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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MULTIPLE SCLEROSIS AND TREATMENT

DEFINATION :

 
Multiple sclerosis (MS) is a autoimmune disease characterised by inflammation,selective demylination and gliosis.it can cause both acute and chronic symptoms and can results in a significant disability and impaired quality of life.MS affects approximately 400,000 persons in the united states ; worldwild MS affects approximately 2.1 millian people.
 

It was first defined by the Dr.jean charcot in 1868 by its clinical ans pathological characteristics : paralysis and the cardinal symptoms of intension tremor, scanning speech and nystagmus later termed ”CHARCOT’S TRIAD”.
using the autopsy studies he identifies the areas of hardened plaques and termed the dieses sclerosis in plaques.
 

Specific symptoms can include double vision, blindness in one eye, muscle weakness, trouble with sensation, or trouble with coordination. MS takes several forms, with new symptoms either occurring in isolated attacks (relapsing forms) or building up over time (progressive forms). Between attacks, symptoms may disappear completely; however, permanent neurological problems often remain, especially as the disease advances.
Multiple sclerosis is a chronic disease that attacks the central nervous systrem, it affects the spinal cord , brain,and optic nerve.
Multiple sclerosis affects the nerve cells.

WHAT IS MULTIPLE SCLEROSIS ?
 

In the CNS, nerve fibers are surrounded by a myelin sheath, which protects them. Myelin also helps the nerves conduct electrical signals quickly and efficiently. In MS, the myelin sheath disappears in multiple areas, leaving a scar, or sclerosis.
Multiple sclerosis means “scar tissue in multiple areas.”
The areas where there is no myelin or a lack of myelin are called plaques or lesions. As the lesions get worse, nerve fibers can break or become damaged. As a result, the electrical impulses from the brain do not flow smoothly to the target nerve.When there is no myelin, the fibers cannot conduct the electrical impulses at all. The messages from the brain to the muscles cannot be transmitted.

CAUSES OF MULTIPLE SCLEROSIS:

 
The cause of multiple sclerosis is unknown. It’s considered an autoimmune disease in which the body’s immune system attacks its own tissues. In the case of MS, this immune system malfunction destroys myelin (the fatty substance that coats and protects nerve fibers in the brain and spinal cord).
Myelin can be compared to the insulation coating on electrical wires. When the protective myelin is damaged and nerve fiber is exposed, the messages that travel along that nerve may be slowed or blocked. The nerve may also become damaged itself.
It isn’t clear why MS develops in some people and not others. A combination of genetics and environmental factors appears to be responsible.
PATHOPHYSIOLOGY:
1 .In patients with MS the immune response triggers activation of immune cells that cross the blood brain barries. these cells activates the autoantigens, producing’‘ AUTO- IMMUNE CYTOTOXIC EFFECTS’‘ within the central nervous system. demylination slows neural transmission and cause nerve to fatigue rapidly.
2.demylinated areas eventually become filled with fibrous astrocytes and undergo a process called ”GLIOSIS”.
DISEASE COURSE:
Most people with MS have a relapsing-remitting disease course. They experience periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These relapses are followed by quiet periods of disease remission that can last months or even years.
Small increases in body temperature can temporarily worsen signs and symptoms of MS, but these aren’t considered disease relapses.
About 60 to 70 percent of people with relapsing-remitting MS eventually develop a steady progression of symptoms, with or without periods of remission, known as secondary-progressive MS.
The worsening of symptoms usually includes problems with mobility and gait. The rate of disease progression varies greatly among people with secondary-progressive MS.
Some people with MS experience a gradual onset and steady progression of signs and symptoms without any relapses. This is known as primary-progressive MS.
TYPES OF MS
There are four types of MS:
1.Clinically isolated syndrome (CIS): This is a single, first episode, with symptoms lasting at least 24 hours.
2.Relapse-remitting MS (RRMS): This is the most common form, affecting around 85 percent of people with MS and involving attacks of new or increasing symptoms.
3.Primary progressive MS (PPMS): Symptoms worsen progressively, without early relapses or remissions. Around 15 percent of cases are PPMS.
4.Secondary progressive MS (SPMS): After initial episodes or relapse and remission, the disease progresses steadily.
RISK FACTORS:
These factors may increase your risk of developing multiple sclerosis:
Age. MS can occur at any age, but most commonly affects people between the ages of 15 and 60.
Sex. Women are about twice as likely as men are to develop MS.
Family history. If one of your parents or siblings has had MS, you are at higher risk of developing the disease.
Certain infections. A variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes infectious mononucleosis.
Race. White people, particularly those of Northern European descent, are at highest risk of developing MS. People of Asian, African or Native American descent have the lowest risk.
Climate. MS is far more common in countries with temperate climates, including Canada, the northern United States, New Zealand, southeastern Australia and Europe.
Certain autoimmune diseases. You have a slightly higher risk of developing MS if you have thyroid disease, type 1 diabetes or inflammatory bowel disease.
Smoking. Smokers who experience an initial event of symptoms that may signal MS are more likely than nonsmokers to develop a second event that confirms relapsing-remitting MS.
SYMPTOMS:
 


