerosis, exercise appears to be beneficial at multiple levels and it may have an important role to play in delaying negative symptoms of the disease. Exercises should be chosen according to one’s strengths and weaknesses . It is suggested that exercise therapy does have efficacy in MS.It is to state the best ’dose’ (intensity, frequency and duration) of treatment to achieve optimal beneficial effects of exercise therapy in terms of activities and participation for patients suffering from MS. There was no evidence describing harmful effects of exercise therapy for MS patients. .Exercise is consider as a safe effective means of rehabilitation.

The PT assessment should focus on posture, movement and function, carefully considering how a patient’s performance may be limited by fatigue, pain or other factors. Analyzing these results together with the proper opinion and interest of the person with MS will enable the physiotherapist to set up an individualized program. This program needs to be set up so that it can easily be performed at home.Education is also important to assist patients in managing their programs as independently as possible. A multidisciplinary treatment for MS patients may lead to positive effects.

During EARLY STAGEof MS patients may present with minimal impairments. At this time, the PT can focus on educating the patient and family members or caregivers on disease progression and compensatory strategies to conserve energy. Physiotherapy emphasize movement outdoors especially in sunlight in order to avail the direct benefits of sunlight in MS.The recent study suggests life time sun exposure appears to reduce the risk of Multiple Sclerosis regardless of race/ethnicity. Study indicates the protective effect of sun exposure in MS is most likely mediated through immunomodulatory mechanisms,

Due to the progressive nature of the disease, those in the MODERATE STAGE might notice impairments at varying degrees and activities of daily living (ADL) may require assistance. At this middle stage,therapy should focus more on improving or maintaining motor functions through strength, endurance, flexibility, balance, respiratory training and assistive device training as well as suggesting environment modifications to the home or assessing mobility aids required to move about in the community to sustain quality of life. Informing the carers about correct postures will prevent further complications. A close collaboration between professional community carers and non-professional caregivers at home is a key factor for the successful management of the rehabilitation.

Advanced stages of MS often present with multiple impairments at incresing severity compared to earlier stages. The primary goals of the PT in late stages is to maximize independence through postural and ADL training, respiratory function, safety and prevention strategies for contracture development or pressure wounds, equipment suggestions, and proper transfer techniques.

PHYSIOTHERAPY TREATMENT : active/passive/active assisted exercises(carried with partner or with help of equipment like elastic bands);techniques like Bobath,Vojtas,Proprioceptive Neuromuscular Techniques; carried out regularly and with sufficient intensity, have evidence of improvement in patients with MS.

Use of therapeutic corticosteriods and inactivity due to fatigue and weakness,may lead to osteoporosis and pathological fractures.Weight bearing exercises can slow down the loss of bone and muscle mass. Resistance training program is recommended for maintaining bone and muscle mass,According to Döring et al. aerobic training seems to have a positive effect on fatigue.Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients,affected with mild or moderate disability.

BALANCE EXERCISE can improve balance.Poor postural control increases risk of falls.MS patients have increased sway in quiet stance,delayed postural perturbations and reduced ability to move towards limits of stability.These impairments are likely causes of falls.Reduced gait speed,decreased stride length, cadence,and joint movement are observed in most studies of gait in MS. The therapist must identify several factors that may be amenable to intervention to prevent falls in people with MS.Comprehensive exercise interventions can facilitate improvements in balance impairments.Functional balance exercises can extensitively impact balance, physical activity and quality of life in adults with multiple sclerosis.

MOTOR IMAGERY is increasingly used in neuro-rehabilitation in-order to facilitate motor performance.Motor imagery and rhythmic auditory stimulation can be used for walking rehabilitation in MS patients..Randomized control trial studying the effects of motor imagery showed significant improvement in walking speed,walking distance,perception and quality of living.

HIPPOTHERAPY has a positive effect on balance of persons with multiple sclerosis and has an added benefit of enhancing quality of life. A systematic review and meta-analysis of therapeutic effect of Horseback riding intervention shows positive physical and emotional effects of horse riding in individuals with neuromotor development and physical disabilities. Therapeutic horseback riding improved balance and gait of ambulatory patients with MS. Hippotherapy helps the rider,by providing effective sensory stimulation and rhythmic anterior and posterior swinging motion.It encourages the rider to achieve proper posture and balance.

AQUATIC EXERCISE program could have a positive effect for persons with progressive multiple sclerosis. Interventions that promote general health, improve energy levels and mental health, and faster social interaction in the presence of physical disability are beneficial for individuals with progressive multiple sclerosis. Because of reduced impact of gravity, aquatic training allows patients with even severe paresis of the lower extremities to perform standing and moving exercises.
In MS patients, beneficial effects of regular physical activity and exercise on mood and quality of life have been repeatedly reported.Valid data on the effect on cognitive function are hardly available.

Cognitive Behavioral Therapy (CBT) ] :

CBT have amoderately positive effect on fatigue in MS. However,this effect declines after cessation of treatment. Since the short-term effect of CBT on MS-related fatigue is positive, there is a need for more research, to develop interventions that, maintain these short-term effects in the long term.To have good results, it is best that the patient should be referred to a CBT specialist. CBT can also be an effective intervention for reducing moderate depression, over a short-term, in MS patients,which may also improve patient quality of life.
Throughout all stages of MS,PT can offer psychological support to the patient and family/caregiver.

PT Interventions for Common Symptoms of Patients with MS:

PAIN- Patients with MS often experience pain directly from the disease, secondary to medication or other symptoms, or from something completely separate. PT helps relieve pain through exercise, stretching, massage, ultrasound, postural training, or hydrotherapy.

SENSORY DEFICITS-Tapping and verbal cues during exercise and resistance training can help improve proprioception losses. Vision issues, such as blurred or double vision, often occur in patients with MS. PT can offer education on how to be safe at home and offer strategies to improve balance and coordination in dimly lit settings. PT treatment interventions for decreased sensation to light touch include education on awareness, protection, and personal care to desensitized body parts. Pressure-relieving devices are a primary prevention strategy along with proper transfer techniques and daily skin inspections for maintaining skin integrity.

FATIGUE– One of the most debilitating symptoms of MS is experienced by an overwhelming majority of patients: fatigue. PT strategies to help patients combat feelings of excessive tiredness include aerobic exercise, energy conservation, and activity pacing. Aerobic exercise activities is closely monitored by a PT to ensure a patient does not overheat, but is able to work on increasing their endurance capacity which will help them be more functional throughout the day. PT’s can also teach energy conservation strategies and activity pacing to help someone sustain their daily activities by minimizing fatigue.

SPASTICITY- The physical and functional limitations spasticity leads to include include a variety of impariments which can present as contractures, postural deformities, decubitus ulcers, and more. PT interventions range from cryotherapy and hydrotherapy to therapeutic exercise, stretching, range of motion activities, postural training, and electrical stimulation. A combination of therapeutic interventions is often the route taken.

Balance, Coordination, & Postural Deficits. Ataxia, postural instability, muscle spasms, and generalized muscle weakness al contribute to balance and coordination deficits. PT techniques to address these issues include postural exercise, core strengthening, rhythmic stabilization, static/dynamic balance training, aquatic therapy, proprioceptive loading, and resistance training.

Mobility Issues. Weakness, particularly in the lower extremity, balance deficits, fatigue, posture, contractures, sensation deficits, heat intolerance, among other deficits, can impede an individual’s ability to be mobile. In combination of the treatment previously described, PT’s work to help patient’s overcome their mobility limitations through locomotor and functional training.
Locomotor training focuses on increasing thigh and hip strength along with posture and balance training through walking activities. Orthotics and assistive devices are added as necessary. Functional training involves bed mobility, transfers, and developing strategies with the patient on how to be able to safely navigate around the home and out in the community.

DIETARY MODIFICATION:

Diet plays a huge role in health.Research suggests adding inflammatory fighting foods to diet can help in chronic inflammation.

Number of factors may be thought to play role in triggering inflammation- gluten and dairy products,vitamin D deficiency.Diet rich in whole fresh foods and eliminating dairy,sugar,high salt and processed food is highly recommended.

Many researchers are exploring dietary intervention approaches in MS to improve lifestyle. Probiotics may improve the health of people with MS by reducing disability and improving inflammatory and metabolic parameters according to an Iranian study.

Vitamin D supplementation helps prevention and treatment of MS. Various research studies are studying the effectiveness of vitamin D therapy in MS.

Fish oil supplementation given together with vitamins and dietary advice can improve clinical outcome in patients with newly diagnosed MS.More research is required to assess the effectiveness of dietary interventions of omega 3 in MS and it’s interaction with medications used for treating MS.

Dysfunction of mitochondria is thought to play an important role in mechanism of progression of demyelinating disorders.Observations in animal and histopathological studies,suggest that,dysfunctional mitochondria are important contributors to damage and loss of both axons and neurons.The relationship between mitochondrial dysfunction and neurodegeneration in MS is explored.The Ketogenic diet has the potential to treat the neurodegenerative component of progressive MS,though more research is required in this field.

 

AMYOTROPIC LATERAL SCLEROSIS(ALS)/ LOU GEHRIG’S DISEASE

DEFINATION

Motor neuron diseases (MND) include a heterogeneous spectrum of inherited and sporadic (no family history) clinical disorders of the upper motor neurons (UMNs), lower motor neurons (LMNs), or a combination of both. Amyotrophic lateralsclerosis (ALS),commonly known as” Lou Gehrig’disease”, is the most common and devastatingly fatal MND among adults.”ALS is characterized by the degeneration and loss of motor neurons in the spinal cord, brainstem, and brain, resulting in a variety of UMN and LMN clinical signs and symptoms”.

Amyotrophic lateral sclerosis (ALS) is a group of rare neurological diseases that mainly involve the nerve cells (neurons) responsible for controlling voluntary muscle movement. Voluntary muscles produce movements like chewing, walking, and talking. The disease is progressive, meaning the symptoms get worse over time. Currently, there is no cure for ALS and no effective treatment to halt, or reverse, the progression of the disease.

ALS belongs to a wider group of disorders known as motor neuron diseases, which are caused by gradual deterioration (degeneration) and death of motor neurons. Motor neurons are nerve cells that extend from the brain to the spinal cord and to muscles throughout the body. These motor neurons initiate and provide vital communication links between the brain and the voluntary muscles. Messages from motor neurons in the brain (called upper motor neurons) are transmitted to motor neurons in the spinal cord and to motor nuclei of brain (called lower motor neurons) and from the spinal cord and motor nuclei of brain to a particular muscle or muscles.

