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Electroencephalogr Clin ventional therapy techniques for the rehabilitation of Neurophysiol 1988; 70:512–523 discount 20 mg cialis soft mastercard. Suffczynski P buy cialis soft 20 mg visa, Kalitzin S generic cialis soft 20mg visa, Pfurtscheller G effective 20 mg cialis soft, Lopes da Phys Med Rehabil 2002; 83:952–959 buy cialis soft 20 mg low cost. Wolpaw JR, Birbaumer N, McFarland D, ing arm movement impairment after chronic brain Pfurtscheller G, Vaughan TM. Answering ques- training of paraplegic patients using a robotic ortho- tions with an electroencephalogram-based brain- sis. Hesse S, Werner C, Uhlenbrock D, Frankenberg S, C, Simpson R, Vanderheiden G, eds. An electromechani- Accessible Telecommunications, Information and cal gait trainer for restoration of gait in hemiparetic Healthcare Technologies: IEEE Press, 2002. Biol Cybern 1991; 65:147– environment training improves motor performance in 159. PART II COMMON PRACTICES ACROSS DISORDERS Chapter 5 The Rehabilitation Team THE TEAM APPROACH designations mean something different in The Rehabilitation Milieu every program of inpatient or outpatient care. PHYSICIANS Intensive does not imply a particular intensity Responsibilities of practice. Intensive may mean that a patient Interventions is assigned to 3 hours a day with therapists. In NURSES reality, the patient may actively participate in Responsibilities therapy for considerably less time. Compre- Interventions hensive may mean that most disciplines are PHYSICAL THERAPISTS represented, not that their activities aim to re- Responsibilities store a broad range of functions. To the pa- Interventions for Skilled Action tient, comprehensive care may mean satisfying OCCUPATIONAL THERAPISTS all health-related needs. Responsibilities Inpatient and outpatient therapy are con- Interventions for Personal Independence strained by the costs of care. The duration and SPEECH AND LANGUAGE THERAPISTS intensity of rehabilitation is also constrained by Responsibilities the ability of a therapist or a team to articulate Interventions for Dysarthria and Aphasia the value of continuing to work on an aspect NEUROPSYCHOLOGISTS of disability and to offer an evidence-based SOCIAL WORKERS practice to enhance gains. The length of inpa- RECREATIONAL THERAPISTS tient rehabilitation stays has been declining in OTHER TEAM MEMBERS the United States since 1985. This trend may SUMMARY continue with the institution of a Prospective Payment System under Medicare and Medic- aid (www. The oppor- and personal needs, require a team of profes- tunities to offer patients therapy beyond lim- sionals who partner in inpatient and outpatient ited compensatory skills for basic activities of settings. I will refer to the team of rehabilita- daily living (ADLs) depends upon research that tion specialists, such as nurses, physical thera- demonstrates evidence-based interventions. To- THE TEAM APPROACH gether, they practice the experiential art and science of the possible. In a Rehabilitationists provide what many pro- multidisciplinary model, each member with grams call intensive and comprehensive neu- specialty training treats particular disabilities. For example, training procedures for health care goals still take a back seat in most motor and cognitive learning or behavioral deliberations. Rehabilitationists, in contrast, modification are reinforced by all members, us- seek both short-term and long-term goals that ing agreed upon strategies. Patients come to be understood in the con- the impediments to a return to a usual role in text of their cultures and values, their senses, daily life activities. In the medical model, team as a group and of its member specialists the physician controls the action and nearly all depends more on interpersonal and interpro- communication with a patient. The patient pas- fessional skills than on a specific model of in- sively awaits amelioration or cure. Rehabilitation services are not a col- professionals play limited, transient roles. Just as tension ing rehabilitation, an imperious physician may exists between the elements of harmony, do harm by failing to listen and to act upon the melody, and rhythm in the structure of a jazz concerns and strategies of the team and the composition, tensions within the elements of client. Rehabilitation of patients, humility, humor, perseverance, services try to quell the anxieties associated creative thinking, and hypothesis-making and with a sudden, debilitating illness and its threat testing. Everyone performs in real time and of death or permanent loss of functional inde- each performance challenges the members of pendence. The team can help patients break a team to play the role that best brings out the from this terrifying link by educating them and mode of learning and cooperation best suited by sharing stories of their own lives and the to each patient.

