CYBER LECTURES

Gait Analysis

                                    Walking disorders are common among people with neurological conditions such as stroke, Parkinson’s disease, multiple sclerosis, cerebral palsy,  Huntington’s disease or a head injury. Gait disorders can also develop from a sporting injury or lower limb fracture.

Role of physiotherapy  : Physiotherapists play an important role in analysing walking patterns in people with movement disorders and  undertake specialist training to analyse gait problems

at all levels of disability.

                                    Gait analysis by a physiotherapist assists in  identifying the underlying cause of the disorder and provides measures of the severity of the condition that can be used to chart the effectiveness of treatment. From the analysis, physiotherapists can advise patients on the appropriate course of treatment.

                                    Physiotherapists can analyse gait either in a research laboratory or in a clinic. Although there are only a small number of gait laboratories, patients can have a full assessment using computerised motion analysis and  footswitch devices, force platforms, electromyography and accelerometry and energy consumption.

                                    Usually physiotherapy clinicians analyse the walking pattern at a clinic using a range of validated clinical assessment procedures to objectively measure movement  disorders, functional outcome and the effects of  treatment on the walking pattern.

Benefits of physiotherapy : When treated with physiotherapy, people with gait disorders can experience improved mobility and independence and reach their maximum performance levels  whether it be in everyday tasks or high level sporting pursuits.

                                    Gait analysis assists physiotherapists to determine if the walking disturbance is due to abnormalities of:  muscle tone including spasticity, rigidity, dystonia, hypotonia; coordination, as occurs in ataxia; muscle strength, including weakness and paresis; balance, including vestibular, visual and somatosensory inputs; soft tissue extensibility, including muscle shortening, joint contractures or hypermobility of joints; extra movements, such as chorea, athetoid movements, dystonia, tremor; reduced movement, such as hypokinesia and  akinesia; bony deformities that can occur in disorders such as scoliosis, kyphosis, talipes equinovarus; sensation, including proprioception, tactile  discrimination, touch, pressure, pain, temperature and vibration; cognitive and perceptual problems such as apraxia, depth perception and vertical perception disorders and neglect.

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Hand Therapy

                                                     Hand therapists treat and rehabilitate patients with upper limb injuries, particularly of the wrist and hand. These injuries include traumatic injuries, congenital deformities, neurological and arthritic conditions, and regional pain syndrome arising from RSI of the hands.

Role of physiotherapy  : A   hand therapist has a range of skills which are invaluable to the patient’s level and rate of recovery. Hand surgeons and hand therapists generally work together to ensure the best possible result for the patient.

Benefits of physiotherapy  :  One of the major skills of the hand therapist is custom-made splinting. Splinting can be used for rest and immobilisation of fractures and soft tissue injuries, protection during sport and work, enhanced function, or for correcting contractures. Other skills include oedema management, scar management and wound care using modalities such as massage, compression and appropriate silicon products and dressings. Return to optimal activity levels is enhanced with the provision of aids and appliances, e.g. recommendations for car alterations, work site assessment and return to work plans.

                                    Other treatment techniques include passive joint mobilisation and soft tissue work such as deep friction  massage. Specific exercise programs are prescribed to mobilise, strengthen, and desensitise. Electrotherapy modalities such as ultrasound, laser, wax, TENS, and electrical stimulation are all frequently employed in treatment.

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Arthritis

                             One of the most common forms of arthritis is osteoarthritis. It damages your joints through wear and tear. It can be painful and depressing. There is no cure, but there are ways of managing the condition and making life easier. Physiotherapy is an important part   of that management.

How Does Osteoarthritis Affect People ?                                                             Most people develop some degree of osteoarthritis especially as they get older. The changes are permanent and will exist even when there are no symptoms. Osteoarthritis affects people in varying degrees. Some people may be symptom-free or suffer only mild or intermittent pain provoked by episodes of increased use or minor trauma. For some people symptoms can be disabling and, when it involves the larger joints of the body such as the hip or the knee, the severity of the problem may require surgical treatment.  Wear and tear of our joints may  occur due to aging, injury, prolonged poor posture, over use of joints, or excess weight.

Diagnosis :   Osteoarthritis is one of 150 different forms of arthritis for which here are different treatments. Your general medical practitioner can make a diagnosis. Treatment may include anti-inflammatory medication and/or physiotherapy.

How Physiotherapy Can Help ?  Physiotherapists are highly qualified in the assessment and treatment of the effects of osteoarthritis.

Physiotherapy  can :

* Reduce pain

* Improve movement and posture

* Strengthen muscles

* Improve independent function

                                    Treatment methods may include gentle passive movement, heat, electrical treatments, hydrotherapy, splints and  advice on preventing further joint damage.

