The Role Of Proprioceptive Neuromuscular Facilitation Stroke

The Role Of Proprioceptive Neuromuscular Facilitation Stroke INTRODUCTION Stroke is a rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin (Aho K Harmsen 1980). Stroke is a disease of developed nation and its the third leading cause of death and long term disability all over the world with an incidence rate of 10 million per year (Sudlow and Warlow 1996). Stroke occurs at any age but it is more common in elderly between 55 to 85 years of age (Boudewejn Kollen and Gert Kwakkel 2006). Stroke is classified into two types based on the pathology and cause, Ischemic stroke, occurs when the blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. The ischemia results when there is Thrombosis, Embolism, Systemic hypoperfusion and venous thrombosis. Hemorrhagic stroke occurs when there is accumulation of blood anywhere within the skull vault. These hemorrhage results when there is microaneurism, arterio venous malformation and inflammatory vasculitis (Capildeo and Habermann 1977). Normal cerebral blood flow is approximately 50 to 60 ml/100g/ Minutes and varies in different parts of the brain. When there is ischemia, the cerebral auto-regulatory mechanism will compensate for the reduction in the cerebral blood flow by local vasodilatation and increase the extraction of oxygen and glucose from the blood. When the Cerebral Blood Flow is reduced to below 20 ml/100g/min, an electrical silence occurs and synaptic activity is greatly diminished in an attempt to preserve energy stored. Cerebral blood flow of less than 10ml/100g/min results in irreversible neuronal injury. These neuronal injuries occurs when there is formation of microscopic thrombi, these microscopic thrombi are triggered by ischemia induced activation of destructive vasoactive enzymes that are released by endothelium, platelets and neuronal cells. These result in the development of hypoxic ischemic neuronal injury which is primarily induced by overreaction of some neurotransmitters like glutamate and aspirate. Within an hour of hypoxic-ischemic insult there will be ischemiec penumbra where auto- regulation is ineffective. This stage of ischemia is called window of opportunity, where the neurological deficit created by ischemia can be partly or completely reversed. After this stage is a stage of neuronal death, in which the deficit is irreversible (Heros 1994). Functional restrictions resulting from stroke are paralysis of upper limb lower limb function, cognitive deficit, visual disturbances, disturbance of gait and mobility, spasticity of muscle, loss of co-ordination and speech problems. The loss of upper extremity control is common after stroke with 88% of survivors having some level of upper extremity dysfunction. Basic Activities of Daily Living (ADL) skills are compromised in acute stroke, with 67% to 88% of patients demonstrating partial or complete independence (Amit Kumar Mandall 2009). Muscle weakness, or the inability to generate normal levels of force, has clinically been recognized as one of the limiting factors in the motor rehabilitation of patients with stroke. Following stroke, some patients lose independent control over select muscle groups, resulting in coupled joint movements that are often inappropriate for the desired task. These coupled movements are known as synergies and, for the upper limb flexor synergy: shoulde r flexion, adduction, internal rotation, elbow flexion, wrist flexion and finger flexion. Upper limb extensor synergy: shoulder, elbow, wrist and finger extension. The rehabilitation of upper extremity is quite challenging. Many therapeutic approaches are currently available in the rehabilitation of upper extremity function. Most commonly used treatment approaches are ROODs approach, Sensory motor approach, PNF, Brunnstroms movement therapy, Bobaths technique and neuro developmental therapy. In this Proprioceptive Neuromuscular Facilitation (PNF) is widely used in the rehabilitation of upper extremity function in stroke patients. (Amit Kumar Mandall 2009). PNF is a therapeutic intervention used in rehabilitation which was originally developed to facilitate performance in patients with movement deficits. PNF exercises are based on the stretch reflex which is caused by stimulation of the Golgi tendon and muscle spindles. This stimulation results in impulses being sent to the brain, which leads to the contraction and relaxation of muscles. When a body part is injured, there is a delay in the stimulation of the muscle spindles and Golgi tendons resulting in weakness of the muscle. PNF exercises help to re-educate the motor units which are lost due to the injury. A variety of methods fall under the rubric of PNF, including the exploitation of postural reflexes, the use of gravity to facilitate movement in weak muscles, the use of eccentric contractions to facilitate agonist muscle activity, hold relax, contract relax, rhythmic stabilization, rhythmic initiation and the use of diagonal