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Professional help with swallowing As soon as you notice any difficulties with swallowing buy advair diskus 250 mcg fast delivery asthmatic bronchitis in adults, it is worth asking the advice of your GP or neurologist at this early stage buy 100 mcg advair diskus amex asthma definition 14th. Increasingly there are more formal evaluations of swallowing problems in order to try and understand exactly where the problems lie. Sometimes this assessment may include what is called ‘videofluoroscopy’, which allows the process of your swallowing to be seen on X-ray following a barium swallow. Occasionally it may also include an endoscopic examination – this involves passing a small fibreoptic tube through and past the throat so that additional information can be obtained. Professional help for swallowing difficulties centres on teaching exercises to try and: • strengthen your muscles involved in swallowing; • enhance the coordination of your breathing and swallowing (so as to avoid choking); • strengthen the muscles controlling your lips and tongue that help in managing the food in your mouth in preparation for swallowing. Self-help in relation to swallowing It is possible to give general guidelines as to what you can do yourself to help swallowing, although it must be remembered each person has slightly different problems, and thus not every strategy will work for everyone. However, things to try yourself include: • changing the type and preparation of your food – solid foods, particularly those that are only half chewed, are much more difficult to swallow than those which are softer, so you may need to consider chopping or blending food; • changing the ways in which you eat and swallow – eating little and often may help; • exercising to strengthen the relevant muscles as much as possible; • making sure that you do not talk (or laugh) and eat at the same EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 131 time – problems of swallowing can often be linked to trying to do two things at once! In MS, coordination of the swallowing reflex with the amount of saliva you have may become a problem. It is not that you are producing more saliva, but the swallowing of it becomes far more noticeable. In general you have to become more conscious of the process of swallowing, and try and systematically swallow. Indeed swallowing exercises may help you and, paradoxically, by stimulating more regular production of salivation through sucking a sweet (preferably sugar free! A problem often arises when you ‘forget’ to swallow for a period of time and then suddenly notice the saliva. You might try a sequence of events as you eat or drink a little at a time, based on the following: ‘Hold your breath, swallow, clear your throat, then swallow again. Some people still have great difficulty but, if food or drink gets into your lungs, which could possibly lead to pneumonia, then more drastic action may be required. The time being taken to eat and drink may also be now so substantial that you run the risk of not getting adequate nutrition or liquids over a period of time. If this happens, then you may find yourself losing weight, getting weaker and having further problems. It is an important decision to move from normal feeding by mouth (oral feeding and drinking) to non-oral feeding, where food is directly channelled into the stomach (often avoiding the mouth and swallowing completely), but this step may be necessary if problems with nutrition and/or concern over choking becomes substantial. For example, after certain kinds of surgery in hospital, not associated with MS, people may be fed on a short-term basis through a tube that passes through the nose and then through the throat directly to the stomach (a ‘nasogastric tube’). This particular kind of arrangement has to be temporary because the throat and nose may become irritated after a while. A more long-term arrangement is to have a PEG (‘percutaneous endoscopic gastrostomy’) in which a tube is inserted through the abdominal wall directly into the stomach. As with any surgical openings through the skin, hygiene is particularly important, and great care has to be taken to prevent infections arising. Although it is a particularly difficult step to move to non-oral feeding, for social reasons as well as because of the loss of the pleasures associated with normal eating and drinking, in some cases it may be the best decision, in order to build up your strength if you have been losing a lot of weight, and to prevent fears associated with choking. If you are very careful, it may also be possible to continue to eat or drink a few things orally, at least to retain some of the pleasures of eating normally. You should keep an eye on how your swallowing goes, and always consult with your professional advisors about the possibility of gradually changing