Symptoms and Signs :

* Recurring pain or tenderness in a joint

* Stiffness, particularly early morning stiffness

* Swelling in a joint

* Obvious redness or heat in a joint

* Inability to move a joint

How You Can Help?

* always respect pain

* avoid overstressing joints

* avoid jerky/sudden movements

* don’t overload joints

* take care with lifting

* watch your weight

* use splints or walking aids as advised

* use labour saving devices

* don’t overdo activity or exercises

Exercises - How Do They Help ?  Exercises for people with osteoarthritis should be individually prescribed. Your physiotherapist can devise a programme of exercises to suit your condition. As a general rule remember if any exercise hurts then DON’T  DO IT.

Exercises help by  :

* maintaining or increasing movement

* improving joint lubrication and nutrition

* restoring muscle balance

* improving circulation

* improving strength and stability

* improving poor posture

                                    Don’t forget to maintain your GENERAL FITNESS LEVEL - this helps you feel better and retain your healthy joints. Gentle regular exercises such as swimming, exercising in water (hydrotherapy), walking or cycling are recommended.

REST :  Rest  is an important part of managing your  Osteoarthritis. Usually rest is balanced with exercises and activity. In particular rest is required when joints are HOT, SWOLLEN OR PAINFUL.

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Neck  Pain

                             Injury and postural problems are the main causes of neck pain. Physiotherapists can identify the reasons for your neck pain and provide effective treatment.

What  Causes Neck Pain ? Your head is heavy and balanced on a narrow support made up of seven bones called vertebrae. The vertebrae are separated from each other by discs, stabilised by joints and ligaments and moved by muscles. Because the neck is so mobile, it is easily damaged. Injury and postural problems are the most common causes of neck pain. Diseases such as arthritis or degeneration of the discs can also cause pain.

                                                            A disorder of the neck joints or muscles can cause referred pain to your head, shoulders, arms and upper back.

Neck Injuries : Neck   injuries most often result from motor vehicle  accidents, sports or occupational accidents. Damage may occur to vertebrae, joints and nerves, discs, ligaments and muscles. A common neck injury is the acceleration/deceleration injury or ‘whiplash’ where the head is thrown forward or back.

Posture :  Bad posture can cause neck pain. Ligaments are overstretched, muscles become tired and the neck joints and nerves are put under pressure.  Slouching  your shoulders with your head pushed forward, sleeping with your head in an awkward position, or working with your head down for long periods, will all tend to cause neck pain.

PREVENTING NECK PAIN             

Here is some useful advice to help you prevent neck pain:

Posture:  Think tall, chest lifted, shoulders relaxed, chin tucked in and head level. Your neck should feel strong, straight and relaxed.

Sleeping : A down pillow or urethane pillow is best for most people. Avoid sleeping on your stomach.

Relaxation : Recognise when your are tense. You may be hunching your  shoulders or clenching your teeth without realising it.

Work:  Avoid  working with your head down or to one side for long periods. Stretch and change position frequently.

Exercise :  Keep your neck joints and muscles flexible and strong with correct neck exercises. Your physiotherapist can show you how.

How Physiotherapists Can Help  ?                                                            Physiotherapists will be able to determine the source of your neck pain and treat it. They may use:

                                          * mobilisation

                                             * manipulation

                                             * massage

                                              * remedial exercise

                                               * postural assessment, correction and advice

                                             * relaxation therapy

                                              * laser, ultrasound, electrotherapy and heat   treatment

                                    Manipulation can be an effective treatment for neck problems. In some situations, it may do more harm than good. Your physiotherapist will carefully check your neck before manipulating it to see if other methods, such as mobilisation would be preferable.

                                    Your physiotherapist can also offer you self-help advice on ways to correct the cause of neck pain, such as practical tips for work and in the home, adjusting furniture, relaxation and exercise.

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Ankle Sprains

                             Ankle joints and feet are the link between your body and the ground. If the ankle twists as the foot hits the ground, particularly during a fall, this may cause a sprain. Physiotherapists provide advice and treatment to speed up healing and restore full performance.

What is Ankle Sprain ?  The ankle joint is made up of four bones. The shape of each bone helps to make the joint stable. Stability around the joint is increased by the ligaments, which are bands of strong connective tissue that prevent unwanted movement.

                                    When the ankle twists, the ligaments usually prevent the joint from moving too much. An ankle sprain occurs when one of the supporting ligaments is stretched too far or too quickly, causing the ligament’s fibres to tear and bleed into the surrounding tissues. This bleeding causes pain then swelling.

