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PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:005 Revision: 01 Page: 1 of 74

PHYSICAL THERAPY MANAGEMENT OF GERIATRIC AND AGED CONDITIONS

NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons

Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.

Medicine: It’s a noble profession, It serves humanity

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SPEC. BY: Abdulrehman S. Mulla DATE: 03/25/2009 REVISION HISTORY REV.

DESCRIPHYSICAL

THERAPYION

CN No.

BY

DATE

01 Initial Release PHYSICAL THERAPY0005 ASM 03/28/2009






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TABLE OF CONTENTS PAGE 1.0 GERIATRIC PHYSICAL THERAPY: ................................................................................................................................................................ 5

RESISTANCE EXERCISE...........................................................................................................................................................7 2.0 PHYSICAL THERAPY FOR ARTHRITIS: ........................................................................................................................................................ 9

1.1 SIGNS AND SYMPHYSICAL THERAPYOMS OF ARTHRITIS:...................................................................................................... 9 1.1.1 WHAT IS TO BE DONE WHEN YOU SUSPECT SYMPTOMS OF ARTHRITIS: ........................................................... 9

1.2 PHYSICAL THERAPY AND EXERCISE:....................................................................................................................................... 10 1.2.1 TYPES OF EXERCISE: ................................................................................................................................................. 10

A. STRENGTHENING EXERCISES: ..........................................................................................................................11 B. ENDURANCE OR AEROBIC EXERCISES: ...........................................................................................................11

1.2.2 OTHER THERAPIES: .................................................................................................................................................... 11 A. HEAT THERAPY:....................................................................................................................................................11 B. COLD THERAPY: ...................................................................................................................................................12 C. WATER THERAPY(Aquatic Therapy): ...................................................................................................................12

I. SHALLOW END: .............................................................................................................................................13 II. DEEP END: ....................................................................................................................................................13

D. Beneficiaries of the Aquatic Physical Therapy:.......................................................................................................14 E. MASSAGE: .............................................................................................................................................................15

I. KNEE & ANKLE PAIN MASSAGE: .................................................................................................................16 II. WRIST, PALM, BACK OF THE PALM & FINGERS MASSAGE: ...................................................................16 III. FOOT MASSAGE: ..........................................................................................................................................16

F. TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION): .................................................................17 1.3 BRACING: ...................................................................................................................................................................................... 18 1.4 ADVANCED NON-INVASIVE TREATMENT FOR ARTHRITIS PAIN............................................................................................ 19

1.4.1 INDICATIONS: ............................................................................................................................................................... 19 1.4.2 MUSCLE STIMULATION: .............................................................................................................................................. 19

2.0 PHYSICAL THERAPY FOR OSTEOPOROSIS TREATMENT: ..................................................................................................................... 20 2.1 OSTEOPOROSIS: ......................................................................................................................................................................... 20

2.1.1 OSTEOPOROSIS TREATMENT: ADVANTAGES OF PHYSICAL THERAPY:............................................................. 20 2.2 OSTEOPOROSIS TREATMENT: .................................................................................................................................................. 21

2.2.1 PHYSICAL THERAPY REHAB AFTER A FRACTURE: ................................................................................................ 21 2.2.2 EMOTIONAL REHAB:.................................................................................................................................................... 23 2.2.3 PHYSICAL THERAPY REHAB BEFORE A FRACTURE: ............................................................................................. 23

3.0 PHYSICAL THERAPY FOR CANCER: .......................................................................................................................................................... 24 3.1 MULTIPLE MYELOMA:.................................................................................................................................................................. 24 3.2 BONE MARROW TRANSPLANT/PER IPHERAL BLOOD STEM CELL TRANSPLANT: ............................................................. 25 3.3 LONG-TERM FOLLOW-UP PATIENTS......................................................................................................................................... 25 3.4 BREAST CANCER:........................................................................................................................................................................ 26

3.4.1 FOR LYMPHEDEMA TREATMENT, PT’s OFFER THE FOLLOWING SERVICES: ..................................................... 27 3.5 MELANOMA:.................................................................................................................................................................................. 30 3.6 FOR LYMPHEDEMA TREATMENT, PT’s OFFER THE FOLLOWING SERVICES: ..................................................................... 32 3.7 HEAD AND NECK CANCER:......................................................................................................................................................... 32 3.8 PROSTATE CANCER:................................................................................................................................................................... 33 3.9 LUNG CANCER: ............................................................................................................................................................................ 34

3.9.1 LUNG CANCER PHYSIOTHERAPY: ............................................................................................................................ 35 3.10 SARCOMA: .................................................................................................................................................................................... 36

3.10.1 FOR LYMPHEDEMA TREATMENT, PT’s OFFER THE FOLLOWING SERVICES: ..................................................... 36 4.0 ALZHEIMER'S DISEASE: .............................................................................................................................................................................. 37

4.1 RISK FACTORS:............................................................................................................................................................................ 38 4.1.1 KNOWN RISK FACTORS:............................................................................................................................................. 38 4.1.2 POTENTIAL CONTRIBUTING FACTORS:.................................................................................................................... 39 4.1.3 HEREDITY AND ALZHEIMER'S DISEASE: .................................................................................................................. 40

4.2 PHYSICAL THERAPY FOR ALZHEIMER'S DISEASE:................................................................................................................. 40 4.2.1 BEGINNER: ................................................................................................................................................................... 41 4.2.2 INTERMEDIATE: ........................................................................................................................................................... 41 4.2.3 CORE STRENGTHENING:............................................................................................................................................ 41 4.2.4 WALL SLIDES: AN EFFECTIVE QUAD STRENGTHENING EXERCISE..................................................................... 41

A. HOW TO DO A WALL SLIDE .................................................................................................................................41 4.2.5 ABDOMINAL MUSCLES................................................................................................................................................ 42 4.2.6 STRETCHING EXERCISES: ......................................................................................................................................... 42

5.0 PHYSICAL THERAPY FOR HIP AND JOINT REPLACEMENT: ................................................................................................................... 43 5.1 WHAT IS HIP REPLACEMENT: .................................................................................................................................................... 43






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5.1.1 THE "NORMAL" HIP: ..................................................................................................................................................... 44 5.1.2 WHEN IS A HIP REPLACEMENT NEEDED? ............................................................................................................... 44

A. OSTEOARTHRITIS:................................................................................................................................................44 B. RHEUMATOID ARTHRITIS: ...................................................................................................................................45 C. TRAUMATIC ARTHRITIS: ......................................................................................................................................45 D. AVASCULAR NECROSIS: .....................................................................................................................................46 E. OTHER REASONS:................................................................................................................................................46

5.2 PHYSICAL THERAPY AFTER HIP REPLACEMENT:................................................................................................................... 47 5.2.1 HEEL SLIDES: ............................................................................................................................................................... 47 5.2.2 STRAIGHT LEG RAISES:.............................................................................................................................................. 47 5.2.3 GLUTEAL SETS: ........................................................................................................................................................... 48

A. ANKLE PUMPS:......................................................................................................................................................48 B. QUAD SETS: ..........................................................................................................................................................48 C. GLUTEAL SQUEEZES: ..........................................................................................................................................48 D. Heel Slides: .............................................................................................................................................................48 E. SHORT ARC QUADS: ............................................................................................................................................48 F. HIP ABDUCTION: ..................................................................................................................................................48 G. LONG ARC QUADS:...............................................................................................................................................48

5.2.4 STANDING EXERCISES: .............................................................................................................................................. 49 A. STANDING KNEE RAISES: ...................................................................................................................................49 B. STANDING HIP ABDUCTION: ...............................................................................................................................49 C. STANDING HIP ABDUCTION: ...............................................................................................................................49 D. STANDING HIP EXTENSIONS: .............................................................................................................................49 E. WALKING AND EARLY ACTIVITY: ........................................................................................................................49 F. WALKING WITH WALKER, FULL WEIGHT BEARING: ........................................................................................49 G. WALKING WITH CANE OR CRUTCH:...................................................................................................................49 H. STAIR CLIMBING AND DESCENDING: ................................................................................................................50 I. ADVANCED EXERCISES AND ACTIVITIES: ........................................................................................................50

5.2.5 ELASTIC TUBE EXERCISES........................................................................................................................................ 50 A. RESISTIVE HIP FLEXION:.....................................................................................................................................50 B. RESISTIVE HIP ABDUCTION: ...............................................................................................................................50 C. RESISTIVE HIP EXTENSIONS: .............................................................................................................................50 D. EXERCYCLING: .....................................................................................................................................................50 E. WALKING:...............................................................................................................................................................50

6.0 BALANCE DISORDERS: ............................................................................................................................................................................... 51 6.1 HOW DOES THE BALANCE SYSTEM WORK? ........................................................................................................................... 51 6.2 WHAT ARE THE SYMPTOMS OF A BALANCE DISORDER? ..................................................................................................... 53 6.3 WHAT CAUSES A BALANCE DISORDER?.................................................................................................................................. 53 6.4 WHAT ARE SOME TYPES OF BALANCE DISORDERS?............................................................................................................ 54 6.5 HOW ARE BALANCE DISORDERS DIAGNOSED? ..................................................................................................................... 55 6.6 HOW ARE BALANCE DISORDERS TREATED? .......................................................................................................................... 56 6.7 HOW CAN THE PATIENT HELP THE DOCTOR MAKE A DIAGNOSIS?..................................................................................... 56 6.8 HOW ARE BALANCE DISORDERS TREATED? .......................................................................................................................... 56

6.8.1 OFFICE TREATMENT OF BPPV: ................................................................................................................................. 56 A. THE EPLEY AND SEMONT MANEUVERS: ..........................................................................................................56 B. INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont manoeuvres)...................57 C. WHAT IF THE MANEUVERS DON'T WORK? .......................................................................................................58 D. HOME TREATMENT OF BPPV:.............................................................................................................................58 E. HOME EPLEY MANEUVER: ..................................................................................................................................59

6.9 AYURVEDA MEDICINE FOR BPPV:............................................................................................................................................. 60 6.9.1 BALANCE IS THE KEY:................................................................................................................................................. 60 6.9.2 PRAKRITI AND VIKRITI: ............................................................................................................................................... 60 6.9.3 THE BEEJ-BHOOMI THEORY: ..................................................................................................................................... 61 6.9.4 THE SCIENCE OF HERB COMBINING AND PROCESSING....................................................................................... 61 6.9.5 SCIENTIFIC SCRUTINY OF AYURVEDA: .................................................................................................................... 61 6.9.6 CUMULATIVE BENEFITS OF AYURVEDA:.................................................................................................................. 62

7.0 PHYSICAL THERAPY FOR INCONTINENCE:.............................................................................................................................................. 63 7.1 NORMAL URINATION: .................................................................................................................................................................. 63 7.2 THE PROCESS OF URINATION:.................................................................................................................................................. 64 7.3 FOUR TYPES OF INCONTINENCE: ............................................................................................................................................. 65

7.3.1 STRESS INCONTINENCE: ........................................................................................................................................... 65 7.3.2 URGE INCONTINENCE: ............................................................................................................................................... 65






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7.3.3 OVERFLOW INCONTINENCE: ..................................................................................................................................... 65 7.3.4 FUNCTIONAL INCONTINENCE:................................................................................................................................... 65

7.4 PHYSICAL THERAPY FOR INCONTINENCE:.............................................................................................................................. 65 7.4.1 KEGEL OR PELVIC FLOOR MUSCLE EXERCISES FOR MEN: ................................................................................. 65

A. WHAT IS THE PELVIC FLOOR?............................................................................................................................65 B. HOW DO YOU EXERCISE THESE MUSCLES? ...................................................................................................66 C. HOW DO I FIND THE RIGHT MUSCLES?.............................................................................................................66 D. HOW DO I DO THESE EXERCISES?....................................................................................................................66 E. WHERE WILL I DO THE EXERCISES? .................................................................................................................66 F. ARE THERE ANY PRECAUTIONS? ......................................................................................................................66

7.4.2 KEGEL OR PELVIC FLOOR MUSCLE EXERCISES FOR WOMEN: ........................................................................... 67 A. WHAT IS THE PELVIC FLOOR?............................................................................................................................67 B. THE PELVIC FLOOR MUSCLES: ..........................................................................................................................67 C. FACTORS CONTRIBUTING TO PELVIC FLOOR MUSCLE WEAKNESS:...........................................................67 E. HOW DO YOU STRENGTHEN MY PELVIC FLOOR MUSCLES? ........................................................................67 F. STARTING YOUR PELVIC FLOOR MUSCLE TRAINING PROGRAM: ................................................................68

8.0 HOW TO MAKE YOUR PARENTS FEEL HAPPY IN THEIR OLD AGE:....................................................................................................... 69






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1.0 GERIATRIC PHYSICAL THERAPY: From the Greek "geron" meaning "old man" + "iatreia" meaning "the treatment of disease.". Geriatric physical therapy covers a wide area of issues concerning people as they go through normal adult aging, but is usually focused on the older adult. There are many conditions that affect many people as they grow older and include but are not limited to:

Arthritis Osteoporosis Cancer Alzheimer’s disease Hip and joint replacement Balance disorders Incontinence and more.

