This document provides recommendations for implementing a multidisciplinary approach to managing Duchenne muscular dystrophy (DMD). It discusses:
1) Physical therapy interventions like stretching, bracing, and assistive devices to prevent contractures and maintain mobility.
2) Surgical options for contractures depending on the patient's ambulatory stage, including tendon lengthening and transfers.
3) Recommendations for exercise emphasizing submaximum aerobic activity and avoiding high resistance to prevent injury.
Artigo - Acupuncture and physiotherapy for painful shoulderRenato Almeida
This randomized controlled trial evaluated the efficacy of single-point acupuncture combined with physiotherapy compared to physiotherapy alone for the treatment of painful shoulder. 425 patients with subacromial syndrome received 15 sessions of physiotherapy over 3 weeks along with either weekly acupuncture at point ST38 or sham TENS. Patients receiving acupuncture showed significantly greater improvement in shoulder function scores and reported less analgesic use compared to the control group receiving only physiotherapy. The study demonstrates that adding acupuncture to physiotherapy can more effectively treat painful shoulder conditions.
Does shortened length of hospital stay affect total knee arthroplasty rehabil...FUAD HAZIME
The study compared rehabilitation outcomes for patients who participated in a hospital joint arthroplasty program designed to decrease length of stay ("Joint Camp") to outcomes for patients before the program was implemented. The program reduced average length of stay by 1.3 days but resulted in decreased range of motion at discharge. No significant differences were found between the groups at 3, 6, and 12 month follow ups for range of motion or Knee Society scores, suggesting primary knee arthroplasty rehabilitation outcomes were not compromised by the reduced hospital stay.
The study evaluated the efficacy of paraffin bath therapy for hand osteoarthritis. 56 patients were randomly assigned to either a treatment group receiving paraffin baths or a control group. Outcome measures including pain, hand function, range of motion and strength were assessed at baseline, 3 weeks and 12 weeks. At 12 weeks, the treatment group showed significantly greater improvements in pain, range of motion and strength compared to the control group. Paraffin bath therapy appeared effective in reducing pain and maintaining strength for hand osteoarthritis over 12 weeks.
This document reviews arguments for and against the traditional general practitioner-led model of care for patients with musculoskeletal pain. It discusses how musculoskeletal pain is common and costly. Currently, most healthcare systems rely on general practitioners to be the first point of contact for patients with musculoskeletal issues like back pain, but some evidence suggests this model may not be best. The review critically analyzes the key arguments for and against different professional groups taking responsibility for early assessment and treatment of musculoskeletal problems.
This document discusses chronic low back pain, including its natural course, diagnosis, interventional treatments, and costs. It notes that while low back pain is very common, affecting 80-90% of people at some point, its definition and classification are inconsistent. The natural course of low back pain is poorly understood. While previously thought to have a generally favorable prognosis, more recent research shows that a majority of patients still experience pain long after initial episodes. The document calls for a standardized classification system to improve research and guide treatment. It also reviews options for diagnostic testing, conservative and interventional treatments, and notes the need to base treatment selection on available evidence. Finally, it discusses issues around the organization and costs of medical specialist care for low
This study investigated the effects of a home exercise program on motor performance in patients with Parkinson's disease. Patients were divided into two groups - an exercise group that received a home exercise schedule and a control group that did not. Both groups were assessed at baseline and after 1 and 2 months. The exercise group showed significant improvements in walking speed, first step length, time to walk around a chair, and hand motor performance compared to the control group. The study concluded that a home-based rehabilitation program can help improve motor function for patients with Parkinson's disease.
The article discusses the impacts of the COVID-19 pandemic on physiatry and rehabilitation medicine. It highlights how physiatrists played a vital role in the front lines during the pandemic by converting rehabilitation units and innovating care delivery. However, the pandemic has also caused significant disruptions and stress for medical practices through reduced patient volumes, higher costs, and threats of reimbursement cuts from insurers and governments. Moving forward, physicians are questioning the level of support they will receive from their employers and the government given the sacrifices many have made during the pandemic.
Artigo - Acupuncture and physiotherapy for painful shoulderRenato Almeida
This randomized controlled trial evaluated the efficacy of single-point acupuncture combined with physiotherapy compared to physiotherapy alone for the treatment of painful shoulder. 425 patients with subacromial syndrome received 15 sessions of physiotherapy over 3 weeks along with either weekly acupuncture at point ST38 or sham TENS. Patients receiving acupuncture showed significantly greater improvement in shoulder function scores and reported less analgesic use compared to the control group receiving only physiotherapy. The study demonstrates that adding acupuncture to physiotherapy can more effectively treat painful shoulder conditions.
Does shortened length of hospital stay affect total knee arthroplasty rehabil...FUAD HAZIME
The study compared rehabilitation outcomes for patients who participated in a hospital joint arthroplasty program designed to decrease length of stay ("Joint Camp") to outcomes for patients before the program was implemented. The program reduced average length of stay by 1.3 days but resulted in decreased range of motion at discharge. No significant differences were found between the groups at 3, 6, and 12 month follow ups for range of motion or Knee Society scores, suggesting primary knee arthroplasty rehabilitation outcomes were not compromised by the reduced hospital stay.
The study evaluated the efficacy of paraffin bath therapy for hand osteoarthritis. 56 patients were randomly assigned to either a treatment group receiving paraffin baths or a control group. Outcome measures including pain, hand function, range of motion and strength were assessed at baseline, 3 weeks and 12 weeks. At 12 weeks, the treatment group showed significantly greater improvements in pain, range of motion and strength compared to the control group. Paraffin bath therapy appeared effective in reducing pain and maintaining strength for hand osteoarthritis over 12 weeks.
This document reviews arguments for and against the traditional general practitioner-led model of care for patients with musculoskeletal pain. It discusses how musculoskeletal pain is common and costly. Currently, most healthcare systems rely on general practitioners to be the first point of contact for patients with musculoskeletal issues like back pain, but some evidence suggests this model may not be best. The review critically analyzes the key arguments for and against different professional groups taking responsibility for early assessment and treatment of musculoskeletal problems.
This document discusses chronic low back pain, including its natural course, diagnosis, interventional treatments, and costs. It notes that while low back pain is very common, affecting 80-90% of people at some point, its definition and classification are inconsistent. The natural course of low back pain is poorly understood. While previously thought to have a generally favorable prognosis, more recent research shows that a majority of patients still experience pain long after initial episodes. The document calls for a standardized classification system to improve research and guide treatment. It also reviews options for diagnostic testing, conservative and interventional treatments, and notes the need to base treatment selection on available evidence. Finally, it discusses issues around the organization and costs of medical specialist care for low
This study investigated the effects of a home exercise program on motor performance in patients with Parkinson's disease. Patients were divided into two groups - an exercise group that received a home exercise schedule and a control group that did not. Both groups were assessed at baseline and after 1 and 2 months. The exercise group showed significant improvements in walking speed, first step length, time to walk around a chair, and hand motor performance compared to the control group. The study concluded that a home-based rehabilitation program can help improve motor function for patients with Parkinson's disease.
The article discusses the impacts of the COVID-19 pandemic on physiatry and rehabilitation medicine. It highlights how physiatrists played a vital role in the front lines during the pandemic by converting rehabilitation units and innovating care delivery. However, the pandemic has also caused significant disruptions and stress for medical practices through reduced patient volumes, higher costs, and threats of reimbursement cuts from insurers and governments. Moving forward, physicians are questioning the level of support they will receive from their employers and the government given the sacrifices many have made during the pandemic.
Comparison of PEMF Therapy of Various Duration in the Treatment of Subacromia...ijtsrd
Introduction Subacromial impingement syndrome SIS is commonest among various joint pains. Study is done in order to compose the efficacy of PEMF treatment of various duration for patients with SIS. Subject and Methods One hundred and eight patients who had been diagnosed with subacromial impingement syndrome by clinical examination. Patients were sequentially enrolled following informed consent were administered PEMF therapy for 15 minutes combined with exercise therapy. The second group received the same treatment except that each of the patients has received 30 minutes therapy the patients were evaluated before and after the treatment. Parameters examined were pain score, disability score and range of motion at shoulder joint. Result Second group was significantly improved in pain score, disability score and range of motion. Conclusion 30 minutes of PEMF therapy was shown to be more effective than 15 minutes of PEMF therapy. Anuja Pasari | Bismay Das | C. Monanty | Saurabh Singh | Sujoy Roy | T. B. Singh "Comparison of PEMF Therapy of Various Duration in the Treatment of Subacromial Impingement Syndrome" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-1 , December 2020, URL: https://www.ijtsrd.com/papers/ijtsrd38177.pdf Paper URL : https://www.ijtsrd.com/medicine/other/38177/comparison-of-pemf-therapy-of-various-duration-in-the-treatment-of-subacromial-impingement-syndrome/anuja-pasari
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
This study examined determinants of intention to continue using a lumbar support among home care workers with recurrent low back pain. The strongest predictor of intention was positive attitude towards lumbar supports, explaining 41% of the variance. A positive attitude indicated that perceived benefits of lumbar supports, such as pain relief, outweighed discomfort of use. Social support and self-efficacy were less influential on intention. Overall, intention to continue lumbar support use was primarily driven by workers' positive evaluation of the device's ability to manage their low back pain.
Does a standard outpatient physiotherapy regime improve the range of knee mot...FUAD HAZIME
This study investigated whether a standard outpatient physiotherapy regime improved range of knee motion after primary total knee arthroplasty (TKA). 150 patients were randomly assigned to either receive 6 weeks of outpatient physiotherapy after TKA (Group A) or no outpatient physiotherapy (Group B). Range of motion measurements found that while Group A achieved greater flexion than Group B, the difference was not statistically significant. The study concluded that outpatient physiotherapy does not improve range of knee motion after primary TKA.
This study assessed outcomes of physical therapy and surgery for 150 patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported measures. 40 patients (27%) had satisfactory improvement with a 6-week physical therapy trial, while 90 (60%) underwent surgery after physical therapy failed. Patients who underwent surgery had greater reductions in disability scores and better patient-rated outcomes compared to those who received only physical therapy. However, pre-treatment factors did not reliably predict who would benefit from each treatment. This study provides information on contemporary outcomes for physical therapy and surgery for NTOS.
Artigo do Fisioterapeuta Dr. Miguel GonçalvesFatima Braga
1) The document provides recommendations for the diagnosis and management of Duchenne muscular dystrophy (DMD) developed by an international group of 84 experts using the RAND/UCLA Appropriateness Method.
2) It describes DMD as a severe, progressive disease affecting 1 in 3,600-6,000 live male births and outlines its genetic basis and multi-system manifestations.
3) The recommendations are presented in two parts, with Part 1 covering diagnosis, pharmacological treatment, and psychosocial management, and Part 2 discussing implementation of multidisciplinary care.
The study examined the effects of high-voltage pulsed current (HVPC) electrical stimulation on chronic leg ulcers. 27 subjects with 42 chronic leg ulcers were randomly assigned to receive either HVPC or sham treatment 3 times per week for 4 weeks. Wound size and appearance were assessed initially and after treatment. HVPC reduced wound size by an average of 44.3% compared to 16.0% for sham treatment, indicating HVPC can accelerate healing of chronic leg ulcers.
Evidence Based Practice (EBP) is defined as clinical decision-making based on, sound external research evidence combined with individual clinical expertise and, the needs of the individual patient.
CBP® is unique, in that, unlike most chiropractic techniques,245 CBP® has laid a solid foundation of basic science research (spine modeling, x-ray line drawing reliability, x-ray positioning repeatability, posture reliability, biomechanical stress analysis), clinical research (case studies, clinical trials), and educational research (reviews, position papers).
