Medicurio

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Functional assessments have become an integral part of the comprehensive rehabilitation medicine evaluation. Descriptions of improvements in function have been consistently performed since rehabilitation medicine developed after World War II. Unfortunately, previously utilized methods lacked the consistency required to study rehabilitation outcomes accurately.

Functional assessment measures an individual’s level of function and ability to perform specific tasks on a safe and dependable basis over a defined period. A detailed assessment should include a pertinent clinical history; a neurologic and musculoskeletal evaluation, a physical effort determination, and a comprehensive evaluation of behaviors that might impact physical performance. Assessments must be valid, reliable, and reproducible. They can be self-administered questionnaires or clinician administered.

From a research standpoint, functional assessments provide supporting evidence to develop, improve and attest to different evidence-based treatments. In the clinical setting, these instruments are commonly used to set rehabilitation goals, to develop specific therapeutic interventions and to monitor clinical changes.

In 2014, functional assessments took a different direction when the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) was signed into law seeking to connect findings on the baseline assessment to functional outcomes. This required that Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs) to report and submit standardized patient assessment data, including quality measures and standardized patient assessment data elements. The collection of this information permitted the exchange of information among providers on specific functional domains that included functional status, cognitive function, and mental status among some. The final goal intended to enhanced rehabilitation outcomes through share decision making, care coordination and improved discharge planning.

Relevance To Clinical Practice

The scope of practice in Rehabilitation Medicine is wide and includes an array of conditions such as neurological (stroke, TBI, neurodegenerative), musculoskeletal (joint pain, tendinopathies, ligamentous injuries, balance dysfunction) pain syndromes, medical (deconditioning, cardiopulmonary), rheumatologic (Rheumatoid Arthritis, Osteoarthritis, Connective Tissue Disorders), among others.

Commonly used assessments include:

Activities of daily living (Table 1A) measures the performance of basic functional skills required to care for oneself independently. They measure basic daily activities (eating, grooming, bathing, dressing, continence) mobility (gait, transfers) and cognition. Examples include: 

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• Barthel Index
• Functional Independence Measure (FIM)
• Functional Independence Measure for Children (WeeFIM)
• GG Functional Abilities and Goal 
• specific Functional Scale
• Canadian Occupational Performance Measure
• Lawton’s Instrumental Activities of Daily Living among others
• WHO International Classification of Functioning, Disability, and Health (ICF)
• International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY)

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An exercise tolerance test (also called a stress test) shows how well your heart handles physical activity. While exercising on a treadmill or stationary bike, a healthcare provider will measure your heart rate, blood pressure, and breathing while monitoring an electrocardiogram (ECG), a test that records your heart’s electrical signals.

Exercise tolerance tests are generally used to detect certain heart conditions or determine safe levels of exercise for people with existing heart conditions.

This article provides an overview on what an exercise tolerance test entails and how to understand the test’s results.

Purpose of an Exercise Tolerance Test

Exercise tolerance tests evaluate how hard your heart works when it’s under the stress of physical activity.

When we exercise, our hearts pump harder and faster to deliver blood and oxygen throughout the body.¹ It’s often easier to detect certain heart conditions while your heart is working hard, since the heart may appear to be working normally while at rest.

After hooking a patient up to a blood pressure cuff and ECG during exercise on a treadmill or stationary bike, healthcare providers can monitor your:

• Heart rate
• Blood pressure
• Breathing
• Level of exertion

Not everyone needs an exercise tolerance test. They’re mainly used to detect a heart condition or monitor a preexisting heart condition. For example, a healthcare provider may recommend this test:

• If you have symptoms like chest pain or shortness of breath that could indicate a heart condition
• If you have an irregular heartbeat
• To determine a safe exercise plan for patients recovering from heart surgery
• To see if treatments you’re receiving for heart disease are working well

Recap

An exercise tolerance test can demonstrate your heart’s ability to endure physical exercise. This in-office exam is often used to help detect heart conditions and determine appropriate treatments or exercise plans for existing heart patients.⁴

Limitations of an Exercise Tolerance Test

As with any medical test, exercise tolerance tests have some limitations. For example:

• Exercise tolerance tests can help detect an artery blockage in coronary artery disease, but they can’t predict things like how much of the artery has thickened or if and when a person may have a heart attack.
• Exercise tolerance test results aren’t always 100% accurate and can vary based on equipment used, experience of the healthcare professional conducting the test, and other factors. Some people may get a false-positive result, indicating a heart condition when there is none.

With this in mind, your healthcare provider will typically use the results of an exercise tolerance test along with other information, like your symptoms, medical history, and results of other tests, to make a determination or diagnosis.

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Recommendations for Exercise Testing

The U.S. Preventive Services Task Force recommends against routine exercise tolerance testing for people who don’t have any heart symptoms and are at low risk for developing heart disease. This is because the risk of false-positive findings can result in unnecessary further testing, treatment, or worry.

Risks of an Exercise Tolerance Test

An exercise tolerance test is a relatively safe test.

That said, sometimes increasing your heart rate through exercise can cause symptoms like dizziness, chest pain, or nausea. A healthcare provider will closely monitor you throughout the test to reduce the chances of this happening and quickly treat any issues that may come up.

In addition, people with certain preexisting heart disease can experience complications like an irregular heartbeat or even a heart attack. To be safe, your healthcare provider would likely not recommend an exercise tolerance test if you have any of the following heart conditions:⁷

• Unstable angina (chest discomfort caused by poor blood flow)
• Uncontrolled arrhythmia (an irregular heartbeat)
• Pulmonary hypertension (a type of high blood pressure)
• Severe aortic stenosis (narrowing of the main artery)
• Congestive heart failure (a condition in which the heart doesn’t pump blood as well as it should)
• Pulmonary embolism (a clot in the arteries of a lung)
• Aortic dissection (a tear in the main artery)
• Another acute illness

Before the Test

There’s not much preparation needed for an exercise tolerance test. Your healthcare provider will give you a set of guidelines to follow, which may include these instructions:⁸

• Avoid eating a heavy meal or consuming anything other than water within a few hours of the test.
• Avoid consuming caffeine the day before the test.
• Wear loose-fitting clothing and comfortable walking shoes.
• Continue to take any usual medication unless otherwise advised by a healthcare provider.

During the Test

Exercise tolerance tests take place at a healthcare provider’s office or at a hospital and will be overseen by a medical professional. They are relatively quick and painless, minus any potential minor discomfort felt while exercising. The test itself should take about 15–20 minutes. 

Here’s what you can expect:⁹

1. Equipment used will include a treadmill or exercise bike, ECG machine connected to electrodes (wires), a blood pressure cuff, and a pulse oximeter to measure blood oxygen levels.
2. The small electrodes will be stuck to the skin of your chest or shoulders and attached to the ECG machine to measure your heartbeat and heart waves. In addition, the blood pressure cuff will be wrapped around your arm, and the pulse oximeter sensor will be clipped to your finger. 
3. You’ll then be asked to start exercising on the treadmill or bike at an easy pace. Gradually, the speed and incline are increased while the ECG monitors your body and heart’s reaction to the stress of exercise.
4. You may be asked to breathe into a mouthpiece that will measure how much air you’re breathing out.

Before, during, and after the test, your ECG, heart rate, blood pressure, and breathing will be monitored and recorded.

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After the Test

When the test is done, you’ll be able to sit or lie down for several minutes until your heart rate returns to its normal resting state. You may be offered a glass of water or towel while you cool down.

If your blood pressure substantially rose during the test, or if the healthcare provider noticed any other concerning symptoms, you may be monitored for a few additional minutes.

After getting clearance, you’ll be free to return home and await the test results, which usually come back within a couple of days.