The goals of an exercise program for individuals with the above ailments are to: 1) Preserve or restore range of motion and flexibility around affected joints, 2) Increase muscle strength and endurance, and 3) Increase aerobic conditioning to improve mood and decrease health risks associated with a sedentary lifestyle. The exercise program can be organized around the Exercise Pyramid for Patients with the above ailments, as pictured below.






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Geriatric physical therapy helps those affected by such problems in developing a specialized program to help restore mobility, reduce pain, increase fitness levels and more.

Many older adults develop functional decline and impaired walking while in the hospital. Preventing and treating hospital-related deconditioning is, therefore, of great importance. Nevertheless, most hospital exercise protocols are untested and poorly described.

Although the exact cause of hospital-related deconditioning is uncertain and the optimal type and intensity of exercise needed to prevent deconditioning is yet to be determined, many studies show that loss of muscle mass and deteriorating muscle strength occurs after several days of bed rest. Moreover, many older adults have impaired muscle strength prior to admission to the hospital. Given low baseline levels of muscle strength at the time of hospital admission, any further deterioration of strength due to bed rest may quickly cause dependency in walking and other functions. Accordingly, it appears logical to use an exercise program that specifically builds strength, such as high intensity resistance training (HIRT), to prevent hospital-related deconditioning. The crucial principle of this technique is to provide sufficient resistance to achieve muscle fatigue within 8 to 12 repetitions of an exercise.

Although the safety and efficacy of HIRT has been demonstrated with both nursing home residents and healthy older adults, the ability to use HIRT in the acute care setting is unknown. Firstly, the acuity of illness might limit the use of resistance exercise. Secondly, it is uncertain whether hospitalized older adults can exercise at a level that would have a significant effect on muscle strength and function. Finally, many studies of HIRT use costly machines that both determine the necessary resistance for each exercise and place the body in a mechanically effective position. This type of exercise equipment is not available in most hospitals, and it is unclear whether the integrity of a resistance exercise program can be maintained without it. Importantly, for frail older adults in hospital, any strengthening exercise program needs to provide enough resistance to train muscles while maintaining safe, correct posture and positioning.

Sets of resistance exercises that can be performed in hospital have been derived. The objectives of the exercise program are to:

Allow the patient to exercise from bed, for ease of administration, Provide enough resistance so that muscle fatigue occurs before 10 repetitions, Strengthen the major muscle groups of the lower extremities, Utilize safe, Effective procedures and postures, and Standardize and describe the exercise program so that it can be precisely reproduced. Patients must exercise 3 times per Week, assisted by the physiotherapist, with a rest day between sessions.

The resistance exercise program targeted the lower extremities, including the gluteal muscles, quadriceps, hamstrings, hip flexors, hip adductors/abductors, and plantar/dorsiflexors. Principles of postural alignment and correct exercise technique were stressed. Exhalation must be coordinated with the exertion phase of the exercise. Each exercise was repeated 10 times, after which the patient can repeat the set to a maximum of three sets. Patients must exercise until discharge from the hospital unit, or for a maximum of 4 Weeks. A physiotherapist must supervise all exercise sessions.

Recognizing the importance of being able to accurately incorporate any therapeutic intervention into medical practice, PT’s have detailed the exercise protocol in Table 1. HIRT techniques were adapted so that exercise could be performed in bed and without the typical equipment used in many studies of HIRT, such as Cybex or Universal machines. The exercises incorporated principles of overload and specificity, consistent with the American College of Sports Medicine guidelines for strength training. The resistance for single leg knee extension, was based on the one-repetition maximum (1RM), calculated using 1 pound increments. The 1RM is the maximum amount of Weight an exerciser can lift while maintaining correct posture. Once exercising, single leg knee extension was performed using a Weight equal to 60% to 80% of the 1RM. For the remaining strengthening exercises, resistance was achieved using Weights, Therabands (rubber tubing) or springs, selecting a Weight or length of tubing or spring that would achieve muscle fatigue within 10 repetitions. Exercises Were progressed during the study. For each subject, the physiotherapist measured the length of Theraband™






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required to cause muscle fatigue within 10 repetitions. If muscle fatigue failed to occur as the study proceeded, the theraband or spring length was shortened. Similarly, if the designated Weight for the 1RM did not cause muscle fatigue within 10 repetitions, the amount of Weight was increased. TABLE 1:

RESISTANCE EXERCISE

EXERCISE GOAL TECHNIQUE 1. Place the legs over a half-barrel (facilitates proper positioning).

2. Place a Weight on the ankle ~70% of the 1RM.

3. On exhalation, while keeping the upper leg on the barrel, extend the knee of 1 leg to a fully lengthened position.

Single leg extension (Figure 1a)

To strengthen the quadriceps muscle while maintaining proper alignment of the knee hip, and ankle. 4. LoWer the leg on the inhale.

1. Wrap a sling in a figure 8 around the foot and ankle, so that a small ring is positioned at the heel (Figure 1b).

2. Attach one end of a spring to this ring. 3. Attach the other end of the spring to the bed in line with the median sagittal plane of the leg and at a distance that will achieve muscle fatigue after 10 repetitions.

4. Lie in a supine position with the working leg flexed at a 110° angle and the resting leg extended.

5. Exhale, activate the gluteal and hamstring muscles, then move the foot as close to the buttock as possible.

Heel drag (Figure 1c) To strengthen the hamstring muscles. 6. Afterwards, on the inhale, return to the starting position.

1. Lie supine with legs over the barrel and the pelvis in a neutral position with a 4-inch piece of dense foam between the knees.

2. To activate the adductor muscles of the thigh, squeeze the foam, then simultaneously extend both legs on the exhale.

3. Return to the starting position on the inhale.

Bilateral leg extension (Figure 1d)

To strengthen the adductor muscles of the thigh and the muscles of the pelvic floor.

1. Wear a shoe or a boot with a rigid bottom.

2. Choose a length of theraband™ that will fatigue the plantarflexor muscles after 10 repetitions. Place the middle of the theraband™ around the sole of the shoe and hold the two free ends of the theraband.

3. Plantarflex the foot on the exhale.

Plantar flexion (Figure 1e) To strengthen the muscles used for plantar flexion. 4. Return to starting position on the inhale.

1. Attach a nylon circular band to one end of a spring.

2. Loop the band around the top of the foot then attach the other end of the spring to the bottom of the bed at a distance that provides enough tension to fatigue the muscle

Dorsiflexion (Figure 1f) To strengthen the muscles used for dorsiflexion.

3. Dorsiflex the foot on the exhale and return to the starting position on the inhale.

Side lying diamond (Figure 1g) To strengthen the gluteal muscles, the 1. Lie on the side, making sure that the shoulders, trunk and






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pelvis are perpendicular to the bed, with the hips and knees flexed at a 45-degree angle and the heels together. Place a Weight over the distal thigh, if necessary, to achieve the appropriate resistance.

2. While exhaling, press the heels together to engage the gluteal muscles, then open the top leg to make a diamond shape.

abductor muscles of the thigh, and the lateral rotators of the hip.

3. On the inhale, return the leg to the starting position.






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2.0 PHYSICAL THERAPY FOR ARTHRITIS:

1.1 SIGNS AND SYMPHYSICAL THERAPYOMS OF ARTHRITIS:

If you feel pain and stiffness in your body or have trouble moving around, you might have arthritis. Most kinds of arthritis cause pain and swelling in your joints. Joints are places where two bones meet, such as your elbow or knee. Over time, a swollen joint can become severely damaged. Some kinds of arthritis can also cause problems in your organs, such as your eyes or skin.

One type of arthritis, osteoarthritis, is often related to aging or to an injury. Other types occur when your immune system, which normally protects your body from infection, attacks your body's own tissues. Rheumatoid arthritis is the most common form of this kind of arthritis. Juvenile rheumatoid arthritis is a form of the disease that happens in children.

1.1.1 WHAT IS TO BE DONE WHEN YOU SUSPECT SYMPTOMS OF ARTHRITIS: The first step you need to take if you suspect you may have arthritis is to visit a qualified medical practitioner. Usually this will involve referral to a hospital where X ray and blood tests will be performed. Sometimes there will be a specialist on site who will be able to administer more advanced forms of tests and give advice on the spot. Once a diagnosis has been made, there are various treatments that can be applied. The most obvious and crude, of these treatments is the simple pain-killing drug, such as aspirin or paracetamol. Aspirin is preferred in many cases as it has anti-inflammatory properties. Many of these basic painkillers are available without prescription. Physical Therapy, so it vitally important to inform your physician if you intend to take these on top of any prescribed medicine.






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1.2 PHYSICAL THERAPY AND EXERCISE: In addition to medications, many people with arthritis can find relief from physical therapy and

exercise. Physical therapy is a treatment method that focuses on pain relief, healing, restoring function and movement, improving body mechanics, as Well as overall fitness and Wellness.

Your doctor will prescribe physical therapy as part of your treatment plan and will refer you to a physical therapist. Physical therapists are rehabilitation professionals trained in the variety of exercises and treatment Physical Therapy that are appropriate for arthritis sufferers. Your therapist will work closely with your doctor and you to develop an exercise regimen specifically for you.

Exercising can help arthritis sufferers in many ways. Exercise reduces joint pain and stiffness and increases flexibility, muscle strength and endurance. It also helps with Weight reduction, which is important since extra Weight can place too much pressure on joints.

1.2.1 TYPES OF EXERCISE: Generally there are 3 types of exercises that are appropriate for people with arthritis:

Range-of-motion exercises. These exercises should be done daily to help maintain normal joint movement, relieve stiffness and increase flexibility. Range-of-motion exercises for the spine may include bending forward, back and to each side.






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A. STRENGTHENING EXERCISES: These exercises can also be done every day (unless you have severe pain) to help increase muscle strength. Strong muscles help support and protect joints affected by arthritis. Your therapist will instruct you on proper ways to lift and flex during these exercises. Follow table 1 exercises for strengthening.

B. ENDURANCE OR AEROBIC EXERCISES:

These exercises can be done three times a Week for 20-30 minutes. They improve cardiovascular fitness, help control Weight and improve overall function. Examples include walking and bike riding.

1.2.2 OTHER THERAPIES: In addition to therapeutic exercise, your therapist may use other treatments such as:

A. HEAT THERAPY:

Warm towels or heat packs are placed on the spine to relieve pain by increasing blood flow and relaxing tissues. Which types of heat therapy are effective for arthritis pain? You can choose from the following popular types of heat therapy: Disposable heat patches or belts available at most drugstores Heated swimming pool Hot packs (you can buy some -- such as Bed Buddy -- that can be warmed in a

microwave) Moist heating pad Therapeutic mixture of paraffin and mineral oil Warm bath Warm shower Warm whirlpool or hot tub Warm, moist towel or cloth You may also sit on a stool that has rubber tips for safety while letting the warm

shower hit the affected area. The constant heat flowing on the arthritic joint or pain site helps to keep pain minimal and allows for easier movement. Many people with arthritis find good relief from pain and stiffness with hot baths or spas. The moist heat increases muscle relaxation, boosts blood supply to the site of pain, and relieves rigidity and spasms in the muscles. But avoid hot tubs or spas if you have diabetes, high blood pressure, or cardiovascular disease, or if you are pregnant.

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B. COLD THERAPY:

Ice packs or ice massage applied to painful areas of the spine to reduce sWelling and pain.

C. WATER THERAPY(Aquatic Therapy): Exercising in a large pool to reduce pressure on the spine. The heat and movement of whirlpools may also provide pain relief. Water has been used for thousands of years as a medium for exercise and healing. Aquatic (or Water) Therapy when provided by a licensed physical therapist may be considered an entity of physical therapy. Water provides a safe and supportive environment in which individuals can perform movements that would be painful or impossible if attempted Physical Therapy on land. The unique properties of the aquatic environment enable one to begin to exercise more quickly after an injury, or earlier in the rehabilitation process if limited in Weight-bearing or by pain, as Well as being used for relief of pain itself.

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I. SHALLOW END: Weight bearing load in your joints is only 50% when submerged in water to waist level. In the shallow end people thus have better tolerance for walking activities, balance retraining and lower extremity strengthening exercises compared to on land. In addition, PT’s can use the viscosity and turbulence of water to get people in a position where their balance is challenged. Also note that the increased hydrostatic pressure around the body helps to reduce or control swelling in the joints and to relieve pain. Assisted flotation is also possible in the shallow end and can be used for relaxation or exercise techniques.