This study evaluated patient controlled sedation (PCS) using propofol and alfentanil for dressing changes in 11 burn patients with over 10% total burn surface area. PCS was compared to sedation provided by an anesthesiologist. Patients preferred PCS due to greater control and less discomfort during recovery. No adverse respiratory or cardiovascular events occurred with PCS. Procedural pain was higher with PCS but lower after the procedure. The study concluded that PCS is an effective and safe alternative to anesthesiologist-provided sedation for burn dressing changes, but noted the small sample size limited the strength of this conclusion and further studies are warranted.
Postmastectomy and Post Thoracotomy PainJason Attaman
This document discusses postmastectomy and postthoracotomy pain. It begins by describing the various mechanisms that can cause injury during breast and chest wall surgeries, including damage to muscles, nerves, and formation of scar tissue. It then discusses two specific pain syndromes - postmastectomy pain, which 4-14% of women experience after mastectomy surgery, and postthoracotomy pain, where 26-67% of patients report long-term pain after thoracic surgery. The causes of pain in both syndromes can include tissue injury from surgery or cancer, as well as nerve injury from surgical trauma, radiation, chemotherapy, fibrosis, or cancer metastasis.
1) The document summarizes several journal articles related to physical medicine and rehabilitation (PMR). It includes abstracts on topics like cognitive communication skills after mild traumatic brain injury, seizure comorbidity and hospital readmissions after traumatic brain injury, effects of traumatic brain injury and spinal cord injury on sexual function, the relationship between white matter hyperintensities and response to language treatment in post-stroke aphasia, using mental imagery therapy to treat neuropathic pain in spinal cord injury patients, and impairments in spatial navigation during walking in younger patients with mild stroke.
2) The editor's preface welcomes readers to the first issue of 2021 and thanks contributors and the recognition from IAPMR. It encourages readers to keep learning with the
This document provides biographical and professional information about Neil D Bressler, D.C., B.S. It includes his contact information, education, certifications, work experience, and postgraduate education. Dr. Bressler received his Doctor of Chiropractic and Bachelor of Science degrees from Cleveland Chiropractic College. He has over 20 years of experience as a chiropractor and owner of several chiropractic clinics. He also has extensive postgraduate education in areas like neurodiagnostics, trauma patient protocols, and MRI interpretation.
This randomized controlled trial compared vertebroplasty to conservative treatment for acute osteoporotic vertebral compression fractures. 202 patients with persistent pain were randomly assigned to vertebroplasty (101 patients) or conservative treatment (101 patients). Vertebroplasty provided significantly greater pain relief than conservative treatment at both 1 month and 1 year, with differences in mean pain scores of 2.6 and 2.0 respectively. No serious complications were reported. Vertebroplasty was found to be an effective and safe treatment for acute osteoporotic vertebral compression fractures with persistent pain.
This normal posture in the AP view correlates with a straight (vertically aligned) spine. In the lateral view of upright normal posture, it is generally
accepted that there exist a cervical lordosis, a thoracic kyphosis, and a lumbar lordosis.
Maladaptive movement and motor control impairments as underlying mechanismMeziat
Artigo (5) importante para a preparação para o curso de dor lombar crônica. "Diagnóstico e classificação da dor lombar crônica: Disfunções de movimento e de controle mal adaptativas como mecanismo principal." É antigo, algumas coisas mudaram, mas vale à pena ler.
This meta-analysis reviewed 22 randomized controlled trials involving 1014 patients to determine the effectiveness of low-level laser therapy (LLLT) for pain relief in various joint areas. The average methodological quality score of the trials was 7.96 out of 10. The analysis found that 11 trials reported positive effects of LLLT for pain relief while 11 reported negative effects. However, when pooling the results, the mean weighted difference in pain reduction on a visual analogue scale was 13.96 mm in favor of the active LLLT groups, indicating LLLT provides statistically significant pain relief for joints. Restricting the analysis to trials using energy doses within previously suggested therapeutic windows produced even greater mean pain relief of 19.88-21
Comparison of Task Oriented Approach Versus Proprioceptive Neuromuscular Faci...ijtsrd
INTRODUCTION Stroke rehabilitation is an organized endeavour to help patients to maximize all opportunities for returning to an active lifestyle. Early intervention in acute stroke rehabilitation plays a major role in restoration of function and reducing the degree of disability and dependence for ADL’s and ambulation. Neuro rehabilitation is a method for relearning a previously learned task in a different way, either by compensatory strategies or by adaptively recruiting alternative pathway. Selection of appropriate and best neuro rehabilitation is critical.OBJECTIVE To compare whether task oriented approach is better than propioceptive neuromuscular facilitation on functional ambulation of stroke patients.DESIGN Single centre randomized control trial.SETTING Occupational Therapy department, Swami Vivekananda National Institute of Rehabilitation Training and Research, Olatpur, Odisha, 754010PARTICIPANTS All participants who fulfill the inclusion criteria randomly assigned to two groups. Following this a baseline assessment of Functional gait assessment scale was done at the beginning of the study.INTERVENTION All participants continued to receive conventional occupational therapy throughout the entire duration of study. Participants received an additional specific intervention one group task oriented approach and the second group PNF approach .Subjects of both the group were provided therapy sessions 45minutes per session 5 days a week for two months.OUTCOME MEASURE Functional Gait Assessment ScaleRESULT From the statistical result of this study, it is seen that there is no significance difference in FGA scale between two groups. This data suggests that TOA and PNF approaches are equally efficacious in treating functional ambulation in stroke patients and there is a significant improvement within the two experimental group.CONCLUSION There has been considerable debate regarding the comparative effectiveness of various treatment approaches with stroke patients. This study is not able to identify any differences between the groups that received Task oriented approach and the group that received Propioceptive neuromuscular facilitation treatment .On the basis of the finding s of this study occupational therapist can consider using either approach in planning treatment for functional ambulation in stroke patients. Rakesh Mahapatra | Mr. Rama Kumar Sahu "Comparison of Task Oriented Approach Versus Proprioceptive Neuromuscular Facilitation Technique on Functional Ambulation in Stroke Patients" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-1 , December 2020, URL: https://www.ijtsrd.com/papers/ijtsrd38237.pdf Paper URL : https://www.ijtsrd.com/medicine/other/38237/comparison-of-task-oriented-approach-versus-proprioceptive-neuromuscular-facilitation-technique-on-functional-ambulation-in-stroke-patients/rakesh-mahapatra
This study evaluated the discriminative validity of classifying musculoskeletal pain into three categories based on assumed underlying pain mechanisms: nociceptive pain, peripheral neuropathic pain, and central sensitization pain. The study assessed 464 patients with low back or leg pain using standardized criteria. Clinicians then assigned each patient's primary pain mechanism and indicated which clinical criteria were present. Statistical analysis identified clusters of 7, 3, and 4 criteria, respectively, that accurately predicted assignment to the three pain categories. The results provide preliminary evidence of discriminative validity for mechanisms-based classification of musculoskeletal pain. Further research is still needed to fully validate such classification systems.
Neural blockade for persistent pain after breast cancer surgery Jason Attaman
1) The review examined evidence for neural blockade as a diagnostic tool or treatment for persistent pain after breast cancer surgery.
2) Only 7 studies with a total of 135 patients were identified that used blocks targeting the stellate ganglion, paravertebral plexus, or intercostal nerves.
3) The quality of evidence from the studies was low and inconclusive about the efficacy of neural blockade for treating persistent pain after breast cancer surgery. More high-quality studies are needed to evaluate this common clinical problem.
This document provides recommendations from the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. It finds that physiotherapy can help address issues like deconditioning, respiratory conditions, and emotional problems in critically ill patients. However, evidence is limited and most recommendations are based on expert opinion rather than randomized controlled trials. Key recommendations include early mobilization and muscle training to prevent deconditioning, using positioning and splinting to preserve mobility in immobile patients, and implementing chest physiotherapy to clear airway secretions and improve ventilation in respiratory conditions. The document provides an overview of evidence and best practices for physiotherapy in critical illness.
Crit care med give your patient a fast hug (at least) once a daybenylondon
This document introduces the "Fast Hug" mnemonic as a simple strategy to improve quality of care for critically ill patients. The mnemonic stands for Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control. Checking each component at least once daily can help identify issues, encourage teamwork, and apply evidence-based guidelines. While protocols have limitations, checklists like "Fast Hug" provide a concise approach to consider key aspects of patient care without restricting clinical judgment.
Comparison of PEMF Therapy of Various Duration in the Treatment of Subacromia...ijtsrd
Introduction Subacromial impingement syndrome SIS is commonest among various joint pains. Study is done in order to compose the efficacy of PEMF treatment of various duration for patients with SIS. Subject and Methods One hundred and eight patients who had been diagnosed with subacromial impingement syndrome by clinical examination. Patients were sequentially enrolled following informed consent were administered PEMF therapy for 15 minutes combined with exercise therapy. The second group received the same treatment except that each of the patients has received 30 minutes therapy the patients were evaluated before and after the treatment. Parameters examined were pain score, disability score and range of motion at shoulder joint. Result Second group was significantly improved in pain score, disability score and range of motion. Conclusion 30 minutes of PEMF therapy was shown to be more effective than 15 minutes of PEMF therapy. Anuja Pasari | Bismay Das | C. Monanty | Saurabh Singh | Sujoy Roy | T. B. Singh "Comparison of PEMF Therapy of Various Duration in the Treatment of Subacromial Impingement Syndrome" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-1 , December 2020, URL: https://www.ijtsrd.com/papers/ijtsrd38177.pdf Paper URL : https://www.ijtsrd.com/medicine/other/38177/comparison-of-pemf-therapy-of-various-duration-in-the-treatment-of-subacromial-impingement-syndrome/anuja-pasari
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
This study examined determinants of intention to continue using a lumbar support among home care workers with recurrent low back pain. The strongest predictor of intention was positive attitude towards lumbar supports, explaining 41% of the variance. A positive attitude indicated that perceived benefits of lumbar supports, such as pain relief, outweighed discomfort of use. Social support and self-efficacy were less influential on intention. Overall, intention to continue lumbar support use was primarily driven by workers' positive evaluation of the device's ability to manage their low back pain.
Does a standard outpatient physiotherapy regime improve the range of knee mot...FUAD HAZIME
This study investigated whether a standard outpatient physiotherapy regime improved range of knee motion after primary total knee arthroplasty (TKA). 150 patients were randomly assigned to either receive 6 weeks of outpatient physiotherapy after TKA (Group A) or no outpatient physiotherapy (Group B). Range of motion measurements found that while Group A achieved greater flexion than Group B, the difference was not statistically significant. The study concluded that outpatient physiotherapy does not improve range of knee motion after primary TKA.
This study assessed outcomes of physical therapy and surgery for 150 patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported measures. 40 patients (27%) had satisfactory improvement with a 6-week physical therapy trial, while 90 (60%) underwent surgery after physical therapy failed. Patients who underwent surgery had greater reductions in disability scores and better patient-rated outcomes compared to those who received only physical therapy. However, pre-treatment factors did not reliably predict who would benefit from each treatment. This study provides information on contemporary outcomes for physical therapy and surgery for NTOS.
Artigo do Fisioterapeuta Dr. Miguel GonçalvesFatima Braga
1) The document provides recommendations for the diagnosis and management of Duchenne muscular dystrophy (DMD) developed by an international group of 84 experts using the RAND/UCLA Appropriateness Method.
2) It describes DMD as a severe, progressive disease affecting 1 in 3,600-6,000 live male births and outlines its genetic basis and multi-system manifestations.
3) The recommendations are presented in two parts, with Part 1 covering diagnosis, pharmacological treatment, and psychosocial management, and Part 2 discussing implementation of multidisciplinary care.
The study examined the effects of high-voltage pulsed current (HVPC) electrical stimulation on chronic leg ulcers. 27 subjects with 42 chronic leg ulcers were randomly assigned to receive either HVPC or sham treatment 3 times per week for 4 weeks. Wound size and appearance were assessed initially and after treatment. HVPC reduced wound size by an average of 44.3% compared to 16.0% for sham treatment, indicating HVPC can accelerate healing of chronic leg ulcers.