Interpreting Results of an Exercise Tolerance Test

After the test is performed, your healthcare provider will look over the results. They’ll be evaluating factors like:¹⁰

• Your ECG reading
• Blood pressure changes
• Heartbeat changes
• Any symptoms reported or noted during the test
• Your estimated exercise capacity 

After summarizing these items, your provider will go over the results with you and offer a conclusion based on their interpretation. Possible results include:¹¹

• Positive (or abnormal): This means the test found potential evidence of a heart condition.
• Negative (or normal): This means the test didn’t find any evidence of a heart condition.
• Inconclusive or uninterpretable: This indicates the test was unable to determine if a heart condition is present. In this case, the equipment may have malfunctioned, or you were unable to complete the test.
• Goal achieved: If you took the test to help establish a safe exercise plan following a heart diagnosis or surgery, your healthcare provider might have set some fitness goals that you were able to meet.

Recap

Stress tests give your healthcare provider important information about the likelihood of a heart problem and to recommend next steps for you. Ultimately, your healthcare provider is the best source of information about interpreting your stress test results.

Follow-Up

Depending on the results, your healthcare provider may want to speak with you about further testing, alternative testing, or treatment options.

In some cases, more appointments or testing may be necessary to:

• Confirm your exercise tolerance test result
• Seek additional information after your exercise tolerance test result

Follow-up tests may include:

• MRI (magnetic resonance imaging) heart scan to evaluate the structure of your heart
• CT coronary scan to look at the arteries that supply blood to your heart
• Myocardial perfusion scan to provide a visual on how well the heart is pumping
• Nuclear stress test to measure the blood flow to your heart

Summary

An exercise tolerance test is one way to record your heart’s response to the stress of physical exercise. It measures the heart’s electrical activity, heart rate, blood pressure, and breathing while you’re on a treadmill or exercise bike.

Exercise tolerance tests may be used to diagnose certain heart conditions, monitor heart attack recovery, or form an appropriate fitness plan for heart disease or surgery patients. Your healthcare provider may recommend this test if you report symptoms of potential heart disease, such as chest pain or shortness of breath. This test generally isn’t recommended for people at low risk of developing heart disease.

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Key facts by WHO-

• Over 1 billion people live with some form of disability.
• The number of people with disability are dramatically increasing. This is due to demographic trends and increases in chronic health conditions, among other causes.
• Almost everyone is likely to experience some form of disability – temporary or permanent – at some point in life.
• People with disability are disproportionately affected during the COVID-19 pandemic.
• When people with disability access health care, they often experience stigma and discrimination, and receive poor quality services.
• There is an urgent need to scale up disability inclusion in all levels of the health system, particularly primary health care.

overview

A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities (activity limitation) and interact with the world around them (participation restrictions).

There are many types of disabilities, such as those that affect a person’s:

• Vision
• Movement
• Thinking
• Remembering
• Learning
• Communicating
• Hearing
• Mental health
• Social relationships

Although “people with disabilities” sometimes refers to a single population, this is actually a diverse group of people with a wide range of needs. Two people with the same type of disability can be affected in very different ways. Some disabilities may be hidden or not easy to see.

Disability is part of being human. Almost everyone will temporarily or permanently experience disability at some point in their life. Over 1 billion people – about 15% of the global population – currently experience disability, and this number is increasing due in part to population ageing and an increase in the prevalence of noncommunicable diseases. 

Disability results from the interaction between individuals with a health condition, such as cerebral palsy, Down syndrome and depression, with personal and environmental factors including negative attitudes, inaccessible transportation and public buildings, and limited social support.

A person’s environment has a huge effect on the experience and extent of disability. Inaccessible environments create barriers that often hinder the full and effective participation of persons with disabilities in society on an equal basis with others. Progress on improving social participation can be made by addressing these barriers and facilitating persons with disabilities in their day to day lives.

Disability can be:

• Related to conditions that are present at birth and may affect functions later in life, including cognition (memory, learning, and understanding), mobility (moving around in the environment), vision, hearing, behavior, and other areas. These conditions may be
  • Disorders in single genes (for example, Duchenne muscular dystrophy);
  • Disorders of chromosomes (for example, Down syndrome); and
  • The result of the mother’s exposure during pregnancy to infections (for example, rubella) or substances, such as alcohol or cigarettes.
• Associated with developmental conditions that become apparent during childhood (for example, autism spectrum disorder and attention-deficit/hyperactivity disorder or ADHD)
• Related to an injury (for example, traumatic brain injury or spinal cord injuryexternal icon).
• Associated with a longstanding condition (for example, diabetes), which can cause a disability such as vision loss, nerve damage, or limb loss.
• Progressive (for example, muscular dystrophy), static (for example, limb loss), or intermittent (for example, some forms of multiple sclerosisexternal icon).

Magnitude of disability –

About 15% of the world’s population lives with some form of disability, of whom 2-4% experience significant difficulties in functioning. The global disability prevalence is higher than previous WHO estimates, which date from the 1970s and suggested a figure of around 10%.

As per the country’s latest statistics, an estimated 2.1 percent of the Indian population has a disability; a humbling figure of over 26 million people. A person can face disability — intellectually and physically — at any point in their life from medical complications or life-altering events.

Epidemiology 

Epidemiology of Intellectual Disability and Comorbid Conditions Epidemiology is essentially the study of a disorder in a given population. Knowledge of the distribution of a disorder in a population can increase understanding of the causes and how best to manage it.

Management

Increasing evidence suggests that, as a group, people with disabilities experience poorer levels of health than the general population. By improving access to quality, affordable health care services, health outcomes for people with disabilities can be improved. Primary health-care services with the support of specialists can provide health services to people with disability. Health services should be focused for the following health conditions:   

Primary health conditions: A primary health condition is the possible starting point for impairment can lead to a wide range of impairments, including mobility, sensory, mental, and communication impairments.

Secondary conditions: Secondary conditions occur in addition to (and are related to) a primary health condition, and are both predictable and therefore preventable; such as depression is a common secondary condition in people with disabilities, osteoporosis is common in people with a spinal cord injury or cerebral palsy.

Co-morbid conditions occur in addition to (and are unrelated to) a primary health condition associated with disability. One study indicated that adults with developmental disabilities had a similar or greater rate of chronic health conditions such as high blood pressure, cardiovascular disease, and diabetes (due to increased physical inactivity) than people without disabilities.

Age-related conditions: The ageing process for some groups of people with disabilities begins earlier than usual and they may experience age related health conditions (such as osteoporosis, loss of strength and balance) more frequently.

Risk behaviours: People with disabilities have higher rates of engaging in risky behaviours such as smoking, alcohol conumption, poor diet and physical inactivity as compare to general population.

Violence :People with disabilities are at greater risk of violence than those without disabilities.

Unintentional injury: People with disabilities are at higher risk of unintentional injury from road traffic crashes, burns, falls, and accidents related to assistive devices.

Assistive technologies and assistive devices such as crutches, prostheses, wheelchairs, and tricycles in mobility impairments; hearing aids and cochlear implants for hearing impairments; ocular devices, talking books, and software for screen magnification and reading for people with visual impairments may be advised according to the user and the user’s environment.

Rehabilitation: It is an important aspect of management for people with disability. It involves combined and coordinated use of medical, social, educational, and vocational measures for training or retraining the individual to the highest possible level of functional ability.

Community-based rehabilitation (CBR) was initiated by WHO to enhance the quality of life for people with disabilities and their families; meet their basic needs; and ensure their inclusion and participation. CBR is implemented through the combined efforts of people with disabilities, their families and communities, and relevant government and non-government health, education, vocational, social and other services.  

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Role of Physiotherapy for disabled people

Disabled people spend their time in same position which affect their range of motion,when body is not mobile,that sedentary life style can affect the health and also weight of disabled people.With the help of physiotherapist the person with disability can stretch and strengthen muscles,this will help to give them more mobility and give positive impact on overall body.

