Ptpm010 Ptm Of Physical Mobility Impairment Medical Journal…

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Ptpm010 Ptm Of Physical Mobility Impairment Medical Journal…

  1. 1. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 1 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. KAL MERA HAATH PAKADNA, JAB MAIN BOODHA HO JAAOON PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS SPEC. BY: Abdulrehman S. Mulla DATE: 04/09/2009 REVISION HISTORY REV. DESCRIPTION CN No. BY DATE 01 Initial Release PT0009 ASM 05/24/2009 Medicine: It’s a noble profession, it serves humanity. 1/124
  2. 2. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 2 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. TABLE OF CONTENTS PAGE 1.0 CEREBRAL PALSY: 7 1.1 FOR CEREBRAL PALSY: 8 1.2 EXERCISING WITH CEREBRAL PALSY: THE WORKOUT: 10 1.2.1 RANGE-OF-MOTION AND OTHER EXERCISES: 10 A. RANGE-OF-MOTION EXERCISES (ROM): 11 I. WARMING UP: 11 II. EXERCISES TO KEEP THE FULL MOTION OF JOINTS, TO AVOID CONTRACTURES: 11 III. STRETCHING: 12 IV. STRENGTHENING EXERCISES WITH MOTION: 12 V. STRENGTHENING EXERCISES WITHOUT MOTION: 12 B. SWIMMING: 13 C. WEIGHT RESISTANCE EXERCISES: 13 D. BREATHING AND MUSCLE STRENGTHENING EXERCISES: 14 E. AEROBIC EXERCISES: 14 F. INFLATABLE THERAPY BALLS: 15 2.0 SPINA BIFIDA: 16 2.1 PHYSIOTHERAPY FOR SPINA BIFIDA: 17 2.1.1 EXERCISE/FITNESS: 18 A. GENERAL GUIDELINES AND SAFETY: 18 I. BREATHING: 18 II. POSTURE: 18 III. BACK SUPPORT: 18 IV. REST: 18 B. SAMPLE PHYSICAL ACTIVITY PROGRAM: 18 C. USE AND CARE OF THE ELASTIC RESISTANCE BAND: 19 I. NECK STRETCH: 19 II. WRIST FLEXION / EXTENSION: 19 III. OVERHEAD STRETCH: 19 IV. UPPER TRUNK FLEXION: 19 V. TRICEPS STRETCH: 20 VI. BUTTERFLY STRETCH: 20 VII. TRUNK ROTATION: 20 VIII. HAMSTRING STRETCH: 20 IX. SEATED EXERCISES: 20 X. ELBOW FLEXION: 20 XI. FORWARD REACH: 21 XII. UPRIGHT ROW: 21 XIII. OVERHEAD REACH: 21 XIV. HIP FLEXION: 21 XV. HIP ABDUCTION: 21 3.0 MUSCULAR DYSTROPHY: 23 3.1 TYPES OF MUSCULAR DYSTROPHY AND NEUROMUSCULAR DISEASES: 24 3.1.1 OTHER NEUROMUSCULAR DISEASES: 25 3.2 PHYSIOTHERAPY FOR MUSCULAR DYSTROPHY: 26 3.2.1 PASSIVE STRETCHING: 26 A. HIPS: 26 B. KNEES: 27 C. FEET AND ANKLES: 27 D. ELBOWS, FOREARMS AND WRISTS: 27 3.2.2 ACTIVE AND ACTIVE ASSISTED EXERCISES: 27 A. ELBOW, WRIST & HAND EXERCISES ELBOW, WRIST & HAND EXERCISES: 27 Medicine: It’s a noble profession, it serves humanity. 2/124
  3. 3. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 3 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. KNEE EXERCISE: 28 C. HEAD & TRUNK EXTENSION: 28 3.2.3 CHEST PHYSIOTHERAPY IN CHILDREN: 28 A. THE MAIN TECHNIQUES USED ARE 28 I. POSTURAL DRAINAGE: 28 II. PERCUSSIONS: 29 III. ASSISTING COUGH: 29 3.2.4 POSITIONING AND SEATING IN MUSCULAR DYSTROPHY: 29 4.0 HEART DEFECTS: 31 4.1 PHYSIOTHERAPY AFTER HEART SURGERY: 32 5.0 AMPUTATION: 35 5.1 CAUSES AND THE NEED FOR AMPUTATIONS: 36 5.2 REHABILITATION AFTER AMPUTATION: 36 5.3 PHYSICAL THERAPY MANAGEMENT OF AMPUTEES: 38 5.3.1 PHYSICAL THERAPY MANAGEMENT OF ADULT : 38 A. PRESURGICAL MANAGEMENT: 38 I. INITIAL PATIENT CONTACT: 38 B. POSTSURGICAL MANAGEMENT: 39 I. MENTAL STATUS: 39 II. RANGE OF MOTION: 39 III. STRENGTH: 39 IV. SENSATION: 39 VI. BED Mobility 40 V. BALANCE/COORDINATION: 40 VI. TRANSFERS: 40 VII. WHEELCHAIR PROPULSION: 40 VII. AMBULATION WITH ASSISTIVE DEVICES WITHOUT A PROSTHESIS: 40 VIII. CARDIAC PRECAUTIONS FOR AMPUTEES: 40 B. PATIENT EDUCATION: LIMB MANAGEMENT 41 I. LIMB CARE: 41 II. PROBLEM DETECTION/SKIN CARE: 41 III. PROSTHETIC MANAGEMENT: 41 IV. SOCK REGULATION 41 V. DONNING AND DOFFING OF THE PROSTHESIS: 41 VI. RESIDUAL-LIMB WRAPPING: 42 C. PREPROSTHETIC EXERCISE: 43 I. STRENGTHENING: 43 II. RANGE OF MOTION: 44 III. FUNCTIONAL ACTIVITIES: 45 IV. GENERAL CONDITIONING: 45 V. BED MOBILITY: 45 VI. WHEELCHAIR PROPULSION: 46 V. UNSUPPORTED STANDING BALANCE: 47 D. PREGAIT TRAINING: 48 I. BALANCE AND COORDINATION: 48 II. ORIENTATION TO THE CENTER OF GRAVITY AND BASE OF SUPPORT: 48 III. SINGLE-LIMB STANDING: 49 E. GAIT-TRAINING SKILLS: 50 I. SOUND LIMB AND PROSTHETIC LIMB TRAINING: 50 II. PELVIC MOTIONS: 50 III. VARIATIONS: 54 F. ADVANCED GAIT-TRAINING ACTIVITIES: 55 I. STAIRS: 55 II. STEP BY STEP: 55 III. STEP OVER STEP: 55 Medicine: It’s a noble profession, it serves humanity. 3/124
  4. 4. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 4 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. IV. TRANSTIBIAL AMPUTEES: STEP OVER STEP 56 V. CRUTCHES: 56 VI. CURBS: 56 V. UNEVEN SURFACES: 56 VI. RAMPS AND HILLS: 56 VII. SIDESTEPPING: 57 VIII. BACKWARD WALKING: 57 IX. MULTIDIRECTIONAL TURNS: 57 X. TANDEM WALKING: 58 XI. BRAIDING: 58 XII. SINGLE-LIMB SQUATTING: 59 XIII. FALLING: 59 XIV. FLOOR TO STANDING: 59 XV. RUNNING SKILLS: 59 XVI.RECREATIONAL ACTIVITIES: 61 5.3.2 ADULT UPPER LIMB PROSTHETIC TRAINING: 62 A. POSTOPERATIVE THERAPY PROGRAM: 62 I. PROMOTE WOUND HEALING: 63 II. CONTROL INCISIONAL AND PHANTOM PAIN: 63 III. MAINTAIN JOINT RANGE OF MOTION: 63 IV. EXPLORE THE FEELINGS OF THE PATIENT AND FAMILY: 64 V. FINANCIAL SPONSORSHIP: 64 B. PREPROSTHETIC THERAPY PROGRAM: 64 I. RESIDUAL LIMB SHRINKAGE AND SHAPING: 65 II. RESIDUAL LIMB DESENSITIZATION: 65 III. MAINTENANCE OF JOINT RANGE OF MOTION: 65 IV. INCREASING MUSCLE STRENGTH: 66 V. INSTRUCTION IN PROPER HYGIENE OF THE LIMB: 66 VI. MAXIMIZING INDEPENDENCE: 66 VII. MYOELECTRIC SITE TESTING: 66 C. DETERMINING THE PROSTHETIC PRESCRIPTION: 67 I. FABRICATION AND TRAINING TIME: 67 D. ADULT UPPER-LIMB PROSTHETIC TRAINING: 68 I. INITIAL ASSESSMENT: 68 II. STATUS OF THE OPPOSITE UPPER LIMB: · 68 III. INITIAL VISIT: 69 IV. ORIENTATION TO PROSTHETIC COMPONENT TERMINOLOGY: 69 V. PROSTHETIC WEARING SCHEDULE: 69 VII. CARE OF THE RESIDUAL LIMB AND PROSTHESIS: 69 VIII. BODY CONTROL MOTIONS: 70 IX. PROSTHETIC EVALUATION: 71 X. PROSTHETIC CONTROLS TRAINING: 71 XI. CONTROLS PRACTICE: 72 XII. FUNCTIONAL USE TRAINING: 72 XIII. CUTTING FOOD: 73 XIV. USING SCISSORS: 73 XV. DRESSING: 73 XVI. OPENING A JAR OR BOTTLE: 74 XVI. WASHING DISHES: 74 XVII. HAMMERING A NAIL AND USING TOOLS: 74 XVIII. DRIVING A CAR: 74 XIX. VOCATIONAL ACTIVITIES: 75 XX. HOME INSTRUCTIONS: 75 XXI. FOLLOW-UP ISSUES: 76 6.0 ARTHRITIS: 78 6.1 OSTEOARTHRITIS: 79 Medicine: It’s a noble profession, it serves humanity. 4/124
  5. 5. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 5 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 6.1.1 THOSE ODD PAINS: 80 A. STRESS: 80 B. AGE: 81 C. HEREDITY: 81 D. DIAGNOSIS: 81 E. IF IT HURTS, WHY DO DOCTORS WANT PATIENTS TO EXERCISE? 81 6.2 RHEUMATOID ARTHRITIS: 82 6.2.1. WHEN THE BODY TURNS ON ITSELF: 82 A. STIFFNESS IN THE MORNING: 83 1. DIAGNOSIS: 83 2. TREATMENT: 83 6.3 JUVENILE RHEUMATOID ARTHRITIS: 84 6.3.1 OTHER FORMS OF ARTHRITIS: 85 A. GOUT: 85 B. FIBROMYALGIA: 86 C. LUPUS: 87 1. TREATMENT: 87 a. Treating Mild Systemic Lupus Erythematosus: 87 b. Treating Severe Systemic Lupus Erythematosus: 87 c. Treating Specific Complications 88 B. DIET AND LUPUS: 88 D. LYME DISEASE: 90 6.4 LIVING WITH ARTHRITIS: 91 7.0 BACK DISORDERS: 92 7.1 RECOMMENDATIONS FOR TREATMENT OF LOWER BACK PAIN: 93 Medicine: It’s a noble profession, it serves humanity. 5/124
  6. 6. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 6 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. PHYSICAL MOBILITY IMPAIRMENT: A physical impairment might be defined as a disabling condition or other health impairment that requires adaptation. Persons with physical impairment disabilities often use assertive devices or mobility aids such as crutches, canes, wheelchairs and artificial limbs to obtain mobility. The physical disability the person experiences may be either congenital, or a result of injury, muscular dystrophy, cerebral palsy, amputation, multiple sclerosis, pulmonary disease, heart disease or other reasons. Some persons may experience non-visible disabilities that may include respiratory disorders, epilepsy, or other conditions. Medicine: It’s a noble profession, it serves humanity. 6/124
  7. 7. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 7 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. PHYSICAL MOBILITY IMPAIRMENT INCLUDES THE FOLLOWING  CEREBRAL PALSY  SPINA BIFIDA o QUADRIPLEGIA o PARAPLEGIA  MUSCULAR DYSTROPHY  HEART DEFECTS  AMPUTATION  ARTHRITIS  BACK DISORDERS 1.0 CEREBRAL PALSY: The term, 'Cerebral Palsy,' is used to describe a group of chronic conditions, which affect body movements and muscle coordination in persons affected with the disorder. Cerebral Palsy causes damage to one or more particular areas of the person's brain, and usually occurs during fetal development or before, during, or shortly after birth; although the damage may be done during infancy. Cerebral Palsy disorders are not caused by problems in the person's nerves or muscles. Faults in the development or damage to motor areas in the person's brain disrupt their brain's ability to control posture and movement. Cerebral Palsy is not progressive, although secondary conditions like muscle spasticity may develop that can worsen or improve over time, or may remain the same. Cerebral Palsy is not a communicable disease. Cerebral Palsy is not curable, but therapy and training may help to improve function. Medicine: It’s a noble profession, it serves humanity. 7/124
  8. 8. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 8 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 1.1 FOR CEREBRAL PALSY: Physical therapy for cerebral palsy patients consists of activities and education to improve flexibility, strength, mobility, and function. A physical therapist also designs, modifies, and orders adaptive equipment. Physical therapy can take place in clinics, hospitals, schools, and should carry on in the home through an exercise program. Physical therapy for cerebral palsy patients will not be successful without an ongoing daily home program. A physical therapy program should consist of a number of exercises that include stretching, strengthening, and positioning. To stretch the muscles, the arms and legs must be moved in ways that produce a slow, steady pull on the muscles to keep them loose. Because of the increased muscle tone of the cerebral palsy patient, they tend to have generally tight muscles. Therefore, it is extremely important to perform daily stretches to keep the arms and legs limber, allowing the child to continue to move and function. Strengthening exercises work specific muscle groups to enable them to support the body better and increase function. Positioning requires the body to be placed in a specific position to attain long stretches. Some positions help to minimize unwanted tone. Positioning can be done in a variety of ways.  