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By U. Sanuyem. Concordia College, Ann Arbor Michigan.

With little scientifically based natural history and few long-term studies generic 50mg zoloft visa anxiety 4 year old symptoms, much of what is written in this text is expert- based observation discount zoloft 100 mg otc anxiety nausea. The goal of writing this is not to say that it is absolute fact, but to provide the starting point of gathering information with the hope that others will be stimulated to ask questions and pursue research to prove or disprove the concepts. The research, which is of help in treating children with cerebral palsy, needs to be planned and evaluated with consideration of its long-term im- pact on the child’s growth and development. All treatment should also con- sider the negative impact on the child. As an example, a number of moder- ately good studies have analyzed the impact of wearing ankle orthotics on the young child. Although the orthotics may provide an immediate benefit by improving the child’s gait, there is probably no long-term benefit. Thus, if the child develops a strong sense of opposition to wearing the brace at 10 years of age because of peer pressure, the brace wear cannot be justified on a cost–benefit analysis. It is also important to consider the quality of the scientific evidence, rang- ing from double-blinded protocols to case reports, but it is equally important not to get hung up on this being the final answer. For example, excellent double-blinded studies show that botulinum toxin decreases spasticity and improves gait for a number of months. Therefore, these studies need to be considered in the context of our goal, which is to give the child the maximum possible function at full maturity. Because no evidence currently suggests that botulinum has either a negative or a positive effect on this long-term goal, the family and physician should decide together if botulinum injection has a pos- itive cost–benefit ratio, as its effects will last only for approximately 6 months. In comparison, no double-blind studies show that Achilles tendon lengthen- ings improve gait three or six months after the surgery, and no such studies are needed because the goal of surgery is to make an improvement in gait several years later and to have improvement at maturity. Most important is that surgery create no disability at maturity. From this perspective, it would be much more useful to have a good controlled case series with a 15-year follow-up than a double-blinded study with six months follow-up. This book should stimulate research that will improve the knowledge base which is focused on the long-term outcome of treatments. However, just be- cause the scientific knowledge base is poor does not mean that we should not apply the best knowledge available to current patients. In addition to research, an individual professional can best extend his or her knowledge base through personal experience. This means that the child and family should be followed over time by the same practitioner with good documentation. By far, my best source of information has been the children whom I have followed for 10 to 20 years with videotapes every year or two. Practitioner experience is ex- tremely important for augmenting the relatively poor scientific knowledge base for musculoskeletal treatment. Careful ongoing follow-up is also crucial to providing hope for the families and the individuals with cerebral palsy. How to Use This Text and CD The text of Cerebral Palsy is set up in three sections, with the first section containing 11 chapters that deal with specific aspects of cerebral palsy from Preface vii the perspective of managing the motor impairment. The first four chapters address primarily global issues of the child and family. The fifth chapter pro- vides an overview of the medical and community care system and philosophy. The sixth chapter addresses the myriad options of equipment encountered in the treatment of the musculoskeletal impairment, and the seventh addresses the problems related to gait. The last four chapters are related to problems encountered in anatomical regions. These chapters also include management of the deformities and management of complications of medical treatment. These chapters are followed by treatment algorithms relevant to the issues discussed within the chapter. Also included in the chapters are patient case examples. Many of the case examples have videos and are designated by a video symbol.

