Physical therapy


Published on

Published in: Health & Medicine
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Physical therapy

  2. 2. CONCEPT…• Physical therapies are treatmentapproaches that use physiologic orphysical interventions to effectbehavioral change.• The most common form of physicaltherapies are: Electroconvulsivetherapy, light therapy, repetitivetranscranial magnetic stimulation4/24/2013
  4. 4. INTRODUCTION…• Electroconvulsive therapy is a type ofsomatic treatment, first introduced by Bini &Cerletti in April 1938.• From 1980 onwards ECT is beingconsidered as a unique psychiatrictreatment.4/24/2013
  5. 5. DEFINITION• ECT is a type of somatic treatment inwhich electric current is applied to thebrain through electrodes placed on thetemples of the patient. The passage ofan electrical stimulus of 70 to 120 voltsto the brain for 0.7 to 1.5 second toproduce a grandmal seizures.4/24/2013
  6. 6. MECHANISM OF ACTION• The exact mechanism of action is notknown.• One hypothesis states that ECT possiblyaffects the catecholamine pathwaysbetween diencephalon (from where seizuregeneralization occurs) & limbic system(which may be responsible for mooddisorders), also involving thehypothalamus.4/24/2013
  7. 7. TYPES / TECHNIQUES / METHODSOF ECT1. Direct ECT2. Modified ECT4/24/2013
  8. 8. 1. Direct ECT:• In this, ECT is given in the absence ofanesthesia & muscular relaxation.• This is not commonly used methodnow.4/24/2013
  9. 9. 2. Modified ECT:• In this, ECT is modified by drug-induced muscular relaxation, generalanesthesia & oxygenation.• Administer the anesthetic agent(thiopental sodium 3-5mg/kg bodyweight) & muscle relaxant (1mg/kgbody weight of succynylcholine)4/24/2013
  10. 10. PLACEMENT OF ELECTODES• There are two types of administration:1. Bilateral ECT2. Unilateral ECT4/24/2013
  11. 11. 1. Bilateral ECT:• Each electrode is placed 2.5-4 cm (1-1½ inch) above the midpoint, on a linejoining the tragus of the ear & thelateral canthus of the eye.4/24/2013
  12. 12. 2. Unilateral ECT:• Electrodes are placed only on one sideof head, usually non-dominant side(right side of head in a right-handedindividual).• Unilateral ECT is safer, with muchfewer side-effects particularly those ofmemory impairment.4/24/2013
  13. 13. PARAMETERS OF ELECTRICALCURRENT APPLIEDStandard dose according to AmericanPsychiatric Association,1978:• Voltage – 70 – 120 volts• Duration – 0.7 – 1.5 seconds4/24/2013
  14. 14. FREQUENCY AND TOTAL NUMBEROF ECT• Frequency: Three times per weekor as indicated.• Total number: 6 to 10; upto 25 maybe preferred as indicated.4/24/2013
  15. 15. OBSERVATION OF PRODUCTION OFSEIZURE• The production of grandmal seizure isnecessary for direct & modified ECT.• In direct ECT, the Tonic Phase that ismuscle contractions last for 10-15 secondapproximately. The Clonic Phase that ismovement or convulsion lasts for 30 to 60seconds approximately. Than patients goesin to the Relaxation Phase. The physiciancan see changes in ECG also4/24/2013
  16. 16. Count…• In modified ECT, mild grimace orblepharo-spasm ( a tonic spasm of theeyelid muscle) is observed when thecurrent is applied. There is a slow planterflexion (reverse Babinskis) during thetonic phase & there are fine movements ofthe toes during the Clonic phase.4/24/2013
  17. 17. INDICATIONS OF ECTI. Major Depression:- With suicidal risk- With stupor; poor intake of food & fluids- Melancholia with psychotic features- Post-partum depression- Unsatisfactory response to drugs or wheredrugs are contraindicated or have seriousside effects4/24/2013
  18. 18. Count…II. Severe catatonia (functional):- With stupor; poor intake of food &fluids- Unsatisfactory response to drugtherapy, or when drugs arecontraindicated or have serious sideeffects.- When speedier recovery is needed4/24/2013
