POSTURAL DRAINAGE

INTRODUCTION-

Postural Drainage removes mucus from certain parts of the lungs by using gravity and proper positioning to bring the secretions into the throat where it is easier to remove them. The lungs are divided into segments called lobes, the right lung is divided into three lobes (right upper lobe, right middle lobe and right lower lobe) while the left lung has only two lobes (left upper lobe and lower lobe).

SCHEDULING TREATMENT
The treatment often works best in the morning. This allows the mucus to be removed that has built up during the night. Sometimes a treatment can be done at night to reduce the need for coughing during sleep. Make sure you wait at least 1-2 hours after eating before starting you treatment. This helps to prevent nausea and or vomiting. CPT just before meals may cause you to become tired and may decrease appetite.

ANATOMY OF LUNGS

                                                           LUNG ANATOMY ILLUSTRATION


STEPS
1. Use specific positions so the force of gravity can assist in the removal of bronchial secretions from affected lung segments to central airways by means of coughing and suctioning.
2. The patient is positioned so that the diseased area is in a near vertical position, and gravity is used to assist the drainage of specific segment.
3. The positions assumed are determined by the location, severity, and duration of mucous obstruction.
4. The exercises are performed two to three times a day, before meals and bedtime. Each position is done for 3-15 minutes.
5. The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs. These symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs.
6. Bronchodilators, mucolytics agents, water, or saline may be nebulised and inhaled before postural drainage and chest percussion to reduce bronchospasm, decrease thickness of mucus and sputum, and combat edema of the bronchial walls, there by enhancing secretion removal.
7. Perform secretion removal procedures before eating.
8. Make sure patient is comfortable before the procedure starts and as comfortable as possible he or she assumes each position.
9. Auscultate the chest to determine the areas of needed drainage.
10. Encourage the patient to deep breathe and cough after spending the allotted time in each position.
11. Encourage diaphragmatic breathing through out postural drainage: this helps widen airways so secretions can be drained.
POSITION

                                                         POSTURAL DRAINAGE POSITIONS

To drain the middle and lower portions of your lungs, you should be positioned with your chest above your head. Possible techniques to achieve this position are:
If a hospital bed is available, put in Trendelenburg position (head lower than feet).
Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip.
Stack 18-20 inches of pillow under hips.
Place on a tilt table, with head lower than feet.
Lower head and chest over the side of the bed.
To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.
Postural drainage therapy is designed to improve the mobilization of bronchial secretions and the matching of ventilation and perfusion, and to normalize functional residual capacity (FRC) based on the effects of gravity and external manipulation of the thorax. This includes turning, postural drainage, percussion, vibration, and cough.

TURNING
Turning is the rotation of the body around the longitudinal axis to promote unilateral or bilateral lung expansion and improve arterial oxygenation. Regular turning can be to either side or the prone position, with the bed at any degree of inclination (as indicated and tolerated). Patients may turn themselves or they may turned by the caregiver or by a special bed or device.

POSTURAL DRAINAGE
Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways (where they can be removed by cough or mechanical aspiration). Each position consists of placing the target lung segment(s) superior to the carina. Positions should generally be held for 3 to 15 minutes (longer in special situations). Standard positions are modified as the patient's condition and tolerance warrant.

EXTERNAL MANIPULATION OF THE THORAX

A-PERCUSSION
Percussion is also referred to as cupping, clapping, and tapotement. The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung. This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained. No convincing evidence demonstrates the superiority of one method over the other.

B-VIBRATION
Vibration involves the application of a fine tremorous action (manually performed by pressing in the direction that the ribs and soft tissue of the chest move during expiration) over the draining area. No conclusive evidence supports the efficacy of vibration, the superiority of either manual or mechanical methods, or an optimum frequency.

INDICATIONS
Turning
Inability or reluctance of patient to change body position. (eg, mechanical ventilation, neuromuscular disease, drug-induced paralysis)
Poor oxygenation associated with position(eg, unilateral lung disease)
Potential for or presence of atelectasis
Presence of artificial airway
Postural Drainage
Evidence or suggestion of difficulty with secretion clearance
(a)Difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult)
(b)Evidence or suggestion of retained secretions in the presence of an artificial airway
-Presence of atelectasis caused by or suspected of being caused by mucus plugging.
-Diagnosis of diseases such as cystic fibrosis,bronchiectasis, or cavitating lung disease
-Presence of foreign body in airway.
-External Manipulation of the Thorax
(a)Sputum volume or consistency suggesting a need for additional manipulation (eg, percussion and/or vibration) to assist movement of secretions by gravity, in a patient receiving postural drainage

CONTRAINDICATIONS
The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks. Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Listed contraindications are relative unless marked as absolute .

1 Positioning
All positions are contraindicated for
Intracranial pressure (ICP) > 20 mm Hg(59,60)
Head and neck injury until stabilized
Active hemorrhage with hemodynamic instability
Recent spinal surgery (eg, laminectomy) or acute spinal injury
Acute spinal injury or active hemoptysis
Empyema
Bronchopleural fistula
Pulmonary edema associated with congestive heart failure
Large pleural effusions
Pulmonary embolism
Aged, confused, or anxious patients who do not tolerate position changes
Rib fracture, with or without flail chest surgical wound or healing tissue
Trendelenburg position is contraindicated for
Intracranial pressure (ICP) > 20 mm Hg(59,60) patients in whom increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye surgery)
Uncontrolled hypertension
Distended abdomen
Esophageal surgery
Recent gross hemoptysis related to recent lung carcinoma treated surgically or with radiation therapy
Uncontrolled airway at risk for aspiration (tube feeding or recent meal)
Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication

2 External Manipulation of the Thorax

In addition to contraindications previously listed
subcutaneous emphysema
Recent epidural spinal infusion or spinal anesthesia
Recent skin grafts, or flaps, on the thorax
Burns, open wounds, and skin infections of the thorax
Recently placed transvenous pacemaker or subcutaneous pacemaker (particularly if mechanical devices are to be used)
Suspected pulmonary tuberculosis lung contusion
Bronchospasm
Osteomyelitis of the ribs
Osteoporosis
Coagulopathy
Complaint of chest-wall pain

COMPLICATIONS

Hypoxemia
Increased Intracranial Pressure
Acute Hypotension during Procedure
Pulmonary Hemorrhage
Pain or Injury to Muscles, Ribs, or Spine
Vomiting and Aspiration
Bronchospasm
Dysrhythmias
LIMITATIONS OF METHOD
1-Presumed effectiveness of PDT and its application may be based more on tradition and anecdotal report than on scientific evidence. The procedure has been used excessively and in patients in whom it is not indicated.
2-Airway clearance may be less than optimal in patients with ineffective cough.
3-Optimal positioning is difficult in critically ill patients.


ASSESSMENT OF OUTCOME

These represent individual criteria that indicate a positive response to therapy (and support continuation of therapy). Not all criteria are required to justify continuation of therapy (eg, a ventilated patient may not have sputum production > 30 mL/day, but have improvement in breath sounds, chest x-ray, or increased compliance or decreased resistance).

1.CHANGE IN SPUTUM PRODUCTION

If sputum production in an optimally hydrated patient is less than 25 mL/day with PDT the procedure is not justified. Some patients have productive coughs with sputum production from 15 to 30 mL/day (occasionally as high as 70 or 100 mL/day) without postural drainage. If postural drainage does not increase sputum in a patient who produces > 30 mL/day of sputum without postural drainage, the continuation of the therapy is not indicated. Because sputum production is affected by systemic hydration, apparently ineffective PDT probably should be continued for at least 24 hours after optimal hydration has been judged to be present.

2. CHANGE IN BREATH SOUNDS AND LUNG FIELDS ARE DRAINED

With effective therapy, breath sounds may 'worsen' following the therapy as secretions move into the larger airways and increase rhonchi. An increase in adventitious breath sounds can be a marked improvement over absent or diminished breath sounds. Note any effect that coughing may have on breath sounds. One of the favorable effects of coughing is clearing of adventitious breath sounds.