movement patterns to facilitate the activation of bi-art icular muscles (Etnyre Abraham L D, 1987; Hardy Jones, 1986 Osternig, Robertson, Troxel, Hansen, 1987). Tomasz  Wolny, Edward  Saulicz and RafaÅ‚Â  Gnat in 2009 conducted a randomized control study on the efficacy of proprioceptive neuro-muscular facilitation in rehabilitation for activities of daily living in late post-stroke patients. In this study sixty four stroke patients were recruited from the neurological rehabilitation centre Subjects for this study were recruited based on some inclusion criteria. The patients with loss of sphincter control, loss of mobility, locomotion and communication were included in this study and patients with grade 5 or 6 Repty Functional lndex scale were included in this study. After the recruitment of patients, all the 64 patients were randomly divided into two groups, group A (control group) and group B (experimental group). Group A will receive conventional treatment like strengthening, gait training etc. Group B will receive PNF based exercise. A pre and post assessment of the functional status of the stroke patients was done using R epty Functional lndex scale. The treatment will be continued for 21 days for both the groups in the neurological rehabilitation centre. . The data were analyzed using chi-square test. Chi-square was used to study associations between the treatments and changes in the criterion measurements. ANOVA was used to compare the average changes among the two groups. The result of this study showed that PNF-based rehabilitation exercise of late post-stroke patients significantly improved in their ADL functional performance and in locomotion when compared to the control group treated with conventional therapy. Kuniyoshi Shimura.A, Tatsuya Kasai. B in 2002 conducted a study on Effects of proprioceptive neuromuscular facilitation on the initiation of voluntary movement and motor evoked potentials in upper limb muscles activity. In this study author investigated the effect of PNF limb positions and neutral limb positions on the initiation of voluntary limb movement and motor evoked potentials in upper limb muscles. In this experimental study the patients were divided into two groups, in experimental group 1 they investigated the effectiveness of PNF by considering the effects of limb position changes on the initiation of voluntary movement in terms of electromyographic reaction times. In experimental group 2 they investigated the effectiveness of no (neutral limb position) movement by considering the effect of limb position changes on the initiation of voluntary movement with electromyographic reaction times. After signing the consent the experiment was conducted on the patients. Two upper ar m positions used in this study, a neutral position (N) and a position facilitating activity of the upper extensor muscles (PNF). The effects of these positions are observed in the EMG. The subject could passively adopt the two upper arm positions using his right (affected) arm by means of especially made arm holders. For each arm position, six blocks of 10 trials were performed. All trials of the first block and the first trial of each of the following blocks were excluded from the analysis to eliminate start-up effects. In addition, a few trials were discarded because of obvious mistakes in the recording. EMGs were recorded simultaneously from three muscles (Brachioradialis, triceps brachii and deltoid) using 3 cm diameter, bipolar, silver surface electrodes connected to an EMG-unit. The result of this study showed that the EMG discharge order differed between the two positions. PNF position improves movement efficiency of the joint by inducing changes in the sequence in which the muscles are activated. Hence PNF has an effective role in the initiation of voluntary movement and motor evoked potential in upper limb muscle activity. Pamela Duncan and Lorie Richards et al., in 1998 conducted a study on the effect of Home-Based Exercise Program for Individuals with Mild and Moderate Stroke. In this randomized controlled pilot study, 20 individuals with mild to moderate stroke who had completed acute rehabilitation program and those who were 30 to 90 days after onset of stroke were randomized to a 12-week (first 8-week will be therapist-supervised program and the next 4-week will be independent program) rehabilitation program. After signing the consent form, patients were selected based on some inclusion criteria like (1) 30 to 90 days after stroke; (2) minimal or moderately impaired sensorimotor function (3) ambulatory with supervision and/or assistive device; (4) living at home; and (5) living within 50 miles of the University. The exclusion criteria for this study are (1) a medical condition that interfered with outcome assessments or limited participation in sub maximal exercise program, (2) a Mini-Mental State score The participants for this study were selected and evaluated by a therapist based on the inclusion and exclusion criteria. If