What Should I Do After a Sprain ?  In the first 24 to 72 hours after injury, use the  R.I.C.E. method:

Rest: Take it easy, but move within your limit of pain.

Ice: Apply ice for 15 minutes every  2 hours. This helps control pain and bleeding.

Compression: Firmly bandage the entire ankle, foot and lower leg. This reduces swelling.

Elevation: Have your ankle and leg well supported, higher than the level of your heart. This reduces bleeding and swelling. If there is still swelling and pain after 24 hours, visit your local physiotherapist or doctor. Your chances of a full recovery will also be helped if you avoid the H.A.R.M. factors in the first 48 hours.

Heat : Increases swelling and bleeding.

Alcohol : Increases swelling and bleeding.

Running or exercise :  Aggravates the injury.

Massage :  Increases swelling and bleeding.

How Can Physiotherapists Help ?  Your physiotherapist will examine the sprain to determine the extent of your injury. Prompt physiotherapy treatment will reduce the swelling, making it easier to walk after two or three days. To help you return to normal activity quickly, your physiotherapist can show you how to tape your ankle and give you exercises to improve strength and control. If necessary, your physiotherapist can order an x-ray, or suggest that you see a doctor.

Will I Need a Lot of Treatment ?  Your physiotherapist will discuss the injury with you and estimate the number of treatments needed. No two injuries are ever the same. A minor ankle sprain may need between one and four treatments.

How Soon Can I Return to Work or Sport ?  This will depend on how badly you have damaged the ankle ligament. Returning to work or sport too early can delay healing and prolong recovery.

                                                            Bracing and taping may allow early return to sport, but normal ankle ligament strength and muscle control will  take longer to return than the time it takes for pain and swelling to subside. Your physiotherapist can help you plan ways to maintain fitness while your ankle is healing.

Can Ankle Sprains be Prevented ?  You can reduce the chance of ankle injury.   Warm up before you exercise. Warm down when you finish.  Avoid activities on slippery, wet or uneven surfaces, or in areas with poor lighting.  Maintain good general fitness.  Wear well-fitting shoes, boots or ankle braces that give good lateral ankle joint support.

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Sensorium in Children

                                                                                                                Dr. Gurdev Chowdhary & Others

Assessment of Sensorium in Children

                                    Infants and young children have a limited repertory (store house) of behavioural responses, making it difficult to detect and quantify  the states of altered sensorium. A detailed, directed history and  thorough physical examination is mandatory in arriving at the diagnosis and the underlying aetiology.

                                    Since an accurate initial evaluation is critical to the management and the ultimate outcome in a child with coma, consistent and practical methods of describing various states of impaired consciousness in children are needed. The Glasgow Coma Scale (GCS),  though effective and widely accepted, has its limitations in clinical practice because of the varied verbal and motor responses in children at different ages.

                                    Several modifications of the Glasgow Coma Scale have come into existence, which are in use for gauging deterioration or improvement in acute stages of coma in children.

Introduction :  Consciousness is a state of normal cerebral activity in which the patient is able to respond to internal changes and to changes in the  external environment. Maintenance of consciousness requires an  intact and functioning reticular activating system and an adequate volume of functional hemispheres. Alterations in consciousness are  apparent as a decrease in spontaneous activity or in the response to environmental stimuli. The term “altered sensorium” lacks precision and is applicable to all states where it is certain that normal sensorium is not present.  Definition of certain terms used in relation to altered sensorium

Sleep : Sleep is a normal variation in consciousness. The sleeping child is easily aroused and is then responsive to stimuli, questions and directions.

Drowsiness:  the patient appears to be in normal sleep but can not be easily awakened. Once awake such patients tend to fall asleep despite attempts to continue conversation or clinical examination. There is disorientation and higher intellectual functions are impaired.

Stupor : defined as a state of impaired consciousness from which a child can be aroused only by vigorous and repeated stimuli. The child slips back into unresponsiveness after a few mumbled words. The superficial and deep tendon reflexes are preserved.

Confusional state : there is an inability to think with customary  speed and clarity. Response to environmental stimuli is inappropriate and the patient is irritable, excitable and easily  distracted.

Delirium : the American Psychiatric Association defines delirium as  :

a. A reduced ability to maintain attention to external stimuli, and to appropriately shift attention to new external stimuli.

b. Disorganised thinking as evidenced by rambling, irrelevant  and incoherent speech.

c. At least two of the following :

            i. Reduced level of consciousness

            ii. Disturbances of perception

            iii. Disturbed sleep wake cycle

            iv. Increased or decreased psychomotor activity

            v. Impaired memory.

Illusions : misinterpretations of actual sensory stimuli.