3 PATIENT SUBJECTIVE RESPONSE TO THERAPY

The caregiver should ask patient how he or she feels before, during, and after therapy. Feelings of pain, discomfort, shortness of breath, dizziness, and nausea should be considered in decisions to modify or stop therapy. Easier clearance of secretions and increased volume of secretions during and after treatments support continuation.

4. CHANGES IN VITAL SIGNS
Moderate changes in respiratory rate and/or pulse rate are expected. Bradycardia, tachycardia, or an increase in irregularity of pulse, or fall or dramatic increase in blood pressure are indications for stopping therapy.

5. CHANGES IN X-RAYS
Resolution or improvement of atelectasis may be slow or dramatic.

6. CHANGES IN ARERIAL BLOOD GAS VALUE AND OXYGN SATURATION
Oxygenation should improve as atelectasis resolves.

7. CHANGE IN VENTILATOE VARIABLE
Resolution of atelectasis and plugging reduces resistance and increases compliance.

LUNG VOLUMES AND CAPACITIES

RESPIRATORY PHYSIOLOGY -
The respiratory physiology is on the process of incorporation of oxygen in the environment for the utilization of energy from the organic compounds and for the elimination of carbon dioxide. 

                                LUNG VOLUMES AND CAPACITIES
TIDAL VOLUME(500 ml)
The volume of air breathed in and out at rest is known as the tidal volume (TV). This is found to be about 500 ml in an averagely built (70 kg), healthy, young adult. The tidal volume tends to decrease in restrictive lung diseases. In restrictive lung diseases, the lungs fail to expand properly as a result of restrictive forces exerted from within the lungs (e.g. – fibrosing alveolitis) or from the thoracic wall (e.g. – severe scoliosis, ankylosing spondylitis). Weakness of the respiratory muscles (e.g. – myasthenia gravis, Guillain Barre syndrome and phrenic nerve palsy) can also give rise to restricted movements of the chest wall resulting in the reduction of the tidal volume.
INSPIRATORY RESERVE VOLUME (IRV)(3100 ml) AND
EXPIRATORY RESERVE VOLUME(ERV)(1200 ml)
In addition to the amount of air that could be inspired at rest, the lungs are capable of accommodating an additional amount of air during a deep inspiration. This amount of air that can be inhaled in addition to the tidal volume is known as the inspiratory reserve volume (IRV). Similarly, in a deep and forceful expiration, the lungs are capable of exhaling a volume which is in excess to the tidal volume and the inspiratory reserve volume. This is known as the expiratory reserve volume (ERV). In a healthy young adult, IRV measures about 3100 ml and the ERV is approximately 1200 ml.
RESIDUAL VOLUME(1200 ml)
The lungs do not collapse completely following a deep, forceful expiration. A certain volume of air remains within the lungs, maintaining the alveoli expanded and the airways patent. This volume, which cannot be expelled even after a maximally forceful expiration, is known as the residual volume (RV).
MEASURMENT OF LUNG VOLUMES - (SPIROMETRY)
The tidal volume, IRV and ERV can be measured using a device known as a spirometer. Here, the volume changes that occur in a closed circuit are measured while an individual is breathing through a mouthpiece into a measuring device. The volume change that occurs while the individual is engaged in quite breathing is the tidal volume. The volume that the individual inhales in excess of the tidal volume during a deep inspiration is the IRV and the volume that is exhaled in excess to the tidal volume during a deep expiration is the ERV.
MEASURMENT OF RESIDUAL VOLUME - (HELIUM DILUTION)
                                                         HELIUM DILUTION METHOD
The residual volume cannot be measured with a conventional spirometer. Therefore, to measure the residual volume, several techniques have been described. In one such technique, an individual breaths into a closed circuit, which contains a known amount of Helium. Helium does not cross the blood-gas barrier and is not excreted by the lungs. Thus, decrease in the concentration of Helium is brought about by the increase in the volume of the circuit by connecting the circuit to the respiratory system. When, the concentration of Helium is measured following a deep expiration, the total volume is the volume of the breathing circuit + the residual volume. Since concentration = amount of a substance / volume of distribution, the residual volume can be calculated.
LUNG CAPACITIES-
Four capacities have been described based on the four lung volumes:
1.Inspiratory Capacity (IC) is the maximum volume of air that can be inhaled following a resting state. This can be calculated by the addition of tidal volume and the IRV-3600 ml
2.Vital Capacity (VC) is the maximum volume of air that can be exhaled following a deep inspiration. This is the total of IRV + TV + ERV- 4800ml
3.Functional Residual Capacity (FRC) is the volume of air that remains in the lungs during quite breathing. FRC = ERV + RV 2400 ml
4.Total Lung Capacity (TLC) is the volume the whole respiratory system can accommodate. Therefore, TLC= IRV + TV + ERV + RV 6000ml.
Lung capacities and lung volumes are affected in different types of physiological processes as well as in lung diseases. The specific changes that occur in different types of diseases will be described in a separate hub along with examples for different patterns of abnormalities seen in the lung volumes.

NEBULISER

DEFINITION
Nebulization is the process of medication administration via inhalation. It utilizes a nebulizer which transports medications to the lungs by means of mist inhalation.

TYPES OF NEBULISER-
There is a huge market for different types of nebulizers and each of them have some unique features although they all function in a similar way. Here are the two basic types of nebulizers available in the market:
STATIONARY NEBULISER – these are the nebulizers that are sturdy, rest on top of the table and they can provide durability as most of them come with a longer warranty period. They are cheaper than the mobile nebulizers and serve as a good aid for usage for children or elderly patients. Stationery nebulizers are mostly for indoor use only and are seldom used outdoors.

MOBILE NEBULISER – these nebulizers provide most mobility as they can be hand held and carried with the patient wherever they go. They have alternative power sources like batteries or auto adapters which enable them with usage at areas where there is no or limited access to AC power. Since they are mobile in nature, these nebulizers are lighter than the stationery ones and also smaller in size.

ULTRASONIC NEBULISER – Ultrasonic nebulizers deliver the medicine through high frequency vibrations in order to change the liquid medication into a mist to inhale and feel relaxed.
The fine mist is inhaled through an attached mask or the mouthpiece as the ultrasonic nebulizers doesn’t condense air, they function quietly and are small in size to fit into any container to begin the function. Being portable, compact and battery operated, they work fast when compared to other nebulizers and utilize the ultrasonic waves to aerosolize the liquid medication.

JET NEBULISER – A jet nebulizer is a machine which changes the prescribed liquid medicine into a fine mist to let the child or the patient breathes in through the mouthpiece or the face mask. It delivers the medicine directly to the inhaler’s lungs, making it easy to use.
These are less expensive and are usually in the form of a plastic cup which holds the medication and allows the air pass through the tube with the help of the compressor. Basically, jet nebulizers require electricity, frequently to function which is not advised safe to carry or depend on during travel. It produces loud sound and offers a range of particle sizes to change a liquid into a mist.

MESH NEBULISER – A Mesh Nebulizer is considered as the fastest working device and is more expensive when compared to the other nebulizers. It operates on a battery power supply and is quiet, efficient and well suits to the aerosolize solutions. It generates the mono-disperse aerosol particles of 4.5 to 5µm. It utilizes a vibrating membrane to generate the aerosol mist from the medication.
Available in a compact and portable body, it is perfect to carry while travelling and use in case of need. Besides this, Mesh nebulizer requires proper care, careful handling and intense cleaning as the membrane is more prone to get blocked and requires replacement many times in a year for proper function of inhalation process.

