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By T. Bufford. Concordia College, Saint Paul Minnesota. 2018.

Discussion Recent guidelines have advocated inclusion of exercise in treatment of osteoarthritis of the knee6 order 20mg erectafil fast delivery. However cheap erectafil 20mg with mastercard, past reports of exercise as an etiologic factor in osteoarthritis of weight bearing joints3–5 may have reduced implementation among physicians cheap 20mg erectafil fast delivery. Further, lack of standard protocols, outcome measures and maintenance strategies may have also contributed to poor exercise implementation. A large, randomised, multicentre study by Ettinger et al10 showed that older patients who engage in either resistance or aerobic exercise achieved better pain control and functional outcomes at 18 months compared to patients who only attended an educational programme. However, patients in that study continued to take various arthritis medications while in the study, and there was no attempt to control for the class of medication. This may make decisions regarding inclusion of exercise difficult for practitioners. We recently reported the effect of a brief home-based, progressive resistance exercise programme for patients with unilateral osteoarthritis of the knee. Compliance with the program at two months was over 96%, no adverse events were reported and pain and physical functioning measured using a self paced walking activity significantly increased from baseline. Despite these positive findings, no dose- response relationship between aerobic or resistance exercise and osteoarthritis has been established. In addition, issues of long-term adherence and efficacy for exercise in the treatment of osteoarthritis are still unresolved. One other application of exercise therapy is the interaction with intra-articular hyaluronate. Petrella et al28 have recently completed a randomised trial of home-based exercise therapy in addition to three intra-articular hyaluronate (10mg/ml) injections and found this combination improved “activity-related” pain more than when exercise was combined with NSAID. These and other future well designed studies combining exercise with neutriceutical products including glucosamine sulfate will further our ability to ensure comprehensive treatment of patients with osteoarthritis of the knee. Key findings Seventeen randomised controlled trials of the effectiveness of exercise therapy in OA of the knee were assessed. It can be concluded, 189 Evidence-based Sports Medicine that exercise is effective in patients with OA of the knee. Available evidence indicates beneficial effects on all studied outcome parameters: pain, self-reported disability, observed disability in walking, self-selected walking and stepping speed and patient global assessment of effect. Summary: Patient type • Mild/moderate osteoarthritis • Contemplating physical activity (contemplative stage of readiness) • Impaired function, pain and stiffness but not severe • Associated co-morbidities that would benefit from exercise (i. Since pain and disability are the main symptoms in patients with OA, exercise therapy seems indicated. It is notable that conclusions are based on a small number of studies. Only five randomised controlled trials had sufficient power. In addition, a number of different instruments have been used for the assessment of specific outcome measures. The recently published list of candidate instruments provided by Bellamy29 can be seen as a first step in the accomplishment of standardisation of assessment. Summary: Exercise type • Aerobic ± resistance exercise • FIT principles (frequency – three times or more/week; intensity – mild/ moderate such as walking or weight-bearing resistance; training duration – at least eight weeks for results but should be encouraged as a “life-time” behavioural change) • Use standard outcome measures • Counsel in office but utilise allied health staff such as physiotherapists and kinesiologists as needed Minimal information is available on long-term effects of exercise therapy on OA of the knee. This lack of information concerning 190 Exercise and osteoarthritis of the knee long-term effects is a remarkable omission, since the clinical impression is that the effects disappear over time. There is insufficient evidence to draw conclusions on the optimal content of an exercise therapy intervention. The three trials with sufficient power showed beneficial effects of different types of exercise therapy: aerobic exercises, resistance exercises, or mixtures of several types of exercise therapy. Blinding of providers and patients was absent in all studies. As a consequence of the nature of exercise therapy, blinding of both providers and patients is not possible. However, in only half of the trial reports, was blinding outcome assessment explicitly reported. Another potential source of bias was the frequently occurring absence of information on adherence to the intervention.