• Decrease Pain: physiotherapist not only help the people to keep them fit but also help to reduce pain and stress.
• Physiotherapist prescribed mobility equipments to help disabled people stand and walk without help of other people like family members or friends.
• Physiotherapist asses, diagnose and provide exercise programs to strengthen the muscles.

For example

Strengthening exercises improve function, quality of life and reduce risk of injury.

Balance exercise helps in preventing falls

Relaxation exercise helps patient to calm mind and progressive muscle relaxation (PMR) relax muscle and reduce tension.

Flexibility exercise increase range of motion, decrease pain and stiffness.

      “During exercise endorphins release to energize mood, relieve stress and also boost self esteem”.

The Equality Act 2010 states “that disabled people should be treated equally, and protection from discrimination applies in many situations such as education, employment, exercise of public functions, goods, services, facilities and transport”.

Goals

• Education:

Should have the right to quality education at all levels of disabled people.

• Employment: 

Disabled people have the right to work in an open and accessible environment.

• Health care: 

They have right to highest standard of health care without discrimination.

Conclusion

People with disabilities have a higher rate of needs than non-disabled. The result indicates the importance of needs and wants of parents and patients should be respected so that the parents play an active role. There is a need to increase the rehabilitation center and staff to make them accessible for their needs in rural areas. Disabled people face problems in dealing with healthcare facilities, the barriers increase when a person is disabled and it can be decreased by giving them education and facilities which are easily accessible.

Occupational therapists ensure the people recovering from disability and promote physical and mental health through therapeutic use of everyday activities. They teach self care skills (cooking, eating, dressing) and enable them to return to their life.

On the other hand, Physiotherapists help the disabled people through exercise, manual therapy, electrotherapy, mobilization, manipulation for the management of pain and improve the range of motion.

legislation and act related to disablility

The Department administers the following three Acts:-

1. The Rights of Persons with Disabilities Act, 2016
2. The National Trust for the Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act, 1999
3. Rehabilitation Council of India Act, 1992

The Rights of Persons with Disabilities (RPwD) Act, 2016

The RPwD Act, 2016 was enacted on 28.12.2016 which came into force from 19.04.2017. The salient features of the Act are:-

1. Responsibility has been cast upon the appropriate governments to take effective measures to ensure that the persons with disabilities enjoy their rights equally with others.
2. Disability has been defined based on an evolving and dynamic concept.
3. The Act covers the following specified disabilities:-

1. Physical Disability
   1. Locomotor Disability
      1. Leprosy Cured Person
      2. Cerebral Palsy
      3. Dwarfism
      4. Muscular Dystrophy
      5. Acid Attack Victims
   2. Visual Impairment
      1. Blindness
      2. Low Vission
   3. Hearing Impairment
      1. Deaf
      2. Hard of Hearing
   4. Speech and Language Disability
2. Intellectual Disability
   1.  Specific Learning Disabilities
   2. Autism Spectrum Disorder
3. Mental Behaviour (Mental Illness)
4. Disability caused due to-
   1. Chronic Neurological Conditions such as-
      1. Multiple Sclerosis
      2. Parkinson’s Disease
   2. Blood Disorder-
      1. Haemophilia
      2. Thalassemia
      3. Sickle Cell Disease
5. Multiple Disabilities

1. Additional benefits have been provided for persons with benchmark disabilities and those with high support needs.
2. Every child with benchmark disability between the age group of 6 and 18 years shall have the right to free education.
3. 5% reservation in seats in Government and Government aided higher educational institutions for persons with benchmark disabilities.
4. Stress has been given to ensure accessibility in public buildings (both Government and private) in a prescribed time-frame.
5. 4% reservation in Government jobs for certain persons or class of persons with benchmark disability.
6. The Act provides for grant of guardianship by District Court or any authority designated by the State Government under which there will be joint decision – making between the guardian and the persons with disabilities.
7. Broad based Central & State Advisory Boards on Disability to be set up as policy making bodies.
8. The Act provides for strengthening of the Office of Chief Commissioner of Persons with Disabilities and State Commissioners of Disabilities which will act as regulatory bodies and Grievance Redressal agencies and also monitor implementation of the Act. These Offices will be assisted by an Advisory Committee comprising of experts in various disabilities.
9. Creation of National and State Fund to provide financial support to the persons with disabilities.
10. The Act provides for penalties for offences committed against persons with disabilities.
11. Designated special Courts to handle cases concerning violation of rights of PwDs.

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THE NATIONAL POLICY FOR PERSONS WITH DISABILITIES, 2006

Recognizing that the Persons with Disabilities constitute a valuable human resource for the country and that a majority of such persons can lead a better quality of life if they have equal opportunities and effective access to rehabilitation measures, the Government, with a view to create an environment that provides such persons equal opportunities for protection of their rights and full participation in society, formulated and brought out the National Policy for Persons with Disabilities.

2. With focus on Prevention of Disabilities and Rehabilitation Measures, the Policy provides for the following:-

I.      Prevention of Disabilities

II.     Rehabilitation Measures

II A. Physical Rehabilitation Strategies :

• Early Detection and Intervention
• Counselling & Medical Rehabilitation
• Assistive Devices
• Development of Rehabilitation Professionals

II B. Education for Persons with Disabilities

II C. Economic Rehabilitation of Persons with Disabilities :

• Employment in Government Establishments
• Wage employment in Private Sector
• Self-employment

III.    Provisions for Women with Disabilities

IV.   Provisions for Children with Disabilities

V.    Barrier-free Environment

VI.   Issue of Disability Certificates

VII.  Social Security

VIII. Promotion of Non-Governmental Organizations (NGOs)

IX.   Collection of regular information on Persons with Disabilities

X.    Research

XI.   Sports, Recreation and Cultural life

XII.  Amendments to existing Acts dealing with the Persons with Disabilities

4. Accordingly, the principal areas of intervention under the Policy are :  Prevention, Early-detection and Intervention; Programmes of Rehabilitation; Human Resource Development; Education of Persons with Disabilities; Employment; Barrier free-environment; Social Protection; Research; Sports, Recreation and Cultural Activities.

5.       The following mechanism is in place for implementation of the National Policy:

        i. Department of Empowerment of Persons with Disabilities, Ministry of Social Justice & Empowerment is the nodal Department to coordinate all             matters relating to implementation of the Policy.

1.  The Central Coordination Committee, with stakeholder representation, coordinates matters relating to implementation of the National Policy. There is a similar Committee at the State level.
2. The Ministries of Home Affairs; Health & Family Welfare; Rural Development; Urban Development; Youth Affairs & Sports; Railways; Science & Technology; Statistics & Programme Implementation; Labour; Panchayati Raj and Women & Child Development and Departments of Elementary Education & Literacy, Secondary & Higher Education; Road Transport & Highways; Public Enterprises; Revenue; Information Technology and Personnel & Training are also identified for implementation of the policy.
3.  Panchayati Raj Institutions and Urban Local Bodies are associated in the functioning of the District Disability Rehabilitation Centres. They are required to play a crucial role in the implementation of the National Policy to address local level issues.
4. The Chief Commissioner for Persons with Disabilities at Central level and State Commissioners at the State level, play key role in implementation of the National Policy, apart from their respective statutory responsibilities.

UNITED NATIONS CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES (UNCRPD), 2006

The Convention was adopted by UN General Assembly on December 13, 2006 and opened for signing by the State Parties on March 30, 2007. Adoption of the Convention has really imparted empowerment to Persons with Disabilities across the globe to demand their rights and make State, private and civil society agencies accountable for enjoying their rights.

2. India is one of the few first countries which ratified the Convention. Consequent upon signing the Convention on March 30, 2007, India  ratified the Convention on 01.10.2007. The Convention has come into force from May 3, 2008. The Convention places the following three important obligations on each State Party: –

a) Implementation of the provisions of the Convention;

b) Harmonization of the country laws with the Convention and

c) Preparation of a Country Report.

