FACIAL NERVE PALSY

 INTRODUCTION

ANATOMY
The facial nerve is the seventh cranial nerve, or simply cranial nerve VII. It emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. The nerves typically travels from the pons through the facial canal in the temporal bone and exits the skull at the stylomastoid foramen. It arises from the brainstem from an area posterior to the cranial nerve VI (abducens nerve) and anterior to cranial nerve VIII (vestibulocochlear nerve).

The facial nerve also supplies preganglionic parasympathetic fibers to several head and neck ganglia.

The facial and intermediate nerves can be collectively referred to as the nervus intermediofacialis.

STRUCTURE
The path of the facial nerve can be divided into six segments.

1. Iintracranial (cisternal) segment
2. Meatal segment (brainstem to internal auditory canal)
3. Labyrinthine segment (internal auditory canal to geniculate ganglion)
4. Tympanic segment (from geniculate ganglion to pyramidal eminence)
5. Mastoid segment (from pyramidal eminence to stylomastoid foramen)
6. Extratemporal segment (from stylomastoid foramen to post parotid branches)

1.The motor part of the facial nerve arises from the facial nerve nucleus in the pons while the sensory and parasympathetic parts of the facial nerve arise from the intermediate nerve.

2.From the brain stem, the motor and sensory parts of the facial nerve join together and traverse the posterior cranial fossa before entering the petrous temporal bone via the internal auditory meatus. Upon exiting the internal auditory meatus, the nerve then runs a tortuous course through the facial canal, which is divided into the labyrinthine, tympanic, and mastoid segments.

3.The labyrinthine segment is very short, and ends where the facial nerve forms a bend known as the geniculum of the facial nerve (“genu” meaning knee), which contains the geniculate ganglion for sensory nerve bodies. The first branch of the facial nerve, the greater superficial petrosal nerve, arises here from the geniculate ganglion. The greater petrosal nerve runs through the pterygoid canal and synapses at the pterygopalatine ganglion. Post synaptic fibers of the greater petrosal nerve innervate the lacrimal gland.

4.In the tympanic segment, the facial nerve runs through the tympanic cavity, medial to the incus.

5The pyramidal eminence is the second bend in the facial nerve, where the nerve runs downward as the mastoid segment. In the temporal part of the facial canal, the nerve gives rise to the stapedius and chorda tympani. The chorda tympani supplies taste fibers to the anterior two thirds of the tongue, and also synapses with the submandibular ganglion. Postsynaptic fibers from the submandibular ganglion supply the sublingual and submandibular glands.

6.Upon emerging from the stylomastoid foramen, the facial nerve gives rise to the posterior auricular branch. The facial nerve then passes through the parotid gland, which it does not innervate, to form the parotid plexus, which splits into five branches innervating the muscles of facial expression (temporal, zygomatic, buccal, marginal mandibular, cervical).

INTRACRANIAL BRANCH
1.Greater petrosal nerve – It arises at the geniculate ganglion and provides parasympathetic innervation to several glands, including the nasal glands, the palatine glands, the lacrimal gland, and the pharyngeal gland. It also provides parasympathetic innervation to the sphenoid sinus, frontal sinus, maxillary sinus, ethmoid sinus and nasal cavity. This nerve also includes taste fibers for palate via lesser palatine nerve and greater palatine nerve.

2.Communicating branch to the otic ganglion – It arises at the geniculate ganglion and joins the lesser petrosal nerve to reach the otic ganglion.

3..Nerve to stapedius – provides motor innervation for stapedius muscle in middle ear

4.Chorda tympani
Parasympathetic innervation to submandibular gland
Parasympathetic innervation to sublingual gland
Special sensory taste fibers for the anterior 2/3 of the tongue.

EXTRACRANIAL BRANCHES
Distal to stylomastoid foramen, the following nerves branch off the facial nerve:

Posterior auricular nerve – controls movements of some of the scalp muscles around the ear
Branch to Posterior belly of Digastric muscle as well as the Stylohyoid muscle
Five major facial branches (in parotid gland) – from top to bottom:

 

EXRACRANIAL BRANCH
EXRACRANIAL BRANCH

1.Temporal branch
2.Zygomatic branch
3.Buccal branch
4.Marginal mandibular branch
5.Cervical branch

Intra operatively the facial nerve is recognized at 3 constant landmarks:

1.At the tip of tragal cartilage where the nerve is 1cm deep and inferior
2.At the posterior belly of digastric by tracing this backwards to the tympanic plate the nerve can be found between these two structures
3.By locating the posterior facial vein at the inferior aspect of the gland where the marginal branch would be seen crossing it.
4.lateral semicircular canal
5.Foot of incus

NUCLEUS
The cell bodies for the facial nerve are grouped in anatomical areas called nuclei or ganglia. The cell bodies for the afferent nerves are found in

the geniculate ganglion for taste sensation. The cell bodies for muscular efferent nerves are found in the facial motor nucleus whereas the cell

bodies for the parasympathetic efferent nerves are found in the superior salivatory nucleus.

DEVELOPMENT
The facial nerve is developmentally derived from the second pharyngeal arch, or branchial arch. The second arch is called the hyoid arch because it contributes to the formation of the lesser horn and upper body of the hyoid bone (the rest of the hyoid is formed by the third arch). The facial nerve supplies motor and sensory innervation to the muscles formed by the second pharyngeal arch, including the muscles of facial expression, the posterior belly of the digastric, stylohyoid and stapedius. The motor division of the facial nerve is derived from the basal plate of the embryonic pons, while the sensory division originates from the cranial neural crest.

Although the anterior two thirds of the tongue are derived from the first pharyngeal arch, which gives rise to cranial nerve V, not all innervation of the tongue is supplied by CN V. The lingual branch of the mandibular division (V3) of CN V supplies non-taste sensation (pressure, heat, texture) from the anterior part of the tongue via general visceral afferent fibers. Nerve fibers for taste are supplied by the chorda tympani branch of cranial nerve VII via special visceral afferent fibers.

FUNCTIONS
Facial expression
The main function of the facial nerve is motor control of all of the muscles of facial expression. It also innervates the posterior belly of the digastric muscle, the stylohyoid muscle, and the stapedius muscle of the middle ear. All of these muscles are striated muscles of branchiomeric origin developing from the 2nd pharyngeal arch.

FACIAL SENSATION
In addition, the facial nerve receives taste sensations from the anterior two-thirds of the tongue via the chorda tympani. Taste sensation is sent to the gustatory portion (superior part) of the solitary nucleus. General sensation from the anterior two-thirds of tongue are supplied by afferent fibers of the third division of the fifth cranial nerve (V-3). These sensory (V-3) and taste (VII) fibers travel together as the lingual nerve briefly before the chorda tympani leaves the lingual nerve to enter the tympanic cavity (middle ear) via the petrotympanic fissure.

It joins the rest of the facial nerve via the canaliculus for chorda tympani. The facial nerve then forms the geniculate ganglion, which contains the cell bodies of the tastefibers of chorda tympani and other taste and sensory pathways. From the geniculate ganglion, the taste fibers continue as the intermediate nervewhich goes to the upper anterior quadrant of the fundus of the internal acoustic meatus along with the motor root of the facial nerve. The intermediate nerve reaches the posterior cranial fossa via the internal acoustic meatus before synapsing in the solitary nucleus.

The facial nerve also supplies a small amount of afferent innervation to the oropharynx below the palatine tonsil. There is also a small amount of cutaneous sensation carried by the nervus intermedius from the skin in and around the auricle (outer ear).

OTHERS-
The facial nerve also supplies parasympathetic fibers to the submandibular gland and sublingual glands via chorda tympani. Parasympathetic innervation serves to increase the flow of saliva from these glands. It also supplies parasympathetic innervation to the nasal mucosa and the lacrimal gland via the pterygopalatine ganglion. The parasympathetic fibers that travel in the facial nerve originate in the superior salivatory nucleus.

