By E. Ugolf. Springfield College. 2018.
One other application of exercise therapy is the interaction with intra-articular hyaluronate buy baclofen 25 mg mastercard. Petrella et al28 have recently completed a randomised trial of home-based exercise therapy in addition to three intra-articular hyaluronate (10mg/ml) injections and found this combination improved “activity-related” pain more than when exercise was combined with NSAID baclofen 10 mg low cost. These and other future well designed studies combining exercise with neutriceutical products including glucosamine sulfate will further our ability to ensure comprehensive treatment of patients with osteoarthritis of the knee generic baclofen 10mg overnight delivery. Key findings Seventeen randomised controlled trials of the effectiveness of exercise therapy in OA of the knee were assessed cheap baclofen 10mg amex. It can be concluded, 189 Evidence-based Sports Medicine that exercise is effective in patients with OA of the knee. Available evidence indicates beneficial effects on all studied outcome parameters: pain, self-reported disability, observed disability in walking, self-selected walking and stepping speed and patient global assessment of effect. Summary: Patient type • Mild/moderate osteoarthritis • Contemplating physical activity (contemplative stage of readiness) • Impaired function, pain and stiffness but not severe • Associated co-morbidities that would benefit from exercise (i. Since pain and disability are the main symptoms in patients with OA, exercise therapy seems indicated. It is notable that conclusions are based on a small number of studies. Only five randomised controlled trials had sufficient power. In addition, a number of different instruments have been used for the assessment of specific outcome measures. The recently published list of candidate instruments provided by Bellamy29 can be seen as a first step in the accomplishment of standardisation of assessment. Summary: Exercise type • Aerobic ± resistance exercise • FIT principles (frequency – three times or more/week; intensity – mild/ moderate such as walking or weight-bearing resistance; training duration – at least eight weeks for results but should be encouraged as a “life-time” behavioural change) • Use standard outcome measures • Counsel in office but utilise allied health staff such as physiotherapists and kinesiologists as needed Minimal information is available on long-term effects of exercise therapy on OA of the knee. This lack of information concerning 190 Exercise and osteoarthritis of the knee long-term effects is a remarkable omission, since the clinical impression is that the effects disappear over time. There is insufficient evidence to draw conclusions on the optimal content of an exercise therapy intervention. The three trials with sufficient power showed beneficial effects of different types of exercise therapy: aerobic exercises, resistance exercises, or mixtures of several types of exercise therapy. Blinding of providers and patients was absent in all studies. As a consequence of the nature of exercise therapy, blinding of both providers and patients is not possible. However, in only half of the trial reports, was blinding outcome assessment explicitly reported. Another potential source of bias was the frequently occurring absence of information on adherence to the intervention. This hampers the interpretation of a study with negative results. It remains unclear whether the exercise therapy intervention was ineffective due to the intervention itself or due to participants’ failure to adhere to therapy. Summary: Key findings and clinical implications • Exercise is indicated for patients with mild/moderate osteoarthritis of the knee but there are limited studies available • Standard interventions and outcomes measures are needed • Physicians should stress behaviour change to engage long-term benefit • Long-term efficacy has not been established • Strategies to promote exercise adoption for general health should be the goal of physicians and their patients In conclusion, the available evidence indicates beneficial short- term effects of exercise therapy in patients with OA of the knee. Given the limited number of studies available, this conclusion applies to patients with mild to moderate OA who were recruited from both outpatient settings and the community. Beneficial effects have been found for various types of exercise therapy and recommended for patients with OA of the knee with mild to moderate stage of disease. Physicians should promote physical activity among their patients with OA of the knee. Exercise can improve symptoms, potentiate concomitant medications and improve health in general.