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This tendency for improvement of planovalgus feet in young children has been previously noted discount 100 mg zoloft mastercard depression symptoms hallucinations,23 but the natural history of planovalgus feet has not been studied purchase zoloft 100 mg line anxiety young living. In general, by 7 years of age, the planovalgus position will be as good as spon- taneous correction can provide. This spontaneous correction probably is due to improving motor control, which starts to make a positive impact in con- trolling foot position because it occurs most in relatively high-functioning ambulatory children with diplegia. In middle childhood, the planovalgus foot position tends to be stable with little change. By adolescent growth, al- most all children with some degree of planovalgus have some progression of the deformity, and this is the time when the foot usually becomes painful. In general, the pain comes from high pressure over the medial bony prominence, which is the talar head and navicular tuberosity. Often, the increased dis- comfort is associated with rapid weight gain and increased crouching. Pathologic Deformity in Ambulators Although it is important to understand the etiology and natural history of planovalgus feet, the treatment also depends on understanding the poorly defined pathologic anatomy. The anatomy of the subtalar joint is complex but well described in many anatomy texts. This anatomical description is based on the acetabulum pedis concept, which defines the talus as the ball structure articulating a cup structure made up of the calcaneus inferiorly and the navicular anteriorly that functions as an acetabulum113,114(Figure 11. In this anatomical concept, the foot articulates through the subtalar joint as a relatively rigid structure. The articulation of the talonavicular joint, middle facet, and anterior facet of the calcaneus makes a very elliptical acetabulum. Continuing to the posterior talus though, the posterior facet has an articulation that is out of the plane, with a condyle on the calcaneus that articulates with a plateau on the talus 744 Cerebral Palsy Management Case 11. He had just started independent ambu- lation, and his parents’ primary concern was related to his severe flat feet. On physical examination the ankle dorsiflexion was to 20° with knee flexion and with knee extension. There was more spasticity on the left, but otherwise there was not much difference between right and left. The feet were clearly in severe planovalgus (Fig- ure C11. He was placed in articulated AFOs to pro- vide support for the feet. Over the next several years, the feet spontaneously improved, but by age 5 years, he had developed significant in-toeing and equinus on the left side. During this development, the tone and movement limita- tions on the right almost disappeared, and he developed a clear hemiplegic pattern. There was complete resolution of the planovalgus on the left with a mild residual on the right (Figure C11. At this time, he had a left-side- only femoral derotation osteotomy, rectus transfer to the sartorius, and lengthening of the hamstrings and gastroc- nemius. One year after this surgery his right foot remained completely normal and the left foot had a mild planoval- gus (Figure C11. This case shows the difficulty in predicting the outcome of feet in young children. The se- vere early planovalgus of the left foot completely resolved without any direct treatment, and the right foot made substantial improvements. With normal anatomy, this arrangement allows relatively free and easy movement of the anterior aspect of the foot joint, but is severely restrained by the out-of-plane posterior facet. This complex joint is ideal in providing a limited degree of free motion that can be controlled by the mus- cles, but has rigid and strong inherent stability created by weight bearing on the posterior facet. Because the posterior facet’s arrangement with a condyle on the calcaneus and a plateau on the talus, the joint is stabilized naturally by weight bearing, especially by heel strike at foot contact, which loads the posterior facet. This construct allows much freer movement in nonweight- bearing or low-weightbearing environments such as preswing and swing phase. The freer movement is allowed as the weight bearing shifts to the acetabular-shaped anterior joint with the implication that more varus and valgus motion is possible at toe-off or with weight bearing on the forefoot.

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These pos- These proteins were given the unimaginative name of “non-histone chromosomal itively charged regions of the histones inter- proteins trusted zoloft 25mg mood disorder lupus. The Human Genome The genome 100 mg zoloft with visa depression relationships, or total genetic content, of a human haploid cell (a sperm or an egg) is distributed in 23 chromosomes. Haploid cells contain one copy of each chromo- some. The haploid egg and haploid sperm cells combine to form the diploid zygote, which continues to divide to form our other cells (mitosis), which are diploid. Diploid cells thus contain 22 pairs of autosomal chromosomes, with each pair com- posed of two homologous chromosomes containing a similar series of genes (Fig. In addition to the autosomal chromosomes, each diploid cell has two sex chromosomes, designated X and Y. A female has two X chromosomes, and a male has one X and one Y chromosome. The total number of chromosomes per diploid cell is 46. A gene, in genetic terms, is the fundamental unit of heredity. In structural terms, a gene encom- passes the DNA sequence encoding the structural components of the gene prod- uct (whether it be a polypeptide chain or RNA molecule) along with the DNA Fig. Chromatin showing “beads on a sequences adjacent to the 5´ end of the gene which regulates its expression. Each gene on a chromosome in a diploid cell is matched by an alternate version of the gene at the same genetic locus on the homologous chromosome (Fig. These alternate versions of a gene are called alleles. We thus have two alleles of each DNA Nucleosome core Linker DNA Histone H1 The solenoid Core histones (H2A, H2B, H3, and H4) Fig. A polynucleosome, indicating the histone cores and linker DNA. A set of homologous chromosomes is shown diagrammatically. Each diploid cell contains 22 CC), or they may differ (e. Thus the corresponding protein diploid cell contains two X chromosomes. Each haploid cell contains chromosomes 1 products may be identical or they may differ in through 22 plus either an X or a Y. If the alleles are identical in base sequence, we are homozygous for this gene. If the alleles differ, we are het- erozygous for this gene and may produce two versions of the encoded protein Will Sichel has sickle cell anemia that differ somewhat in primary structure. He has two The genomes of prokaryotic and eukaryotic cells differ in size. The genome of alleles for the -globin gene that the bacterium E. All of this bacterial DNA both generate the mutated form of hemo- has a function; it either codes for proteins, rRNA, and tRNA, or it serves to regulate globin, HbS. His younger sister Amanda, a the synthesis of these gene products. In contrast, the genome of the human haploid carrier for sickle cell trait, has one normal cell contains between 30,000 and 50,000 genes, 10 to 15 times the number in allele (that produces HbA) and one that pro- E. The function of most of this extra DNA has not been determined (an issue duces HbS. A carrier would theoretically be considered in more detail in Chapter 15). However, what is generally seen in electrophoresis is 60:40 ratio of HbA:HbS. STRUCTURE OF RNA Dramatic deviations from this ratio imply the occurrence of an additional hemoglobin A. Like DNA, it is composed of nucleotides joined by 3 - to 5 -phosphodiester bonds, the purine bases adenine and guanine, and the pyrimidine base cytosine. However, its other pyrimidine base is uracil rather than thymine.