INDICATION
Nebulization therapy is used to deliver medications along the respiratory tract and is indicated to various respiratory problems and diseases such as:
•Broncho-spasms
•chest tightness
•Excessive and thick mucus secretions
•Respiratory congestions
•Pneumonia

CONTRAINDICATIONS
In some cases, nebulization is restricted or avoided due to possible untoward results or rather decreased effectiveness such as:
•Patients with unstable and increased blood pressure
•Individuals with cardiac irritability (may result to dysrhythmias)
•Persons with increased pulses
•Unconscious patients (inhalation may be done via mask but the therapeutic effect may be significantly low

EQUIPMENTS
•Nebulizer and nebulizer connecting tubes
•Compressor oxygen tank
•Mouthpies, Respiratory medication to be administered
•Normal saline solution

PROCEDURE
1.Position the patient appropriately, allowing optimal ventilation.
2.Assess and record breath sounds, respiratory status, pulse rate and other significant respiratory functions.
3.Teach patient the proper way of inhalation:
Slow inhalation through the mouth via the mouthpiece
Short pause after the inspiration
Slow and complete exhalation
Some resting breaths before another deep inhalation.
4.Prepare equipments at hand
5.Check doctor’s orders for the medication, prepare thereafter
6.Place the medication in the nebulizer while adding the amount of saline solution ordered
7.Attach the nebulizer to the compressed gas source
8.Attach the connecting tubes and mouthpiece to the nebulizer
9.Turn the machine on (notice the mist produced by the nebulizer)
10.Offer the nebulizer to the patient, offer assistance until he is able to perform proper inhalation (if unable to hold the nebulizer [pediatric/geriatric/special cases], replace the mouthpiece with mask.

COMPLICATIONS
Possible effects and reactions after nebulization therapy are as follows:
•Palpitations
•Tremors
•Tachycardia
•Headache
•Nausea
•Broncho-spasms (too mu
NEBULISERch ventilation may result or exacerbate Broncho-spasms)

•TEACHINGS
As nurses, it is important that we teach the patients the proper way of doing the therapy to facilitate effective results and prevent complications (demonstration is very useful). Emphasize compliance to therapy and to report untoward symptoms immediately for apposite intervention.
Auscultatory gap is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high and the reappearance of the sounds at a lower level.
Provide excellent clues to the physiological functioning of the body.
•Alterations in body flexion are reflected in the body temp, pulse, respirations and blood pressure.
•These data provide part of the baseline info from which plan of care is developed.
•Any change from normal is considered to be an indication of the person’s state of health.

PNEUMOTHORAX AND PHYSIOTHERAPY MANAGEMENT

DEFINATION-
''A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall''. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax.
This condition can cause a steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, it can result in death.Very rarely both lungs may be affected by a pneumothorax.It is often called a collapsed lung, although that term may also refer to atelectasis.

TYPES OF PNEUMOTHORAX


 TYPES OF PNEUMOTHORAX

The two basic types of pneumothorax are traumatic pneumothorax and nontraumatic pneumothorax. Either type can lead to a tension pneumothorax if the air surrounding the lung increases in pressure. A tension pneumothorax is common in cases of trauma and requires emergency medical treatment.     TENSION PNEUMOTHORAX

TRAUMATIC PNEUMOTHORAX
Traumatic pneumothorax occurs after some type of trauma or injury has happened to the chest or lung wall. It can be a minor or significant injury. The trauma can damage chest structures and cause air to leak into the pleural space.
Examples of injuries that can cause a traumatic pneumothorax include:
Trauma to the chest from a motor vehicle accident
Broken ribs
A hard hit to the chest from a contact sport, such as from a football tackle
A stab wound or bullet wound to the chest
Medical procedures that can damage the lung, such as a central line placement, ventilator use, lung biopsies, or CPR
Changes in air pressure from scuba diving or mountain climbing can also cause a traumatic pneumothorax.
The change in altitude can result in air blisters developing on your lungs and then rupturing, leading to the lung collapsing.
Quick treatment of a pneumothorax due to significant chest trauma is critical. The symptoms are often severe, and they could contribute to potentially fatal complications such as cardiac arrest, respiratory failure, shock, and death.
NON-TRAUMATIC PNEUMOTHORAX-
This type of pneumothorax doesn’t occur after injury. Instead, it happens spontaneously, which is why it’s also referred to as spontaneous pneumothorax.
There are two major types of spontaneous pneumothorax:
1.primary and 2. secondary.
1.Primary spontaneous pneumothorax (PSP) occurs in people who have no known lung disease, often affecting young males who are tall and thin.
2.Secondary spontaneous pneumothorax (SSP) tends to occur in older people with known lung problems.
Some conditions that increase your risk of SSP include:

• Chronic obstructive pulmonary disease (COPD), such as emphysema or chronic bronchitis
• Acute or chronic infection, such as tuberculosis or pneumonia
• Lung cancer
• Cystic fibrosis, a genetic lung disease that causes mucus to build up in the lungs
• Asthma, a chronic obstructive airway disease that causes inflammation
• Spontaneous hemopneumothorax (SHP) is a rare subtype of spontaneous pneumothorax. It occurs when both blood and air fill the pleural cavity Without any recent trauma or history of lung disease.

SYMPTOMS OF PNEUMOTHORAX
The symptoms of a traumatic pneumothorax often appear at the time of chest trauma or injury, or shortly afterward. The onset of symptoms for a spontaneous pneumothorax normally occurs at rest. A sudden attack of chest pain is often the first symptom.
Other symptoms may include:

• A steady ache in the chest
• Shortness of breath, or dyspnea
• Breaking out in a cold sweat
• Tightness in the chest
• Turning blue, or cyanosis
• Severe tachycardia, or a fast heart rate

RISK FACTOR FOR TRAUMATIC PNEUMOTHORAX
The risk factors are different for a traumatic and spontaneous pneumothorax.
Risk factors for a traumatic pneumothorax include:

• Playing hard contact sports, such as football or hockey
• Performing stunts that may cause damage to the chest
• Having a history of violent fighting
• Having a recent car accident or fall from a height
• Recent medical procedure or ongoing assisted respiratory care

The people at highest risk for a PSP are those who are:

• Young
• Thin
• Male
• Between the ages of 10 and 30
• Affected by congenital disorders like Marfan’s syndrome
• Smokers
• Exposed to environmental or occupational factors, such as silicosis
• Exposed to changes in atmospheric pressure and severe weather changes
• The main risk factor for SSP is having previously been diagnosed with a lung disease. It’s more common in people over 40.

DIAGNOSIS
Diagnosis is based on the presence of air in the space around the lungs. A stethoscope may pick up changes in lungs sounds, but detecting a small pneumothorax can be difficult. Some imaging tests may be hard to interpret due to the air’s position between the chest wall and lung.
Imaging tests commonly used to diagnose pneumothorax include:
An upright posteroanterior chest radiograph
                                            CHEST RADIOGRAPHA CT scan
A thoracic ultrasound
TREATMENT
Treatment will depend on the severity of condition. It will also depend on whether you’ve experienced pneumothorax before and what symptoms you are experiencing. Both surgical and nonsurgical treatments are available.Treatment options can include close observation combined with the insertion of chest tubes, or more invasive surgical procedures to resolve and prevent further collapse of the lung. Oxygen may be administered.
OBSERVATION-
Observation or “watchful waiting” is typically recommended for those with a small PSP and who aren’t short of breath. In this case, your doctor will monitor your condition on a regular basis as the air absorbs from the pleural space. Frequent X-rays will be taken to check if your lung has fully expanded again. doctor will likely instruct you to avoid air travel until the pneumothorax as completely resolved.
Routine physical activity hasn’t been shown to worsen or delay healing of a pneumothorax. However, it’s often advised that intense physical activity or high-contact sports be delayed until the lung is fully healed and the pneumothorax is gone.
A pneumothorax can cause oxygen levels to drop in some people. This condition is called HYPOXEMIA . If this is the case, doctor will order oxygen supplementation along with activity limitations.
DRAINING EXCESS AIR
Needle aspiration and chest tube insertion are two procedures designed to remove excess air from the pleural space in the chest. These can be done at the bedside without requiring general anesthesia.Needle aspiration may be less uncomfortable than placement of a chest tube, but it’s also more likely to need to be repeated.For a chest tube insertion, doctor will insert a hollowed tube between your ribs. This allows air to drain and the lung to reinflate. The chest tube may remain in place for several days if a large pneumothorax exists.
PLEURODESIS
Pleurodesis is a more invasive form of treatment for a pneumothorax. This procedure is commonly recommended for individuals who’ve had repeated episodes of pneumothorax.During pleurodesis, doctor irritates the pleural space so that air and fluid can no longer accumulate. The term “PLEURA” refers to the membrane surrounding each lung. Pleurodesis is performed to make your lungs’ membranes stick to the chest cavity. Once the pleura adheres to the chest wall, the pleural space no longer expands, and this prevents formation of a future pneumothorax.
Mechanical pleurodesis is performed manually. During surgery, your surgeon brushes the pleura to cause inflammation. Chemical pleurodesis is another form of treatment. doctor will deliver chemical irritants to the pleura through a chest tube. The irritation and inflammation cause the lung pleura and chest wall lining to stick together.
SURGERY
Surgical treatment for pneumothorax is required in certain situations. You may need surgery if you’ve had a repeated spontaneous pneumothorax. A large amount of air trapped in chest cavity or other lung conditions may also warrant surgical repair.There are several types of surgery for pneumothorax. One option is a THORACOTOMY. During this surgery, surgeon will create an incision in the pleural space to help them see the problem. Once your surgeon has performed a thoracotomy, they’ll decide what must be done to help you heal.
Another option is THORACOSCOPY, also known as video-assisted thoracoscopic surgery (VATS). surgeon inserts a tiny camera through chest wall to help them see inside your chest. A thoracoscopy can help surgeon decide on the treatment for pneumothorax. The possibilities include sewing blisters closed, closing air leaks, or removing the collapsed portion of lung, which is called a LOBECTOMY.