While some patients require the use of prescribed medications or over- the-counter analgesics for pain control discount 10 mg baclofen visa, there are a variety of other nonpharmacological interventions that may offer relief or reduce discom- fort generic baclofen 25mg with visa. Many patients have reported improvements as a result of complemen- tary therapies generic baclofen 10 mg otc, such as massage and acupuncture 10 mg baclofen fast delivery, though further research is required to assess the benefits of these treatments (13,14). Use of superficial heat, cold, or physical therapy modalities may also be effective in pain management. Instruction in proper positioning, seating systems, and posture principles is recommended to decrease discomfort resulting from improper postural alignment. Relaxation strategies and other forms of complementary medicine may also prove beneficial as part of a holistic approach to pain management. SPEECH/VOICE/COMMUNICATION An estimated 70–100% of people with PD experience changes in their ability to communicate effectively. Rarely, these changes are a first or very early Copyright 2003 by Marcel Dekker, Inc. The primary changes in speech and voice include soft or fading voice volume, monotone pitch, imprecise or slurred articulation of speech sounds, rapid and irregular rate of speech, ‘‘stutter- like’’ speech, and hoarse voice quality. The changes in speech and voice are caused by the physiological changes that occur with PD. Muscle rigidity, tremor, freezing, slowness, and diminished coordination of movements can all have an impact on the complicated coordinations of movement needed for clear, loud speech and voice. The emotional, social, and economic impact of this decreased vocal ability can be significant—reduced self-confidence, social isolation, frustra- tion related to communication breakdowns, and reduced ability to continue working. Medication management of PD, while extremely important and helpful in managing symptoms, does not typically improve speech and voice skills. Intervention by a speech language pathologist, initiated early in the disease process, offers the best possible outcomes of speech therapy. Traditional speech therapy techniques, such as practice on oral motor exercises, specific speech sound drills, and techniques to control speech rate and better coordinate breathing with voice, have been shown to be helpful. The most effective treatment, however, that has documented positive and long-lasting results is the Lee Silverman Intensive Voice Treatment (LSVT) (16,17). The treatment concepts are quite simple: ‘‘Think Loud/Think Shout. As PD progresses, it is sometimes necessary to ‘‘augment’’ speech and voice skills with devices such as personal amplifiers, word or picture boards, or computerized communication systems. Speech pathology intervention to maximize communication abilities may be needed at many different times during the course of PD as individual abilities change. HEARING While hearing loss is not caused by PD, it should be considered in any progressive neurological disease that occurs in an elderly population. Identifying hearing loss and providing amplification in the form of hearing aids can be very important in improving communication. Other adaptations that can improve communication with hearing loss are making sure the speaker is always visible to the listener, preferably face to face, and reducing background or competing noise. EATING AND SWALLOWING PD often has an impact on an individual’s ability to eat and drink safely, requiring intervention by a number of professionals on the rehabilitation team. The speech pathologist focuses on the safety of the swallowing action, identifying underlying problems, making any necessary compensation for reduced ability and modifying the diet as needed for safety. The occupational therapist focuses on meal-preparation skills and strategies for getting the food from the plate to the mouth. The social worker’s focus is on financial resources for purchasing food and assistance in getting the food to the home. The nurse and dietitian address general nutrition, constipation, hydration, and maximizing medication absorption with diet. Warning signs of an eating- or swallowing-related problem include coughing or choking during eating, difficulty swallowing pills, weight loss, frequent respiratory infections, slowed rate of eating, and decreased pleasure in eating. The speech pathologist’s evaluation of swallowing safety typically includes a videofluoroscopic swallow evaluation. The patient is observed, using moving x-ray, eating and drinking substances with a variety of consistencies (thin and thick liquid, puree and solids) and trying a variety of safety techniques (e.
Percy’s liver function studies returned to normal baclofen 25mg, and a follow-up liver biopsy showed no histologic abnormalities safe 25mg baclofen. BIOCHEMICAL COMMENTS Disorders of the urea cycle are dangerous because of the accumulation of ammonia in the circulation 25 mg baclofen mastercard. Ammonia is toxic to the nervous system purchase baclofen 10mg overnight delivery, and its concentration in the body must be carefully controlled. Under normal conditions, free ammonia is rapidly fixed into either -ketoglutarate (by glutamate dehydrogenase, to form glutamate) or glutamate (by glutamine synthease, to form glutamine). The glutamine can be used by many tissues, including the liver; the glu- tamate donates nitrogens to pyruvate to form alanine, which travels to the liver. Within the liver, as the nitrogens are removed from their carriers, carbamoyl phos- phate synthetase I fixes the ammonia into