the balance between oral and non-oral feeding, so that you can try and resume a greater proportion of oral feeding, with a view to removing the PEG method of feeding if you can. Diet and nutrition There are two broad ways in which diet and nutrition can be considered in relation to MS. The first and less contentious relates to your general health: ideas about what is a good diet for general health do, of course, change from time to time. The second deals with the possible beneficial or harmful effects that some diets themselves might have on either symptoms or, more fundamentally, on the underlying cause of the MS. Diet is the most obvious and easy to implement factor that could be changed by people with MS, and many people have focused on this issue. Also, health care professionals are often very interested in diet and its effects on all aspects of general health. Although there has been research on diet and MS, it has not been a core interest of most EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 133 researchers because Western populations are largely well-nourished – obesity and overeating, on the contrary, are major health concerns. There have been many diets that have been suggested to affect either specific symptoms or the cause of MS. There is little evidence that any of these diets has the effects that their supporters suggest – however, we here discuss a number of the more plausible diets. Essential fatty acids One of the areas of nutrition that has been researched in relation to MS has been that of ‘essential fatty acids’, which form part of the building blocks of the brain and nervous system tissue, and are essential to the development and maintenance of the CNS. Actually essential fatty acid is rather an odd phrase in lay terms, for we are used to thinking of anything ‘fatty’ as very bad for you. However, there are many kinds of ‘fats’, ranging from the saturated fats, often found in meat and dairy produce, too much of which is not good for you, to the unsaturated and polyunsaturated fats, many of which are found in vegetable sources, and from some of which key essential fatty acids are derived – these are broadly very good for you. About 60% of normal nervous system tissue is made up of these ‘essential fatty acids’. Some research has suggested that several of these essential fatty acids are present in lower quantities in the CNS of people with MS than in that of people without the disease; one theory has been that MS arose because, in their early years such people were deprived of (or unable to assimilate) these essential fatty acids in the development or maintenance of the structure and function of the CNS.

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Fatigue As with other symptoms associated with MS generic advair diskus 250 mcg amex asthma symptoms vs pneumonia, it is important to discuss this with your doctor who will assess the best means of managing it buy advair diskus 500 mcg with amex asthma treatment oils. Although there are one or two drugs which may help (for example amantadine or pemoline) and which – if prescribed for you – might be taken a few minutes before sexual activity, currently the best help is through various appropriate lifestyle changes. The use of various techniques to assist with fatigue is discussed in more detail in Chapter 7. Although this may not necessarily be the time when you feel that you should be having sex – such as in the morning, or during the day, rather than at a more conventional time – you may be less tired and enjoy it more. Rather than thinking of sexual intercourse as the major element, you could agree with your partner to engage in some other less energetic sexual activities – such as gentle stroking or foreplay – that you could participate in more frequently. As with so many other aspects of living with MS, it is a question of finding ways to adapt to the situation through experimentation. When you visit your doctor, particularly your GP, you may find that he or she puts virtually all your symptoms down to MS itself. Whilst statistically it is probably correct that most of your symptoms will be related to the MS, many will not. It is easy for both of you to say ‘Oh, that’s another symptom of MS’ and not realize that, like other people, you can have other everyday problems. It is important that both are recognized in relation to pain as well as other symptoms. If GPs do confuse MS and non-MS symptoms, this is not through incompetence – even specialists sometimes have similar problems. Most GPs have so few people with MS on their patient lists – often only one or two – that, because of all the other pressing demands on their time, they have not been able to study, and experience, all the many twists and turns of the disease. Try a little persistence if you feel that your symptoms are not being treated as carefully as you wish; you can