PHYSIOTHERAPY MANAGEMENT
Indications for Physiotherapy
Lung collapse
Increased work of breathing
Thick sputum plugs predisposing to ventilation difficulty
Blood gas abnormalities
Sputum retention
Goals for Physiotherapy
To reinflate atelectatic lung areas
To improve distribution of ventilation
To increase oxygenation
Maintain airway clearance
Improve exercise tolerance
Physiotherapy Management
       To reduce work of breathing

• Body positioning
• Breathing control
• Relaxation technique
  To improve ventilation
• Localised thoracic expansion exercise
• Sputum mobilisation techniques
• Postural drainage
• Deep breathing exercise
• Percussion, shaking and vibrations
• Sputum removal techniques
• Coughing and huffing
• Airway suctioning

Physiotherapy outcome evaluation includes
Respiratory rate
Breathing pattern
Sputum quantity
Ausculatation
Cough sound
Oxygen requirement
SpO2
Arterial blood gases
Chest x-ray changes
Muscle strength
Functional performance

FRENKEL'S COORDINATION EXERCISE FOR CEREBELLER ATAXIA

FRENKLE 'S CO-ORDINATION EXERCISE FOR CEREBELLER ATAXIA
Definition of coordination Exercises:
It is the ability to execute smooth, accurate, controlled motor responses (optimal interaction of muscle function).
Coordination is the ability to select the right muscle at the right time with proper intensity to achieve proper action.
Coordinated movement is characterized by appropriate speed, distance, direction, timing and muscular tension.
It is the process that results in activation of motor units of multiple muscles with simultaneous inhibition of all other muscles in order to carry out a desired activity.

Importance of the cerebellum in co-ordination :





The cerebellum is the primary center in the brain for co-ordination of movement.
Components of coordinated movement:
Volition: is the ability to initiate,maintain or stop an activity or motion.
Perception:in tact proprioception and subcortical centres to integrate motor impulses and the sensory feedback. When proprioception is affected it is compensated with visual feedback.
Engramformation:is the neurologica lmuscular activity developed in the extrapyramidal system. Research proved that high repetitions of precise performance must be performed in order to develop an engram
.
Types of coordination:
1) Fine motor skills:
Require coordinated movement of small muscles (hands, face).
Examples: include writing, drawing, buttoning a shirt, blowing bubbles
2) Gross motor skills:
Require coordinated movement of large muscles or groups of muscles (trunk, extremities).
Examples: include walking, running, lifting activities.
3)Hand-eye skills:
The ability of the visual system to coordinate visual information. Received and then control or direct the hands in the accomplishment of a task .
Examples : include catching a ball,sewing,computer mouse use.
Causes of coordination impairments , Causes of Ataxia
Degeneration, damage or loss of nerve cells in the cerebellum, which is that part of the brain that controls muscle coordination, causes ataxia. The cerebellum comprises of two small ball-shaped folded tissues present at the base of the brain near the brainstem. Diseases which damage the spinal cord and peripheral nerves which connect the cerebellum to the muscles can also cause ataxia
.
Other causes of ataxia include:
Stroke is a condition where the blood supply to a part of the brain gets severely diminished or interrupted, which deprives the brain tissue of oxygen and other nutrients resulting in death of brain cells.
Trauma or injury to the head, which causes damage to the brain or spinal cord, can cause sudden-onset ataxia (acute cerebellar ataxia).
Chickenpox can result in a complication in the form of Ataxia; although this is not common. Ataxia can appear during the healing stages of the infection and persist for days to weeks and gradually resolve over the time.
Transient ischemic attack (TIA) is caused by a temporary reduction in blood supply to a part of the brain. Majority of the TIAs last only for a few minutes. Some of the symptoms of TIA include ataxia, which is temporary.
Multiple sclerosis is a chronic, potentially debilitating medical condition, which affects the central nervous system.
Cerebral palsy consists of a group of disorders, which occurs as a result of damage to a child's brain during its early development. It can be before, during or shortly after birth. It affects the ability to coordinate movements of the body.
Paraneoplastic syndromes are rare, degenerative disorders, which are triggered by the response of the immune system to a tumor or neoplasm. This tumor is commonly in the lungs, ovaries, lymph nodes or breast. Patient can experience ataxia many months or years before cancer is actually diagnosed.
Toxic reaction to some medications can also cause ataxia. Medicines, especially barbiturates and certain sedatives, like benzodiazepine, can cause ataxia as a side effect. Other things, which could cause toxic reactions, are heavy metal poisoning, alcohol and drug intoxication and solvent poisoning.
Any type of growth on the brain, either cancerous or noncancerous, can damage cerebellum and cause ataxia.
Deficiency of vitamin E or B-12 can also lead to ataxia.
No specific cause can be found for some adults who develop sporadic ataxia, also known as sporadic degenerative ataxia, which can be of many types, such as multiple system atrophy which is a progressive and degenerative disorder.

Examples of coordination tests:
1) In the upper limb:


                     A) Finger-to-nose test

The shoulder is abducted to 90o with the elbow extended, the patient is asked to bring tip of the index finger to the tip of nose.Finger to therapist finger: the patient and the therapist site opposite to each other, the therapist index finger is held in front of the patient, the patient is asked to touch the tip of the index finger to the therapist index finger.
B) Finger-to-finger test
Both shoulders are abducted to bring both the elbow extended, the patient is asked to bring both the hand toward the midline and approximate the index finger from opposing hand
C) Finger-to-doctor's finger test
the patient alternately touch the tip of the nose and the tip of the therapist's finger with the index finger.
D) Adiadokokinesia or dysdiadokokinesia:
The patient asked to do rapidly alternating movement e.g. forearm supination and pronation, hand tapping.
E) Rebound phenomena:
The patient with his elbow fixed, flex it against resistance. When the resistance is suddenly released the patient's forearm flies upward and may hit his face or shoulder.
F) Buttoning and unbuttoning test.
In any of the previous tests, we may find:
Intention tremors and Decomposition of movements
Dysmetria: in the form of hypermetria or hypometria
2) In the lower limb :



          (A) Heel-to-knee test

B) Walking along a straight line Foot close to foot :In case of cerebellar lesion, there is deviation of gait
C) Rom-berg test: Ask the patient to stand with heels together. Swaying or loss of balance occurs while his eyes are open or closed.

General principles of coordination exercises involve:
Constant repetition of a few motor activities
Use of sensory cues (tactile, visual,proprioceptive) to enhance motor performance
Increase of speed of the activity over time
Activities are broken down into components that are simple enough to be performed correctly.
Assistance is provided when ever necessary.
The patient there fore should have a short rest after two or three repetitions,to avoid fatigue.
High repetition of precise performance must be performed for the engram to form.
When ever a new movement is trained, various inputs are given, like instruction(auditory), sensory stimulation(touch) ,or positions in which the patient can view the movement (visual stimulation) to enhance motor performance.
Therapeutic exercises used to improve coordination:
Frenkel’s exercises
1.Proprioceptive Neuromuscular Facilitation
2.Neurophysiological Basis of Developmental techniques
3.Sensory Integrative Therapy

FRENKEL’S EXERCISES:
 


Frenkel aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.
The process of learning this alternative method of control is similar to that required to learn any new exercise,the essentials being: Concentration of the attention, Precision and Repetition.