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It depends on the duration of illness purchase erectafil 20 mg otc, the severity of motor signs generic 20mg erectafil visa, the presence of dementia discount 20 mg erectafil with visa, sleep disturbances, and possibly depression. For instance, in the early stages of PD, levodopa treatment can improve executive functions normally regulated by the prefrontal cortex. However, this improvement is incomplete and task specific. As the disease advances, patients with a stable clinical response to levodopa fail to exhibit a notable improvement in vigilance and executive function, and patients who exhibit motor fluctuations tend to exhibit transient deterioration in these functions (8). Finally, the effect of these drugs in patients with PD and dementia is likely to be more notable and complex. Other negative iatrogenic influences on cognitive function in PD include the use of drugs like anticholinergics and amantadine, often used to treat tremor and dyskinesias, and psychotropics used to treat sleep disturbances and affective symptoms. These drugs can negatively affect different aspects of memory and attention, particularly in already demented patients. Like these drug effects, many intercurrent medical illnesses and Copyright 2003 by Marcel Dekker, Inc. DEMENTIA: THE PD/AD/LBD OVERLAP SYNDROMES Dementia occurs in approximately 20–30% of PD patients. It represents a major risk factor for the development of many behavioral disturbances, including psychotic symptoms. Dementia appears to be associated with the combined effect of age and the severity of extrapyramidal symptoms (9). Pathologically, up to 40% of autopsy cases with a primary diagnosis of PD have comorbid findings consistent with senile dementia of the Alzheimer’s type (SDAT) (10,11). Conversely, up to 30–40% of patients with SDAT have comorbid parkinsonian features and harbor Lewy body pathology that extends beyond the dopamine neurons in the brainstem to involve the frontal cortex, hippocampus, amygdala, and basal forebrain (12). These defects conspire with aminergic deficits to increase disability and the incidence of psychotropic-induced side effects. They also contribute to the progression of parkinsonian motor symptoms by narrowing the therapeutic window of all antiparkinsonian agents. Lewy body dementia (LBD) is an increasingly recognized syndrome in which dementia is accompanied by spontaneous parkinsonian features, depressive features, and apathy (5,13). Unlike SDAT, this form of dementia exhibits significant fluctuations in arousal ranging from ‘‘narcoleptic-like’’ sleep attacks to delirium in advanced cases. Sleep is often disrupted by sleep fragmentation due to rapid eye movement (REM)–related behavioral disorders. Patients have spontaneous features of PD and are extremely sensitive to drug-induced parkinsonism. Although parkinsonism associated with LBD can be indistinguishable from idiopathic PD, several clinical features tend to help differentiate the two. The course of LBD is more rapid than that of idiopathic PD (5–7 vs. Compared to SDAT patients, LBD patients have spontaneous and drug-induced visual hallucinations early in the course of the illness and frequently exhibit fixed delusions. Although memory is clearly impaired in both conditions, visuospatial and frontal neuropsycho- logical functions are more prominently affected in LBD than in SDAT. BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA IN PARKINSONIAN SYNDROMES Disturbances of behavior, mood, and perception are common in patients with dementia. These so-called behavioral psychological symptoms of Copyright 2003 by Marcel Dekker, Inc. Clinically they include symptoms prominent in Alzheimer’s disease including apathy, depression, delusional jealousy, paranoia, auditory hallucinations, screaming, and agitation (14). Before DSM-IV helped codify these symptoms as a defined clinical entity, they were thought to be secondary to the distress associated with the dementing process (15). The mechanisms mediating this heterogeneous group of symptoms are poorly understood, but in Alzheimer’s disease and LBD, they appear to be linked to the accumulating cholinergic pathology (16). Clinical and research assessment methods are now being developed to assess these symptoms (17).

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Furthermore discount erectafil 20 mg line, both human and primate studies have shown that the discharge rate of the parkinsonian internal pallidal neurons is sustained at a high rate (80 Hz) (45 discount erectafil 20 mg on line,87) discount erectafil 20mg online. The internal pallidal output via the ansa lenticularis and lenticular fasciculus terminates in the ventral anterior and lateral thalamic nuclei (88) and uses the inhibitory neurotransmitter g- aminobutyric acid. On the basis of these observations, it is hypothesized that medial pallidotomy would be most effective if the lesion were large enough to include the sensorimotor arm and leg areas and include the neurons that give rise to the ansa lenticularis and lenticular fasciculus (Fig. Such a lesion would interrupt the overactive inhibitory ‘‘noisy’’ outflow of clinically relevant sensorimotor regions of the internal pallidum, thereby disinhibiting the motor thalamus (12). Direct evidence for this is still lacking, but in a retrospective analysis it was documented that lesions were more effective when located within the internal pallidum, and the efficacy was reduced when the lesion encroached on the external pallidum (61). Although now it is generally accepted that the lesion should be in the posterior and ventral pallidum, whether lateral pallidum should be included in the lesion is still controversial. This is likely to remain so until a large data set of clinicopathological cases is gathered worldwide. There has been recent quantitative evidence supporting the rationale for use of microelectrode recording in guiding lesion placement in pallidotomy. In only 45% of the patients did