always ask for a second opinion if necessary. Sensations Initially strange and sometimes uncomfortable sensations of many kinds are typical effects of MS. A person can feel these symptoms but the doctor may to be able to find clear physical evidence of why particular symptoms are caused. Doctors often regard these symptoms as relatively benign because, although they may be irritating, they do not, on the whole, tend to result in major problems in daily functioning. Many people with MS get to know the situations in which these sensations occur and adjust their everyday lives as much as possible to avoid those situations. Medically, this is often called ‘dysaesthesia’ and results from abnormalities in the sensory pathways in the nervous system. Unfortunately, ordinary pain medications do not usually have much effect on this kind of sensation. Antidepressant medications such as amitriptyline may be used for relief if it becomes too problematic, or other remedies, such as antiepileptic drugs (gabapentin and carbamazepine), may be used to try and alter conduction along the nerve fibres, which has produced the sensation. Depending on where the damage occurs, you may feel all sorts of unusual sensations in those areas. The sensation of pins and needles commonly occurs with the interruption and resumption of nerve signals to particular areas of the body. Closely related sensations, such as tingling, may also appear occasionally, as signals to and from the affected area vary. Some clinicians treat this symptom as relatively unimportant, albeit a disconcerting, symptom of MS, for it has generally a less direct effect on everyday activities than ‘motor (movement) symptoms’, and is associated with a slower course of MS. As with the burning sensation, there is no specific drug therapy for such symptoms although, if the symptoms are associated with pain, a tricyclic antidepressant or sometimes medications such as carbamazepine and valproic acid (usually given for antiepileptic purposes) can help. Trembling Most people have some kind of ‘tremor’ (or trembling), albeit slight, as there are several different types. Your limbs will normally be the parts affected, as the course of the disease progresses. The most common is 70 MANAGING YOUR MULTIPLE SCLEROSIS what is known as action tremor, although it can be described as intention tremor, goal-directed tremor, or hyperkinetic tremor. This is caused by damage to the nerve pathways to the balance centre of the brain. The nearer your hand approaches an object when reaching for it, the more your hand trembles, so it then becomes difficult either to pick up or control something like a cup. As there are no specific drugs for the treatment of action tremor, doctors tend to try a range of different ones in the hope that one or other may prove of benefit, but it is difficult to avoid unwanted effects. These include such things as: • bracing an arm against a piece of furniture; • making the arm immobile for a specific task; • working out movements with a physiotherapist that are as smooth as possible; • adding weights to an arm, using weighted utensils such as forks and spoons. A far more drastic approach to reduce action tremor is through surgery, but currently this operation carries considerable risks of exacerbating other problems, and could make life worse, not better, for you.

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Much of the conceptual framework for Gait Analysis Laboratory was de- veloped during 1983-84 in England at the University of Oxford’s Ortho- paedic Engineering Centre (OOEC) advair diskus 100mcg discount asthma definition revenant. Ros Jefferson advair diskus 100mcg low cost asthma symptoms on skin, mathematician, provided insight and encouragement during this time. They have maintained an interest in our work and recently shared some of their kinematic and force plate data, which are included in GaitLab. Tom Kepple, research scientist, of the Biomechanics Labora- tory at the National Institutes of Health in Bethesda, Maryland; and by Mr. Patty Payne, research physical therapist, of the Motion Analysis Laboratory at the Children’s Hospital in Richmond, Virginia. Francisco Sepulveda, graduate student in bioengineering, in the gathering and analysis of the clinical data. Finally, it is a pleasure to acknowledge the efforts of the staff at Human Kinetics. Larret Galasyn-Wright, developmental editors, who have been enthusi- astic, supportive, and above all, patient. Second Edition Since the first edition was published seven years ago, there have been other people who have provided significant input to this second edition. At the University of Virginia, from 1992-1995, the Motion Analysis Labo- ratory provided an important intellectual home. Stephanie Goar, labo- ratory manager, assisted with the preparation of the revised manuscript and updated the references in the GaitBib