The ultimate aim is to establish control of movement so that the patient is able and confident in his ability to carry out these activities which are essential for independence in everyday life.
They are a system of slow repetitious exercises. They increase in difficulty over the time of the program. The patient watches his hand or arm movements (for example) and corrects them as needed.
Although the technique is simple, needs virtually no exercise equipment, and can be done on one's own, concentration and some degree of perseverance is required. Research has shown that 20,000 to 30,000 repetitions may be required to produce results. A simple calculation will show that this can be achieved by doing 60 repetitions every hour for six weeks in a 16-hour daily waking period. The repetitions will take just a few minutes every hour.
The brain as a whole learns to compensate for motor deficits in the cerebellum (or the spinal cord where applicable). If the ataxia affects say, head movements, the patient can use a mirror or combination of mirrors to watch their own head movements.
History
Best Physiotherapy Exercises for In-Coordination--Frenkel’s Exercises :
Frenkel Exercises are a series of motions of increasing difficulty performed by ataxic patients to facilitate the restoration of coordination. Frenkel's exercises are used to bring back the rhythmic, smooth and coordinated movements.
Dr. H S Frenkel was a physician from Switzerland who aimed at establishing voluntary control of movement by the use of any part of the sensory mechanism which remained intact, notably sight, sound and touch, to compensate for the loss of kinaesthetic sensation.
Frenkel Exercises were originally developed in 1889 to treat patients of tabes dorsalis and problems of sensory ataxia owing to loss of proprioception. These exercises have been applied in the treatment of individuals with ataxia, in particular cerebellar ataxia. The exercises are performed in supine, sitting, standing and walking. Each activity is performed slowly with the patient using vision to carefully guide correct movement. These exercises require a high degree of mental concentration and effort. For those patients with the prerequisite abilities, they may be helpful in regaining control of movement through cognitive compensation strategies. Patients with partial sensation can progress to practicing exercises with eyes closed.

The main principles of Frenkel exercises are the following:
1.Concentration or attention
2.Precision
3.Repetition

This program consists of a planned series of exercises designed to help patient compensate for the inability to tell where the arms and legs are- in space without looking.
1. Exercises are designed primarily for coordination; they are not intended for strengthening.
2. Commands should be given in an event, slow voice; the exercises should be done to counting.
3. It is important that the area is well lit and that patients are positioned so that they can watch the movement of their legs.
4. Avoid fatigue. Perform each exercise not more than four times. Rest between each exercise.
5. Exercises should be done within normal range of motion to avoid over-stretching of muscles.

General Instructions for frenkel exercises
Exercises can be performed with the part supported or unsupported, unilaterally or bilaterally.
They should be practiced as smooth, timed movements, performed at a slow, even tempo by counting out loud.
Consistency of performance is stressed and a specified target can be used to determine range.
Four basic positions are used: lying, sitting, standing and walking.
The exercises progress from postures of greatest stability (lying, sitting) to postures of greatest challenge (standing, walking).
As voluntary control improves, the exercises progress to stopping and starting on command, increasing the range and performing the same exercises with eyes closed.
Concentration and repetition are the keys to success.
Frenkel exercises for lower limb

• Exercises for the legs in lying
• Flex and extend one leg by the heel sliding down a straight line on the table.
• Abduct and adduct hip smoothly with knee bent and heel on the table.
• Abduct and adduct leg with knee and hip extended by sliding the whole leg on the table.
• Flex and extend hip and knee with heel off the table.
• Flex and extend both the legs together with the heel sliding on the table.
• Flex one leg while extending the other
• Flex and extend one leg while taking the other leg into abduction and adduction.
• Heel of one limb to opposite leg (toes, ankle, shin, patella).
• Heel of one limb to opposite knee, sliding down crest of tibia to ankle.

Whether the patient slides the heels or lifts it off the bed he has to touch it to the marks indicated by the patient on the plinth. The patient may also be told to place the heel of one leg on various points of the opposite leg under the guidance of the therapist.

Exercises for the legs in Sitting

• One leg is stretched to slide the heel to a position indicated by a mark on the floor.
• The alternate leg is lifted to place the heel on the marked point.
• From stride sitting posture patient is asked to stand and then sit.
• Rise and sit with knees together.
• Sitting hip abduction and adduction.
• Exercises for the legs in Standing
• In stride standing weight is transferred from one foot to other.
• Place foot forward and backward on a straight line.
• Walk along a winding strip.
• Walk between two parallel lines
• Walk sideways by placing feet on the marked point.
• Walk and turn around
• Walk and change direction to avoid obstacles.

Frenkel exercises for upper limb :
Similar exercises can be devised for the upper limb wherein the patient may be directed to place the hand on the various points marked on the table or wall board to improve coordination of all the movements in the upper limb.
Some examples of Frankel exercises of upper limb in sitting position

• Have patient sit in front of a table and place a number of objects on the table. The patient then touches each object with the right hand and then the left hand.The patient flexes the right shoulder to 90 degree with elbow and wrist extended. The patient then takes his or her right 
• index finger and touches the tip of his or her nose. This exercise is then repeated with the left hand. The exercise is performed alternating right and left index finger.
• patient taps bilateral hands on bilateral thighs while alternating palmer and dorsal surfaces as fast as possible.
• Certain diversional activities such as building with toy bricks or drawing on a black board, buttoning, combing, writing, typing are some of the activities that also improves the coordination.
  

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DUPUYTREN'S CONTRACTUTE AND PHYSIOTHERAPY MANAGEMENT

DEFINATION-

Dupuytren's contracture is a condition in which one or more fingers become permanently bent in a flexed position. It usually begins as small hard nodules just under the skin of the palm. It then worsens over time until the fingers can no longer be straightened. While typically not painful some aching or itching may be present.The ring finger followed by the little and middle fingers are most commonly affected. 

 

It can interfere with preparing food, writing, and other activities.
The cause is unknown. Risk factors include family history, alcoholism, smoking, thyroid problems, liver disease, diabetes, previous hand trauma, and epilepsy. The underlying mechanism involves the formation of abnormal connective tissue within the palmar fascia.

 

Diagnosis is usually based on symptoms.
Initial treatment is typically with steroid injections into the affected area and physical therapy. Among those who worsen, clostridial collagenase injections or surgery may be tried. 

 

While radiation therapy is used to treat this condition, the evidence for this use is poor.The condition may recur despite treatment.

Dupuytren's most often occurs in males over the age of 50.It mostly affects white people and is rare among Asians and Africans.In the United States about 5% of people are affected at some point in time, while in Norway about 30% of men over 60 years old have the condition. In the United Kingdom, about 20% of people over 65 have some form of the disease.It is named after Guillaume Dupuytren, who first described the underlying mechanism in 1833.

Signs and symptoms :

 
Dupuytren's contracture of the right little finger. Arrow marks the area of scarring
Typically, Dupuytren's contracture first presents as a thickening or nodule in the palm, which initially can be with or without pain. Later in the disease process, there is painless increasing loss of range of motion of the affected fingers. The earliest sign of a contracture is a triangular “puckering” of the skin of the palm as it passes over the flexor tendon just before the flexor crease of the finger, at the metacarpophalangeal (MCP) joint. Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. 

 

The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected.The disease begins in the palm and moves towards the fingers, with the metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.

In Dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren's contracture decreases a person's ability to hold objects. People may report pain, aching and itching with the contractions. Normally, the palmar fascia consists of collagen type I, but in Dupuytren sufferers, the collagen changes to collagen type III, which is significantly thicker than collagen type I.
 