3. Taking concrete measures for effective implementation of the Convention, all the concerned Central Ministries were requested to implement the provisions of the Convention as might be applicable to each of them. Similarly, all the Chief Ministers of States and Administrators of UTs were also requested to examine different provisions/obligations under the Convention as might relate to them and to take effective steps for their early implementation. The State Governments/UT Administrators were also asked to furnish a status report in this regard so that the same could be utilized towards preparing the Country Report. Rigorous monitoring and follow-up was being done in this regard so as to fulfill obligations of the Convention. India’s First Country Report was submitted to UN Committee on Rights of Persons in November, 2015.

Incheon Strategy

Incheon Strategy “To make the Right Real” for Persons with Disabilities in Asia and Pacific. The Ministers and representative of members and associate members of the United Nations Economic and Social Commission for Asia and the Pacific (ESCAP) assembled at the High Level Inter Governmental meeting on the final review of the implementation of the Asian and Pacific Decade of Disabled Persons, 2003-2012 held at Incheon, Korea from 29th October – 2 nd November, 2012 and adopted the Incheon Strategy “Make the Right Real” for Persons with Disabilities in Asia and the Pacific. The ESCAP in its 69th Session held from 25th April – 1 st May, 2013 passed the resolution endorsing the Ministerial declaration and Incheon Strategy.

2. The Incheon Strategy to make the Right Real for Persons with Disabilities in Asia and Pacific sets out the following 10 goals:-

1. Reduce Poverty and enhance work and employment prospects;
2. Promote participation in political processes and in decision making;
3. Enhance access to the physical environment, public transportation, knowledge, information and communication;
4. Strengthen social protection;
5. Expand early intervention and education of children with disabilities;
6. Ensure gender equality and women‟s empowerment;
7. Ensure disability-inclusive disaster risk reduction and management;
8. Improve the reliability and comparability of disability data;
9. Accelerate the ratification and implementation of the Convention on the Rights of Persons with Disabilities and harmonisation of National Legislation with the Convention; and x. Advance sub-regional, regional and inter-regional co-operation.

3. The Incheon Strategy spells out Action Plans at the regional, sub-regional and regional levels to achieve the above goals and also contains the core indicators for tracking the progress of implementation.

4.  In order to oversee implementation of the Incheon Strategy, the UNESCAP has constituted a Working Group on the Asian and Pacific Decade for Persons with Disabilities, 2013-2022. The Working Group consists for Government representatives from 15 member countries including India and 15 Civil Society Organisations in the Asia and Pacific Region. The First meeting of the Working Group was held at Incheon, Korea during 25-26 February, 2014. The Second Session of the Working Group was held in Delhi during 2-3 March, 2015 hosted by Department of Empowerment of Persons with Disabilities in association with UNESCAP Secretariat. Third and Fourth Session of the Working Group were held in Bangkok.

5. Subsequently, high-level inter-Governmental meeting was held on mid-point review of the Asia Pacific Decade for Persons with Disabilities in Beijing from 27^th November to 1^st December, 2017. After deliberations in the meeting, Beijing Declaration was adopted which outlines action plan for the State parties to achieve the targets of Incheon Strategy in the next five years.

Scheme

Research and Development

The Department of Empowerment of Persons with Disabilities has launched a new Central sector scheme on “Research on disability related technology, products and issues‟. In January, 2015 with the objective to promote research of service models and programmes on the basis of life cycle needs, holistic development of the individuals and their families and creating an enabling environment for the empowerment of the persons with disabilities and promote research in prevention and prevalence of disability and the application of science & technology for the development of indigenous, appropriate aids and appliances.

The scheme has 2 components

(i) Research and Development of assistive technology and product development devices; and

(ii) Scheme for study/research/survey/internship and periodical collection of data related to disability. The State Governments, the national institutes under the Department have been requested to submit their proposal in accordance with the scheme. Until 2017-18 the scheme was implemented as a standalone scheme of the Department. From the year 2018-19 it has become part of the umbrella scheme SIPDA.

2. The Department has developed guidelines for grant of financial assistance for R&D projects under SIPDA.

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Polymyalgia rheumatica is an inflammatory disorder that causes muscle pain and stiffness, especially in the shoulders and hips. Signs and symptoms of polymyalgia rheumatica (pol-e-my-AL-juh rue-MAT-ih-kuh) usually begin quickly and are worse in the morning.

Most people who develop polymyalgia rheumatica are older than 65. It rarely affects people under 50.

This condition is related to another inflammatory condition called giant cell arteritis. Giant cell arteritis can cause headaches, vision difficulties, jaw pain and scalp tenderness. It’s possible to have both conditions together.

Polymyalgia rheumatica (PMR) is a relatively common chronic inflammatory condition of unknown etiology that affects elderly individuals. It is characterized by proximal myalgia of the hip and shoulder girdles with accompanying morning stiffness that lasts for more than 1 hour.  Approximately 15% of patients with PMR develop giant cell arteritis (GCA), and 40-50% of patients with GCA have associated PMR. Despite the similarities of age at onset and some of the clinical manifestations, the relationship between GCA and PMR is not yet clearly established. 

Pathophysiology

The cause of polymyalgia rheumatica (PMR) is unknown. PMR is closely linked to giant cell arteritis (GCA, temporal arteritis), although it is controversial whether GCA and PMR are two separate diseases or part of the same spectrum of disease. One hypothesis is that in a genetically predisposed patient, an environmental factor, possibly a virus, causes monocyte activation, which helps determine the production of cytokines that induce manifestations characteristic of PMR and GCA. However, although several infectious agents have been investigated as possible triggers, results are inconclusive. 

Immunogenetic studies support a polygenic basis for GCA and PMR. Occurrence in siblings and increased prevalence in those of Northern European heritage suggest a genetic role in the pathophysiology of the disease. Although most studies confirm an association between HLA-DRB1*04 alleles and GCA, the strength of this association with PMR varies between different populations. Interleukin (IL)–1 and tumor necrosis factor–alpha (TNF-α) gene polymorphisms have weak association with GCA and PMR. In Spain, an IL-6 polymorphism was associated with the expression of PMR symptoms in GCA patients. Additionally, in this Spanish population, the RANTES polymorphism was associated with PMR and not GCA. 

Pathologically, GCA and PMR are similar, except that significant vascular involvement does not occur in pure PMR. Synovitis, bursitis, and tenosynovitis around the joints, especially the shoulders, hips, knees, metacarpal phalangeal joints, and wrists, are seen in PMR. Inflammation is thought to start within the synovium and bursae, with recognition of an unknown antigen by dendritic cells or macrophages.

Systemic macrophage and T-cell activation are characteristic of both GCA and PMR. Patients often have an elevated IL-6 level, which is likely responsible for the systemic inflammatory response in both GCA and PMR. Most studies in PMR show that a decrease in the level of circulating IL-6 correlates with remission of clinical symptoms. Data on other circulating cytokines (eg, IL-1, IL-2, TNF-α, IL-10) are too scant to draw any conclusions. However, studies do show that interferon-gamma (IFN-γ) is expressed in nearly 70% of temporal artery biopsy samples from patients with GCA but is not detected in patients with isolated PMR, suggesting IFN-γ may be crucial to the development of GCA. 

Although PMR causes severe pain and stiffness in the proximal muscle groups, no evidence of disease is present on muscle biopsy. Muscle strength and electromyographic findings are normal. Instead, the inflammation is at the level of the synovium and bursae, with MRI studies revealing periarticular inflammation as well as bursitis in the bursae associated with both the shoulder and hip girdles. 

Some evidence suggests the presence of cell-mediated injury to the elastic lamina in the blood vessels in the affected muscle groups. A prospective study of 35 patients with isolated PMR noted vascular (¹⁸F) fluorodeoxyglucose positron emission tomography (FDG-PET) imaging at diagnosis in 31% of patients, predominantly at the subclavian arteries, but at a much lower intensity than in GCA patients. Increased FDG uptake in the shoulders was seen in 95% of the patients, in the hips in 89%, and in the spinous processes of the cervical and lumbar vertebrae (correlating with interspinous bursitis) of 51% of the patients with isolated PMR. 