Bracing,  Abduction pillows,  Knee immobilizers,  Wheelchair inserts,  Sitting recommendations,  Handling techniques are all part of positioning techniques used in physical therapy for cerebral palsy patients. New techniques of physical therapy for cerebral palsy patients have taken to the water. Medicine: It’s a noble profession, it serves humanity. 8/124
  9. 9. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 9 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Aquatic-based rehabilitation uses the physical properties of water to resist or assist in the performance of exercises. Cerebral palsy patients experience muscle shortening in most of their involved extremities and it becomes a difficult task to lengthen the affected musculature with regular stretching while having to deal with the affects that gravity has on the spastic arm or leg. In the past, there was clinical prejudice against strengthening activities for this population. However, recent research findings are revealing that children with cerebral palsy can benefit from strengthening programs and that strength is directly related to motor function. Some of the documented benefits are optimization of neuromuscular responses, improved motor unit contraction synchrony and facilitation of maximal muscle contraction along a joint's available range of motion. Physical therapy for cerebral palsy patients does not cure spasticity but can improve impairments and limitations. Physical therapy for cerebral palsy patients is an important step towards an independent lifestyle. If these changes happen only in the therapy gym, the disability remains unchanged. Therapy must improve abilities to perform meaningful tasks in everyday life. Changing the level of disability is the ultimate goal of physical therapy for cerebral palsy Medicine: It’s a noble profession, it serves humanity. 9/124
  10. 10. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 10 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 1.2 EXERCISING WITH CEREBRAL PALSY: THE WORKOUT: Exercising with cerebral palsy is not only good for the patient but in most cases it is absolutely essential for the well-being of the patient and for loosening the muscles which can be very constricted at times. The exercises must be adapted to the particular patient's needs but general movement is agreeable as well. Playing outdoors, swimming, aerobic exercise, weight resistance training, all are acceptable forms of exercise for people suffering from cerebral palsy. 1.2.1 RANGE-OF-MOTION AND OTHER EXERCISES: All children need exercise to keep their bodies strong, flexible, and healthy. Most village children get all the exercise they need through ordinary daily activity: crawling, walking, running, climbing, playing games, lifting things, carrying the baby, and helping with work in the house and farm. Disabled children should get their exercise in ways that are useful and fun! As much as is possible, disabled children should get their exercise in these same ways. However, sometimes a child's disability does not let him use or move his body, or parts of it, well enough to get the exercise he needs. Muscles that are not used regularly grow weak. Joints that are not moved through their full range of motion get stiff and can no longer be completely straightened or bent. So we need to make sure that the disabled child uses and keeps strong whatever muscles he has, and that he moves all the parts of his body through their full range of motion. Sometimes a child may need help with these exercises. But as much as possible, he should be encouraged to do them himself, in ways that are useful and fun. No matter at what age you begin to exercise, or how long you may have been inactive, proper exercise will always improve your physical condition. People who have been inactive for some time can do the exercises in this booklet. Programs to improve flexibility, strength, and endurance are arranged in three levels of difficulty. It is important to begin any exercise program slowly and build up gradually. Remember, it may take several months to attain the minimal levels of physical fitness identified in Level I activities. Some people will take less time, others more. Before beginning an exercise program, have a physical examination and discuss the program with your doctor. In addition, if your mobility is limited as a result of a chronic or disabling condition, be sure to review these exercises with your doctor. Keep in mind your level of ability and endurance so that you don't risk discomfort or injury. If you experience pain while exercising, stop that particular movement and ask your doctor about it on your next visit. Stick with it, and you will see results! Different exercises for different needs Different kinds of exercises are needed to meet the special needs of different children. On the next two pages we give an example of each kind of exercise. Then we look at some of the different exercises in more detail. Medicine: It’s a noble profession, it serves humanity. 10/124
