BOTOX dosage in Lower Limb Spasticity.pptx
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Botox injections are noted primarily for the ability to reduce the appearance of facial wrinkles. They're also used to treat conditions such as neck spasms (cervical dystonia), excessive sweating (hyperhidrosis), an overactive bladder and lazy eye. Botox injections may also help prevent chronic migraines
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Osteoarthritis knee- introduction and approach
Osteoarthritis (OA) of the knee is a degenerative joint disorder characterized by structural changes like cartilage loss, synovial inflammation, and bone remodeling . Knee OA commonly affects daily activities due to symptoms like joint pain and stiffness, impacting functional abilities . Various factors contribute to knee OA development, including mechanical, enzymatic, and biological factors . In knee OA patients, proinflammatory cytokines like IL-6 and TNF-α have been found to correlate with functional impairment assessed by WOMAC scores, indicating a potential impact on knee joint function . Understanding the interplay between aging and knee OA is crucial, as aging processes can exacerbate the degenerative changes in the knee joint, leading to functional limitations . Evaluating patients' perspectives on knee OA management through instruments like the Knee Outcome Survey Activity Daily Living Scale (KOS-ADLS) is essential for assessing the success of interventions
Gait deviations in Transtibial prosthesis users
Gait deviations in transtibial amputations involve altered biomechanics and asymmetries. Research highlights that spatiotemporal gait parameters are affected, with reduced propulsive force, knee extension moment, and increased knee abduction moment in the amputated leg. Additionally, individuals with transtibial amputations exhibit shorter stance times, longer swing times, and larger step lengths compared to able-bodied individuals. These deviations can lead to asymmetrical loads, potentially causing issues like osteoarthritis or lower back pain. Furthermore, gait asymmetry in transtibial amputees is associated with poor functional outcomes, impacting performance-based physical function tests like the Timed Up and Go, the 10-Meter Walk Test, and the 6-Minute Walk Test. Understanding these gait abnormalities is crucial for tailored interventions and prosthetic design to improve outcomes for individuals with transtibial amputations.
Basics of electro myo graphy study (EMG)
Electromyography (EMG) is a vital technique in the field of bioelectrical signal analysis. It involves capturing muscle activity through surface or needle electrodes for diagnostic purposes. EMG signals can be analyzed to detect various muscle conditions, such as myopathic or neuropathic lesions, using numerical parameters. The spatial frequency bandwidth of surface EMG signals is crucial for detailed muscle activity reconstruction, with appropriate inter-electrode distances being essential for accurate mapping. In the context of neuro-monitoring, EMG plays a role in intra-operative detection of adverse events and predicting postoperative outcomes, especially when used complementarily with other modalities like motor evoked potentials. Overall, EMG serves as a valuable tool for understanding muscle function, diagnosing muscle disorders, and enhancing neuro-monitoring practices
Principles of tendon transfer surgeries in rehabilitation
Tendon transfers, a fundamental aspect of reconstructive surgery, represent a sophisticated intervention in the domain of orthopedics and plastic surgery. This intricate procedure involves the repositioning or redirection of tendons to restore lost function, correct deformities, or alleviate debilitating conditions resulting from tendon injuries, neurological disorders, or musculoskeletal anomalies. By harnessing the body's inherent capacity for adaptation and regeneration, tendon transfers offer a transformative solution to patients grappling with impairments affecting mobility, dexterity, and overall quality of life.
Within the realm of medical science, tendon transfers stand as a testament to the innovative intersection of anatomy, biomechanics, and surgical expertise. Guided by meticulous anatomical knowledge and informed by patient-specific considerations, surgeons meticulously navigate the intricate network of tendinous structures to achieve optimal outcomes. This precise manipulation of tendons demands not only technical proficiency but also a profound understanding of functional anatomy, pathological processes, and the dynamic interplay between muscles and joints.
The rationale underlying tendon transfers rests upon the principle of functional restoration through strategic tendon re-routing. Whether addressing paralysis resulting from nerve injury or rectifying muscular imbalances precipitated by congenital anomalies, the overarching goal remains consistent: to enhance musculoskeletal function and foster meaningful improvements in patient well-being. By redistributing the forces exerted by muscles across joints, tendon transfers serve as a cornerstone in the rehabilitation arsenal, offering a pathway towards enhanced motor control, stability, and range of motion.
In this discourse, we embark on a comprehensive exploration of tendon transfers, delving into the intricacies of surgical technique, patient selection criteria, rehabilitative protocols, and outcomes assessment. Through a synthesis of clinical insights, scientific inquiry, and empirical evidence, we endeavor to illuminate the multifaceted dimensions of this therapeutic modality. By elucidating the underlying principles and practical applications of tendon transfers, we aspire to equip healthcare practitioners with the requisite knowledge and insights to navigate this dynamic landscape and empower patients with newfound avenues for functional restoration and renewed vitality.
International standards for neurological classification of spinal cord
The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) or more commonly referred to as the ASIA Impairment Scale (AIS), was developed by the American Spinal Injury Association (ASIA) as a universal classification tool for Spinal Cord Injury based on a standardized sensory and motor assessment, with the most recent revised edition published in 2011. The impairment scale involves both a motor and sensory examination to determine the sensory and motor levels for the right and left side, the overall neurological level of the injury and completeness of the injury i.e. whether the injury is complete or incomplete.
Wheelchairs in rehabilitation
Wheelchairs and seating systems allow individuals with mobility impairments to actively participate at home, work, school, and the community. The quality of life of an individual is reflective of the overall effectiveness of the wheelchair and seating system when considering activities of daily living (ADLs). Therefore it is imperative that the multidisciplinary team of rehabilitation professionals
considers not only the individual and the wheelchair but also the
activities, context, policies, and personal assistance associated with the technology. Historically, rehabilitation professionals have
focused on functional mobility at the time of implementation of
the wheelchair and seating system. Now, as a result of changes in the overall health care environment, driven by a need for increased value, rehabilitation professionals must integrate a more holistic
approach to manage costs while improving outcomes at the time
of implementation and throughout the life of the wheelchair and seating systems.To better understand the long-term effects of the wheelchair and seating system and to maximize the functional
outcomes of the individual, rehabilitation professionals across the multidisciplinary health care team must understand the advances in current technology as well as best practices in the service delivery.
process. The value of the wheelchair and seating system within
the context of health care now extends beyond the four walls of a
traditional clinic to the community in which the individual uses
the wheelchair and seating system.