In ALS, both the upper motor neurons and the lower motor neurons degenerate or die, and stop sending messages to the muscles. Unable to function, the muscles gradually weaken, start to twitch (called fasciculations), and waste away (atrophy). Eventually, the brain loses its ability to initiate and control voluntary movements. Early symptoms of ALS usually include muscle weakness or stiffness. Gradually all muscles under voluntary control are affected, and individuals lose their strength and the ability to speak, eat, move, and even breathe. Most people with ALS die from respiratory failure, usually within 3 to 5 years from when the symptoms first appear. However,about 10 percent of people with ALS survive for 10 or more years.

EPIDEMIOLOGY-

Amyotrophic lateral sclerosis (ALS) is an adult-onset neurodegenerative disorder of unknown etiology. ALS onset is rare before age 40 and increases with age thereafter. Men are at higher risk than women (ratio 1.3:1). Other than age and gender,the only indisputable risk factor for ALS is genetic susceptibility, with familial cases occurring in about 10% of most case series.Genetic linkage studies have provided evidence that a mutant form of the gene that codes for Cu/Zn superoxide dismutase1(SOD1), an endogenous free radical scavenger, is important in 15-20% of familial cases. Epidemiologic studies have identified associations of sporadic ALS with work in occupations that involve toxicant exposure. Environmental toxicants may act againsta background of increased genetic susceptibility; however, genetically acquired biochemical defects have not been identified in sporadic ALS patients. Other epidemiologic theories of disease etiology have emphasized the potential role of physical trauma, electrical shock, and vigorous physical exertion, but evidence regarding these factors is inconsistent.

RISK FACTORS-
In 2016 the Centers for Disease Control and Prevention estimated that between 14,000 – 15,000 Americans have ALS. ALS is a common neuromuscular disease worldwide. It affects people of all races and ethnic backgrounds.There are several potential risk factors for ALS including:

AGE- Although the disease can strike at any age, symptoms most commonly develop between the ages of 55 and 75.
GENDER-. Men are slightly more likely than women to develop ALS. However, as we age the difference between men and women disappears.
RACE-and ethnicity. Most likely to develop the disease are Caucasians and non-Hispanics.
Some studies suggest that military veterans are about 1.5 to 2 times more likely to develop ALS. Although the reason for this is unclear, possible risk factors for veterans include exposure to lead, pesticides, and other environmental toxins. ALS is recognized as a service-connected disease by the U.S. Department of Veterans Affairs.

TYPES OF AMYOTROPHIC LATERAL SCLEROSIS-

1-SPORADIC ALS:
The majority of ALS cases (90 percent or more) are considered sporadic. This means the disease seems to occur at random with no clearly associated risk factors and no family history of the disease. Although family members of people with sporadicALS are at an increased risk for the disease, the overall risk is very low and most will not develop ALS.

2-FAMILIAL (GENETIC) ALS:
About 5 to 10 percent of all ALS cases are familial, which means that an individual inherits the disease from his or her parents.The familial form of ALS usually only requires one parent to carry the gene responsible for the disease. Mutations in more thana dozen genes have been found to cause familial ALS. About 25 to 40 percent of all familial cases (and a small percentage of sporadic cases) are caused by a defect in a gene known as “chromosome 9 open reading frame 72,” or C9ORF72.Interestingly, the same mutation can be associated with atrophy of frontal-temporal lobes of the brain causing frontal-temporal lobe dementia. Some individuals carrying this mutation may show signs of both motor neuron and dementia symptoms (ALS-FTD). Another 12 to 20 percent of familial cases result from mutations in the gene that provides instructions for the production of the enzyme copper-zinc superoxide dismutase 1 (SOD1).

CAUSES OF ALS

The cause of ALS is not known, and scientists do not yet know why ALS strikes some people and not others. However, evidence from scientific studies suggests that both genetics and environment play a role in the development of ALS.

*Genetics
An important step toward determining ALS risk factors was made in 1993 when scientists supported by the National Institute of Neurological Disorders and Stroke (NINDS) discovered that mutations in the SOD1 gene were associated with some cases of familial ALS. Although it is still not clear how mutations in the SOD1 gene lead to motor neuron degeneration, there is increasing evidence that the gene playing a role in producing mutant SOD1 protein can become toxic. Since then, more than a dozen additional genetic mutations have been identified, many through NINDS-supported research,and each of these gene discoveries is providing new insights into possible mechanisms of ALS.The discovery of certain genetic mutations involved in ALS suggests that changes in the processing of RNA molecules may lead to ALS-related motor neuron degeneration. RNA molecules are one of the major macromolecules in the cell involved in directing the synthesis of specific proteins as well as gene regulation and activity.

Other gene mutations indicate defects in the natural process in which malfunctioning proteins are broken down and used to build new ones, known as protein recycling. Still others point to possible defects in the structure and shape of motor neurons, as well as increased susceptibility to environmental toxins. Overall, it is becoming increasingly clear that a number of cellular defects can lead to motor neuron degeneration in ALS.

In 2011 another important discovery was made when scientists found that a defect in the C9ORF72 gene is not only present in a significant subset of individuals with ALS but also in some people with a type of frontotemporal dementia (FTD). This observation provides evidence for genetic ties between these two neurodegenerative disorders. Most researchers now believe ALS and some forms of FTD are related disorders.

*Environmental factors-
In searching for the cause of ALS, researchers are also studying the impact of environmental factors. Researchers are investigating a number of possible causes such as exposure to toxic or infectious agents, viruses, physical trauma, diet, and behavioral and occupational factors.

For example, researchers have suggested that exposure to toxins during warfare, or strenuous physical activity, are possible reasons for why some veterans and athletes may be at increased risk of developing ALS. Although there has been no consistent association between any environmental factor and the risk of developing ALS, futureresearch may show that some factors are involved in the development or progression of the disease.

CLINICAL MENIFESTATION-

The onset of ALS can be so subtle that the symptoms are overlooked but gradually these symptoms develop into more obvious weakness or atrophy that may cause a physician to suspect ALS. Some of the early symptoms include:

IMPAIRMENTS RELATED TO THE LMN PATHOLOGY-

  • Weakness of the upper extrimity(UE), lower etremity(LE),or the weakness of the bulbar muscles.
  • muscle weakness is the cardinal sign of the ALS.
  • Cervical extensor weakness is typical.
  • Sensory pathways are spared for the most part in people with ALS.
  • Muscle weakness leads to secondary impairments,including decrease ROM,predisposing the patient to joint subluxation,joint contracture(commonly claw hand deformity),tendon shortening(achilles) and adhesive capsulitis.

FOOT DROP secondary to the distal weakness,and INSTABILITY secondary to the proximal weakness,are common.
Severel factors affect the FATIGUE levels in the ALS.
As motor neuron die,the remaining neurons or sprouted neurons are overbuedened.weak muscles must work at a higher

  • percentage of their maximal strength to perform the same activity.this hatens the muscle fatigue.
  • Fasciculations (muscle twitches) in the arm, leg, shoulder, or tongue
  • Muscle cramps
  • Muscle weakness affecting an arm, a leg, neck or diaphragm.
  • Other LMN signs include hyporeflexia,decreased or absent reflex,flaccidity and muscle cramping.
  • For many individuals the first sign of ALS may appear in the hand or arm as they experience difficulty with simple tasks such as Buttoning a shirt, writing, or turning a key in a lock. In other cases, symptoms initially affect one of the legs, and people Experience awkwardness when walking or running or they notice that they are tripping or stumbling more often.

IMAPIRMENTS RELATED TO UMN PATHOLOGY-

  • UMN loss characterised by spasticity,hyperflexia,clonus,and pathological reflexes, such as a babinski or hoffmann sign, and may also cause muscle weakness.

IMPAIRMENTS RELATED TO BULBAR PATHOLOGY-

When symptoms begin in the arms or legs, it is referred to as “limb onset” ALS. Other individuals first notice speech or Swallowing problems, termed “bulbar onset” ALS.

Regardless of where the symptoms first appear, muscle weakness and atrophy spread to other parts of the body as the disease progresses. Individuals may develop problems with moving, swallowing (dysphagia), speaking or forming words (dysarthria), and breathing (dyspnea).Although the sequence of emerging symptoms and the rate of disease progression vary from person to person, eventually individuals will not be able to stand or walk, get in or out of bed on their own, or use their hands and arms.Individuals with ALS usually have difficulty swallowing and chewing food, which makes it hard to eat normally and increases the risk of choking. They also burn calories at a faster rate than  most people without ALS. Due to these factors, people with ALS tend to lose weight rapidly and can become malnourished.

Because people with ALS usually retain their ability to perform higher mental processes such as reasoning, remembering, understanding, and problem solving, they are aware of their progressive loss of function and may become anxious and depressed.

A small percentage of individuals may experience problems with language or decision-making, and there is growing evidence that some may even develop a form of dementia over time. Individuals with ALS will have difficulty breathing as the muscles of the respiratory system weaken. They eventually lose the ability to breathe on their own and must depend on a ventilator. Affected individuals also face an increased risk of pneumonia during later stages of the disease. Besides muscle cramps that may cause discomfort, some individuals with ALS may develop painful neuropathy (nerve disease or damage).

SYMPTOMS-

1-ADVANCE SYMPTOMS-

  • Muscle weakness
  • Muscle Atrophy
  • Movement difficulty
  • Spasticity
  • Excess saliva from reduced swallowing
  • Thicker saliva may sometimes be difficult to clear from the chest or throat due to
  • weakening of muscles
  • Excess yawning
  • Emotionality
  • Difficulties with concentration, planning and use of language
  • Fronto-temporal dementia – this affects their ability to problem solve and respond to new situations
  • Breathing difficulties, such as shortness of breath

END STAGE SYMPTOMS-

  • Increasing body paralysis
  • Significant shortness of breath

2-SECONDERY SYMPTOMS-

  • These are not directly caused by the disease but are related to the stress of living with it.
  • Depression
  • Insomnia
  • Anxiety

DIAGNOSIS:

Amyotrophic lateral sclerosis (ALS) is difficult to diagnose early because it may mimic several other neurological diseases.

Tests to rule out other conditions may include:

ELECTOMYOGRAM (EMG)- During an EMG, your doctor inserts a needle electrode through your skin into various muscles.

The test evaluates the electrical activity of your muscles when they contract and when they’re at rest. Abnormalities in muscles seen in an electromyogram can help doctors diagnose ALS, or determine if you have a different muscle or nerve condition that may be causing your symptoms. It can also help guide your exercise therapy.

NERVE CONDUCTION STUDY(NCS)-This study measures your nerves’ ability to send impulses to muscles in different areas of your body. This test can determine if you have nerve damage or certain muscle diseases.

MAGNETIC RESONANCE IMAGINE (MRI)- Using radio waves and a powerful magnetic field, an MRI produces detailed images of your brain and spinal cord. An MRI can spot spinal cord tumors, herniated disks in your neck or other conditions that may be causing your symptoms.