  11. 11. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 11 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. PURPOSE OF EXERCISE KIND OF EXERCISE To maintain or increase joint 1. Range-of-motion exercises (ROM) motion 2. Stretching exercises 3. Strengthening exercise with motion: exercises that work the muscles and move the joint against To maintain or increase resistance strength 4. Strengthening exercises without motion: exercises that work the muscles without moving the joint 5. Practice at holding things or doing things in To improve position good positions 6. Practice doing certain movements and actions, To improve control to improve balance or control A. RANGE-OF-MOTION EXERCISES (ROM): I. WARMING UP: Preparing the body for exercise is important for people at any age and all fitness levels. A warm-up period should begin with slow, rhythmic activities such as walking or jogging in place. Gradually increase the intensity until your pulse rate, respiration rate and body temperature are elevated, which is usually about the time that you break a light sweat. It also is advisable to do some easy stretching exercises (such as the ones on page 6) before moving on to the strength and endurance activities. II. EXERCISES TO KEEP THE FULL MOTION OF JOINTS, TO AVOID CONTRACTURES: PT slowly bends, straightens, and moves all the joints as far as they normally go. At least 2 times a day, these exercises must be carried out at home. Medicine: It’s a noble profession, it serves humanity. 11/124
  12. 12. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 12 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. III. STRETCHING: Stretch tightened muscles by working on the problem area for several minutes each day. For example, if the problem is tight calf muscles, the patient should exercise the legs by standing on his or her toes and slowly bouncing up and down. Also, flexing the calves in a sitting position, with the toes flexed and touching the toes, is a great stretching exercise. Stretching is a basic exercise for all cerebral palsy patients. Different kinds of exercises can promote stretching. Just standing as tall as the palsy will allow is strongly beneficial. Supports should be used where needed, in case the patient is not capable of standing alone. IV. STRENGTHENING EXERCISES WITH MOTION: To strengthen the weak muscles in the thighs, raise and lower one at a time as shown below without added weight and later with a sandbag on the ankle. As the leg gets stronger the weight can be increased. V. STRENGTHENING EXERCISES WITHOUT MOTION: For a painful knee with weak thighs, that hurts when moved and standing is impaired. The muscles of the thighs need to be strengthened by following the muscle contracting and releasing exercise This strengthening exercise must be done without the movement of the knee. The leg must be held straight and the muscles thigh contracted and released for a certain amount of time. Repeatability of this exercise will add strength to the thigh. Medicine: It’s a noble profession, it serves humanity. 12/124
  13. 13. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 13 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. B. SWIMMING: Swimming is an excellent exercise for patients with cerebral palsy as the water has a certain amount of resistance to it. The patient can float and his or her weight is much more buoyant than it is without water, so the person's movements are less restricted. Cold water is beneficial for increasing muscle tone while warm water tends to relax muscles. Whatever is needed for the muscle tone of the individual is what should be selected. C. WEIGHT RESISTANCE EXERCISES: Assist the patient in performing weight resistance exercises, using only the amount of weight that the patient can safely handle. , Ankle bands and small dumbbells are ideal for this purpose. Medicine: It’s a noble profession, it serves humanity. 13/124
  14. 14. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 14 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. D. BREATHING AND MUSCLE STRENGTHENING EXERCISES: Work the arms and legs in a cycling motion, using stationary bikes or hand machines. This can provide many positive effects for improving breathing and muscle strengthening. E. AEROBIC EXERCISES: Try different types of aerobic exercises, such as jogging, walking and climbing the stairs. These exercises work on improving circulation as well as muscle flexibility and strength. Many children enjoy dancing and it can be a great way to improve muscle tone and tightness as well as their breathing and circulation. Medicine: It’s a noble profession, it serves humanity. 14/124