The facial nerve also functions as the efferent limb of the corneal reflex.

FUNCTIONAL COMPONNENT-
The facial nerve carries axons of type GSA, general somatic afferent, to skin of the posterior ear.

The facial nerve also carries axons of type GVE, general visceral efferent, which innervate the sublingual, submandibular, and lacrimal glands, also mucosa of nasal cavity.

Axons of type SVE, special visceral efferent, innervate muscles of facial expression, stapedius, the posterior belly of digastric, and the stylohyoid.

The axons of type SVA, special visceral afferent, provide taste to the anterior two-thirds of tongue via chorda tympani.

Finally, the facial nerve also carries axons of type GVA, general visceral afferent, which provide sensation to the soft palate and parts of the nasal

cavity.

ClINICAL SIGNIFICANCE

PALSY
People may suffer from acute facial nerve paralysis, which is usually manifested by facial paralysis. Bell’s palsy is one type of idiopathic acute facial nerve paralysis, which is more accurately described as a multiple cranial nerve ganglionitis that involves the facial nerve, and most likely results from viral infection and also sometimes as a result of Lyme disease. Iatrogenic Bell’s Palsy may also be as a result of an incorrectly placed dental local-anesthetic (Inferior alveolar nerve block). Although giving the appearance of a hemi-plegic stroke, effects dissipate with the drug.

When the facial nerve is permanently damaged due to a birth defect, trauma, or other disorder, surgery including a cross facial nerve graft or masseteric facial nerve transfer may be performed to help regain facial movement.Facial nerve decompression surgery is also sometimes carried out in certain cases of facial nerve compression.

EXAMINATION-

 

u1
Voluntary facial movements, such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly (inability to do so is called lagophthalmos) , pursing the lips and puffing out the cheeks, all test the facial nerve. There should be no noticeable asymmetry.

In an UMN lesion, called central seven, only the lower part of the face on the contralateral side will be affected, due to the bilateral control to the upper facial muscles (frontalis and orbicularis oculi).

LMN lesions can result in a CNVII palsy (Bell’s palsy is the idiopathic form of facial nerve palsy), manifested as both upper and lower facial weakness on the same side of the lesion.

Taste can be tested on the anterior 2/3 of the tongue. This can be tested with a swab dipped in a flavoured solution, or with electronic stimulation (similar to putting your tongue on a battery).

Corneal reflex. The afferent arc is mediated by the General Sensory afferents of the Trigeminal Nerve. The efferent arc occurs via the Facial Nerve.

The reflex involves consensual blinking of both eyes in response to stimulation of one eye. This is due to the Facial Nerve’s innervation of the muscles of facial expression, namely Orbicularis oculi, responsible for blinking. Thus, the corneal reflex effectively tests the proper functioning of both Cranial Nerves V and VII.

FACIAL NERVE PALSY-
A facial palsy is weakness or paralysis of the muscles of the face.

Whilst the majority of cases are idiopathic, termed Bell’s Palsy, there are a wide range of potential causes of a facial palsy .

Bell’s palsy is a diagnosis of exclusion and hence all possible causes have to be excluded first prior to diagnosing Bell’s palsy. The majority of this article will discuss Bell’s Palsy and its associated clinical features and management.

RISK FACTORS-
Bell’s palsy remains a poorly understood condition. Many causative associations have been proposed, the most universally accepted theory suggests a viral origin, yet no conclusive evidence is available at present.

The main risk factor for developing Bell’s palsy is known concurrent viral infection, such as HSV-1(HERPES SIMPLEX  VIRUS 1), CMV (CYTOMEGALOVIRUS), and EBV (EBSTEIN VIRUS), whilst less common risk factors.

include diabetes mellitus and pregnancy.

CLINICAL FEATURE-
Patients with a Bell’s Palsy will present with varying severity of painless unilateral lower motor neuron weakness of the facial muscles .

Depending on the severity and the ximity of the nerve affected, it can also result in:

Inability to close their eye (temporal and zygomatic branches)
Hyperacusis (nerve to stapedius)
Metallic taste (chorda tympani)
Reduced lacrimation (greater petrosal nerve)

DIFFERENCE BETWEEN THE UMN AND LMN LESION-
To distinguish clinically between a LMN cause and UMN cause of the facial palsy, a patient with forehead sparing (i.e. no involvement to the occipitofrontalis muscle) will have a UMN origin to the palsy, due to the bilateral innervation of the forehead muscle).

DIFFERENTIAL DIAGNOSIS-

LMN AND UMN LESION
LMN AND UMN LESION

Important differential diagnosis for a facial palsy, other than Bell’s Palsy, include:

      UMN causes, such as a stroke, SDH, or tumour
Will present with forehead sparing

  • LMN CAUSES
  • Infective such as acute otitis media, cholesteatoma, viral infection (including HSV-1, CMV, and EBV)
  • Neoplasm (parotid malignancy)
  • Trauma or iatrogenic
  • Neurological (Multiple sclerosis or Guillain-Barré syndrome)

SYMPTOMS OF BELL’S PALSY

symptoms of bells palsy
symptoms of bells palsy

 

The onset of facial paralysis is sudden with Bell’s palsy, and can worsen during the early stages. Symptoms will usually manifest and peak within 2-3 days, although it can take as long as 2 weeks. Common symptoms include, but are not limited to:

Muscle weakness or paralysis
Facial droop
Impossible or difficult to blink
Difficulty speaking
Difficulty eating and drinking
Nose runs
Nose is constantly stuffed
Difficulty breathing out of nostril on affected side
Nostril collapse on affected side
Forehead wrinkles disappear
Sensitivity to sound
Excess or reduced salivation
Facial swelling
Drooling
Diminished or distorted taste
Pain behind ear
There are also some eye related symptoms, which may include but are not limited to:

Difficulty closing the eye
Sensitivity to light
Lower eyelid droop
Tears fail to coat cornea
Brow droop
Excessive tearing
Lack of tears

INVESTIGATION
Most cases of Bell’s Palsy can be diagnosed clinically and no further investigations are required, unless any other clinical features are present that suggest another pathology.

Serology for HSV-1 and VZV can be performed, yet will unlikely alter future management if detected.

MANAGEMENT-
Patient reassurance is essential, as most cases return spontaneously to full function. Eye care is one of the most important aspect of the management, ensuring the patient uses lubricating drops hourly and potential for eye ointment at night and / or an eye patch.

MEDICAL MANAGEMENT
All patients presenting within 72 hours of symptoms onset should be started oral steroids. Current NICE guidance recommends either:

Giving 25 mg twice daily for 10 days
Giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg
Use of anti-viral agents is controversial.

A Cochrane Review found low level evidence that the combination of anti-virals and corticosteroids are more effective in Bell’s palsy treatment; many centers currently treat Bell’s palsy with both.

SURGICAL REFFERAL
Referral to an ENT surgeon should be considered if there is any doubt over the diagnosis, recurrent or bilateral Bell’s palsy, or no sign of improvement after 1 month. There are surgical options available for patients who have persistent weakness or synkinesis. Synkinesis could be treated with botox injections whilst persistent weakness can be treated with anterior belly of diagastric transfer, fascia lata sling, or cross-facial nerve grafting.

A referral to ophthalmology should be made if the cornea remains exposed after attempting to close the eyelid (House Brackmann grade of IV or more).

