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By: C. Nerusul, M.A., M.D.

Co-Director, University of South Carolina School of Medicine Greenville

Basic safety strategies allergy medicine by kirkland order loratadine with american express, including instruction in appropriate footwear and the removal of home environmental barriers allergy levels nj buy discount loratadine 10 mg on-line, should not be overlooked during gait instruction yorkie allergy treatment discount loratadine 10mg mastercard. Gait training should include practice on a variety of floor surfaces and with daily tasks such as reaching, turning, and carrying objects. Balance declines as the patient tries to focus on several tasks simultaneously; therefore, multitasking capabilities should also be assessed within the gait training session (5). Music therapy techniques, including rhythmic auditory stimulation, may also be effective in facilitating and optimizing ambulation (6). PREVENTING FALLS Balance changes are frequently seen in the moderate stages of PD. Injury related to balance loss and falling is directly related to increased mortality rates, rising health care costs, and reduced quality of life (7–9). Repeated falls can also contribute to chronic pain, heightened anxiety, and/or decreased activity levels. Unfortunately, medications currently used in PD symptom control prove less efficacious in controlling symptoms of postural instability than other primary symptoms. A multidisciplinary approach is the most effective for assessing the many reasons falls may occur and to provide appropriate interventions that can improve patient safety. Loss of flexibility, postural changes, reduced muscle strength, joint pain, postural hypotension, dizziness, changes in vision, and other medical conditions may all contribute to loss of balance and falls. Exercise programs, medications, rehabilitation therapies, com- plementary therapies such as tai chi, and other treatments should all be considered within a comprehensive fall-prevention program. Compensation strategies may be helpful for patients experiencing retropulsion or freezing. Thorough assessments of the home environment and the patient’s performance of daily living activities are also important in the fall- prevention plan. Home modifications and use of appropriate adaptive equipment can be best identified after evaluation and treatment by an Copyright 2003 by Marcel Dekker, Inc. Occupational therapy sessions may include practi- cing safety strategies in the kitchen, bathroom, and other areas in the home environment where falls are most likely to occur. Reduced cognitive skills may also impact patient safety and contribute to falls. Cognitive screening and assessment is recommended in order to tailor patient instruction and safety strategies to an appropriate level. Family or other caregivers may need to be involved in the education process to ensure that the recommendations are understood and utilized. An emergency plan should be devised for all patients who experience frequent falling. Caregivers should also be instructed in safe methods for helping patients get up from the ground after a fall, as they frequently provide primary assistance in these situations. CONTROLLING PAIN Complaints of pain are not uncommon in patients with PD and may be related to excessive rigidity, postural changes, inability to perform independent position change, dystonia, injuries sustained from falling, or other medical conditions. A complete assessment is needed to determine the source, frequency and intensity of pain. Instruction in recognizing pain behaviors (symptoms) may be required for caregivers as patients experien- cing significant cognitive changes may exhibit agitation, wandering, anxiety, or increased confusion as pain-related behaviors. While some patients require the use of prescribed medications or over- the-counter analgesics for pain control, there are a variety of other nonpharmacological interventions that may offer relief or reduce discom- fort. Many patients have reported improvements as a result of complemen- tary therapies, such as massage and acupuncture, though further research is required to assess the benefits of these treatments (13,14). Use of superficial heat, cold, or physical therapy modalities may also be effective in pain management. Instruction in proper positioning, seating systems, and posture principles is recommended to decrease discomfort resulting from improper postural alignment. Relaxation strategies and other forms of complementary medicine may also prove beneficial as part of a holistic approach to pain management. SPEECH/VOICE/COMMUNICATION An estimated 70–100% of people with PD experience changes in their ability to communicate effectively. Rarely, these changes are a first or very early Copyright 2003 by Marcel Dekker, Inc.

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If this difference is more than 2 cm allergy testing mckinney purchase genuine loratadine, a leg equal- ization procedure may be needed allergy symptoms cold symptoms buy loratadine 10 mg lowest price. Another area of force effects on bone is the prevention of infantile bone shape maturation into adult-shaped bone configurations allergy zinc oxide buy discount loratadine 10mg on-line. This bone matura- tion occurs through the influence of the muscle action, causing remodeling effects on the growing bone through Pauwel’s law. Although unclear, there are suggestions that in very young children, under age 5 years, abnormal forces can cause the bones to develop abnormal torsion. However, there is no evidence to suggest that cor- recting these forces can cause correction of infantile torsional deformities. Joint Mechanics The joints require motion for normal development during childhood. The ligament and joint capsules, which provide stability to the joints, have in- terstitial growth throughout their entire length. For example, hamstring contractures, which prevent full knee extension, only very slowly allow the development of a fixed knee contracture; however, by adolescence and after puberty, this process occurs much faster. Also, these flexion contractures are much more amenable to stretching out in young children. Gait 267 joints are very sensitive to abnormal joint reaction forces. These abnormal forces may cause substantial abnormalities in the development of the joints and, in some cases, lead to joint dislocation. Joint dislocation is a prominent problem at the hip and is a lesser problem in the other joints. The specific joint problems are addressed in the sections devoted to those joints. Children with spastic CP have a tendency to have short muscles, which translates into decreased joint range of motion. The decreased range of motion subsequently leads to fixed joint contractures, even when there are no structural joint deformities. Joint Motor Mechanics Often, the mechanics of a single joint are based on the specifics of the in- volved joint; however, the only active way to move a joint is by the muscle attached to that joint. These muscle–tendon units attach in the bone and work by creating a moment through a moment arm. An excellent example of this is the knee, where the hamstring muscles attach to the tibia by being posterior to the joint’s center of motion. A moment arm is created and a ten- sion force is applied to create a moment that may cause motion. The mo- ment created is called the strength of the hamstring in clinical scenarios (Figure 7. The amount of strength, or joint moment, that is created in- cludes the percent of the muscle’s contraction, the cross-sectional area of the muscle, the position of the muscle fiber length on the Blix curve, the direc- tion and velocity of the change in the muscle fiber, and the moment arm of the muscle. Another variable is muscle fiber configuration with the degree of pennation of the fibers to the line of action of the muscle. In the hamstring muscles, this variable is of no significance because of a very low pennation angle. Some of these variables can be actively altered, and others are struc- tural variables. The variables that can be actively altered are the percent of muscle firing, the moment arm length, the position on the Blix curve, and the velocity of length change. The variables with the structural characteristics that can change over time are the diameter of the muscle through muscle Figure 7. To understand the force-gener- ating ability of the muscle, it is very impor- tant to understand the concept of stable ver- sus changing moment arms. An example is the quadriceps, which has a relatively con- sistent moment arm length independent of the joint position. The hamstrings, on the other hand, have a moment arm that is very dependent on joint position with the moment arm being very short at knee extension and very long at full knee flexion. Thus, the im- pact of a hamstring contracture very quickly becomes more significant as the degree of knee flexion increases. Single-Joint Muscles From the perspective of the central program generator, muscle activation that crosses a single joint requires consideration of the impact of at least three variables, including the percent of motor units to activate, the current length of the fiber that will define the moment arm and the Blix curve location, and the velocity of muscle fiber shortening. The system also has to consider its longer-term organization caused by structural alterations.

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