  15. 15. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 15 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. F. INFLATABLE THERAPY BALLS: Using certain tools to help with stretching therapy is a good idea. Inflatable therapy balls and therapy bolsters are useful for stretching the tight muscles of the cerebral palsy patient. Stretch the hamstrings with standers and floor sitters. Standers are comparable to wheelchairs that keep the child strapped into a standing position and floor sitters are padded chairs with chest brace straps so the child can sit on the floor upright like other children. Pediatric Pressure Splints, are inflatable hand and ankle foot orthoses and wrist and forearm splints designed for therapy and proper limb positioning for infants, children, and adolescents with cerebral palsy. The transparent, durable PVC splints feature a softer inner layer which conforms to and equalizes pressure over the limb. The splints may be inflated orally or with a blower, and they may also be filled with water and refrigerated for use as a cold pack. Medicine: It’s a noble profession, it serves humanity. 15/124
  16. 16. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 16 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.0 SPINA BIFIDA: Spina Bifida is a form of neural tube defect. Neural tube defects involve incomplete development of the brain, spinal cord, and/or their protective coverings, which are caused by the failure of the fetus' spine to close properly during the first month of pregnancy. Children who are born with Spina Bifida may have an open lesion on their spine where notable damage to their nerves and spinal cord has happened. The nerve damage is permanent, although the opening in the spine can be surgically repaired. The damage to the child's nerves may result in various degrees of paralysis in their lower limbs. In cases where there is no lesion present there is still the potential for the presence of improperly formed or missing vertebrae, as well as nerve damage. Persons with Spina Bifida often experience a form of learning disability in conjunction with physical and mobility disability. There is currently no cure for Spina Bifida; the nerve tissue can neither be repaired nor replaced. Treatment for Spina Bifida may involve surgery, physiotherapy, and medication. Many persons with Spina Bifida use assistive devices including braces, crutches, or wheelchairs.  QUADRIPLEGIA is paralysis of the extremities and trunk caused by a neck injury. People with quadriplegia have limited or no use of their arms and hands and often use electric wheelchairs.  PARAPLEGIA is paralysis of the lower extremities and the lower trunk caused by an injury to the mid-back. People often use a manual wheelchair and have full movement of arms and hands. Below are brief descriptions of other causes of mobility impairments. Medicine: It’s a noble profession, it serves humanity. 16/124
  17. 17. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 17 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.1 PHYSIOTHERAPY FOR SPINA BIFIDA: Management of spina bifida depends on its severity. Medical specialists, nurses, physiotherapists, speech and occupational therapists, social workers and neuropsychologists all contribute to manage the condition. As there is damage to the central nervous system, there is currently no cure. Generally, limitations in mobility can result in poor skin and muscle tone, and weight gain and declining mobility in adolescents. The child's normal social development may be hampered because of frequent hospital stays, outpatient appointments, and periods in plaster. The spinal cord: An operation is performed immediately after birth to close the lesion on the back. For the majority of children, no further treatment of the spinal cord is required. For a minority, further complications including spinal curvature and spinal cord adhesion will require additional surgery. Incontinence: Varying degrees of incontinence are a result of the nerve signals between the brain and bowel/bladder being impaired. Surgery of various types may be helpful in some cases. Bladder management usually involves Clean Intermittent Catheterisation. Initially parents, and then the individuals, learn to insert a catheter to empty the bladder a number of times daily. Social continence is thus achieved. Bowel management requires additional training and dietary considerations. However, by the time the child reaches the age of seven, incontinence problems are usually under control, although occasional 'accidents' will occur.  