COMPLICATIONS
85% of cases will recover from Bell’s palsy, the majority of which make a fully recovery with no evidence of residual symptoms. The factors that suggest a poor prognosis from a facial palsy include:

Complete palsy
No signs of recovery within 3 weeks
Age >60yrs
Associated pain
Ramsey Hunt syndrome
Associated HTN, DM, or pregnancy

PHYSICAL THERAPY TECHNIQUES FOR FACIAL PARALYSIS

In the first couple of days to a week after symptoms start,  physical therapist will evaluate your condition, including:

Review your medical history, and discuss any previous surgery or health conditions
Review when your current symptoms started and what makes them worse or better
Conduct a physical examination, focusing on identifying the patterns of weakness that are caused by Bell palsy

  • Facial movements of the eyebrow
  •  Eye closure
  • Ability to use the cheek in smiling
  • Ability to use the lips in a pucker
  • Ability to suck the cheeks between the teeth
  • Raising the upper lip
  • Raising or lowering the lower lip

Your physical therapist will immediately:

  • Educate you about how to protect your face and your eye
  • Show you how to manage your daily life functions while you have facial paralysis
  • Explain the expected path to recovery, so that you will know the signs and symptoms of recovery
  • Evaluate your progress, and determine whether you need to be referred to a specialist if progress is not being made The first priority is to protect your eye. The inability to completely and quickly
  • close your eye makes the eye vulnerable to injury from dryness and debris. Debris can scratch the cornea—the transparent front part of the eye that covers the iris, pupil, and front chamber of the eye—and couldpermanently harm your vision. physical therapist will immediately show you how to protect your eye, such as:
  • Using self-made and commercial patches
  • Setting a regular schedule for refreshing eye fluids
  • Carefully closing the eye with your fingers
  • If you have partial facial movement, your therapist will teach you a few general facial exercises to do at home. These exercises will help you learn to move the weak side of your face and help you use both sides of your face together. One of the exercises is a gentle blowing action through your lips.

DURING RECOVERY
Physical therapist will help you regain the healthy pattern of movements that you need for facial expressions and function. Recovery can be challenging because:

Normally, the ability to make facial expressions and many facial movements is “automatic”;—that is, you’re born with this ability and never had to think about it before Unlike other muscles in your body, the facial muscles do not have sensors that tell your brain all of the necessary “details” about how to move Physical therapist will be your coach throughout this challenging time, guiding you through special exercises that are designed to help you relearn facial movements based on your particular movement problems. Your exercises may change over the course of recovery:

“Initiation” exercises. In the early stages, when you might have difficulty producing any facial movement at all, your therapist will teach you exercises that cause (“initiate”) facial movement. Your therapist will show you how to position your face to make it easier to move (called “assisted range of motion”) or how to “trigger” the facial muscles to do what you want them to do.

“Facilitation” exercises. Once you’re able to initiate movement of the facial muscles, your therapist will design exercises to increase the activity of the muscles, strengthen the muscles, and improve your ability to use the muscles for longer periods of time (“facilitate” muscle activity).

Movement control exercises. therapist will design exercises to:

  • Improve the coordination of your facial muscles
  • Refine your facial movements for specific functions, such as speaking or closing your eye
  • Refine movements for facial expressions, such as smiling
  • Correct abnormal patterns of facial movement that can occur during recovery
  • To work on coordinating your facial muscles, you’ll need to have a sufficient level of activation of facial muscles first.

RELAXATION- During recovery, you might have facial spasms or twitches. Your physical therapist will design exercises to reduce this unwanted muscle activity. The therapist will teach you how to recognize when you are activating the facial muscle and when the muscle is at rest. By learning to contract the facial muscle forcefully and then stop, you will be able to relax your facial muscles at will and decrease twitches and spasms.

AFTER RECOVERY-
Some people might have greater difficulty moving their face after a period of improvement in facial movement, which can make them worry that the facial paralysis is returning. However, actual recurrence of facial paralysis of the Bell Palsy type is uncommon.

New difficulty in moving the face is more likely the result of increasing the strength of the facial muscles without improving the ability to coordinate and control the movement. To keep this from happening, physical therapist will show you what facial movements you should avoid during recovery. For instance, the following might lead to abnormal patterns of facial muscle use:

Trying to make the biggest facial movement or muscle contraction that you can, such as smiling as much as you can

  • Chewing gum with great force
  • Blowing up a balloon with all of your effort to work the facial muscles
    Therapist will coach you to use your face as naturally as possible, without trying to restrict facial expressions because they look “different.”

NEUROMUSCULAR RETRAINING (NMR)
NMR involves the use of subtle but critically important exercises to teach and retrain the brain to coordinate the facial muscles more effectively and efficiently.

BENEFITS OF NMR
NMR re-teaches facial paralysis patients which muscles are required to move different parts of the face. This type of physical therapy enables a patient’s brain to reconnect facial muscles and corresponding facial movements. It teaches patients how to isolate facial muscles, use only the correct muscles to make their desired facial movements and suppress muscles that otherwise cause unwanted facial movements.

VIABLE CANDIDATE FOR NMR
Patients dealing with Bell’s palsy or other viral infections of the facial nerve often recover on their own completely and spontaneously within about three months of an initial diagnosis. For those who do not fully recover, it is possible that the facial nerve will heal improperly, which causes spontaneous, unwanted facial movements (or synkinesis). For example, when a Bell’s palsy patient tries to smile, his or her eye may twitch at the same time. In this scenario, the patient does not require additional strength in the facial muscles. Instead, he or she needs to improve facial muscle coordination to prevent facial muscles from flexing out of sequence – something that causes distorted facial movements.

MANUAL MASSAGE
Manual massage involves a series of different massage techniques. The goal of manual massage is to decrease facial muscle tightness and improve flexibility and range of motion. Initially, manual massage techniques may be performed by physical therapists, but the therapist ultimately will teach a patient the techniques so he or she can perform them regularly at home.

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AEROBIC EXERCISE

AEROBIC
Aerobic exercise is sometimes known as “cardio” — exercise that requires pumping of oxygenated blood by the heart to deliver oxygen to working muscles.
Aerobic exercise stimulates the heart rate and breathing rate to increase in a way that can be sustained for the exercise session. In contrast, anaerobic (“without oxygen”) exercise is activity that causes you to be quickly out of breath, like sprinting or lifting a heavy weight.
Examples of aerobic exercises include cardio machines, spinning, running, swimming, walking, hiking, aerobics classes, dancing, cross country skiing, and kickboxing. There are many other types.
Aerobic exercises can become anaerobic exercises if performed at a level of intensity that is too high.
Aerobic exercise not only improves fitness; it also has known benefits for both physical and emotional health.
Aerobic exercise can help prevent or reduce the chance of developing some cancers, diabetes, depression, cardiovascular disease, and osteoporosis.
An aerobic exercise plan should be simple, practical, and realistic. Specific equipment (such as cardio machines) may be used but is not necessary for successful aerobic exercise.

TYPES OF AEROBICS
Actually, the best aerobic exercise depends on level of fitness. Aerobic exercise is a moderate intensity workout that extends over a certain period of time and uses oxygen in this process. Well, in these years, the practice of aerobics has become the most happening workout trend between the youth. Not only is performing aerobic exercise interesting, but also is very beneficial for health. There are diverse types of aerobics such as fitness, water aerobics, step aerobics, swimming, kickboxing, fitness walking, inline skating, bicycling etc.

Here we have the more generals:

LOW IMPACT AEROBICS

low impact aerobics
low impact aerobics

There exist people, who can’t perform high intensity workout, because maybe they have some health problems or their poor health conditions. For such people, low impact aerobics is the precise workout choice. Low impact aerobic exercise comprehends rhythmic movements, with exercising of the large muscle groups.

WATER AEROBICS

 

water aerobics
water aerobics

Water aerobic exercises are an agreeable way to exercise over the hot summers. Maybe the work out can seem like one splashing surrounding the pool waters, yet those who are seriously into water aerobic exercise claim it’s an excellent method to burn out unwanted flab from the body and build inner strength. In effect, health experts declare that the water aerobic exercise is good for people ailing from arthritis and other problems many times.