the electrophysiological and anatomical targets overlap. Similar posterior and lateral misregistration of the actual target from the electrophysiological target has been described by Tsao et al. These findings imply that surgery based solely on anatomical landmarks may miss the physiological target, even when the lesion is in the correct nucleus. There remain concerns that the increased number of needle tracts necessary for intraoperative microelectrode recordings increase the overall length of the procedure without clear added benefit and also may increase the overall risk of surgical morbidity from hemorrhage or by increasing the overall lesion volume (the summation of multiple microlesions). FIGURE 3 Drawing of the coronal and horizontal sections through the human basal ganglia showing the output pathways from the pallidum. Put ¼ putamen, GPe ¼ external pallidum, GPi ¼ internal pallidum, H, H1, H2 ¼ fields of Forel, IC ¼ internal capsule, ZI ¼ zona incerta. Conversely, there are no studies demonstrating additional morbidity from intraoperative recordings, and so the choice of method of target identification is still largely determined by individual preferences, available equipment, and local expertise. Another group has specifically targeted only the most ventral region of the posterior pallidum and attempted to produce pallidotomy and ansotomy (62). They have performed 31 pallidotomy/ansotomy operations just 0. In this series, they described a 63% reduction in ‘‘off’’ parkinsonism and the cessation of contralateral dyskinesia in 21 of 23 patients who had disabling dyskinesias preoperatively. These reports, however, require further validation before general acceptance. It is clear from these variable lesion locations that the optimal target for unilateral pallidotomy remains a matter of controversy and that neither the ventroposterolateral pallidotomy of Laitinen (73), nor pallidoansotomy of Iacono (62), nor the more extensive internal pallidotomy (46,69,74) can fully explain the clinical findings of alleviation in parkinsonism and levodopa- induced dyskinesia concurrently. BILATERAL PALLIDOTOMY Laitinen (73) and Iacono et al. There are, however, concerns regarding permanent cognitive and bulbar side effects of bilateral pallidotomy, which have been confirmed in a study of 4 patients in whom contemparous bilateral pallidotomy was performed (91). Despite a 40% improvement in motor UPDRS scores and resolution of dyskinesias, one patient developed dysarthria, dysphagia, and eyelid opening apraxia, another developed abulia, and a third developed mental automatisms. An open-label trial of bilateral simultaneous pallidotomy compared with unilateral pallidotomy plus DBS had to be halted early as all three patients with bilateral lesions developed deterioration in speech, swallowing, salivation, depression, apathy, freezing, and falling (92). In another recent series, staged bilateral pallidotomy was associated with a deficit in speech in four patients, one patient had a decline in memory, and there were three cases of infarction Copyright 2003 by Marcel Dekker, Inc. Further, a reduced response to levodopa has been documented in a small number of patients undergoing bilateral staged pallidotomy (93). These results are in contrast to the milder side effects reported in one series of 14 patients who underwent staged bilateral pallidotomy, in whom no overall effect on speech and cognitive function was detected 6 months postoperatively, but in whom five had mild hypophonia, two had transient confusion, two had deterioration of gait, and one had deterioration of a preexisting dysarthria postoperatively (94). A series of 53 bilaterally operated patients was presented with a follow-up of 17 patients for 12 months (95).

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If there is a severe knee flexion contracture of more than 30° buy cheap erectafil 20 mg line, this too gets worse buy erectafil 20mg low cost. As the knee flexion contracture goes over 30° to 40° order erectafil 20 mg, standing rapidly becomes more difficult. Correcting the knee flexion contracture is a difficult decision because the contracture may make standing more difficult, but if individu- als can only stand and spend most of their time sitting in their wheelchairs, correction of knee flexion contracture is not likely to be successful, as the knee will just recontract. Therefore, correction of significant knee flexion contractures should be reserved for individuals who do some community ambulation, or who surgeons believe have the ability to do some community ambulation. Correction of torsional malalignment, such as tibial torsion or femoral anteversion, is indicated if the correction will improve an individ- ual’s ability to sit. Often, the benefit from treatment for sitting takes prece- dence over problems of ambulation unless it is a very severe torsional mal- alignment. The problems of stiff leg gait with rectus spasticity are often much less of a problem in this group of individuals than individuals who are full community ambulators with faster walking speed. Also, the quadriplegic pattern involved individuals have a high tendency for recurrence of knee stiffness in swing phase, sometimes even recruiting the vastus muscles to keep the knees stiff during swing phase if the rectus is removed. It seems these in- dividuals with limited ambulatory ability need the knee stiffness to be able to provide stability and control of their standing. One of the problems that occurs with these quadriplegic patterns is care- takers who insist the children used to walk everywhere but now they can no longer walk, except in the house. Parents and caretakers tend to forget how these children walked 3 years prior, and most often, the video record will show that there is little difference. If there is a real difference and it is due to progressive musculoskeletal problems, these deformities must be corrected. If the deterioration cannot be explained by musculoskeletal changes, a full neurologic