Burns Rehabilitation
Significant advances in management have resulted in an increase in survival after burn injury in regions of the world with access to current medical and surgical resources. As a consequence, burn survivors with access to up-to-date care and who tend to be young adults have long-term sequelae that impair function and limit
return to preinjury function, including work and community
reintegration. Up to 1 million burns require treatment annually in North America, and over 10 times as many burns occur worldwide. In low-income and middle-income countries, mortality is significantly greater than in high-income countries.The future
of burn care will be challenged by the expense and complexity of treatment, a predicted shortage of qualified burn care providers, and an aging population.
Stroke rehabilitation
Physical medicine and rehabilitation (PM&R) is a relatively young specialty that developed during the 20th century, with signifi cant growth and development stimulated by
two World Wars and by increasingly severe epidemics of
paralytic poliomyelitis during the fi rst half of the 20th century
(1–4). During and after each of the World Wars, many soldiers returned with serious injuries and severe disabilities, and physicians and therapists were needed to treat and manage their chronic disabling conditions. This was particularly true after World War II, when the availability of antibiotics and improved surgical techniques allowed more injured soldiers to survive, albeit with significant
disabilities. Similarly, over the same time period, increasingly
severe epidemics of polio, frequent industrial accidents,
and escalating motor vehicle accidents as a result of
the increased availability of automobiles and higher-speed
roadways added greatly to the burden of impairment and
disability among the civilian population. Thus, events in the
fi rst half of the 20th century necessitated the development
of new restorative treatment programs incorporating new
physical and rehabilitative techniques, and the establishment
of training programs for physicians and therapists to
administer the treatments.
Nevertheless, with the exception of a relatively few scattered physical medicine physicians, it was not until the second half of the 20th century that specialists in rehabilitation medicine could profi tably direct their energies exclusively, or even preferentially, to rehabilitation outside of the unprecedented and unsustainable circumstances of wartime
military programs. Also largely missing until the second half
of the 20th century were separate departments in academic and nonacademic medical centers devoted to the specialty, established training programs in PM&R, a sufficient number of PM&R practitioners, separate dedicated facilities for
provision of rehabilitation services (e.g., dedicated wards in hospitals or separate rehabilitation centers), forums for the interchange of ideas (e.g., texts, journals, and professional societies), recognition by professional colleagues and the
public that rehabilitation medicine specialists provided a
needed service, and supportive legislation that would provide
fi nancial mechanisms to develop and provide such
resources
Recommended
Osteoarthritis knee- introduction and approach
Osteoarthritis (OA) of the knee is a degenerative joint disorder characterized by structural changes like cartilage loss, synovial inflammation, and bone remodeling . Knee OA commonly affects daily activities due to symptoms like joint pain and stiffness, impacting functional abilities . Various factors contribute to knee OA development, including mechanical, enzymatic, and biological factors . In knee OA patients, proinflammatory cytokines like IL-6 and TNF-α have been found to correlate with functional impairment assessed by WOMAC scores, indicating a potential impact on knee joint function . Understanding the interplay between aging and knee OA is crucial, as aging processes can exacerbate the degenerative changes in the knee joint, leading to functional limitations . Evaluating patients' perspectives on knee OA management through instruments like the Knee Outcome Survey Activity Daily Living Scale (KOS-ADLS) is essential for assessing the success of interventions
Gait deviations in Transtibial prosthesis users
Gait deviations in transtibial amputations involve altered biomechanics and asymmetries. Research highlights that spatiotemporal gait parameters are affected, with reduced propulsive force, knee extension moment, and increased knee abduction moment in the amputated leg. Additionally, individuals with transtibial amputations exhibit shorter stance times, longer swing times, and larger step lengths compared to able-bodied individuals. These deviations can lead to asymmetrical loads, potentially causing issues like osteoarthritis or lower back pain. Furthermore, gait asymmetry in transtibial amputees is associated with poor functional outcomes, impacting performance-based physical function tests like the Timed Up and Go, the 10-Meter Walk Test, and the 6-Minute Walk Test. Understanding these gait abnormalities is crucial for tailored interventions and prosthetic design to improve outcomes for individuals with transtibial amputations.
Basics of electro myo graphy study (EMG)
Electromyography (EMG) is a vital technique in the field of bioelectrical signal analysis. It involves capturing muscle activity through surface or needle electrodes for diagnostic purposes. EMG signals can be analyzed to detect various muscle conditions, such as myopathic or neuropathic lesions, using numerical parameters. The spatial frequency bandwidth of surface EMG signals is crucial for detailed muscle activity reconstruction, with appropriate inter-electrode distances being essential for accurate mapping. In the context of neuro-monitoring, EMG plays a role in intra-operative detection of adverse events and predicting postoperative outcomes, especially when used complementarily with other modalities like motor evoked potentials. Overall, EMG serves as a valuable tool for understanding muscle function, diagnosing muscle disorders, and enhancing neuro-monitoring practices
Principles of tendon transfer surgeries in rehabilitation
Tendon transfers, a fundamental aspect of reconstructive surgery, represent a sophisticated intervention in the domain of orthopedics and plastic surgery. This intricate procedure involves the repositioning or redirection of tendons to restore lost function, correct deformities, or alleviate debilitating conditions resulting from tendon injuries, neurological disorders, or musculoskeletal anomalies. By harnessing the body's inherent capacity for adaptation and regeneration, tendon transfers offer a transformative solution to patients grappling with impairments affecting mobility, dexterity, and overall quality of life.
Within the realm of medical science, tendon transfers stand as a testament to the innovative intersection of anatomy, biomechanics, and surgical expertise. Guided by meticulous anatomical knowledge and informed by patient-specific considerations, surgeons meticulously navigate the intricate network of tendinous structures to achieve optimal outcomes. This precise manipulation of tendons demands not only technical proficiency but also a profound understanding of functional anatomy, pathological processes, and the dynamic interplay between muscles and joints.
The rationale underlying tendon transfers rests upon the principle of functional restoration through strategic tendon re-routing. Whether addressing paralysis resulting from nerve injury or rectifying muscular imbalances precipitated by congenital anomalies, the overarching goal remains consistent: to enhance musculoskeletal function and foster meaningful improvements in patient well-being. By redistributing the forces exerted by muscles across joints, tendon transfers serve as a cornerstone in the rehabilitation arsenal, offering a pathway towards enhanced motor control, stability, and range of motion.
