physical therapy

PHYSICAL

THERAPY

MR. JAYESH PATIDAR

www.drjayeshpatidar.blogspot.com

CONCEPT…

• Physical therapies are treatment

approaches that use physiologic or

physical interventions to effect

behavioral change.

• The most common form of physical

therapies are: Electroconvulsive

therapy, light therapy, repetitive

transcranial magnetic stimulation

4/24/2013 www.drjayeshpatidar.blogspot.co

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ELECTROCONVULSIVE

THERAPY


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INTRODUCTION…

• Electroconvulsive therapy is a type of

somatic treatment, first introduced by Bini &

Cerletti in April 1938.

• From 1980 onwards ECT is being

considered as a unique psychiatric

treatment.


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DEFINITION

• ECT is a type of somatic treatment in

which electric current is applied to the

brain through electrodes placed on the

temples of the patient. The passage of

an electrical stimulus of 70 to 120 volts

to the brain for 0.7 to 1.5 second to

produce a grandmal seizures.


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MECHANISM OF ACTION

• The exact mechanism of action is not

known.

• One hypothesis states that ECT possibly

affects the catecholamine pathways

between diencephalon (from where seizure

generalization occurs) & limbic system

(which may be responsible for mood

disorders), also involving the

hypothalamus.


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TYPES / TECHNIQUES / METHODS

OF ECT

1. Direct ECT

2. Modified ECT


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1. Direct ECT:

• In this, ECT is given in the absence of

anesthesia & muscular relaxation.

• This is not commonly used method

now.


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2. Modified ECT:

• In this, ECT is modified by drug-

induced muscular relaxation, general

anesthesia & oxygenation.

• Administer the anesthetic agent

(thiopental sodium 3-5mg/kg body

weight) & muscle relaxant (1mg/kg

body weight of succynylcholine)


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PLACEMENT OF ELECTODES

• There are two types of administration:

1. Bilateral ECT

2. Unilateral ECT


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1. Bilateral ECT:

• Each electrode is placed 2.5-4 cm (1-

1½ inch) above the midpoint, on a line

joining the tragus of the ear & the

lateral canthus of the eye.


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2. Unilateral ECT:

• Electrodes are placed only on one side

of head, usually non-dominant side

(right side of head in a right-handed

individual).

• Unilateral ECT is safer, with much

fewer side-effects particularly those of

memory impairment.


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PARAMETERS OF ELECTRICAL

CURRENT APPLIED

Standard dose according to American

Psychiatric Association,1978:

• Voltage – 70 – 120 volts

• Duration – 0.7 – 1.5 seconds


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FREQUENCY AND TOTAL NUMBER

OF ECT

• Frequency: Three times per week

or as indicated.

• Total number: 6 to 10; upto 25 may

be preferred as indicated.


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OBSERVATION OF PRODUCTION OF

SEIZURE

• The production of grandmal seizure is

necessary for direct & modified ECT.

• In direct ECT, the Tonic Phase that is

muscle contractions last for 10-15 second

approximately. The Clonic Phase that is

movement or convulsion lasts for 30 to 60

seconds approximately. Than patients goes

in to the Relaxation Phase. The physician

can see changes in ECG also


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• In modified ECT, mild grimace or

blepharo-spasm ( a tonic spasm of the

eyelid muscle) is observed when the

current is applied. There is a slow planter

flexion (reverse Babinski's) during the

tonic phase & there are fine movements of

the toes during the Clonic phase.


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INDICATIONS OF ECT

I. Major Depression:

- With suicidal risk

- With stupor; poor intake of food & fluids

- Melancholia with psychotic features

- Post-partum depression

- Unsatisfactory response to drugs or where

drugs are contraindicated or have serious

side effects


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II. Severe catatonia (functional):

- With stupor; poor intake of food &

fluids

- Unsatisfactory response to drug

therapy, or when drugs are

contraindicated or have serious side

effects.

- When speedier recovery is needed


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III. Severe psychosis (schizophrenia or

mania):

- With risk of suicide, homicide or danger

of physical assault

- Depressive features

- Unsatisfactory response to drug therapy,

or when drugs are contraindicated or

have serious side effects.


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IV.Organic mental disorders:

- Organic mood disorders

- Organic psychosis


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V. Other indications:

- Premorbid personality

- Previous depressive episode

- Paranoid delusion

- Anorexia

- Early morning insomnia

- Wight loss

- Lack of concentration

- Ideas of guilt & worthlessness

- Suicidal thought & suicidal attempts


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- ECT is preferred to antidepressant therapy

in some cases, such as for patient with

cardiac disease; when tricyclics are

contraindicated because of the potential for

dysrhythmias & congestive heart failure; &

for pregnant women, in whom

antidepressants place the fetus at risk for

congenital defects


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CONTRAINDICATIONS OF ECT

A. Absolute:

• Raised ICP

(intracranial

pressure)

B. Relative:

• Cerebral aneurysm

• Cerebral hemorrhage

• Brain tumor

• Acute myocardial infarction

• Congestive heart failure

• Pneumonia or aortic aneurysm

• Retinal detachment

• CVA

• Hypertension

• Thrombophelebitis

• bleeding disorder 4/24/2013 www.drjayeshpatidar.blogspot.co

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SIDE EFFECTS OF ECT

• Memory impairment

• Drowsiness, confusion & restlessness

• Poor concentration, anxiety

• Headache, weakness/fatigue, backache,

muscle aches

• Dryness of mouth, palpitation, nausea, vomiting

• Unsteady gait

• Tongue bite & incontinence


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COMPLICATION OF ECT

1. Fractures & dislocations

2. Complication in the respiratory system

3. Other complication


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1. Fractures & dislocations:

Most frequently the fracture & dislocation are

caused by muscular contraction due to ECT

Compression fracture of vertebrae of dorsal area

between the 2nd & 8th usually 3rd , 4th & 5th

vertebrae is common.