Shunt complications: Once inserted, the modern shunt causes few problems. Sometimes, however, a shunt may need to be replaced if it becomes blocked or infected. Symptoms of shunt malfunction are diverse and varying. Early signs can be detected in a gradual deterioration of the child's overall performance. Sometimes, symptoms are severe and include headaches and vomiting. A suspected shunt malfunction should be immediately communicated to parents and requires medical intervention.  Mobility: special braces help weakness and paralysis of the lower limbs (eg. Ankle Foot Orthosis: AFOs), crutches or wheelchairs. Surgery may be performed to enable functioning muscles to work more effectively. Some children will be involved in ongoing physiotherapy programs to maximize muscles and joint function.  Skin care: Children with spina bifida often have a lack of sensation due to nerve damage and poor circulation. They are prone to injury from prolonged pressure, friction, heat or cold. To prevent sores and burns, conscientious skin care, frequent position changes and careful monitoring of the child's environment is essential.  Testing: Professional neuropsychological assessment of the child to identify visual perception, auditory processing and cognitive differences is also essential in overall management. A range of specific interventions may be required from an early age.  It is important that the school does its best to manage the physical environment for students with SBH. Impaired mobility requires appropriate modifications to buildings and grounds. Incontinence requires access to toilet and washroom facilities that provide additional space, provision for support and privacy. Medicine: It’s a noble profession, it serves humanity. 17/124
  18. 18. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 18 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 2.1.1 EXERCISE/FITNESS:  Make sure you are healthy enough to exercise. Inform your physician that you are starting an exercise program.  Choose the right program for YOU and make sure to keep activities that you choose VARIED, FUN, and REWARDING.  Exercise a minimum of five days a week, ideally performing strengthening exercises 3 to 4 days a week.  Be active throughout the day - just keep moving. A. GENERAL GUIDELINES AND SAFETY: Many people with spina bifida have latex allergy. If this is the case, always check beforehand to make sure that the exercise equipment is not made of latex. Equipment manufacturers such as Thera-band offer latex-free versions of their products. I. BREATHING: Breathe normally while performing the exercises. Do not hold your breath at any time. To make sure that you are not overdoing the exercises, you should be able to maintain a normal conversation. If you are exercising alone, it is best to count out loud while doing the exercises. A useful technique is to slowly count 1-2 when performing the exercise action, and count 1-4 when going back returning to the starting position. II. POSTURE: Sit up tall with both feet planted firmly on the floor. III. BACK SUPPORT: To make sure that your lower back is supported, roll up a small towel and place it behind your back. IV. REST: Give your muscles a day's rest between strength training sessions. Your muscles may feel sore a day or two after you've started a new exercise. IF you are sore, wait until soreness has diminished before going back to strength training. Consult with your doctor if the muscle soreness lasts longer than two days. In addition, if muscle soreness last 2-3 hours after exercise, you know you have done too much. During the next exercise session, decrease the number of repetitions, sets, or weight until you find the right settings for you. B. SAMPLE PHYSICAL ACTIVITY PROGRAM: Include as much variety as possible. M, W, F - walk 30 minutes, lift weights for 20 minutes, stretch for 10 minutes. Tuesday/Thursday: ride the stationary bike for 15 minutes and perform a dance video for 15 minutes. On the weekends, go hiking in a local park, swim during the summer months or ride a bike (three wheeled bicycles are becoming popular). Medicine: It’s a noble profession, it serves humanity. 18/124
  19. 19. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 19 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. C. USE AND CARE OF THE ELASTIC RESISTANCE BAND: Before starting, always check the band for damage. Make sure that the elastic band is wrapped firmly (but not too tight!) around your fists. Adjust the length of the band so that there is just enough slack/elastic resistance and you are able to go through the full or comfortable range of motion when exercising. Avoid pinching or pulling of body hair by covering area of skin. Control the band to avoid snapping back The resistance level of the band increases by decreasing the bands distance between your hands or by folding it over. As you increase strength, move to another color band for increased resistance. Store the band in a dark location. Keep away from pets and children. I. NECK STRETCH:  Tilt your head to the side, moving your ear toward your shoulder  Hold for 20 seconds.  Return your head to an upright position.  Repeat on the opposite side.  