Symptoms of MS vary considerably, depending on the location of the lesion.Early symptoms typically include minor visual disturbance, and paresthesias, progressing to numbness, weakness and fatigability.
Multiple sclerosis signs and symptoms may differ greatly from person to person and over the course of the disease depending on the location of affected nerve fibers.
They may include:
1.SENSORY- Altered sensations are far more common and can including paresthesias, numbness of face , body and extremities.
Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or the legs and trunk
2.VISION -Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
Prolonged double vision
”MARCUS GUNN PUPIL”
Scotoma
Optic neuritis
Nystagmus
INO-interneuclear ophthelmoplegia , produce lateral gaze palsy
Tingling or pain in parts of your body
Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign)
Tremor, lack of coordination or unsteady gait
Slurred speech
Fatigue
Dizziness
Headache.
trigeminal neuralgia
Paroxysmal limb pain
hyperpathia
chronic neuropathic pain
Musculoskeletal pain
Problems with bowel and bladder function
3.PAIN – Approximately 80% patients with MS experience pain.almost half experience pain.Anxiety and fear woersen the pain symptoms.
4.MOTOR-
Weakness
Spasticity
5.FATIGUE.
6.COORDINATION AND BALANCE-Ataxia
7.GAIT AND MOBILITY-Ataxic gait
8.SPEECH AND SWALLOWING-Dysarthria
9. COGNITIVE-In MS short term memory , attension and concentration ,information processing, executive functions, visuospatial functions affected.
10.DEPRESSION
11.EMOTIONAL-Pseudobulbar affect.
12.SEXUAL DYSFUNCTION.
13.UTTHOF’S SYMPTOMS
DIAGNOSIS:
Tests for MS include:
1.Neurological examination
2.MRI scanning
3.Evoked potentials
4.Lumbar puncture
5.Other tests
The neurologist will use specific criteria to diagnose MS, known as the McDonald criteria.
1-Neurological examination
Your neurologist will ask you lots of questions about your ‘history’, meaning your health problems and symptoms, now and in the past. This helps the neurologist get a better picture of you and can help identify any other problems that may explain current symptoms.
A physical examination checks for changes or weaknesses in your eye movements, leg or hand coordination, balance, sensation, speech or reflexes. Whilst a neurologist may strongly suspect MS at this stage, a diagnosis won’t be given until other test results confirm MS.
2-Magnetic Resonance Imaging (MRI)
 

DIAGNOSIS OF MS- ”BRIGHT SPOT”