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The use of high-resolution lateral spine images generic cialis soft 20 mg without prescription, Conclusion obtained with fan-beam X-ray bone densitometry systems (Fig purchase cialis soft 20mg on line. Most new vertebral fractures buy cialis soft 20mg with amex, even lar to that used by computed tomography (CT) systems purchase cialis soft 20 mg overnight delivery, painful ones cialis soft 20 mg on line, remain unrecognized by patients and their can image the lateral spine in as little as 10 s. It is established that the presence of a verte- scout scans, with about the same image resolution as fan- bral fracture is a strong risk factor for subsequent osteo- beam DXA scans, have been used for vertebral fracture porotic fractures, and that those with low bone density and identification [24, 43, 48]. Large-scale clinical As with radiographs, however, CT images are expen- trials have demonstrated that osteoporosis therapies can sive and are not available clinically without referral. Con- reverse bone loss and reduce fracture rates, and that these sequently CT is not generally an option unless performed benefits are most pronounced in patients with low BMD in conjunction with quantitative CT for BMD assessment. Clinical guidelines promulgated In contrast, DXA images can be performed at the point of by the National Osteoporosis Foundation, International care, in conjunction with standard BMD determination, Osteoporosis Foundation, and others recognize the impor- with a radiation dose as much as 100 times lower than that tance of vertebral fractures, along with BMD, as the key of conventional radiographs. The most notable strength of risk factors for use in patient evaluation. However, while radiographs, of course, is image resolution, which is supe- BMD is widely used in patient evaluation, radiological as- rior to that of DXA images. The digital or if performed, is inadequately standardized and inter- nature allows for electronic data storage, digital image en- preted. By understanding the clinical principles of osteo- hancement and processing, as with magnification and con- porosis diagnosis and management provided in this docu- trast adjustment, which is not possible with conventional ment and by adopting the radiological guidelines for as- radiographic techniques. Cone-beam distortion, inherent sessing vertebral fractures provided herein, clinicians world- in the radiographic technique, is not present when using wide can contribute substantially to reducing the conse- the scanning fan-beam geometry of DXA devices. Kado DM, Duong T, Stone KL, Ensrud Genant HK, Epstein R, San Valentin (2003) Visual identification of verte- KE, Nevitt MC, Greendale GA, Cum- R, Cummings SR, and the Study of Os- bral fractures in osteoporosis using mings SR (2003) Incident vertebral teoporotic Fractures Research Group morphometric X-ray absorptiometry. Genant HK, Jergas M (2003) Assess- 589–594 ties: the study of osteoporotic fractures. Kanis JA, Delmas P, Burckhardt P, J Bone Miner Res 10:890–902 bral fractures in osteoporosis research. Black DM, Arden NK, Palermo L, Osteoporos Int 14 Suppl 3:S43–S55 lines for diagnosis and management of Pearson J, Cummings SR (1999) 13. The European Founda- Prevalent vertebral deformities predict Nevitt MC, Valentin RS, Black D, tion for Osteoporosis and Bone Dis- hip fractures and new vertebral defor- Cummings SR (1996) Comparison of ease. Katragadda CS, Fogel SR, Cohen G, Osteoporotic Fractures Research tive morphometric assessment of Wagner LK, Morgan C 3rd, Handel Group. J Bone Miner Res 14:821–828 prevalent and incident vertebral frac- SF, Amtey SR, Lester RG (1979) Digi- 3. The Study of Os- tal radiography using a computed to- Hudes E, Palermo L, Steiger P (1991) teoporotic Fractures Research Group. Radiology 133: A new approach to defining normal J Bone Miner Res 11:984–996 83–87 vertebral dimensions. Kiel D (1995) Assessing vertebral frac- Res 6:883–892 (1995) Vertebral fracture in osteoporo- tures. Radiology Research and Education tion Working Group on Vertebral Frac- Vertebral morphometry studies using Foundation, San Francisco tures. Kleerekoper M, Nelson DA (1992) Semin Nucl Med 27:276–290 Nevitt MC (1993) Vertebral fracture Vertebral fracture or vertebral defor- 5. Davis JW, Grove JS, Wasnich RD, assessment using a semiquantitative mity. Calcif Tissue Int 50:5–6 Ross PD (1999) Spatial relationships technique. Gold DT (2001) The nonskeletal con- BL (1994) Risk of hip fracture in 6. J Bone Ingersleben G, van de Langerijt L, Ca- Psychologic and social outcomes. Miner Res 9:599–605 hall DL (2001) Underdiagnosis of ver- Rheum Dis Clin North Am 27:255– 28. Lang T, Takada M, Gee R, Wu C, Li J, tebral fractures is a worldwide prob- 262 Hayashi-Clark C, Schoen S, March V, lem: The IMPACT Study. Grados F, Roux C, de Vernejoul MC, Genant HK (1997) A preliminary eval- Miner Res 16 Suppl.

