Workshop in Cairo University - School of Medicine
Objectives:
Rehabilitation Process
Spasticity – Definition – Pathophysiology – Impact
Assessment of spasticity and ADL
Spasticity management options
Outcome measures – BTX injection sheet
Clinical cases – video
Physiotherapy management of spasticity using diffrent modalities as well as manual techniques is described along with possible dosage ijn clinical use is also menstined.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
This is most widely used manual technique which is widely used nowadays in as advanced rehabilitation processes. it is used in several conditions like stroke, cardiovascular disorders,to release diaphragm muscles,to release muscle tightness,to decrease spasticity,to increase range of motions of joints etc.
Physiotherapy management of spasticity using diffrent modalities as well as manual techniques is described along with possible dosage ijn clinical use is also menstined.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
This is most widely used manual technique which is widely used nowadays in as advanced rehabilitation processes. it is used in several conditions like stroke, cardiovascular disorders,to release diaphragm muscles,to release muscle tightness,to decrease spasticity,to increase range of motions of joints etc.
At the end of the lecture, the students should be able to:
Discuss the theoretical basis of the neurodevelopmental approaches
Discuss the concepts and principles underlying the Bobath approach
Discuss the concepts and principles underlying the Brunnstrom approach
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
constraint induced movement therapy.pptxibtesaam huma
Constraint induced movement therapy
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
History of CIMT
Components of CIMT
Population for CIMT
Advantages of CIMT
Recent advances
Introduction
History of CIMT
CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”.
It was observed that patients with hemiparesis did not use their affected extremity .
Overcoming learned non use
Mechanisms of CIMT
Population for CIMT
Stroke
Traumatic Brain Injury
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Brachial Plexus Injury
Advantages of CIMT
Overall greater improvement in function than traditional treatment.
Highly researched and credible treatment approach.
There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
Increase social participation
Components Of CIMT
Types of CIMT
Restraining Tools for CIMT
Minimal Requirement of hand function for CIMT
Recent Advances
The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008)
The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care.
This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites.
CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks.
Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months.
Because the control group was crossed over to receive CIMT after one year.
Primary outcome measures – Wolf Motor Function Test
Motor Activity Log
Secondary outcome measure - Stroke Impact Scale (SIS)
were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL.
In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern.
Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Walking is a phenomenon that is taken for granted by healthy individuals, but requires a complex control of the neuromusculoskeletal system. Walking is mainly a result of an automatic process, involving the spinal cord and brainstem mechanisms. Hemiplegic type of gait of a person who has had a brain insult and depends on which area of the brain is affected. Hemiplegic gait usually has:
Decreased stance phase and prolonged swing phase of the paretic side.
Decreased walking speed and shorter stride length.
A type of manual therapy in which the muscle or the joint is altered and placed in a position of comfort for certain duration after which the pain disappears completely or gets reduced. this slide show explains about the principles, mechanism and Phases of PRT
Movement disorders are not only realm of chronic disorders that are treated without requiring emergent intervention, but also they can present acutely with more aggressive forms
At the end of the lecture, the students should be able to:
Discuss the theoretical basis of the neurodevelopmental approaches
Discuss the concepts and principles underlying the Bobath approach
Discuss the concepts and principles underlying the Brunnstrom approach
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
constraint induced movement therapy.pptxibtesaam huma
Constraint induced movement therapy
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
History of CIMT
Components of CIMT
Population for CIMT
Advantages of CIMT
Recent advances
Introduction
History of CIMT
CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”.
It was observed that patients with hemiparesis did not use their affected extremity .
Overcoming learned non use
Mechanisms of CIMT
Population for CIMT
Stroke
Traumatic Brain Injury
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Brachial Plexus Injury
Advantages of CIMT
Overall greater improvement in function than traditional treatment.
Highly researched and credible treatment approach.
There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
Increase social participation
Components Of CIMT
Types of CIMT
Restraining Tools for CIMT
Minimal Requirement of hand function for CIMT
Recent Advances
The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008)
The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care.