Evidence Based Practice (EBP) is defined as clinical decision-making based on, sound external research evidence combined with individual clinical expertise and, the needs of the individual patient.
CBP® is unique, in that, unlike most chiropractic techniques,245 CBP® has laid a solid foundation of basic science research (spine modeling, x-ray line drawing reliability, x-ray positioning repeatability, posture reliability, biomechanical stress analysis), clinical research (case studies, clinical trials), and educational research (reviews, position papers).
This study evaluated patient controlled sedation (PCS) using propofol and alfentanil for dressing changes in 11 burn patients with over 10% total burn surface area. PCS was compared to sedation provided by an anesthesiologist. Patients preferred PCS due to greater control and less discomfort during recovery. No adverse respiratory or cardiovascular events occurred with PCS. Procedural pain was higher with PCS but lower after the procedure. The study concluded that PCS is an effective and safe alternative to anesthesiologist-provided sedation for burn dressing changes, but noted the small sample size limited the strength of this conclusion and further studies are warranted.
Postmastectomy and Post Thoracotomy PainJason Attaman
This document discusses postmastectomy and postthoracotomy pain. It begins by describing the various mechanisms that can cause injury during breast and chest wall surgeries, including damage to muscles, nerves, and formation of scar tissue. It then discusses two specific pain syndromes - postmastectomy pain, which 4-14% of women experience after mastectomy surgery, and postthoracotomy pain, where 26-67% of patients report long-term pain after thoracic surgery. The causes of pain in both syndromes can include tissue injury from surgery or cancer, as well as nerve injury from surgical trauma, radiation, chemotherapy, fibrosis, or cancer metastasis.
1) The document summarizes several journal articles related to physical medicine and rehabilitation (PMR). It includes abstracts on topics like cognitive communication skills after mild traumatic brain injury, seizure comorbidity and hospital readmissions after traumatic brain injury, effects of traumatic brain injury and spinal cord injury on sexual function, the relationship between white matter hyperintensities and response to language treatment in post-stroke aphasia, using mental imagery therapy to treat neuropathic pain in spinal cord injury patients, and impairments in spatial navigation during walking in younger patients with mild stroke.
2) The editor's preface welcomes readers to the first issue of 2021 and thanks contributors and the recognition from IAPMR. It encourages readers to keep learning with the
This document provides biographical and professional information about Neil D Bressler, D.C., B.S. It includes his contact information, education, certifications, work experience, and postgraduate education. Dr. Bressler received his Doctor of Chiropractic and Bachelor of Science degrees from Cleveland Chiropractic College. He has over 20 years of experience as a chiropractor and owner of several chiropractic clinics. He also has extensive postgraduate education in areas like neurodiagnostics, trauma patient protocols, and MRI interpretation.
This randomized controlled trial compared vertebroplasty to conservative treatment for acute osteoporotic vertebral compression fractures. 202 patients with persistent pain were randomly assigned to vertebroplasty (101 patients) or conservative treatment (101 patients). Vertebroplasty provided significantly greater pain relief than conservative treatment at both 1 month and 1 year, with differences in mean pain scores of 2.6 and 2.0 respectively. No serious complications were reported. Vertebroplasty was found to be an effective and safe treatment for acute osteoporotic vertebral compression fractures with persistent pain.
This normal posture in the AP view correlates with a straight (vertically aligned) spine. In the lateral view of upright normal posture, it is generally
accepted that there exist a cervical lordosis, a thoracic kyphosis, and a lumbar lordosis.
Maladaptive movement and motor control impairments as underlying mechanismMeziat
Artigo (5) importante para a preparação para o curso de dor lombar crônica. "Diagnóstico e classificação da dor lombar crônica: Disfunções de movimento e de controle mal adaptativas como mecanismo principal." É antigo, algumas coisas mudaram, mas vale à pena ler.
This meta-analysis reviewed 22 randomized controlled trials involving 1014 patients to determine the effectiveness of low-level laser therapy (LLLT) for pain relief in various joint areas. The average methodological quality score of the trials was 7.96 out of 10. The analysis found that 11 trials reported positive effects of LLLT for pain relief while 11 reported negative effects. However, when pooling the results, the mean weighted difference in pain reduction on a visual analogue scale was 13.96 mm in favor of the active LLLT groups, indicating LLLT provides statistically significant pain relief for joints. Restricting the analysis to trials using energy doses within previously suggested therapeutic windows produced even greater mean pain relief of 19.88-21
Comparison of Task Oriented Approach Versus Proprioceptive Neuromuscular Faci...ijtsrd
INTRODUCTION Stroke rehabilitation is an organized endeavour to help patients to maximize all opportunities for returning to an active lifestyle. Early intervention in acute stroke rehabilitation plays a major role in restoration of function and reducing the degree of disability and dependence for ADL’s and ambulation. Neuro rehabilitation is a method for relearning a previously learned task in a different way, either by compensatory strategies or by adaptively recruiting alternative pathway. Selection of appropriate and best neuro rehabilitation is critical.OBJECTIVE To compare whether task oriented approach is better than propioceptive neuromuscular facilitation on functional ambulation of stroke patients.DESIGN Single centre randomized control trial.SETTING Occupational Therapy department, Swami Vivekananda National Institute of Rehabilitation Training and Research, Olatpur, Odisha, 754010PARTICIPANTS All participants who fulfill the inclusion criteria randomly assigned to two groups. Following this a baseline assessment of Functional gait assessment scale was done at the beginning of the study.INTERVENTION All participants continued to receive conventional occupational therapy throughout the entire duration of study. Participants received an additional specific intervention one group task oriented approach and the second group PNF approach .Subjects of both the group were provided therapy sessions 45minutes per session 5 days a week for two months.OUTCOME MEASURE Functional Gait Assessment ScaleRESULT From the statistical result of this study, it is seen that there is no significance difference in FGA scale between two groups. This data suggests that TOA and PNF approaches are equally efficacious in treating functional ambulation in stroke patients and there is a significant improvement within the two experimental group.CONCLUSION There has been considerable debate regarding the comparative effectiveness of various treatment approaches with stroke patients. This study is not able to identify any differences between the groups that received Task oriented approach and the group that received Propioceptive neuromuscular facilitation treatment .On the basis of the finding s of this study occupational therapist can consider using either approach in planning treatment for functional ambulation in stroke patients. Rakesh Mahapatra | Mr. Rama Kumar Sahu "Comparison of Task Oriented Approach Versus Proprioceptive Neuromuscular Facilitation Technique on Functional Ambulation in Stroke Patients" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-1 , December 2020, URL: https://www.ijtsrd.com/papers/ijtsrd38237.pdf Paper URL : https://www.ijtsrd.com/medicine/other/38237/comparison-of-task-oriented-approach-versus-proprioceptive-neuromuscular-facilitation-technique-on-functional-ambulation-in-stroke-patients/rakesh-mahapatra
This study evaluated the discriminative validity of classifying musculoskeletal pain into three categories based on assumed underlying pain mechanisms: nociceptive pain, peripheral neuropathic pain, and central sensitization pain. The study assessed 464 patients with low back or leg pain using standardized criteria. Clinicians then assigned each patient's primary pain mechanism and indicated which clinical criteria were present. Statistical analysis identified clusters of 7, 3, and 4 criteria, respectively, that accurately predicted assignment to the three pain categories. The results provide preliminary evidence of discriminative validity for mechanisms-based classification of musculoskeletal pain. Further research is still needed to fully validate such classification systems.
Neural blockade for persistent pain after breast cancer surgery Jason Attaman
1) The review examined evidence for neural blockade as a diagnostic tool or treatment for persistent pain after breast cancer surgery.
2) Only 7 studies with a total of 135 patients were identified that used blocks targeting the stellate ganglion, paravertebral plexus, or intercostal nerves.
3) The quality of evidence from the studies was low and inconclusive about the efficacy of neural blockade for treating persistent pain after breast cancer surgery. More high-quality studies are needed to evaluate this common clinical problem.
This document provides recommendations from the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. It finds that physiotherapy can help address issues like deconditioning, respiratory conditions, and emotional problems in critically ill patients. However, evidence is limited and most recommendations are based on expert opinion rather than randomized controlled trials. Key recommendations include early mobilization and muscle training to prevent deconditioning, using positioning and splinting to preserve mobility in immobile patients, and implementing chest physiotherapy to clear airway secretions and improve ventilation in respiratory conditions. The document provides an overview of evidence and best practices for physiotherapy in critical illness.
Crit care med give your patient a fast hug (at least) once a daybenylondon
This document introduces the "Fast Hug" mnemonic as a simple strategy to improve quality of care for critically ill patients. The mnemonic stands for Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control. Checking each component at least once daily can help identify issues, encourage teamwork, and apply evidence-based guidelines. While protocols have limitations, checklists like "Fast Hug" provide a concise approach to consider key aspects of patient care without restricting clinical judgment.
This document provides an overview of two studies being presented at an LDI symposium. The first study analyzes video recordings of clinician interactions with patients, nurses and families in the surgical intensive care unit. It aims to evaluate the extent of clinician involvement and how it may impact outcomes. The second study seeks to identify characteristics of effective ad hoc trauma resuscitation teams and how team functioning affects patient outcomes. It will survey team members and analyze responses to identify qualities of high performing teams with the goal of developing training to improve collaboration and outcomes.
Glasziou taking healthcare interventions from trial to practiceMarilyn Mann
The document discusses improving the reporting of healthcare interventions in clinical trials to facilitate moving findings from trials into practice. It notes that currently many trial reports do not adequately describe interventions, making it difficult or impossible for clinicians to replicate them. The document proposes that trial protocols and publications should provide detailed descriptions of intervention contents, delivery personnel, locations, doses, schedules, and the degree of flexibility allowed. This would help reduce waste from unusable findings and better support evidence synthesis, clinical practice, and health policy decisions.
Acs0109 Fast Track Inpatient And Ambulatory Surgerymedbookonline
Fast track surgery aims to reduce complications, facilitate earlier discharge, and speed recovery after elective surgery. It involves a coordinated preoperative, intraoperative, and postoperative care plan using multiple evidence-based practices. The goal is that a multimodal approach will have synergistic benefits over using individual components alone. Key elements include preoperative education and optimization, attenuating the surgical stress response intraoperatively through techniques like neural blockade, and aggressive postoperative rehabilitation with early feeding and mobility. Successful implementation requires significant resources and coordination across specialties.
This study examined the prognosis of 118 patients with chronic low back pain who participated in a private, community-based group exercise program over 12 months. The patients experienced substantial improvements in pain intensity, disability, function and bothersomeness during the study period. Pain intensity and bothersomeness improved most in the first 6 months, while disability and function continued improving throughout the full year. At 12 months, 25% of patients were fully recovered from their back pain. Baseline pain intensity predicted 10% of the variation in pain outcomes at 12 months, while duration of current episode, disability, and education level together predicted 15% of the variation in disability outcomes.
1) The study investigated the differences in cerebral activity and clinical efficacy between acupuncture and sham acupuncture treatment for functional dyspepsia (FD).
2) 72 FD patients were randomly assigned to receive either real acupuncture or sham acupuncture for 4 weeks. 10 patients from each group also underwent PET scans before and after treatment.
3) Results showed acupuncture was more effective at reducing dyspeptic symptoms compared to sham acupuncture based on clinical scores. Acupuncture also produced greater deactivation of brain regions like the brainstem, anterior cingulate cortex, insula, thalamus, and hypothalamus compared to sham acupuncture. Deactivation of these regions correlated with improvement in clinical scores for
This randomized controlled trial investigated the effectiveness of pulsatile dry cupping therapy compared to no intervention for knee osteoarthritis. 40 patients were randomly assigned to receive either 8 cupping sessions over 4 weeks or no treatment. Outcome measures including pain, stiffness, physical function, and quality of life were assessed at 4 and 12 weeks. At 4 weeks, cupping resulted in significantly greater improvements in pain, physical function, and quality of life scores compared to the control group. Many benefits were still present at 12 weeks, though some scores were no longer significantly different. The study provides preliminary evidence that cupping may be an effective treatment for relieving symptoms of knee osteoarthritis.