STEP AEROBICS

step aerobics
step aerobics

This kind of exercise is a newer version and interesting technique of aerobics. Conventional aerobics are practiced on the floor: you discover a series of dance steps such as the Pony or the Jazz Square, which are often done in four, two steps taking you in one direction, two more taking you the other direction.

DANCE AEROBICS

dance aerobics
dance aerobics

Aerobic dance integrates exercise and dance movements into routines that are practiced with the music. Many dance ways are used, including ballet, jazz, and disco. Aerobic dance classes integrate fat-burning aerobics with develop of the muscle and stretching exercises.

Your foot is on the ground all times. This kind of aerobic is slower and it is simpler to do than intermediate and advanced classes.

SPORT AEROBICS

sports aerobics
sports aerobics

Sport Aerobics is a hard and competitive sport that has a singular connection of aerobic choreography and gymnastics elements. This sport generate a chance for adolescents, and adult individuals to compete in a sport that demands less risk than gymnastics while keeping the artistic quality and fun of aerobics.

AEROBIC EXERCISE MOVES-

Aerobic exercise is good for each person. Aerobic fitness moves integrate rhythmic calisthenics or dance moves with stretching and strength training routines to provide a full-body exercise experience.

Here some moves you need to give your body a full aerobic workout:

WARM-UP MOVES
Warm-Up Moves Aerobic moves that change the heart from a resting heart rate to a warm-up rate start slowly and build in energy and intensity.Walking or marching in place is the most regular warm-up aerobic move, with your steps deepening into lunges at the end of the warm-up to add intensity, energy and increase the circulation of blood to the muscles. Other first phase moves comprehend stepping from side to side and moving the arms at waist level or higher.

Aerobic moves over the warm-up phase should also comprehend a gentle stretch of each of the major muscle groups, including the lower back.

The warm-up phase of an aerobic workout should be from 5 to 10 minutes. The objective during the warm-up phase is to elevate the body’s core temperature, warm up the muscles and joints, and get ready the body for the training portion of the workout.

AEROBIC MOVES IN THE ZONE-
Aerobic Moves In The Zone The next phase of your workout carries your body toward your target heart rate. The intensity of the movement grows and the pace of the movement grows. Some aerobic moves are universally recognized to augment intensity; for example, stopping the body’s momentum and moving the body in the contrary direction is a high intensity move. For this reason, is why aerobic routines comprehend a lot of back and forth movements and up and back movements in the middle part of the workout.

Lifting the weight of body is another high intensity aerobic move. Leaping, hopping, and powering through a move are all high intensity actions.

This part of the workout should be from 15 to 25 minutes, with intensity building at the beginning of the session, peaking mid-session, and subsiding toward the end of this phase of the aerobic workout.

COOL-DOWN AEROBIC MOVES
Cool-Down Aerobic Moves The last segment of an aerobic exercise workout is the cool-down and stretch period. The intense movements terminate, the pace of the workout decelerates, and the activity returns to the modest, gentler motions of the warm-up phase. You should not stop exercising abruptly without this cool-down phase. Maybe, you could sense dizziness and could collapse if you do. Instead, delay the pace of your exercise until your heart is beating fewer than 100 times per minute.

Terminate your aerobic moves workout by stretching all the muscles you exercised to help them return to their normal length, to increase your flexibility, and to keep your muscles flexible and toned.

THE BEGINING
It all starts with breathing. The average healthy adult inhales and exhales about 7 to 8 liters of air per minute. Once you fill your lungs, the oxygen in the air (air contains approximately 20% oxygen) is filtered through small branches of tubes (called bronchioles) until it reaches the alveoli. The alveoli are microscopic sacs where oxygen diffuses (enters) into the blood. From there, it’s a beeline direct to the heart.

AEROBIC ROUTINE

Aerobic Routine There are several millions of Americans that train with some form of aerobics routine or the other and aerobics routines have become a sport that are pleasure to perform for losing weight and staying in shape. The most common aerobics routines are the low-impact routines and dance besides is a preponderant factor that has been inspired by ballet, salsa and even hip-hop. The aerobic routine serves to increasing cardiopulmonary efficiency besides strengthening the heart and lungs. Additionally, the aerobic routine

should also assist to increase blood circulation and lower cholesterol levels as well as reduce stress and anxiety. Being a somewhat hard exercise form, the aerobics routine maybe require profound preparation and wise election, which should ensure that proper equipment is used, to avoid being injured.

A sample schedule for the beginner’s fitness enthusiast:
DAY ONE:
You should take as easy twenty-minute walk at a beautiful bright place. Look a friendly place to walk, avoid the pollution. If you can’t find one, maybe you can go to a park, beach, grassland or the countryside away from pollution. You require being able to keep up an interesting conversation. If you are in oxygen debt you won’t burn calories as well so take it easy at first. Upon returning, use approximately ten or fifteen minutes stretching. You should practice it periodically; otherwise the extra calories can accumulate in thighs or butt. When you begin with some periodic activity, the brain stars to think this body is active and needs to increase the metabolism. Then the brain will get to a higher metabolic level. As you augment your exercise program you will have more byproducts known as free radicals. This is the argument for us to work with nutrition as well, because you need to increase the antioxidants to keep the body healthy from the free radicals.
DAY TWO:
Just stretch for ten to fifteen minutes. If you find a pool, maybe you can choose swimming for ten to fifteen minutes.
DAY THREE:
Walk fast for twenty-five minutes. Stretch for fifteen, or if you have it down, it could only take ten minutes to get a fantastic stretch.
DAY FOUR:
Swim and stretch for at least twenty minutes and ten respectively.
DAY FIVE:
You might miss one. Or walk maybe longer and easy or hard depending on how you feel.
DAY SIX:
Walk a good distance faster for thirty minutes. If you feel tight walking, stop after you break into a light sweat and stretch for a few minutes. Regarding the legs and gluteus muscles. Then continue, finishing up with a good ten minute stretch.
DAY SEVEN:
If you didn’t miss one day, consider an easy walk, swim or stretch, may be do something with family or friends. If you got distressed at all during the week, then rest and just stretch or swim.

Keep this program until you may be able to walk thirty minutes without losing your breath at all. This can last two weeks for most people and up to four weeks for others. If it takes you longer, stay with twenty-five minutes for two months, and then move into the next level. If within two weeks your body serves you well, you can proceed with the next level.

Keep on the following day with an energetic walk for thirty minutes. Now we will begin to burn some fat. From now on, you workouts should last approximately forty-five minutes. As you each time get stronger, your hard days go by like your easy days, when you first started. Walking can escalate to five times per week within the first few months, depending on your body. At this level it’s not as critical as it will be when we start the strengthening program using weights, running or strengthening exercises.
SIX TO EIGHT WEEK :
After six or eight weeks, begin your strength-training program. Once again, listen to your body. If you don’t feel quite ready at six weeks, take eight. You can go in either of two directions with this addition to your program, with diverse levels of intensity depending on your body and your abilities.

If you are able and you are willing to run for your particular objectives, you may now commence to run. Begin with simple jogging for 20 minutes every day, and weight training every other day. Running at this time should be at least three days a week, the same for weight training. There is some evidence, nevertheless, that we could get by with two days of weight training and still do okay. Have one day of rest. The day you rest should be a very easy workout, stretching, swimming or family fun.

GETTING TO THE HEART OF IT
The heart has four chambers that fill with blood and pump blood (two atria and two ventricles) and some very active coronary arteries. Because of all this action, the heart needs a fresh supply of oxygen, and as you just learned, the lungs provide it. Once the heart uses what it needs, it pumps the blood, the oxygen, and other nutrients out through the large left ventricle and through the circulatory system to all the organs, muscles, and tissues that need it.

