Referral centers and specialized care. Based on a presentation by Ronald P. Lesser, MD.
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Appropriate diagnosis and treatment and the correct use of specialized services at epilepsy referral centers make it possible to control seizures relatively quickly in a large number of patients. Timeliness is extremely important, however, because delaying treatment decreases the likelihood of achieving complete remission from seizures. Epilepsy has a tremendous impact on quality of life. Concerns about concomitant illnesses, seizure-related injuries, and the psychosocial effects of seizures and anticonvulsants on patients are very real and should be addressed. An accurate diagnosis is the first step in effective seizure control, because not every patient with a seizure disorder has epilepsy. The second step is choosing an antiepileptic drug (AED) that is appropriate for the patient and using the correct dose and dosing schedule. When seizures remain uncontrolled or are poorly controlled despite medical therapy, the patient should be reevaluated to ascertain why the drug or drug combination is not working. The reason may be the wrong diagnosis, the wrong drug, or the wrong dose. If the seizures remain uncontrolled, the patient should be evaluated as a possible candidate for epilepsy surgery. If the patient is a good candidate, a presurgical work-up that includes monitoring and imaging studies should be performed, ideally at an epilepsy referral center. Quality care depends on access, communication, and knowledge, which involves patients who know how to achieve the best possible seizure control, doctors who are well informed and know what to do to ensure that their patients are receiving the best care, and mechanisms that permit consultation among everyone involved in caring for patients with epilepsy. Developing a system of quality, cost-effective care for the management of epilepsy also offers an excellent opportunity to apply such a system to the larger arena of medical care in general. (+info)
Thermal biofeedback for claudication in diabetes: a literature review and case study.
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Temperature biofeedback (TBFB) is designed to alter cutaneous temperature in treated extremities by providing information corresponding to minor temperature fluctuations in the context of therapeutic structure and reinforcement. Toe TBFB may improve vascular flow and walking tolerance in patients with peripheral vascular disease. This case study documents improved walking in a diabetes patient with lower extremity complications, and suggests TBFB might increase lower extremity temperature and blood flow volume pulse in uncomplicated diabetes. Ankle-brachial index (ABI) and walking function were assessed in a 60-year-old woman with type 2 diabetes and intermittent claudication, before and after five sessions of TBFB applied to the ventral surface of the great toe. Toe temperature increased during feedback phases but not during baseline phases. Improvements were seen in ankle-brachial index, walking distance, walking speed, and stair climbing. This case indicates the need for extended and controlled study of TBFB for improved vascular and ambulatory function in diabetic claudication. (+info)
A neurobehavioral treatment for unilateral complex partial seizure disorders: a comparison of right- and left-hemisphere patients.
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This study looked at the efficacy of a multi-disciplinary neurobehavioral approach for treating patients with complex partial seizure disorders. Patients with a seizure focus in either the left or right hemisphere were compared for overall effectiveness of this approach in achieving control of complex partial seizures. Patients in this study received short-term treatment based on a model of self-control developed by the Andrews/Reiter Epilepsy Research Program. This research selected all patients who met the lateralization criterion from among cases receiving short-term treatment between 1992 and 1996. Forty-four patients were identified, a group of 21 right-hemisphere subjects and a second group of 23 left-hemisphere subjects. These patients were treated in a short-term (5 consecutive days) treatment protocol and then released, with weekly phone contact for 6 months following treatment. They were then followed for an additional 19 months through the continued submission of their seizure logs and journals. Subjects in both groups kept seizure records throughout the study starting with a two-month baseline period. Other data collected allowed study of the interaction of emotional states with seizure occurrence. This project produced valuable and relevant information regarding neurobehavioral management interventions as an effective adjunctive or alternative treatment for obtaining seizure control in epilepsy patients. Overall, 79% of patients treated achieved seizure control. More than 64% identified a recognizable emotional state that triggered seizures. The emotional trigger was specific for either the right or left hemisphere. (+info)
A guide for use and interpretation of kinesiologic electromyographic data.
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Physical therapists are among the most common users of electromyography as a method for understanding function and dysfunction of the neuromuscular system. However, there is no collection of references or a source that provides an overview or synthesis of information that serves to guide either the user or the consumer of electromyography and the data derived. Thus, the purpose of this article is to present a guide, accompanied by an inclusive reference list, for the use and interpretation of kinesiologic electromyographic data. The guide is divided into 4 major sections: collecting, managing, normalizing, and analyzing kinesiologic electromyographic data. In the first of these sections, the issues affecting data collection with both indwelling and surface electrodes are discussed. In the second section, data management through alternative forms of data processing is addressed. In the third section, various reasons and procedures for data normalization are discussed. The last section reviews qualitative descriptors once used as the only means of analyzing data, then focuses on more quantitative procedures that predominate today. The guide is intended as a tool for students, educators, clinicians, and beginning researchers who use and interpret kinesiologic electromyographic data. Modifications will likely be needed as alternative forms of collecting, managing, normalizing, and analyzing electromyographic data are proposed, used in various settings, and reported in the literature. (+info)
Empirically supported treatments in pediatric psychology: nocturnal enuresis.