database. Robert Abramczyk, laboratory engineers, were responsible for gathering and tracking the expanded set of clinical data files used by the latest version of GaitLab. The database of 3D kinematic and force plate data for normal children was assembled by Mr. Scott Seastrand, architectural student, converted all the original artwork into computer format for this electronic version of Dynam- ics of Human Gait. Mark Abel, ortho- paedic surgeon – provided important insights regarding the clinical applica- tions of gait analysis, especially applied to children with cerebral palsy. Kit Vaughan returned to the University of Cape Town where he re-established contact with Mr. In the Department of Biomedical Engineering, and with the financial support of the Harry Crossley Foundation and the South African Foundation for Research Development, the project continued. The desktop publishing of the whole of Dynamics of Human Gait was performed by Mr. Edmund Cramp of Motion Lab Systems in Baton Rouge, Louisiana, who provided us with the software tools to translate binary format C3D files into the text- based DST files used by the GaitLab package. IN SEARCH OF THE HOMUNCULUS 1 CHAPTER 1 In Search of the Homunculus Homunculus: An exceedingly minute body that according to medical scientists of the 16th and 17th centuries, was contained in a sex cell and whose preformed structure formed the basis for the human body. Stedman’s Medical Dictionary When we think about the way in which the human body walks, the analogy of a marionette springs to mind. Perhaps the puppeteer who pulls the strings and controls our movements is a homunculus, a supreme commander of our locomo- tor program. Though it seems simplis- tic, we can build on this idea and create a structural framework or model that will help us to understand the way gait analysis should be performed. The process that we are most interested in starts as a nerve impulse in the central nervous system and ends with the generation of ground reaction forces. Sequence of Gait-Related Processes We need to recognise that locomotor programming occurs in supraspinal centres and involves the conversion of an idea into the pattern of muscle activity that is necessary for walking (Enoka, 1988). The neural output that results from this supraspinal programming may be thought of as a central locomotor command being transmitted to the brainstem and spinal cord. Activation of the lower neural centres, which subsequently establish the sequence of muscle activation patterns 2. Sensory feedback from muscles, joints, and other receptors that modifies the movements This interaction between the central nervous system, peripheral nervous system, and musculoskeletal effector system is illustrated in Figure 1. For the sake of clarity, the feedback loops have not been included in this figure. The muscles, when activated, develop tension, which in turn generates forces at, and moments across, the synovial joints. This top-down Muscles 3 approach constitutes a 4 Synovial joint cause-and-effect model. Rigid link segment 5 Movement 6 External forces 7 IN SEARCH OF THE HOMUNCULUS 3 The joint forces and moments cause the rigid skeletal links (segments such as the thigh, calf, foot, etc. The sequence of events that must take place for walking to occur may be summarized as follows: 1. Regulation of the joint forces and moments by the rigid skeletal segments based on their anthropometry 6. Generation of ground reaction forces These seven links in the chain of events that result in the pattern of movement we readily recognize as human walking are illustrated in Figure 1.

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Thus purchase 500 mcg advair diskus overnight delivery asthmatic bronchitis elderly, activation of the sympathetic 6 advair diskus 250mcg discount asthma treatment in ayurveda,7 1,8 growing older, it is abnormal at any age. Although its nervous system facilitates storage of urine in a coordi- prevalence increases with age, at no age does inconti- nated manner. The somatic nervous system is the primary nence affect the majority of individuals, even above age source of innervation for the urogenital diaphragm and 9 85. The central nervous system inte- the elderly is likely the diseases and functional impair- grates control of the urinary tract; the pontine micturi- ments that become more common with age rather than tion center mediates synchronous detrusor contraction 8–10 age itself. Regardless, incontinence is usually treatable and sphincter relaxation, while higher centers in the and often curable at all ages, even in frail elderly,11–14 but frontal lobe, basal ganglia, and cerebellum (among the approach must differ significantly from that used in others) exert inhibitory and facilitatory effects. Storage of urine is mediated by detrusor relaxation and closure of the sphincters. Detrusor relaxation