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The occupational therapist is also involved with advising people on home modifications quality sildigra 25 mg erectile dysfunction just before intercourse, mobility including wheelchairs generic 50mg sildigra fast delivery impotence depression, driving and transport 120 mg sildigra erectile dysfunction treatment san antonio, returning to work, college or school, and the pursuit of leisure activities and hobbies. Hand and upper limb management Individual assessment of the hand and upper limb of tetraplegic patients is essential to maintain their hands in the optimum position for function. Hand management of patients with incomplete lesions needs close monitoring and if motor function improves activities are performed to enable the patient to achieve their maximum potential. Tetraplegic patients with active wrist extensors should be encouraged to participate in activities to strengthen these muscles and to facilitate the use of their tenodesis grip. This occurs in the individual with a complete spinal cord lesion at C6 who is able to use active wrist extension to produce a grip between thumb and index fingers. Some tetraplegic patients may require a variety of splints, such as those for writing and typing, wrist support splints, feeding straps, or pushing gloves, to enable them to carry out their daily activities. Home resettlement Establishing early dialogue with the patient, the patient’s family and friends is vital to enable the occupational therapist to be in a position to offer early advice and reassurance regarding (b) living in the community. When an individual does not have a suitable home to return to alternatives are discussed, i. An assessment visit involves a team from the spinal unit, including the occupational therapist and representatives from the patient’s home area—usually the occupational therapist and social worker/care manager and the patient’s family. The visit begins the lengthy processes of planning for the patient’s discharge and providing accessible accommodation. Recommendations are made to enable weekends to be spent away from hospital. Weekends away begin when the patient and family or friends feel confident to be away from the hospital. Enabling this to occur may involve the whole team in teaching techniques, procedures and instruction in the use of equipment to both patient and family. Spending time away from the hospital may enable the patient, their family and friends to decide upon what plans they wish to make for long-term resettlement in the community. The procedures involved in making alterations to a property require careful thought and planning and may take many months before completion. As well as the availability of suitable accommodation, the organising of an appropriate care package may be necessary, which involves the whole team and may take time to organise. In the event of completion of a patient’s rehabilitation occurring before long-term accommodation is accessible or available, it may be necessary for alternative interim accommodation to be sought. Activities of daily living Once tetraplegic patients are out of bed and have started work on strengthening and balance, they begin to explore methods to relearn eating, drinking, washing, brushing their hair, cleaning their teeth, and shaving. These activities often entail the use of adapted tools or splints and straps made by the occupational therapist. The patient may need to relearn writing skills and may also explore the use of a computer, telephone, page- turner, and environmental control system. As the patient becomes more confident and the wearing of a hard collar or brace all day is discontinued, he or she is able to progress to tasks involving bed mobility, in preparation for dressing, transfers, showering, and domestic activities. This can cover the whole range of domestic living and include being able to make a cup of tea, using a microwave, washing machine, vacuum cleaner or changing a duvet cover independently. Despite the patient’s social situation they should be given the opportunity to relearn these activities. Communication For tetraplegic patients unable to use their upper limbs functionally with standard communication systems, the role of the occupational therapist is to enable the patient to access alternative systems. Individual writing splints or mouthsticks may be made to enable those with limited writing skill to make a signature, which can be important to an individual for both business and personal correspondence. Alternative methods of being able to turn the pages of books, magazines and newspapers may be pursued. Trial and selection of electrically powered equipment includes telephone, computer and assessment of environmental control systems, which can enable the individual to operate via a switch a range of functions, including television, video, intercom, computer, lights, radio, and accessing the telephone. In incomplete spinal cord lesions, where there can be use variable potential for neurological recovery, it may not be possible to • May be able to assist with transfer from wheelchair onto level predict functional outcome, which can lead to increased anxiety for the surfaces using a sliding board and an assistant patient. Complete lesion below C6: As the adult