This stretches the side of the neck. II. WRIST FLEXION / EXTENSION:  Extend the arm and hand forward. Palm facing outward.  Bend your wrist and assist the movement with your other hand.  Hold.  Then straighten your wrist and assist the movement with your other hand.  Hold. III. OVERHEAD STRETCH:  Sit on the chair with back and neck straight. Feet are planted firmly on the floor.  Raise arms up overhead.  Interlock fingers if possible, for a stronger stretch.  Extend your arms, straightening the elbows.  This stretches the muscles of the shoulder. IV. UPPER TRUNK FLEXION:  Sit with proper posture. Eyes looking forward, and feet planted firmly on the floor.  Bring your chin to your chest and round the upper trunk keeping head, neck, and shoulders relaxed.  Keep your bottom firmly on the seat.  Slowly straighten the back, and then bring head back to neutral/ starting position.  Repeat. Medicine: It’s a noble profession, it serves humanity. 19/124
  20. 20. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 20 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. V. TRICEPS STRETCH:  Stand or sit with proper posture. Bring one arm across your body.  Using your other hand, gently pull your elbow farther across your body.  Feel the stretch along the back of your shoulder.  Hold for 20 seconds.  Release the stretch briefly. Do the stretch 2 times with each arm. VI. BUTTERFLY STRETCH:  Sit with proper posture and place your hands behind your neck.  Slowly and gently bring your elbows backward, being careful not to pull on your neck.  When your elbows are as far back as they will go, pause briefly.  Feel the stretch in your shoulders and chest  Relax and return to the starting position  Repeat 10 times. VII. TRUNK ROTATION:  Sit in chair and gently rotate you trunk and shoulders to one side  Use your arms to help rotate  Repeat in opposite direction.  You should feel a stretch in your trunk. VIII.HAMSTRING STRETCH:  Sit in chair and extend one leg forward  Keep knee straight and gently lean toward your toes  Repeat on the other leg  You should feel a stretch in the hamstrings.  Don't perform this exercise if it increases leg pain. IX. SEATED EXERCISES:  For seated exercises, sit up tall with both feet planted firmly on the floor.  You may want to use a rolled up towel to support your lower back.  Begin with a few repetitions and progress to 12 as you increase your strength X. ELBOW FLEXION:  Place the band crosswise on the seat of the chair. Adjust the length of the band so that there is enough slack.  Sit in chair or wheelchair arm free.  Wrap the band around the hand with palm facing upwards.  Tie the exerciser at knee level on the side of the chair or across legs  Bend elbow  Hold.  Return to start position. Medicine: It’s a noble profession, it serves humanity. 20/124
  21. 21. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 21 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. XI. ELBOW EXTENSION:  Place the half of the band crosswise on the seat of the chair. Adjust the length of the band so that there is enough slack.  Sit on the band, arm free. Make sure that the band crosses diagonally across the back.  Wrap the band around your hand with elbow bent, and palm facing downward.  Straighten elbow. Hold.  Return to start position. XII. FORWARD REACH:  Begin with band wrapped around your upper back.  Grasp both ends of band with elbows bent and palms facing inward.  Push band forward, extending your elbows to shoulder level.  Slowly return to starting position. XIII.UPRIGHT ROW:  Place center of band under both feet and grasp each end of the band with palms facing down  Pull band upward toward chin, lifting elbows outward.  Slowly return to the starting position. XIV.OVERHEAD REACH:  Place center of band under feet and grasp each end of the band with palms facing forward.  Lift arms forward and upward, extending your elbows with palms facing forward.  Don't lift above your shoulders if it causes pain.  Slowly return to the starting position. XV. HIP FLEXION:  Sit on firm surface, the exerciser around thighs.  Raise knee to chest, keeping opposite leg stationary.  Hold.  Return to start position. XVI.HIP ABDUCTION:  Sit on firm surface, the exerciser around thighs, near knees.  Lift one leg slightly and pull away from other leg.  Hold.  Return to start position. LEG PRESS:  Begin looping middle of band around foot with your knee bent.  Hold both ends of the band at your waist.  Keeping ends of band at your waist, extend knee to straighten leg.  Slowly return to starting position  Repeat on other leg. Medicine: It’s a noble profession, it serves humanity. 21/124