An MRI scanner uses a strong magnetic field to create a detailed image of inside your brain and spinal cord. It is very accurate and can pinpoint the exact location and size of any inflammation, damage or scarring (lesions). MRI scans confirm a diagnosis in over 90 per cent of people with MS.
To get the image of a person’s brain and spinal cord they must lie down and enter a small tunnel in the centre of the MRI scanner. The process can take between 10 and 60 minutes and is painless, though some people can feel a little claustrophobic in the scanner. The Newcastle Upon Tyne Hospitals NHS Foundation Trust has produced a video which explains what to expect when you have an MRI
3-Evoked potentials tests
This painless test involves measuring the time it takes for your brain to receive messages from your eyes, ears and skin. Small electrodes are placed on your head. These check how your brain reacts to sounds you hear in headphones, patterns you see on a screen or sensations you feel on your skin. Messages to and from your brain will be slower if MS has damaged the myelin covering around some of your nerves.
4-Lumbar puncture
This is sometimes called a spinal tap. A needle is inserted in your lower back, into the space around your spinal cord. You have a local anaesthetic for this. A small sample of the fluid around your spinal cord is taken and tested for signs of MS. People with MS often have antibodies in this fluid. Antibodies show your immune system is active in your brain and spinal cord. This is something that isn’t seen in people who don’t have MS.
People often get headaches following a lumbar puncture. The medical staff should advise you on how to manage this. Lumbar punctures are used less now that MRI scans are more common.
5-Other tests
To rule out conditions that are similar to MS, other tests may also be done. These may include blood tests to reveal certain antibodies, and inner ear tests to check your balance.
The McDonald Criteria is distinguished by incorporating clinical evaluation with magnetic resonance imaging (MRI) scans in establishing MS. But, like an earlier approach, it too requires:
Evidence of damage to the central nervous system (CNS; the brain, spinal cord and optic nerves) that is “disseminated in time,” meaning damage that occurs on different dates;
Evidence of damage “disseminated in space,” or found on two or more parts of the CNS.
TREATMENT:
There is no cure for multiple sclerosis. Treatment typically focuses on speeding recovery from attacks, slowing the progression of the disease and managing MS symptoms. Some people have such mild symptoms that no treatment is necessary.
Treatments for MS attacks
1-Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are prescribed to reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, mood swings and fluid retention.
2-Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. Plasma exchange may be used if your symptoms are new, severe and haven’t responded to steroids.
Symptom: Sensory symptoms (parasthesias)
Numbness, tingling, pins and needles
Treatment
No treatment required unless interfering with function; medication if necessary; referral to PT/OT if necessary
Symptom: Primary pain
*Central neuropathic pain – continuous (dysesthesias)
Medications:
Tricyclic antidepressant medications (amitriptyline, nortriptyline, desipramine); antiepileptic medications (pregabalin, gabapentin)
Other:
topical appliation of capsaic acid cream;behavioral self-management (mindfulness,meditation)
hypnosis,cognitive behavior therapy
*Central neuropathic pain – intermittent (trigeminal neuralgia)
Treatment
Medications
First-line: carbamazepine
Alternate options: oxcarbazepine, lamotrigine, baclofen
Additional options with lower levels of evidence: phenytoin, clonazepam, valproic acid, intranasal lidocaine
Surgery:
radiofrequency rhizotomy; radiofrequency electrocoagulation; glycerol rhizotomy
Psychosocial Implications for each pain symptom
Clumsiness, balance problems, and loss of dexterity from sensory loss
Discomfort that is sometimes excruciating
Increase in fatigue caused by medications and interrupted sleep
NOTE: Many people are still told by doctors that MS does not cause pain, yet pain is a common symptom of MS that is distracting, depressing, and debilitating.
*Symptom: Secondary pain (musculoskeletal)
Resulting from poor posture/balance in ambulatory individuals or improper use/fitting of wheelchair
Treatment
Interventions:Referral to PT: gait and balance training; assessment of all seating (home, automobile, work, and wheelchair/scooter);
Medications:analgesics
PHYSICAL THERAPY MANAGEMENT:
Physical therapy can play an essential role in keeping a patient with MS active and functional within the community.While there is no cure for multiple sclerosis, exercise appears to be beneficial at multiple levels and it may have an important role to play in delaying negative symptoms of the disease. Exercises should be chosen according to one’s strengths and weaknesses . It is suggested that exercise therapy does have efficacy in MS.It is to state the best ’dose’ (intensity, frequency and duration) of treatment to achieve optimal beneficial effects of exercise therapy in terms of activities and participation for patients suffering from MS. There was no evidence describing harmful effects of exercise therapy for MS patients. .Exercise is consider as a safe effective means of rehabilitation.
The PT assessment should focus on posture, movement and function, carefully considering how a patient’s performance may be limited by fatigue, pain or other factors. Analyzing these results together with the proper opinion and interest of the person with MS will enable the physiotherapist to set up an individualized program. This program needs to be set up so that it can easily be performed at home.Education is also important to assist patients in managing their programs as independently as possible. A multidisciplinary treatment for MS patients may lead to positive effects.

