Physical therapy
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  • 2. CONCEPT… • Physical therapies are treatment approaches that use physiologic or physical interventions to effect behavioral change. • The most common form of physical therapies are: Electroconvulsive therapy, light therapy, repetitive transcranial magnetic stimulation 4/24/2013
  • 4. INTRODUCTION… • Electroconvulsive therapy is a type of somatic treatment, first introduced by Bini & Cerletti in April 1938. • From 1980 onwards ECT is being considered as a unique psychiatric treatment. 4/24/2013
  • 5. DEFINITION • ECT is a type of somatic treatment in which electric current is applied to the brain through electrodes placed on the temples of the patient. The passage of an electrical stimulus of 70 to 120 volts to the brain for 0.7 to 1.5 second to produce a grandmal seizures. 4/24/2013
  • 6. MECHANISM OF ACTION • The exact mechanism of action is not known. • One hypothesis states that ECT possibly affects the catecholamine pathways between diencephalon (from where seizure generalization occurs) & limbic system (which may be responsible for mood disorders), also involving the hypothalamus. 4/24/2013
  • 7. TYPES / TECHNIQUES / METHODS OF ECT 1. Direct ECT 2. Modified ECT 4/24/2013
  • 8. 1. Direct ECT: • In this, ECT is given in the absence of anesthesia & muscular relaxation. • This is not commonly used method now. 4/24/2013
  • 9. 2. Modified ECT: • In this, ECT is modified by drug- induced muscular relaxation, general anesthesia & oxygenation. • Administer the anesthetic agent (thiopental sodium 3-5mg/kg body weight) & muscle relaxant (1mg/kg body weight of succynylcholine) 4/24/2013
  • 10. PLACEMENT OF ELECTODES • There are two types of administration: 1. Bilateral ECT 2. Unilateral ECT 4/24/2013
  • 11. 1. Bilateral ECT: • Each electrode is placed 2.5-4 cm (1- 1½ inch) above the midpoint, on a line joining the tragus of the ear & the lateral canthus of the eye. 4/24/2013
  • 12. 2. Unilateral ECT: • Electrodes are placed only on one side of head, usually non-dominant side (right side of head in a right-handed individual). • Unilateral ECT is safer, with much fewer side-effects particularly those of memory impairment. 4/24/2013
  • 13. PARAMETERS OF ELECTRICAL CURRENT APPLIED Standard dose according to American Psychiatric Association,1978: • Voltage – 70 – 120 volts • Duration – 0.7 – 1.5 seconds 4/24/2013
  • 14. FREQUENCY AND TOTAL NUMBER OF ECT • Frequency: Three times per week or as indicated. • Total number: 6 to 10; upto 25 may be preferred as indicated. 4/24/2013
  • 15. OBSERVATION OF PRODUCTION OF SEIZURE • The production of grandmal seizure is necessary for direct & modified ECT. • In direct ECT, the Tonic Phase that is muscle contractions last for 10-15 second approximately. The Clonic Phase that is movement or convulsion lasts for 30 to 60 seconds approximately. Than patients goes in to the Relaxation Phase. The physician can see changes in ECG also 4/24/2013
  • 16. Count… • In modified ECT, mild grimace or blepharo-spasm ( a tonic spasm of the eyelid muscle) is observed when the current is applied. There is a slow planter flexion (reverse Babinski's) during the tonic phase & there are fine movements of the toes during the Clonic phase. 4/24/2013
  • 17. INDICATIONS OF ECT I. Major Depression: - With suicidal risk - With stupor; poor intake of food & fluids - Melancholia with psychotic features - Post-partum depression - Unsatisfactory response to drugs or where drugs are contraindicated or have serious side effects 4/24/2013
  • 18. Count… II. Severe catatonia (functional): - With stupor; poor intake of food & fluids - Unsatisfactory response to drug therapy, or when drugs are contraindicated or have serious side effects. - When speedier recovery is needed 4/24/2013
  • 19. Count… III. Severe psychosis (schizophrenia or mania): - With risk of suicide, homicide or danger of physical assault - Depressive features - Unsatisfactory response to drug therapy, or when drugs are contraindicated or have serious side effects. 4/24/2013
  • 20. Count… IV.Organic mental disorders: - Organic mood disorders - Organic psychosis 4/24/2013
  • 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 attempts 4/24/2013
  • 22. Count… - ECT is preferred to antidepressant therapy in some cases, such as for patient with cardiac disease; when tricyclics are contraindicated because of the potential for dysrhythmias & congestive heart failure; & for pregnant women, in whom antidepressants place the fetus at risk for congenital defects 4/24/2013
  • 23. CONTRAINDICATIONS OF ECT A. Absolute: • Raised ICP (intracranial pressure) B. Relative: • Cerebral aneurysm • Cerebral hemorrhage • Brain tumor • Acute myocardial infarction • Congestive heart failure • Pneumonia or aortic aneurysm • Retinal detachment • CVA • Hypertension • Thrombophelebitis • bleeding disorder 4/24/2013
  • 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 & incontinence 4/24/2013
  • 25. COMPLICATION OF ECT 1. Fractures & dislocations 2. Complication in the respiratory system 3. Other complication 4/24/2013
  • 26. Count… 1. Fractures & dislocations:  Most frequently the fracture & dislocation are caused by muscular contraction due to ECT  Compression fracture of vertebrae of dorsal area between the 2nd & 8th usually 3rd , 4th & 5th vertebrae is common.  Fracture of femur & humerus occurs in young muscular individuals.  Dislocation of jaw is the most frequent complication of the tonic phase. 4/24/2013