  19. 19. Count…III. Severe psychosis (schizophrenia ormania):- With risk of suicide, homicide or dangerof physical assault- Depressive features- Unsatisfactory response to drug therapy,or when drugs are contraindicated orhave serious side effects.4/24/2013
  20. 20. Count…IV.Organic mental disorders:- Organic mood disorders- Organic psychosis4/24/2013
  21. 21. Count…V. Other indications:- Premorbid personality- Previous depressive episode- Paranoid delusion- Anorexia- Early morning insomnia- Wight loss- Lack of concentration- Ideas of guilt & worthlessness- Suicidal thought & suicidal attempts4/24/2013
  22. 22. Count…- ECT is preferred to antidepressant therapyin some cases, such as for patient withcardiac disease; when tricyclics arecontraindicated because of the potential fordysrhythmias & congestive heart failure; &for pregnant women, in whomantidepressants place the fetus at risk forcongenital defects4/24/2013
  23. 23. CONTRAINDICATIONS OF ECTA. Absolute:• Raised ICP(intracranialpressure)B. Relative:• Cerebral aneurysm• Cerebral hemorrhage• Brain tumor• Acute myocardial infarction• Congestive heart failure• Pneumonia or aortic aneurysm• Retinal detachment• CVA• Hypertension• Thrombophelebitis• bleeding disorder4/24/2013
  24. 24. SIDE EFFECTS OF ECT• Memory impairment• Drowsiness, confusion & restlessness• Poor concentration, anxiety• Headache, weakness/fatigue, backache,muscle aches• Dryness of mouth, palpitation, nausea, vomiting• Unsteady gait• Tongue bite & incontinence4/24/2013
  25. 25. COMPLICATION OF ECT1. Fractures & dislocations2. Complication in the respiratory system3. Other complication4/24/2013
  26. 26. Count…1. Fractures & dislocations: Most frequently the fracture & dislocation arecaused by muscular contraction due to ECT Compression fracture of vertebrae of dorsal areabetween the 2nd & 8th usually 3rd , 4th & 5thvertebrae is common. Fracture of femur & humerus occurs in youngmuscular individuals. Dislocation of jaw is the most frequentcomplication of the tonic phase.4/24/2013
  27. 27. Count…2. Complication in the respiratory system: Apnea Respiratory arrest4/24/2013
  28. 28. Count…3. Other complication: Headache, backache, painful mastication, injuryof mouth & tongue. Fear due to an unpleasant experience onwalking up after the treatment. Stuns & subshocks occur due to an insufficientcurrent applied to the patient which does notresult in a full convulsive stage. Thesesubshocks or stuns will sometimes producecardiac irregularities, respiratory distress &collapse.4/24/2013
  29. 29. ECT TEAM• Psychiatrist• Anesthesiologist• Trained nurses & aides4/24/2013
  30. 30. TREATMENT FACILITIESThere should be a suite of three rooms:1. A pleasant, comfortable waiting room (pre-ECTroom).2. ECT room, which should be equipped with ECTmachine & accessories, an anesthetic appliance,suction apparatus, face masks, oxygen cylinderswith adjustable flow valves, curved tonguedepressors, mouth gags, resuscitation apparatus& emergency drugs. There should be immediateaccess to defibrillator.3. A well-equipped recovery room.4/24/2013
  31. 31. ROLE OF THE NURSEA. Pre-treatment EvaluationB. Intra-procedure CareC.Post-procedure Care4/24/2013
  32. 32. A. Pre-treatment Evaluation:• Detailed medical & psychiatric history, includinghistory of allergies.• Assessment of patients’ & families knowledge ofindications, side-effects, therapeutic effects &risks associated with ECT.• An informed consent should be taken. Allay anyunfounded fears & anxieties regarding theprocedure.• Assess baseline vital signs.• Patient should be on empty stomach for 4-6hours prior to ECT.4/24/2013