Spinal manipulation therapy (SMT) was more effective than medication for relieving acute or subacute neck pain in both the short and long term. Home exercise with advice (HEA) resulted in similar pain outcomes to SMT at most time points. For 272 participants with neck pain lasting 2-12 weeks, SMT had statistically significantly less pain than medication after 8 weeks and up to 1 year later. HEA was superior to medication for pain relief at 26 weeks. No important differences in pain were found between SMT and HEA. The trial demonstrated that SMT and HEA were both more effective than medication for acute or subacute neck pain.
The document discusses improving patient safety in intensive care medicine. It describes launching a major initiative through the European Society of Intensive Care Medicine (ESICM) to bring together representatives from critical care societies around the world. The goal is to pledge efforts to improving patient care and outcomes. Key areas of focus include changing medical culture and priorities to better address patient safety issues, and evaluating patient safety at both the individual patient level and collective level to maximize benefits and minimize harms. The initiative aims to raise awareness of patient safety and help transform daily practice to improve quality of care for all patients.
Consensus Guidelines For The Management Of Chronic Pelvic PainEliana Cordero
The document provides clinical practice guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC) for the management of chronic pelvic pain (CPP). It includes:
1) An overview of CPP, including its burden and complex multifactorial causes.
2) Recommendations across various areas of CPP management, including general assessment, myofascial pain, medications, imaging, and multidisciplinary care.
3) Evidence and guidelines related to specific sources of CPP, such as endometriosis, adnexal torsion, hysterectomy, and interstitial cystitis.
4) Emphasis on the need for improved education of healthcare professionals and research
This document systematically reviewed the literature on nonsurgical treatments for carpal tunnel syndrome (CTS). It found strong or moderate evidence for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and ergonomic keyboards in the short term. Moderate evidence was found for ultrasound in the midterm. No long-term results were reported except for oral steroids and steroid injections. Future studies should evaluate mid- and long-term effectiveness of nonsurgical CTS treatments.
This document presents clinical guidelines for veterinary cardiopulmonary resuscitation (CPR) in dogs and cats based on an evidence-based review. A total of 101 individual guidelines were developed across five domains: preparedness and prevention, basic life support, advanced life support, monitoring, and post-cardiac arrest care. The guidelines were reviewed by veterinary professionals and refined. A CPR algorithm and resuscitation drug-dosing scheme were also created to standardize CPR procedures and minimize interruptions to chest compressions. While knowledge gaps remain, the guidelines provide an evidence-based approach to veterinary CPR for the first time. Further evaluation is still needed to assess the impact of the guidelines on CPR
This document summarizes research on the effects of COX-2 inhibitors on fracture healing and implications for patient recovery. The main points are:
1) Past research has found that COX-2 inhibitors like celecoxib can impair fracture healing in animal models by reducing callus strength and increasing nonunion rates.
2) A recent study in rats found celecoxib administration was associated with weaker fracture calluses, more nonunions, and duration of inhibition correlated with decreased healing.
3) The investigators concluded NSAID use after fractures may negatively affect healing in humans, though more research is needed, and COX-2 drug use should be avoided in fusion patients for now.
Medical shockwaves for chronic low back pain - a case seriesKenneth Craig
This case series examines the use of medical shockwave therapy for 10 patients with chronic low back pain. Shockwave therapy involves using focused acoustic pulses to target deep tissue. After 3 sessions of 1000 pulses each over 3 weeks, 8 of the 9 patients showed excellent improvement in pain levels, functional disability, and reduced need for pain medication that was maintained at the 12 week follow up. This positive preliminary outcome supports further investigation of shockwave therapy as a potential disease-modifying treatment for chronic low back pain.
This study evaluated the effectiveness of progressive muscle relaxation (PMR) exercises in reducing pain and fatigue among 100 hospitalized cancer patients receiving radiotherapy. The patients were randomly assigned to an intervention group that received four PMR sessions over 4 weeks or a control group that received standard treatment. Pain was measured using a numerical pain rating scale and fatigue was measured using a cancer fatigue scale before and after the intervention. The results showed a significant reduction in reported pain and fatigue scores in the PMR group compared to the control group, indicating that PMR exercises can effectively reduce pain and fatigue in hospitalized cancer patients receiving radiotherapy when used as an adjuvant therapy.
Effectiveness of Stretch Interventions for Children With Neuromuscular Disabi...Sarah Craig
This systematic review examined the effectiveness of stretch interventions for children with neuromuscular disabilities. Sixteen studies were included, with sample sizes ranging from 14 to 1110 participants. The studies evaluated casting, orthoses, passive stretching, and supported standing programs. Low-grade evidence suggests casting can temporarily increase ankle range of motion. Orthoses may improve gait parameters while worn. Supported standing programs may improve bone mineral density. However, there is limited evidence stretch interventions benefit body functions and structures. The evidence is also inconclusive regarding whether stretching prevents contractures or impacts activity or participation. Overall, the methodological quality of included studies was poor.
Brough et al perspectives on the effects and mechanisms of CST a qualitative ...Nicola Brough
This document summarizes a qualitative study on the effects and mechanisms of craniosacral therapy according to users' views. 29 participants were interviewed about their experiences with craniosacral therapy. Most participants reported improvements in at least two dimensions of holistic wellbeing: body, mind and spirit. Experiences during therapy included altered perceptual states and specific sensations and emotions. Participants emphasized the importance of the therapeutic relationship. The emerging theory from the study suggests that the trusting relationship in craniosacral therapy allows clients to experience altered states of awareness, which facilitates a new understanding of the interrelatedness of body, mind and spirit and an enhanced ability to care for oneself and manage health problems.
The use of pulsed radiofrequency for the treatment of pudendal neuralgia a c...Jason Attaman
This study evaluated the use of pulsed radiofrequency (PRF) for treating pudendal neuralgia in 7 patients. PRF is a minimally invasive technique that uses radiofrequency energy to modulate nerves without damaging tissue. The average number of PRF treatments was 4.4, and the average duration of pain relief was 11.4 weeks. There were no complications reported. The study concludes that PRF may be an effective and safe treatment for pudendal neuralgia in patients where conservative treatments have not provided adequate relief, but larger controlled studies are still needed.
Similar to Artigo fisioterapeuta Dr.Miguel Gonçalves (20)
1) Duas mães, Fátima e Rafaela, lutam pelo tratamento de seus filhos, Lucas e Tiago, que têm Amiotrofia Espinhal, uma doença degenerativa muscular.
2) A doença limita bastante as crianças, mas o tratamento pode melhorar sua qualidade de vida e sobrevida.
3) A Associação Brasileira de Amiotrofia Espinhal (ABRAME) ajuda famílias de crianças com AME e defende melhorias no atendimento público à doença.
Este documento apresenta as diretrizes do II Consenso Brasileiro sobre Ventilação Mecânica Não Invasiva e o Suporte Ventilatório Mecânico Artificial Domiciliar. Ele descreve os principais métodos de ventilação não invasiva, como CPAP e BIPAP, e fornece recomendações sobre suas indicações, contraindicações, monitorização e complicações. O documento também aborda o suporte ventilatório mecânico domiciliar, discutindo equipamentos, monitorização, controle de infecção e frequência do suporte.
Miguel Gonçalves:Extubation In Nmd Chest 2010 Miguel GonçAlvesFatima Braga
This document describes a new protocol for extubating patients with neuromuscular weakness who could not pass conventional spontaneous breathing trials. The protocol involved extubating 157 patients directly to noninvasive ventilation and aggressive mechanically assisted coughing. Extubation success was defined as not requiring re-intubation during hospitalization. Using this protocol, the first attempt extubation success rate was 95%. Factors associated with success included higher assisted cough peak flows, prior dependence on continuous noninvasive ventilation, and longer duration of prior noninvasive ventilation use. The protocol demonstrated that patients considered unweanable by conventional standards can often be safely extubated using noninvasive ventilation and cough assistance.
Este documento estabelece os requisitos mínimos de funcionamento para serviços de atenção domiciliar no Brasil. Define termos como assistência domiciliar, internação domiciliar e equipe multiprofissional de atenção domiciliar. Estabelece condições gerais, específicas e recursos humanos necessários para a prestação adequada de serviços de atenção domiciliar.
Este artigo descreve o uso da prótese vertical expansível de titânio (VEPTR) para tratamento de escoliose neuromuscular sem fusão da coluna vertebral em 17 pacientes. Os resultados mostraram uma correção média de 40,5° da curva espinhal e redução de 60,6° na obliqüidade pélvica após a cirurgia com VEPTR, demonstrando a eficácia deste método no tratamento provisório desta condição.
Guia Familias Com Amiotrofia Espinhal!Fatima Braga
The document provides a summary of expert recommendations for standard of care in spinal muscular atrophy (SMA) from a consensus statement published in the Journal of Child Neurology. The summary outlines 5 key areas of care: 1) confirming SMA diagnosis, 2) managing breathing problems, 3) managing feeding problems, 4) managing movement and daily activities, and 5) preparing for illness. The recommendations emphasize developing individualized care plans, monitoring for complications, and ensuring access to specialists who understand SMA management.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Know the difference between Endodontics and Orthodontics.