is accom- plished by central nervous system inhibition of parasym- pathetic tone, while sphincter closure is mediated by a reflex increase in the activity of the alpha-adrenergic and somatic nervous systems. Voiding occurs when detrusor contraction, stimulated by the parasympathetic nervous Details of the anatomy and physiology of normal system, is coordinated with sphincter relaxation. The lower urinary tract includes the bladder (detrusor), the urethra, and two urethral sphincters. The internal sphincter lies in the proximal urethra, at the bladder neck and is composed predominantly of smooth muscle. The external sphincter At any age, continence depends on not only the integrity lies distally, at the level of the urogenital diaphragm, and of urinary tract function and innervation, but also the is composed of striated muscle. History Type (urge, reflex, stress, overflow, or mixed) Frequency, severity, duration Pattern (diurnal, nocturnal, or both; also after taking medications, for example) Associated symptoms (straining to void, incomplete emptying, dysuria, hematuria, suprapubic/perineal discomfort) Alteration in bowel habit/sexual function Other relevant factors (cancer, diabetes, acute illness, neurologic disease, urinary tract infections, and pelvic or lower urinary tract surgery or radiation therapy) Medications, including nonprescription agents Functional assessment (mobility, manual dexterity, mentation, motivation) Physical examination Identify other medical conditions (e. Gen- of urine in the absence of a stress maneuver can be erally, individuals with detrusor overactivity gush inter- termed precipitant leakage, and it is almost invariably mittently both day and night, whereas those with pure due to DO. For those who do sense a warning, it is of less stress incontinence are usually dry at night because they value to focus on the leakage, because the presence and are in the supine position and not straining. However, volume of leakage in this situation depend on bladder individuals with intrinsic sphincter deficiency, especially volume, amount of warning, toilet accessibility, the those who also have a poorly compliant bladder, may leak patient’s mobility, and whether the individual can over- only at night if they allow their bladder to fill to a volume come the relative sphincter relaxation that normally greater than their weakened outlet can withstand. Impact of in- quency and importance of postprandial blood pressure tracardiac electrophysiologic testing on the management reduction in elderly nursing-home patients. The diagnostic value of the EEG and hyper- evaluating syncope: a comprehensive literature review. Risk stratification of up tilt testing potentiated with sublingual nitroglycerin to patients with syncope. Comparison of patients with and without of sublingual nitroglycerin test and low-dose isoproterenol syncope. Syncope in the atenolol in patients with unexplained syncope and positive elderly. Di Girolamo E, Di Iorio C, Sabatini P, Leonzio L, Barbone examination, and electrocardiography. Effects of paroxetine hydrochloride, a selec- assessment project of the American College of Physicians. The North clinical efficacy assessment project of the American College American Vasovagal Pacemaker Study (VPS). Pacemaker versus no therapy: a mul- monitoring in patients with syncope: is 24 hours enough? Use of extended monitoring patients with lethal ventricular arrhythmia resume driving? Surgical treatment of neuropathic and effect of topically applied recombinant basic fibro- ulcerations under the first metatarsal head. Peripheral neuropathy and the diabetic chronic diabetic neuropathic ulcer of the foot. Surgical correc- silver sulfadiazine, povidone-iodine and physiologic saline tion of pressure ulcers in an urban center: is it efficacious? Management of stage III nidazole therapy for anaerobically infected pressure sores. Foot-ulcer prevention in the the microbial flora of healing and non-healing decubitus elderly diabetic patient. Treatment of leg ulcers with split management of uncomplicated lower-extremity infections skin grafts: early and late results. Air-fluidized beds or conventional therapy for pressure sores: a randomized AHCPR Pub 95-0652. Finally, patterns on floors or walls, changes in dose and the total number of medications depending on their quality, may either distort or improve have been associated with an increased risk of falling. Drop attacks may occur while walking, while have attempted to identify the "most likely cause of indi- turning the neck, while looking up, or without an obvious vidual falls," falling among nursing home residents, as precipitating movement. Some individuals note that their among community-living residents, most often results knees buckled or "just gave out. The prevalence of the impairments is higher etiology and frequency of drop attacks are unknown.