In this discourse, we embark on a comprehensive exploration of tendon transfers, delving into the intricacies of surgical technique, patient selection criteria, rehabilitative protocols, and outcomes assessment. Through a synthesis of clinical insights, scientific inquiry, and empirical evidence, we endeavor to illuminate the multifaceted dimensions of this therapeutic modality. By elucidating the underlying principles and practical applications of tendon transfers, we aspire to equip healthcare practitioners with the requisite knowledge and insights to navigate this dynamic landscape and empower patients with newfound avenues for functional restoration and renewed vitality.
International standards for neurological classification of spinal cord
The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) or more commonly referred to as the ASIA Impairment Scale (AIS), was developed by the American Spinal Injury Association (ASIA) as a universal classification tool for Spinal Cord Injury based on a standardized sensory and motor assessment, with the most recent revised edition published in 2011. The impairment scale involves both a motor and sensory examination to determine the sensory and motor levels for the right and left side, the overall neurological level of the injury and completeness of the injury i.e. whether the injury is complete or incomplete.
Wheelchairs in rehabilitation
Wheelchairs and seating systems allow individuals with mobility impairments to actively participate at home, work, school, and the community. The quality of life of an individual is reflective of the overall effectiveness of the wheelchair and seating system when considering activities of daily living (ADLs). Therefore it is imperative that the multidisciplinary team of rehabilitation professionals
considers not only the individual and the wheelchair but also the
activities, context, policies, and personal assistance associated with the technology. Historically, rehabilitation professionals have
focused on functional mobility at the time of implementation of
the wheelchair and seating system. Now, as a result of changes in the overall health care environment, driven by a need for increased value, rehabilitation professionals must integrate a more holistic
approach to manage costs while improving outcomes at the time
of implementation and throughout the life of the wheelchair and seating systems.To better understand the long-term effects of the wheelchair and seating system and to maximize the functional
outcomes of the individual, rehabilitation professionals across the multidisciplinary health care team must understand the advances in current technology as well as best practices in the service delivery.
process. The value of the wheelchair and seating system within
the context of health care now extends beyond the four walls of a
traditional clinic to the community in which the individual uses
the wheelchair and seating system.
Burns Rehabilitation
Significant advances in management have resulted in an increase in survival after burn injury in regions of the world with access to current medical and surgical resources. As a consequence, burn survivors with access to up-to-date care and who tend to be young adults have long-term sequelae that impair function and limit
return to preinjury function, including work and community
reintegration. Up to 1 million burns require treatment annually in North America, and over 10 times as many burns occur worldwide. In low-income and middle-income countries, mortality is significantly greater than in high-income countries.The future
of burn care will be challenged by the expense and complexity of treatment, a predicted shortage of qualified burn care providers, and an aging population.
Stroke rehabilitation
Physical medicine and rehabilitation (PM&R) is a relatively young specialty that developed during the 20th century, with signifi cant growth and development stimulated by
two World Wars and by increasingly severe epidemics of
paralytic poliomyelitis during the fi rst half of the 20th century
(1–4). During and after each of the World Wars, many soldiers returned with serious injuries and severe disabilities, and physicians and therapists were needed to treat and manage their chronic disabling conditions. This was particularly true after World War II, when the availability of antibiotics and improved surgical techniques allowed more injured soldiers to survive, albeit with significant
disabilities. Similarly, over the same time period, increasingly
severe epidemics of polio, frequent industrial accidents,
and escalating motor vehicle accidents as a result of
the increased availability of automobiles and higher-speed
roadways added greatly to the burden of impairment and
disability among the civilian population. Thus, events in the
fi rst half of the 20th century necessitated the development
of new restorative treatment programs incorporating new
physical and rehabilitative techniques, and the establishment
of training programs for physicians and therapists to
administer the treatments.
Nevertheless, with the exception of a relatively few scattered physical medicine physicians, it was not until the second half of the 20th century that specialists in rehabilitation medicine could profi tably direct their energies exclusively, or even preferentially, to rehabilitation outside of the unprecedented and unsustainable circumstances of wartime
military programs. Also largely missing until the second half
of the 20th century were separate departments in academic and nonacademic medical centers devoted to the specialty, established training programs in PM&R, a sufficient number of PM&R practitioners, separate dedicated facilities for
provision of rehabilitation services (e.g., dedicated wards in hospitals or separate rehabilitation centers), forums for the interchange of ideas (e.g., texts, journals, and professional societies), recognition by professional colleagues and the
public that rehabilitation medicine specialists provided a
needed service, and supportive legislation that would provide
fi nancial mechanisms to develop and provide such
resources
Pathophysiology of Spasticity
In lesions below the mid-pons, a state of flaccidity, termed spinal shock, ensues immediately after injury with loss of all reflexes caudal to the injury.
The resolution of spinal shock occurs gradually , taking weeks to months.
The recovery from spinal shock is poorly understood and likely results from multiple, simultaneous adaptations in spinal processing that allow motor neuron to function independently from supraspinal control.
Existence of spinal shock, followed by a gradual return of reflexes that eventually become hyperactive, suggests that spasticity is not just a result of a simple on/off switch triggered by an alteration in inhibitory and facilitative signals
Lower limb Prostheses
Walking depends on the repeated performance by the lower limbs of a sequence of motions that simultaneously advances the body along the desired line of progression while also maintaining a stable weight-bearing posture. Effectiveness depends on free joint mobility and muscle action that is selective in both timing and intensity. Normal function is also optimally conservative of physiologic energy. Pathologic conditions alter the mode and efficiency of walking. The loss of some actions necessitates substitution of others if forward progression and stance stability are to be preserved. Through a detailed knowledge of normal function and the types of gait errors that the various pathologic conditions can introduce, the clinician becomes able to define the significant deficits and plan appropriate corrective measures
Tendo Achilles tenotomy as a part of Ponsetti technique
Most CTEV children will need the tenotomy, which is a minor procedure usually done
with local anaesthetic. Children need the tenotomy because their heel (Achilles) tendon is short and tight
and it pulls the heel up.If it is not corrected the child will walk on tiptoes. Some doctors use general anaesthetic for older patients. After the tenotomy a final POP cast is applied and left on for three weeks. During this time the tendon regenerates in the lengthened position and the foot
can be bent up easily towards the front of the leg (dorsiflexion). If your baby is unhappy after the tenotomy, it is fine to use some paracetamol
as you would after vaccinations
Upper limb prostheses
Prosthetic management of individuals with upper extremity
amputations presents all health professionals, including
prosthetists and therapists, with a set of unique challenges.