with a spinal cord lesion becomes older their ability to • Able to extend wrists maintain their level of independence may diminish and require review. As soon as is practicable liaison occurs between the spinal centre staff, the patient and the patient’s local district wheelchair service. They are able to assess and provide wheelchairs from a range, which includes self-propelling, lightweight, indoor powered, indoor/outdoor powered and Figure 10. The occupational therapist should be able to guide the individual to trial and select a wheelchair with features that suit the patient’s functional ability and lifestyle. An extensive range of wheelchairs is available commercially, including those that tilt in space and enable standing, and outdoor powered wheelchairs. Driving and vehicles Several centres specialise in assessing an individual prior to returning to driving and give advice on the trial and selection of controls that suit an individual’s functional ability. The assessment also includes advice on methods of storage of the Figure 10. For individuals who wish to remain in their wheelchair whilst travelling, either as a driver or a passenger, the choice of wheelchair must be matched with the choice of vehicle and the individual’s size. Leisure Constructive use of leisure time is vital to maintain self-esteem and self-confidence. Some previous activities and interests can be continued, with a little thought and suitable adjustment. There are many national groups and organisations with facilities to support individuals to pursue their hobbies, sporting interests, travel and holidays, and access to the internet has widened the range of information available. Work consider some alternative employment they can contact their local employment service, which may be able to offer practical Work is of varying importance to patients, but some will see it advice and financial support. Early contact with employer, school, or college, the occupational therapist is able the patient’s employer to discuss the feasibility of eventual to assess the suitability of the premises for wheelchair return to his or her previous job is important. If the degree of a accessibility and make recommendations on the facilities which patient’s disability precludes this, some employers are would be necessary. The advance of information technology sympathetic and flexible and will offer a job that will be has increased employment opportunities for patients of all possible from a wheelchair. As a result of their spinal cord injury, some people use the opportunity to take stock of their lives and retrain or enter further education. Some people choose not to return to paid Further reading employment but seek occupation in the voluntary sector. Many patients find life outside hospital difficult enough initially, • Curtin M. Development of a tetraplegic hand assessment however, without the added responsibility of a job, and in these and splinting protocol. Paraplegia 1994;32:159–69 circumstances a period of adjustment at home is advisable • Whalley Hammell K. When such patients feel ready to London: Chapman and Hall 1995 56 11 Social needs of patient and family Julia Ingram, David Grundy The aim of successful rehabilitation is to enable the patient to live as satisfactory and fulfilling a life as possible. This will mean different choices and decisions for each individual depending on the degree of disability, the family and social environment, and preferred lifestyle. The vast majority of patients want to live in their own homes and not in residential care, and very severely disabled Table 11.

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Preoperative CT find- ings: narrow true acetabulum and normal medullary canal of the femur THA for High Congenital Hip Dislocation 227 A Fig 100 mg sildigra sale erectile dysfunction patient.co.uk doctor. D Second stage of operation Figure 10 show the findings at 1 month (A) and at 15 years (B) after surgery discount 120mg sildigra with amex erectile dysfunction hypertension medications. The patient is now 75 years old safe 100mg sildigra erectile dysfunction pills in india, and X-ray findings show slight wear of the HDP cup component on the left side, which indicates the process should be carefully followed up. Patient 2 A 50-year-old woman with Crowe group III dysplasia of the right hip is shown in Fig. After the enlargement of the true acetabulum, the patient received a 228 M. X-ray findings at 1 month (A) and 15 years post- operative (B) A B bipolar-type prosthesis, which showed central migration over a short period (Fig. The bipolar prosthesis was revised and converted to a total hip prosthesis. Thirteen years after the conversion to total prosthesis, the hip is in good condition (Fig. In this case, the total hip prosthesis would have been a better choice than the bipolar prosthesis at the first surgery. Bipolar prosthesis shows central migration in a short period after surgery. Enlargement of the medullary canal of the femur In the second technique, to treat the slender femur, enlargement of the medullary canal (Fig. After femoral osteotomy at the base of the neck, multiple drill holes are made in the femur shaft in the anteroposterior direction 5mm apart for 25cm distally. A longitudinal osteotomy is made with an osteotome