BLOOD AND URINE TEST- Analyzing samples of your blood and urine in the laboratory may help your doctor eliminate other possible causes of your signs and symptoms.

SPINAL TAP (lumbar puncture)- Sometimes a specialist may remove a sample of your spinal fluid for analysis. A specialist inserts a small needle between two vertebrae in your lower back and removes a small amount of cerebrospinal fluid for testing in the laboratory.

MUSCLE BIOPSY- If your doctor believes you may have a muscle disease rather than ALS, you may undergo a muscle biopsy. While you’re under local anesthesia, a small portion of your muscle is removed and sent to a lab for analysis.

TREATMENT AND PREVENTION-

Physical therapy can help people with ALS manage pain and address mobility issues.

A physical therapist can provide help and information with:

low-impact exercises to enhance cardiovascular fitness and overall well-being mobility aids, such as walkers and wheelchairs devices to make life easier, such as ramps
Occupational therapy can help a patient maintain their independence for longer by: helping patients choose adaptive equipment and assistive technologies to help them keep up their daily routines train them in ways to compensate for hand and arm weaknesses
Breathing therapy may be needed in time, as the respiratory muscles get weaker. Breathing devices- can help the patient breathe better at night. Some patients may need mechanical ventilation. One end of a tube is connected to a respirator, while the other end is inserted into the windpipe through a surgically-created hole in the neck, or tracheostomy.

Speech therapy- is useful when ALS begins to make it harder to talk. Speech therapists can help by teaching adaptivetechniques. Other methods of communication include writing and computer-based communications equipment.

Nutritional support is important, as difficulty with swallowing can make it hard to get enough nutrients. Nutritionists can advise on preparing nutritious meals that are easier to swallow. Suction devices and feeding tubes may help.
There is no cure for ALS, so treatment aims to alleviate symptoms, prevent unnecessary complications, and slow the rate of disease progression.

ALS can cause a range of physical, mental, and social changes, so a team of specialists will often help patients manage their symptoms and care, improve their qualify of life, and prolong survival.

Riluzole (Rilutek) was approved for ALS treatment by the Food and Drug Administration (FDA) in 1995, and it appears to slow the progression of the disease. It may work by reducing the body’s levels of glutamate, an excitotoxin that has been linked to neuronal damage.

In May 2017, Radicava (Edaravone) was approved to treat ALS. It may slow the decline in physical function by one third. A number of research projects are looking at ways to use new and existing drugs to treat different aspects of ALS. Doctors can also prescribe medications to treat the different symptoms.

PHYSICAL THERAPY INTERVENTION-

Physiotherapy helps maintain movement and function when someone is affected by injury, illness or disability. This is achieved

through movement and exercise, manual therapy, education and advice. Although physiotherapy can’t reverse the effects of
MND, it can help you to stay mobile and comfortable for as long as possible.

Exercise can also help to:

• keep you mobile for as long as possible by preventing muscles and joints from
becoming stiff
• maintain maximum range of movement (ROM) of joints
• maintain comfort and reduce problems associated with muscle weakness and
stiff joints
• maintain circulation through active muscle movement.
Breathing exercises can help with chest clearance and reducing the chance of chest infections

1. Carry out a full assessment to check your mobility, range of movement of joints and muscles, strength of muscles and

discuss / see any particular difficulties you’re experiencing.

2. Advise on and provide walking aids that will help to keep your mobility as long and as safely as possible.
3. Relieve pain and tension from muscle cramps with gentle passive stretches and massage.
4. Devised a tailored exercise programme to strenghten the muscles that have not been affected by MND – some exercises may be active and some active-assistsed meaning the physio helps you to carry out the exercises.
5. Passive exercises to help move the joints you find difficult, reduce tension and aid circulation.

6.Teach stretches that can be carried out on your own to help keep muscles from becoming tight.
7. Help posture and positioning in the later stages and show carers how to use pillows to keep individuals as comfortable as possible and ensure breathing is maximised.8. Teach breathing exercises and check chest clearing techniques. The Active Cycle of Breathing Techniques is shown in the picture.
9. Teach how to pace your exercises and stop you overdoing it and being in pain.
10. Advise on pain relief and using a TENS machine, heat or ice.

BRONCHIAL ASTHMA AND MANAGEMENT

1.DEFINATION

”Bronchial asthma is a chronic, inflammatory disease of the respiratory tract, which is characterized by bronchial hyperreactivity and respiratory obstruction which is reversible (spontaneously or under influence of bronchodilater) marked by wheezing ,shortness of breath,chest tightness and coughing”.

symptoms may be episodic or chronic but the pattern may vary considerably from time to time in individual patients.The changes causing airway obstruction in asthma include the hypertrophy and hyperplasia of bronchal smooth muscles,thickening of the epithelial basement membraneof the airways, oedema and eosinophilic infiltration of the bronchial wall and hypertrophy of the bronchial mucus glands with increase in number of the goblet cells.This leads to narrowing of the larger bronchi and and plugging of bronchi and bronchioles with viscid mucus which contains eosinophils and shed respiratory epithelial cells.

The lungs of patients dying from asthma show overinflation with widespread mucus plugs in airways of all sizes.

2 ETIOLOGY

The development of bronchial asthma is a multicausal process, which is caused by exogenic factors (environmental factors), and also by genetic dispositions. In addition, the course of the disease can be influenced by climatic changes and mental factors. Important exogenic activators are: · Allergens or Environmental allergens (house dust mites, pollen) Allergenic work substances (flour) or Food allergens · Toxins or chemical irritants ·Respiratory diseases · Pseudoallergic reactions (PAR) to analgesics (analgesic-induced asthma) · Physical exertion (mainly in children) Patients with allergic asthma or other atopical diseases show a polygenic inherited trait for an overshooting immune response of IgE. If both parents suffer from atopy, the children have an atopical disease as well in 40-50% of the cases.

3 EPIDEMIOLOGY

As a rule, bronchial asthma already occurs in infancy and is the most common chronic disease of this stage of life. There exist differing statements on the prevalence of bronchial asthma in Germany. Some authors mention 2-4%; other sources even 6-10%. The number of deaths caused by asthma in Germany is approx. 5000/year.

4 CLASSIFICATION
According to etiology

1.Allergic or extrinsic asthma- This generely begins earlier in life and is associated with atrophy-the presence of immediate hypersensitivity to external allergens associated with positive skin-prick tests.These patients show a high incidence of seasonal rhinitis and flexural eczema.There is usually a strong family history of asthma,hay fever or eczema.

In patients with the extrinsic asthma episodes may be precipitated by exposure to antigenic materials, including pollens, house dust, animal furs and feathers.Foodstuffs including milk,eggs,fish and chocolate may, very occasionally,be incriminated. Patients with extrinsic asthma may also react adversely to non-allergic provoking factors including air temperature changes, emotional disturbances, exercise laughter and respiratory tract infection(RTI).

2.Non-allergic or intrinsic asthma-This occur later in life and allewrgic featurs are usually absent so that the skin-prick test to common allergens are negetive.This is common in women than men.

3.Mixed form-Worsening symptoms of the both types include bronchial irritation by the streneous exercise ,exposure to cold air,dust,tobbaco smoke,fumes, emotional stress and respiratory infections.

According to degree of severity

  • Grade 1: Intermittent
  • Grade 2: Persistent, mild
  • Grade 3: Persistent, moderate
  • Grade 4: Persistent, severe

According to clinical types.

1.Episodic asthma-May occur at any time by feeling of chest tightness with breathlessness and wheezing.Expiration becomes difficult with short gasping inspiration,and wheezes are usually expiratory and often audible without the aid of a stethoscope.A troublesome cough is common with scanty viscid mucus.

In severe episodes there will be a tachycardia,pulsus paradoxus and central cyanosis.

2.Chronic asthma-There is persistence wheezing with breathlessness.cough with mucoid sputum and recurrent episodes of respiratory infections.

3.Childhood asthma-Wheeziness is common with the minor respiratory infections.Non-asthmatic wheeziness usually resolves as the child grows.childhood asthma is commener in boys than girls and usually accompnies atopy.

4.Adult asthma-Asthma may persist into adult life from childhood.Irritanta including smog,ciggarette smoke, and pollens.

5.Status asthmaticus-These has been supersedes by ”SEVERE ACUTE ASTHMA” refers to episodes of severe wheezing and breathlessness lasting more than 24 hours not responding to normal medication and potentially threatning”PULSUS PARADOXUS ”and very quite breath sounds on auscultation.

5 PATHOPHYSIOLOGY

Genetic disposition and exogenous noxa trigger three pathophysiological processes which characterize bronchial asthma:

1. Inflammation of the bronchi

Allergens or infections elicit an infectious reaction of the bronchial mucous membrane. In allergic asthma, an IgE-induced reaction of the immediate type (Type 1 reaction) occurs immediately after inhalation of the allergen. The mast cells in the mucous membrane degranulate and thereby release inflammation mediators like histamine, ECF-A, bradykinin and leukotrienes (“immediate reaction”). Apart from this immediate reaction, there also exists an IgG-induced late reaction after 6-12 hours or a combination of both reaction types (“dual reaction”). As a rule, the triggering allergen can only be identified at the early stage of the disease. In the course of years, the range of allergens often becomes wider, thereby making it more difficult or even impossible for the patient to avoid allergens.

2. Bronchial hyperreactivity

An unspecific bronchial hyperreactivity can be detected in almost all asthmatics. In case of the inhalation of irritants, the hyperreactivity manifests as a very strong constriction of the bronchial tubes, and can be objectified by the methacholine test.

3.Endobronchial obstruction

The endobronchial obstruction is the first clinically discernible “end product” of the pathophysiological processes of bronchial asthma. It develops through the shift of the bronchial lumen as a consequence of mucosal edema, increased mucus secretion (dyscrinism) and bronchospasms.

6 SYMPTOMS-

asthma-symptoms
asthma-symptoms

The severity of asthma varies from mild to severe and it is a chronic disease. An asthma attack is actually an acute exacerbation of the disease. When an attack is not there, it does not mean that Asthma is not there. The symptoms of Asthma consist of a triad of Dyspnea, Wheezing and Cough.

Symptoms of Asthma include:

  • Cough: Cough can be productive or dry, and is especially seen in early morning and at night.
  • Breathlessness: Difficulty in breathing due to mucous plugging and airway spasm is worse by any physical activity like climbing stairs.
  • Chest tightness: Tightness of chest or pain in chest is present along with other symptoms of asthma.
  • Wheezing: Wheezing is an abnormal whistling sound due to difficult respiration. Wheezing is more commonly seen in children than adults.