For those wearing an upper extremity prosthesis, the terminal
device (TD) of the prosthesis is not covered or obscured
by clothing in the same way that a lower extremity prosthesis
is “hidden” by pants, socks, and shoes. The person with
upper extremity amputation must cope with not only physical
appearance changes, but the loss of some of the most
complex movement patterns and functional activities of
the human body.
In addition, upper extremity limb loss deprives the patient
of an extensive and valuable system of tactile and proprioceptive
inputs that previously provided “feedback” to guide and
refine functional movement. Even the simplest tasks
related to grasp and release become challenging. The ability
to position the prosthetic limb segments in space, as well as
the ability to maintain advantageous postures needed to
manipulate objects, challenge the medical community to
continuously improve the functional and aesthetic outcomes
of prostheses for patients in this population.
PELVIC FLOOR REHABILITATION
Pelvic floor disorders include a wide-ranging group of potentially
disabling, embarrassing, and often painful conditions that can
greatly affect a person’s quality of life. The pelvic floor consists of
muscles, fascia, and ligaments that support the pelvic organs and
help to provide control for bodily functions. Pathology within the
musculoskeletal and neurologic structures of the deep pelvis can
lead to the development of pelvic pain, dyspareunia, voiding dysfunction
including urinary incontinence or urinary urgency, fecal
incontinence (FI), constipation, and pelvic organ prolapse (POP)
.
Both women and men can develop pelvic floor disorders,
although women are at increased risk compared with men because
of their unique anatomy and biomechanics. The female pelvis is
broader and shallower, requiring greater muscular and ligamentous
stiffness to provide support and stability. Women are also
more likely to incur injury to the pelvic floor as a result of pregnancy
and childbirth. As a result, abnormal biomechanics of the
pelvic floor muscles (PFMs) may lead to changes in contraction,
relaxation, muscle strength, and myofascial pain. In a 2014 study,
the prevalence of symptomatic pelvic floor disorders in the United
States was estimated to be approximately 25%. It is important
to note that this percentage does not consider women with pelvic
pain due to high-tone pelvic floor dysfunction.
People with pelvic floor disorders benefit from an interdisciplinary
rehabilitation approach to improve function and reduce pain.
Physiatrists with experience in acute and chronic pain, neurologic
and musculoskeletal conditions, and neurogenic bowel/bladder
management are well suited to direct such a patient’s care.In
addition to diagnosing and managing the patient’s pelvic floor
disorder medically, the physiatrist plays a key role in providing
a detailed prescription for physical therapy.
Ergonomic modification for a person with a desk job
It was estimated that about 40.7 % of the global population was surfing the computers in the year 2012 as compared to 2006 of only 26.2%. [1]
Marshall et al study reveal that on average, six out of 10 employees used a chair at work and the number was expected to grow.[2]
Many researchers report that working 5.41 hours sitting at desk and 7 hour sleeping at night had a great impact on the physical and mental health.[2]
Sitting on a chair is one of the most common positions adopted by humans.
children and adults spend approx. 55% of their working hours or 7.7 hours/day in sitting postures.[2]
The ergonomic fit workstations have become a standard practice in various developed countries
Charcot Restraint Orthotic Walker
CROW boot is a custom-molded bivalve plastic ankle-foot orthosis that is fully padded on the inside with total contact of the foot, ankle, and leg.
Reciprocating Gait Orthosis
A special HKAFO, which uses a mechanical linkage to couple flexion of one hip with extension of the other, which enables a reciprocal step-over-step gait.
Also allow swing through and swing to gaits
Floor reaction Ankle foot orthosis or Gravity reaction ankle foot orthosis
Prevent knee buckling without actually including knee in orthosis
Sense of freedom and more control over external devices
Light weight- 300gms
Cosmetically acceptable
Prevents pressure sore
Easy maintenance
Posterior leaf spring orthosis
A plastic or carbon fibre orthosis designed to assist in dorsiflexion in swing phase.
Total contact cast
Total contact cast is rigid or semi-rigid molded cast which extends from the patient’s foot to just below the knee, maintaining contact with the entire plantar surface of the foot and lower leg and immobilizing surrounding joints and soft tissue while allowing the patient to remain ambulatory.
Considered as gold standard of offloading techniques
Started in early 1930s as a treatment modality for post hansens neuropathic ulcer
Effective , Rapid and ambulatory
Goals in rehabilitaion of cerebral palsy child
What do you want for your child’s current life and future? The goals should answer this critical question. Without goals, a life care plan will have a lot of details but no direction. Rely on your trusted experts and your family to help you develop the goals to give your child the best life possible.
The life care plan for a child with cerebral palsy has several purposes and is essential for several reasons. The main reason to have a care plan is to have something that acts as a roadmap for your child’s best life.
Get Matched with a Leading Cerebral Palsy Attorney in Your Area
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It includes everything you need to give them the best life, from a complete diagnosis and evaluation of their condition, limitations, and abilities, to an assessment of how much care will cost over a lifetime.
The primary purpose of having goals as part of the life care plan is to fuel the efforts you and your care team are making to give your child a great life and enable them to live their best life.
Goals may be short-term and health-related, such as changing the diet to make sure your child has no nutritional deficits. They may also be long-term, like achieving living independence or finding a job.
Experts Help You Develop Goals
Your child’s care plan will include a diagnosis, evaluation, and the establishment of a care team.
The team of specialists, caregivers, and supportive family and friends will help you decide on the goals for your child.
Once you have those goals lined up—and these will change and adapt over time—you can start making a plan for achieving them, the actual roadmap for your child’s care.
Developing goals will seem overwhelming, especially when the only goal you can think about is a healthy child. Rely on the expertise of your care team.
People such as educational experts, neurologists, nutritionists, and therapists can help you understand what is possible for your child and their future and will guide you as you create the goals.
Goal Categories
As you develop your care plan and start to think about the goals you have for your child, it can help to break them down into categories. Your child’s condition is complex, and organizing it in this way makes a complicated situation a little easier to understand.
Managing the primary disability. Cerebral palsy is complicated, but the first goal you should consider is how to manage the prime condition. This is an overreaching kind of objective and one that your neurologist and pediatrician can help you develop.