During EARLY STAGEof MS patients may present with minimal impairments. At this time, the PT can focus on educating the patient and family members or caregivers on disease progression and compensatory strategies to conserve energy. Physiotherapy emphasize movement outdoors especially in sunlight in order to avail the direct benefits of sunlight in MS.The recent study suggests life time sun exposure appears to reduce the risk of Multiple Sclerosis regardless of race/ethnicity. Study indicates the protective effect of sun exposure in MS is most likely mediated throgh immunomodulatory mechanisms.

Due to the progressive nature of the disease, those in the MODERATE STAGE might notice impairments at varying degrees and activities of daily living (ADL) may require assistance. At this middle stage,therapy should focus more on improving or maintaining motor functions through strength, endurance, flexibility, balance, respiratory training and assistive device training as well as suggesting environment modifications to the home or assessing mobility aids required to move about in the community to sustain quality of life. Informing the carers about correct postures will prevent further complications. A close collaboration between professional community carers and non-professional caregivers at home is a key factor for the successful management of the rehabilitation.
Advanced stages of MS often present with multiple impairments at incresing severity compared to earlier stages. The primary goals of the PT in late stages is to maximize independence through postural and ADL training, respiratory function, safety and prevention strategies for contracture development or pressure wounds, equipment suggestions, and proper transfer techniques.

PHYSIOTHERAPY TREATMENT : active/passive/active assisted exercises(carried with partner or with help of equipment like elastic bands);techniques like Bobath,Vojtas,Proprioceptive Neuromuscular Techniques; carried out regularly and with sufficient intensity, have evidence of improvement in patients with MS.
Use of therapeutic corticosteriods and inactivity due to fatigue and weakness,may lead to osteoporosis and pathological fractures.Weight bearing exercises can slow down the loss of bone and muscle mass. Resistance training program is recommended for maintaining bone and muscle mass,According to Döring et al. aerobic training seems to have a positive effect on fatigue.Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients,affected with mild or moderate disability.

BALANCE EXERCISE can improve balance.Poor postural control increases risk of falls.MS patients have increased sway in quiet stance,delayed postural perturbations and reduced ability to move towards limits of stability.These impairments are likely causes of falls.Reduced gait speed,decreased stride length, cadence,and joint movement are observed in most studies of gait in MS. The therapist must identify several factors that may be amenable to intervention to prevent falls in people with MS.Comprehensive exercise interventions can facilitate improvements in balance impairments.Functional balance exercises can extensitively impact balance, physical activity and quality of life in adults with multiple sclerosis.

MOTOR IMAGERY is increasingly used in neuro-rehabilitation in-order to facilitate motor performance.Motor imagery and rhythmic auditory stimulation can be used for walking rehabilitation in MS patients..Randomized control trial studying the effects of motor imagery showed significant improvement in walking speed,walking distance,perception and quality of living.

HIPPOTHERAPY has a positive effect on balance of persons with multiple sclerosis and has an added benefit of enhancing quality of life. A systematic review and meta-analysis of therapeutic effect of Horseback riding intervention shows positive physical and emotional effects of horse riding in individuals with neuromotor development and physical disabilities. Therapeutic horseback riding improved balance and gait of ambulatory patients with MS. Hippotherapy helps the rider,by providing effective sensory stimulation and rhythmic anterior and posterior swinging motion.It encourages the rider to achieve proper posture and balance.

AQUATIC EXERCISE program could have a positive effect for persons with progressive multiple sclerosis. Interventions that promote general health, improve energy levels and mental health, and faster social interaction in the presence of physical disability are beneficial for individuals with progressive multiple sclerosis. Because of reduced impact of gravity, aquatic training allows patients with even severe paresis of the lower extremities to perform standing and moving exercises.
In MS patients, beneficial effects of regular physical activity and exercise on mood and quality of life have been repeatedly reported.Valid data on the effect on cognitive function are hardly available.