A WHOLE LOT OF PUMPING GOING ON
Heart beats approximately 60-80 times per minute at rest, 100,000 times a day, more than 30 million times per year, and about 2.5 billion times in a 70-year lifetime! Every beat of your heart sends a volume of blood , along with oxygen and many other life-sustaining nutrients, circulating through your body. The average healthy adult heart pumps about 5 liters of blood per minute.

OXYGEN CONSUMPTION AND MUSCLES
All that oxygen being pumped by the blood is important. In science, it’s labeled VO2, or volume of oxygen consumed. It’s the amount of oxygen the muscles extract, or consume from the blood, and it’s expressed as ml/kg/minute (milliliters per kilogram of body weight). Muscles are like engines that run on fuel (just like an automobile that runs on fuel); only our muscles use fat and carbohydrates instead of gasoline. Oxygen is a key player because, once inside the muscle, it’s used to burn fat and carbohydrate for fuel to keep our engines running. The more efficient our muscles are at consuming oxygen, the more fuel we can burn, the more fit we are, and the longer we can exercise.

AEROBICS AND FITNESS
The average sedentary adult will reach a level of oxygen consumption close to 35 ml/kg/minute during a maximal treadmill test (where you’re asked to walk as hard as you can). Translated, that means the person is consuming 35 milliliters of oxygen for every kilogram of body weight per minute.

That’ll get you through the day, but elite athletes can reach values as high as 90 ml/kg/minute! They may have good genes for one, but they also train hard. And when they do, their bodies adapt. The good news is that the bodies of mere mortals like the rest of us adapt to training too.

Heart gets stronger and pumps more blood with each beat (larger stroke volume). Elite athletes, can have stroke volumes more than twice as high as average individuals. But it’s not just that. Conditioned hearts also have greater diameter and mass (the heart’s a muscle too and gets bigger when you train it), and they pump efficiently enough to allow for greater filling time, which is a good thing because it means that more blood fills the chambers of the heart before they pump so that more blood gets pumped with each beat. Greater stroke volume means the heart doesn’t have to pump as fast to meet the demands of exercise. Fewer beats and more stroke volume mean greater efficiency. Think about a pump emptying water out of a flooded basement. The pump works better and lasts longer if it can pump larger volumes of water with each cycle than if it has to pump faster and strain to get rid of the water. High stroke volume is why athletes’ hearts don’t pump as fast during exercise and why they have such low resting heart rates; sometimes as low as 40 beats per minute, whereas the average is 60-80 beats per minutes.

Downstream from the heart are your muscles, which get more efficient at consuming oxygen when you do regular aerobic exercise (remember, “consuming” oxygen means that the muscles are taking the oxygen out of the blood). This happens because of an increase in the activity and number of enzymes that transport oxygen out of the bloodstream and into the muscle. Imagine 100 oxygen molecules circulating past a muscle.

You’re twice as fit if the muscle can consume all 100 molecules than if it can only consume 50. Another way of saying it is that you’re twice as fit as someone if your VO2 max is 60ml/kg/min. and theirs is 30ml/kg/min. In terms of performance in this scenario, you’ll have more endurance because your muscles won’t run out of oxygen as quickly.
Mitochondria inside the muscle increase in number and activity. Mitochondria are the powerhouses of your cells. They do all the heavy-duty work to keep you moving. They use the oxygen to burn the fat and carbohydrate that makes you go. The good news is that they increase in number and activity, by as much as 50%, in just a matter of days to weeks in response to regular aerobic exercise in adults of all ages.

FAT AND CARBOHYDRATE BURNING
Fat and carbohydrate are the fuels our muscles burn. The difference between them is that fat is high-test; it contains 9 calories per gram whereas carbohydrate has only 4, and so you get more energy and can go farther on a gram of fat than on a gram of carbohydrate. You want to burn fat because it’s such an efficient fuel, plus it’s nice to lose some of your excess fat! The catch is that you need more oxygen to burn fat because it’s denser than carbohydrate. The good news is that your body gets better at using oxygen and burning fat when you do regular aerobic exercise; like I described, your heart pumps more blood, your muscles consume more oxygen, and you have more mitochondria.

DIFFERENCE BETWEEN THE AEROBIC AND ANEROBIC EXERCIS
AEROBIC EXERCISE is an activity that stimulates your heart rate and breathing to increase but not so much that you can’t sustain the activity for more than a few minutes. AEROBIC means “WITH OXYGEN ,” and ANEROBIC means “WITHOUT OXYGEN.” Anaerobic exercise is the type where you get out of breath in just a few moments, like when you lift weights for improving strength, when you sprint, or when you climb a long flight of stairs.

BENEFITS OF AEROBIC EXERCISE TRAINING-

STRENGTHEN THE HEART
Aerobic exercise training is excellent for strengthening hearts and lungs. During these exercises, the tissues demand more oxygen from the blood

The heart has to beat faster to cope up with this demand, which in longer duration makes it stronger and healthier. The fast movement of the blood and heart helps to unclog the arteries.
This means that it reduces LDL (bad cholesterol).

BURNS CALORIES
Longer duration cardio can burn lots of calories
It creates a calorie deficit which is required for reducing weight.
These excess calories are burned by utilizing the excess fat content in the body making Aerobic training very effective for fat burn.

REDUCE BLOOD PRESSURE
Improves glucose tolerance and reduces insulin resistance.
Decreases clinical symptoms of ANXIETY, TENSION , and DEPRESSION.
Enhances muscles’ ability to use oxygen and increase its blood supply.
Lowers resting heart rate.
Increased muscle endurance.

Aerobics can be used as a starting step. It is a good way to start weight loss for beginners and for people who have excess body fat. Aerobic exercise steps are less demanding on the body and can be easily understood and followed.

CANCER PREVENTION
Colon cancer. Research is clear that physically active men and women have about a 30%-40% reduction in the risk of developing colon cancer compared with inactive individuals. It appears that 30-60 minutes per day of moderate- to vigorous-intensity physical activity is needed to decrease the risk, and there is a dose-response relationship, which means that the risk declines the more active you are. Breast cancer. There is reasonably clear evidence that physically active women have a greater reduction in risk compared with inactive women. Like colon cancer, it appears that 75 to 150 minutes per day of moderate- to vigorous-intensity physical activity is needed to decrease the risk, and it is likely that there is a dose-response relationship as well. Prostate cancer. Research is inconsistent regarding whether physical activity plays any role in the prevention of this cancer. Lung cancer. There are relatively few studies on physical activity and lung cancer prevention. The available data suggest that physically active individuals have a lower risk of lung cancer; however, it is difficult to completely account for the risks of active and passive cigarette smoking as well as radon exposure. Other cancers. There is little information on the role of physical activity in preventing other cancers.

CANCER TREATMENT
There’s some good news for people undergoing cancer treatment. In one study, aerobic exercise performed five days per week for 30-35 minutes for six weeks at 80% of maximal heart rate reduced fatigue in women being treated for cancer. In another study, 10 weeks of aerobic exercise at 60% of maximum heart rate for 30-40 minutes, four days per week, reduced depression and anxiety in female cancer patients. Aerobic exercise isn’t a panacea when it comes to cancer, but evidence suggests that it certainly can help.

OSTEOPOROSIS
Osteoporosis is a disease characterized by low bone density, which can lead to an increased risk of fracture. The good news is that exercise may increase bone density or at least slow the rate of decrease in both men and women. It may not work for everyone, and the precise amount and type of exercise necessary to accrue benefits is unknown, but there is evidence that it can help. In children there is good news, too. It seems that active children have greater bone density than sedentary children and that this may help prevent fractures later in life.

DEPRESSION
Most of us who exercise regularly understand that exercise can elevate our mood. There have been a number of studies investigating the effects of exercise on depression. In one of the most recent studies, it was shown that three to five days per week for 12 weeks of biking or treadmill for approximately 30 minutes per workout reduced scores on a depression questionnaire by 47%. It’s not a substitute for therapy in a depression that causes someone to be unable to function (in which case medication and/or psychotherapy may be necessary), but for milder forms of depression, the evidence is persuasive that it can help.