to split the femur along these holes. A rasp is used to enlarge the medullary canal to fit the selected stem size. After implantation of the prosthesis stem, four or five cerclage wires are wound around the femoral bone to stabilize the osteotomized portion (Fig. Patient 3 A 57-year-old woman with left unilateral high hip dislocation, Crowe group IV, is shown in Fig. In the CT scan, the upwardly displaced, slender femur and the narrow true acetabulum can be confirmed (Fig. In the first stage of the operation, enlargement of the true acetabulum and implantation of the metal shell were performed (Fig. X-ray findings at 57 years of age, preoperative (A), and at 72 years of age, 15 years postoperative (B) After the first stage of the operation was completed, the leg was pulled distally and the adjusting down of the femur was accomplished (Fig. In the second stage of the procedure, enlargement of the femoral medullary canal and implanting of the stem prosthesis were performed. After stabilizing the enlarged femur by cerclage wire, the femoral head was reduced and arthroplasty was completed (Fig. CT findings (arrows): upward displaced slender femur (A) and small acetabu- lum (B) A B A C D E Fig. Progression of the procedure: preoperative (A); first stage of operation (B); adjusting the femur downward by traction (C); second stage of operation (D); and 10 years after surgery (E) THA for High Congenital Hip Dislocation 233 Materials Since 1987 we have treated 36 cases, 45 joints, with the above-described technique (Tables 1, 2). Of 25 unilateral cases, 16 of the contralateral hips were in a low dislocation, Crowe group I or II, and 9 hips were normal. Except for the two bipolar-type prosthetic joints, 43 joints of the cementless-type prosthesis with multiholed metal cup and straight stem were implanted. One-stage operations were done in 18 joints and two-stage operations were done in 27 joints. Enlargement of the acetabular side was done in 45 joints and of the femoral side in 4 joints. The size of acetabular component used was from 50 to 54mm outside diameter. The size of femoral prosthesis used was number 7 or 8 from Stryker, or 10 or 11mm from Zimmer. Cases of dysplastic hip, Crowe III and IV, treated with enlargement in 1987 to 2003 Number of cases: 36 (1 male, 35 female) Number of joints: 45 Age (in years): 40 to 69 (mean: 57. Cases of dysplastic hip, Crowe III and IV, treated with enlargement in 1987 to 2003 Prosthesis: Bipolar: 2 joints Cementless THR: 43 joints Operation stage: 1 stage: 18 joints 2 stages: 27 joints Enlargement: True acetabulum: 45 joints Femur: 4 joints Size of acetabular cup: 50 to 54mm Size of femoral prosthesis: Nr 7 to 8 mm (Stryker) Nr 10 to 11 mm (Zimmer) THR, total hip replacement 234 M. Endo Results Preoperative limb shortening ranged from 20 to 70mm with an average of 44. Limb shortening was corrected after surgery in all cases to less than 10mm. The preoperative hip score, according to the Japanese Orthopaedic Association (JOA), was 34. Trendelenburg’s sign was clearly positive in all 45 preoperative joints. After surgery, 17 joints improved into negative and 20 joints showed a decrease of pelvic inclination. Of 7 cases of peroneal nerve palsy, 5 cases completely recovered in 6 months and slight paresthesia remained in 2 cases. Cases of dysplastic hip, Crowe III and IV, treated with enlargement in 1987 to 2003 Limb shortening (preoperative): 20–70mm (mean: 44. Complications in cases of dysplastic hip, Crowe III and IV, treated with enlargement in 1987 to 2003 Nerve palsy: 12 cases Peroneal nerve: 7 cases 5: fully recovered; 2: paraesthesia) Femoral nerve: 5 cases (all fully recovered) Dislocation: 7 cases Closed reduction: 4 cases Open reduction: 1 case Converted to consrained type: 2 cases Loosening: 9 cases Acetabular side: 8 cases Bipolar → cementless THR: 2 cases (within 3 years postoperative) Cementless THR: 6 cases Larger cementless: 4 cases Supportring cementless: 2 cases Femur side: Revision to cementless stem: 1 case THA for High Congenital Hip Dislocation 235 procedure. In 4 cases, closed reduction was performed under intravenous anesthesia and no further episodes were observed. In 1 case, an open reduction was necessary and no further episodes were seen. Because of the recurrent dislocations, it was necessary to convert to the constrained-type prosthesis in 2 cases. Among 6 cases of cementless total hip arthroplasty, 4 cases were revised by using the larger cementless cups and 2 cases had to be revised by using the cup supporter with bone cement. One case of femoral side loosening was revised by using the cementless type of revision prosthesis. Discussion In patients with poor acetabular bone stock, superior coverage of the acetabulum can be achieved by performing a horizontal osteotomy at the margin of the acetabulum, or by femoral head grafting as proposed by Harris et al. However, these techniques cannot improve anteroposterior bone deficiency, and extensive reaming of the acetabulum may lead to additional bone loss of anteroposterior osseous support. Furthermore, it is not possible to remedy the thin femur and narrow femoral med- ullary canal solely with bone grafting. For treating a narrow medullary canal, the use of a narrow stem has been described by Charnley and Feagin, Buchholz et al.