the subjects agreed to participate in this study, then the basic assessment is done after getting the informed consent. The severity of the stroke were assessed using Orpington Prognostic Scale (Sue-Min Lai and Pamela W. Duncan 1998) and Fugl-Meyer Motor Score (Pamela W Duncan 1982) that includes assessment of motor function of the arm, upper extremity proprioception, coordination, balance, and 10 cognitive questions. The functional assessments are performed using Barthel Index Activities of Daily Living (Fricke and Unsworth 1997) Lawton Instrumental Activities of Daily Living and Medical Outcomes Study-36 Health Status Measurement (Colleen and John 1992). Functional assessments of balance and gait of the participants were assessed using 10-Meter Walk, 6-Minute Walk (Kosak and Smith 2005) and Berg Balance Scale (Berg, Wood-Dauphinee and Williams 1995). Upper extremity hand function was evaluated with the Jebsen Test of Hand Function.The Jebsen is a standardized assessment to measure the time taken to perform hand activities. These includes: writing a short sentence, turning over 35 cards, picking up small objects, stacking checkers, simulated eating, moving empty large cans, and moving weighted cans(Jebsen, Taylor, Trieschmann 1969). After baseline assessment the subjects were randomly assigned into two groups, experimental group and control group. In experimental groups the PNF exercise were taught to the patients on day one as an home exercise and they were asked to continue the same exercise as an home program for eight weeks with three visits to the physical therapy department every week. The exercise includes assistive and resistive exercises using Proprioceptive Neuromuscular Facilitation Patterns and Theraband exercise to the major muscle groups of the upper and lower extremities. Subjects in the control group received usual care as prescribed by the physicians. The subjects of this group were assessed by the research assistant. The demographic data of both the groups were statistically compared using Wilcoxon rank sum tests. The results of this study showed that there is no difference in the pre and post exercise treatment. There is no change in the upper extremity function and the functional health status in both the experimental group as well as in control group after the treatment interventions. Ruth Dickstein, Shraga Hochman, Thomas Pillar, and Rachel Shaham in 1992 conducted a study on Stroke Rehabilitation with Three Exercise Therapy Approaches. One hundred and ninety-six hemiplegic patients were randomly selected for this study. All subjects were referred to the physical therapy department of a geriatric-rehabilitation hospital over a period of 18 months were admitted to the study. All patients had a recent cerebrovascular accident and came for a rehabilitation program after an average stay of 16 days in a general hospital. Sex distribution was equal with a mean age of 70.5 years. Thirteen physiotherapists were enrolled in the study for exercise administration and the subjects were assigned randomly to each therapist. The data were collected in a separate form, which has two parts; first part was used to collect the basic information like age, gender, side affected and location of the damaged artery. The second part was used to record the variable data. Each therapist tr eated their first five patients with conventional method, next five with PNF method and the last five with Bobath method. All patients were treated for five days a week for six weeks, and each treatment sessions were last for 30 to 45 minutes. The outcomes of each patient are measured before the treatment and every week thereafter. The functional independence is measured with Barthal index. Muscle tone of the involved extremities was checked by passive movements of the extremities with the patients in supine position. Muscle tone was graded using an ordinal scale composed of five points: a) flaccid, b) low, c) normal, d) high, and e) spastic. Ambulatory status of the patient was assessed and classified with a nominal four category scale: a) patient does not walk, b) patient walks with an assistive device and persons help, c) patient walks with an assistive device, and d) patient walks independently. The treatment was continued for 6weeks in both the groups. The data were analyzed using chi-square test. Chi-square was used to study associations between the treatments and changes in the criterion measurements. The Kruskal-Wallis one-way analysis of variance (ANOVA) was used to compare the average changes among the three groups. The results of this study showed that there is no significant difference in the improvement of activities of daily living and in the walking ability. But there is significant difference in the improvement of muscle tone in PNF group and in Bobath group when compared to the conventional treatment group. CONCLUSION: The poor quality of the trials reviewed severely limits the conclusions that can be drawn. However, it seems that