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Other ways to define this population are patients with a standing (dimension D) on the GMFM of less than 25% purchase 100 mg zoloft depression symptoms during menstrual cycle, a walking speed less than 50 cm/s buy zoloft 25 mg on line depression symptoms nimh, or an oxygen cost that is greater than 0. Many of these are children or adolescents who used a gait trainer in early childhood and are transitioned to a walker adapted with forearm supports in middle child- hood. At adolescence, these individuals are usually transfer ambulators, able to move in their home environment and do weightbearing transfers. Many of these individuals have high tone from spasticity and many in the late 1980s and early 1990s had dorsal rhizotomies. The typical experience of this group with rhizotomy, in which spasticity was removed, is that these chil- dren can no longer stand or walk, except with the assistance of a gait trainer. If the rhizotomy is less aggressive, leaving some spasticity, most of the spas- ticity will return over a few years and these children will be back where they started. The use of the in- trathecal baclofen pump, especially for middle childhood and adolescence, is an excellent option. Correctly adjusting the pump so there is enough spas- ticity to stand but not cause problems requires trial and error. Early Childhood In early childhood the children should be placed in standers, and as they de- velop coordination, start in gait trainers. Many of these children are at high risk for developing spastic hip disease and need to be monitored for the pre- vention of spastic hip disease. Encouraging ambulation in a gait trainer may not allow individuals to move to walking with an unsupported walker; however, it still gives them a sense of movement and weight bearing. Usually, these children are provided distal support with a solid ankle AFO so they can focus on proximal motor control at the hip and knee. There is really nothing to be gained by using articulated AFOs for these children. Often, these children will have significant scissoring with adduction in initial swing phase. If the adductors are very spastic and contracted, these children may benefit from adductor lengthening; however, this is often not due to spastic- ity but is a motor control problem. The best way to address this motor con- trol problem is to use lateral ankle restraints, which are available on many commercial gait trainers. If severe equinus limits orthotic tolerance, the use 372 Cerebral Palsy Management of Botox may help, or surgical lengthening is required. Aggressive attempts to lengthen muscles, correct foot deformities, and correct torsional mal- alignments in young children less than 6 or 7 years of age often leads to disappointment unless an evaluation has clearly demonstrated that the musculoskeletal impairment is the direct cause of the limited function. Of- ten, parents will identify some problem, such as scissoring, and focus on the assumption that if this problem were removed, the children could walk. If adductor lengthening is performed in these children but they still can adduct, the scissoring is seldom improved. These children’s central motor control generators are using a flexor posture that causes the legs to scissor but is not directly responsible for simple, single-muscle overactivity. The scissoring is part of the primitive stepping mass reflex that children are using to advance the limbs. Often, as these children mature, they learn to overcome scissoring and subsequently will slowly do less scissoring. If the musculoskeletal im- pairment is blocking progress, it is reasonable to correct the deformity, usu- ally around 5 to 7 years of age at the youngest. If there is a question of the significance of the musculoskeletal impairment, it may be beneficial to wait until 8 to 10 years of age when a better assessment can be made, with more time to evaluate how these children are changing. Middle Childhood Quadriplegic Ambulators In middle childhood, most children will reach a plateau with motor function. An evaluation of the benefits of correction of musculoskeletal deformities should be performed. If there are limitations that are significantly impairing the children, correction should be made. Correcting the contractures that are causing impairments is often beneficial, and these contractures may include equinus contractures, hamstring contractures, knee flexion contractures, hip flexion contractures, and adductor contractures. Sometimes the parents report that these releases help the caretakers provide personal hygiene more easily, such as easier bathing or dressing.

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A narrowed base of support cheap 50 mg zoloft with visa depression short definition, reduced heel strike zoloft 100 mg amex depression glass patterns, and difficulty turning corners prohibit safe use of four-post walkers and quad canes for the majority of PD patients. Single-end canes, walking Copyright 2003 by Marcel Dekker, Inc. Inappropriate or poorly fitting devices will not maximize patient safety, and may contribute to balance problems. Basic safety strategies, including instruction in appropriate footwear and the removal of home environmental barriers, should not be overlooked during gait instruction. 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.

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