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It not only cuts us off from very practical gains to be made in solidarity with others buy discount sildigra 100mg line erectile dysfunction vacuum pump reviews, it radically distorts our view of the human situation” (1995 100 mg sildigra free shipping wellbutrin xl impotence, 55) discount 120mg sildigra with mastercard erectile dysfunction treatment levitra. New tactics for getting through each day can alter how people interact with others and how they see their role in life. The interviewees did acknowledge changes in their personalities and feelings about themselves, albeit not their core convictions. Another woman wishes she could “deal with things better,” be less angry. One man who formerly kept his feelings to himself now realizes, after divorce, that he How People Feel about Their Difficulty Walking / 79 must talk openly about his emotions. Another man wants to feel more rec- onciled to “not being able to do the things I used to do. Once reticent, they become feisty, albeit recog- nizing that self-advocacy sometimes appears shrill, strident, narcissistic, or rude. They take that risk, often surprising even themselves, beginning per- haps to identify with other disabled people. If I don’t feel like doing something, I ain’t doing nothing I don’t have to do. I know deep in my heart that there was a reason for this happening, but I always still think, why me? I’m from the school that these are the cards that I’ve been dealt, and I have to do the best I can with these cards. It’s not that I accepted it or embraced it with open arms, but I say this is it, and I just have to go on. Sometimes those who are “worse off” embody people’s fears for their own future, but they also can offer hope. Although Lester Goodall still walks with a cane, needing a wheelchair is never far from his mind: I think about it especially when I see people on the street in a wheel- chair. When I see them, it seems like it’s not the worst thing in the world that can happen. I see they’re active, they’re on the train, they’re doing jobs, and they’re in a lot worse shape than I am.... An unspoken subtext to many comments was the question about when to adopt a “disability identity”—incorporating disability into their core self- image. Near the end of our interview, I asked people if they were “disabled,” and I got three types of responses: about two-fifths of people said “yes”; a 80 / How People Feel about Their Difficulty Walking comparable fraction said “no”; and the remaining fifth answered both “yes” and “no. The federal survey asked people two questions about perceived disability: Do you consider yourself to have a disability? While the percentage reporting disability increases with worsening mobil- ity difficulties, substantial numbers reject this label even among those with major mobility problems (Table 6). Those who do typically say that they cannot do physically what they wish to do. Those who deny being disabled generally see disability as associated with complete physical incapacity. As Jimmy Howard observed, Maybe I need a little more time to do things, but I’ve never really used neither of those words, “disabled” or “handicapped. Things are a hindrance to me, but it’s not like I’m bedridden, that I can’t get up and do nothing. That’s what I consider being disabled—that if you want to go to the bathroom, you got to call somebody to help you or wipe your butt. About one-fifth of interviewees said they both are and aren’t disabled— recognizing the contradiction but explaining it by distinguishing the mind from the body. I’m able to do things other people wouldn’t even try to do, like going to school even though I’m almost forty- nine years old. Two feelings predominate: first, the need to live with uncertainty; and second, the intention to deal with whatever happens. Only two or three interviewees (admittedly a selected group) seemed to have given up, retreated from the world. Instead, some felt their health problem had jolted them out of complacency, stimulated them to be better people. Perceptions of Disability Self- Others’ Perception (%) Perception (%) Respondent’s mobility difficulty None 4 3 Minor 36 30 Moderate 60 50 Major 75 69 Respondent using mobility aid Cane or crutches 67 62 Walker 78 74 Manual wheelchair 82 81 Electric wheelchair 90 82 Scooter 94 91 somebody by showing that I can get through all this,” said Brianna Vicks. Now I’m working on just being able to stand and pivot—you change your priorities. It makes me nuts, and I don’t know what I’m gonna do about it