This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites.
CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks.
Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months.
Because the control group was crossed over to receive CIMT after one year.
Primary outcome measures – Wolf Motor Function Test
Motor Activity Log
Secondary outcome measure - Stroke Impact Scale (SIS)
were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL.
In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern.
Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Walking is a phenomenon that is taken for granted by healthy individuals, but requires a complex control of the neuromusculoskeletal system. Walking is mainly a result of an automatic process, involving the spinal cord and brainstem mechanisms. Hemiplegic type of gait of a person who has had a brain insult and depends on which area of the brain is affected. Hemiplegic gait usually has:
Decreased stance phase and prolonged swing phase of the paretic side.
Decreased walking speed and shorter stride length.
A type of manual therapy in which the muscle or the joint is altered and placed in a position of comfort for certain duration after which the pain disappears completely or gets reduced. this slide show explains about the principles, mechanism and Phases of PRT
Movement disorders are not only realm of chronic disorders that are treated without requiring emergent intervention, but also they can present acutely with more aggressive forms
Lecture will cover:
1- NEW DIAGNOSTIC CRITERIA OF ALZHEIMER’S DISEASE (NEUROCOGNITIVE DISORDERS)
2- EARLY AND PRODROMAL PHASES OF NCD
3- THE CURRENT , MOST VALIDATED BIOMARKERS
4- ATYPICAL FORMS OF Dementia of Alzheimer's type, ‘POSTERIOR SHIFT’
This presentation summarizes the problem of spastic hand and arm problems in patients who have had strokes or traumatic brain injury. Some surgical considerations are reviewed for specific problems.
Linkedin Türkiye Kurumsal Çözüm Ortağı Tick Tock Boom'un iş Dünyasının Sosyal Ağı LinkedIn için hazırladığı "Markalar İçin LinkedIn" sunumu.
Sunum: Elvan Salman
Tick Tock Boom Digital PR & Marketing Agency'nin Nisan 2016 bülteninde neler var? Sosyal Medya Takip Programımız BoomSonar Suite'in sosyal medya hesap yönetim modülü BoomManager'ın yeni versiyonu çıktı.
Nisan ayında sosyal medyanın videoya, özellikle de canlı yayın videolarına odaklandığını görüyoruz. Facebook, video arama özelliğini aktifleştirirken canlı yayın videolarını öneri olarak göstermeye başladı.
Facebook Live; canlı yayınlara 5 farklı renk filtreleme seçeneği, yayın sırasında etkileşim yaratan reaksiyonlar, yayına arkadaş davet etme ve dünya canlı yayın haritası gibi yeni özelliklerini sundu.
Instagram, video arama özelliğinin yanında video önermeyi de sunmaya başladı.
The term Spinal Cord Injury is used to refer to neurological damage of the spinal cord
Any lesion involving the spinal cord result a syndrome called a “myelopathy”
Spinal cord injuries are defined as complete or incomplete according to the International Standards for the Neurological Classifification of SCI and the American Spinal Injuries Association Impairment Scale (AIS)
Complete lesions are defifined as AIS A, and incomplete lesions are defifined as AIS B, AIS C, AIS D or AIS E (Harvey, 2016)
Multiple sclerosis a devastating progressive condition cased due to demyelination and gliotic changes in CNS. Physiotherapy managemnet options available for most of the clinical features are enumerated
There are evidence in History of treatment by Passive stretching techniques.
Over past 30-40 years many therapists have worked to identify and learn the techniques which are are more suitable and effective for the patient’s problem.
Joint mobilisations and manipulations techniques are used to safely stretch or snap structures to restore normal joint mechanics with less trauma.