workup is indicated to determine if there is any pathology not previously diagnosed. Forgetting how these children walked is a very impor- tant reason for having video records of ambulation, even in children with limited walking ability. Video records are an important and relatively cheap tool to assess change in ambulatory ability for children with some ambula- tory ability during development. The outcome of treating gait problems in children with limited ambula- tory ability is the same as it is for children with more function. These chil- dren should not lose substantial ambulatory ability that they gained. If they do lose ambulatory ability, the cause should be found. Movement Disordered Gait Athetosis Gait problems in individuals with movement disorders can be especially dif- ficult to address. Individuals with athetosis often have spasticity associated with the athetosis, which works as a shock absorber on the pathologic move- ment. Individuals with athetosis may develop significant deformities that make ambulation more difficult, and there is merit in addressing these prob- lems. Therapy to improve athetoid gait is limited but sometimes adding re- sistance through the use of ankle weights or a weighted vest can be helpful. Procedures that will provide stability have the most reliable outcome. For example, correction of planovalgus feet with a fusion is a reliable procedure. There is no benefit of trying muscle balancing or joint preservation treatment in the face of athetosis. Although the post- operative course may be difficult, the outcome of the surgical treatment of fixed knee flexion contractures is usually good. Often, these patients have very high cognitive function and are very hesitant to undertake the correction, even if severe deforming musculoskeletal problems are clearly limiting their activities. Both a full analysis and an experienced surgeon will usually be able to convince them of the benefit if the problem is clear and straightforward. These patients also need an explanation of the corrections planned, which are limited to bony correction, joint fusion, or muscle lengthening. There is no role for tendon transfer in individuals with significant athetosis.

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This correction should be part of a reconstruction of a whole problem generic erectafil 20 mg without prescription, which usually includes the planoval- gus foot buy erectafil 20mg amex, equinus ankle generic erectafil 20mg free shipping, and external tibial torsion. Indications for correc- tion are more than 10° of ankle joint valgus relative to the long axis of the tibia. If the external tibial torsion is being corrected as well, no more than 5° of valgus should be tolerated at the ankle joint. If more valgus is present on the postoperative radiograph, the cast should be wedged to correct the deformity (Case 11. The presence of the ankle valgus must be recognized when correcting the hindfoot because it is important to avoid overcorrection of the hindfoot valgus. If no tibial derotation is required, then correction of the ankle valgus can usually be done with a screw epiphyseodesis of the me- dial malleolars if there is adequate growth remaining. The ankle has to be monitored with radiographs every 4 to 6 months, and when the valgus has corrected, the screw should be removed (Case 11. For individuals with a closed growth plate, up to 15° of valgus can be accepted if the foot is cor- rected close to a neutral position below the ankle. This residual ankle valgus causes the foot to fall into external rotation and valgus with increased dor- siflexion, but tends to be less of a problem in individuals who are dependent on orthotics for ankle stability. Having the ankle valgus corrected is more important in individuals who are high-functioning community ambulators without orthotics or assistive devices. Outcome of Treatment There are no reports of the outcome of treating valgus deformity in spastic feet. Our experience has been that it is important not to overcorrect the de- formity because a little valgus is better tolerated than a little varus. Also, there does not seem to be much loss of correction, although we have not had enough children corrected by the screw epiphyseodesis who have completed growth to be confident of this fact. A stable correction has been reported in several series with a wide variety of other diagnoses. She and her family desired goal should be to have 0° to 5° of valgus at the ankle joint. A percutaneous If after the cast is applied and there is more than 10° of val- osteotomy was performed with the application of a short- gus or more than 5° of varus, the cast should be wedged leg cast and a proximal tibial pin. The radiograph in the op- and the angulation corrected. The technique for doing the erating room showed a significant valgus deformity of the wedge is to make two lines down the middle of the frag- ankle (Figure C11. This tech- kle to neutral alignment nique will correct both displacement and angulation. In gen- by measuring the width of the cast on the X-ray at level A eral, a little valgus is bet- (Figure C11. He had significant amount of growth remain- deformities. On ing so a medial malleolar epiphyseodesis screw was placed physical examination, he was hypotonic but could walk (Figure C11. He was then monitored carefully, and without assistance. He had severe planovalgus feet but no by the 24-month follow-up, he had acquired approxi- muscle contractures. In the operating room his feet were mately 20° of correction, (Figure C11. Under fluoroscopy, he was thought to when he had slight overcorrection and the foot appeared have mild instability of the ankle joint and approximately in a good position. Equinus As noted previously, ankle equinus was the first deformity of individuals with spastic CP that gained the attention of surgeons, namely Dr. Strohmeyer’s tenotomy of the tendon Achilles, and the promotion of this operation by Dr.

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