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This Functional Neuroimaging of Recovery 165 mechanism could also cause fatigability lowed by recovery of thalamic activity is de- with repetitive attempts to use a paretic scribed in Experimental Case Study 2–1 discount 0.5mg requip free shipping medicine information. Tissue remote cortex may participate in cross-modal visuo- from the ischemic injury can be hypometabolic motor plasticity after stroke order requip 2 mg with mastercard medicine while breastfeeding. Remote hypometabolism is most hours of onset, no proportional relationship often reported in the contralesional cerebellum was discerned between regional oxygen me- and ipsilesional thalamus and frontal cortex fol- tabolism of the contralateral hemisphere and lowing a subcortical lesion. Color Figure 2–2 neurologic recovery using the Orgogozo scale (in separate color insert) reveals the transsy- when these studies were repeated 3 weeks naptic effects of an infarction of the caudate later. The contralesional cortex by the second scan, sug- patient had no sensorimotor impairments, but gesting degeneration of transcallosal connec- had poor working memory and could no longer tions from the infarcted hemisphere. Resting metabolic studies that show transsy- Color Figure 3–3 (in separate color insert) re- naptic hypometabolism in cortex may not mean veals the remote metabolic sequelae of a small that the tissue is not functional. Color Figure sions often cause hypometabolism of their cor- 3–4 (in separate color insert) reveals the pro- tical connections (see Color Fig. The patient could not chronic infarcts in the ventroposterior nucleus form new memories and confabulated. The of the thalamus who had contralateral impair- PET scans of both patients included hypome- ment of hand sensation were compared to nor- tabolism of the frontal lobes, basal ganglia, and mal controls and to subjects with infarcts in the thalamus. A vibratory stimulus overlapped the territory of some of the recov- to the hand, however, produced no difference ery-related activity during finger tapping. Subjects with sensory impairment technique called principal components analy- had a decrease in sensory perception, but pre- sis to allow a comparison between the extent served awareness of sensory stimuli. Partial of a lesion with connectivity patterns and to deafferentation with the partial sparing of in- identify the cerebral areas that participated in puts and outputs in the thalamic nucleus or in- finger tapping with the affected hand, the un- put from other thalamic vibratory pathways affected hand, and at rest. The bilateral thala- lateral thalamus and visual association cortex mic nuclei have connections that may enhance were the only regions involved both by a pas- plasticity after unilateral damage. Diaschisis fol- of spared projections in the presence of di- 166 Neuroscientific Foundations for Rehabilitation aschisis and become part of a rehabilitative Traumatic Brain Injury strategy. Most functional imaging studies after Imaging CBF and metabolism at rest reveals stroke and traumatic brain injury have not the cortical deafferentation that accompanies shown clearly that the presence of transneu- diffuse axonal injury (DAI). These studies can- ronal hypometabolism limits functional re- not always distinguish between loss of inputs covery or that some level of clinical restitu- from corticocortical damage and from afferents tion accompanies the resolution of apparent that ascend through cerebral white matter. In addition, activation studies can be Aphasia designed to assess whether or not a patient is able to learn novel information or likely to ben- Mimura and colleagues84 made comparisons efit from a particular rehabilitative interven- of resting CBF using SPECT for single brain tion. Regions of interest were restricted to Positron emission tomography has revealed the frontal operculum and Rolandic area, focal and diffuse cortical hypometabolism in thalamus, and superior temporal gyrus. The areas remote from, but transsynaptically con- initial mean CBF in the left hemisphere, but nected to subcortical regions affected by DAI. These phy measures of diminished CBF show some findings suggest that when the language skills general relationships to executive dysfunction of aphasic patients improve over a long pe- and neurobehavioral impairments in more riod, some of the physiologic and structural chronic TBI. Low frontal CBF occurs with dis- lower than normal CBF bilaterally in the inhibited behavior. Improvements in neu- group with poor recovery of language and did ropsychologic test scores during rehabilitation not reveal higher than normal resting regional correlates with increases in CBF by SPECT,88 or mean CBF in the right hemisphere in sub- although associations between rCBF changes jects whose aphasia scores had improved. Hypometabolism in the limbic and par- of CBF in relation to clinical recovery will be alimbic areas, when MRI showed no lesion, more than simple unchanging ones over time. At the time of test- As described in Chapters 1 and 2, the CNS ing, only two had a good recovery on the does have a remarkable capacity for reorgani- Glasgow Outcome Scale. Cognitive and be- zation at the cellular level and within its neu- havioural disorders correlated with decreased ronal assemblies and networks. Rapid changes metabolism in the prefrontal cortex and cin- occur with unmasking of relatively latent gulate gyrus. Slower changes are related to induc- ecutive functions occurred with hypometabo- tion of LTP and dendritic sprouts. Some of the lism in the mesial and lateral prefrontal cortex drive for these changes derives from intrinsic and cingulate gyrus. Much of so- lated with mesial prefrontal and cingulate hy- called spontaneous plasticity, however, derives pometabolism. As expected, BA 9 and 10 were from extrinsic influences such as experience most involved (see Chapter 1), especially in the and learning, which induce a range of activity- left hemisphere for subjects with impaired ver- dependent adaptations over acute, subacute, bal memory and attention/executive impair- and long-term intervals. The bilateral dorsolateral prefrontal Spontaneous plasticity should not imply that cortices were most hypometabolic in the most gains in behavior and regional adaptations in impaired subjects.