II. DEEP END: When performing deep-water exercises PT’s use a specialized flotation belt that suspends you in the water. When you are submerged in water to shoulder Physical Therapy, 90 % of your body Weight is removed due to the buoyancy of water. This "unloading" provides decompression and reduced shearing of the spine and other joints allowing for greater ease of movement with less pain. In addition, the core muscles are activated and strengthened when you are asked to balance the centre of buoyancy over the center of gravity by staying vertical (vertical stability exercises). It is a unique challenge to be still in the water versus moving in the water (swimming)! Improved body awareness, postural control and restoration of functional movement patterns are skills a person gains while activating these core stabilizing muscles, and they translate Well to land-based stability programs, such as those given for home programs or those done using a "Swiss ball". An added benefit is that aquatic therapy involves use of the entire body, not just the injured part, thereby enhancing overall fitness. Deep water conditioning activities can be utilized to improve or maintain cardiovascular health with less strain on joints, either for general health or for returning to a specific sport. For example, a high school athlete with a knee sprain can work out in the aquatic environment to maintain his or her level of fitness while the injury heals and therapy progresses, until they are ready to return to the field.

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Other beneficial properties of water therapy include:

Hydrostatic pressure - helps decrease sWelling and improve venous blood flow back to the heart.

Viscosity - can be utilized to either assist, support or resist movement. Performing exercises against the resistance of the water is a great way to strengthen muscles and build bone mass without stressing the joints.

FUN - Exercises performed in the pool are usually a fun and social experience that make it easy to continue even when formal treatment is complete.

D. Beneficiaries of the Aquatic Physical Therapy: Anyone with: Osteoarthritis Rheumatoid Arthritis Joint Replacement Surgery Arthroscopic Surgery Low Back Pain Fibromyalgia Parkinson's Disease Tendonitis Multiple Sclerosis Idiopathic Joint Pain Balance Disorders Scoliosis Stroke Sprains and Strains TBI/SCI

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E. MASSAGE: Can help increase flexibility and circulation. Be sure to find a trained professional who is experienced in treating people with arthritis.






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I. KNEE & ANKLE PAIN MASSAGE: Arthritis causes a lot of painful knee problems. There are some things you can do for yourself that can make a big difference.

1. The first step with any inflammation is to cool it down with ice. In the case of a sports injury ice for 10-15 minutes on and off is a great first step. I don't recommend ice for arthritis.

2. Next comes warmth from massage or a heating pad. Actually both is best. First warm up the knee for a few minutes and then massage the oil you have bought into the knee using circular friction movements. Massaging in this fashion suits the shape of the knee. You can do it for yourself or if you are lucky ask a friend. Professional massage is best.

3. The massaging of the knee will not cause pain. Make sure it is oiled enough not to irritate the skin. Work all around the knee for at least 15 minutes. Now try to walk and see how you feel. You can do this as often as you want. It speeds up recovery. In the sports stadiums the work on the injured football, basketball, hockey and baseball players on and off all day which is why they get better so quickly.

II. WRIST, PALM, BACK OF THE PALM & FINGERS MASSAGE: 1. Use one hand to flex the wrist of your other hand. Work your thumb into your wrist

joint, then up the outside of your hand and up each finger. Repeat on the other side.

2. Using your thumb, press firmly on your palm. Work your way across the inside of your hand. Repeat on the other side.

3. Run your thumb down the back of your hand from your wrist to your knuckles, pressing in between the bones of your hand. Repeat on the other side.

4. Gentle pull each finger and massage each joint of your fingers and thumb, both from the side of the joint and on top of each joint. Repeat on the other side.

III. FOOT MASSAGE: 1. Start by soaking your feet in warm water for 5 to 10 minutes. You may add scented oil

if desired. This will help clean and warm the feet and provide aromatherapy if scented oil was added to the water. Dry your feet with a warm toWel.

2. Lay or sit back and start to relax. The feet and legs should be supported by a surface (massage table, sofa or bed) or by the person giving the foot massage. Massage one foot at a time. Keep the other foot wrapped in a towel to keep the foot warm.

3. You may use oil or lotion for the foot massage. Run warm water over your hands to warm them before beginning the foot massage. Rub the oil or lotion over the entire foot to above the ankle.

4. You want to warm up the foot by doing some basic stretches. Gently stretch the foot up and down and around in circles. One hand should be cupping and supporting the heel and one hand should be moving the foot at the ankle joint.

5. Place the foot back down onto the supporting surface. Now squeeze the foot with both hands starting at the toes and work your way up to above the ankles and back down. One hand should be grasping the inside of the foot and one hand the outside of the foot.

6. Instead of squeezing, you are now going to use both hands and twist the foot in opposite directions starting at the toes and working up to the ankles and back down. One hand should be on the inside of the foot and one hand on the outside of the foot.






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7. The foot should be warmed up and now it is time to do strokes. Use the fingers of both hands to do strokes on the top of the foot and use your thumbs to do strokes on the bottom of the foot. Again, start at the toes and work up to the ankles and back down. Try to find the grooves between the bones and tendons of your feet and apply the strokes in those areas. Don't forget the areas around the anklebones.

8. Next, turn your focus toward the toes. Find the areas where the bases of your toes bend (metatarsalphalangeal joints), with your fingers on top of the foot and your thumb on the bottom, make circular motions at these areas for toes 1 through 5.

9. Starting with toe number five (little toe), use your index and middle finger on top of the toe and your thumb on the bottom and start at the base of the toe and massage to the tip of the toe then make a circle with the toe. Follow that by gently pulling on the toe, you may hear the toe pop. Do this for all five toes, ending with the big toe.

10. Continue with the toes by running your four fingers of one hand into the four interspaces of the toes. You can start from the top of the foot or the bottom. Do several gentle back and forth movements. Finish the toes by using your index finger on top and your thumb on the bottom and gently massaging the toe interspaces, then stroke the interspaces by pulling your index finger and thumb towards you.

11. Now, you should focus on the bottom of the foot. Start with your thumbs and make circular motions, then do strokes both up and down and side to side. For a little more pressure, you can use your knuckles and knead the bottom of the foot.

12. Finish the foot massage by doing light strokes with your fingers on top of the foot and your thumbs on the bottom of the foot and starting at the toes and working up above the ankles.

F. TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION): This is a technique that directs small pulses of electricity to specific nerves. The aim is to reduce the sensitivity of nerve endings in the spinal cord, thereby closing the pain "gates." Although TENS is not effective in all arthritis sufferers, some people find it to be a practical means of pain control. The procedure, which produces a tingling sensation at the site of the electrical pads, has few side effects. (Some people have reported allergic reactions to the jelly used to apply the pads.) TENS instruction usually is provided by a physiotherapist, who can explain how to position the pads, select the correct electrical frequency and pulse strength, and time how long the treatment should last. Many people continue their exercise programs even after their prescribed physical therapy is finished. Your therapist will instruct you on the proper ways to do your exercises at home and give you tips on how to continue your treatment on your own.






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1.3 BRACING: Another area of treatment for arthritis pain involves the use of braces or "assistive devices" to help

support your back and/or relieve pain. Spinal bracing can help control back pain by limiting motion and relieving pressure on the vertebrae. Your doctor will let you know if bracing is an Physical Therapy for you. In addition, devices such as canes, splints or walkers may also help you get around easier and with less pain.

Orthotics, Lumbar (LoWer Back) Braces, Cervical (Neck) Braces, Wrist Braces, Ankle Braces,

Knee Braces,

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1.4 ADVANCED NON-INVASIVE TREATMENT FOR ARTHRITIS PAIN. The answer to pain from osteoarthritis is here; Horizontal Therapy. Patented technology that

relieves over 80% of your patients with pain from osteoarthritis. This safe, effective, and easy to use modality is available to your practice now with no out-of-pocket expense. Being non-invasive and having no negative side effects when used correctly this revolutionary treatment enables you to expand and retain your patient base.

1.4.1 INDICATIONS: Pain Management For adjunctive use in post traumatic pain syndromes For management and symptomatic relief of chronic (long term) pain As an adjunctive treatment in the management of post surgical pain problems

1.4.2 MUSCLE STIMULATION: Relaxation of muscle spasms Prevention or retardation of tissue atrophy Increasing blood circulation Muscle re-education Immediate post surgical stimulation of calf muscles to prevent phlebothrombosis Maintaining or increasing range of motion Stimulate peripheral nerves for the purpose of providing pain relief Stimulate motor nerves for the purpose of muscle rehabilitation

EMS devices should only be used under medical supervision for adjunctive treatment of

medical diseases and conditions.






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2.0 PHYSICAL THERAPY FOR OSTEOPOROSIS TREATMENT: 2.1 OSTEOPOROSIS:

Is a condition characterized by progressive loss of bone density, thinning of bone tissue and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

Both the diagnosis of osteoporosis and a bone fracture can have a paralyzing effect: You might find that you are scared to engage in activities that could potentially cause a new fracture or injury. Fortunately, following a rehabilitation treatment plan outlined and supervised by a physical therapist can not only getting you back on your feet, but also help you feel confident about doing so.

2.1.1 OSTEOPOROSIS TREATMENT: ADVANTAGES OF PHYSICAL THERAPY: “If a person is afraid of falling or they are afraid of having another fracture, that’s a specific time when they need to get to a physical therapist (physical therapy) because a physical therapy can help divide the world into very safe activity and activity that is more likely to cause a fracture”.

“Physical therapists can help provide people to be maximally active in a safe way. And that is what will prevent future fractures.”

While many patients receive most of their osteoporosis management information from their family doctor, not all doctors are aware of the role that physical therapists can play in rehabilitation and management of osteoporosis symptoms Physical Therapy. Patients may have to ask directly about some of the services they need as part of their rehabilitation.






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2.2 OSTEOPOROSIS TREATMENT:

2.2.1 PHYSICAL THERAPY REHAB AFTER A FRACTURE: For many people, their first experience with osteoporosis comes by way of a fracture to the

spine, hip, wrist, or ankle from an impact that would not have caused injury in earlier years. Even rolling over in bed can cause vertebral (spinal) fractures for some people,.

At this point, rehabilitation focuses on pain management immediately after the fracture, and then on returning to an active lifestyle as the fracture heals.

“For both wrist and hip fractures there is a lot of evidence that people don’t return to full function unless they go to physical therapy after the sub acute phase (about six Weeks after injury)”.






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Studies show six months of progressive resistance exercises done three times a Week and supervised by a physical therapist provide the best outcomes for patients with hip fractures.

Meeting with a physical therapy once a Week and then doing recommended exercises in a fitness facility as an alternative. Supervision by a trained physical therapist helps to prevent additional fractures, so be especially cautious when exercising on your own.

A physical therapist can also help you to find the best fitting assistive device, such as a cane or walker to use during your healing period.

“After a fracture, you might not need to use one for a long time, but a cane or walker can keep up your fitness during recovery and also reduce pain”.

Activities of daily living can be very difficult to manage alone after this disabling injury. The patient often needs assistance walking and managing stairs. Studies show that patients who are able to return home after a hip fracture have better results than those who go to a skilled nursing facility or nursing home. And there are fewer deaths among patients who receive home care physical therapy after a hip fracture.

The current status of home care physical therapy includes active range of motion exercises and functional training activities. These training activities include moving in bed (rolling over, sitting up), getting in and out of bed, and tub or shower transfers. Balance and safety training are also included. Some therapists add stretching and resistance training. Balance training, some, but not all, therapists included breathing exercises, and aerobic conditioning. The next step is to identify treatments that lead to the best results or outcomes for home physical therapy after hip fracture. Some studies already show that exercise with resistance is needed. With this added feature of the treatment program, mobility disabilities may be decreased. Specific exercises and the intensity, frequency, and duration of the chosen exercises remain to be determined.

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2.2.2 EMOTIONAL REHAB: Another element of rehabilitation is managing the emotional impact of fractures and breaks. Therapists, social workers, and osteoporosis support groups can help you cope with the fear and grief that accompany osteoporosis-related life changes and loss of independence.

2.2.3 PHYSICAL THERAPY REHAB BEFORE A FRACTURE: Injury prevention is a part of rehabilitation, and ideally people with osteoporosis should work with a physical therapist before they experience an injury, says Shipp. If your doctor has diagnosed you with osteoporosis, you should start making the changes that will prevent an injury now. Such changes include:

Learning how to lift items without using your back Learning how to move without twisting your spine Implementing fall prevention strategies at home, work, and on the go Identifying exercises that can keep you safely active Asking for help with tasks that require lifting heavy items or climbing Preventing fractures before they happen is obviously best. But if you do suffer a fracture,

healing properly and getting advice on how to prevent another one are going to be even more important, and that’s where a physical therapist can be your best ally.