sometimes. Her husband, Chet, who died from cancer, had been her helpmate and true partner. The other day I heard about somebody whose husband divorced her 82 / How People Feel about Their Difficulty Walking twenty minutes post-diagnosis. He had immigrated from Af- ghanistan and wore traditional garb—colorful crocheted cap and multilayered thigh-length cotton shirting—despite the biting December cold. The first time he had driven me, he had asked immediately if I was married, then said how happy he was to bring me home to my husband. He had driven me sev- eral times since, always asking the same question: “How is your husband? The driver told me about his brother, still in their homeland, who was “born paralyzed” by cerebral palsy and uses a wheelchair. At the most basic level, people may have difficulty performing routine daily activi- ties—dressing, getting to the bathroom, moving around home, preparing meals, housecleaning, shopping. They may rely on those they live with to assist with many tasks, including the most private. For many people, walking dif- ficulties affect how they see themselves—and how others see them—as 83 84 / At Home—with Family and Friends spouse, partner, parent, child, or friend. For some, relationships strengthen as the inevitable shifts and redefinitions affect everybody over time. Or, as for the taxi driver’s brother, social attitudes can also erect enormous barri- ers to the most fundamental human connections: gaining the intimacy and friendship of a spouse or partner or the joys and challenges of parenthood. Chapter 6 examines how walking difficulties affect routine daily life and relationships with family and friends. Certain tasks are almost always performed by individuals themselves (like bathing, dressing, going to the toilet), while some may be performed by another (like preparing meals, grocery shopping, cleaning house). When mobility problems intrude, alternative strategies become necessary. Meeting daily needs can demand calculated logistics: every aspect of life is planned. Fear creeps in—of falling, of being im- mobilized, trapped in a fire, burned while cooking, being alone.

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In most cases of high dislocation cheap sildigra 100 mg with amex erectile dysfunction joliet, the true acetabulum is small and the upwardly displaced femur is dysplastic with a narrow medullary canal sildigra 120mg line impotence herbal medicine, a small head and an anteverted neck cheap sildigra 100mg with mastercard venogenic erectile dysfunction treatment. A joint-preserving procedure is not recommended for patients with this condition. Total hip arthroplasty is the most suitable procedure for responding to the needs of the present-day patient by providing a pain-free and mobile hip. The surgeon should keep in mind that the choice of components is directly related to postsurgery durability. To satisfying this requirement, the authors have developed two new techniques. Herein authors report the cases that were treated with these techniques. High dislocation of the hip, Crowe classification of the dysplastic hip, Enlargement of the true acetabulum, Enlargement of the medullary canal of the femur, Total hip arthroplasty Introduction Among patients with osteoarthritis secondary to congenital dislocation of the hip, those with high dislocations show poor ambulation with severe limping and usually experience a dull pain at the lumbar and pelvic region rather than pain of the hip joint itself. However, it is a known fact that symptoms and functional impairments caused by high dislocations increase with age and that conservative treatment alone is insufficient for middle-aged or older patients. In high congenital dislocation of the hip, Crowe group III or IV, the femoral head is entirely outside the original acetabulum. A joint-preserving procedure is not recommended for patients with this condition. However, recent techniques of total hip arthroplasty have been established, and a certain degree of confidence has been acquired with regard to the lasting effectiveness of these techniques. Thus, painless- ness, ability for weight-bearing, and mobility can be regained simultaneously by 1Department of Orthopaedic Surgery, Nakajo Central Hospital, 12-1 Nishihoncho, Tainai, Niigata 959-2656, Japan 2Division of Orthopaedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata 951-8510, Japan 221 222 M. Endo appropriate surgery, and such treatments are the most suitable for responding to the needs of the present-day patient. In most cases of high dislocation, the