Rehabilitation of dominant upper limb amputationJoe Antony
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)
Appraoch to patient with polytrauma and Damage control orthopedicsKaushal Kafle
A brief approach to patient with polytrauma, physiological response of body with trauma, the trimodal mortality, golden hour, lethal triad of trauma, two hit hypothesis, inflammatory mediators, prehospital care, primary survey, secondary survey, ABCDE approach, Adjucts are included. Besides thc concept of Damage control orthopedics, trend in fracture management , evolution , principle, indication , surgical stratergies, advantage, limitation, definitive fixation and EAC and ETC are included in breif.
Topic : Introduction to Physical Therapy
By : Dr. Kaiynat Shafique PT
Contents
▪️ Definition and History of Physiotherapy
▪️ The Profession of Physical Therapy - Current practice
▪️ Pain assessment and Outcome measures
▪️Medical Terminologies
▪️Introduction of Physiotherapy Modalities
▪️Introduction to Therapeutic Exercises
▪️Patient Positioning and bed mobility
▪️Gait Training and assistive devices ▪️Musculoskeletal disorders presentation
▪️MSK disorders and Treatments
-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-
Subscribe my YouTube Channel
https://www.youtube.com/c/IamPhysiotherapist_Dr-Kaiynat-PT
-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-
Follow on Facebook
https://www.facebook.com/Iamphysio2340/
-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-
Follow on Instagram
https://www.instagram.com/iamphysiotherapist_/
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Spasticity Management, A rehab art. Hatem S. Shehata
1. HATEM SAMIR M. SHEHATA, M.D
PROFESSOR OF NEUROLOGY
CAIRO UNIVERSITY
SPASTICITY MANAGEMENT.
REHABILITATION ART
nt.
Faculty:
Prof. M Eltamawy
Prof. Hanan Amer
Prof Hatem Shehata
Prof. Nevin Shalaby
Prof. Amr Hassan
Prof. Sandra Ahmad
Dr. Shaimaa Al-Jaafary
Dr. Wael Ezzat
Dr. Haidy Shebawy
2. HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process
• Spasticity – Definition – Pathophysiology – Impact
• Assessment of spasticity and ADL
• Spasticity management options
• Outcome measures – BTX injection sheet
• Clinical cases – video
2
3. HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process
• Spasticity – Definition – Pathophysiology – Impact
• Assessment of spasticity and ADL
• Spasticity management options
• Outcome measures – BTX injection sheet
• Clinical cases – video
3
4. HATEM SAMIR MOHAMMED, M.D 4
GOALS
1. Optimizing social participation (considering persons’ wishes)
2. Minimizing distress of both patients and caregivers
3. Help patients to maximize behavioral repertoire
SPASTICITY. “HABILITATION/REHABILITATION”
• Rehabilitation is a long-term (may be life-long), problem-solving
process of recovery from an injury to obtain ‘optimum function’ despite of
residual disability
• It is the process by which physical, sensory, and mental capacities are
RESTORED or DEVELOPED in disabled patients
5. Change/abnormalities (molecular/cellular) - - organ (e.g.,
(cord malacia, hemorrhage, infarction, TBIDiseasePathology
(Change/abnormalities of whole body set (functional loss
S. & S.
((functional loss
Impairment
How impairment restricts the social tasks (roles). It is the
expression of the gap between a person's capabilities and
(the demands of the environment (environment interaction
Social Roles
((participation
Activity
((disability
TERMINOLOGIES SHOULD BE CHANGED
5
REHABILITATION MODEL (ICF-WHO)
HATEM SAMIR MOHAMMED, M.D
6. REAL CASE SCENARIO . . .
• 56 male patient, married (3 daughters), Banker ,
HTN, non diabetic
• 1 month ago right sided hemiplegia and dysphasia
• Assessment now: hemiparesis (G2 D, 3 P), mild
dysphasia
• Pathology: ICH
• Impairment: weakness +/- spasticity,
communication disorders
• Disability: toilet, dressing, hygiene, chocking,
decision making etc…
• Handicap: work / family / carer
6
What is the concern of his
primary physician ?
HATEM SAMIR MOHAMMED, M.D
7. HATEM SAMIR MOHAMMED, M.D
NEUROLOGICAL REHABILITATION
• Acute onset disability, with a phase of improvement followed by
relative stability: CVS, traumatic insults, infections, etc..