Managing complications. Cerebral palsy often comes along with co-existing conditions like seizure disorders and cognitive impairment. Setting goals for managing these is the next important step.
Improving mobility. Mobility is a significant issue for most children with cerebral palsy.[2] Some will be severely impaired and unable to walk. In contrast, others may have more minor disabilities. Goals that address how well your child moves are essential for making them comfortable
Rehabilitation of dominant upper limb amputation
Hand dominance is the preferential use of one hand over the other for motor tasks.
90% of people are right-hand dominant, and the majority of injuries (acute and cumulative trauma) occur to the dominant limb, creating a double-impact injury whereby a person is left in a functional state of single-handedness and must rely on the less dexterous, non-dominant hand.
When loss of dominant hand function is permanent, a forced shift of dominance is termed injury-induced hand dominance transfer
There are innate differences in dexterity influenced by hand dominance.
Although most activities are accomplished bimanually, the dominant hand acts as the more dexterous, main executor while the non-dominant hand acts as supporter.
In the context of rehabilitation, permanent loss of dexterity in dominant hand is more devastating because dexterity skill previously endowed to dominant hand must be transferred to non-dominant hand
Persons with unilateral dexterity loss of the dominant limb have two challenges
they are forced to complete two handed tasks with one hand.
the remaining limb, which primarily functioned as the supporting limb, must assume dexterity responsibilities of the dominant limb.
Hand dominance is therefore a critical factor related to rehabilitation addressing dexterity of persons with upper limb injuries.
Persons with unilateral dexterity loss of the dominant limb have two challenges
they are forced to complete two handed tasks with one hand.
the remaining limb, which primarily functioned as the supporting limb, must assume dexterity responsibilities of the dominant limb.
Hand dominance is therefore a critical factor related to rehabilitation addressing dexterity of persons with upper limb injuries.
Persons with unilateral dexterity loss of the dominant limb have two challenges
they are forced to complete two handed tasks with one hand.
the remaining limb, which primarily functioned as the supporting limb, must assume dexterity responsibilities of the dominant limb.
Hand dominance is therefore a critical factor related to rehabilitation addressing dexterity of persons with upper limb injuries.
Leading cause of upper limb amputations is trauma occurring in males ages 15-25 years,
Most of traumatic amputation happen on dominant limb
vascular complications of diseases.
No limb prefernces
cancer/tumors (common cause of more proximal amputations such as a shoulder disarticulation or forequarter amputation)
Principles Of Amputation
Amputation is the most ancient of all surgical procedures.
Neolithic man is known to have survived amputation as evidenced
from the skeletons with amputated stumps and from the knives
and saws made of stone used at that time. Even the murals of La
Tene and the drawings on the Peruvian pottery depict human
figures with amputated stumps. In the olden times, amputations
were practiced not only for disease but also as a punishment for
criminals and as rituals to appease Gods or even in the practice of
Black Magic. It is considered that the first account of amputation
as a purposeful medical procedure is found in the Hippocratic
Treatise and it was concerned with amputation for vascular
gangrene.
Indications for amputations vary according to availability of skill,
facilities and line of treatment adopted. Many limb cancers are
treated by amputations, but in some advanced centers limb
preservation surgeries are done. A severely traumatized limb
where the circulation is good may be amputated if the facilities
for reconstruction are not available. Although the designs and the
usability of the prostheses continue to advance, a well performed
amputation is necessary for optimum results.
when the blood supply of a limb is irreparably destroyed or when
the limb is so severely damaged that reasonable reconstruction is
impossible, amputation of the limb is indicated. In injuries of limbs,
if three or more out of the five components (blood vessels, nerves,
skin, muscles and bones) are badly damaged, amputation can be
considered . The amputation can be early, intermediate
or late depending on the timing after injury as will be discussed
later in type of amputation. Thermal burns, frostbite or electrical
burns are other injuries that may require amputation.
Residual short stump can have excellent function.1 In the past,
amputation through specific levels was necessary for proper fitting
of prosthesis. The accepted ideal stump lengths are 23–28 cm from
greater trochanter in above-knee amputations, 13 cm from the
tibial articular surface in below-knee amputations, 10 cm above
elbow in amputations through arm, and 17 cm from olecranon in
forearm amputations. With modern prosthetic fitting techniques,
a prosthesis can be fitted to any well-healed nontender stump.
Determining the level of amputation requires an understanding
of the trade-offs between increased function with more distal level
of amputation and a decreased complication rate with a more
proximal level of amputation.
Osteoarthritis – Knee
Knee osteoarthritis (OA), also known as degenerative joint disease, is typically the result of wear and tear and progressive loss of articular cartilage. It is most common in the elderly. Knee osteoarthritis can be divided into two types, primary and secondary. Primary osteoarthritis is articular degeneration without any apparent underlying reason. Secondary osteoarthritis is the consequence of either an abnormal concentration of force across the joint as with post-traumatic causes or abnormal articular cartilage, such as rheumatoid arthritis (RA).
Osteoarthritis is typically a progressive disease that may eventually lead to disability. The intensity of the clinical symptoms may vary for each individual. However, they typically become more severe, more frequent, and more debilitating over time. The rate of progression also varies for each individual. Common clinical symptoms include knee pain that is gradual in onset and worse with activity, knee stiffness and swelling, pain after prolonged sitting or resting, and pain that worsens over time. Treatment for knee osteoarthritis begins with conservative methods and progresses to surgical treatment options when conservative treatment fails. While medications can help slow the progression of RA and other inflammatory conditions, no proven disease-modifying agents for the treatment of knee osteoarthritis currently exist.
Pathophysiology of Spasticity
Spasticity is a common motor control disorder frequently encountered in the
spectrum of the upper motor neuron (UMN) syndrome. It can result in pain,
fatigue, joint restrictions, functional impairments, and skin breakdown that may
negatively affect many domains of life by causing social avoidance and
diminished life satisfaction . Spasticity was originally defined as a velocity dependent increase in tonic stretch reflexes or muscle tone with exaggerated
tendon jerks resulting from increased excitability of the stretch reflex . This
definition has been criticized for being too narrow and inadequately depicting
the clinical sequelae. In 2005, a European Thematic Network to Develop
Standardized Measures of Spasticity (the SPASM consortium) suggested
broadening the definition to reflect a more clinical entity . They defined
spasticity as “disordered sensory-motor control, resulting from an upper motor
neuron lesion, presenting as intermittent or sustained involuntary activation of
muscles.
physiology of muscle contraction and basics of exercise
ithin the fi eld of physiology, there are a number of fundamental principles. Some of these key principles are
(a) homeostasis, (b) the linkage between gene expression
and physiology, and (c) structure–function relationships.