currently there is no evidence, that interventions based on the Proprioceptive Neuro-muscular Facilitation (PNF) are more effective than other approaches. One Study done by Ruth Dickstein on PNF vs. Bobath concluded that PNF exercise given in conjunction with Bobath technique are more effective in improving wrist strength and upper limb function than giving PNF alone. But the outcomes used in these studies are ordinal rating scales, which may not be sensitive enough to differentiate the effect of the two techniques. The number of subjects recruited for these studies is very less. We cannot come to conclusion on the effect of PNF in upper limb function with these less number of studies. Stroke patients may vary widely on factors such as physical impairments, speech impairments, severity of impairments, cognitive impairments, and also in the individual personality and learning styles. So, we cannot assume that this PNF technique is superior to all other techniques, because we cannot say this technique can be used in individuals with stroke and at every stage of recovery. For example one approach may be effective in initial stage of stroke, but the same approach may not be effective for chronic stroke patients. Factors such as depression, spatial awareness, cognition, comprehension and sensory loss could also have an impact on the response of a technique. In most of the studies there is no exact clinical finding about the problem, size of lesion and the site of lesion. Characteristics of the lesion may explain the variability in responsiveness to the intervention. There is no ideal timing of the interventions, whether the technique should be given in the initial stage or late stage of stroke. In this review on the effect of PNF in upper limb function in stroke, evidence on the current practice is lacking. Because of the lack of evidence on current practice it is very difficult to make a conclusion. Evidence of support and treatment used in these articles is not standard to use in todays health care practice. It is suggested that further studies comparing the effect of PNF with other approaches using sensitive, reliable outcome measures and with homogenous sample size should be done. Therefore it is important that future studies clarify the analysis and interventions used within the PNF technique to enable accurate evaluation of the study. No studies on this review assessed the efficacy and the effectiveness adequately, so further studies should be done to get an effective and optimal approach in the rehabilitation of upper limb function in stroke patients.

Eleanor, Duchess of Aquitaine :: European Europe History

Eleanor, Duchess of Aquitaine In the year 1122, soon to be Duke William X of Aquitaine was informed that his bride of one year, Aenor, daughter of the Viscount Aimery, had bore him a daughter. She was christened Alia-Aenor, or Eleanor. Since Aquitaine consisted of more than a third of the entire land of France, she was a heiress of some esteem. Soon after, Aenor gave birth to another daughter, Aelith (Petronella) and then to the heir that William so desired, William Aigret. Unfortunately, when Eleanor was eight, both her mother and brother died, leaving her heiress to the whole of Aquitaine. Eleanor's close childhood friends were her uncle Raymond, who was only eight years older than herself, and her sister. She was influenced by the great heroines in her family, like her grandmother, who sacrificed her place as a Viscountess, for love. When Eleanor was fifteen, her father went on a pilgrimage. On the way, he encountered food poisoning. He left Eleanor in the charge of King Louis the Fat, to marry her off. King L ouis married her to his own son, and made her Queen of France upon his death, some days after the wedding. Louis Capet, Eleanor's new husband, was only sixteen when they wed. The second son, he had grown up in a monastery, preparing for a life in the service of the Lord. However, when his older brother fell off his horse and broke his neck, Louis became heir to the throne of France. Louis was a quiet, deeply religious man, eager to show off for his new, rich and beautiful wife. Eleanor dreamed of a warrior for a husband, and Louis, despite his shyness, desperately wished to fill that part. Quickly he went to war, against his vassals and anyone else that would oppose him. When Petronella was married to Count Ralph of Vermandois, his first wife's family-who he had divorced to marry Petronella-quickly took up arms against him. Louis jumped in to protect his sister-in-law's interests. Even so, Louis's war was badly planned and his army ended up burning an entire village who had taken refuge in a church. The experience left him virtually destroyed, he who had been so in God's favour. The King and Queen went to a respected and feared Abbot, Abbot Bernard. Louis wished to repent for his sins and Eleanor wished to bear Louis a child. By the time they left, Louis was committed to going on a crusade, and Eleanor was pregnant.