• Fluctuating and/or unpredictable disability, often with some
progression: M.S
• Progressive, relatively predictable disability: MND
• Stable diseases present from childhood: C.P
– Categories of Neurological Conditions
7
8. HATEM SAMIR MOHAMMED, M.D
• A comprehensive service with a multidisciplinary team who should be
involved in an integrated program
• This team includes ‘a list of related specialties‘: Neurologist/Neurosurgeons/
Orthopedics/PMR/Therapists/ Occupational and Speech therapy/
Psychologists/Support workers
• Target: increase patients activities and reduce burden of the patient and
carers
8
STRATEGIES FOR NEURO-REHABILITATION
9. HATEM SAMIR MOHAMMED, M.D
Assessment (to collect data)
Identify problem
Genesis of problem
Prognostic factors
Expectations (patients / others)
Goals Setting (PLANNING)
Short term actions
Middle term directions
Long term goals
Interventons
Deliver treatment (alter natural Hx.)
Health education and support
Collect further data
Evaluations
Compare Goals vs. Set
Identify resolvable problems remain
9
REHABILITATION PROCESS
More Actions Needed
No Actions Needed
10. HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process
• Spasticity – Definition – Pathophysiology – Impact
• Assessment of spasticity and ADL
• Spasticity management options
• Outcome measures – BTX injection sheet
• Clinical cases – video
10
11. HATEM SAMIR MOHAMMED, M.D 26/01/2016
SPASTICITY . . . DEFINITION
• One of the most specific
impairment that results in
muscle over activity resulting
from UMNL (++ tonic SR)
• It is one of positive UMNL signs
that involves a long-term
monitoring
11
Mild weakness, loss of ‘precision
grip’ which involves opposition
12. HATEM SAMIR MOHAMMED, M.D
• Spasticity is distinct from other motor disturbances:
• Sensori-motor disorder
• Velocity-dependent increase in tonic stretch reflex activity
• Length-dependent (clasp knife)
• State-dependent (variables)
• Usually seen in the anti-gravity muscles like the arm flexors and the leg
extensors
• Associated with high tone spasms and soft tissues changes
12
Pandyan et al., Disabil and Rehab, 2005
SPASTICITY . . . DEFINITION
13. HATEM SAMIR MOHAMMED, M.D
(1) Disability: weakness / dexterity
(2) Mask actions of antagonists
(3) Seating and postural problems
(4) Pains, stiffness and spasms (discomfort–
contractures–deformities)
(5) Hygiene and self care problems
(6) Mood changes and loss of self-esteem
(disfigurement–sexuality problems)
(7) Fatigue – Sleep disruption
Disability
Com
plications
13
SPASTICITY . . . CONSEQUENCES
14. HATEM SAMIR MOHAMMED, M.D
Loss of cortical drive after cerebral
or above lesion spinal insults
Loss of descending inhibitory spinal
circuits (Dorsal RST)
Increase muscle SR by intact Medial
reticulospinal and vestibulospinal tracts
Spastic hypertonia, spasms, and clonus
Greenwood, 1998
INCREASE MUSCLE
STRETCH REFLEX
14
SPASTICITY . . . PATHOPHYSIOLOGY
15. HATEM SAMIR MOHAMMED, M.D
• As a result neural pathways show
changes in their level of excitability:
• Altered α-motoneuron excitability
• Altered Ia and Ib inhibition
• Some studies also report changes in
the γ-motoneuron excitability (not
commonly accepted)
Voerman and Hermens, Disabil and Rehab, 2005
Spasticity (Pathophysiology)
15
16. HATEM SAMIR MOHAMMED, M.D
NEURAL AND NON-NEURAL COMPONENTS
OF SPASTIC LIMB DYSFUNCTION