DIABETES
No study has been more conclusive about the role of lifestyle changes (diet and exercise) in preventing diabetes than the Diabetes Prevention Program. It was a study of more than 3,000 individuals at high risk for diabetes who lost 12-15 pounds and walked 150 minutes per week (five 30- minute walks per day) for three years. They reduced their risk of diabetes by 58%. That’s significant considering there are 1 million new cases of diabetes diagnosed each year. Aerobic exercise can also improve insulin resistance. Insulin resistance is a condition in which the body doesn’t use insulin properly, and this condition can occur in individuals who do and do not have diabetes. Insulin is a hormone that helps the cells in the body convert glucose (sugar) to energy. Many studies have shown the positive effects of exercise on insulin resistance. In one, 28 obese postmenopausal women with type 2 diabetes did aerobic exercise for 16 weeks, three times per week, for 45-60 minutes, and their insulin sensitivity improved by 20%.

CARDIOVASCULAR DISEASE
The list of studies that show that aerobic exercise prevents or reduces the occurrence of cardiovascular disease is so long that it would take this entire article and probably five others just like it to review all of the research. One of the most important is one of the earliest. In a study of more than 13,000 men and women, it was shown that the least fit individuals had much higher rates of cardiovascular disease than fit individuals  in some cases, the risk was twice as high. Aerobic exercise works in many ways to prevent heart disease; two of the most important are by reducing blood pressure and allowing blood vessels to be more compliant (more compliant means that they become less stiff and it’s less likely for fat to accumulate and clog up the vessels). Results like these have been proven over and over again.

OBESITY AND WEIGHT COTROL
Aerobic exercise is believed by many scientists to be the single best predictor of weight maintenance. You can lose weight without exercise by reducing your caloric intake enough so that you burn more calories than you consume, but it takes a regular dose of exercise to keep your weight

off. How much is not clear, but somewhere between 30 and 40 minutes of vigorous exercise several times per week, to 45 to 75 minutes of moderate intensity exercise five or more days per week is probably about right. Your mileage will vary, and so once you get to the weight that you want to be at you’ll need to experiment with different amounts of exercise until you find the one that works for you. The American College of Sports Medicine recommends that overweight and obese individuals progressively increase to a minimum of 150 minutes of moderate intensity physical activity per week, but for long-term weight loss, overweight and obese adults should eventually progress to 200 to 300 minutes per week of moderate-intensity physical activity. These are general guidelines, and so again, you need to experiment to see what works for you. Aerobic exercise definitely burns lots of calories. Below is a table of minutes of continuous activity necessary to expend 300 calories based on your body weight.

COGNITIVE FUNCTION-

Scientists have recently become interested in the effects of aerobic exercise on cognitive function. It has been shown in rats that use of a running wheel every day stimulates new brain cells to grow in as few as 12 days. Brain cells in humans can’t be studied directly, but what has been shown is that rates of dementia and Alzheimer’s disease are lower in older individuals who exercise three or more times per week compared with older adults who exercise fewer than three times per week. In some cases, the risk is 62% lower. Evidence is also accumulating that active individuals perform better on cognitive function tests such as tests of memory and spatial relations than sedentary individuals.

AEROBIC EXERCISE PROGRAME-

Keep it simple, keep it practical, keep it convenient, keep it realistic, keep it specific, and don’t try to make up for years of inactivity all at once. Select any activity and amount of time where the probability of sticking with it is high. You may not love walking, but if you can do it right outside your door, and it requires no special equipment, and you already know how to do it (you’ve been walking your entire life!), then walking might be your best bet for getting started because it’s so convenient.

HEART RATE RESERVE
Heart rate rises during aerobic exercise. It can rise from 70 beats per minutes (bpm) at rest to as high as 170 bpm or even higher during exercise, depending on the intensity of the exercise, your fitness level, your age, and other factors. Whether you’re training is aerobic or anaerobic is determined by the intensity of your workout, and monitoring the intensity is the key to know which one you’re doing.

For many individuals, simply monitoring how the body feels while exercising is enough to determine the proper aerobic intensity.  “warm and slightly out of breath” as the cue for aerobic activity; that is if you feel warm and slightly out of breath while you’re exercising, then that’s good enough.

Heart-rate reserve method for calculating a target heart rate. Here’s the formula and an example of the method for someone 27 years of age, assuming a resting heart rate of 70 bpm, and a training range of 70%. If you plug in other values, you can get other ranges.

220-age = Max HR.
Subtract resting heart rate from Max HR = Heart Rate Reserve (HRR).
Multiply HRR times percent you want to train at.
Add back resting heart rate.
Assuming a resting heart rate of 70 bpm, 27 years old, and 70% training range:
220 – 27 = 193
193 – 70 = 123
123 x .70% = 86
86 + 70 = 156
Please note: There’s been some recent research to suggest a new way of estimating maximum heart rate. The formula is the following:

Multiply 0.7 times your age
.
Subtract that number from 208.
An example if you’re 26 years old is: 0.7 x 26 = 18, then 208 – 18 = 190. You’d then take 190 and plug it in as usual to the formula above. This new

formula makes a slightly bigger difference as you get older.SSS

TRAINING METHOD OF AEROBIC EXERCISE
The main methods of aerobics exercise are:

1.LONG DURATION CARDIO
2.INTERVAL TRAINING

1. LONG DURATION CARDIO
Long Duration Cardio is the moves which you perform for an extended period at a steady pace.

  • For example, a walk for one hour at a speed of 4 mph or a 30 minute run at 6 mph.
  • This burns a lot of calories
  • The longer the duration, the more calories get burnt.
  • It gives the daily calorie deficit which is sought after for losing weight.
  • This is great for heavier people.
  • It can be used as a starting point for workout programs as it will help in increasing endurance and will prep the body for further exercising.

EFFECTS
The effects of Long Duration Cardio are more immediate.

  • While doing these exercises, you have the “burn,” which means you burn calories even as you are working out.
  • They don’t have any after effects.
  • There is no hike in the metabolic process after you stop performing this cardio.

2. INTERVAL TRAINING
Interval Training workout comprises of alternate high and low-intensity intervals.

  • Like any other cardio workouts, these increase the calorie burn and build endurance.
  • These give better and faster results in less time compared to Long Duration Cardio.
  • These can be the second step for the weight loss program and is better for people who have better endurance than the beginners.
  • EFFECTS
  • An ideal Interval Training session will include alternate short, high-intensity intervals and longer, lower-intensity recovery periods.
  • In high-intensity intervals, maximum effort (as hard as you can) is required (this is a form of anaerobic exercise).
  • For beginners, it can be a little less intense, which can be in a little more aerobic form.
    You’ll know that you have reached your high-intensity period when you’ll have muscle burn (the burning sensation the muscle utilized).
  • Adding few of these intervals can give better results.
  • As these are very hard and taxing they are needed to be kept short and should be accompanied by longer lower intensity intervals (which are even called recovery intervals, as you recover from the burn of the muscle).
  • In a complete workout, there are five to ten cycles of high and low intensity. According to your fitness, you can vary the lengths of each interval, the number of cycles, and intensity of the cycle.

HEART RATE TRAINING
Let’s use jogging on a treadmill as the aerobic activity in this example. For example, if your heart rate is at 70% of your predicted maximum when you jog at 6 mph, then start at that speed and either increase the speed or elevation so that your heart rate increases to 85% or even 90% for one minute, then back to your usual jogging speed for three minutes to elicit a heart rate of 70%. Start with a 1:3 work:active-rest ratio. That’s a goodstarting point, and as you increase the work intervals and decrease the active-rest ratios like in the examples above, you’ll notice that your  conditioning improves so that your heart rate will be lower at the higher speeds.