A study of circadian variation in PMR found that plasma concentrations of IL-6, IL-8, TNF-α, and IL-4 peaked between 4 and 8 am in both untreated patients and controls, although levels of those cytokines were higher throughout the day in patients. The peak in cytokines matched the early-morning peak of pain and stiffness in untreated patients. In addition, melatonin levels were consistently higher in patients than in controls and varied with time, peaking around 2 am, suggesting that melatonin stimulates cytokine production, which in turn accounts at least partly for PMR symptoms. 

PMR is a clinical diagnosis based on the complex of presenting symptoms and the exclusion of the other potential diseases . Corticosteroids are considered the treatment of choice, and a rapid response to low-dose corticosteroids is considered pathognomonic. Patients who are at risk for relapse, have steroid-related adverse effects, or need prolonged steroid therapy may benefit from the addition of methotrexate or tocilizumab. 

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Etiology

The exact cause (or causes) of polymyalgia rheumatica (PMR) is unknown. The disease is more common among northern Europeans, which may indicate a genetic predisposition. Other risk factors for PMR are an age of 50 years or older and the presence of GCA. PMR has been reported as a rare complication of cancer therapy with immune checkpoint inhibitors (eg, nivolumab).

An autoimmune process may play a role in PMR development. PMR is associated with the HLA-DR4 haplotype. A high level of IL-6 is associated with increased disease activity.

History

Patients with polymyalgia rheumatica (PMR) were often in good health prior to disease onset, which is abrupt in about 50% of patients. In most patients, symptoms appear first in the shoulder girdle. In the remainder, the hip or neck are involved at onset. At presentation, symptoms may be unilateral but they usually become bilateral within a few weeks.

The symptoms include pain and stiffness of the shoulder and hip girdle. The stiffness may be so severe that the patient may have a great difficulty rising from a chair, turning over in bed, or raising the arms above shoulder height. Stiffness after periods of rest (gel phenomenon) as well as morning stiffness of more than 1 hour typically occurs.

Muscle weakness is not a feature of PMR. However, this can be difficult to assess in the setting of pain, especially if symptoms are protracted and untreated, resulting in disuse atrophy.

Patients may also describe distal peripheral joint swelling or, more rarely, limb edema. Carpal tunnel syndrome can occur in some patients. Most patients report systemic features as listed below.

Several diagnostic criteria for PMR exist. One set of diagnostic criteria is as follows  :

• Age of onset 50 years or older
• Erythrocyte sedimentation rate ≥40 mm/h
• Pain persisting for ≥1 month and involving 2 of the following areas: neck, shoulders, and pelvic girdle
• Absence of other diseases capable of causing the same musculoskeletal symptoms
• Morning stiffness lasting ≥1 hour
• Rapid response to prednisone (≤20 mg)

In 2012, the European League Against Rheumatism and the American College of Rheumatology published new provisional classification criteria for PMR in patients aged 50 or older with bilateral shoulder aching and elevated inflammatory markers. These are not diagnostic criteria, but rather are designed for enrolling patients into clinical trials of new treatments for PMR. This collaborative initiative resulted in a scoring algorithm based on the following criteria:

• Morning stiffness >45 minutes (2 points)
• Hip pain/limited range of motion (1 point)
• Absence of rheumatoid factor and/or anti–citrullinated protein antibody (anti-CCP) (2 points)
• Absence of peripheral joint pain (1 point)

A score of ≥4 points has a 68% sensitivity and 78% specificity for discriminating PMR from other comparison patients. There is also an additional ultrasound criteria (1 point if positive findings), which can add up to a score of ≥5 points that is associated with a 66% sensitivity and 81% specificity for PMR. 

Systemic findings in more than 50% of patients are as follows:

• Low-grade fever and weight loss
• Malaise, fatigue, and depression
• Difficulty rising from bed in the morning
• Difficulty getting up from the toilet or out of a chair
• Difficulty completing daily life activitiesHigh, spiking fevers (rare, should prompt evaluation for underlying infection, malignancy, or vasculitis)

Musculoskeletal findings are as follows  :

• Morning stiffness for ≥1 hour, often more prolonged
• Muscle stiffness after prolonged inactivity
• Synovitis of proximal joints and periarticular structures
• Peripheral arthritis (in 25% of patients)
• Carpal tunnel syndrome (in about 15% of patients)
• Distal extremity swelling (in approximately 12%)
• Possible development of arthralgia and myalgia up to 6 months after onset of systemic symptoms

Many investigators believe that nonerosive synovitis and tenosynovitis are responsible for many symptoms of PMR.

Physical Examination

PMR is a clinical diagnosis based on the complex of the presenting symptoms and exclusion of the other potential diseases. The symptoms and signs of PMR are nonspecific, and objective findings on physical examination are often lacking.

General symptoms are as follows:

• Fatigued appearance
• Low-grade temperature
• Distal extremity swelling with pitting edema

Musculoskeletal findings are as follows:

• Normal muscle strength; no muscle atrophy typically present at initial presentation
• Pain in the shoulder and hip with movement; active range of motion may be decreased because of pain
• Transient synovitis of the knee, wrist, and sternoclavicular joints; a more peripheral nonerosive arthritis may be seen in some cases
• Tenderness to palpation with decreased active range of motion in the musculature of the proximal hip/leg and/or shoulder/arm girdle

In later stages, disuse muscle atrophy with proximal muscle weakness may occur. Contractures of the shoulder capsule may lead to limitation of passive and active movements.

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Symptoms

The signs and symptoms of polymyalgia rheumatica usually occur on both sides of the body and might include:

• Aches or pain in your shoulders
• Aches or pain in your neck, upper arms, buttocks, hips or thighs
• Stiffness in affected areas, particularly in the morning or after being inactive for a time
• Limited range of motion in affected areas
• Pain or stiffness in your wrists, elbows or knees

You might also have more-general signs and symptoms, including:

• Mild fever
• Fatigue
• A general feeling of not being well (malaise)
• Loss of appetite
• Unintended weight loss
• Depression

Risk factors

Risk factors for polymyalgia rheumatica include:

• Age. Polymyalgia rheumatica affects older adults almost exclusively. It most often occurs between ages 70 and 80.
• Sex. Women are about two to three times more likely to develop the disorder.
• Race. Polymyalgia rheumatica is most common among white people whose ancestors were from Scandinavia or northern Europe.

Complications

Symptoms of polymyalgia rheumatica can greatly affect your ability to perform everyday activities, such as:

• Getting out of bed, standing up from a chair or getting out of a car
• Combing your hair or bathing
• Getting dressed

Diagnosis

A physical exam, including joint and neurological exams, and test results can help your doctor determine the cause of your pain and stiffness. During the exam, he or she might gently move your head and limbs to assess your range of motion.

Your doctor might reassess your diagnosis as your treatment progresses. Some people initially given a diagnosis of polymyalgia rheumatica are later reclassified as having rheumatoid arthritis.

Tests your doctor might recommend include:

• Blood tests. Besides checking your complete blood counts, your doctor will look for two indicators of inflammation — erythrocyte sedimentation rate (sed rate) and C-reactive protein. However, in some people with polymyalgia rheumatica, these tests are normal or only slightly high.
• Imaging tests. Increasingly, ultrasound is being used to distinguish polymyalgia rheumatica from other conditions that cause similar symptoms. MRI can also identify other causes of shoulder pain, such as joint changes.