Artigo fisioterapeuta Dr.Miguel Gonçalves
1. Review
Diagnosis and management of Duchenne muscular
dystrophy, part 2: implementation of multidisciplinary care
Katharine Bushby, Richard Finkel, David J Birnkrant, Laura E Case, Paula R Clemens, Linda Cripe, Ajay Kaul, Kathi Kinnett, Craig McDonald,
Shree Pandya, James Poysky, Frederic Shapiro, Jean Tomezsko, Carolyn Constantin, for the DMD Care Considerations Working Group*
Optimum management of Duchenne muscular dystrophy (DMD) requires a multidisciplinary approach that focuses Published Online
on anticipatory and preventive measures as well as active interventions to address the primary and secondary aspects November 30, 2009
DOI:10.1016/S1474-
of the disorder. Implementing comprehensive management strategies can favourably alter the natural history of the
4422(09)70272-8
disease and improve function, quality of life, and longevity. Standardised care can also facilitate planning for
See Online/Review
multicentre trials and help with the identification of areas in which care can be improved. Here, we present a DOI:10.1016/S1474-
comprehensive set of DMD care recommendations for management of rehabilitation, orthopaedic, respiratory, 4422(09)70271-6
cardiovascular, gastroenterology/nutrition, and pain issues, as well as general surgical and emergency-room *Members listed at end of part 1
precautions. Together with part 1 of this Review, which focuses on diagnosis, pharmacological treatment, and of this Review
psychosocial care, these recommendations allow diagnosis and management to occur in a coordinated Institute of Human Genetics,
multidisciplinary fashion. Newcastle University,
Newcastle upon Tyne, UK
(K Bushby MD); Division of
Introduction Physical therapy interventions Neurology (R Finkel MD) and
In part 1 of this Review, the importance of multidisciplin- Stretching and positioning Divisions of Pulmonary
ary care was underscored in the context of diagnosis and Effective stretching of the musculotendinous unit Medicine and
Gastroenterology,
pharmacological and psychosocial management of requires a combination of interventions, including active Hepatology, and Nutrition
Duchenne muscular dystrophy (DMD), emphasising that stretching, active-assisted stretching, passive stretching, (J Tomezsko PhD), Children’s
no one aspect of the care of this disease can be taken in and prolonged elongation using positioning, splinting, Hospital of Philadelphia,
isolation.1 This model of care emphasises the value of orthoses, and standing devices.9,10,12,17–20 As standing and Philadelphia, PA, USA;
Division of Pediatric
multidisciplinary involvement to anticipate early changes walking become more difficult, standing programmes Pulmonary Medicine,
in many systems and to manage the wide spectrum of are recommended. MetroHealth Medical Center,
complications that can be predicted in DMD. We applied Active, active-assisted, and/or passive stretching to Case Western Reserve
this model of care to the patient and family across the prevent or minimise contractures should be done a University, Cleveland, OH, USA
(D J Birnkrant MD); Division of
different stages of the disease. The optimum delivery of minimum of 4–6 days per week for any specific joint or Physical Therapy, Department
care by rehabilitation, cardiovascular, gastroenterology/ muscle group. Stretching should be done at home and/ of Community and Family
nutrition, orthopaedic/surgical, and respiratory specialties or school, as well as in the clinic. Medicine, Duke University,
Durham, NC, USA
is presented in this second part of the Review. As before, During both the ambulatory and non-ambulatory
(L E Case DPT); Department of
the RAND Corporation–University of California Los phases, regular stretching at the ankle, knee, and hip is Neurology, Molecular Genetics
Angeles Appropriateness Method was used2 (full details necessary. During the non-ambulatory phase, regular and Biochemistry, University
of the methods are described in part 1 of this Review1). stretching of the upper extremities, including the long of Pittsburgh, and
Department of Veteran Affairs
finger flexors and wrist, elbow, and shoulder joints, also
Medical Center, Pittsburgh,
Management of muscle extensibility and joint becomes necessary. Additional areas that require PA, USA (P R Clemens MD);
contractures stretching can be identified by individual examination. Division of Cardiology
Decreased muscle extensibility and joint contractures in (L Cripe MD, K Kinnett MSN)
and Division of Pediatric
DMD occur as a result of various factors, including loss Assistive devices for musculoskeletal management
Gastroenterology,
of ability to actively move a joint through its full range of Orthoses Hepatology, and Nutrition
motion, static positioning in a position of flexion, muscle Prevention of contractures also relies on resting orthoses, (A Kaul MD), Cincinnati
imbalance about a joint, and fibrotic changes in muscle joint positioning, and standing programmes. Resting Children’s Hospital Medical
Center, Cincinnati, OH, USA;
tissue.3–8 The maintenance of good ranges of movement ankle–foot orthoses (AFOs) used at night can help to
Department of Physical
and bilateral symmetry are important to allow optimum prevent or minimise progressive equinus contractures Medicine and Rehabilitation,
movement and functional positioning, to maintain and are appropriate throughout life.6,17–19,21,22 AFOs should University of California, Davis,
ambulation, prevent development of fixed deformities, be custom-moulded and fabricated for comfort and CA, USA (C McDonald MD);
Department of Neurology,
and maintain skin integrity.9–14 optimum foot and ankle alignment. Knee–ankle–foot University of Rochester,
The management of joint contractures requires input orthoses (KAFOs; eg, long leg braces or callipers) for Rochester, NY, USA
from neuromuscular specialists, physical therapists, prevention of contracture and deformity can be of value (S Pandya PT); School of Allied
rehabilitation physicians, and orthopaedic surgeons.15,16 in the late ambulatory and early non-ambulatory stages Health Sciences, Baylor
College of Medicine, Houston,
Programmes to prevent contractures are usually mon- to allow standing and limited ambulation for therapeutic TX, USA (J Poysky PhD);
itored and implemented by a physical therapist and purposes,23 but might not be well tolerated at night.6 Use Department of Orthopaedic
tailored to individual needs, stage of the disease, response of AFOs during the daytime can be appropriate for Surgery, Children’s Hospital
to therapy, and tolerance. Local care needs to be augmented full-time wheelchair users. Resting hand splints for Boston, Boston, MA, USA
(F Shapiro MD); and National
by guidance from a specialist every 4 months. patients with tight long finger flexors are appropriate.
www.thelancet.com/neurology Published online November 30, 2009 DOI:10.1016/S1474-4422(09)70272-8 1
2. Review
Center on Birth Defects and Standing devices wide range of ages. Consequently, use of mean age as a
Developmental Disabilities, A passive standing device for patients with either no or comparator for a particular intervention is not statistically
Centers for Disease Control
and Prevention, Atlanta, GA,
mild hip, knee, or ankle contractures is necessary for late relevant if small numbers are compared. We found that
USA (C Constantin PhD) ambulatory and early non-ambulatory stages. Many few studies have addressed the fact that, rather than a
Correspondence to: advocate continued use of passive standing devices or a sudden loss of ambulation, walking ability gradually
Katharine Bushby, Newcastle power standing wheelchair into the late non-ambulatory decreases over a 1–2-year period. This makes it difficult
University, Institute of Human stage if contractures are not too severe to restrict to assess prolongation of walking with specific
Genetics, International Centre
positioning and if devices are tolerable.24 interventions. Prolonging ambulation by use of steroids
for Life, Centre Parkway,
Newcastle upon Tyne NE1 3BZ, has, for the moment, further increased uncertainty of the
UK Surgical intervention for lower-limb contractures value of contracture corrective surgery. Bearing these
kate.bushby@newcastle.ac.uk No unequivocal situations exist in which lower-limb considerations in mind, certain recommendations can
contracture surgery is invariably indicated. If lower-limb be offered to prolong the period of walking, irrespective
contractures are present despite range-of-motion of steroid status. Muscle strength and range of motion
exercises and splinting, there are certain scenarios in around individual joints should be considered before
which surgery can be considered.15,25–32 In such cases, the deciding on surgery.
approach must be strictly individualised. Approaches to lower-extremity surgery to maintain
Joints most amenable to surgical correction, and even walking include bilateral multi-level (hip–knee–ankle or
subsequent bracing, are the ankles, and to a slightly knee–ankle) procedures, bilateral single-level (ankle)
lesser extent, the knees. The hip responds poorly to procedures, and, rarely, unilateral single-level (ankle)
surgery for fixed flexion contractures and cannot be procedures for asymmetric involvement.15,25–32 The
effectively braced. Surgical release or lengthening of the surgeries involve tendon lengthening, tendon transfer,
iliopsoas muscle and other hip flexors might further tenotomy (cutting the tendon), along with release of
weaken these muscles and make the patient unable to fibrotic joint contractures (ankle) or removal of tight
walk, even with contracture correction. In ambulant fibrous bands (iliotibial band at lateral thigh from hip to
patients, hip deformity often corrects itself if knees and knee). Single-level surgery (eg, correction of ankle
ankles are straightened because hip flexion and lumbar equinus deformity >20°) is not indicated if there are knee
lordosis might be compensatory and not fixed. flexion contractures of 10° or greater and quadriceps
Various surgical options exist, none of which could be strength of grade 3/5 or less. Equinus foot deformity
recommended above any other. Options for surgery will (toe-walking) and varus foot deformities (severe
depend on individual circumstances, but there can be a inversion) can be corrected by heel-cord lengthening and
role for surgery in the ambulatory and non-ambulatory tibialis posterior tendon transfer through the interosseous
phases. membrane onto the dorsolateral aspect of the foot to
change plantar flexion–inversion activity of the tibialis
Early ambulatory phase posterior to dorsiflexion–eversion.15,27–29,32 Hamstring
Procedures for early contractures including heel-cord lengthening behind the knee is generally needed if there
(tendo-Achillis) lengthenings for equinus contractures, is a knee-flexion contracture of more than 15°.
hamstring tendon lengthenings for knee-flexion After tendon lengthening and tendon transfer,
contractures, anterior hip-muscle releases for hip-flexion postoperative bracing might be needed, which should be
contractures, and even excision of the iliotibial band for discussed preoperatively. Following tenotomy, bracing is
hip-abduction contractures have been performed in always needed. When surgery is performed to maintain
patients as young as 4–7 years.25,26 Some clinics even walking, the patient must be mobilised using a walker or
recommend that the procedures are done before crutches on the first or second postoperative day to prevent
contractures develop.25,26 However, this approach, further disuse atrophy of lower-extremity muscles.
developed 20–25 years ago in an attempt to balance Post-surgery walking must continue throughout limb
musculature when muscle strength is good,25 is not widely immobilisation and post-cast rehabilitation. An experienced
practised today but does still have some proponents. team with close coordination between the orthopaedic
surgeon, physical therapist, and orthotist is required.
Middle ambulatory phase
Interventions in this phase are designed to prolong Late ambulatory phase
ambulation because a contracted joint can limit walking, Despite promising early results,30–32 surgery in the late
even if overall limb musculature has sufficient strength. ambulatory phase has generally been ineffective and
There is some evidence to suggest that walking can be served to obscure the benefits gained by more timely and
prolonged by surgical intervention for 1–3 years,15,25–27,30–32 earlier interventions.
but consensus on surgical correction of contractures for
prolonging ambulation is difficult because it is hard to Early non-ambulatory phase
assess objectively the results reported. Non-operated In the early non-ambulatory phase, some clinics perform
patients who are not on steroids lose ambulation over a extensive lower-extremity surgery and bracing to regain
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3. Review
ambulation within 3–6 months after walking ability is Recommendations for exercise
lost. However, this is generally ineffective and not Limited research has been carried out on the type,
currently considered appropriate. frequency, and intensity of exercise that is optimum in
DMD.36–48 Many recommendations are made on the basis
Late non-ambulatory phase of the known pathophysiology and animal studies
Severe equinus foot deformities of more than 30° can be showing contraction-induced muscle injury in dys-
corrected with heel-cord lengthening or tenotomy and trophinopathy.49
varus deformities (if present) with tibialis posterior Submaximum, aerobic exercise/activity is recommended
tendon transfer, lengthening, or tenotomy. This is done by some clinicians, especially early in the course of the
for specific symptomatic problems, generally to alleviate disease when residual strength is higher, whereas others
pain and pressure, to allow the patient to wear shoes, and emphasise avoidance of overexertion and overwork
to correctly place the feet on wheelchair footrests.27,28 This weakness.44 High-resistance strength training and eccentric
approach is not recommended as routine. exercise are inappropriate across the lifespan owing to
concerns about contraction-induced muscle-fibre injury.
Assistive/adaptive devices for function To avoid disuse atrophy and other secondary complications
AFOs are not indicated for use during ambulation because of inactivity, it is necessary that all boys who are ambulatory
they typically limit compensatory movements needed for or in the early non-ambulatory stage participate in regular
efficient ambulation, add weight that can compromise submaximum (gentle) functional strengthening/activity,
ambulation, and make it difficult to rise from the floor. including a combination of swimming-pool exercises and
During the late ambulatory stage, a KAFO with locked recreation-based exercises in the community. Swimming,
knee might prolong ambulation but is not essential. which might have benefits for aerobic conditioning and
During the early ambulatory stage, a lightweight manual respiratory exercise, is highly recommended from the early
mobility device is appropriate to allow the child to be ambulatory to early non-ambulatory phases and could be
pushed on occasions when long-distance mobility continued in the non-ambulatory phase as long as it is
demands exceed endurance. In the late ambulatory stage, medically safe. Additional benefits might be provided by
an ultra lightweight manual wheelchair with solid seat low-resistance strength training and optimisation of upper
and back, seating to support spinal symmetry and neutral body function. Significant muscle pain or myoglobinuria
lower extremity alignment, and swing-away footrests is in the 24-h period after a specific activity is a sign of
necessary. In the early non-ambulatory stage, a manual overexertion and contraction-induced injury, and if this
wheelchair with custom seating and recline features might occurs the activity should be modified.50
serve as a necessary back-up to a powered wheelchair.