It’s a good idea to plan your intervals in advance. Write them down so that you don’t have to think about it while you’re working out. intervals no more than one to two times per week because they are tough workouts and you will need some time to recover. It’s okay to do aerobic activity on days in between your intervals, but give your body a chance to recover from the intervals before doing them again.

INCEASING DURATION AND INTENSITY
The general rule for increasing aerobic activity is 10% per week. Interestingly, there’s no evidence to suggest that a 10% increase is the safest and most effective amount of time to increase, but that’s the rule of thumb and it seems to work pretty well. So, if you’re walking for 20 minutes then the next increase ought to be two minutes for the following week. The bottom line though is to listen to your body. If you find that increasing by 10% is very easy, then go ahead and try a little more. But if you find that you are tired for hours after your workout, or chronically sore or achy from your workouts, then you know you need to cut back to 10% increases. Learn how to listen to your body and everything should be OK.

EQUIPMENTS USED IN AEROBIC
Rowers, treadmills, bikes, and cross-country skiers are all effective if you use them. There is some suggestion that some individuals are more inclined to exercise at home with equipment than at the gym or a class. The activity you choose is a personal choice and it varies for everyone, and so you need to experiment until you find what works best for you. Some individuals prefer to go to the gym while others are perfectly content to work out at home on their own equipment in front of their TV. TV can make the time pass quickly, and so can your favorite movie, music, scholarly courses taught by professors, or books on tape (see resources for online vendors). Finding something that will distract you might just make that 30-minute workout bearable, and believe it or not you might even look forward to it! After all, it could be the only 30 minutes in your day that you have all to yourself.

AEROBIC CLASSES-

Classes are generally rated as beginner, intermediate, and advanced. Choose the level that fits your condition. It’s no fun taking an advanced class if you’re a beginner. It will be hard and frustrating and you won’t enjoy the experience. Watch the class or speak with the instructor to help you decide what’s right for you. Sometimes it comes down to the class time that fits your schedule, but just be sure to not get in too far over your head.
Low-impact classes mean that one foot always stays on the ground. They are less intense than high-impact and may be more suitable if you are a beginner. Some classes are now called, “high-low” or “mixed-impact” which means they combine low and high-impact moves. High-impact means both feet leave the ground, so there will be jumping and balance moves. Stick with lower-impact and more gentle and rhythmic.

 

POSTURAL DRAINAGE

INTRODUCTION-
Postural Drainage removes mucus from certain parts of the lungs by using gravity and proper positioning to bring the secretions into the throat where it is easier to remove them. The lungs are divided into segments called lobes, the right lung is divided into three lobes (right upper lobe, right middle lobe and right lower lobe) while the left lung has only two lobes (left upper lobe and lower lobe).

SCHEDULING TREATMENT
The treatment often works best in the morning. This allows the mucus to be removed that has built up during the night. Sometimes a treatment can be done at night to reduce the need for coughing during sleep. Make sure you wait at least 1-2 hours after eating before starting you treatment. This helps to prevent nausea and or vomiting. CPT just before meals may cause you to become tired and may decrease appetite.

ANATOMY OF LUNGS

 

lung-anatomy-illustration
LUNG ANATOMY ILLUSTRATION

STEPS
1. Use specific positions so the force of gravity can assist in the removal of bronchial secretions from affected lung segments to central airways by means of coughing and suctioning.
2. The patient is positioned so that the diseased area is in a near vertical position, and gravity is used to assist the drainage of specific segment.
3. The positions assumed are determined by the location, severity, and duration of mucous obstruction.
4. The exercises are performed two to three times a day, before meals and bedtime. Each position is done for 3-15 minutes.
5. The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs. These symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs.
6. Bronchodilators, mucolytics agents, water, or saline may be nebulised and inhaled before postural drainage and chest percussion to reduce bronchospasm, decrease thickness of mucus and sputum, and combat edema of the bronchial walls, there by enhancing secretion removal.
7. Perform secretion removal procedures before eating.
8. Make sure patient is comfortable before the procedure starts and as comfortable as possible he or she assumes each position.
9. Auscultate the chest to determine the areas of needed drainage.
10. Encourage the patient to deep breathe and cough after spending the allotted time in each position.
11. Encourage diaphragmatic breathing through out postural drainage: this helps widen airways so secretions can be drained.

POSITION

POSTURAL DRAINAGE POSITIONS
POSTURAL DRAINAGE POSITIONS

To drain the middle and lower portions of your lungs, you should be positioned with your chest above your head. Possible techniques to achieve this position are:

If a hospital bed is available, put in Trendelenburg position (head lower than feet).
Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip.
Stack 18-20 inches of pillow under hips.
Place on a tilt table, with head lower than feet.
Lower head and chest over the side of the bed.
To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.

Postural drainage therapy is designed to improve the mobilization of bronchial secretions and the matching of ventilation and perfusion, and to normalize functional residual capacity (FRC) based on the effects of gravity and external manipulation of the thorax. This includes turning, postural drainage, percussion, vibration, and cough.

TURNING
Turning is the rotation of the body around the longitudinal axis to promote unilateral or bilateral lung expansion and improve arterial oxygenation. Regular turning can be to either side or the prone position, with the bed at any degree of inclination (as indicated and tolerated). Patients may turn themselves or they may turned by the caregiver or by a special bed or device.

POSTURAL DRAINAGE
Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways (where they can be removed by cough or mechanical aspiration). Each position consists of placing the target lung segment(s) superior to the carina. Positions should generally be held for 3 to 15 minutes (longer in special situations). Standard positions are modified as the patient’s condition and tolerance warrant.

EXTERNAL MANIPULATION OF THE THORAX
A-PERCUSSION
Percussion is also referred to as cupping, clapping, and tapotement. The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung. This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained. No convincing evidence demonstrates the superiority of one method over the other.

B-VIBRATION
Vibration involves the application of a fine tremorous action (manually performed by pressing in the direction that the ribs and soft tissue of the chest move during expiration) over the draining area. No conclusive evidence supports the efficacy of vibration, the superiority of either manual or mechanical methods, or an optimum frequency.

INDICATIONS
Turning
Inability or reluctance of patient to change body position. (eg, mechanical ventilation, neuromuscular disease, drug-induced paralysis)
Poor oxygenation associated with position(eg, unilateral lung disease)
Potential for or presence of atelectasis
Presence of artificial airway
Postural Drainage

Evidence or suggestion of difficulty with secretion clearance
(a)Difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult)

(b)Evidence or suggestion of retained secretions in the presence of an artificial airway

-Presence of atelectasis caused by or suspected of being caused by mucus plugging.
-Diagnosis of diseases such as cystic fibrosis,bronchiectasis, or cavitating lung disease
-Presence of foreign body in airway.
-External Manipulation of the Thorax

(a)Sputum volume or consistency suggesting a need for additional manipulation (eg, percussion and/or vibration) to assist movement of secretions by gravity, in a patient receiving postural drainage

CONTRAINDICATIONS
The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Listed contraindications are relative unless marked as absolute .