true acetabulum is usually small, porotic, and triangularly shaped. The upwardly displaced femur is also dysplastic with a narrow medullary canal, a small head, and an anteverted neck, but of normal length (Fig. Initial attempts to reconstruct a high dislocation Crowe group III or IV, using a secondary acetabulum with formed osteophytes, have been performed in two cases. In these patients, however, poor ambulation persisted and a biomechanically stable joint could not be obtained, resulting in loosening of the acetabular cup at an early postoperative stage. These experiences suggest a neces- sity to improve the biomechanical relationship between the femoral head and the pelvis by implanting the artificial joint at the level of the original acetabulum. This necessity has also been stated in the literature by Eftekhar, Arcq, Azuma, and Yamamuro. A second attempt to reconstruct the high dislocation, using a small-sized cup in the true acetabulum, had been performed, but this technique had a risk of abrasion of the high density polyethylene (HDP) and breakage of the com- ponent. Figure 2D–F shows a case in which the small-cup component was used, which A C B Fig. A 62-year-old woman: three-dimensional (3D) computed tomography (CT) findings of right hip, Crowe group IV. C Right lateral: narrow true acetabulum and pressure mark of the femoral head on iliac bone wall (double-headed arrow) THA for High Congenital Hip Dislocation 223 A B C D E Fig. C Upward migration (arrow) of the cup in a short period (2 years) after surgery. F Breakdown of the cup (arrow) in a short period (2 years) after surgery resulted in a breakdown of the cup in a short period after surgery. These failures taught us that we should reconstruct a biomechanically stable condi- tion around the hip by implanting the component in an anatomically correct position and keep in mind that using a normal-sized component is also of importance. Original Technique To satisfy this requirement, authors developed two new techniques: the first one is for the acetabular side and the second one is for the femoral side. In the first technique, to treat this narrow acetabulum, enlargement of its width is needed (see Fig. L- or T-osteotomy In the dislocated hip, in addition to the narrow true acetabulum the pelvic bone at the true acetabular level is narrow, especially in the anteroposterior direction. Next, the oste- otomized portion is enlarged while preserving the anterior and posterior walls (Fig. Then, bone grafting is done at the superior portion of the acetabulum and in the bone defect that is produced by the enlargement (Fig. If a very large enlargement is not needed, a L-shaped osteotomy is available (Fig. After enlargement, the metal shell component with multiple screw holes should be implanted. The screws stabilize the shell, while at the same time stabilizing the enlarged portion (see Figs. Case Reports Patient 1 A 60-year-old woman with a bilateral hip dislocation, Crowe group IV, is shown in Fig. The CT scan shows a narrow true acetabulum but a normal medullary canal of the femur on both sides (Fig. After enlargement of the true acetabulum, the metal shell was implanted in the first stage of the operation (Fig. The right leg was pulled down by skeletal traction while the patient was con- scious. For the left side, the same two-stage procedure was performed, and the total hip arthroplasty was successfully finished (Fig. Preoperative CT find- ings: narrow true acetabulum and normal medullary canal of the femur THA for High Congenital Hip Dislocation 227 A Fig. D Second stage of operation Figure 10 show the findings at 1 month (A) and at 15 years (B) after surgery. The patient is now 75 years old, and X-ray findings show slight wear of the HDP cup component on the left side, which indicates the process should be carefully followed up. Patient 2 A 50-year-old woman with Crowe group III dysplasia of the right hip is shown in Fig. After the enlargement of the true acetabulum, the patient received a 228 M. X-ray findings at 1 month (A) and 15 years post- operative (B) A B bipolar-type prosthesis, which showed central migration over a short period (Fig. The bipolar prosthesis was revised and converted to a total hip prosthesis. Thirteen years after the conversion to total prosthesis, the hip is in good condition (Fig. In this case, the total hip prosthesis would have been a better choice than the bipolar prosthesis at the first surgery. Bipolar prosthesis shows central migration in a short period after surgery.

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