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It is important that the patient is aware of the exact nature of the follow-up system available purchase advair diskus 100mcg without prescription asthma treatment reliever. Continuation and progression of appropriate physical activities are encour- aged outside the hospital setting buy generic advair diskus 100 mcg line asthma symptoms 7 days, on either a formal or informal basis. By this time it is hoped that individuals will be aware of their exercise capabilities 14 Exercise Leadership in Cardiac Rehabilitation and be able to monitor themselves appropriately. The BACR offers a comprehensive training course in phase IV exercise for exercise profession- als, such as health and fitness officers who may be involved in community- based programmes. Phase III discharge information, including goals set, should be sent to the relevant healthcare professional in the community, and formal referral to phase IV exercise classes made. As for earlier phases of CR motivational interviewing and exercise consultation are methods that can be used to main- tain behaviour change (see Chapter 8). SUMMARY The number and variety of subjects with CHD who are involved in exercise- based CR is increasing. Cardiac rehabilitation is now well established and is part of care of different cardiac groups. There are many benefits for the patient, family and com- munity from regular, long-term participation in CR. The following chapters will address the assessment of the CR participant, design and delivery of the exercise programmes. REFERENCES American College of Sports Medicine (2000) Guidelines for Exercise Testing and Pre- scription, 6th edn. British Association for Cardiac Rehabilitation (BACR) (1995) BACR Guidelines for Cardiac Rehabilitation, Blackwell Science, Oxford. British Heart Foundation (BHF) (2003) Coronary heart disease statistics (2003 edn) [online] available from http://www. British Heart Foundation (BHF) (2004) Coronary heart disease statistics (2004 edn) [online] available from http://www. Department of Health (DoH) (2000) National service framework for coronary heart disease modern standards and service models [online] available from http://www. European Heart Failure Training Group (1998) Experience from controlled trials of physical training in chronic heart failure. ExTraMATCH Collaborative (2004) Exercise training meta-analysis of trials in patients with chronic heart failure. National Institute for Clinical Excellence (NICE) (2000) Guidance on the use of implantable cardioverter defibrillators for arrhythmias. Scottish Intercollegiate Guidelines Network (SIGN) (2002) Cardiac Rehabilitation,no. World Health Organisation (1993) Needs and Action Priorities in Cardiac Rehabilita- tion and Secondary Prevention in Patients with Coronary Heart Disease, WHO Regional Office for Europe, Geneva. Chapter 2 Risk Stratification and Health Screening for Exercise in Cardiac Rehabilitation Ann Ross and Mhairi Campbell Chapter outline The previous chapter has provided an overview of the content and background to Cardiac Rehabilitation CR within the UK context. The aim of this chapter is to highlight available evidence and/or the rationale for the risk stratification and health screening process, as currently applied. In addition, it directs the CR practitioner to reflect on current practice in risk stratification for CR exercise. APPROACH TO RISK STRATIFICATION In this chapter we deliberate over current patient assessment procedures for entry into CR programmes. We do not attempt to describe the ultimate blue- print for the risk stratification and assessment of patients for the exercise com- ponent. Nonetheless, we discuss current accepted practice and explore the evidence to support it. In addition, we will describe a fresh approach proposed by the Canadian Association of Cardiac Rehabilitation (Stone, et al. The chapter will explore the variety of different processes and approaches used to understand assessment and risk stratification and the characteristics of each including pros and cons. ISBN 0-470-01971-9 20 Exercise Leadership in Cardiac Rehabilitation Risk stratification can be considered as the crux of assessment prior to entry into CR, but this approach should form part of a process of sound clinical rea- soning. The reader will find reference to commonly used coronary heart disease (CHD) risk-stratification guidelines for supervised exercise. These guidelines are produced by authoritative organisations well respected in this field – American Heart Association (AHA, 2001), SIGN (2002) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR, 2004). DEFINITION OF RISK STRATIFICATION When using the term ‘risk stratification’, it becomes apparent that for CR professionals the concept is very different from that used by those concerned with the medical management of CHD patients. In medical practice the physi- cian or health practitioner considers quantifying the risk of CHD for an indi- vidual either in terms of absolute or relative risk. Absolute risk relates to a specific ‘risky behaviour’ where statistics define the risk within a population. Relative risk relates risk to an individual and compares that person’s risk within a specific group, i. Both approaches are useful predictors in the primary care (PC) setting for CHD prevention and effective medical management.

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