It is this latter principle that forms the foundation of the
current chapter. The concept of structure–function relationships extends across the organism-to-molecule spectrum. At the organism level, one can think about a number
of examples. For instance, the structural relationship
between the glenoid fossa and the head of the humerus
gives the shoulder six degrees of motion—a motion that
is uncommon among other joints. At the molecular level,
one can think about the structure of myosin heavy chains
(MHCs) and how this translates into certain functional
properties like the force–velocity relationship.
The discipline of exercise physiology really represents
a subdiscipline or an extension of the fi eld of physiology;
and, as such, the fundamental principles are essentially
the same except that they are examined typically under
conditions where physical activity has been altered. In this
context, a great deal of interest has been given to understanding the effects of both activity and inactivity on the
structural and functional properties of skeletal muscle during the past 30 to 35 years.
Of any cell/tissue type, skeletal muscle certainly
exhibits some of the clearest structure–function relationships. Given this perspective, one of the key objectives of
this chapter is to provide a backdrop for some of the more
detailed discussions that follow in successive chapters. The
current chapter is organized into three distinct sections.
The fi rst section provides an overview of some of the key
structural properties of skeletal muscle (macroscopic to
molecular anatomy). The second part of the chapter addresses the linkage between structure and function and the
topic of skeletal muscle plasticity as infl uenced by altered
physical activity. The fi nal section of this chapter examines
issues of muscle plasticity from a comparative perspective
and introduces the concept of symmorphosis, a concept
related to the optimality of design
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Pathophysiology of Spasticity
In lesions below the mid-pons, a state of flaccidity, termed spinal shock, ensues immediately after injury with loss of all reflexes caudal to the injury.
The resolution of spinal shock occurs gradually , taking weeks to months.
The recovery from spinal shock is poorly understood and likely results from multiple, simultaneous adaptations in spinal processing that allow motor neuron to function independently from supraspinal control.
Existence of spinal shock, followed by a gradual return of reflexes that eventually become hyperactive, suggests that spasticity is not just a result of a simple on/off switch triggered by an alteration in inhibitory and facilitative signals
Lower limb Prostheses
Walking depends on the repeated performance by the lower limbs of a sequence of motions that simultaneously advances the body along the desired line of progression while also maintaining a stable weight-bearing posture. Effectiveness depends on free joint mobility and muscle action that is selective in both timing and intensity. Normal function is also optimally conservative of physiologic energy. Pathologic conditions alter the mode and efficiency of walking. The loss of some actions necessitates substitution of others if forward progression and stance stability are to be preserved. Through a detailed knowledge of normal function and the types of gait errors that the various pathologic conditions can introduce, the clinician becomes able to define the significant deficits and plan appropriate corrective measures
Tendo Achilles tenotomy as a part of Ponsetti technique
Most CTEV children will need the tenotomy, which is a minor procedure usually done
with local anaesthetic. Children need the tenotomy because their heel (Achilles) tendon is short and tight
and it pulls the heel up.If it is not corrected the child will walk on tiptoes. Some doctors use general anaesthetic for older patients. After the tenotomy a final POP cast is applied and left on for three weeks. During this time the tendon regenerates in the lengthened position and the foot
can be bent up easily towards the front of the leg (dorsiflexion). If your baby is unhappy after the tenotomy, it is fine to use some paracetamol
as you would after vaccinations
Upper limb prostheses
Prosthetic management of individuals with upper extremity
amputations presents all health professionals, including
prosthetists and therapists, with a set of unique challenges.
For those wearing an upper extremity prosthesis, the terminal
device (TD) of the prosthesis is not covered or obscured
by clothing in the same way that a lower extremity prosthesis
is “hidden” by pants, socks, and shoes. The person with
upper extremity amputation must cope with not only physical
appearance changes, but the loss of some of the most
complex movement patterns and functional activities of
the human body.
In addition, upper extremity limb loss deprives the patient
of an extensive and valuable system of tactile and proprioceptive
inputs that previously provided “feedback” to guide and
refine functional movement. Even the simplest tasks
related to grasp and release become challenging. The ability
to position the prosthetic limb segments in space, as well as
the ability to maintain advantageous postures needed to
manipulate objects, challenge the medical community to
continuously improve the functional and aesthetic outcomes
of prostheses for patients in this population.
PELVIC FLOOR REHABILITATION
Pelvic floor disorders include a wide-ranging group of potentially
disabling, embarrassing, and often painful conditions that can
greatly affect a person’s quality of life. The pelvic floor consists of
muscles, fascia, and ligaments that support the pelvic organs and
help to provide control for bodily functions. Pathology within the
musculoskeletal and neurologic structures of the deep pelvis can
lead to the development of pelvic pain, dyspareunia, voiding dysfunction
including urinary incontinence or urinary urgency, fecal
incontinence (FI), constipation, and pelvic organ prolapse (POP)
.
Both women and men can develop pelvic floor disorders,
although women are at increased risk compared with men because
of their unique anatomy and biomechanics. The female pelvis is
broader and shallower, requiring greater muscular and ligamentous
stiffness to provide support and stability. Women are also
more likely to incur injury to the pelvic floor as a result of pregnancy
and childbirth. As a result, abnormal biomechanics of the
pelvic floor muscles (PFMs) may lead to changes in contraction,
relaxation, muscle strength, and myofascial pain. In a 2014 study,
the prevalence of symptomatic pelvic floor disorders in the United
States was estimated to be approximately 25%. It is important
to note that this percentage does not consider women with pelvic
pain due to high-tone pelvic floor dysfunction.
People with pelvic floor disorders benefit from an interdisciplinary
rehabilitation approach to improve function and reduce pain.
Physiatrists with experience in acute and chronic pain, neurologic
and musculoskeletal conditions, and neurogenic bowel/bladder
management are well suited to direct such a patient’s care.In
addition to diagnosing and managing the patient’s pelvic floor
disorder medically, the physiatrist plays a key role in providing
a detailed prescription for physical therapy.