As functional community ambulation declines, a Skeletal management
powered wheelchair is advocated. Increasingly, rehabili- Spinal management
tation providers recommend custom seating and power- Patients not treated with glucocorticoids have a 90%
positioning components for the initial powered wheelchair, chance of developing significant progressive scoliosis28,51
to include a headrest, solid seat and back, lateral trunk and a small chance of developing vertebral compression
supports, power tilt and recline, power-adjustable seat fractures due to osteoporosis. Daily glucocorticoid
height, and power-elevating leg rests (with swing-away or treatment has been shown to reduce the risk of scoliosis;52,53
flip-up footrests to facilitate transfers). Some recommend however, risk of vertebral fracture is increased.54,55 Whether
power standing chairs. Additional custom seating glucocorticoids reduce the risk of scoliosis in the long term
modifications could include a pressure-relieving cushion, or simply delay its onset is, as yet, unclear. Spinal care
hip guides, and flip-down knee adductors. should involve an experienced spinal surgeon, and
As upper-extremity strength declines, referral to a comprises scoliosis monitoring, support of spinal/pelvic
specialist in rehabilitation assistive technology is symmetry and spinal extension by the wheelchair seating
necessary for evaluation of alternative computer or system, and (in patients using glucocorticoids, in particular)
environmental control access, such as a tongue-touch monitoring for painful vertebral body fractures.
control system, switch scanning, infrared pointing, or Monitoring for scoliosis should be by clinical
eye-gaze selection.33–35 observation through the ambulatory phase, with spinal
Other adaptations in the late ambulatory and radiography warranted only if scoliosis is observed. In
non-ambulatory stages could include an elevated lap tray, the non-ambulatory phase, clinical assessment for
with adaptive straw, hands-free water pouch, and/or scoliosis is essential at each visit. Spinal radiography is
turntable (indicated if the hand cannot be brought to the indicated as a baseline assessment for all patients around
mouth or if biceps strength is grade 2/5), power adjustable the time that wheelchair dependency begins with a sitting
bed with pressure relief cushion or mattress, bathing and anteroposterior full-spine radiograph and lateral
bathroom equipment, and transfer devices, including a projection film. An anteroposterior spinal radiograph is
hydraulic patient lift, ceiling lift (hoist), slide sheets, and warranted annually for curves of less than 15–20° and
environmental control options. every 6 months for curves of more than 20°, irrespective
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4. Review
of glucocorticoid treatment, up to skeletal maturity. Gaps bone fusion from the upper thoracic region to the
of more than a year between radiographs increase the sacrum.59,60 If there is no pelvic obliquity, these
risk of missing a worsening of scoliosis. After skeletal recommendations can also be used, but fusion to the
maturity, decisions about radiographs again relate to fifth lumbar vertebra is also effective. Use of a
clinical assessment. thoraco–lumbar–sacral orthosis is inappropriate if
Spinal fusion is done to straighten the spine, prevent surgery is to be done, but it can be considered for patients
further worsening of deformity, eliminate pain due to unable to undergo spinal fusion.
vertebral fracture with osteoporosis, and slow the rate of
respiratory decline.28,56 Anterior spinal fusion is in- Bone-health management
appropriate in DMD. Posterior spinal fusion is warranted Bone health is an important part of the lifelong care of
only in non-ambulatory patients who have spinal curvature patients with DMD. Two previous consensus statements
of more than 20°, are not on glucocorticoids, and have yet have been published.61,62 Figure 1 outlines the risk factors,
to reach skeletal maturity.28,57,58 In patients on gluco- possible assessments, and treatment strategies for
corticoids, surgery might also be warranted if curve patients who have DMD. Awareness of potential problems
progression continues and is associated with vertebral and means to assess these problems and interventions
fractures and pain after optimisation of medical therapy to are important, preferably in conjunction with local
strengthen the bones, irrespective of skeletal maturation. specialists in bone health and endocrine assessment.
When deciding the extent of surgical stabilisation for This is an area in which further research is needed to
scoliosis, if there is pelvic obliquity of more than 15°, it is establish parameters for best practice.
necessary to perform correction and stabilisation with
Fracture management
Fractures are common in DMD and an increased
Bone-health issues Recommended bone-health assessments Possible bone-health
interventions frequency of fractures has been observed with
glucocorticoid treatment.63 Taking into account the
Underlying factors Suggested tests Bone imaging* Possible
for poor bone health study indications interventions
guidelines for safe anaesthesia in DMD, internal fixation
is warranted for severe lower-limb fractures in ambulatory
Decreased mobility Serum DEXA scan† Vitamin D patients to allow prompt rehabilitation and the greatest
• Calcium • Obtain a baseline at: • Vitamin D treatment
Muscle weakness • Phosphorus Age 3+ years for proven deficiency possible chance of maintaining ambulation. In the
• Alkaline phosphorus Start of glucocorticoid is necessary non-ambulatory patient, the requirement for internal
Glucocorticoid • 25-OH vitamin D therapy • Supplementation
level (in springtime • Repeat annually for should be considered
fixation is less acute. Splinting or casting of a fracture is
therapy
or bi-annually) those at risk: in all children if levels necessary for the non-ambulatory patient, and is
• Consider: magnesium, History of fractures cannot be maintained appropriate in an ambulatory patient if it is the fastest
PTH level On chronic
glucocorticoid therapy Calcium
and safest way to promote healing and does not
Resulting in:
Urine
DEXA Z score <–2 • Calcium intake compromise ambulation during healing.
Fractures (long and possible
• Calcium (for calciuria)
bone and vertebral) Spine radiograph‡ supplementation
• Sodium
• Creatinine
• If kyphoscoliosis is should be carried out Respiratory management
Osteopenia noted on clinical in consultation with The aim of respiratory care is to allow timely prevention
examination a dietitian
Osteoporosis therapy and management of complications. A structured, proactive
• If back pain is
Bisphosphonates
approach to respiratory management that includes use of
Kyphoscoliosis present, to assess
vertebral compression • Intravenous assisted cough and nocturnal ventilation has been shown
fracture bisphosphonates for to prolong survival.64–66 Patients with DMD are at risk of
Bone pain
vertebral fracture are
indicated respiratory complications as their condition deteriorates
Reduced quality Bone age (left wrist)
of life radiography§ • Oral bisphosphonates due to progressive loss of respiratory muscle strength.
as treatment or as a
To assess growth
prophylactic measure
These complications include ineffective cough,67–75
failure (on or off
glucocorticoid therapy) remain controversial nocturnal hypoventilation, sleep disordered breathing, and
ultimately daytime respiratory failure.76–84
Figure 1: Bone-health management
Guidelines for respiratory management in DMD have
Information provided in this figure was not derived from RAND Corporation–University of California Los Angeles already been published.85 The care team must include a
Appropriateness Method data and was produced solely using expert discussion. DEXA=dual-energy x-ray physician and therapist with skill in the initiation and
absorptiometry. PTH=parathyroid hormone. *All imaging assessments should be done at a facility capable of management of non-invasive ventilation and associated
performing and interpreting age-appropriate studies. †A DEXA scan is a better measure than plain film
radiographs for detection of osteopenia or osteoporosis. DEXA scans, to assess bone mineral content or body
interfaces,36,86–91 lung-volume recruitment techniques,92–94
composition, need to be interpreted as a Z score for children and a T score for adults (compared with age-matched and manual and mechanically assisted cough.95–102
and sex-matched controls). ‡Spine radiographs (posterior/anterior and lateral views) are used for the assessment Assessments and interventions will need to be re-evaluated
of scoliosis, bone pain, and compression fractures. It is preferable to obtain them in the standing position, as the condition changes (figures 2 and 3, panel 1). In the
especially if bone pain is the presenting symptom. Useful information can still be obtained in the sitting position
for the non-weight-bearing patient. §Bone-age measurements should be done in patients with growth failure
ambulatory stage, minimum assessment of pulmonary
(height for age <5% percentile or if linear growth is faltering). If abnormal (>2 SD below the mean), a referral needs function (such as measurement of forced vital capacity at
to be made to a paediatric endocrinologist. least annually) allows familiarity with the equipment and
4 www.thelancet.com/neurology Published online November 30, 2009 DOI:10.1016/S1474-4422(09)70272-8
5. Review
the team can assess the maximum respiratory function
achieved. The main need for pulmonary care is in the Patient’s status Recommended measurements to Frequency
be taken during each clinic visit
period after the loss of independent ambulation. The
pulmonary section of figure 2 in part 1 of this Review Ambulatory and age
links these assessments and interventions to the various Sitting FVC At least annually
6 years or older
stages of disease, and comprises a respiratory action plan
that should be enacted with increasing disease severity.1 Oxyhaemoglobin saturation
Although the expert panel recognises that assisted by pulse oximetry
ventilation via tracheostomy can prolong survival, the
Sitting FVC
schema is intended to advocate strongly for the use of Non-ambulatory
At least every
6 months
non-invasive modes of assisted ventilation. Particular Peak cough flow
attention to respiratory status is required around the time
Maximum inspiratory and
of planned surgery (see below). expiratory pressures
Immunisation with 23-valent pneumococcal poly-
saccharide vaccine is indicated for patients aged 2 years
and older. Annual immunisation with trivalent inactiva- Non-ambulatory and
any of the following:
ted influenza vaccine is indicated for patients 6 months • Suspected Awake end-tidal CO2 level by
of age and older. Neither the pneumococcal vaccine nor hypoventilation At least annually
capnography*
• FVC <50% predicted
the influenza vaccine are live vaccines, so can be • Current use of
administered to patients treated with glucocorticoids, but assisted ventilation
the immune response to vaccination might be
diminished. Up-to-date and detailed information on Recommended measurement
Optional measurement
immunisation indications, contraindications, and
schedules can be obtained from various sources, Figure 2: Respiratory assessment (in the clinic) of patients with Duchenne muscular dystrophy
including the American Academy of Pediatrics and the FVC=forced vital capacity. *Also measure end-tidal CO2 any time that a patient with an FVC of <50% predicted has
a respiratory infection.
US Centers for Disease Control and Prevention (CDC).
During an established infection, in addition to use of For the American Academy of
Patient’s status Recommended measurements to Pediatrics see http://
manually and mechanically assisted cough, antibiotics be taken in a home setting
aapredbook.aappublications.org/
are necessary, irrespective of oxygen saturation if positive
For the CDC’s information on
evidence of an infection is established on culture, and During acute respiratory influenza see http://www.cdc.
irrespective of culture results if pulse oximetry remains infections, if baseline peak cough gov/flu/
flow is <270 L/min* Pulse oximetry
below 95% in room air. Supplemental oxygen therapy (if available)
should be used with caution because oxygen therapy can Any time baseline peak cough
apparently improve hypoxaemia while masking the flow is <160 L/min
underlying cause, such as atelectasis or hypoventilation.
Assessment of gas exchange
Oxygen therapy might impair central respiratory drive Signs/symptoms of
during sleep‡
hypoventilation†
and exacerbate hypercapnia.91,95,103 If a patient has (home or laboratory setting)
hypoxaemia due to hypoventilation, retained respiratory
secretions, and/or atelectasis, then manual and Baseline FVC <40% predicted
and/or awake baseline blood or
mechanically assisted cough and non-invasive ventilatory ETCO2 >45 mm Hg and/or awake Assessment of gas exchange
support are necessary.66 Substitution of these methods by baseline SpO2 <95% during sleep*
(home or laboratory setting)
oxygen therapy is dangerous.66
FVC <1·25 L
(in any teenage or older patient)
Cardiac management
Cardiac disease in DMD manifests most often as a Strongly recommended measurement
cardiomyopathy and/or cardiac arrhythmia.104–106 The Measurement to be strongly considered
myocardium at autopsy displays areas of myocyte
Figure 3: Respiratory assessment (at home) of patients with Duchenne
hypertrophy, atrophy, and fibrosis.107 Progressive muscular dystrophy
cardiomyopathy is currently a major source of morbidity ETCO2=end-tidal CO2. FVC=forced vital capacity. SpO2=pulse oximetry. *All
and mortality in DMD and Becker muscular dystrophy, specified threshold values of peak cough flow and maximum expiratory
pressure apply to older teenage and adult patients. †Signs/symptoms of
particularly since advances have been made in the hypoventilation include fatigue, dyspnoea, morning or continuous headaches,
treatment of the muscle disease and pulmonary sleep dysfunction (frequent nocturnal awakenings [>3], difficult arousal),
function.65,85,89,108 The natural history of cardiac disease in hypersomnolence, awakenings with dyspnoea and tachycardia, difficulty with
DMD requires further study, especially to define its onset concentration, frequent nightmares. ‡Dual-channel oximetry-capnography in
the home is strongly recommended, but other recommended methods
more precisely with newer imaging technologies; include home oximetry during sleep and polysomnography, the method of
however, there is clearly disease in the myocardium long choice being determined by local availability, expertise, and clinician
before the onset of clinical symptoms.104,109–112 preference.
