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By L. Tarok. Ursinus College.
Good response in decreasing midstance plantar flexion moment has been reported second- ary to gastrocnemius fascial lengthening buy 100 mg viagra super active erectile dysfunction drugs nz. Other Treatment There are many other techniques described for lengthening the tendon Achilles; however, the only technique that has a confirmed impact on lengthening the muscle tendon unit for at least a moderate time of several years is surgical lengthening. There are many surgical lengthenings described to accomplish this goal, from the Strohmeyer tenotomy to the proximal resection of Silfvers- 11. Options for addressing equi- nus contractures include tenotomy or myo- fascial recession of the proximal gastrocne- mius tendons (A), myofascial lengthening of the distal gastrocnemius tendon (B), com- plete release of the distal gastrocnemius ten- don from the underlying soleus tendon and allowing it to retract proximally and reattach itself (C), myofascial lengthening of the com- bined gastrocsoleus tendon (D), tenotomy of the tendon Achilles (E), anterior transfer of the distal insertion of the tendon Achilles (F), percutaneous or open sliding lengthening of the tendon Achilles (G), open Z-lengthening of the tendon Achilles (H), and neurectomy of the gastrocnemius. There is very little recent enthusiasm for the complete Achilles tenotomy or proximal recession. There are many papers describing the sliding techniques originally described by White in 1943 and Hoke in 1953. The rates of overlengthening with these procedures were reported as 3% in one series,73 but were largely unreported, probably because most papers were not very concerned with the gait function. Also, during the midpart of the 1900s, neurectomy of the gastrocnemius was popular as a way of decreasing the spasticity of the muscle. Recently, neurectomy has been reported again and has been found to decrease toe walking when there is no fixed contracture, although no assessment of gait was reported. Neither the theoretical advantages nor the historical experience suggests that gastrocnemius neurectomy is a viable modern treatment option. Another surgical technique is anterior transposition of the Achilles ten- don from the calcaneal tuberosity to the area on the calcaneus just poste- rior to the ankle joint. This procedure was originally described by Murphy 716 Cerebral Palsy Management in 1974,77 and a report of a large series suggested a good outcome; however, there was no real evaluation of the patients. By shortening the ankle moment arm, the magnitude of the ankle moment is de- creased. Because the spastic muscle is already weak, as defined by the de- creased cross-sectional area, this anterior transfer of the insertion further weakens the muscle mechanically. Also, by shortening the moment arm and increasing the magnitude of motion at the ankle joint produced by a given increment of muscle contraction, more delicate control of the muscle is re- quired. Because there are no scientific data available from gait studies and the theoretical function of this procedure is suspect, it is not recommended. Many studies evaluate biofeedback techniques to improve functional dorsiflexion during ambulation on the basis of many children not having fixed contractures but still being toe walkers. Also, the use of neuromuscular stimulation on dorsiflexors has been attempted to improve dorsiflexion. Pos- itive results are reported in a few children in whom biofeedback has been tried79; however, there is no long-term carryover after the intervention has ceased. Range-of-motion exercises are routinely used, but there are few or no data to document their effectiveness. For young children, passive range of motion is a reasonable option, but as they get close to adult size, it is no longer possible to do passive range-of-motion stretching effectively because of the strength of the gastrocnemius and soleus and the small lever arm af- forded by the foot. One study has reported that stretching is easier if the calf is warmed to 40°C before the passive stretching occurs. This concept makes theoretical sense; however, there are no supportive data. There has been widespread use of casting to reduce equinus in children with CP. Casting has had periods of enthusiastic promotion; however, no study has demonstrated any long-term benefit. Because casting is simple and cheap, it is still promoted by some82 (Figure 11. Recently, there has been an in- creased interest in combining the use of cast immobilization with botulinum toxin injections because both are recognized to relapse quickly. There has been a debate of the relative merits of repeated casting to treat equinus contractures of the ankle. This is often presented as the low-risk approach; however, the impact of casting is significant muscle atrophy and therefore creation of a small muscle mass. The tension of casting has never shown that it adds muscle fiber length, but if it does, it also adds tendon length.