Certain Catalysts Can Affect Change, Gow’s Away Compared to the Help

People can act as catalysts for change. Both Gow and Taylor use the main character’s circumstances to affect change in attitude amongst the other characters. In ‘Away’, Tom’s fatal illness causes the other characters to realise the value of their lives and become more positive about life. In ‘The help', Skeeter’s mission to write a book to uncover the harsh mistreatment of the African American helpers to change the white community’s attitude. In both texts the authors use techniques appropriate to their medium to demonstrate this change in attitude. In ‘The Help’ the character Skeeter is the catalyst for change. The change she causes is a change in mentality towards the African American helpers. This change in mentality is represented through Skeeter’s mother. Gow uses contrasting scenes to show the mother’s change in mentality, which is also represented through the general change in the attitude of the white community. This is shown through the juxtaposition of the early scene where Skeeter and her helpers are sitting in the television room watching an African American speak on TV. Skeeter’s mother finds them watching the African American and commands them to turn it off. With the use of a low camera angle Skeeter’s mother shows authority and power over the African American helpers as well as Skeeter herself. In the end scene Skeeter and the African American helpers are watching the same thing on TV. Skeeter sees her mother and goes to turn off the TV. Skeeter’s mother says to leave it on and joins them on the couch. The camera angle changes in this scene from the early scene whereby Taylor makes use of a low camera angle. Skeeter’s mother does not show authority or power over everyone including the African American helpers. Skeeter is shocked by this change in attitude, but is happy that her mother is finally changing her mentality towards the helpers. Therefore through the use of contrasting camera angles, Taylor shows a change in attitude, brought about by the catalyst of Skeeter’s character. In ‘Away’, Gow also uses the main character as the catalyst for change. Like in â€Å"The Help†, the change he causes is a change in mentality of the other characters. This change occurs due to Tom’s fatal illness, which makes the other characters in the play become more positive and realise how precious life is. The change in mentality is shown through one particular character, Gwen. The techniques used to show the change in mentality is the use of stage directions and dialogue. The use of these techniques show the way that Gwen changes her attitude towards life. At the beginning of the play, the use of repetition of the word ‘no’ demonstrates her negativity. This negativity is changed when Gwen finds out that Tom has a fatal illness and does not have very long to live. This causes Gwen to see her life in a different mentality, changing her into a nicer and more appreciative person. This is shown through the technique of stage directions in the final scene of the play, where ‘the applause is led thunderously by Gwen’. This technique shows the shift in mentality to a much more positive outlook on life. In conclusion, both Gow and Taylor show how people can act as catalysts for change. In both ‘Away’ and ‘The Help’ the main characters are the catalysts for a change in mentality. This change is a time consuming process, however both Gow and Taylor show how valuable this change can be.

My Trip On My Vacation - 867 Words

It was saturday 08/21/2012, one week before I flew out to America, my friends and I went on a trip. It was the greatest time in my life. It is the day that I will never forget in my life. My friends and I were so close and we love each other. When I told them I got a visa to go to America, they were so sad. Because the did not want to leave me. So they decide to have unforgettable day before I fly to america. That s why we decided to go to trip on that day. In the morning, before we go to the trip, we started our day by eating breakfast together. Afternoon, we went to another city to have unforgettable day and finally in the night we had a great party. When I woke up in the morning at 7:00 am, I got one of my friends message. He told me that we will have a breakfast before we go to the party. And I took shower and I spent about 2 hours with my family and I went out with my friends. I had a great breakfast with them. when I asked them to share the money they said I won t spend any money today. while we eat the food we were discussing about what will be happening in the party and we created the plan what we will do on the party. At that time I did not have a good mood because I was thinking too much. After we eat breakfast, we packed everything we need. Our plan was to go to another state, which is the great city to have party. The place was so beautiful. we choose that place to have unforgettable day in our life. It took 3 hours to get there from where weShow MoreRelatedMy Trip On My Vacation1441 Words   |  6 Pagesgood trips with my family some them was with all of them and some with one of us always missing. But that is all in there and you can find out so much about me. Just read on and see what happens on my vacations. Disney 2009 In the morning I wake up and my mom say’s â€Å"Belle do you what to get dressed and go see some princess this morning.