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OBJECTIVE: To review the medical and psychological literature concerning enuresis treatments in light of the Chambless criteria for empirically supported treatment. METHOD: A systematic search of the medical and psychological literature was performed using Medline and Psychlit. RESULTS: Several review studies and numerous well-controlled experiments have clearly documented the importance of the basic urine alarm alone as a necessary component in the treatment of enuresis or combined with the "Dry-Bed Training" intervention, establishing them as "effective treatments." Other multicomponent behavioral interventions that also include the urine alarm such as "Full Spectrum Home Training" have further improved the outcome for bed-wetters, but are classified as "probably efficacious" at this time because independent researchers have not replicated them. Less rigorously examined approaches that focus on improving compliance with treatment or include a "cognitive" focus (i.e., hypnosis) warrant further study. CONCLUSIONS: We recommend a "biobehavioral" perspective in the assessment and treatment of bed-wetting and suggest that combining the urine alarm with desmopressin offers the most promise and could well push the already high success rates of conditioning approaches closer to 100%. Much important work is yet to be completed that elucidates the mechanism of action for the success of the urine alarm and in educating society about its effectiveness so that its availability is improved. (+info)
Empirically supported treatments in pediatric psychology: constipation and encopresis.
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OBJECTIVE: To review the empirical research examining behavioral and medical treatments for constipation and fecal incontinence. METHOD: Sixty-five articles investigating intervention efficacy were identified and reviewed. Twenty-three of the studies were excluded because they were case studies or were less well-controlled single-case designs. The intervention protocol for each study was identified and coded, with studies employing the same interventions matched and evaluated according to the Chambless criteria. RESULTS: From the literature base to date, no well-established interventions have emerged. However, four probably efficacious treatments and three promising interventions were identified. Two different medical interventions plus positive reinforcement fit the criteria for the probably efficacious category (one with fiber recommendation and one without). Three biofeedback plus medical interventions fit efficacy category criteria: one probably efficacious for constipation with abnormal defecation dynamics (full medical intervention plus biofeedback for paradoxical contraction), and two fit the promising intervention criteria for constipation and abnormal defecation dynamics (full medical intervention plus biofeedback for EAS strengthening, correction of paradoxical contraction and home practice; and biofeedback focused on correction of paradoxical contraction, medical intervention without fiber recommendation, and positive reinforcement). Two extensive behavioral interventions plus medical intervention also met efficacy criteria for constipation plus incontinence (medical intervention without laxative maintenance plus positive reinforcement, dietary education, goal setting, and skills building presented in a small-group format fits criteria for a promising intervention; and positive reinforcement and skills building focused on relaxation of the EAS during defecation, but without biofeedback, plus medical intervention meets the probably efficacious criteria). CONCLUSIONS: A discussion of the current weaknesses in this research area follows. Specific recommendations for future research are made including greater clarity in treatment protocol and sample descriptions, reporting cure rates rather than success rates, utilization of adherence checks, and investigation of potential differential outcomes for subgroups of children with constipation and incontinence. (+info)
FES-biofeedback versus intensive pelvic floor muscle exercise for the prevention and treatment of genuine stress incontinence.
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We undertook this work to compare the treatment efficacies and the changes of quality of life after pelvic floor muscle (PFM) exercise and the functional electrical stimulation (FES)-biofeedback treatment, both of which are being widely used as conservative treatment methods for female urinary incontinence. We randomly selected 60 female incontinence patients who visited our department and divided them evenly into two groups. They were treated for a period of 6 weeks. The subjective changes in the severity of incontinence and discomfort in daily and social life were measured using a translated version of the questionnaire by Jackson. Objective changes of pelvic muscle contraction force were measured using a perineometer. Pre- and post-treatment maximal pelvic floor muscle contractile (PMC) pressure and changes in the severity of urinary incontinence and discomfort of the two groups showed statistically significant differences (p<0.001). In particular the FES-biofeedback group showed significantly increased maximal PMC pressure and a decreased severity of urinary incontinence and discomfort compared to the intensive PFM exercise group (p<0.001). In conclusion, FES-biofeedback proved more effective than simple PFM exercise. (+info)
Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis.
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OBJECTIVES: To determine whether gut focused behavioural treatment (biofeedback) is a useful therapy in multiple sclerosis patients referred for constipation, incontinence, or a combination of these symptoms. Most patients with multiple sclerosis complain of constipation, faecal incontinence, or a combination of the two. Patients rate these bowel symptoms as having a major impact on their life. Until now the management of these problems has been empirical, with a lack of evaluated therapeutic regimes. METHODS: Thirteen patients (eight women, median age 38 years, median duration of multiple sclerosis 10 years) complaining of constipation, with or without faecal incontinence underwent a median of four sessions of behavioural treatment. Anorectal physiological tests were performed before therapy. Impairment and disability were rated with the Kurtzke score and the Cambridge multiple sclerosis basic score (CAMBS). Patients were contacted a median of 14 months after completion of treatment. RESULTS: A beneficial effect was attributed to biofeedback in five patients. Mild to moderate disability, quiescent and non-relapsing disease, and absence of progression of multiple sclerosis over the year before biofeedback were predictive of symptom improvement. No physiological test predicted the response to therapy. CONCLUSION: Biofeedback retraining is an effective treatment in some patients with multiple sclerosis complaining of constipation or faecal incontinence. A response is more likely in patients with limited disability and a non-progressive disease course. (+info)