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Parallel descend- FRA reflexes ing excitation of FRA pathways mediating inhibition New perspective on the FRA concept to other motoneurone pools (e generic 20mg cialis soft. Lundberg (1973 buy 20mg cialis soft with mastercard, 1979) formulated the hypothesis that purchase cialis soft 20 mg without a prescription, during normal movement cheap cialis soft 20mg without prescription, pathways medi- Convergence of nociceptive afferents on ating short-latency FRA reflexes could provide selec- FRA interneurones tive reinforcement of the voluntary command from thebrain cheap cialis soft 20 mg with mastercard. Thehypothesisreliedonexperimentalevi- Convergence would facilitate correction of a move- dence for the following findings. Due to spatial facilitation the required nocicep- ion reflex (see above). The strong mutual inhibition between neurones exciting muscles with opposite function is reminiscent of the half-centre organi- FRA-induced excitation of other pathways sation postulated by Graham Brown (1914)togive Strong excitatory effects from the FRAs have been alternating activation of extensors and flexors dur- described on interneurones belonging to different ing locomotion. Accordingly, when DOPA is given reflex pathways: reciprocal Ia inhibition (Chapter 5, after pretreatment by nialamide, stimulation of p. These findings suggest that facil- activation, dependent on the half-centre organi- itation of impulse transmission in the FRA path- sation of the late FRA pathways (see Lundberg, ways evoked by the active movement might have 1979). There is inhibition of pathways mediating long-latency FRA reflexes by pathways mediating short-latency FRA reflexes Pathways mediating long-latency FRA reflexes After DOPA, prolonging a train of FRA volleys delays With DOPA, short-latency FRA reflexes are the onset of the long-latency response, which then depressed and replaced by long-latency responses appears only after the end of the stimulus train. By several lines of evidence indicate that the short- and causing release of transmitter from a noradrenergic long-latency FRA responses are mediated through pathway, DOPA would inhibit pathway X, thereby different pathways (cf. Lundberg, 1979; Schomburg, releasing transmission through the pathway Y (cf. After DOPA, short-latency reflex (i) Primary afferent depolarisation is exerted actions to motoneurones are blocked, but short- mainly on FRA terminals before DOPA, and on Ia latency pathways still have an inhibitory action on terminals after DOPA. A possible functional outcome IPSPs evoked before DOPA are mediated via a pri- of the inhibition of long-latency FRA pathways by vate inhibitory pathway. It has been suggested (Lundberg, 1979) but peripheral afferents and have different central cir- so far without experimental evidence that there is cuits, similar general principles apply to all cuta- also inhibition from the long-latency to the short- neous reflexes. Conclusions (iii) Cutaneous volleys may be produced by electri- cal or mechanical stimuli. Cutaneous volleys contribute to many spinal (iv) Temporal summation or spatial and tem- reflexes. Stimulation of these fields produces ment which afferents are activated and to dis- withdrawaloftheareafromthepotentiallyinju- tinguish responses produced by stimulation of rious