• These two mechanisms are responsible for the clinically observed resistance to
passive movement associated with spasticity
• Muscle hyperactivity (muscle contraction and shortening)
• Bio mechanical changes (soft tissues; tendons, ligaments, joints):
thixotropy, intra-articular adhesions
(Gracies, 2005)
16
17. HATEM SAMIR MOHAMMED, M.D
PRO / CONS
POSSIBLE BENEFITS OF SPASTICITY
• A common argument
• > 38% of stroke survivors affected by spasticity
☞ May help patients to walk, stand or transfer (e.g., stand pivot transfers)
☞ May assist in maintaining muscle bulk (inherently prevents atrophy)
☞ May assist in preventing DVTs
☞ May assist in preventing pressure ulcer formation over bony prominences
• No positive overall benefit to spasticity in an individual at any stage of life
17
18. HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process
• Spasticity – Definition – Pathophysiology – Impact
• Assessment of spasticity and ADL
• Spasticity management options
• Outcome measures – BTX injection sheet
• Clinical cases – video
18
19. HATEM SAMIR MOHAMMED, M.D
ASSESSMENT TOOLS
• Clinical Assessment: subjectivity - inter-rater variability
• Neurophysiological
Voerman et al., 2005
Neurophysiological response to electric stimulation
•(H / M reflex)
Evoked potentials
•(motor and sensory evoked potentials)
19
20. HATEM SAMIR MOHAMMED, M.D 20
Muscle Tone
ADL Barthel index, Others QoL tests
Sensory
Gait
assessment
Other tools
MAS, Tardeau scale, Bilateral adductor tone
VAS: for pain and dyasthesia
Cramps (Spasms)– Spasms Frequency Scale
Gait analysis laboratory
Timed-TMWT
Goal Attainment Scale ‘the most difficult’
ROM ‘the easiest – don’t forget’
Assessment Axes
21. HATEM SAMIR MOHAMMED, M.D
Q: WHICH TOOL WILL YOU USE ??
A: THAT HELPS TO ASSESS THE TARGETED OUT COME
Impairment related measures
Spasticity
Range of movement
Functional measures
Reduction of pain
Ease of applying splint/orthosis
Ease of maintaining hygiene
Ease of dressing
Improved seating position
Improved gait pattern
Improved gait efficiency
MAS / Tardeu scale / dynamic EMG
Goniometry
Suggested outcome measure
Visual analogue scale/Spasm Frequency Scale
Timing of tasks/number of helpers/carer rating scale
Timing of tasks/number of helpers/carer rating scale
Timing of tasks/number of helpers/carer rating scale
Photographic record/measurement i.e. pelvis level
Video analysis/10 meter walk test
Video analysis/patient rating/energy cost assessment
21
22. HATEM SAMIR MOHAMMED, M.D
CLINICAL SCALES
It measures Stiffness not Spasticity – No Speed of Movement is Specified
Modified Ashworth Scale
22
23. HATEM SAMIR MOHAMMED, M.D
Measurements take place at 3 velocities
Responses are recorded at each velocity as X/Y, with X
indicating the 0 to 5 rating, and Y indicating the degree of
angle at which the muscle reaction occurs.
Patient position:
supine, with head in midline
Tardieu Scale
23
26. HATEM SAMIR MOHAMMED, M.D
VAS: a subjective pain measure, ranged from 0
(no pain) to 10 (unbearable pain).
The patients mark the point that represents their
perception of the current status
Horizontal line
100 mm in length
Visual Analogue Scale (VAS)
No spasms0
One spasm or less a day1
One to five spasms a day2
Five to nine spasms a day3
Ten or more a day4
Spasm Frequency Scale
How many spasms occurred in the
affected muscles or extremities during the
last 24 hours ?