Fracture of femur & humerus occurs in young

muscular individuals.

Dislocation of jaw is the most frequent

complication of the tonic phase.


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2. Complication in the respiratory system:

Apnea

Respiratory arrest


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3. Other complication:

Headache, backache, painful mastication, injury

of mouth & tongue.

Fear due to an unpleasant experience on

walking up after the treatment.

Stuns & subshocks occur due to an insufficient

current applied to the patient which does not

result in a full convulsive stage. These

subshocks or stuns will sometimes produce

cardiac irregularities, respiratory distress &

collapse.


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ECT TEAM

• Psychiatrist

• Anesthesiologist

• Trained nurses & aides


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TREATMENT FACILITIES

There should be a suite of three rooms:

1. A pleasant, comfortable waiting room (pre-ECT

room).

2. ECT room, which should be equipped with ECT

machine & accessories, an anesthetic appliance,

suction apparatus, face masks, oxygen cylinders

with adjustable flow valves, curved tongue

depressors, mouth gags, resuscitation apparatus

& emergency drugs. There should be immediate

access to defibrillator.

3. A well-equipped recovery room.


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ROLE OF THE NURSE

A. Pre-treatment Evaluation

B. Intra-procedure Care

C.Post-procedure Care


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A. Pre-treatment Evaluation:

• Detailed medical & psychiatric history, including

history of allergies.

• Assessment of patients’ & families knowledge of

indications, side-effects, therapeutic effects &

risks associated with ECT.

• An informed consent should be taken. Allay any

unfounded fears & anxieties regarding the

procedure.

• Assess baseline vital signs.

• Patient should be on empty stomach for 4-6

hours prior to ECT.4/24/2013 www.drjayeshpatidar.blogspot.co

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• Withhold night doses of drugs, which increase seizure

threshold like diazepam, barbiturates &

anticonvulsants.

• Withhold oral medications in the morning .

• Head shampooing in the morning since oil causes

impedance of passage of electricity to brain.

• Any jewellery, prosthesis, dentures, contact lens,

metallic objects & tight clothing should be removed

from the patient’s body.

• Empty bladder & bowel just before ECT.

• Administration of 0.6 mg atropine IM or SC 30 minutes

before ECT, or IV just before ECT.4/24/2013 www.drjayeshpatidar.blogspot.co

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B. Intra-procedure Care:

• Place the patient comfortably on the ECT table in

supine position.

• Stay with the patient to allay anxiety & fear.

• Assist in administering the anesthetic agent

(thiopental sodium 3-5 mg/kg body weight) & muscle

relaxant (1 mg/kg body weight of succynylcholine).

• Since the muscle relaxant paralyzes all muscles

including respiratory muscles, patient airway should

be ensured & ventilatory support should be started.

• Mouth gag should be inserted to prevent possible

tongue bite.


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• The place(s) of electrode placement should be

cleaned with normal saline or 25% bicarbonate

solution, or a conducting gel applied.

• Monitor voltage, intensity & duration of electrical

stimulus given.

• Monitor seizure activity using cuff method.

• 100% oxygen should be provided.

• During seizure monitor vital signs, ECG, oxygen

saturation, ECG, etc.

• Record the findings & medicines given in the

patient’s chart4/24/2013 www.drjayeshpatidar.blogspot.co

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C. Post-procedure Care:

• Monitor vital signs.

• Continue oxygenation till spontaneous respiration starts.

• Assess for post-ictal confusion & restlessness.

• Take safety precautions to prevent injury (side-lying position &

suctioning to prevent aspiration of secretions, use of side rails

to prevent falls).

• If there is severe post-ictal confusion & restlessness, IV

diazepam may be administered.

• Reorient the patient after recovery & stay with him until fully

oriented.

• Document any findings as relevant in the patient’s record.


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LIGHT

THERAPY


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CONCEPT…

• Light therapy sometimes called

phototherapy involves exposing the

patient to an artificial light source during

winter months to relieve seasonal

depression.

• The light source must be very bright,

full-spectrum light, usually 2,500 lux.


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INDICATIONS

• Bulimia

• Sleep maintenance insomnia

• Seasonal depression


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ADVERSE EFFECTS

• Nausea

• Eye irritation

• Headache


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CONTRAINDICATIONS

• Glaucoma

• Cataract

• Use of photosensitizing medications.


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NURSE’S ROLE

• The patient is instructed to sit in front of

the light at a distance of about 3 feet,

engaging in a variety of the other

activities but glancing directly into the

light every few minutes.

• The duration of administration is 1-2 hrs

daily.


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REPETITIVE

TRANSCRANIAL

MAGNETIC

STIMULATION


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REPETITIVE TRANSCRANIAL

MAGNETIC STIMULATION:

• Transcranial Magnetic Stimulation (TMS) or

Repetitive Transcranial Magnetic Stimulation

(RTMS) produces a magnetic field over the brain,

influencing brain activity.

• TMS increases the release of neurotransmitters &

downregulates bets-adrenergic receptors, thus

ameliorating depressive symptoms & other

disorders.

• Because TMS does not require anesthesia, it is

an attractive alternative to ECT if convulsive

evidence of its efficiency can be demonstrated.


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• Some studies have suggested that it is as

effective as ECT in non-psychotic patients.

• Adverse effects include seizures in

previously seizure-free individuals,

headache, & transient hearing loss.

• Patient with metal implanted in their bodies

(for example, plates), pacemakers, heart

disease or increased intracranial pressure

should be carefully evaluated before

receiving TMS 4/24/2013 www.drjayeshpatidar.blogspot.co

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Thank

You


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physical therapy

Education