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3.0 PHYSICAL THERAPY FOR CANCER: Common patient types referred for physical therapy: Leukemia/Lymphoma Patients may be Weak from abnormal blood counts and/or from cancer treatments. The

following services are offered: Strength training – gently according to SCCA blood value guidelines Cardiovascular and stretching education Safety and fatigue management 3.1 MULTIPLE MYELOMA:

Patients often have disease spread to multiple bones upon diagnosis. Careful, tailored exercise is important to help maintain function, quality of life and to gently enhance the non-cancerous portions of the bone. The following services are offered: Strength training – gently strengthening the muscles surrounding the bones help provide increased

bone strength and stability to decrease the risk of falls, fractures or pain. Cardiovascular and stretching training Spinal bracing to assist proper healing and pain relief Safety management Pain management

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3.2 BONE MARROW TRANSPLANT/PER IPHERAL BLOOD STEM CELL TRANSPLANT: Pediatric and adult patients should exercise as much as possible prior to the transplant in order to maximize function and strength. Exercise before, throughout and after the transplant is critical to decrease the possibility of complications such as severe muscle atrophy, infections, falls and depression. The following services are offered: Strength training – gently according to SCCA blood value guidelines Cardiovascular and stretching training Safety and fatigue management 3.3 LONG-TERM FOLLOW-UP PATIENTS

Patients with chronic Graft Versus Host Disease (GVHD) often return to the SCCA for continued management of symptoms and medications. The following services are offered: Range of motion stretching exercise Strength training Cardiovascular exercise education Fatigue management

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3.4 BREAST CANCER: All patients who have had a mastectomy and/or axillary lymph node dissection are automatically

referred to a physical or occupational therapist specializing in breast cancer. Patients who have had a lumpectomy may also have rehabilitation needs. PT’s offer the following services:

Radiation precaution education Overall shoulder stretching, strengthening, and cardiovascular conditioning programs Lymphedema risk reduction education Baseline arm girth measurements Assessment for Axillary Web Syndrome (cording) Scar tissue work

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3.4.1 FOR LYMPHEDEMA TREATMENT, PT’s OFFER THE FOLLOWING SERVICES: 1. Management with compression bandaging

2. Manual lymph drainage

3. Lymphedema exercises

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4. Education of self-manual lymph drainage massage

5. Compression sleeve/gauntlet

The following instructions should be reviewed carefully before your procedure, and discussed with your physician or physical therapist.

If you notice a development of swelling in your arm or hand, even if slight, consult with your physician for a lymphedema evaluation. Lymphedema is much easier to treat if caught early.

Never allow an injection, IV or a blood drawing in the affected areas (s), unless it is an emergency.

Have blood pressure checked in the unaffected arm. Be sure your arm has full range of motion after surgery. If you are having any difficulty

moving your arm, physical therapy may be of benefit. Consult your physician about a referral for physical therapy.

Keep the swollen arm, or ¿at-risk¿ arm, spotlessly clean. Use lotion after bathing. Make sure your arm is dry in any creases and between the fingers.

For the fist month to six weeks after surgery, avoid any heavy lifting with the affected arm. Avoid carrying bags with over-the-shoulder straps.

Be sure that the jewelry and clothing that you wear is loose fitting and is not too tight on your arm or hand.

If your arm is swollen, avoid saunas and hot tubs as the extreme heat may cause an increase in your swelling.

Use sunscreen to avoid blisters and burns on the affected arm.

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Wear gloves while doing housework, gardening or any type of work that could result in a scratch or cut. If a cut or scratch does occur, cover it with an antibacterial ointment and band=aid until it is well healed.

When manicuring your nails, avoid cutting your cuticles. You may, however, push your cuticles back.

Make every effort to return to your previous exercise level slowly. If your arm becomes sore after exercise, decrease the intensity immediately. If you use weights to exercise, decrease the amount of weight and/or number of repetitions initially.

When traveling by air, patients with lymphedema should wear a compression sleeve and gauntlet. Additional bandages may be required on a long flight. Increase fluid intake while in the air. Avoid caffeine and alcohol and try to get up and walk around at least once an hour.

Use extra care when shaving your armpit, as you may have some numbness in the area after surgery.

If your arm begins to feel full or heavy, consult your physician about a possible physical therapy evaluation in order to have your baseline arm-girth measurements taken for future reference.

Warning:

If you notice a rash, blistering, redness, fever or an increase of arm temperature, see your physician immediately. An inflammation or infection in the affected arm could be the beginning, or a worsening of lymphedema.

Maintain your ideal weight with well-balanced, low sodium, high-fiber diet. Avoid smoking and alcoholic beverages. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid. Rather, this will weaken the connective tissue and worsen the condition.






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3.5 MELANOMA: Patients that have had melanoma surgically removed often have lymph nodes removed as Well. If

lymph nodes have been removed, patients are automatically referred to a physical or occupational therapist. PT’s offer the following services:

1. Overall shoulder stretching, strengthening, and cardiovascular conditioning programs

2. Lymphedema risk reduction education

3. Baseline arm or leg girth measurements

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4. Assessment for Axillary Web Syndrome (cording)

5. Scar tissue work

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3.6 FOR LYMPHEDEMA TREATMENT, PT’s OFFER THE FOLLOWING SERVICES: Management with compression bandaging Manual lymph drainage Lymphedema exercises Education of self-manual lymph drainage massage Compression garment

3.7 HEAD AND NECK CANCER:

Patients who have had a neck dissection, lymph node removal, plastic surgery reconstruction and/or radiation benefit from physical therapy. PT’s offer the following services:

Radiation precaution education Overall shoulder stretching, strengthening, and cardiovascular conditioning programs Lymphedema risk reduction education Scar tissue work For lymphedema treatment, PT’s offer the following services: Management with compression bandaging Manual lymph drainage Lymphedema exercises Education of self-manual lymph drainage massage

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3.8 PROSTATE CANCER: Patients undergoing prostate cancer surgery usually have lymph nodes removed also. Physical

therapy will address lymphedema risk reduction education. Hormone manipulation (testosterone/androgen depletion) often causes severe muscle loss and osteoporosis, and strength training is important to maintain bone health, body mass and function. PT’s offer the following services:

Overall shoulder stretching, strengthening, and cardiovascular conditioning programs Lymphedema risk reduction education Baseline leg girth measurements Assessment for cording Scar tissue work Pain management For lymphedema treatment, PT’s offer the following services: Management with compression bandaging Manual lymph drainage Lymphedema exercises Education of self-manual lymph drainage massage Compression garment

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3.9 LUNG CANCER: Both the disease and the treatment (i.e. removal of part of a lung) can cause a decrease in the

patient’s lung capacity. In addition, many patients also have underlying chronic lung disease such as emphysema or chronic bronchitis. Scars from lung surgeries can further reduce chest wall mobility, cause decreased shoulder range of motion, pain and impair breathing. The following services are offered:

1. Scar tissue work taught to the patient and caregiver

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2. Cardiovascular, strength and stretching training to maximize lung function before, during and after cancer treatment

3.9.1 LUNG CANCER PHYSIOTHERAPY: When you get home, it is important to exercise to get yourself fit again. Check with your doctor or physiotherapist about exercise before you leave the hospital. It is important to start slowly and not overdo it. Once you get back on your feet try

Brisk walking Swimming

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3.10 SARCOMA: Depending on whether or not the sarcoma is located in the tissue or the bone, different types of

physical therapy are prescribed. Patients who have had a joint replacement, reconstruction or an amputation require specific therapy to decrease phantom limb pain and to increase functional mobility. The following services are offered:

Cardiovascular, strength and stretching training Lymphedema risk reduction education Baseline arm or leg girth measurements Assessment for cording Scar tissue work Limb desensitization post amputation

3.10.1 FOR LYMPHEDEMA TREATMENT, PT’s OFFER THE FOLLOWING SERVICES: Management with compression bandaging Manual lymph drainage Lymphedema exercises Education of self-manual lymph drainage massage Compression garment

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4.0 ALZHEIMER'S DISEASE: Progressive mental deterioration in old age has been recognized and described throughout history. However, it was not until 1906 that a German physician, Dr. Alois Alzheimer, specifically identified a collection of brain cell abnormalities as a disease. One of Dr. Alzheimer’s patients died after years of severe memory problems, confusion and difficulty understanding questions. Upon her death, while performing a brain autopsy, the doctor noted dense deposits surrounding the nerve cells (neuritic plaques). Inside the nerve cells he observed twisted bands of fibers (neurofibrillary tangles). Today, this degenerative brain disorder bears his name, and when found during an autopsy, these plaques and tangles mean a definite diagnosis of Alzheimer's disease (AD). Since its discovery more than 100 years ago, there have been many scientific breakthroughs in AD research. In the 1960s, scientists discovered a link between cognitive decline and the number of plaques and tangles in the brain. The medical community then formally recognized Alzheimer’s as a disease and not a normal part of aging. In the 1970s, scientists made great strides in understanding the human body as a whole, and AD emerged as a significant area of research interest. This increased attention led in the 1990s to important discoveries and a better understanding of complex nerve cells in the brains of AD patients. More research was done on AD susceptibility genes, and several drugs were approved to treat the cognitive symptoms of the disease. Over the last decade, scientists have substantially progressed in understanding potential environmental, genetic and other risk factors for AD, the processes leading to formation of plaques and tangles in the brain, and the brain regions that are affected. Specific genes related to both the early-onset and late-onset forms of AD have been identified, but genetic risk factors alone do not fully explain its causes, so researchers are actively exploring environment and lifestyle to learn what role they might play in the development of this disease.






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4.1 RISK FACTORS: Scientists have identified factors that appear to play a role in the development of Alzheimer’s

disease, but no definitive causes have been found for this complex disorder.

4.1.1 KNOWN RISK FACTORS: Age: The single greatest risk of developing Alzheimer’s disease is age. Approximately 5 percent of Americans between the ages of 65 and 74, and almost half of those 85 years and older are estimated to have Alzheimer's.

Genetics: The majority of Alzheimer’s cases are late-onset, usually developing after age 65, and this form of the disease shows no obvious inheritance pattern. However, in some families, clusters of cases are seen. A gene called Apolipoprotein E (ApoE) appears to be a risk factor for the late-onset form of Alzheimer’s. There are three forms of this gene: ApoE2, ApoE3 and ApoE4. Roughly one in four Americans has ApoE4 and one in twenty has ApoE2. While inheritance of ApoE4 increases the risk of developing the disease, ApoE2 substantially protects against it. Some current research is focused on the association between these two forms of ApoE and Alzheimer's disease. Familial Alzheimer’s disease (FAD) or early-onset Alzheimer's is an inherited, rare form of the disease, affecting less than 10 percent of patients. Familial Alzheimer's Disease develops before age 65, in people as young as 35. It is caused by one of three gene mutations on chromosomes 1, 14 and 21.






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4.1.2 POTENTIAL CONTRIBUTING FACTORS: Cardiovascular disease: Risk factors associated with heart disease and stroke, such as

high blood pressure and high cholesterol, may also increase one's risk of developing Alzheimer's disease. High blood pressure may damage blood vessels in the brain, disrupting regions that are important in decision-making, memory and verbal skills. This could contribute to the progression of the disease. High cholesterol may inhibit the ability of the blood to clear protein from the brain.

Type 2 Diabetes: There is growing evidence of a link between Alzheimer's disease and type 2 diabetes. In Type 2 diabetes insulin does not work effectively to convert blood sugar into energy. This inefficiency results in production of higher levels of insulin and blood sugar which may harm the brain and contribute to the progression of Alzheimer's.

Oxidative Damage: Free radicals are unstable molecules that sometimes result from chemical reactions within cells. These molecules seek stability by attacking other molecules, which can harm cells and tissue and may contribute to the neuronal brain cell damage caused by Alzheimer's.

Inflammation: Inflammation is a natural, but sometimes harmful, healing bodily function in which immune cells rid themselves of dead cells and other waste products. As protein plaques develop, inflammation results, but it is not known whether this process is damaging and a cause of Alzheimer's, or part of an immune response attempting to contain the disease.

Other Possible Risk Factors: Some studies have implicated prior traumatic head injury, lower education level and female gender as possible risk factors. Alzheimer's disease may also be associated with an immune system reaction or a virus.






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4.1.3 HEREDITY AND ALZHEIMER'S DISEASE: Familial Alzheimer’s disease (FAD) or early-onset Alzheimer’s is an inherited and rare. It affects less than 10 percent of Alzheimer’s disease patients. Familial Alzheimer's disease develops before age 65, in people as young as 35. It is caused by gene mutations on chromosomes 1, 14 and 21. If even one of these mutated genes is inherited from a parent, the person will almost always develop Familial Alzheimer's disease. All offspring in the same generation have a 50/50 chance of developing this type of Alzheimer's if one parent has it.