  33. 33. Count…• Withhold night doses of drugs, which increase seizurethreshold like diazepam, barbiturates &anticonvulsants.• Withhold oral medications in the morning .• Head shampooing in the morning since oil causesimpedance of passage of electricity to brain.• Any jewellery, prosthesis, dentures, contact lens,metallic objects & tight clothing should be removedfrom the patient’s body.• Empty bladder & bowel just before ECT.• Administration of 0.6 mg atropine IM or SC 30 minutesbefore ECT, or IV just before ECT.4/24/2013
  34. 34. B. Intra-procedure Care:• Place the patient comfortably on the ECT table insupine position.• Stay with the patient to allay anxiety & fear.• Assist in administering the anesthetic agent(thiopental sodium 3-5 mg/kg body weight) & musclerelaxant (1 mg/kg body weight of succynylcholine).• Since the muscle relaxant paralyzes all musclesincluding respiratory muscles, patient airway shouldbe ensured & ventilatory support should be started.• Mouth gag should be inserted to prevent possibletongue bite.4/24/2013
  35. 35. Count…• The place(s) of electrode placement should becleaned with normal saline or 25% bicarbonatesolution, or a conducting gel applied.• Monitor voltage, intensity & duration of electricalstimulus given.• Monitor seizure activity using cuff method.• 100% oxygen should be provided.• During seizure monitor vital signs, ECG, oxygensaturation, ECG, etc.• Record the findings & medicines given in thepatient’s chart4/24/2013
  36. 36. C. Post-procedure Care:• Monitor vital signs.• Continue oxygenation till spontaneous respiration starts.• Assess for post-ictal confusion & restlessness.• Take safety precautions to prevent injury (side-lying position &suctioning to prevent aspiration of secretions, use of side railsto prevent falls).• If there is severe post-ictal confusion & restlessness, IVdiazepam may be administered.• Reorient the patient after recovery & stay with him until fullyoriented.• Document any findings as relevant in the patient’s record.4/24/2013
  37. 37. LIGHTTHERAPY4/24/2013
  38. 38. CONCEPT…• Light therapy sometimes calledphototherapy involves exposing thepatient to an artificial light source duringwinter months to relieve seasonaldepression.• The light source must be very bright,full-spectrum light, usually 2,500 lux.4/24/2013
  39. 39. INDICATIONS• Bulimia• Sleep maintenance insomnia• Seasonal depression4/24/2013
  40. 40. ADVERSE EFFECTS• Nausea• Eye irritation• Headache4/24/2013
  41. 41. CONTRAINDICATIONS• Glaucoma• Cataract• Use of photosensitizing medications.4/24/2013
  42. 42. NURSE’S ROLE• The patient is instructed to sit in front ofthe light at a distance of about 3 feet,engaging in a variety of the otheractivities but glancing directly into thelight every few minutes.• The duration of administration is 1-2 hrsdaily.4/24/2013
  44. 44. REPETITIVE TRANSCRANIALMAGNETIC STIMULATION:• Transcranial Magnetic Stimulation (TMS) orRepetitive Transcranial Magnetic Stimulation(RTMS) produces a magnetic field over the brain,influencing brain activity.• TMS increases the release of neurotransmitters &downregulates bets-adrenergic receptors, thusameliorating depressive symptoms & otherdisorders.• Because TMS does not require anesthesia, it isan attractive alternative to ECT if convulsiveevidence of its efficiency can be demonstrated.4/24/2013
  45. 45. Count…• Some studies have suggested that it is aseffective as ECT in non-psychotic patients.• Adverse effects include seizures inpreviously seizure-free individuals,headache, & transient hearing loss.• Patient with metal implanted in their bodies(for example, plates), pacemakers, heartdisease or increased intracranial pressureshould be carefully evaluated beforereceiving TMS4/24/2013
  46. 46. ThankYou4/24/2013