† I jumped out of bed put on pants and t-shirt and ran to my mom s room the door was open and I walked in they were all ready and watching TV with my threeRead MoreFamily Memories : My Family Vacation994 Words   |  4 Pagesyesterday. Many of those memories that have special meaning to me were of family vacations when I was young growing up with my brothers and sisters. Family memories are important to many of us because they take us back to a time or place that was special. One particular family vacation I remember vividly, and it’s a story I have shared with my kids on many occasions. Over the 40 or more years since that memorable vacation, I still smile and think how lucky I was growing up with a mother and father thatRead MoreMy Experience At My Part Time Job1569 Words   |  7 Pagesdiligently at my part time job. After saving every last penny that I earned, I now have a total of $3,000. What better way to spend my summer earnings than to treat myself to an extravagant vacation? To make my extremely difficult decision of where to go easier, I have narrowed down my choice to only two destinations: Brussels, Belgium, and Dubai, United Arab Emirates. Although I have simplified my selection to only two vacations, the decision is still quite difficult; after comparing my transportationRead MoreMy Memories A Favorite Memory880 Words   |  4 Pages good or bad, develops the entity of a person’s personality or logic. I considered one of my worst memories a favorite memory because, from that experience, I gained development as an individual. The start of that development occurred on vacation without my parents attending. Like any other child, I became very enthusiastic of the whole idea of freedom and self-guidance. After the majority of the trip, I became uninterested with self-guidance and I wanted to rely on the adults to plan fun-filledRead MoreHow Vacation Is A Good Time1094 Words   |  5 PagesGoing on vacation is a way to relax, reduce stress, and spend time with my family. The different cultures, places, and laughs that we experience on vacations are truly memorable. When I was younger, my sister and I would take vacations with my grandparents. On these road trips, we would go hiking, go to water parks, and have picnics. On every trip, either someone was embarrassed or injured. When I was 8 or 9 years old, I was afraid that my grandpa was seriously hurt on one of our trips. UltimatelyRead MoreDescriptive Essay On Family Vacations850 Words   |  4 Pagesfamily vacation. I was probably eighteen months old. Needless to say, I remember none of it. However, from that one vacation to Lake Powell, spurred so many others. Apparently, it was a blast. For the next ten years, our full family vacations were few and far between, after all, there were so many new cousins being born, new jobs being obtained, and kids starting school, we hardly had time to all get together for a week away. By the time I was maybe 11, we thought it was time for another vacation, andRead MoreMy Favorite Vacation724 Words   |  3 PagesVacation is the time to relax and have fun. Taking the carnival cruise to Cozumel was one of the most fun and memorable vacations I have been on. Out of all the vacations I, have taken, this vacation was the best. If anyone asks me about my favorite vacation I have taken, the first vacation I would choose would be the trip to Cozumel. This is because I hung out with friends, exploring and trying new things, and went to the beach. First of all, hanging out with my friends made this one of myRead MoreI Am At A Safe Big Resort1311 Words   |  6 Pageshi mom and dad I didn t want to ruin the trip with another fight. so I m going to say this via email. I know it would ve been ideal to have figured this out before our trip but I didn t and I m sorry for that. I understand that you have various concerns about me going to Florida with danny s family and I get that. it makes sense. However, soon I will be an adult and in a little over a year I will be off to college. Allowing me to go in this trip would build trust in our parent/ child relationshipRead MoreA Trip On A Family Vacation At California, Disneyland, The Beach, And Family Reunion Camping Trip847 Words   |  4 PagesI’ve been on a family vacation for ten days that included a road trip to California, Disneyland, the beach, and a family reunion camping trip. It was a pretty ambitious trip and has provided an interesting reflection on budgeting à ¢â‚¬â€œ budgeting time, budgeting money, and budgeting food. I read an article recently that said the biggest reason people are late is that they are too optimistic. I laughed out loud when I read that. I so often optimistically try to fit in one more thing before I leave andRead MoreBest Vacation Planning Tips With Soufeel886 Words   |  4 PagesBest Vacation Planning Tips with Soufeel As you know, Ben and I just came back from an amazing vacation to Spain. I can t be happier as I finally saw with my own eyes all of the creations of my favorite artist/architect Antoni Gaudi and tasted all of the amazing dishes from Spanish cuisine. I love to take the time and plan our vacation on my own so we can see not only basic tourist attractions but also live for a couple of days as locals of the place we visit. Even though this year we booked the