stimulus. However, it must be remem- FRA pathways are evoked mainly from afferents bered that an electrical stimulus sufficiently activated during normal movement, though strong to activate nociceptive afferents will also nociceptive afferents may also contribute. These responses may provide positive feedback designed to prolong and reinforce the voluntary command from the brain. Stimuli (v) The half-centre organisation of pathways medi- ating long-latency FRA responses might be Electrical stimuli responsibleforthealternatingactivationofflex- Electrical stimuli to cutaneous nerves ors and extensors during locomotion. Electricalstimulicanbeappliedtocutaneousnerves, which are generally stimulated where the nerve is Methodology superficial, through bipolar surface electrodes with the cathode proximal. The more commonly stimu- Underlying principles lated nerves are the sural nerve behind or just below the lateral malleolus, the superficial peroneal nerve Although the reflex responses evoked by tactile on the dorsal side of the foot proximal to the exten- and nociceptive stimuli are carried by different sor digitorum brevis, the superficial radial nerve on 392 Cutaneomuscular and withdrawal reflexes the inferior part of the radial edge of the forearm, of 1–3 Hz provide the optimal trade-off between the digital nerves of the fingers and toes using ring reflex attenuation and the need to average more electrodes. Electrical stimulation may also be delivered directly to the skin Mechanical stimuli Direct cutaneous stimulation may be delivered Mechanical stimuli have been used to provide infor- through plate electrodes placed over the skin, at a mation about (i) the responses elicited in forearm site where there is no muscle beneath the skin, to and hand muscles from low-threshold mechano- avoid stimulation of muscle afferents. Stimuli can receptors activated under natural conditions, and also be delivered through pairs of needle electrodes (ii) the mechanisms underlying the reflex responses inserted into the skin. Withdrawal reflexes Natural stimulation of cutaneous afferents Withdrawal reflexes are elicited by painful stimuli from the fingers applied to a nerve or to skin. Temporal summation Natural stimulation may be produced using a small will facilitate the appearance of withdrawal reflexes probe to indent the skin or a controlled puff of air. The inten- cles has been undertaken by McNulty & Macefield sity of stimulation may be expressed with respect to (2002). Rapidly adapting type I and II units (FAI, the threshold for perception or to the threshold for FAII) were activated by stroking across the receptive pain. The latter is the same as the threshold for the fieldoftheunit,whileslowlyadaptingreceptorswere nociceptive reflex (see Fig. Recordings from single cutaneous thewithdrawalreflexesrelatedtothestimulatedskin afferents allowed a further characterisation of the field (cf. Single shocks of weak intensity may have little effect, particularly when Plantar responses applied to skin, and most authors use trains of stimuli applied to nerves. The trains must be short Plantar responses are evoked by firm stroking of the (e. At rest, the reflex ical extension) may be replaced by dorsiflexion to response is suppressed at repetition rates above 0. Methodology 393 (a) (b) (c) (d) (e) (f ) (g) (h) (l) (i ) (m) (j) (k) (n) p) q) Fig.