Hallucinations : perceptions of sensory stimuli that are not present e.g. hearing voices, music or sound, seeing objects, animals, people, insects etc.

Delusions : incorrect beliefs that cannot be changed by evidence or  reason.

Coma : condition in which a patient is unreasonable and unresponsive to all external stimuli.

Akinetic mutism or Coma vigile : patient has a blank staring look and appears to be awake but is unresponsive by way of movement and speech. This state may precede coma or occur during the course of recovery.

Prolonged Coma : when a patient is in coma for longer than 2 weeks.

Persistent vegetative state : this is the end stage of severe and  extensive brain damage and has the following features :

i. Present for more than one month

ii. No evidence of awareness of self or environment.

iii. All responses are reflex.

iv. There is no meaningful or voluntary response to stimulation.

v. No evidence of language comprehension.

vi. Preserved cranial nerve functions.

vii. Intact hypothalamic/autonomic functions.

Brain death : this is a state of coma in which the brain has ceased to function completely, but pulmonary and cardiac functions can still be maintained by artificial means for hours to few days. In children, systems for describing patients with impaired consciousness are not consistent. Moreover, infants and young children have a restricted repertoire of experience and behavioural responses. Therefore, the detection of and quantitation of  alterations of consciousness are much more difficult.

Clinical Evaluation :  A systematic approach to the initial evaluation of the child with altered sensorium may mean the difference between survival or death and permanent neurologic sequelae or full recovery.

                                    A functional airway, adequate ventilation, effective cardiac output and perfusion pressure must be ensured before any attempt to reach at the diagnosis is made. A thorough, yet gentle examination for signs of internal or external haemorrhage must be performed.   Assessment consists of taking a directed history, general physical examination, neurological examination, neuro-imaging, EEG and determination of chemical, cytologic and microbiologic content of the various body fluids. The specific objectives aimed for assessment of a patient with  altered sensorium are :

            i. To determine the cause of coma.

            ii. To delineate the area of the brain which is involved.

            iii. To determine further course of management which will result in

                reversing the process and enhance the chances of recovery.

History  : The history must be directed at the following :

            i. Mode of onset of illness.

             ii. Presence or absence of preceding warning symptoms.

            iii. Temporal course of illness.

            iv. Treatment given and the response to the treatment.

                                    In addition, factors like age of the child may have a bearing on the   cause of altered sensorium e.g. inborn-errors of metabolism present during neonatal period or early infancy. Pyogenic meningitis is more common below 3 years of age, whereas, viral encephalitis usually occurs after the age of 6 years. Cardio-vascular accidents take place more commonly in older children as compared to infants.

                                    The clinician must be aware of the racial, geographic and seasonal variations in causes of coma e.g. polio encephalitis is more common during the monsoons whereas, ARBO viral encephalitides and cerebral malaria epidemics fall usually in summers.

Mode of onset : The onset of illness may be acute, subacute or insidious depending on the cause.

Preceding warning symptoms :  Altered sensorium may or may not be preceded by warning symptoms like fever, headache, jaundice, seizures, vomiting, anuria, polyuria/polydipsia, diarrhoea and exposure to heat/cold depending upon the cause.

Nutritional status : Patient may be poorly nourished in :

            Insulin dependent diabetes mellitus

           Inborn errors of metabolism

           Renal failure

Breath odour : Certain distinct odours may be discernable in the  following conditions :

          Diabetic ketoacidosis : fruity smell

          Hepatic encephalopathy : mousy odour

          Uremic encephalopathy : mousy odour

           Aluminium phosphide poisoning : Garlic odour

          Kerosene poisoning : Smell of hydrocarbon

Heart  Rate :

           - Tachycardia : alongwith decreased blood pressure may suggest  hypovolemic shock.

           - Bradycardia : increased intracranial tension. 

Pattern of breathing :

a) Cheyne - Stokes breathing (also called periodic breathing ) :

Term used for a pattern of breathing in which there is a phase of gradual deepening of respiration followed by a phase of slowly decreasing respiratory rate. Respiration gradually becomes quieter and may cease for a few seconds. The cycle is then repeated. This is a sign of raised intracranial tension and can occur in coma due to any cause.        

b) Kussmaul breathing : manifests as a deep, sighing and rapid breathing at a regular rate and is suggestive of metabolic acidosis.

c) Central pontine hyperventilation : Term used for the deep and regular breathing that occurs in rostral brainstem damage due to reticular pontine infarction or in central brainstem dysfunction secondary to herniation. Interspersed deep sighs or yawns may precede the development of this respiratory pattern.

Hyperventilation : comatose conditions associated with hyperventilation are :

Metabolic acidosis