Monitoring for giant cell arteritis

Your doctor will monitor you for signs and symptoms that can indicate the onset of giant cell arteritis. Talk to your doctor immediately if you have any of the following:

• New, unusual or persistent headaches
• Jaw pain or tenderness
• Blurred or double vision or visual loss
• Scalp tenderness

If your doctor suspects you might have giant cell arteritis, he or she will likely order a biopsy of the artery in one of your temples. This procedure, performed during local anesthesia, involves removing a small sample of the artery, which is then examined for inflammation.

Treatment

Treatment usually involves medications to help ease your signs and symptoms. Relapses are common.

Medications

• Corticosteroids. Polymyalgia rheumatica is usually treated with a low dose of an oral corticosteroid, such as prednisone (Rayos). You’ll likely start to feel relief from pain and stiffness within the first two or three days.After the first two to four weeks of treatment, your doctor might begin to gradually decrease your dosage depending on your symptoms and the results of blood tests. Because of potential side effects, the goal is to keep you on as low a dose as possible without triggering a relapse in your symptoms.Most people with polymyalgia rheumatica need to continue the corticosteroid treatment for a year or more. You’ll need frequent follow-up visits with your doctor to monitor how the treatment is working and whether you have side effects.Long-term use of corticosteroids can result in serious side effects, including weight gain, loss of bone density, high blood pressure, diabetes and cataracts. Your doctor will monitor you closely for problems. He or she might adjust your dose and prescribe treatments to manage reactions to corticosteroid treatment.
• Calcium and vitamin D. Your doctor will likely prescribe daily doses of calcium and vitamin D supplements to help prevent bone loss as a result of corticosteroid treatment. The American College of Rheumatology recommends 1,000 to 1,200 milligrams of calcium supplements and 600 to 800 international units of vitamin D supplements for anyone taking corticosteroids for three months or more.
• Methotrexate. Joint guidelines from the American College of Rheumatology and the European League Against Rheumatism suggest using methotrexate (Trexall) with corticosteroids in some patients. This is an immune-suppressing medication that’s taken by mouth. It might be useful early in the course of treatment or later, if you relapse or don’t respond to corticosteroids.

Medication Summary

The goals of therapy in polymyalgia rheumatica (PMR) are to control painful myalgia, to improve muscle stiffness, and to resolve constitutional features of the disease. Oral corticosteroids are the first line of treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful as adjuncts to corticosteroids during tapering, or alone in mild cases; however, because they are associated with increased drug-related morbidity, they should be used with caution, especially in elderly patients. Steroid-sparing agents may be beneficial.

The interleukin-6 receptor antagonist tocilizumab is approved for use in giant cell arteritis and has demonstrated benefit for PMR in several case series and retrospective studies.  However, controlled trials are needed to fully establish the efficacy of tocilizumab in PMR, and it has not yet been approved for this indication by the US Food and Drug Administration.

Physical therapy

Most people who take corticosteroids for polymyalgia rheumatic return to their previous levels of activity. However, if you’ve had a long stretch of limited activity, you might benefit from physical therapy. Talk with your doctor about whether physical therapy is a good option for you.

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Penis captivus allegedly occurs when a penis becomes stuck in a vagina during sexual intercourse. Reports of this happening are incredibly rare.

Very few reports have documented the existence of penis captivus. What reports there are have led many people to question whether it really happens.

The penis becoming stuck in the vagina is one possible outcome of a condition called vaginismus, in which the vagina involuntarily closes due to muscle spasms in the pelvic floor.

If penis captivus occurs, the effect is likely very temporary. If both partners relax and give it some time, the muscles should relax, allowing the couple to separate.

Is it common?

It sounds like the stuff of urban legend, but it’s possible for a penis to get stuck inside a vagina during intercourse. This condition is called penis captivus, and it’s a  occurrence. It’s so rare, in fact, that anecdotal reports are the only way doctors and health experts know it happens.

It’s unclear how often penis captivus occurs because couples may be able to disconnect from one another before medical attention is necessary. And they may never report the incident to a doctor.

In the event that you find yourself unable to disengage from intercourse, it’s important to stay calm. Knowing what’s happening can help you and your partner wait out penis captivus.

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How can it occur?

During arousal, the penis fills with blood, becoming erect in preparation for sexual intercourse. For females, the walls of the vagina relax and the vulva lubricates in preparation for sexual penetration.

The vaginal walls are made up of muscular tissue, which expands and contracts at different times during sex, such as during an orgasm. These contractions can be very strong, and they are sometimes stronger than usual.

In some rare cases, the vagina may contract with enough force to latch onto the penis. This could make it difficult for the partners to separate.

However, after these vaginal contractions come to an end, the vaginal walls will relax. The time that it takes for this to happen varies. The blood will eventually flow away from the penis, and it will become smaller and softer. When either or both of these things occur, the partners should be able to separate.

Due to the lack of medical documentation, it may be safe to assume that penis captivus — when it does occur — is a temporary phenomenon that may only cause fleeting discomfort.

What to do if it occurs

If either partner feels penis captivus starting to happen, they should try to stay calm. Added stress can lead to more muscular tension, which can make the phenomenon last longer.

It is important not to try to force the penis out of the vagina. Doing so can hurt one or both partners. It is also important not to try to open the vagina or pry the penis out manually.

Taking deep breaths may help both partners become or remain calm. Distracting each other or making a joke out of the situation can also relieve the tension and reduce arousal in the genitals.

Staying calm and allowing the muscles in both bodies to relax can help resolve the issue as soon as possible without complication.

If this phenomenon does occur, it will likely only last for a moment before the penis and vagina relax.

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Motor neurones are cells in the brain and spinal cord that allow us to move, speak, swallow and breathe by sending commands from the brain to the muscles that carry out these functions.  Their nerve fibers are the longest in the body, a single axon can stretch from the base of the spinal cord all the way to the toes.

Motor neurons divided into either upper or lower motor neurones, forming various tightly controlled, complex circuits throughout the body. This controls both voluntary and involuntary movements through the innervation of effector muscles and glands. The upper and lower motor neurons form a two-neuron circuit.

• The upper motor neurons originate in the cerebral cortex and travel down to the brain stem or spinal cord
• The lower motor neurons begin in the spinal cord and go on to innervate muscles and glands throughout the body.

Upper and lower motor neurons utilize different neurotransmitters to relay their signals.

• Upper motor neurons use glutamate
• Lower motor neurons use acetylcholine.

Causes

Conditions that damage upper motor neurons include:

• Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS)
• Primary lateral sclerosis (PLS)
• Traumatic brain injury
• Spinal cord injury
• Multiple sclerosis
• Stroke
• Huntington’s disease

Symptoms

Upper motor neuron lesions prevent signals from traveling from your brain and spinal cord to your muscles. Your muscles can’t move without these signals and become stiff and weak.

Damage to upper motor neurons leads to a group of symptoms called upper motor neuron syndrome:

Muscle weakness. The weakness can range from mild to severe.

Overactive reflexes. Your muscles tense when they shouldn’t. For example, just rubbing your hand over your belly might cause your abdominal muscles to tighten up.

Tight muscles. The muscles become rigid and hard to move.

Clonus. This is muscular spasm that involve repeated, often rhythmic, contractions.

The Babinski response. Young children have a reflex called the Babinski reflex. If you stroke the bottom of their foot, their big toe will pull back and their other toes will spread out. This reflex usually disappears after age 2. In adults, the Babinski response is a sign of damage to the nervous system.

Upper motor neuron lesions can get worse over time. Over time, you can have trouble controlling your muscles.

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Diagnosis

Motor neuron diseases can be tricky to diagnose. Their symptoms are often very similar to those of other diseases.

Your doctor can do blood and urine tests to check for infections, muscle diseases, and other conditions that have symptoms similar to those of motor neuron diseases.

During an exam, your doctor will look for signs of a nervous system problem by checking your:

• Balance and coordination
• Movement
• Hearing, speech, and vision
• Memory and concentration

A few other tests can help your doctor diagnose upper motor neuron lesions:

MRI, or magnetic resonance imaging. It uses powerful magnets and radio waves to make pictures of structures inside your body. An MRI can show damage to upper motor neurons.