Symptoms of Asthma in severe cases include:

  • Bluish discoloration of lips and face with nasal flaring
  • Rapid pulse
  • Sweating
  • Decreased level of consciousness
  • In severe attacks, the accessory muscles (sternocleidomastoid and scalene muscles of the neck) become visibly active and in extreme situations, patient may begin a gasping type of respiratory pattern.

Less typically, a patient with asthma may complain of intermittent episodes of non-productive cough or breathlessness on exertion. Children most often experience these symptoms of Asthma and they tend to interfere in daily activities, sports and games.

7 DIAGNOSIS

Physical exam-

  • To rule out other possible conditions — such as a respiratory infection or chronic obstructive pulmonary disease (COPD) — your doctor will do a physical exam and ask you questions about your signs and symptoms and about any other health problems.

Tests to measure lung function

You may also be given lung (pulmonary) function tests to determine how much air moves in and out as you breathe. These tests may include:

  • Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.
    Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.
    Lung function tests often are done before and after taking a medication called a bronchodilator , such as albuterol, to open your airways. If your lung function improves with use of a bronchodilator, it’s likely you have asthma.

Additional tests
Other tests to diagnose asthma include:

1.Methacholine challenge- Methacholine is a known asthma trigger that, when inhaled, will cause mild constriction of your airways. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.

2.Nitric oxide test-This test, though not widely available, measures the amount of the gas, nitric oxide, that you have in your breath. When your airways are inflamed — a sign of asthma — you may have higher than normal nitric oxide levels.

3.Imaging tests- A chest X-ray and high-resolution computerized tomography (CT) scan of your lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.

4.Allergy testing-This can be performed by a skin test or blood test. Allergy tests can identify allergy to pets, dust, mold and pollen. If important allergy triggers are identified, this can lead to a recommendation for allergen immunotherapy.

5.Sputum eosinophils- This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye .

6.Provocative testing- for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.

7 PREVENTIVE TREATMENT OF BRONCHIAL ASTHMA-

Avoid your triggers
Taking steps to reduce your exposure asthma triggers is a key part of asthma control, including:

USE YOUR AIR CONDITIONER- Air conditioning reduces the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your exposure to dust mites. If you don’t have air conditioning, try to keep your windows closed during pollen season.

DECONTAMINAT YOUR DECOR- Minimize dust that may worsen nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dustproof covers. Remove carpeting and install hardwood or linoleum flooring. Use washable curtains and blinds.

MAINTAIN OPTIMAL HUMIDITY- If you live in a damp climate, talk to your doctor about using a dehumidifier.
PREVENT MOLD SPORES- Clean damp areas in the bath, kitchen and around the house to keep mold spores from developing. Get rid of moldy leaves or damp firewood in the yard.

REDUCE PET DANDER- If you’re allergic to dander, avoid pets with fur or feathers. Having pets regularly bathed or groomed also may reduce the amount of dander in your surroundings.
Clean regular Clean your home at least once a week. If you’re likely to stir up dust, wear a mask or have someone else do the cleaning.
Cover your nose and mouth if it’s cold out. If your asthma is worsened by cold or dry air, wearing a face mask can help.

8 TREATMENT-

Prevention and long-term control are key in stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, taking steps to avoid them and tracking your breathing to make sure your daily asthma medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler, such as albuterol.

MEDICATIONS-

drugs-for-asthma-

The right medications for you depend on a number of things — your age, symptoms, asthma triggers and what works best to keep your asthma under control.

Preventive, long-term control medications reduce the inflammation in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you’ll have an asthma attack. Types of long-term control medications include:

INHALED CORTICOSTEROIDS-These anti-inflammatory drugs include fluticasone , budesonide , flunisolide , ciclesonide , beclomethasone , mometasone and fluticasone furoate .

You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, these corticosteroid medications have a relatively low risk of side effects and are generally safe for long-term use.

LEUCOTRIEN MODIFIERS – These oral medications — including montelukast , zafirlukast and zileuton — help relieve asthma symptoms for up to 24 hours.

In rare cases, these medications have been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away for any unusual reaction.

LONG-ACTING BETA AGONIST-These inhaled medications, which include salmeterol and formoterol , open the airways.

Some research shows that they may increase the risk of a severe asthma attack, so take them only in combination with an inhaled corticosteroid. And because these drugs can mask asthma deterioration, don’t use them for an acute asthma attack.

COMBINATION INHALERS- These medications — such as fluticasone-salmeterol , budesonide-formoterol and formoterol-mometasone — contain a long-acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-acting beta agonists, they may increase your risk of having a severe asthma attack.

THEOPHYLIN- Theophylline is a daily pill that helps keep the airways open (bronchodilator) by relaxing the muscles around the airways. It’s not used as often now as in past years.
Quick-relief medications are used as needed for rapid, short-term symptom relief during an asthma attack — or before exercise if your doctor recommends it. Types of quick-relief medications include:

SHORT ACTING BETA-AGONIST- These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol and levalbuterol .

SHORT ACTING BETA-AGONIST- can be taken using a portable, hand-held inhaler or a nebulizer — a machine that converts asthma medications to a fine mist — so that they can be inhaled through a face mask or a mouthpiece.

IPRATROPIUM – Like other bronchodilators, ipratropium acts quickly to immediately relax your airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis, but it’s sometimes used to treat asthma attacks.

ORAL AND INTRAVENOUS CORTICOSTEROIDS-These medications — which include prednisone and methylprednisolone — relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so they’re used only on a short-term basis to treat severe asthma symptoms.

If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But if your long-term control medications are working properly, you shouldn’t need to use your quick-relief inhaler very often.

Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication.

Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

ALLERGY SHOTS (immunotherapy)- Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years.

OMALIZUMAB (Xolair)-This medication, given as an injection every two to four weeks, is specifically for people who have allergies and severe asthma. It acts by altering the immune system.

asthma-education
asthma-management

PHYSIOTHERAPY MANAGEMENT-

The majority of patients suffering from asthma will seek physiotherapy for dyspnoea and hyperventilation . Physiotherapists treatment in a variety of ways with the aim to improve breathing technique. Physiotherapy techniques for asthma are in addition to medication and should never be used as a replacement to prescribed medication, however may reduce the dosage required.

Breathing Techniques

1. BREATHING RETRAINING TEQNICS-

Breathing techniques may have more benefit on mild – moderate asthma [31]. The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. Instructions are given from the physiotherapist on how to complete this technique, with the following components:

  • Decreasing Breaths Taken (Reducing Respiratory Rate)
  • Taking Smaller Breaths (Reducing Tidal Volume)
  • Deep Breathing (Diaphragmatic breathing through use of abdominal muscles and lower
  • thoracic chest movement)
  • Breathing through the Nose (Nasal Breathing)
  • Relaxation (Relaxed, controlled breathing)
  • Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)
  • These retraining techniques help control breathing and reduce airflow turbulence,
  • hyperinflation, variable breathing pattern and anxiety.

2. BUTEYKO BREATHING TEQNIC-

The Buteyko breathing technique is another breathing retraining technique; however it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO2 and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently lung volume, as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient .

The Buteyko breathing Technic

  • Breathe normally through the nose for 2-3 mins
  • Breathe out normally, close nose with fingers, and hold
  • Record number of seconds
  • On first need to breathe, release nose and return to nasal breathing (Control Pause)
  • Wait 3 minutes
  • Repeat and hold breath for as long as possible (Maximum Pause)

Breathing pattern retraining and relaxed breathing techniques are two approaches to physiotherapy management of asthma. The aim of breathing pattern retraining is to develop a more efficient pattern of respiration, thereby reducing breathlessness. This is usually accomplished by slowing the breathing rate, and encouraging relaxed, ‘abdominal’ breathing (Bruton, 2006). Another potential mechanism for breathing pattern retraining is that by encouraging a longer expiratory time, the effects of any static/ dynamic hyperinflation may be reduced.
Mild asthmatics can hold their breath for up to twenty seconds, moderate asthmatics for fifteen seconds and severe asthmatics for up to ten seconds. The aim of this method is to increase the control pause to 60 seconds and the maximum pause to 2 minutes. It is practiced twice a day, with the practitioner there to help with breath holding and ensure safety. Its aim is to reduce minute volume through reduction of respiratory rate, and increasing carbon dioxide levels through breath holding, reducing bronchospasm caused by hyperventilation in the asthmatic patient.

3 PHYSICAL TRAINING-

Physical training with asthma is advised when taking the proper precautions, and should not be avoided. The American College of Sports Medicine (ACSM) Guidelines provide tips and safety precautions for asthmatics to exercise safely.

Physical training should be prescribed by physiotherapists for asthmatics to increase fitness and cardiorespiratory performance, reduce symptoms such as breathlessness and improve quality of life . Breathlessness, chest tightness and wheezing can occur when exercising, deterring patients from physical exertion . Fear avoidance can contribute to a further deterioration of physical health and quality of life, leading to anxiety and depression. It has been shown that maintaining physical training in asthmatics improves disease symptoms and quality of life, therefore making it a crucial management strategy.

4 RESPIRATORY MUSCLE TRAINING-

breathing-exercise
breathing-exercise

Hyperinflation in asthma causes increased lung volume, leading to altered inspiratory muscle mechanics. Inspiratory muscles are shortened resulting in a sub-optimal length-tension relationship for contraction. There is a decreased capacity for tension generation when breathing, resulting in accessory muscles of inspiration being utilised.

Breathing exercises are carried out using an external device to make breathing more difficult. This helps to strengthen the inspiratory muscles, making it easier to breathe in everyday life .A breathing device is used , which sets up a load to breathe against. During inspiration air is only released if enough effort is used to force open the valves of the device. Respiratory muscles are forced to work harder, increasing their strength, leading to diaphragmatic breathing becoming easier, reducing hyperinflation.

The following physiotherapy management techniques would also be beneficial:

Removal of secretions

  • Percussions,
  • Shaking,
  • Vibrations,
  • Postural drainage and,
  • Effective coughing
  • Range of motion exercises for patients who need hospitalisation.

BRONCHITIS AND MANAGEMENT

DEFINATION-

Bronchitis is inflammation of the bronchi (large and medium-sized airways) in the lungs. Symptoms include coughing up mucus, wheezing, shortness of breath, and chest discomfort.Bronchitis is divided into two types: acute and chronic. Acute bronchitis is also known as a chest cold.

Acute bronchitis usually has a cough that lasts around three weeks. In more than 90% of cases the cause is a viral infection. These viruses may be spread through the air when people cough or by direct contact. Risk factors include exposure to tobacco smoke, dust, and other air pollution.A small number of cases are due to high levels of air pollution or bacteria such as Mycoplasma pneumoniae or Bordetella pertussis.Treatment of acute bronchitis typically involves rest, paracetamol (acetaminophen), and NSAIDs to help with the fever.