Liver glycogen is used Glucose Glycogenolysis to maintain blood glucose during fasting and during exercise or periods of enhanced need cheap 25mg viagra super active visa impotence unani treatment in india. UDP-Glucose is also used for the formation of other sugars, and galactose and Glucose–1–P glucose are interconverted while attached to UDP. UDP-Galactose is used for lac- tose synthesis in the mammary gland. In the liver, UDP-glucose is oxidized to UDP- Glucose–6–P glucuronate, which is used to convert bilirubin and other toxic compounds to glu- Gluconeogenesis curonides for excretion (see Fig. Nucleotide sugars are also used for the synthesis of proteoglycans, glycopro- Glycerol–3–P teins, and glycolipids (see Fig. Proteoglycans are major carbohydrate compo- nents of the extracellular matrix, cartilage, and extracellular fluids (such as the syn- ovial fluid of joints), and they are discussed in more detail in Chapter 49. Most Glycerol extracellular proteins are glycoproteins, i. For both cell membrane glycoproteins and glycolipids, the carbohy- PEP drate portion extends into the extracellular space. Alanine All cells are continuously supplied with glucose under normal circumstances; the body maintains a relatively narrow range of glucose concentration in the blood Pyruvate Lactate (approximately 80-100 mg/dL) in spite of the changes in dietary supply and tissue demand as we sleep and exercise. Low blood glucose levels (hypoglycemia) are prevented by a release of glucose from the OAA large glycogen stores in the liver (glycogenolysis); by synthesis of glucose from lac- TCA tate, glycerol, and amino acids in liver (gluconeogenesis) (Fig. Production of blood glucose from glycemia) are prevented both by the conversion of glucose to glycogen and by its glycogen (by glycogenolysis) and from ala- conversion to triacylglycerols in liver and adipose tissue. Thus, the pathways for nine, lactate, and glycerol (by gluconeogene- glucose utilization as a fuel cannot be considered as totally separate from pathways sis). PEP phosphoenolpyruvate; OAA involving amino acid and fatty acid metabolism (Fig. Overview of the major pathways of glucose metabolism. Pathways for production of blood glucose are shown by dashed lines. FA fatty acids; TG triacylglycerols; OAA oxaloacetate; PEP phosphoenolpyruvate; UDP-G UDP-glucose; DHAP dihydroxyacetone phosphate. Intertissue balance in the utilization and storage of glucose during fasting and feeding is accomplished principally by the actions of the hormones of metabolic homeostasis—insulin and glucagon (Fig. However, cortisol, epinephrine, nor- epinephrine, and other hormones are also involved in intertissue adjustments of supply and demand in response to changes of physiologic state. Glucagon release Blood glucose Insulin release Glycogenolysis Glycogen synthesis Gluconeogenesis Fatty acid synthesis Lipolysis Triglyceride synthesis Liver glycolysis Liver glycolysis Fig 10. Pathways regulated by the release of glucagon (in response to a lowering of blood glucose levels) and insulin (released in response to an elevation of blood glucose levels). Tissue-specific differences occur in the response to these hormones, as detailed in the subse- quent chapters of this section. Insulin and glucagon are Brain the two major hormones that regulate fuel mobilization and storage. Their func- tion is to ensure that cells have a constant source of glucose, fatty acids, and [ATP] amino acids for ATP generation and for cellular maintenance (Fig. Because most tissues are partially or totally dependent on glucose for ATP generation and for production of precursors of other pathways, insulin and glucagon maintain blood glucose levels near 80 to 100 mg/dL (90 mg/dL is the Glucose same as 5 mM), despite the fact that carbohydrate intake varies considerably over the course of a day. The maintenance of constant blood glucose levels (glucose homeostasis) requires these two hormones to regulate carbohydrate, lipid, and Liver amino acid metabolism in accordance with the needs and capacities of individual Ketone bodies tissues. Basically, the dietary intake of all fuels in excess of immediate need is stored, and the appropriate fuel is mobilized when a demand occurs. For example, when dietary glucose is not available in sufficient quantities that all tissues can use it, fatty acids are mobilized and made available to skeletal muscle for use as a fuel (see Chapters 2 and 23), and the liver can convert fatty acids to ketone bod- Fatty [ATP] ies for use by the brain. Fatty acids spare glucose for use by the brain and other acids glucose-dependent tissues (such as the red blood cell). Skeletal The concentrations of insulin and glucagon in the blood regulate fuel storage Adipocyte muscle and mobilization (Fig. Insulin, released in response to carbohydrate inges- tion, promotes glucose utilization as a fuel and glucose storage as fat and glyco- gen. Insulin is also the major anabolic hormone of the body.