4.2 PHYSICAL THERAPY FOR ALZHEIMER'S DISEASE:

Benefits of regular exercises in people with Alzheimer's disease include maintenance of motor skills, decreased falls, and reduced rate of disease associated mental decline. Improved behavior, improved memory, and better communication skills are a few other benefits associated with routine exercise programs in Alzheimer's disease.

Flexibility, balance, and strength exercises have been studied in patients with Alzheimer's disease versus medical management alone. At the end of the study, the patient's who were treated with both exercise and medical management were less depressed than those in the other group, and showed marked improvements in their physical functioning.

Physical therapy plays an important role in exercises for patients with Alzheimer's disease by tailoring routines to meet the individual needs of each patient.

In the links below review strength, flexibility, and balance activities that people with Alzheimer's disease can participate in.

A Physical Therapist is a source of information to understand these changes and offer assistance for regaining lost abilities or develop new ones.

A Physical Therapist, working with the older adult, understands the anatomical and physiological changes that occur with normal aging. The Physical Therapist will evaluate and develop a specially designed therapeutic exercise program. Physical therapy intervention may prevent life long disability and restore the highest level of functioning. Through the use of tests, evaluations, exercises, treatments with modalities, screening programs, as Well as educational information, Physical Therapists:

Increase, restore or maintain range of motion, physical strength, flexibility, coordination, balance and endurance

Recommend adaptations to make the home accessible and safe Teach positioning, transfers, and walking skills promote maximum function and independence

within an individual's capability Increase overall fitness through exercise programs Prevent further decline in functional abilities through education, energy conservation

techniques, joint protection, and use of assistive devices to promote independence Improve sensation, joint proprioception Reduce pain Often as PT’s age, our balance skills deteriorate. For this reason it is important to do exercises to

improve and maintain balance throughout our lives. Balance exercises can be performed daily and in your own home. You can start out with simple balance activities and increase the difficulty as your balance improves. Improving your balance takes practice. One simple exercise can be done and modified as your skill level improves. Read on to learn how to improve your balance starting today.






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4.2.1 BEGINNER: Stand up straight behind a tall chair or at a counter top. Lightly grasp the chair or counter top with your fingertips. Raise one leg a foot off the ground. Maintain your balance while standing on one leg. Hold for a count of ten seconds. Repeat with other leg. Perform five on each leg.

4.2.2 INTERMEDIATE: Stand up straight behind a tall chair or at a counter top for safety only. Without holding on to the chair or countertop raise one leg a foot off the ground. Maintain your balance while standing on one leg.

4.2.3 CORE STRENGTHENING: The body's "core" refers to the muscles around the abdomen, pelvis, and back. This core is in

the body's center of gravity. As a result, it plays a role in almost all activities. From sitting to standing, walking to running, the core muscles are at work stabilizing our body from the force of gravity.

Weak core muscles make one more susceptible to poor posture, back pain, and injuries during activity. For this reason it is important to have strong core muscles. Ideally core-strengthening exercises should be performed three times per Week for maximum effectiveness.

4.2.4 WALL SLIDES: AN EFFECTIVE QUAD STRENGTHENING EXERCISE Wall slides are an effective way to strengthen your quadriceps muscles, more commonly referred to as "the quads." Begin with low reps of five, increasing as quad muscle strength improves. This exercise should be done three times a day for effective strengthening. Although wall slides appear easy, if you have an injury, it is an exercise that should not be done too early in the rehabilitation process. Discuss this exercise with your physician or physical therapist before proceeding.

A. HOW TO DO A WALL SLIDE

Stand upright with your back against a wall and feet shoulder-width apart. Slowly bend your knees, sliding your back down the wall for a count of five until your

knees are bent at a 45-degree angle. (Do not bend too much further than this, as it will cause increased strain on your knees.)

Hold this position for 5 seconds. Begin straightening your knees for a count of five, sliding up the wall until you are fully

upright with knees straight. Repeat the above steps five more times. Do this three times per day. As this gets exercise becomes easier, increase the number of repetitions per day. Also, as your quads become stronger, try one-legged wall slides, or do the above while holding Weights in your hands. Although primarily a strengthening exercise, this activity will also help you improve your balance.






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4.2.5 ABDOMINAL MUSCLES The abdominal muscles are made up of four muscle groups. These are the rectus abdominus, transversus abdominus, internal oblique, and external oblique muscles. This group of muscles help to stabilize the trunk, provide organ stability, and assist in flexion and rotation of the trunk. Strengthening these muscles helps support the body's frame and decreases back injuries. Click on the links below to learn easy exercises to help strengthen your abdominal muscles.

4.2.6 STRETCHING EXERCISES: Stretching in the morning is a great way to "waken" up your muscles, and get them ready for

the day. Stretching losens up your body while increasing blood flow to your muscles. Incorporating morning stretches into your daily routine is a positive way to begin each day.

Click on the links below to learn an easy and effective morning stretch exercise program. Sit on the edge of your bed with your feet on the floor. Bend over, reaching your hands toward your feet. Arch your back. Hold for a count of 10. Repeat 5 more times. Remain seated on the edge of your bed with your feet on the floor. Rotate your neck in a circle, touching your ears to your shoulders. Rotate slowly in a clockwise direction 5 times. Rotate slowly in a counter clockwise direction 5 times. Remain seated on the edge of your bed with your feet on the floor. Shrug your shoulders up to your ears. Repeat 10 more times.






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5.0 PHYSICAL THERAPY FOR HIP AND JOINT REPLACEMENT:

5.1 WHAT IS HIP REPLACEMENT: A total hip replacement (THR) - also called a hip arthroplasty- is a surgical procedure that re-forms

the hip joint. In THR, the head of the femur (the bone that extends from the hip to the knee) is removed along

with the surface layer of the socket in the pelvis (the two large bones that rest on the loWer limbs and support the spinal column).

The head of the femur, which is situated within the pelvis socket, is replaced with a metal ball and stem. This stem fits into the shaft of the femur.

The socket is replaced with a plastic or a metal and plastic cup. For nearly a century, doctors have been putting various materials into diseased and painful hip

joints to relieve pain. Up until the 1960s, outcomes had been unreliable. At that time, the metal ball and plastic socket for the replacement of the hip joint was introduced. Today, the artificial components used in THR are stronger and more designs are available.

There are many different shapes, sizes, and designs of artificial components of the hip joint. For the most part these are composed of chrome, cobalt, titanium, or ceramic materials. Some surgeons are also using custom-made components to improve the fit in the femur.






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5.1.1 THE "NORMAL" HIP: The hip is a ball-and-socket joint comprised of the following structures:

Head of the femur Acetabulum The cup-shaped cavity or socket at the base of the hipbone where the ball-

shaped head of the femur fits. of the pelvis Ligaments of the hip joint The head of the femur or "ball" of the hip joint articulates or moves within the cup-like

"socket" called the acetabulum of the pelvic bone. Together, these structures are referred to as a "ball and socket" joint. The femoral head and acetabulum are covered by a specialized surface called articular cartilage Cartilage covering and protecting surfaces of bones or of a joint or joints . This allows smooth and painless motion of the hip joint.

Several strong ligaments help hold the head of the femur within the acetabulum. They are named according to their attachments:

The iliofemoral ligament attaches the front of the ilium (pelvic bone) to the femur. It is fan-shaped, resembling an inverted Y and is sometimes referred to as the Y ligament of Bigalow.

The pubofemoral ligament attaches from an area on the front region of the pelvis called the pubis and connects to the femur.

The ishchiofemoral ligament attaches to a bony area on the rear aspect of the pelvis (where the hamstrings attach) and then connects to the femur bone.

The articular capsule, which is very dense and strong, encompasses the entire acetabulum.

5.1.2 WHEN IS A HIP REPLACEMENT NEEDED? Total hip replacement can benefit individuals suffering from a variety of hip problems resulting from either Wear and tear from a lifetime of activity or from disease and injury. Some of the common hip problems leading to total hip replacement are:

Osteoarthritis Rheumatoid arthritis Traumatic arthritis Avascular necrosis Other reasons

A. OSTEOARTHRITIS:

Osteoarthritis is a specific form of degenerative arthritis caused by Wear and tear from overuse or from aging. The cartilage surface that normally covers and cushions the ends of the femur and the lining of the acetabulum, begins to Wear thin causing the hip bone to rub against the socket. This results the erosion and misshaping of bone tissue. When the hip joint deteriorates, as a result either of arthritis or injury, the resulting pain, stiffness, and limitation of motion can be oppressive. Early symptoms of osteoarthritis may be controlled through medication and exercise. HoWever, when pain becomes so severe that the individual can no longer be helped with medication and when activities of daily living are significantly reduced, hip replacement surgery may be the next step.






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B. RHEUMATOID ARTHRITIS: Rheumatoid arthritis is a chronic, autoimmune disease Relating to or caused by antiboides or T cells that attack molecules, cells, or tissues of the organism producing them. causing inflammation of the joint lining called the synovial membrane Part of a sac surrounding the cavity of a freely movable joint; the dense connective tissue membrane secretes synovia, a joint lubricating fluid. , and destruction and deformity of bone, cartilage, ligament, and muscle tissue.

C. TRAUMATIC ARTHRITIS:

Traumatic arthritis is a type of arthritis resulting from a hip injury that can cause debilitating pain leading to replacement of the hip. The articular cartilage covering and protecting surfaces of bones or of a joint or joints can tear, allowing the potential for increased friction and accelerated degeneration of the joint.

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D. AVASCULAR NECROSIS: Avascular necrosis is the result of a loss of blood supply to the ball or head of the femur bone. As a result, articular cartilage Wears away leaving a "bone on bone" interaction for hip joint movement.

E. OTHER REASONS: Other abnormalities of the hip joint that could result in a need for a hip replacement include: Benign and malignant bone tissue that is threatening to life; such as in a malignant disease and has the potential and tendency to metastasize. Tumors can alter the shape and congruency of the joint and also disrupt blood supply of the joint, affecting articular cartilage. Paget's disease occurs mainly in the elderly. Bones become enlarged and Weakened, with the potential of a fracture or deformity of the hipbones.






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5.2 PHYSICAL THERAPY AFTER HIP REPLACEMENT: The rehabilitation process after total hip replacement occurs early in the post-operative period.

Most patients start physical therapy the day after their surgery. Early therapeutic exercises help you regain and improve strength around the operative hip. Therapy also helps patients learn to walk on their new joint. Here are the most common exercises done on the road to recovery after a total hip replacement.

5.2.1 HEEL SLIDES: This exercise helps strengthen the quadriceps muscles at the hip and the hamstring muscles at the knee. Perform as follows:

Sit with your legs straight out in front of you. Begin by sliding your heel toward your buttox by bending your knee. Keep your heel on the

ground during this motion. Slowly straighten your knee and slide your leg back to the starting position. Relax and repeat 10 more times.

5.2.2 STRAIGHT LEG RAISES: Straight leg raises help strengthen the hip joint. Perform as follows: Lay on your back on a flat surface. Bend the knee of your uninvolved leg (the one that wasn't operated on) to a 90-degree angle,

and keep your foot flat on the surface. Keep your involved leg straight without the knee bent. Slowly lift the involved leg six inches off the floor (by contracting the front thigh muscles).

Hold for five seconds. Slowly lower your leg to the floor.






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5.2.3 GLUTEAL SETS: Gluteal sets are easy exercises that help strengthen the gluteal muscles of the hip. Strong gluteal muscles help in hip extension as Well as stabilization of the joint. Perform as follows: Lie on your back with your knees bent in a 10- to 15-degree angle. Squeeze your buttock muscles together. Hold for five seconds. Relax. Repeat 10 more times. Perform three sets of 10, three times a day. A. ANKLE PUMPS:

Slowly push your foot up and down. Do this exercise several times as often as every 5 or 10 minutes. This exercise can begin immediately after surgery and continue until you are fully recovered.

B. QUAD SETS:

Slowly tighten muscles on thigh of straight leg while counting out loud to 10. Repeat with other leg to complete set.

C. GLUTEAL SQUEEZES:

Squeeze buttocks muscles as tightly as possible while counting out loud to 10.

D. Heel Slides: Make sure bed is flat. Bend knee and pull heel toward buttocks. Do not bend hip more than 90°. Hold for 10 seconds. Return. Repeat with other knee to complete set.

E. SHORT ARC QUADS: Place a rolled towel under your knee. Raise the lower part of your leg until your knee is straight. Hold for 10 seconds.

F. HIP ABDUCTION: Keep your toes pointed toward the ceiling. Move your leg out to the side as far as possible. Slowly return to the starting position and relax.