Chronic bronchitis is defined as a productive cough that lasts for three months or more per year for at least two years. Most people with chronic bronchitis have chronic obstructive pulmonary disease (COPD). Tobacco smoking is the most common cause, with a number of other factors such as air pollution and genetics playing a smaller role.Treatments include quitting smoking, vaccinations, rehabilitation, and often inhaled bronchodilators and steroids.Some people may benefit from long-term oxygen therapy or lung transplantation.

EPIDEMIOLOGY-
COPD kills around 30,000 people per year in the UK alone and it is estimated that around 3 million people in the UK have COPD, 2 million of which are undiagnosed.CB occurs in 3.4 to 22% of the US adult population and rates are even higher in patients with COPD.The prevalence of the disease has a great impact on society and on the health care system around the world.The primary risk factor for CB is smoking, and up to 25% of long-term smokers will go on to develop COPD. Other factors are long-term exposure to air pollution, fumes, and dust from the environment or workplace.

AETIOLOGY-
CB is caused by overproduction and hypersecretion of mucus by goblet cells, increasing airflow obstruction. This can be due to smoke inhalation, a viral or bacterial infection, or inflammatory cell activation of mucin gene transcription.

As mentioned, smoking is the primary risk factor, this can be from those who inhale second-hand smoke as well as smokers. This is caused by the inflammation and permanent damage to the airways due to toxins in cigarette smoke. Other factors include fumes and dust and air pollution which can all affect your lung tissue when inhaled.

There is also a genetic factor associated with COPD, it is a deficiency in alpha-1-antitrypsin. This genetic marker is indicative of Emphysema, but many patients on the COPD spectrum have characteristics of both Emphysema and CRONIC BRONCHITIS and should be taken into account.

PATHOPHYSIOLOGY-

CHRONIC BRONCHITIS
The main morphological feature in chronic bronchitis is hypertrophy of mucus gland tissue in the trachea, bronchi and bronchioles,becuse of this a great incrase in number of goblet cells especially in the bronchioles.The pathological foundation for CB is due to the over-production of mucus in response to the inflammatory signals, this is known as ”MUCUS METAPLASIA’‘. In COPD patients this overproduction and hypersecretion is due to the goblet cells and decreased the elimination of mucus. The mechanisms responsible for mucous metaplasia in COPD patients is associated with the function of the T cells, although it is still poorly understood. It is believed to be linked to end production of the Th2 inflammation cells while the cellular response is thought to be attributed to the Th1 inflammation cells, both produce cytokines that have an influence on mucus production associated with COPD patients

”MUCUS METAPLASIA” causes airflow obstruction by several mechanisms: it causes luminal occlusion; the thickening of the epithelial layer intrudes on the airway lumen, and the mucus alters the airway surface tension. These all leave the airway at a greater risk for collapsing and decreases the capacity for airflow and gas exchange.

It was also found that smokers with moderate COPD and CRONIC BRONCHITIS had a greater number of goblet cells in their peripheral airways, which increases the potential of mucus in the lungs. It was found that as a greater number of small airways were blocked with mucus the greater the severity of the disease.

Mucus hypersecretion is one of the risks associated with cigarette smoke exposure, viral infections, bacterial infections, or inflammatory cell activation. When combined with poor ciliary function, distal airway occlusion, ineffective cough, respiratory muscle weakness and reduced peak expiratory flow clearing secretions is extremely difficult and requires high energy consumption.

CLINICAL MENIFESTATION-
The clinical presentation can be increased exacerbation rate, accelerated decline in lung function, worse health-related quality of life and increase in mortality.

Common symptoms outlined by the British Lung Foundation include:

  • Wheezing, particularly breathing out
  • Breathlessness when resting or active
  • Tight chest
  • Cough
  • Producing more mucus or phlegm than usual
  • These symptoms would be persistent for at least 3 months a year for 2 consecutive years to be considered Chronic Bronchitis.

INVESTIGATIONS-
If a patient presents with some or all of the symptoms your doctor will follow up with more investigations such as:

1.Spirometry Test: This is a breathing test to assess how well your lungs work. You breathe into a machine and two measurements are taken; forced expiratory volume (FEV1) and forced vital capacity (FVC). The readings are then compared to normal ranges for your age, to determine if your airways are compromised.

2.Chest X-ray: This will show whether there are other lung conditions that may be causing the symptoms, or in what area the obstruction is in. This can give an indication of what areas to focus on during treatment, and the severity and progression of the obstruction.

3.Blood test: This is to see if your symptoms could be due to anemia, or to see if the symptoms are due to the genetic marker alpha-1-antitrypsin deficiency.

4.Phlegm sample: This is to check to see if there is an infection that is causing the symptoms, this is to primarily rule out other possibilities to ensure proper treatment.

PHYSIOTHERAPY AND OTHER MANAGEMENT-
The treatment of CB may include a variety of interventions including management through medications, education, physical exercise and respiratory exercises. The goal of the physiotherapist should involve education, improve exercise tolerance, reduce exacerbations and hospitalization, assist in sputum clearance, and increase thoracic mobility and lung volume.

MEDICATIONS-
There are various kinds of short term and long term medications individuals with CRONIC BRONCHITIS might take to reduce flare-ups, decrease obstruction, improve activity and decrease shortness of breath. These medications may include bronchodilators, corticosteroids, and antibiotics.

EXERCISE-
Regular exercise can have positive effects on the management, treatment, and prevention of CB and COPD. Aerobic exercise and upper & lower limb resistance training have shown positive changes in the reduction of air flow obstruction, clearing of airways, improved functional capabilities increased energy levels and sputum expectoration. Exercise programs should be under the supervision of the treating clinical team and a discussion with the general practitioner should be had before taking part in any exercise program.

POSTURAL DRAINAGE-
The use of various positions to assist in the expectoration of sputum by using gravity to move sputum towards the throat and mouth. Is can be used with other treatment techniques. These positions can be modified for each clients condition and their preferences. Ideally, the client is placed in a position where the affected area is higher up than the unaffected area.

ACTIVE CYCLE OF BREATHING TECNIC-
The Active Cycle of Breathing Techniques(ACBT) is one way to help you to clear sputumfrom your chest. ACBT is a set of breathingexercises that loosens and moves the sputum from your airways. It is best to be taught ACBT by a physiotherapist.
The ACBT exercises are breathing control, deep breathing and huffing which are performed in a cycle until your chest feels clear.

1.Breathing control exercise-
Breathing control is breathing gently, using as little effort as possible (also see leaflet GL- 02) Breathe in and out gently through your nose if you can. If you cannot, breathe through your mouth instead If you breathe out through your mouth you can use breathing control with ‘pursed lips breathing.Try to let go of any tension in your body with each breath out Gradually try to make the breaths slower Try closing your eyes to help you to focus on your breathing and to relax It is very important to do Breathing Control in between the more active exercises of ACBT as it allows your airways to relax. Breathing control can also help you when you are short of breath or feeling fearful, anxious or in a panic.

2-Deep breathing exercise-
Take a long, slow, deep breath in, through your nose if you can. Try to keep your chest and shoulders relaxed. Breathe out gently and relaxed, like a sigh. You should do 3-5 deep breaths. Ask your physiotherapist to help you choose the right number of deep breaths for you. Some people find it helpful to hold their breath for about 2-3 seconds at the end of the breath in,before breathing out. Try the deep breathing exercises both with and without holding your breath and see which works best for you.

3.Huffing
A huff is exhaling through an open mouth and throat instead of coughing. It helps move sputum up your airways so that you can clear it in a controlled way. To ‘huff’ you squeeze air quickly from your lungs, out through your open mouth and throat, as if you were trying to mist up a mirror or your glasses. Use your tummy muscles to help you squeeze the air out, but do not force it so much that you cause wheezing or tightness in your chest. Huffing should always be followed by breathing control. There are 2 types of huff, which help to move sputum from different parts of the lungs.

The Small-long huff
This will move sputum from low down in your chest. Take a small to medium breath in and then huff (squeeze) the air out until your lungs feel quite empty, as detailed above.

The Big-short huff
This moves sputum from higher up in your chest, so use this huff when it feels ready to come out, but not before. Take a deep breath in and then huff the air out quickly. This should clear your sputum without coughing.

AUTOGENIC DRAINAGE-

Autogenic Drainage (AD), is an airway clearance technique that uses controlled breathing and minimal coughing to clear secretions from your chest. It involves hearing and feeling your secretions as you breathe out and controlling the desire to cough until secretions are high up and easily reached with minimal effort.

It uses breathing at different lung volumes to loosen, mobilise and move secretions in three stages towards the larger central airways. (fig.1)

Stages of AD
It consists of three stages:

stages

Stage 1 :- Unstick secretions – breathe as much air out of your chest as you can then take a small breath in, using your tummy, feeling your breath at the bottom of your chest. You may hear secretions start to crackle. Resist any desire to cough.

Loosening peripheral secretions by breathing at low lung volumes (slow, deep air movement)

Repeat for at least 3 breaths.

Stage 2 :-Collect secretions – as the crackle of secretions starts to get louder change to medium sized breaths in. Feel the breaths more in the middle of your chest.

Repeat for at least 3 breaths.

Collecting secretions from central airways by breathing at low to middle lung volumes (slow, mid-range air movement)

Stage 3:-Evacuate secretions – when the crackles are louder still, take long, slow, full breaths in to your absolute maximum.

Repeat for at least 3 breaths.

Expelling secretions from the central airways by breathing at mid to high lung volumes (shallow air movements)

The velocity or force of the expiratory airflow must be adjusted at each level of inspiration so that the highest possible airflow is reached in that generation of bronchi, without being high enough to cause the airways to collapse during coughing. Autogenic drainage does not utilise Postural Drainage positions but is performed while sitting upright.

Rationale behind the Autogenic Drainage Technique
The rationale for the technique is the generation of shearing forces induced by airflow. The speed of the expiratory flow may mobilise secretions by shearing them from the bronchial walls and transporting them from the peripheral to the central airways.

TEQNIC OF AUTOGENIC DRAINAGE-

Posture

 

Sitting_posture

Clear your nose and throat by blowing your nose and huffing.

  • BREATHING IN-
    Slowly breathe in through the nose to keep the upper airways open. Use the diaphragm and/or the abdomen if possible.
    First take a large breath in, hold it for a moment. Breathe all the way out for as long as you can. Now you are at low lung volume. See picture below. The size of breath and level at which you breathe depends on where the mucus is located.
    Take a small to normal breath in, and pause. Hold your breath for about 3 seconds. All the upper airways should be kept open. This improves the even filling of all lung parts. The pause allows time for the air to get behind the mucus.