Cognitive Behavioral Therapy (CBT) ] :

CBT have amoderately positive effect on fatigue in MS. However,this effect declines after cessation of treatment. Since the short-term effect of CBT on MS-related fatigue is positive, there is a need for more research, to develop interventions that, maintain these short-term effects in the long term.To have good results, it is best that the patient should be referred to a CBT specialist. CBT can also be an effective intervention for reducing moderate depression, over a short-term, in MS patients,which may also improve patient quality of life.
Throughout all stages of MS,PT can offer psychological support to the patient and family/caregiver.
PT Interventions for Common Symptoms of Patients with MS:
PAIN- Patients with MS often experience pain directly from the disease, secondary to medication or other symptoms, or from something completely separate. PT helps relieve pain through exercise, stretching, massage, ultrasound, postural training, or hydrotherapy.

SENSORY DEFICITS-Tapping and verbal cues during exercise and resistance training can help improve proprioception losses. Vision issues, such as blurred or double vision, often occur in patients with MS. PT can offer education on how to be safe at home and offer strategies to improve balance and coordination in dimly lit settings. PT treatment interventions for decreased sensation to light touch include education on awareness, protection, and personal care to desensitized body parts. Pressure-relieving devices are a primary prevention strategy along with proper transfer techniques and daily skin inspections for maintaining skin integrity.

FATIGUE– One of the most debilitating symptoms of MS is experienced by an overwhelming majority of patients: fatigue. PT strategies to help patients combat feelings of excessive tiredness include aerobic exercise, energy conservation, and activity pacing. Aerobic exercise activities is closely monitored by a PT to ensure a patient does not overheat, but is able to work on increasing their endurance capacity which will help them be more functional throughout the day. PT’s can also teach energy conservation strategies and activity pacing to help someone sustain their daily activities by minimizing fatigue.

SPASTICITY- The physical and functional limitations spasticity leads to include include a variety of impariments which can present as contractures, postural deformities, decubitus ulcers, and more. PT interventions range from cryotherapy and hydrotherapy to therapeutic exercise, stretching, range of motion activities, postural training, and electrical stimulation. A combination of therapeutic interventions is often the route taken.
Balance, Coordination, & Postural Deficits. Ataxia, postural instability, muscle spasms, and generalized muscle weakness al contribute to balance and coordination deficits. PT techniques to address these issues include postural exercise, core strengthening, rhythmic stabilization, static/dynamic balance training, aquatic therapy, proprioceptive loading, and resistance training.
Mobility Issues. Weakness, particularly in the lower extremity, balance deficits, fatigue, posture, contractures, sensation deficits, heat intolerance, among other deficits, can impede an individual’s ability to be mobile. In combination of the treatment previously described, PT’s work to help patient’s overcome their mobility limitations through locomotor and functional training.
Locomotor training focuses on increasing thigh and hip strength along with posture and balance training through walking activities. Orthotics and assistive devices are added as necessary. Functional training involves bed mobility, transfers, and developing strategies with the patient on how to be able to safely navigate around the home and out in the community.
 
DIETARY MODIFICATION:
Diet plays a huge role in health.Research suggests adding inflammatory fighting foods to diet can help in chronic inflammation.

Number of factors may be thought to play role in triggering inflammation- gluten and dairy products,vitamin D deficiency.Diet rich in whole fresh foods and eliminating dairy,sugar,high salt and processed food is highly recommended.

Many researchers are exploring dietary intervention approaches in MS to improve lifestyle. Probiotics may improve the health of people with MS by reducing disability and improving inflammatory and metabolic parameters according to an Iranian study.

Vitamin D supplementation helps prevention and treatment of MS. Various research studies are studying the effectiveness of vitamin D therapy in MS.

Fish oil supplementation given together with vitamins and dietary advice can improve clinical outcome in patients with newly diagnosed MS.More research is required to assess the effectiveness of dietary interventions of omega 3 in MS and it’s interaction with medications used for treating MS.

Dysfunction of mitochondria is thought to play an important role in mechanism of progression of demyelinating disorders.Observations in animal and histopathological studies,suggest that,dysfunctional mitochondria are important contributors to damage and loss of both axons and neurons.The relationship between mitochondrial dysfunction and neurodegeneration in MS is explored.The Ketogenic diet has the potential to treat the neurodegenerative component of progressive MS,though more research is required in this field.

 

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