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6. Review
manifestations of heart failure (fatigue, weight loss,
Panel 1: Respiratory interventions indicated in patients with Duchenne vomiting, abdominal pain, sleep disturbance, and
muscular dystrophy inability to tolerate daily activities) are often unrecognised
Step 1: volume recruitment/deep lung inflation technique until very late owing to musculoskeletal limitations.104
Volume recruitment/deep lung inflation technique (by self-inflating manual ventilation bag Two overlapping sets of published guidelines on the
or mechanical insufflation–exsufflation) when FVC <40% predicted cardiac care of patients who have DMD are currently
available.104,113 The care team should include a cardiac
Step 2: manual and mechanically assisted cough techniques specialist who should be involved with the patient and
Necessary when: family after confirmation of the diagnosis, not only to
• Respiratory infection present and baseline peak cough flow <270 L/min* manage cardiomyopathy, but also to initiate a relationship
• Baseline peak cough flow <160 L/min or maximum expiratory pressure <40 cm water to ensure long-term cardiovascular health.
• Baseline FVC <40% predicted or <1·25 L in older teenager/adult Baseline assessment of cardiac function should be done
Step 3: nocturnal ventilation at diagnosis or by the age of 6 years, especially if this can
Nocturnal ventilation† is indicated in patients who have any of the following: be done without sedation. Clinical judgment should be
• Signs or symptoms of hypoventilation (patients with FVC <30% predicted are at used for patients under the age of 6 years who require
especially high risk) sedation. The recommendation to initiate echocardio-
• A baseline SpO2 <95% and/or blood or end-tidal CO2 >45 mm Hg while awake graphic screening at the time of diagnosis or by the age of
• An apnoea–hypopnoea index >10 per hour on polysomnography or four or more 6 years was judged necessary, even though the incidence
episodes of SpO2 <92% or drops in SpO2 of at least 4% per hour of sleep of echocardiographic abnormalities is low in children
Optimally, use of lung volume recruitment and assisted cough techniques should always aged less than 8–10 years. However, there are cases in
precede initiation of non-invasive ventilation which abnormalities do exist, which can affect clinical
decision making, including decisions about the initiation
Step 4: daytime ventilation of corticosteroids and planning for any anaesthesia.114 A
In patients already using nocturnally assisted ventilation, daytime ventilation‡ is baseline echocardiogram obtained at this age also allows
indicated for: for screening for anatomical abnormalities (eg, atrial or
• Self extension of nocturnal ventilation into waking hours ventricular septal defects, patent ductus arteriosus), which
• Abnormal deglutition due to dyspnoea, which is relieved by ventilatory assistance might affect long-term cardiovascular function.
• Inability to speak a full sentence without breathlessness, and/or Minimum assessment should include, although is not
• Symptoms of hypoventilation with baseline SpO2 <95% and/or blood or end-tidal CO2 limited to, an electrocardiogram and a non-invasive
>45 mm Hg while awake cardiac imaging study (ie, echocardiogram). Assessment
Continuous non-invasive assisted ventilation (with mechanically assisted cough) can of cardiac function should occur at least once every
facilitate endotracheal extubation for patients who were intubated during acute 2 years until the age of 10 years. Annual complete cardiac
illness or during anaesthesia, followed by weaning to nocturnal non-invasive assisted assessments should begin at the age of 10 years or at the
ventilation, if applicable onset of cardiac signs and symptoms if they occur earlier.
Step 5: tracheostomy Abnormalities of ventricular function on non-invasive
Indications for tracheostomy include: cardiac imaging studies warrant increased surveillance
• Patient and clinician preference§ (at least every 6 months) and should prompt initiation of
• Patient cannot successfully use non-invasive ventilation pharmacological therapy, irrespective of the age at which
• Inability of the local medical infrastructure to support non-invasive ventilation they are detected.104,113
• Three failures to achieve extubation during critical illness despite optimum use of Consideration should be given to the use of
non-invasive ventilation and mechanically assisted cough angiotensin-converting-enzyme inhibitors as first-line
• The failure of non-invasive methods of cough assistance to prevent aspiration of therapy. β blockers and diuretics are also appropriate,
secretions into the lung and drops in oxygen saturation below 95% or the patient’s and published guidelines should be followed for the
baseline, necessitating frequent direct tracheal suctioning via tracheostomy management of heart failure.104,113,115–118 Recent evidence
from clinical trials supports the treatment of
FVC=forced vital capacity. SpO2=pulse oximetry. *All specified threshold values of peak cough flow and maximum expiratory cardiomyopathy associated with DMD before signs of
pressure apply to older teenage and adult patients. †Recommended for nocturnal use: non-invasive ventilation with pressure
cycled bi-level devices or volume cycled ventilators or combination volume-pressure ventilators. In bi-level or pressure support abnormal functioning. Further studies are awaited to
modes of ventilation, add a back-up rate of breathing. Recommended interfaces include a nasal mask or a nasal pillow. Other allow firm recommendations to be made.108,119–123
interfaces can be used and each has its own potential benefits. ‡Recommended for day use: non-invasive ventilation with
portable volume cycled or volume-pressure ventilators; bi-level devices are an alternative. A mouthpiece interface is strongly
Signs or symptoms of abnormalities of cardiac rhythm
recommended during day use of portable volume-cycled or volume-pressure ventilators, but other ventilator-interface should be promptly investigated with Holter or event
combinations can be used depending on clinician preference and patient comfort. §However, the panel advocates the monitor recording and should be treated.124–127 Sinus
long-term use of non-invasive ventilation up to and including 24 h/day in eligible patients.
tachycardia is common in DMD, but is also noted in
systolic dysfunction. New-onset sinus tachycardia in the
In the traditional reactive approach, failure to see a absence of a clear cause should prompt assessment,
cardiac specialist until late in the disease, after clinical including that of left-ventricular function.
manifestations of cardiac dysfunction are evident, have Individuals on glucocorticoids need additional monitor-
led to late treatment and poor outcomes.104 Clinical ing from the cardiovascular perspective, particularly for
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7. Review
hypertension, which might necessitate adjustment in the overweight/obese should be goals from diagnosis
glucocorticoid dose (table 2 in part 1 of this Review).1 throughout life. The monitoring and triggers for referral
Systemic arterial hypertension should be treated. to an expert dietitian/nutritionist in DMD are described
Prevention of systemic thromboembolic events by in panel 2.128–132 Diet should be assessed for energy,
anticoagulation therapy can be considered in severe protein, fluid, calcium, vitamin D, and other nutrients.
cardiac dysfunction, but is inappropriate in earlier cardiac We recommend that each patient should receive a daily
dysfunction. The usefulness of an internal cardiac multivitamin supplement with vitamin D and minerals.
defibrillator has not been established and needs further If this is not general practice, a computer nutrient
research. analysis of the patient’s diet can provide evidence for the
Because of the morbidity and mortality associated with possible need for specific foods or nutrient supplements.
cardiomyopathy, additional research is clearly needed, If there is a suspicion of undernutrition/malnutrition
not only to define the natural history of the disease and poor intake, serum vitamin concentrations can be
process, but also to establish treatments specific for the obtained and supplements could be recommended.
dystrophin-deficient myocardium. Further studies of Nutritional recommendations with regard to bone health
pharmacological approaches aimed at early intervention are shown in figure 1.
are needed to delay the underlying disease process. With
generally improved fitness of patients who have DMD, Swallowing management
the option of cardiac transplant might need to be Clinical swallowing examination is indicated if there is
addressed in the future. unintentional weight loss of 10% or more or a decline in
the expected age-related weight gain. Prolonged meal
Nutritional, swallowing, gastrointestinal, and times (>30 min) or meal times accompanied by fatigue,
speech and language management excessive spilling, drooling, pocketing, or any other
Patients might be at risk of both undernutrition/ clinical indicators of dysphagia make referral necessary,
malnutrition and being overweight/obese at different as do persistent coughing, choking, gagging, or wet vocal
ages and under different circumstances, in addition to quality during eating or drinking.133 An episode of
deficiencies in calorie, protein, vitamin, mineral, and aspiration pneumonia, unexplained decline in pulmonary
fluid intake. In later stages, pharyngeal weakness leads to function, or fever of unknown origin might be signs of
dysphagia, further accentuating nutritional issues and unsafe swallowing, necessitating assessment. There
gradual loss of respiratory muscle strength, combined might be contributory factors for weight loss due to
with poor oral intake, and can result in severe weight loss complications in other systems, such as cardiac or
and the need to consider tube feeding. Constipation respiratory compromise.
might also be seen, typically in older patients and after A videofluoroscopic study of swallowing (also referred
surgery. With increasing survival, other complications to as a modified barium swallow) is necessary for patients
are being reported, including gastric and intestinal with clinical indicators of possible aspiration and
dilatation related to air swallowing due to ventilator use, pharyngeal dysmotility.134 Swallowing interventions and
or more rarely to delayed gastric emptying and ileus. As compensatory strategies are appropriate for patients with
the condition progresses, access to a dietitian or dysphagia. These should be delivered by a speech and
nutritionist, a swallowing/speech and language therapist, language pathologist, with training and expertise in the
and a gastroenterologist is needed for the following treatment of oral-pharyngeal dysphagia, who can assess
reasons: (1) to guide the patient to maintain good the likely appropriateness of interventions and deliver an
nutritional status to prevent both undernutrition/ individualised dysphagia treatment plan with the aim of
malnutrition and being overweight/obese, and to provide preserving optimum swallowing function.
a well-balanced, nutrient-complete diet (adding tube As the disease progresses, most patients begin to
feeding, if necessary); (2) to monitor and treat swallowing experience increasing difficulty with chewing and
problems (dysphagia) to prevent aspiration and weight subsequently exhibit pharyngeal-phase swallowing
loss, and to assess and treat delayed speech and language deficits in young adulthood.135–140 The onset of dysphagia
problems; and (3) to treat the common problems of symptoms can be gradual and the impact of
constipation and gastro-oesophageal reflux with both oral-pharyngeal dysphagia might be under-recognised
medication and non-medication therapies. and under-reported by patients.140 This leads to risk of
complications, such as aspiration and inability to take in
Nutritional management enough fluids and food energy to maintain weight.135–139
Maintaining good nutritional status, defined as weight Weight problems can also be due to an inability to meet
for age or body-mass index for age from the 10th to 85th the increased effort of breathing.135–139
percentiles on national percentile charts, is essential. When it is no longer possible to maintain weight and For the US national percentile
Poor nutrition can potentially have a negative effect on hydration by oral means, gastric-tube placement should charts see http://www.cdc.gov/
growthcharts/
almost every organ system. Anticipatory guidance and be offered. Discussions between other specialists and the
prevention of undernutrition/malnutrition and being family should involve explanations of the potential risks
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8. Review
acid blockers in children on corticosteroid therapy or oral
Panel 2: Improving underweight and overweight status bisphosphonates to avoid complications such as gastritis
Monitor regularly for: and to prevent reflux oesophagitis. It is necessary to
• Weight* recommend nutritional interventions for a patient who
• Linear height in ambulatory patients (measured every has symptoms suggestive of reflux.