G. LONG ARC QUADS: Straighten operated leg and try to hold it for 10 seconds.






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5.2.4 STANDING EXERCISES: Soon after your surgery, you will be out of bed and able to stand. You will require help since you may become dizzy the first several times you stand. As you regain your strength, you will be able to stand independently. While doing these standing exercises, make sure you are holding on to a firm surface such as a bar attached to your bed or a wall.

A. STANDING KNEE RAISES: Lift your operated leg toward your chest. Do not lift your knee higher than your waist. Hold for 2 or 3 counts and put your leg down.

B. STANDING HIP ABDUCTION: Be sure your hip, knee and foot are pointing straight forward. Keep your body straight. With your knee straight, lift your leg out to the side. Slowly lower your leg so your foot is back on the floor. Repeat 10 times 3 or 4 times a day

C. STANDING HIP ABDUCTION: Be sure your hip, knee and foot are pointing straight forward. Keep your body straight. With your knee straight, lift your leg out to the side. Slowly loWer your leg so your foot is back on the floor. Repeat 10 times 3 or 4 times a day

D. STANDING HIP EXTENSIONS: Lift your operated leg backward slowly. Try to keep your back straight. Hold for 2 or 3 counts. Return your foot to the floor. Repeat 10 times 3 or 4 times a day

E. WALKING AND EARLY ACTIVITY: Soon after surgery, you will begin to walk short distances in your hospital room and perform light everyday activities. This early activity helps your recovery by helping your hip muscles regain strength and movement.

F. WALKING WITH WALKER, FULL WEIGHT BEARING: Stand comfortably and erect with your Weight evenly balanced on your walker or crutches. Move your walker or crutches forward a short distance. Then move forward, lifting your operated leg so that the heel of your foot will touch the floor first. As you move, your knee and ankle will bend and your entire foot will rest evenly on the floor. As you complete the step allow your toe to lift off the floor. Move the walker again and your knee and hip will again reach forward for your next step. Remember, touch your heel first, then flatten your foot, then lift your toes off the floor. Try to walk as smoothly as you can. Don't hurry. As your muscle strength and endurance improve, you may spend more time walking. Gradually, you will put more and more Weight on your leg.

G. WALKING WITH CANE OR CRUTCH: A walker is often used for the first several Weeks to help your balance and to avoid falls. A cane or a crutch is then used for several more Weeks until your full strength and balance skills have returned. Use the cane or crutch in the hand opposite the operated hip. You are ready to use a cane or single crutch when you can stand and balance without your walker, when your Weight is placed fully on both feet, and when you are no longer leaning on your hands while using your walker.






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H. STAIR CLIMBING AND DESCENDING: The ability to go up and down stairs requires both flexibility and strength. At first, you will need a handrail for support and you will only be able to go one step at a time. Always lead up the stairs with your good leg and down the stairs with your operated leg. Remember "up with the good" and "down with the bad." You may want to have someone help you until you have regained most of your strength and mobility. Stair climbing is an excellent strengthening and endurance activity. Do not try to climb steps higher than those of the standard height of seven inches and always use the handrail for balance.

I. ADVANCED EXERCISES AND ACTIVITIES: A full recovery will take many months. The pain from your problem hip before your surgery and the pain and swelling after surgery have Weakened your hip muscles. The following exercises and activities will help your hip muscles recover fully. These exercises should be done in 10 repetitions four times a day with one end of the tubing around the ankle of your operated leg and the opposite end of the tubing attached to a stationary object such as a locked door or heavy furniture. Hold on to a chair or bar for balance.

5.2.5 ELASTIC TUBE EXERCISES A. RESISTIVE HIP FLEXION:

Stand with your feet slightly apart. Bring your operated leg forward keeping the knee straight. Allow your leg to return to its previous position.

B. RESISTIVE HIP ABDUCTION:

Stand sideways from the door and extend your operated leg out to the side. Allow your leg to return to its previous position.

C. RESISTIVE HIP EXTENSIONS:

Face the door or heavy object to which the tubing is attached and pull your leg straight back. Allow your leg to return to its previous position.

D. EXERCYCLING:

Exercycling is an excellent activity to help you regain muscle strength and hip mobility. Adjust the seat height so that the bottom of your foot just touches the pedal with your knee almost straight. Pedal backwards at first. Pedal forward only after comfortable cycling motion is possible backwards. As you become stronger (at about 4 to 6 Weeks) slowly increase the tension on the Exercycle. Exercycle forward 10 to 15 minutes twice a day, gradually building up to 20 to 30 minutes 3 to 4 times a Week.

E. WALKING:

Take a cane with you until you have regained your balance skills. In the beginning, walk 5 or 10 minutes 3 or 4 times a day. As your strength and endurance improves, you can walk for 20 or 30 minutes 2 or 3 times a day. Once you have fully recovered, regular walks, 20 or 30 minutes 3 or 4 times a Week, will help maintain your strength.






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6.0 BALANCE DISORDERS: A balance disorder is a disturbance that causes an individual to feel unsteady, giddy, woozy, or have a sensation of movement, spinning, or floating. An organ in our inner ear, the labyrinth, is an important part of our vestibular (balance) system. The labyrinth interacts with other systems in the body, such as the visual (eyes) and skeletal (bones and joints) systems, to maintain the body's position. These systems, along with the brain and the nervous system, can be the source of balance problems. Three structures of the labyrinth, the semicircular canals, let us know when PT’s are in a rotary (circular) motion. The semicircular canals, the superior, posterior, and horizontal, are fluid-filled. Motion of the fluid tells us if PT’s are moving. The semicircular canals and the visual and skeletal systems have specific functions that determine an individual's orientation. The vestibule is the region of the inner ear where the semicircular canals converge, close to the cochlea (the hearing organ). The vestibular system works with the visual system to keep objects in focus when the head is moving. Joint and muscle receptors also are important in maintaining balance. The brain receives, interprets, and processes the information from these systems that control our balance.

6.1 HOW DOES THE BALANCE SYSTEM WORK?

Movement of fluid in the semicircular canals signals the brain about the direction and speed of rotation of the head--for example, whether PT’s are nodding our head up and down or looking from right to left. Each semicircular canal has a bulbed end, or enlarged portion, that contains hair cells. Rotation of the head causes a flow of fluid, which in turn causes displacement of the top portion of the hair cells that are embedded in the jelly-like cupula. Two other organs that are part of the vestibular system are the utricle and saccule. These are called the otolithic organs and are responsible for detecting linear acceleration, or movement in a straight line. The hair cells of the otolithic organs are blanketed with a jelly-like layer studded with tiny calcium stones called otoconia. When the head is tilted or the body position is changed with respect to gravity, the displacement of the stones causes the hair cells to bend.






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Illustration A The balance system works with the visual and skeletal systems (the muscles and joints and their

sensors) to maintain orientation or balance. For example, visual signals are sent to the brain about the body's position in relation to its surroundings. These signals are processed by the brain, and compared to information from the vestibular and the skeletal systems. An example of interaction betWeen the visual and vestibular systems is called the vestibular-ocular reflex. The nystagmus (an involuntary rhythmic eye movement) that occurs when a person is spun around and then suddenly stops is an example of a vestibular-ocular reflex.

Illustration B This figure shows nerve activity associated with rotational-induced physiologic nystagmus and

spontaneous nystagmus resulting from a lesion of one labyrinth. Thin straight arrows--direction of slow components; thick straight arrows--direction of fast components; curved arrows--direction of end lymph flow in the horizontal semicircular canals: AC--anterior canal, PC--posterior canal, HC--horizontal canal.

Illustration A Illustration B






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6.2 WHAT ARE THE SYMPTOMS OF A BALANCE DISORDER?

When balance is impaired, an individual has difficulty maintaining orientation. For example, an individual may experience the "room spinning" and may not be able to walk without staggering, or may not even be able to arise. Some of the symptoms a person with a balance disorder may experience are: Falling or a feeling of falling. Lightheadedness or feeling woozy. Visual blurring.

Disorientation. A sensation of dizziness or vertigo (spinning). Some individuals may also experience nausea and vomiting, diarrhea, faintness, changes in heart rate and blood pressure, fear, anxiety, or panic. Some reactions to the symptoms are fatigue, depression, and decreased concentration. The symptoms may appear and disappear over short time periods or may last for a longer period of time. 6.3 WHAT CAUSES A BALANCE DISORDER?

Infections (viral or bacterial), head injury, disorders of blood circulation affecting the inner ear or brain, certain medications, and aging may change our balance system and result in a balance problem. Individuals who have illnesses, brain disorders, or injuries of the visual or skeletal systems, such as eye muscle imbalance and arthritis, may also experience balance difficulties. A conflict of signals to the brain about the sensation of movement can cause motion sickness (for instance, when an individual tries to read while riding in a car). Some symptoms of motion sickness are dizziness, sWeating, nausea, vomiting, and generalized discomfort. Balance disorders can be due to problems in any of four areas: Peripheral vestibular disorder, a disturbance in the labyrinth. Central vestibular disorder, a problem in the brain or its connecting nerves. Systemic disorder, a problem of the body other than the head and brain. Vascular disorder, or blood flow problems.






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6.4 WHAT ARE SOME TYPES OF BALANCE DISORDERS? Some of the more common balance disorders are: Benign Paroxysmal Positional Vertigo (BPPV)--a brief, intense sensation of vertigo that occurs

because of a specific positional change of the head. An individual may experience BPPV when rolling over to the left or right upon getting out of bed in the morning, or when looking up for an object on a high shelf. The cause of BPPV is not known, although it may be caused by an inner ear infection, head injury, or aging. Labyrinthitis--an infection or inflammation of the inner ear causing dizziness and loss of balance.

Ménière's disease--an inner ear fluid balance disorder that causes episodes of vertigo, fluctuating hearing loss, tinnitus (a ringing or roaring in the ears), and the sensation of fullness in the ear. The cause of Ménière's disease is unknown.

Vestibular neuronitis[A2]--an infection of the vestibular nerve, generally viral.






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Perilymph fistula--a leakage of inner ear fluid to the middle ear. It can occur after head injury, physical exertion or, rarely, without a known cause.

6.5 HOW ARE BALANCE DISORDERS DIAGNOSED?

Diagnosis of a balance disorder is complicated because there are many kinds of balance disorders and because other medical conditions--including ear infections, blood pressure changes, and some vision problems--and some medications may contribute to a balance disorder. A person experiencing dizziness should see a physician for an evaluation.

The primary physician may request the opinion of an otolaryngologist to help evaluate a balance problem. An otolaryngologist is a physician/surgeon who specializes in diseases and disorders of the ear, nose, throat, head, and neck, with expertise in balance disorders. He or she will usually obtain a detailed medical history and perform a physical examination to start to sort out possible causes of the balance disorder. The physician may require tests to assess the cause and extent of the disruption of balance. The kinds of tests needed will vary based on the patient's symptoms and health status. Because there are so many variables, not all patients will require every test.

Some examples of diagnostic tests the otolaryngologist may request are a hearing examination, blood tests, an electronystagmogram (ENG--a test of the vestibular system), or imaging studies of the head and brain.

The caloric test may be performed as part of the ENG. In this test, each ear is flushed with warm and then cool water, usually one ear at a time; the amount of nystagmus resulting is measured. Weak nystagmus or the absence of nystagmus may indicate an inner ear disorder.

Another test of the vestibular system, posturography, requires the individual to stand on a special platform capable of movement within a controlled visual environment; body sway is recorded in response to movement of the platform and/or the visual environment.






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6.6 HOW ARE BALANCE DISORDERS TREATED? There are various options for treating balance disorders. One option includes treatment for a

disease or disorder that may be contributing to the balance problem, such as ear infection, stroke, or multiple sclerosis. Individual treatment will vary and will be based upon symptoms, medical history, general health, and examination by a physician, and the results of medical tests.

Another treatment option includes balance-retraining exercises (vestibular rehabilitation). The exercises include movements of the head and body specifically developed for the patient. This form of therapy is thought to promote compensation for the disorder. Professionals with knowledge and understanding of the vestibular system and its relationship with other systems in the body administer vestibular retraining programs.

For people diagnosed with Ménière's disease, dietary changes such as reducing intake of sodium may help. For some people, reducing alcohol, caffeine, and/or avoiding nicotine may be helpful. Some aminoglycoside antibiotics, such as gentamicin and streptomycin, are used to treat Ménière's disease. Systemic streptomycin (given by injection) and topical gentamicin (given directly to the inner ear) are useful for their ability to affect the hair cells of the balance system. Gentamicin also can affect the hair cells of the cochlea, though, and cause hearing loss. In cases that do not respond to medical management, surgery may be indicated.