 

  • BREATHING OUT-
    Breathe out through the mouth. Keep the upper airways open. This is your glottis, throat and mouth. Breathing out is done in a sighing manner. When you force your breath out the airways can collapse. You will hear a wheeze.
    At low lung level breathing use your abdominal muscles. Squeeze all the air out until you can breathe out no more.
    You hear the mucus rattling in the airways when breathing the right way. Put a hand on your upper chest, and feel the mucus vibrating. High frequencies mean that the mucus is in the small airways. Low frequencies mean that the mucus is in the large airways. Using this feedback lets you easily adjust the technique.

Repeat the cycle. Inhale slowly to avoid sending the mucus back down. Keep breathing at the low level until the mucus collects and moves upward.

SIGNS OF THIS ARE:

Crackling of the mucus can be heard as you exhale.
You feel the mucus moving up.
You feel a strong urge to cough.
The level of breathing is raised when any of the above occurs. Moving the breathing from lower to higher lung area takes the mucus with it.Finally the collected mucus reaches the large airways where it can be cleared by a high lung volume huff. Don’t cough until the mucus is in the larger airways. Cough only if a huff did not move the mucus to the mouth.

You have now finished one cycle. Take a break of one to two minutes. Relax and perform breathing control before you start on the next cycle. The cycles are repeated during the session. A session lasts between twenty to forty-five minutes or until you feel all the mucus has been cleared. Do sessions of AD more often if you still have mucus present at the end of a session.

BENEFITS OF AD-

  • No equipment is required
  • Patients can perform their airway clearance independently.
  • Less effort is be required to expectorate which reduces stress on the pelvic floor.                                                                                                                                        DISADVANTAGE OF AD-
  • Patients generally need to be over 8 years old.
  • The technique can be difficult to teach
  • Patients need the cognitive ability to understand the basic physiology behind the technique
  • To benefit from the auditory feedback, patients need to have a moderate or large amount of sputum

Greater expectoration was achieved with AD compared to PEP therapy .

PERCUSSION AND VIBRATION-
Usually used in conjunction with postural drainage. The theory behind the use of percussions and vibrations is that it will assist with clearing of sputum stuck on the airways. There is little evidence of this effect however, some clients do believe it helps with sputum expectoration. Percussion is the rhythmic clapping on the chest or back of the client with a loose wrist and cupped hands. The clapping should be soothing and relaxing to the client, each client may have their own personal preference. Vibrations consists of while the therapists hands are against the clients chest or back performing fine movements of the hands down and inwards while the client is exhaling after a large breath.

PERCUSSION-
Clapping (percussion) by the caregiver on the chest wall over the part of the lung to be drained helps move the mucus into the larger airways. The hand is cupped as if to hold water but with the palm facing down (as shown in the figure below). The cupped hand curves to the chest wall and traps a cushion of air to soften the claout this type of breathing.

                                            cupped-hand-illustration

cupped-hand-illustration
Percussion is done forcefully and with a steady beat. Each beat should have a hollow sound. Most of the movement is in the wrist with the arm relaxed, making percussion less tiring to do. If the hand is cupped properly, percussion should not be painful or sting.

Special attention must be taken to not clap over the:

  • Spine.
  • Breastbone.
  • Stomach.
  • Lower ribs or back (to prevent injury to the spleen on the left, the liver on the right and the kidneys in the lower back).

VIBRATION-
Vibration is a technique that gently shakes the mucus so it can move into the larger airways. The caregiver places a firm hand on the chest wall over the part of the lung being drained and tenses the muscles of the arm and shoulder to create a fine shaking motion. Then, the caregiver applies a light pressure over the area being vibrated. (The caregiver may also place one hand over the other, then press the top and bottom hand into each other to vibrate.)

Vibration is done with the flattened hand, not the cupped hand (see the figure below).

Exhalation should be as slow and as complete as possible. each treatment session can last between 20 to 40 minutes. CPT is best done before meals or one-and-a-half to two hours after eating, to decrease the chance of vomiting. Early morning and bedtimes are usually recommended.

                                          flat-hand-illustration

flat-hand-illustration

Deep breathing moves the loosened mucus and may lead to coughing. Breathing with the diaphragm (belly breathing or lower chest breathing) is used to help the person take deeper breaths and get the air into the lower lungs. The belly moves outward when the person breathes in and sinks in when he or she breathes out. Your CF respiratory or physical therapist can help you learn more about this type of breathing.

EDUCATION
Education of the individual with CHRONIC BRONCHITIS by the treating clinical staff in terms of the presenting condition, medication use, treatment options and self-management may help the psychological effects associated with having a chronic condition and promote a proactive approach to management.

PREVENTION-
There is presently no cure for CHRONIC BRONCHITIS. However, with lifestyle changes, education and proper management it is possible to prevent exacerbations of the condition.

  • Stopping Smoking
    Smoking can irritate the lungs leading to irritation, inflammation, and scar. The longer an individual smokes the more damage occurs to the lungs which can lead to increased amounts of exacerbations of the condition. By quitting smoking this can decrease the amount of exacerbations, hospital visits and lead to a better quality of life.
  • Physical Fitness
    Aerobic exercise and upper & lower limb resistance training have the ability to increase physical fitness, functional tolerance, energy levels and decrease concern over the shortness of breath, exacerbations, and hospital visits. Specific guidelines are put in place in concern to exercise for individuals with chronic bronchitis and COPD.The Discussion should be held with the treating clinical team before participation in any exercise program begins.
  • Avoiding Irritants
    Being aware of possible irritants within the household, work place and places of recreation can help reduce risk factors associated with chronic bronchitis and reduce exacerbations. Irritants to be aware of can include dust, chemicals, vapors, air pollution and smoke. Proper respiratory protective equipment should be made readily available if contact with irritants in the work place commonly occurs.
  • Practice Proper Hygiene
    Practicing good hygiene can reduce the spread of germs, bacteria, and infections. This can help reduce the risk factors associated with bronchitis and help reduce exacerbations of chronic bronchitis.
  • Education
    Education can play a vital aspect in the prevention and management of CRONIC BRONCHITIS. Education about the presenting condition, risk factors associated with it and treatment can help reduce anxiety associated with the development of any chronic condition and a proper understanding of the condition and how to manage it can encourage the individual to take a proactive approach to their management program.

CYSTIC FIBROSIS AND MANAGEMENT

  • DEFINATION – CYSTIC FIBROSIS(CF) is a hereditary disorder of the exocrine glands, with a high sodium chloride content in sweat and pancreatic insufficiency, resulting in the, malabsorption . There is hypertrophy and hyperplasia of mucus secreting glands, resulting in the excessive mucus production in the lining if the bronchi , which predispose the patient to chronic bronchopulmonary infection”.

    Cystic fibrosis is an inherited disorder that causes severe damage to the lungs, digestive system and other organs in the body.

    Cystic fibrosis affects the cells that produce mucus, sweat and digestive juices. These secreted fluids are normally thin and slippery. But in people with cystic fibrosis, a defective gene causes the secretions to become sticky and thick. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the lungs and pancreas.

    Although cystic fibrosis requires daily care, people with the condition are usually able to attend school and work, and often have a better quality of life than people with cystic fibrosis had in previous decades. Improvements in screening and treatments mean people with cystic fibrosis now may live into their mid- to late 30s, on average, and some are living into their 40s and 50s.

    SYMPTOMS-

     

    SYMPTOMS IN CF
    SYMPTOMS IN CF

     

    Cystic fibrosis signs and symptoms vary, depending on the severity of the disease. Even in the same person, symptoms may worsen or improve as time passes. Some people may not experience symptoms until adolescence or adulthood.

    People with cystic fibrosis have a higher than normal level of salt in their sweat. Parents often can taste the salt when they kiss their children. Most of the other signs and symptoms of cystic fibrosis affect the respiratory system and digestive system. However, adults diagnosed with cystic fibrosis are more likely to have atypical symptoms, such as recurring bouts of inflamed pancreas (pancreatitis), infertility and recurring pneumonia.

    RESPIRATORY SIGNS AND SYMPTOMS-
    The thick and sticky mucus associated with cystic fibrosis clogs the tubes that carry air in and out of your lungs. This can cause signs and symptoms such as:

    • A persistent cough that produces thick mucus (sputum)
    • Wheezing
    • Breathlessness
    • Exercise intolerance
    • Repeated lung infections
    • Inflamed nasal passages or a stuffy nose

    DIGESTIVE SIGNS AND SYMPTOMS-
    The thick mucus can also block tubes that carry digestive enzymes from your pancreas to your small intestine. Without these digestive enzymes, your intestines aren’t able to completely absorb the nutrients in the food you eat. The result is often:

    • Foul-smelling, greasy stools
    • Poor weight gain and growth
    • Intestinal blockage, particularly in newborns (meconium ileus)
    • Severe constipation

    Frequent straining while passing stool can cause part of the rectum — the end of the large intestine , to protrude outside the anus (rectal prolapse). When this occurs in children, it may be a sign of cystic fibrosis. Parents should consult a physician knowledgeable about cystic fibrosis. Rectal prolapse in children may sometimes require surgery. Rectal prolapse in children with cystic fibrosis is less common than it was in the past, which may be due to earlier testing, diagnosis and treatment of cystic fibrosis.
    CAUSES AND RISK FACTORS-

    CF AND HEREDITARY
    CYTIC FIBROSIS  AND HEREDITARY

    Cystic Fibrosis is an autosomal recessive disease caused by defects in the CFTR gene . This CFTR gene normally encodes for a protein that functions as a chloride channel and is regulated by cyclic AMP, but in cystic fibrosis, the CFTR gene mutates and results in abnormalities of cyclic AMP, which regulates the transport of chloride across the epithelial cells on mucosal surfaces. This defective gene causes the body to produce an abnormally thick and sticky fluid in the respiratory and GI tracts, the pancreas and in the sweat glands.

    In order to develop CF, two CF genes must be inherited, one from the mother and the other from the father. If only one CF gene is inherited, then the person is called a carrier and will have no symptoms. When both parents are carriers, with each pregnancy there is a: 1 in 4 chance of having a child with cystic fibrosis, 1 in 2 chance of having a child who is a carrier or 1 in 4 chance of having an unaffected child.