6 months)
• Arm span/segmental length in non-ambulatory patients† Speech and language management
Delayed acquisition of early language milestones is
Refer for a nutritional/dietetic assessment: common in boys who have DMD, with differences in
• At diagnosis language acquisition and language-skill deficits persisting
• At initiation of glucocorticoids throughout childhood.144 Referral to a speech and
• If the patient is underweight (<10th age percentile)‡ language pathologist for assessment and treatment is
• If the patient is at risk of becoming overweight necessary on suspicion of difficulties with speech
(85–95th age percentile)‡ acquisition or with continuing deficits in language
• If the patient is overweight (>95th age percentile)‡ comprehension or oral expression. Oral motor exercises
• If there has been unintentional weight loss or gain and articulation therapy are necessary for young boys
• If there has been poor weight gain with DMD with hypotonia and in older patients who have
• If major surgery is planned deteriorating oral muscle strength and/or impaired
• If the patient is chronically constipated speech intelligibility. For older patients, compensatory
• If dysphagia is present strategies, voice exercises, and speech amplifications are
National guidelines and recommendations for diets for underweight and overweight appropriate if intelligibility deteriorates due to problems
individuals can be found in Kleinman,128 and are often available from charities/ with respiratory support for speech and vocal
associations for cardiac disorders and diabetes. *In non-ambulatory patients,
wheelchair weight should be obtained first, then patient and wheelchair weight, or
intensity. Voice output communication aid assessment
caregiver weight should be obtained first, then the weight of the patient held by the could be appropriate at all ages if speech output is
caregiver. †If the patient has scoliosis, the arm span should be measured if possible. limited.
‡Overweight/underweight status should be judged on the basis of local body-mass
index percentiles (weight for age is a possible alternative if height is unavailable). Body
composition is altered in Duchenne muscular dystrophy (DMD) owing to the relatively Pain management
low lean body mass seen in DMD with a relatively higher fat body mass.129 Pain of varying intensity occurs in DMD.145,146 Effective pain
management requires accurate determination of the cause.
and benefits of the procedure. A gastrostomy can be Interventions to address pain include physical therapy,
placed endoscopically or via open surgery, taking into postural correction, appropriate and individualised
account anaesthetic and ethical considerations and family orthoses, wheelchair and bed enhancements, and
and personal preference.141 pharmacological approaches (eg, muscle relaxants and
anti-inflammatory medications). Pharmacological inter-
Gastrointestinal management ventions must take into account possible interactions with
Constipation and gastro-oesophageal reflux are the two other medications (eg, steroids and non-steroidal
most common gastrointestinal conditions seen in children anti-inflammatory drugs) and their side-effects, particularly
with DMD in clinical practice.133,142,143 Stool softeners, those that might negatively affect cardiac or respiratory
laxatives, and stimulants are necessary if the patient has function. Rarely, orthopaedic intervention might be
acute constipation or faecal impaction, and use of enemas indicated for intractable pain that is amenable to surgery.
might be needed occasionally. Daily use of laxatives, such Back pain, particularly in the context of glucocorticoid
as milk of magnesia, lactulose, or polyethylene glycol, is treatment, is an indication that a careful search for vertebral
necessary if symptoms persist. In the case of persistent fractures is needed; such fractures respond well to
constipation, adequacy of free fluid intake should be bisphosphonate treatment and/or calcitonin.147,148 Research
determined and addressed. In cases of faecal impaction, on effective pain interventions across the lifespan of
manual/digital disimpaction under sedation or general individuals with DMD is warranted.146,149,150
anaesthesia is of uncertain benefit. Enemas, stimulant
laxatives, such as dulcolax and senna, and stool softeners Surgical considerations
can be tried before considering manual disimpaction. Milk Various situations, related (muscle biopsy, joint
and molasses enemas are not recommended for paediatric contracture surgery, spinal surgery, and gastrostomy)
patients. Supplementation with dietary fibre for chronic or and unrelated (intercurrent acute surgical events) to
severe constipation might worsen symptoms, particularly DMD, might require the use of general anaesthesia.
if fluid intake is not increased. There are several condition-specific issues that need to
Gastro-oesophageal reflux is typically treated with be taken into account for the planning of safe surgery.
proton-pump inhibitors or H2 receptor antagonists, with Surgery in a patient who has DMD should be done in a
prokinetics, sucralfate, and neutralising antacids as full-service hospital that has experience of patients with
adjunctive therapies. Common practice is to prescribe DMD. In addition, as with any situation in which
8 www.thelancet.com/neurology Published online November 30, 2009 DOI:10.1016/S1474-4422(09)70272-8
9. Review
patients are on chronic corticosteroid treatment, necessary with a forced vital capacity of below 30%
consideration needs to be given to steroid cover over predicted.155 Incentive spirometry is not indicated owing
the period of surgery.151 to potential lack of efficacy in patients with respiratory-
muscle weakness and the availability of preferred
Anaesthetic agents alternatives, such as mechanical insufflation–exsufflation.
The exclusive use of a total intravenous anaesthetic After careful consideration of the risks and benefits,
technique is strongly recommended owing to the risk of patients with significant respiratory-muscle weakness
malignant hyperthermia-like reactions and rhabdomyolysis might be eligible for surgery, albeit with increased risk, if
with exposure to inhalational anaesthetic agents, such as these patients are highly skilled preoperatively in the use
halothane and isoflurane.152,153 Depolarising muscle of non-invasive ventilation and assisted cough.156,157
relaxants, such as suxamethonium chloride, are absolutely
contraindicated owing to the risk of fatal reactions.152,153 Emergency-care considerations
Because of the involvement of different systems in DMD,
Blood loss many factors must be taken into account on presentation
To minimise blood loss and its effects intraoperatively in of a patient to an emergency room. From the outset, the
major surgeries, such as spinal fusion, it is necessary to diagnosis, current medication, respiratory status, cardiac
use mildly hypotensive anaesthetics, crystalloid bone status, and associated medical disorders should be made
allograft, and cell-saver technology. Other interventions, clear to the emergency-room staff. Because many health
such as the use of aminocaproic acid or tranexamic acid professionals are not aware of the potential management
to diminish intraoperative bleeding, can be considered.154 strategies available for DMD, the current life expectancy
Postoperative anticoagulation with heparin and/or and expected good quality of life should also be explained
aspirin is inappropriate. Use of compression stockings to reduce the risk of therapeutic nihilism in acute care.
or sequential compression for prevention of deep-vein Chronic glucocorticoid use (if relevant) needs to be made
thrombosis might be indicated. clear, with its concomitant risk of reduced stress response,
masking of infection, and possible gastric ulceration. Risk
Cardiac considerations of respiratory failure supervening during an intercurrent
An echocardiogram and electrocardiogram should be infection is high in those with borderline respiratory
done before general anaesthesia. They should also be function. Use of opiates and other sedating medication is
done if the patient is undergoing conscious sedation or essential, as is the use of oxygen without ventilation owing
regional anaesthesia if the last investigation was more to the risk of hypercapnia. If nocturnal ventilation is
than 1 year previously or if there had been an abnormal already being used, then access to the ventilator is essential
echocardiogram in the preceding 7–12 months. For local during any acute event or intervention. For patients who
anaesthesia, an echocardiogram should be done if an are already using ventilation, the team involved in the
abnormal result had been obtained previously. respiratory care of the patient should be contacted as soon
as possible. Awareness of the risk of arrhythmias and
Respiratory considerations cardiomyopathy is important. Anaesthetic issues, as
Respiratory interventions are intended to provide previously discussed, need to be taken into account at all
adequate respiratory support during induction of, times if surgery or sedation is needed.
maintenance of, and recovery from procedural sedation
or general anaesthesia. In particular, they are designed to Conclusions
reduce the risk of post-procedure endotracheal extubation This Review is the result of the first international
failure, postoperative atelectasis, and pneumonia.153 collaboration of a uniquely broad group of experts in DMD
These goals can be achieved by providing non-invasively management to develop comprehensive care recom-
assisted ventilation and assisted cough after surgery for mendations. This effort was supported by a rigorous
patients with significant respiratory-muscle weakness, as method—the RAND Corporation–University of California
indicated by sub-threshold preoperative pulmonary Los Angeles Appropriateness Method2—which expands
function test results. the consensus-building process, not only to establish the
Preoperative training in and postoperative use of parameters for optimum care, but also to identify areas of
manual and assisted cough techniques are necessary for uncertainty in which further work is needed.
patients whose baseline peak cough flow is below A model of care emerged during the process of
270 L/min or whose baseline maximum expiratory evaluating assessments and interventions for DMD that
pressure is below 60 cm water (these threshold levels of emphasises the importance of multidisciplinary care for
peak cough flow and maximum expiratory pressure apply patients with DMD. For example, the input of physio-
to older teenage and adult patients).155 Preoperative therapy, rehabilitation and orthopaedic management of
training in and postoperative use of non-invasive contractures (where necessary) has to be taken as a whole,
ventilation is strongly recommended for patients with a together with the impact of the use of corticosteroids,
baseline forced vital capacity of below 50% predicted and which in most boys has a significant effect on muscle
www.thelancet.com/neurology Published online November 30, 2009 DOI:10.1016/S1474-4422(09)70272-8 9
10. Review
Conflicts of interest
Search strategy and selection criteria KB is a consultant for Acceleron, AVI, Debiopharm, Prosensa, and
Santhera. LEC has received honoraria from Genzyme Corporation, has
Peer-reviewed literature was searched using the key search participated in research supported by Genzyme Corporation, PTC
terms of “Duchenne” or “muscular dystrophy”, or both, paired Therapeutics, the Leal Foundation, and Families of Spinal Muscular
Atrophy, has been awarded grant support from the National Skeletal
with one of 410 other search terms related to a comprehensive
Muscle Research Center, and is a member of the Pompe Registry Board
list of assessment tools and interventions used in DMD of Advisors. All other authors have no conflicts of interest.
management. The full list of search terms is available on
Acknowledgments
request. The databases used included Medline, Embase, Web of We thank P Eubanks, A Kenneson, A Vatave (CDC); A Cyrus and E Levy
Science, and the Cochrane Library. Initial inclusion criteria (Oak Ridge Institute for Science and Education); B Bradshaw, H Desai,
consisted of available abstracts of human studies published in P Haskell, E Hunt, A Marsden, C Muse, and L Yuson (Booz/Allen/
Hamilton); and B Tseng (Massachusetts General Hospital, Harvard
English between 1986 and 2006. Each working group also
Medical School) for their contributions to this study and manuscript. We
incorporated major articles from its discipline published before also thank the following organisations for their collaboration on this
1986 and from 2007 to mid-2009 in the process of study: Muscular Dystrophy Association, National Institute on Disability
discussions, final assessments, and write-up of and Rehabilitation Research, Parent Project Muscular Dystrophy, and
TREAT-NMD (EC036825). In addition, we thank M Levine,
recommendations.
M Mascarenhas, and M Thayu (Children’s Hospital of Philadelphia) for
their participation in discussions about bone health; and G Carter,
J Engel (University of Washington), H Posselt (Montrose Access,
strength and function. In this context, the various specialty Australia), and C Trout (University of Iowa Children’s Hospital) for their
reports are presented in this second part of the Review. advice on pain management. The CDC provided support for the project
Clearly staged assessments and interventions have through funding, study design, collection, analysis, and interpretation of
data and manuscript preparation. The findings and conclusions in this
been described to address the cardiac and respiratory report are those of the authors and do not necessarily represent the
complications that are common in DMD and provide the official position of the CDC.
framework for the safe management of these References
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All authors provided intellectual expertise in the study design, J Bone Joint Surg Am 1996; 78: 1844–52.
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approved the final version. DJB, LEC, LC, SP, and CC were involved in Elizabeth Licht, 1968.
the literature search.
10 www.thelancet.com/neurology Published online November 30, 2009 DOI:10.1016/S1474-4422(09)70272-8