Related conditions :
 

Dupuytren’s contracture is related to a number of similar conditions that affect different areas of the body, including:
Garrod’s pads – nodules that develop on the back of the knuckles on the fingers
Ledderhose’s disease (plantar fibromatosis) – nodules and contractures that affect the foot
Peyronie’s disease – where the tissue of the penis is affected, causing it to become abnormally curved
Risk factors
Dupuytren's contracture is a non-specific affliction but primarily affects:
Non-modifiable
People of Scandinavian or Northern European ancestry, it has been called the "Viking disease", though it is also widespread in some Mediterranean countries (e.g., Spain and Bosnia Dupuytren's is unusual among ethnic groups such as Chinese and Africans.
Men rather than women; men are more likely to develop the condition)
People over the age of 50; the likelihood of getting Dupuytren's disease increases with age.
People with a family history (60% to 70% of those afflicted have a genetic predisposition to Dupuytren's contracture)
Modifiable
Smokers, especially those who smoke 25 cigarettes or more a day
Thinner people (i.e., those with a lower than average body mass index)
Manual workers
Alcoholics
Other conditions
People with a higher-than-average fasting blood glucose level
People with previous hand injury
People with Ledderhose disease (plantar fibromatosis)
People with epilepsy (possibly due to anti-convulsive medication)
People with diabetes mellitus
People with HIV
In one study, those with stage 2 of the disease were found to have a slightly increased risk of mortality, especially from cancer.
 

Diagnosis :

 
Types
According to the American Dupuytren's specialist Dr Charles Eaton, there may be three types of Dupuytren's disease:
Type 1: A very aggressive form of the disease found in only 3% of people with Dupuytren's, which can affect men under 50 with a family history of Dupuytren's. It is often associated with other symptoms such as knuckle pads and Ledderhose disease. This type is sometimes known as Dupuytren's diathesis.
Type 2: The more normal type of Dupuytren's disease, usually found in the palm only, and which generally begins above the age of 50. According to Dr Eaton, this type may be made more severe by other factors such as diabetes or heavy manual labour.
Type 3: A mild form of Dupuytren's which is common among diabetics or which may also be caused by certain medications such as the anti-convulsants taken by people with epilepsy. This type does not lead to full contracture of the fingers and is probably not inherited.
Staging of Dupuytren’s disease.( TFD- Total flexion deformity )
Stage Deformity
0        No lesion
N       Palmar nodule without presence of contracture
1        TFD between 0° and 45°
2        TFD between 45° and 90°
3       TFD between 90° and 135°
4       TFD greater tha
 

Treatment :

Currently, there is no cure for Dupuytren's; however, the condition is not dangerous.
Although it varies from patient to patient, Dupuytren's usually progresses very slowly and may not become troublesome for many years. In fact, for some patients, the condition may never progress beyond developing lumps in the palm.
If the condition progresses, your doctor may first recommend nonsurgical treatment to help slow the disease.
1. Nonsurgical Treatment
Steroid injection. Corticosteroids are powerful anti-inflammatory medications that can be injected into a painful nodule. In some cases, a corticosteroid injection may slow the progression of a contracture. The effectiveness of a steroid injection varies from patient to patient.
Splinting. Splinting is not known to prevent the progression of a finger contracture. Forceful stretching of the contracted finger may not be helpful and, in fact, could cause an injury to the finger or hand.
Splinting may be used after surgery for Dupuytren's contracture to protect the surgical site; however, it is not known if it reduces the risk of recurrent contracture or tightening of the healing wound.
2. Surgical Treatment
If the contracture interferes with hand function, your doctor may recommend surgical treatment. The goal of surgery is to reduce the contracture and improve motion in the affected fingers.
There is no known cure for Dupuytren's contracture; however, surgery is intended to "set back the clock" by reducing the restricting effect of the cords by either disrupting or removing them. Unfortunately, the healing tissues will form with the same potential to develop cords in the future—but the gains in hand function can still be substantial.
The surgical procedures most commonly performed for Dupuytren's contracture are:
Fasciotomy
Subtotal palmar fasciectomy
Fasciotomy.
Treatment is indicated when the so-called table top test is positive. With this test, the person places their hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the table, leaving a space between the table and a part of the hand as big as the diameter of a ballpoint pen, the test is considered positive and surgery or other treatment may be indicated. Additionally, finger joints may become fixed and rigid.
3. Recent Developments in Treatment
The recently developed treatments described below are intended to reduce a contracture and improve motion in the affected fingers by disrupting the tethering effect of the Dupuytren's cords.
Enzyme Injection
The injection of an enzyme solution for treatment of Dupuytren's contracture has recently been approved by the Federal Drug Administration. The enzyme, a collagenase, is administered on an outpatient basis by doctors who have been specifically trained in the technique.
To begin, your doctor will inject the enzyme directly into the cords in your hand. During the 24 to 72 hours following the injection, the enzyme will weaken/dissolve the contracted tissue.
The next step is performed under local anesthesia. Your doctor will manipulate and straighten your bent fingers to break or pull apart the restrictive cords. Often, this improves the contracture and increases range of motion in the fingers.
Enzyme injection typically results in less pain and swelling than major surgery. Although rare, the injection may cause an allergic reaction or flexor tendon rupture. Other potential complications are the same as those for surgery.
Early results for enzyme injection are promising, but long-term results and recurrence rates are not yet known.
4. Physiotherapy, massage and exercise before surgery
Physiotherapy may help relieve some of the pain and tension that patients feel in their hands or arms.
Massaging the palm of the hand and the forearm may help reduce the tension in the palmar fascia and the Palmaris Longus muscle (a muscle in most people’s arms that pulls on the fascia).
Physiotherapy will not remove the nodules, though some therapists can help with releasing tension in the arm and treating the tissues around the lumps to give relieve of pain and increase the range of movement. Physiotherapy can consist of massaging or exercises.
Some patients will wear splints to try slow down contracture, an example can be found on this page.
Acupuncture and reflexology are other treatments sometimes used to try slow or even reverse the progression.
Many consultants believe that physiotherapy will not stop the disease progress, but can help with the symptoms for a while.
Exercises are not commonly recommended and are unlikely to prevent contractures. However some patients do report good results, even if for a limited period of time until the condition worsens and they need further treatment.
Some treatments that have helped patients:
massaging the whole arm and hand to create good flow of fluid from the hand to the heart and from the heart to the hand.
gentle stretching exercises ( if stretching too vigorously you risk microtrauma to the fascia which can aggravate Dupuytren’s it should not be painful, at most a bit uncomfortable). Gentle stretching and holding the position for 10-15 seconds , then release and repeat 10 times is better and will tire the contracted strands more than brute force)
hot wax treatments to the hand or other warm applications, for many people applying heat or at least warmth first help to make exercises easier.
ultrasound treatment of the nodules to soften them and maybe reduce the pain
acupuncture
after heat treatment or ultrasound, massaging sideways over the palm may help to loosen the tissues a bit, with the other hand or done by a professional with tools made for tissue release techniques.
wearing night splints, the idea being that at night many people have their fingers slightly curved which makes it easier for the contracture to settle in a curved position.
for painful palms or nodules a lot of patients wear weightlifting gloves that are padded in the palm, to protect their hand and reduce the pain, and still have good grip
There are different type of exercises with different goals.
Remember that most exercises work best if you stretch until you feel resistance, NOT stretch until it really hurts. Hold that tension for 10-15 seconds, release and repeat 10 times.
Tendon Glide exercises : are meant to make the deep and superficial flexor tendons (the ones that bend your fingers) move separately. The are done by making different types of fists, as shown in the pictures here, going from a flat hand via fingers only bend at the hand joint to a fist with bend fingers to a fist with fingers straight.