26
Clinical Scales (Cont’d)
27. HATEM SAMIR MOHAMMED, M.D
TIMED 10-METER WALKING TEST (TMWT)
• Patient walks with/without assistance 10 meters (32.8 feet) and the time is measured for the
intermediate 6 meters (19.7 feet)
• Start timing when the toes of the leading foot crosses the 2-meter mark
• Stop timing when the toes of the leading foot crosses the 8-meter mark
• It can be performed at preferred walking speed or fastest speed possible (preferred vs.
fast)
• Collect 3 trials and calculate
the average of the three trials
Acceleration Deceleration
27
28. HATEM SAMIR MOHAMMED, M.D
• 3 components:
• Kinematics: analysis of
body positions, angles,
velocities, accelerations of
body segments and joints
during motion)
• Kinetics: analysis of forces
• EMG
28
Gait Analysis
Assessment Tools (Cont’d)
30. HATEM SAMIR MOHAMMED, M.D
PATHOMECHANICS OF HEMIPLEGIC GAIT
• Reduced knee flexion in swing phase (stiff-legged gait)
• Equinus (excessive ankle plantar flexion) which leads to: increase
energy required to initiate swing period of gait cycle
• Gait asymmetry, short step length, speed reduction and longer gait cycle
• Mass limb movement pattern: on the paretic side requiring
compensatory pelvic adjustment in non-paretic side
• Defective “body image”
30
31. HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process
• Spasticity – Definition – Pathophysiology – Impact
• Assessment of spasticity and ADL
• Spasticity management options
• Outcome measures – BTX injection sheet
• Clinical cases – video
31
33. HATEM SAMIR MOHAMMED, M.D
SPASTICITY MANAGEMENT OPTIONS
Physical therapy
Regular exercises
Physiotherapy
Surgery
Severe spasticity
Medical
therapy
Generalized
Oral agents
Regional
Intra-thecal baclofen
Focal
BTX-A injection
Phenol blockade
Consider each in combination with others
33
34. HATEM SAMIR MOHAMMED, M.D
PHARMACOLOGIC MANAGEMENT
• Systemic
• Baclofen (30-90 mg/d), diazepam (5-15 mg/d), dantrolene sodium
(100-400 mg/d), clonidine (0.3-0.9 mg/d), tizanidine (< 36 mg/d),
carbamates (methocarbamol 3–6 g, carisoprodol), endocannabinoids
(Sativex)
• Limitations: non-selective; large dosages often required which may
result in intolerable side effects (sedation, weakness, GIT disturbances
and hepatotoxicity)
34
35. HATEM SAMIR MOHAMMED, M.D 35
ECB.
‘Retrograde’ inhibition of nerve impulse transmission
1. Action potential at the presynaptic
2. Neurotransmitter (NT) release
3. Glutamate and GABA
4. Binding to GABA-R and iGlu-R
5. Inhibitory …………… Excitatory
6. Activated Glu
7. Increase Calcium
8. ECBs bind to pre-synaptic cannabinoid
receptors (CB1-R)
9. Net result is inhibition of further Ca
influx, and so inhibition of NT release
stimulates
endocannabinoid
(ECB) synthesis
36. HATEM SAMIR MOHAMMED, M.D
• Local treatment options.
• Motor point and nerve blocks: aqueous phenol (Neurolysis by coagulate
proteins)
Limitations: tissue necrosis, pain and dysesthesia; variable duration of effect;
often irreversible
• Local injections of BTX-A
36
Pharmacologic Management (Cont’d)
37. Indications: generalized moderately severe spasticity
(not adequately treated with oral medications and
BTX).
The spasticity reduction in LL (+/-) UL depends on the
catheter position in the spinal fluid.
Low catheters (T 10-12): improve mainly the legs.
Higher catheters (T 1-2): arm spasticity is targeted.