The hip on the side to be measured is then flexed to 90° and the knee slowly extended until the pelvis starts to move purchase 100mg viagra super active with amex erectile dysfunction 23. This is the point when the angle should be measured. The measurement of the popliteal angle is not the angle at the point of maxi- mum knee extension because this only meas- ures how much the knee can extend with maximum pelvic rotation. Ankle dorsiflexion needs to be measured both with the knee in full extension as shown in this image, and the dorsiflexion should be measured with the knee flexed at least 45° to relax the gastrocnemius muscle. The measurement with the knee extended measures the length of the gastrocnemius muscle, and ankle dorsiflexion with the knee flexed measures the soleus length. In normal individuals, there is little difference; however, in some children with CP there is a large difference. The leg rotational profile is as- sessed with the child in the prone position and the knee flexed 90°. The thigh–foot alignment gives a measurement of the overall alignment of the leg and foot. A more specific measurement of tibial torsion is measuring the transmalle- olar to thigh angle. This age is also when a standing program should be started. Most children should be followed every 6 months for a musculoskeletal evaluation. By the time these children have scoliosis corrected at puberty, much less change occurs over time and the follow-up can be lengthened, often to 1 year or more. Usually, solid ankle-foot orthoses (AFOs) are fitted at approximately 24 months of age so weight bearing in a stander, with a goal of standing for at least 1 hour per day, can begin. Children with adequate motor control of their head should be started in a prone stander, and those who do not have good head control should be placed in a supine stander. As these children enter late childhood to prepuberty, scoliosis becomes the main concern. As these children go through puberty, their increased height and weight often make their care much more difficult for caretakers, causing anxiety about how they will be cared for as they become full adult size. This issue should be addressed by a social worker familiar with state laws and avail- able resources. Because of multiple medical problems and total custodial care requirements, the parents or caretakers often have significant periods of stress or just fatigue. Parents should be educated on the available options, espe- cially what options they have if they get to the point where they acutely can- not cope with their growing child. If available, this resource should ideally be through a prearranged respite care provider, but few of these are avail- able. The only option may be the hospital; however, it often helps the parents just to know what their options are. The problems the caretakers focus on may not be the problems the physi- cian focuses on, and often they are diametrically opposed. Nutrition and feeding are areas physicians are often concerned with, especially when a child is very small and malnourished; however, from the parents’ perspective, oral feeding of the child may be the most positive interactive experience the child and parent have. Also, the parents may be happy for the child to stay small, so that they are easier to lift and transfer. For these reasons, parents may re- sist interventions, such as gastrostomy tubes, to make the child grow heavier and make feeding easier, all of which would be very positive from the physi- cian’s perspective. Feeding, Growth, and Weight Problems A major problem for many children with CP is poor nutrition. Many pri- mary care physicians in the community do not have the physical equipment in their offices to weigh and measure children who cannot walk, and many do not have a good knowledge base or an available nutritionist to help them assess current food intake or dietary needs. Part of the evaluation in a CP clinic should be to measure the height and weight of these children. Weight is easy to get with an appropriate scale, which should always be available in this type of clinic environment. Height measurement is more difficult and less reliable for individuals who cannot stand. If scoliosis is present, stand- ing height is also not reliable.
There- fore buy viagra super active 50 mg on line impotence from anxiety, hip rotation and tibial torsion have to always be compared with the physical examination and with the knee varus-valgus measures on the kine- matics as an assurance of accuracy. If the knee joint axis is incorrect, the knee will demonstrate increased varus-valgus movement as the knee flexes. There also needs to always be a careful evaluation of EMG patterns with the thought that leads may have gotten switched. If the pattern is really confus- ing, consider lead mix-up as a possibility and have the EMG repeated. Complications of Surgery Planning Complications of surgery planning are mostly related to not identifying all the problems or misinterpreting a compensatory problem for a primary prob- lem. A common example of missing problems is not identifying the spastic rectus in the crouched gait pattern, missing internally rotated hips in children with an ipsilateral posterior rotation of the pelvis, and missing internal tibial torsion when there is severe planovalgus deformity that needs to be corrected (Case 7. Some common misinterpreted secondary problems are the mid- stance phase equinus on the normal side of a child with hemiplegia, hip flexor weakness in children with increased hip flexion and anterior pelvic tilt but high lordosis as they rest on the anterior hip capsule, weakness of the quad- riceps as a cause of crouch, and intraarticular knee pathology as a cause of knee pain in adolescents with crouched gait. Many decisions on specific data are somewhat arbitrary, but having the data is an excellent way to develop an understanding of what the data mean. As a clinical decision is made, the result is then evaluated after the rehabilitation period, and understanding of the significance of the data is developed. Also, some of the errors in inter- pretation are related to not taking natural history into account. An example is the response of the common equinovarus foot position seen in early child- hood. If these children are diplegic, the natural history is for this deformity 376 Cerebral Palsy Management Case 7. Following the rehabilitation, cern that she was having trouble controlling her feet. Ac- she was taught to use Lofstrand crutches, with which she cording to her mother she had made good progress in her became proficient. Her main problem after the rehabili- walking ability in the past 3 months. Her hip radiographs tation was a severe stiff knee gait, but because of the were normal. She was continued in her physical therapy trauma of the surgery, neither she nor her mother was program to work on balance and motor control issues. This case is also a good example of She continued to make good progress until age 6 years, a family that is happy because of the excellent gains, even when she plateaued in her motor skills development. At though the surgeon would grade this outcome as dis- that time she had a full evaluation. On physical exami- appointing because of the severe stiff knee gait, which nation she was noted to have hip abduction of 25°, and should have been treated at the initial procedure. Hip external rotation was 5° on the right and 12° on the left. Popliteal angles were 65° on the right and 73° on the left. Extended knee ankle dorsiflexion was −8° on the right and −10° on the left. Flexed knee ankle dorsiflexion was 5° on the right and 3° on the left. Observation of her gait demonstrated that she was efficient in ambulating with a posterior walker. However, she had severe internal rotation of the hips, with knee flexion at foot contact and in midstance, and a toe strike without getting flat foot at any time. The kinematics confirmed the same and the EMG showed sig- nificant activity in swing phase of the rectus muscles. There was minimal motion at the knee with ankle equi- nus and lack of hip extension and internal rotation of the hip (Figure C7. She had femoral derotation osteo- tomies, distal hamstring lengthenings, and gastrocnemius lengthenings. A rectus transfer was also recommended, but because of the fear of causing further crouch, she did Figure C7.
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