TENDON GLIDE 1:
 

TENDON GLIDE 2





TENDON GLIDE 3 EXERCISE
 


TENDON GLIDE 4 EXERCISE





TENDON GLIDE  5 EXERCISE
 



TENDON GLIDE 6 EXERCISE
 

Range of motion exercises : can be to stretch the fingers and joints or to widen the reach of the fingers. A lot of websites will give ideas for this, especially sites for guitar or piano players. Some examples follow here:
To strengthen the fingers and increase the reach:
Place your hand against each other with the fingers stretches and the tips touching, try pushing the palms together as well. If you can get palms and fingertips touching, try to push the fingertips of one hand away with the tips of the other hand.
Place hand on a flat tabletop. Lift the palm off the table while keeping your fingers on the table, to stretch the joints between the hands and fingers.
Place the hand flat on the table and try to lift each finger up separately
With the hand flat on the table try to spread your fingers as wide as they will go. Then move each finger toward the thumb (start with the index finger) while holding the hand flat to create as much space between the fingers as you can each time. This exercise can be doe the other way around as well by moving each finger toward the little finger.
Hold you hand up, and make the thumb touch the tip of each finger in turning, creating a circle of the finger and thumb.
Gripping exercises
Use a folded up towel, or a sponge (cut to size of you want). Place it in your hand and squeeze tight, then release after 10 seconds and repeat. Soft exercise balls or babies toy balls work as well.
Exercises after the surgery:
Exercises may need to be done for up to 6 months. Repeat each one 10 times, do at least 3 times per day. It may be easier to do the exercises with the hand in lukewarm water, soapy or plain.
Please note exercising can be uncomfortable but should not be really painful. It is better to go gently, hold for 10 seconds and release, and try to get more movement slowly than to force the issue, that may do damage!
Any exercises where you use the other hand to push the joints (passive exercises) are best only started when the wound has healed and any scabs have come off.
Straightening the fingers: (note that a swollen finger will not straighten completely)
Finger Walking (Spreading the finger)s Rest palm on flat surface, move thumb to the side, slide one finger at the time toward the thumb.Finger Walking (Spreading the finger)s Rest palm on flat surface, move thumb to the side, slide one finger at the time toward the thumb.
Tendon Glide
Start with the hand open, make a fist by bending each joint one by one, then open the fist the same way.
Cat’s Paw– open hand wide, bend the fingertips but not the large knuckles, hold six seconds.
Making a fist (whole hand, try first around a ping pong ball or even small foam ball or sponge, later without anything between the fingers and the palm)
Making a fist finger by finger by using your other hand to bend the joints, passive exercises, only start these when the wound has healed and any scabs have come off.
Use the other hand to gently bend the affected finger at the large knuckle, hold for 10 seconds.

Complications.

 
As with any surgery, there are risks associated with surgery for Dupuytren's contracture. The likelihood of complications increases with the following:
The severity of the contracture
The number of contractures addressed in a single procedure
The presence of any other medical conditions
Possible risks and complications of surgery for Dupuytren's include:
Pain
Scarring
Injury to nerves and/or blood vessels
Wound infection
Stiffness
Loss of sensation. Temporary loss of sensation may result from stretching nerves that have been contracted for a long time.
Loss of viability of a finger/loss of a finger (rare)
 

Prognosis :

 
Dupuytren’s disease has a high recurrence rate, especially when a person has so called Dupuytren’s diathesis. The term diathesis relates to certain features of Dupuytren's disease and indicates an aggressive course of disease
The presence of all new Dupuytren’s diathesis factors increases the risk of recurrent Dupuytren’s disease by 71% compared with a baseline risk of 23% in people lacking the factors. In another study the prognostic value of diathesis was evaluated. They concluded that presence of diathesis can predict recurrence and extension. A scoring system was made to evaluate the risk of recurrence and extension evaluating the following values: bilateral hand involvement, little finger surgery, early onset of disease, plantar fibrosis, knuckle pads and radial side involvement.
Minimally invasive therapies may precede higher recurrence rates. Recurrence lacks a consensus definition. Furthermore, different standards and measurements follow from the various definitions.
 

Post-operative care :

 
Postoperative care involves hand therapy and splinting. Hand therapy is prescribed to optimize post-surgical function and to prevent joint stiffness. Besides hand therapy, many surgeons advise the use of static or dynamic splints after surgery to maintain finger mobility. The splint is used to provide prolonged stretch to the healing tissues and prevent flexion contractures. 

 

Although splinting is a widely used post-operative intervention, evidence of its effectiveness is limited, leading to variation in splinting approaches. Most surgeons use clinical experience to decide whether to splint.Cited advantages include maintenance of finger extension and prevention of new flexion contractures. Cited disadvantages include joint stiffness, prolonged pain, discomfort, subsequently reduced function and edema.
A third approach emphasizes early self-exercise and stretching.

 

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LEPROSY AND PHYSITHERAPY MANAGEMENT

DEFINATION OF LEPROSY :
1 : A chronic infectious disease caused by a mycobacterium (Mycobacterium leprae) affecting especially the skin and peripheral nerves and characterized by the formation of nodules or macules that enlarge and spread accompanied by loss of sensation with eventual paralysis, wasting of muscle, and production of deformities — called also Hansen’s disease
2 : A morally or spiritually harmful influenceThe first system recognizes two types of leprosy: tuberculoid and lepromatous. A person’s immune response to the disease determines their type of leprosy.
The immune response is good and the disease only exhibits a few lesions (sores on the skin) in tuberculoid leprosy. The disease is mild and only mildly contagious.
The immune response is poor in lepromatous leprosy and affects the skin, nerves, and other organs. There are widespread lesions and nodules (large lumps and bumps). This disease is more contagious.
WHO categorizes the disease based on the type and number of affected skin areas. The first category is paucibacillary, in which five or fewer lesions with no bacteria are detected in the skin sample. The second category is multibacillary, in which there are more than five lesions, bacteria is detected in the skin smear, or both.
CLASSIFICATION OF LEPROSY :
Clinical studies use the Ridley-Jopling system. It has six classifications based on severity of symptoms. They are:
1. Intermediate leprosy: a few flat lesions that sometimes heal by themselves and can progress to a more severe type
2. Tuberculoid leprosy: a few flat lesions, some large and numb; some nerve involvement; can heal on its own, persist, or may progress to a more severe form.
3. Borderline tuberculoid leprosy: lesions similar to tuberculoid but smaller and more numerous; less nerve enlargement; may persist, revert to tuberculoid, or advance to another form.
4. Mid-borderline leprosy: reddish plaques, moderate numbness, swollen lymph glands; may regress, persist, or progress to other forms.
5. Borderline lepromatous leprosy: many lesions including flat lesions, raised bumps, plaques, and nodules, sometimes numb; may persist, regress, or progress.
6. Lepromatous leprosy: many lesions with bacteria; hair loss; nerve involvement; limb weakness; disfigurement; doesn’t regress.
TRANSMISSION OF LEPROSY :
Leprosy spreads through contact with the mucus of an infected person. This usually occurs when the infected person sneezes or coughs. The disease isn’t highly contagious. Close, repeated contact with an untreated person can lead to contracting leprosy.
The bacteria responsible for leprosy multiply very slowly. The disease has an incubation period (the time between infection and the appearance of the first symptoms) of up to five years. Symptoms may not appear for as long as 20 years.
According to the New England Journal of Medicine, an armadillo native to the southern United States can also carry and transmit the disease to humans.
SYMPTOMS :

BLISTER FORMATION IN LEPROSY

Symptoms mainly affect the skin, nerves, and mucous membranes (the soft, moist areas just inside the body’s openings).
The disease can cause skin symptoms such as:
A large, discolored lesion on the chest of a person with Hansen’s disease.
A large, discolored lesion on the chest of a person with Hansen’s disease.
Discolored patches of skin, usually flat, that may be numb and look faded (lighter than the skin around)
Growths (nodules) on the skin
Thick, stiff or dry skin
Painless ulcers on the soles of feet
Painless swelling or lumps on the face or earlobes
Loss of eyebrows or eyelashes
Symptoms caused by damage to the nerves are:
Numbness of affected areas of the skin
Muscle weakness or paralysis (especially in the hands and feet)
Enlarged nerves (especially those around the elbow and knee and in the sides of the neck)
Eye problems that may lead to blindness (when facial nerves are affected)
Enlarged nerves below the skin and dark reddish skin patch overlying the nerves affected by the bacteria on the chest of a patient with Hansen’s disease. This skin patch was numb when touched.
Enlarged nerves below the skin and dark reddish skin patch overlying the nerves affected by the bacteria on the chest of a patient with Hansen’s disease. This skin patch was numb when touched.
Symptoms caused by the disease in the mucous membranes are:
A stuffy nose
Nosebleeds
Since Hansen’s disease affects the nerves, loss of feeling or sensation can occur. When loss of sensation occurs, injuries such as burns may go unnoticed. Because you may not feel the pain that can warn you of harm to your body, take extra caution to ensure the affected parts of your body are not injured.
If left untreated, the signs of advanced leprosy can include:
Paralysis and crippling of hands and feet
Shortening of toes and fingers due to reabsorption
Chronic non-healing ulcers on the bottoms of the feet
Blindness
Loss of eyebrows
Nose disfigurement
Other complications that may sometimes occur are:
Painful or tender nerves
Redness and pain around the affected area
Burning sensation in the skin

LEPROSY DIAGNOSIS :
The diagnosis of leprosy is often established from the patient’s clinical signs and symptoms. A careful skin exam and neurologic exam will be undertaken by a health-care professional. If a laboratory is available, skin smears or skin biopsies may be obtained for a more definitive diagnosis. Skin smears or biopsy material that show acid-fast bacilli with the Ziel-Neelsen stain or the Fite stain can diagnose multibacillary leprosy. If bacteria are absent, paucibacillary leprosy can be diagnosed. Other less commonly used tests include blood exams, nasal smears, and nerve biopsies. Specialized tests can be done to place the patient in the more detailed Ridley-Jopling classification.