    There are several different types of genetic mutation which are associated with different degrees of severity of the disease

    • COMPLICATIONS-
      RESPIRATORY SYSTEM AND COMPLICATIONS-
      1.Damaged airways (bronchiectasis). Cystic fibrosis is one of the leading causes of bronchiectasis, a condition that damages the airways. This makes it harder to move air in and out of the lungs and clear mucus from the airways (bronchial tubes).
    • 2.Chronic infections. Thick mucus in the lungs and sinuses provides an ideal breeding ground for bacteria and fungi. People with cystic fibrosis may often have sinus infections, bronchitis or pneumonia.
    • 3.Growths in the nose (nasal polyps). Because the lining inside the nose is inflamed and swollen, it can develop soft, fleshy growths (polyps).
    • 4.Coughing up blood (hemoptysis). Over time, cystic fibrosis can cause thinning of the airway walls. As a result, teenagers and adults with cystic fibrosis may cough up blood.
    • 5.Pneumothorax. This condition, in which air collects in the space that separates the lungs from the chest wall, also is more common in older people with cystic fibrosis. Pneumothorax can cause chest pain and breathlessness.
    • 6.Respiratory failure. Over time, cystic fibrosis can damage lung tissue so badly that it no longer works. Lung function usually worsens gradually, and it eventually can become life-threatening.
    • 7.Acute exacerbations. People with cystic fibrosis may experience worsening of their respiratory symptoms, such as coughing and shortness of breath, for several days to weeks. This is called an acute exacerbation and requires treatment in the hospital.
    • DIGESTIVE SYSTEM AND COMPLICATIONS-
    • 1.Nutritional deficiencies. Thick mucus can block the tubes that carry digestive enzymes from your pancreas to your intestines. Without these enzymes, your body can’t absorb protein, fats or fat-soluble vitamins.
    • 2.Diabetes. The pancreas produces insulin, which your body needs to use sugar. Cystic fibrosis increases the risk of diabetes. Around 30 percent of people with cystic fibrosis develop diabetes by age 30.
    • 3.Blocked bile duct. The tube that carries bile from your liver and gallbladder to your small intestine may become blocked and inflamed, leading to liver problems and sometimes gallstones.
    • 4.Intestinal obstruction. Intestinal obstruction can happen to people with cystic fibrosis at all ages. Children and adults with cystic fibrosis are more likely than are infants to develop intussusception, a condition in which a section of the intestines folds in on itself like an accordion.
    • 5.Distal intestinal obstruction syndrome (DIOS). DIOS is partial or complete obstruction where the small intestine meets the large intestine.
    • REPRODUCTIVE SYSTEM AND COMPLICATIONS-
      1.Almost all MEN with cystic fibrosis are infertile because the tube that connects the testes and prostate gland (vas deferens) is either blocked with mucus or missing entirely. Certain fertility treatments and surgical procedures sometimes make it possible for men with cystic fibrosis to become biological fathers.
    • 2.Although WOMEN with cystic fibrosis may be less fertile than other women, it’s possible for them to conceive and to have successful pregnancies. Still, pregnancy can worsen the signs and symptoms of cystic fibrosis, so be sure to discuss the possible risks with your doctor.

    OTHER COMPLICATIONS-
    1.Thinning of the bones (osteoporosis). People with cystic fibrosis are at higher risk of developing a dangerous thinning of bones.
    2.Electrolyte imbalances and dehydration. Because people with cystic fibrosis have saltier sweat, the balance of minerals in their blood may be upset. Signs and symptoms include increased heart rate, fatigue, weakness and low blood pressure.

    DIAGNOSIS-
    With a complete medical history and physical examination, diagnostic procedure may include the following:

    SWEAT (CHLORIDE)TEST: A test, which measures the amount of chloride in the sweat. If the amount of chloride is higher than the normal amounts it may suggest cystic fobrosis. The sweat test is not painful.

    1.BLOOD TEST: Blood or cheek scraping cells can also be used to detect mutations of the CFTR gene.
    2.CHEST X-RAY: A diagnostic test, which produce images of internal tissues, bones and organs.

    CHEST X-RAY IN CF
    CHEST X-RAY IN CYSTIC FIBROSIS

    cystic-fibrosiss3.PULMONARY FUNCTION TEST: Measures the lungs’ ability to exhange oxygen and carbondioxide appropriately.
    4.SPUTUM CULTURE: Is often performed to determine if an infection is present.
    5.STOOL EVACUATION-: To measure stool fat absorption.Pancreatic function
    6.COMPUTED TOMOGRAPHY SCAN: Detect early pulmonary disease before synptoms occur.
    7.MAGNETIC RESONANCE IMAGINE(MRI): Is not only used to screen the lung, but also the heart, sinuses and GI tract.

    PROGNOSIS-
    Prognosis has improved over the past fifty years because of advancement in the management, especially before the irreversible pulmonary changes. The median age for survival is 35 years, long term survival is better in patients without pancreatic insufficiency. The following have been associated with worse prognosis; females, early colonization with mucoid Pseudomonas, presentation with respiratory symptoms, tobacco smoke exposure and airway hyperactivity.

    MEDICAL MANAGEMENT-

    Although airway clearance continues to be an integral part of care, physical exercise, postural care and the need to address the unique complications which emerge as a result of improved longevity have significantly changed the nature of physiotherapy in CF.

    There is no cure for CF and most people with the disease die between the ages of 20 and 30 as a result of lung failure. Early diagnosis and a complete treatment plan can improve both survival and quality of life for the person suffering from CF.

    MEDICAL MANAGEMENT-
    Treatment of CF includes:

    Antibiotics for respiratory infections
    Vitamin supplements
    Inhaled medicines to help open the airways
    DNAse enzyme replacement therapy to thin the mucus and makes it easier to expectorate
    Pain relievers

    Enzyme therapy is done with each meal or snack, where most people with CF will need to take replacement enzymes such as pancreatin (eg Pancrex). These supply the missing pancreatic enzymes and allow proper digestion. People with CF normally need vitamin and mineral supplements too.

    The usual childhood vaccinations, such as measles, mumps and rubella (MMR) and diphtheria, tetanus and whooping cough (DTP) are important for the children with CF. If you have CF you should also be vaccinated against flu and pneumococcus to help prevent chest infections.

    CF is one of the most extensively researched genetic diseases as a target for gene therapy development and this can also serve as an important model for gene therapy of other diseases. The aim of gene therapy is to correct the basic defect in CF. This can be achieved by the development of a vector. This can be done by doing preclinical and clinical research. Clinical studies have identified the host immune response and low vector efficiency as key impediments to effective CF gene therapy.

  • PHYSIOTHERAPY MANAGEMENT-
    The main aim of physiotherapy is to remove excessive mucoid secretions in order to improve ventilation. A person suffering from CF will require intensive chest physiotherapy. This will include the following:

    • VIGOROUS MASSAGE to help loosen the sticky mucus
    • PERCUSSION-This technique is also known as chest clapping, and is used to help loosen secretions. To perform this technique a cupped hand is used to clap the chest firmly and rhythmically (over a layer of clothing or a towel) .
    • SHAKING AND VIBRATION- This technique consists of several short rhythmical squeezes to the chest while exhaling to mobilze secretions .
      Regular assessment and monitoring is necessary during physiotherapy treatment as the patient may require supplemental oxygen, especially in advanced cystic fibrosis.

    Other techniques include:

    • POSITIONING- lying on either side, front or back and sitting
      Active cycle of breathing (ACBT): This technique consist of 1.Breathing Control (BC), 2.Thoracic Expansion Exercises (TEE), and 3.Forced Expiration Technique (FET).
    • ACBT
      1.Breathing Control (BC): Relaxed diaphragmatic breathing which allows for rest and helps avoid any tightening of airways, which can make it difficult to clear secretions
      2.Thoracic expansion exercises (TEE): Deep breathing exercises that help the lungs to expand more effectively and allow air to get behind secretions so that they can be “pushed” up the airways towards the mouth. The breaths should be slow and deep with a pause at the end of inspiration then followed by relaxed quiet expiration .
      3.Forced Expiration Technique (FET): This consists of huffing or a sigh, to help move secretions from the smaller to the larger airways from where they can be cleared more easily.
    • Positive expiratory pressure (PEP): A technique that helps to open up airways and get air behind secretions to help move them higher up the airway. The PEP device (mask or mouthpiece) gives a small degree of resistance to the breath out and this resistance splints open the airways. Bubble PEP is used in young children and involves the child blowing through a straw placed in a bottle of water and soap to produce bubbles
    • Oscillating PEP- These devices combine vibrations of airways with PEP and there are several different types. The Flutter is a small pipe shaped device that interrupts the flow of air and gives an intermittent back pressure to the airways as well as causing them to vibrate. The Cornet and the Acapella are two other oscillating PEP devices that function similarily to the Flutter device
    • POSTURAL DRAINAGE-
      Postural drainage sounds complicated, but it’s really just a way to use gravity to drain mucus out of your lungs by changing positions. It’s used to treat a variety of conditions, including chronic diseases such as cystic fibrosis and bronchiectasis, as well as temporary infections, such as pneumonia.

    If you have a bad cold or flu, you can also use postural drainage to help keep mucus out of your lungs. The goal is to move mucus into the central airway, where it can be coughed up. It’s safe for people of all ages and can be done either at home or in a hospital or nursing facility.

    Postural drainage is often done at the same time as percussion, sometimes called clapping, which involves someone clapping on your back, chest, or sides with a cupped hand in order to shake mucus loose from the lungs. These techniques, along with vibration, deep breathing, and huffing and coughing, are referred to as chest physiotherapy, chest physical therapy, or airway clearance therapy.

    TEQNIC OF POSTURAL DRAINAGE-
    You can do postural drainage with many positions, either on your own or with a physical therapist or nurse.

    • General guidelines
      Each position should be held for a minimum of five minutes.
      Positions can be done on a bed or on the floor.
      In each position, your chest should be lower than your hips to allow mucus to drain.
      Use pillows, foam wedges, and other devices to make yourself as comfortable as possible.
      While in the positions, try to breathe in through your nose and out through your mouth for longer than you breathe in for maximum effectiveness.
      Do these positions in the morning to clear mucus that’s built up overnight or right before bed to prevent coughing during the night.
      A respiratory therapist, nurse, or doctor can recommend the best ways to perform postural drainage based on where the mucus is.
    • ON YOUR BACK-
      Your chest should be lower than your hips, which you can achieve by lying on a slanted surface or propping your hips up about 18 to 20 inches with pillows or another item.
      This position is best for draining the bottom front parts of your lungs.
    • ON YOUR SIDES-
      With pillows under your hips, lie on one side so that your chest is lower than your hips.
      To clear congestion from the bottom part of the right lung, lie on your left side.
      To clear congestion from the bottom part of your left lung, lie on your right side.
    • ON YOUR STOMACH-
      Drape your body over a stack of pillows or other object, such as a beanbag, and rest your arms by your head, with your chest lower than your hips.
      This position is best for clearing mucus in the lower back area of the lungs.

    More research is needed to know how effective postural drainage really is. In the meantime, your doctor may be able to suggest postural drainage positions or other chest physiotherapy techniques that may work for you. They can also refer you to a respiratory therapist or physical therapist who specializes in chest physiotherapy.