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When they are activated by acetylcholine order 1mg requip with mastercard medicine video, the cell membrane depolarizes and produces muscle contraction generic requip 0.25mg without prescription in treatment 2. Muscarinic CHARACTERISTICS OF receptors are located in most internal organs, including the AUTONOMIC DRUGS cardiovascular, respiratory, gastrointestinal, and genitourinary systems. When muscarinic receptors are activated by acetyl- Many drugs are used clinically because of their ability to stim- choline, the affected cells may be excited or inhibited in their ulate or block activity of the SNS or PNS. These receptors have been further subdivided, with activity act like endogenous neurotransmitter substances; two types of nicotinic and five types of muscarinic receptors drugs that block activity prevent the action of both endogenous identified. Although the subtypes of cholinergic receptors have not Drugs that act on the ANS usually affect the entire body been as well characterized as those of the adrenergic re- rather than certain organs and tissues. Drug effects depend on ceptors, the intracellular events (of signal transduction) which branch of the ANS is involved and whether it is stimu- after stimulation are thought to include the following lated or inhibited by drug therapy. Thus, knowledge of the mechanisms: physiology of the ANS is required if drug effects are to be un- • Muscarinic1 receptors: Activation of these receptors re- derstood and predicted. In addition, it is becoming increasingly sults in a series of processes during which phospholipids important to understand receptor activity and the consequences in the cell membrane and inside the cell are broken down. More drugs are being developed One of the products of phospholipid metabolism is ino- to stimulate or inhibit particular subtypes of receptors. The inositol phosphate acts as a second part of the continuing effort to design drugs that act more messenger to increase the intracellular concentration of selectively on particular body tissues and decrease adverse calcium. Calcium also acts as a second messenger and effects on other body tissues. For example, drugs such as terbu- functions to activate several intracellular enzymes, initi- taline have been developed to stimulate beta2 receptors in the ate contraction of smooth muscle cells, and increase se- respiratory tract and produce bronchodilation (a desired effect) cretions of exocrine glands. As a result, less cAMP is formed to confusing because different terms are used to refer to the act as a second messenger and stimulate intracellular ac- same phenomenon. Receptor stimulation also results in activation of alpha- and beta-adrenergic agonists are used to describe a potassium channels in cell membranes of the heart. The drug that has the same effects on the human body as stimula- overall consequence of M2 activation is inhibition of tion of the SNS. There are also the same cascade of intracellular processes as with acti- drugs that oppose or block stimulation of these systems. In addition, nitrous oxide is patholytic, antiadrenergic, and alpha- and beta-adrenergic generated from vascular endothelial cells, resulting in blocking drugs inhibit sympathetic stimulation. Their loca- adrenergic, antiadrenergic, cholinergic, and anticholinergic tion and function have not yet been delineated. CHAPTER 17 PHYSIOLOGY OF THE AUTONOMIC NERVOUS SYSTEM 267 SELECTED REFERENCES Review and Application Exercises Hoffman, B. List commonly used over-the-counter prepara- alpha- and beta-adrenergic receptors. Discuss principles of therapy and nursing for use, adverse effects, nursing process impli- process for using adrenergic drugs in special cations, principles of therapy, and observation populations. Discuss use of epinephrine to treat anaphylac- noncatecholamine adrenergic drugs. Teach the client about safe, effective use of effects with adrenergic drugs. Critical Thinking Scenario Jill, 8 years old, is brought to the clinic for allergy desensitization. After her injection, as usual, you ask her to remain in the waiting room for 30 minutes. Jill is restless, her voice is high-pitched, she feels odd, and her respiration rate has increased to 30 breaths per minute. If Jill were experiencing an anaphylactic reaction, what would be the treatment of choice? DESCRIPTION peutic uses and adverse effects stem from drug effects on the heart, blood vessels, and lungs. The drugs discussed in this Adrenergic (sympathomimetic) drugs produce effects sim- chapter (epinephrine, ephedrine, pseudoephedrine, isopro- ilar to those produced by stimulation of the sympathetic ner- terenol, and phenylephrine) are those with multiple effects and vous system (see Chap. Some of the drugs are exogenous Because epinephrine, ephedrine, and pseudoephedrine stimu- formulations of naturally occurring neurotransmitters and late both alpha- and beta-adrenergic receptors, these drugs hormones such as norepinephrine (Levophed), epinephrine have widespread effects on body tissues and multiple clinical (Adrenalin), and dopamine (Intropin).