carbamoyl phosphate to initiate the urea CHAPTER 38 / FATE OF AMINO ACID NITROGEN: UREA CYCLE 709 cycle. However, when a urea cycle enzyme is defective, the cycle is interrupted, which leads to an accumulation of urea cycle intermediates before the block. Because of the block in the urea cycle, glutamine levels increase in the circulation, and because -ketoglutarate is no longer being regenerated by removal of nitrogen from glutamine, the -ketoglutarate levels are too low to fix more free ammonia, leading to elevated ammonia levels in the blood. So how does one reduce ammonia and glutamine levels in such patients? The key to treating patients with urea cycle defects is to diagnose the disease early and then aggressively treat with compounds that can aid in nitrogen removal −SCoA A ATP AMP + PPi C (activation) C O O − SCoA O H −O C C H (Glycine) NH + 3 −SCoA C O C O Hippuric acid SCoA NH (excreted) CH2 C O − B O O CH2CH2CH2 C CH2 C O− O− β-oxidation Phenylbutyrate Phenylacetate O CoAS− CH2 C ATP SCoA O AMP + PPi C NH2 CH2 CH2 H C + HSCoA 3 C O − O O (Glutamine) H CH2 CH2CH2 C NH2 C O − Phenylacetylglutamine (excreted) Fig. The metabolism of benzoic acid (A) and phenylbutyrate (B), two agents used to reduce nitrogen levels in patients with urea cycle defects. Low-protein diets are essential to reduce the potential for exces- sive amino acid degradation. If the enzyme defect in the urea cycle comes after the synthesis of argininosuccinate, massive arginine supplementation has proved bene- ficial. Once argininosuccinate has been synthesized, the two nitrogen molecules destined for excretion have been incorporated into the substrate; the problem is that ornithine cannot be regenerated. If ornithine could be replenished to allow the cycle to continue, argininosuccinate could be used as the carrier for nitrogen excretion from the body. Thus, ingesting large levels of arginine leads to ornithine production by the arginase reaction, and nitrogen excretion via argininosuccinate in the urine can be enhanced. Arginine therapy will not work for enzyme defects that exist in steps before the synthesis of argininosuccinate. For these disorders, drugs are used that form conju- gates with amino acids. The conjugated amino acids are excreted, and the body then has to use its nitrogen to resynthesize the excreted amino acid. The two compounds most frequently used are benzoic acid and phenylbutyrate (the active component of pheylbutyrate is pheylacetate, its oxidation product. Phenylacetate has a bad odor, which makes it difficult to take orally). As glycine is synthesized from serine, the body now uses nitrogens to synthesize ser- ine, so more glycine can be produced. This conjugate removes two nitrogens per molecule and requires the body to resynthesize glutamine from glucose, thereby using another two nitrogen molecules. Urea cycle defects are excellent candidates for treatment by gene therapy. This is because the defect only has to be repaired in one cell type (in this case, the hepa- tocyte), which makes it easier to target the vector carrying the replacement gene. Preliminary gene therapy experiments had been carried out on individuals with ornithine transcarbamolyase deficiency (the most common inherited defect in the urea cycle), but the experiments came to a halt when one of the patients died of a severe immunologic reaction to the vector used to deliver the gene. This incident has placed gene replacement therapy in the United States “on hold” for the fore- seeable future. The Metabolic and Molecular Bases of Inherited Disease, vol II, 8th Ed. Gene therapy death prompts review of adenovirus vector. Regulation of enzymes of the urea cycle and arginine metabolism.
For a few children 10mg baclofen otc, this pain is increasing and parents may want to have the problem treated cheap baclofen 25mg mastercard. As the radial head becomes dislocated order baclofen 10 mg overnight delivery, both the contracture and the radial head dislocation usually limit elbow extension and forearm supination buy baclofen 25 mg on line. As children continue to grow, the radial head may become very prominent on the posterolateral aspect of the elbow. During late adolescence or young adulthood, the prominence of the radial head may lead to skin breakdown from rubbing on wheelchair trays. Also, in individuals who have functional use of the elbow, pain from degenerative arthritis may develop. Treatment Most children with radial head dislocations do not need active treatment. Early recognition and preventive treatment directed at splinting and early contracture release has been recommended as a way to prevent radial head dislocations. Although radial head dislocation is a common problem in children with CP, there are only a few reports that mostly focus on reporting that the deformity ex- ists. If children do have pain that is persistent and parents wish to pursue intervention, surgical stabilization is the only option. The surgical procedure requires release of the elbow flexors and pronation contracture, followed by stabilizing the radial humeral joint by reconstruction of the annular ligament, usually using the transected biceps tendon. The indication for this procedure in children with passively reducible radial head dislocations is not clear (Case 8. The outcome of this proce- dure is usually a fixed dislocated radial head that is pain free. Fixed disloca- tions in childhood CP are best left untreated, as they are seldom painful. Pain, if it develops, occurs in adolescents or young adults. At this time, the best option is radial head excision. Excision may also be occasionally indi- cated for adolescents with