PREVENTION:
Early detection of the disease is important, since physical and neurological damage may be irreversible even if cured. Medications can decrease the risk of those living with people with leprosy from acquiring the disease and likely those with whom people with leprosy come into contact outside the home.However, concerns are known of resistance, cost, and disclosure of a person’s infection status when doing follow-up of contacts. Therefore, the WHO recommends that people who live in the same household be examined for leprosy and be treated only if symptoms are present.
The Bacillus Calmette–Guérin (BCG) vaccine offers a variable amount of protection against leprosy in addition to its target of tuberculosis. It appears to be 26 to 41% effective (based on controlled trials) and about 60% effective based on observational studies with two doses possibly working better than one. Development of a more effective vaccine is ongoing.

SELF-CARE AT HOME FOR LEPROSY
Prescribed antibiotics medications are the primary treatment for leprosy. Compliance with the full course of antibiotics is crucial to successful treatment.
Patients should also be educated to closely inspect their hands and feet for possible injuries sustained which may go unnoticed because of the loss of sensation.
1. Ulcers or tissue damage can result, leading to skin infections and disability.
2. Proper footwear and injury prevention should be encouraged.

LEPROSY TREATMENT:
Leprosy is a curable disease using the highly effective MDT (multidrug therapy).
In 1981, a World Health Organization Study Group recommended multidrug treatment with three medications: dapsone, rifampicin (Rifadin), and clofazimine (Lamprene).
This long-term treatment regimen cures the disease and prevents the complications associated with leprosy if started in its early stages.
The National Hansen’s Disease Programs (NHDP) currently recommends different treatment regimens for patients with tuberculoid and lepromatous leprosy.
NHDP recommendations:

1.Tuberculoid leprosy:
Twelve months of treatment using rifampin and Dapsone daily

2. Lepromatous leprosy
Twenty-four months of treatment using rifampin, dapsone, and clofazimine daily
The WHO recommended therapy for leprosy is given significantly shorter and less often, as this treatment policy is based upon practical considerations in countries with fewer medical resources. However, the relapses with treatment according to the WHO recommendations are significantly greater than those with the NHDP recommended therapy.
Individuals who develop type 1 or type 2 reactions may require other medications.
Type 1 reaction (reversal reaction):
Treatment may include the use of corticosteroids, salicylates, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Type 2 reaction (ENL):
Treatment may include the use of corticosteroids, salicylates, NSAIDs, clofazimine, and thalidomide (Thalomid).

SYRGICAL TREATMENT FOR LEPROSY:
There are various surgical procedures available for certain patients with leprosy. These surgical procedures are aimed at restoring function of affected body parts (for example, correcting clawed hand deformities) and to cosmetically improving areas damaged by the disease. Amputation of affected body parts is sometimes necessary. Surgery may also be necessary to drain a nerve abscess (pus collection) or to relieve the compression of nerves.
Some patients with leprosy may require psychological counseling, physical therapy, and occupational therapy.

DEFORMITIES IN LEPROSY:
Deformities occurring in leprosy:
1 .nose deformities
2. Face Deformities
3. Mask face, faces leonina, sagging face, lagophthaimos, loss of eye brows (supercilliary madorosis and eyelashes (ciliary madarosis),
4. ulcers and opacities, perforated nose, depressed nose, ear deformities, e.g. nodules on the ear and elongated lobules.
5. Hands deformities Hands deformitiesHands Deformities:
 

CLAW HAND DEFORMITY

Claw hand, wrist drop, ulcers, absorption of digits, thumb – web contracture, hollowing of the interossecus spaces and swollen hand.
6. Feet Deformities
Planter ulcer, foot drop, inversion of the foot, clawing of the toes, absorption of the toes, collapsed foot, swollen foot and callosities.
7. Other Deformities
Gynecomastia and perforation of the palate. All along it has commonly been believed that it is highly contagious and incurable. Even today, in spite of scientific information available about leprosy, it is deeply rooted in the minds of most people at all levels of society, with the result that social ostracism is apparent everywhere. This has led patients to hide their early lesions, and thereby delay treatment just at the period when they could be most speedily cured. Failure to appreciate the importance of the social and psychological factors has resulted in the failure of otherwise well conceived programs.
GOALS OF PHYSICAL THERAPY FOR NON-SURGICAL PATIENT’S OF LEPROSY DISEASE :
The major aim is to prevent or reduce complication, deformity and disability in body through Physical Therapy.
Means
The ways of reaching these Goals are-
By teaching the patient.
By treating and helping the patient.
Teachings
What the disease of leprosy is?
The possible complications and deformities resulting from leprosy.
prevention of complication, deformities and disabilities.
Treating and Helping
To respect themselves enough to take medication regularly and to take care of complications.
To protect their own anaesthetic hands, feets and eyes.
To keep their skin soft and supple.
To keep their joint flexible.
To preserve all posible movements of hands and feet.
To keep their muscles strong.
To use their hands, feet and eyes safely, in daily work
GOALS OF PHYSICAL THERAPY FOR SURGICAL PATIENTS OF LEPROSY:
To protect and prevent further damage and deformity.
To improve and restore function.
To improve appearance of hands, feet, face and eyes.




 
LEPROSY AND SPLINT FOR HAND
Surgical Techniques used in Leprosy Disease
Tendon Transfer: Moving the distal end of the tendon to a new place so that contraction of muscle belly will produce a needed movements used to replace paralysed muscles. Example- Transfer of fore-arm muscle to make finger movements.
Tendon Lengthening: Lengthening the tendon of a muscle to permit more movement and reduce contracture. Example- Tendo Calcaneus lengthening.
Capsulotomy: To loosen tight joint capsule often done with tendon lengthening and tendon transfer to improve range of motions. Tighten the loose joint capsule using suture.
Arthrodesis: Elimination of unstable and deformed joints.
Tenodesis: Attach a piece of tendon across the joint to reduce the movement. The tendon then act as ligament. Example- Tenodesis of MCP joint to prevent hyperextension.
Physical Therapy Goals:
To increase and regain range of motion.
Improve muscle strength perticularly in muscles to be transferred.
Clean supple skin in areas of surgery.
Teach home self care.
Protect tissue during wearing.
Prevent/reduce swelling.
Muscle re-education after tendon transfer.
Safe use of any new restored skill in work.
PHYSICAL THERAPY TREATMENT::
For increasing/regaining ROM: ROM can be increased by soaking the skin or part in warm water and then performing passive movement to the part affected.
To improve strength specially in tendon transfer: Active exercise in all part in which surgery is performed.
Clean supple skin: It is provided by soaking the part in soap water, rubbing off thick skin, oiling, self massage and protecting the part from infection.
Home care: teaching skin, hand, foot and eye care to groups and individuals and teaching the patients actual home care.
Protect tissue during healing: Rest, body position and POP cast.
Prevent/Reduce swelling: Elevation, active and passive exercise.
Muscle Re-education after tendon transfer: Teaching new restored skills in movements provided by tendon transfer.
Self restored skills in daily work: Teaching patient ot use any new skill safely in specific task. Providing hand, eye and foot protection.
 

SPLINT FOR LEG