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Neurodevelop- desired movement and inhibit unwanted mental techniques (NDT) call for reproducing movements generic 0.5mg requip free shipping treatment neuropathy. For example generic requip 0.25mg line pretreatment, the therapist places the developmental sequence shown by infants the upper extremity in extension, abduction, as they evolve motor control. Specific techniques include repeated abnormal motor behaviors are compensatory, quick stretch, contraction, contraction-relax- and that the quality of motor experiences helps ation, and rhythmic stabilization in which the train subjects for normal movement. Practi- patient tries to hold the arm still as resistance tioners emphasize normal postural alignment is applied by the therapist in an opposite di- prior to any movement. Proprioceptive neuromuscular facilita- ceed in a developmental pattern from rolling tion stretching techniques call for an isometric onto the side with arm and leg flexion on the contraction of the muscle under stretch, such same side, to extension of the neck and legs as the hamstrings, followed by a concentric while prone, to lying prone while supported by contraction of the opposing quadriceps muscle the elbows, and then to static and weight-shift- during stretch of the hamstrings, designated as ing movements while crawling on all four ex- contract-relax agonist-contract (CRAC). These mat activities are followed by sequence is thought to alter the responses of sitting, standing, and, finally, walking. Differ- muscle spindles in a way that increases the ent schools vary in their attempts to activate or maximum range of motion; stimulation may in- mimimize reflexive movements and to train crease in force produced by each muscle as functional movements during ordinary physi- well. Similar One of the potential problems with NDT is spiral and diagonal movement patterns are the delay of standing and walking until the pa- later used for functional activities and walking. These be- liefs, however, are not backed by data from Bobath clinical trials or by information drawn from cur- This NDT approach popularized by the Bo- rent theories regarding motor learning and baths aims to give patients control of abnormal practice-induced skills learning and associated patterns of posture and movement associated neuroplasticity. Abnormal movements provide abnormal sure across joints and allows weight bearing, sensory feedback, which reinforces limited, for example, on the arm through the extended nonselective, abnormal movement. They use pressure or support on key proximal limb or Brunnstrom trunk points to inhibit or facilitate movement. For example, the hemiplegic Specific techniques are recommended for each patient with flexor spasticity of an arm that of the 6 stages of recovery that emerge: (1) flac- rides up during walking is trained to bend for- cidity, (2) limb synergies with onset of spastic- ward in a chair with the arm hanging down. The subject slowly out of synergy, (5) selective over synergistic sits upright with the neck flexed while the arm movement, and (6) near normal control. When stages of recovery have been used as both de- the elbow starts to flex again, the patient re- scriptors and, inappropriately, as outcome peats these steps. During the early patients who have persistent hypotonia and stages of recovery, weight bearing, postural re- hemiplegia. Ankle-foot orthoses are discouraged, be- Rood cause braces are believed to facilitate abnormal tone. A survey of threshold receptors are thought to increase United Kingdom physiotherapsits found the tonic responses and low threshold receptors ac- Bobath approach preferred by 67% of senior tivate phasic ones. The Bobath therapists ing, tapping, applying pressure and resistance, said they delay task-related therapies if the pa- and truncal rocking and rolling. The response tient does not have normal tone and cannot use to cutaneous and other sensory inputs is used The Rehabilitation Team 223 to facilitate developmental patterns and then recovery of some motor control must take into purposeful movement. Bobath teaches that these increase abnormal Efficacy of Neurofacilitation Techniques movements, whereas Kabat encourages resist- The approaches of the pioneering schools of ance exercises, and Brunnstrom uses associ- physical therapy were derived from clinical ob- ated reactions early in treatment. At least one servations that drew upon narrow assumptions Brunnstrom technique for eliciting associated about motor control. This approach may both injury following a predictable sequence similar strengthen and improve the motor control of to infant development. None of these assump- hip movements, particularly if resistance is ap- tions can be taken as correct. For example, plied to the normal leg during gait training and techniques for shifting weight onto the affected during treadmill training with body weight hemiparetic leg prior to stepping has been a support. Joint Some of the neurophysiologic principles compression is considered to increase propri- used by the schools appear reasonable. Pre- oceptive and cutaneous stimuli, affect tone, dictable motor responses are elicited by reflex and help train the leg to participate in postural reactions, by vibration to stimulate a muscle tasks. One study, however, suggested that load- contraction,45 by cutaneous stimulation to fa- ing only accentuates the extensor synergy of cilitate a voluntary contraction,46 and by upper the lower leg muscles, rather than facilitating extremity weight-bearing through the ex- normal postural responses. Consider the whole limb precedes more selective move- tonic neck reflexes after a brain injury. Neck extension of motor recovery after hemiplegia by can facilitate extension of the affected arm and Twitchell,42 from which the Brunnstrom tech- flexion of the leg. Neck flexion may produce nique derives its stages, is often quoted as the flexion of the arms and extension of the legs.

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