very prominent radial heads that cause skin break- down (Case 8. Complications of Treatment Surgical reconstruction in children with severe spasticity has led to a 66% (four of six) rate of repeat dislocations. These dislocations did not cause pain; therefore, if the surgery was done for pain relief, it would be successful but maintaining a reduced radial head was not successful. Radial head excisions have been successful in decreasing pain and removing the lateral mass. Ra- dial head excision is not recommended before completion of growth because of fear of radial overgrowth proximally and of proximal migration of the radius causing increased problems at the radioulnar joint at the wrist. Forearm Pronation Pronation contracture is a very common deformity in both quadriplegia and hemiplegia (Figure 8. The primary deforming muscle is the two-joint pronator teres. At the later stage, the one-joint muscle, pronator quadratus, may become contracted. The pronation contracture is almost always com- bined with a significant flexion contracture caused by the biceps, which is the strongest supinator. Therefore, the typical release or lengthening of the biceps to treat the flexion contracture also weakens the forearm supination. She also reported feeling a click to a fixed dislocation within 3 months postoperatively but when she moved his arm. Shakoor was a dependent sitter again was pain free (Figure C8. Another example with no functional use of the upper extremity. With forearm however, this led to a dislocation of the ulna trochlea joint supination and flexion, the radial head reduced easily and severe elbow stiffness (Figure C8. When the arm was As demonstrated in these cases, we do not have a good pronated and extended, the radial head again dislocated, operative solution for the spastic radial head dislocation, which again caused the child some discomfort. Radio- which is the reason we favor decreasing activity and al- graphs confirmed the physical examination (Figure lowing the dislocation to become fixed, then the pain will C8.
Effects of a physical conditioning programme on asthmatic patients buy discount baclofen 25 mg line. Effect of aerobic training on forced expiratory airflow in exercising asthmatic humans purchase 25 mg baclofen overnight delivery. Exercise Physiology: Human Bioenergetics and Its Applications generic baclofen 25 mg. Effects of pulmonary rehabilitation on physiologic and psychological outcomes in patients with chronic obstructive pulmonary disease discount baclofen 10mg line. Identifying relevant studies for systematic reviews. ROBERT J PETRELLA Introduction Persons with chronic conditions of ageing such as osteoarthritis comprise a large and growing proportion of the population. Certainly, patients with osteoarthritis can improve pain control, proprioception, strength, instability and endurance, all of which will improve functional independence with regular exercise. Until recently, however, evidence regarding exercise and osteoarthritis has been equivocal. This perception may have limited the use of exercise for these patients, despite published guidelines, including those of American College of Rheumatology. For the purpose of this review, we have limited the scope to the knee, which includes the bulk of the evidence related to exercise to date. Treatment guidelines for osteoarthritis of the knee have considered exercise therapy as an important non-pharmacological treatment approach. Since the publication of treatment guidelines mentioned above6, several new randomised trials of exercise therapy for osteoarthritis of the knee have been published. This paper describes the current evidence for exercise in the treatment of osteoarthritis of the knee. Effort has been made to identify key determinants of effect including elements of the training programme, quality of studies and appropriateness of the outcome measures used. Methods What materials were used in the literature search? Comprehensive computer assisted search of medical, sport and rehabilitation literature (between June 1966 and January 2000) was conducted using Medline search systems. Highly sensitive search strategy of randomised controlled trials8 and systematic reviews was used. References of relevant review articles and trials were screened to identify references not contained in the main search. The search for literature was conducted using the MeSH headings and textwords (tw) of osteoarthritis or arthritis and knee (MeSH), exercise or physical training (tw) (Table 11. What were the criteria for studies considered for inclusion? Exercise therapy was defined as a range of activities to improve strength, range of motion, endurance, balance, coordination, posture, motor function or motor development. Exercise therapy can be performed actively, passively, or against resistance9. No restrictions were made as to type of supervision or group size. Trial reports were excluded if 1) they concerned peri-operative exercise therapy, or 2) intervention groups received identical exercise therapy and therefore no contrast existed between intervention groups. No restrictions were made concerning the language of publication. Sixty-seven publications were initially identified (Table 11. Thirty- seven studies were excluded because of methodological criteria, eight studies were excluded as they included review material, four concerned peri-operative exercise therapy and two included data reported in previous publications. Consequently, 16 publications concerning 19 trials (Table 11. As a consequence of the nature of exercise therapy neither care providers nor patients can be blinded to the exercise therapy.