  22. 22. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 22 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. Tatyana McFadden, a young woman with spina bifida, was featured last week in the Washington Post for the inspiration she receives competing in wheelchair track events. Tatyana, who is 16, will be among the youngest of the 1,247 athletes competing at the European Wheelchair Championships in Espoo, Finland this month. quot;McFadden, 16, a sophomore at the Columbia school, will be among the youngest of the 1,247 athletes at the event; they will represent 47 countries. But she is considered a rising star on the U.S. Paralympic Team and one of the world's most talented wheelchair athletes, quite an accomplishment for a girl who wasn't expected to live more than a few weeks. McFadden was born in St. Petersburg, Russia, with spina bifida, a congenital defect in the spinal column that left her paralysed from the waist down. Abandoned by her mother, she lived in an orphanage until an American woman who worked for the U.S. Department of Health and Human Services providing humanitarian aid overseas spotted her. quot;She's already one of the top athletes in the world,quot; said Joe Walsh, the managing director for U.S. Paralympics. quot;If she keeps improving the way she has, then three or four years from now she could be challenging to be the best ever at her sport.quot; Medicine: It’s a noble profession, it serves humanity. 22/124
  23. 23. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 23 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 3.0 MUSCULAR DYSTROPHY: 'Muscular Dystrophy,' describes a group of genetic diseases, which are characterized by progressive weakness, and degeneration of the person's skeletal or voluntary muscles used to control movement. Some forms of Muscular Dystrophy affect heart muscles, as well as some additional, involuntary muscles. Some forms of Muscular Dystrophy affect a person's organs as well. Duchene is the form of Muscular Dystrophy that affects children most commonly; Myotonic Muscular Dystrophy is the most common form of the disease affecting adult populations. There are some forms of Muscular Dystrophy that appear in infancy or childhood, while other forms may not appear until a person reaches middle age or older. Muscular Dystrophy has the potential to affect persons of any age group. There is no specific treatment for any form of Muscular Dystrophy. Both Physical therapy and corrective orthopedic surgery may improve a person's quality of life. Medicine: It’s a noble profession, it serves humanity. 23/124
  24. 24. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 24 of 124 PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. 3.1 TYPES OF MUSCULAR DYSTROPHY AND NEUROMUSCULAR DISEASES: Muscular dystrophy is a group of inherited diseases that are characterized by weakness and wasting away of muscle tissue, with or without the breakdown of nerve tissue. There are nine types of muscular dystrophy, with each type involving an eventual loss of strength, increasing disability, and possible deformity. The most well known of the muscular dystrophies is Duchenne muscular dystrophy (DMD), followed by Becker muscular dystrophy (BMD). Listed below are the nine different types of muscular dystrophy. Each type differs in the muscles affected, the age of onset, and its rate of progression. Some types are named for the affected muscles, including the following: TYPE AGE AT ONSET SYMPTOMS, RATE OF PROGRESSION, AND LIFE EXPECTANCY Becker Adolescence to early Symptoms are almost identical to Duchenne but less severe; adulthood progresses more slowly than Duchenne; survival into middle age. Congenital birth Symptoms include general muscle weakness and possible joint deformities; disease progresses slowly; shortened life span. Duchenne 2 to 6 years Symptoms include general muscle weakness and wasting; affects pelvis, upper arms, and upper legs; eventually involves all voluntary muscles; survival beyond 20s is rare. Distal 40 to 60 years Symptoms include weakness and wasting of muscles of the hands, forearms, and lower legs; progression is slow; rarely leads to total incapacity. Emery-Dreifuss Childhood to early teens Symptoms include weakness and wasting of shoulder, upper arm, and shin muscles; joint deformities are common; progression is slow; sudden death may occur from cardiac problems. Facioscapulohumeral Childhood to early adults Symptoms include facial muscle weakness and weakness with some wasting of shoulders and upper arms; progression is slow, with periods of rapid deterioration; life span may be many decades after onset. Limb-Girdle Late childhood to middle Symptoms include weakness and wasting, affecting shoulder age girdle and pelvic girdle first; progression is slow; death is usually due to cardiopulmonary complications. Myotonic 20 to 40 years Symptoms include weakness of all muscle groups accompanied by delayed relaxation of muscles after contraction; affects face, feet, hands, and neck first; progression is slow, sometimes spanning 50 to 60 years. Oculopharyngeal 40 to 70 years Symptoms affect muscles of eyelids and throat causing weakening of throat muscles, which, in time, causes inability to swallow and emaciation from lack of food; progression is slow. Medicine: It’s a noble profession, it serves humanity. 24/124

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