Ergonomic modification for a person with a desk job
It was estimated that about 40.7 % of the global population was surfing the computers in the year 2012 as compared to 2006 of only 26.2%. [1]
Marshall et al study reveal that on average, six out of 10 employees used a chair at work and the number was expected to grow.[2]
Many researchers report that working 5.41 hours sitting at desk and 7 hour sleeping at night had a great impact on the physical and mental health.[2]
Sitting on a chair is one of the most common positions adopted by humans.
children and adults spend approx. 55% of their working hours or 7.7 hours/day in sitting postures.[2]
The ergonomic fit workstations have become a standard practice in various developed countries
Charcot Restraint Orthotic Walker
CROW boot is a custom-molded bivalve plastic ankle-foot orthosis that is fully padded on the inside with total contact of the foot, ankle, and leg.
Reciprocating Gait Orthosis
A special HKAFO, which uses a mechanical linkage to couple flexion of one hip with extension of the other, which enables a reciprocal step-over-step gait.
Also allow swing through and swing to gaits
Floor reaction Ankle foot orthosis or Gravity reaction ankle foot orthosis
Prevent knee buckling without actually including knee in orthosis
Sense of freedom and more control over external devices
Light weight- 300gms
Cosmetically acceptable
Prevents pressure sore
Easy maintenance
Posterior leaf spring orthosis
A plastic or carbon fibre orthosis designed to assist in dorsiflexion in swing phase.
Total contact cast
Total contact cast is rigid or semi-rigid molded cast which extends from the patient’s foot to just below the knee, maintaining contact with the entire plantar surface of the foot and lower leg and immobilizing surrounding joints and soft tissue while allowing the patient to remain ambulatory.
Considered as gold standard of offloading techniques
Started in early 1930s as a treatment modality for post hansens neuropathic ulcer
Effective , Rapid and ambulatory
Goals in rehabilitaion of cerebral palsy child
What do you want for your child’s current life and future? The goals should answer this critical question. Without goals, a life care plan will have a lot of details but no direction. Rely on your trusted experts and your family to help you develop the goals to give your child the best life possible.
The life care plan for a child with cerebral palsy has several purposes and is essential for several reasons. The main reason to have a care plan is to have something that acts as a roadmap for your child’s best life.
Get Matched with a Leading Cerebral Palsy Attorney in Your Area
GET HELP NOW
It includes everything you need to give them the best life, from a complete diagnosis and evaluation of their condition, limitations, and abilities, to an assessment of how much care will cost over a lifetime.
The primary purpose of having goals as part of the life care plan is to fuel the efforts you and your care team are making to give your child a great life and enable them to live their best life.
Goals may be short-term and health-related, such as changing the diet to make sure your child has no nutritional deficits. They may also be long-term, like achieving living independence or finding a job.
Experts Help You Develop Goals
Your child’s care plan will include a diagnosis, evaluation, and the establishment of a care team.
The team of specialists, caregivers, and supportive family and friends will help you decide on the goals for your child.
Once you have those goals lined up—and these will change and adapt over time—you can start making a plan for achieving them, the actual roadmap for your child’s care.
Developing goals will seem overwhelming, especially when the only goal you can think about is a healthy child. Rely on the expertise of your care team.
People such as educational experts, neurologists, nutritionists, and therapists can help you understand what is possible for your child and their future and will guide you as you create the goals.
Goal Categories
As you develop your care plan and start to think about the goals you have for your child, it can help to break them down into categories. Your child’s condition is complex, and organizing it in this way makes a complicated situation a little easier to understand.
Managing the primary disability. Cerebral palsy is complicated, but the first goal you should consider is how to manage the prime condition. This is an overreaching kind of objective and one that your neurologist and pediatrician can help you develop.
Managing complications. Cerebral palsy often comes along with co-existing conditions like seizure disorders and cognitive impairment. Setting goals for managing these is the next important step.
Improving mobility. Mobility is a significant issue for most children with cerebral palsy.[2] Some will be severely impaired and unable to walk. In contrast, others may have more minor disabilities. Goals that address how well your child moves are essential for making them comfortable
Rehabilitation of dominant upper limb amputation
Hand dominance is the preferential use of one hand over the other for motor tasks.
90% of people are right-hand dominant, and the majority of injuries (acute and cumulative trauma) occur to the dominant limb, creating a double-impact injury whereby a person is left in a functional state of single-handedness and must rely on the less dexterous, non-dominant hand.
When loss of dominant hand function is permanent, a forced shift of dominance is termed injury-induced hand dominance transfer
There are innate differences in dexterity influenced by hand dominance.
Although most activities are accomplished bimanually, the dominant hand acts as the more dexterous, main executor while the non-dominant hand acts as supporter.
In the context of rehabilitation, permanent loss of dexterity in dominant hand is more devastating because dexterity skill previously endowed to dominant hand must be transferred to non-dominant hand
Persons with unilateral dexterity loss of the dominant limb have two challenges
they are forced to complete two handed tasks with one hand.
the remaining limb, which primarily functioned as the supporting limb, must assume dexterity responsibilities of the dominant limb.
Hand dominance is therefore a critical factor related to rehabilitation addressing dexterity of persons with upper limb injuries.
Persons with unilateral dexterity loss of the dominant limb have two challenges
they are forced to complete two handed tasks with one hand.
the remaining limb, which primarily functioned as the supporting limb, must assume dexterity responsibilities of the dominant limb.
Hand dominance is therefore a critical factor related to rehabilitation addressing dexterity of persons with upper limb injuries.
Persons with unilateral dexterity loss of the dominant limb have two challenges
they are forced to complete two handed tasks with one hand.
the remaining limb, which primarily functioned as the supporting limb, must assume dexterity responsibilities of the dominant limb.
Hand dominance is therefore a critical factor related to rehabilitation addressing dexterity of persons with upper limb injuries.
Leading cause of upper limb amputations is trauma occurring in males ages 15-25 years,
Most of traumatic amputation happen on dominant limb
vascular complications of diseases.
No limb prefernces
cancer/tumors (common cause of more proximal amputations such as a shoulder disarticulation or forequarter amputation)
Principles Of Amputation
Amputation is the most ancient of all surgical procedures.