EMG, or electromyogram. It uses a thin needle to check the activity in your muscles when they contract and when they’re at rest. An EMG can check for problems with your lower motor neurons and help diagnose ALS and PLS.

Nerve conduction study. This test measures how quickly an electrical current moves through your nerve. It can show how well your nerves are sending signals to your muscles and if you have nerve damage.

Spinal tap or lumbar puncture. It removes a small amount of fluid from your spine to show whether MS or an infection is causing your symptoms.

Nerve biopsy. It removes a small sample of the nerve to check for damage. It’s not likely that you’ll have this done. Doctors hardly ever use this method when trying to diagnose an upper motor neuron disease.

Treatment

Which treatment you get depends on what disease caused your upper motor neuron lesions.

Medicines won’t stop diseases like ALS or PLS, but they can help you manage symptoms. Some of the drugs used to treat upper motor neuron symptoms include:

Muscle relaxants.Baclofen, clonazepam (Klonopin), and tizanidine (Zanaflex) control muscle spasms in PLS. Doctors may also use Botox to treat tightness and stiffness of muscles.

ALS drugs. Edaravone (Radicava) and riluzole (Rilutek) slow the progression of ALS.

MS drugs. drugs which can slow MS damage to nerve cells. Beta interferons, alemtuzumab (Lemtrada), cladribine (Mavenclad), dimethyl fumarate (Tecfidera), diroximel fumarate (Vumerity), fingolimod (Gilenya), glatiramer acetate (Copaxone), mitoxantrone (Novantrone), monomethyl fumarate (Bafiertam), natalizumab (Tysabri), ocrelizumab (Ocrevus), ozanimod (Zeposia), siponimod (Mayzent), teriflunomide (Aubagio)

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An atrial septal defect (ASD) is a hole in the wall (septum) between the two upper chambers of your heart (atria). The condition is present at birth (congenital).

Small defects might be found by chance and never cause a problem. Some small atrial septal defects close during infancy or early childhood.

The hole increases the amount of blood that flows through the lungs. A large, long-standing atrial septal defect can damage your heart and lungs. Surgery or device closure might be necessary to repair atrial septal defects to prevent complications.

An atrial septal defect (ASD) is a hole in the septum, which is the muscular wall that separates the heart’s two upper chambers (atria). An ASD is a defect you are born with (congenital defect) that happens when the septum does not form properly. It is commonly called a “hole in the heart.”

A secundum ASD is a hole in the middle of the septum. The hole lets blood flow from one side of the atria to the other. The direction depends on how much pressure is in the atria.

More complicated and rare types of ASDs involve different parts of the septum and abnormal blood return from the lungs (sinus venosus) or heart valve defects (primum ASDs).

Causes

How the heart normally works

The heart is divided into four chambers, two on the right and two on the left. To pump blood throughout the body, the heart uses its left and right sides for different tasks.

The right side of the heart moves blood to the lungs. In the lungs, blood picks up oxygen then returns it to the heart’s left side. The left side of the heart then pumps the blood through the aorta and out to the rest of the body.

Why do heart defects develop?

Doctors know that heart defects present at birth (congenital) arise from errors early in the heart’s development, but there’s often no clear cause. Genetics and environmental factors might play a role.

How the heart works with an atrial septal defect

A large atrial septal defect can cause extra blood to overfill the lungs and overwork the right side of the heart. If not treated, the right side of the heart eventually enlarges and weakens. The blood pressure in your lungs can also increase, leading to pulmonary hypertension.

There are several types of atrial septal defects, including:

• Secundum. This is the most common type of ASD and occurs in the middle of the wall between the atria (atrial septum).
• Primum. This defect occurs in the lower part of the atrial septum and might occur with other congenital heart problems.
• Sinus venosus. This rare defect usually occurs in the upper part of the atrial septum and is often associated with other congenital heart problems.
• Coronary sinus. In this rare defect, part of the wall between the coronary sinus — which is part of the vein system of the heart — and the left atrium is missing.

Symptoms

Many babies born with atrial septal defects have no signs or symptoms. Signs or symptoms can begin in adulthood.

Atrial septal defect signs and symptoms can include:

• Shortness of breath, especially when exercising
• Fatigue
• Swelling of legs, feet or belly (abdomen)
• Irregular heartbeats (arrhythmias)
• Sensation of a rapid, pounding heartbeat (palpitations) or skipped beats
• Whooshing sound that can be heard through a stethoscope (heart murmur)

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Risk factors

Atrial septal defect (ASD) occurs as the baby’s heart is developing during pregnancy. Certain health conditions or drug use during pregnancy may increase a baby’s risk of atrial septal defect or other congenital heart defect. These things include:

• German measles (rubella) infection during the first few months of pregnancy
• Diabetes
• Lupus
• Alcohol or tobacco use
• Illegal drug use, such as cocaine
• Use of certain medications, including some anti-seizure medications and drugs to treat mood disorders

Some types of congenital heart defects occur in families (inherited). If you have or someone in your family has congenital heart disease, including ASD, screening by a genetic counselor can help determine the risk of certain heart defects in future children.

Complications

A small atrial septal defect might never cause any concern. Small atrial septal defects often close during infancy.

Larger atrial septal defects can cause serious complications, including:

• Right-sided heart failure
• Irregular heartbeats (arrhythmias)
• Stroke
• Early death
• High blood pressure in the lung arteries (pulmonary hypertension)

Pulmonary hypertension can cause permanent lung damage. This complication, called Eisenmenger syndrome, usually develops over many years and occurs uncommonly in people with large atrial septal defects.

Treatment can prevent or help manage many of these complications.

Atrial septal defect and pregnancy

If you have an atrial septal defect and are pregnant or thinking about becoming pregnant, it’s important to talk to your health care provider and to seek proper prenatal care. A health care provider may recommend ASD repair before conceiving. A large atrial septal defect or its complications can lead to a high-risk pregnancy.

Prevention

Because the cause of atrial septal defect (ASD) is unclear, prevention may not be possible. But getting good prenatal care is important. If you have an ASD and are planning to become pregnant, schedule a visit with your health care provider. This visit should include:

• Discussing current health conditions and medications. You’ll need to monitor certain health conditions, such as diabetes or lupus, during pregnancy. Your health care provider might also recommend adjusting or stopping certain medications before pregnancy.
• Reviewing your family medical history. If you have a family history of congenital heart defects or other genetic conditions, consider talking with a genetic counselor to determine your specific risks.
• Getting tested for immunity to German measles (rubella). Rubella in the mother has been linked to some types of congenital heart defects in the baby. If you’re not immune, ask your health care provider about getting vaccinated.

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Vojta-Therapy is a dynamic neuromuscular treatment method based on the developmental kinesiology and principles of reflex locomotion. This method is supposed to treat patients with disorders of central nervous system and musculoskeletal system.

The Vojta principle was developed by child neurologist Dr Vaclav Vojta. Vojta therapy stimulates the brain, activating “innate, stored movement patterns” that are then transferred into coordinated movements of the muscles in trunk and extremities.

With repeated activation new networking within the brain and central nervous system takes place, therefore Vojta therapy has a positive influence on the entire coordination of the client and his or her spontaneous movement. As a result, improved “uprighting” against gravity, balance, gait, grasp, speech production and many other important functions can be achieved.

In Vojta Therapy, goal-directed pressure is applied to defined zones on the body while lying on the back, front or on the side. These stimuli automatically lead to two movement complexes called Reflex Rolling and Reflex Creeping.

For Vojta therapy to be most successful parents perform the treatment at home for 5-20 minutes several times a day. The therapist supports the parents and regularly reviews the treatment program and frequency of therapy according to the child’s goals and progress.