A program of talk therapy and/or physical rehabilitation may be recommended for people with anxiety.

6.7 HOW CAN THE PATIENT HELP THE DOCTOR MAKE A DIAGNOSIS?

The patient can take the following steps that may be helpful to your physician in determining a diagnosis and treatment plan.

Bring a written list of symptoms to your doctor. Bring a list of medications currently being used for balance disorders to your doctor. Be specific when you describe the nature of your symptoms to your doctor. For example, describe

how, when, and where you experience dizziness. Lastly, remember to write down any instructions or tips your doctor gives you.

6.8 HOW ARE BALANCE DISORDERS TREATED?

Office Treatment Home Treatment Surgical Treatment

BPPV has often been described as "self-limiting" because symptoms often subside or disappear within six months of onset. Symptoms tend to wax and wane. Motion sickness medications are sometimes helpful in controlling the nausea associated with BPPV but are otherwise rarely beneficial. However, various kinds of physical maneuvers and exercises have proved effective. Three varieties of conservative treatment, which involve exercises, and a treatment that involves surgery are described in the next sections.

6.8.1 OFFICE TREATMENT OF BPPV: A. THE EPLEY AND SEMONT MANEUVERS:

There are two treatments of BPPV that are usually performed in the doctor's office. Both treatments are very effective, with roughly an 80% cure rate, according to a study by Herdman and others (1993). If your doctor is unfamiliar with these treatments, you can find a list of knowledgeable doctors from the Vestibular Disorders Association (VEDA) . The maneuvers, named after their inventors, are both intended to move debris or "ear rocks" out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each






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maneuver takes about 15 minutes to complete. The Semont maneuver (also called the "liberatory" maneuver) involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other. It is a brisk maneuver that is not currently favored in the United States.

The Epley maneuver is also called the particle repositioning, canalith repositioning procedure, and modified liberatory maneuver. It is illustrated in figure 2. Click here for an animation. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary. While some authors advocate use of vibration in the Epley maneuver, PT’s have not found this useful in a study of our patients (Hain et al, 2000). Some authors also suggest leaving out some of the positions in the Epley maneuver, especially position 'D'. PT’s suggest that you avoid therapy using this methodology. After either of these maneuvers, you should be prepared to follow the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.

B. INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont manoeuvres)

I. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don't drive yourself home. II. Sleep semi-recumbent for the next two nights. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure 3). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise, which






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requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. III. For at least one Week, avoid provoking head positions that might bring BPPV on again. Use two pillows when you sleep. Avoid sleeping on the "bad" side. Don't turn your head far up or far down. Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist's office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped for a Week. No "sit-ups" should be done for at least one Week and no "crawl" swimming. (Breaststroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your health care provider. IV. At one Week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did.

C. WHAT IF THE MANEUVERS DON'T WORK? These maneuvers are effective in about 80% of patients with BPPV (Herdman et al, 1993). If you are among the other 20 percent, your doctor may wish you to proceed with the Brandt-Daroff exercises, as described below. If a maneuver works but symptoms recur or the response is only partial (about 40% of the time according to Smouha, 1997), another trial of the maneuver might be advised. The "habituation" exercises are also sometimes useful in the situation where all other maneuvers (Epley, Semont, Brandt-Daroff) have been tried -- in essence these consist of a more intense and prolonged series of positional exercises. When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management (posterior canal plugging) may be offered. BPPV often recurs. About 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence (Hain et al, 2000; Nunez et al; 2000). If BPPV recurs, in our practice PT’s usually retreat with one of the maneuvers above, and then follow this with a once/day set of the Brandt-Daroff exercises. In some persons, the positional vertigo can be eliminated but imbalance persists. In these persons it may be reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to compensate for a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Fujino et al (1994) reported conventional rehab has some efficacy, even without specific maneuvers.

D. HOME TREATMENT OF BPPV:

BRANDT-DAROFF EXERCISES Brandt-Daroff Exercises for BPPV The Brandt-Daroff Exercises are a method of treating BPPV, usually used when the office treatment fails. They succeed in 95% of cases but are more arduous than the office treatments. These exercises are performed in three sets per day for two Weeks. In each set, one performs the maneuver as shown five times.






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1 repetition = maneuver done to each side in turn (takes 2 minutes) Suggested Schedule for Brandt-Daroff exercises Time Exercise Duration Morning 5 repetitions 10 minutes Noon 5 repetitions 10 minutes Evening 5 repetitions 10 minutes Start sitting upright (position 1). Then move into the side-lying position (position 2), with the head angled upward about halfway. An easy way to remember this is to imagine someone standing about 6 feet in front of you, and just keep looking at their head at all times. Stay in the side-lying position for 30 seconds, or until the dizziness subsides if this is longer, then go back to the sitting position (position 3). Stay there for 30 seconds, and then go to the opposite side (position 4) and follow the same routine. These exercises should be performed for two Weeks, three times per day, or for three Weeks, twice per day. This adds up to 52 sets in total. In most persons, complete relief from symptoms is obtained after 30 sets, or about 10 days. In approximately 30 percent of patients, BPPV will recur within one year. If BPPV recurs, you may wish to add one 10-minute exercise to your daily routine. The Brandt-Dar off exercises as Well as the Semont and Epley maneuvers are compared in an article by Brandt (1994), listed in the reference section. Home Epley Left Home Epley (for the left ear).

E. HOME EPLEY MANEUVER: The Epley and/or Semont maneuvers as described above can be done at home (Radke et al, 1999; Furman and Hain, 2004). PT’s often recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a Week. The method (for the left side) is performed as shown on the figure to the right. One stays in each of the supine (lying down) positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping. The mirror image of this procedure is used for the right ear. There are several problems with the "do it yourself" method. If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition (such as a brain tumor or stroke) with positional exercises -- this is unlikely to be successful and may delay proper treatment. A second problem is that the home-Epley requires knowledge of the "bad" side. Sometimes this can be tricky to establish. Complications such as conversion to another canal (see below) can occur during the Epley maneuver, which are better handled in a doctor's office than at home. Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries. In our opinion, it is safer to have the first Epley performed in a doctors office where appropriate action can be taken in this eventuality.






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6.9 AYURVEDA MEDICINE FOR BPPV:

VATA, PITTA AND KAPHA

6.9.1 BALANCE IS THE KEY: The three doshas According to Ayurveda, perfect health is a state where mind, body and spirit are balanced.

All activities of the mind and body are governed by three biological principles or doshas -- Vata, Pitta and Kapha, each of which is made up of some of the five elements of creation or mahabhutas.

Vata is mainly air and space, and governs movement in the body-the flow of blood, for example, or elimination, or breathing or thoughts flitting across the mind. Since the other two doshas, Pitta and Kapha, cannot move without Vata, Vata is considered the lead dosha.

Pitta, mainly fire and water, governs heat, metabolism and transformation. Digestion is an important Pitta activity.

Kapha is made up mainly of earth and water, and, accordingly, is linked to structure and moisture balance in the physiology. Among other things, Kapha controls Weight and lubrication in the lungs, for example. Each of the doshas is also related to a season of the year -- Kapha with Spring, Pitta with Summer and Vata with Fall and Winter. When all of these doshas are perfectly in balance in an individual, it means that all the systems and activities of mind and body are functioning at optimal levels, and the individual, therefore, enjoys perfect health. When one or more of these doshas goes out of balance, disorders result. Some factors that can cause these doshas to become imbalanced are improper diet or eating habits, stress, pollution or the Weather. Then, to restore good health, the dosha that has become imbalanced needs to be restored to its original make-up in that specific individual.

6.9.2 PRAKRITI AND VIKRITI: It has become common to associate Ayurveda just with superficial body typing, based on the fact that every individual is born as a combination of one or more of the three doshas described above. Asking What is your dosha? or Are you Vata, Pitta or Kapha? is just barely scratching the surface of Ayurveda. It is much more important to go beyond introductory body-typing or finding out the Prakriti of an individual to determining what imbalances exist in a person's physiology (Vikriti) -- and then finding out how to restore balance.






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6.9.3 THE BEEJ-BHOOMI THEORY: Ayurveda proposes an interesting theory of disease -- the Beej-Bhoomi theory. Proper digestion is crucial for good health. If digestion is not optimal, toxins, called ama or digestive impurities, build up in the body and clog the channels of flow. Not just the blood vessels, but all the microcirculatory channels in the body as Well as the energy pathways. Ama Weakens the physiology, creating conditions fertile for disease and infection to take root. Ayurvedic rejuvenation and cleansing programs -- Panchakarma -- are techniques designed to flush ama out of the physiology.

6.9.4 THE SCIENCE OF HERB COMBINING AND PROCESSING Although single Ayurvedic herbs and spices such as Brahmi, Turmeric and Ashwagandha are popular, one of the most significant contributions offered by Ayurveda is the science of herbal combination -- formulations that personify sanyoga, the fortuitous blending of a variety of herbs that results in a formulation offering the dual benefits of synergy and balance. An Ayurvedic formulation can often contain twenty or more herbs and spices -- primary herbs that target the area of imbalance, supporting herbs to enhance the benefits of the primary herbs, balancing herbs to counter any possible side-effects from the actions of the main herbs, and bio-availability enhancers to expedite the transfer of the benefits of the formulation to the parts of the physiology. The most complex of the traditional Ayurvedic herbal combinations are an elite group called rasayanas, extolled at length in the Ayurvedic texts for their positive impact on the physiology.

The second principle, sanskar, refers to the way the herbs are harvested, used and processed. Ayurvedic formulations traditionally use the whole herb instead of extracting the active ingredient from the plant. Nature's healing wisdom is perceived to reside best in the plant in its entirety. Using the whole herb rather than the isolated ingredient also contributes to a balanced formula less likely to have side effects, because according to Ayurveda, each medicinal plant has both the primary effect and the antidote present in it in its natural state. At the best Ayurvedic manufacturing facilities, the natural intelligence of the plants is carefully preserved in the final product by using traditional processing techniques that eschew chemical solvents and damaging high temperatures. Following the harvesting and processing techniques enunciated in the traditional texts results in a potent, balanced formulation.

6.9.5 SCIENTIFIC SCRUTINY OF AYURVEDA: Ayurvedic herbs and formulations are increasingly catching the attention of researchers all over the world. In a heartening trend that seeks to blend the best of the ancient and the modern, not only individual Ayurvedic herbs such as Brahmi and Guggul, but even proprietary rasayanas such as the antioxidant formula Amrit from Maharishi Ayurveda have been and continue to be extensively researched at independent institutions to scientifically validate and document their beneficial effects.






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6.9.6 CUMULATIVE BENEFITS OF AYURVEDA: The Ayurvedic approach to health is gentle and comprehensive. The concepts of instant cures and pill popping for immediate relief are foreign to Ayurveda. Because the endeavor is to seek and correct the source of problems -- imbalances in the physiology -- the best results from Ayurveda come to those who are patient and persistent, who diligently adopt the associated dietary and lifestyle changes needed, and take a degree of responsibility for their own Well-being. For those who do make the commitment, Ayurveda offers rich, cumulative health benefits that can help you enjoy a long, healthy and blissful life.

Mansur ibn Ilyas’s 14th-century work on anatomy contained illustrated chapters on five systems of the body: bones, nerves, muscles, veins and arteries. This page depicts the arteries, with the internal organs shown in watercolors.

This page from a 14th-century copy of Avicenna’s five-volume Canon of Medicine describes several internal organs, as well as the skull and bones. The Canon was a compilation of Greek and Islamic medical knowledge.

Two types of thyme are depicted on these pages of De Materia Medica, a guide to remedies by the Greek physician Dioscorides that was translated into Arabic in Baghdad in 1240.

he 10th-century Andalusian surgeon Abu al-Qasim Khalaf ibn al-Abbas al-Zahrawi (known as Abulcasis in the West) wrote many medical books, including The Properties of Various Products. This page discusses the use and preparation of absinthe.






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7.0 PHYSICAL THERAPY FOR INCONTINENCE: Definition: Incontinence is the inability to control urination. It affects people of all ages and gender, but woman are twice as likely as men to develop incontinence. 7.1 NORMAL URINATION:

The urinary system helps to maintain proper water and salt balance throughout the body: The process of urination begins in the two kidneys, which process fluids and dissolve waste matter

to produce urine. Urine flows out of the kidneys into the bladder through two long tubes called urethras. The bladder is a sac that acts as a reservoir for urine. It is covered with a membrane and enclosed

in a powerful muscle called the detrusor. The bladder rests on top of the pelvic floor. This is a muscular structure similar to a sling running between the pubic bone in front to the base of the spine.

The bladder stores the urine until it is eliminated from the body via a tube called the urethra, which is the lowest part of the urinary tract. (In men it is enclosed in the penis. In women it leads directly out.)