Therefore discount cialis soft 20mg otc, scheduling activities to avoid Nursing Process excessive fatigue and to allow adequate rest periods may be beneficial purchase 20 mg cialis soft. This may be manifested by ptosis (drooping) simple directions discount 20mg cialis soft amex, adequate lighting generic cialis soft 20 mg with amex, calendars discount cialis soft 20mg with amex, and of the upper eyelid and diplopia (double vision) caused by personal objects within view and reach). More severe disease may be • Avoid altering dosage or stopping the drug without indicated by difficulty in chewing, swallowing, and speak- consulting the prescribing physician. CHAPTER 20 CHOLINERGIC DRUGS 303 with increased physical activity, emotional stress, and • With myasthenia gravis, recommend that one or more fam- infections, and sometimes premenstrually. Some clients with myasthenia gravis cannot tolerate op- Evaluation timal doses of anticholinesterase drugs unless atropine • Observe and interview about the adequacy of urinary is given to decrease the severity of adverse reactions elimination. However, atropine should • Observe abilities and limitations in self-care. This increase is the first clients with myasthenia gravis about correct drug usage, sign of overdose. If early symptoms are not treated, hypotension and respiratory failure may occur. At high doses, anti- PRINCIPLES OF THERAPY cholinesterase drugs weaken rather than strengthen skeletal muscle contraction because excessive amounts Use in Myasthenia Gravis of acetylcholine accumulate at motor endplates and re- duce nerve impulse transmission to muscle tissue. Treatment for cholinergic crisis includes with- thenia gravis include the following: drawal of anticholinesterase drugs, administration 1. Drug dosage should be increased gradually until maxi- of atropine, and measures to maintain respiration. Larger doses are often required Endotracheal intubation and mechanical ventilation CLIENT TEACHING GUIDELINES Cholinergic Drugs General Considerations continuation of drugs and treatment by the physician. Res- ✔ Cholinergic drugs used for urinary retention usually act piratory failure can result if this condition is not recognized within 60 minutes after administration. The drug ✔ Record symptoms of myasthenia gravis and effects of should not be suddenly discontinued. The amount of donepezil, or other anticholinesterase drugs, ambulation medication required to control symptoms of myasthenia should be supervised to avoid injury. Although the dose of medication improve cognitive function and delay symptom progres- may be increased during periods of increased activity, it sion, and this information will be helpful to the prescriber. These are signs of drug underdosage (myasthenic ✔ Take oral cholinergics on an empty stomach to lessen crisis) and indicate a need to increase or change drug nausea and vomiting. Older adults are more likely to experience is not counteracted by atropine. Differentiating myasthenic crisis from cholinergic changes and superimposed pathologic conditions. It is necessary to Use in Renal Impairment differentiate between them, however, because they require opposite treatment measures. Myasthenic cri- Because bethanechol and other cholinergic drugs increase sis requires more anticholinesterase drug, whereas pressure in the urinary tract by stimulating detrusor muscle cholinergic crisis requires discontinuing any anti- contraction and relaxation of urinary sphincters, they are cholinesterase drug the client has been receiving. Administering a cholinergic agnosis from signs and symptoms and their timing drug to these people might result in rupture of the bladder. Many of the drugs are degraded enzymatically caused by cholinergic crisis (too much drug). However, a few (eg, neostigmine and pyri- and symptoms beginning 3 hours or more after a drug dostigmine) undergo hepatic metabolism and tubular excretion dose are more likely to be caused by myasthenic in the kidneys. If the differential diagnosis cannot be made on the basis of signs and symptoms, the client can be intu- Use in Hepatic Impairment bated, mechanically ventilated, and observed closely until a diagnosis is possible. Still another way to dif- The hepatic metabolism of neostigmine and pyridostigmine ferentiate between the two conditions is for the may be impaired by liver disease, resulting in increased ad- physician to inject a small dose of IV edrophonium. If the edrophonium causes a dramatic improvement Tacrine is contraindicated in liver disease. Approxi- in breathing, the diagnosis is myasthenic crisis; if it mately 20% to 50% of clients experience an increase in liver makes the client even weaker, the diagnosis is cholin- aminotransferase levels after beginning therapy with tacrine. Note, however, that edrophonium or any Most enzyme elevation occurs in the first 18 weeks of ther- other pharmacologic agent should be administered apy and is more common in female clients. When tacrine only after endotracheal intubation and controlled is started, serum ALT should be monitored weekly for ventilation have been instituted. Some people acquire partial or total resistance to anti- of liver damage do not occur, the test can be done every cholinesterase drugs after taking them for months or 3 months. Therefore, do not assume that drug therapy that restores liver enzymes to normal levels with no permanent is effective initially will continue to be effective over liver injury. Use in Critical Illness Use in Children Cholinergic drugs have several specific uses in critical ill- Bethanechol is occasionally used to treat urinary retention ness.

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