■ Regional treatment options. Intra-thecal Baclofen (ITB)
37
Pharmacologic Management (Cont’d)
HATEM SAMIR MOHAMMED, M.D
38. Test dose: 50 ug baclofen injection in spinal fluid. Then
evaluate for 4-8 hours (response)
Pump is inserted under abdominal muscles
A catheter is inserted through a needle intrathecally and is
threaded upward
Catheter is tunneled under the skin to the abdomen and is
connected to the pump
The pump filled with baclofen is programmed by a
computer to continuously release a specified dose
38
Pharmacologic Management (Cont’d)
HATEM SAMIR MOHAMMED, M.D
39. HATEM SAMIR MOHAMMED, M.D
SURGICAL MANAGEMENT
• Selective dorsal rhizotomy
• Selective Neurotomy: partial section of motor nerve branches
• Orthopedic surgery as tendon release (depending on age of patient)
Limitations: invasive; irreversible; parathesia; effectiveness varies
39
40. Selective Dorsal Rhizotomy (SDR)
1. Exposing LL nerve roots through a midline lumbar
incision.
2. Sensory roots are divided into 3 – 5 rootles, that
are electrically stimulated to identify and cut nerves
with abnormal responses.
Commonly in young patients with LL spasticity (with
relative good strength and good back extensors
power) or (to improve hygiene).
Prerequisites: No contractures.
Complications rate: 5 – 10%
PT should start after a month (1-2 times/wk)
if the goal is to improve ROM; and (4-5/wk)
if the goal is to improve strength
40HATEM SAMIR MOHAMMED, M.D
41. HATEM SAMIR MOHAMMED, M.D
Orthopedic Surgery
• Indications:
(1) ease care, (2) improve function, (3) cosmetics
• Both bony and soft tissue surgeries
• The major soft tissue procedure involves lengthening the muscle-tendon unit
(tenotomy) – and (tendon transfer)
• Other surgeries include:
• Capsulotomy
• Fascial arthroplasty
• Removal of excessive callus formation
41
42. HATEM SAMIR MOHAMMED, M.D
OVERVIEW OF REHABILITATION INTERVENTION
• Early start – better outcome.
• Positioning ‘bed, wheelchair, splinting, casting, AFO)
• Joints stretching and PROM to prevent contractures or shortening
• Full stretch for 2 hours / 24 hours (Medical Disability Society, 1988)
• Re-educate ‘Relearning’ and facilitate balance/equilibrium
• Gait training
• In advanced spasticity, (Biomechanical hypertonia) resistant disability
▪ Not velocity-dependent and poor response to antispastic agents.
▪ The only treatment: stretching, positioning, splinting and casting
42
43. HATEM SAMIR MOHAMMED, M.D
DOES REHABILITATION WORK ???
ROLE OF NEURONAL PLASTICITY
• Late recovery (neuronal plasticity) is
proposed to underlie cortical map
reorganization following neurological
insults
• The undamaged regions of the brain can
progressively adopt the function of the
lesioned area by neuronal sprouting and
synaptogensis leading to change in
cortical representations (maps)
This can be enhanced by
enriched environment,
structured physiotherapy and
TMS
43
44. HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process
• Spasticity – Definition – Pathophysiology – Impact
• Assessment of spasticity and ADL
• Spasticity management options
• Outcome measures – BTX injection sheet
• Clinical cases – video
44
45. HATEM SAMIR MOHAMMED, M.D
NOW . . . I DECIDED TO INJECT BTX
WHY ?? HOW ??
• Selection criteria for injection (identify the problem precisely):
(1) Preserved functionality (type of spasticity) , (2) Others
• Understanding and expectations of treatment by patient and caregiver
• Dosage and site of injection
45
46. HATEM SAMIR MOHAMMED, M.D
PREPARATORY STEPS
• Before injection: Checklist
• Complete examination
• Goal determined: a contract with patient
• Take into account patients on anti-coagulants
• Muscles to inject
• Muscle localization
• Techniques of injection
• Evaluation after 2-4-6 weeks
46
47. HATEM SAMIR MOHAMMED, M.D
PROBLEM DISTRIBUTION GOAL SETTING
Regional
Multifocal
(generalized with focal problems)
Focal
47
48. HATEM SAMIR MOHAMMED, M.D
COMMON CLINICAL PATTERNS – UPPER LIMB
Adducted/internally
rotated shoulder
Flexed wrist Pronated forearm
Clenched fist Flexed elbow Thumb in palm
Courtesy WE MOVE, 2006
48
50. HATEM SAMIR MOHAMMED, M.D
COMMON CLINICAL PATTERNS – LOWER LIMB
Equinovarus
Striatal toe
Stiff knee Flexed knee Adducted thighs
50
Courtesy WE MOVE, 2006
51. HATEM SAMIR MOHAMMED, M.D
WHICH MUSCLES TO TREAT ?