The connection between the bladder and the urethra is called the bladder neck. Strong muscles called sphincter muscles encircle the bladder neck (the smooth internal sphincter muscles) and urethra (the fibrous external sphincter muscles).






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7.2 THE PROCESS OF URINATION:

The process of urination is a combination of automatic and conscious muscle actions. There are two phases: The emptying phase and The filling and storage phase.

The Filling and Storage Phase. When a person has completed urination, the bladder is empty. This triggers the filling and storage phase, which includes both automatic and conscious actions.

The Automatic Actions. The automatic signaling process in the brain relies on a pathway of nerve cells and chemical messengers (neurotransmitters) called the cholinergic and adrenergic systems. Important neurotransmitters include serotonin and noradrenaline. This pathway signals the detrusor muscle, which surrounds the bladder, to relax. As the muscles relax, the bladder expands and allows urine to flow into it from the kidney. As the bladder fills to its capacity (about 8 to 16 oz of fluid) the nerves in the bladder send back signals of fullness to the spinal cord and the brain.

The Conscious Actions. As the bladder swells, the person becomes conscious of a sensation of fullness. In response, the individual holds the urine back by voluntarily contracting the external sphincter muscles, the muscle group surrounding the urethra. These are the muscles that children learn to control during the toilet training process.

When the need to urinate becomes greater than one's ability to control it, urination (the emptying phase) begins.

The Emptying Phase. This phase also involves automatic and conscious actions. The Automatic Actions. When a person is ready to urinate, the nervous system initiates the

voiding reflex. The nerves in the spinal cord (not the brain) signal the detrusor muscles to contract. At the same time, nerves are also telling the involuntary internal sphincter (a strong muscle encircling the bladder neck) to relax. With the bladder neck now open, the urine flows out of the bladder into the urethra.

The Conscious Actions. Once the urine enters the urethra, a person consciously relaxes the external sphincter muscles, which allows urine to completely drain out from the bladder.

The female and male urinary tracts are relatively the same except for the length of the urethra.






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7.3 FOUR TYPES OF INCONTINENCE:

7.3.1 STRESS INCONTINENCE: Incontinence that occurs during coughing, sneezing, laughing, lifting heavy objects or making other movements that put pressure, or stress, on the bladder. This results from Weak pelvic muscles or a Weakening of the wall between the bladder and vagina. The Weakness is due to pregnancy and childbirth or from lower levels of the hormone estrogen during menstrual periods or after menopause.

7.3.2 URGE INCONTINENCE: Incontinence after feeling a sudden urge to urinate with inability to control the bladder, such as while sleeping, drinking water or listening to water running.

7.3.3 OVERFLOW INCONTINENCE: Incontinence that occurs when the bladder is constantly full, and reaches a point where it overflows and leaks urine. This condition can occur when the urethra is blocked due to causes such as kidney or urinary stones, tumors or, an enlarged prostate. It may also be the result of Weak bladder muscles, due to nerve damage from diabetes or other diseases.

7.3.4 FUNCTIONAL INCONTINENCE: Incontinence that occurs when physical disabilities, external obstacles, or problems in thinking or communicating prevent a person from getting to a bathroom before they urinate.

7.4 PHYSICAL THERAPY FOR INCONTINENCE:

Behavioral techniques and noninvasive devices. They include Kegel exercises, Weighted vaginal cones, biofeedback, and others.

7.4.1 KEGEL OR PELVIC FLOOR MUSCLE EXERCISES FOR MEN: Kegel or pelvic floor muscle exercises are to help strengthen Weak muscles around the bladder. When these muscles are Weak, urine can leak from the bladder.

A. WHAT IS THE PELVIC FLOOR?

The Pelvic Floor is a ''hammock'' of muscles that supports the internal abdominal and pelvic organs. This is shown in the picture below. These muscles run in different directions and are different sizes. The job of these muscles is to support, lift, and control the muscles that close the urethra (tube that urine passes through).






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B. HOW DO YOU EXERCISE THESE MUSCLES? You exercise these muscles by squeezing and relaxing them. This takes effort and practice.

C. HOW DO I FIND THE RIGHT MUSCLES? To make sure that you are exercising the right muscles, try starting and stopping your

urine stream. This exercise will help you find the correct muscles. Repeat this exercise once a Week to check whether or not you are using the right muscles. Do not tighten your buttock or thigh muscles when doing these exercises. Relax your stomach muscles as much as possible.

When you are standing and squeeze your pelvic floor muscles, you should see your penis move slightly.

D. HOW DO I DO THESE EXERCISES?

Begin by squeezing the muscles for a count of four, then relax for a count of four. At first, you can only squeeze the muscles for 1-2 seconds, but as your muscles get stronger, you will be able to hold to the count of four.

Work up to repeating these exercises for five minutes twice a day. Remember to relax betWeen each squeeze and just let the muscles go loose. Do not

push down.

E. WHERE WILL I DO THE EXERCISES? When you first start doing the exercises, you need to set aside time when you can do

them without being interrupted. After you have done them for awhile, you can practice these exercises any time and anywhere.

Remember: Always squeeze your pelvic floor muscles when you: Sit up from lying down Stand from a sitting position Lift something heavy You can practice squeezing these muscles when you are watching TV, standing in line, or driving a car. Since these muscles are inside your body, people will not know you are doing exercises. It usually takes 6-12 Weeks to see results. Do these exercises regularly.

F. ARE THERE ANY PRECAUTIONS?

Some people exercise more than they should, hoping that they will regain bladder control quicker. If you exercise too much or too soon, your bladder control may get worse for awhile. Start slowing and increase the amount of exercise slowly. Follow the guidelines that your health care team have given you. Be sure to breathe during the exercises. Holding your breath may put extra pressure on your pelvic muscles.






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7.4.2 KEGEL OR PELVIC FLOOR MUSCLE EXERCISES FOR WOMEN:

A. WHAT IS THE PELVIC FLOOR? The pelvic floor is the layer of muscle that stretches from your pubic bone in the front to

your tail bone at the back, forming the floor of the pelvis. It is the main support structure for the pelvic organs (bladder, uterus, boWel).

A toned pelvic floor supports the bladder and boWel A toned pelvic floor helps close off the bladder and boWel outlets to help prevent

leakage. Relaxation of the pelvic floor allows effective bladder and boWel emptying A functional pelvic floor also contributes to sexual response and orgasm.

B. THE PELVIC FLOOR MUSCLES:

C. FACTORS CONTRIBUTING TO PELVIC FLOOR MUSCLE WEAKNESS: Pregnancy Childbirth Straining to empty the bladder or boWel with or without constipation Constipation Persistent heavy lifting Chronic cough (from smoking, chronic bronchitis or asthma) Being overWeight Lack of general fitness

E. HOW DO YOU STRENGTHEN MY PELVIC FLOOR MUSCLES?

The first step is to correctly identify the muscles. Sit comfortably - your thighs, buttocks and tummy muscles should be relaxed. Lift and squeeze inside as if you are trying to hold back urine or wind from the back passage.

If you are unable to feel a definite 'squeeze and lift' action of your pelvic floor - don't worry! even people with very Weak muscles can be taught these exercises.

If you feel unsure whether you have identified the correct muscles, try to stop your flow when passing urine, then restart it. Only do this to identify the correct muscles to use - this is a test, NOT an exercise.

If you are unable to feel a definite 'squeeze and lift' action in your pelvic floor muscles you should seek professional advice.






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F. STARTING YOUR PELVIC FLOOR MUSCLE TRAINING PROGRAM: At first you may need to perform these exercises while sitting or lying down. As the muscles strengthen, you can progress to exercise standing up. As in any muscle training activity, start with what you can achieve and progress from there. If you can feel the muscles working, exercise them by: I. Squeezing/ tightening and drawing in and up around your anus (back passage),

vagina and urethra (bladder outlet). Lift up inside and try to hold this contraction strongly for as long as you can (1 - 10 seconds). Keep breathing! Now release and relax. You should have a definite feeling of letting go.

II. Rest 10 - 20 seconds. Repeat Step 1 and remember, it is important to rest. If you find it

easy to hold, try to hold longer and repeat as many as you are able. Work towards 12 long, strong holds.

III. Now try 5 - 10 short, fast strong contractions. While you are exercising:

Do NOT hold your breath Do NOT push down instead of squeeze and lift Do NOT pull your tummy in tightly Do NOT tighten your buttocks and thighs. Try to set aside 5 - 10 minutes in your day for this exercise routine and remember quality is important. A few good contractions are more beneficial than many half-hearted ones and good results take time and effort. Remember to use the muscles when you need them most: always tighten before you cough, sneeze, lift, bend, get up out of a chair, etc.

IV. How do I progress my program?

Increase the length of time you contract the muscle and number of holds you do in succession before experiencing muscle fatigue. Work towards 12 long, strong holds. Increase the number of short, fast contractions. Always do your maximum number of quality contractions.

Some helpful hints Seek medical advice for chronic cough Keep your Weight within a healthy range for your height and age. Develop good bowel habits You should anticipate that improvement in pelvic floor muscle strength will take 3 -

6 months of regular training of the muscles. The best results will be achieved by seeking help from a physiotherapist/

continence advisor who will design an individual training program especially suited to you. Pelvic floor exercises may also be useful for people on a bladder-training program.






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8.0 HOW TO MAKE YOUR PARENTS FEEL HAPPY IN THEIR OLD AGE: When we grow up as adults and form our own family, we understand better the role our own parents had when they were raising us up: the joy, the pain, and challenges that comes with having a family. As our parents get older and their kids have grown up and have their own families, it can be a lonely experience for them to miss the chaos, fun, and noise of having their kids around when they were still small and growing up. As a tribute to your parents, you can do something to make them happy even in their old age. Read on:






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First, we must free ourselves of guilt. Yes, our parents are aging. It's a fact of life, but we are not to blame because they have lost a mate or their bodies are deteriorating. Once we accept that we cannot stop the aging process, than we are ready to care for the elderly and help them cope with the changes.

Learning to communicate is the most important task we face as our parents try to hide their true feelings.

Before we can understand them, we need to understand the times that they grew up in. Most elderly people were taught to keep their feelings suppressed and never discuss issues with their children. Remember, "Children are to be seen, not heard." So when they refuse to tell us what ails them, it's because we are the children; they are the parent. Be patient and observe. Mom may not let you know about her personal problems, and Dad may not want to go to the social because he's afraid.

Be attentive. Sometimes it's tough, but let Mom vent. If she lives alone, she needs to talk. Show that you are

listening by nodding and repeating some of what she says. Don't judge. Our parents have a right to their opinions, no matter how we feel about the issues.






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Spend time with your parents. Take them out for coffee. Have physical contact with a touch of the hand or a hug. Ask their opinion on different subjects. Play games, watch their favorite tv show, and have dinner with them. Show them they are still important.

Let you parents know that everything in your life is good and you are in perfect control. Your parents worry

about you and what’s going in your life at any point. By letting them know you are doing great, they will be at ease. If you are going thru difficulties, refrain from sharing it with them (unless extremely important) and try to fix it the best way you can without them knowing. This way you save them the stress by keeping the burden off their back.

Show respect to your parents at all times. It brings great happiness to parents to see that their kids respect

them. There’s no amount of money that can equal to receiving respect. When you show respect to your parents, you are giving them a priceless gift that makes them happy and proud.






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Be grateful. Showing gratitude to your parents for everything they have done to you in the past as well as in

the present brings happiness to them. Even if their upbringing is less than perfect, you still owe your life to them. Acknowledge your parents’ contribution to your growth as a person and don’t forget to thank them every moment.

Remember your parents’ birthdays and important anniversaries. There’s no better way for you to let your

parents feel happy and special than remembering important dates that matter to them and doing something for them on those special days. Send cards, buy gifts, treat them to special dinners, and spend time with them on those occasions. The memories you created for them will stay in their hearts and make them feel you still love and care for them in their old age.






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Keep them involved. Take them with you everywhere to parties, birthday celebrations, holiday events, and

other family activities you will hold. It makes them happy to still be part of the fun even if they are old.

Keep your parents informed and update them what’s going on in your life. Give them a call if you are abroad or out of state on business trips and ask how they are especially if you don’t see them everyday or you live far from them.

They inspire us through their Lives,Uphold us through Prayers

Support us through their Mites Help us in all Ways possible

& Do all things for us.






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Send them photos of yourself and your family. Likewise, give them updates how you’ve been doing and the

activities you are involved in. Make the news positive and uplifting for your parents. Just letting them know how you are brings happiness to them.

Filename: PTP&M005 PTM of Geriatric and aged conditions Medical Journal

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Title: PHYSICAL THERAPY MANAGEMENT OF GERIATRIC AND AGED CONDITIONS

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