Due to the fact that Vojta therapy stimulates the brain, it directly targets the source of neurological problems like brain injuries and other neurological disorders. In Vojta therapy the musculature of the whole body is activated on a subconscious level. This is exactly the way the human body has to function when we hold ourselves upright against gravity while performing different tasks.

What is a Reflex Locomotion?

Reflex is an involuntary movement as a response to external stimuli. Locomotion is defined as an ability to perform a movement from one place to another. In reflex locomotion, there is a coordinated, rhythmic activation of the total skeletal musculature and a CNS response at various circuit levels.

Disturbances of posture and movement require a very complex and often a lengthy treatment, especially when they are connected with a cerebral (brain) dysfunction.

OBJECTIVES

The Vojta “method”is for the physician a precious clinic tool for the evaluation of the child development from birth, and a reliable element of diagnosis; it is for the physiotherapist an efficient global therapy which can be used from the first days of life, in a preventive or curative intention.

The treatment based on the reflex locomotion contributes to:
* Modify the reflex activity of the young child and to orient the neuromotor development in a more physiological direction, by the induction of a different central neurological activity that supplies to the patient a new corporal perception. The muscular “proprioception” plays here a very important part.

* Modify the spinal automatisms in lesions of the spinal cord .

* Control the breathing in order to increase the vital capacity.

* Control the neurovegetative reactions , and promote an harmonious growth of the locomotor anatomical system .

* Prevent the orthopaedic degradation, frequent in severe pathological situations.

INDICATIONS OF THE VOJTA TECHNIQUE

• Severe and medium central coordination disorders
• Light but asymmetrical central coordination disorders
• Cerebral palsy
• Muscular and neurogen torticolis
• Peripheral Paralyses (child and adult)
• Spina bifida
• Congenital myopathies – congenital deformities (athrogryposis, club foot etc…)
• Morbus-Down syndrome and other syndromes – motor delays
• Various postural disorders (scoliosis, cyphosis)
• Hip dysplasies
• Adult hemiplegy (unexhaustive list)…

Comparison of reflex creeping sequences with spontaneous motor sequences of the ontogenese

Reflex creeping (artficially provoked activity) Activity	Appearance age	Ontogenese (finalized, spontaneous activity) Appearance age
lateral step of the upper limb in prone position elbow support	from the birth (nape arm) (face arm)	3 months
Free coordinated head rotation with symmetric vertebral axis	from the birth	3 months
Lateral movements of the eyes, independent of the head posture	from the birth	end of the 1 quarter
One elbow support (support stabilizing synergisms)	from the birth (face arm)	middle of the 2 quarter
Total opening of the hand, with radial bending of the wrist , abduction of the metacarpus	from the birth (nape hand)	end of the 2 quarter
Coordinate differentiation of the shoulder and pelvic belts	from the birth	6 months, rolling from dorsal to ventral
Activ creation of the knee support with loading	from the birth nape lower limb, variant of the ref. creeping)	quarter 3
Coordinate push with the lower limb and heel support, foot in the 90° position, support on the external foot edge.	from the birth (nape lower limb)	14 -15 months

Implementation

The application of Vojta therapies.

Vojta describes different zones that are available to stimulate the motor patterns of reflex locomotion. A light pressure on certain stimulus zone (muscles or bones) and resistance to the current movement is applied to cause patient’s involuntary motor response and performance of certain movement patterns.

The Vojta method can be divided into 2 main phases:

1. Reflex creeping (lying flat with the chest down and back up)
2. Reflex rolling (lying flat with the chest up and back down)

Reflex locomotion is activated from the three main positions:

• prone,
• supine,
• side lying.

Reflex locomotion patterns (ref.creeping and ref. rolling) are global; during these activities, the totality of the musculature is activated according to a coordinate mode. The different levels of the CNS are concerned by this activation . The reflex locomotion is provoked by specific stimulations (pressures) applied on defined zones.

Picture : Start position for the reflex creeping and general situation of the zones:
The head position determines the position of the limbs, different on the face-side and the nape-side

The reflex creeping appears from two opposite start positions called “reciprocal positions”; each zone is therefore bilateral and the therapist has at one’s disposal access points to the afferent nervous system (proprioceptors, exteroceptors, connective tissue…) that can be used in an infinity of combinations. Defined pressure directions, are applied on one or several zones; during this stimulation, the therapist must be able to control the position of the patient, and to apply, if he wishes it, a continuous resistance to the provoked motor answering. In order to achieve this, the therapist may use different parts of his own body (abdomen, forearm, knees, etc…)

Picture : Direction of the motor answering composing the reflex creeping pattern:

The phasic movements of the limbs ( visible displacement of corporal segments) and the head rotation are conditioned by the active creation of fix points at the extremities of the “support diagonal ” (face-elbow and nape-heel); the therapist has to be very attentive to this point. The isometric motor activity of this diagonal includes a finely differentiated work of vertebral muscles and of the limbs roots .

The coordination of the antigravitic muscular activity, of the vertebral alignment, of the opposite rotation between the pelvis and shoulder belts, of the muscular contractions that radiate to extremities of the limbs, belongs to the patterns of the superior human locomotion (creeping, walking).

Picture : Pull direction of the muscular chains during the reflex creeping.

The active creation of peripheral fix points, enables the muscular organization in oblique chains that exert tractions on the bone levers according to differentiated directions. Isotonic chains have a phasic mission and determine segmental movements; isometric chainsare devoted to the stabilization and govern the emergence of the antigravitic and locomotor function. The convergence place of these muscular chains is the spine and especially the dorso-lumbar transition.

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The experienced therapist will certainly note
– that the dorso-lumbar region is frequently the place of the infantile cyphosis in neuropediatric disturbances compromising the stabilization of the vertebral axis,
– that this region is also the opposition place of the physiological double rotation in all the differentiated locomotor patterns (quadrupedic locomotion, walking)
– that the coordinate vertebral rotation is the privilege of all the fine posturo-motor functions and is cruelly missing in the totality of neurological pathologies from central origin,
– finally, that the dorso-lumbar transition is subjected, in the active human life, to many mechanical constraints which require a rigourous automatic control based on the proprioceptive information.
This enumeration underlines the interest to obtain for our patients of all ages, through the activation of precise automatic muscular games, a good corporal experience , that makes largely call in the deep sensitivity, and contributes to the elaboration, or to the restoration, of the unconscious corporal scheme.

Picture: Main muscular elements of the support diagonal during the reflex creeping

Picture: Other examples of start position: a- half-quadrupedic position called “first position”, b – lateral decubitus, phase 4 of the reflex rolling, c – lateral decubitus, phase 3 of the reflex rolling…

There are different start positions (prone position for the reflex creeping, supine or lateral for the reflex rolling etc…); therefore the therapist can choose between innumerable combinations of start positions, zones and stimulations corresponding to the same number of activation procedures for a coordinated central function.

The application of resistances against the provoked activity, transforms the phasic movement into an isometric muscular activity (without segmental displacement), whose duration can be modulated by the therapist without addiction (proprioceptive receivers). This practise leads to a temporo-spacial accumulation , then to a neuronal “overflowing” phenomenon to “force” a new neuronal itinerary. This enables, by the recruitment of new afferent ways to the CNS, the activation of possibly underexploited central territories. This technique is called pathing, it consists in provoking, then artificially maintaining , from outside, the muscular isometric contraction with the aim of soliciting a widened and coordinated activity of the CNS.

Each reflex locomotion pattern (creeping or rolling) has specific zones and can be activated from several start positions. Accessing to the same pattern from different stimulating combinations, forces the central nervous system to resort to diversified processing procedures of the afferenting flows; that means varied neuronal itineraries. These neurological procedures are to the basis of the physiological postural adaptability.

The pattern sequences ( muscular synergisms) observable during the reflex locomotion present a strict analogy with motor sequences of the normal motor development.

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