• Elbow flexion:
• Biceps brachii, brachialis, brachioradialis, pronator teres
• Spastic hand:
• FCR, FCU, FDS, FDP, FPL, interosseii, opponens
• Stiff knee gait:
• Rectus femoris, hamstrings
• Equinovarus:
• Triceps sure, tibialis posterior
• Toe flexion:
• Flexor digitorum longus and brevis, FHL
• Muscle treated frequently depends on patient condition and practitioner
personal experience,
51
52. HATEM SAMIR MOHAMMED, M.D
WHAT IS THE BEST DILUTION ?
• 1 or 2, or 5 ml / 100 U BOTOX ®
• High volume dilution and end-plate targeting achieve greater muscle
blockade
• Low volume for small muscles - - - Large volume for large muscles
52
53. HATEM SAMIR MOHAMMED, M.D
WHAT IS THE BEST INJECTION
TECHNIQUE AND SITE?
• The best technique is the one you feel confident with
• Blind technique:
• Poor accuracy / not to recommend
• Risk to inject ‘between’ muscles
• Unrelated to injector experience
• In one study assessed 121 practitioners injected cadaver muscles, 43%
succeeded and 57% failed
• EMG if large and superficial
• ES if small and deep
• U/S-guided: if deep or failed to be stimulated
53
54. HATEM SAMIR MOHAMMED, M.D
BTX INJECTION SHEET . . . .
• Signed consent: information – patient and caregivers
• Agent used: . . . . . Dilution: (. . . units / ml saline)
• Muscle identification: palpation / EMG / Others
• Muscle injected Units:
………………… ……..
• Appointment date for splinting (type, method of applications, review appointment)
• Appointment date for further review (2-4-6 wks):
• Response to injection ?
• Has functional goal been achieved ?
• Is further injection needed at current time ?
54
56. HATEM SAMIR MOHAMMED, M.D
DIAGNOSTIC NERVE BLOCK WITH ANAESTHETICS
• Lidocaine injection (1 ml) at the level of motor nerve branches
innervating spastic muscles
• Immediate and transient spasticity reduction
• Determine the respective responsibility of spasticity, contracture and
weakness
• Evaluation of function without spasticity
56
68. CASE VIDEOS
Disability:
(1) weak back extensors
(2) flexed posture (overacting left
iliopsoas) – left loin pain
(3) overacting adductors
(4) co-contraction (hamstrings/
quadriceps F)
(5) left talipus eq varus
(6) disabling spontaneous clonus
Plan:
(1) BoNT injection: Iliopsoas (left):
50. Quadriceps (rectus femoris – vastus medialis):
25 X 2 (small doses to minimize clonus).
Hamstrings: 50 X 2. Adductors (bilateral), left
gracilis: 50 X 2. Left Gastromedialis & lateralis:
30. Left tibialis posterior: 50
(2) Stretching of injected muscles
(3) Strengthening of back extensors
(4) Then gait and balance ex
A.S, 36-yr, SPMS. Diagnosed 10 yr ago
Wheel-chair: 18 mo
On CPM (9 mo)
This patient was subjected to 3 injection sessions
4 mo apart
18 Sep 2011
68
69. 3 WEEKS AFTER 1
ST
INJECTION
(DECREASED HAMSTRINGS OVERACTIVITY
– KNEE EXTENDED)
STILL BACK EXTENSORS (WEAK)
LEFT LOIN PAIN DISAPPEARED
8 weeks after 2nd injection
(Back extensors can support walking)
69
20 Mar 2012
16 Oct 2011