Neolithic man is known to have survived amputation as evidenced
from the skeletons with amputated stumps and from the knives
and saws made of stone used at that time. Even the murals of La
Tene and the drawings on the Peruvian pottery depict human
figures with amputated stumps. In the olden times, amputations
were practiced not only for disease but also as a punishment for
criminals and as rituals to appease Gods or even in the practice of
Black Magic. It is considered that the first account of amputation
as a purposeful medical procedure is found in the Hippocratic
Treatise and it was concerned with amputation for vascular
gangrene.
Indications for amputations vary according to availability of skill,
facilities and line of treatment adopted. Many limb cancers are
treated by amputations, but in some advanced centers limb
preservation surgeries are done. A severely traumatized limb
where the circulation is good may be amputated if the facilities
for reconstruction are not available. Although the designs and the
usability of the prostheses continue to advance, a well performed
amputation is necessary for optimum results.
when the blood supply of a limb is irreparably destroyed or when
the limb is so severely damaged that reasonable reconstruction is
impossible, amputation of the limb is indicated. In injuries of limbs,
if three or more out of the five components (blood vessels, nerves,
skin, muscles and bones) are badly damaged, amputation can be
considered . The amputation can be early, intermediate
or late depending on the timing after injury as will be discussed
later in type of amputation. Thermal burns, frostbite or electrical
burns are other injuries that may require amputation.
Residual short stump can have excellent function.1 In the past,
amputation through specific levels was necessary for proper fitting
of prosthesis. The accepted ideal stump lengths are 23–28 cm from
greater trochanter in above-knee amputations, 13 cm from the
tibial articular surface in below-knee amputations, 10 cm above
elbow in amputations through arm, and 17 cm from olecranon in
forearm amputations. With modern prosthetic fitting techniques,
a prosthesis can be fitted to any well-healed nontender stump.
Determining the level of amputation requires an understanding
of the trade-offs between increased function with more distal level
of amputation and a decreased complication rate with a more
proximal level of amputation.
Osteoarthritis – Knee
Knee osteoarthritis (OA), also known as degenerative joint disease, is typically the result of wear and tear and progressive loss of articular cartilage. It is most common in the elderly. Knee osteoarthritis can be divided into two types, primary and secondary. Primary osteoarthritis is articular degeneration without any apparent underlying reason. Secondary osteoarthritis is the consequence of either an abnormal concentration of force across the joint as with post-traumatic causes or abnormal articular cartilage, such as rheumatoid arthritis (RA).
Osteoarthritis is typically a progressive disease that may eventually lead to disability. The intensity of the clinical symptoms may vary for each individual. However, they typically become more severe, more frequent, and more debilitating over time. The rate of progression also varies for each individual. Common clinical symptoms include knee pain that is gradual in onset and worse with activity, knee stiffness and swelling, pain after prolonged sitting or resting, and pain that worsens over time. Treatment for knee osteoarthritis begins with conservative methods and progresses to surgical treatment options when conservative treatment fails. While medications can help slow the progression of RA and other inflammatory conditions, no proven disease-modifying agents for the treatment of knee osteoarthritis currently exist.
Pathophysiology of Spasticity
Spasticity is a common motor control disorder frequently encountered in the
spectrum of the upper motor neuron (UMN) syndrome. It can result in pain,
fatigue, joint restrictions, functional impairments, and skin breakdown that may
negatively affect many domains of life by causing social avoidance and
diminished life satisfaction . Spasticity was originally defined as a velocity dependent increase in tonic stretch reflexes or muscle tone with exaggerated
tendon jerks resulting from increased excitability of the stretch reflex . This
definition has been criticized for being too narrow and inadequately depicting
the clinical sequelae. In 2005, a European Thematic Network to Develop
Standardized Measures of Spasticity (the SPASM consortium) suggested
broadening the definition to reflect a more clinical entity . They defined
spasticity as “disordered sensory-motor control, resulting from an upper motor
neuron lesion, presenting as intermittent or sustained involuntary activation of
muscles.
physiology of muscle contraction and basics of exercise
ithin the fi eld of physiology, there are a number of fundamental principles. Some of these key principles are
(a) homeostasis, (b) the linkage between gene expression
and physiology, and (c) structure–function relationships.
It is this latter principle that forms the foundation of the
current chapter. The concept of structure–function relationships extends across the organism-to-molecule spectrum. At the organism level, one can think about a number
of examples. For instance, the structural relationship
between the glenoid fossa and the head of the humerus
gives the shoulder six degrees of motion—a motion that
is uncommon among other joints. At the molecular level,
one can think about the structure of myosin heavy chains
(MHCs) and how this translates into certain functional
properties like the force–velocity relationship.
The discipline of exercise physiology really represents
a subdiscipline or an extension of the fi eld of physiology;
and, as such, the fundamental principles are essentially
the same except that they are examined typically under
conditions where physical activity has been altered. In this
context, a great deal of interest has been given to understanding the effects of both activity and inactivity on the
structural and functional properties of skeletal muscle during the past 30 to 35 years.
Of any cell/tissue type, skeletal muscle certainly
exhibits some of the clearest structure–function relationships. Given this perspective, one of the key objectives of
this chapter is to provide a backdrop for some of the more
detailed discussions that follow in successive chapters. The
current chapter is organized into three distinct sections.
The fi rst section provides an overview of some of the key
structural properties of skeletal muscle (macroscopic to
molecular anatomy). The second part of the chapter addresses the linkage between structure and function and the
topic of skeletal muscle plasticity as infl uenced by altered
physical activity. The fi nal section of this chapter examines
issues of muscle plasticity from a comparative perspective
and introduces the concept of symmorphosis, a concept
related to the optimality of design
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- 1. BOTOX DOSAGE IN LOWER LIMB SPASTICITY Dr Joe Antony JR2 PMR
- 2. FACTORS AFFECTING DOSAGE Higher dosage Higher grade spasticity Bigger muscle Less number of muscles injected simultaneously Higher body weight Poor response last time Frequency of injection is less Lower dosage Lower grade spasticity Small/ Atrophied muscle Higher number of muscles injected simultaneously Low body weight Muscle weakness last time Higher frequency of injection THE HELP GUIDE TO CP 2
- 3. THE HELP GUIDE TO CP 3
- 4. DILUTION 100U diluted in 2 ml 0.9%NaCl Each 0.1ml will have 5IU 4
- 5. PRECAUTIONS Maximum dose per session- 400IU Maximum dose per site- 50IU Frequency- Not more than once in 3 months Usually atleast 6 months interval THE HELP GUID TO CP 5
- 6. THANK YOU Refernce The HELP Guide to CP 6