    RISK ASSOCIATED POSTURAL DRAINAGE-
    You may vomit if you do postural drainage right after eating. Try to do the positions before eating or 1 1/2 to 2 hours after a meal.

    If left untreated, mucus in the lungs can turn into a serious condition, so make sure to follow up with your doctor if you decide to try postural drainage. You may need additional treatment. Mucus in the lungs can also be a sign of an underlying condition that needs medical treatment, such as chronic pulmonary obstructive disease (COPD).

    Get emergency treatment if you have any of the following symptoms during or after postural drainage:

    • Shortness of breath
    • Trouble breathing
    • Confusion
    • Skin that turns blue
    • Coughing up blood

BRONCHIECTASIS AND MANAGEMENT

DEFINATION- Bronchiectasis is an obstructive lung disease that results from the presence of chronic inflammatory secretions and microbes leading to the permanent dilation and distortion of airway walls, as well as recurrent infection .

MECHANISM OF INJURY/ PATHOLOGICAL PROCESS-
Bronchiectasis is chronic irreversible dilation of the bronchi on the lungs. It follows a severe lung infection or aspiration. It is more common in conditions such as Cystic Fibrosis, Rheumatoid Arthritis, Immunodeficiency, Young’s syndrome and Allergic Bronchopulmonary Aspergillosis, and after chilhoos diseases such as whooping cough, TB and measles.

CLINICALLY RELEVANT ANATOMY-

 

anatomy of lung

Bronchiectasis involves inflammation of the airway walls, specifically the bronchial walls . The airway walls are the ‘tubes’ that run from the mouth and nose and travel to the lung. The main area that is affected in bronchiectasis is the bronchi . The trachea bifurcates into the right and left main bronchi, which then further divide into secondary bronchi; one for each lobe of the lung . They then divide into tertiary bronchi; one for each bronchopulmonary segment .

The cilia are also damaged in bronchiectasis. Cilia line the airway and are attached to the epithelium. They are hair-like with tiny hooks on the tip to grab the mucous and help move the mucous up to the throat .

EPIDEMIOLOGY-
It is underestimated in prevalence, incidence, and morbidity because symptoms are often ascribed to smoking. A study by Hill found that one in 1000 Britans have bronchiectasis, with associated deaths increasing at a rate of approximately 3% per year in England and Wales . Though the overall mortality rate is increasing in these countries, rates in older groups are rising whereas rates in younger groups are falling . A disproportionate amount of cases found in developing countries and in Aboriginal populations in affluent communities . In some populations, an improvement in socio-economic status, housing, and education can improve overall health and reduce the incidence of respiratory infection and development of bronchiectasis .

AETIOLOGY-
The cause is unknown for 50% of cases, but it has been linked to inflammatory bowel disease, rheumatoid arthritis, and in 29-50% of patients, COPD .There are several associated conditions with bronchiectasis including; cystic fibrosis, primary ciliary dyskinesia, lung tuberculosis, allergic bronchopulmonary aspergilosis, rheumatoid diseases, symptomatic lupus erythematosus, immune deficiency, severe childhood respiratory infection and exposure to foreign body or corrosive substance . It has also been linked to an x1-antitrypsin deficiency . Bronchiectasis tends to predispose patients to acquired and congenital lung infections.

PATHOPHYSIOLOGY-
Currently, a high-resolution CT scan is the gold standard for diagnosis of bronchiectasis. Parallel tramlines and ring shadows may be present on the scan, indicating thickened airway walls and dilated airways, respectively. There may also be ‘glove finger shadows’, which are finger –like projections that represent the dilated bronchi filled with solidified secretion.
Spirometry will simply identify if there is an airway obstruction, but this can be indicative of many other diseases.
Microbiology can also be used to identify the bacteria present during an exacerbation . A sputum sample is sent off and the results are returned with the incidence of bacterial colonization measured .

CLINICAL MENIFESTATION-
As delicate cilia are often damaged due to the presence of thick mucus, the voluminous quantities of sputum formed cannot be efficiently cleared. These secretions will lead to the production of wheezes, coarse crackles and squeaks on auscultation. Often times, patients will also present with muscular dysfunction due to inflammation, gas exchange abnormalities, inactivity, malnutrition, hypoxia and medications. Dyspnoea on exertion seems to be a major clinical manifestation as it is experienced by three out of four patients. Other physical manifestations include chest pain, snoring, finger clubbing, fatigue, persistent cough, recurrent infection, and loss of appetite. Stress incontinence can also be a result of excess coughing. Bronchiectasis tends to also have psychological manifestations, such as anxiety, depression, reduced confidence, altered relationships and time off work.

Exacerbations can occur several times a year and are identified by four or more of the following signs and/or symptoms: change in sputum, increased dyspnoea, increased cough, fever of greater than 38°, increased wheeze, decreased exercise tolerance, fatigue, lethargy, and radiographic signs of a new infection.

DIAGNOSIS-

abnormal airway dilation of lung

Currently, a high-resolution CT scan is the gold standard for diagnosis of bronchiectasis . Parallel tramlines and ring shadows may be present on the scan, indicating thickened airway walls and dilated airways, respectively. There may also be ‘glove finger shadows’, which are finger –like projections that represent the dilated bronchi filled with solidified secretions.
Spirometry will simply identify if there is an airway obstruction, but this can be indicative of many other diseases.
Microbiology can also be used to identify the bacteria present during an exacerbation . A sputum sample is sent off and the results are returned with the incidence of bacterial colonization measured .

PHYSIOTHERAPY AND OTHER MANAGEMENT-

Treatment for bronchiectasis aims to:

  • Decrease symptoms (such as cough and fatigue)
  • Decrease frequency and severity of exacerbations
  • Decrease hospital admissions
  • Improve quality of life
  • Improve exercise tolerance
  • Maintain or improve lung function
  • Prolong survival
  • Defining patient specific treatment goals.

An important part of a management plan is to define patient specific treatment goals. This may include:
Identifying:

  • Symptoms type and duration
  • Sputum volume and characteristics (colour thickness, smell, ease of clearance, presence of blood)
  • Frequency of exacerbations (previous hospitalisations and antibiotics)
  • Responses (and adverse effects) to previous treatments (antibiotics)
  • Haemoptysis volume and frequenc

 

  • Identifying co-morbidities that can contribute to bronchiectasis symptoms
  • Sinusitis
  • Gastro Oesophageal Reflux (GORD)
  • Asthma / ABPA
  • COPD and chronic bronchitis
  • Identify and promoting self-care activities
  • Exercise
  • Airway clearance
  • Symptom monitoring

The overall treatment plan aims to minimise symptoms and exacerbations with the long-term objective of maintaining lung function.

Physiotherapy is an essential part of the treatment for bronchiectasis. Because of the infection in the lung, secretions build up. Being able to cough the secretions up is important as this drains the chest of infected mucus.

All patients with bronchiectasis will have time with a physiotherapist, who will teach the techniques for getting the mucus up and draining the secretions from the lungs. The three methods illustrated in the video are the commonest forms of physiotherapy.

The first two, Acapalla and Active cycle of breathing can be taught by a physiotherapist. This will enable the you to perform these chest clearance methods on your own helping to keep you as healthy and infection free as possible.

The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient to help clear their sputum the lungs. The ACBT is a group of techniques which use breathing exercises to improve the effectiveness of a cough, loosen and clear secretions and improve ventilation.

ACBT consists of three main phases:

 

ACBT teqnic

1.Breathing Control
2.Deep Breathing Exercises or thoracic expansion exercises
3.Huffing OR Forced Expiratory Technique (F.E.T)
Additionally, a manual technique (MT) or positive pressure can be added if and when indicated, to create a more complex cycle to help improve removal of secretions on the lungs.

1.BREATHING CONTROL
Breathing control is used to relax the airways and relieve the symptoms of wheezing and tightness which normally occur after coughing or breathlesnes. Breathing should be performed gently through the nose using as little effort as possible. If this is not possible then breathing should be done by mouth. If it is necessary to breathe out through the mouth this should be done with ‘pursed lips breathing’. While performing this technique it is important to encourage the patient use it as an opportunity to reduce any tension they may have, Encouraging the patient to close their eyes while performing Breath Control can also be beneficial in helping to promote relaxation. It is very important to use Breathing Control in between the more active exercises of ACBT as it allows for relaxation of the airways. Breathing Control can also help you when you are short of breath or feeling fearful, anxious or in a panic. The length of time spent performing Breathing Control will vary depending on how breathless patient feels.

When using this technique with a patient as part of the ACBT the patient should be instructed to usually 6 breaths. Instructions to patient: Rest one hand on your stomach and keep your shoulders relaxed to drop down. Feel your stomach rise as you breathe in and fall when you breathe out.

2.DEEP BREATHING EXERCISE
Deep breathing is used to get air behind the sputum stuck in small airways:
Relax your upper chest.
Breathe in slowly and deeply.
Breathe out gently until your lungs are empty – don’t force the air out.
Repeat 3 – 4 times, if the patient feels light headed then it is important that they revert back to the Breathing Control portion of the cycle.
At the end of the breath in, hold the air in your lungs for 3 seconds (this is known as an inspiratory hold).
Deep breathing/thoracic expansion exercises recruit the collateral ventilatory system assisting, the movement of air distal to mucus plugs in the peripheral airways.
Deep breaths to utilise collateral channels and get air behind sputum to mobilise it towards larger airways and towards the mouth. Instructions to patient:

Relax your shoulders.
Place both hands on either side of ribs.
Breathe in deeply feeling as your ribs expand.
Breathe out gently as far as you can until your lungs feel empty.
Deep breathing/thoracic expansion is usually repeated 4 times.

3.HUFFING or FET
The FET is an integral part of the ACBT described by Pryor and Webber .

A huff is exhaling through an open mouth and throat instead of coughing.Huffing moves sputum from the small airways to the larger airways, from where they are removed by coughing. Coughing alone does not remove sputum from small airways.

Take a small-medium sized breath in
Squeeze the breath out by contracting your tummy muscles and keep your mouth and throat open to perform a huff. This small-medium sized huff helps with the removal of sputum in the lower reaches of the lungs.

To remove sputum in the higher portions of the lungs take a large breath in.
Squeeze the air out as before to perform a huff.

Cough and expectorate any sputum. If no sputum is produced with 1 or 2 coughs, try to stop coughing by encouraging the patient to use Breathing Control, the main technique used in between the more active stages of the as ACBT.
Allow your breathing to settle with breathing control and then repeat the cycle until your chest feels clear.
Small long huffs move sputum from low down into chest whereas big short huffs moves sputum from higher up into chest, so use this huff when it feels ready to come out, but not before; huffs work via dynamic compression.