1 Positioning

All positions are contraindicated for

Intracranial pressure (ICP) > 20 mm Hg(59,60)
Head and neck injury until stabilized
Active hemorrhage with hemodynamic instability
Recent spinal surgery (eg, laminectomy) or acute spinal injury
Acute spinal injury or active hemoptysis
Empyema
Bronchopleural fistula
Pulmonary edema associated with congestive heart failure
Large pleural effusions
Pulmonary embolism
Aged, confused, or anxious patients who do not tolerate position changes
Rib fracture, with or without flail chest surgical wound or healing tissue

Trendelenburg position is contraindicated for

Intracranial pressure (ICP) > 20 mm Hg(59,60) patients in whom increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye surgery)
Uncontrolled hypertension
Distended abdomen
Esophageal surgery
Recent gross hemoptysis related to recent lung carcinoma treated surgically or with radiation therapy
Uncontrolled airway at risk for aspiration (tube feeding or recent meal)

Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication

2 External Manipulation of the Thorax
In addition to contraindications previously listed

subcutaneous emphysema
Recent epidural spinal infusion or spinal anesthesia
Recent skin grafts, or flaps, on the thorax
Burns, open wounds, and skin infections of the thorax
Recently placed transvenous pacemaker or subcutaneous pacemaker (particularly if mechanical devices are to be used)
Suspected pulmonary tuberculosis lung contusion
Bronchospasm
Osteomyelitis of the ribs
Osteoporosis
Coagulopathy
Complaint of chest-wall pain

COMPLICATIONS
Hypoxemia
Increased Intracranial Pressure
Acute Hypotension during Procedure
Pulmonary Hemorrhage
Pain or Injury to Muscles, Ribs, or Spine
Vomiting and Aspiration
Bronchospasm
Dysrhythmias

LIMITATIONS OF METHOD
1-Presumed effectiveness of PDT and its application may be based more on tradition and anecdotal report than on scientific evidence. The procedure has been used excessively and in patients in whom it is not indicated.

2-Airway clearance may be less than optimal in patients with ineffective cough.
3-Optimal positioning is difficult in critically ill patients.

ASSESSMENT OF OUTCOME

These represent individual criteria that indicate a positive response to therapy (and support continuation of therapy). Not all criteria are required to justify continuation of therapy (eg, a ventilated patient may not have sputum production > 30 mL/day, but have improvement in breath sounds, chest x-ray, or increased compliance or decreased resistance).

1.CHANGE IN SPUTUM PRODUCTION
If sputum production in an optimally hydrated patient is less than 25 mL/day with PDT the procedure is not justified. Some patients have productive coughs with sputum production from 15 to 30 mL/day (occasionally as high as 70 or 100 mL/day) without postural drainage. If postural drainage does not increase sputum in a patient who produces > 30 mL/day of sputum without postural drainage, the continuation of the therapy is not indicated. Because sputum production is affected by systemic hydration, apparently ineffective PDT probably should be continued for at least 24 hours after optimal hydration has been judged to be present.

2. CHANGE IN BREATH SOUNDS AND LUNG FIELDS ARE DRAINED
With effective therapy, breath sounds may ‘worsen’ following the therapy as secretions move into the larger airways and increase rhonchi. An increase in adventitious breath sounds can be a marked improvement over absent or diminished breath sounds. Note any effect that coughing may have on breath sounds. One of the favorable effects of coughing is clearing of adventitious breath sounds.

3 PATIENT SUBJECTIVE RESPONSE TO THERAPY
The caregiver should ask patient how he or she feels before, during, and after therapy. Feelings of pain, discomfort, shortness of breath, dizziness, and nausea should be considered in decisions to modify or stop therapy. Easier clearance of secretions and increased volume of secretions during and after treatments support continuation.

4. CHANGES IN VITAL SIGNS
Moderate changes in respiratory rate and/or pulse rate are expected. Bradycardia, tachycardia, or an increase in irregularity of pulse, or fall or dramatic increase in blood pressure are indications for stopping therapy.

5. CHANGES IN X-RAYS
Resolution or improvement of atelectasis may be slow or dramatic.

6. CHANGES IN ARERIAL BLOOD GAS VALUE AND OXYGN SATURATION
Oxygenation should improve as atelectasis resolves.

7. CHANGE IN VENTILATOE VARIABLE
Resolution of atelectasis and plugging reduces resistance and increases compliance.

LUNG VOLUMES AND CAPACITIES

RESPIRATORY PHYSIOLOGY
The respiratory physiology is on the process of incorporation of oxygen in the environment for the utilization of energy from the organic compounds and for the elimination of carbon dioxide.

 

LUNG VOLUMES AND CAPACITIES
                              LUNG VOLUMES AND CAPACITIES

TIDAL VOLUME(500 ml)
The volume of air breathed in and out at rest is known as the tidal volume (TV). This is found to be about 500 ml in an averagely built (70 kg), healthy, young adult. The tidal volume tends to decrease in restrictive lung diseases. In restrictive lung diseases, the lungs fail to expand properly as a result of restrictive forces exerted from within the lungs (e.g. – fibrosing alveolitis) or from the thoracic wall (e.g. – severe scoliosis, ankylosing spondylitis). Weakness of the respiratory muscles (e.g. – myasthenia gravis, Guillain Barre syndrome and phrenic nerve palsy) can also give rise to restricted movements of the chest wall resulting in the reduction of the tidal volume.

INSPIRATORY RESERVE VOLUME (IRV)(3100 ml) AND
EXPIRATORY RESERVE VOLUME(ERV)(1200 ml)
In addition to the amount of air that could be inspired at rest, the lungs are capable of accommodating an additional amount of air during a deep inspiration. This amount of air that can be inhaled in addition to the tidal volume is known as the inspiratory reserve volume (IRV). Similarly, in a deep and forceful expiration, the lungs are capable of exhaling a volume which is in excess to the tidal volume and the inspiratory reserve volume. This is known as the expiratory reserve volume (ERV). In a healthy young adult, IRV measures about 3100 ml and the ERV is approximately 1200 ml.

RESIDUAL VOLUME(1200 ml)
The lungs do not collapse completely following a deep, forceful expiration. A certain volume of air remains within the lungs, maintaining the alveoli expanded and the airways patent. This volume, which cannot be expelled even after a maximally forceful expiration, is known as the residual volume (RV).

MEASURMENT OF LUNG VOLUMES – (SPIROMETRY)

The tidal volume,tidal volume, IRV and ERV can be measured using a device known as a spirometer. Here, the volume changes that occur in a closed circuit are measured while an individual is breathing through a mouthpiece into a measuring device. The volume change that occurs while the individual is engaged in quite breathing is the tidal volume. The volume that the individual inhales in excess of the tidal volume during a deep inspiration is the IRV and the volume that is exhaled in excess to the tidal volume during a deep expiration is the ERV.

MEASURMENT OF RESIDUAL VOLUME – (HELIUM DILUTION)

 

helium dilution method
                         HELIUM DILUTION METHOD

The residual volume cannot be measured with a conventional spirometer. Therefore, to measure the residual volume, several techniques have been described. In one such technique, an individual breaths into a closed circuit, which contains a known amount of Helium. Helium does not cross the blood-gas barrier and is not excreted by the lungs. Thus, decrease in the concentration of Helium is brought about by the increase in the volume of the circuit by connecting the circuit to the respiratory system. When, the concentration of Helium is measured following a deep expiration, the total volume is the volume of the breathing circuit + the residual volume. Since concentration = amount of a substance / volume of distribution, the residual volume can be calculated.

LUNG CAPACITIES-

Four capacities have been described based on the four lung volumes:

1.Inspiratory Capacity (IC) is the maximum volume of air that can be inhaled following a resting state. This can be calculated by the addition of tidal volume and the IRV-3600 ml

2.Vital Capacity (VC) is the maximum volume of air that can be exhaled following a deep inspiration. This is the total of IRV + TV + ERV- 4800ml

3.Functional Residual Capacity (FRC) is the volume of air that remains in the lungs during quite breathing. FRC = ERV + RV 2400 ml

4.Total Lung Capacity (TLC) is the volume the whole respiratory system can accommodate. Therefore, TLC= IRV + TV + ERV + RV 6000ml.

Lung capacities and lung volumes are affected in different types of physiological processes as well as in lung diseases. The specific changes that occur in different types of diseases will be described in a separate hub along with examples for different patterns of abnormalities seen in the lung volumes.

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.

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.