  • 27. Count… 2. Complication in the respiratory system:  Apnea  Respiratory arrest 4/24/2013
  • 28. Count… 3. Other complication:  Headache, backache, painful mastication, injury of mouth & tongue.  Fear due to an unpleasant experience on walking up after the treatment.  Stuns & subshocks occur due to an insufficient current applied to the patient which does not result in a full convulsive stage. These subshocks or stuns will sometimes produce cardiac irregularities, respiratory distress & collapse. 4/24/2013
  • 29. ECT TEAM • Psychiatrist • Anesthesiologist • Trained nurses & aides 4/24/2013
  • 30. TREATMENT FACILITIES There should be a suite of three rooms: 1. A pleasant, comfortable waiting room (pre-ECT room). 2. ECT room, which should be equipped with ECT machine & accessories, an anesthetic appliance, suction apparatus, face masks, oxygen cylinders with adjustable flow valves, curved tongue depressors, mouth gags, resuscitation apparatus & emergency drugs. There should be immediate access to defibrillator. 3. A well-equipped recovery room. 4/24/2013
  • 31. ROLE OF THE NURSE A. Pre-treatment Evaluation B. Intra-procedure Care C.Post-procedure Care 4/24/2013
  • 32. A. Pre-treatment Evaluation: • Detailed medical & psychiatric history, including history of allergies. • Assessment of patients’ & families knowledge of indications, side-effects, therapeutic effects & risks associated with ECT. • An informed consent should be taken. Allay any unfounded fears & anxieties regarding the procedure. • Assess baseline vital signs. • Patient should be on empty stomach for 4-6 hours prior to ECT. 4/24/2013
  • 33. Count… • Withhold night doses of drugs, which increase seizure threshold like diazepam, barbiturates & anticonvulsants. • Withhold oral medications in the morning . • Head shampooing in the morning since oil causes impedance of passage of electricity to brain. • Any jewellery, prosthesis, dentures, contact lens, metallic objects & tight clothing should be removed from the patient’s body. • Empty bladder & bowel just before ECT. • Administration of 0.6 mg atropine IM or SC 30 minutes before ECT, or IV just before ECT. 4/24/2013
  • 34. B. Intra-procedure Care: • Place the patient comfortably on the ECT table in supine position. • Stay with the patient to allay anxiety & fear. • Assist in administering the anesthetic agent (thiopental sodium 3-5 mg/kg body weight) & muscle relaxant (1 mg/kg body weight of succynylcholine). • Since the muscle relaxant paralyzes all muscles including respiratory muscles, patient airway should be ensured & ventilatory support should be started. • Mouth gag should be inserted to prevent possible tongue bite. 4/24/2013
  • 35. Count… • The place(s) of electrode placement should be cleaned with normal saline or 25% bicarbonate solution, or a conducting gel applied. • Monitor voltage, intensity & duration of electrical stimulus given. • Monitor seizure activity using cuff method. • 100% oxygen should be provided. • During seizure monitor vital signs, ECG, oxygen saturation, ECG, etc. • Record the findings & medicines given in the patient’s chart 4/24/2013
  • 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 rails to prevent falls). • If there is severe post-ictal confusion & restlessness, IV diazepam may be administered. • Reorient the patient after recovery & stay with him until fully oriented. • Document any findings as relevant in the patient’s record. 4/24/2013
  • 37. LIGHT THERAPY 4/24/2013
  • 38. CONCEPT… • Light therapy sometimes called phototherapy involves exposing the patient to an artificial light source during winter months to relieve seasonal depression. • The light source must be very bright, full-spectrum light, usually 2,500 lux. 4/24/2013
  • 39. INDICATIONS • Bulimia • Sleep maintenance insomnia • Seasonal depression 4/24/2013
  • 40. ADVERSE EFFECTS • Nausea • Eye irritation • Headache 4/24/2013
  • 41. CONTRAINDICATIONS • Glaucoma • Cataract • Use of photosensitizing medications. 4/24/2013
  • 42. NURSE’S ROLE • The patient is instructed to sit in front of the light at a distance of about 3 feet, engaging in a variety of the other activities but glancing directly into the light every few minutes. • The duration of administration is 1-2 hrs daily. 4/24/2013
  • 44. REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION: • Transcranial Magnetic Stimulation (TMS) or Repetitive Transcranial Magnetic Stimulation (RTMS) produces a magnetic field over the brain, influencing brain activity. • TMS increases the release of neurotransmitters & downregulates bets-adrenergic receptors, thus ameliorating depressive symptoms & other disorders. • Because TMS does not require anesthesia, it is an attractive alternative to ECT if convulsive evidence of its efficiency can be demonstrated. 4/24/2013
  • 45. Count… • Some studies have suggested that it is as effective as ECT in non-psychotic patients. • Adverse effects include seizures in previously seizure-free individuals, headache, & transient hearing loss. • Patient with metal implanted in their bodies (for example, plates), pacemakers, heart disease or increased intracranial pressure should be carefully evaluated before receiving TMS 4/24/2013
  • 46. Thank You 4/24/2013